Developing the National Accreditation Program for Rectal Cancer

Two Cleveland Clinic physicians lead the way

In October 2017, the American College of Surgeons’ Commission on Cancer, the American Society of Colon and Rectal Surgeons, the College of American Pathologists and the American College of Radiology launched a new quality improvement initiative for rectal cancer care called the National Accreditation Program for Rectal Cancer (NAPRC). The NAPRC is the result of a concerted effort of an interdisciplinary team of experts spanning the past seven years.

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Together with his colleagues, Steven D. Wexner, MD, PhD, Chairman of Cleveland Clinic Florida’s Department of Colorectal Surgery, played an instrumental role in launching the initiative and facilitating its early implementation. Matthew F. Kalady, MD, Co-Director of Cleveland Clinic’s Comprehensive Colorectal Cancer Program, took the lead in verifying the importance of NAPRC standards in improving patient outcomes.

A multidisciplinary approach to rectal cancer care

“This initiative brings together a multi-institutional team of colorectal surgeons, medical oncologists, radiation oncologists, radiologists and pathologists on a common mission of improving rectal cancer care in the U.S.,” says Dr. Kalady. “The NAPRC aims to achieve this goal through the application of specific standards of process measures, quality and performance indicators.”

Dr. Kalady explains that one of the focal points of the NAPRC is a multidisciplinary approach to rectal cancer care.

“Rectal cancer is usually treated with different types of therapy used in combination or in sequence,” he says. “It is really important that not only are the specialists delivering care experts at what they do but also work to collaborate with all other physicians involved in caring for the patient.”

The importance of colorectal cancer multidisciplinary conferences

One important aspect of a multidisciplinary approach to care outlined in the NAPRC Standards Manual is the colorectal cancer multidisciplinary conferences (CRC-MDC) or tumor board. In an article in the Journal of the American College of Surgeons, Dr. Kalady and his colleagues reported the results of a study that assessed the impact of CRC-MDC on the management of rectal cancer patients.

The study included 408 rectal cancer cases presented at a weekly CRC-MDC at Cleveland Clinic main campus between July 2015 and June 2016. Physician survey responses documenting a change in management plan were obtained for 371 patients.

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“The CRC-MDC resulted in a change in management of 26 percent of patients,” Dr. Kalady says. “The change was categorized as a change in therapy, change in therapy sequence or recommendation for additional evaluation and was independent of the presenting surgeon’s years of clinical experience.”

Dr. Kalady says that the CRC-MDCs have been an important part of colorectal cancer care at Cleveland Clinic in the past ten years by providing a forum for review and discussion of each case.

“After examining the key decision-making factors, which include the patient’s history and characteristics, pathology findings and imaging results, the physicians participating in the conference decide as a group on the best treatment plan,” he says. “This approach promotes discussion, is very efficient and allows for the implementation of standards and quality check of the treatment plan.”

Implementing the NAPRC standards

Published in October 2017, the updated NAPRC Standards Manual outlines the current standards and performance indicators of rectal cancer care.

“The standards are divided into three main groups: process standards, performance standards and outcome measures,” says Dr. Wexner. “The first standard is institutional commission on cancer accreditation. Having a multidisciplinary rectal cancer team in place is critical, as well as having all the specialists work through their respective societies to ensure participation in educational initiatives and use of synoptic reports. Synoptic reports, comprised for pathology, radiology and surgery data, serve as checklists and ensure that none of the important information about the patient is missed.”

Cleveland Clinic was among the first medical centers to implement the NAPRC standards.

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“Having implemented the NAPRC standards at Cleveland Clinic main campus and Florida throughout the past few years, we are confident that we will see our patients derive the same benefits as patients have achieved in similar programs in Europe,” says Dr. Wexner. “We anticipate some of these benefits to be lower rates of colostomy construction, lower rates of local tumor occurrence and greater tumor-free survival.”

Plans are also in place to seek NAPRC accreditation of the rectal cancer program at Cleveland Clinic main campus and Florida.

“We are optimistic that both Cleveland Clinic sites, main campus and Florida, will be visited and ideally accredited during 2018,” Dr. Wexner says.