NAPRC Accreditation Is Associated with Improvements in Care Quality, Increases in Patient Volume

The ACS National Accreditation Program for Rectal Cancer (NAPRC) was launched by the ACS Cancer Programs in 2017.

NAPRC was the second disease-site-specific accreditation program, after the National Accreditation Program for Breast Cancer (NAPBC). The first NAPRC centers were accredited in 2018, and the program has since grown to 128 accredited centers across 36 states and the District of Columbia.¹ 

Prior to the establishment of the NAPRC, there was a body of evidence showing variability in the quality of care for rectal cancer in North America, as well as in cancer outcomes.^2,3 This disparity in rectal cancer care resulted in the formation of a grassroots organization known as the OSTRiCh (Optimizing the Surgical Treatment of Rectal Cancer) Consortium in 2011.^2,3 The collaborative promoted standardization of rectal cancer care, based on the European model of training, centralization, and standardization. 

While the organization began with just 18 North American centers, more than 400 centers ultimately expressed interest in joining OSTRiCh. Given the widespread interest in a “centers of excellence” program for rectal cancer care, the leaders of OSTRiCh partnered with the ACS Cancer Programs, and NAPRC was established. 

The NAPRC program follows five core principles of evidence-based rectal cancer care.⁴ 

1. Total mesorectal excision surgery should be performed.  This is a surgical technique that had been standardized in Europe and was associated with decreased local recurrence rates and improved survival.⁵
2. Quality of surgery should be measured by specific techniques of pathology assessment. 
3. Specialist imaging techniques should identify patients at high risk for local recurrence.
4. Modern neoadjuvant and adjuvant therapies should be used as appropriate based on cancer stage. 
5. A multidisciplinary team (MDT) should care for patients with rectal cancer to identify, coordinate, deliver, and monitor optimized treatment “on an individual patient-by-patient basis.”⁴

Based on these principles, all NAPRC programs must have a defined MDT, with surgeons, pathologists, and radiologists who have completed additional training in rectal cancer care, along with medical oncologists and radiation oncologists. All patients must be evaluated by the MDT at multiple points in the care pathway, with a coordinator who organizes the MDT and helps navigate patients and scheduling. 

Photographs of surgical specimens are reviewed, and synoptic reporting is used for surgery, rectal cancer staging, magnetic resonance imaging (MRI), and pathology reporting. The expectation is that these best practices should result in better surgical and nonsurgical oncologic care and improved outcomes for patients.

While there has been limited evidence to support that becoming an NAPRC-accredited center improves the quality of care, new research demonstrates a decrease in hospitals’ rates of circumferential resection margin (CRM) positivity after becoming NAPRC-accredited.⁶ A low rate of CRM positivity is an important indicator of surgical quality for rectal cancer and is associated with decreased cancer recurrence rates.

Another publication shows an increase in patient volume after NAPRC accreditation.⁷ This research is the result of a collaboration between three groups: health services researchers at the University of Rochester in New York, the ACS Cancer Research Program’s (CRP) Standards Investigation and Validation Committee, and the NAPRC Executive Committee.

The research team, led by coauthor Dr. Fleming, used a statistical technique called “difference in difference,” designed to evaluate whether a policy change or intervention results in a change in performance or outcomes.

The first paper, recently published in the Journal of the American College of Surgeons, examined hospital-level circumferential resection margin positivity rate, considered an important measure of surgical and multidisciplinary care quality.

Researchers also examined secondary outcomes of carcinoembryonic antigen (CEA) measurement, a part of the recommended staging workup for rectal cancer patients, and delayed initiation of treatment (greater than 60 days). They found that obtaining NAPRC accreditation was associated with a significant reduction in circumferential resection margin positivity (absolute reduction of 1.1% and relative reduction of 8.7%).

Becoming accredited also was associated with an increase in guideline-concordant CEA testing. Furthermore, no difference in rates of delayed treatment were determined by the study.

In the second article, recently published in JAMA Surgery, the research question addressed by the study’s authors considered whether becoming NAPRC-accredited was associated with higher volumes of rectal cancer care at those centers.

The study found that baseline procedural volumes were similar across NAPRC-accredited and nonaccredited hospitals, which also had similar geographic distributions and facility characteristics. However, after accreditation, rectal cancer volumes increased in the NAPRC centers. This increase was observed in both patient volume and surgical volume. Notably, these changes were not seen in hospitals that did not become accredited.

Researchers also were concerned that referring more patients to accredited centers might increase “care fragmentation.” However, the study showed that accreditation did not significantly worsen fragmentation.

These studies, which are retrospective analyses of data from the National Cancer Database^® (NCDB^®) registry, feature compelling results, according to Dr. Fleming.

“This research demonstrates that becoming NAPRC-accredited improves quality of patient care and increases volume. Centers that are considering accreditation may find the evidence helpful in committing the resources required for establishing an NAPRC program,” he said.

“It’s important for the ACS Cancer Research Programs to demonstrate their value to participating centers, and most importantly, to patients,” added coauthor Dr. Lizarraga, who chairs the ACS CRP’s Standards Investigation and Validation Committee. “This new research is an important step in demonstrating the value of NAPRC accreditation.”

Despite NAPRC’s growth to 128 accredited sites, this represents a small fraction of the 1,400 CoC-accredited programs; by comparison, the NAPBC currently has 547 accredited sites. In fact, it is estimated that only about 10% of rectal cancer patients now receive treatment in an NAPRC center.⁸

According to Dr.  Lizarraga, the ACS CRP Standards Investigation and Validation Committee is currently conducting a study on the barriers to NAPRC and NAPBC subspecialty accreditation. The study involves interviews with representatives from CoC-accredited sites that are not subspecialty accredited.

“It is more important than ever to understand the barriers to more centers becoming a part of NAPRC, now that we see this evidence that the program improves the quality of care,” explained Dr. Lizarraga.

To become NAPRC-accredited, a CoC institution must implement the NAPRC Standards and then apply for an accreditation site visit.⁹ Once accredited, a center will be reaccredited on a 3-year cycle. The NAPRC standards include:

• Program structure requirements
• Patient care protocols
• Data and quality improvement
• Educational requirements

Key program structure elements include a physician program director, a program coordinator (usually a nurse or administrator), and a defined MDT that meets at least twice a month (also known as a tumor board). Representatives from five key specialties (i.e., surgery, medical oncology, radiation oncology, radiology, and pathology) must be present at every meeting.

Patient care protocols include standardized staging evaluation and presentation of all primary rectal cancer patients at the MDT meeting prior to treatment, after neoadjuvant therapy, and after surgery.  Surgical pathology and surgical specimen photos are reviewed by the MDT to promote optimal care for the surgical patient. Synoptic reporting is used for MRI, pathology, and operative notes. Protocols are put in place for several aspects of patient care, and treatment must begin in a timely manner.

In terms of data and quality improvement, NCDB quality measure performance is reviewed regularly, and the results drive targeted quality improvement projects. The educational standard requires all the surgeons, radiologists, and pathologists involved with the program to complete rectal cancer educational modules designed by their respective specialty societies. 

The NAPRC accreditation standards recently were revised to acknowledge important changes in rectal cancer care. Specifically, there are new standards on “watch and wait” and local excision surgery. Additionally, a standard on adjuvant therapy was removed with the nationwide change to total neoadjuvant therapy for rectal cancer.  Another notable change is that the threshold for compliance was reduced for several standards in an effort to make the program accessible to more centers.

For more information, visit facs.org/quality-programs/cancer-programs/national-accreditation-program-for-rectal-cancer.

Dr. Samantha Hendren is a professor in the Department of Surgery at Indiana University in Indianapolis.

Dr. Fergal Fleming is an associate professor of surgery and oncology in the Department of Surgery and Wilmot Cancer Institute at the University of Rochester Medical Center in NY.

Dr. Ingrid Lizarraga is a professor in the Department of Surgery at the University of Iowa in Iowa City.

References

1. American College of Surgeons. ACS Quality Programs. Find a Hospital. Available at: https://www.facs.org/find-a-hospital/?nearMe=off&companyType=NAPRC&orderBy=a-z. Accessed June 2, 2026.
2. Dietz DW. Consortium for Optimizing Surgical Treatment of Rectal Cancer (OSTRiCh). Multidisciplinary management of rectal cancer: The OSTRiCh. J Gastrointest Surg. 2013;17(10):1863-1868.
3. Rickles AS, Dietz DW, Chang GJ, Wexner SD, et al. Consortium for Optimizing the Treatment of Rectal Cancer (OSTRiCh). High rate of Positive Circumferential Resection Margins Following Rectal Cancer Surgery: A Call to Action. Ann Surg. 2015;262(6):891-898.
4. Wolford D, Westcott L, Fleshman J. Specialization improves outcomes in rectal cancer surgery. Surg Oncol. 2022 Aug;43:101740.
5. Quirke P, Steele R, Monson J, Grieve R, et al Effect of the plane of surgery achieved on local recurrence in patients with operable rectal cancer: A prospective study using data from the MRC CR07 and NCIC-CTG CO16 randomised clinical trial. Lancet. 2009; 373(9666):821-828.
6. Becerra A,  Lizarraga I,  Weigel, RJ,  Hendren S, et al. Evaluation of the National Accreditation Program for Rectal Cancer and association with oncologic outcomes after proctectomy. J Am Coll Surg. May 19, 2026. Available at: https://journals.lww.com/journalacs/abstract/9900/evaluation_of_the_national_accreditation_program.1692.aspx. Accessed June 2, 2026.
7. Loria A, Jia Y, Weigel RJ, Wexner SD, et al Association of rectal cancer accreditation with patient volume and procedural trends in the US. JAMA Surg. May 6, 2026:e261259. 
8. Harbaugh CM, Kunnath NJ, Suwanabol PA, Dimick JB, et al. Association of National Accreditation Program for Rectal Cancer accreditation with outcomes after rectal cancer surgery. J Am Coll Surg. 2024 Aug 1;239(2):98-105.
9. American College of Surgeons. Optimal Resources for Rectal Cancer Care (2026 Standards). 2024. American College of Surgeons: Chicago, IL.