1. NPCR Data Completeness and Quality Audits Review of: Collaborative Stage and Surgery Data Mary Lewis, CTR NPCR Program Consultant

2. Objectives: Assess quality of: Assess quality of: ► Collaborative Stage ► Derived Summary Stage ► Surgery Data Identify data resources Identify data resources Summarize solutions Summarize solutions ► Training Issues ► Improvement of processes

3. Background Data Completeness and Quality Audit Data Completeness and Quality Audit Timeframe: 2007 - 2011 Timeframe: 2007 - 2011 √ 2004 – 2008 Data Years New Focus: New Focus: √ Coordinated Data Submission √ Collaborative Stage √ Derived Summary Stage √ Treatment Data √ All Sites

4. NPCR Data Completeness and Quality Audit Year 1: Year 1: √ Reabstracted 2,673 cases in 9 states √ 2004 Diagnosis Year √ Accuracy Rate – 96.2% Year 2: Year 2: √ Reabstracted 2,574 cases in 9 states √ 2005 Diagnosis Year √ Accuracy Rate – 94.8%

5. Most Common Sites: Digestive Digestive Colon and Rectum Colon and Rectum Breast Breast Respiratory Respiratory Lung Lung Prostate Prostate

6. Evaluation of: Breast Breast Colon Colon Rectum Rectum Lung Lung Prostate Prostate Melanoma Melanoma Gynecologic Gynecologic Other Digestive Sites Other Digestive Sites Stomach Stomach Pancreas Pancreas Liver Liver Small Intestine Small Intestine

7. Stage of Disease Error Rate All Sites % Errors Collaborative Stage Data Elements

8. Digestive Primaries: C15 – C26 Esophagus Esophagus Stomach Stomach Small Intestine Small Intestine Colon and Rectum Colon and Rectum Rectosigmoid Jct Rectosigmoid Jct Anus and Anal Canal Anus and Anal Canal Liver and Bile Ducts Liver and Bile Ducts Gallbladder Gallbladder Other/unspecified Biliary Tract Other/unspecified Biliary Tract Pancreas Pancreas Other/ill-defined Digestive Organs Other/ill-defined Digestive Organs

9. Stage of Disease Error Rates Digestive Primaries % Errors Collaborative Stage Data Elements

10. CS Errors – Digestive Primary CS Extent of Disease (17.8% / 17.1%) CS Extent of Disease (17.8% / 17.1%) ► NOS vs Specific Code: 42 – Fat, NOS vs. 45 – Pericolic Fat 42 – Fat, NOS vs. 45 – Pericolic Fat ► Specific Information: 00 – In Situ vs. 05 - Non-invasive in a Polyp ► Consolidation of Data/Update to: 10 - Mucosa, NOS vs 40 – Muscularis Propria

11. CS Errors – Digestive Primary CS Lymph Node (9.1%/ 9.6%) CS Lymph Node (9.1%/ 9.6%) ► Specific Information: 10 – Colic Node vs. 30 - Mesenteric Node 10 – Colic Node vs. 30 - Mesenteric Node ► Additional Information: 00 - None vs 10 – Update/More Information 00 - None vs 10 – Update/More Information ► “N” Information: “N1” in record vs. Pathology Report “N1” in record vs. Pathology Report

12. CS Errors – Digestive Primary CS Metastasis at Dx: (5.3% / 6.5%) CS Metastasis at Dx: (5.3% / 6.5%) ► None vs. Unknown 00 – Negative w/up vs.99 – No information 00 – Negative w/up vs.99 – No information ► Known vs. Unknown 40 – Liver involved vs. 99 – No information 40 – Liver involved vs. 99 – No information ► Additional Information: 10 – Distant Nodes vs 50 – Nodes + Other 10 – Distant Nodes vs 50 – Nodes + Other

13. CS Errors – Colo-rectal Derived Summary Stage 2000: (9.8%/7.3) Derived Summary Stage 2000: (9.8%/7.3) ► Overall impact - 9% in Digestive Primaries ► Due to changes is CS data fields: ► Unknown to Known ► Is situ to Invasive ► Additional surgery, scans, workup ► Lack of supporting documentation

14. Stage of Disease Error Rates Respiratory Primaries

15. CS Error – Lung Primary CS Extent of Disease: (21% / 27%) CS Extent of Disease: (21% / 27%) ► Local vs Specific Code 30 – Lung, NOS vs. 45 – Extends to Pleura 30 – Lung, NOS vs. 45 – Extends to Pleura ► Definitive Information: 30 - Lung, NOS vs. 10 – One Lung 30 - Lung, NOS vs. 10 – One Lung 50 – Bronchus vs. 70 – Mediastinum 50 – Bronchus vs. 70 – Mediastinum ► Known vs. Unknown: 99 – Unknown vs. 80 – “T4” 99 – Unknown vs. 80 – “T4” 45 – Ext to Pleura vs. 99 – No Documentation 45 – Ext to Pleura vs. 99 – No Documentation

16. CS Error – Lung Primary CS Lymph Node (10%/10%) CS Lymph Node (10%/10%) ► None vs. Unknown: 00 – None vs. 99 – No w/up or Documentation 00 – None vs. 99 – No w/up or Documentation ► None vs. Known: 00 – None vs. 60 – Bilateral Supraclavicular 00 – None vs. 60 – Bilateral Supraclavicular ► Specified vs. NOS: 20 – Pericardial vs. 50 – Regional Nodes, NOS 20 – Pericardial vs. 50 – Regional Nodes, NOS ► Unknown vs. Known 99 – Unknown vs. 00 – Negative Workup 99 – Unknown vs. 00 – Negative Workup

17. CS Error – Lung Primary CS Metastasis at Dx: CS Metastasis at Dx: ► Unknown vs Known: 99 – Unknown vs. 00 – Documentation 99 – Unknown vs. 00 – Documentation ► None vs. Known: 00 – None vs. 40 – Bone Metastasis 00 – None vs. 40 – Bone Metastasis ► Specific Information: 10 – Distant Nodes vs. 50 – Nodes and Mets 10 – Distant Nodes vs. 50 – Nodes and Mets

18. CS Errors - Lung Derived Summary Stage 2000: 8.8%/12.9% Derived Summary Stage 2000: 8.8%/12.9% ► Overall impact - 11% in Lung Primaries ► Changes in CS fields: ► Consolidation of Data ► Additional Surgery, scans, work-up ► Physician Documentation ► Lack of supporting documentation

19. Stage of Disease Error Rates Breast Primaries % Errors

20. CS Errors – Breast Primary CS Extent of Disease: CS Extent of Disease: ► Lack of Supporting Documentation: 20–Subcutaneous vs. 10 – Confined to Breast Tissue 20–Subcutaneous vs. 10 – Confined to Breast Tissue ► Physical Examination Information: 20–Subcutaneous vs. 51 – Ulceration of Skin 20–Subcutaneous vs. 51 – Ulceration of Skin

21. CS Errors – Breast Primary CS Lymph Nodes: CS Lymph Nodes: ► Pathology Report vs. NOS 25 – Axillary Node <2mm vs 26 – NOS, N1 ► None vs. Involvement 00 – None vs. 05 – H&E Stains ► Staging Information vs. Pathology N2 – 28 vs. 50 – Multiple “Matted” Nodes on Pathology Report

22. CS Errors – Breast Primary CS Metastasis: CS Metastasis: ► Stated as “non-invasive” 00 – None vs 99 – Unknown 00 – None vs 99 – Unknown ► None vs. Unknown 00 – None vs. 99 – Lack of Documentation 00 – None vs. 99 – Lack of Documentation ► Specifics vs. coded as: 40 – Distant, NOS vs. 00 – Staged as M0 40 – Distant, NOS vs. 00 – Staged as M0

23. CS Errors - Breast Derived Summary Stage 2000: (2.5%/6.1%) Derived Summary Stage 2000: (2.5%/6.1%) ► Overall impact was 4% in Breast Primaries ► Changes in CS fields: ► Lack of supporting documentation ► Information from physical exam ► Unknown vs Known ► Rules re: in-situ tumor

24. Stage of Disease Error Rates Prostate Primaries % Errors Collaborative Stage Data Elements

25. CS Errors – Prostate Primary CS Extent of Disease: CS Extent of Disease: ► Lack of Supporting Documentation: 15 – Elevated PSA vs. 30 – Localized Disease 15 – PSA vs. 99 – No Documentation ► Definitive/Better Information: 99 – Unknown vs. 45 – Seminal Vesicle 30 – Local, NOS vs. 13 – Previous Biopsy ► Known vs. Unknown: 99 – Unknown vs. 15 – Clinically Inapparent, Elevated PSA Elevated PSA

26. CS Errors – Prostate Primary CS Lymph Node: CS Lymph Node: ► None vs. Unknown 00 – None vs. 99 – Lack of Information 00 – None vs. 99 – Lack of Information ► Unknown vs. None 99 – Unknown vs. 00 – Early Stage Disease 99 – Unknown vs. 00 – Early Stage Disease CS Metastasis: CS Metastasis: ► Unknown vs. Known 99 – Unknown vs. 00 – Negative Scans- Early Stage

27. CS Errors – Prostate Primary Pathologic Extent of Disease (SSF3) Pathologic Extent of Disease (SSF3) ► NOS vs. Specific Information: 020 – 1 lobe, NOS vs. 023 – Both Lobes 020 – 1 lobe, NOS vs. 023 – Both Lobes ► Specific Information: 042 – Extracapsular vs. 048 – ► Extracapsular and Positive Margins 021 – Half Lobe vs. 096/097 – 021 – Half Lobe vs. 096/097 – Unknown/No Prostatectomy Unknown/No Prostatectomy 099 – Unknown vs. 021 – Half Lobe or Less, 099 – Unknown vs. 021 – Half Lobe or Less, or 023 – Both Lobes or 023 – Both Lobes

28. CS Errors - Prostate Derived Summary Stage 2000: (5%/5%) Derived Summary Stage 2000: (5%/5%) ► Overall impact – 5% in Prostate Primaries ► Due to changes in CS fields ► Physical Exam ► Unknown to Known ► Documentation ► Additional scans, work-up

29. Other Digestive Sites - Pancreas CS Extent of Disease: CS Extent of Disease: ► Known vs. Unknown 10 – Confined to tail vs. 99 – No information ► Documentation, CT Scans 60 – Mesenteric artery vs. 50 - Vessels, NOS 60 – Mesenteric artery vs. 50 - Vessels, NOS 63 – Liver vs. 30 – Localized, NOS 63 – Liver vs. 30 – Localized, NOS 3-Regional vs. 1-Localized 3-Regional vs. 1-Localized

30. Other Digestive Sites - Stomach CS Extent of Disease: CS Extent of Disease: ► No Supporting Documentation 60 – Liver, Pancreas vs. 30 – Localized, NOS 3-Regional vs. 1-Localized ► Pathology Documentation 40 – Through Wall, NOS vs. 45 – Perigastric Fat 50 – Through Serosa vs. 45 – Gastric Artery

31. Other Digestive Sites - Liver CS Extent of Disease: CS Extent of Disease: ► No Information vs. Localized 99 – Unknown vs. 50 – Confined to Liver 9-Unknown vs. 1-Localized ► Specific Information: 65 – Liver Nodules vs. 80 - Pancreas 2-Regional vs. 7 - Distant 2-Regional vs. 7 - Distant

32. Other Digestive Sites CS Lymph Nodes: CS Lymph Nodes: 00 vs. 99 – No Documentation Known vs. Unknown 99 vs. 00 – CT Scan With No Lymph Node Involvement Unknown vs. Known Unknown vs. Known 00 vs. 10 – CT Scan Shows Regional Nodes Local vs. Regional Nodes Local vs. Regional Nodes

33. Other Digestive Sites CS Metastasis at Diagnosis: CS Metastasis at Diagnosis: 00 vs. 99 – No Information 99 vs. 00 – Negative Workup

34. Skin: Melanoma CS Extent of Disease : CS Extent of Disease : ► Specific Information: 50 – Clark’s Level V vs. 10 – Clark’s Level IV 40 – Local, NOS vs. 10 – Clark’s Level I 1 – Local vs. O – In situ 1 – Local vs. O – In situ

35. Gynecologic Sites - Cervix Specific Information CS Extent of Disease: CS Extent of Disease: 99 – Unknown vs. 20 – Stage 1B CS Lymph Nodes: CS Lymph Nodes: 99 – Unknown vs. 00 – Neg Nodes per Pathology Report CS Metastasis at Diagnosis: CS Metastasis at Diagnosis: 99 – Unknown vs. 00 – Neg PET Scan 99 – Unknown vs. 00 – Neg PET Scan

36. Gynecologic Sites - Ovary Specific Information CS Extent of Disease: CS Extent of Disease: 99 – Unknown vs. 72 – Stage IIIC 30 – Local, NOS vs. 00 – Neg Nodes Per Pathology Report 30 – Local, NOS vs. 00 – Neg Nodes Per Pathology Report 99 – Unknown vs. 00 – Neg PET Scan 99 – Unknown vs. 00 – Neg PET Scan

37. Gynecologic Sites - Uterus Specific Information CS Extent of Disease: CS Extent of Disease: 50 – FIGO II (NOS) vs. 12 – 1/3 Myometrium 2 – Regional vs. 1 - Localized 99 – Unknown vs. 00 – Non-invasive 99 – Unknown vs. 00 – Non-invasive 12 – Stage IB vs. 40 – Local, NOS 12 – Stage IB vs. 40 – Local, NOS

38. Brain/Cerebral Meninges Specific Information CS Extent of Disease: CS Extent of Disease: 10 – One Side vs. 40 – Crosses Midline 10 – One Side vs. 40 – Crosses Midline 1 – Localized vs. 2 – Regional

39. Surgery Data Data Fields: 1. Surgery Date 2. Surgery of Primary Site 3. Regional Lymph Node Surgery 4. Surgery Other Regional/Distant Site

40. Surgery Data Surgery Date ► Evaluates date of first surgery for: ► Primary Site ► Regional Lymph Nodes ► Other Regional/Distant Sites ► Doesn’t always coincide with most definitive Surgery ► Error Rate – 5%

41. Surgery Data Surgery Date ► None vs. Known Date 00/00/0000 vs. 07/01/05 ► Doesn’t Agree With Surgery Code 7/1 – Exc Mass; 7/7 – Wide Re-excision 7/1 – Exc Mass; 7/7 – Wide Re-excision ► Applies to ALL Surgery Fields 7/1 – Exc Brain Mets; 7/1 – Exc Brain Mets; 7/7 – Primary Site Resection 7/7 – Primary Site Resection

42. Surgery Data Surgery of Primary Site ► Rx Summ Surg Prim Site – Item 1290 ► Error Rate – Yr 1 – 10.3% Yr 2 – 12.3% ► Highest Errors in: ► Breast ► Colon ► Urinary Bladder

43. Surgery Data Surgery of Primary Site – Continued Issues ► 00 vs. Known Code ► NOS vs. Specifics Breast: Specifics re: Mastectomy 41 – Simple vs. 50 Modified Radical (MRM) Colon: 27 – Excision Bx vs. 28 – Polypectomy Colon: 27 – Excision Bx vs. 28 – Polypectomy Bladder: 20 – Excision, NOS vs. 27 Excisional Bx vs. 22 – Combination 20 or 27 With Electrocautery Bladder: 20 – Excision, NOS vs. 27 Excisional Bx vs. 22 – Combination 20 or 27 With Electrocautery ► Consolidation of Data ► 20-Lumpectomy vs. 40 - Mastectomy

44. Surgery Data Regional Lymph Node Surgery ► Rx Summ Scope Reg LN ► Item 1292 ► Error Rate – Yr 1–5.7%; Yr 2–6.8% Issues: Issues: ► Cumulative ► Combination Code

45. Surgery Data Other Regional/Distant Surgery ► Rx Summ Surg Oth Reg/Dis ► Item 1294 ► Error Rate – Yr 1–2.6%; Yr 2–2.3% Issues: Unknown vs. Known Issues: Unknown vs. Known 99 vs. 00 – Early Stage Disease 99 vs. 00 – Early Stage Disease

46. Summary To increase accuracy in: To increase accuracy in: Collaborative Stage of Disease Collaborative Stage of Disease Summary Stage 2000 Summary Stage 2000 Surgery Data Surgery Data Methods: Methods: Training Training Consolidation Rules Consolidation Rules Method to update Method to update

47. Mary Lewis, CTR MLewis2@cdc.gov 770-488-4827 http://www.cdc.gov/cancer.npcr/index.htm The findings and conclusions in this report are those of the author and do not necessarily represent the official position of the Centers for Disease Control and Prevention