abstracting a cancer case · rx text radiation #2620 •date radiation treatment began and ended...

Abstracting a Cancer Case

Texas Cancer Registry

Objectives

By the end of this training, you should be able to:• Describe the types of information commonly

contained in most medical records.• Identify frequently used forms, records, notes, and

summary sheets that may be found in a facility's medical record.

• Describe how medical records are organized.• Describe the types of cancer cases that must be

abstracted, when they should be abstracted, and how to abstract tumor registry information.

• Abstract the pertinent information from a medical record.

5/8/2019 Texas Cancer Registry | Abstracting a Cancer Case 2

Reportable Cancer Cases

• All neoplasms with a behavior code of /2 (in situ) or /3 (malignant) in the ICD-O-3, with some exceptions.

• All primary tumors with a behavior code of /0 (benign), /1 (borderline), or /3 (malignant) occurring in any of the following sites:

• Meninges (C700-C709), brain (C710-C719), spinal cord (C720), cauda equina (C721), cranial nerve or nerves (C722-C725), or any other part of the central nervous system (CNS) (C728- C729)

• Pituitary gland (C751), craniopharyngeal duct (C752), or pineal gland (C753)

• Refer to the 2017 Cancer Reporting Handbook for reportabilityand casefinding methods.

• Any patient with active disease and/or receiving cancer-directed therapy in Texas must be reported to the TCR regardless of the patient’s state or country of residence.


When to Abstract Cases

• An abstract cannot be completed until all the pertinent reports are filed in the medical record.

• All reportable cancer cases should be abstracted and submitted within six months of initial diagnosis or admission.

• Efforts should be made to capture all available information on first course of treatment received.

• The medical record should contain various diagnostic and treatment reports.

• Treatment may be continued over a period of weeks or months. It might cover more than one admission to your hospital or more than one visit to the out-patient department.

• Some treatment which should be incorporated into the registry record may be administered at another institution, on an out-patient basis, or in the physician's office.


Abstracting Diagnostic Procedures

Certain diagnostic examinations are used to determine the presence or absence of cancer. Depending on the necessary tests, findings may appear on report types such as hematology, pathology, cytology, radiology, or endoscopy.

Always record certain basic information:• Date of the test/procedure• Name of the test/procedure• Results of the test/procedure (i.e., all pertinent positive or

negative information)• Diagnostic impression (if available)


Clinical Examinations

Clinical exams include:• Physical Examination• Radiologic Examination—Plain Films• Computerized (Axial) Tomography (CT

and ECT)• Diagnostic Nuclear Medicine• Magnetic Resonance Imaging• Hematologic Examination


Pathological Examinations

The most accurate ways of diagnosing cancer are: • microscopic examination of tissues

removed from site of suspected cancer• microscopic examination of cells contained

in fluid which bathes suspected site

Both the operative reports and the pathologic reports should be reviewed by the tumor registry abstractor.


Types of Reports to Review

• Medical Imaging• Physical Exams, History & Physicals• Pathology Reports• Operative Reports• Discharge Summaries• Clinical Notes• Progress Reports• Lab Results• Autopsies


How to Abstract Cancer Registry Information

• Certain information is basic to any abstract, such as the medical record number, diagnosis, date of diagnosis, age, sex, race, treatment, date of last follow-up, and status of the patient at last follow-up.

• For a detailed list of information requirements for a cancer registry, refer to the Facility Oncology Registry Data Standards (FORDS) manual on the Commission on Cancer website.https://www.facs.org/quality-programs/cancer/ncdb/registrymanuals/cocmanuals


https://www.facs.org/quality-programs/cancer/ncdb/registrymanuals/cocmanuals

Text Documentation Guidelines

• Specific information about metastatic spread of disease to lymph nodes and/or other organs & tissues at time of DX

• Patient demographic information (age at diagnosis, race, and sex)

• Patient height and weight

• Where cancer was found if the primary site is unidentified


Height and Weight Guidelines

• Height• 2 digit code• Measured in inches

• Weight• 3 digit code• Pounds• If less than 100 lbs, lead with 0 (95 lbs as 095)

• Rounding rule for height or weight ending in .5:• Round down if whole number is even• Round up if whole number is odd• Examples: 62.5” rounds down to 62”; 155.5 lbs rounds

up to 156 lbs.

• These data items cannot be left blank

• Code 99/999 if Unknown


Lymph Node Involvement Terms

5/8/2019 Texas Cancer Registry | SEER Summary Staging 12

Lymph Node Involvement

Tumor Terms

Solid TumorsFixed, matted, mass in the mediastinum, retroperitoneum and /or mesentery

Lung only*Palpable, enlarged, visible swelling, shotty,lymphadenopathy

Lymphoma Any mention of lymph nodes

Lymph nodes described with “no involvement” terms should be ignored unless there is a physician’s statement of involvement (clinical or pathological). *SEER Summary Staging ONLY; not true for AJCC

No Lymph Node Involvement

Tumor Terms

Any Tumor (except lung)

Palpable, enlarged, visible swelling, shotty,lymphadenopathy

Important Terminology

• Venous Invasion – assessment of blood vessels within primary organ. Does not constitute regional or distant spread of malignancy.

• Lymphatic Invasion – microscopic assessment of involvement of lymphatic channels within primary organ & resection margins

• Residual Tumor – refers to status of margins after surgical procedure of primary site. Document this information if it is available in the pathology and/or operative report

• Microscopic residual tumor – identified by the pathologist through the microscope but is not grossly visualized


Other Pertinent Data


Text Suggestions Example

Other Pertinent Data #2680

• Age, sex and race of patient• Spanish/Hispanic Origin• Place of birth• Country of Birth• Insurance/primary payer

information• Name of Follow Up Physician• Unknown demographic information

(unknown SS#, unknown address at diagnosis)

• Overflow or problematic coding issues

56 y/o white male, Hispanic, Born in Puerto Rico, Medicaid, F/U Physician Dr. Grady, Unknown SSN ** Other treatment : blinded clinical trial for melanoma of the scalp, HX of diabetes II, BPH, HBP

Other Primary Tumor and Summary Stage Documentation



Other Primary Tumor #2220

• Site of other primary• Morphology of other primary• Diagnosis date of other primary

6/15/15 pt dx with colon cancer rectosigmoid; adenocarcinoma, poorly differentiated

Summary Stage Documentation #2600

• Date(s) of procedure(s) including biopsies and clinical procedures that provide staging information such as x-rays

• Organs involved by direct extension • Size of tumor • Status of margins • Number and sites of positive lymph

nodes • Metastatic sites • Physician’s specialty (Surgeon,

Oncologist, etc.) • Physician’s comments

Per path: Size = 2.5 cm, margins neg. 03/22 LNS pos for adenoca; wedge bx of liver posfor mets.

Summary Stage Documentation –Physical Exam & X-ray/Scan



Summary Stage Documentation – PE #2520

• Date of diagnosis• History relating to cancer diagnosis• Impression pertaining to cancer

diagnosis• Positive and negative clinical findings• Palpable lymph nodes• Treatment plan

05/17/15 60 Y/O WF with bxproven Rt breast CA at Titusville Cancer Center on 04/02/15; thyroid ca dx/tx1980. Rt Breast : 3cm mass LIQ; prominent skin retraction, Lt breast WNL; Axillae: neg; Imp: CA Rt breast; Plan Rtbreast mastectomy

Summary Stage Documentation – X-ray/Scan #2530

• Date and type of X-ray or Scan• Primary site• Histology (if given)• Tumor location• Tumor size• Lymph nodes• Record positive and negative findings• Distant disease or mets

05/23/15 CXR:Neg

06/24/15 CT Chest, abd, pelvis: Osseous lsn of a rib c/w mets: mediastinum: no LAD; no pulm nodules

Summary Stage Documentation –Scopes and Lab Tests



Summary Stage Documentation – Scopes #2540

• Dates of endoscopic exams• Primary site• Histology• Tumor location• Tumor size• Site and type of endoscopic biopsy• Positive and negative clinical findings

07/04/2015 C’scope/bx 5cm sessile mass in cecum

08/04/2015 Cysto: Golf-ball size bladder tumor Lt side of bladder close to trigone area

Summary Stage Documentation – Lab Tests #2550

• Type of lab test/tissue specimen• Both positive and negative findings• Tumor markers, special studies etc.

Including : Estrogen Receptor Assay (ERA), Progesterone Receptor Assay (PRA), Her2/neu, Human Chorionic Gonadotropin (hCG)

• Date of lab tests

12/26/2015 PSA 12.10 (High =; nl <2.5 ng/ml)

01/08/2015 CEA: 1.0 (normal)

Summary Stage Documentation – Operations



Summary Stage Documentation – Op #2560

• Dates and descriptions of biopsies and all other surgical procedures from which staging information was derived

• Number of lymph nodes removed• Size of tumor removed• Documentation of residual tumor• Evidence of invasion of surrounding

areas• Reason primary site surgery could

not be completed

6/15/2015 Hepatic flexure resection with wedge resection of liver lesion: Palpable mass in liver suspicious for malignancy, resected. Palpable lesion in hep flex w/extension through wall. Regional LNs dissected.

Summary Stage Documentation – Pathology



Summary Stage Documentation – Path #2570

• Dates of procedures• Anatomic source of specimen• Type of tissue specimen• Tumor type and grade (include all

modifying adjectives: predominantly, with features of etc.)

• Gross tumor size• Extent of tumor spread• Involvement of resection margin• Number of lymph nodes involved

and examined• Both positive and negative findings• Record any additional comments

from the pathologist, including differential diagnosis considered and any ruled out or favored

3/1/2015 RLL Resection: MD Squamous cell car, 2 nodules 5cm and 0.5cm, margin free, 0/3 peribronchial, paratracheal and pretracheal LNs

Final Diagnosis



Final Diagnosis (Primary, Laterality) #2580

• Location of primary site of tumor• Information on laterality of tumor

UOQ Left Breast

Final Diagnosis (Morphology, Behavior, Grade) #2590

• Morphology/behavior• Grade of tumor

Moderately differentiatedadenocarcinoma

Treatment Text - Surgery


Text Suggestions Examples

Rx Text Surgery #2610

• Date of each surgical procedure • Type(s) of surgical procedure(s),

including surgery to other and distant sites

• Lymph nodes removed • Regional tissues removed • Metastatic Sites • Facility and date for each

procedure • Record positive and negative

findings. Record Positive findings first.

• Reason for no surgery • Other treatment information, e.g.

planned procedure aborted

6/25/15 L MRM w/ALND

7/3/2015 Texas Surgery Center: Resection of sigmoid tumor

5/10/2015 Surgery recommended, but pt refused. Prefers RX w/XRT

Treatment Text – Radiation and Chemotherapy



Rx Text Radiation #2620

• Date radiation treatment began and ended

• Where treatment given• Type(s) of radiation• Planned doses• Other treatment information (e.g.,

discontinued after 2 treatments, unknown if radiation was given)

External beam radiation therapy completed on 6/15/2015, start date not given; estimate start date 5/2015

Rx Text Chemo #2640

• Date chemotherapy began and ended• Where chemo was given• Type of chemo – name of agent(s) and

doses planned/received• Other treatment information (e.g.,

treatment cycle incomplete, unknown if chemo was given)

3/15/2015 Oncologist recommends 4 cycles adjuvant taxol and carboplatin. PT wants treatment closer to home, referred to oncologist in his area, unknown if chemo done.

Treatment Text -Hormone



Rx Text Hormone #2650

• Planned hormone treatment• Date treatment was started• Where treatment was given• Type of hormone or antihormone• Type of endocrine surgery or

radiation• Other treatment Information, e.g.

Treatment cycle incomplete.

1/1/2015-2/1/2015 Prednisone (as part of CHOP)

Treatment Text – Radiation and Chemotherapy



Rx Text BRM Immunotherapy #2660

• Date treatment began• Where treatment was given e.g. at this

facility, at another facility• Planned immunotherapy treatment• BRM procedures, e.g. bone marrow

transplant, stem cell transplant• Type of immunotherapy given• Type of BRM agent, e.g. Interferon, BCG• Other treatment information e.g.

treatment cycle incomplete.

6/15/2015 ABC Cancer Center: started interferon regimen

Rx Text Other #2670

• Date treatment was started• Where treatment was given• Type of other treatment• Other treatment information

(incomplete)

8/7/2015 Phlebotomy

Tumor Size Summary

• Tumor size summary records the most accurate measurement of a solid primary tumor, usually measured on the surgical resection specimen.

• Tumor size is one indication of the extent of disease. As such, it is used by both clinicians and researchers. Tumor size that is independent of stage is also useful for quality assurance efforts.


Selecting Measurement for Tumor Size Summary

• When surgery is first treatment, size is measured on the surgical resection specimen.

• If neoadjuvant therapy is given prior to surgery, do not record the size of the pathologic specimen. Code the largest size of tumor prior to neoadjuvant treatment; if unknown code size 999.

• If there no surgical resection, then the largest measurement of the tumor from physical exam, imaging, or other diagnostic procedures prior to any other form of treatment.

• If the above guidelines do not apply, use the largest size from all information available within four months of the date of diagnosis, in the absence of disease progression.


Tumor Size Summary Estimation Guide

• Tumor size is the diameter of the tumor, not the depth or thickness of the tumor.

• If tumor size is reported as “less than” or “great than” a certain size, code up or down one mm.

• Round the tumor size only if it is described in fractions of millimeters. If the largest dimension is less than 1mm, always round up to 1mm.


Reported Size Coding

< 10mm 009

> 10cm 011

Between 2-3cm 025

.3mm 001

2.2mm 002

3.6mm 004

4.1cm (41mm) 041

Tumor Size Summary Guidelines

• Information on size from imaging/radiographic techniques can be used to code size when there is no more specific size information from a pathology or operative report, but it should be taken as low priority, over a physical exam.

• If there is a difference in reported tumor size among imaging and radiographic techniques, unless the physician specifies which imaging is most accurate, record the largest size in the record, regardless of which imaging technique reports it.

• Always code the size of the primary tumor, not the size of the polyp, ulcer, cyst, or distant metastasis. However, if the tumor is described as a “cystic mass,” and only the size of the entire mass is given, code the size of the entire mass, since the cysts are part of the tumor itself.


Tumor Size Summary Guidelines –In Situ vs Invasive

• If both in situ and invasive components are present and the invasive component is measured, record the size of the invasive component even if it is smaller.

Example: Tumor is mixed in situ and invasive adenocarcinoma, total 3.7 cm in size, of which 1.4 cm is invasive. Record tumor size as 014 (14 mm)

• If the size of the invasive component is not given, record the size of the entire tumor from the surgical report, pathology report, radiology report or clinical examination.

Example A: A breast tumor with infiltrating ductal carcinoma with extensive in situ component; total size 2.3 cm. Record tumor size as 023 (23 mm).

Example B: Duct carcinoma in situ measuring 1.9 cm with an area of invasive ductal carcinoma. Record tumor size as 019 (19 mm).


Recording the Tumor Size Summary

• Record the largest dimension or diameter of tumor, whether it is from an excisional biopsy specimen or the complete resection of the primary tumor.

Example: Tumor is 2.4 x 5.1 x 1.8 cm. Record size as 051 (51 mm).

• Record the size as stated for purely in situ lesions.

• Disregard microscopic residual or positive surgical margins when coding tumor size. Microscopic residual tumor does not affect overall tumor size. The status of primary tumor margins may be recorded in a separate data field.

• Do not add the size of pieces or chips together to create a whole. They may not be from the same location or may represent a small portion of a large tumor. However, if the pathologist states an composite size (determined by fitting the tumor pieces together and measuring the total size), record that size. If the only measurement describes pieces or chips, record tumor size as 999.


Recording the Tumor Size Summary (continued)

• If the tumor is multi-focal or if multiple tumors are reported as a single primary, code the size of the largest invasive tumor. If all of the tumors are in situ, code the size of the largest in situ tumor.

• Tumor size code 999 is used when size is unknown or not applicable.

Sites/morphologies that aren’t applicable are hematopoietic, reticuloendothelial, and myeloproliferative neoplasms (histology codes 9590- 9992), Kaposi sarcoma, melanoma choroid, melanoma ciliary body, and melanoma iris

• Document the information to support coded tumor size in the appropriate text field of the abstract.


Abbreviations

A list of abbreviations is available in Appendix G of NAACCR Volume II: Data Standards and Data Dictionary.http://datadictionary.naaccr.org/?c=17


http://datadictionary.naaccr.org/?c=17

Context-Sensitive Abbreviations


Summary

You should now be able to:• Describe the types of information commonly

contained in most medical records.• Identify frequently used forms, records, notes, and

summary sheets that may found in a facility's medical record.

• Describe how medical records are organized.• Describe the types of cancer cases that must be

abstracted, when they should be abstracted, and how to abstract tumor registry information.

• Abstract the pertinent information from a medical record.


Thank you

5/8/2019Texas Cancer Registry | Abstracting a

Cancer Case35

abstracting a cancer case · rx text radiation #2620 •date radiation treatment began and ended...

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