2. The Voyage to Direct Coding of AJCC TNM...

3. .... and How to Get There!! Jayne Holubowsky, CTR Director, Virginia Cancer Registry Division of Population Health Data, Virginia Dept of Health Kentucky Cancer Registry 30 th Annual Advanced Cancer Registrars’ Workshop September 8, 2016

4. OVERVIEW Provide information on how to code AJCC TNM Provide information regarding the coding of X vs Blank Provide exercises to demonstrate learned information

5. Learning Objectives  Understand the process for TNM staging  Understand the difference between X and Blank in TNM Coding  Demonstrate learned information through exercises

6. TO START WITH.....

7. Where do I even start?? Make sure YOU know what you need to make decisions ◦ Know the general rules ◦ Use resources beside the medical record ◦ Be sure to include text to qualify your codes ◦ Do not be afraid to ask for help

8. OTHER RESOURCES

9. Help from NCRA The abstract is the basis of all registry functions. It is a tool used to help accurately determine stage and to aid cancer research; therefore, the abstract must be complete, containing all the information needed to provide a concise analysis of the patient’s disease from diagnosis to treatment. To assist registrars in preparing abstracts, NCRA’s Education Committee has created a series of informational abstracts. These site-specific abstracts provide an outline to follow when determining what text to include. The outline has a specific sequence designed to maximize efficiency and includes eight sections: Physical Exam/History; X-Rays/Scopes/Scans; Labs; Diagnostic Procedures; Pathology; Primary Site; Histology; and Treatment. A list of relevant resources is located at the end of each informational abstract. The sources of information noted in the various sections below are not all inclusive, but they are the most common. You may need to do additional research to complete the abstract. When using the informational abstract, follow the outline and strive to complete all the sections. Be concise by using phrases, not sentences. Make sure to use text relevant to the disease process and the specific cancer site and to use NAACCR Standard Abbreviations. When the abstract is completed, review thoroughly to ensure accuracy INFORMATIONAL ABSTRACT A Guide to Determining What Text to Include

12. Get Ready....?? What is the TNM Staging Premise? What are the general rules? ◦ Provide information on where the tables are located in the manuals ◦ Go over the rules one by one What you cannot use

13. GENERAL TNM CODING RULES TNM Staging Premise ◦Cancer has a finite length and certain measurable events along time continuum  Mutations of a single cell  Local growth (increase in size)  Invasion of organ’s parenchyma  Invasion of lymphatics within organ

14. Cancer Timeline - continued  Spread to regional lymph nodes  Direct invasion of adjacent tissues  Invasion of blood vessels and spread to distant organs ◦Time continuum varies by cancer type  Marker points defined for each type of cancer GENERAL TNM CODING RULES

15. All General Rules are in Chapter 1 of the AJCC Manual Used for ALL sites Exceptions or additions in site-specific chapters Remember – THERE ARE NO AMBIGUOUS TERMS IN TNM STAGING!!

16. Microscopic confirmation Required for TNM classification Rare cases without micro confirm should be analyzed separately Cancers classified by ICD-O-3 Recommend pathology reporting using CAP cancer protocols Timing of data eligible for clinical staging Data obtained before definitive tx as part of primary tx or w/in 4 months, whichever is shorter Time frame for collecting clinical stage data also ends when a decision is made for “watchful waiting” without therapy Timing of data eligible for pathological staging Data obtained through definitive surgery as part of primary tx or w/in 4 months, whichever is longer Timing of data eligible for staging with neoadjuvant therapy Stage in cases w/neoadjuvant tx is: (a) clinical as defined earlier before initiation of therapy; and, (b) clinical or pathological using data obtained after completion of neoadj therapy (ycTNM or ypTNM) Cases w/uncertainty among T, N, or M categories Assign the lower (less advanced) category of T, N, or M, prognostic factor or stage grouping Absence of staging-required nonanatomic prognostic factor Assign stage grouping by the group defined by the lower (less advanced) designation for that factor Mult synchronous primary tumors in single organ Stage T by most advanced tumor; use “m” suffix or the number of tumors in parentheses, e.g., pT3(m)N0 M0 or pT3(4)N0M0 Synchronous prim tumors in paired organs Stage and report independently Metachronous prim tumors in single organ (not recurrence) Stage and report independently T0 staging – unknown primaryStage based on clinical suspicion of primary tumor (e.g., T0 N1 M0 Stg IIA breast cancer) GENERAL TNM CODING RULES Adapted from AJCC Cancer Staging Manual, 7 th ed, Table 1.3, page 8

17. GENERAL TNM CODING RULES 1. MICROSCOPIC CONFIRMATION ◦All cases should be confirmed microscopically ◦Clinically diagnosed cases should be reported separately ◦Cancers are classified by their ICD-O- 3 primary site code

18. GENERAL TNM CODING RULES 2. TIMING – Clinical Staging (cTNM) ◦All information obtained prior to initiation of any treatment or within 4 months of diagnosis, whichever is shorter, with no disease progression  Treatment decision includes watchful waiting

19. GENERAL TNM CODING RULES 2. TIMING – Clinical Staging (cTNM) – continued ◦May be only common factor for some sites ◦Information used includes:  Symptoms  Physical exam  Endoscopies  Biopsy for diagnosis  Imaging  Tumor, Lymph nodes, Distant sites  Surgical exploration w/o resection ◦Application  Define initial treatment choice  International population comparison

20. GENERAL TNM CODING RULES CLINICAL STAGE ◦Assigned prior to cancer-directed treatment ◦Derived from clinical observations  Specified in each chapter ◦Ends when 1 st cancer directed treatment starts OR when decision is made not to treat ◦Should not be changed based on subsequent information ◦Clinicians will use when:  No surgical treatment  Adjuvant treatment prior to surgery  Insufficient information to stage pathologically

21. GENERAL TNM CODING RULES – POP QUIZ A patient is diagnosed with prostate cancer on June 1. He decides on June 14 that he would prefer active surveillance. July 1, he goes to his family physician, complaining of shoulder pain. The physician orders an x-ray which is done on July 5 and reveals metastatic disease in the shoulder. Is this a recurrence or is this Stage 4 at diagnosis?

22. GENERAL TNM CODING RULES CLINICAL STAGE – continued ◦Clinical Stage MUST be reported in CoC- accredited facilities ◦Pathology information may be included in Clinical Staging when there is:  Biopsy of primary site without resection (cT)  No pathologic information obtained (cT)  Biopsy of lymph node(s) w/o pathologic information about the primary site (cN) ◦ Sentinel node biopsy prior to neoadjuvant tx for breast CA  Negative biopsy of metastatic site (cM not pM)

23. GENERAL TNM CODING RULES TIMING – Pathological Staging (pTNM) ◦All information obtained through completion of 1 st course tx or within 4 months of diagnosis whichever is longer, with no neoadjuvant tx or disease progression

24. GENERAL TNM CODING RULES TIMING – Pathological Staging (pTNM) – continued ◦Information used  Clinical TNM  Pathology from resected tissue (T, N, or M)  EXCEPTION ◦ If only clinical T, then any LN biopsy = cN ◦Uses  Most precise diagnosis  Adjuvant treatment decisions

25. GENERAL TNM CODING RULES PATHOLOGICAL STAGE ◦Most precise estimate of prognosis ◦Based on: PLUS  Clinical information acquired before tx PLUS  Pathologic examination of surgical specimen ◦If primary tumor cannot be removed ◦ Case can be pathologically staged ◦Specific requirements for pT, pN, pM ◦ Presence of a path report is not automatically pathological staging

26. GENERAL TNM CODING RULES STAGING BASIS ◦c – Clinical Stage  essential to select & evaluate therapy options ◦p – Pathological Stage  provides most precise data to estimate prognosis, plan subsequent therapy & calculate end results ◦r – Recurrence/Retreatment Stage  Assessment of extent of tumor after recurrence after disease- free interval when further tx is planned ◦a – Autopsy Stage  Classification 1 st determined @ autopsy (no previous dx of cancer)

27. GENERAL TNM CODING RULES 3. CASES WITH NEOADJUVANT TREATMENT ◦Cases treated with neoadjuvant therapy may have a second staging after treatment ◦  Should have clinical staging as baseline  Post-treatment staging is labeled yc or yp ◦ Also called intercurrent staging

28. GENERAL TNM CODING RULES Post-Therapy Classification – continued ◦Measures response to neoadjuvant treatment  Pt had systemic and/or radiation tx before surgery  Case staged at conclusion of therapy ◦ Clinical if no further treatment (ycTNM) ◦ Pathological if resection (ypTNM)  Stage group notation for no residual cancer ◦ ypT0 ypN0 ycM0  Should have clinical stage as baseline ◦ Allows assessment of response to therapy ◦ Surgery must meet criteria for pathological staging  Provides prognostic information  Helps determine subsequent non-surgical treatment

29. GENERAL TNM CODING RULES 4. PROGRESSION OF DISEASE ◦Only information obtained prior to documented progression of disease is used for staging 5. UNCERTAINTY ABOUT CATEGORY ◦If in doubt about correct T, N, or M value, Stage grouping, or Prognostic factor, use the less advanced category

30. GENERAL TNM CODING RULES ◦Uncertain information examples –Imaging unclear if one node (N1) or two nodes (N2) are involved Use N1 which is lower category –Colonoscopy states at least in situ Use TX since information is unknown Cannot assign Tis or T1 as this falsely skews data –Lung clinical stage group for T2a NX M0 Use stage group unknown since no information on nodes Cannot assign stage group using N0 as this falsely skews data

31. GENERAL TNM CODING RULES 6. MISSING PROGNOSTIC FACTOR ◦If required non-anatomic factor is not available, stage group case assuming lowest value for factor  Example: T2a, N0, M0 prostate CA but Gleason score & PSA unknown Assign Stage Group I (PSA x, Gleason x)

32. GENERAL TNM CODING RULES OPTIONAL DESCRIPTORS

33. GENERAL TNM CODING RULES Multiple Primary Tumors 7.Simultaneous tumors of same histology in 1 organ ◦ Classify by highest T category ◦ Add suffix of m for multiplicity or # of tumors  Mastectomy specimen: 1cm IDC UOQ & 23mm IDC LOQ ◦Use largest tumor (23mm) for staging; assign pT2m or pT2(2) 8.Simultaneous bilat tumors – classify separately ◦ Thyroid, ovary, fallopian tube, liver exception  Multiplicity part of T definitions ◦ Lung exception  Multiple tumors may be classified in T or M depending on location

34. GENERAL TNM CODING RULES 9.Metachronous tumors in single primary ◦ Abstract separately 10.Unknown primary site ◦ No evidence of primary tumor (T0) ◦ Stage according to site suspected by clinician Additional Notes from AJCC ◦Carcinoma in situ  Must be pathologically determined (pTis)  Report as clinical AND pathological stage 0

35. ELEMENTS OF TNM Descriptors of extent of spread – 3 dimensions ◦T – Primary tumor & contiguous tumor growth ◦N – Regional lymph node involvement ◦M – Distant metastases Timing of description – Staging Basis ◦Clinical ◦Pathological Aggression of cases ◦Stage grouping

36. ELEMENTS OF TNM - T T determined by site-specific rules based on size and/or local extension Clinical assessment of T (cT) based on PE, imaging, endoscopy and biopsy and surgical exploration w/o resection Pathologic assessment of T (pT) entails a resection of the tumor or may be assigned with biopsy only of it assigns the highest T category pT generally based on resection in single specimen; if resected in >1 specimen, make reasonable estimate of size/extension. Disease-specific rules may apply Tumor size should be recorded in whole millimeters. If the size is reported in smaller units, such as tenths or hundredths of a millimeter, it should be rounded to the nearest whole millimeter for reporting stage. Rounding is performed as follows: 1 through 4 are rounded down, 5 through 9 are rounded up. If not resected, and highest T and N category can be confirmed microscopically, case may be classified as pT or pN w/o resection T Classification Rules Taken from AJCC Cancer Staging Manual, 7 th ed, Table 1.5, page 10

37. ELEMENTS OF TNM - T T – TUMOR  Locoregional Spread ◦Assessment of the primary cancer & any organs involved by contiguous extension  Local growth  Invasion of blood vessels or lymphatics within organ of origin  Within a body cavity, tumor seeding of organ tissues via body fluid  Direct invasion of adjacent tissues

38. ELEMENTS OF TNM - T T Classification: Different Criteria for Different Cancers ◦Tumor Size  Breast, parotid gland, oral cavity ◦Depth of Invasion  Colon, bladder, melanoma ◦Location and extension  Lung, larynx, pancreas ◦Other factors  Tumor multiplicity (thyroid, liver)  Grade (sarcomas)  Prognostic factors (prostate, testis )

39. ELEMENTS OF TNM - T T Values Range 1-4 – SIZE ◦Example: Breast  T1Less than or equal to 2cm  T2Greater than 2cm to 5cm  T3Greater than 5cm  T4Involving chest wall or skin Image source: http://www.medinfo.net/imi/tissue-areas/breast-cancer /

40. ELEMENTS OF TNM - T T Values Range 1-4 – Invasion ◦Example: Bladder  T0No evidence of primary tumor  TaNoninvasive papillary carcinoma  TisCarcinoma in situ  T1Subepithelial connective tissue  T2Muscularis propria  T3Perivesical tissue  T4Beyond bladder Image source: http://www.cancerresearchuk.org/cancer-help/type/bladder-cancer/treatment/bladder-cancer- stage-and-grade /

41. ELEMENTS OF TNM T Values Range 1-4 – Extension ◦Example: Vocal Cord (glottic larynx)  T1Limited to cords (normal mobility  T2Extends to supra- or subglottis or impaired cord mobility  T3Confined to larynx w/vocal cord fixation; or, extending to paraglottic space or inner cortex of thyroid cartilage  T4aThru thyroid cartilage; trachea, soft ti of neck, deep extrinsic muscles of tongue  T4bPrevertebral space, encasing carotid artery, invading mediastinal structures Image source: http://www.oncolex.org/en/Head-and-Neck-cancer/Diagnoses/Larynx/Background/Staging

42. ELEMENTS OF TNM - T Tis – Carcinoma In Situ ◦Primary tumor MUST be removed and microscopically proven to be non-invasive (pTis) ◦May be part of Clinical Stage Group 0 T0 – No Evidence of Primary Tumor ◦Tumor in primary site cannot be found

43. ELEMENTS OF TNM - T Pathologic Staging – T ◦Minimal requirement for assigning pT  Gross resection of primary  Margins may be microscopically involved  Must be able to evaluate highest pT category  If bx documents highest T category, classify as pT ◦Some sites have specific rules  Prostate: Radical prostatectomy required  Bladder: Radical cystectomy required  Breast: Lumpectomy at a minimum

44. ELEMENTS OF TNM - N Categorize N by disease-specific rules based on number & location of positive LNs Minimum expected number & location of LNs to examine for staging defined by disease type If LN surgery is performed, classify N category as pathologic even if minimum number is not examined Pathological assessment f the primary tumor (pT) is necessary to assign pathological assessment of LNs (pN) except w/unknown primary (T0). If pathological T (pT) is available, then any microscopic evaluation of LNs is pN In cases with only clinical T in the absence of pT excision of a single LN or SLN(s) is classified as clinical nodal status (cN) Microscopic examination of a single LN or LNs in the highest N category is classified as pN even in the absence of pathological information on other LNs Sentinel LN biopsy is denoted with (sn), e.g. pN0(sn); pN1(sn) LNs with ITC only generally staged as pN0; disease-specific rules may apply (e.g., melanoma) Direct extension of primary tumor into regional LN is classified as node positive Tumor nodule with smooth contour in regional LN area are classified as positive LNs When size is the criterion for N category, stage by size of metastasis, not size of node when reported (unless specified in disease-specific rules) N Classification Rules Adapted from AJCC Cancer Staging Manual, 7 th ed, Table 1.6, page 10

45. ELEMENTS OF TNM - N N – Regional LN Involvement ◦ N0 – Regional LNs have been clinically or pathologically proven to be free of metastatic dz ◦N1 – N3  Increasing involvement of regional lymph nodes by number, location or size ◦ Subcategories such as N0(i+), N1mi, N2a may be used

46. ELEMENTS OF TNM - N N – Regional LN Involvement - continued ◦N1 – 3 by # of LNs positive  Example: Stomach ◦ N1 1-2 regional LNs involved ◦ N2 3-4 regional LNs involved ◦ N3a 7-15 regional LNs involved ◦ N3b 16 or more reg LNs involved Picture source: http://openi.nlm.nih.gov/detailedresult.php?img=3175221_1471-2407-11-329-2&req=4

47. ELEMENTS OF TNM - N N – Regional LN Involvement – continued ◦N1 – 3 by Location  Example: Lung ◦ N1 – Peritracheal and perihilar LNs ◦ N2 – Ipsilateral mediastinal and/or subcarinal LNs ◦ N3 – Contralateral mediastinal or hilar LNs; scalene or supraclavicular LNs Picture source: http://www.fudahospital.com/zh_asp_new/zt/english/t&t/lung/00016_b.htm

48. ELEMENTS OF TNM - N N – Regional LN Involvement – continued ◦N1 – 3 by Size and Number  Example: Renal Pelvis and Ureter ◦ N1Single node, ≤2cm ◦ N2Single node >2 to 5cm or multiple LNs, all ≤5cm ◦ N3Any metastasis >5cm Picture source: http://uronotes2012.blogspot.com/2012/07/illustrated-tnm-staging-of-renal-pelvis.html

49. ELEMENTS OF TNM - N Pathologic Staging – N ◦Minimal requirement for assigning pN  Resection of minimum number of LNs to assure adequate sampling  Number varies by primary site  Exception: sentinel node procedure  EXAMPLE: Lumpectomy for breast cancer with sentinel LN bx of only Level I nodes=pT_ pN_(sn)  If recommended # of LNs not removed, still classify pN  Pathologic examination of enough LNs to:  Validate absence of region LN mets (pN0)  Evaluate highest pN category

50. ELEMENTS OF TNM - N Pathologic Staging – N – continued ◦pN assigned in conjunction with pT  If removal of primary tumor meets criteria for pathological T, then not necessary to have microscopic confirmation of highest N category  If highest N category microscopically proven, then case is pN regardless of status of T ◦ EXAMPLE: Lung cancer with + FNA of supraclavicular= pN3 regardless of how T is determined  If no removal of primary tumor, then LN bx or SLN procedure is cN

51. ELEMENTS OF TNM - N Pathologic Staging – N – continued ◦Isolated Tumor Cells (ITCs)  Identified by immunohistochemistry or molecular techniques, flow cytometry or DNA analysis  Definition: ◦ Single tumor cells or small clusters of cells 0.2mm in diameter  Breast classified as pN0  Melanoma & Merkel cell carcinoma classified as pN1

52. ELEMENTS OF TNM - M M Classification Rules Clinical M classification only requires H&P; imaging of distant organ sites not required to assign cM0; infer status as clinical M0 status unless known clinical M1 “MX” is not a valid category and my not be assigned. Elimination of “MX” is new with AJCC/UICC, 7 th ed Pathological M classification requires a positive biopsy of the metastatic site (pM) Pathological M0 (pM0) is not a valid category and may not be assigned. Stage a case with a negative biopsy of suspected metastatic site as cM0 Case with pathological T and N may be grouped as pathological TNM using clinical M designator (cM0 or cM1) (e.g., pT1 pN0 cM0 = pathological stage I) Case with pathological M1 (pM1) may be grouped as clinical and pathological Stage IV regardless of “c” or “p” status of T and N (e.g., cT1 cN1 pM1 = clinical or pathological Stage IV) ITC in metastatic sites (e.g., bone marrow) or circulating or DTCs classified as cM0(i+). Disease-specific rules may apply

53. ELEMENTS OF TNM - M M – Distant Metastases/Systemic Involvement ◦Absence or presence of distant metastases  Blood-borne metastases ◦ Discontinuous from primary site  Direct distant extension  Progressive LN involvement  Seeding w/in cavity

54. ELEMENTS OF TNM - M M – Distant Mets/Systemic Involv – continued ◦Categories  M0Absence of metastatic disease  M1Presence of at least 1 area of distant metastasis ◦ Example: Prostate M1 category  M1aNon-regional lymph nodes  M1bBone(s)  M1cOther site(s) ◦Notes  MXNot available in classification ◦ Minimal physical examination results in cM0 ◦ pM0 not possible except at autopsy ◦ Classification choices: cM0, cM1, pM1

55. ELEMENTS OF TNM - M M – Distant Mets/Systemic Involv – continued ◦TNM7 Rule:cMx and pMx DELETED  Inappropriate – clinical assessment of mets can be based on PE alone  Makes cases unstageable  If pathologist does not know clinical M, Mx should NOT be recorded  Leave pathological M blank if unknown ◦ If a tissue equivalent to cM1 is biopsied & is negative, it becomes cM0, NOT pM0  CTCs and DTCs or bone marrow micrometastasis are cM0(i+)

56. Blank or X? Registry data fields seen on software screen ◦Clinical TN MStage Group ◦PathologicalTNMStage Group Use appropriate c or p data fields ◦Based on what is needed to assign stage correctly ◦Follows AJCC staging rules Do NOT use just elements in that one line Match stage assigned by physician ◦According to AJCC rules

57. Blank or X? AJCC defines X for T and N categories ◦Cannot be assessed Cannot use X for other situations ◦No surgical resection is NOT pTx pNx pM blank Stage 99 Blank should be used when: ◦No information is available in chart ◦Cannot be assigned a valid AJCC value ◦Patient not eligible for pathologic stage

58. Blank or X? Patient had bowel obstruction & went directly to surgery where colon cancer was found Physician assigned pathological stage ◦pT4a pN2a cM0 Stage IIIC How should you record the cStage and pStage? ◦cTblank cNblank cMblank cStage Blank or 99 ◦pT4apN2a cM0pStage 3C Cannot assign clinical stage, cancer not known prior to definitive treatment ◦AJCC is stage group blank, but CoC requires non-blank value for clinical stage

59. Blank or X? Patient had CT chest w/LLL tumor & mediastinal LNs, mediastinitomy removed 4 LNs confirming N3 disease; concurrent chemoradiation will be given Physician assigned clinical stage ◦T2a N3 M0 Stage IIIB (implied c) How would you record cStage & pStage? ◦cT2acN3 cM0cStage 3B ◦pTblankpNblankpMblankpStage blank Biopsy of LNs is part of staging workup, cN Cannot assign path stage – no resection of primary ◦Not stage 99 – implies criteria met but information unknown

60. Blank or X? Clinical stage of insitu cancer of breast; total mastectomy, no LN resection pTiscN0 cM0Stage 0 CAN assign clinical & pathological stage ◦Rules state in situ assigned pTis cN0 cM0 for CLINICAL AND PATHOLOGICAL ◦Rules state both clinical & path stage is 0 ◦Rule put in place because LNs are not usually resected for in situ cancers ◦Meets breast criteria for pathological classification

61. Clinical stage of in situ CA of bladder w/ TURBT and no cystectomy pTis cN0 cM0 cStage 0 pTblankpNblank pMblank pStage blank or 99 Cannot assign pathological stage ◦Bladder criteria of cystectomy has not been met ◦Common to not find invasive tumor on TURBT ◦Do NOT use stage 99, path stage criteria not met  99 implies criteria met but information unknown ◦Rules state that in situ assigned pTis cN0 cM0 Blank or X?

62. Diagnostic workup includes biopsy of bone showing mets from breast CA, no resection done; tumor 1.5cm, palp axillary LNs ◦cT1ccN1 pM1Stage 4 ◦pTblankpNblank pM1Stage 4 pM1 for clinical stage, biopsy done during workup pM1 is both clinical & pathological stage IV according to AJCC rules ◦Case with pM1 may be grouped as clinical AND pathological stage IV regardless of c or p status of T and N Blank or X?

63. Stage group data fields ◦Blank indicates:  No information in medical record; OR  Criteria not met for pathologic staging ◦ CoC does NOT allow blank for clinical staging ◦99 indicates:  Unknown T or N, stage cannot be assigned  T, N, or M are not specific enough to assign stage ◦ Example: T2 assigned when T2a or T2b needed to assign stage  CoC mandates non-blank for clinical stage – use 99  Do not use 99 if pathological staging criteria not met – use BLANK ◦88 indicates not appleicable Blank or X?

64. CoC FORDS Values – Blank, X, 99 ◦Blank indicates :  No information in medical record  Do not know if any assessment was performed  Criteria not met for this stage classification so each category (T, N, M) is blank ◦X indicates:  Not assessed ◦ T cannot be assessed ◦ N cannot be assessed ◦ Does not apply to M  If patient was examined it can be assigned ◦ Criteria met for this stage classification so each category is valid value or X ◦88 indicates not applicable, not defined by AJCC Blank or X?

65. Key points for Blank or X ◦Does the patient meet criteria for that stage classification?  YES – patient meets classification criteria ◦ If physician could not assess T and/or N for the patient, & ◦ Definitive information for T and N not in chart ◦ Use Tx and/or Nx  Yes – patient meets classification criteria ◦ No information about diagnostic workup or no resection pathology in chart  Do NOT use X ◦Implies physician did not assess or have info on pt’s T and/or N  DO use blank ◦Indicates registrar could not find information in chart Blank or X?

66. Key Points for Blank & X, continued ◦Does the patient meet criteria for that stage classification?  NO – patient does NOT meet classification criteria ◦ Do NOT use X  Indicates patient eligible for staging  Implies physician did not assess or have info on patient’s T and/or N ◦ Must use BLANKS  Indicates patient did not meet classification criteria Blank or X?

67. ELEMENTS OF TNM Non-anatomic Factors ◦Also called prognostic factors  You may recognize them as SSF’s ◦Necessary for staging of some sites  Number of tumors (thyroid)  Grade (sarcoma, prostate, bone)  Depth of invasion (melanoma)  Risk factors (gestational trophoblastic tumor)  Tumor markers (testis, prostate)  Vascular invasion (testis)

68. ELEMENTS OF TNM Anatomic stage/prognostic grouping rules Define separate clinical and pathological group for each case. May combine clinical and pathological information as a “working stage” in either the pathological or clinical classification when only partial information is available – this may be necessary for clinical care. Minimize use of Tx and Nx; use of “x” for any component makes case unstageable. Case will not be usable in comparison analyses (exception: any combination of T and N including Tx and/or Nx with M1 is Stage IV) For grouping that require a nonanatomic factor, if factor is missing, stage using lowest category for that factor. Case with pT and pN and cM0 or cM1 staged as pathological stage group. Case with cT and cN and pM1 staged as clinical AND pathological stage group. Carcinoma in situ, stage pTis cN0 cM0 stage as both clinical AND pathological stage 0.

69. ELEMENTS OF TNM Stage Grouping ◦AKA anatomic stage/prognostic groups  Easily communicated summary of extent of disease & prognosis ◦Gathers cases based on anatomic extent of disease (T, N, M) plus relevant non- anatomic factors into categories to facilitate analysis ◦TNM classification and stage groups, once established, must remain unchanged in the medical record

70. ELEMENTS OF TNM Stage Grouping - continued ◦Generally “pure clinical” and “pure pathological” stage groups defined  Elements can be combined in a “working stage” while treatment decisions are being made or when only partial information is available for either ◦General concepts  Stage 0Carcinoma in situ  Stage IConfined to primary site  Stage IILimited to local ext &/or limited reg LN mets  Stage IIIMore advance local ext or reg LN involv  Stage IVInvolvement of distant sites

71. ELEMENTS OF TNM Stage Grouping - continued ◦Page 5, 7 th ed Cancer Staging Manual:  “…in clinical medicine, it is often expedient to combine clinical and pathological T, N, and M information to define a mixed stage group for treatment planning. And example of a clinical situation where such “mixed staging” is used clinically is a woman with breast cancer who has had the primary tumor resected providing pathological T, but for whom there was no lymph node surgery, requiring use of clinical N. The mixed stage combining clinical and pathological information is sometimes referred to as working stage.  Continued…

72. ELEMENTS OF TNM Stage Grouping - continued ◦Page 5, 7 th ed Cancer Staging Manual - continued :  “…However, pure clinical and pathological stage is still defined for comparative purposes. In addition, clinical M status (M0 or M1) may be mixed with pathological T and N information to define pathological stage, and the same pTis cNo cM0 define both clinical and pathological stage for in situ carcinoma. If there is pathological evidence of metastases (pM1), it may be used with clinical T and N information to define clinical Stage IV and pathological Stage IV.

73. OTHER REQUIRED ELEMENTS Per memorandum emailed to everyone on June 20 th, 2014 SSF’s are NOT going away “ On June 17, the CS Transition Group agreed to continue collecting Site Specific Factors using the current NAACCR data layout and definitions at least through 2016. This approach will continue to use the programming and logic structure established in Collaborative Stage to collect those variables. The CS Transition Group felt that this would be the least disruptive way to proceed for 2016. The intention is to maintain the SSFs as they are until there is an opportunity to carefully evaluate the SSFs and to make decisions on how to structure the collection of these variables within the NAACCR record layout. In addition, any changes that will be needed to accommodate prognostic indicators in the AJCC 8 th edition will be better known in 2016.”

74. OTHER REQUIRED ELEMENTS Memorandum - continued “ Excerpt from the SSF Data Structure Task Force Summary Option 3: Maintain current CS data structure and definitions. Standard setters would continue to specify requirements. Continue to collect required CS data items in their current CS locations. The existing CS DLL could continue to be used for site group determination, valid code definitions and documentation. Once the AJCC 8th edition is published, the structure will need to be altered to accommodate this change.” Betsy Kohler Executive Director, NAACCR Inc.

75. OTHER REQUIRED ELEMENTS SCHEMAREQUIRED SSF’s Bladder SSF 2 – Size of Mets in Lymph Nodes Breast SSF1 – ERA SSF2 – PRA SSF3 - # Positive Ipsilat Level I-II Lymph Nodes SSF4 – IHC of Lymph Nodes SSF5 – MOL of Lymph Nodes SSF8 – HER-2 IHC Lab Value SSF9 – HER-2 IHC Interpretation SSF11 – HER-2 Fish Lab Interpre tation SSF13 – HER-2 CISH Lab Value SSF14 – Result of Other/ Unknown HER-2 Test SSF15 – HER-2 Summar y Result of Testing SSF16 – Combinations of ER/PR/HER-2 Results Colon SSF2 – Clinical Assessment of Regional LNs

76. OTHER REQUIRED ELEMENTS SCHEMAREQUIRED SSF’s Corpus Adenosarcoma SSF2 – Peritoneal Cytology Corpus Carcinoma SSF2 – Peritoneal Cytology Corpus Sarcoma SSF2 – Peritoneal Cytology Lung SSF1 – Separate Tumor Nodules – Ipsilateral Lung Prostate SSF1 – PSA Lab Value SSF3 – CS Extension – Pathological Extension SSF8 – Gleason Score on Needle Core Bx/TURP SSF10 – Gleason Score on Prostatectomy/Autopsy

77. OTHER REQUIRED ELEMENTS You may continue to collect any SSF your Cancer Committee deems significant ◦You can get the list of required SSF’s from an application in SEER ◦http://seer.cancer.gov/csreqstatus/application. html

78. AJCC CODING QUIZ #1 2.5 cm tumor RUOQ breast. No palpable axillary nodes. Rest of exam WNL Lumpectomy and sentinel node biopsy: 1.8cm duct carcinoma. 0/4 nodes. What are the T, N, M and Stage Group?

79. AJCC CODING QUIZ #2 Elevated PSA (8; normal 0 – 2.5) DRE: normal prostate Needle biopsy: adenoCA, Gleason 3+4 Pelvic CT: WNL Metastatic work up: negative Treatment: active surveillance What are the T, N, M and Stage Group?

80. AJCC CODING QUIZ #3 TURBT: TCC of bladder dome involv superficial muscle Workup: negative No further treatment What are the T, N, M and Stage Group?

81. SUMMARY How To: Direct Coding T, N, M and Stage 1.Determine primary site & histology  Ask: “Where did it start?” (primary site)  Ask: “Where did it go? (spread to LNs &/or distant sites)  Ask: “How did it get there?” ◦ Direct extension (T) ◦ Lymphatics (N) ◦ Discontinuous mets (M)  Blood  Seeding/Nodules 2.Look up site chapter 3.Is histology included in this chapter?

82. SUMMARY How To: Direct Coding T, N, M and Stage - continued 4.Review list of regional LNs 5.Review rules for classification  Clinical vs Pathological 6.Find staging information in manual  Look for key words in medical record  Match key words to lists in staging manual section for primary site 7.Assign appropriate SSF’s  Some have impact on Stage Group 8.Determine T, N, M, assign Stage Group

83. SUMMARY This is not an easy concept to embrace It will take lots of reading Most important – ANALYZE!! ◦ Then read again!! ◦ No list to go through to help ◦ Don’t use CS as a crutch IF YOU ARE UNSURE – ASK FOR HELP!!!

84. And FINALLY.....

88. jayne.holubowsky@vdh.virginia.gov 804-864-7873 804-864-7870 Thank you!!!