ODM Standards for CTRs

The Importance of Understanding the American College of Surgeons Commission on Cancer, National Accreditation Program for Breast Centers and National Accreditation Program for Rectal Cancer Standards

Jennifer Rohleder BS, CTR
Compliance Director, Oncology Data Management and Accreditation Services

Many CTRs are familiar with the Commission on Cancer (CoC) Program data quality measurements, CP3R and RQRS. But are they aware of the National Accreditation Program for Breast Centers (NAPBC) and National Accreditation Program for Rectal Cancer (NAPRC) standards dedicated to clinical diagnostics, treatment, services and quality improvement.  Facilities may be tasking cancer registries with the responsibility of collecting the additional information, it is up to Certified Tumor Registrars (CTRs) to become educated on the expanding scope of knowledge necessary to perform data collection for these quality measures.

CTRs should be making efforts to learn the specific requirements of the various types of accreditation for cancer programs.  To progress in this career field, CTRs must be fully informed and feel at ease with educating facility administrators and clinicians of State oncology data collection and reporting rules and guidelines as well as those of the American College of Surgeons (ACS) COC, NAPBC and NAPRC. While standards tiles and data elements may appear the same, they are not.

Consider the statement: “Staging before Definitive Treatment”.  The rules for AJCC Staging 8th Edition state that assignment of stage is the responsibility of the “managing physician” and the “clinical staging be done before initiation of treatment…”   The requirement for clinical staging goes on to say that “no specific imaging is required to assign a clinical stage for any cancer site.”  And then there is the section stating that documentation of the cancer stage should be documented in the medial record.

If a facility seeks NAPBC accreditation Standard 2.6 requires that “all staging classification are documented in the medical record’. This will be confirmed by a chart audit at the time of survey.

In order for a CTR to collect the AJCC Stage correctly the facility MUST institute binding rules for the medical staff to define and identify the “managing physician”.  The facility must establish requirements for documenting the clinical stage in the medical record prior to the initiation of treatment and institute a hard-stop for all treatment of cancer patients without the complete clinical stage in the medical record by a managing physician.

More to consider- If a program is to be NAPRC accredited, the facility must go one step further to create an addional clinical stage documentation requirement for patients with rectal cancer.  Per the NAPRC Standard 2.2 “Staging Before Definitive Treatment”; the facility must have a policy for local tumor staging of rectal cancer using MRI of the pelvis.  This will be confirmed by a chart review at the time of the survey.

It is more important than ever for CTRs to know their role, responsibilities and limitations for time, knowledge and personal credentialing.  For instance, many CTRs have volunteered or acquiesced to the responsibility for determining and reporting CAP compliant synoptic reporting for accreditation purposes. Yet the standard definition and requirements state “The cancer committee may delegate this quality control activity to the pathologists who report the quality control activity and a summary of findings regularly to the cancer committee or to other physicians on the cancer committee.”   Both the NAPBC and NAPRC have similar rules for their specific pathology related standards. CTRs must be encouraged and permitted to inform facility leadership that this is not a cancer registry responsibility.


There are many other ways for CTRs to seize the opportunity to demonstrate their unique skill sets and abilities for contributing to cancer programs. They must learn and understand the ACS -CoC, NAPBC and NAPRC Standards; and learn how to effectively communicate their differences and the fact that seemingly equivalent data elements have dissimilar collection and recording criteria.

A few points to highlight to administrators and physicians as data collection requests come forth:

  • Cancer Registry data collection and coding rules are not negotiable.
  • Cancer Registry software has its limitations for collecting “User Defined” (non-standard) data elements
  • Every additional data item collected requires:
    • Supplementary cancer registry staff education
    • Accompanying quality assurance and quality control monitoring and action plans
    • Adjusted productivity standards for abstracting
    • Time

Bottom-line: for any outcome data to be valuable for analysis and outcomes the data must be correct at the point of entry.


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