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Initiative Promotes Multidisciplinary Approach To Improve Rectal Cancer Outcomes

Oct 13,2017


Thomas Rosenthal


Hospitals across the United States can now apply to participate in the new National Accreditation Program for Rectal Cancer (NAPRC) that uses a multidisciplinary team approach to achieve better outcomes for patients, according to the societies that developed the program.

“The ability of numerous specialists in multiple disciplines to work together in a collaborative effort to improve outcomes of patients attests to what we hope will be the success of the project,” said Steven D. Wexner, MD, FACS, the chair of the Department of Colorectal Surgery at Cleveland Clinic Florida, in Weston.

The program holds the potential to reduce the use of permanent colostomies, improve the quality of surgery, and also decrease the local recurrence of cancer, thereby significantly decreasing patient morbidity and mortality and local cancer recurrence, said Dr. Wexner, a member of the NAPRC steering committee who helped spearhead the development of the program.

The NAPRC was created through a collaboration among the ACS Commission on Cancer (CoC) and the Optimizing the Surgical Treatment of Rectal Cancer (OSTRiCh) Consortium, the ASCRS, the College of American Pathologists and the American College of Radiology. The OSTRiCh Consortium was founded in 2011 to improve the quality of rectal cancer care in the United States.

“All of the stakeholders working together for six years augurs well for the success of the program,” Dr. Wexner said. About 50 doctors from the different societies formed the core of the effort to create the program, he said. “It’s a program designed to be inclusive and that’s why it’s a program likely to succeed.”

Frederick L. Greene, MD, FACS, a surgeon in Charlotte, N.C., and past chair of the ACS CoC, who is also a surveyor for the commission, said there has been a need for NAPRC during the past decade because of the significant breakthroughs in the management of rectal cancer in the past 10 to 15 years. The American Cancer Society estimates that 39,910 new cases of rectal cancer will be diagnosed in the United States this year.

One of these breakthroughs was the use of chemoradiation treatment before surgery, he said. Other significant changes include “the multiple new operations that have come into play that have enabled patients to have their tumors removed but can save their sphincters. They don’t have to have a colostomy. Not every institution has people who have the ability to do these operations.”

Dr. Greene said NAPRC standards were beta tested at six hospitals to ensure the standards are reasonable. The six hospitals set the standards, which were formalized and published as part of the NAPRC application process.

David P. Winchester, MD, FACS, medical director of cancer programs at the ACS and principal investigator for the National Cancer Database, said a hospital participating in the NAPRC will be accountable to the ACS CoC for meeting the evidence-based and consensus-based standards for rectal cancer established by ASCRS and the OSTRiCh Consortium. An improvement in outcomes will be beneficial to surgeons and their patients, he said.

For many years, hospitals in European countries—led by the United Kingdom—have been improving their outcomes for rectal cancer patients by working in multidisciplinary teams, whereas tremendous variability exists in rectal cancer care in U.S. hospitals, Dr. Wexner said. “It has been shown in Europe, in multiple countries, that having a program like this one improves outcomes for patients.” An estimated 300 of the nation’s 1,500 hospitals with ASC CoC accreditation have already expressed interest in earning accreditation from NAPRC, he said.

The program will improve adherence to evidence-based guidelines so that more patients will appropriately receive, or conversely not receive, chemotherapy and radiotherapy, according to Dr. Wexner. “We know from multiple national projects this type of initiative improves outcomes for patients. That’s why the program is needed.”

Every rectal cancer case will be discussed several times during a multidisciplinary tumor board, Dr. Wexner explained. “A big room filled with people will listen to the data about every patient. Every decision will be discussed with input in advance from the radiation and medical oncologist, the MRI radiologist, the rectal cancer pathologist. The patient is getting the benefit of many people thinking from many different angles.”

Dr. Wexner said photographs of specimens will be reviewed by the tumor board. “There is no better motivator for a competitive perfectionist surgeon than to see the product of one’s surgery projected on a big screen in front of all of our peers. That’s a wonderful compelling reason to want to produce quality surgical specimens which ultimately translates into better outcomes for the patient.” He said the surgeon operates after the group has decided and reviewed the case. “It is a dynamic, continuous quality improvement initiative.”

For the patient, “it is always better to have you looked at by a group so that nothing is missed. One collective opinion is communicated to the patient,” said Dr. Wexner, who uses the team approach in his role as head of colorectal surgery at Cleveland Clinic Florida. “My patients love the fact that I tell them we’re going to discuss their case at the [multidisciplinary] tumor board. My patients have rapidly embraced it. The American public deserves the same opportunity for the optimal care and standardized best practices that patients in Europe have been enjoying for up to the past two decades.” Dr. Wexner said he envisions NAPRC serving as a template for care of other types of cancer.

“NAPRC is needed, and now, because the evaluation and management of patients with rectal cancer in the U.S. is below that of our European and Scandinavian counterparts,” Dr. Winchester said. “We have the capacity to improve.”

Hospital programs wishing to apply for accreditation from the NAPRC must assess and demonstrate compliance with the requirements for all standards outlined in the standards manual, The National Accreditation Program for Rectal Cancer Standards Manual: 2017 Edition.

The initial NAPRC survey, which includes an on-site visit to the applying facility, occurs after the facility has achieved CoC accreditation and attests that the NAPRC standards have been in place at the site and complied with for at least 12 months. The initial NAPRC survey cannot take place at the same time as the initial CoC survey.

Once a representative of the applying facility fills out the application, signs the Business Associate and Data Use Agreements and the NAPRC Participation Agreement, and pays the application fee, the facility will receive access to the NAPRC Survey Application Record. This application record will indicate what information must be provided to show compliance with the NAPRC standards.

Several hospitals have applied, Dr. Winchester said, and several hundred are projected to receive accreditation by NAPRC over the next several years.