Surgical Trainee Familiarity and Knowledge of the Commission on Cancer (CoC) Operative Standards: A National Survey Study

Abstract

Introduction:

The Commission on Cancer (CoC) implemented six operative standards to reduce technical variation in cancer surgery. While designed to guide surgeons in performing key oncologic techniques, these standards also provide a framework for teaching high-quality cancer surgery to trainees. We assessed surgical trainees’ familiarity with the CoC Operative Standards and underlying cancer surgery principles to identify knowledge gaps and opportunities for improved education.

Methods:

The American College of Surgeons Cancer Surgery Standards Program distributed an anonymous survey to general surgery residents and surgical fellows across the US. Questions addressed the CoC Operative Standards and cancer surgery principles, with scores calculated for correctness. Univariate logistic regression evaluated associations between trainee or program characteristics and knowledge. Trainees were also asked about their role in procedural documentation, given the synoptic operative report requirements of the standards.

Results:

244 surveys were completed by 205 residents and 39 fellows. Fellows reported greater familiarity with the CoC Operative Standards (68% vs 24%, P<0.001). Only 30% of trainees reported receiving formal curriculum on the standards. Correct response rates were 30% for CoC Operative Standards questions versus 50% for cancer surgery principles, with minimal association between knowledge and trainee/program characteristics. Most residents (71%) reported contributing to operative documentation.

Conclusions:

Surgical trainees demonstrated limited knowledge of the CoC Operative Standards, highlighting the need for multifaceted educational strategies at the national and institutional levels. Incorporating education about the CoC Operative Standards into surgical training can help emphasize the importance of performing and documenting critical elements of cancer operations.

Precis:

This survey study explores surgical trainees’ familiarity with the CoC Operative Standards. There is a substantial gap in trainees’ knowledge of these standards and underlying principles of high-quality cancer surgery. There is an important opportunity to strengthen surgical education on quality metrics essential for optimal cancer care.

Introduction

For most early-stage solid-organ cancers, high-quality surgery offers the best chance for long-term survival. Effective cancer surgery includes both the resection of the primary tumor (local control) and adequate evaluation of lymph nodes, which informs prognosis and guides adjuvant treatment decisions. However, significant variation has existed in the technical quality of cancer operations across the United States (US).^1-6

To bridge this gap, in 2015, the American College of Surgeons (ACS) published the first volume of the Operative Standards for Cancer Surgery, which is a series of best practices outlining surgical techniques essential to achieve optimal oncologic outcomes.^7-9 These standards are grounded in the best available evidence and expert consensus.

In 2020, two major initiatives were launched to advance the quality of surgical cancer care. Specifically, the ACS established the Cancer Surgery Standards Program (CSSP) to help develop, implement, and educate surgeons about the operative standards.¹⁰ Concurrently, the Commission on Cancer (CoC), which is the nation’s largest cancer center accreditation body, incorporated six operative standards into its list of accreditation requirements.⁵ Known as CoC Operative Standards 5.3-5.8, these standards address key elements of curative-intent operations across five common cancer types—breast, colon, rectum, lung, and cutaneous melanoma (Appendix A). Starting in 2021, all 1,400 CoC-accredited cancer programs have been required to document compliance with these standards in a synoptic format, characterized by standardized and discrete data fields, such that required data elements and responses must be organized in a structured checklist. Synoptic formatting has the potential benefit of ensuring that all data elements necessary for high-quality care are captured, that information is recorded clearly and efficiently, and that data can be more readily extracted, exchanged, and analyzed.¹¹

The CoC Operative Standards represent an unprecedented effort to standardize the technical quality of cancer surgery, as well as operative and pathologic reporting, with engagement from hospitals, surgeons, and other oncology experts nationwide. Prior survey-based research exploring surgeons’ familiarity with these standards during the initial implementation period demonstrated significant variability in awareness of the CoC Operative Standards across specialties.¹² More specifically, 74% of surgeons interviewed in 2021 (first year of implementation) reported awareness of the CoC Operative Standards. To support implementation practices, the CoC, CSSP, and ACS Cancer Programs have led a series of national educational outreach efforts.^13-19 Separately, several initiatives have specifically targeted surgical trainees, given that the CoC Operative Standards may provide a framework for teaching critical aspects of high-quality cancer surgery to surgical residents and fellows.^20-22

Despite these efforts to promote the CoC Operative Standards and encourage their adoption, little is known about surgical trainees’ familiarity with the standards or the technical principles they emphasize. To address this gap, we surveyed general surgery residents and surgical fellows about the CoC Operative Standards to identify key knowledge deficits and inform future educational strategies aimed at ensuring adoption of optimal cancer surgery techniques among the next generation of surgeons.

Methods

Approval and Reporting

Approval for this cross-sectional survey study was obtained from the leadership of the CSSP, ACS Cancer Programs, and Resident and Associate Society of the ACS. We report this study in adherence to the Consensus-Based Checklist for Reporting of Survey Studies.²³

Study Participants and Survey Distribution

We administered an anonymous electronic online survey (Qualtrics, Provo, UT) to surgical trainees across the US between February and April 2025 (Appendix B). Eligible participants included general surgery residents at all levels of training and surgical fellows only in subspecialties relevant to the CoC Operative Standards (i.e., Breast Surgical Oncology, Cardiothoracic, Colorectal, and Surgical Oncology). We used a convenience sampling approach. The survey was distributed via the email listservs of CSSP member organization representatives, the Association of Residency Administrators in Surgery, and the ACS regional chapters, all of whom were asked to forward the invitation to surgical trainees affiliated with their organizations or programs. Additionally, the survey was promoted in newsletters and on the social media and networking platforms of the ACS Cancer Programs, ACS Communities, and Resident and Associate Society of the ACS.²⁴

Survey Development

Our survey was modeled after a previously published instrument that assessed over 750 practicing surgeons’ knowledge of the CoC Operative Standards.¹² We adapted and expanded questions from that study with input from ACS leadership and a multidisciplinary panel of disease-site experts in breast surgical oncology, complex surgical oncology, melanoma, and thoracic surgery to ensure content validity and relevance across specialties. In addition, we piloted the survey among surgical residents at varying training levels across four geographically diverse institutions.

Data Collection

Participants self-identified their level of training and received a version of the survey tailored to their training status (i.e., resident or fellow). Fellows were also asked to indicate their subspecialty and received subspecialty-specific questions based on the cancer types they treat. The survey assessed each trainee’s familiarity with the CoC, the CSSP, and the CoC Operative Standards, as well as their knowledge of select cancer surgery principles underlying the standards through a series of questions formatted as multiple-choice or “select all that apply”. Trainees who answered that they were unaware of the CoC or the CoC Operative Standards were asked only about cancer surgery principles and not about the accreditation-related requirements of the CoC Operative Standards. All respondents were asked about their knowledge of synoptic documentation and their role in creating operative notes. Given the tailored nature of this survey, the total number of questions ranged from 23 to 40 depending on the participant’s level of training, subspecialty, and reported prior familiarity with the CoC and the CoC Operative Standards.

Data Analysis

All completed and partially completed surveys with required information on the respondent’s training level and familiarity with the CoC or CoC Operative Standards were included in data analysis. Familiarity with the CoC Operative Standards and knowledge of cancer surgery principles and synoptic documentation were compared between residents and fellows using Pearson’s chi-square tests or Fisher’s exact tests.

As in the prior study evaluating surgeons’ understanding of the CoC Operative Standards,¹² responses to questions on the CoC Operative Standards accreditation requirements were used to calculate a Standard Score, while responses related to cancer surgery principles were used to generate a Surgery Score. Only respondents who had reported familiarity with the CoC Operative Standards were asked questions about the accreditation requirements (Standard Score). All respondents were asked questions about cancer surgery principles (Surgery Score). Scores were treated as proportions, calculated by dividing the number of correct responses by the number of answered questions. Participants were not penalized for skipping questions. Mean Standard and Surgery Scores were compared between residents and fellows using two-sample t-tests. The paired t-test was used to compare the Standard Score and the Surgery Score from the same individual.

Lastly, we explored associations between trainee and program characteristics and knowledge (i.e., Standard Score or Surgery Score) through univariate logistic regression analyses with scores as dichotomized variables (i.e., above or below the median score). In cases of complete separation, Firth’s penalized likelihood logistic regression method was used.²⁵

P < 0.05 was considered significant, and all P values were two-sided. All statistical analyses were performed using Stata statistical software, Version 18.0 (StataCorp, College Station, TX).

Results

Trainee Demographics

A total of 244 trainees answered the survey, including 205 (84%) residents and 39 (16%) fellows (Table 1). Among residents, there was broad representation across post-graduate year (PGY) levels. Most respondents were trained in academic or university-affiliated programs (n = 168, 85%) and urban environments (n = 147, 75%). Respondents represented programs across the US, including the Midwest (n = 62, 32%), West (n = 57, 29%), Southeast (n = 36, 18%), Northeast (n = 34, 17%), and Southwest (n = 7, 4%).

Table 1. Surgical Trainee and Training Program Characteristics.

Characteristic	Frequency, n (%)
Level of training (n = 244)
PGY 1	36 (15)
PGY 2-3	58 (24)
PGY 4-5	69 (28)
Research Resident	42 (17)
Fellow	39 (16)
Program Type (n = 197)
Academic/University-Affiliated	168 (85)
Community	27 (14)
Military	0 (0)
Othera	2 (1)
Program Setting (n = 197)
Rural	8 (4)
Suburban	42 (21)
Urban	147 (75)
Other	0 (0)
Program Location (n = 196)
Northeast	34 (17)
Southeast	36 (18)
Midwest	62 (32)
Southwest	7 (4)
West	57 (29)
Residency Size (n = 168)
1–2 residents	1 (1)
3–7 residents	81 (48)
>7 residents	86 (51)
Residents' Desired Subspecialty (n = 168)
Breast Surgical Oncology	8 (5)
Cardiothoracic	18 (11)
Colorectal	17 (10)
Endocrine	1 (1)
Minimally Invasive or Bariatric	9 (5)
Pediatric	16 (10)
Plastic and Reconstructive	4 (2)
Surgical Oncology	27 (16)
Transplant	6 (4)
Trauma/Critical Care	26 (15)
Vascular	10 (6)
Undecided	19 (11)
General Surgery Without Fellowship	5 (3)
Otherb	1 (1)
Residents' Rotations in the Preceding 3 Years. Select all that applyc (n = 191)
Breast	135 (71)
Surgical Oncology	158 (83)
Colorectal	150 (79)
Thoracic	106 (55)
None	5 (3)
Fellowship Size (n = 29)
1 fellow	1 (3)
2–3 fellows	13 (45)
>3 fellows	15 (52)
Fellows’ Subspecialty (n = 39)
Breast Surgical Oncology	3 (8)
Cardiothoracic	1 (3)
Colorectal	4 (10)
Surgical Oncology	30 (77)
Other	1 (3)
Fellowship Program is ACGME-Accredited (n = 29)
Yes	28 (97)
No	1 (3)
Unsure	0 (0)
To my knowledge, my program has an affiliated cancer center. (n = 242)
Yes	200 (83)
No	25 (10)
Unsure	18 (7)
To my knowledge, my program’s hospital is accredited by the CoC. (n = 243)
Yes	137 (56)
No	4 (2)
Unsure	102 (42)

^aOther: Hybrid

^bOther: Neurosurgery

^cMore than one answer option permitted; percentages do not sum to 100%

Abbreviations: ACGME, Accreditation Council for Graduate Medical Education; CoC, Commission on Cancer; PGY, postgraduate year

Residents reported future career interest in a variety of surgical subspecialties, including 42% (71/168) in an oncology-related specialty (i.e., Breast Surgical Oncology, Cardiothoracic Surgery, Colorectal Surgery, Endocrine Surgery, and Surgical Oncology). The majority had completed a rotation within the past three years in cancer-related specialties addressed by the CoC Operative Standards, including Surgical Oncology (158/191, 83%), Colorectal Surgery (150/191, 79%), Breast Surgery (135/191, 71%), and Thoracic Surgery (106/191, 55%). The most common fellowship training programs were in Surgical Oncology (30/39, 77%), followed by Colorectal Surgery (4/39, 10%), and Breast Surgical Oncology (3/39, 8%), and nearly all were identified as an Accreditation Council for Graduate Medical Education (ACGME)-accredited program (28/29, 97%).

Overall, 83% (200/242) of trainees reported that their program has an affiliated cancer center. However, only 56% (137/243) reported that the CoC accredited their institution’s cancer center and 42% (102/243) were unsure of their cancer center’s CoC accreditation status.

Familiarity with the CoC, CSSP, and CoC Operative Standards

Compared to residents, fellows reported significantly greater familiarity with the CoC (86/204, 42% vs 31/39, 80%), the CSSP (43/197, 22% vs 23/37, 62%), and the CoC Operative Standards (46/195, 24% vs 25/37, 68%, all P < 0.001) (Table 2). However, among the residents and fellows familiar with the CoC, there was no significant difference in correctly identifying the primary goals of the CoC or the cancer types addressed by the CoC Operative Standards. Fellows correctly identified CoC Operative Standard documentation requirements (i.e., synoptic operative and pathology reports) more frequently than residents, but this difference was not significant. There was a considerable difference, however, in fellows’ ability to correctly describe the concept of synoptic documentation (90/168, 54% residents vs 27/30, 90% fellows, P = 0.001).

Table 2. Trainees’ Familiarity with the Commission on Cancer and Cancer Surgery Standards Program.

Questionnaire	Residents, n (%)	Fellows, n (%)	P a
Did you know about the CoC before this survey? (n = 243)b			<0.001
Yes	86 (42)	31 (79)
No	118 (58)	8 (21)
If yes, how familiar are you with the primary goals of the CoC? (n = 110)			0.14
Not	19 (24)	4 (13)
Slightly	34 (42)	9 (30)
Moderately	20 (25)	11 (37)
Very	7 (9)	5 (17)
Extremely	0 (0)	1 (3)
If yes, correctly identified goals of CoC. (n = 110)			0.40
Yes	69 (86)	29 (97)
No	2 (3)	0 (0)
Unsure	9 (11)	1 (3)
Did you know about the CSSP before this survey? (n = 234)			<0.001
Yes	43 (22)	23 (62)
No	154 (78)	14 (38)
Did you know about the CoC Operative Standards before this survey? (n = 232)			<0.001
Yes	46 (24)	25 (68)
No	149 (76)	12 (32)
If yes, correctly identified all CoC Operative Standard cancer types. (n = 65)			0.07
Yes / Mostly Yesc	10 (23)	10 (46)
No	33 (77)	12 (55)
If yes, correctly identified how compliance is documented. (n = 64)			0.36
Yes	19 (45)	14 (64)
No	18 (43)	7 (32)
Unsure	5 (12)	1 (5)
Correctly described synoptic documentation. (n = 198)			0.001
Yes	90 (54)	27 (90)
No	20 (12)	1 (3)
Unsure	58 (35)	2 (7)
Have the CoC Operative Standards been included in your surgical training curriculum/didactics? (n = 68)			0.09
Yes, in-depth	3 (7)	4 (16)
Yes, briefly	10 (23)	11 (44)
No	28 (65)	9 (36)
Unsure	2 (5)	1 (4)
Other than in formal didactics, when/where have you most discussed the CoC Operative Standards with an attending? (n = 68)			0.48
During an operative case	8 (19)	7 (28)
After an operative case	11 (26)	4 (16)
I cannot recall when/where	7 (16)	8 (32)
They have not been discussed	12 (28)	4 (16)
Unsure	1 (2)	0 (0)
Otherd	4 (9)	2 (8)
Have you independently studied the CoC Operative Standards? (n = 68)			0.01
Yes	15 (34)	16 (64)
No	28 (64)	8 (32)
Unsure	1 (2)	1 (4)
What materials did you use to learn about the CoC Operative Standards? Select all that applye (n = 31)			0.47
Education/Study Podcast	5 (33)	8 (50)
Society Podcast	3 (20)	6 (38)
ACS Webinar	3 (20)	3 (19)
Other Webinar	1 (7)	1 (6)
CoC or ACS Website	6 (40)	7 (44)
CoC Optimal Resources for Cancer Care	4 (27)	4 (25)
Operative Standards for Cancer Surgery Manuals	5 (33)	9 (56)
Otherf	1 (7)	0 (0)
If a fellow, when did you first learn about the CoC Operative Standards? Select all that applye (n = 24)
Residency	----	18 (75)
Fellowship	----	10 (42)
Unsure	----	1 (4)
How might the CoC Operative Standards affect your future surgical practice? (n = 64)			0.12
No impact	0 (0)	0 (0)
Minimal	5 (12)	0 (0)
Moderate	17 (41)	12 (55)
Significant	12 (29)	9 (41)
Unsure	8 (19)	1 (5)

^aTotal number includes resident and fellow responses

^bPearson’s chi-square test or Fisher’s exact test

^cIdentified all cancer types correctly or made one mistake (e.g., missing one cancer type or reported one extra cancer type)

^dOther: In clinic and During Research

^eMore than one answer option permitted, percentages do not add to 100%

^fOther: National Comprehensive Cancer Network (NCCN) Guidelines

Abbreviations: ACS, American College of Surgeons; CoC, Commission on Cancer; CSSP, Cancer Surgery Standards Program

Only 30% (13/43) of residents reported that the CoC Operative Standards had been included in their surgical training curriculum compared to 60% (15/25) of fellows. Residents were less likely to have independently studied the CoC Operative Standards (15/44, 34% vs 16/25, 64%, P = 0.01). Both groups reported using a variety of materials to learn about the CoC Operative Standards, with podcasts and webinars being the most common. Despite differences in prior exposure, both residents and fellows believed that the CoC Operative Standards would influence their future surgical practice.

Knowledge of CoC Operative Standard Requirements and Cancer Surgery Principles

Among respondents familiar with the CoC Operative Standards, knowledge of standard-specific requirements varied widely by cancer type (Table 3). The proportion of correct responses was highest for lung cancer (21/40, 53%) and colon cancer (22/58, 38%), and lowest for cutaneous melanoma (9/60, 15%), rectal cancer (12/56, 21%), and breast cancer (14/62, 23%). Mean scores for standard-specific questions (Standard Score) were similar between residents and fellows (0.30 [SD 0.22] vs 0.33 [SD 0.21], P = 0.71).

Table 3. Knowledge of the CoC Operative Standard Accreditation Requirements and Underlying Cancer Surgery Principles.

Multiple Choice Questionnaire
Breast			Correct/Totala, (%)
CoC Standards 5.3 and 5.4 address techniques for breast cancer surgery. Which two topics do these standards cover?b			14/62 (23)
If a blue dye and a radioactive tracer are used in a sentinel lymph node biopsy (SLNB) for breast cancer, which lymph nodes should be removed in the procedure? Select all that apply.			87/212 (41)
What are the boundaries of the axilla? Select all that apply.			48/212 (23)
When performing an axillary dissection for breast cancer, which lymph node levels should be routinely removed? Select all that apply.			179/213 (84)
Melanoma			Correct/Totala, (%)
CoC Standard 5.5 addresses melanoma. Which of the following elements is not considered in determining compliance?b			9/60 (15)
What determines the appropriate margin width for a wide local excision for melanoma?			205/207 (99)
The correct depth of resection for an invasive melanoma is to which level?			118/205 (58)
Colon			Correct/Totala, (%)
CoC Standard 5.6 outlines requirements for colon cancer surgery. Which of the following topics does this standard address?b			22/58 (38)
What is the purpose of performing a high, central vascular ligation for colon cancer? Select all that apply.			7/202 (4)
Rectal			Correct/Totala, (%)
CoC Standard 5.7 requires a total mesorectal excision (TME) for all radical rectal cancer surgeries performed with curative intent. How is this standard measured?b			12/56 (21)
For tumors located in which part(s) of the rectum should a total mesorectal excision (TME) be performed? Select all that apply.			70/203 (35)
Lung			Correct/Totala, (%)
CoC Standard 5.8 for lung cancer outlines requirements for mediastinal lymph node sampling for surgery with curative intent. Which is required by the standard?b			21/40 (53)
Which of the following lymph node stations are within the hilum of the lung? Select all that apply.			29/196 (15)
Score Summary: Comparison of Residents and Fellows
Standard Score c	Resident (n = 58)	Fellow (n = 7)		P d
Median (IQR)	0.3 (0.1-0.3)	0.3 (0.2-0.4)
Mean (SD)	0.3 (0.2)	0.3 (0.2)		0.71
Surgery Score c	Resident (n = 180)	Fellow (n = 31)		P d
Median (IQR)	0.5 (0.3-0.6)	0.5 (0.4-0.5)
Mean (SD)	0.5 (0.2)	0.5 (0.1)		0.72
Comparison of Standard and Surgery Scores (All Trainees)
	Standard Score	Surgery Score		P e
Median (IQR)	0.3 (0.1-0.4)	0.5 (0.4-0.6)
Mean (SD)	0.3 (0.2)	0.5 (0.2)		<0.001

^aTotal includes correct, incorrect, and ‘unsure’ responses.

^bStandard Score question (asked only if the respondents reported familiarity with the CoC Operative Standards). All other questions part of Surgery Score.

^cProportion of correct questions (correct/total questions answered)

^dTwo-sample t-test to compare means

^ePaired t-test to compare means from the same individual

Abbreviations: CoC, Commission on Cancer; IQR, Interquartile Range; SD, Standard deviation

Respondents demonstrated greater knowledge of cancer surgery principles underlying the CoC Operative Standards. For example, nearly all respondents (205/207, 99%) correctly identified margin width guidelines for wide local excision in cutaneous melanoma, and 84% (179/213) correctly identified which lymph node levels should be removed during an axillary lymph node dissection for breast cancer. However, trainees’ knowledge was much more limited for anatomical concepts, such as the boundaries of the axilla (48/212, 23%) and the appropriate lymph node stations in lung cancer (9/60, 15%). Very few respondents (7/202, 4%) fully understood the rationale for central vascular ligation in colon cancer. Mean scores for cancer surgery principles questions (Surgery Score) were the same for residents and fellows (0.45 [SD 0.18] vs 0.46 [SD 0.12]; P = 0.72).

In a paired comparison of residents and fellows, mean Surgery Scores were significantly higher than mean Standard Scores (P < 0.001).

Predictors of CoC Operative Standard Familiarity and Surgical Knowledge

In univariate logistic regression analysis, there were no statistically significant associations between trainee or program characteristics and Standard Scores (Appendix C). Surgery Scores significantly varied based on trainees’ clinical interest (i.e., residents’ desired subspecialty or fellows’ current subspecialty) (P = 0.04) and the number of recently completed rotations in cancer-related specialties addressed by the CoC Operative Standards (P = 0.04). Residents with oncology-related clinical interests were more likely to have a Surgery Score above the median (OR 3.01, 95% Confidence Interval 1.1-8.5, P = 0.04).

Participation in Operative Documentation

Residents reported being sometimes (73/170, 43%) and frequently (48/170, 28%) expected to write operative notes, including during their Colorectal Surgery (54/149, 36%), Surgical Oncology (51/149, 34%), and Breast Surgery (40/149, 27%) rotations (Table 4). These included both brief (68/72, 94%) and long (63/72, 88%) operative report formats, with most residents (53/63, 84%) using SmartPhrases. Nearly half of residents who reported writing long operative notes (29/63, 46%) had been asked to include specific elements in their long-form operative notes to comply with the CoC Operative Standards documentation requirements. Most fellows (24/29, 83%) reported previously incorporating a synoptic template into their operative notes to comply with one of the standards.

Table 4. Operative Notes and Synoptic Documentation Practices.

Resident Questionnaire	Frequency, n (%)
Are you expected write/draft/dictate operative notes? (n = 170)
Never	21 (12)
Rarely	28 (17)
Sometimes	73 (43)
Frequently	48 (28)
If yes, on which services are you expected to write/draft/dictate operative notes? Select all that apply.a (n = 149)
Breast	40 (27)
Surgical Oncology	51 (34)
Colorectal	54 (36)
Thoracic	21 (14)
Other service	78 (52)
If yes, which types of notes have you been expected to write/draft/dictate? Select all that apply.a (n = 72)
Brief operative note	68 (94)
Long operative note	63 (88)
Unsure	1 (1)
If you write long operative notes in the EHR, do you use SmartPhrases or dot phrases? (n = 63)
Yes	53 (84)
No	8 (13)
Unsure	0 (0)
I do not write operative notes directly into the EHR (e.g., write notes in a word document and send to my attending)	2 (3)
If yes, have you been asked to include specific information in your long operative notes to comply with the CoC Operative Standards? (n = 63)
Yes	29 (46)
No	26 (41)
Unsure	8 (13)
Fellow Questionnaire	Frequency, n (%)
Have you ever included a synoptic template in your operative note to comply with one of the CoC Operative Standards? (n = 29)
Yes	24 (83)
No	5 (17)
Unsure	0 (0)

^aMore than one answer choice permitted, percentages do not sum to 100%

Abbreviations: CoC, Commission on Cancer; EHR, electronic health record

Discussion

Beginning in 2021, all 1,400 CoC-accredited hospitals have been required to comply with the CoC Operative Standards. While prior research has evaluated practicing surgeons’ awareness of these requirements, this is the first study to assess familiarity among surgical residents and fellows. Only 30% of respondents reported prior awareness of the CoC Operative Standards, compared to 74% of practicing surgeons surveyed by Zaveri et al. in 2021 (first year of implementation) and 87% of those surveyed in 2023.¹² The relatively low Standard and Surgery Scores, which reflect knowledge of CoC accreditation requirements and fundamental principles of optimal cancer surgery, highlight a notable gap in trainee knowledge. Specifically, trainees had a median Standard Score of 0.3 compared to 0.62 among practicing surgeons surveyed using similar questions in 2021, and a median Surgery Score of 0.5 compared to 0.84 among practicing surgeons that same year. These differences are not unexpected, as practicing surgeons presumably have greater clinical experience, higher specialty-specific knowledge, and are directly accountable for meeting CoC accreditation requirements. Nonetheless, these findings emphasize the need for formal integration of the CoC Operative Standards into surgical training curricula nationwide.

Grounded in the best available evidence and expert consensus, the Operative Standards for Cancer Surgery are intended to support surgeons in delivering high-quality cancer care. Although still in early phases of implementation, the CoC Operative Standards are expected to reduce variation in care across institutions, elevate surgical care, improve the efficiency of clinical documentation, and strengthen multidisciplinary care coordination.²⁶ Surgical trainees also stand to benefit from their adoption. By emphasizing essential components of cancer operations, the standards provide a practical framework for residents and fellows to understand factors influencing oncologic outcomes, including surgical techniques with limited training exposure. For example, CoC Operative Standard 5.4 addresses axillary lymph node dissection for breast cancer, a procedure performed less frequently today than in prior years.^27,28 With only 23% of survey respondents correctly identifying the anatomic boundaries of the axilla, Standard 5.4 may help reinforce key principles of axillary lymph node dissection despite its decreasing practice. This example illustrates how the CoC Operative Standards can broadly help fill a knowledge gap arising from evolving clinical practice, which may differentially impact trainees across training programs. Additionally, given that 74% of cancer cases are treated at a CoC-accredited program,²⁹ many trainees will be responsible for maintaining compliance with CoC accreditation requirements as future practicing surgeons. Knowledge of the CoC Operative Standards is important not only for trainees planning to pursue oncology-based surgical fellowships, but also for those entering general surgery practice without fellowship training, given the large proportion of surgery performed in community-based settings by general surgeons. Altogether, these considerations illustrate the importance of early and consistent exposure to the CoC Operative Standards and the more than 130 critical elements outlined in the Operative Standards for Cancer Surgery manuals.

Although our study did not directly explore barriers to awareness of the CoC Operative Standards, we found limited evidence of a standardized approach to educating trainees about them, which is likely a key contributing factor. While residents reported learning about the CoC Operative Standards in various settings, including intraoperatively, exposure appeared inconsistent and often dependent on individual attending preferences rather than a structured curriculum. Moreover, given the minimal association between trainee or program characteristics and standard-specific knowledge, familiarity with the CoC Operative Standards may largely be opportunistic or incidental.

To increase awareness of the CoC Operative Standards and underlying surgical principles across general surgery residency and fellowship programs nationwide, several strategies may be considered (Figure 1). First, incorporating concepts related to the Operative Standards into national standardized assessments (e.g., American Board of Surgery In-Training Examination (ABSITE) and the American Board of Surgery (ABS) Qualifying Examination and Certifying Examination) may incentivize both training programs and learners to prioritize this content. Similarly, the core principles underlying the Operative Standards may be formally integrated into the ABS’s competency-based assessments, known as Entrustable Professional Activities (EPAs), particularly those focused on the management of breast, colon, and cutaneous neoplasms.³⁰ Inclusion of the Operative Standards for Cancer Surgery into the Continuous Certification Assessments for General Surgery and Complex General Surgical Oncology as part of a new ABS-ACS collaboration may model how this material can be assessed at the trainee-level in the future. Given that aspects of the current CoC Operative Standards overlap with existing content in surgical trainee curricula, such integration is likely to be feasible, but it could also be limited by competing curricular priorities.

Figure 1.

Goals for Increased Surgical Trainee Knowledge of the CoC Operative Standards and Suggested Strategies for Improvement

As part of a coordinated educational effort, faculty at training institutions could be equipped with case-based intraoperative teaching tools to highlight elements of the Operative Standards during eligible procedures. This would require that faculty have adequate knowledge and acceptance of the Operative Standards themselves. Involving residents in departmental quality improvement initiatives aimed at tracking and improving compliance with the CoC Operative Standards could align with existing ACGME requirements for resident participation in quality improvement practice.³¹ Additional opportunities to reinforce this content and develop the technical skills emphasized by these requirements include expanding online modules (such as those offered by the Surgical Council for Resident Education (SCORE)), advancing simulation-based training, and integrating the standards into a formalized national surgical curricula. Given that the Operative Standards for Cancer Surgery series encompasses 15 different cancer types (i.e., ten additional malignancies beyond the five addressed by the current slate of CoC Operative Standards), their use as an educational resource for residents and fellows can be widely applied across disciplines and training programs.^7-9

Another key finding from this study is the substantial role residents play in drafting operative documentation. More than 70% of residents reported contributing to operative notes, presenting an opportunity to introduce synoptic documentation early in training. This structured documentation format, which uses discrete, standardized data fields, has been shown to improve the clarity and completeness of clinical documentation.^32,33 Although its adoption in surgery remains in the early stages, synoptic documentation is likely to become increasingly important. With nearly 90% of note-writing residents contributing to long-form operative reports (compared to brief or short-form reports), and four of the six CoC Operative Standards (5.3-5.6) requiring synoptically formatted data elements and responses in operative notes, trainees may influence institutional compliance. Efforts to improve adherence to the CoC Operative Standards should potentially include targeted trainee education on the principles and application of synoptic documentation in tandem with a broad understanding of the critical elements of cancer operations, recognizing the potential limitation of different electronic health record systems.

Limitations

This study has several limitations. First, as a survey-based study, it is subject to selection bias and non-response bias. Trainees already familiar with the CoC or the CoC Operative Standards may have been more likely to participate, potentially leading to an overestimation of awareness. In addition, our findings may not be generalizable to all surgical residents. Although we sought to mitigate this limitation through broad survey distribution across the US, this approach prevented us from determining the exact survey response rate. Instead, we can only provide an estimate, which we believe is between 12-24% if approximately 1,000-2,000 trainees were reached through our various distribution channels. This is not an unreasonable response rate for a voluntary online survey of busy surgical trainees. Similarly, we cannot discern the proportion of respondents affiliated with a CoC-accredited program. Although affiliation with a CoC-accredited cancer center could theoretically influence a trainee’s knowledge of the Operative Standards, we did not find an association between reported CoC affiliation and either the Standard Score or Surgery Score. Additionally, half of the survey assessed cancer surgery principles and operative documentation practices, which are relevant to all surgical trainees regardless of institutional CoC-accreditation status. Further, because the survey was anonymous, we could not account for potential clustering by training program and program-level effects. Additionally, the proportion of surgical fellows was relatively low (16%); however, this percentage overrepresents fellows’ prevalence relative to general surgery residents in the US.^34,35 Lastly, responses were incomplete for some questions, as the survey was tailored to self-reported demographics and prior familiarity with the CoC Operative Standards, ensuring appropriateness and reducing respondent fatigue. Despite this design, response rates for key items remained high, supporting descriptive and comparative analyses.

Conclusion

In this national survey study, we assessed surgical residents’ and fellows’ familiarity with the CoC Operative Standards and the cancer surgery principles they emphasize. We identified a significant knowledge gap, highlighting the need to improve trainee education on these accreditation requirements and their respective surgical techniques. Since knowledge of the CoC Operative Standards had limited association with trainee or program characteristics, a broad, multifaceted, and multilevel approach will be necessary to increase awareness. The active role trainees already play in operative documentation indicates that the CoC Operative Standards could be leveraged to introduce synoptic formatting earlier in training, while simultaneously reinforcing the importance of performing and documenting critical elements of cancer operations.

Abbreviations

ACGME

Accreditation Council for Graduate Medical Education

ABS

American Board of Surgery

ABSITE

American Board of Surgery In-Training Examination

ACS

American College of Surgeons

CSSP

Cancer Surgery Standards Program

CoC

Commission on Cancer

EPA

Entrustable Professional Activity

PGY

Post-graduate Year

SCORE

Surgical Council on Resident Education

US

United States