TRAM Educational Conference September 19, 2014 Meritus Medical Center 1

Objectives: - Discuss the Central Registry practice for reviews - Review common errors seen in the Central Registry - Focus on FORDS standards for palliative care and first course of treatment - Update from the MCR 2

Audit Process MCR 5 year cycle Completeness Re-abstraction 3

Audit Process NPCR – Data Quality Evaluation 5 year cycle Visual Editing (Text to Code) Re-consolidation 4

Top Primary Sites Breast Lung Colon Rectosigmoid Colon Rectum Uterus Prostate 5

Grade most frequent error 6

Conversion issues FIGO Grade Coding Grade from a metastatic site Following Rule G in the ICD-O-3 manual 7

If the information is not in FORDS refer to the SEER Coding and Staging Manual Appendix C 8 Nottingham Histologic Scores BR GradeNuclear Grade TerminologyHistologic Grade SEER Code 3-5Low1/3; 1/2Well differentiated I, I/III, 1/31 6, 7Intermediate2/3Moderately differentiated II, II/III; 2/32 8, 9High2/2; 3/3Poorly differentiated III, III/III, 3/ /4Undifferentiat ed/anaplastic IV, IV/IV, 4/44 Grade Conversion Table for Invasive Carcinoma of the Breast

For Breast In-Situ 9 DCIS GradeTerminologySEER Code Grade ILow1 Grade IIIntermediate2 Grade IIIHigh3 DCIS Grade Conversion Table

The FIGO grading system for carcinomas of the uterine corpus is only officially designated for endometrioid carcinomas and is based on architectural features as follows: Grade 15% or less nonsquamous solid growth pattern Grade 26% to 50% nonsquamous solid growth pattern Grade 3> 50% nonsquamous solid growth pattern Ref: CAP Protocols for Cancer Reporting

Rule G. Grading or differentiation code: Assign the highest grade or differentiation code described in the diagnostic statement. “Grade High/Stage Low” DO NOT code grade from a metastatic site, use code 9. Ref: ICD-O-3 Coding Manual page 21 11

Date of First Surgical Procedure Date of First Surgical Procedure is the date the first Surgical Procedure of Primary Site, Scope of Regional Lymph Node Surgery, or Surgical Procedure/Other Site is performed as part of first course of treatment. Ref: FORDS 2013 page 21 12

The date in this item may be the same as that in Date of Most Definitive Surgical Resection of the Primary Site (NAACCR Item #3170), if the patient received only one surgical procedure and it was a resection of the primary site.Date of Most Definitive Surgical Resection of the Primary Site If surgery is the first or only treatment administered to the patient, then the date of surgery should be the same as the date entered into the item Date of First Course Treatment (NAACCR Item #1270).Date of First Course Treatment 13

14 Examples: A melanoma patient had an excisional biopsy on March 23, 2008, then a wide excision on March 28, March 23, 2008 The patient had a small (0.5 cm) lump removed from her breast on November 16, November 16, 2009 The patient’s primary tumor was treated with radiation beginning on April 16, 2007, after a distant metastasis was removed surgically on March 27, March 27, 2007

Palliative Care and Date First Course of Treatment Surgical procedures, radiation therapy, or systemic therapy provided to prolong the patient's life by controlling symptoms, to alleviate pain, or to make the patient comfortable should be coded palliative care and as first course therapy if that procedure removes or modifies either primary or metastatic malignant tissue. 15

Examples for Code 0: No Palliative Care is provided; diagnosed at autopsy Source: FORDS: Facility Oncology Registry Data Standards: Revised for

Examples for Code 1: Surgery (which may involve a bypass procedure) to alleviate symptoms, but no attempt to diagnose, stage, or treat the primary tumor is made. Source: FORDS: Facility Oncology Registry Data Standards: Revised for A patient undergoes palliative surgical removal of brain metastasis. [Surgery recorded in Surgical Procedure/Other Site (NAACCR Item #1294)]Surgical Procedure/Other Site 1A patient with unresectable pancreatic carcinoma (no surgical procedure of the primary site is performed) receives bypass surgery to alleviate jaundice and pain.

Examples for Code 2: RT to alleviate symptoms, but no attempt to diagnose, stage, or treat the primary tumor is made. 18 2A patient is diagnosed with Stage IV prostate cancer. His only symptoms are painful bony metastases in his right hip and lower spine. XRT is given to those areas. (Record all radiotherapy items also). 2A patient with lung cancer with a primary tumor extending into the spine is treated with XRT to shrink tumor away from spine/nerves to provide pain relief. (Record all radiotherapy items also).

Examples for Code 3: Chemo, Hormonal or other systemic drugs to alleviate symptoms, but no attempt to diagnose, stage, or treat the primary tumor is made A patient is given palliative chemotherapy for Stage IIIB lung cancer. (Record all chemotherapy items also).

Examples for Code 4: Patient received or was referred for pain management w/ no other palliative care A 93-year old patient is diagnosed with multiple myeloma and enters a pain management clinic to treat symptoms. No other therapy is planned due to other medical problems.

Examples for Code 5, 6, and 7: Any combination of 1, 2, and/or 3 w/ or without 4 or no info available. 21 5A patient is diagnosed with widely disseminated small cell lung cancer. A palliative resection of a solitary brain metastasis is performed followed by XRT to the lower spine for painful bony metastasis. There is no known pain management. (Record all surgery and radiotherapy items also). 6A patient diagnosed with colon cancer receives bypass surgery to alleviate symptoms and XRT to the liver for metastasis, and then enters a pain management clinic for treatment for unremitting abdominal pain. (Record all radiotherapy items also). 7A patient enters the facility with a clinical diagnosis of unresectable carcinoma of the pancreas. A stent was inserted into the bile duct to relieve obstruction and improve the bile duct flow.

Regional Nodes Positive/Regional Nodes Examined 00/98 vs. 98/00 98 No nodes examined for RN Positive 00 No nodes examined for RN Examined 22

What are regional nodes??? 23

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Use of code 95. Use code 95 when the only procedure for regional lymph nodes is a needle aspiration (cytology) or core biopsy (tissue). Example: Patient with esophageal cancer. Enlarged mid- esophageal node found on CT scan, which is aspirated and found to be positive. Patient undergoes radiation therapy and no surgery. Code Regional Nodes Positive as 95 and Regional Nodes Examined as 95.Regional Nodes Positive 25

Lymph node biopsy. If a lymph node biopsy was performed, code the number of nodes removed, if known. If the number of nodes removed by biopsy is not known, use code 96. Definition of “sampling” (code 96). A lymph node “sampling” is removal of a limited number of lymph nodes. Other terms for removal of a limited number of nodes include lymph node biopsy, berry picking, sentinel lymph node procedure, sentinel node biopsy, selective dissection. Use code 96 when a limited number of nodes are removed but the number is unknown. (Less than or equal to 4) 26

27 Multiple lymph node procedures. If both a lymph node sampling and a lymph node dissection are performed and the total number of lymph nodes examined is unknown, use code 97.

Other issues: - Dates for treatment fields not in text - 00 vs. 99 when text indicates ‘none’ or the treatment is not indicated for the diagnosis vs. 999 in the CS SSF fields - lack of adequate text to validate coding 28

Questions? 29

Death and Lab Only Follow-back Disease Indices and Accession Registers Submission Monitoring 30