How to go Above and Beyond the Commission on Cancer Standards

Jan 3, 2020


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The Commission on Cancer outlined its 2020 updated standards with the goals of establishing consistency with the structure of quality programs across the American College of Surgeons and ensuring standards result in the improvement of patient care.

The updates are based on 6 principles:

  • Results in the improvement of patient care
  • Evidence-based
  • Current
  • Clearly interpretable
  • For the benefit of cancer patients
  • Objectively verifiable by experienced site visit reviews.

After the updates were announced by the American College of Surgeons, we hosted a webinar with Dr. William Dooley, Surgical Oncologist at the University of Oklahoma and Commission on Cancer Surveyor, and Kelly Hall, former oncology administrator and Vice President of Commercial Operations at CancerIQ. The webinar focused on Commission on Cancer Standard 4.4 and debuted a tool to meet this standard. Here's a few highlights from the webinar. 



This post provides an overview of Standard 4.4, how you can meet the standard, and how incorporating software can help oncology leaders easily demonstrate compliance with these new standards. 


Dr. Dooley defined cancer risk assessment and genetic counseling as, “The processes to identify and counsel people at risk for familial or hereditary cancer syndromes.”

The major purposes of cancer genetics include:

  • Educating patients on their risks
  • Helping patients find personal meaning with genetic information
  • Empowering patients to manage their health effectively

To meet standard 4.4, you must develop the proper policy and procedure for your cancer risk assessment services, both for your on-site services and/or referral services.

The correct cancer risk assessment services policy and procedure must include:

  • Criteria for genetic evaluation referral
  • Identification of your genetics professionals available on site and/or by referral
  • Identification of your genetics professionals qualified to do post-test counseling either on-site and/or by referral

After you have developed your policy and procedure, your cancer committee needs to evaluate your cancer risk assessment program.

Identify Your Genetics Professionals

According to Dr. Dooley, “Cancer risk assessment and genetic counseling are performed by a genetic professional with an educational background in cancer genetics and hereditary cancer syndromes. Specialized training in cancer genetics is required.

The American College of Surgeons defines a genetic professional as one of the following:

  • An individual who is board certified/eligible by the American Board of Genetic Counseling or American Board of Medical Genetics and Genomics
  • An individual who is a board certified/eligible physician with experience in cancer genetics
    • Experience is defined by providing cancer risk assessment on a regular basis and continuing medical education in cancer genetics and hereditary cancer predisposition syndromes
  • An individual who is an Advanced Practice Nurse in Genetics, Genetics Clinical Nurse, or holds an Advanced Genetics Nursing Certification credentialed by the American Nurses Credentialing Center
  • An individual who is an Advanced Practice Oncology Nurse or Physician Assistant who is prepared at the graduate level with specialized education in cancer genetics and hereditary cancer predisposition syndromes.
  • An individual who is a Registered Nurse with specialized education in cancer genetics and hereditary cancer predisposition syndromes.

It's important to note your genetic professionals do not need to be on-site. However, if you identify a referral provider, you still need to show they meet criteria.

How to Evaluate Your Cancer Risk Assessment Program

Each year, your cancer committee must evaluate your cancer risk assessment program. Aside from meeting the criteria mentioned above, you must report on certain metrics.

Dr. Dooley explained your cancer committee evaluation has to answer the following questions:

  • Who do you provide genetic services to?
  • How many patients are referred to genetic services?
  • How many patients receive testing?
  • How many patients test positive?
  • What was done for positive test results?

He states,

"A correct answer when you do an evaluation for any of the CoC Standards will be a data dense statement that is a series of numerators and denominators."

Evaluating your genetic counseling and risk management services involves 3 steps:

  1. Selecting a specific cancer site
  2. Establish process for identifying patients eligible for genetic services in-line with evidence-based guidelines
  3. Reviewing compliance with your process
How to Evaluate Your Cancer Risk Management Services


The most time consuming aspect of the evaluation is reviewing patient compliance by reporting patient metrics. While tracking and reporting patient metrics is important for accreditation purposes, it also allows you to recognize gaps and allocate resources to appropriate places. 

CancerIQ Analytics Module

After Dr. Dooley's overview of Standard 4.4, Kelly Hall debuted a solution CancerIQ clients can use to not only improve the productivity of their genetic counseling program, but demonstrate how their program is aligned with Standard 4.4.

We understand this final step of reporting metrics is time consuming, so we designed a tool to track and report information for you automatically. The CancerIQ Analytics Module generates all patient metrics needed to meet Standard 4.4 allowing you to recognize gaps, allocate resources where appropriate, and use your time to assess the effective of your program.

CoC Report


In addition to meeting CoC Standard 4.4, the CancerIQ Analytics Module offers benchmarking with other centers, which further arms you with information to target areas for improvement.

Learn more about how CancerIQ clients are able to easily generate reports for the new standard in the webinar - Going Above and Beyond CoC Standard 4.4 - Genetics and Risk Assessment.

View Webinar 


Topics: Standard 4.4| Accreditation