1. TEXT, FOLLOW –UP AND THE CANCER REGISTRAR
NOW SHOWING
TEXT, FOLLOW –UP AND THE CANCER REGISTRAR

2. STARRING
PERFECT TEXT
&
FABULOUS FOLLOW-UP

3. CO-STARRING
YOU!!!!
Text documentation supporting your coding is critical. Text is where you really put your stamp on the abstract!!! It’s amazing to me, but some folks here at KCR can look at nothing more than the text of a case and tell you what facility it’s from and which registrar there abstracted it. They just have their own style. There are guidelines, but really very little right vs wrong way of doing text. Abstractor’s will have different styles as will different facilities…. Some facilities have very defined formats for entering text that each registrar is expected to use that format, while other facilities leave more up to each individual registrar.

4. Everybody’s Got A Story………..
Text tells “the story” in readable language that supports the coding
Accurate, concise summary of the patient’s cancer
Text serves to summarize the patient’s medical experience and the numerical codes then collapse the information into assigned data fields.
If you only get one thing from this presentation, let it be that the purpose of text is to support your coding!

5. Text Uses…… Support coding Support unusual site/histology combos
Explain unusual abstract entries
Document ambiguous terminology
Document additional info or questions
Yet again…..it’s the primary use
Marynell talked to you about those suggested sites in the purple book….the ones where a topography code (CXX.X) is found next to a morphology code. Sometimes that’s just not going to work for you and you need to document why.
Eventually, things are going to get weird and you’re going to run across THAT case
Seen “the list” of amb terms by now…..it’s always good to have that verbage documented….you want that definitive diagnostic statement in your abstract
Can be anything……it’s not unusual for us to see in an abstract “….discussed this case with X and she agreed that the code should be YYYY.”

6. And Even More Text Uses Support accuracy and validity of data
Eliminate the need to pull charts again
Edit check verification
Re-coding/re-staging of historical data
Researcher/facility use
What it’s ultimately all about!! GIGO—Garbage In Garbage Out
Pulling charts=Not fun
Much easier with good text
See above—you don’t have to go looking for info again
Facilities and researchers use (and don’t use) text in different ways

7. Text Uses At Central Registry
Validate codes in the abstract
Sequence
Extent
Treatment
Reconcile codes and consolidate abstracts from different facilities
QC audits
Seq: Is this the first cancer? If not, don’t describe the first in great detail….”Previously dx’d with ALL in 2005…….”
Ext: Where is it? How far has the cancer spread? You’ve seen the layers of the colon wall…..does the tumor extend to the submucosa? All the way to the peritoneum?
Tx: Like clinical trials, capturing first course treatment information is becoming more and more important, so it’s key to document that info in the treatment notes or in text
Patients are seen at multiple facilities….certainly not unusual for a patient to be diagnosed in say, Pikeville, but then be referred to UK for all of their treatment. Both facilities will abstract that case and the info will be combined here at the central registry. Good text helps that process go smoothly and also helps if things aren’t matching up.
QC audits are our way of ensuring that we have quality data.

8. Critical Data Items Age ** DOB Sex Race Sequence number Stage
Date of diagnosis
Laterality
Primary site
Histology
Behavior
Grade
Dates and types of all treatments
Include age at diagnosis, but DOB is also nice…these abstracts are going to be read for years so it’s nice to have that reference in there
Age changes, but DOB doesn’t

9. Picturing this???
Promise it won’t be that bad….

10. It’s not the amount of text… it’s how you use it!
Be concise- quality is more important than quantity
Only document what’s relevant to the site/disease
Use abbreviations
Lots of useless info doesn’t help anyone. Keep your text simple! KISS!
Don’t repeat…you only have to document once!
Otherwise, don’t record PSA test values/results for a man dx’d with lung cancer….stick to the tests for the specific cancer being dx’d or tx’d
Abbreviations are totally acceptable!!! Don’t be afraid to abbreviate when entering your text.

11. Abbreviations!!! Use ‘em…..
Use accepted abbreviations from the Abstractor’s Manual available at
Appendix I
(Common Acceptable Abbreviations)
We gave you a whoooooooole big list of them in the Abstractor’s Manual!

12. ….But Use Caution! Make sure your abbreviations aren’t confusing
Spell out, at least once, any abbreviation that might not be easily recognized
Use abbreviations in context
SCC---is that small cell carcinoma or squamous cell carcinoma??? Stick to the list!!! For survey---they will read text and they need to be able to understand it!
DLBCL---diffuse large b-cell lymphoma
Place abbreviation in a place where the context make sense. Example “ MD “ alone on a line is confusing. Is it “doctor” or is it “moderately differentiated”??

13. In addition to abbreviations, using symbols is also acceptable.
YES.
<, >, =, &
+ (positive), x (times)
2/7 (two of seven)
Also POS (+)

14. You can omit vowels or use apostrophes to shorten words.
YES.
Glsn (Gleason), Blm-Rch (Bloom-Richardson)
Rec’d, dx’d
LNs

15. Match the abbreviations!
Abdomen
ANT
Bilateral BX
Biopsy
ABD
Bone Marrow
BIL
Anterior BM

16. Health and Physical: Demographics
Name(s)
Social Security Number
Age….and DOB added is nice
Sex
Race
Ethnicity
Birth place
It’s good practice to include these in your text because they are great for quick visual edits….you can double check age vs DOB, Hisp origin field, sex vs. first name

17. History and Physical Any previous cancer dx? When? Where?
Describe the symptoms leading to the current admission (inpt or outpt) for dx and/or tx
Remember to focus text on the cancer being dx’d and/or tx’d at this time
BE SURE TO INCLUDE THE REASON FOR THE CURRENT VISIT!!!!!!

18. History and Physical
Was this cancer dx’d at your facility or a different one?
Where? (give the facility, office, etc.)
Give the date, site and histology
Has this cancer been previously treated?
Procedures, treatment, drugs, dose
Dates
Location
End with your initials and the date
Reference point for when data was obtained

19. Example
W/F, non-Hispanic with pelvic pain growing worse over the past 3 months. US at outside facility showed solid 10 cm mass rt ovary. Referred here for eval and tx. TR 6/15/16

20. Imaging Include the date, scan type, and facility where performed
Include only info relevant to the primary site
Any positive findings
Any negative findings that define stage
Support your codes for CS Tumor Size, CS Extension, CS Lymph Nodes, CS Mets at Dx
End with your initials and the date
Aka…x-rays, scans, and ultrasounds
For neg--- CT neg for mets

21. End with your initials and the date
Scopes
Include the date, scope type, facility where performed, and the relevant findings
End with your initials and the date
Proximal/distal from what reference point

22. Lab Work Document tumor markers and site specific factors
Document factors affecting prognosis or staging
Gleason score (prostate)
PSA (prostate)
ER/PR status (breast)
CA-125 (ovary)
CEA (colorectal)
Her2 expression
Copying over your list of site specific factors into your text is fine, but use that opportunity to justify your codes.

23. Lab Work 10/21/16 UK: CEA 12.3 (nl < 5.0 ng/ml) TR 11/13/16
Include :
Date of Test
Facility Where Performed
Result (value)
Normal Range
Your Initials with Date
10/21/16 UK: CEA 12.3 (nl < 5.0 ng/ml) TR 11/13/16

24. Operative Findings
Include the date, name of procedure, facility where performed, relevant findings and may also include
Organs removed
Any differences between intended procedure and actual procedure
Important site, size or staging info
End with your initials and the date
Tumor size, extension, seeding, LN involvement
Sometimes procedures don’t go as planned….. e.g. find unresectable tumor in OR

25. Pathology
Include the date, tissue taken, report number, facility where performed, site tissue was taken from, final diagnosis
Include results regarding size, location, histology, grade, extension, LNs
Comments and addenda are important and should also be included
End with your initials and the date
Bx, resection, cytology
Include microscopic information if relevant to histology
Metastatic involvement

26. Site
Document the primary site (topography) as described in the medical record
Document laterality
End with your initials and the date
Be sure to follow schema directed instructions for choosing reported topography (site)
Be brief!

27. Histology Document the date and source of tissue
Support your code for the primary tumor type
Include the final dx from cyto, path or clinical assessment
Document behavior and grade
End with your initials and the date
Support your code, but be brief.

28. Staging Document TNM staging and who staged the patient
Document whether there is clinical and/or pathologic staging
For Collaborative Stage, show the original measurements and include the sources
Include any info for Site Specific Factors if not covered elsewhere
End with your initials and the date
Support your code
Include statements about tumor extent, lymph nodes, metastases, type of evaluation, and site specific factors

29. Other Include info for :
Date of Dx, if not covered in earlier text
Class of case
Therapy planned and/or received including type, volume, modality
Following physicians
Follow-up info sources
Follow-up info will typically be added here each year…along with your initials and the date
Support your code

30. Reabstracting Audits!
Are often performed using text information only….data not documented will be counted as errors.

31. Conflicting Info
What if you follow the rules and your staging doesn’t match the physician staging?
Code according to the rules and document how you arrived at your code (i.e. support your coding with text)

32. Follow-Up
Systematic process of obtaining accurate information, at least annually, on the patient’s health, vital status, and progression of disease

33. Follow-Up Can assist in the early identification of recurrence
Assists physician’s in getting former cancer patients to return for treatment or checkups
Encourages periodic examination of cancer patients since they are prone to develop other cancers
One very, very important word…..survival

34. Follow-Up Rules
Follow-up info necessary for analytic cases only, with the following exceptions Patients who are currently residing in foreign countries e Patients whose only malignancy is carcinoma in situ of the cervix
Analytic cases: Case diagnosed and/or receiving all or part of the first course of therapy at your facility----Class of case 00-22
The exceptions are not required to be followed regardless of the class of case

35. The College (aka ACoS)
Follow-up is considered delinquent by ACoS if info is not obtained and documented within 15 months of the patient’s previous date of last contact
For an approved program, a follow-up rate of 90% of a hospital’s analytic cases in the past 5 years is needed to be in compliance
American College of Surgeons

36. Follow-Up with KCR
Current follow-up must be reported to KCR for every case dx’d since 1995 that is class 00-22
Considered current if Date of Last Contact is within 15 months of current date
CPDMS.net can create a report for patients needing updated follow-up

37. Word To The Wise…..
Always maintain the highest follow-up rate possible!
Falling behind is trouble that’s easy to get into….and hard to get out of
Easier and less worry for you…..It’s a NIGHTMARE to catch up once you get behind!!!!!!!
Survival rates and stats

38. What To Collect Date of Last Contact Survival status Current address
Disease status
Recurrence info
Additional treatment received
Cause of death, if deceased
Method of obtaining follow-up
Date of Last Contact: May be date of death or most current date the patient is known to be alive
Survival Status: Alive ( w/ or w/o disease) or dead (related or unrelated to ca?)
Current address: May be different than original
Disease status: Ever disease free and if so what is the date
Recurrence info: Date, type and site
Additional treatment: ****Types and dates of therapy given after the DLC
Cause of death: Include any autopsy info if available
Method of follow-up: Includes any change in name or address of the primary/alternate contact persons or in the method for purusing follow-up on the next attempt

39. A Few Words About Treatment
Obtaining complete first course treatment info is extremely important
Follow your registry rules, but a brief documentation (date, type, drug(s), start & stop dates) in the treatment notes section is ideal
Must be doc somewhere…either in text or in tx notes…not both
Be brief!!
Putting info in tx notes will allow it to come out on the tx report (web) it will save you phone calls because other registrar’s will have access

40. Questions?
Resources for clarification: Your facility manager for facility specific preferences and your regional coordinator.