Is your Pathology Report compliant with CAP guidelines?


Marketing Manager

Often times, the cancer committee members are uncertain if their pathology reports are meeting Standard 2.1.  The College of American Pathologists (CAP)protocols must be followed to report the required data elements in 90% of the eligible cancer pathology reports each year.  No one wants to be surprised to hear the CoC surveyor state he does not see the required data elements as mandated by CAP.  Below are a summary of information received by the CoC-trained consultants during a recent webinar.

  • If there is no residual tumor found,  CAP is not required.
  • CoC Survey will include a random sample of 30 cases from the 3 most completed years (10 paths reviewed per year).
  • Maximum cases reviewed will be 30.
  • Synoptic reporting is not required, but encouraged.
    • RDE header followed by answer must be included.
    • Tabular format is accepted.
    • EachRDE  must be on a separate line… 3 exceptions.
      •  Anatomic site, laterality and procedure can be combined.
      • Negative margins can be combined unless stated in the protocol that they must be separate, such as Colon.
      •  TNM staging can be combined.
    • RDE can be in any order, but should be consistent for facility.
    • Narrative can include RDE, but the RDE must be included later on the report in the required format to be considered synoptic.
  • Additional information not considered RDE can be included and can be listed in any format.
  • Summary of changes for protocol can be found on the CAP website.
  • Cheat sheets can be found on CAP website.
  • Work Aids available, but recommend using cheat sheets.
  • It is difficult to stay current with updates since there are so many. Should look at the summary of changes mentioned above.
  • 66 protocols have been created.
  • Submit questions to
  • New Cancer Biomarker templates should replace ancillary reports. An example is  ancillary reports for ER/PR.
  • Cancer Biomarkers Reporting Template is not required.
  • Do reports need to use exact wording in protocol case summary? – Yes
  • Does  not applicable need to be included in pathology report? – Yes
  • What percentage of facilities are both CoC and CAP Accredited? –Estimated 70%.
  • Is lymph node sampling for breast cancer required? – Only if lymph nodes are present in specimen.
  • Are resections with no residual tumor or nodal involvement (including neoadjuvant therapy) required to have synoptic pathology report? – No
  • Data can be presented in any order, but does it need to be consistent amongst your pathologist? – This is a decision of the  facility, but recommend a standardized report for consistency and help the surgeons know where things are located on the pathology report.
  • Use of Mx should not be used. Should bepM1 or nothing.
    • Built in flags.
    •  May look different depending on vendor.
    • Order may be different, which is okay as long as all RDE are present.