1. Surgical Cancer Treatment
August 8, 2017

2. Outline Analytical questions Sources
Treatment episodes (eras)
Formal connection between diagnosis and treatment
Response to treatment
Sources
EMR/Claims
Cancer Registry
Critical dimensions and attributes
Representation in OMOP CDM
Is granularity of the respective domain/vocabulary sufficient to represent all treatment attributes and dimensions
Vocabularies and Mapping

3. Sources EMR, Billing Procedures Cancer Registry Clinical Trials
Billing focused
Provides all treatment information
No identification of a primary procedure
Few treatment dimensions for analysis
Time lag depends on a billing cycle (45 days)
Cancer Registry
Epidemiology/treatment focused
Provides selected treatment information: only reportable cancer types, mostly first treatment course at best and sometimes following
Clear identification of a primary procedure
Multiple treatment dimensions for analysis
Time lag 6 months
Clinical Trials
EMR, Medical History

4. CR Dimensions Temporal: In relation to other treatment modalities
first treatment course vs. others
initial/primary surgery and re-surgeries
In relation to other treatment modalities
radiation (before, after, together)
systemic
endocrine/transplant
Purpose
treatment: resection vs. delivery of other treatment type (e.g. radiation)
diagnostic
non-cancer
palliative procedures
Site and site specific procedure types:
primary
metastatic sites
lymph node biopsy or removal
Surgical method
State of surgical margins after the surgery
Why surgery (or any other treatment) was not performed)
Data QA and more. Example: Surgery of the primary site was not recommended/performed because it was contraindicated due to patient risk factors (comorbid conditions, advanced age, etc.).

5. Dimensions covered by vocabulary
Anatomic site
Surgical method
Cancer site?
primary
metastatic sites
lymph node biopsy or removal
Morphology

6. SNOMED Procedure Dimensions
Procedure site – direct/indirect (all)
Method (all)
Direct morphology (some)
Direct substance (s0me)
Examples:
, Biopsy of lung
Procedure site – direct: Lung Structure
Method: Biopsy - action
, Craniectomy with excision of tumor
Procedure site – direct: Brain Structure
Method: Excision – action
Direct morphology: Neoplasm
, Injection of therapeutic substance into cerebrospinal fluid
Procedure site – indirect: Structure of spinal subarachnoid space
Method: Injection – action
Direct substance: Drug or medicament

7. Cancer Registry Mappings?
Site specific procedure types -> Method
90 Surgery, NOS -> Surgical action
Anatomy -> Site direct/indirect
C > Procedure site – direct: Lung Structure
, Excision of malignant neoplastic lesion of skin of extremities (procedure)
Malignant neoplasm of primary, secondary, or uncertain origin (morphologic abnormality)

8. 1032 of 1119 (92%) CPT codes mapped to SNOMED
EMR Mappings
CPT Mappings in OMOP
1032 of 1119 (92%) CPT codes mapped to SNOMED
446 one-to-many (up to 7)
859 many-to-one
586 one-to-one

9. Candidate CDM extensions
Procedure modifiers (new table)
Site and site specific procedure types:
primary
metastatic sites
lymph node biopsy or removal
Number of lymph nodes removed
Relation to other treatment modalities
radiation (before, after, together)
systemic
endocrine/transplant
Treatment regimen /era (new table)
Purpose
treatment: resection vs. delivery of other treatment type (e.g. radiation)
diagnostic
non-cancer
palliative procedures
Temporal
first treatment course vs. others
initial/primary surgery and re-surgeries
Response to treatment
State of surgical margins after the surgery
Radiological response

10. NAACCR Data Dictionary http://datadictionary.naaccr.org/?c=10
References
FORDS
NAACCR Data Dictionary

11. Appendix

12. Surgery of Primary Site Codes

13. CR: Primary Procedure Types
10-19 Site-specific codes. Tumor destruction; no pathologic specimen produced.
20-80 Site-specific codes. Resection. Path specimen produced.
90 Surgery, NOS; surgical treatment of the primary site was done, but no information on the type of procedure is provided.
98 Site specific codes; special.

14. CR: Lymph Node Procedure Types
1 Biopsy or aspiration of regional lymph node, NOS 2 Sentinel lymph node biopsy 3 Number of regional lymph nodes removed unknown, not stated; regional lymph nodes removed, NOS 4 1 to 3 regional lymph nodes removed 5 4 or more regional lymph nodes removed 6 Sentinel node biopsy and code 3, 4, or 5 at same time or timing not noted 7 Sentinel node biopsy and code 3, 4, or 5 at different times

15. CR: Non-Primary Procedure Types
1 Non-primary surgical procedure performed 2 Non-primary surgical procedure to other regional sites 3 Non-primary surgical procedure to distant lymph node(s) 4 Non-primary surgical procedure to distant site 5 Any combination of codes 2, 3, or 4

16. CR: State of Margins after Surgery
0 No residual tumor
1 Residual tumor, NOS
2 Microscopic residual tumor
3 Macroscopic residual tumor
7 Margins not evaluable
8 No primary site surgery
9 Unknown or not applicable

17. CR: In Relation to Systemic Treatment
0 No systemic therapy and/or surgical procedures; unknown if surgery and/or systemic therapy given 2 Systemic therapy before surgery 3 Systemic therapy after surgery 4 Systemic therapy both before and after surgery 5 Intraoperative systemic therapy 6 Intraoperative systemic therapy with other therapy administered before and/or after surgery 7 Surgery both before and after systemic therapy 9 Sequence unknown, but both surgery and systemic therapy given

18. CR: In Relation to Radiation
No radiation and/or no surgery; unknown if surgery and/or radiation given
2 Radiation before surgery
3 Radiation after surgery
4 Radiation both before and after surgery
5 Intraoperative radiation
6 Intraoperative radiation with other radiation given before and/or after surgery
7 Surgery both before and after radiation
9 Sequence unknown, but both surgery and radiation were given