Surgical Cancer Treatment August 8, 2017

Outline Analytical questions Sources Treatment episodes (eras) Formal connection between diagnosis and treatment Response to treatment Sources EMR/Claims Cancer Registry Critical dimensions and attributes Representation in OMOP CDM Is granularity of the respective domain/vocabulary sufficient to represent all treatment attributes and dimensions Vocabularies and Mapping

Sources EMR, Billing Procedures Cancer Registry Clinical Trials Billing focused Provides all treatment information No identification of a primary procedure Few treatment dimensions for analysis Time lag depends on a billing cycle (45 days) Cancer Registry Epidemiology/treatment focused Provides selected treatment information: only reportable cancer types, mostly first treatment course at best and sometimes following Clear identification of a primary procedure Multiple treatment dimensions for analysis Time lag 6 months Clinical Trials EMR, Medical History

CR Dimensions Temporal: In relation to other treatment modalities first treatment course vs. others initial/primary surgery and re-surgeries In relation to other treatment modalities radiation (before, after, together) systemic endocrine/transplant Purpose treatment: resection vs. delivery of other treatment type (e.g. radiation) diagnostic non-cancer palliative procedures Site and site specific procedure types: primary metastatic sites lymph node biopsy or removal Surgical method State of surgical margins after the surgery Why surgery (or any other treatment) was not performed) Data QA and more. Example: Surgery of the primary site was not recommended/performed because it was contraindicated due to patient risk factors (comorbid conditions, advanced age, etc.).

Dimensions covered by vocabulary Anatomic site Surgical method Cancer site? primary metastatic sites lymph node biopsy or removal Morphology

SNOMED Procedure Dimensions Procedure site – direct/indirect (all) Method (all) Direct morphology (some) Direct substance (s0me) Examples: 78603008, Biopsy of lung Procedure site – direct: Lung Structure Method: Biopsy - action 82443007, Craniectomy with excision of tumor Procedure site – direct: Brain Structure Method: Excision – action Direct morphology: Neoplasm 171764000, Injection of therapeutic substance into cerebrospinal fluid Procedure site – indirect: Structure of spinal subarachnoid space Method: Injection – action Direct substance: Drug or medicament

Cancer Registry Mappings? Site specific procedure types -> Method 90 Surgery, NOS -> Surgical action Anatomy -> Site direct/indirect C34.0 - > Procedure site – direct: Lung Structure 5621009, Excision of malignant neoplastic lesion of skin of extremities (procedure) Malignant neoplasm of primary, secondary, or uncertain origin (morphologic abnormality)

1032 of 1119 (92%) CPT codes mapped to SNOMED EMR Mappings CPT Mappings in OMOP 1032 of 1119 (92%) CPT codes mapped to SNOMED 446 one-to-many (up to 7) 859 many-to-one 586 one-to-one

Candidate CDM extensions Procedure modifiers (new table) Site and site specific procedure types: primary metastatic sites lymph node biopsy or removal Number of lymph nodes removed Relation to other treatment modalities radiation (before, after, together) systemic endocrine/transplant Treatment regimen /era (new table) Purpose treatment: resection vs. delivery of other treatment type (e.g. radiation) diagnostic non-cancer palliative procedures Temporal first treatment course vs. others initial/primary surgery and re-surgeries Response to treatment State of surgical margins after the surgery Radiological response

NAACCR Data Dictionary http://datadictionary.naaccr.org/?c=10 References FORDS https://www.facs.org/~/media/files/quality%20programs/cancer/ncdb/fords%202016.ashx NAACCR Data Dictionary http://datadictionary.naaccr.org/?c=10

Appendix

Surgery of Primary Site Codes https://seer.cancer.gov/archive/tools/SEER2003.surg.prim.site.codes.pdf

CR: Primary Procedure Types 10-19 Site-specific codes. Tumor destruction; no pathologic specimen produced. 20-80 Site-specific codes. Resection. Path specimen produced. 90 Surgery, NOS; surgical treatment of the primary site was done, but no information on the type of procedure is provided. 98 Site specific codes; special.

CR: Lymph Node Procedure Types 1 Biopsy or aspiration of regional lymph node, NOS 2 Sentinel lymph node biopsy 3 Number of regional lymph nodes removed unknown, not stated; regional lymph nodes removed, NOS 4 1 to 3 regional lymph nodes removed 5 4 or more regional lymph nodes removed 6 Sentinel node biopsy and code 3, 4, or 5 at same time or timing not noted 7 Sentinel node biopsy and code 3, 4, or 5 at different times

CR: Non-Primary Procedure Types 1 Non-primary surgical procedure performed 2 Non-primary surgical procedure to other regional sites 3 Non-primary surgical procedure to distant lymph node(s) 4 Non-primary surgical procedure to distant site 5 Any combination of codes 2, 3, or 4

CR: State of Margins after Surgery 0 No residual tumor 1 Residual tumor, NOS 2 Microscopic residual tumor 3 Macroscopic residual tumor 7 Margins not evaluable 8 No primary site surgery 9 Unknown or not applicable

CR: In Relation to Systemic Treatment 0 No systemic therapy and/or surgical procedures; unknown if surgery and/or systemic therapy given 2 Systemic therapy before surgery 3 Systemic therapy after surgery 4 Systemic therapy both before and after surgery 5 Intraoperative systemic therapy 6 Intraoperative systemic therapy with other therapy administered before and/or after surgery 7 Surgery both before and after systemic therapy 9 Sequence unknown, but both surgery and systemic therapy given

CR: In Relation to Radiation No radiation and/or no surgery; unknown if surgery and/or radiation given 2 Radiation before surgery 3 Radiation after surgery 4 Radiation both before and after surgery 5 Intraoperative radiation 6 Intraoperative radiation with other radiation given before and/or after surgery 7 Surgery both before and after radiation 9 Sequence unknown, but both surgery and radiation were given