Module 2: Reporting

This module consists of 4 units. Unit 2.1 provides basic information about which healthcare facilities are responsible for reporting cancer cases and maintaining confidentiality. Unit 2.2 refers users to the International Classification of Diseases for Oncology, Third Edition (ICD-O-3): the list source for reportable tumors. Unit 2.3 categorizes the information collected by cancer registrars. Unit 2.4 offers a basic list of medical record reports from which cancer registrars can find patient and cancer information.

After completing this module, cancer abstractors will be able to:

• Recognize if a healthcare facility is responsible for reporting a case.
• Know where to find the list of reportable tumors.
• Know which categories of cancer information to collect.
• Know where to find this cancer information.

Module 2 Units:

• Who Reports the Information?
• Reportable Malignancies
• What Information is Reported?
• Where is the Information Found?
• Review & Quiz

Click here for a printer friendly version of Module 2.

Unit 2.1: Who Reports the Information?

Healthcare Facilities

• Hospitals
• Outpatient Surgery Centers
• Labs
• Diagnostic & Treatment Centers

Healthcare Practitioners

Diagnose or Treat Cancer

By law, all cancer cases diagnosed and/or treated at these type facilities are required to be reported to the Tennessee Cancer Registry. (See Tennessee Cancer Reporting Act.)

Cancer data are highly confidential. Therefore, one of the most important responsibilities of cancer registry professionals is to protect the confidentiality of cancer patient information. (See HIPAA Privacy Rule.)

Unit 2.2: Reportable Malignancies

The TCR collects information on in situ tumors, invasive/malignant tumors, benign tumors of the brain and central nervous system, borderline tumors of the brain and central nervous system, various hematopoietic diseases, and various lymphoid neoplasms.

Reportable Diagnoses:

1. All histologies in the International Classification of Diseases for Oncology, Third Edition (ICD-O-3) with a behavior of /2 or /3 are reportable. 

   ❖ Exceptions:

   1. Prostatic intraepithelial neoplasia (PIN III) of the prostate (C619) is not reportable.
   2. Carcinoma in situ of the cervix (/2) or cervical intraepithelial neoplasia (CIN III) of the cervix is not reportable by hospitals and surgery centers.
   3. Malignant (In-Situ or Invasive) primary skin cancers (C440-C449) with any of the following histology codes are not reportable:

   Malignant neoplasm (8000-8005)

   Epithelial carcinoma (8010-8046)

   Papillary and squamous cell carcinoma (8050-8084)

   Basal cell carcinoma (8090-8110)

   AIN III (8077) arising in perianal skin (C445)

   ✔ Note:  Squamous cell carcinoma originating in a mucoepidermoid site must be reported to the TCR.  These sites are:               

                                                   Lip          C00.1 – C00.9                     Vagina                  C52.9

                                                   Anus      C21.0                                     Prepuce               C60.0

                                                   Labia      C51.0 – C51.1                     Penis                     C60.1-C60.9

                                                   Clitoris  C51.2                                     Scrotum               C63.2

                                                   Vulva     C51.9

2. For cases diagnosed January 1, 2010 onward, all histologies in the WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues (2008) with a behavior code /3 are reportable.  Instructions for determining reportability for hematopoietic and lymphoid neoplasms are located in the Reportability Instructions of the Hematopoietic and Lymphoid Neoplasm Case Reportability and Coding Manual.  The manual is available online at: http://seer.cancer.gov/seertools/hemelymph/ (Use the 2015 version of the manual for diagnosis dates 1/1/2010 onward). Use of the Hematopoietic and Lymphoid Neoplasm Case Reportability and Coding Manual for hematopoietic and lymphoid neoplasms is REQUIRED.
3. Pilocytic/Juvenile astrocytomas are reportable.  Code the histology and behavior code as: 9421/3.
4. Carcinoid, NOS of the appendix is reportable. As of 1/1/15, the ICD-O-3 behavior code changed from /1 to /3.
5. Anal intraepithelial neoplasia III (AIN III) of the anus or anal canal (C210-C211), laryngeal intraepithelial neoplasia III (LIN III) (C320-C329), squamous intraepithelial neoplasia III (SIN III) excluding cervix, vaginal intraepithelial neoplasia III (VAIN III) (C529), and vulvar intraepithelial neoplasia III (VIN III) (C510-C519) are reportable.
6. Urine cytology positive for malignancy is reportable:
   1. Code the primary site to C689 in the absence of any other information.
      ❖ Exception: When a subsequent biopsy of a urinary site is negative, do not report the case.
7. Non-invasive mucinous cystic neoplasm (MCN) of the pancreas with high-grade dysplasia is reportable. For neoplasms of the pancreas, the term MCN with high-grade dysplasia replaces the term mucinous cystadenocarcinoma, non-invasive.
8. Mature teratoma of the testes in adults is malignant and reportable as 9080/3.
9. Gastro-intestinal stromal tumors (GIST) and thymomas are frequently non-malignant. However, they must be abstracted and assigned a Behavior Code of 3 if they are noted to have multiple foci, metastasis or positive lymph nodes.
10. Effective with cases diagnosed 1/1/2004 onward, benign and borderline primary intracranial and CNS tumors with a behavior /0 or /1 in the ICD-O-3 are reportable for the sites listed below:
    1. Report Pilocytic/Juvenile astrocytomas; code the histology and behavior as 9421/3
    2. Neoplasm and tumor are reportable terms for brain and CNS because they are listed in   ICD-O-3 with behavior codes of /0 and /1.
       1. Note: Benign and borderline tumors of the cranial bones (C410) are not reportable

Source: Adamo M Dickie, L, Ruhl J. (January 2015). SEER Program Coding and Staging Manual 2015. National Cancer Institute, Bethesda, MD 20850-9765.

❖ Reporting Timeline/Calendar

Unit 2.3: What Information Is Reported?

The information collected by cancer registries can be placed into different categories: 

Patient Information:

• Demographics: name, date of birth, gender, race ethnicity, place of birth, etc. This information identifies the cancer patient and helps to prevent duplicate reporting.
• Risks: Occupation and Industry.

Cancer Information:

• Primary Site Identification: Breast / Lung / Colon / Prostate, etc.
• Histology (Cell Type): Adenocarcinoma, Squamous Cell Carcinoma, etc.
• Stage: Extent of Disease – local , regional, distant
• Treatment: surgery, radiation therapy, chemotherapy, hormone, immunotherapy, etc.

Administrative Information

• Reporting Facility – important for Quality Assurance(QA) follow-back
• Abstractor – important for QA follow-back
• Attending Physician – important for QA follow-back 

Unit 2.4: Where Is The Information Found?

Cancer information is found in the medical record

• Face Sheet
• H & P
• Imaging
• Operative Report
• Pathology Report
• Consult Reports

Diagnostic and clinical findings, dates, surgical procedures, and treatment information can be identified by analyzing documents in the medical record.

Cancer data collection is a time and labor-intensive effort, but the great value of its product, cancer statistics, makes all of the hard work worthwhile.

Module 2: Review & Quiz

Review for Module 2 

Cancer data is placed into different categories:

• Demographic information relates personal facts about the patient e.g. name, date of birth, gender, race ethnicity, place of birth, etc.
• Cancer information relates specific information about the type of cancer and the extent of disease e.g. primary site identification, histology (cell type), local regional or distant spread of disease.
• Treatment information identifies the methods utilized to eradicate or control the disease e.g. surgery, radiation therapy, chemotherapy, hormone, immunotherapy, etc.
• Administrative information is used to run reports and for registry specific purposes.

 
The collection of data begins with the diagnosis of cancer. Facilities that diagnose and/or treat cancer patients are required by law, the Tennessee Cancer Reporting Act of 1983, to report cases and provide cancer data to the Tennessee Cancer Registry. 

To protect the confidentiality of cancer patients, physicians, and health care facilities, relevant regulations, policies, and laws are strictly implemented to standardize the handling of information in cancer registries.

Quiz for Module 2

Click here to take the  Module 2 Quiz.