The ACS released new National Accreditation Program for Rectal Cancer (NAPRC) standards in 2025 that address recent advancements in rectal cancer care. The current standards, published in Optimal Resources for Rectal Cancer Care and originally released in July 2020, serve as a comprehensive guide that details the requirements for NAPRC accreditation.
Since the original standards were published, many advancements and changes have occurred in rectal cancer treatment. Among the most paradigm shifting of these advances has been the tremendous growth in the “watch and wait” approach, wherein treatment with neoadjuvant chemoradiotherapy becomes the definitive treatment, rather than the originally intended neoadjuvant treatment followed by planned surgical resection.
Because of the large increase in the number of patients assigned to “watch and wait” protocols, a new standard was introduced to establish definitions, documentation requirements, and compliance measures for the management of patients who are using this protocol. Previously, many patients in a “watch and wait” protocol were not discussed at a Rectal Cancer Multidisciplinary Team (RC-MDT) meeting, which now will be a requirement.
Another patient group that the previous standards did not include were those who undergo transanal excision of lesions thought to be benign adenomas in whom invasive cancer is identified. This scenario is addressed by the new standard “Local Excision of Rectal Cancer,” and patients presenting or referred to an NAPRC-accredited program will have their details discussed at a RC-MDT.
The third new standard relates to RC-MDT review following neoadjuvant therapy. Many patients receive neoadjuvant therapy. The NAPRC deems it mandatory to have each of these patients undergo RC-MDT review following neoadjuvant therapy to help develop a consensus on whether they should be offered “watch and wait” or proceed to surgery. In conjunction with the release of the revised standards, the NAPRC developed four templates that NAPRC-accredited programs (and those seeking accreditation) will have the option to use when documenting the review of patients by the RC-MDT. These templates are included in Optimal Resources for Rectal Cancer Care.
The fourth major change in the NAPRC standards involves lowering the minimum compliance percentage required to meet a standard to 90%. Algorithms are included in Optimal Resources for Rectal Cancer Care in order to assist programs in understanding where each standard fits into the patient care journey for individuals diagnosed with rectal cancer.
The program also is retiring some standards. As mentioned, nearly all patients undergo neoadjuvant therapy. Because of this extensive change in care, the standard Adjuvant Therapy after Surgical Resection was retired in 2023. These many changes join the core NAPRC standards that address administrative commitment, rectal cancer multidisciplinary care, the need for a rectal cancer program director and rectal cancer program coordinator, as well as rectal cancer multidisciplinary team meetings with rectal cancer multidisciplinary team attendance.
Standards also involve ACS Commission on Cancer accreditation, routine review of diagnostic pathology, guidance on the use of systemic staging with computerized tomography, local staging and standardized reporting with magnetic resonance imaging, carcinoembryonic antigen level, as well as treatment planning discussion and recommendation summary, definitive treatment timing, surgical resection and standardized operative reporting, specimen photographs, and treatment outcome discussion and outcome summary. Furthermore, the quality measures, quality improvement initiative, and rectal cancer program education remain as standards.
The field of rectal cancer care is rapidly evolving. We can envision that in the not-too-distant future we may introduce additional new standards related to other evolving topics such as immunotherapy. We also hope to develop standards relating to value that describe pathways for delivering the best possible care at the least possible cost.
Cost has many forms, including financial expenditures, patient morbidity and mortality, and quality of life. The NAPRC looks forward to continuing to improve the care of rectal cancer patients, specifically through these standards, which define how we achieve this mission.
Dr. Steven Wexner is director of the Ellen Leifer Shulman and Steven Shulman Digestive Disease Center and emeritus chair of the Department of Colorectal Surgery at the Cleveland Clinic Florida in Weston. He is Chair of the ACS Commission on Cancer (CoC) National Accreditation Program for Rectal Cancer and a member of the CoC Executive Committee.
