S02 D.9 ER 5 CANCER REGISTRY POLICY AND PROCEDURE.docx

Attachment D.9 36C25522Q0114

CANCER REGISTRY POLICY AND PROCEDURE: September 20, 2017

DEPARTMENT OF VETERANS AFFAIRS MEDICAL CENTER

4801 E. Linwood Boulevard Kansas City, Missouri 64128

September 20, 2017

CANCER REGISTRY POLICY AND PROCEDURE

1. PURPOSE: To establish a policy and procedure manual to comply with current Commission on Cancer data definitions and coding instructions used to describe all reportable cases.

2. POLICY:

a. PRINCIPAL DUTIES AND RESPONSIBILITIES

The Tumor Registry's principal function in accordance with standards set forth by the American College of Surgeons (ACoS) is to contribute to the overall objectives and efficient operation of the Kansas City VA Cancer Program through the collection, organization and maintenance of an efficient system of data. Its retrieval, analysis, dissemination and use, will assist in reducing the morbidity and mortality of patients diagnosed and treated for cancer at this facility and will improve the quality of cancer care. The Kansas City VA Cancer Program reference date is July 1988 and became an ACoS approved program in 1990. The registry has been staffed internally since the inception of the program.

The goals of the Kansas City VA Cancer Program are to promote cancer prevention and screening, to decrease the morbidity and mortality of patients with cancer and to improve the quality of cancer care. These goals will be pursued by encouraging a comprehensive approach to cancer prevention and therapy, including cancer screening, pretreatment evaluation and staging, multidisciplinary therapy, rehabilitation, and appropriate follow-up. The Cancer Program provides a forum for interdisciplinary communication and interaction and ensures that patients receive the highest quality care.

The Cancer Registry Manager oversees the development, use and maintenance of the Kansas City VA cancer registry database and ensure that it meets the needs of physicians, administrators, and planners. The Cancer Registry Manager also protects the patients’ rights to privacy and complies with ethical and legal requirements of the health care delivery system.

The Cancer Registry staff collects, manages, analyzes, and disseminates information on all cancer patients diagnosed or treated at the Kansas City VA. The Registry also collects information on patients in accordance with the state cancer registry requirements. The data collected are used to assist in evaluating diagnostic and therapeutic efforts and to assess the quality of care provided to cancer patients.

1) The primary functions of the Cancer Registry are:

a) To register all patients with malignant neoplasms, benign tumors of the brain and central nervous system and other reportable neoplasms.

b) To conduct lifetime follow-up on patients with invasive cancers.

c) To provide cancer information to staff physicians, hospital administrators, and researchers (local, state and national).

d) To submit cases to the National Cancer Data Base (NCDB) Call for Data. RQRS data submission is sent quarterly as of 8/3/2016

2) The duties and responsibilities of the Tumor Registrar encompass:

a) Data Collection

i. The initiation of procedures for identification of all malignant disease from records, reports, listings, and data files of the various departments and clinics of this facility.

ii. The synthesis of data abstracted from patients' medical records including demographic characteristics, history of cancer, diagnostic procedures, principal diagnoses, the extent of disease, stage of disease, treatment, and follow-up after treatment and discharge.

iii. The procurement of end-results information on all patients diagnosed with cancer. A request log for data research was created in 2005. A spreadsheet contains the researcher’s name, reason for request and date of request.

b) Data Management

i. The organization and maintenance of an efficient data system which is responsible to the needs of end users.

ii. The maintenance of confidentiality and security of patient data stored within the tumor registry files.

iii. The knowledge of various surgical, radiological, chemical and hormonal modalities of cancer therapy and the ability to distinguish between primary and secondary treatment, and definitive, palliative, and supportive therapy.

iv. The knowledge of tumor nomenclature and classification systems and the ability to code topography and morphology of accessioned tumor cases.

v. The preparation of a procedure manual detailing all operations of the tumor registry, and the annual review of this material with the Cancer Committee in order to reflect current practices and procedures. The DHCP Oncology Package 2.11 manual will maintain continuity in the registry; the manual gives detailed information on how to initiate and terminate computer operations, instructions for performing routine tasks, a description of possible conditions and operator responses; backup procedures, and other measures which can be taken to prevent loss of data.

vi. The development and maintenance of quality control procedures for case finding, abstracting, coding, follow up and data processing.

vii. The design of requisite forms for collecting, processing and analyzing data.

c) Data Retrieval and Analysis

i. The compilation of procedures for manual retrieval of tumor registry information and updating of such procedures to reflect current methodology.

ii. The acquisition of data and dissemination of information processed by the Tumor Registrar in the form of routine and special statistical reports which summarize a particular facet of patient diagnosis and cancer care at this Medical Center.

iii. The provision of staff assistance and administrative services to the Cancer Conference Board and the Cancer Committee for meetings and special projects.

iv. Assistance to the Cancer Committee in the formulation of relevant, understandable, and measurable criteria for patient care evaluations, identification of total population, selection of sample, analysis of charts and abstracts for measurement of compliance or failure to comply criteria, synthesis and summarization of data. Assist with the determination of action needed and implementation of necessary action.

d) Administration

i. The familiarity with government-wide agency and facility systems and requirements in various administrative areas.

ii. The formulation of short and long-term goals and objectives for improvement of effectiveness and efficiency of the Registry.

iii. The planning and administration of daily operations of the Tumor Registry.

iv. The training and supervision of clerical, work-study and volunteer personnel assigned to the Tumor Registry.

v. The acquisition of equipment, annuals, reference materials, forms and supplies needed for the Registry to function efficiently.

vi. The accurate preparation and control of registry records.

vii. The coordination of annual and administrative leave to ensure the continuity of registry operations.

viii. The coordination of administrative activities with the Cancer Committee to which the registry reports operationally and the coordination of operational activities is the responsibility of the Cancer Program Director

ix. The maintenance of close internal liaison and cooperation with other departments and services within the Medical Center for the attainment of mutual goals and objectives.

x. The maintenance of close external liaison with the ACoS, the medical community, local, state and national professional societies, the National Cancer Institute, Department of Health and Human Affairs, other local, state and VA hospitals.

e) Training and Education

i. The orientation of medical staff, medical records personnel, appropriate new employees and volunteers to the activities and purpose of the Cancer Registry.

ii. The participation in continuing educational activities through attendance at lectures, workshops, meetings, and training programs in order to maintain proficiency and expand skills and knowledge of the craft, and to comply with requirements of the National Cancer Registrars' Association (NCRA) and/or American Health Information Medical Association (AHIMA) to complete continuing education during a two-year cycle in order to maintain certified status.

iii. The acquisition of knowledge, education and skills for automated data input and retrieval in the Tumor Registry, and coordination with data processing management to incorporate the patient data base into a workable program for utilization by the registry in on-line operations for data storage and information retrieval.

f) Confidentiality

Confidentiality and security of patient data should always be maintained. The release of information from the Cancer Registry is in compliance with MCP 00-001PO-005, Privacy, Freedom of Information Act. The use of registry data should be encouraged by hospital staff for staff conferences and for the preparation of manuscripts, reports, studies, etc. These requests will be documented in the request log with the date of request, topic of the report - including the period covered, variable included in the report, person(s) requesting the report, purpose of the report (study, paper, oral presentation), and final disposition of the report (published in medical staff bulletin, presented at Medical Association meeting, etc.)

Precautions to assure confidentiality in the computerized registry must be taken. Access must be restricted to Tumor Registry personnel only. Adherence to MCP 00-001PO-005, Privacy, Freedom of Information, is required including: “All facility staff, to include employees, contractors, students, WOC, volunteers, and any other appointed workforce members, are prohibited from accessing their own records (i.e., CPRS or business records). The records of spouses, relatives, neighbors, friends, significant others etc., must not be accessed unless the individual is directly involved in providing care to the patient, or for official business purposes only. If it is deemed necessary to access the records of individuals identified above, staff are responsible for reporting such access to the Information Security Officer or Privacy Officer.”

Care must be taken in the destruction of the computer print-out listings no longer required; this will be accomplished by shredding. Federal law prohibits disclosure of any patient information to non-VHA facilities. The Kansas City VAMC can only release information to other Federal government facilities. Patient information can be released under the following conditions:

g) Other Significant Factors

i. The Cancer Registrar is responsible for ensuring that the Cancer Registry meets the standards of approval for Cancer Registries set forth by the American College of Surgeons (ACoS) with the understanding of the regulations and standards of this credentialing body.

ii. The Cancer Registry must comply with VA regulations and requirements as well as reconcile any conflicting requirements between this agency and the ACoS.

b. Tumor Registry job description

1) Duties The successful candidate works directly with the Cancer Program Coordinator to plan, organize, actuate, and control all activities in the Tumor Registry. S/he is responsible for providing advisory and technical service to administrative, medical and ancillary professional staff as it relates to the integration of the Cancer Committee policy and procedures, the accreditation standards of the American College of Surgeons Commission on Cancer Program, the VA Oncology Program, and the National Cancer Institute's SEER program. You will abstract, code and maintain Registry Records by searching the medical record to identifying and coding all information pertinent to the patient's diagnosis including demographics, diagnosis, site and histology, diagnostic procedures, extent of disease, and treatment; utilizing coding references to code information contained on forms and documents using specific codes required in a cancer registry. You will perform research and period statistical reports and prepare correspondence; monitor cancer committee processes and procedures to verify compliance. You will also develop and monitor Quality Management and Improvement, Performance Projects and Special Studies to enhance cancer patient care and to meet the requirements of the Commission on Cancer; provide technical advice to clinical staff relative to development and implementation of QM&I projects and assists in the technical portion of the projects; initiate, conduct and facilitate special projects, studies and surveys which improve patient care and support the patient with cancer.

c. Job Requirements Key Requirements

· Must pass pre-employment examination

· Must be proficient in written and spoken English

· Background and-or Security Investigation required Qualifications

BASIC REQUIREMENTS:

· a. U.S. citizenship. Non-citizens may be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy.

· b. Experience and Education

(1) Experience. Two years of experience that demonstrates the applicant’s ability to perform the work, or provides familiarity with the work. Six months of the required 2 years of experience must have provided the knowledge, skills, abilities, and other characteristics (KSAs) needed to perform MRT work.

OR,

(2) Education. Successful completion of an associate’s degree with a major field of study in medical record technology/health information technology which was accredited by the American Health Information Management Association (AHIMA) at the time the program was completed.

OR,

(3) Experience/Education Combination. Equivalent combinations of experience and education are qualifying. The following educational/training substitutions are appropriate in this provision for combining education and experience:

(a) Successful completion of an associate’s degree in a field of study other than medical records/health information will substitute for 18 months of the required experience.

(b) Successful completion of a course for medical technicians, hospital corpsmen, medical service specialists, or hospital training, obtained in a training program given by the Armed Forces or the U.S. Maritime Service under close medical and professional supervision, may be substituted on a month-for-month basis for up to 1 year of experience.

(c) Successful completion of a post-high school course of study in medical record technology, which includes courses in anatomy, physiology, and medical record techniques and procedures, may substitute on a month-for-month basis for up to 1 year of experience.

(d) Successful completion of post-high school courses for medical administrative personnel, obtained in a closely supervised training program given by the Armed Forces, may be substituted for experience on a month-for-month basis for up to 6 months provided the training program included courses in anatomy, physiology, and medical record techniques and procedures.

Specialized Areas for Medical Record Technicians:

Tumor (or Cancer) Registry positions maintain clinical registries and work to meet the standards of regulatory and accrediting agencies related to approved cancer and/or other programs requiring registries. Certification is offered by the National Cancer Registrars Association as a Certified Tumor Registrar (CTR). Certification is highly desired.

GRADE DETERMINATIONS:

GS-6

4. If assigned to medical record analysis, ability to judge whether medical records contain sufficient information for regulatory requirements; are acceptable as legal documents; are adequate for continuity of patient care; and support education and research needs. This includes the ability to take appropriate actions if medical record contents are not adequate; accurate, timely, and/or reliable;

GS-7

a. Demonstrated Knowledge, Skills and Abilities

GS-8

(a) Experience. One year of experience comparable to the next lower grade level for the appropriate assignment area and must fully meet the KSAs at that level.

(b) Assignments. Employees at this grade level will be assigned to a specific area of medical record/health information, e.g., tumor registry, medical coding, or medical records. They may be in lead or supervisory positions, as appropriate to the assignment. Core competencies for the different assignments are listed with the assignment.

1. Tumor Registry Positions. This is considered to be the full performance level for tumor registry assignments. Certification at this grade level is highly desired. In addition, the candidate must demonstrate the following KSAs:

a. Demonstrated Knowledge, Skills, Abilities

(1) Knowledge of chronic disease registration/data basing and specific cancer registration;

(2) Advanced knowledge of medical terminology, staging of cancer, and requirements of external approving organizations;

(3) Knowledge of the design, conduct, and interpretation of case ascertainment, re-abstracting, and quality assurance studies;

(4) Knowledge of cancer committee processes and procedures in order to improve patient care and to verify compliance;

(5) Ability to serve as subject matter expert on cancer program issues for the medical center and Veterans Integrated Service Network (VISN) administration as tasked; and

(6) Ability to manage priorities and coordinate work in order to complete duties in an accurate and timely fashion.

References: VA Handbook 5005/15, Part II, Appendix G35, MEDICAL RECORD TECHNICIAN QUALIFICATION STANDARD, dated March 17, 2006,

c. CANCER REGISTRY OPERATIONS

1) The Cancer Registry serves as a means for collection and utilization of data on patients with diagnoses of cancer, or any benign or questionable tumors which are considered reportable. It is also a function to follow the cancer patient as part of total patient care. A Cancer Registry should be an ACTIVE repository of information about cancer patients.

The Registry is only as valuable as the information it contains, such information being the RESPONSIBILITY OF THE PHYSICIAN through her or his documentation in the medical record as well as her/his follow-up information. The QUALITY of information in the Registry is only as good as what the registrar is able to abstract from the patient's medical record.

The uses of a hospital Cancer Registry are many and varied. One of the main functions is data collection. Physicians, hospitals, community, state and national medical organizations need information on cancer patients. The Cancer Registry is the most basic and logical place to go for this information, as it must collect a variety of information and provide it in a usable and retrievable form. Individual physicians and hospitals use this information to review their own efforts on how well they do at early detection of cancer cases, how frequently, specific treatments are used for different types of cancer, and how effective these treatments are, how long patients survive after incurring various types of cancer, and multiple other clinical questions.

The Registry provides education to the medical student, intern and resident, fellow and specialist to improve their ability to diagnose and treat the cancer patient. It is used for the lifetime follow-up of the cancer patient, as well as providing information for research purposes.

2) When the American College of Surgeons Commission on Cancer surveys a hospital's cancer program, the cancer registry, and clinical cancer program are reviewed in detail. The approvals program is voluntary and a hospital may appeal the decision of the Committee on Approvals. Hospital cancer programs surveyed for approval are charged $9,000.00 for each survey. First-time, three-year approval is granted when the clinical program has been in operation for at least one year, cancer database contains at least two years with one year of successful follow-up, and program meets all criteria for approval at the time of survey. The four major components of a hospital cancer program are weighted equally in the approval process. They are: 1) Cancer Committee, 2) Tumor Boards/Conferences, 3) Eligibility Requirements, and 4) Cancer Registry.

a) This is a fully computerized Cancer Registry and 100% of all data is in the computer. To access the system an access and verify code must be obtained from IRM. The codes are secret.

b) Casefinding is performed at least bi-monthly. To access the casefinding system type SUS, then CF. Running these options automatically enters these cases into the suspense files for abstracting.

c) Add any new cases to the suspense list through option SUS: SE

d) TNM staging forms are to be inserted into the electronic medical record by the abstracting registrar. If the Cancer Staging is not completed by the time of abstracting the registrar identifies the appropriate site and forwards this to the managing physician for completion.

e) Abstracting is done in accordance with FORDS requirements, the ACoS manual of staging requirements, and SEER guidelines. All abstracting is done on-line. Once an abstract is completed ,it is automatically sent to the Central Office cancer database in Washington D.C.

f) The accession register is run monthly, and the patient alphabetical index is also run monthly.

g) The registrar will randomly select 10% of the completed abstracts to be reviewed by a member of the Cancer Committee. The abstracts will be QA'd and results documented on the forms prepared by the registrar.

h) The follow-up list will be run at the beginning of each month using the option FOL, DF. The MAS option, PATIENT INQUIRY will be used to see if the patient is being actively followed or has expired. The list will be used to pull records for a chart review. If no information is available, a letter will be generated.

i) The following options are available in the DHCP system:

i. PATIENT INQUIRY - This is the MAS option for listing patient demographics, appointments, and deaths.

ii. DISPLAY PATIENT APPOINTMENTS: Another MAS option that will list all previous or future appointments, and give disposition of the previous ones.

iii. DETAILED PATIENT INQUIRY: Lists all data related to hospitalizations.

iv. CLINICAL ANATOMY PATHOLOGY: The option CL, CS gives a cumulative summary to determine if the patient has any recurrences or new primaries.

v. SURG/CYTO: Gives pathology results on patients.

j) The following options are available in the CPRS (Computerized Patient Record System):

i. Cover Sheet- contains Active Problems, Allergies, Active Medications, Clinical Reminders, Recent Lab Results, Vitals, Appointments/Visits/Admissions.

ii. Problem List

iii. Medications- current inpatient and outpatient medications.

iv. Orders- recent orders for all disciplines.

v. Notes- progress notes.

d. CASE ELIGIBILITY: To define the criteria for inclusion of a case in the registry database. ACoS, COC, VACCR, the KCVA Cancer Committee and the Cancer Registry designate which cases are eligible and required for complete reporting.

1) Reportable and Non-Reportable Case

a) Reportable Cases: The following list includes those diagnoses that are to be included in the registry. Malignancies with an ICD-O-3 behavior code of 2 or 3 must be included. This behavior code is used to indicate the presence or absence of malignancy. All cases of cancer must be included, even those that are not histologically confirmed; a clinical diagnosis is made if a physician determines that a patient has cancer. When it is questionable which facility should include the patient, the ownership of the medical record is the determining factor. Nonmalignant primary intracranial and central nervous system tumors diagnosed on or after January 1, 2004

a. VA CENTRAL CANCER REGISTRY REPORTABLE LIST

Effective 1/1/2020 Veterans Affairs Central Cancer Registry (VACCR) Reference Date 1/1/1995

Reporting Requirements: VHA Directive 2003-034, National Cancer Strategy VHA Directive 1412, Department of Veterans Affairs Cancer Registry System

All tumors as required by The American College of Surgeons Commission on Cancer (CoC) (see STORE 2018 Manual page 15)

All malignancies with a behavior code of /2 or /3 as listed in the ICD-0 3RD Edition. (https://seer.cancer.gov/icd-o-3/)

All diagnoses that include the terms cancer, carcinoma, malignant, myeloma or lymphoma are reportable.

All leukemias and all sarcomas are reportable.

All Meninges tumors (C70._), Brain tumors (C71._), Spinal Cord, Cranial Nerves and other parts of Central Nervous System tumors (C72._), Pituitary gland tumors (C75.1), Craniopharyngeal duct tumors (C75.2) and Pineal gland tumors (C75.3), with an ICD-O-3 behavior code of 0 or 1 are reportable. (as of 1/2004)

Gastro-intestinal stromal tumors (GIST), malignant and/or if it is noted to have multiple foci, metastasis or positive lymph nodes is reportable. (as of 1/2017)

Thymomas, malignant and/or if it is noted to have multiple foci, metastasis or positive lymph nodes is reportable.

Squamous and basal cell cancers originating in mucoepidermoid sites: Lip (C00.0 – C00.9), Anus (C21.0), Vulva (C51.0 – C51.9), Vagina (C52.9), Penis (C60.0 – C60.9) and Scrotum (C63.2) are reportable.

Intraepithelial Neoplasia, Grade III (8077/2) is reportable. Includes: AIN III, LIN III, VAIN III, VIN III, SIN III (excluding cervix, See Reportable–By-Agreement list for CIN III).

For other Reportable malignant conditions not containing cancer or malignant terms, see Addendum 1.

For the Reportable-By-Agreement list, see Addendum 2.

For the Exclusions, list of Ambiguous Terms and Common Reportable Acronyms, see Addendum 3.

Addendum 1: Reportable conditions not containing cancer or malignant terms: 1/1/2020 Addendum 1: Reportable conditions not containing cancer or malignant terms: 1/1/2020

Continued on next page

Reportable conditions not containing cancer or malignant terms: 1/1/2020 continued from previous page

Neuroendocrine tumor

Pseudomyxoma peritonei

Neuroectodermal tumor (except melanotic)

Queyrat erythroplasia (C60._) 8080/2

Oligodendroglioma, NOS (C71._) 9450/3

Refractory anemia (C42.1)

Osteomyelofibrosis (9961/3)

Refractory cytopenia with multilineage dysplasia 9980/3

Paget disease (except bone)

Refractory neutropenia 9991/3

Pagetoid reticulosis 9700/3

Refractory thrombocytopenia 9992/3

Pancreatoblastoma (C25._) 8971/3

Rhabdoid

Pineal gland, all tumors/neoplasms

Seminoma

Pineal tumor (C75.3) 9362/3

Sertoli-Leydig cell tumor, poorly differentiated or sarcomatoid

Pituitary, all tumors (C75.1)

Sezary disease/syndrome 9701/3

Plasmacytoma

Spinal cord, all tumors/neoplasms (C72.0)

Polycythemia, proliferative, rubra vera, vera, familial

Spindle epithelial tumor with thymus-like differentiation/

9950/3

/element 8588/3

Polyembryoma 9072/3

Thrombocythemia (C42.1) 9962/3

Post transplant lymphoproliferative disorder 9987/3

Waldenstrom macroglobulinemia

(See Reportable-By-Agreement list for 9970/1)

Wilms tumor (C64.9) 8960/3

Precancerous melanosis (C44._)

Yolk sac tumor 9071/3

List of Common Reportable Acronyms

Malignant Peripheral Nerve Sheath Tumor

Primitive Neuroectodermal Tumor

Peripheral Primitive Neuroectodermal Tumor

Refractory Anemia

Refractory Anemia with Excess Blasts

Refractory Anemia with Excess Blasts in Transformation

Refractory Anemia with Ringed Sideroblasts

Skin Associated Lymphoid Tissue

Squamous Intraepithelial Neoplasia, Grade 3

Spindle Epithelial Tumor with Thymus-like Element

See the ICD-O-3 for additional information

Addendum 2: REPORTABLE-BY-AGREEMENT

VA CENTRAL CANCER REGISTRY

REPORTABLE-BY-AGREEMENT

Effective 1/1/2020

1.) Basal cell carcinoma of the skin, with positive lymph nodes or distant metastasis*

2.) Canthus Eyelid (C44.1) (as of 1/1995)

3.) Class of Case 30, 32, 34, 37 and 38 cases** (as of 1/2010)

4.) Class of Case 40 and 41 (Non-VA Medical Care, Choice Program, Fee Basis)

5.) Epithelial carcinoma of the skin, with positive lymph nodes or distant metastasis*

6.) Intraepithelial neoplasia, grade III. The pathology report should state something like “HIGH GRADE DYSPLASIA BORDERING ON IN SITU.

Includes:

Bi IIN III – Biliary 8148/2

CIN III – Cervical 8077/2

7.) Lymphoproliferative, disorder NOS 9970/1 (as of 1/2001)

8.) Mast Cell tumor, NOS 9740/1

9.) Medulloepithelioma, all types 10.) MGUS (Monoclonal Gammopathy of Undetermined Significance) 9765/1 (as of 1/2014)***

11.) PIN III – Prostatic 8148/2 (as of 1/2006)#

12.) Squamous cell carcinoma of the skin, with positive lymph nodes or distant metastasis*

*Malignant primary skin cancers (C44.) with histology codes 8000–8110 and with positive lymph nodes and/or distant metastasis AT DIAGNOSIS - are reportable-by-agreement as of 1/2011. Starting with the 2018 cases, abstract as ACC (Accession Only). (Class of Case 34).

Class of Case 30 thru 38 **Class of Case 30 – Treatment Plan Only – is reportable-by-agreement.

**Class of Case 32 – Disease recurrence or persistence: Reportable-by-agreement when surgery, radiation and/or chemotherapy are given to manage the recurrence/persistence. Not reportable for hospice placement or no treatment.

**Class of Case 34 – Use this code for Reportable-By-Agreement diseases.

**Class of Case 37 – Dx elsewhere and before your reference date and all or part of first course treatment at your facility.

**Class of Case 38 – Cancer diagnosed at AUTOPSY

***MGUS - is reportable-by-agreement. Abstract as ACC (Accession Only), SITE/GP = PLASMA CELL DISORDERS (Class of Case 34)

#Prostatic Intraepithelial Neoplasia, grade III (PIN III) – is reportable-by-agreement. (Class of Case 34) Addendum 3: General Information: 1/2020

Exclusions: 1.) Malignant primary skin cancer (C44.x) with histology codes 8000-8110 are not reportable, except as listed on the Reportable-By-Agreement List.

2.) Cases diagnosed prior to your cancer program Reference Date are not reportable, except for the Class of Cases listed on the Reportable-By-Agreement List.

3.) Borderline colorectal polyps are not reportable.

4.) Non-Analytic cases, except for those listed on the Reportable-By-Agreement List, are not reportable.

Qualifier List: (see STORE 2018 Manual, pages 15 thur 17) Qualifiers (Ambiguous Terms) that Constitute a Diagnosis

Qualifiers (Ambiguous Terms) that DO NOT Constitute a Diagnosis without additional information

Reportable

Not Reportable

*Neoplasm & Tumor (beginning with 2004 diagnoses and only for C70.0 – C72.9, C75.1 – C75.3).

If a CYTOLOGY is identified only with an ambiguous term, do not interpret it as a diagnosis of cancer. See STORE 2018 page 16.

Severe Dysplasia & High Grade Dysplasia - Review with your pathologist and Cancer Committee to determine if your facility should accession and abstract high grade dysplasia and severe dysplasia as in-situ for primary sites ESOPHAGUS, COLON and STOMACH.

Grade Coding Instructions and Tables https://www.naaccr.org/SSDI/Grade-Manual.pdf?v=1548876169

Follow-up - On all eligible analytic cases.

All Cancer programs (accredited and non-accredited) are required by Central Office to maintain 80% follow-up rate on all eligible analytic cases from your cancer registry reference date. A 90% follow-up rate is maintained for all eligible analytic cases diagnosed within the last 5 years or from your cancer registry reference date, whichever is shorter.

Class of Case 00 abstracts are not required to be followed. (If diagnosed at your facility and if it is not known if the patient actually went elsewhere for treatment, it is not a Class of Case 00 for your facility; it is a Class of Case 10 for your facility) See STORE 2018 Manual, page 18.

Class of Case 00 abstracts are not required to be staged.

Nonanalytic cases, Cass of Case 30 – 99, are not required to be followed.

(Addendum 2)

2) Casefinding/Suspense

Casefinding is a systematic method of identifying all reportable cancer cases at this facility. In the automated registry, the process is the same as in a manual registry. The DHCP Oncology Program allows automated searching of the multiple hospital databases both in patient and out patient for cases that meet the eligibility criteria for possible inclusion into the registry.

a) Pathology Department Every 2-4weeks, computer option SUS: CF (Automatic Casefinding: Lab Search) will be run. This will provide a diagnosis listing of all completed surgical and cytological pathologies. The program will add these automatically into the suspense files for abstracting.

b) Diagnostic Code Searches The disease index is a listing of cases by date of discharge from the hospital, arranged in diagnostic groupings according to codes from the ICD-10 classification manual and is available through the DHCP system. Every 2-4 weeks, the computer option SUS: PT (Patient Treatment File) will be run for the following codes: C00.00 through D49.89

(Eliminating BENIGN 805-808,809) Those cases which have not yet been accessioned or identified will be added to the casefinding suspense file by manual entry into the computer).

c) Tumor Board (Conferences) All cases reviewed during the weekly Cancer Board Conferences will be added to the suspense files for inclusion into the registry. Cases can be entered through option SUS: SE.

d) Radiology- Every 2-4 weeks, RA option will be run to identify abnormal imaging reports

3) Accession Register & Cancer Registry Files

The Cancer registry files consist of:

a) Accession register

b) Patient index file

c) Abstract file

d) Follow-up

e) Request log

The Accession Register is an annual and sequential listing of all cases. It may be presented either on-screen or in hardcopy and is readily available from our Cancer registry software system. To generate the Accession Register for a particular year using (Cancer registry software) follow (the instructions in the manual)

The master patient index file is an alphabetic list of living and dead patients entered into the registry since the reference date. The list contains the patient’s name, sex, date of birth, primary site(s), laterality, histology (ies), date (s) of diagnosis, accession number, sequence number(s), medical record number, and date of death. To generate the Master Patient Index file follow the instructions in (the instructions the cancer registry software manual)

The abstract is a summary of pertinent information about the patient and the cancer and its management. One abstract is completed for each primary site and contains the following core data items: patient and hospital identification, cancer information, extent of disease, treatment data, recurrence information, and follow-up. This information must be in natural language. Abstracts are retained electronically in the database indefinitely. See Section ( ) in this Procedure Manual for instructions on abstracting.

The follow-up file is used to obtain annually updated information regarding a patient’s health status to ensure continued medical surveillance. To prepare the follow-up file for printing control lists and letters follow the instructions in.

The request log is used to document registry usage and contain the following information: date of the request, topic of the report and period covered, person requesting the report, and purpose of the report and its final disposition. The cancer registry software keeps an electronic log.

The accession register is computer generated and records a sequential listing of all primary site malignant behavior cases as well as other cancer designated as reportable. A printout will run at least monthly using the LIS, (4), prompt; this is the Patient Index in the 132 column format, which contains all the elements required by the ACoS. The register must contain as a minimum the following information.

a) Accession Number The Accession Number consists of an eight-digit sequential number. The first four digits are the year of accession. The last four digits are the numerical order in which the case was accessioned, e.g., 0001, 0002, etc. It is important to note that a case was accessioned under the year of diagnosis or first treatment at this facility not under the year of abstraction. Multiple primary cases utilize the accession number of the original primary and a sequence number is generated by the computer. The original accession number will most often be from a previous year, e.g., a patient diagnosed with Adenocarcinoma of the prostate in 1990 was accessioned as 1990-0100; in 1991 accessioned for squamous cell carcinoma of the prostate will not acquire a sequence number of -1, e.g., 1990-0100-1 and the squamous cell carcinoma a sequence number of -2. e.g., 1990-0100-2; this will be generated automatically in the computer by indicating that it is an additional primary.

b) Date of Diagnosis The date of initial diagnosis is the month, day and year this primary cancer was first diagnosed by a recognized medical practitioner. Clinical diagnosis can be made according to terms defined in the FORDS Manual.

c) Hospital Number This is the patient's social security number.

d) Patient's Name Last, first, and middle name/initial.

e) Topography The Primary Site or ICD-0-3 code

4) Principles of Abstracting PURPOSE: To collect and record pertinent cancer data from the electronic record (s) about the patient, the disease, the cancer directed treatment and the disease process from the time of diagnosis until the patient’s death.

a) General Rules

Every effort will be made to abstract a new cancer case within six months of diagnosis in order to meet the time frame established by the Cancer Committee.

As of 8/24/06 per the Cancer Committee and the Standards, the date of first contact should always be the date of diagnosis and/or date of treatment (this could be pathological or clinical if the physician states that the patient has cancer). Also the registry data will be reviewed quarterly for compliance.

A separate abstract is prepared for each primary malignancy. Patients having multiple primary sites must have an abstract prepared for each primary site diagnosed and/or treated at this hospital; they will be listed in the computer under the patients name/accession number.

Changing the primary site or histology is permitted if information becomes more complete.

If two or more reportable primaries are diagnosed simultaneously, the lowest sequence number is assigned to the primary with the worst prognosis.

After resection, residual tumor refers only to the tumor at the primary site, not to metastatic or regional disease.

Recurrence denotes a return of disease or reappearance of the cancer after an intermission or remission (disease free interval).

Kaposi's Sarcoma (9140/3) is reported only once. Kaposi's Sarcoma is coded to the site in which it arises. If Kaposi's Sarcoma arises in skin and another site simultaneously, code to skin (C44._). If no primary is stated, code to skin (C44._).

When both an Adenocarcinoma (8140/3) and an Adenocarcinoma in a(n) adenomatous) polyp (8210/3) or an Adenocarcinoma in a (tubulo) villous adenoma (8261/3, 8263/3) arise in the same segment of the colon or of the rectum, code as Adenocarcinoma (8140/3).

When both a carcinoma (8010/3) and an Adenocarcinoma in a(n) (adenomatous) polyp (8210/3) arise in the same segment of the colon or of the rectum, code as carcinoma (8010/3).

Some tumors have more than one histologic pattern. The most frequent combinations are listed in ICD-0-3, under the term "mixed" in the alphabetic index. In addition combination terms such as "adenosquamous carcinoma" (8560/3) are included. Any of these mixed histologies are to be considered one primary. Refer to the rule on Compound Morphologic Diagnoses: pg. xxxi, ICD-0-3 for rules on coding compound morphologic diagnoses or diagnoses including modifying adjectives which have different code numbers. For a diagnosis with more than one modifying adjective, consider this to be one primary and code to the highest histology.

Multiple lesions of different histologic types occurring in different sites are considered separate primaries whether occurring simultaneously or at different times.

Each site (side) of a paired organ is considered a separate primary unless stated to be metastatic.

Exception: Bilateral involvement of the ovaries is considered as one primary in which a single histology is reported.

Bilateral retinoblastomas and bilateral Wilm's tumor are always considered single primaries (whether simultaneous or not)

If there is a discrepancy between the pathology report and the operative report, the pathology report has priority.

Do not add the measurements of prostatic chips or bladder chips to determine tumor size.

b) Core Data Set

The following data items must be abstracted in accordance with ACoS.

Date and type of treatment for first recurrence or persistent disease (2nd course)

c) Multiple Primaries Determination Definitions:

Site difference: For colon, rectum, bone, connective tissue, and melanoma of skin, each subcategory as delineated in the International Classification of Diseases for Oncology, Third Edition (ICD-0-3) is considered to be a separate site. For all other sites, each category as delineated in ICD-0-3 is considered to be a separate site.

Example: Transverse colon (ICD-0-2 code C18.4) and descending colon (C18.6) are each considered to be separate sites while trigone of urinary bladder (C67.0) and lateral of urinary bladder (C67.2) are considered to be subsites of the urinary bladder and would be coded as one primary -- bladder (C67.9).

Histologic type differences: Differences in histologic type refer to the FIRST THREE digits of the morphology code, except for lymphatic and hematopoietic diseases.

Simultaneous/Synchronous: Diagnoses within two months of each other.

Rules for Determining Multiple Primary Cancers (except for lymphatic and hematopoietic diseases):

A single lesion of one histologic type is considered a single primary even if the lesion crosses site boundaries.

A single lesion with multiple histologic types is to be considered as a single primary.

If a new cancer of the same histology as an earlier one is diagnosed in the same site within two months, consider this to be the same primary cancer. If a new cancer of the same histology is diagnosed in the same site after two months, consider this new cancer a separate primary unless stated to be recurrent or metastatic.

Multiple lesions of the same histologic type:

Simultaneous multiple lesions of the same histologic type within the same site will be considered a single primary. Further, if one lesion has a behavior code of in site and another a behavior code of malignant, still consider this to be a single primary whose behavior is malignant.

Multiple lesions of the same histologic type occurring in different sites are considered to be separate primaries unless stated to be metastatic.

Multiple lesions of different histologic types:

Multiple lesions of different histologic types within a single site are to be…