Home

2005 Replacement Pages - California Cancer Registry

1. HORMONE THERAPY WAS NOT ADMINISTERED IT WAS RECOMMENDED BY THE PATIENT S PHYSICIAN BUT WAS NOT ADMINISTERED AS PART OF THE FIRST COURSE THERAPY NO REASON WAS STATED IN PATIENT RECORD HORMONE THERAPY WAS NOT ADMINISTERED IT WAS RECOMMENDED BY THE PATIENT S PHYSICIAN BUT THIS TREATMENT WAS REFUSED BY THE PATIENT A PATIENT S FAMILY MEMBER OR THE PATIENT S GUARDIAN THE REFUSAL WAS NOTED IN THE PATIENT RECORD HORMONE THERAPY WAS RECOMMENDED BUT IT IS UNKNOWN IF IT WAS ADMINISTERED IT IS UNKNOWN WHETHER A HORMONAL AGENT S WAS RECOMMENDED OR ADMINISTERED BECAUSE IT IS NOT STATED IN PATIENT RECORD DEATH CERTIFICATE ONLY March 2005 VL5 5 Date Of Hormone Therapy 00000000 88888888 99999999 VI 6 Immunotherapy 00 Biological Response Modifier 01 82 85 86 87 88 99 March 2005 NO HORMONE THERAPY ADMINISTERED AUTOPSY ONLY WHEN HORMONE THERAPY IS PLANNED AS PART OF THE FIRST COURSE OF TREATMENT BUT HAD NOT BEEN STARTED AT THE TIME OF THE MOST RECENT FOLLOW UP THE DATE SHOULD BE REVISED AT THE NEXT FOLLOW UP THE DATE IS UNKNOWN OR THE CASE WAS IDENTIFIED BY DEATH CERTIFICATE ONLY NONE IMMUNOTHERAPY WAS NOT PART OF PART OF THE PLANNED FIRST COURSE OF THERAPY DIAGNOSED AT AUTOPSY IMMUNOTHERAPY ADMINISTERED AS FIRST COURSE THERAPY IMMUNOTHERAPY WAS NOT RECOMMENDED ADMINISTERED BECAUSE IT WAS CONTRAINDICATED DUE TO PATIENT RISK FACTORS i e COMORBID CONDITIONS ADVANCED AGE IMM
2. The sequencing of non malignant tumors does not effect the sequencing of malignant tumors and vice versa A malignancy sequence 00 will remain 00 if followed by a non malignant tumor sequence 60 87 March 2005 Page 32A Example First tumor benign meningioma sequence 60 Second tumor astrocytoma sequence 00 11 1 9 5 Malignant Transformation If a benign or borderline tumor transforms into a malignancy abstract the malignancy as a new primary If there is a change in WHO grade from a WHO I to a higher WHO grade abstract as a new primary malignancy If a malignant CNS tumor transforms into a higher grade tumor do not change histology or grade and do not abstract as a new primary This determination is made by the pathologist based on review of slides Example Non malignant WHO grade I to malignant WHO grade III Complete two abstracts one for the non malignant tumor and one for the malignant tumor Situation Create new abstract Benign 0 to borderline 1 No Benign 0 to malignant 3 Yes Borderline 1 to malignant 3 Yes Malignant 3 to malignant 3 No WHO Grade I to Grade II III or IV Yes WHO Grade II to III or IV No WHO Grade Ill to IV No Abstract as one primary using original histology and note progression in remarks 11 1 9 6 Tumor Grade Always assign code 9 for non malignant tumors Do not code WHO grade in the 6 digit histology data field 1 9 7 WHO Grade Code the WHO grade cla
3. for example code the appropriate radiation modality item to the highest level of complexity i e the IMRT NOTE For cases diagnosed prior to January 1 2003 the codes reported in this data item describe any radiation administered to the patient as part or all of the first course of therapy Codes 80 and 85 describe specific converted descriptions of radiation therapy coded according to Vol II ROADS and DAM rules and should not be used to record regional radiation for cases diagnosed on or later than January 1 2003 VL3 4 RADIATION BOOST RX MODALITY Record the dominant modality of radiation therapy used to deliver the most clinically significant boost dose to the primary volume of interest during the first course of treatment This is accomplished with external beam fields of reduced size relative to the regional treatment fields implants stereotactic radiosurgery conformal therapy or IMRT External beam boosts may consist of two or more successive phases with progressively smaller fields generally coded as a single entity The CCR requires the collection of this field As noted above this data item and Radiation Regional RX Modality will be converted to generate the RX Summ Radiation There is no corresponding At this Hospital field The codes are as follows 00 NO BOOST TREATMENT DIAGNOSED AT AUTOPSY 20 EXTERNAL BEAM NOS 21 ORTHOVOLTAGE 22 COBALT 60 CESIUM 137 23 PHOTONS 2 5 MV 24 PHOTONS 6 10 MV 25 PHOT
4. TIME OF THE MOST RECENT FOLLOW UP FOR CoC APPROVED FACILITIES THE DATE SHOULD BE REVISED AT THE NEXT FOLLOW UP NOTE THE CCR REQUIRES THE USE OF 8 s IN THIS FIELD FOR CASES UNDERGOING IMMUNOTHERAPY LATER THAN SIX MONTHS FROM THE DATE OF ADMISSION See the Timeliness Section IX 2 3 99999999 THE DATE IS UNKNOWN OR THE CASE WAS IDENTIFIED BY DEATH CERTIFICATE ONLY Page 148 March 2005 Section VI 7 First Course of Treatment Transplant Endocrine Procedures Record systemic therapeutic procedures administered as part of first course of treatment These include bone marrow transplants stem cell harvests surgical and or radiation endocrine therapy Information on transplants and endocrine procedures was removed from the Rx Summ BRM Immunotherapy field and moved to this field Bone marrow and stem cell procedures are now coded in this field along with endocrine surgery or radiation A conversion will be required for cases diagnosed prior to January 1 2003 using both the Rx Summ BRM Immunotherapy and Rx Summ Hormone fields Although the CoC did not add a corresponding At this Hospital field the CCR will be requiring this field in order to provide consistency 1 all of the other treatment fields except radiation have a hospital level field There is no text field for bone marrow transplant and endocrine procedures Record text information regarding bone marrow transplants and endocrine procedures in the immunotherapy tex
5. and will be reported in the six month accuracy rates Page 176 March 2005 Quality Control In July 2004 Collaborative Staging fields will be added to the list of data items visually edited by the regional registries Discrepancies will be counted in a facility s accuracy rate beginning July 1 2005 Another method of assessing accuracy is to reabstract cases in the hospitals A sample of cases from each facility is reabstracted by specially trained personnel The measure used is the number of discrepancies found in related categories of items IX 2 3 TIMELINESS Timeliness involves how quickly the reporting hospital submits a case to a regional registry after admission of the patient Regional registries monitor the timeliness of data submitted by hospitals The standard set by CCR is that 97 percent of cases must be received by the regional registry within six months of admission and 100 percent must be received within 12 months of admission Although every effort should be made to complete cases before they are transmitted to the regional registry it is recognized that some cancer cases undergo treatment later than six months from the date of admission If these or other cases are going to exceed the six month due date they must be transmitted without treatment data and this must be documented on the abstract This treatment information must be submitted later in a correction record These correction records should not be sent in any la
6. BUT THIS TREATMENT WAS REFUSED BY THE PATIENT A PATIENT S FAMILY MEMBER OR THE PATIENT S GUARDIAN THE REFUSAL WAS NOTED IN THE PATIENT RECORD HORMONE THERAPY WAS RECOMMENDED BUT IT IS UNKNOWN IF IT WAS ADMINISTERED IT IS UNKNOWN WHETHER A HORMONAL AGENT S WAS RECOMMENDED OR ADMINISTERED BECAUSE IT IS NOT STATED IN PATIENT RECORD DEATH CERTIFICATE ONLY March 2005 Page 145 First Course of Treatment Hormone Therapy VL5 5 DATE OF HORMONE THERAPY Record the date on which hormone therapy began at any facility as part of first course of treatment If hormone therapy was not administered leave the date field blank If hormone therapy is planned but had not started at the time the case is transmitted to the regional registry enter 8 s If hormone therapy is known to have been given but the date is not known enter 9 s 00000000 NO HORMONE THERAPY ADMINISTERED AUTOPSY ONLY CASE 88888888 WHEN HORMONE THERAPY IS PLANNED AS PART OF THE FIRST COURSE OF TREATMENT BUT HAD NOT BEEN STARTED AT THE TIME OF THE MOST RECENT FOLLOW UP FOR CoC APPROVED FACILITIES THE DATE SHOULD BE REVISED AT THE NEXT FOLLOW UP NOTE THE CCR REQUIRES THE USE OF 8 s IN THIS FIELD FOR CASES UNDERGOING HORMONE THERAPY LATER THAN SIX MONTHS FROM THE DATE OF ADMISSION See the Timeliness Section IX 2 3 99999999 THE DATE IS UNKNOWN OR THE CASE WAS IDENTIFIED BY DEATH CERTIFICATE ONLY Page 146 March 2005 Section VI 6 First Course of Treatment Im
7. ENDORCRINE SURGERY RADIATION WERE NOT ADMINISTERED IT WAS RECOMMENDED BY THE PATIENT S PHYSICIAN BUT THIS TREATMENT WAS REFUSED BY THE PATIENT A PATIENT S FAMILY MEMBER OR THE PATIENT S GUARDIAN THE REFUSAL WAS NOTED IN PATIENT RECORD HEMATOLOGIC TRANSPLANT AND OR ENDOCRINE SURGERY RADIATION WAS RECOMMENDED BUT IT IS UNKNOWN IF IT WAS ADMINISTERED IT IS UNKNOWN WHETHER HEMATOLOGIC TRANSPLANT AND OR ENDOCRINE SURGERY RADIATION WAS RECOMMENDED OR ADMINISTERED BECAUSE IT IS NOT STATED IN PATIENT RECORD DEATH CERTIFICATE ONLY V1 7 2 DATE OF TRANSPLANT ENDOCRINE PROCEDURE Record the date on which transplant endocrine therapy began at any facility as part of first course of treatment If transplant endocrine therapy was not administered leave the date field blank Jf transplant endocrine therapy is planned but had not started at the time the case is initially transmitted to the regional registry enter 8 s If transplant endocrine therapy is known to have been given but the date is not known enter 9 s 00000000 NO TRANSPLANT ENDOCRINE THERAPY ADMINISTERED AUTOPSY ONLY CASE 88888888 WHEN TRANPLANT ENDOCRINE THERAPY IS PLANNED AS PART OF Page 150 THE FIRST COURSE OF TREATMENT BUT HAD NOT BEEN STARTED AT THE TIME OF THE MOST RECENT FOLLOW UP FOR CoC APPROVED FACILITIES THE DATE SHOULD BE REVISED AT THE NEXT FOLLOW UP March 2005 NOTE 99999999 March 2005 First Course of Treatment Transplant Endocrine Proce
8. INCLUDING BANGLADESHI BHUTANESE NEPALESE SIKKIMESE SRI LANKAN CEYLONESE OTHER ASIAN INCLUDING BURMESE INDONESIAN ASIAN NOS AND ORIENTAL NOS PACIFIC ISLANDER NOS OTHER UNKNOWN H 3 III 2 9 1 Race 2 5 01 02 03 04 05 06 07 08 09 10 11 12 13 14 20 21 22 25 26 27 28 30 31 32 88 90 96 97 98 99 WHITE BLACK AMERICAN INDIAN ALEUTIAN OR ESKIMO CHINESE JAPANESE FILIPINO HAWAIIAN KOREAN ASIAN INDIAN PAKISTANI VIETNAMESE LAOTIAN HMONG KAMPUCHEAN CAMBODIAN THAI MICRONESIAN NOS CHAMORRO GUAMANIAN NOS POLYNESIAN NOS TAHITIAN SAMOAN TONGAN MELANESIAN NOS FIJI ISLANDER NEW GUINEAN NO FURTHER RACE DOCUMENTED OTHER SOUTH ASIAN INCLUDING BANGLADESHI BHUTANESE NEPALESE SIKKIMESE SRI LANKAN CEYLONESE OTHER ASIAN INCLUDING BURMESE INDONESIAN ASIAN NOS AND ORIENTAL NOS PACIFIC ISLANDER NOS OTHER UNKNOWN Note these races were previously coded 09 Asian Indian Per the 2004 SEER Race Code Guideline these cases are coded as 96 Other Asian For consistency in these codes over time the CCR created a new code code 90 for Other South Asian These cases will be converted from 90 to 96 for calls for data 1 2 9 2 Spanish Hispanic Origin CA H 4 NON SPANISH NON HISPANIC MEXICAN including CHICANO NOS PUERTO RICAN CUBAN SOUTH OR CENTRAL AMERICAN except BRAZILIAN OTHER SPECIFIED SPANISH ORIGIN includes EUROPEAN exclu
9. THE PATIENT S PHYSICIAN BUT WAS NOT ADMINISTERED AS PART OF THE FIRST COURSE OF THERAPY NO REASON WAS STATED IN PATIENT RECORD CHEMOTHERAPY WAS NOT ADMINISTERED IT WAS RECOMMENDED BY THE PATIENT S PHYSICIAN BUT THIS TREATMENT WAS REFUSED BY THE PATIENT A PATIENT S FAMILY MEMBER OR THE PATIENT S GUARDIAN THE REFUSAL WAS NOTED IN PATIENT RECORD CHEMOTHERAPY WAS RECOMMENDED BUT IT IS UNKNOWN IF IT WAS ADMINISTERED H 19 VL4 3 Date of Chemotherapy V1 5 4 H 20 Hormone Therapy 00 01 82 85 86 87 99 99 ITIS UNKNOWN WHETHER A CHEMOTHERAPEUTIC AGENT S WAS RECOMMENDED OR ADMINISTERED BECAUSE IT IS NOT STATED IN PATIENT RECORD DEATH CERTIFICATE ONLY 00000000 NO CHEMOTHERAPY ADMINISTERED AUTOPSY ONLY CASE 88888888 WHEN CHEMOTHERAPY IS PLANNED AS PART OF THE FIRST COURSE OF TREATMENT BUT HAD NOT BEEN STARTED AT THE TIME OF THE MOST RECENT FOLLOW UP THE DATE SHOULD BE REVISED AT THE NEXT FOLLOW UP 99999999 THE DATE IS UNKNOWN OR THE CASE WAS IDENTIFIED BY DEATH CERTIFICATE ONLY NONE HORMONE THERAPY WAS NOT PART OF THE PLANNED FIRST COURSE THERAPY DIAGNOSED AT AUTOPSY HORMONE THERAPY ADMINISTERED AS FIRST COURSE THERAPY HORMONE THERAPY WAS NOT RECOMMENDED ADMINISTERED BECAUSE IT WAS CONTRAINDICATED DUE TO PATIENT RISK FACTORS IE COMORBID CONDITIONS ADVANCED AGE HORMONE THERAPY WAS NOT ADMINISTERED BECAUSE THE PATIENT DIED PRIOR TO PLANNED OR RECOMMENDED THERAPY
10. ZZ not applicable If the residence was in the U S or Canada but the state or province is unknown or the place of residence is unknown enter ZZ For residents of countries other than the U S and Canada and the country is known enter XX For residents of countries other than the U S and Canada and the country is unknown enter Enter the five digit or nine digit U S postal zip code or the proper postal code for any other country When entering only five digits leave the last spaces blank If the patient resided outside the U S or Canada at time of diagnosis and the zip code is unknown enter 8 s in the entire field To obtain an unknown zip code consult the U S Postal Service National Zip Code and Post Office Directory published by the U S Postal Service or phone the local post office If the code cannot be determined and it is a U S or Canadian resident enter 9 s in the entire field For California residents enter the code for the county of residence at the time of diagnosis Appendix L contains a list of the codes used CNExT automatically supplies the code if the county s name is entered Consult maps or reference works as needed to determine the correct county Enter code 000 if the county of residence is not known or if it is a state and is other than California and its name is known Enter code 220 for Canada NOS or the specific code for the known Canadian province Canadian province codes are listed in
11. a lymph node dissection i e modified radical mastectomy or if the operative report documents removal of the nodes CNEXT will fill the fields with 00 The Summary field will be computed automatically by CNEXT It will contain the number of nodes associated with the highest coded regional lymph node surgery If no nodes were identified in the specimen from this procedure then the Summary field will contain 00 NOTE This field is not cumulative It does not replace or duplicate the Regional Lymph Nodes Examined field used in Extent of Disease coding Effective with cases diagnosed on or after January 1 2003 the fields for Rx Summ Reg LN Examined and Rx Hosp Reg LN Examined are no longer required by the CCR and the CoC Information regarding the number of lymph nodes has been incorporated into the scope fields However the summary field for cases diagnosed prior to January 1 2003 must continue to be coded For Unknown Primary Hematopoietic Reticuloendothelial Immunoproliferative Myeloprolifera tive Disease Primaries Lymphoma Brain and Primaries of Ill Defined Sites use code 99 July 2004 Page 127 VL2 4 SURGERY OF OTHER REGIONAL SITE S DISTANT SITE S OR DISTANT LYMPH NODES There are three one character fields to be used to record removal of tissue other than the primary tumor or organ of origin This would not be an en bloc resection See example 1 Code the removal of non primary site tissue which the surgeon may have suspected t
12. cava adrenal gland s Gerota s fascia perinephric fat or partial total ureter Q 2 38 July 2003 70 74 80 99 Surgery Codes BLADDER C67 0 C67 9 Except for M 9750 9760 9764 9800 9820 9826 9831 9920 9931 9964 9980 9989 Pelvic exenteration NOS 71 Radical cystectomy female only anterior exenteration A radical cystectomy in a female includes removal of bladder uterus ovaries entire vaginal wall and entire urethra 72 Posterior exenteration 73 Total exenteration Includes removal of all pelvic contents and pelvic lymph nodes The lymph node dissection should also be coded under Scope of Lymph Node Surgery NAACCR Item 1292 or Scope of Regional Lymph Node Surgery at This Hospital NAACCR Item 672 Extended exenteration Includes pelvic blood vessels or bony pelvis Cystectomy NOS Surgery NOS Unknown if surgery performed death certificate ONLY March 2005 Q 2 41 Surgery Codes BRAIN Meninges C70 0 C70 9 Brain C71 0 C71 9 Spinal Cord Cranial Nerves and Other Parts of Central Nervous System C72 0 C72 9 Except for M 9750 9760 9764 9800 9820 9826 9831 9920 9931 9964 9980 9989 Do not code laminectomies for spinal cord primaries Codes 00 None no surgery of primary site autopsy ONLY 10 Local Tumor destruction NOS No specimen sent to pathology from surgical event 10 Do not record stereotactic radiosurgery as tumor destruction It should be recorded in the radiation tre
13. certificate only cases July 2004 Page 107 Tumor Markers For breast cancer cases diagnosed before January 1 1990 for prostate and testicular cancers before January 1 1998 and for other sites not mentioned above enter 9 NOT APPLICABLE Use codes 0 1 2 3 8 and 9 for breast and prostate Use codes 0 2 4 5 6 8 and 9 for testicular cancer Record the lowest nadir value of AFP after orchiectomy if serial serum tumor makers are done during the first course of treatment Do not record the results of tumor marker studies that are not performed on the primary tumor Breast tumors too small to evaluate with the conventional estrogen receptor assays might be measured by immunostaining which is a procedure for identifying antigens in body fluids in aspirations of tumor masses or in biopsy specimens The procedure is based on an antigen antibody reaction If immunostaining results are available use them to code Estrogen Receptor Status For cases diagnosed January 1 2004 forward Tumor Markers 1 3 will be collected in the Collaborative Staging Site Specific Factor fields The California tumor marker Tumor Marker California 1 Her2 neu is still a required data item for the CCR and will continue to be collected in its designated field V 6 2 TUMOR MARKER 2 Use the following codes for PRA for breast cancer cases diagnosed on or after January 1 1990 and for PSA for prostate cancer cases and hCG for testicular cancer cases
14. event 17 25 Total removal of tumor or single ovary NOS 26 Resection of ovary wedge subtotal or partial ONLY NOS unknown if hysterectomy done 27 WITHOUT hysterectomy 28 WITH hysterectomy Specimen sent to pathology from surgical events 25 28 35 Unilateral salpingo oophorectomy unknown if hysterectomy done formerly SEER code 50 55 60 70 14 36 WITHOUT hysterectomy formerly SEER code 15 37 WITH hysterectomy formerly SEER code 16 Bilateral salpingo oophorectomy unknown if hysterectomy done formerly SEER code 20 51 WITHOUT hysterectomy formerly SEER code 21 52 WITH hysterectomy formerly SEER code 22 Unilateral or bilateral salpingo oophorectomy WITH OMENTECTOMY NOS partial or total unknown if hysterectomy done formerly SEER code 30 56 WITHOUT hysterectomy formerly SEER code 31 57 WITH hysterectomy formerly SEER code 32 Debulking cytoreductive surgery NOS 61 WITH colon including appendix and or small intestine resection not incidental 62 WITH partial resection of urinary tract not incidental 63 Combination of 61 and 62 Debulking is a partial or total removal of the tumor mass and can involve the removal of multiple organ sites It may include removal of ovaries and or the uterus a hysterectomy The pathology report may or may not identify ovarian tissue A debulking is usually followed by another treatment modality such as chemotherapy Pelvic exenteration NOS 71 Ante
15. identify a consultation only case especially at a large teaching hospital As a guideline the CCR recommends determination of who is ultimately responsible for treatment decisions and follow up of the patient If the reporting hospital is responsible an abstract should be submitted If the reporting hospital is confirming a diagnosis made elsewhere rendering a second opinion or recommending treatment to be delivered and managed elsewhere an abstract is not required although the regional registry should be notified of the case When in doubt about whether or not to submit a report either consult the regional registry or report the case 11 1 8 NEWLY REPORTABLE HEMATOPOIETIC DISEASES NRHD Newly Reportable Hematopoietic Diseases NRHD are defined as any of the myeloproliferative or myelodysplastic diseases that changed behavior from 1 borderline to 3 malignant in ICD O 3 Abstract and report only NRHD cases diagnosed 1 1 2001 forward If disease is known prior to 2001 do not report the case NRHD cases diagnosed prior to 1 1 2001 undergoing active treatment at your facility are not reportable cases NRHD include the following CHRONIC MYELOPROLIFERATIVE DISEASES Polycythemia vera 9950 3 Chronic myeloproliferative disease 9960 3 Myelosclerosis with myeloid metaplasia 9961 3 Essential thrombocythemia 9962 3 Chronic neutrophilic leukemia 9963 3 Hypereosinophilic syndrome 9964 3 MYELODYSPLASTIC SYNDROMES Refractory anemia 9980 3 Refract
16. not mentioned radical orchiectomy 80 Orchiectomy NOS unspecified whether partial or total testicle removed 90 Surgery NOS 99 Unknown if surgery performed death certificate ONLY March 2005 Q 2 37 Surgery Codes KIDNEY RENAL PELVIS AND URETER Kidney C64 9 Renal Pelvis C65 9 Ureter C66 9 Except for M 9750 9760 9764 9800 9820 9826 9831 9920 9931 9964 9980 9989 Codes 00 10 20 30 40 50 None no surgery of primary site autopsy ONLY Local tumor destruction NOS 11 Photodynamic therapy PDT 12 Hlectrocautery fulguration includes use of hot forceps for tumor destruction 13 Cryosurgery 14 Laser 15 Thermal ablation No specimen sent to pathology from this surgical event 10 15 Local tumor excision NOS 26 Polypectomy 27 Excisional biopsy Any combination of 20 or 26 27 WITH SEER Guideline the following codes INCLUDE local tumor excision polypectomy or excisional biopsy 21 Photodynamic therapy PDT 22 Electrocautery 23 Cryosurgery 24 Laser ablation 25 Laser excision Specimen sent to pathology from surgical events 20 27 Partial or subtotal nephrectomy kidney or renal pelvis or partial ureterectomy ureter Procedures coded 30 include but are not limited to Segmental resection Wedge resection Complete total simple nephrectomy for kidney parenchyma Nephroureterectomy Includes bladder cuff for renal pelvis or ureter Radical nephrectomy May include removal of a portion of vena
17. were converted The new codes and definitions are to be used for all cases Page 46 July 2003 Following are some of the ethnic groups included in the White category Afghan Czechoslovakian Lebanese Spanish Albanian Dominican Mexican Syrian Algerian Egyptian Moroccan Tunisian Arabian Greek Palestinian Turkish Armenian Gypsy Polish Yugoslavian Australian Hungarian Portuguese Austrian Iranian Puerto Rican Bulgarian Iraqi Rumanian Caucasian Israeli Russian Central American Italian Saudi Arabian Cuban Jordanian Slavic Cypriot Latino South American Unless specified as Indian code 03 Unless specified as Black code 02 July 2004 Page 50C 111 2 9 2 Spanish Hispanic Origin The Spanish Hispanic Origin field is for identifying patients of Spanish or Hispanic origin or descent The field corresponds to a question asked in the U S census of population Included are people whose native tongue is Spanish who are nationals of a Spanish speaking Latin American country or Spain and or who identify with Spanish or Hispanic culture such as Chicanos living in the American Southwest Coding is independent of the Race field since persons of Hispanic origin might be described as white black or some other race in the medical record Spanish origin is not the same as birth in a Spanish language country Birthplace might provide guidance in determining the correct code but do not rely on it exclusively Information about bir
18. 1 3 Parietal lobe C71 4 Occipital lobe C72 2 Olfactory nerve C72 3 Optic nerve C72 4 Acoustic nerve C72 5 Cranial nerve Laterality is used to determine if multiple non malignant CNS tumors are counted as multiple primary tumors e Ifsame site and same histology and laterality is same side one side unknown or not applicable then single primary e Ifsame site and same histology and laterality is both sides then separate primaries Counting Non Malignant Primaries Same Histology Tumor Timing Same Site Different Site 1 2 months Same Other Unkn Same Other Unkn side side side side side side B B NA 1 2 1 2 2 2 B M lt 2 2 2 2 2 2 2 B M 2 2 2 2 2 2 2 Different Histology Tumor Timing Same Site Different Site 1 jnd months Same Other Unkn Same Other Unkn side side side side side side B B NA 2 2 2 2 2 2 B M lt 2 2 2 2 2 2 2 B M 2 2 2 2 2 2 2 B Benign borderline tumor M Malignant tumor Page 32 July 2004 Counting Malignant Primaries Same Histology unless stated to be metastatic or recurrent Tumor Timing Same Site Different Site 1 one months Same Other Unkn Same Other Unkn side side side side side side M M lt 2 1 1 1 25 2 2 M M 2 2 De 2 2 2 2 M B NA 2 2 2 2 2 2 Different Histology unless one histology is a specific subtype of the other
19. Appendix C If residence was in a foreign country enter the country and CNExT will supply the code Country codes are listed in Appendix D If the state or country is not known enter code 999 NOTE To maintain consistency in the CCR database codes must be entered as described above for state and county country Page 45 III 2 6 Studies cancer carried MARITAL STATUS have shown a correlation between marital status and the incidence and sites of and that these patterns are different among races So that further analyses can be out to identify high risk groups report the patient s marital status at the time of first diagnosis Use the following codes vu Q 11 2 7 SINGLE never married including only marriage annulled MARRIED including common law SEPARATED DIVORCED WIDOWED UNKNOWN SEX Enter one of the following codes for the patient s sex O 111 2 8 MALE FEMALE HERMAPHRODITE persons with sex chromosome abnormalities TRANSSEXUAL persons who have undergone sex change surgery UNKNOWN RELIGION Enter the code for the patient s religion or creed see Appendix G for codes or enter the name of the religion and CNExT automatically provides the code CNEXT currently defaults this field to 99 Use code 99 if the religion is not stated NOTE Effective with cases diagnosed January 1 1998 new codes and definitions were added for religion Religion codes prior to 1998
20. As noted above this data item and Radiation Boost RX Modality will be converted to generate the RX Summ Radiation There is no corresponding At this Hospital field The codes for Radiation Regional RX Modality are as follows 00 NO RADIATION TREATMENT DIAGNOSED AT AUTOPSY 20 EXTERNAL BEAM NOS 21 ORTHOVOLTAGE 22 COBALT 60 CESIUM 137 23 PHOTONS 2 5 MV 24 PHOTONS 6 10 MV 25 PHOTONS 11 19 MV 26 PHOTONS 219 MV 27 PHOTONS MIXED ENERGIES 28 ELECTRONS 29 PHOTONS AND ELECTRONS MIXED 30 NEUTRONS WITH OR WITHOUT PHOTONS ELECTRONS 31 IMRT 32 CONFORMAL OR 3 D THERAPY 40 PROTONS 41 STEREOTACTIC RADIOSURGERY NOS 42 LINAC RADIOSURGERY NOS 43 GAMMA KNIFE 50 BRACHYTHERAPY NOS March 2005 Page 137 51 BRACHYTHERAPY INTRACAVITARY LDR 52 BRACHYTHERAPY INTRACAVITARY HDR 53 BRACHYTHERAPY INTERSTITIAL LDR 54 BRACHYTHERAPY INTERSTITIAL HDR 55 RADIUM 60 RADIOISOTOPES NOS 61 STRONTIUM 89 62 STRONTIUM 90 80 COMBINATION MODALITY SPECIFIED 85 COMBINATION MODALITY NOS 98 OTHER NOS 99 UNKNOWN DEATH CERTIFICATE ONLY Clarification Intracavitary use of Cobalt 60 or Cesium 137 should be coded as 50 or 51 See FORDS Manual for code definitions There is no hierarchy for this data item If multiple radiation therapy modalities are used to treat the patient code the dominant modality In the rare occasion where 2 modalities are combined in a single volume IMRT photons with an electron patch
21. BEEN STARTED AT THE TIME OF THE MOST RECENT FOLLOW UP FOR CoC APPROVED FACILITIES THE DATE SHOULD BE REVISED AT THE NEXT FOLLOW UP NOTE THE CCR REQUIRES THE USE OF 8 S IN THIS FIELD FOR CASES UNDERGOING RADIATION THERAPY LATER THAN SIX MONTHS FROM THE DATE OF ADMISSION See Timeliness Section IX 2 3 99999999 THE DATE IS UNKNOWN OR THE CASE WAS IDENTIFIED BY DEATH CERTIFICATE ONLY March 2005 Page 139 VL3 6 REASON FOR NO RADIATION The following codes are to be used to record the reason the patient did not undergo radiation treatment 0 1 RADIATION TREATMENT PERFORMED RADIATION TREATMENT NOT PERFORMED BECAUSE IT WAS NOT A PART OF THE PLANNED FIRST COURSE TREATMENT RADIATION CONTRAINDICATED BECAUSE OF OTHER CONDITIONS OR OTHER PATIENT RISK FACTORS CO MORBID CONDITIONS ADVANCED AGE ETC RADIATION TREATMENT NOT PERFORMED BECAUSE THE PATIENT DIED PRIOR TO PLANNED OR RECOMMENDED TREATMENT RADIATION TREATMENT WAS RECOMMENDED BUT NOT PERFORMED NO REASON WAS NOTED IN THE PATIENT S RECORD RADIATION TREATMENT WAS RECOMMENDED BUT REFUSED BY THE PATIENT FAMILY MEMBER OR GUARDIAN THE REFUSAL IS NOTED IN THE PATIENT S RECORD RADIATION RECOMMENDED UNKNOWN IF DONE UNKNOWN IF RADIATION RECOMMENDED OR PERFORMED DEATH CERTIFICATE AND AUTOPSY ONLY CASES NOTE Include radiation to the brain and central nervous system when coding this field NOTE Beginning with cases diagnosed 1 1 2003 a new code Code 5 radiati
22. BRADOR NORTHWEST TERRITORIES NS NU ON PE QC SK YT XX Page Revised 4 25 2005 March 2005 NOVA SCOTIA NUNAVUT ONTARIO PRINCE EDWARD ISLAND QUEBEC SASKATCHEWAN YUKON TERRITORIES CANADA NOS APPENDIX H SUMMARY OF CODES The codes used for reporting cancer data to the CCR are summarized below For explanations of the codes and status of data item reportability to the CCR refer to the sections indicated Only coded items not text fields are listed here SECTION ITEM CODE REGISTRY INFORMATION 1 1 Abstractor Three initials of abstractor flush left no spaces between initials XXX unknown 11 2 3 Accession Number Nine digit number assigned to patient by hospital tumor registry 11 2 4 Sequence Number 00 ONE PRIMARY MALIGNANCY 01 FIRST OF TWO OR MORE PRIMARIES 02 SECOND OF TWO OR MORE PRIMARIES 10 TENTH OF TEN OR MORE PRIMARIES 11 ELEVENTH OF ELEVEN OR MORE PRIMARIES 99 SEQUENCE UNKNOWN 11 2 1 Year First Seen Four digit number assigned by the hospital tumor registry to each registered case IIL1 4 Reporting Hospital Six digit number assigned by CCR see Appendix F blank if none assigned III 1 6 ACoS Approved 1 CANCER PROGRAM APPROVED Flag 2 CANCER PROGRAM NOT APPROVED Blank CASES DIAGNOSED BEFORE 1999 PATIENT IDENTIFICATION 11 2 1 Patient s Name Uppercase alpha except single hyphen allowed within last name maximum of 25 characters for last name 14 letters for first name and 14 letters for
23. CANCER REPORTING IN CALIFORNIA ABSTRACTING AND CODING PROCEDURES FOR HOSPITALS CALIFORNIA CANCER REPORTING SYSTEM STANDARDS VOLUME ONE Seventh Edition July 2003 Revised July 2004 Revised March 2005 PREPARED BY California Cancer Registry Data Standards and Quality Control Unit STATE OF CALIFORNIA DEPARTMENT OF HEALTH SERVICES Sandra Shewry Director CANCER SURVEILLANCE SECTION William E Wright Ph D Chief il Reporting Cancer Statistics 1 1 6 5 Coding Sources A registry must have certain reference works for coding in addition to this manual Collaborative Staging Task Force of the American Joint Committee on Cancer Collaborative Staging Manual and Coding Instructions Version 1 0 Jointly published by American Joint Committee on Cancer CHICAGO IL U S Department of Health and Human Services Bethesda MD 2004 NIH Publication Number 04 5496 Fritz A Percy C et al eds International Classification of Diseases for Oncology 3rd ed Geneva World Health Organization 2000 Percy C VanHolten V and Muir C eds International Classification of Diseases for Oncology 2nd ed Geneva World Health Organization 1990 SEER Surveillance Epidemiology and End Results Program SEER Extent of Disease 1988 Codes and Coding Instructions 3rd ed Bethesda National Institutes of Health National Cancer Institute 1998 NIH Pub No 98 1999 SEER Surveillance Epidemiology and End Results Pro
24. FNA and Pathology Report Number Surgery need not be entered in the text field if there is only one pathology report or if it is clear from the information recorded which number belongs to which specimen Record pathology report numbers in the text field for all additional pathology reports including outside pathology if available Do not record pathology report numbers from autopsies in these fields Page 68 July 2003 Section IV 2 Diagnostic Confirmation A gauge of the reliability of histologic and other data is the method of confirming that the patient has cancer Coding for the confirmation field is in the order of the conclusiveness of the method the lowest number taking precedence over other codes The most conclusive method microscopic analysis of tissue is therefore coded as 1 while microscopic analysis of cells the next most conclusive method is coded as 2 Medical records should be studied to determine what methods were used to confirm the diagnosis of cancer and the most conclusive method should be coded in the confirmation field Since the confirmation field covers the patient s entire medical history in regard to the primary tumor follow up data see Section VII 1 might change the coding Although there is a priority order based on the most conclusive method of diagnosis the clinical source utilized by the clinician to establish the cancer diagnosis should be used to select the best diagnostic confirmation code The c
25. HE CASE WAS IDENTIFIED BY DEATH CERTIFICATE ONLY Page 142 March 2005 First Course of Treatment Hormone Therapy VI 5 3 HORMONE ENDOCRINE RADIATION This data item is coded in the Transplant Endocrine Procedure field Section VI 7 Report any type of radiation directed toward an endocrine gland to affect hormonal balance if The treatment is for cancers of the breast and prostate Both paired glands ovaries testes adrenals or all of a remaining gland have been irradiated VL5 4 HORMONE THERAPY CODES Use the following codes for recording hormone therapy in the Summary field Use codes 00 87 for recording hormone therapy at this hospital The codes for Reason No Hormone have been incorporated into this field 00 01 82 85 86 87 88 99 NONE HORMONE THERAPY WAS NOT PART OF THE PLANNED FIRST COURSE THERAPY DIAGNOSED AT AUTOPSY HORMONE THERAPY ADMINISTERED AS FIRST COURSE THERAPY HORMONE THERAPY WAS NOT RECOMMENDED ADMINISTERED BECAUSE IT WAS CONTRAINDICATED DUE TO PATIENT RISK FACTORS LE COMORBID CONDITIONS ADVANCED AGE HORMONE THERAPY WAS NOT ADMINISTERED BECAUSE THE PATIENT DIED PRIOR TO PLANNED OR RECOMMENDED THERAPY HORMONE THERAPY WAS NOT ADMINISTERED IT WAS RECOMMENDED BY THE PATIENT S PHYSICIAN BUT WAS NOT ADMINISTERED AS PART OF THE FIRST COURSE THERAPY NO REASON WAS STATED IN PATIENT RECORD HORMONE THERAPY WAS NOT ADMINISTERED IT WAS RECOMMENDED BY THE PATIENT S PHYSICIAN
26. I 7 2 Date of Transplant Endocrine Procedure 00000000 NO TRANSPLANT OR ENDOCRINE THERAPY VI 8 Other Therapy VL8 2 Date of Other Therapy March 2005 WAS PERFORMED AUTOPSY ONLY CASE 88888888 WHEN TRANSPLANT ENDOCRINE THERAPY IS PLANNED AS PART OF THE FIRST COURSE OF TREATMENT BUT HAD NOT BEEN STARTED AT THE TIME OF THE MOST RECENT FOLLOW UP THE DATE SHOULD BE REVISED AT THE NEXT FOLLOW UP 99999999 THE DATE IS UNKNOWN OR THE CASE WAS MO IDENTIFIED BY DEATH CERTIFICATE ONLY NO OTHER CANCER DIRECTED THERAPY EXCEPT AS CODED ELSEWHERE DIAGNOSED AT AUTOPSY OTHER CANCER DIRECTED THERAPY OTHER EXPERIMENTAL CANCER DIRECTED THERAPY not included elsewhere DOUBLE BLIND CLINICAL TRIAL CODE NOT YET BROKEN UNPROVEN THERAPY PATIENT OR PATIENT S GUARDIAN REFUSED THERAPY WHICH WOULD HAVE BEEN CODED 1 3 ABOVE OTHER CANCER DIRECTED THERAPY RECOMMENDED UNKNOWN IF ADMINISTERED UNKNOWN IF OTHER THERAPY RECOMMENDED OR ADMINISTERED DEATH CERTIFICATE ONLY 00000000 NO OTHER THERAPY ADMINISTERED AUTOPSY ONLY CASE 99999999 UNKNOWN IF ANY OTHER THERAPY WAS ADMINISTERED THE DATE IS UNKNOWN OR THE CASE WAS IDENTIFIED BY DEATH CERTIFICATE ONLY H 23 VI 9 Protocol Participation 00 Not Applicable National Protocols 01 NSABP 02 GOG 03 RTOG 04 SWOG 05 ECOG 06 POG 07 CCG 08 CALGB 09 NCI 10 ACS 11 National Protocol NOS 12 ACOS OG 13 VA Veterans Administration 14 COG Children s Oncology Group 15 CTS
27. IENT S PHYSICIAN BUT WAS NOT ADMINISTERED AS PART OF THE FIRST COURSE OF THERAPY NO REASON WAS STATED IN PATIENT RECORD CHEMOTHERAPY WAS NOT ADMINISTERED IT WAS RECOMMENDED BY THE PATIENT S PHYSICIAN BUT THIS TREATMENT WAS REFUSED BY THE PATIENT A PATIENT S FAMILY MEMBER OR THE PATIENT S GUARDIAN THE REFUSAL WAS NOTED IN PATIENT RECORD CHEMOTHERAPY WAS RECOMMENDED BUT IT IS UNKNOWN IF IT WAS ADMINISTERED ITIS UNKNOWN WHETHER A CHEMOTHERAPEUTIC AGENT S WAS RECOMMENDED OR ADMINISTERED BECAUSE IT IS NOT STATED IN PATIENT RECORD DEATH CERTIFICATE ONLY VI1 4 3 DATE OF CHEMOTHERAPY Record the date on which chemotherapy began at any facility as part of first course of treatment If chemotherapy was not administered leave the date field blank If chemotherapy is planned but had not started at the time the case is transmitted to the regional registry enter 8 s If chemotherapy is known to have been given but the date is not known enter 9 s 00000000 NO CHEMOTHERAPY ADMINISTERED AUTOPSY ONLY CASE 88888888 WHEN CHEMOTHERAPY IS PLANNED AS PART OF THE FIRST COURSE OF TREATMENT BUT HAD NOT BEEN STARTED AT THE TIME OF THE MOST RECENT FOLLOW UP FOR CoC APPROVED FACILITIES THE DATE SHOULD BE REVISED AT THE NEXT FOLLOW UP NOTE THE CCR REQUIRES THE USE OF 8 s IN THIS FIELD FOR CASES UNDERGOING CHEMOTHERAPY LATER THAN SIX MONTHS FROM THE DATE OF ADMISSION See Timeliness Section IX 2 3 99999999 THE DATE IS UNKNOWN OR T
28. INATION OF 5 WITH 1 2 OR 3 STAGING ASSIGNED AT ANOTHER FACILITY CASE IS NOT ELIGIBLE FOR STAGING UNKNOWN IF STAGED 4 A tD V 7 7 TNM EDITION Record which edition of TNM staging was used to stage a case The codes are as follows 00 NOT STAGED 01 FIRST EDITION 02 SECOND EDITION 03 THIRD EDITION 04 FOURTH EDITION 05 FIFTH EDITION 06 SIXTH EDITION 88 NOT APPLICABLE cases that do not have an AJCC staging scheme and staging was not done 99 UNKNOWN May be left blank V 7 8 PEDIATRIC STAGE This scheme is to be used for the purpose of entering the stage for pediatric patients only This includes patients who are younger than twenty 20 years of age and diagnosed January 1 1996 or later For patients twenty years of age and older this field would be coded 88 not applicable Use code 99 for pediatric leukemia cases For cases diagnosed prior to 1996 both pediatric and non pediatric this field may be left blank Record the stage assigned by the Managing Physician The codes are as follows Page 114 July 2003 First Course of Treatment Surgery Introduction 7 SENTINEL NODE BIOPSY AND CODE 3 4 OR 5 AT DIFFERENT TIMES Code 2 was followed in a subsequent surgical event by procedures coded as 3 4 or 5 9 UNKNOWN OR NOT APPLICABLE It is unknown whether regional lymph node surgery was performed death certificate only for lymphomas with a lymph node primary site an unknown or ill defined primary prima
29. M STAGING ELEMENTS CLINICAL AND PATHOLOGICAL Consult the AJCC manual for detailed information by site for assigning the appropriate numbers to each element for both clinical and pathological TNM elements Enter only the numbers not the letter T N or M If only one number follows a T or N enter it in the first space of the field leaving the second space blank Additional spaces have been added so that there are now three spaces available to record the T and the N and two spaces to record the M The TNM codes generally used are T CODES TX T2 TO T2A 2A Ta A T2B 2B Tis IS T2C 2C Tispu SU T3 Tispd SD T3A 3A Tlmic 1M T3B 3B T1 T3C 3C TIA 1A T4 4 TIAL Al T4A 4A TIA2 A2 T4B 4B TIB 1B T4C 4C TIBI 1 T4D 4D TIB2 B2 Not applicable 88 TIC 1C N CODES NX X NO 0 N2B 2B NO i 1 N2C 2C NO i 1 N3 3 NO mol M N3A 3A NO mol M N3B 3B N1 1 N3C 3C Nimi 1M Not applicable 88 NIA 1A NIB 1B NIC 1C N2 2 N2A 2A Page 112 March 2005 AJCC Staging and Other ACoS Items M CODES MIA 1 MX X MIB 1B MO 0 MIC 1C MI 1 Not applicable 88 Prostate cancer has codes Mla b and c Codes indicate metastases to Mla Nonregional lymph node s Mib Bone s Mic Other site s Malignant melanoma of the skin and of the eyelid have codes Mla b and c Codes indicate metastases to Mla Skin or subcutaneous tissue or lymph node s beyond the regional lymph
30. NE MARROW TRANSPLANT AUTOLOGOUS BONE MARROW TRANSPLANT ALLOGENEIC STEM CELL HARVEST AND INFUSION ENDOCRINE SURGERY AND OR ENDOCRINE RADIATION THERAPY COMBINATION OF ENDOCRINE SURGERY AND OR RADIATION WITH A TRANSPLANT PROCEDURE COMBINATION OF CODES 30 AND 10 11 12 OR 20 HEMATOLOGIC TRANSPLANT AND OR ENDOCRINE SURGERY RADIATION WERE NOT RECOMMENDED ADMINISTERED BECAUSE IT WAS CONTRAINDICATED DUE TO PATIENT RISK FACTORS i e COMORBID CONDITIONS ADVANCED AGE HEMATOLOGIC TRANSPLANT AND OR ENDOCRINE SURGERY RADIATION WERE NOT ADMINISTERED BECAUSE THE PATIENT DIED PRIOR TO PLANNED OR RECOMMENDED THERAPY HEMATOLOGIC TRANSPLANT AND OR ENDOCRINE SURGERY RADIATION WERE NOT ADMINISTERED IT WAS RECOMMENDED BY THE PATIENT S PHYSICIAN BUT WAS NOT ADMINISTERED AS PART OF THE FIRST COURSE THERAPY NO REASON WAS STATED IN PATIENT RECORD HEMATOLOGIC TRANSPLANT AND OR ENDOCRINE SURGERY RADIATION WERE NOT ADMINISTERED IT WAS RECOMMENDED BY THE PATIENT S PHYSICIAN BUT THIS TREATMENT WAS REFUSED BY THE PATIENT A PATIENT S FAMILY MEMBER OR THE PATIENT S GUARDIAN THE REFUSAL WAS NOTED IN PATIENT RECORD March 2005 88 99 HEMATOLOGIC TRANSPLANT AND OR ENDOCRINE SURGERY RADIATION WAS RECOMMENDED BUT IT IS UNKNOWN IF IT WAS ADMINISTERED IT IS UNKNOWN WHETHER HEMATOLOGIC TRANSPLANT AND OR ENDOCRINE SURGERY RADIATION WAS RECOMMENDED OR ADMINISTERED BECAUSE IT IS NOT STATED IN PATIENT RECORD DEATH CERTIFICATE ONLY V
31. ONS 11 19 MV 26 PHOTONS gt 19 MV 27 PHOTONS MIXED ENERGIES 28 ELECTRONS 29 PHOTONS AND ELECTRONS MIXED Page 138 March 2005 30 NEUTRONS WITH OR WITHOUT PHOTONS ELECTRON 31 IMRT 32 CONFORMAL OR 3 D THERAPY 40 PROTONS 41 STEREOTACTIC RADIOSURGERY NOS 42 LINAC RADIOSURGERY NOS 43 GAMMA KNIFE 50 BRACHYTHERAPY NOS 51 BRACHYTHERAPY INTRACAVITARY LDR 52 BRACHYTHERAPY INTRACAVITARY HDR 53 BRACHYTHERAPY INTERSTITIAL LDR 54 BRACHYTHERAPY INTERSTITIAL HDR 55 RADIUM 60 RADIOISOTOPES NOS 61 STRONTIUM 89 62 STRONTIUM 90 98 OTHER NOS 99 UNKNOWN DEATH CERTIFICATE ONLY Clarification Intracavitary use of Cobalt 60 or Cesium 137 should be coded as 50 or 51 See the FORDS Manual for code definitions There is no hierarchy for this data item If multiple radiation therapy boost modalities are used to treat the patient code the dominant modality 1 3 5 DATE OF RADIATION THERAPY Record the date on which radiation therapy began at any facility as part of the first course treatment If radiation therapy was not administered enter O s f radiation therapy is planned but had not started at the time the case is transmitted to the regional registry enter 8 s If radiation therapy is known to have been given but the date is not known enter 9 s 00000000 NO RADIATION THERAPY ADMINISTERED AUTOPSY ONLY CASE 88888888 WHEN RADIATION THERAPY IS PLANNED AS PART OF THE FIRST COURSE OF TREATMENT BUT HAD NOT
32. OT SPECIFIED UNKNOWN IF STAGED NOT STAGED FIRST EDITION SECOND EDITION THIRD EDITION FOURTH EDITION FIFTH EDITION SIXTH EDITION NOT APPLICABLE cases that do not have an AJCC staging scheme and staging was not done UNKNOWN May be left blank July 2003 V1 3 2 Radiation Generated field for cases diagnosed on or after January 1 2003 V1 3 3 Radiation Regional RX Modality V13 4 Radiation Boost RX Modality March 2005 CQ j OQ c NONE BEAM RADIATION RADIOACTIVE IMPLANTS RADIOISOTOPES COMBINATION OF 1 WITH 2 OR 3 RADIATION NOS METHOD OR SOURCE NOT SPECIFIED UNKNOWN IF RADIATION THERAPY RECOMMENDED OR GIVEN NOTE Code 6 may appear in converted cases 00 20 21 22 23 24 25 26 27 28 29 30 31 32 40 41 42 43 50 51 52 53 54 55 60 61 62 80 85 98 99 00 20 21 22 23 24 NO RADIATION TREATMENT DIAGNOSED AT AUTOPSY EXTERNAL BEAM NOS ORTHOVOLTAGE COBALT 60 CESIUM 137 PHOTONS 2 5 MV PHOTONS 6 10 MV PHOTONS 11 19 MV PHOTONS gt 19 MV PHOTONS MIXED ENERGIES ELECTRONS PHOTONS AND ELECTRONS MIXED NEUTRONS WITH OR WITHOUT PHOTONS ELECTRONS IMRT CONFORMAL OR 3 D THERAPY PROTONS STEREOTACTIC RADIOSURGERY NOS LINAC RADIOSURGERY NOS GAMMA KNIFE BRACHYTHERAPY NOS BRACHYTHERAPY INTRACAVIATARY LDR BRACHYTHERAPY INTRACAVIATARY HDR BRACHYTHERAPY INTERSTITIAL LDR BRACHYTHERAPY INTERSTITIAL HDR RADIUM RADIOISOTOPES NOS S
33. PY WAS NOT RECOMMENDED ADMINISTERED BECAUSE IT WAS CONTRAINDICATED DUE TO PATIENT RISK FACTORS i e COMORBID CONDITIONS ADVANCED AGE IMMUNOTHERAPY WAS NOT ADMINISTERED BECAUSE THE PATIENT DIED PRIOR TO PLANNED OR RECOMMENDED THERAPY IMMUNOTHERAPY WAS NOT ADMINISTERED IT WAS RECOMMENDED BY THE PATIENT S PHYSICIAN BUT WAS NOT ADMINISTERED AS PART OF THE FIRST COURSE OF THERAPY NO REASON WAS STATED IN PATIENT RECORD IMMUNOTHERAPY WAS NOT ADMINISTERED IT WAS RECOMMENDED BY THE PATIENT S PHYSICIAN BUT THIS TREATMENT WAS REFUSED BY THE PATIENT A PATIENT S FAMILY MEMBER OR THE PATIENT S GUARDIAN THE REFUSAL WAS NOTED IN THE PATIENT RECORD IMMUNOTHERAPY WAS RECOMMENDED BUT IT IS UNKNOWN IF IT WAS ADMINISTERED ITIS UNKNOWN WHETHER AN IMMUNOTHERAPEUTIC AGENT S WAS RECOMMENDED OR ADMINISTERED BECAUSE IT IS NOT STATED IN PATIENT RECORD DEATH CERTIFICATE ONLY V1 6 3 DATE OF IMMUNOTHERAPY Record the date on which immunotherapy began at any facility as part of first course of treatment If immunotherapy was not administered leave the date field blank If immunotherapy is planned but had not started at the time the case is transmitted to the regional registry enter 8 s If immunotherapy is known to have been given but the date is not known enter 9 s 00000000 NO IMMUNOTHERAPY ADMINISTERED AUTOPSY ONLY CASE 88888888 WHEN IMMUNOTHERAPY IS PLANNED AS PART OF THE FIRST COURSE OF TREATMENT BUT HAD NOT BEEN STARTED AT THE
34. RST COURSE TREATMENT RADIATION CONTRAINDICATED BECAUSE OF OTHER CONDITIONS OR OTHER PATIENT RISK FACTORS CO MORBID CONDITIONS ADVANCED AGE ETC RADIATION TREATMENT NOT PERFORMED BECAUSE THE PATIENT DIED PRIOR TO PLANNED OR RECOMMENDED TREATMENT March 2005 V1 3 7 Radiation Sequence With Surgery VI 4 Chemotherapy March 2005 AUNO UA 00 01 02 03 82 85 86 87 88 RADIATION TREATMENT WAS RECOMMENDED BUT NOT PERFORMED NO REASON WAS NOTED IN THE PATIENT S RECORD RADIATION TREATMENT WAS RECOMMENDED BUT REFUSED BY THE PATIENT FAMILY MEMBER OR GUARDIAN THE REFUSAL IS NOTED IN THE PATIENT S RECORD RADIATION RECOMMENDED UNKNOWN IF DONE UNKNOWN IF RADIATION RECOMMENDED OR PERFORMED DEATH CERTIFICATE AND AUTOPSY ONLY CASES NOT APPLICABLE DJAGNOSED AT AUTOPSY RADIATION BEFORE SURGERY RADIATION AFTER SURGERY RADIATION BOTH BEFORE AND AFTER SURGERY INTRAOPERATIVE RADIATION INTRAOPERATIVE RADIATION WITH OTHER RADIATION GIVEN BEFORE OR AFTER SURGERY SEQUENCE UNKNOWN BUT BOTH SURGERY AND RADIATION WERE GIVEN NONE CHEMOTHERAPY WAS NOT PART OF THE PLANNED FIRST COURSE OF THERAPY DIAGNOSED AT AUTOPSY CHEMOTHERAPY NOS SINGLE AGENT CHEMOTHERAPY MULTIAGENT CHEMOTHERAPY ADMINISTERED AS FIRST COURSE THERAPY CHEMOTHERAPY WAS NOT RECOMMENDED ADMINISTERED DUE TO CONTRAINDICATIONS CHEMOTHERAPY NOT ADMINISTERED BECAUSE THE PATIENT DIED CHEMOTHERAPY WAS NOT ADMINISTERED IT WAS RECOMMENDED BY
35. TRONTIUM 89 STRONTIUM 90 COMBINATION MODALITY SPECIFIED COMBINATION MODALITY NOS OTHER NOS UNKNOWN DEATH CERTIFICATE ONLY NO BOOST TREATMENT DIAGNOSED AT AUTOPSY EXTERNAL BEAM NOS ORTHOVOLTAGE COBALT 60 CESIUM 137 PHOTONS 2 5 MV PHOTONS 6 10 MV H 17 VI 3 5 VI 3 6 H 18 Date of Radiation Therapy Reason for No Radiation 25 26 27 28 29 30 3l 32 40 41 42 43 50 51 52 53 54 55 60 61 62 98 99 PHOTONS 11 19 MV PHOTONS gt 19 MV PHOTONS MIXED ENERGIES ELECTRONS PHOTONS AND ELECTRONS MIXED NEUTRONS WITH OR WITHOUT PHOTONS ELECTRONS MRT CONFORMAL OR 3 D THERAPY PROTONS STEREOTACTIC RADIOSURGERY NOS LINAC RADIOSURGERY NOS GAMMA KNIFE BACHYTHERAPY NOS BRACHYTHERAPY INTRACAVIATARY LDR BRACHYTHERAPY INTRACAVIATARY HDR BRACHYTHERAPY INTERSTITIAL LDR BRACHYTHERAPY INTERSTITIAL HDR RADIUM RADIOISOTOPES NOS STONTIUM 89 STONTIUM 90 OTHER NOS UNKNOWN DEATH CERTIFICATE ONLY 00000000 NO RADIATION THERAPY ADMINISTERED AUTOPSY ONLY CASE 88888888 WHEN RADIATION THERAPY IS PLANNED AS PART OF THE FIRST COURSE OF TREATMENT BUT HAD NOT BEEN STARTED AT THE TIME OF THE MOST RECENT FOLLOW UP THE DATE SHOULD BE REVISED AT THE NEXT FOLLOW UP 99999999 THE DATE IS UNKNOWN OR THE CASE WAS IDENTIFIED BY DEATH CERTIFICATE ONLY RADIATION TREATMENT PERFORMED RADIATION TREATMENT NOT PERFORMED BECAUSE IT WAS NOT A PART OF THE PLANNED FI
36. The size of the untreated cancer or tumor T increases progressively and at some point in time regional lymph node involvement N and finally distant metastases M occur Because classifications are different for each primary site and coding for extension depends on precise anatomical identification the AJCC manual must be referred to for data entry unless the coding is provided by physicians in the medical records But fundamentally the system consists of assigning appropriate numbers or letters to the three fields T primary tumor N nodal involvement and M distant metastasis For those sites not included in the AJCC Manual for Staging of Cancer the Summary Staging Guide for Surveillance Epidemiology and End Results Group SEER is to be used For a list of these sites please refer to the AJCC Manual for Staging of Cancer 6 Edition V 7 2 DATA ENTRY In entering data do not include the letters T N or M even though they are part of the code Fill in the digits from left to right leaving the second digit blank if there is no entry for it V 7 3 TNM STAGE BASIS TNM Basis indicates the nature of the information on which AJCC staging is based The Manual for Staging of Cancer provides specific recommendations about which information should be used for each type of staging at each primary site This field has been prefilled for clinical and pathological staging July 2003 Page 111 AJCC Staging and Other AcoS Items 7 4 TN
37. Tumor Timing Same Site Different Site 2rd months Same Other Unkn Same Other Unkn side side side side side side M M lt 2 2ER 2 Pa 2 2 2 M M 2 2 2 2 2 2 2 M B NA 2 2 2 2 2 2 B Benign borderline tumor M Malignant tumor 1 1 9 3 Date of Diagnosis Since the CCR began reporting benign brain and CNS tumors prior to national reporting implementation there are two sets of rules for establishing the Date of Diagnosis for benign and malignant brain tumors For cases diagnosed January 1 2001 to December 31 2003 use the most definitive source of diagnostic confirmation as the date of diagnosis Example A CT scan done 2 1 03 states brain tumor The patient has surgery on 2 5 03 and a biopsy reveals an astrocytoma The date of diagnosis is 2 5 03 For cases diagnosed January 1 2004 forward record the date a recognized medical practitioner states the patient has a reportable tumor whether that diagnosis was made clinically or pathologically If a clinical diagnosis do not change the date of diagnosis when there is a subsequent tissue diagnosis Example A CT scan done 4 1 04 states brain tumor The patient has surgery on 4 5 04 and a biopsy reveals an astrocytoma The date of diagnosis is 4 1 04 1 9 4 Sequence Number A primary non malignant tumor of any of the sites specified on or after January 1 2001 is reportable The sequence number for the tumor is in the range 60 87
38. U Clinical Trials Support Unit 16 50 National Trials Locally Defined Pharmaceutical Locally Defined In House Trial Locally Defined Other Locally Defined Unknown FIRST COURSE OF TREATMENT GIVEN AT REPORTING HOSPITAL Fields and codes are the same as for First Course of Treatment Summary FOLLOW UP VIL2 1 Date of Last Contact MMDDY YYY do not leave blank or code year as unknown VII 2 2 Vital Status 0 DEAD 1 ALIVE VII 2 3 Date of Last Tumor MMDDYYYY do not leave blank if patient alive Status do not code year as unknown 2 4 Tumor Status 1 FREE NO EVIDENCE OF THIS PRIMARY CANCER 2 NOTFREE THIS PRIMARY CANCER STILL EXISTS 9 UNKNOWN H 24 July 2004 Surgery Codes CERVIX UTERI C53 0 C53 9 Except for M 9750 9760 9764 9800 9820 9826 9831 9920 9931 9964 9980 9989 For invasive cancers dilation and curettage is coded as an incisional biopsy 02 under the data item Surgical Diagnostic and Staging Procedure NAACCR Item 1350 Codes 00 10 20 30 40 None no surgery of primary site autopsy ONLY Local tumor destruction NOS 11 Photodynamic therapy PDT 12 EElectrocautery fulguration includes use of hot forceps for tumor destruction 13 Cryosurgery 14 Laser 15 Loop Electrocautery Excision Procedure LEEP 16 Laser ablation 17 Thermal ablation No specimen sent to pathology from surgical events 10 17 Local tumor excision NOS 26 Excisional biopsy NOS 27 Cone biopsy 24 Cone biops
39. UNOTHERAPY WAS NOT ADMINISTERED BECAUSE THE PATIENT DIED PRIOR TO PLANNED OR RECOMMENDED THERAPY IMMUNOTHERAPY WAS NOT ADMINISTERED IT WAS RECOMMENDED BY THE PATIENT S PHYSICIAN BUT WAS NOT ADMINISTERED AS PART OF THE FIRST COURSE OF THERAPY NO REASON WAS STATED IN PATIENT RECORD IMMUNOTHERAPY WAS NOT ADMINISTERED IT WAS RECOMMENDED BY THE PATIENT S PHYSICIAN BUT THIS TREATMENT WAS REFUSED BY THE PATIENT A PATIENT S FAMILY MEMBER OR THE PATIENT S GUARDIAN THE REFUSAL WAS NOTED IN THE PATIENT RECORD IMMUNOTHERAPY WAS RECOMMENDED BUT IS UNKNOWN IF IT WAS ADMINISTERED IS UNKNOWN WHETHER AN IMMUNOTHERAPEUTIC AGENT S WAS RECOMMENDED OR ADMINISTERED BECAUSE IT IS NOT STATED IN PATIENT RECORD DEATH CERTIFICATE ONLY H 21 V1 6 3 Date of Immunotherapy 00000000 NO IMMUNOTHERAPY ADMINISTERED AUTOPSY ONLY CASE 88888888 WHEN IMMUNOTHERAPY ISPLANNED AS PART OF THE FIRST COURSE OF TREATMENT BUT HAD NOT BEEN STARTED AT THE TIME OF THE MOST RECENT FOLLOW UP THE DATE SHOULD BE REVISED AT THE NEXT FOLLOW UP 99999999 THE DATE IS UNKNOWN OR THE CASE WAS IDENTIFIED BY DEATH CERTIFICATE ONLY VL7 Transplant Endocrine Procedures 00 10 11 12 20 30 40 82 85 86 87 H 22 NO TRANSPLANT PROCEDURE OR ENDOCRINE THERAPY WAS ADMINISTERED AS PART OF THE FIRST COURSE THERAPY DIAGNOSED AT AUTOPSY A BONE MARROW TRANSPLANT PROCEDURE WAS ADMINISTERED BUT THE TYPE WAS NOT SPECIFIED BO
40. ary 1 2003 forward code Gleason s 7 to grade 3 If only the predominant pattern 1 5 is mentioned in the medical record enter the code as follows Gleason s Pattern Grade Code 1 2 I 1 3 II 2 4 5 3 Effective with prostate cases diagnosed January 1 2004 forward the priority order for coding grade of tumor is 1 Gleason s grade 2 Terminology well diff mod diff 3 Histologic grade I grade II 4 Nuclear grade V 3 5 7 Lymphomas and Leukemias In ICD O 3 the WHO Classification of Hematopoietic and Lymphoid Neoplasms is followed Under this classification two groups are identified lymphoid neoplasms and myeloid neoplasms Lymphoid neoplasms consist of B cell T cell NK cell lymphomas Hodgkin s lymphoma Lymphocytic leukemias Other lymphoid malignancies Page 92 March 2005 Section V 6 Tumor Markers Three fields are available for collecting information about prognostic indicators referred to as tumor markers Tumor marker information is currently required on the status of estrogen and progesterone receptors for ERA and PRA breast cancers sites C50 0 C50 9 diagnosed on or after January 1 1990 Beginning with January 1 1996 cases facilities which collect ACoS data items were allowed to use these fields for other sites The codes are the same Please refer to the ROADS Manual for further information Beginning with January 1 1998 diagnoses the CCR requires that tumor markers be collected for
41. ational Cancer Institute 1993 NIH Pub No 93 3640 SEER Surveillance Epidemiology and End Results Program The SEER Program Coding and Staging Manual 2004 4th ed Bethesda National Institutes of Health National Cancer Institute 2004 NIH Pub No 04 5581 Shambaugh E ed in chief SEER Program Self Instructional Manual for Cancer Registrars Bethesda U S Department of Health and Human Services Public Health Service National Institutes of Health various years Book One Objectives and Functions of a Tumor Registry 2d ed 1980 New edition is in preparation Book Two Cancer Characteristics and Selection of Cases 3d ed 1992 NIH Pub No 92 993 Book Three Tumor Registrar Vocabulary The Composition of Medical Terms 2d ed 1993 NIH Pub No 93 1078 Book Four Human Anatomy as Related to Tumor Formation 2d ed 1993 NIH Pub No 93 2161 Book Five Abstracting a Medical Record Patient Identification History and Examinations 2d ed 1993 NIH Pub No 93 1263 Book Seven Statistics and Epidemiology for Tumor Registrars 1994 World Health Organization International Classification of Diseases for Oncology Geneva World Health Organization 1976 Percy C and VanHolten V International Classification of Diseases for Oncology Field Trial Edition Geneva World Health Organization 1988 U S Postal Service National Zip Code amp Post Office Directory Page 8 March 2005 It is sometimes difficult to
42. atment item Regional Treatment Modality NAACCR Item 1570 20 Local excision biopsy of tumor lesion or mass Specimen sent to pathology from surgical event 20 40 Partial resection NOS 55 Gross total resection formerly SEER codes 31 32 50 60 90 Surgery NOS 99 Unknown if surgery performed death certificate ONLY Q 2 42 March 2005 Surgery Codes ALL OTHER SITES C14 2 C14 8 C17 0 C17 9 C23 9 C24 0 C24 9 C26 0 C26 9 C30 0 C 30 1 C31 0 C31 9 C33 9 C37 9 C38 0 C38 8 C39 0 C39 9 C48 0 C48 8 C51 0 C51 9 C52 9 C57 0 C57 9 C58 9 C60 0 C 60 9 C63 0 C63 9 C68 0 C68 9 C69 0 C69 9 C74 0 C74 9 C75 0 C75 9 Except for M 9750 9760 9764 9800 9820 9826 9831 9920 9931 9964 9980 9989 Codes 00 10 20 30 40 50 60 90 99 None no surgery of primary site autopsy ONLY Local tumor destruction NOS 11 Photodynamic therapy PDT 12 EElectrocautery fulguration includes use of hot forceps for tumor destruction 13 Cryosurgery 14 Laser No specimen sent to pathology from surgical events 10 14 Local tumor excision NOS 26 Polypectomy 27 Excisional biopsy Any combination of 20 or 26 27 WITH SEER Guideline the following codes INCLUDE local tumor excision polypectomy or excisional biopsy 21 Photodynamic therapy PDT 22 HEElectrocautery 23 Cryosurgery 24 Laser ablation 25 Laser excision Specimen sent to pathology from surgical events 20 27 Simple partial surgical removal of
43. ber of edits that require review After review and confirmation that the abstracted information is correct a flag must be set so that repeated review is not necessary and a case can be set to complete Many hospital registry software programs also contain these over ride flags See Appendix T for a list of these over rides Please follow the instructions provided by your hospital software vendor for using these flags July 2003 Page 175 Quality Control In addition to computer edits to assess accuracy regional registries perform visual editing on 100 of the abstracts submitted by hospital registries Feedback is routinely provided to hospitals on visual editing Beginning January 1 2000 the California Cancer Registry implemented visual editing standards The purpose of these standards is to provide consistency in the visual editing process and to quantify the accuracy of cancer data from cancer reporting facilities Initially thirteen data items were included in this standard They are as follows County of Residence at Diagnosis Sex Race Spanish Hispanic Origin Date of Diagnosis Diagnostic Confirmation Site Subsite Laterality only paired sites listed in Volume I Histology Tumor Size EOD Extension for prostate count as one discrepancy EOD Lymph Node Involvement Number of Regional Nodes Positive Examined Counted as one discrepancy The visual editing accuracy rate for the thirteen data items was establishe
44. c or Staging Procedures Date of Surgery Procedures 1 3 Date of Therapy Date of Transplant Endocrine Procedures Death File Number Diagnostic Confirmation EOD Extension EOD Extension Path EOD Lymph Node Involvement First Name Follow up Contact Address Other Follow up Contact Address Other Supplemental Follow up Contact City Other Follow up Contact Name Other Follow up Contact State Other Follow up Contact Zip Other Follow up Last Type Patient Follow up Last Type Tumor Follow up Next Type Follow up Hospital Next Follow up Hospital Last Histology Text Histology Behavior ICD O 2 Histology Behavior ICD O 3 Histology Grade Differentiation Histology Type ICD O 2 Histology Type ICD O 3 Hormone Therapy at This Hospital Hormone Therapy Summary Data Items and Their Required Status Manual V1 2 5 VI 1 3 2 VI 1 3 2 VL1 3 2 VL1 3 2 12 12 VI2 5 Vol III VI 7 2 VIL2 14 IV 2 V 4 V 4 V 4 IIL2 1 2 VIL3 VIL3 VIL3 VIL3 VIL3 VIL3 VIL2 6 2 VIL2 6 1 VIL2 8 VIL2 9 VIL2 7 IV 1 7 V 3 4 V 3 4 V 3 5 V3 V3 VL5 VL5 gen sel sel gen gen sel sel no sel may yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes RX Ctr gen sel sel gen gen sel sel no sel Transmitted from Hospital to Region yes ye
45. d at 97 These data items were selected because they affect the overall quality for data usage This rate applies to cancer reporting facilities and not to individual cancer registry abstractors The reporting facility is responsible for cancer reporting requirements not specific individuals therefore an accuracy rate reflects the facility s compliance with regulations Non analytic cases are included in the accuracy rate The regions visually edit them although not as extensively as analytic cases Review is limited to verifying that there is supporting documentation to validate the coded data field Beginning July 1 2001 the CCR s Regional Registries began visual editing treatment data items in addition to tumor data items A total of nineteen treatment data items were added to the list of data items to be visually edited One discrepancy will be counted for each treatment modality grouping For example a discrepancy in Date of Hormone Therapy and a discrepancy in Hormone Therapy would be counted as only one discrepancy These data items will be included in the semi annual accuracy rate using a phased approach For the period July 1 2001 to December 31 2001 visual editing of treatment items will not be included in calculating accuracy rates but they will be tracked and feedback will be provided to hospital registrars Beginning in January 2005 discrepancies in treatment fields will be counted towards the overall facility accuracy rate
46. ded hysterectomy 63 Radical hysterectomy Wertheim procedure 64 Extended radical hysterectomy Hysterectomy NOS WITH or WITHOUT removal of tube s and ovary ies formerly SEER code 70 66 WITHOUT removal of tube s and ovary ies formerly SEER code 71 67 WITH removal of tube s and ovary ies formerly SEER code 72 Pelvic exenteration formerly SEER code 80 76 Anterior exenteration formerly SEER code 81 Includes bladder distal ureters and genital organs WITH their ligamentous attachments and pelvic lymph nodes NOTE Do not code removal of pelvic lymph nodes under Surgical Procedure Other Site Posterior exenteration formerly SEER code 82 0 Includes rectum and rectosigmoid WITH ligamentous attachments and pelvic lymph nodes NOTE Do not code removal of pelvic lymph nodes under Surgical Procedure Other Site Total exenteration formerly SEER code 83 Includes removal of all pelvic contents and pelvic lymph nodes NOTE Do not code removal of pelvic lymph nodes under Surgical Procedure Other Site Extended exenteration formerly SEER code 84 Includes pelvic blood vessels or bony pelvis Surgery NOS Unknown if surgery performed death certificate ONLY Q 2 32 March 2005 Surgery Codes OVARY C56 9 Except for M 9750 9760 9764 9800 9820 9826 9831 9920 9931 9964 9980 9989 Codes 00 None no surgery of primary site autopsy ONLY 17 Local tumor destruction NOS No specimen sent to pathology from surgical
47. des DOMINICAN REPUBLIC for cases diagnosed on or after January 1 2005 forward SPANISH NOS HISPANIC NOS LATINO NOS evidence that Hispanic cannot be assigned to codes 1 5 SPANISH SURNAME ONLY only evidence is surname or maiden name DOMINICAN REPUBLIC for cases diagnosed on or after January 1 2005 UNKNOWN WHETHER SPANISH OR NOT Use Appendix O to code this field March 2005 V 6 1 Tumor Marker 1 V 6 2 Tumor Marker 2 V 6 3 Tumor Marker 3 V 6 4 Tumor Marker CA 1 ACoS Items V 7 4 TNM T Code Clinical V 7 4 TNM N Code Clinical V 7 4 TNM M Code Clinical V 7 4 TNM T Code Pathological March 2005 5 REGIONAL NOS 7 DISTANT METASTASES OR SYSTEMIC DISEASE REMOTE 8 NOT APPLICABLE for coding benign brain tumors effective with cases diagnosed 1 1 2004 forward 9 UNSTAGEABLE UNKNOWN Blank NOT DONE For breast cancer cases C50 0 C50 9 diagnosed on or after 1 1 90 and prostate C61 9 and testicular C62 0 C62 9 cancer cases diagnosed on or after 1 1 98 For colorectal cancer cases Carcinoembryonic Antigen CEA For ovarian cancer cases Carbohydrate Antigen 125 CA 125 For cases diagnosed January 1 2004 forward Tumor Markers 1 3 will be collected in the Collaborative Staging Site Specific Factor fields Refer to Section V 6 1 for codes For breast cancer cases C50 0 C50 9 diagnosed on or after 1 1 90 and prostate C61 9 and testicular 62 0 62 9 cancer cases diagnosed on or a
48. diagnosed after January 1 1998 0 TEST NOT DONE includes cases diagnosed at autopsy 1 TEST DONE RESULTS POSITIVE 2 TEST DONE RESULTS NEGATIVE 3 TEST DONE RESULTS BORDERLINE OR UNDETERMINED WHETHER POSITIVE OR NEGATIVE 4 RANGE 1 lt 5 000 mIU ml S1 5 RANGE 2 5 000 50 000 mIU ml S2 6 RANGE 3 gt 50 000 mIU ml S3 8 TEST ORDERED RESULTS NOT IN CHART 9 UNKNOWN IF TEST DONE OR ORDERED NO INFORMATION includes death certificate only cases Page 108 March 2005 Tumor Markers For breast cancer cases diagnosed before January 1 1990 for cancers of the prostate and testis before January 1 1998 and for all other sites enter 9 NOT APPLICABLE Use codes 0 1 2 3 8 and 9 for breast and prostate Use codes 0 2 4 5 6 8 and 9 for testis Record the lowest nadir value of hCG after orchiectomy if serial serum tumor markers are done during the first course of treatment Breast tumors too small to evaluate with the conventional progesterone receptor assays might be measured by immunostaining which is a procedure for identifying antigens in body fluids in aspirations of tumor masses or in biopsy specimens The procedure is based on an antigen antibody reaction If immunostaining results are available use them to code Progesterone Receptor Status For cases diagnosed January 1 2004 forward Tumor Markers 1 3 will be collected in the Collaborative Staging Site Specific Factor fields The California tumor ma
49. dures THE CCR REQUIRES THE USE OF 8 s IN THIS FIELD FOR CASES UNDERGOING TRANSPLANT ENDOCRINE THERAPY LATER THAN SIX MONTHS FROM THE DATE OF ADMISSION See the Timeliness Section IX 2 3 THE DATE IS UNKNOWN OR THE CASE WAS IDENTIFIED BY DEATH CERTIFICATE ONLY Page 150A Page 150B March 2005 Section VI 8 First Course Treatment Other Therapy Record definitive cancer directed treatment that cannot be assigned to any other category for example e Tumor embolization arterial block if the surgeon s intent is to kill tumor cells e Hyperbaric oxygen as adjunct to definitive treatment e Hyperthermia given alone or in combination with chemotherapy as in isolated heated limb perfusion for melanoma e Any experimental drug that cannot be classified elsewhere e Double blind clinical trial information where the type of agent administered is unknown and or there is any use of a placebo However after the code is broken report the treatment under the appropriate category a correction record should be submitted when the data are available e Unorthodox and unproven treatment such as laetrile or krebiozen e For Newly Reportable Hematopoietic Diseases NRHD only specify in the Remarks field and use code 1 Other Therapy for the following e Transfusions Plasmapheresis e Phlebotomy Blood Removal e Supportive Care e Aspirin e Observation VL8 1 OTHER THERAPY CODES Use the following codes for recording other therapy
50. ee of differentiation as follows Term Grade Code Low grade LII 2 Medium grade intermediate grade II III 3 High grade M IV 4 Partially well differentiated I U 2 Moderately undifferentiated III 3 Relatively undifferentiated III 3 Occasionally a grade is written as 2 3 or 2 4 meaning this is grade 2 of a 3 grade system or grade 2 of a 4 grade system respectively To code in a three grade system refer to the following codes Histologic Nuclear Grade Description Code Grade 1 3 or VIII 1 2 1 3 Low Grade 2 2 3 2 3 Medium Grade 3 3 3 or IMAI 2 2 3 3 High Grade 4 To code in a two grade system refer to the following codes Histologic Description Code Grade 1 2 or VII Low Grade 2 2 2 or I II High Grade 4 V 3 5 4 In Situ Medical reports ordinarily do not contain statements about differentiation of in situ lesions But if a statement is made enter the code indicated V 3 5 5 Brain Tumors Magnetic Resonance Imaging MRI or Positron Emission Tomography PET can sometimes establish the grade of a brain tumor If there is no tissue diagnosis but grade or differentiation is stated in a MRI or PET report base the grade code on the report If there is a tissue diagnosis however do not base the grade code on any other source V 3 5 6 Gleason s Score A special descriptive method Gleason s Score is used for prostate cancer It is obtained by adding two separa
51. ess accuracy and timeliness IX 2 1 COMPLETENESS Completeness the extent to which all required cases have been reported is assessed by a casefinding audit performed at the reporting facility and by monitoring of death certificates The minimum acceptable level of completeness for a reporting facility is 97 percent See Section II Reportable Neoplasms for a discussion of which cases must be abstracted Descriptions of the protocols and procedures for evaluating completeness are available from the CCR IX 2 2 ACCURACY Accuracy is the extent to which the data submitted match the information in the medical record and have been correctly coded It encompasses accurate abstracting correct application of coding rules and correct entry into and retrieval from the computer Regional registries use computer edits to assess the quality of data submitted The CCR provides a standard set of edits for regions and many of the same edits are performed on CNExT data at the time of abstracting The measure used to evaluate accuracy is the percent of a hospital s cases that fail an edit CCR s standards specify that for computerized data all submitted codes must be valid as described in this manual and in Cancer Reporting in California Data Standards for Regional Registries and California Cancer Registry California Cancer Reporting System Standards Vol 3 Data submitted via CNExT automatically meet these standards The CCR s software contains a num
52. field V 6 4 TUMOR MARKER CALIFORNIA 1 Tumor Marker California 1 is a tumor marker for breast cancer Her2 neu also known as c erbB2 or ERBB2 The codes are as follows 0 8 9 TEST NOT DONE include cases diagnosed at autopsy TEST DONE RESULTS POSITIVE TEST DONE RESULTS NEGATIVE TEST DONE RESULTS BORDERLINE OR UNDETERMINED WHETHER POSITIVE OR NEGATIVE TESTS ORDERED RESULTS NOT IN CHART UNKNOWN IF TEST DONE OR ORDERED NO INFORMATION includes death certificate only cases For breast cancer cases prior to January 1 1999 or all other sites enter 9 NOT APPLICABLE Page 110 March 2005 Section V 7 AJCC Staging and Other ACoS Items Hospitals with American College of Surgeons ACoS approved registries are required to employ the TNM classification system for staging developed by the American Joint Committee on Cancer AJCC Clinical and pathological TNM staging are required by ACoS The CCR does not require hospitals to report TNM however it does request that if TNM clinical and pathological only is collected it be transmitted to the regional registry and then sent on to the CCR There are a number of other data items in this section which hospitals may be required to collect either by ACoS or the CCR V 7 1 THE TNM SYSTEM As the AJCC Manual for Staging of Cancer explains the TNM system is based on the premise that cancers of similar histology or site of origin share similar patterns of growth and extension
53. fter 1 1 98 For cases diagnosed January 1 2004 forward Tumor Markers 1 3 will be collected in the Collaborative Staging Site Specific Factor fields Refer to Section V 6 2 for codes For testicular cancer cases diagnosed on or after 1 1 98 For cases diagnosed January 1 2004 forward Tumor Markers 1 3 will be collected in the Collaborative Staging Site Specific Factor fields Refer to Section V 6 3 for codes Her 2 neu tumor marker for breast cancer Refer to Section V 6 4 for codes Site specific code one two or three characters ACoS flush left Site specific code one two or three characters ACoS flush left Site specific code two characters ACoS Site specific code one two or three characters ACoS flush left V 7 4 V 7 4 7 5 7 6 V 7 7 H 12 TNM N Code Pathological TNM M Code Pathological TNM Stage Clinical amp Pathological TNM Coder Clinical Pathological and Other ACoS TNM Edition ACoS Site specific code one two or three characters ACoS flush left Site specific code two characters ACoS Site specific code one or two characters ACoS entered as Arabic not Roman numerals flush left 4 amp 00 01 02 03 04 05 06 88 99 NOT STAGED MANAGING PHYSICIAN PATHOLOGIST OTHER PHYSICIAN ANY COMBINATION OF 1 2 OR 3 REGISTRAR ANY COMBINATION OF 5 WITH 1 2 OR 3 OTHER STAGED INDIVIDUAL N
54. ge Date of Hormone Therapy Date of Immunotherapy Date of Last Patient Contact or Death Date of Last Tumor Status Derived AJCC T Derived AJCC T Descriptor Derived AJCC N Derived AJCC N Descriptor Derived AJCC M Derived AJCC M Descriptor Derived AJCC Stage Group Derived SS2000 Derived SS1977 Derived AJCC Flag Derived SS2000 Flag Derived SS1977 Flag March 2005 Manual V4 2 V4 2 V4 2 V4 2 V4 2 4 2 4 2 4 2 4 2 4 2 VI 1 3 2 HL3 3 11 3 1 11 3 2 11 3 2 1 1 3 2 VL1 3 2 VIL2 1 VIL2 3 V 4 2 V 4 2 V 4 2 V 4 2 V 4 2 V 4 2 V4 2 V4 2 V4 2 V4 2 V4 2 V4 2 C N yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes RX Ctr yes yes yes yes yes yes yes yes yes yes sel yes yes no no sel sel yes yes yes yes yes yes yes yes yes yes yes yes yes yes Transmitted from Hospital to Region yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes SEER Collect yes no yes yes yes yes yes yes yes yes no yes no no no no no yes no yes no yes no yes no yes yes yes yes yes yes no no yes no yes yes yes yes yes yes yes yes yes yes yes yes U 3 U 4 Item Name Date of Most Definitive Surgery of the Primary Site Date of Other Therapy Date of Radiation Date of Systemic Therapy Date of Surgery Date of Surgery Diagnosti
55. gram Summary Staging Guide for the Cancer Surveillance Epidemiology and End Results Reporting SEER Program Bethesda U S Department of Health and Human Services Public Health Services National Institutes of Health April 1977 reprinted July 1986 SEER Surveillance Epidemiology and End Results Program Self Instructional Manual for Tumor Registrars Book 8 Antineoplastic Drugs 3d ed Bethesda U S Department of Health and Human Services Public Health Services National Institutes of Health 1994 AJCC American Joint Committee on Cancer Manual for Staging of Cancer 6th ed New York Springer Verlag 2002 C NET Solutions CNExT User Manual Berkeley Public Health Institute CNEXT Project References that are very helpful although not necessary for abstracting and coding include ACoS American College of Surgeons Commission on Cancer Standards of the Commission on Cancer Volume II Facility Oncology Registry Data Standards FORDS Chicago American College of Surgeons Commission on Cancer January 2003 revised for 2004 March 2005 Page 7 Reporting Cancer Statistics California Cancer Registry California Cancer Registry Inquiry System Version 2002 1 SEER Surveillance Epidemiology and End Results Program SEER Inquiry System Resolved Questions SEER Surveillance Epidemiology and End Results Program SEER Program Comparative Staging Guide for Cancer Bethesda National Institutes of Health N
56. ians because they are not Spanish If the record does not state an origin that can be assigned to codes 1 5 and there is evidence other than surname that the person is Hispanic use code 6 Spanish NOS If the record does not state an origin that can be assigned to codes 0 6 base the code on the patient s name and use code 7 Spanish Surname Only Use code 7 Spanish Surname Only for a woman with a Spanish maiden name or a male patient with a Spanish Surname If a woman s maiden name is not Spanish use code 0 Non Spanish Non Hispanic But if her maiden name is not known or not applicable and she has a Spanish Surname use code 7 If race is not known Race code 99 use code 9 Unknown Whether Spanish or Not Code 7 Spanish Surname Only or code 6 Spanish NOS if diagnosed prior to January 1 1994 may Page 50D March 2005 Diagnostic Procedures IV 1 4 SCOPES Note dates and positive and negative findings of laryngoscopies sigmoidoscopies mediastinoscopies and other endoscopic procedures Include mention of biopsies washings and other procedures performed during the examinations but enter their results in the Pathology section Record size of an observed lesion if given Enter none if no endoscopic examination was performed IV 1 5 LABORATORY TESTS Enter dates names and results of laboratory tests or procedures used in establishing the diagnoses of neoplasms or metastases such as serum protein electrophoresis for multiple m
57. ic lymph nodes under Surgical Procedure Other Site 72 Posterior exenteration Includes rectum and rectosigmoid WITH ligamentous attachments and pelvic lymph nodes NOTE Do not code removal of pelvic lymph nodes under Surgical Procedure Other Site 73 Total exenteration Includes removal of all pelvic contents and pelvic lymph nodes NOTE Do not code removal of pelvic lymph nodes under Surgical Procedure Other Site 74 Extended exenteration Includes pelvic blood vessels or bony pelvis 90 Surgery NOS 99 Unknown if surgery performed death certificate ONLY Q 2 30 March 2005 Surgery Codes CORPUS UTERI C54 0 C55 9 Except for M 9750 9760 9764 9800 9820 9826 9831 9920 9931 9964 9980 9989 For invasive cancers dilation and curettage is coded as an incisional biopsy 02 under the data item Surgical Diagnostic and Staging Procedure NAACCR Item 1350 Codes 00 None no surgery of primary site autopsy ONLY 19 Local tumor destruction or excision NOS Unknown whether a specimen was sent to pathology for surgical events coded 19 principally for cases diagnosed prior to January 1 2003 10 Local tumor destruction NOS 11 Photodynamic therapy PDT 12 Hlectrocautery fulguration includes use of hot forceps for tumor destruction 13 Cryosurgery 14 Laser 15 Loop Electocautery Excision Procedure LEEP 16 Thermal ablation No specimen sent to pathology from surgical events 10 16 20 Local tumor excision NOS simple exci
58. in the Summary field Use codes 0 7 for recording other therapy in the At This Hospital Field 0 NO OTHER CANCER DIRECTED THERAPY EXCEPT AS CODED ELSEWHERE DIAGNOSED AT AUTOPSY 1 OTHER CANCER DIRECTED THERAPY OTHER EXPERIMENTAL CANCER DIRECTED THERAPY not included elsewhere 3 DOUBLE BLIND CLINICAL TRIAL CODE NOT YET BROKEN UNPROVEN THERAPY 7 PATIENT OR PATIENTS GUARDIAN REFUSED THERAPY WHICH WOULD HAVE BEEN CODED 1 3 ABOVE 8 OTHER CANCER DIRECTED THERAPY RECOMMENDED UNKNOWN IF ADMINISTERED 9 UNKNOWN IF OTHER THERAPY RECOMMENDED OR ADMINISTERED DEATH CERTIFICATE ONLY ON March 2005 Page 151 First Course Treatment Other Therapy 1 8 2 DATE OF OTHER THERAPY Record the date on which Other Therapy began at any facility as part of first course treatment If Other Therapy was not administered leave the date field blank If Other Therapy was known to have been given but the date is unknown enter 9 s 00000000 NO OTHER THERAPY ADMINISTERED AUTOPSY ONLY CASE 99999999 THE DATE IS UNKNOWN OR THE CASE WAS IDENTIFIED BY DEATH CERTIFICATE ONLY Page 152 July 2003 Section IX 2 Quality Control The CCR and regional registries have procedures for assuring the quality of the data produced by the reporting system Staff from both the regional registry and the CCR visit cancer reporting facilities to perform quality control audits The CCR has established uniform standards of quality for hospital data in three areas completen
59. ing the occipital lobe C70 0 cerebral meninges Count and abstract as 2 separate primary tumors The exception is when one of the primaries has an NOS site code C 9 and the other primary is a specific subsite within the same rubic Meninges NOS C70 9 with spinal meninges C70 1 or cerebral meninges C70 0 Count as a single primary and code to the specific subsite Page 30 March 2005 Histology Refer to the Histology Groups Table below using the rules in priority order Histologic groupings to determine same histology for non malignant brain tumors Histologic Group ICD O 3 Histology Code Choroid plexus neoplasms 9390 0 9390 1 Ependymomas 9383 9394 9444 Neuronal and neuronal glial 9384 9412 9413 9442 9505 1 9506 neoplasms Neurofibromas 9540 0 9540 1 9541 9550 9560 0 Neurinomatosis 9560 1 Neurothekeoma 9562 Neuroma 9570 Perineuroma NOS 9571 0 1 If all histologies are in the same histologic grouping or row in the table then the histology is the same Histologies that are in the same groupings are a progression differentiation or subtype of a single histologic category Example A subependymal giant cell astrocytoma 9384 1 of the cerebrum C71 0 and a gliofibroma 9442 1 of the Island of Reil C71 0 count as a single primary 2 Ifthe first 3 digits are the same as the first 3 digits of any histology in a grouping or row in the table ab
60. lignancy Serous tumor NOS of low malignant potential Papillary cystadenoma borderline malignancy Serous papillary cystic tumor of borderline malignancy Papillary serous cystadenoma borderline malignancy Papillary serous tumor of low malignant potential Atypical proliferative papillary serous tumor Mucinous cystic tumor of borderline malignancy Mucinous cystadenoma borderline malignancy Pseudomucinous cystadenoma borderline malignancy Mucinous tumor NOS of low malignant potential Papillary mucinous cystadenoma borderline malignancy Papillary pseudomucinous cystadenoma borderline malignancy Papillary mucinous tumor of low malignant potential 8442 1 8442 1 8451 1 8462 1 8462 1 8462 1 8462 1 8472 1 8472 1 8472 1 8472 1 8473 1 8473 1 8473 1 For cases diagnosed prior to January 1 2004 these cases are to be staged according to the ovary scheme in the EOD Manual Apply the Collaborative Staging ovary scheme for cases diagnosed on or after January 1 2004 Follow up is required for these cases March 2005 Page 32C Page 32D March 2005 STATE ZIP COUNTY March 2005 Patient Identification For states in the U S and Canadian provinces enter the standard two letter Postal Service abbreviation California is CA For other states U S Territories and Canadian provinces see Appendix B For U S Territories with a postal abbreviation such as Guam GU use the abbreviation or if no postal abbreviation enter
61. middle name initial no spaces within name middle name may be blank July 2004 H 1 2 1 4 2 1 5 2 1 6 2 1 8 2 1 9 2 2 2 3 2 5 2 2 5 2 2 5 2 2 5 2 2 5 2 2 Maiden Alias Last Alias First Name Name Suffix Mother s First Name Medical Record No Social Security No and Suffix Number amp Street City State Zip County of Residence Uppercase alpha except hyphen first 15 characters of maiden surname no spaces within name blank if not applicable Uppercase alpha except hyphen first 15 characters of alias surname no spaces within name blank if not applicable Uppercase alpha except hyphen 15 characters no spaces within name blank if not applicable Alpha 3 characters may be left blank Alpha 14 characters may be left blank Maximum of 12 letters or numbers assigned to patient admission by reporting hospital flush left without special characters or spaces within number blank if none assigned Nine digit number up to two character suffix flush left blank if unknown valid suffixes determined by Social Security Administration Maximum of 40 letters numbers spaces and the special characters and flush left if unknown enter UNKNOWN Maximum of 20 letters and spaces only if unknown enter UNKNOWN Two letter postal abbreviation see Appendix B XX Resident of country other
62. munotherapy Biological Response Modifier Therapy Immunotherapy Biological response modifier therapy BRM is a generic term covering everything done to the immune system to alter it or change the host response to a cancer defense mechanism VL6 1 IMMUNOTHERAPY AGENTS In addition to the agents listed in the SEER Self Instructional Manual for Tumor Registrars Book 8 3rd ed 1994 report the following as immunotherapy ASILI active specific intralymphatic immunotherapy Blocking factors Interferon Monoclonal antibodies Transfer factor specific or non specific Vaccine therapy Virus therapy VI 6 2 IMMUNOTHERAPY CODES Effective with cases diagnosed 1 1 2003 this data item has been modified Codes for transplants and endocrine procedures have been removed and are coded in a separate field called RX Summ Transplnt Endocr The length of this field has been changed from 1 to 2 characters The codes for reason for no immunotherapy BRM given have been incorporated into this scheme A conversation will be required Use the following codes for recoding immunotherapy in the Summary field Use codes 00 87 for recoding immunotherapy in the At This Hospital Field 00 NONE IMMUNOTHERAPY WAS NOT PART OF THE PLANNED FIRST COURSE OF THERAPY DIAGNOSED AT AUTOPSY 01 IMMUNOTHERAPY ADMINISTERED AS FIRST COURSE THERAPY March 2005 Page 147 82 85 86 87 88 99 First Course of Treatment Immunotherapy IMMUNOTHERA
63. national implementation any tumor diagnosed on January 1 2004 or later with a behavior code of 0 or 1 will be collected for the following site codes based on ICD O 3 Meninges C70 0 C70 9 Brain C71 0 C71 9 Spinal Cord Cranial Nerves and Other Parts of Central Nervous System C72 0 C72 9 Pituitary gland C75 1 Craniopharyngeal duct C75 2 Pineal gland C75 3 The histology codes also based on ICD O 3 have been expanded and are listed in Appendix V for ICD O 3 Primary Brain and CNS Site Histology Listing Juvenile astrocytomas pilocytic astrocytomas should continue to be reported as 9421 3 Reportable Terminology For non malignant brain and CNS primaries the terms tumor and neoplasm are diagnostic and reportable The terms mass and lesion are not reportable for non malignant brain and CNS primaries but may be used for initial casefinding purposes The terms hypodense mass or cystic neoplasm are not reportable even for CNS tumors In order to be reportable there must be a corresponding ICD 0 3 histology code for any CNS tumor related diagnosis 1 9 2 Determining Multiple Primaries Determining the number of primaries for non malignant CNS tumors requires a review of the following Site s Histologies Timing Laterality Site Non malignant CNS tumors are different primaries at the subsite level Examples Meningioma of cervical spine dura C70 1 and separate meningioma overly
64. nodes MIb Lung metastasis Mlc Visceral metastasis at any site associated with an elevated serum lactic dehydrogenase LDH V 7 5 AJCC STAGE GROUP CLINICAL AND PATHOLOGICAL The AJCC manual contains instructions for coding summaries of TNM staging When entering a stage summary code be sure to include any letter used for the tumor for example 3A 2C If there is no letter leave the second digit in the field blank The codes are STAGE 0 0 STAGE ITA 2A STAGE 0A STAGE 2 STAGE 015 05 STAGE 2 STAGEI 1 STAGE III 3 STAGE IA 1A STAGE IIIA 3A STAGE IAl Al STAGE IIIB STAGE IA2 A2 STAGE IIIC 3C STAGE IB 1B STAGE IV 4 STAGE IB1 Bl STAGE IVA 4A STAGE IB2 B2 STAGE IVB 4B STAGE IS 1S OCCULT OC STAGE II NOT APPLICABLE 88 RECURRENT UNKNOWN STAGE X 99 March 2005 Page 113 AJCC Staging and Other ACoS Items V 7 6 TNM CODER CLINICAL PATHOLOGICAL AND OTHER Record who was responsible for performing the TNM staging on the case The TNM Coder Clinical and TNM Coder Pathological are to be used in conjunction with clinical and pathological TNM staging These fields will be transmitted to the regional and state registries CNExT will have the TNM Coder Other field available for hospitals but it will not be transmitted The codes are as follows NOT STAGED MANAGING PHYSICIAN PATHOLOGIST PATHOLOGIST AND MANAGING PHYSICIAN ANY COMBINATION OF 1 2 OR 3 REGISTRAR ANY COMB
65. o be involved with malignancy even if the pathology was negative Do not code the incidental removal of tissue for reasons other than malignancy See example 2 These procedures are to be entered in chronological order If no surgery was performed of other regional or distant sites or distant lymph nodes leave the fields blank They will be filled with 0 by CNExT The Summary field will be computed automatically by CNEXT Starting with cases diagnosed January 1 2003 forward RX Summ Surg Oth Reg Dis and its corresponding procedure fields will not be coded according to site It will be coded using a single scheme for all sites The new codes are as follows 0 NONE No surgical procedure of nonprimary site 1 NONPRIMARY SURGICAL PROCEDURE PERFORMED Nonprimary surgical resection to other site s unknown if whether the site s is regional or distant 2 NONPRIMARY SURGICAL PROCEDURE TO OTHER REGIONAL SITES Resection of regional site 3 NONPRIMARY SURGICAL PROCEDURE TO DISTANT LYMPH NODE S Resection of distant lymph node s 4 NONPRIMARY SURGICAL PROCEDURE TO DISTANT SITE Resection of distant site 5 COMBINATION OF CODES Any combination of surgical procedures 2 3 or 4 9 UNKNOWN It is unknown whether any surgical procedure of a nonprimary site was performed Death certificate only NOTE Use code 1 if any surgery is performed to treat tumors of Unknown or Ill defined Primary sites C76 0 76 8 C80 9 o
66. odes in the order of their conclusiveness are Microscopic Confirmation 1 POSITIVE HISTOLOGY Use for microscopic confirmation based on biopsy including punch biopsy needle biopsy bone marrow aspiration curettage and conization Code 1 also includes microscopic examination of frozen section specimens and surgically removed tumor tissue whether taken from the primary or a metastatic site In addition positive hematologic findings regarding leukemia and NRHD are coded 1 Cancers first diagnosed as a result of an autopsy or previously suspected and confirmed in an autopsy are coded 1 if microscopic examination is performed on the autopsy specimens 2 POSITIVE CYTOLOGY NO POSITIVE HISTOLOGY Cytologic diagnoses based on microscopic examination of cells rather than tissue Do not use code 2 if cancer is ruled out by a histologic examination Included are sputum cervical and vaginal smears fine needle aspiration from breast or other organs bronchial brushings and washings tracheal washings prostatic secretions gastric spinal or peritoneal fluid and urinary sediment Also include diagnoses based on paraffin block specimens from concentrated spinal pleural or peritoneal fluid 4 POSITIVE MICROSCOPIC CONFIRMATION METHOD NOT SPECIFIED Cases with a history of microscopic confirmation but with no information about whether based on examination of tissue or cells March 2005 Page 69 Page 70 Diagnostic Confirmation No Micr
67. on not performed because patient died was added Definitions for codes 1 2 and 6 were also modified VI 3 7 RADIATION SEQUENCE WITH SURGERY Code the sequence in which radiation and surgical procedures were performed as part of the first course of treatment Use the following codes ON Q RUN NOT APPLICABLE treatment did not include both surgery and radiation or unknown whether both were administered diagnosed at autopsy RADIATION BEFORE SURGER Y RADIATION AFTER SURGERY RADIATION BOTH BEFORE AND AFTER SURGERY INTRAOPERATIVE RADIATION INTRAOPERATIVE RADIATION WITH OTHER RADIATION GIVEN BEFORE OR AFTER SURGERY SEQUENCE UNKNOWN BUT BOTH SURGERY AND RADIATION WERE GIVEN Page 140 March 2005 If first course of treatment includes codes 10 90 in Surgery of the Primary Site fields codes 1 7 in the Scope of Regional Lymph Node Surgery fields and codes 1 8 in the Surgery of Other Regional Site s Distant Site s or Distant Lymph Node s fields and radiation use codes 2 9 For all other cases use code 0 March 2005 Page 140A Page 140B March 2005 Section VI 4 First Course of Treatment Chemotherapy Chemotherapy includes the use of any chemical to attack or treat cancer tissue unless the chemical achieves its effect through change of the hormone balance or by affecting the patient s immune system In coding consider only the agent not the method of administering it although the method of administration may be recorded Chemo
68. ory anemia with sideroblasts 9982 3 Refractory anemia with excess blasts 9983 3 Refractory anemia with excess blasts in Transformation 9984 3 Refractory cytopenia with multilineage Dysplasia 9985 3 Myelodysplastic syndrome with 5q syndrome 9986 3 Therapy related myelodysplastic syndrome 9987 3 OTHER NEW DIAGNOSES Langerhans cell histiocytosis disseminated 9754 3 Acute biphenotypic leukemia 9805 3 Precursor lymphoblastic leukemia 983_ 3 Aggressive NK cell leukemia 9948 3 Chronic neutrophilic leukemia 9963 3 Hypereosinophilic syndrome 9964 3 Leukemias with cytogenetic abnormalities Dendritic cell sarcoma Other new terms in the lymphomas and leukemias Compare diagnoses to check for transition to another hematopoietic disease Use the ICD O 3 Hematopoietic Primaries Table For treatment information specific to NRHD see Section VI 8 July 2004 Page 29 II 1 9 INTRACRANIAL CNS TUMORS Although the CCR has required reporting of all intracranial and CNS benign and borderline tumors since 1 1 2001 the National Benign Brain Tumor Cancer Registries Amendment Act signed into law in October 2002 created Public law 107 260 requiring the collection of benign and borderline intracranial and CNS tumors beginning with cases diagnosed 1 1 2004 forward The CCR still requires that follow up be performed on these cases Due to this national implementation several elements of reporting these entities have changed 1 9 1 Reportability With the
69. oscopic Confirmation POSITIVELABORATORY TEST OR MARKER STUDY Clinical diagnosis of cancer based on certain laboratory tests or marker studies that are clinically diagnostic for cancer Examples are the presence of alpha fetoprotein AFP for liver cancer and an abnormal electrophoretic spike for multiple myeloma or Waldenstrom s macroglobulinemia Although an elevated PSA is nondiagnostic of cancer if the physician uses the PSA as a basis for diagnosing prostate cancer with no other workup record as code 5 DIRECT VISUALIZATION WITHOUT MICROSCOPIC CONFIRMATION Includes diagnoses by visualization and or palpation during surgical or endoscopic exploration or by gross autopsy But do not use code 6 if visualization or palpation during surgery or endoscopy is confirmed by a positive histology or cytology report RADIOGRAPHY WITHOUT MICROSCOPIC CONFIRMATION Includes all diagnostic radiology scans ultrasound and other imaging technologies not confirmed by a positive histologic or cytologic report or by direct visualization CLINICAL DIAGNOSIS ONLY Cases diagnosed by clinical methods other than direct visualization and or palpation during surgery endoscopy or gross autopsy if not confirmed microscopically UNKNOWN WHETHER OR NOT MICROSCOPICALLY CONFIRMED Death Certificate Only cases are included in code 9 July 2004 V 3 5 3 Variation in Terms for Degree of Differentiation Use the higher grade when different terms are used for the degr
70. ove then the histology is the same Example A ganglioglioma 9505 1 of the cerebellum C71 6 and a neurocytoma 9506 1 of the cerebellopontine angle C71 6 count as a single primary NOTE If one histology is an NOS and the other is more specific code the specific histology If both histologies are NOS or both are specific code the histology that was diagnosed first 3 If the first 3 digits are the same but one or both histology codes are not found on the table above then the histology is considered the same Example Clear cell meningioma 9538 1 of the cerebral meninges and a separate transitional meningioma 9537 0 in another part of the same hemisphere count as a single primary 4 If the histologies are listed in different groupings in the table they are different histologies 5 If the first three digits of the histology code are different and or both histologies is not listed in the table above the histology types are different Report as 2 primaries March 2005 Page 31 Timing If a non malignant tumor of the same histology and same site as an earlier one is subsequently diagnosed at any time it is considered to be the same primary Laterality Beginning with malignant and benign borderline CNS tumors diagnosed January 1 2004 forward the following sites require a laterality code of 1 4 or 9 C70 0 Cerebral meninges NOS C71 0 Cerebrum C71 1 Frontal lobe C71 2 Temporal lobe C7
71. primary site Total surgical removal of primary site enucleation 41 Total enucleation for eye surgery only Surgery stated to be debulking Radical surgery Partial or total removal of the primary site WITH a resection in continuity partial or total removal with other organs SEER Guideline in continuity with or en bloc means that all of the tissues were removed during the same procedure but not necessarily in a single specimen Surgery NOS Unknown if surgery performed death certificate ONLY March 2005 Q 2 45 UNKNOWN AND ILL DEFINED PRIMARY SITES C76 0 C76 8 C80 9 Except for M 9750 9760 9764 9800 9820 9826 9831 9920 9931 9964 9980 9989 Code 98 unknown and ill defined disease sites WITH or WITHOUT surgical treatment Surgical procedures for unknown and ill defined primaries are to be recorded using the data item Surgical Procedure Other Site NAACCR Item 1294 or Surgical Procedure Other Site at This Hospital NAACCR Item 647 99 Death certificate only Q 2 46 March 2005 Data Items and Their Required Status Item Name CS Metastasis at Diagnosis CS Metastasis Evaluation CS Site Specific Factor 1 CS Site Specific Factor 2 CS Site Specific Factor 3 CS Site Specific Factor 4 CS Site Specific Factor 5 CS Site Specific Factor 6 CS Version 1 CS Version Latest Date of Chemotherapy Date of Diagnosis Date of First Admission Date of Inpatient Admission Date of Inpatient Dischar
72. prostate acid phosphatase PAP and prostate specific antigen PSA and for testicular cancers alpha feto protein AFP human chorionic gonadotropin hCG and lactate dehydro genase LDH Ranges for testicular cancer tumor markers have been added in codes 4 6 Beginning with January 1 2000 diagnoses Tumor Marker I may be used to record carcinoembryonic antigen CEA for colorectal cancers and CA 125 for ovarian cancers For cases diagnosed January 1 2004 forward Tumor Markers 1 3 will be collected in the Collaborative Staging Site Specific Factor fields The California tumor marker Tumor Marker California 1 Her2 neu is still a required data item for the CCR and will continue to be collected in its designated field V 6 1 TUMOR MARKER 1 Use the following codes for ERA for breast cancer cases diagnosed on or after January 1 1990 PAP for prostate cancer cases and AFP for testicular cancer cases diagnosed after January 1 1998 and CEA for colorectal cancer cases and CA 125 for ovarian cancer cases diagnosed after January 1 2000 0 TEST NOT DONE includes cases diagnosed at autopsy 1 TEST DONE RESULTS POSITIVE 2 TEST DONE RESULTS NEGATIVE 3 TEST DONE RESULTS BORDERLINE OR UNDETERMINED WHETHER POSITIVE OR NEGATIVE 4 RANGE 1 lt 1 000 NG ML S1 5 RANGE 2 1 000 10 000 NG ML S2 6 RANGE 3 gt 10 000 NG ML S3 8 TESTORDERED RESULTS NOT IN CHART 9 UNKNOWN IF TEST DONE OR ORDERED NO INFORMATION includes death
73. r for Hematopoietic Reticuloendothelial Immunoproliferative disease C42 0 C42 1 C42 3 C42 4 or 9750 9760 9764 9800 9820 9826 9831 9964 9980 9989 Page 128 March 2005 NONE BEAM RADIATION RADIOACTIVE IMPLANTS RADIOISOTOPES COMBINATION OF 1 WITH 2 OR 3 RADIATION NOS method or source not specified UNKNOWN IF RADIATION THERAPY RECOMMENDED OR GIVEN NN Q NOTE Code 6 may appear in old cases that were converted to the 1988 codes SEER converted old code 2 Other Radiation to code 6 Beginning with cases diagnosed January 1 1998 radiation to the brain and central nervous system for lung cancers and leukemias only is to be recorded in the Radiation Summary and Radiation At This Hospital fields Include prophylactic treatment and treatment of known spread to the CNS Beginning with cases diagnosed on or after January 1 2003 or cases entered after the software conversion radiation to the brain and CNS for lung and leukemia cases are to be coded in the Radiation Regional RX Modality and Radiation Boost RX Modality fields As stated previously software conversion of these two fields will generate the Radiation Therapy Summary field VI 3 3 RADIATION REGIONAL RX MODALITY Record the dominant modality of radiation therapy used to deliver the most clinically significant regional dose to the primary volume of interest during the first course of treatment The CCR requires the collection of this field
74. rade and differentiation see Section V 3 5 Also enter the dates source of specimen s pathology report number size of the largest tumor and other details needed to e Describe the location of the primary site or subsite and laterality of the primary tumor see sections V 1 and V 2 for discussions of site and laterality e Record the histologic diagnosis and identify the appropriate ICD O code see sections V 3 2 and V 3 3 e Describe multiple tumors and multiple sites of origin e Document the extent of disease see Section V 4 and stage at diagnosis see Section V 5 e Describe the number of lymph nodes examined and the number positive for cancer March 2005 Page 67 Diagnostic Procedures e Determine the method of diagnosis or confirmation e Identify all specimens examined microscopically IV 1 7 1 Pathology Report Number Biopsy FNA Record the pathology report number for the first positive biopsy or fine needle aspirate FNA performed at your facility This field may be left blank if biopsy FNA was not performed or the results were negative IV 1 7 2 Pathology Report Number Surgery Record the surgical pathology report number for the first definitive surgical resection performed at your facility on the patient s cancer This should be recorded whether there was cancer present or not in the surgical specimen This field may be left blank if definitive surgery was not performed Pathology Report Number Biopsy
75. ries of the brain and central nervous system or for hematopoietic reticuloendothelial immunoproliferative or myeloproliferative disease Cases diagnosed prior to January 1 2003 are to be coded in a new field Scope of Regional LN 98 02 Refer to Appendix Q 1 for these codes Each site contains a list of nodes which are regional Any nodes not contained on these lists are distant and should be coded in Surgery of Other Regional Site s Distant Site s or Distant Lymph Node s In Appendix Q 1 for head and neck primaries diagnosed prior to January 1 2003 these fields are to be used for neck dissections Codes 2 5 indicate only that a neck dissection procedure was done they do not imply that nodes were found during the pathologic examination of the surgical specimen Code the neck dissection even if no nodes were found in the specimen For Unknown Primary Hematopoietic Reticuloendothelial Immunoproliferative Myeloprolifera tive Disease Primaries Lymphoma Brain and Primaries of Ill Defined Sites use code 9 VI 2 3 NUMBER OF REGIONAL LYMPH NODES EXAMINED Record the number of lymph nodes identified in the pathology report during each surgical procedure of the regional lymph nodes The codes are the same for all sites Please refer to Appendix Q 1 for these codes These are to be entered in chronological order If no regional lymph nodes were identified in the pathology report leave the field blank even if the surgical procedure includes
76. rior exenteration Includes bladder distal ureters and genital organs WITH their ligamentous attachments and pelvic lymph nodes NOTE Do not code removal of pelvic lymph nodes under Surgical Procedure OtherSite March 2005 Q 2 33 80 90 99 Surgery Codes OVARY C56 9 Except for M 9750 9760 9764 9800 9820 9826 9831 9920 9931 9964 9980 9989 72 Posterior extenteration Includes rectum and rectosigmoid WITH ligamentous attachments and pelvic lymph nodes NOTE Do not code removal of pelvic lymph nodes Surgical Procedure Other Site 73 Total extenteration Includes removal of all pelvic contents and pelvic lymph nodes NOTE Do not code removal of pelvic lymph nodes Surgical Procedure Other Site 74 Extended extenteration Includes pelvic blood vessels or bony pelvis NOTE Do not code removal of pelvic lymph nodes Surgical Procedure Other Site Salpingo oophorectomy NOS Surgery NOS Unknown if surgery performed death certificate ONLY Q 2 34 March 2005 Surgery Codes TESTIS C62 0 C62 9 Except for M 9750 9760 9764 9800 9820 9826 9831 9920 9931 9964 9980 9989 Codes 00 None no surgery of primary site autopsy ONLY 12 Local tumor destruction NOS No specimen sent to pathology from surgical event 12 20 Local or partial excision of testicle formerly SEER code 10 Specimen sent to pathology from surgical event 20 30 Excision of testicle WITHOUT cord 40 Excision of testicle WITH cord or cord
77. rker Tumor Marker California 1 Her2 neu is still a required data item for the CCR and will continue to be collected in its designated field V 6 3 TUMOR MARKER 3 0 TEST NOT DONE includes cases diagnosed at autopsy 1 TEST DONE RESULTS POSITIVE 2 TEST DONE RESULTS NEGATIVE 3 TEST DONE RESULTS BORDERLINE OR UNDETERMINED WHETHER POSITIVE OR NEGATIVE 4 RANGE 1 lt 1 5 N 51 5 RANGE 2 1 5 10 N S2 NOTE N the upper limit of normal RANGE 3 gt 10 N S3 8 TEST ORDERED RESULTS NOT IN CHART 9 UNKNOWN IF TEST DONE OR ORDERED NO INFORMATION includes death certificate only cases For testis cases before January 1 1998 and all other sites enter 9 NOT APPLICABLE March 2005 Page 109 Tumor Markers For testicular cancer cases diagnosed on or after January 1 1998 record the status of the Lactate Dehydrogenase LDH level as follows NOT DONE SX WITHIN NORMAL LIMITS SO RANGE 1 S1 lt 1 5 x UPPER LIMIT OF NORMAL FOR LDH ASSAY RANGE 2 S2 1 5 10 x UPPER LIMIT OF NORMAL FOR LDH ASSAY RANGE 3 S3 gt 10 x UPPER LIMIT OF NORMAL FOR LDH ASSAY ORDERED BUT RESULTS NOT IN CHART UNKNOWN OR NO INFORMATION For cases diagnosed January 1 2004 forward Tumor Markers 1 3 will be collected in the Collaborative Staging Site Specific Factor fields The California tumor marker Tumor Marker California 1 Her2 neu is still a required data item for the CCR and will continue to be collected in its designated
78. s yes yes yes yes yes no yes no yes yes yes yes yes yes no yes yes yes SEER Collect no no no no no no no yes no yes yes no yes yes no no no no no yes yes ACoS yes yes yes yes yes yes no no no no no no yes no no no no no no no no no yes no no no yes no yes yes July 2004
79. sion NOS 24 Excisional biopsy 25 Polypectomy 26 Myomectomy Any combination of 20 or 24 26 WITH SEER Guideline the following codes INCLUDE local tumor excision polypectomy or excisional biopsy 21 Hlectrocautery 22 Cryosurgery 23 Laser ablation or excision Specimen sent to pathology from surgical events 20 26 Margins of resection may have microscopic involvement SEER Guideline Procedures in code 20 include but are not limited to cryosurgery electrocautery excisional biopsy laser ablation thermal ablation 30 Subtotal hysterectomy supracervical hysterectomy fundectomy WITH or WITHOUT removal of tube s and ovary ies 31 WITHOUT tube s and ovary ies 32 WITH tube s and ovary ies SEER Guideline for these procedures the cervix is left in place July 2003 Q 2 31 40 50 60 65 75 71 78 79 90 99 Surgery Codes CORPUS UTERI C54 0 C55 9 Except for M 9750 9760 9764 9800 9820 9826 9831 9920 9931 9964 9980 9989 Total hysterectomy simple pan WITHOUT removal of tube s and ovary ies Removes both the corpus and cervix uteri It may also include a portion of the vaginal cuff Total hysterectomy simple pan WITH removal of tube s and or ovary ies Removes both the corpus and cervix uteri It may also include a portion of the vaginal cuff Modified radical or extended hysterectomy radical hysterectomy extended radical hysterectomy 61 Modified radical hysterectomy 62 Exten
80. ssification as documented in the medical record in Collaborative Staging Site Specific Factor 1 for Brain and other Central Nervous System sites WHO grade I generally describes non malignant or benign tumors however non malignant tumors should not be coded as Grade I unless WHO grade is specifically stated in the source document WHO grade II generally describes a malignant tumor but it can describe a non malignant tumor depending on histologic type WHO grade III and IV describe malignant tumors For certain types of CNS tumors no WHO grade is assigned 1 1 9 8 Staging For intracranial and CNS benign and borderline tumor cases diagnosed from January 1 2001 to December 31 2003 the CCR does not require that these cases be staged The CCR recommends that these cases be coded as EOD 99 Unknown If your registry uses SEER Summary Stage it is recommended that these cases be coded to 9 For intracranial and CNS benign and borderline tumor cases diagnosed January 1 2004 forward apply Collaborative Staging Page 32B March 2005 1 10 BORDERLINE OVARIAN TUMORS Although borderline ovarian tumors changed behavior in ICD O 3 from 3 malignant to 1 borderline the CCR will continue to require reporting them They are to be coded with a behavior code of 1 As listed in Appendix 6 of the ICD O 3 Code Manual reportable borderline ovarian tumors include the following terms and morphology codes Serous cystadenoma borderline ma
81. t field VL7 1 TRANSPLANT ENDOCRINE CODES Use the following codes for recording transplant endocrine procedures in the Summary field Use codes 00 87 for recording transplant endocrine procedures in the At This Hospital Field 00 NO TRANSPLANT PROCEDURE OR ENDOCRINE THERAPY WAS ADMINISTERED AS PART OF THE FIRST COURSE THERAPY DIAGNOSED AT AUTOPSY 10 ABONE MARROW TRANSPLANT PROCEDURE WAS ADMINISTERED BUT THE TYPE WAS NOT SPECIFIED 11 BONE MARROW TRANSPLANT AUTOLOGOUS 12 BONE MARROW TRANSPLANT ALLOGENEIC 20 STEM CELL HARVEST AND INFUSION 30 ENDOCRINE SURGERY AND OR ENDOCRINE RADIATION THERAPY 40 COMBINATION OF ENDOCRINE SURGERY AND OR RADIATION WITH A TRANSPLANT PROCEDURE COMBINATION OF CODES 30 AND 10 11 12 OR 20 March 2005 Page 149 82 85 86 87 88 99 First Course of Treatment Transplant Endocrine Procedures HEMATOLOGIC TRANSPLANT AND OR ENDOCRINE SURGERY RADIATION WERE NOT RECOMMENDED ADMINISTERED BECAUSE IT WAS CONTRAINDICATED DUE TO PATIENT RISK FACTORS i e COMORBID CONDITIONS ADVANCED AGE HEMATOLOGIC TRANSPLANT AND OR ENDORCRINE SURGERY RADIATION WERE NOT ADMINISTERED BECAUSE THE PATIENT DIED PRIOR TO PLANNED OR RECOMMENDED THERAPY HEMATOLOGIC TRANSPLANT AND OR ENDORCRINE SURGERY RADIATION WERE NOT ADMINISTERED IT WAS RECOMMENDED BY THE PATIENT S PHYSICIAN BUT WAS NOT ADMINISTERED AS PART OF THE FIRST COURSE THERAPY NO REASON WAS STATED IN PATIENT RECORD HEMATOLOGIC TRANSPLANT AND OR
82. te numbers to produce a score in the range of 2 to 10 First a number is assigned to the predominant primary pattern i e the pattern that comprises more than half the tumor Then a number is assigned to the lesser secondary pattern and the two numbers are added to obtain Gleason s Score July 2004 Page 91 If only one number is stated and it is 5 or less assume that it represents the primary pattern If the number is higher than 5 assume that it is the score If there are two numbers add them to obtain the score Sometimes the number 10 is written after Gleason s Score to show the relationship between the actual score and the highest possible score e g Gleason s 3 10 indicates a score of 3 If a number is not identified as Gleason s assume that a different grading system was used and code appropriately When both grade and Gleason s Score are provided in the same specimen code the grade When they are in different specimens code to the highest grade If only Gleason s Score 2 10 is available convert it to grade according to the following table Gleason s Score Grade Code 2 3 4 I 1 5 6 II 2 7 8 9 10 3 For cases diagnosed prior to January 1 2003 code Gleason s 7 to grade code 2 The exception for cases diagnosed prior to January 1 2003 is if the pathology report states that the tumor is moderately to poorly differentiated and Gleason s score is reported as 7 assign code 3 For cases diagnosed Janu
83. ter than two months after the six month deadline or eight months after the date of admission If these corrections will be sent in later than eight months because treatment has not been completed the region must be notified March 2005 Page 177 Page 178 July 2003 APPENDIX B POSTAL ABBREVIATIONS FOR STATES AND TERRITORIES OF THE UNITED STATES ALABAMA ALASKA AMERICAN SAMOA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA FLORIDA GEORGIA GUAM HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARYLAND MARSHALL ISLANDS MASSACHUSETTS MICHIGAN MICRONESIA FERERATED STATE OF MINNESOTA MISSISSIPPI MISSOURI MONTANA March 2005 NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA NORTHERN MARIANA ISLANDS OHIO OKLAHOMA OREGON PALAU PENNSYLVANIA PUERTO RICO RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TRUST TERRITORIES TEXAS UTAH VERMONT VIRGINIA VIRGIN ISLANDS WASHINGTON DISTRICT OF WASHINGTON STATE OF WEST VIRGINIA WISCONSIN WYOMING NOT U S U S TERRITORY NOT CANADA AND COUNTRY IS KNOWN YY NOT U S U S TERRITORY NOT CANADA AND COUNTRY IS UNKNOWN ZZ U S NOS U S TERRITORY NOS CANADA NOS RESIDENCE IS UNKNOWN B1 AB BC NB NL NT B2 CANADIAN PROVINCE TERRITOR Y ALBERTA BRITISH COLUMBIA MANITOBA NEW BRUNSWICK NEWFOUNDLAND AND LA
84. than the US or Canada and the country is known YY Resident of country other than the US or Canada and country is unknown ZZ Resident of the US NOS Canada NOS residence unknown Nine character field for five or nine digit postal code flush left 8 s NON USA NON CANADIAN RESIDENT 9 s UNKNOWN Three digit code for county at DX in California see Appendix L for non USA or non Canadian resi dents three digit code for country see Appendix D 000 NON CALIFORNIA RESIDENT USA NOS CALIFORNIA RESIDENT COUNTY UNKNOWN 999 COUNTRY UNKNOWN March 2005 2 4 amp 3 2 2 6 2 7 2 8 2 9 1 July 2004 Phone Marital Status Sex Religion Race 1 Ten digit telephone number including area code no hyphens may be blank enter 0 s for no phone NNN Q i N O N SINGLE MARRIED SEPARATED DIVORCED WIDOWED UNKNOWN MALE FEMALE HERMAPHRODITE TRANSSEXUAL UNKNOWN Two digit code see Appendix G 01 02 03 04 05 06 07 08 09 10 11 12 13 14 20 21 22 25 26 27 28 30 31 32 90 96 97 98 99 WHITE BLACK AMERICAN INDIAN ALEUTIAN OR ESKIMO CHINESE JAPANESE FILIPINO HAWAIIAN KOREAN ASIAN INDIAN PAKISTANI VIETNAMESE LAOTIAN HMONG KAMPUCHEAN CAMBODIAN THAI MICRONESIAN NOS CHAMORRO GUAMANIAN NOS POLYNESIAN NOS TAHITIAN SAMOAN TONGAN MELANESIAN NOS FIJI ISLANDER NEW GUINEAN OTHER SOUTH ASIAN
85. therapy typically is administered orally intravenously or intracavitarily and sometimes topically or by isolated limb perfusion The drugs are frequently given in combinations that are referred to by acronyms or protocols Do not record the protocol numbers alone Two or more single agents given at separate times during the first course of cancer directed therapy are considered to be a combination regimen VL4 1 NAMES OF CHEMOTHERAPEUTIC AGENTS In the text field record the generic or trade names of the drugs used for chemotherapy Include agents that are in the investigative or clinical trial phase See the SEER Self Instructional Manual Jor Tumor Registrars Book 8 3rd ed 1994 for a comprehensive list of chemotherapeutic agents in use at the time of its publication VL4 2 CHEMOTHERAPY CODES Use the following codes for recording chemotherapy in the Summary field Use codes 00 87 for recording chemotherapy in the At This Hospital field 00 NONE CHEMOTHERAPY WAS NOT PART OF THE PLANNED FIRST COURSE OF THERAPY DIAGNOSED AT AUTOPSY 01 CHEMOTHERAPY NOS 02 SINGLE AGENT CHEMOTHERAPY 03 MULTIAGENT CHEMOTHERAPY ADMINISTERED AS FIRST COURSE THERAPY 82 CHEMOTHERAPY WAS NOT RECOMMENDED ADMINISTERED DUE TO CONTRAINDICATIONS 85 CHEMOTHERAPY NOT ADMINISTERED BECAUSE THE PATIENT DIED March 2005 Page 141 86 87 88 99 First Course of Treatment Chemotherapy CHEMOTHERAPY WAS NOT ADMINISTERED IT WAS RECOMMENDED BY THE PAT
86. thplace is entered separately see Section IIL2 12 In the Spanish Hispanic Origin field enter one of the following codes NON SPANISH NON HISPANIC MEXICAN including Chicano NOS PUERTO RICAN CUBAN SOUTH OR CENTRAL AMERICAN except Brazilian OTHER SPECIFIED SPANISH ORIGIN includes European excludes DOMINICAN REPUBLIC for cases diagnosed January 1 2005 forward SPANISH NOS HISPANIC NOS LATINO NOS There is evidence other than surname or maiden name that the person is Hispanic but he she cannot be assigned to any category of 1 5 7 SPANISH SURNAME ONLY only evidence of person s Hispanic origin is surname or maiden name and there is no contrary evidence that the person is not Hispanic 8 DOMINICAN REPUBLIC for cases diagnosed on or after January I 2005 9 UNKNOWN WHETHER SPANISH OR NOT OQ ON The primary source for coding is an ethnic identifier stated in the medical record If the record describes the patient as Mexican Puerto Rican or another specific ethnicity or origin included in codes 1 to 5 enter the appropriate code whether or not the patient s surname or maiden name is Spanish If the patient has a Spanish surname but the record contains information that he or she is not of Hispanic origin use code 0 Non Spanish American Indians and Filipinos frequently have Spanish surnames but are not considered to be of Spanish origin in the sense meant here Enter code 0 for Portuguese and Brazil
87. y WITH gross excision of lesion 29 Trachelectomy removal of cervical stump cervicectomy Any combination of 20 24 26 27 or 29 WITH 21 EHlectrocautery 22 Cryosurgery 23 Laser ablation or excision 25 Dilatation and curettage endocervical curettage for in situ only 28 Loop electrocautery excision procedure LEEP Specimen sent to pathology from surgical events 20 29 Total hysterectomy simple pan WITHOUT removal of tubes and ovaries Total hysterectomy removes both the corpus and cervix uteri and may also include a portion of vaginal cuff Total hysterectomy simple pan WITH removal of tubes and or ovary Total hysterectomy removes both the corpus and cervix uteri and may also include a portion of vaginal cuff 50 Modified radical or extended hysterectomy radical hysterectomy extended radical hysterectomy 51 Modified radical hysterectomy 52 Extended hysterectomy 53 Radical hysterectomy Wertheim procedure 54 Extended radical hysterectomy July 2003 Q 2 29 Surgery Codes CERVIX UTERI C53 0 C53 9 Except for M 9750 9760 9764 9800 9820 9826 9831 9920 9931 9964 9980 9989 60 Hysterectomy NOS WITH or WITHOUT removal of tubes and ovaries 61 WITHOUT removal of tubes and ovaries 62 WITH removal of tubes and ovaries 70 Pelvic exenteration 71 Anterior exenteration Includes bladder distal ureters and genital organs WITH their ligamentous attachments and pelvic lymph nodes NOTE Do not code removal of pelv
88. yeloma or Waldenstrom s macroglobulinemia serum alpha fetoprotein AFP for liver cancer and other tumor marker studies Record T and B cell marker studies on leukemias and lymphomas but enter hematology reports for leukemia and myeloma under Pathology In leukemia cases where both bone marrow and chromosomes are analyzed the bone marrow results take precedence in coding histologic type see Section IV 2 unless more specific information is given in the cytogenetic report Subcategories of acute myeloid leukemia are described according to cytogenetic abnormalities If these abnormalities are included in a laboratory report they take precedence in coding histologic type The chromosome study or cytogenetic and molecular biological data results can be recorded here Enter none if no pertinent laboratory tests were performed IV 1 6 OPERATIVE FINDINGS Record dates names and relevant findings of diagnostic surgical procedures such as biopsies dilation and curettage D amp C and laparotomy For definitive surgery entered under treatment see Section VI 2 1 9 record pertinent findings Note tumor size if given and any statements about observed nodes even if they are not involved IV 1 7 PATHOLOGY Record all tumor related gross non microscopic and microscopic cytologic and histologic findings see Section V 3 3 whether positive or negative and include differentiation For details about microscopic diagnoses see Section IV 2 for g

2005 Replacement Pages - California Cancer Registry

Contents

Download Pdf Manuals

Related Search

Related Contents