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Accreditation program offers path to improved rectal cancer outcomes

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Steven Wexner

Nearly 7 years after its inception, the National Accreditation Program for Rectal Cancer recently accredited four sites in the United States to improve patient outcomes.

“We have room for improvement by standardization and through multidisciplinary teamwork. We have room for improvement across the country by raising the bar,” Steven Wexner, MD, PhD (Hon), chairman of Cleveland Clinic Florida’s Department of Colorectal Surgery and director of the Digestive Disease Center, told Healio Gastroenterology and Liver Disease.

Development of accreditation

This program began 7 years ago when Wexner and his colleagues from Cleveland Clinic Ohio and Florida convened with other experts from around the U.S. as the Optimizing the Surgical Treatment of Rectal Cancer (OSTRiCh) consortium. This consortium gathered to discuss how rectal cancer outcomes were inferior to those in Europe and the U.K.

“The way those outcomes in Europe and U.K. had been improved was by having standardization, best practices,” Wexner said. “There, they are called Centers of Excellence where people focus on multidisciplinary care.”

To devise a plan, Wexner and his colleagues pulled together a diverse group of physicians: “We tried to pick physicians from university, community practice, private practice, different geographic settings, rural, urban, suburban, big city, little city and including a multidisciplinary group from pathology, radiology, surgery, all three of the perioperative elements.”

In 2014, Wexner presented the plan for accreditation to the American College of Surgeons’ (ACS) Commission on Cancer (CoC), which approved the creation of a program. Wexner noted that the ACS and the CoC have a track record for successful accreditation programs in many clinical areas. The CoC established a steering committee that devised an accreditation standards manual and conducted pilot surveys, eventually combining the original manual, the surveys and input from various societies such as the American Society for Colorectal Surgeons, the Society of Surgical Oncology, the Society for Surgery of the Alimentary Tract, The Society of Gastrointestinal and Endoscopic Surgeons, the College of American Pathologists and the American College of Radiologists.

The final National Accreditation Program for Rectal Cancer (NAPRC) launched at the annual clinical congress of the American College of Surgeons in October 2017 and Wexner said both Cleveland Clinic Ohio and Florida were among the first to apply for accreditation.

“Why? Because of the proof throughout multiple countries in Europe that these types of programs improve patient outcomes. Secondly, all the consortium’s awareness articles we published in those 7 years showed that our outcomes in United States were highly variable and, in aggregate, suboptimal and inferior to the outcomes in Europe,” Wexner said.

The 3-year accreditation was also awarded to two other institutions – Florida Hospital Cancer Institute and John Muir Health Rectal Cancer Program – and others have applied.

“The predicate is outside the country for the disease entity treatment. The predicate is in the country for what the American College of Surgeons and Commission on Cancer already do. It’s not surprising that many institutions are interested in doing it,” Wexner said.

Choose your focus

Wexner expects that more than 200 rectal cancer programs within the nearly 1,700 CoC-accredited programs will ultimately be interested in accreditation. To reach that goal, Wexner said programs will ultimately meet 20 standards: process standards, performance metrics and, ultimately, quality improvement metrics.

“The three most important long-term values – all three of which improved in the European programs – are decreased local recurrence, decreased rates of permanent colostomy and increased survival,” he said. “Those 20 standards are evidence-based and we know that by following those 20 standards, the outcomes will improve.”

But a cancer center must be honest in their focus, he said.

“We know that the outcomes of rectal cancer are highly variable. We know that they can be optimized in the context of this program. Therefore, I’d say as a cancer provider, the choice shouldn’t be whether or not to be accredited. It should be do we operate on rectal cancer? If the answer is yes, you should be accredited,” he said. “If you only occasionally operate on rectal cancer, you need to make the decision to make this a focus of your practice and get accredited or ideally forego those few patients and instead refer them to an accredited program.”

Wexner explained this is not just a matter of volume, but a consideration of acting as a multidisciplinary team in which all disciplines can improve and better serve patients.

“You have to be honest with yourself and your patients. If taking care of rectal cancer is not a priority or a core strength, then focus elsewhere. Conversely, if it’s a core competency and you pride yourself on how you do it, then you should want to be accredited,” he said. “All of us can improve. All of us.”

Patient education

Lastly, Wexner said it is incumbent on “all of us” to educate patients about the importance of this focus.

“Patients need to learn about this important new national initiative. Patients need to know. Patients need to ask questions,” he said. “We need to educate the public. Patients are pretty treatment-site and care-team agnostic. Patients go in equal numbers to low, medium and high-volume centers, but study after study after study shows that the outcomes are worse at the low volume centers, intermediate at the intermediate centers and best at high volume centers. Yet, patients somehow don’t follow those pathways.”

As this path to accreditation hopefully leads to improved outcomes, patients need the education and support to understand the importance of where they seek their care, Wexner said. – by Katrina Altersitz

For more information: National Accreditation Program for Rectal Cancer, https://www.facs.org/quality-programs/cancer/naprc. Wexner can be reached at WEXNERS@ccf.org.