Reporting Pathology Protocols Reporting Pathology Protocols for Colorectal Cancerfor Colorectal Cancer

2005 NAACCR Conference: June 9, 20052005 NAACCR Conference: June 9, 2005

Ken Gerlach: CDCKen Gerlach: CDC--NPCRNPCRBette Smith: Ohio Cancer RegistryBette Smith: Ohio Cancer Registry

Kathleen DavidsonKathleen Davidson--Allen: PHI/California Allen: PHI/California Cancer RegistryCancer Registry

PurposePurposeEncourage standard exchange of data between Encourage standard exchange of data between two key public health partners two key public health partners

Anatomical Pathology LaboratoriesAnatomical Pathology Laboratories

Cancer Registries: California and OhioCancer Registries: California and Ohio

Evaluate the use of national data standards to Evaluate the use of national data standards to transmit data: HL7 with LOINC/SNOMED CTtransmit data: HL7 with LOINC/SNOMED CT

Evaluate completeness, timeliness, and quality Evaluate completeness, timeliness, and quality of cancer checklists with textof cancer checklists with text--based narrative based narrative reportsreports

CollaboratorsCollaboratorsState and hospital cancer registriesState and hospital cancer registriesCancer registry information system vendorsCancer registry information system vendorsPathologists and pathology labsPathologists and pathology labsAnatomical pathology laboratory information Anatomical pathology laboratory information system vendors (AP LIS)system vendors (AP LIS)College of American Pathologists (CAP)College of American Pathologists (CAP)

Principal organization of boardPrincipal organization of board--certified certified pathologistspathologists

SNOMED International SNOMED International Experts in vocabulary and messaging standardsExperts in vocabulary and messaging standards

Colon and Rectum Cancer Colon and Rectum Cancer ChecklistChecklist

Colon and RectumColon and RectumProtocol applies to all invasive carcinomas Protocol applies to all invasive carcinomas of the colon and rectum. Carcinoid tumors, of the colon and rectum. Carcinoid tumors, lymphomas, sarcomas, and tumors of the lymphomas, sarcomas, and tumors of the vermiform appendix are excluded.vermiform appendix are excluded.

Protocol revision date: January 2004Protocol revision date: January 2004Based on AJCC/UICC TNM, 6th editionBased on AJCC/UICC TNM, 6th edition

ProceduresProcedures• Incisional Biopsy (No Accompanying Checklist)• Incisional Biopsy (No Accompanying Checklist)• Excisional Biopsy, Polypectomy• Excisional Biopsy, Polypectomy• Local Excision (Transanal Disk Excision)• Local Excision (Transanal Disk Excision)• Segmental Resection• Segmental Resection• Rectal Resection (Low Anterior Resection; Abdominoperineal Res• Rectal Resection (Low Anterior Resection; Abdominoperineal Resection)ection)

Colon and Rectum Cancer Colon and Rectum Cancer ChecklistChecklist

COLON AND RECTUM: PolypectomyCOLON AND RECTUM: PolypectomyPatient name:Patient name:Surgical pathology number:Surgical pathology number:

Note: Check 1 response unless otherwise indicated.Note: Check 1 response unless otherwise indicated.MACROSCOPICMACROSCOPIC

Tumor SiteTumor Site___ Cecum___ Cecum___ Right (ascending) colon___ Right (ascending) colon___ Hepatic flexure___ Hepatic flexure___ Transverse colon___ Transverse colon___ Splenic flexure___ Splenic flexure___ Left (descending) colon___ Left (descending) colon___ Sigmoid colon___ Sigmoid colon___ Rectum___ Rectum___ Not specified___ Not specified

SNOMED CT Encoded CAP SNOMED CT Encoded CAP ChecklistChecklist

TUMOR SITETUMOR SITE [R[R--0025A, 371480007] Tumor site (observable entity)0025A, 371480007] Tumor site (observable entity)___ Cecum ___ Cecum [T[T--59100, 32713005] Cecum structure (body structure)59100, 32713005] Cecum structure (body structure)______ Right (ascending) colon Right (ascending) colon [T[T--59400, 51342009] Right colon structure 59400, 51342009] Right colon structure

(body structure)(body structure)___ Hepatic flexure ___ Hepatic flexure [T[T--59438, 48338005] Structure of right colic flexure 59438, 48338005] Structure of right colic flexure

(body structure)(body structure)___ Transverse colon ___ Transverse colon [T[T--59440, 485005] Transverse colon structure (body 59440, 485005] Transverse colon structure (body

structure)structure)___ Splenic flexure ___ Splenic flexure [T[T--59442, 72592005] Structure of left colic flexure 59442, 72592005] Structure of left colic flexure

(body structure)(body structure)___ Left (descending) colon ___ Left (descending) colon [T[T--59450, 55572008] Left colon structure 59450, 55572008] Left colon structure

(body structure)(body structure)___ Sigmoid colon ___ Sigmoid colon [T[T--59470, 60184004] Sigmoid colon structure (body 59470, 60184004] Sigmoid colon structure (body

structure)structure)___ Rectum ___ Rectum [T[T--59600, 34402009] Rectum structure (body structure)59600, 34402009] Rectum structure (body structure)___ Not specified ___ Not specified [T[T--59000, 14742008] Large intestinal structure (body 59000, 14742008] Large intestinal structure (body

structure)structure)

Cancer Protocols Project WorkflowCancer Protocols Project WorkflowLaboratory System Hospital Cancer Registry Central Cancer Registry

Receive Specimen from Surgeon

Prepare and Analyze Specimen

Input Data into CAP Checklist

Transmit Checklist

To physician

Receive Report______________________Exit/Send acknowledgement

Format Checklist: National Standards

Receive Report______________________Exit/Send acknowledgement

Cancer?

Yes

California: Quality/Accuracy California: Quality/Accuracy MeasureMeasure

Does using the checklist format enhance the Does using the checklist format enhance the quality of the data?quality of the data?

Process: Using narrative pathology reports from Process: Using narrative pathology reports from the previous year, complete a checklist for each the previous year, complete a checklist for each reportreport

Analysis: Identify the data items on the checklist Analysis: Identify the data items on the checklist that could not be completed using the narrative that could not be completed using the narrative

California Preliminary ResultsCalifornia Preliminary Results

Analysis: Identify data items on checklist Analysis: Identify data items on checklist that could not be completed using narrative that could not be completed using narrative

Resection Checklist (N=50):Resection Checklist (N=50):

17 required data items 17 required data items –– 96% were completed96% were completed

13 non13 non--required data items required data items –– 63% were 63% were completedcompleted

Resection Checklist Resection Checklist –– Items Items Unable to be CodedUnable to be Coded

4.04.03535TotalTotal0.90.988Other Other

0.90.988Venous (Large Vessel) Venous (Large Vessel) InvasionInvasion

0.90.988Lymphatic (Small Vessel) Lymphatic (Small Vessel) InvasionInvasion

1.31.31111Specify Margin (Orientation Specify Margin (Orientation by Surgeon)by Surgeon)

PercentagePercentageNumberNumberChecklist ConceptChecklist Concept

N = 50

Number of Reports by Missing Number of Reports by Missing Data ItemsData Items

1001005050TotalTotal

221144442233

16168822

18189911

60603030NoneNone

PercentagePercentageNumberNumberMissing Required Data Missing Required Data ItemsItems

California: Quality/AccuracyCalifornia: Quality/AccuracyAre the codes generated for certain data Are the codes generated for certain data items from the CAP checklist as accurate as items from the CAP checklist as accurate as the codes produced by cancer registry staff?the codes produced by cancer registry staff?

Process: Compare cancer registrar staff coded Process: Compare cancer registrar staff coded data items with the synoptic reports created by data items with the synoptic reports created by the pathologist: primary site, histology, and the pathologist: primary site, histology, and AJCC staging (T and N only)AJCC staging (T and N only)

Analysis: Compare data items using 15 reports.Analysis: Compare data items using 15 reports.

California Preliminary Result California Preliminary Result ––Histologic TypeHistologic Type

Cancer Registrar Codes from NarrativeCancer Registrar Codes from Narrative3 Cases: Adenocarcinoma arising in an adenoma3 Cases: Adenocarcinoma arising in an adenoma

2 2 –– Adenocarcinoma arising in a tubulovillous adenoma Adenocarcinoma arising in a tubulovillous adenoma (8263/3)(8263/3)1 1 –– Adenocarcinoma in a tubular adenoma (8210/3)Adenocarcinoma in a tubular adenoma (8210/3)

Pathologist Codes from ChecklistPathologist Codes from Checklist3 3 -- Adenocarcinoma (8140/3)Adenocarcinoma (8140/3)

1 1 –– Contained the more specific code in a narrative Contained the more specific code in a narrative sectionsection

Ohio Evaluation MeasuresOhio Evaluation Measures

Completeness/QualityCompleteness/Quality::Lab/OCISS Assessment of Quality, CompletenessLab/OCISS Assessment of Quality, Completeness

Physician Assessment of Quality Physician Assessment of Quality

Pathologists Assessment of QualityPathologists Assessment of Quality

Timeliness:Timeliness:Survey pathology staff and cancer registrars entering Survey pathology staff and cancer registrars entering data to determine time saved by using checklistsdata to determine time saved by using checklists

Ohio Data Field Quality ReviewOhio Data Field Quality Review

Primary Site, Histology, Grade, Stage (TNM)Primary Site, Histology, Grade, Stage (TNM)ProcessProcess

Two Certified Cancer Registrars coded four data Two Certified Cancer Registrars coded four data items from retrospective narrative pathology reportsitems from retrospective narrative pathology reports

Cerner sent the HL7 messages to Rocky MountainCerner sent the HL7 messages to Rocky Mountain

Rocky converted to the NAACCR format and sent a Rocky converted to the NAACCR format and sent a line listing for each case to the OCISSline listing for each case to the OCISS

OCISS staff compared the registrars coded data and OCISS staff compared the registrars coded data and the checklist datathe checklist data

•• OCISS staff coded site/type, histology, grade, stage from 76 OCISS staff coded site/type, histology, grade, stage from 76 narrative pathology reportsnarrative pathology reports

••These codes were compared to the Checklist output These codes were compared to the Checklist output

••Discrepancies found included:Discrepancies found included:

15 site (19.7%)………. Location of tumor15 site (19.7%)………. Location of tumor

20 histology (26.2%)… Tumor “arising in” issues20 histology (26.2%)… Tumor “arising in” issues

2 grade (2.6%) ……... 2 or 4 grading system2 grade (2.6%) ……... 2 or 4 grading system

10 stage (13.2%)………Conversion had two digit T 10 stage (13.2%)………Conversion had two digit T

47 total (15.5%) (47 / 304 chances for discrepancies)47 total (15.5%) (47 / 304 chances for discrepancies)

Ohio IdentifiedOhio Identified DiscrepanciesDiscrepancies:

Ohio TimelinessOhio Timeliness

Survey physicians, pathologists and Survey physicians, pathologists and registrars to determine if the checklist report registrars to determine if the checklist report would save time. would save time.

Timed studies not performedTimed studies not performed

An Ad hoc survey was conducted in four An Ad hoc survey was conducted in four hospitals and OCISS staff hospitals and OCISS staff

Unanimous agreement that the checklist format saves Unanimous agreement that the checklist format saves timetime

Ohio Unresolved IssuesOhio Unresolved IssuesHL7 messages contained a 2HL7 messages contained a 2--digit pT category digit pT category

Discrepancy between Checklist pT codes and Discrepancy between Checklist pT codes and AJCC Cancer Staging Manual AJCC Cancer Staging Manual

NeuroendocrineNeuroendocrine tumor, transfer was texttumor, transfer was textOther (specify) has no associated codeOther (specify) has no associated codeNeeds human interventionNeeds human intervention

HL7 message for 2 records for HL7 message for 2 records for pTpNpTpN stagestagewas blankwas blank

Need Need intrafieldintrafield editedit

Lessons Learned Lessons Learned -- QuestionsQuestionsNot all procedures or cancers included in the Not all procedures or cancers included in the Colorectal Checklists Colorectal Checklists

Incisional Biopsy Incisional Biopsy –– not includednot includedIn In situssitus, , carcinoidscarcinoids, sarcomas, lymphomas , sarcomas, lymphomas -- not includednot includedCannot use exclusively for caseCannot use exclusively for case--findingfinding

Checklists evolved: e.g. Checklist Identifier, Type of Checklists evolved: e.g. Checklist Identifier, Type of Polyp Polyp pTpNpTpN Stage DifferencesStage DifferencesWhat type of text? Clinical History? What type of text? Clinical History? Loss of histology, lymph node chain specificityLoss of histology, lymph node chain specificity

Acknowledgements: Project TeamAcknowledgements: Project TeamCaliforniaCalifornia

Kathleen DavidsonKathleen Davidson--Allen, Allen, PHI/California Cancer PHI/California Cancer RegistryRegistryBarry Gordon, C/NeXT Barry Gordon, C/NeXT Software Software –– LOINC Clinical LOINC Clinical CommitteeCommitteeLinda Jund, Linda Jund, LouellaLouellaHerrmann, Fritz Lin, Herrmann, Fritz Lin, University of California, IrvineUniversity of California, Irvine

OhioOhioMichele Connors, Zeke Michele Connors, Zeke Holland, Linda Coles, Mark Holland, Linda Coles, Mark Jordan, and Dieter Thum, Jordan, and Dieter Thum, Cerner CorporationCerner CorporationLarry Derrick, Rocky Larry Derrick, Rocky Mountain Cancer Data Mountain Cancer Data SystemSystem

Ohio (continued) Ohio (continued) Georgette Haydu and Bette Georgette Haydu and Bette Smith, OCISSSmith, OCISSPat Patterson, Mary Abbuhl, Pat Patterson, Mary Abbuhl, Joseph Willis, University Joseph Willis, University Hospitals of ClevelandHospitals of Cleveland

SNOMEDSNOMEDMary Kennedy, Monique van Mary Kennedy, Monique van Berkum, and John Kilborne, Berkum, and John Kilborne, SNOMED InternationalSNOMED International

CDCCDC--NPCRNPCRWarren Williams, Ken Warren Williams, Ken Gerlach Gerlach