1. What’s New in 2016? For TCR, NPCR, COC April Fritz, RHIT, CTR

2. What We’ll Cover  Newly reportable conditions and tumors  Continuation of current codes for new terms  NPCR Requirements  Data items from COC/FORDS 2016  Continuing data items  Revised data items  New data items  Other standards setter requirements  Discontinued data items

3. Newly Reportable Tumors  8470/2 Non-invasive mucinous cystic neoplasm of the pancreas with high-grade dysplasia  Same as mucinous cystadenocarcinoma, non-invasive  8452/3 Solid pseudopapillary neoplasm of pancreas  Same as solid pseudopapillary carcinoma (C25._)  8150/3 Cystic pancreatic endocrine neoplasm (CPEN).  Unless specified as a neuroendocrine tumor, Grade 1 (8240/3) or neuroendocrine tumor, Grade 2 (8249/3)  9080/3 Mature teratoma of testes in adults  Continues to be non-reportable in prepubescent children (9080/0). Report only if pubescence is explicitly stated in the medical record. Do not report if there is no mention of pubescence in the medical record.

4. Newly Reportable* Tumors  8077/2 Laryngeal intraepithelial neoplasia, grade III (LINIII) (C320-C329)  8077/2 Squamous intraepithelial neoplasia, grade III (SINIII) except Cervix and Skin * Except COC

5. New Reportable Terms with Existing Codes 2016 (No changes from 2015) 8163/3 Pancreatobiliary-type carcinoma (C24.1) Use 8255/3 Adenocarcinoma, pancreatobiliary-type (C24.1) 8213/3 Serrated adenocarcinoma Use 8213/3* 8265/3 Micropapillary carcinoma, NOS (C18._, C19.9, C20.9) Use 8507/3* 8552/3 Mixed acinar ductal carcinoma Use 8523/3

6. New Reportable CNS Terms with Existing Codes 2016 (No changes from 2015) 9395/3Papillary tumor of the pineal region Use 9361/3* 9425/3 Pilomyxoid astrocytoma Use 9421/3 9431/1 Angiocentric glioma Use 9380/1* 9432/1Pituicytoma Use 9380/1* 9509/1 Papillary glioneuronal tumor Use 9505/1 Rosette-forming glioneuronal tumor

7. NPCR Staging Requirements  Directly coded AJCC  Clinical and Pathologic T, N, M, Stage Group  Necessary biomarkers and prognostic factors  Why use AJCC?  Infrastructure in place to update AJCC regularly  Physicians readily participate  Widespread knowledge of system across individuals and specialties Adapted from NPCR staging presentation, NCRA 2016

8. NPCR Staging Requirements  Directly coded Summary Stage  All registries, all providers Why use Summary Stage?  Provides continuity across nation and time  Easier to learn and collect  Provides stage information with lowest cost for training and effort  Few extra fields needed  Lymph nodes positive/examined  Tumor Size Summary Adapted from NPCR staging presentation, NCRA 2016

9. NPCR Newly Required Treatment Fields  Surg/rad sequence  Systemic/surg sequence

10. Continuing Data Items  Regional Nodes Positive  Regional Nodes Examined  Lymph-vascular Invasion  CS Site-Specific Factors  Requirements vary by standards setter  CS Version Input Original  CS Version Input Current

11. NPCR Required SSFs Required for Directly Assigned AJCC TNM Stage  Site (CS Schema) SSF Description  Appendix 11 Histopathologic Grading  GISTPeritoneum 5, 10 Mitotic Count; Location of Primary Tum  GISTs: Esoph,  Sm Int, Stomach 6 Mitotic Count  GISTs: Appendix,  Colon, Rectum 11 Mitotic Count  MycosisFungoides 1 Peripheral Blood Involvement  Placenta 1 Prognostic Scoring Index  Prostate 1 PSA Lab Value  Testis 13, 15, 16 Post Orch AFP, hCG, and LDH Range SSF 25 (Schema Discriminator) required for: BileDuctsDistal, BileDuctsPerihilar, CysticDuct, EsophagusGEJunction, LacrimalGland, LacrimalSac, MelanomaCiliaryBody, MelanomaIris, Nasopharynx, PharyngealTonsil, Stomach

12. NPCR Required SSFs Required by NPCR (but not for AJCC Staging)  Site (CS Schema) SSF Description  Brain, CNS Other, 1 WHO Grade  Intracranial Gland  Breast 1 ERA 2 PRA 8 HER2: IHC value 9 HER2: IHC Interpretation 11 HER2: FISH Interpretation 13 HER2: CISH Interpretation 14 HER2: Result of other test 15 HER2: Summary Result testing 16 Combination of ERA, PRA and HER2 Testing

13. Revised Data Items TNM Clin Staged By – to 2 digits TNM Path Staged By – to 2 digits  Conversion of previous to new codes available Conversion Table 1 to 2 digits  0 00  1 10  2 14  3 15  4 10  5 20  6 30  7 50  8 88 Code 9 converted separately based on T, N, M, Stage Group values (blank, X, 88) or directly to 99 00Not staged 10 Physician, NOS, or physician type not specified in codes 11-15 11Surgeon 12Radiation Oncologist 13Medical Oncologist 14Pathologist 15Multiple Physicians; tumor board, etc 20Cancer registrar 30Cancer registrar and physician 40 Nurse, physician assistant, or other non-physician medical staff 50Staging assigned at another facility 60Staging by Central Registry 88Case is not eligible for staging 99 Staged but unknown who assigned stage TNM Staged By

14. Revised Data Items Sex 3 – Other (intersex, disorders of sexual development/DSD) 4 – Transsexual, NOS* 5 – Transsexual, Natal Male* 6 – Transsexual, Natal Female* *changed in 2015

15. Revised Data Items  Definitions of many fields (53) modified to accommodate EHR reporting  Example: change ‘hospital’ to ‘reporting facility’

16. New Data Items  Tumor Size Summary  Tumor Size Clinical  Tumor Size Pathologic  Mets at Dx – Distant Lymph Nodes  Mets at Dx – Other  Mets at Dx – Bone  Mets at Dx – Brain  Mets at Dx – Liver  Mets at Dx – Lung  Summary Stage 2000 now Just “Mets at Dx – ”

17. Tumor Size Summary  Required by COC, NPCR  FORDS defines as “the most accurate measurement of a solid primary tumor…”  Priority 1. Surgical resection specimen if no neoadjuvant treatment 2. If neoadjuvant treatment then surgery, tumor size prior to neoadjuvant treatment 3. If no surgical resection, largest measurement from PE, imaging or other diagnostic procedure prior to any treatment 4. If 1, 2, and 3 do not apply, largest size from all information available within 4 months of diagnosis, with no disease progression

18. Tumor Size Summary  No special codes for “less than x cm” etc.  Specific FORDS instructions for coding less than x / greater than x  Examples 3 cm  031 Between 2 and 3 cm  025  Rounding rules, priority of imaging techniques, and other tumor size guidelines very similar to CS

19. Tumor Size Clinical  Required by SEER  Tumor size before any treatment  Priority 1. Largest measurement from PE, imaging or other diagnostic procedure prior to any form of treatment 2. Largest size from all information available within 4 months of diagnosis, with no treatment or disease progression  Same guidelines for less than x / greater than x, rounding, priority of imaging, etc., as Tumor Size Summary

20. Tumor Size Pathologic  Required by SEER  Tumor size from resected specimen  Priority 1. Largest measurement of invasive portion of tumor on specimen when surgery is part of first definitive treatment a. CAP protocol b. Final diagnosis c. Microscopic examination d. Gross examination  Same guidelines for less than x / greater than x, rounding, priority of imaging, etc., as Tumor Size Summary

21. Consider Yourself Fortunate That you don’t work in a COC-accredited hospital in a state jointly funded by NPCR and SEER where SEER continues to require CS data elements… You would have to enter  Tumor Size Summary (for COC and NPCR)  Tumor Size Clinical (for SEER)  Tumor Size Pathologic (for SEER)  Tumor Size in text field (for everyone)  CS Tumor Size (for SEER)  Plus everything else…

22. Mets at Dx – Distant Nodes  Required by all standards setters  Similar to Mets at Dx lung/liver/bone/brain  Codes  0None, no distant lymph node metastases  1Yes; distant lymph node metastases  8Not applicable  9Unknown whether distant nodes are involved; not documented in patient record  Guidelines  Distant nodes as defined in TNM  May be clinical or pathologic  Code whether or not there was neoadj Tx  Use code 9 when distant nodes not specifically mentioned as involved

23. Mets at Dx – Other  Required by all standards setters  Similar to Mets at Dx lung/liver/bone/brain  Codes  0None, no other metastases  1Yes; distant metastases in known site(s) other than bone, brain, liver, lung, distant nodes  2Generalized metastases such as carcinomatosis  8Not applicable  9Unknown whether other metastatic site or generalized metastases; not documented in patient record  Guidelines  Same as for Mets at Dx – Distant Nodes

24. COC Required SSFs No changes/additions/deletions from 2015 requirements One less thing to remember…

25. No Changes (as of 4/1/2016)  Multiple Primary and Histology Coding Rules for solid tumors  New version likely 2018  Hematopoietic and Lymphoid Neoplasms Database  Stand-alone and web-based versions  SEER*Rx Drug Database  Stand-alone and web-based versions

26. Other New Data Items (Central Registries)  Items Populated by Software  County at Dx Geocode 1990  County at Dx Geocode 2000  County at Dx Geocode 2010  County at Dx Geocode 2020  Rural Urban Continuum 2013  NPCR Derived Clin Stg Grp  NPCR Derived Path Stg Grp  SEER Derived data items (9)

27. Discontinued* Data Items  * Still required historically for cases diagnosed 2004-2015 and in some SEER areas:  CS Tumor Size  CS Extension  CS Tumor Size/Ext Eval  CS Lymph Nodes  CS Lymph Nodes Eval  CS Mets at DX Data Items  CS Mets Eval  CS Version Derived  Derived AJCC-6 Data Items  Derived SS and Flag Data Items  Derived AJCC-7 Data Items

28. AJCC TNM 8 th Edition  Publication date: October 31, 2016  Implementation date: January 1, 2017 diagnoses  Changes expected  Focus on evidence based medicine  Based on multiple data sources  Content harmonization to resolve inconsistencies  Personalized medicine approach  Non-anatomic prognostic factors as relevant to site  Factors required for staging, recommended for collection  AJCC-approved prognostic risk calculation models  Clearer staging rules with easy reference  New chapters and split chapters  More education/training  8 th Edition dedicated to cancer registrars

29. FORDS Ambiguous Terminology  Clarification issued by NCDB 4-28-2016  Ambiguous Terminology Lists: References of Last Resort …When abstracting, registrars are to use the “Ambiguous Terms at Diagnosis” list with respect to case reportability, and the “Ambiguous Terms Describing Tumor Spread” list with respect to tumor spread for staging purposes. However, these lists need to be used correctly.

30. FORDS Ambiguous Terminology  [Abridged] …When the medical record is not clear is to follow up with the physician.  If the physician is not available, the medical record, and any other pertinent reports (e.g., pathology, etc.) should be read closely for the required information.  Where wording in the patient record is ambiguous with respect to reportability or tumor spread and no further information is available from any resource, refer to Ambiguous Terminology Lists.  Do not refer to Ambiguous Terminology Lists when there is a clear statement of malignancy or tumor spread (i.e., the registrar can determine malignancy or tumor spread from the resources available)

31. FORDS Ambiguous Terminology  [Abridged]  The CoC recognizes that not every registrar has access to the physician who diagnosed and/or staged the tumor, as a result, the Ambiguous Terminology lists continue to be used in CoC-accredited programs and maintained by CoC as "references of last resort".

32. COC Standards  New Name: Cancer Program Standards: Ensuring Patient-Centered Care (2016 Edition)  12 Eligibility Requirements  34 Standards  Program management  Clinical services  Continuum of care services  Patient outcomes  Data quality

33. COC Standards Revisions 2016  Standard definitions and requirements required effective 01/01/2016  First surveys on requirements in 2017  Eligibility requirements  Wording changes ER3 to ER12  Standards requirements changes  1.7 Monitoring Cancer Conference Activity  Each calendar year, the cancer conference coordinator monitors and evaluates the cancer conference activities and reports the findings to the cancer committee Source: Brief Summary of 2016 Edition Revisions, https://www.facs.org/quality- programs/cancer/coc/standards

34. COC Standards Revisions 2016  Standards requirements changes  1.8 Monitoring of Prevention, Screening, and Outreach Activities  Each calendar year, the community outreach coordinator, under the direction of the cancer committee, monitors the effectiveness of prevention, screening, and outreach activities. The activities and monitoring results are documented in an annual community outreach activity summary that is presented to the cancer committee at the end of each calendar year.  1.9 Clinical Research Accrual  As appropriate to the cancer program category, the required percentages of patients are accrued to cancer-related clinical research studies each calendar year. The Clinical Research Coordinator documents and reports clinical research study enrollment information to the cancer committee annually. Source: Brief Summary of 2016 Edition Revisions, https://www.facs.org/quality- programs/cancer/coc/standards

35. COC Standards Revisions 2016  Standards requirements changes  2.1 College of American Pathologists Protocols and Synoptic Reporting  Each calendar year, 95 percent of the eligible cancer pathology contain all required data elements of the College of American Pathologists (CAP) protocols and are structured using the synoptic reporting format as defined by the CAP Cancer Committee.  2.2 Oncology Nursing Care  Oncology nursing care is provided by nurses with specialized knowledge and skills. Nursing competency is evaluated each calendar year. Results are reported to the cancer committee and documented in the cancer committee minutes.  2.3 Genetic Counseling and Risk Assessment  Cancer risk assessment, genetic counseling, and genetic testing services are provided to patients either on-site or by referral to a qualified genetics professional. Source: Brief Summary of 2016 Edition Revisions, https://www.facs.org/quality- programs/cancer/coc/standards

36. COC Standards Revisions 2016  Standards requirements changes  4.1 Cancer Prevention Programs  Each calendar year, the cancer committee organizes and offers at least one cancer prevention program designed to reduce the incidence of a specific cancer type and targeted to meet the prevention needs of the community. Each prevention program is consistent with evidence-based national guidelines for cancer prevention  4.2 Cancer Screening Programs  Each calendar year, the cancer committee organizes and offers at least one cancer screening program that is designed to decrease the number of patients with late-stage disease and is targeted to meet the screening needs of the community. Each screening program is consistent with evidence-based national guidelines and interventions and must have a formal process developed to follow up on all positive findings Source: Brief Summary of 2016 Edition Revisions, https://www.facs.org/quality- programs/cancer/coc/standards

37. CP3R  Cancer Program Practice Profile Reports  19 Quality measures covering 8 primary cancers  3 types of measures  Accountability  Quality improvement  Surveillance  More measures for 2016  Melanoma  Bladder  Pediatric cancers

38. 2016 CP3R New Quality Measures  Melanoma  M10AxLN – At least 10 regional lymph nodes are removed and examined in Axillary lymph node dissection  M05IgLN – At least 5 regional lymph nodes are removed and examined in Inguinal lymph node dissection  MCLND – Completion Lymph Node Dissection use after positive Sentinel Lymph Nodes biopsy  Bladder:  BL2RLN – At least 2 lymph nodes are removed in patients under 80 undergoing partial or radical cystectomy

39. RQRS  Rapid Quality Reporting System  2016 Updates  New measure added: Radiation therapy is recommended or administered following any mastectomy within 1 year (365 days) of diagnosis of breast cancer for women with greater than or equal to 4 positive regional lymph nodes (MASTRT).  Manual case exclusions will now be allowed in RQRS. Measure exclusions will be added to the RQRS case list and updated nightly.  The abbreviation of the RQRS "BCS" measure 'Radiation therapy is administered within 1 year (365 days) of diagnosis for women under age 70 receiving breast conserving surgery for breast cancer' has been updated to "BCSRT" to be more consistent with CP 3 R.

40. RQRS  Rapid Quality Reporting System Purpose  Allows expedited data entry of a critical subset of items specifically relevant to anticipated standard of care treatments  Enables accredited cancer programs to report data on patients concurrently.   Shows cancer programs up ‐ to ‐ date concordance rates relative to the state, other similar programs, and all CoC accredited programs across the country.   Provides the hospitals timely notification of treatment expectations. Source: RQRS User Guide 04/2016

41. RQRS  Rapid Quality Reporting System Benefits  Improve patient care with access to real clinical time performance rates.  Evaluate historical performance to compare with current practice.  Use the information in RQRS to develop real clinical time interventions to enhance the quality of care in your cancer program.  Monitor and prevent patients from experiencing a delay in treatment or catch patients who are at risk of “slipping through the cracks.”  Compare performance rates in your cancer program with other participating cancer programs.  Encourage timely and accurate collection of adjuvant treatment information.  Negotiate favorable reimbursement rates with payors through demonstrating current practices. Source: RQRS User Guide 04/2016

42. RQRS  REQUIRED participation starting 2017  Potential Changes In Registry Operations  Concurrent abstraction may take time to master.  RQRS cases are followed from diagnosis through the end of treatment, which can be as much as one year after diagnosis.  Registrars may need to follow up with treating physicians regularly to determine the treatment status of RQRS cases with alerts.  RQRS case alerts may be reviewed in cancer conferences or at cancer committee meetings. Source: RQRS User Guide 04/2016

43. Future COC Initiatives  Integrate NAPBC (breast center accreditation) with COC  Launch of NAPRC (rectal cancer accreditation)  Phase II Oncology Medical Home Accreditation Program

44. Housekeeping Details  Finish 2015 cases before you start 2016 diagnoses  Use consistent rules for entire diagnosis year  New data fields, new c/p indicators, discontinued data items effective for 01/01/2016 diagnoses and forward  Follow your standards setter(s) instructions

45. Any Questions?