The management of rectal cancer has significantly improved over the last 50 years; rectal cancer was previously a disease with high morbidity and mortality that was managed almost exclusively with surgical resection, often resulting in a permanent end colostomy [1]. Improvements in both surgical management and refinement in neoadjuvant chemotherapy and radiation regimens has changed the management of rectal cancer towards a multidisciplinary team approach of care for patients [[1], [2], [3]].

With the development of multidisciplinary rectal cancer care and the continued rapid evolution of treatment techniques, it became apparent that clinical outcomes in rectal cancer care are highly variable, often dependent on surgeon specialization as well as rectal cancer volume at a given center [[4], [5], [6], [7], [8]]. Previous research demonstrated that the majority of patients with rectal cancer were receiving care at low volume centers, and many patients who are treated for rectal cancer in the US do not receive guideline concordant care [9,10]. Further studies have demonstrated that patients who underwent proctectomy at high volume centers had more favorable outcomes even if they were required to travel substantial distances to receive care [11]. These findings demonstrate that despite the burden associated with increased distance of travel, patients benefit from improved cancer and survival outcomes when treated at high volume rectal cancer centers. This may be attributed to high volume centers utilizing the most up to date treatment protocols, and treatment by specialists in rectal cancer care [10].

In an effort to improve the delivery of standardized, evidence-based rectal cancer care, the National Accreditation Program for Rectal Cancer (NAPRC) was established in 2017 via the Optimizing the Surgical Treatment of Rectal Cancer (OSTRiCh) and the Commission on Cancer (CoC), programs of the American College of Surgeons (ACS) [12,13]. The guidelines outlined by the ACS through NAPRC follow core tenants of quality care for patients with rectal cancer including: program management of the multidisciplinary team via a single rectal cancer program director, appropriate clinical services based upon defined and specified time targets, and ongoing quality improvement to improve patient outcomes [13]. Further, NAPRC guidelines recommend standardized practices and reporting for initial staging workup, standardized operative notes, pathology reports including the T and N stage along with photographic documentation of the completeness of the mesorectal envelope, margin status, and Tumor Regression Grade [13]. A center is eligible for NAPRC accreditation following 1 year of compliance to the NAPRC guidelines. Following accreditation by NAPRC, institutions are endorsed by the ACS as a NAPRC accredited institution which may serve to increase visibility to patients and referrals from outside clinics and healthcare centers.

It is unknown how implementing NAPRC guidelines at high volume centers, compared to low volume centers, may influence outcomes. As a high-volume academic tertiary medical center with a large referral network, our medical center previously emphasized interdisciplinary and collaborative cancer care for patients presenting with newly diagnosed rectal cancer. We hypothesized that since our institution previously emphasized interdisciplinary care and served as a high-volume center for the treatment of patients with rectal cancer, implementation of the NAPRC guidelines at our institution would fail to demonstrate a significant difference in margin status or patient outcomes in treating rectal cancer. This finding would demonstrate that high volume centers for rectal cancer care are able to achieve the outcomes that the NAPRC guidelines aim for, and reinforce that the NAPRC guidelines should be adopted by all centers to provide the best outcomes for patients with rectal cancer.