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Integrated Manual - Missouri Cancer Registry and Research Center

1. To print more than one abstract Click on REPORTS and select the appropriate report to print multiple abstracts WEBPLUS USER S MANUAL Page 25 MISSOURI CANCER REGISTRY OS FI ND OPEN ABSTRACTS WebPlus provides an abstract query system This query system allows you to search your database to retrieve a desired abstract Select FIND OPEN ABSTRACT Abstracts may be searched by either name both first and last or social security number When search ing by name a partial name search is also allowed For example entering SMITH will produce a list of all patients with the last name Smith Smithson or any other name beginning with Smith Entering SM will produce a list of all patients with the last name beginning with Sm such as Smith Smothers or Smuckers Entering S will produce a list of all patients with a last name beginning with S Once the specific abstract is found select OPEN to either edit data or DELETE to delete record Web Plus New Abstract Find Open Abstract Release Abstracts Reports Change Password Log out Find Abstract Enter patient s name or social security to search for Search on partial name and social security is supported Name monterey Social Security Find AbsReflD Last Name DxDate Social Birth Date Abstractor Security 4285 MONTEREY 09 14 2004 999999999 02 07 1957 Complete Open Delete Web Plus New Abstract Find Open Abstract Release Abstracts
2. CHAPTER 1 Overall Learning Objectives These are the overall learning objectives for this WebPlus training course for abstractors 1 Learn the major functions of WebPlus 2 Create an abstract using a medical record 3 Correct errors so that the complete abstract is error free 4 Release abstracts 5 Create abstracts in compliance with cancer registry standards 6 Recognize the major reports of WebPlus Overview of the WebPlus Training Manual The WebPlus Abstractor Training Manual provides you with the information to understand and use this web application In this manual you not only learn about the tools in WebPlus you also create an abstract and follow the process of abstracting a medical case until it is complete and released to the central registry Also each chapter contains questions that test your knowledge of WebPlus and activities that allow you to practice your new skills on your own Although WebPlus can use any of a number of edit sets this manual uses the edit set Central VS10 NPCR Required The edit sets you use at your facility may differ WebPlus Features WebPlus is a web based application used to collect cancer data securely over the public Internet It is most suited for physicians offices and other low volume reporting sources that do not have facility based cancer registries Records are saved in a database at the hosting central registry and cases entered by one facility or office are not visib
3. Text Fields One of the WebPlus tabs that you need to use to complete your abstract is the Text Fields tab This is an area where you use text to describe diagnostic and treatment information such as X rays or surgery You use the fields to document supplemental information not contained within the coded values You can also provide information that you are uncertain how to code so that a central abstractor reviewer can be able to code it properly in the data fields when the abstract is released to the central registry The text is limited only by the maximum number of characters indicated for each field The information in text fields are not subject to WebPlus edits However some text fields can be designated as critical and required to have information in the fields In this case the system does not read the information it only requires the field to have text Edit Errors Text Fields Help Diagnosis Treatment Miscellaneous Text DX Proc PE Max 200 chars WEG FINDINGS Pa Text D Proc Kk raviscan Max 250 chars HRI BRAIN SHOWED ENHANCING MASS HIGH 5 _OWYEZITY MEDIALLY OF THE PARIETAL OCCIPITAL LOBE zi These are the text fields available which are divided into three sections Scopes endoscopic procedures such Radiation other as cystoscopy ee E e Pathology e BRM Biological Response Modifier also known as im munotherapy Page 90 CHAPTER 4 In the Text Fields area follow these steps to enter infor
4. SO PN 9 n eR Text DX Proc Missing Critical Field PE Missing Critical Field Text DX Proc X ray scan Missing Critical Field Text DX Proc Lab Tests Missing Critical Field Text DX Proc Op Missing Critical Field Text DX Proc Path Missing Critical Field Text Histology Title Missing Critical Field Text Staging Missing Critical Field RX Text Hormone Missing Critical Field RX Text Other Missing Critical Field Text Remarks WEBPLUS USER S MANUAL MISSOURI CANCER REGISTRY PRINT and PRINT PREVIEW To print one abstract Click on the PRINT PREVIEW icon in the upper right hand corner to preview abstract patient information Users can then return to the abstract to correct any errors or go to FILE and PRINT to print the abstract Web Plus New Abstract Find Open Abstract Release Abstracts Reports Change Password Log out Update abstract PHYSICIAN FACILITY SPECIFIC Reporting Facility Physician 60200000 wi Abstractor SEL fi 1172005 PATIENT CONFIDENTIAL East Name MONTEREY Jisa jE JUNE 333399393 PATIENT DEMOGRAPHICS m 1234 ANYWHERE AVE BSSNVILLE Date Case Completed First Name Middle Name Maiden name Alias Spouse Name Social Security Number Supplemental Address City State Zipcode County Tobacco History Edit
5. Medicare If Insurance requires a referral referring office to notify patient to bring referral to initial office visit Secondary Insurance None Patient Notified Hospital called WEBPLUS USER S MANUAL Page 31 MISSOURI CANCER REGISTRY OSA SAMPLE CASE 1200 Paris Road METRO AREA UROLOGY ASSOCI ATES Kansas City MO 64116 Suite 150 Tel 816 425 1572 Carmen R Smith MD Randy D J ones MD Russell R Stephens MD 08 06 04 PATI ENT SUMMARY RE Johnston Samuel PR9887 DOB 11 27 27 Referring Doctors Steve Cowell MD Ryan David MD HISTORY OF PRESENT ILLNESS 07 25 04 Mr Johnston is a now a 77 year old white male presenting with a slightly elevated PSA performed by his account either in early 2002 or late 2001 This was subsequently repeated in J une and further elevated to 6 56 He believed that the prior reading had been just over 4 0 The patient has an enlarged prostate on digital rectal exam but it is free of any specific nodules or areas of induration The overall size was 51 0 cc therefore we plan to biopsy 08 05 04 Biopsies were obtained with pathology returned showing a Gleason score of 3 3 adenocarcinoma involving one of the cores form the right side of the gland Approximately 30 involvement was noted From the left a Gleason score of 2 3 was identified involving 5 of one needle core biopsy This is clinical stage T1C NO MO The patient was relatively asymptomatic He had good urinary flow with nocturia at
6. Microsoft Internet Explorer Search Search 12 Next Atkinson County Bacon County Baker County Baldwin County Banks County Barrow County Bartow County Ben Hill County Berrien County Bibb County 10 In the Search field type Dekalb and click Search Result The system finds DeKalb county and its code Note You can also find the code by scrolling down the page and by clicking the number at the top of the page to see other codes in the list 11 Click the code number for DeKalb county Result The system enters the code in the DxCounty field 12 Click in the DxPostalZip field Result A text box opens with a description of the format and codes needed for the zip code field Dex ity 7 Addr at DX Postal Code DiState LIS Enter 5 or 9 digits Blanks follow the 5 digit code i Canada Enter 6 alphanumeric characters Blanks follow De aunty E code Other countries Enter postal code if known Blanks follow DxFostalzip de Face 550550855 Not US not Canada postal code unknown 999999999 US Canada postal code unknown OR Races residence unknown Page 82 CHAPTER 3 13 In the DxPostalZip field type 30030 14 To save your entries click Save Result The WebPlus system saves your new abstract You can open it later and continue to work on it until completion Inthe next chapter Adding Data to an Abstract you continue to add data to this abstract Quest
7. please remember to save work frequently to prevent this occurrence For security WebPlus is also configured with an automatic lock out after users have attempted unsuccess fully 3 times to log in If this occurs please contact the MCR administrator so that your password can be re set MCR recommends the use of Internet Explorer to access WebPlus as users of other browsers will some times experience difficulties MCR staff recognizes that many users will not have any previous experience in abstracting If having diffi culties for most fields it is permissible to enter 9 for Unknown However we would like to stress that this WEBPLUS USER S MANUAL Page 12 MISSOURI CANCER REGISTRY h HELPFUL TI PS FOR USING WEBPLUS should be reserved for cases in which information is not readily obtainable and not as a routine practice MCR staff are also available to answer questions at 866 240 8809 toll free e For patient confidentiality concerns we ask that users remember to keep all patient information in a secure location while entering information into WebPlus e Please remember that for test purposes johndoe and test ID and password only e Glossary a helpful list of acronyms is included in the glossary located at the end of this manual for under standing terms abbreviations used throughout this manual WEBPLUS USER S MANUAL Page 13 MISSOURI CANCER REGISTRY OSA OPENI NG WEBPLUS 1
8. record an approximate date Example 03992005 if exact day of month is unknown Vital Status Enter the appropriate vital status of patient dead or alive Cancer Status Enter the appropriate cancer status evidence no evidence unknown of patient Place of Death For deceased patients You may simply enter 063 Missouri For residents of other states use the special look up icon to find code Cause of Death Field currently defaulted to 0000 patient currently alive If patient is not living use one of the corresponding codes available using the special look up icon to populate field Reporting Physician Enter the reporting physician s license number or NPI in this field If a number is not available enter the first 8 characters of the physician s name Physician Other Enter the referring physician s license number or NPI in this field If a number is not available enter the first 8 characters of the physician s last name Text Remarks Type any other pertinent information which may be contained within the medical record e g history of previous cancer family history of cancer smoking history etc and which would be rele vant in determining multiple primary secondary sites WEBPLUS USER S MANUAL Page 22 MISSOURI CANCER REGISTRY E E E TT TT TT VO SAVING AN ABSTRACT After all data items are entered select Save If there are no errors the abstract will be saved and marked comple
9. secondary pattern unknown Primary pattern 3 secondary pattern 1 032 Primary pattern 3 secondary pattern 2 033 Primary pattern 3 secondary pattern 3 034 Primary pattern 3 secondary pattern 4 035 Primary pattern 3 secondary pattern 5 Version date April 25 2005 526 Version 01 02 00 WEBPLUS USER S MANUAL Page 56 MISSOURI CANCER REGISTRY EEE sVs COLLABORATIVE STAGI NG CODI NG INSTRUCTIONS Collaborative Staging Manual and Coding Instructions Part Il Primary Site Schema 039 Primary pattern 3 secondary pattern unknown Primary pattern 4 secondary pattern 1 042 Primary pattern 4 secondary pattern 2 043 Primary pattern 4 secondary pattern 3 044 Primary pattern 4 secondary pattern 4 045 Primary pattern 4 secondary pattern 5 049 Primary pattern 4 secondary pattern unknown Primary pattern 5 secondary pattern 1 052 Primary pattern 5 secondary pattern 2 053 Primary pattern 5 secondary pattern 3 Primary pattern 5 secondary pattern 4 Primary pattern 5 secondary pattern 5 059 Primary pattern 5 secondary pattern unknown 099 Primary pattern unknown 999 Unknown or no information Not documented in patient record Prostate CS Site Specific Factor 6 Gleason s Score Note 1 Usually prostate cancers are graded using Gleason s score or pattern Gleason s grading for prostate primaries is based on a 5 component system 5 histologic patterns Prostatic cancer generally shows two main histologic patterns T
10. 999 if unknown Note Lab values for SSFs 1 and 2 should be from the same laboratory test WEBPLUS USER S MANUAL Page 20 MISSOURI CANCER REGISTRY h DATA ENTRY PROCEDURE continued CSSF2 PSA or Occasionally the information says the PSA is elevated but does not tell the specific value By using CSSF2 we can code if the test was elevated normal or unknown Example Information used from the previous field 065 tells us that this patient had an elevated PSA of 6 56 therefore we can determine that the code for this field will be 10 positive elevated CSSF5 Gleason Pattern Used to record the Gleason s pattern as given in the pathology report Example The pathology report reads Adenocarcinoma Gleason score 3 3 6 Use the special look up icon to select the appropriate code For this example the three digit code will be recorded as 033 for this field primary pattern 3 secondary pattern 3 CSSF6 Gleason Value Records the total Gleason s score by adding the primary and secondary pattern as shown in the pathology report Example Gleason score 3 3 6 The field must be 3 characters in length so the code will be recorded as 006 Derived SS2000 When CS data items are coded a computer algorithm determines SEER Summary Stage 2000 This is automatically calculated when the form is saved Text Stage Type text to support CS summary stage information If the physician provides t
11. AJCC staging basis for transurethral resection of prostate TURP is clinical and is recorded as CS TS Ext Eval 1 c Code Description Staging Basis No surgical resection done Evaluation based on physical examination imaging c examination or other non invasive clinical evidence No autopsy evidence used Version date April 25 2005 519 Version 01 02 00 WEBPLUS USER S MANUAL Page 48 MISSOURI CANCER REGISTRY j COLLABORATIVE STAGI NG CODI NG INSTRUCTIONS Collaborative Staging Manual and Coding Instructions Part II Primary Site Schema No surgical resection done Evaluation based on endoscopic examination diaenostic biopsy including fine needle aspiration biopsy or other invasive techniques including surgical observation without biopsy No autopsy evidence used Does not meet criteria for AJCC pathological T staging No surgical resection done but positive biopsy of extraprostatic tissue allows assignment to CS Extension Codes 41 to 70 see Note 2 No surgical resection done but ewidence derived from autopsy tumor was suspected or diagnosed prior to autopsy Surgical resection performed WITHOUT pre surgical systemic treatment or radiation OR surgical resection performed unknown if pre surgical systemic treatment or radiation performed Evidence acquired before treatment supplemented or modified by the additional evidence acquired during and from surgery particularly from pathologic examination of
12. Access website https webplus umh edu webplus 2 Log on to application by using either the MCR assigned username and password or the test User ID johndoe one word and Password test Note Please remember to use ONLY practice cases with the TEST ID and password 3 Select either New Abstract or Find Open Abstract REGISTRY PLUS PONE National Program of Cancer Please log in User ID Password Log in Log out New Abstract Find Open Abstract Release Abstracts Reports Change Password Welcome WEBPLUS USER S MANUAL Page 14 MISSOURI CANCER REGISTRY h ENTERING A NEW ABSTRACT DATA ENTRY PROCEDURE The following are data entry instructions for each data item However please remember to review the patient summary and or pathology report before proceeding further Note For additional help please refer to pages 39 40 for a complete listing of fields and corresponding locale in documentation 1 Select new abstract from the menu A blank abstract data form will appear 2 Begin entering the requested information in each field By clicking on the special help icon Ya RegistryPlus on line screen appears based on he NAACCR Standards for Cancer Registries Volume Il It includes information about the size of the field what information to input and the organization that requires the field Note Help titles may not match field titles MCR administrators have re set many titles d
13. Errors Print Preview Help EDIT RESULT Editset Name Central Vs10 NP CF Required There are edit errors in the abstract Error messages along with the error fieldg are listed below Click on a field below any efror message to move to it in the data entry area Click on Save to save the changeg and rerun Edits Total edit errors 10 PO PN 0 n h M K P Missing Critical Field T xt DX Proc PE Missing Critical Field ext DX Proc X ray scan Missing Critical Field Text DX Proc Lab Tests Missing Critical Fieldf Text DX Proc Op Missing Critical Field Text DX Proc Path Missing Critical Field Text Histology Race 1 Jt Y Title Missing Critical Field Text Staging dE Jes LA Missing Critical Fjeld RX Text Missing Critical Field RX Text Other R 4 jes KA Br 8 7 Missing Critical Field Text Remarks Race 5 jes Ea Hispanic Date of Birth 4 Patient s Name MONTEREY JIM E Reporting Hospital Abstracted By Date Case Completed Name Last Name First Name Middle Name Maiden Name Alias Name Spouse Parent Social Security Number Addr at DX No amp Street Addr at DX Supplementl Addr at DX City Addr at DX State Addr at DX Postal Code County at Dx SEL 11 17 2005 MONTEREY JIM E JUNE 999999999 1234 ANYWHERE AVE BOONVILLE Missouri 65233 053
14. Jaue ssaud pue 0998 adh ABOjOISIH 10 0998 ajduex3 pay e azendod o sexoq umop do p ay asn o aney jou Op NOA fapod ay ul adA jduns pai e 107 apos Buipuodsa1109 ay mouy NOA Ji ILON Sul SIP JO SOINUILU OE Je Jno uun Iewe UE JIM paunbuoo si sn qq AA se Anuonbau eyep anes o saquiaua aseajd OM JO SSO juanald OL We SAS ou Jo yo Boj Aew noA JO uoieuojul peuonippe 18jU9 1IpS 0 ases Bunsixa ue uado puy Joe sqe mau e Buu l u JO uondo ay asooyo Jaya Aew noA panes si eased e sun ONES 91 pue s1011 1991109 jduwis usajos y jo 1yBu ay UO Bare 1xa au ul S1011 Aue Buifeldsip Supe unu peonewome uonounij SIU UOBuLIojul SACS o UOYNG SACS y UO yao Sjajduoo SI UOEULOQUI je BOUD Peusqe y Bulnes noyym au Aue ye uogeuojui anes Aew NOA ypao9 sua HUIDOD ae noA Ji mouy o SPEAISAE y uima PES HAN dieu IIM SIUL ewo uloseoouape Aes pinoys pja 1xa ou ueu ABojojsiy 104 Oy 18 SSOYI noA y ejduuexe JOY s poo y JUALUNIOP O SP A 1x3 Sy SSN URI noA y sneo q jueuodul ae spiel ay SPO paposx 0 puodsa 109 Spjal 1X9 EU JO ISON SP10981 eoipau juared JO joda Bojoyjed eu JOYE LOU SIIEISP ooeds jusungop 0 spjal aesayl asn SPIEL 1x8 OU ajajduoo 0 ans ag 949 49 Uu39 uonelpe jendsoy lu uu e 1n 103 e 9 e9yYe9y 19yjoue o Huloh JON 3 oym sjuaned Woda o noA Bumse juo ale am squuaulay sapos djay au Buisn Aoyeue dxe J es ae spj y lu ule 1 ay
15. Johnston left prostate biopsies are 5 tan cylindrical core biopsies each averaging 0 5 1 5 x 0 1 cm Submitted entirely in one cassette 2 1 right prostate 2 left prostate bas Randy M Booker MD Diagnosis Date 8 20 2004 PATHOLOGY S04 00805 JOHNSTON SAMUEL WEBPLUS USER S MANUAL Page 34 MISSOURI CANCER REGISTRY D SAMPLE CASE Patient s Name JOHNSON SAMUEL Abstractor Date Case Completed Last Name First Name Middle Name Maiden name Alias Spouse Name Social Security Number Street Address Supplemental Address City State Zipcode County Tobacco History Alcohol History Race 1 Race 2 Race 3 Race 4 Race 5 Hispanic Date of Birth Sex Marital Primary Payer at Diagnosis Occupation Industry Diagnosis Date Age at Diagnosis Primary Site Histology ICD 0 3 Text Histology Text Pathology Report Info Grade Text Imaging Studies Text Physical exam Tumor Size CS 1 Extent of Disease CS 2 CS 3 How evaluated Lymph Node Involvement CS 4 WEBPLUS USER S MANUAL SE i JOHNSON SAMUEL 999999999 1234 WATERFRONT DRIVE COLUMBIA Missouri 65202 109 Previous use Unknown White No further race documented No further race documented No further race documented No further race documented Non Spanish non Hispanic 11 27 1927 Male Married including common law Medicare other than described in codes 51 a
16. Metastatic having the characteristics of a secondary tumor Neoplasia the growth of cells under conditions that would tend to prevent the development of normal tissue e g a cancer Palliative designed to relieve a particular problem without necessarily solving it for example palliative therapy is given in order to relieve symptoms and improve quality of life but does not cure the patient WEBPLUS USER S MANUAL Page 43 MISSOURI CANCER REGISTRY OSA GLOSSARY Palpable capable of being felt during a physical examination by an experienced physician in the case of prostate cancer this normally refers to some form of abnormality of the prostate which can be felt during a digital rectal exam PAP Prostatic Acid Phosphate an enzyme now measured only rarely to decide whether prostate cancer has escaped from the prostate PIN Prostatic Intraepithelial or intraductal Neoplasia a pathologically identifiable condition believed to be a possible pre cursor of prostate cancer also Known more simply as dysplasia by many physicians Prolactin PRL a trophic hormone produced by the pituitary that increases androgen receptors increases sensitivity to androgens amp regulates production amp secretion of citrate Prostatectomy surgical removal of part or all of the prostate gland Prostate Specific Antigen see PSA Prostatic Acid Phosphatase see PAP PSA Prostate Specific Antigen a protein secreted by the epithe
17. Work on correcting abstract errors begins in Chapter 5 Correcting Errors beginning on page 78 Print Preview The Print Preview feature allows you to view all of the fields and the content you have entered in your abstract You can also print a copy of the abstract from the Print Preview window 1 Open an abstract 2 Click the Print Preview link Result A separate window opens that displays all of your abstract entry fields and content 3 To print a copy of the abstract use your browser s printer Deleting an Abstract To delete an incomplete abstract use the Find Abstract page To delete an abstract 1 Login if you are not already as described in Log In page 52 2 Onthe WebPlus menu click New Abstract Result The Data Entry page opens 3 Create a new abstract by typing Derrick Chung in the name fields and 891234567 as a Social Security Number 4 Click Save Result The system saves the abstract to the database 5 On the WebPlus menu click Find Open Abstract Result The Find Abstract page opens 6 Type 891234567 in the Social Security number field Result The results display the Chung abstract entry Page 92 CHAPTER 4 7 Click Delete in the Action column Be sure to note the Abstract Reference ID AbsReflD number Result The Confirm Delete window opens It displays the ID number of the abstract you want to delete Confirm Delete Abstract Reference ID to delete 4287 Delete Canc
18. as T1cN0 MO therefore by using the table provided when using the help screen we can determine that the code for this field will be 15 Lymph Node Involvement CS4 Identifies the regional lymph nodes involved with cancer at the time of diagnosis Also corresponds to the N in TNM staging T1cNOMO Typically because these are non surgery patients there will be no lymph node involvement therefore this field will most commonly be 00 Clinically positive nodes would be recorded here Mets at Diagnosis CS6 Identifies the site s of metastatic involvement if any at time of diagnosis Corresponds to the M in TNM staging For most of the patients you are reporting the diagnosis is very early or local ized disease represented in the staging by T1cNOMO For those patients you would use code 00 no metastasis However some patients may not have surgery because the physician has determined there is metastatic disease For these patients use the help screen to select the code that identifies the type of metastatic disease distant lymph node or other distant metastasis CSSF1 PSA Value Record the highest PSA lab value prior to diagnostic biopsy or treatment Example Patient summary reveals an elevated PSA of 6 56 By using these numbers a three digit code will be recorded as 065 for this field Otherwise use the special look up icon for help in selecting the appropriate code or 000 if none and
19. follow back on patients that have not been reported by other facilities Means delay of 12 15 months from date of diagnosis WEBPLUS USER S MANUAL Page 10 MISSOURI CANCER REGISTRY AR p DETERMI NING REPORTABILITY continued 4 Other This is where you can help us Most efficient Least time consuming Logical for your practice Remember Physician s offices are only required to report patients who are have not been treated elsewhere for the current cancer diagnosis WEBPLUS USER S MANUAL Page I MISSOURI CANCER REGISTRY OSA HELPFUL TI PS FOR USI NG WEBPLUS The following items serve as quick reminders for users of WebPlus MCR staff will set up an account for each practice that will include a Facility ID In addition MCR will set up an account for each user User ID After the account is set up WebPlus will generate an e mail to the person who will be completing the web based data form also known as an abstract This e mail will provide a pass word that may be used to enter the system but may be changed later if desired Multiple users for one practice More than one person may submit information for a single practice The practice will have a single facility ID Each user will have their own password Multiple physicians One person may submit information for more than one physician The practice will have a single facility ID The physicians will be identified by the license number or national pr
20. leyjo uyan sapos adod y JO yoess 0 NOA smoje yolym rf e ses ose IM NO spjall auos 104 pamoI9 Ji pal y ajaejduoo 1981109 YOIUM spjal jo Jaquunu e JO CE sexoq umop doJp osje ae ausy pli OU salmbal oym pue ndu o UONEWWOJUI JEUM ple y JO azis ay se YONS UOEUHOQUI sepinold yey sesdde im usas dieu e fa uoo deu ernads ay uo Huyo Ag uoneuroui 1lu ned y Buu lu uibaq JOeBNSgYW MeN BUISOOU uoljpuuuojui juened Aue Buuajue 810199 oda A ojoyjed 10 pue sp 1o9a1 uoda jes paw ay Buima na Aly no4oy Ag uibag 9e1sqy usdo puly 10 198211S MON 109199 p omssed pue q 1S31 24 yum SISEI 32ed ATNO 9SN o JAQUIDUIAI ISLA 9ON 159 pIOMSSEY pue pom auo opuyof q Saz au 10 P omssed pue qI JOS paubisse yn au Buisn Ag uoyeodde o uo 607 sni dqam np3 yuin sn dqam sdyy ye sn dqq AA 01 uo 607 SN Id393M ONISN 40 AGINS 319N343334 MOINO cl HE OL MISSOURI CANCER REGISTRY MCR DATA SET Physician Facility Specific Abstractor Defaults to your initials Facility Specific information Date case completed Defaults when saved Facility Specific information Patient Confidential Last name Medical Accounting Records First name Enter any nicknames in alias field Medical Accounting Records Middle name May leave blank Medical Accounting Records Maiden name May leave blank Medical Accounting Records Alias Leave blank if none Medical Accounting Records Spouse name Leave blank i
21. most once per night and no hesitancy He was not sexually active Discussed treatment options with patient and recommendations Patient agreed to begin Zoladex as a neoadjuvant hormonal therapy PREVIOUS MEDICAL HISTORY MEDICATIONS His previous medical history is otherwise significant for cardiac disease He has an arrhythmia and has both a pacemaker and a defibrillator He is also on amiodarone and diltiazem He has hypercho lesteremia for which he takes Zocor He is on omerprazole for reflux disease He also has Parkinson s disease for which he take ropinirole The patient is not diabetic He does have vascular disease and has had a past abdominal aortic aneurysm repair He has had a TURB and some type of a bladder lesion 18 years ago He has had spinal surgery in the cervical area a remote appendectomy and herniography FAMILY HISTORY Noncontributory SOCIAL HISTORY Pertinent for tobacco use which he discontinued in 1996 The patient is married he lives in the Columbia Missouri area WEBPLUS USER S MANUAL Page 32 MISSOURI CANCER REGISTRY Vo SAMPLE CASE PATIENT SUMMARY RE Johnston Samuel PR9887 Page 2 REVIEW OF SYSTEMS Negative for any constitutional problems such as fevers or weight loss Patient denies any HEENT symptoms such as change in vision hearing nasal stuffiness change of voice quality or dysphagia Chest is negative for exertional chest pain or palpitations No cough sputum production or hemo
22. of these cases was effective with patients diagnosed January 2000 and later e WebPlus is available to the physician at no charge The hardware and software are maintained by the Missouri Cancer Registry with the assistance and support of the CDC e Abstracting Resources http mer umh edu includes a list of the required data elements This list is based on Missouri statutes NPCR and NAACCR requirements data quality requirements and projected needs of the citizens of this state Hospital based registries are required to submit additional data items that may or may not be available in a physician s office e Completed cases should be submitted quarterly io the MCR within six months of diagnosis for that facility For additional help or information please contact Nancy Cole Assistant Project Manager Toll free 866 240 8809 Phone 573 884 2491 Email colen health missouri edu Sharon El Shoubasi Web Plus Coordinator Toll free 866 240 8809 Phone 573 884 6928 Email elshoubasis health missouri edu Alena Headd System Support Analyst Toll free 866 240 8809 Phone 573 882 0315 Email headda health missouri edu Website http mcr umh edu WEBPLUS USER S MANUAL Page 9 MISSOURI CANCER REGISTRY OS DETERMI NI NG REPORTABILITY ELIGIBILITY REPORTABILITY Invasive prostate cancer only no prostate intraepithelial neoplasia PIN Diagnosed and or treated in Missouri for now Newly diagnosed cases or Patients wi
23. the Action column of the incomplete abstract you started for Samuel J ohnson Result The Reason for Opening page opens Select ine reason for opening this case HIP RS requireret Enter the reason if its is not in tie list Shore i Fr add ne reason bo ihe list per Cancel Page 87 CHAPTER 4 Note Any time that you open an abstract you must give a reason for your action It is required by the Health Insurance Portability and Accountability Act of 1996 HIPAA Your WebPlus administrator has ready made reasons for you to select However you can create your own in the Enter the reason Field 5 Select a reason from the drop down list and click Open Result The Data Entry page opens and displays the previously entered data for the abstract The heading above the entry fields now is Update Abstract because the abstract already contains some information 6 Atthe AgeDx field click the calculator icon Result An error message is displayed Microsoft Internet Explorer i x AN Date of Diagnosis is missing Cannot compute age In order to use the calculator to calculate patient age at diagnosis you must first enter the date of diagnosis and the patient s birth date 7 Type 06211945 in the BirthDate field and 03252004 in the DxDate field 8 At the AgeDx field click again Result The age of the patient is automatically computed and the age entered into the field 9 Click inthe DthCause Cause
24. the first name field separated by a blank space For example MARY JO MARY ANN JOHN ED etc 3 Patients who go by their initials may have them both typed in the first name field separated by a blank space but with no punctuation 4 Patients with a name and an initial should have them recorded in separate fields For example H EDWARD SMITH should have H in first name and EDWARD in middle name Middle Name Enter the Middle Name or Middle Initial If the name exceeds the number of spaces enter as much as possible If only an initial is given enter the initial You may also record the patient s title or name suffix in this field such as DR JR SR Ill MD etc If there is no middle name or initial press Enter and the field will remain blank Maiden Name Enter the Maiden name of married females If there is no maiden name or you do not know the maiden name press Enter and the field will remain blank Alias Record the patient s alias if chart indicates there is one If there is no alias press Enter and the field will remain blank For example Bob for a man named Robert Spouse Name Type the name of the spouse If unmarried press Enter and the field will remain blank Social Security Number Type the 9 digit number 123456789 leaving no spaces or hyphens If unknown enter all 9 s 999999999 WEBPLUS USER S MANUAL Page 17 MISSOURI CANCER REGISTRY OSA DATA ENTRY PROCEDURE continued PATIENT DEMO
25. 2006 MISSOURI CANCER REGISTRY a WebPlus User s Manual Urological Cancer Reporting URL Reporting requirements https webplus umh edu webplus Entering Saving Abstracts Username e Reports Password This project was supported in part by a cooperative agreement between the Centers for Disease Control and Prevention CDC and the Missouri Department of Health and Senior Services DHSS U55 CCU721904 and a Surveillance Contract between DHSS and the University of Missouri NATIONAL PROGRAM OF CANCER REGISTRIES University of Missouri Health Care Missouri Cancer Registry WebPlus User s Manual Urological Cancer 1st Edition February 2006 WEBPLUS USER S MANUAL TABLE OF CONTENTS Preface ann ann aan vue nee ue nee tee vue tet ue tes tet que des ee ven ces use IDIEOGUCHON 23 223 e 22 esa 222 Ed GAD ot es Gk Gen Bod he dr at ie Basic Rules Information a au aus ec ann een ann een tet tev een nee een ee en een 7 Determining Reportability as zu cee san sen men nee nen sar ne sss nen rer nen 10 11 Helpful Tips for Using WebPlus oo aoa oos coo coo aaa cn cnn na ILL Opening WebPlus cee cee cue nen nu nee nae nen tee nen nan ane nee sss 14 Entering a New Abstract Data Entry Procedures ec cee ee vee ee 15 22 SAVNO AMADOSI L o whe sek wae wi was 20 za Ba ae ate DD ene een whew ods 23 Edits oe coe cee cee cee cee cee cee tee mas tne ten 2 Print amp Previ
26. 768 or higher resolution Page 69 CHAPTER 1 Notes Page 70 CHAPTER 2 Chapter 2 The Basics CHAPTER 2 Learning Objectives In this lesson you will learn to Identify the menu options of WebPlus e Understand the process of working on an abstract e Login and out of WebPlus e Change your password Overview This lesson covers the basics of WebPlus You ll learn about logging in and out of WebPlus and the key elements of WebPlus Log In To log in complete these steps 1 Open your Internet browser and type the web address for the WebPlus in the Address field 2 Press Enter Result Either the network password window or the WebPlus window opens e If the Enter Network Password window opens go to step 3 e If the WebPlus window opens go to step 5 Enter Network Password aj x yo Please type pour user name and password Site broadband ngcits com Realm broadband ngcits com User Mame Password Save this password in your password list Cancel 3 Click within the User ID field to place your cursor there Page 72 CHAPTER 2 4 Type demo into each field and click OK Result The WebPlus log in page opens Please log in Lser ID Password 5 Type johndoe in the User ID field and abstractor in the Password field 6 Click Login Result The WebPlus home page opens Home Page After you log in the Home page is displayed Mew Abstract Find Open Abstra
27. CODI NG I NSTRUCTI ONS Collaborative Staging Manual and Coding Instructions Part Il Primary Site Schema Extension to or fixation to adjacent structures other than seminal vesicles Bladder neck Bladder NOS Fixation WOS Rectovesical Denonvillier s fascia Rectum external sphincter A z z Levator muscle Skeletal muscle NOS Ureter Extension to or fixation to pelvic wall or pelvic bone Frozen pelvis NOS See Note 6 5 y Further contiguous extension Stage D2 including to Bone Penis Sigmoid colon Soft tissue other than periprostatic tissue Other organs No evidence of primary tumor CIC H A Unknown if prostatectomy done H A CT G No prostatectomy done within first course of treatment a Prostatectomy performed but not considered first course of treatment because of for example disease progression v a Prostatectomy done Extension unknown Primary tumor cannot be assessed Not documented in patient record Prostate CS Site Specific Factor 4 Prostate Apex Involvement OBSOLETE Prostatic Acid Phosphatase PAP Note Historically apex involvement has affected the stage classification although it does not affect the ATCC 6 edition This item allows collection of information about the involwement of the prostate apex with cancer both clinically and at prostatectomy In codes 110 550 the first digit represents the clinical status of apex involvement
28. Data Entry page click the Edit Errors tab in the information pane if it is not already open 4 Click the BPCode link Result The cursor moves to the BPCode field 5 At the BPCode field click Result A separate window opens for the birthplace codes Page 98 CHAPTER 5 3 BPCode Microsoft Internet Explorer Search Georgia Label Abyssinia Aden Afars and lssas 6 Inthe Search field type Georgia and click Search Result The Birthplace Code page displays the code for Georgia BPCode Microsoft Internet Explorer Search Georgia Search Label Georgia Georgia U 5 A Georgia LES F 7 Click the Georgia USA code number Result The system enters the code in the BPCode field 8 Click Save Result The system again runs an edit check View the Edit Errors area now the system has deleted the error for the BP code The procedure for correcting errors is the same for each error Find an error identified by the system and correct or add the field information for the field Page 99 CHAPTER 5 9 Inthe Edit Errors box scroll until you see the error for the Date of Diagnosis 11 lf year of Date of Diagnosis gt 2000 then Behavior Code ICD O 3 cannot be blank UxDate 05252004 i Behaviorl DOs 12 H year of Date of Diagnosis gt 2000 then Histologic Type ICD 3 cannot be blank OxDate 03252004 I HistIiypel CODOS The message shows that the field for Behavior
29. GRAPHICS Street Address Type the number and street address at diagnosis No punctuation is allowed in this field If the address contains 1 2 the words one half must be typed out Leave a blank between numbers and words if space permits Do not use periods after abbreviations Supplemental address field Type in any additional address information For example the name of a nursing home or apartment complex No punctuation is allowed in this field City Type the City at time of diagnosis No abbreviations are allowed in this field State Type the two letter abbreviation example MO for Missouri Or use the drop down icon and click on the appropriate state Zipcode Type the nine digit extended zip code if available if unavailable type the five digit zip code and press Enter County Click on the special help icon to bring up the county codes and click on the appropriate code to populate field If unknown use the MCR link htip www dhss mo gov Geocodes GeocodelList html to find the appropriate three digit county code Tobacco History Use the drop down icon to enter the appropriate code If you do not know the tobacco history enter the unknown value 9 Alcohol History Use the drop down icon to enter the appropriate code If you do not know the alcohol history leave blank Race 1 Use the drop down icon to select a code from the available options in order to populate this field If you do not know the race enter th
30. ICDO3 must be filled in because the date of diagnosis is after gt greater than the year 2000 10 In the Edit Errors list click the BehaviorlCDO3 link Note You do not have to click the link for the diagnosis date because it is correct This field link is shown to Indicate the correlation between it and the Behavior field Result The cursor is moved to the BehaviorlCDO3 field in the data entry section of the page 11 At the BehaviorlCDO3 field click the drop down arrow and select 3 Malignant from the list BehaviorlCDO3 Behavior Code ICO 0 3 0 Benign 1 Uncertain whether benign or malignant gt Carcinoma in stu 3 Malignant primary site Result The system places the value in the BehaviorlCO3 field 12 Click in the HistTypelCDO3 field above the Behavior 1C03 field and click Result The Histology Type ICD03 lookup window opens 13 Type 8850 in the Search field and click Search 0 9 5 0 Carcinoma acinar Page 100 CHAPTER 5 14 Click the 8850 code for Carcinoma acinar Result The code fills the HistTypelCDO3 field 15 Click Save and check the errors box to ensure that the errors have been eliminated Activity Correcting Errors Continue correcting the errors saving the abstract and re running Edits until no errors remain Use the information in this table to complete the abstract 1 Click on the field in the Edit Error area and enter the values listed in this table RxCodSysCur Treatment Coding S
31. IENT CONFIDENTIAL Last Name Y 3 Click your cursor in the Last Name field and type J ohnson ed 4 Click the Help icon beside the Last Name field Result A separate window opens giving you information about the field The Help information for WebPlus is from the NAACCR Standards for Cancer Registries Volume Il Data Standards and Data Dictionary Each field has a help icon that you can click to open a page with information about the field Page 80 CHAPTER 3 5 Close the Help window 6 Type this information into these fields C Social Security 666600000 7 Go to the DxState field and click the arrow for the drop down list Result A list of states opens ddr at Dx State Alberta Alaska AL Alabama AR Arkansas AS American Samoa AZ Arizona EC British Columbia CA California CO Colorado Connecticut 8 Select GA Georgia from the list Result The state code is entered in the field Note If you know the two letter code for the state you can type it in the field 9 Now that you have designated the state of the patient s residence you can select the county At the DxCounty field click the Special Lookup icon Page 81 CHAPTER 3 Result A separate window opens Special Lookup pages provide the coding information for the a WebPlus fields Clicking the Special Lookup icon opens a separate window with a list ing of the codes for your selected field 3 DxCounty
32. JO ISON Spa WNL 34 o puods81109 sapos eu jo auos SdIJOU IAA NOA sapos Jene ay ases o usa os djey eu Jo Wed s ay u uonoes sajou e ay Ised 0 105 p l YORS ul p pio5 1 q 0 Spasu uoljeuojul JO ad Jeym ass o SUOTING dieu au sN Hues Arewuns Y33S pue WNL 8ul JO uoreuIquo e Buisn mou 812 YOUN pue OGD Sy S 10 9e 9 nsouBoid Bels pia SIU 104 xoq uMOP dop eu asn 918 Ppajenualayip jayjesapou pajenualayp 19m joda Bojoyed ay uo puno aq ospe Aew siy pe uo y UMOUY J 8P00 au u adA Ajduuis JO apos ayeudoudde y o oB o Jajua yy uay euwoutoesouspe edA pue uondo yoless eu asf 0GG8 JO 9pPO9 E UIM RUIOUIDIEO 89 ube se pasoubelp aq m ases ayejso d e ARUOISE990 Or Lg JO apos Bojo siy sou euouroesouspe 3q s emye sow im y soseo ayejsoud 104 siBojoyed au Aq apew sisoubelp anssi au JO Si pou siy PJoly BOJOISIH V sway s u ajajduoo o jodas Bojoyyed 10 pue eopau ay wo UOIEWWOJUI asf tuoyeuojul ayun Aue Jajua o Bundwaye 210j0q os op aseajd ode A ojoyjed Joypue joda eopau ay Pama na JOU sey sn au J UONEIIMUSP 199ues fenuew uiue ou JO 9 SBed 0 Jaja aseajd sasn rey pue suool Buipie6 1 UOMeWUOJUI ayun 104 9e uonen iound jo asn ay equunu junoss peros umouyun Ue MOUS 0 moy e djay euonippe s piAod YOIUM pret Buipuodsa uos ay Buu lu uodn tesdde Ajeonewomne m yo ym xoq An dod ue e aney spiel
33. NG REQUIREMENTS Missouri statutes National Program of Cancer Registries NPCR and North American Association of Central Cancer Registries NAACCR requirements data quality and projected needs of the citizens of this state govern reporting requirements In 1999 the statutes were revised to include patients diagnosed and or treated as hospital outpatients and in non hospital facilities e g pathology laboratories ambulatory surgery centers freestanding treatment centers physician offices and long term care facilities in an effort to become a true population based central registry For reportability MCR generally follows the rules of the Surveillance Epidemiology and End Results SEER program of the National Cancer Institute Data requirements are based on NPCR and NAACCR recommendations for central registries collecting incidence data Additional requirements may include fields required by the American College of Surgeons Commission on Cancer CoC ROLE OF NON HOSPITAL REPORTING FACILITIES The primary sources for obtaining information of prostate cancer cases treated outside of a hospital may be freestanding treatment centers pathology labs and physicians offices Facilities may be large or small and the extent of information submitted varies depending on size and reporting methods Each reporting facility is however responsible for providing pertinent information regarding the patient s disease and some non hospital facilities have alr
34. R S MANUAL Page 16 MISSOURI CANCER REGISTRY h DATA ENTRY PROCEDURE continued PATIENT CONFIDENTIAL INFORMATION Last Name Enter the patient s last name in the spaces provided If the name exceeds the number of spaces provided enter as much as possible Use the following rules when recording patient last names Name fields should contain alpha characters and blanks only no special characters such as apos trophes commas hyphens etc 2 Any name titles or suffixes such as DR MD MR MS JR SR Ill IV and so on should be recorded In the middle name field after or instead of the middle name These data are optional 3 When a patient has two last names or a hyphenated last name you may type both in the last name field separated by a blank space 4 Patients with two part last names such as VAN HORN or ST JOHN may have a space between the two parts but no special punctuation marks 5 Names like MCCOY or O BRYAN should be typed MCCOY or OBRYAN with no spaces and no punctuation First Name Enter the patient s first name in the spaces provided If the name exceeds the number of spaces provided enter as much as possible Use the following rules when recording the patient s first name 1 Name fields should contain alpha characters and blanks only no special characters such as apos trophes commas hyphens etc 2 Patients with two part first names or two first names may have them both recorded in
35. Reports Change Password Log out Find Abstract Enter patient s name or social security to search for Search on partial name and social security is supported Name Social Security 999999999 Find F4 AbsReflD Last Name DxDate Social Birth Date Abstractor Security aara pones Jaen fosse fe frs _ 4285 MONTEREY sim __ 0071272004 00090090 02 07 1987 ser o compiere Compiete e CSN Incomplete 4288 999999999 sr 4291 JONES ELMER 01 01 2005 999999999 10 10 1944 4293 JONES JACK 01 01 2005 999999999 01 05 1945 WEBPLUS USER S MANUAL Page 26 MISSOURI CANCER REGISTRY E E E TT TT TT VO RELEASI NG ABSTRACTS Click on RELEASE ABSTRACTS Only COMPLETE abstracts will be selected A list of abstracts will appear with check boxes appearing after each item For those abstracts determined as ready for release users can either select each item individually or by using the menu bar at the bottom of the page select either SELECT ALL UNSELECT ALL or RELEASE SELECTED ABSTRACTS For further information on releasing abstracts please refer to page 102 in the appendix section of this manual Web Plus New Abstract Find Open Abstract Release Abstracts Please select the abstracts you want to release to your central registry Only completed abstracts are available for release Abs Remb LastName FirstName Abstractor s s s Date Case Completed Release a z e fones fe
36. State The original legislation involved only hospital inpatients nevertheless in 1999 legislation was amended to include reporting of all hospital patients outpatients as well as inpatients Because of changes in healthcare delivery and advances in medical practices non hospital health care providers such as long term care facilities pathology laboratories freestanding cancer treatment facilities ambulatory surgery centers and in some instances physician offices were also included in this legislation 192 650 192 657 RSMo However physicians need report only those cancers that are diagnosed or treated in the office setting cases in which the patient does not enter a hospital or other treatment facility Reporting by non hospital facilities is being phased in gradually so that MCR staff can work with facilities providing education and training to facility staff and developing reporting processes that minimize the burden on reporting facility staff without compromising data quality or com pleteness While the overall quality and completeness of Missouri s cancer incidence data is high gaps remain that can only be closed by implementing physician office reporting The two largest groups that have been identified are patients diagnosed with melanoma skin cancer or prostate cancer In 2004 MCR began working with dermatologists around the state who are now submitting cases on paper cancer reporting forms In less than 18 months MCR identifi
37. TABLE Prostate CS Mets at DX 552000 NONE Distant lymph node s NOS Common iliac Distant lymph node s Aortic NOS Lateral lumbar Para aortic Periaortic Cervical Inguinal NOS Deep NOS Node of Coquet or Rosenmuller highest deep inguinal Superficial femoral Retroperitoneal NOS Scalene inferior deep cervical Supraclavicular transverse cervical Distant lymph node s NOS Metastasis in bone s 30 11 or 12 Distant metastasis other than distant lymph node s codes 11 or 12 or bone s Carcinomatosis Distant metastasis NOS Stage D2 NOS 40 any of 11 or 12 M D Unknown if distant metastasis Distant metastasis cannot be assessed Not documented in patient record Version date April 25 2005 521 Version 01 02 00 WEBPLUS USER S MANUAL Page 50 MISSOURI CANCER REGISTRY EEK PJ COLLABORATI VE STAGI NG CODI NG INSTRUCTI ONS Collaborative Staging Manual and Coding Instructions Part Il Primary Site Schema Prostate CS Mets Eval SEE STANDARD TABLE Prostate CS Site Specific Factor 1 Prostatic Specific Antigen PSA Lab Value Note 1 Record the highest PSA lab value prior to diagnostic biopsy or treatment For example a pretreatment PSA of 20 0 ng ml would be recorded as 200 Note 2 Lab values for SSFs 1 and 2 should be from the same laboratory test Code Description Test not done test was not ordered and was not performed 001 0 1
38. UPZ ejep uni pue 39e13sqe Sy SASS 0 1919 SABS SIOUS POUO THN 03 uo 307 A poodiz 3484S Auo i O SSSIPPY y e N 3 ejuawa ddns pensqe ajo duo gt T gt 999 32843SqU BY se 4 UBY pue SUOI294109 ss ippv 1881S SIIHAVIDON30O LNAILVd J9qQUINN oyew Aew nod sioiis Aue 89494 SIIPp9 yuno99aS e190s eneA pla ejemojeo E auen ssnods Ul 311Nq JY Jl a3a duio si 39e13sqe ay sdny007 ennads e sey sweu uspielh jun 497e oO p uJn3 4 pue wm Aue Je OWEN SIPPIN Swen 15113 poaes oq ew S9113U3 sn qq AA u SUOP swen 1527 dieu samsuss yxejuo9 Mains uud pusbe 29999959 sioui PS sie 81e y uane Ssegejep eu o1 panes eq jllm se uey gt noA _ IV Bere eBessew si u UMOYS eq IIIA Aue ese eau J sico PPI AR RN oq jje ued AJ3si8 4 e13u9 y 0 31 aAes noA aun Y9es pelipe si Peujsge sy Sseqejep ay 03 y anes pejejduoo o 6ed eu jo tuonoq eu ye BABS uo 39119 pue 1oensqv ue Jajuy espo oG L Jopensav Suise 4 Ajayewizjn pue ejep Sulj ju disH IL S1O113 VIP 92141934S ALIMIDVS NVIDISAHd maneia Tuna q5 ejysqe ue Sunve 43 jo ssadold ouL gt Ppe nnsge Mou JISJUA I 9 no 607 puomssed ehueuD suodey SPENSgqY esesjey pensqy u do puij 1281154 MeN se l 1 CG sn d M uo Bo T weer pee QI 4881 uj Boy siraja Pense SSD Z PAOMSSEd SUWUPUADS o ol Sid ASS SPINDH 92U919 9M HINO SNA SMN
39. age a term used to define the size and physical extent of a cancer WEBPLUS USER S MANUAL Page 44 MISSOURI CANCER REGISTRY o GLOSSARY Staging the process of assigning a stage to a particular cancer in a specific patient in light of all the available information it is used to help determine appropriate therapy there are two staging methods the Whitmore Jewett staging classification 1956 and the more detailed TNM tumor nodes metastases classification 1992 of the American Joint Committee on Cancer and the International Union Against Cancer TNM tumor nodes metastases see Staging TRUS Transrectal ultrasound a method that uses echoes of ultrasound waves far beyond the hearing range to image the prostate by inserting an ultrasound probe into the rectum commonly used to visualize prostate biopsy procedures TURP Transurethral Resection of the Prostate a surgical procedure to remove tissue obstructing the urethra the technique involves the insertion of an instrument called a resectoscope into the penile urethra and is intended to relieve obstruction of urine flow die to enlargement of the prostate TUR P see TURP Watchful Waiting active observation and regular monitoring of a patient without actual treatment Zoladex trade or brand name for goserelin acetate a LHRH agonist WEBPLUS USER S MANUAL Page 45 MISSOURI CANCER REGISTRY Oc COLLABORATI VE STAGI NG CODI NG I NSTRUCTI ONS Collabora
40. and the second digit represents apex involvement found at prostatectomy following these definitions 1 No involvement of prostatic apex 2 Into prostatic apex airising in prostatic apex NOS 3 Arising in prostatic apex 4 Extension into prostatic apex 5 Apex extension unknown When abstracting and coding apex involvement try to determine if the cancer has extended into the apex from another part of the prostate or has arisen in the apex Code Description 000 OBSOLETE PAP Test not done test was not ordered and was not performed OBSOLETE PAP Positive elevated 020 OBSOLETE PAP Negative normal within normal limits 030 OBSOLETE PAP Borderline undetermined whether positive or negative Version date April 25 2005 524 Version 01 02 00 WEBPLUS USER S MANUAL Page 54 MISSOURI CANCER REGISTRY o COLLABORATI VE STAGI NG CODI NG I NSTRUCTI ONS Collaborative Staging Manual and Coding Instructions Part Il Primary Site Schema 080 OBSOLETE PAP Ordered but results not in chart 110 No involvement of prostatic apex Clinical apex involvement No involvement AND 120 E Prostatectomy apex involvement Into arising in NOS Clinical apex involvement No involvement AND Prostatectomy apex involvement Arising in Clinical apex involvement No involvement AND Prostatectomy apex involvement Extension into Clinical apex involvement No involvement AND a Prostatectomy apex involvement Unknown Cl
41. apparent only ba E Clinically apparent tumor confined to prostate NOS Stage B NOS o Localized NOS Contined to prostate NOS Intracapsular involvement only Not stated if Stage A or B T1 or TZ clinically apparent or inapparent OBSOLETE See Notes 2 3 and Site Specific Factor 4 T2NOS L OBSOLETE See Notes 2 3 and Site Specific Factor 4 T2NOS L OBSOLETE See Notes 2 3 and Site Specific Factor 4 T2NOS L Extension to periprostatic tissue Stage C1 RE RE Extracapsular extension beyond prostatic capsule NOS Through capsule NOS j fe ty u bao FF hs t N a La Es w b uy Version date April 25 2005 518 Version 01 02 00 WEBPLUS USER S MANUAL Page 47 MISSOURI CANCER REGISTRY Oc COLLABORATI VE STAGI NG CODI NG I NSTRUCTI ONS Collaborative Staging Manual and Coding Instructions Part Il Primary Site Schema Unilateral extracapsular extension Bilateral extracapsular extension Extension to seminal vesicle s Stage C2 Periprostatic extension NOS Unknown if seminal vesicle s involved Stage C NOS Extension to or fixation to adjacent structures other than seminal vesicles Bladder neck Bladder NOS Fixation NOS Rectovesical Denonvillier s fascia Rectum external sphincter Levator muscles Skeletal muscle NOS Ureter s Extension to or fixation to pelvic wall or pelvic bone Frozen pelvis NOS See Note 5 Further contiguous extension Stage D2 m
42. ar part of the body e g the prostate in order to check for abnormalities such as cancer in the case of prostate cancer biopsies are usually carried out under ultrasound guidance using a specially designed device known as a prostate biopsy gun removed tissue is typically examined microscopically by a pathologist in order to make a precise diagnosis of the patient s condition BPH see Benign Prostatic Hyperplasia Brachytherapy a form of radiation therapy in which radioactive seeds or pellets which emit radiation are implanted in order to kill surrounding tissue e g the prostate including prostate cancer cells WEBPLUS USER S MANUAL Page 41 MISSOURI CANCER REGISTRY OSA GLOSSARY CAB Complete Androgen Blockade see CHT Carcinoma a form of cancer that originates in tissues which line or cover a particular organ see Adenocarcinoma CGA chromogranin A a small cell prostate cancer or neuroendocrine cell marker CHT Combined Hormonal Therapy the use of more than one hormone in therapy especially the use of LHRH analogs e g Lupron Zoladex to block the production of testosterone by the testes plus antiandrogens e g CAsodex bicalutamide Eulexin flutamide Anadron nilutamide Androcur cyproterone to compete with DHT for cell sites therapy thereby depriving cancer cells of DHT needed for growth Combination Therapy see CHT Cryoabulation see cryosurgery Cryosurgery the use of liquid nitrogen probes
43. ature on the Lookup page to find the proper code Page 114 CHAPTER 7 Notes Page 115
44. cluding to Bone Other organs Penis Sigmoid colon Soft tissue other than periprostatic No evidence of primary tumor Extension unknown Primary tumor cannot be assessed Not documented in patient record Prostate CS TS Ext Eval Note 1 For this site use this item to evaluate the coding of tumor size and extension as coded in both CS Extension clinical for prostate and Site Specific Factor 3 Pathologic Extension if prostatectomy was performed Note 2 The codes for this item for prostate differ from the codes used for most other sites AJCC allows pathologic staging to be assigned on the basis of some biopsies without resection According to the AJCC manual In general total prostatoseminal vesiculectomy including regional node specimen and histologic confirmation are required for pathologic T classification However under certain circumstances pathologic T classification can be determined with other means For example 1 positive biopsy of the rectum permits a pT4 classification without prostatoseminal vesiculectomy and 2 a biopsy revealing carcinoma in extraprostatic soft tissue permits a pT3 classification as does a biopsy revealing adenocarcinoma infiltrating the seminal vesicles P 310 Note 3 For this site the T category and its associated c p y or a indicator are assigned based on the values in CS Extension CS TS Ext Eval and Site Specific Factor 3 For details see Note 7 under CS Extension Note 4 According to
45. ct Release Abstracts Choose one of the above options to proceed From this page you can access the main parts of WebPlus Click on an option to open the page for the option This table describes the menu options on the home page Release Abstracts Change Password Opens the change password page Log off Logs off WebPlus and opens the Log in page Opens the page that lists the reports available to abstractors To create a New Abstract go to Entering Information into Fields on page 80 Page 73 CHAPTER 2 Process The process of creating an abstract entering data and ultimately releasing it to the central registry can all be done in WebPlus After you create the abstract you can save your entries at any time and then return to your work until you have completed the abstract You can release the abstract only after you have eliminated all errors 1 Create 2 Update data 3 Correct 4 Complete 5 Release abstract errors abstract abstract 1 Create the abstract with the patient s name and social security number and save You can add more information to the abstract whenever you want and save it until it is completed 2 Enter other relevant medical information in the fields provided using the codes provided by WebPlus Save the abstract to retain your information and to allow the system to edit the abstract and show errors 3 Correct errors Each time you open or save th
46. d Digital rectum examination was not performed Extremeties are otherwise without deformity there is no joint swelling or nail clubbing Skin is warm and dry The lymph node areas of the cervical and supraclavicular areas are negative Neurologically the patient is intact with not focal motor or sensory deficits or cranial nerve deficits Carmen R Smith MD CRS sel DD 08 06 04 DT 08 06 04 WEBPLUS USER S MANUAL Page 33 MISSOURI CANCER REGISTRY OcA SAMPLE CASE KCM Pathology Laboratory 1234 Ridgeway Suite 501 Kansas City KS 63211 Tel 913 314 6572 Fax 913 314 6573 JOHNSTON SAMUEL Dr Carmen R Smith Age 76 Male DOB 11 27 1927 1200 Paris Road Suite 150 Kansas City MO 64116 SURGERY DATE 08 18 04 RECEIVED DATE 8 19 04 Tel 816 425 1572 Page 1 of 1 SURGICAL PATHOLOGY REPORT CLINICAL INFORMATION PATHOLOGY S04 00805 PHYSICIAN Smith C HISTORY DRE PSA 6 56 51 cc TISSUE 1 Prostate biopsy right 2 Prostate biopsy left DIAGNOSIS AFTER MICROSCOPY 1 Needle biopsy of right prostate Adenocarcinoma Gleason score 3 3 6 involving 30 of one core biopsy 2 Needle biopsy of left prostate Adenocarcinoma Gleason score 2 3 5 involving 5 of one core biopsy GROSS DESCRIPTION 1 Received in zinc formalin labeled Johnston right prostate biopsies are 5 tan cylindrical core biopsies each averaging 1 0 1 2 x 0 1 cm Submitted entirely in one cassette 1 2 Received in zinc formalin labeled
47. d facilities Although MCR began receiving CDC NPCR funding in 1995 our index reference year is 1996 MCR collects data that 1 is compliant with required NPCR data elements 2 meets standard requirements designated by NAACCR for incidence reporting and endorsed by CDC and 3 assists in determining data quality Data collected also provides useful feedback to submitting facilities that can be used for QA activities and administrative purposes Data collected is submitted annually to NAACCR for Registry Certification and publication in Cancer in North America CINA Registries whose data meet established criteria including criteria for timeliness accuracy and completeness are recognized annually as Silver Certified or Gold Certified registries MCR became a Silver Certified registry following submission of 1998 data in December 2000 and retained its status as a Silver Certified registry following submission of 1999 data in December 2001 MCR was also recognized as a Gold Certified registry with the submission of 2000 data and data for 1999 was later certified Gold for CINA publication in 2001 MCR staff are available to answer registry related questions and to provide workshops educational presentations and one on one training For additional information and contact information please refer to the MCR website http mer umh edu WEBPLUS USER S MANUAL Page 6 MISSOURI CANCER REGISTRY o I NTRODUCTI ON MISSOURI CANCER REPORTI
48. e a S lt gt lt gt Web Plus New Abstract Find Open Abstract Refease Abstracts Reports Change Password Log ol Change Password New password Retype Password Change WEBPLUS USER S MANUAL Page 29 MISSOURI CANCER REGISTRY 8 LOG OUT Once all tasks are completed within WebPlus the user is required to log out Simply choose LOG OUT to exit the system See also page 77 located in the back of this manual for further instructions regarding logging out of WebPlus Web Plus New Abstract Update abstract Find Open Abstract Release Abstracts PHY SICIAN FACILITY SPECIFIC Reporting Facility Physician Abstractor Date Case Completed Joo200000 KA SEL fi 1172005 PATIENT CONFIDENTIAL Last Name First Name Middle Name Maiden name Alias Spouse Name Social Security Number JMONTEREY farma jE PUNE 393533993 PATIENT DEMOGRAPHICS Street Address Supplemental Address City State Zipcode County Tobacco History Race 1 Race 2 Race 3 Race 4 Race 5 Hispanic Date of Birth 4 Page 30 fi 234 ANYWHERE AVE j eoonv EEE us KA 65233 Joss 88 88 5 KA 5525971957 ul gt l jor a ese Kad ss Kad chec a a gt Print Preview Edit Errors Help EDIT RESULT Editset Name Central Vs10 NP CF Required There are edit errors in the abstract Error messages alon
49. e abstract WebPlus automatically checks the en tered information and edits the fields for accuracy and thoroughness using any of a variety of edit sets provided by your administrator 4 After you have entered all your data and corrected all errors the system saves your new abstract as completed 5 Release the completed abstract to the central registry You can release abstracts one at a time or several at a time Data Entry Page You enter your case information on the Data Entry page To open the Data Entry page and view its content follow these steps 1 Loginto WebPlus 2 Onthe WebPlus menu click New Abstract Result The Data Entry page opens Page 74 CHAPTER 2 Enter new abstract FATIEHE L ONPFIDEMERREL Edit Errora Text Fights Help Lasi Names FirsiName MiddleNarme i Enter an Abstract and cick on Save at the botiom of the page to save 7 it to the database The abstract is edited each time you save Eda Mali ane errors Y there are any wall be shpen m the message area All your MamePrefix Y changes will be saved to the database even dthere are edit errors NameSuffie Legend SpouseNanre Soc Sec LE ce Print Preview Cried SF 1 LEN Contest sens re help CrSupp m Special Lookups Phone i Calculate Field Value DEMOGRAPHIC Crt iby Cr tate Ce cum OxPostalZip Racel Rare Data Entry Fields Information Tabs Save Notice that the page has two boxes The box on the left contai
50. e of a report complete these steps 1 On the WebPlus menu click Reports 2 Click Descriptive Statistics on Released Cases Result The Descriptive Statistics on Released Cases window opens Page 108 CHAPTER 6 Web Plus for State Cancer Registry Descriptive Statistics on Released Cases Frintable Form Select a Date Range From _ To Z Select all released Select Level of Site Group Detail Aggregate 18 categories Include Site Groups with no cases Yes No Group by managing physician Yas t Ho Run County of Residence Out of State 26 100 Total 26 100 3 Inthe Select all released box clear the check mark 4 Inthe From date field click the date one month before today s date 5 Inthe To date field click today s date 6 Inthe Select Level of Site Group Detail field select Aggregate from the drop down list The site Group Detail includes these options Aggregate 18 categories Subaggregate 60 categories 78 groups 7 Click Run Result The system runs with the new criteria and displays a new report 8 Click Printable Form Result A separate window opens with the data of the report Print the report using your browser s printer Page 109 CHAPTER 6 Activity Finding Report Information Look at the list of reports and find this information e The case you abstracted earlier e The number of updates done to abstracts in the last month e The last us
51. e patient s birth date and his diagnosis date 3 View a print preview of your abstract 4 Delete the abstract Page 94 CHAPTER 4 Notes Page 95 CHAPTER 5 Correcting Errors A u aw mM u A CHAPTER 5 Learning Objectives In this lesson you will learn to 1 Correct errorsto complete an abstract 2 Understand how edit sets affect the completion of an abstract 3 Understand the Edit Errors messages Overview In this chapter you continue working on your abstract You will use the Edit Errors feature of WebPlus to find errors or blank required fields and work toward the completion of your abstract You can only release completed abstracts which have no errors Understanding Edit Sets Each abstract is edited whenever you save or open it The edits applied to the information depend on the edit set selected by your administrator for your facility These edit sets may differ from ones at the local and the state level The edit set used for this training guide is Central VS10 NPCR Required As an abstractor you must correct all identified errors to complete your abstract before you release it to the central registry Edit Errors Tab The edit errors pane lists edits in the abstract The edit set runs each time the abstract is saved To correct your abstract errors complete these steps 1 Log in as described in Log In page 52 2 Find and open the J ohnson abstract 3 Onthe
52. e unknown value 99 Race 2 5 These fields are used when the patient has more than one race For example a person who is both caucasian and black Race 1 would be coded as white 01 and Race 2 would be coded black 02 The same rules would apply for any combination of races Fields 2 5 are currently set on a default value of 88 for no further race documented If you do not know the race enter the unknown value 99 Spanish Hispanic Origin Use the drop down icon to select a code from the available options to populate the field If unknown enter the unknown value 9 Date of Birth Type the patient s date of birth in the MMDDYYYY format no slashes Sex Use the drop down icon to enter the appropriate code for patient s gender Marital Use the drop down icon to enter the appropriate code for patient s marital status WEBPLUS USER S MANUAL Page 18 MISSOURI CANCER REGISTRY h DATA ENTRY PROCEDURE continued Primary Payer at Diagnosis Use the drop down icon to select the appropriate code regarding insurance status of patient Occupation Enter the patient s occupation as listed on medical accounting records if unknown type UNKNOWN Industry Enter the patient s industry as listed on medical accounting records if unknown type UNKNOWN CANCER IDENTIFICATION Before entering information i e codes to describe Primary Site Histology Treatment etc be sure to review the entire medical rec
53. eady begun reporting incidences of cancer as initiated by the Missouri expanded cancer reporting requirements ROLE OF MISSOURI CANCER REGISTRY In an effort to effectively monitor the incidence of cancer within the state the Missouri Cancer Registry MCR gathers information from multiple types of reporting facilities This data is then used for epidemiological research and may later be used to develop and evaluate cancer prevention control Data received from reporting facilities on a regular basis is an invaluable tool in determining risk factors in certain populations environmental impacts ethnic and social variations and impact of state cancer control programs CONFIDENTIALITY Per Missouri statute 192 655 RSMo 1999 the department of health shall protect the identity of the patient physician health care provider hospital pathology laboratory ambulatory surgical center residential care facilities or Il intermediate care facilities or skilled nursing facilities and free standing cancer clinic or treatment center and that such identity shall not be revealed except only upon written consent This con fidentiality provision is necessary to ensure all reporting entities that neither their identity nor the confidential data they submit will be released In addition MCR employees are required to sign confidentiality agreements and follow confidentiality proce dures set forth in the Missouri Cancer Registry Policy and Proced
54. ed approximately 500 cases of invasive melanoma that would otherwise have gone unreported As evidenced reporting of melanoma skin cancers has been greatly improved with the initiation of reporting by dermatologists Underreporting of prostate cancer cases is not only an issue in Missouri but also nationwide Recently Missouri was one of six states that the Centers for Disease Control amp Prevention National Program of Cancer Registries CDC NPCR selected to participate in a special one year pilot project to increase the reporting of prostate and other urological cancers by physicians With funding and technical assistance from CDC MCR will be able to offer a web based cancer reporting option using free software developed by CDC to urologists Eventually the software will be customized to accommodate melanoma cases as well MCR is pleased to be involved in this pilot project It offers an advantage to Missouri urologists who otherwise would have been asked to complete paper forms While we do not have specific details to share with you we wanted to inform you about physician cancer reporting in Missouri and alert you to the upcoming project Our website http mcr umh edu provides details about HIPAA as well as cancer report ing information for both hospital and non hospital facilities Thank you in advance for your cooperation We welcome your input and assistance in establishing effective procedures for capturing cancer data If you
55. el 8 Click Delete Result On the Confirm Delete window a message confirms the deletion Confirm Delete Abstract Reference ID to delete 4287 Delete Close Abstract Reference I0 4257 has been deleted The list will be refreshed when you rerun the query 9 Click Close 10 On the Find Abstract window click Find and confirm in the results window that the system has deleted the abstract Questions Answer these questions about adding data to an abstract 1 What isthe purpose of the text fields 2 How can you print your abstract and what does the printed copy contain 3 Which menu option do you click to open the page where you can delete your abstract Page 93 CHAPTER 4 Activity Adding Information and Deleting In this activity you continue with the abstract you created on page 63 view a print preview and delete the abstract 1 Find your own abstract you created and add this information into the text fields Diagnosis Dx Proc X ray scan 9 11 97 CT Neck Showed no def abnormalities noted Treatment Rx Text Chemo 9 27 97 Chemo Misc Text remarks Lesion Tongue BX Proven CA 9 9 ADM for def TRX According to obit If there are any critical text fields indicated by an asterisk that do not have an entry type NA in the fields Once the field has an entry the next edit of the abstract will eliminate the error for an empty critical field 2 Calculate the diagnosis age by first adding th
56. em may appear at a time If you forget to close the help screen it will remain open preventing other help items from appearing WEBPLUS USER S MANUAL Page 15 MISSOURI CANCER REGISTRY OS DATA ENTRY PROCEDURE continued 4 Certain fields become tan colored when you click on them This usually provides additional help how to show an unknown social security number the use of punctuation etc Maiden name gt Print Preview Alias Cont ti Y Context sensitive help Spouse Name gt Special Lookups Social Security Number Social Security Number ajeuato Field Value Enter 999999999 for Unknown PATIENT DEMOGRAPHICS ee 11234 ANYWHERE AVE 5 For some fields you will also see a magnifying glass or special help icon which allows you to search for the proper codes Click on the symbol for options or instructions required to popu late the appropriate field City BOONVILLE Y i State mo EZ Zipcode 85233 Y Tobacco History County Gloss 5 O i y Save PHYSICIAN FACILITY SPECIFIC INFORMATION Please note All fields are required however specific Missouri MCR required fields are indicated with an asterisk Abstractor This field records the initials of the person completing the form This field defaults to the initials created in the user profile Date Case Completed This field will be populated automatically once the case abstract has been saved WEBPLUS USE
57. ent Unknown Clinical apex involvement Unknown AND Prostatectomy apex involvement No involvement Clinical apex involvement Unknown AND Prostatectomy apex involvement Into arising in NOS Clinical apex involvement Unknown AND Prostatectomy apex involvement Arising into 520 530 Version date April 25 2005 525 Version 01 02 00 WEBPLUS USER S MANUAL Page 55 MISSOURI CANCER REGISTRY OS COLLABORATI VE STAGI NG CODI NG I NSTRUCTI ONS Collaborative Staging Manual and Coding Instructions Part Il Primary Site Schema Clinical apex involvement Unknown AND an Prostatectomy apex involvement Extension into 550 Clinical apex involvement Unknown AND Prostatectomy apex involvement Unknown OBSOLETE PAP Unknown or no information 999 2 Not documented in patient record Prostate CS Site Specific Factor 5 Gleason s Primary Pattern and Secondary Pattern Value Note 1 Usually prostate cancers are graded using Gleason s score or pattern Gleason s grading for prostate primaries is based on a 5 component system 5 histologic patterns Prostatic cancer generally shows two main histologic patterns The primary pattern that is the pattern occupying greater than 50 of the cancer is usually indicated by the first number of the Gleason s grade and the secondary pattern is usually indicated by the second number These two numbers are added together to create a pattern score ranging from 2 to 10 If there are two n
58. ented in patient record Version date April 25 2005 526a Version 01 02 00 WEBPLUS USER S MANUAL Page 57 MISSOURI CANCER REGISTRY LINKS TO IMPORTANT CANCER RESOURCES NTI 10 m E Click here For text menu Format IMPORTANT LINKS TO CANCER RESOURCES Site Map A WEBPLUS USER S MANUAL Page 58 APPENDIX CENTERS FOR DISEASE CONTROL WebPlus Tutorial NATIONAL OGRAM ISTRIES Please note that this section was created by the CDC and meant to serve as a separate tutorial therefore accuracy of information cannot be guaranteed by the MCR Screen set up and placement of some fields have changed since the initial phase of this project and time of creation However information contained in this section can be used as a more detailed reference guide for correctly entering information into required fields TABLE OF CONTENTS Contents Introduction 1 Creating an Abstract 3 Learning ObDJeCCtIVES 0c cece cece ccc eee cece eee e ae ee seen ea ea ta eeesesetnentaenennnnsntnnatnnnegy 80 VETVE chicane ee enh ld NED 80 Entering Information into Fields u000 40000 sa 80 Page 63 TABLE OF CONTENTS Correcting Errors 5 Final Learner Activity 7 L IPP A ENEE canada beanie E noo cd kn ded E EUR 114 Medical Record cc ri a a race a ka hr ar ah 114 el A ee 114 Page 64 CHAPTER 1 Chapter 1 Introduction ale o m u mA w ER
59. er stages of prostate cancer WEBPLUS USER S MANUAL Page 42 MISSOURI CANCER REGISTRY o GLOSSARY Gleason Score a widely used method for classifying the cellular differentiation of cancerous tissues the less the cancerous cells appear like normal cells the more malignant the cancer two numbers each from 1 5 are assigned successively to the two most predominant patterns of differentiation present in the examined tissue sample and are added together to produce the Gleason score high numbers indicate poor differentiation and therefore cancer GNRH enadotropin releasing hormone see LHRH Analogs Grade a means of describing the potential degree of severity of a cancer based on the appearance of cancer cells under a microscope see also Gleason Score Histology the study of the appearance and behavior of tissue usually carried out under a microscope by a path ologist who is a physician or a histologist who is not necessarily a physician Hormone Therapy the use of hormones hormone analogs and certain surgical techniques to treat disease in this case advanced prostate cancer either on their own or in combination with other hormones or in combination with other methods of treatment because prostate cancer is usually dependent on male hormones to grow hormonal therapy can be an effective means of alleviating symptoms and retarding the development of the disease Interstitial within a particular organ for example in
60. er to update the J ohn Wilson abstract Page 110 CHAPTER 6 Notes Page 111 CHAPTER 7 Chapter 7 Final Learner Activity A u aw mA w ESR CHAPTER 7 Overview For your final activity you will use a medical record and create an abstract Enter the information into the appropriate fields save it correct errors and release the abstract Medical Record Seaford Nantucket Memorial Hospital Discharge Summary Reporting Physician Anne Bobula Patient Information Medical Record Number 67234 Last Name Orvis First Name John Middle Name Wayne Address 22 6 Waverly St Philadelphia PA 19101 County Philadelphia Race Black Sex Male Date of Birth February 28 1925 Social Security Number 456456456 Admission June 12 2004 Discharge June 18 2004 Notes Mr Orvis was admitted for follow up of prostate biopsy positive for cancer performed May 30 in Doctor s Clinic Radical prostatectomy was performed on 6 13 04 Findings included a 1 5cm adenocarcinoma in prostate grade 1 All nodes negative Patient was discharged in good condition No further treatment is contemplated Hints These are a few hints to help you complete your abstract e Fill in what you know at first and then save your work WebPlus will run the edit check and show the entry fields blanks or errors e Look at the Help page for a field if you need to interpret the field name e Use the Search fe
61. ew ue cee ue vue vue un tee tee vue tte tee vue nee dun des Find Open Abstracts sio 222 a des doh man dos be nee pce een eee men rer She des 26 Releasing ADS TAC S zu 222 coo coo nun nun nun cee nos see nen nen see serno 27 ODON zen fue E o 28 Changing PASSWOIGES si ce s kas mate een ae sep ew Bite idr an wap dae Moke oem con 29 POO OUP 2 ens dsp e Gee es was ae wni aa ee ee ee Sus ee ee a 30 11 9 10 zen meer Z gee ces ae Lee eae ER 31 36 MCR Quick Reference Guide au cee aaa coo coo ann ce tee tee te tee tee tee en 27 38 MCR Data Set ee tev tee men tee tet tee tee tee ee ce tener 3940 PACKONVTAS CIOSG AY us a a Gas wae aa are le Hae ue ed cee dative dope aku one gee Oe 41 45 Collaborative Staging Coding Instructions a aa ooa sun nee men en 46 57 Links to Important Cancer Resources a un une ann ann nen nen nee 58 Appendix CDC Tutorial oa cic ccc ae see tee ev tee tee een testes sev nn 01 16 WEBPLUS USER S MANUAL Page 3 di ma Ill I kl EH HE I ill ill un II acoso I II Missouri Cancer Registry PO Box 718 Columbia Missouri 65205 nn 866 240 8809 or 573 884 2491 The Missouri Cancer Registry MCR was established by a group of forward thinking physicians more than 30 years ago as a means to col lect and provide accurate up do date information about cancer in Missouri Since 1984 reporting has been mandated by the
62. f unknown Medical Accounting Records Social security number Use 9s if unknown Medical Accounting Records Patient Demographics Street address Do not use periods Medical Accounting Records Supplemental address Use this for Apartment nursing home name etc Medical Accounting Records Medical Accounting Records State Medical Accounting Records Zip code Medical Accounting Records County Use list found at http mcr umh edu in Abstracting Medical Accounting Records Resoursces section Tobacco History Use 99 if unknown Medical Accounting Records Alcohol History Use 99 if unknown Medical Accounting Records Race 1 01 white 02 black Medical Accounting Records Race 2 5 Defaults to 9s Medical Accounting Records Spanish Hispanic Origin Select code or use 9 Medical Accounting Records Date of Birth No slashes Medical Accounting Records O lt Sex Medical Accounting Records Marital Use 9 if unknown Medical Accounting Records Primary payer at diagnosis Choose most appropriate code Medical Accounting Records Occupation Use 9 if unknown History amp Physical Industry Use 9 if unknown History amp Physical Cancer Identification Diagnosis date Date of Biopsy Diagnostic Op Path Reports Age at diagnosis Automatically calculated when you click on the calcu Diagnostic Op Path Reports lator icon WEBPLUS USER S MANUAL Page 39 MISSOURI CANCER REGISTRY OS MCR DATA SET ancer Identification co
63. g and invasive tumor was present in the prostatectomy specimen the mapping values are taken from the Site Specific Factor 3 mapping and the T category is identified as a pT If Site Specific Factor 3 Pathologic Extension code is 095 or greater meaning that prostatectomy was not performed or it was performed but the information is not usable for staging the mapping values are taken from the CS Extension Clinical Extension mapping and the c p y or a indicator is taken from the TS Ext Eval mapping If Site Specific Factor 3 Pathologic Staging code is 000 in situ and 1f CS Extension code Clinical Extension is greater than 00 and less than 95 not in situ the mapping values are taken from the CS Extension Clinical Extension mapping and the c p y or a indicator is taken from the TX Ext Eval mapping If Site Specific Factor 3 is 000 in situ and CS Extension code is 00 in situ or greater than 95 the mapping values are taken from the Site Specific Factor 3 mapping and the T category 1s identified as a pT Prostate CS Site Specific Factor 3 CS Extension Pathologic Extension In situ non invasive intraepithelial 1 S s Involvement in one lobe NOS Involves one half of one lobe or less Imvolves more than one half of one lobe but not both lobes Involves both lobes Localized NOS Confined to prostate NOS Intracapsular involvement only Stage B NOS S 12 2 19 OBSOLETE See Note 5 and Site Specific Factor 4 Invas
64. g with the error fields are listed below Click on a field below any error message to move to it in the data entry area Click on Save to save the changes and rerun Edits Total edit errors 10 mk Missing Critical Text DX Proc PE Missing Critical X ray scan Missing Critical Lab Tests Missing Critical Op Missing Critical Path Missing Critical Tithe Missing Critical Missing Critical Hormone Missing Critical Missing Critical Text DX Proc Text DX Proc Text DX Proc Text DX Proc Text Histology Text Staging RX T ext 00 ONO n h Q N RX Text Other Text Remarks lt WEBPLUS USER S MANUAL MISSOURI CANCER REGISTRY o SAMPLE CASE The following pages contain sample documents similar to those which will be used by your facility when entering data in WebPlus By using the following data we have completed an abstract and printed the results to be used as an easy reference guide when entering cases into the WebPlus system METRO AREA UROLOGY ASSOCI ATES Date 07 31 04 Name Samuel Johnston Address 1234 Waterfront Drive Columbia MO 65202 Phone 573 987 6543 Date of Birth 11 27 27 Age Diagnosis site for Tx PSA check Referring Physician Dr Cowell Referring Physician Phone 888 6625 Primary Care Physician Dr Cowell Referring Office Contact Person Susan INSURANCE I NFORMATI ON Primary Insurance
65. hanges and rerun Edits For further information please refer to Chapter 5 Correcting Errors located on pages 98 103 in the back of this manual Remember abstracts containing errors may be saved INCOMPLETE but only those with no errors COMPLETE maybe released to MCR Users can check for incomplete abstracts by either running detailed reports listed under REPORTS heading or by going to the FIND OPEN ABSTRACT and entering either last name or social security number for a case The case will give the option to either OPEN or DELETE Web Plus New Abstract Find Open Abstract Release Abstracts Update abstract PHY SICIAN FACILITY SPECIFIC Reporting Facility Physici Abstractor Date Case Completed Joo200000 wi SEL 11172005 PATIENT CONFIDENTIAL Last Name First Name Middle Name Maiden name Alias Spouse Name MONTEREY JIM JUNE Social Security Number 999999999 PATIENT DEMOGRAPHICS Street Address 1234 ANY VW RE AVE Supplemental Address City State Zipcode County Tobacco History Race 1 Race 2 Race 3 Race 4 Race 5 Hispanic Date of Birth 4 Page 24 BOONWI E mo 55233 1053 a O 3 38 Jes js fasn71957 El EDI TRESULT Editset Name Central Vs10 NP CF Required below Click on a field below any error essage to move to itin the data entry area lick on Save to save the changes and rerun Edits otal edit errors 10 mk
66. he TNM staging include that as well Terms like localized are acceptable See pages 35 36 for examples if needed TREATMENT 1ST COURSE Date of 1st Contact Type the date of the first office visit for this diagnosis using MMDDYYYY format Reason No Surgery As nearly all cases involved will not have had surgery performed this field is currently defaulted to 1 surgery of primary site not performed not part of planned 1st course Hormone Therapy Record hormone therapy administered if any Use the drop down box to enter the appropriate code or if no hormone therapy was given enter 00 or 99 if unknown Hormone Therapy Date If hormone therapy was given type the date in the MMDDYYYY format If hormone therapy was not given leave blank Text Hormone Treatment Detail any hormore therapy administered Include date of treatment initiated If none given type N A Reason No Hormone Therapy Use the drop down box to enter the appropriate code or if hormone therapy was given enter 00 or 99 if unknown Example if patient refused or if hormone therapy was not recommended use the drop down box to record the reason it was not administered WEBPLUS USER S MANUAL Page 21 MISSOURI CANCER REGISTRY OSA DATA ENTRY PROCEDURE continued FOLLOW UP DEATH Date Last Contact Type the date of last contact or date of death in MMDDYYYY format If the exact date of last contact or death is not available
67. he primary pattern that is the pattern occupying greater than 50 of the cancer is usually indicated by the first number of the Gleason s grade and the secondary pattern is usually indicated by the second number These two numbers are added together to create a pattern score ranging from 2 to 10 If there are two numbers assume that they refer to two patterns the first number being the primary and the second number being the secondary and sum them to obtain the score If only one number is given and it is less than or equal to 5 assume that it describes a pattern and uses the number as the primary pattern and code the secondary as 9 If only one number is given and it is greater than 5 assume that it 15 a score If the pathology report specifies a specific number out of a total of 10 the first number given is the score Example The pathology report says Gleason s 3 10 The Gleason s score would be 3 Note 2 Record the Gleason s score based on the addition of the primary and secondary pattern Note 3 Following AJCC guidelines for coding multiple Gleason s Scores in prostate cancer if there is more than one primary and secondary pattern value the value to be coded is the one base on the larger tumor specimen Please note that this rule is not the same as the rule for coding grade Code Description Test not done test was not ordered and was not performed 002 010 Gleason s Score See Notes 999 Unknown or no information Not docum
68. inical apex involvement Into arising in NOS AND Prostatectomy apex involvement No involvement Clinical apex involvement Into arising in NOS AND Prostatectomy apex involvement Into arising in NOS 210 220 230 Clinical apex involvement Into arising in NOS AND Prostatectomy apex involvement Arising in Clinical apex involvement Into arising in NOS AND x a Prostatectomy apex involvement Extension into 250 Clinical apex involvement Into arising in NOS AND i Prostatectomy apex involvement Unknown Clinical apex involvement Arising in AND 310 se E Prostatectomy apex involvement No involvement Clinical apex involvement Arising in AND Prostatectomy apex involvement Into arising in NOS Clinical apex involvement Arising in AND Prostatectomy apex involvement Arising in Clinical apex involvement Arising in AND Prostatectomy apex involvement Extension into Clinical apex involvement Arising in AND Prostatectomy apex involvement Unknown 320 330 Clinical apex involvement Extension into AND e Prostatectomy apex involvement No involvement Clinical apex involwement Extension into AND Prostatectomy apex involvement Into arising in NOS 430 Clinical apex involvement Extension into AND Prostatectomy apex involvement Arising in Clinical apex involwement Extension into AND Prostatectomy apex involvement Extension into Clinical apex involvement Extension into AND Prostatectomy apex involvem
69. ion into but not beyond prostatic capsule OBSOLETE See Note 5 and Site Specific Factor 4 OBSOLETE See Note 5 and Site Specific Factor 4 No extracapsular extension but margins involved See Note 4 Extension to periprostatic tissue Stage C1 Extracapsular extension beyond prostatic capsule NOS Through capsule NOS Unilateral extracapsular extension Bilateral extracapsular extension Extension to seminal vesicle s Stage C2 Extracapsular extension and margins involved Excluding seminal vesicle margins see code 045 Version date April 25 2005 523 Version 01 02 00 WEBPLUS USER S MANUAL Page 52 MISSOURI CANCER REGISTRY o COLLABORATI VE STAGI NG CODI NG I NSTRUCTI ONS Collaborative Staging Manual and Coding Instructions Part Il Primary Site Schema Extension to or fixation to adjacent structures other than semimal vesicles Bladder neck Bladder NOS Fixation NOS Rectovesical Denonvillier s fascia Rectum external sphincter Levator muscle Skeletal muscle NOS Ureter Extension to or fixation to pelvic wall or pelvic bone Frozen pelvis NOS See Note 6 Further contiguous extension Stage D2 including to Bone Penis Sigmoid colon Soft tissue other than periprostatic tissue Other organs No evidence of primary tumor Unknown if prostatectomy done No prostatectomy done within first course of treatment Prostatectomy performed but not considered first course of treatment becau
70. ions Answer the following questions about entering data 1 Which icon do you click to learn more about a field 2 What isthe purpose of a Special Lookup page Activity Creating an Abstract Create a new abstract of your own Provide this information and then save your new abstract e Patient name e Social Security number e City e State e County e Zip Code Remember this abstract name because you will use this information in another activity Activity Adding Information and Deleting page 94 Page 83 CHAPTER 4 Notes Page 84 CHAPTER 4 Chapter 4 Adding Data to an Abstract A u aw mA IE CHAPTER 4 Learning Objectives In this lesson you will learn to e Finda specific abstract e Use text fields for entering information e Identify and use tools necessary for entering an abstract e Preview an abstract for printing Overview In this chapter you continue to enter data in the abstract you have already started This chapter does not address correcting edits this will be done in Chapter 5 Correcting Errors beginning on page 78 First you will find your abstract and then add data to the abstract Opening and Updating an Abstract In this section you learn to find an abstract select reasons use a calculator field and use pop up window information To update an abstract follow these steps 1 Login as described in Log In page 52 2 Onthe WebPlus men
71. le to other facilities Data entered are validated by the CDC EDITS Engine running on a web server User display types and edit configurations are managed at the hosting central registry WebPlus is hosted on a secure web server that has a digital certificate installed the communication between the client and the server is encrypted with Secure Socket Layer SSL technology Page 68 CHAPTER 1 Users The results from the design staff and usability testing have identified these types of WebPlus users users Description ICI Works in a local facility and handles patients medical records and paperwork When a patient is diagnosed with cancer the facility administrator reports the case to the state s central cancer registry Facility Abstractor Reviews abstract submitted by hospitals and doctors offices for completeness and accuracy Central Registry compares text in the abstract against codes submitted to make sure they are the correct codes Abstractor corrects any errors or discrepancies found Sets up the local facilities with access to the WebPlus software to report their data creates a Central Registry configuration for the facilities and defines their required fields and validation rules Administrator Requirements for Web Access WebPlus requires Microsoft Internet Explorer version 5 0 or later to operate the system fully Although WebPlus works at 800 X 600 resolution it can be best viewed at 1024 X
72. lial cells of the prostate gland including cancer cells an elevated level in the blood indicates an abnormal condition of the prostate gland either benign or malignant it is used to detect potential problems in the prostate gland and to follow the progress of Pca therapy see SCREEN ING PSA Velocity PSAV the rate at which PSA values increase assuming that the rate does not change Radical Prostatectomy an operation to remove the entire prostate gland and seminal vesicles Refractory resistant to therapy e g hormone refractory prostate cancer is resistant to forms of treatment based on the use of hormones see mutation Resection surgical removal Retropubic Prostatectomy surgical removal of the prostate through an incision in the abdomen RP see Radical Prostatectomy RTPCR see RT PCR RT PCR reverse transcriptase polymerase chain reaction a technique which allows a physician to search for tiny quantities of protein such as PSA in the blood or other body fluids and tissues because today s reproducability is poor the test results are reported in vague terms like positive or negative rather than as numbers see PSA RT PCR Screening to separate patients with tumors form those without tumors multiple criteria are often used the follow ing PSA screening cutoff levels for PCa are replacing the older 4 0 value Age PSA cutoff 40 49 2 5ng ml 50 59 3 5ng ml 60 69 4 5ng ml 70 79 6 5ng ml St
73. ll button 3 Click Release Selected Abstracts Result The system releases the selected abstracts to your designated central registry and changes the status of the abstracts to Released Use the Find Open page to view the released abstracts You can view them but cannot amend them Page 102 CHAPTER 5 Questions Answer these questions about correcting abstracts 1 How can you release more than one abstract at a time 2 What are two waysto release a single abstract 3 Where do you find the errors list Page 103 CHAPTER 5 Notes Page 104 CHAPTER 6 Chapter 6 Running Reports A u aw mA w ESR CHAPTER 6 Learning Objectives In this chapter you will learn to 1 Open a report 2 Describe the reports available in WebPlus 3 Set a date range for a report Overview WebPlus provides reports for auditing activity and for analyzing cancer reporting You can view and print several types of reports You can also set the date ranges for the information in the report Opening Reports To open a report after you have logged in complete these steps 1 Onthe WebPlus menu click Reports Result WebPlus displays a list of reports available for you Local Keports Cases submitted sored by Abstractor Cases Accessed sorted by Patient Name Descriptive Statistics on Released Cases Activity Report Audit Reports System Log ins Abstract Updates Abstract Searches Abstract Deletion
74. mation 1 Onthe Data Entry page click the Text Fields tab Result The Text Fields open The first set of text fields is for diagnosis 2 Clickin the DX Proc PE field and type the following information Susp Firm RT Lobe Prostate 3 Click the Treatment link The treatment fields open 4 Click in the Radiation beam field and type this information 2 19 4 12 95 38F 52D 7040 CGY total tumor dose 5040 CGY to Pelvis with 2000 CGY boost prostate St J oe s 5 Click the Miscellaneous link The Miscellaneous text fields open 6 Click in the Place of Diagnosis field and type St J oseph s 7 Save your work Activity Using Text Fields Practice entering information into text fields by typing more information for your abstract 1 In the Diagnosis text fields type this information Field om DX Proc Lab tests Slightly elevated PSA DX Proc OP 2 15 1995 Ultrasound guided BX RT lobe prostate DX Proc Path 2 15 95 S95 354 Prostate BX R lobe Adenoca presumably infil acinar type GR2 Primary Site title Site title Prostate Histology title Adenoca acinar cell type Page 91 CHAPTER 4 2 Click Save and check that the data you entered in the fields have been saved If there are any critical text fields indicated by an asterisk that do not have an entry type NA in the fields Once the field has an entry the next edit of the abstract will eliminate the error for an empty critical field
75. men fe zo __ NZ Select All Unselect All Release selected abstracts WEBPLUS USER S MANUAL Page 27 MISSOURI CANCER REGISTRY OS REPORTS To run reports simply choose REPORTS and select the appropriate option on the Reports page For further information on running reports please refer to Chapter 6 Running Reports on pages 106 110 located in the back of this manual Web Plus New Abstract Find Open Abstract Release Abstracts Change Password Log out Update abstract Print Preview ES By Edit Errors Help PHYSICIAN FACILITY SPECIFIC Reporting Facility Physician 606200000 KA sec fi 1172005 CONFIDENTIAL MONTEREY farm JE PUNE 99995955 Abstractor EDIT RESULT Date Case Completed Efiitset Name Central Vs10 NPCR PATIENT Required Last Name First Name here are edit errors in the abstract Error essages along with the error fields are listed below Click on a field below any error message to move to it in the data entry area Click on Save to save the changes and rerun Edits Middle Name Maiden name Alias Spouse Name Social Security Number Total edit errors 10 City State Supplemental Address Zipcode PATIENT DEMOGRAPHICS Street Address h 234 ANYWHERE AVE JBCONV a MO Text DX Proc Missing Critical Field PE Missing Cri
76. nd 52 UNKNOWN UNKNOWN 08 02 2004 076 Prostate gland 8140 Adenocarcinoma Moderately differentiated Gleasons 3 3 srade Il moderately differentiated No documentation DRE negative nothing palpable Lymph node areas of cervical and supraclavicular areas negative 999 15 00 Continued MISSOURI CANCER REGISTRY OS SAMPLE CASE continued CS 5 How Nodes Evaluated 0 Mets at diagnosis CS 6 O0 CS 7 How Mets Evaluated 0 CSSSF 1 PSA value 065 CSSSF 2 PSA or 010 CSSSF 3 097 CSSSF 4 Apex involvement 550 CSSSF 5 Gleason Pattern 033 CSSSF 6 Gleason value 006 DerivedSS2000 1 Text Stage T1C NO MO one core from Rt side 30 one core from Lt side 5 Date of First Contact 07 31 2004 Reason No Surgery Surgery of primary site not performed not part of planned 1st course Hormone Therapy Hormone therapy Hormone Therapy Date 01 09 2005 Text Hormone Treatment Zoladex Reason No Hormone Therapy Hormone therapy administered Date of Last Contact 01 09 2005 Vital Status Alive Cancer Status Evidence of this cancer Place of Death Cause of Death 0000 Reporting Physician 12345678 Physician Other 91011121 Text Remarks HX of cardiac disease Metro Area Urology Associates Cowell Smith End of Abstract WEBPLUS USER S MANUAL Page 36 snidasm np3 ukun sn dasam sdyy panes SI j9ensge eu sun yes Synsei Sup3 103 Jy Bu Sy 0 xoq Sy Ses s
77. ns the fields where you enter your case information The box on the right contains two tabs Help and Edit Errors 3 In the entry box on the left scroll down the list to see all of the fields The fields you see depend on your facility or center and the set up done by your administrator The headings such as Patient and Demographic can vary These are only headings they do not signify a group of required fields Your administrator uses them to organize the fields for clearer viewing and to help with data entry Note Refer to Creating an Abstract Chapter 3 beginning on page 80 to learn how to enter data in these fields 4 Inthe right box click each of the tabs to see the content These are the WebPlus tabs Help This area describes the saving and editing of an abstract and provides a legend of the field icons Edit Errors This area lists the errors after you have opened or saved an abstract This editing feature helps you complete the abstract until it meets the standards acceptable to the central registry Note You will learn more about the edit errors tab on page 98 Page 75 CHAPTER 2 5 Click the Help tab if the section is not already open This area provides a legend for the icons and briefly describes the process of saving your abstract Result The Help box opens Print Previews Enter an Abstract and click on Save al the botiom of the page lo save it to the database The abstract is edited each
78. nt of involvement assign this to code 60 Note 7 AUA stage Some of the American Urological Association AUA stages A D are provided as guidelines for coding in the absence of more specific information in the medical record If physician assigned AUA stage D1 D2 is based on involvement of lymph nodes only code under CS Lymph Nodes or CS Mets at DX not CS Extension Note 8 This schema includes evaluation of other pathologic tissue such as a biopsy of the rectum Version date April 25 2005 517 Version 01 02 00 WEBPLUS USER S MANUAL Page 46 MISSOURI CANCER REGISTRY COLLABORATI VE STAGI NG CODI NG INSTRUCTI ONS Collaborative Staging Manual and Coding Instructions Part Il Primary Site Schema Note 9 For the extension fields for this site the mapping values for TNM 5577 and SS2000 and the associated c p y or a indicator are assigned based on the values in CS Extension CS TS Ext Eval and Site Specific Factor 3 If the value of Site Specific Factor 3 is greater than 000 and less than 095 1 e prostatectomy was done extension information is available for staging and invasive tumor was present in the prostatectomy specimen the mapping values are taken from the Site Specific Factor 3 mapping and the T category is identified as a pT If Site Specific Factor 3 Pathologic Extension code is 095 or greater meaning that prostatectomy was not performed or it was performed but the information is not usable for staging
79. ntinued eee Stage Prognostic Factors Derived S852000 SS2000 Derived S62000 Automatically calculated when you save Calculated field field Text Stage Ex TNM localized confined to prostate palpable aan _ notes nodes Distant mets to bones etc Treatment 1st Course Date of first contact First date for this diagnosis Office notes Use codes Not recommended Patient declined Office notes etc Hormone therapy Hormone therapy 00 none OT given see other values Office notes Office notes Follow up Death Deo Mean Code 7777 unless you have death certificate WEBPLUS USER S MANUAL Page 40 MISSOURI CANCER REGISTRY E E E TT TT TT VO ACRONYMS GLOSSARY ACoS American College of Surgeons ASC Ambulatory Surgical Center CDC Centers for Disease Control and Prevention CoC Commission on Cancer CTR Certified Tumor Registrar DHSS Missouri Department of Health and Senior Services IRB Institutional Review Board LTCF Long term care facility a generic term for residential care facilities and Il intermediate care facilities and skilled nursing facilities SNFs HIM Health Information Management HMI Department of Health Management and Informatics MU MCR Missouri Cancer Registry MICA Missouri Information for Community Assessment DHSS s interactive web based tool NAACCR North American Association
80. of Central Cancer Registries NPCR National Program of Cancer Registries CDC Adenocarcinoma a form of cancer that develops from a malignant abnormality in the cells lining a glandular organ such as the prostsate almost all prostate cancers are adenocarcinomas Age adjusted modified to take account of the age of an individual or group of individuals for example prostate cancaer survival data and average normal PSA values can be adjusted according to the ages of groups of men Alpha blockers pharmaceuticals that act on the prostate by relaxing certain types of muscle tissue these pharmaceuticals are often used in the treatment of BPH Antiandrogen A substance which interferes with the function of an androgen or male sex hormone by taking over the androgen s receptors Apex the tip or bottom of the prostate e g the part of the prostate farthest away from the bladder Benign relatively harmless not cancerous not malignant Benign Prostatic Hyperplasia or Hypertrophy BPH a noncancerous condition of the prostate that results in the growth of both glandular and stromal Supporting connective tumorous tissue enlarging the prostate and obstructing urination see prostatitis Bilateral both sides for example a bilateral orchiectomy is an orchiectomy in which both testicles are removed and a bilateral adrenalectomy is an operation in which both adrenal glands are removed Biopsy sampling of tissue from a particul
81. of Death field Result A pop up box appears The pop up window is another method of providing a field code to you Update abstract Cause Of Death Othtause i I 0000 Patient alive at last contact IC DRevklum 7777 Death certificate not available 7797 Death certificate available but underlying cause of Au I death not coded 10 Type 0000 alive in the DthCause Cause of Death field 11 Click Save to retain your changes to the abstract Page 88 CHAPTER 4 Activity Adding Data Part One Continue entering information into your abstract Enter the following information in the appropriate fields use the fields drop down lists to get the proper codes Field Content SSS O DxNumAndSt 101 Clairemont Ave 404 555 1212 After you have finished entering the information save your work Adding Data Part Two More data can be added that pertains to the medical history of the patient 1 Add this information to the entry fields as shown Field content Vale Prostate NOS C619 Not a paired site CS HistTypelCD02 8550 BehaviorlCD02 Grade 3 poorly differentiated 2 Click Save Page 89 CHAPTER 4 Please note that the screen set up and placement of text fields has changed since the initial phase of this project when this tutorial was created However information contained in this section can be used as a more detailed reference guide for correctly entering information into required text fields
82. or less ng ml actual value with implied decimal point 002 989 0 2 98 9 ng ml actual value with implied decimal point 99 0 or greater ng ml Unknown or no information Not documented in patient record Prostate CS Site Specific Factor 2 Prostatic Specific Antigen PSA Note 1 Use the highest PSA lab value prior to diagnostic biopsy or treatment Note 2 Lab values for SSFs 1 and 2 should be from the same laboratory test Code Description Test not done test was not ordered and was not performed 010 Positive elevated 020 Negative normal within normal limits 030 Borderline undetermined whether positive or negative 080 Ordered but results not in chart Unknown or no information Not documented in patient record a m un ge CS Site Specific Factor 3 CS Extension Pathologic Extension Note 1 Include information from prostatectomy in this field and not in CS Extension Clinical Extension Use all Note 2 Limit information in this field to first course of treatment in the absence of disease progression Note 3 Involvement of the prostatic urethra does not alter the extension code Note 4 When the apical margin distal urethral margin bladder base or bladder neck margin is involved and there is no extracapsular extension use code 040 Note 5 Codes 031 033 and 034 have been made OBSOLETE CODES NO LONGER USED Information about prostate apex involvement has been moved to Site Specific Factor 4 Prostate Apex In
83. or your staff have questions or comments about physician cancer reporting please contact Nancy Cole MCR s non hospital reporting coordinator at 866 240 8809 or colen health missouri edu Sincerely Pen ate Jeannette J ackson Thompson MSPH PhD Operations Director WEBPLUS USER S MANUAL Page 5 MISSOURI CANCER REGISTRY OSA PREFACE The primary purpose of the Missouri Cancer Registry MCR WebPlus Manual is to assist physicians offices in reporting cancer cases As WebPlus is a new software developed by the Centers for Disease Control and Prevention CDC for collection of cancer information this is the first edition of the manual which includes recent changes in coding structures and requirements from the National Program of Cancer Registries NPCR the North American Association of Central Cancer Registries NAACCR and the Commission on Cancer CoC Facility Oncology Required Data Standards FORDS Since the passage of Public Law 102 515 entitled the Cancer Registries Amendment Act by the 102nd Congress in October 1992 there has been a tremendous effort by all agencies collecting cancer data to unify and standardize data sets With the establishment of NPCR in 1994 all central registries funded by the CDC through NPCR are required to follow stringent data management procedures provide training for state personnel all reporting facility staff publish an annual report and conduct case finding re abstracting audits at selecte
84. ord For additional help please refer to pages 39 40 Diagnosis Date Enter the date the cancer was first diagnosed as listed in Diagnostic Op Path reports Age at Diagnosis Once diagnosis date has been entered use calculator to calculate correct age at diagnosis If left blank and edit error will appear when saving abstract Primary Site For prostate cases the primary site defaults to C619 the ICD O 3 site code If necessary use the special look up icon to determine the appropriate code Histology Histology is the tissue diagnosis made by the pathologist For prostate cases the histology code will almost always be adenocarcinoma nos code 8140 Occasionally a prostate case will be diagnosed as acinar cell carcinoma with a code of 8550 If the histology is one of these two terms simply the code 8140 or 8550 Otherwise click on the special lookup icon and a search screen will appear Type the text for the histology click on search and a list of codes will appear Scroll down the list until you see the correct histology term Text Histology Include text describing histology and grade as detailed in the medical record Text Pathology Report Info Include other pertinent text from the pathology report including Gleason score Prostate Grade Conversion Table WEBPLUS USER S MANUAL Page 19 MISSOURI CANCER REGISTRY OSA DATA ENTRY PROCEDURE continued Grade Review the pathology report to dete
85. ovide identification NPI number in each web based data form Single practice One person may submit information The practice will have a single facility ID The physi cian will be identified by the license number or national provide identification NPI number in each web based data form Users will create a new case or abstract for each patient The abstract or web based data form may be saved whether or not information entered is complete Users may return to the abstract at any time by using the open feature Users may view the abstract even after it has been released or sent to MCR via the web Abstract information is divided into 7 main areas Physician Facility Specific Patient Confidential Patient Demographic Cancer Identification Stage Prognostic Factors Treatment 1st Course and Follow up Death Reportable cases are those cases prostate identified either thru patient treatment information or pathology reports which indicate the patient as having been diagnosed with cancer at your facility and who will not receive treatment elsewhere When users click on the Save button edits are activated Edit messages contain helpful information to explain how to correct the information Once a case has passed all edits it may then be released to MCR WebPlus is configured with an automatic time out mechanism after 30 minutes of idle time in which users will have to log in again to access the system Therefore
86. ptysis noted Gastrointestinal review of systems is negative for change in bowel habits melena or hematochezia Genitourinary review of systems is as per the history of the present illness Musculo skeletal review of systems is negative for bone pain No skin problems such as pruritis or rash No stigmata of diabetes such as polyphagia or polydipsia No hemologic symptoms such as easy bruising bleeding or anemia at this time No lymphatic trouble such as peripheral edema or nodules No neurologic symptoms of seizures or focal motor or sensory deficits No psychiatric disturbance such as change of cognition or affect PHYSICAL EXAMINATION On exam this is a well appearing elderly white male Weight is 176 pounds Blood pressure 120 62 Pulse 60 Respirations 20 Extraocular movements are intact and sclerae are non icteric Pupils are equal and reactive Examination of the oral cavity reveals the patient is edentulous There are no nodules or masses present Neck is soft and sup ple There is no evidence of thyromegaly or thyroid nodules Chest is clear with breath sounds throughout There are no rales rhonchi or wheezes present Cardiac exam is unremarkable with the patient having a regular rate and rhythm without rubs or murmurs There are no carotid bruits Abdomen is soft and nontender There is no sign of ascites or mass There is no hepato megaly appreciated There is no CV angle tenderness No pain to palpation of the chest wall or spine appreciate
87. rmine the correct grade Use the drop down box to include information about grade by number The terms will be 1 well differentiated 2 moderately differen tiated 3 poorly differentiated or 4 undifferentiated If the pathology report does not indicate a grade use the nos value 9 The Gleasons score may be used with the table on the previous page to deter mine grade STAGE PROGNOSTIC FACTORS Collaborative Stage CS Please use the drop down icons and or special look up icons to select the appropriate code for the following fields For additional help please refer to pages 46 57 Text Imaging Studies Type text information from diagnostic imaging reports Use standard abbrevia tions CXR chest x ray etc Document positive and negative findings see pages 35 36 for examples If no test performed state same Text Physical Exam Type text information from the history amp physical examination see pages 35 36 for examples Tumor Size CS1 This field is currently defaulted to 999 as most commonly there will be no tumor size indicated in prostate cases If however tumor size is indicated please refer to the codes listed when us ing the special look up icon Extent of Disease CS2 Identifies primary tumor growth within the organ of origin or its extension into neighboring organs Also corresponds to the T in TNM staging and is based on clinical informa tion Example Patient summary reveals patient
88. rted first by the name of the abstractor and then by patient name Cases Accessed all cases that a facility has transmitted released for a given time Sorted by Patient Name period by patient name Descriptive Statistics on descriptive statistics on released cases such as demographics Released Cases and site group Audit Reports Activity Report the number of cases released or unreleased for each month of the selected date range within a selected date range Abstract Releases information about abstract releases including release time and date abstractor and facility Page 107 CHAPTER 6 Changing the Date Range of a Report To change the date range of a report complete these steps 1 Onthe WebPlus menu click Reports 2 Click Cases Accessed Sorted by Patient Name Result The Case Accessed sorted by Patient Name window opens Choose a date range 0042005 EB To ftos RB Select 3 Click the calendar icon beside the From date field Result The calendar window opens Tip You can also type the date in the window by using the mm dd yyyy format such as 10 01 2005 for October 1 2005 4 Double click the date you want The system inserts the date in the field 5 Click Select Result WebPlus displays the report again with the information in the date range you selected Modifying the Report for Descriptive Statistics on Released Cases To modify the report for Descriptive Statistics on Released Cases date rang
89. s Change Password Log out Update abstract Print Preview Es PHYSICIAN FACILITY SPECIFIC Edit Errors Help Reporting Facility Physician 66200000 G j pp EDIT RESUL T Date Case Completed 11172005 PATIENT CONFIDENTIAL Editset Name Centraj Vs10 NP CF al MONTEREY s Sue ENS farm There are edit errors Jn the abstract Error Middle Name EE messages along with the error fields are listed Martenmname below Click on a fiefd below any error message to move tg it in the data entry area Alias I Click on Save to safve the changes and rerun Spouse Name JUNE Edits Social Security Number Total isdit errors o Jesssssss9s PATIENT DEMOGRAPHICS a SS 1234 ANYWHERE AVE mk Missing Gritical Field Text DX Proc PE Supplemental Address Missing ritical Field Text DX Proc P X ray sgan EUR JBCONVILLE 3 Missing Critical Field Text DX Proc State Mo KA Lab Tests Zi a ee 4 Missirfg Critical Field Text DX Proc A 65233 Op Count 5 Missing Critical Field Text DX Proc d Joss Pat TOOTE Kapari Jo Ka 6 Misging Critical Field Text Histology Race 1 bi KA Titlg Pacsa We Migsing Critical Field Text Staging Jes Ka 8 Mising Critical Field RX Text Race 3 jes Wma Hormone Race 4 9 issing Critical Field RX Text Other Jes ha TO issing Critical Field Text Remarks bes KA Hispanic Bs KA Dale of Dit hoars
90. s Abstract Releases 2 Click the Cases Submitted Sorted by Abstractor link Result A separate window opens with a list of transmitted or released cases sorted by name of the abstractor Page 106 CHAPTER 6 Web Plus for State Cancer Registry Cases Submitted Sorted by Abstractor hoose a date range From 09 30 2005 FA To 10 31 2006 FA Select Ahstractor DOE Patient Name 2 SocSec Birth Date Date Entered Date Completed Date Transmitted BOMPASSE EDWARD 784500000 07 29 1955 17172005 08 03 2005 214 d 08 03 2005 214 d ENDICOTT ANNA 760006229 01 16 1918 1 1 2005 05 17 2005 136 d 08 18 2005 229 d KEAYNE BENJAMIN 790037349 01 30 1902 1 1 2005 13 31 2005 88 d 03 31 2005 89 d WILLIAMS ANNE 790000740 05 12 1934 1 1 2005 13 31 2005 89 d 03 31 2005 89 d Abstractor SRB Patient Name SocSec Birth Date Date Entered Date Completed Date Transmitted BAGIN HENRY 750008679 10271929 1 1 2005 13 31 2005 69d 03 31 2005 9 d BEALE WILLIAM 770228679 10271929 1 1 2005 13 31 2005 88 d 03 31 2005 89 d CANNON JOHN 761180000 07 14 1916 1 1 2005 03 31 2005 69 d 03 31 2005 89 d Reports This table describes reports that may be part of your WebPlus display Click the name of the report to open a separate window displaying the report This report Cases Submitted all cases that a facility has transmitted released for a given time Sorted by Abstractor period The cases are so
91. se of for example disease progression Prostatectomy done Extension unknown Primary tumor cannot be assessed Not documented in patient record Prostate CS Site Specific Factor 4 Prostate Apex Involvement OBSOLETE Prostatic Acid Phosphatase PAP Note Historically apex involvement has affected the stage classification although it does not affect the AJCC 6 edition This item allows collection of information about the involvement of the prostate apex with cancer both clinically and at prostatectomy In codes 110 550 the first digit represents the clinical status of apex involvement and the second digit represents apex involvement found at prostatectomy following these definitions 1 No involvement of prostatic apex 2 Into prostatic apex airising in prostatic apex NOS 3 Arising in prostatic apex 4 Extension into prostatic apex 5 Apex extension unknown When abstracting and coding apex involvement try to determine if the cancer has extended into the apex from another part of the prostate or has arisen in the apex Code Description OBSOLETE PAP Test not done test was not ordered and was not performed 010 OBSOLETE PAP Positive elevated 020 OBSOLETE PAP Negative normal within normal limits 030 OBSOLETE PAP Borderline undetermined whether positive or negative Version date April 25 2005 524 Version 01 02 00 WEBPLUS USER S MANUAL Page 53 MISSOURI CANCER REGISTRY O COLLABORATI VE STAGI NG
92. t in one or both lobes Within this range give priority to codes 13 15 over code 10 2 When tumor is found in one lobe or in both lobes by needle biopsy but is not palpable or visible by imaging use code 15 E CODES 20 to 24 are used only for clinically radiographically apparent tumor i e that which is palpable or visible by imaging Codes 21 and 22 have precedence over code 20 Code 20 has precedence over code 24 C CODE 30 is used for localized cancer when it is unknown if clinically or radiographically apparent An example would be when a diagnosis 1s made prior to admission for a prostatectomy with no details provided on clinical findings prior to admission D CODES 31 33 and 34 have been made OBSOLETE CODES NO LONGER USED Information about prostate apex involvement has been moved to Site Specific Factor 4 Prostate Apex Involvement AJCC does not use prostate apex involwement in the T classification E CODES 41 to 49 are used for extension beyond the prostate Note 3 Prostate Apex Involwement This field and Site Specific Factor 4 Prostate Apex Involwement are both coded whether or not a prostatectomy was performed Note 4 Use codes 13 14 when a TURP is done not for a biopsy only Do not use code 15 when a TURP is done Note 5 Involvement of the prostatic urethra does not alter the extension code Note 6 Frozen pelvis is a clinical term which means tumor extends to pelvic sidewall s In the absence ofa more detailed stateme
93. tame you save Eda errors A there are any wall be shown m this message area All your changes will be saved to the database even there are edit errors Legend Print Free ka i Contest Ssensare help pee chal Lookups alculale Field value These are the WebPlus icons Print Preview open page that shows all of the fields and the content you have entered in your abstract this page allows you to print a copy of your abstract Context sensitive Help open Help page with the NAACCR Standards for Cancer Registries Volume Il Data Standards and Data Dictionary for information about the data item When a specific code is clicked it is automatically filled into the abstract for the data item Drop down boxes open a listing of codes or specific data items to choose from Find the item that best applies and click on the code to populate the field When a specific code is clicked it is automatically filled into the abstract for the data item Calculate Field Value calculate a field value Special Lookups open a listing of codes and terms to choose from Find the term a that best applies and click on the code to the left of the term Page 76 CHAPTER 2 Changing Your Password To change your password complete these steps 1 On the Home page menu click Change Password Result The Change Password page opens Change Password Mew password Retpe Password Change 2 Type your new password in both of
94. te The first time the abstract is saved the Date Case Completed field will be set with the current date Once the report is saved you may enter a new abstract perform other WebPlus functions or exit WebPlus lf there are errors appropriate error messages will appear in the EDIT field box detailing all errors For informa tion about correcting errors see the Edits Section on the following page Errors can then be corrected and the abstract can be saved again You may save the abstract despite errors however only abstracts that are consid ered COMPLETE i e they have passed all edits and have no critical fields missing will be exported If the saved abstract has edit errors or contains missing critical fields the abstract is considered INCOMPLETE by the system For more information on Saving an Abstract see page 83 in the appendix section of this manual Users may update abstracts by clicking on the SAVE button at the bottom of the page to save changes Edits run each time you save and the EDIT result will be shown in the EDIT area Note Abstracts are always saved to the database when the SAVE featured is utilized whether or not there are Edit errors in it Web Plus New Abstract Find Open Abstract Update abstract PHY SICIAN FACILITY SPECIFIC Reporting Facility Phy Joo200000 KA Abstractor set COCO EDIT RESULT Date Case Completed 11172005 PATIENT CONFIDENTIAL Seinen ee Central Vs10 NPCR eq
95. terstitial prostate radiation therapy is radiation therapy applied within the prostate using implanted radioactive pellets or seeds see also brachytherapy LHRH Analogs or agonists Synthetic compounds that are chemically similar to Luteinizing Hormone Releasing Hormone LHRH but are sufficiently different that they suppress testicular production of testosterone by binding to the LHRH receptor in the pituitary gland and either have no biological activity and therefore competitively inhibit the action of LHRH or has LHRH activity that exhausts the production of LH by the pituitary used in the hormonal treatment of advanced prostate cancer and in the adjuvant and neoadjuvant hormonal treatment of earlier stages of prostate cancer LHRH agonist mimics natural LHRH but then shuts down LH production after continuous exposure Lymph Nodes the small glands which occure throughout the body and which filter the clear fluid known as lymph or Ilymphatic fluid lymph node filter out bacteria and other toxins as well as cancer cells Malignancy a growth or tumor composed of cancerous cells Malignant cancerous tending to become progressively worse and to result in death having the invasive and metastatic spreading properties of cancer Metastasis plural metastases a secondary tumor formed as a result of a cancer cell or cells form the primary tumor site e g the prostate traveling through the body to a new site and then growing there
96. th continuing hormonal therapy who have never had radiation therapy or surgery for this diagnosis Patients who are not going to be treated at a hospital with surgery or brachytherapy Patients who are not going to be treated at a freestanding treatment center with external beam radiation Dp Zu a Cases where planned treatment is Hormonal therapy Observation only also known as watchful waiting or No treatment due to other health conditions patient refusal etc 8 Clinical diagnosis METHODS OF CASEFINDING 1 Pathology Reports Flag each chart when prostate cancer is diagnosed Colored paper Colored tab Visible reminder that chart needs to be reviewed to determine case elegibility reportability 2 Office reports Used to rule out cases ICD 9 185 9 CPT procedure codes radical prostatectomy brachytherapy Place of service codes hospital IP hospital OP etc Exception patients referred for external beam radiation 3 Central registry follow back Based on path reports submitted directly to MCR from the path lab As pathology reports are intended as a means of case finding and do not include the details needed to adequately report cancer cases as in race social security number patient address etc MCR is currently developing a method by which to notify physicians when cases have been identified through pathology reports so that complete ness of cancer reporting may be met by both parties Would only
97. the mapping values are taken from the CS Extension Clinical Extension mapping and the c p y or a indicator is taken from the TS Ext Eval mapping If Site Specific Factor 3 Pathologic Staging code is 000 in situ and if CS Extension code Clinical Extension is greater than 00 and less than 95 not in situ the mapping values are taken from the CS Extension Clinical Extension mapping and the c p y or a indicator is taken from the TX Ext Eval mapping If Site Specific Factor 3 is 000 in situ and CS Extension code is 00 in situ or greater than 95 the mapping values are taken from the Site Specific Factor 3 mapping and the T category is identified as a pT Prostate In situ noninvasive intraepithelial E f pa fb WA p ji O A ES A di Clinically inapparent tumor number of foci or percent involved tissue not specified Stage A NOS Incidental histologic finding in 5 or less of tissue resected clinically inapparent E Incidental histologic finding more than 5 of tissue resected clinically inapparent Un Tumor identified by needle biopsy e g for elevated PSA clinically inapparent td Involvement in one lobe NOS clinically apparent only Involves one half of one lobe or less clinically apparent only by hb Involves more than one half of one lobe but not both lobes clinically apparent only Involves both lobes clinically
98. the password fields 3 Click Change Log Out To log off click Log out on the Home page menu Result The Log In page opens Questions Answer the following questions about the basics of WebPlus 1 Which icon do you click to open a separate window to insert a code into a field 2 How do you log out 3 Do have to complete filling out the abstract at one time What can you do to begin an abstract and then return to it later Page 77 CHAPTER 3 Notes Page 78 CHAPTER 3 Chapter 3 Creating an Abstract A a mas gt w ER CHAPTER 3 Learning Objectives In this lesson you learn to e Enter information into the entry fields e Understand the process for completing an abstract e Use these entry tools drop down lists help and lookups Overview In this chapter you create an abstract that you use throughout this book In succeeding chapters you will complete and release this abstract This chapter also introduces you to some basic entry tools to help you enter information in WebPlus Entering Information into Fields In this section you create an abstract by entering essential data into the designated fields You will also learn to use Help drop down lists and special lookups To create an abstract complete these steps 1 Login as described in Log In page 72 2 Onthe home page click New Abstract Result The Data Entry page opens Enter new abstract PAT
99. the resected specimen Meets criteria for AJCC pathologic T staging Surgical resection performed WITH pre surgical systemic treatment or radiation BUT tumor size extension based on clinical evidence Surgical resection performed WITH pre surgical systemic treatment or radiation BUT tumor size extension based on pathologic evidence Evidence from autopsy only tumor was unsuspected or undiagnosed prior to autopsy Unknown 1f surgical resection done Not assessed cannot be assessed Unknown if assessed Not documented in patient record Prostate CS Lymph Nodes Note Code only regional nodes and nodes NOS in this field Distant nodes are coded in the field Mets at DX Description None no regional lymph node involvement Regional nodes including contralateral or bilateral lymph nodes Ihac NOS External Internal hypogastric NOS Obturator Pelvic NOS Periprostatic Sacral NOS Lateral laterosacral Middle promontorial Gerota s node Presacral Regional lymph node s NOS 99 Unknown not stated Regional lymph node s cannot be assessed Version date April 25 2005 520 Version 01 02 00 WEBPLUS USER S MANUAL Page 49 MISSOURI CANCER REGISTRY OS COLLABORATI VE STAGI NG CODI NG I NSTRUCTI ONS Collaborative Staging Manual and Coding Instructions Part Il Primary Site Schema Prostate CS Reg Nodes Eval SEE STANDARD TABLE Prostate Reg LN Pos SEE STANDARD TABLE Prostate Reg LN Exam SEE STANDARD
100. tical Field Text DX Proc X ray scan Missing Critical Field Text DX Proc Lab Tests Missing Critical Field Text DX Proc 65233 Op County bss Missing Critical Field Text DX Proc ag Path Pees ee Missing Critical Field Text Histology Race 1 4 Tithe Missing Critical Field Text Staging nz Jes Ka Missing Critical Field RX Text Race 3 Hormone Race 4 Missing Critical Field RX Text Other Missing Critical Field Text Remarks Race5 Hispanic Date of Birth 4 Web Plus New Abstract Find Open Abstract Release Abstracts Reports Change Password Log out Local Reports Cases Submitted Sorted by Abstractor Cases Accessed Sorted by Patient Name Descriptive Statistics on Released Cases Activity Report Audit Reports System Log ins Abstract Updates Abstract Searches Abstract Deletions Abstract Releases WEBPLUS USER S MANUAL Page 28 MISSOURI CANCER REGISTRY o CHANGI NG PASSWORDS To change passwords simply choose CHANGE PASSWORDS and type in the new password on the New Password page Once new passwords have been typed enter CHANGE to save new data For further information regarding passwords please refer to page 77 located in the back of this manual Note If you forget your password an MCR administrator can re set it for you Web Plus New Abstract Find Open Abstract Release Abstracts Report
101. tive Staging Manual and Coding Instructions Part Il Primary Site Schema Prostate C61 9 C61 9 Prostate gland Note Transitional cell carcinoma of the prostatic urethra is to be coded to primary site C68 0 Urethra and assigned Collaborative Stage codes according to the urethra scheme CS Tumor Size CS Site Specific Factor 1 The following tables are available CS Extension Clinical Extension Prostatic Specific Antigen PSA at the collaborative staging CS TS Ext Eval Lab Value website CS Lymph Nodes CS Site Specific Factor 2 Histology Exclusion Table CS Reg Nodes Eval Prostatic Specific Antigen PSA AJCC Stage Reg LN Pos CS Site Specific Factor 3 CS Reg LN Exam Extension Pathologic Extension CS Mets at DX CS Site Specific Factor 4 CS Mets Eval Prostatic Acid Phosphatase PAP CS Site Specific Factor 5 Gleason s Primary Pattern and Secondary Pattern Value CS Site Specific Factor 6 Gleason s Score Prostate CS Tumor Size SEE STANDARD TABLE Prostate CS Extension Clinical Extension Note 1 This field and Site Specific Factor 3 CS Extension Pathologic Extension must both be coded whether or not a prostatectomy was performed Information from prostatectomy is EXCLUDED from this field and coded only in Site Specific Factor 3 Note 2 A Codes 10 15 1 CODES 10 to 15 are used only for clinically inapparent tumor not palpable or visible by imaging and incidentally found microscopic carcinoma latent occul
102. to freeze a particular organ to extremely low temperatures to kill the tissue including any cancerous tissue when used to treat prostate cancer the cryoprobes are guided by trans rectal ultrasound Cyproterone an antiandrogen DES see diethylstilbestrol DHT see dihydrotestosterone Diethylstilbestrol DES a female hormone commonly used in the 1960s and 1970s for treatment of prostate cancer Dihydrotestosterone DHT 5 alpha dihydrotestosterone the male hormone which is most active in the prostate it is made when an enzyme 5 alpha reductase in the prostate stimulates the transformation of testosterone to DHT Differentiation the use of the differences between prostate cancer cells when seen under the microscope as a method to grade the severity of the disease well differentiated cells are easily recognized as normal cells while poorly differentiated cells are abnormal cancerous and difficult to recognize as belonging to any particular type of cell group Dysplasia see PIN Dysuria urination which is problematic or painful Eulexin the brand or trade name of flutamide in the USA External Radiation Therapy also External Beam Therapy a form of radiation therapy in which radiation is delivered by a machine pointed at the area to be radiated Flutamide an antiandrogen used in the palliative hormonal treatment of advanced prostate cancer and some times in the adjuvant and neoadjuvant hormonal treatment of earli
103. u click Find Open Abstract Result The Find Abstract page opens Find Abstract Enter patients name or social security to search for Search on partial name and social security is supported Name Social Security Find Note To find a specific abstract you can type in a name or a social security number such as 784500000 or even a partial name or number 3 Click Find Page 86 CHAPTER 4 Result A list of all abstracts opens First ama A E MARGARET avants SRA Reltagsd BAGIN HENRY Open D14995 rsonoeere toavnazo ere o Relmased onen CANNON JOHN nansnass reie orten SRB O Released onen SHEPHERD SARAH arzsnass 761005483 Ttmmanazs SRB Released Quen CAQUELIN JEAN Ganges 7504890101 1114959 SRB Released Omen MORGAN BENEDICT 0323995 amoraa O00932 SRB Released Onen The list of abstracts has ten columns This table describes these columns Social Security Patient s social security number Birth Date Patient s date of birth Abstractor Code for the person who created the abstract Edit Errors The number of errors found in the edit process after an abstract has been saved Status WebPlus has three types of statuses e incomplete not all data have been entered e complete all errors have been addressed e released sent to the central registry You have the option to open or delete an abstract 4 Click Open in
104. ue to usability issues Please remember to press Enter before moving to the next data item EE Abstracted By Microsoft Internet Explor REGISTRY PLUS ONLINE HELP 2 ighli 43 i LAPS gt 7 Search PP Highlight I Options XIP gt NAACCR Standards for Cancer Registries Yolume II search web LA E3 m Ce My Wet Se Data Standards and Data Dictionary s Ao cance eras ee ae aera eas istries Volume II Dz Standards and D FF th Edition 03 2002 ABSTRACTED BY Alternate Name Abstractor SE Date Case Completed Description PATIENT CONFIDENTIAL an alph d ig Last Name I ndivi dual abstracting the case First Name Middle Name Coc FOROS entry available Maiden name Alias 3 There are also drop down boxes M that provide choices for your answer By double clicking on the correct response the field will become populated Web Plus Release Abstracts A a 8 3 Edit Errors Help Enter an Abstract and click to the database The abstre Zipcode a tdr gt DK State gt lif there are any will be sho art il be saved to the databa Courts Alaska Tobacco egend History Alabama bs Alcohol History Arkansas ese Print Previews EH Context sensitive help Race 1 Special Lookups British Columbia Calculate Field value Race i California Face Face 4 Race Note Remember to close the help screen as only one help it
105. uire Sash iene MONTEREY ESO farma There are edit errors in the abstract Error Middle Name EE messages along with the error fields are listed NASA EE below Click on a field below any error message to move to it in the data entry area i J Click on Save to save the changes and rerun Edits DUONE Social Security Number Total edit errors 10 35953555333 PATIENT DEMOGRAPHICS eS 1233 ANYWHERE AVE ing Critical Field Text DX Proc g Critical Field Text D gt X Proc X ray scan Mi ing Critical Field Text DX Proc Supplemental Address Mrs IBSSNVILLE Da Mo KA Zipcode 5233 County ing Critical Field Text DxX lt Proc 2 Text DX Proc N ing Critical Field Text Histology Race 1 ing Critical Field Text Staging Race 2 ing Critical Field RX Text Race 3 PO PN POS PR Critical Field RX Text Other mM R 4 ae Missing Critical Field Text Remarks ml Race 5 Hispanic EE Date of Birth 5537139257 En el nvsn ITE gt I WEBPLUS USER S MANUAL Page 23 MISSOURI CANCER REGISTRY Oc EDITS In cases where errors are found information is displayed in the EDIT ERRORS tab A list of fields con taining errors will be displayed below the error message Users can click on an error message to return to the active grid cell of the corresponding field in order to correct data Once data is corrected click on SAVE to save the c
106. umbers assume that they refer to two patterns the first number being the primary and the second number being the secondary and sum them to obtain the score If only one number is given and it is less than or equal to 5 assume that it describes a pattern and uses the number as the primary pattern and code the secondary as 9 If only one number is given and it is greater than 5 assume that it 1s a score If the pathology report specifies a specific number out of a total of 10 the first number given is the score Example The pathology report says Gleason s 3 10 The Gleason s score would be 3 Note 2 Following AJCC guidelines for coding multiple Gleason s Scores for prostate cancer if there is more than one primary and secondary pattern value the value to be coded is the one based on the larger tumor specimen Please note that this rule is not the same as the rule for coding grade Code Description Test not done test was not ordered and was not performed F sssi Primary pattern 1 secondary pattern 1 Primary pattern 1 secondary pattern 2 Primary pattern 1 secondary pattern 3 Primary pattern 1 secondary pattern 4 Primary pattern 1 secondary pattern 5 Primary pattern 1 secondary pattern 9 Primary pattern 2 secondary pattern 1 022 Primary pattern 2 secondary pattern 2 023 Primary pattern 2 secondary pattern 3 024 Primary pattern 2 secondary pattern 4 025 Primary pattern 2 secondary pattern 5 029 Primary pattern 2
107. ure Manual These regulations include the use of locked offices and cabinets for confidential data procedures for handling requests for data and policies for handling breaches of confidentiality WEBPLUS USER S MANUAL Page 7 MISSOURI CANCER REGISTRY O I NTRODUCTI ON continued HIPAA Health Insurance Portability and Accountability Act of 1996 allows for the reporting of identifiable cancer data to public health entities Because the Missouri Cancer Registry falls under the definition of a public health authority HIPAA allows your facility to report cancer incidence data in compliance with state statutes 192 650 192 657RSMo and regulations 19 CSR 70 21 Written informed consent from each cancer patient reported to public health entities is not required under HIPAA nor is a Business Associate Agreement required rather reporting facilities must simply document that reporting has occurred WEBPLUS USER S MANUAL Page 8 MISSOURI CANCER REGISTRY h BASIC RULES INFORMATION The following information provides some basic rules information regarding cancer reporting to the state central cancer registry e Physicians offices are required by Missouri statute 192 650 192 657 RSMo 1999 to submit requested Information on patients not diagnosed or treated for the cancer at another healthcare facility i e hospital freestanding cancer treatment center freestanding ambulatory surgery center etc The inclusion
108. volvement AJCC does not use prostate apex involvement in the T classification Note 6 When prostate cancer is an incidental finding during a prostatectomy for other reasons for example a cystoprostatectomy for bladder cancer use the appropriate code for the extent of disease found for example one Version date April 25 2005 522 Version 01 02 00 WEBPLUS USER S MANUAL Page 51 MISSOURI CANCER REGISTRY OS COLLABORATI VE STAGI NG CODI NG I NSTRUCTI ONS Collaborative Staging Manual and Coding Instructions Part Il Primary Site Schema Note 7 Frozen pelvis is a clinical term which means tumor extends to pelvic sidewalls In the absence of a more detailed statement of involvement assign this to code 060 Note 8 AUA stage Some of the American Urological Association AULA stages A D are provided as guidelines for coding in the absence of more specific information in the medical record If physician assigned AUA stage D1 D2 is based on involvement of lymph nodes only code under CS Lymph Nodes or CS Mets at DX not CS Extension Pathologic Extension Note 9 For the extension fields for this site the mapping values for TNM 5577 and SS2000 and the associated c p y or a indicator are assigned based on the values in CS Extension CS TS Ext Eval and Site Specific Factor 3 If the value of Site Specific Factor 3 is greater than 000 and less than 095 i e prostatectomy was done extension information is available for stagin
109. ystem 06 FORDS Manual codes Current RxSumScopeRegLN Scope of Regional Lymph 9 Unknown or not applicable Node Surger RxSumSurgOthReg Surgery of Other Regional 9 Unknown Site s Distant Site s or Distant Lymph Nodes SEER COC Site and Morphology con Override Site Type 1 flict OvrdSiteType Page 101 CHAPTER 5 2 Save your work until the Edit Result shows no errors Edit Errors Text Fields Editset Name Central Ys1D HPCR Required This abstract passed all edits and can be released to your central cancer registry Do you want to release it Yes No 3 Do not release the abstract now Click No and go to the next section Releasing the Abstract Note You can release your abstract here by clicking Yes but you can also release one or more abstracts on the Release Abstract page For further details see the next section Releasing the Abstract Releasing the Abstract Once your abstract has no errors it is completed and you can release it to the central registry Follow these steps to release an abstract 1 Onthe WebPlus menu click Release Abstract Result The system displays a list of completed abstracts Release Abstracts Please selectthe abstracts you want to release to your central registry Only completed abstracts are available for release 2 Click the Release box of the abstracts you want to release Note To select all of the abstracts listed click the Select A

Integrated Manual - Missouri Cancer Registry and Research Center

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