Tennessee Cancer Registry

The Introduction to Tennessee Cancer Registry for Cancer Care Abstractors provides information about cancer reporting procedures to cancer care abstractors in Tennessee. The site is designed to be an online training tool as well as a reference tool.

To use the site as an online training tool and learn at your own pace, you should carefully review the content of each page before moving on to the next page. Proceed through the site by clicking the “next” button at the bottom of each page, then complete the quiz at the end of each module as a means to self-test individual knowledge of that module's content.

After you have reviewed all the material and completed all quizzes in the training modules, you have the option to obtain a Certificate of Achievement.

This module consists of three units. Units 1.1 and 1.2 cover some basic concepts related to cancer registration. Unit 1.3 introduces different types of cancer registries.

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

• Define some basic concepts related to cancer registration
• Name the three general types of cancer registries

Module 1 Units:

• What is a Cancer Registry?
• What Does a Cancer Registry Do?
• Types of Cancer Registries
• Review & Quiz

Unit 1.1: What is a Cancer Registry?

A cancer registry is a particular type of disease registry. It is an organized system for the collection, storage, management, and analysis of data on persons with cancer who have been diagnosed and/or treated at a facility. 

Cancer registration is a process of a systematic collection of data on the occurrence and characteristics of reportable malignancies. Cancer registrars are trained to collect accurate, complete, and timely data on cancer patients.

Major purposes of a cancer registry are: 

1. to establish and maintain a cancer incidence reporting system;
2. to be an informational resource for the investigation of cancer and its causes; and
3. to provide information to assist public health officials and agencies in the planning and evaluation of cancer prevention and cancer control programs.

Unit 1.2: What Does a Cancer Registry Do?

• Casefinding: Identify reportable cases (See Module 4)
• Collect cancer data: Abstracting (See Module 3)
• Quality control: Accuracy, completeness
• Follow-up patients: ACOS, COC hospitals only
• American College of Surgeons, Commission on Cancer
• Analyze and distribute information using the database
• Serve as a resource for education and research

Unit 1.3: Types of Cancer Registries 

There are Three General Types of Cancer Registries:

• Hospital and Ambulatory Surgical Treatment Center (ASTC)-Based Registries
• Population-Based Registries
• Special Registries
• Hospital and ASTC based cancer registries maintain data on all patients diagnosed and/or treated at their facility.

Population based cancer registries (Central Registries) maintain data on all cancer patients in a particular geographic area. These registries can be administrative, research, or cancer control oriented.

Special cancer registries maintain data on one aspect or one type of cancer e.g. bone tumors, brain tumors, or pediatric tumors. They often provide educational opportunities for those who want to learn more about a particular type of cancer, and support for those who may suffer from it.

Tennessee Cancer Registry is the Central Cancer Registry for The State of Tennessee. The Tennessee Cancer Registry (TCR) is a population based incidence only cancer registry which collects data on all cancer cases within the state of Tennessee. It provides data free of charge through Research Data Requests from cancer research programs. The data is used for monitoring the distribution of cancer among certain communities, ethnicities, ages and other demographic groups. It is also used to evaluate suspected clusters of cancer within communities or population groups.

Module 1: Review & Quiz

Unit 1.1 and 1.2: The cancer registry is an information system established for the collection, storage management, and analysis of cancer data. Cancer registration refers to the process of systematic collection of data on the occurrence and characteristics of reportable malignancies. Behind the system are people, cancer registrars, who are responsible for collecting the cancer data and making sure they are timely, accurate, and complete.

Unit 1.3: There are three general types of cancer registries: population-based cancer registries, hospital and ASTC-based cancer registries, and special cancer registries.

Data collected by population-based registries are used by physicians, researchers, medical students, and health care administrators alike. Research can be conducted based on an unbiased group of cases. In addition, using data collected from population-based cancer registries, cancer control agencies and programs make important decisions regarding the allocation of resources and prevention strategies. 

Click the dropdown below for the Module 1 Cancer Registry Quiz.

Cancer Registry

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

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.

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.

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

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.

Click the dropdown below for the Module 2 Reporting Quiz.

Reporting

This module consists of seven units. Units 3.1-3.6 demonstrate that certain information is basic to any cancer registry abstract. Ideas for navigating through a medical record and locating pertinent information are provided. Unit 3.7 provides a list of ambiguous terms to be used when determining the reportability of a case. 

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

• Locate patient demographic information
• Locate diagnosing information
• Locate cancer information
• Locate extent of disease information
• Locate treatment information
• Be able to abstract pertinent information from a medical record
• Be able to provide summarized text documentation for the coding of diagnostic procedures, findings and treatment information
• Be able to recognize ambiguous terms considered as diagnostic of cancer, as well as, a list of terms not considered as cancer

Module 3 Units:

• Abstracting Hints
• Face Sheet/History & Physical
• Imaging
• Specimen Reports
• Surgery & Other Treatment
• One Last Step
• Ambiguous Terminology
• Review & Quiz

Abstracting module was borrowed in part from note pages of a PowerPoint presentation The Art of Abstracting by Susan Van Loon, RN, CTR.

Unit 3.1: Abstracting Hints

Each healthcare facility has its own procedures for organizing a medical record. However, medical records have certain characteristics in common. Usually, a record will be organized with the latest admission located at the front of the record. Most information includes patient identification, biographical information, medical history, physical exam, summary sheets and reports pertinent to the malignancy. Abstracting should be done from the actual reports in the record and not from the point of view of the attending physician.

A separate abstract is prepared for each unrelated malignancy.

It is acceptable to change data items such as primary site, histology, and stage, when information about the original diagnosis becomes more complete. If information has been added to the patient's medical record that was not available at initial diagnosis or at discharge, it is the practice to accept documentation about the case based on the latest or most complete information. The information must be supplementing the original diagnosis and not be based on changes as a result of tumor progression. 

It is usually not beneficial to abstract a case immediately upon patient discharge from the healthcare facility; especially if cancer directed treatment has not been completed. Accepted practice allows that cases be abstracted within six months of the date of diagnosis. This offers the opportunity for all pertinent diagnostic and treatment information to be collected in the medical record.

Before abstracting cases, the cancer registrar should:

• Be well acquainted with medical terminology and anatomy and physiology
• Understand the composition and organization of the medical record
• Determine whether a case is reportable

Getting Started

Review the medical record for clues

• Face Sheet
• History & Physical (H&P)
• Imaging Reports
• Cytology Reports
• Pathology Reports
• Surgery Reports
• Consult Reports
• Discharge Summary

Note: An abstract is a composite of information taken from multiple sources. Use as many of these reports as possible to obtain complete and accurate information. Unless no other reports are available, do not use the Discharge Summary as the sole source of information.

Unit 3.2: Face Sheet/History and Physical Face Sheet 

The face sheet contains pertinent patient information, such as: 

• Name
• Use the full name - avoid use of initials, if possible
• Use a married woman’s first name – do not use her husband’s first name 
• Example: Mrs. Jane Smith not Mrs. John Smith
• Social Security Number
• Date of birth:
• Record month, day and year
• Age at initial diagnosis for the reported cancer
• Place of Birth:
• Record state or country
• Race – if not on the face sheet, it may be found in the H&P or Nurse’s notes
• Spanish/Hispanic Origin
• Gender
• Marital status
• Address:
• Record the street, city and zip of current residence
• Use the patient’s residence, not the patient’s billing address
• Occupation/Industry:
• Use specific occupation/industry information, such as Carpenter/Construction
• Do not record RETIRED.
• If unknown, then record UNKNOWN.
• Hospital Medical Record Number

History & Physical (H&P)

The H&P contains:

• Findings relative to various body regions
• Important diagnostic statements
• Procedures planned for the patient such as, x-rays, scopes, lab tests, etc.
• Record any pertinent information related to the malignancy. 
• Example: Mass in left breast and palpable lymph node in left axilla. 

Unit 3.3: Imaging

X-rays/Scans/Scopes

Imaging reports contain:

• Pertinent findings about the primary tumor and metastatic sites
• Record the date, type of x-ray, scan or scope.
• Record all pertinent findings whether it is the primary site, extension or information about metastasis.
• Be sure to read the whole report.
• Be brief, highlight important information only.
• Most pertinent information can be found in the final assessment, the final impression, or the final diagnosis; however, some important information can be found in the body of the report.

Examples: 
02/05/05 Ultrasound of abdomen-mass lesion, superior portion of the left kidney
05/29/05 Chest x-ray negative for cancer
09-01-05 Bronchoscopy – bronchogenic ca, tumor involving RUL
10/3/05 Liver scan-abnormal. consistent with a central lesion, possible mets. 

Unit 3.4: Specimen Reports

Pathology/Bone Marrow/Cytology Reports/Laboratory Reports

Speciment Reports

Specimen reports contain:

• Pertinent findings with respect to the malignancy and metastatic sites. 
   

Pathology Reports 

Pathology reports contain very important information that may:

• Identify the primary site
• State the tumor size in the gross section or final diagnosis
• State structure and organ involvement
• State lymph node involvement
• State the extent to which the disease has spread
• State surgical margin involvement
• State Tumor Marker results
• Record the date and pathology number
• Record the name of the procedure performed
• Record the location of the primary site
• Record the size of the tumor
• Record the histologic (cell type) diagnosis, including grade (differentiation)
• Record the extent of disease within the primary site and beyond
• Record the number of lymph nodes removed and number of lymph nodes involved with the disease
• Record the tumor markers. For example: PSA levels for prostate cancer and CEA levels for colorectal cancer.

Bone Marrow Aspirations

• Record the date and report number
• Record the malignant diagnosis such as leukemia, metastasis, or any pertinent comment.
• It is not critical to abstract all of the actual lab values.

Cytology Reports

• Record the date and cytology number
• Record the results of brushings, washings, thoracentesis, and paracentesis with a cancer diagnosis.
  • For example: 09-01-05 Fine Needle Aspirate (FNA) of pleural effusion returns as positive for malignant cells. 
    

Unit 3.5: Surgery and Other Treatment

Cancer directed treatment is any procedure that modifies, controls, removes, or destroys cancer tissue. 

First course of treatment includes all methods of cancer directed therapy documented in the treatment plan and administered to the patient before disease progression or recurrence. Treatment may include multiple modalities. The time frame for first course of treatment may cover a long period of time e.g. a year or more. No therapy is a treatment option that occurs if the patient refuses treatment, the family or guardian refuses treatment, the patient dies before treatment starts, or the physician recommends no treatment be given.

Treatment Information

Treatment information may be located in:

• Surgical report
• Pathology report
• Radiation therapy records
• Progress notes
• Physician order sheets
• Medicine sheets
• Discharge notes

Surgery Reports

• Report the date of the surgery and name of the procedure.
• Report the primary site, tumor size, lymph node involvement and metastasis.
• Report the spread of disease on tissues that were not excised. 
   

Note: If there is conflicting information on the reports, please use the following hierarchy to determine the best information:

• Pathologic information takes precedence over operative information
• Operative information takes precedence over information from imaging reports
• Information from imaging reports takes precedence over the physical exam. 
• Example: If the imaging report states the tumor size is 3cm, but the pathology report states it is 2cm, then record tumor size as 2cm. If the physical exam states the tumor size as a 2cm lesion, but the imaging states it is 3cm, then record the tumor size as 3cm.

Other Treatment – Chemotherapy, Hormone therapy, Radiation therapy, Biological Response Modifiers (BRM), and Other therapy

• Report the dates
• Report all methods of therapy recorded in the treatment plan and administered to the patient 

Unit 3.6: One Last Step...Before Moving on to the Next Case

Perform visual editing:

• Check all dates
• Check demographic information
• Does the text support the primary site, laterality, histology and stage?
• Well summarized documentation aids in quality assurance activities
• Text documentation is required data for reporting to the Tennessee Cancer Registry.

Unit 3.7: Ambiguous Terminology

Often times, the medical record clearly indicates the patient has cancer by using specific terms that are synonymous with cancer (i.e., carcinoma, adenocarcinoma, etc.). However, a diagnosis of cancer is not always clearly stated and ambiguous terminology may be used. Ambiguous terminology may appear in any source document, such as pathology report, radiology report, or from a clinical report. 
An abstract must be submitted if any ambiguous term which is considered diagnostic of cancer is used (see the following list of ambiguous terms). 

Ambiguous terms that are reportable

• Apparent(ly)
• Appears (effective with cases diagnosed 1/1/1998 and later)
• Comparable with (effective with cases diagnosed 1/1/1998 and later)
• Compatible with (effective with cases diagnosed 1/1/1998 and later)
• Consistent with
• Favor(s)
• Malignant appearing (effective with cases diagnosed 1/1/1998 and later)
• Most likely
• Presumed
• Probable
• Suspect(ed)
• Suspicious (for)**
• Typical (of)

Ambiguous terms that are NOT reportable 
(Do not accession cases with a diagnosis based on only these terms)

• Cannot be ruled out
• Equivocal
• Possible
• Potentially malignant
• Questionable
• Rule(d) out
• Suggests
• Worrisome

**Exception: Cytology: Ambiguous terminology should not be used when evaluating cytology for reportability. Abstract the case only if a positive biopsy or a physicians's clinical impression of cancer supports the ambiguous cytology finding.

For example: A diagnosis of probable carcinoma of the colon would be considered diagnostic and the case would be reported. 

A diagnosis of questionable carcinoma of the left breast would not be considered diagnostic and the case would not be reported

A possible carcinoma is not reportable. 

Module 3 Review and Quiz

To accurately abstract pertinent information from a medical record, a cancer registrar should be familiar with medical terminology and diagnostic procedures.

Most medical records contain patient identification information, biographical information, medical history, and physical examination. 

Reports contained within a medical record include, but are not limited to: face sheet, imaging reports, cytology reports, pathology reports, surgery reports, consult reports, discharge summary. 

Each healthcare facility has its own measures for organizing a medical record. Usually, a record will be organized with the latest admission located at the front of the record.

A separate abstract is generally prepared for each unrelated malignancy.
Information may be added to the patient's medical record that was not available at initial diagnosis or at discharge. 

It is usually not beneficial to abstract a case immediately upon discharge from the healthcare facility. Accepted practice allows for cases to be abstracted within six months of the date of diagnosis. This offers the opportunity for all pertinent diagnostic and treatment information to be collected in the medical record.

Click the dropdown below for the Module 3 Abstracting Quiz.

Abstracting

This module consists of four units which will deal with some basic procedures for casefinding in a healthcare facility.

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

• Briefly describe the concept of casefinding
• Name the different types of casefinding
• List casefinding sources
• Describe the role of a suspense file

Module 4 Units:

• Casefinding
• Types of Casefinding Methods
• Casefinding Sources
• Cancer-Screening Lists of ICD-9-CM Codes for Casefinding
• Suspense File
• Review & Quiz

Click here for a printer friendly version of Module 4.

Unit 4.1: Casefinding

Casefinding is a system for identifying every patient - inpatient or outpatient, who is diagnosed and/or treated with a reportable diagnosis of cancer.

Casefinding is one of the most important duties a cancer registrar performs. Cancer data collection begins by identifying those patients with a clinical or pathological diagnosis of cancer. All healthcare facilities should create a casefinding system to ensure all reportable cases are identified. It is important that all personnel involved in the casefinding be thoroughly familiar with reportable diagnoses. (See Module 2 and Module 3)

A clinical diagnosis results when a recognized medical practitioner says the patient has a cancer or carcinoma; the case is reportable. Some malignancies are never histologically or cytologically confirmed. A diagnosis of cancer can be made during a diagnostic workup e.g. imaging exams, radiographic scans, tumor markers, blood work, visualization of tumor at exploratory laparotomy, etc. These cases are reportable based on the clinical diagnosis. A clinical diagnosis may be recorded in the final diagnosis on the face sheet or other parts of the medical record.

Note: A pathology report normally takes precedence over a clinical diagnosis. If the patient has a negative biopsy, the case would not be reported.

Exception 1: If the physician treats a patient for cancer in spite of the negative biopsy, report the case.

Exception 2: If enough time has passed that it is reasonable to assume that the physician has seen the negative pathology, but the clinician continues to call this a reportable disease, report the case. A reasonable amount of time would be equal to or greater than 6 months.

A pathologic diagnosis is based upon tissue specimens taken during surgical procedures or autopsies; positive hematological findings relative to leukemia are included, as well as bone marrow exams. This type diagnosis can also be based upon examination of cells e.g. sputum cytology, fine needle aspirate (FNA), peritoneal washings, or examination of cells in pleural fluid. (See Module 3)

Casefinding is an important part of the cancer registry. All healthcare facilities must perform casefinding in order to assure that all reportable cases are submitted to the Tennessee Cancer Registry and to adhere to the reporting requirements.

Cancer registrars do not wait for cancer information to filter in to a registry. Registrars should become actively involved in casefinding so that the cancer information they receive is as complete as possible. Cancer registrars often accomplish this by visiting other areas of the healthcare facility to ensure that no cancer data or cases are missed.

Unit 4.2: Types of Casefinding Methods

There are two types of casefinding methods used by registries: active and passive.

Active Casefinding

• The cancer registrar retrieves and screens all source documents to identify reportable cases; e.g. disease indices, pathology reports, radiology reports etc.
• This method is more thorough and accurate because cancer registrars possess medical terminology and diagnostic procedure knowledge to help them identify reportable cases.

Passive Casefinding

• The cancer registrar relies on other departments to notify the registrar of potential reportable cases.
• The cancer registrar determines which departments can provide high quality case finding information.

Active and passive case finding ensures more complete cancer case reporting. The most effective casefinding system includes reviewing specimen reports e.g. pathology, cytology, bone marrow, and autopsy reports, as well as, non-specimen reports e.g. disease indices, radiology reports, or oncology logs.

Unit 4.3: Casefinding Sources

There are several source documents available for casefinding. The documents may vary from one facility to another based on what specialty departments exist. In general the source documents in a hospital can include, but are not limited to, the following:

• Pathology Reports
• Cytology Reports
• Bone Marrow Reports
• Autopsy Reports
• Imaging Reports
• Surgery Schedule
• Medical Oncology Logs
• Radiation Oncology Logs
• Nuclear Medicine
• Admission and Discharge Summaries
• Outpatient
• Disease Index

Specimen Sources 

Pathology and Cytology Reports: Generally, 90 percent of all cancers are histologically confirmed. The reviewing of all pathology and cytology reports is essential to complete cancer reporting. The cancer registrar or designated personnel should review ALL these reports.

• Bone Marrow Reports: A blood smear and/or a bone marrow specimen may be the sole basis of diagnosis for patients with leukemia/hematopoietic diseases. Bone marrow reports are similar to pathology reports and can be reviewed in the same manner.
• Autopsy reports: Autopsy reports are usually filed separately from pathology reports in the pathology department or in the Health Information Management department. Review of autopsy reports is usually beneficial for casefinding and identifies cases of cancer that were not diagnosed prior to death.

Non-Specimen Sources

• Imaging Reports: Review for clinical diagnosis. Some patients may be diagnosed on the basis of radiological findings alone and may never be histologically confirmed. Benign brain tumors are often initially diagnosed through scanning procedures. Review of radiology reports whose findings indicate the presence of neoplastic disease should be reviewed to prevent missed cases.
• Surgery Schedule/ Medical Oncology/ Radiation Oncology/ Nuclear medicine logs:
  The surgery department, nuclear medicine department, radiation oncology department, and the medical oncology department logs should be reviewed to help ensure complete case ascertainment. These logs often identify cases that are diagnosed at one facility and then referred to another facility for treatment.
• Admission and discharge documents: Routine review of all inpatient and outpatient admissions and discharges should be performed. Cases that are histologically confirmed at one facility and then referred to a subsequent facility for treatment are often identified within these documents.
• Outpatient departments: Reviewing pathology reports from outpatient surgeries, radiation, and chemotherapy logs will often yield cases that might otherwise be missed.
• Disease Indices: The disease index is an excellent casefinding source, however, it is NOT accurate enough to use as the only source of casefinding. The disease index is a listing of cases by date of discharge and can be arranged in diagnostic groupings. A report can be generated by the health information management (HIM) department specifying a group of ICD-9-CM codes to be reviewed. The cancer-screening list in Unit 4.4 can be used to narrow the report to appropriate reportable cases.

Important: Review of only one type of source document cannot identify all cancer cases diagnosed and/or treated in a facility. USE AS MANY SOURCES AS POSSIBLE TO ASSURE COMPLETE CASE ASCERTAINMENT.

Casefinding and abstracting are not done at the same time.

• Casefinding is done first
• A list is kept of the identified cases (suspense file)
• Abstracting is done at least six months after date of diagnosis

Unit 4.4: Year 2015 ICD 9 and ICD 10 Casefinding List

Unit 4.5: Suspense File

After identifying a probable case, evaluate whether the case is reportable or already reported.

A suspense file (tracking system) is kept which contains information on cases that may be reportable.

A suspense file is maintained so that the status of casefinding can be ascertained at any time.

The suspense file can be maintained in at least two ways:

• Enter the case into a computerized data base, which has a suspense file designed into it.
• Fill out a brief form of identifying information:
• Name
• Date of Birth
• Medical Record Number
• Date of Diagnosis
• Primary Site
• Location of Source documents
• File this form in month order by date of diagnosis

The suspense file should be reviewed periodically to ensure that cases are completed promptly; within six months after date of diagnosis.

Module 4 Review and Quiz

Casefinding is a system for locating every patient, either inpatient or outpatient, who is diagnosed and/or treated with a reportable diagnosis.

All healthcare facilities must perform case finding. Although these facilities may use different source documents, the procedures involved in their casefinding cycles are similar.

In the casefinding process, a suspense file is kept so that the status of casefinding can be ascertained at any time.

There are two types of casefinding methods used by healthcare facilities: active and passive.

In active casefinding procedures, cancer registrars retrieve and screen the source documents (such as disease indices, pathology reports, and so on).

A benefit of active casefinding procedures is that this method is more thorough and accurate, because the registry personnel have extensive training in terminology that identifies reportable cases.

In case of passive casefinding the cancer registrar relies on other health care professionals to notify the registrar of potentially reportable cases.

A concern with passive casefinding is that non-cancer registry staff are not as familiar with reporting terminology and rules, so incomplete casefinding may occur.

A combination of active and passive casefinding is a commonly used system in registries.

There are many casefinding sources; Reliance on multiple sources is necessary to obtain a complete description of the patient's cancer experience.

Review of all inpatient and outpatient admissions and discharges facilitates quick casefinding process since these documents present clinical or pathological diagnosis of cancer.

One method of casefinding is the reviewing of all pathology and cytology reports which is essential to complete cancer reporting. The cancer registrar or designated personnel should review ALL these reports.

Other casefinding sources include cytology and autopsy reports, nuclear medicine documents, radiation oncology and medical oncology logs.

After identifying a potential case from a casefinding source, the registrar processes the case into a suspense file.

The suspense file contains information on cases that are potentially reportable.

The suspense file can be maintained in at least two ways:

• Enter the case into a computerized data base, which has a suspense file designed into it.
• Fill out a brief form of identifying information:
• Name
• Date of Birth
• Medical Record Number
• Date of Diagnosis
• Primary Site
• Location of Source documents
• File this form in month order by date of diagnosis

The suspense file should be reviewed periodically to ensure that cases are completed promptly.

Click the dropdown below for the Module 4 Casefinding Quiz.

Casefinding

This module consists of four units which will provide the user a basic knowledge of cancer as a disease.

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

• Define the term "cancer"
• Be familiar with the common terms related to cancer
• Name some of the known cancer risk factors
• Name some examples of cancer types

Module 5 Units:

• Definition of Cancer
• Cancer Terms
• Risk Factors
• Cancer Classification
• Review & Quiz

Click here for a printer friendly version of Module 5.

Unit 5.1: Definition of Cancer

General Definition of Cancer

The American Cancer Society (ACS) defines cancer as a group of diseases characterized by uncontrolled growth and spread of abnormal cells. If the spread is not controlled, it can result in death.

A cancer cell is a cell that grows out of control. Unlike normal cells, cancer cells ignore signals to stop dividing, to specialize, or to die and be shed. Growing in an uncontrollable manner and unable to recognize its own natural boundary, the cancer cells may spread to areas of the body where they do not belong.

Cancer cells have defects in normal cellular functions that allow them to divide, invade the surrounding tissue, and spread by way of vascular and/or lymphatic systems.

Characteristics of Cancer

Abnormality
Cells are the structural and functional units of all living things. The trillions of cells in the human body include some 200 different types that vary greatly in shape, size, and function. Cells make it possible for us to carry out all kinds of functions of life: the beating of the heart, breathing, digesting food, thinking, walking, and so on. However, all of these functions can only be carried out by normal healthy cells. Some cells fail normal controls of cell division and stop functioning or behaving as they should, as a result, serve no useful purpose in the body at all, and can become cancerous cells.

Uncontrollability
The most fundamental characteristic of cells is their ability to reproduce themselves. They do this simply by dividing. The division of normal and healthy cells occurs in a regulated and systematic fashion: one cell becomes two, the two become four, and so on. Cancer was once perceived as disorganized cell growth, however, it is now known to be a logical, coordinated process in which a precise sequence of tiny alterations changes a normal cell. When these cells fail normal controls of cell division and multiply excessively, an abnormal mass forms.

Invasiveness
Sometimes tumors do not stay harmlessly in one place. They destroy the part of the body in which they originate and then spread to other parts where they start new growth and cause more destruction. This characteristic distinguishes cancer from benign growths, which remain in the part of the body in which they start. Although benign tumors may grow quite large and press on neighboring structures, they do not spread to other parts of the body. Frequently, they are completely enclosed in a protective capsule of tissue and they typically do not pose danger to human life like malignant tumors (cancer) do.

A Group of Diseases
Although cancer is often referred to as a single condition, it actually consists of more than 100 different diseases. These diseases are characterized by uncontrolled growth and spread of abnormal cells. Cancer can arise in many sites and behave differently depending on its organ of origin. Breast cancer, for example, has different characteristics than lung cancer. It is important to understand that cancer originating in one body organ takes its characteristics with it even if it spreads to another part of the body. For example, metastatic breast cancer in the lungs continues to behave like breast cancer when viewed under a microscope, and it continues to look like a cancer that originated in the breast.

Unit 5.2: Cancer Terms

Cancer, Neoplasia, Tumor, Neoplasm

The word cancer comes from the Latin (originally Greek) derived term for crab, because of the way a cancer adheres to any part that it seizes upon in an obstinate manner like the crab. Hippocrates first described cancer as having a central body with the tendency to reach out and spread like, "the arms of a crab." Besides the popular, generic term "cancer" used by most people, there is another more technical term: neoplasia. Neoplasia (neo = new, plasia = tissue or cells) or neoplasm literally means new tissue in Greek. This term indicates that cancers are actually new growths of cells in the body.

Another term for cancer is "malignant tumor." Tumor literally means "swelling" or "mass." In this case, it refers to a mass of non-structured new cells, which have no known purpose in the physiological function of the body.

There are two general types of tumors: benign (non-cancerous) tumors and malignant (cancerous) tumors. A benign tumor is composed of cells that will not invade other unrelated tissues or organs of the body, although it may continue to grow in size abnormally. A malignant tumor is composed of cells that resemble immature cells and invade the basement membrane or spread to other parts of the body. Malignant cells can also break away from the primary tumor and travel by blood or lymph to other body organs or by seeding or implantation in body cavities. This capability is called metastasis.

Terms such as "mass" and "lump" are used to describe any overgrowth of tissue. However, these terms may not necessarily mean that such growths contain cancer cells.

Types of Abnormal Cell Growth

In addition to neoplasia, there are several other terms referring to abnormal cell growth. These include the following:

Hyperplasia refers to an abnormal increase in the number of cells, which are in a normal component of that tissue and are arranged in a normal fashion with subsequent enlargement of the affected part. One example is thyroid hyperplasia, an enlargement of the thyroid gland caused by an abnormal rapid growth of the epithelial cells lining the follicles. Another example is: Guitar strumming leads to hyperplasia of the cells on the thumb (a callus is formed). The callus on the thumb is a hyperplastic growth.
Hypertrophy refers to an abnormal increase in the size of each cell, for example, the increase in cell size of cardiac muscle.
Metaplasia refers to the replacement of one mature cell type with another mature cell type, for example, squamous metaplasia of the respiratory columnar epithelium - as evidenced by the metaplastic cough of a smoker.
Dysplasia refers to the replacement of one mature cell type with a less mature cell type, for example, dysplasia of the cervix epithelium.

Hyperplasia, metaplasia, and dysplasia are reversible because they are results of a stimulus. Neoplasia is irreversible because it is autonomous.

Tumor Terminology Generalizations

Names of benign tumors usually end with "oma" as suffixes regardless of their cell type. For example, a benign glandular tumor (epithelium tissue) is called adenoma and a benign bone tumor is called osteoma while a malignant glandular tumor is called adenocarcinoma and a malignant bone tumor is called osteosarcoma.

In addition to benign tumors, there are in situ tumors and invasive tumors. In situ tumors do not invade the basement membrane, whereas invasive tumors do invade the basement membrane.

Unit 5.3: Risk Factors

Risk Factors

Smoking
Cigarette smoking alone is directly related to at least one-third of all cancer deaths annually in the United States. Cigarette smoking is the most significant cause of lung cancer and the leading cause of lung cancer death in both men and women. Smoking is also responsible for most cancers of the larynx, oral cavity, and esophagus. In addition, it is highly associated with the development of, and deaths from bladder, kidney, pancreatic, and cervical cancers. Tobacco smoke contains thousands of chemical agents, including 60 substances that are known to cause cancer (carcinogens).

The health risks with cigarette smoking are not limited to smokers. Exposure to environmental tobacco smoke significantly increases a nonsmoker's risk of developing lung cancer. Environmental tobacco smoke is the smoke that nonsmokers are exposed to when they share air space with someone who is smoking.

Diet
The life style factor that has received the most attention in recent years is diet. Evidence suggests that about one-third of the cancer deaths each year that occur in the United States are related to dietary factors. These include types of food, preparation methods, portion size, variety, and overall caloric balance

Genetics
Research has determined that certain genetic factors may predispose individuals to specific cancers. In some families cancer can recur generation after generation. Some of the most common cancers that can recur are: breast, colon, ovarian, and uterine cancer.

Occupation and Environment 
People who have direct contact to carcinogenic agents in the workplace are at the highest risk for developing cancer. For example, a recent study suggests that people with brain cancer are more likely to have worked in certain occupations than similarly aged people without brain cancer. Many cancer-causing chemicals have been identified and many of them are banned from manufacture in the United States.

The common body surfaces that are exposed to carcinogens are the skin, nasal passages, and lung. The primary internal body surface that has contact with carcinogens is the urinary bladder

Infectious Agents
Because viruses can invade and alter cells' genetic material, viral infections are implicated in some cancers. The Epstein-Barr virus, for example, is associated with Burkitt lymphoma, a tumor found mainly among children in Africa. The hepatitis B virus is responsible for much of the liver cancer around the world. The highest rates of hepatitis B infection in the world are in China, Taiwan, Japan, and Thailand with equally high rates of liver cancer in these countries. The human papilloma virus that causes genital warts has been shown to play an important causative role in cervical cancer. The human T-cell leukemia virus, a close relative of the virus that causes acquired immunodeficiency syndrome (AIDS), is associated with a cancer known as Kaposi sarcoma and some types of Non-Hodgkin lymphomas.

Cancer risk factors are not limited to those listed above. There are still other risk factors such as ethanol use, use of certain medications, hormones, and reproductive and sexual behavior. With further scientific research, more cancer risk factors will be identified in the future.

Unit 5.4: Cancer Classification

Cancers are classified in two ways: by the type of tissue in which the cancer originates, also known as the cancer’s histological type, and by the primary site, also known as the location in the body where the cancer first developed. This unit introduces you to the first method: cancer classification based on histological type. The international standard for the classification and nomenclature of histologies is the International Classification of Diseases for Oncology, Third Edition (ICD-O-3).

From a histological standpoint there are hundreds of different cancers, which are grouped into five major categories: carcinoma, sarcoma, myeloma, leukemia, and lymphoma. In addition, there are also some cancers of mixed types.

Carcinoma
Carcinoma refers to a malignant neoplasm of epithelial origin, also referred to as cancer of the internal or external lining of the body. Carcinomas account for 80 to 90 percent of all cancer cases.

Epithelial tissue is found throughout the body. It is present in the skin, as well as the covering and lining of organs and internal passageways, such as the gastrointestinal tract.

Carcinomas are divided into two major subtypes: adenocarcinoma, which develops in an organ or gland, and squamous cell carcinoma, which originates in the squamous epithelium.

Adenocarcinoma generally occurs in mucus membranes and is first seen as a thickened plaque-like white mucosa. They often spread easily through the soft tissue where they occur. Squamous cell carcinoma occurs in many areas of the body.

Most carcinomas affect organs or glands capable of secretion, such as the breasts, which produce milk, or the lungs, which secrete mucus, or colon or prostate or bladder.

Sarcoma
Sarcoma refers to cancer that originates in supportive and connective tissues such as bones, tendons, cartilage, muscle, and fat. Generally occurring in young adults, the most common sarcoma often develops as a painful mass on the bone. Sarcoma tumors usually resemble the tissue in which they grow.

Examples of sarcomas are:

• Osteosarcoma or osteogenic sarcoma (bone)
• Chondrosarcoma (cartilage)
• Leiomyosarcoma (smooth muscle)
• Rhabdomyosarcoma (skeletal muscle)
• Mesothelial sarcoma or mesothelioma (membranous lining of body cavities)
• Fibrosarcoma (fibrous tissue)
• Angiosarcoma or hemangioendothelioma (blood vessels)
• Liposarcoma (adipose tissue)
• Glioma or astrocytoma (neurogenic connective tissue found in the brain)
• Myxosarcoma (primitive embryonic connective tissue)
• Mesenchymous or mixed mesodermal tumor (mixed connective tissue types)

Myeloma
Myeloma is cancer that originates in the plasma cells of bone marrow. The plasma cells produce some of the proteins found in blood.

Leukemia
Leukemias ("liquid cancers" or "blood cancers") are cancers of the bone marrow (the site of blood cell production). The word leukemia means "white blood" in Greek. The disease is often associated with the overproduction of immature white blood cells. These immature white blood cells do not perform as well as they should, therefore the patient is often prone to infection. Leukemia also affects red blood cells and can cause poor blood clotting and fatigue due to anemia. Examples of leukemia include:

• Myelogenous or granulocytic leukemia (malignancy of the myeloid and granulocytic white blood cell series)
• Lymphatic, lymphocytic, or lymphoblastic leukemia (malignancy of the lymphoid and lymphocytic blood cell series)
• Polycythemia vera or erythremia (malignancy of various blood cell products, but with red cells predominating)

Lymphoma
Lymphomas develop in the glands or nodes of the lymphatic system, a network of vessels, nodes, and organs (specifically the spleen, tonsils, and thymus) that purify bodily fluids and produce infection-fighting white blood cells, or lymphocytes. Unlike the leukemias which are sometimes called "liquid cancers," lymphomas are "solid cancers." Lymphomas may also occur in specific organs such as the stomach, breast or brain. These lymphomas are referred to as extranodal lymphomas. The lymphomas are subclassified into two categories: Hodgkin lymphoma and Non-Hodgkin lymphoma. The presence of Reed-Sternberg cells in Hodgkin lymphoma diagnostically distinguishes Hodgkin lymphoma from Non-Hodgkin lymphoma.

Mixed Types 
The type components may be within one category or from different categories. Some examples are:

• Adenosquamous carcinoma
• Mixed mesodermal tumor
• Carcinosarcoma
• Teratocarcinoma

Cancer Types by Site
Medical processionals frequently refer to cancers based on their histological type. However, the general public is more familiar with cancer names based on their primary sites. The most common sites in which cancer develops include the skin, lungs, female breasts, prostate, colon and rectum, cervix and uterus.

Compared to those based on histological type, cancers named after the primary site may not be as accurate. For example lung cancer; the name does not specify the type of tissue involved. It simply indicates where the cancer is located. In fact, depending on how the cells look under a microscope, there are two major types of lung cancer: non-small cell lung cancer and small cell lung cancer. Non-small cell lung cancer can be further divided into various types named for the type of cells in which the cancer develops, typically: squamous cell carcinoma, adenocarcinoma, and large cell carcinoma. Small cell lung cancer, sometimes called oat cell carcinoma, is the less common form of lung cancer, making up 20% of cases. There are three types of small cell lung cancer named for the kinds of cells found in the cancer and how the cells look when viewed under a microscope. These include small cell, mixed small cell/large cell and combined small cell.

Cancers are named according to the organ in which they originate. Even if a cancer metastasizes to another part of the body, it keeps its original name. Cancer names such as breast cancer, brain cancer, lung cancer, skin cancers are examples.

Module 5 Review and Quiz

The American Cancer Society defines cancer as "a group of diseases characterized by uncontrolled growth and spread of abnormal cells. If the spread is not controlled, it can result in death."

Cancer does not refer to a single disease. Rather, it consists of more than 100 different diseases.

A few cancer related terms are introduced: cancer, neoplasia, tumor, neoplasm, and growth. Neoplasia, a synonym of cancer, is often used by medical professionals. Neoplasm is a synonym for tumor, which literally means "new growth." Several other terms referring to abnormal cell growth which are not cancer include: hyperplasia, metaplasia, and dysplasia.

Although scientists have not yet pinpointed an exact cause for cancer, many factors have been identified that are likely to cause development of cancer in the body. These factors are called "cancer risk factors" and include smoking, diet, genetics, occupation, environment, and infectious agents.

Cancers can be classified based either on histological type or their primary site (the location where the cancer originated).

Five major categories of cancer, based on their histological characteristics, are: carcinoma; sarcoma; myeloma; leukemia; and lymphoma. In addition, there are also some mixed types.

The most common sites in which cancer develops include skin, lung, female breast, prostate, and colon, rectum, and corpus uteri.

Click the dropdown below for the Module 5 What is Cancer? Quiz.

What is Cancer?

This module consists of one unit. Unit 6.1 is presented as informational content to assist administrators, directors or supervisors with selecting cancer registry personnel who will be responsible for identifying and reporting cancer cases to the Tennessee Cancer Registry. 

Click here for a printer friendly version of Module 6.

6.1 Cancer Abstractor Qualifications 

Cancer abstractors are the data management experts who collect cancer data from a variety of sources. The primary responsibility of the cancer abstractor is to ensure that timely, accurate, and complete cancer data is collected and maintained on all types of cancer diagnosed and/or treated within a healthcare facility. 

To be successful, the cancer abstractor must possess the following:

Knowledge of Anatomy and Physiology

• The cancer abstractor must possess a good working knowledge of anatomy and physiology in order to identify and code the primary site of cancer, determine the extension of disease to other organs, and be able to stage the disease appropriately.

Knowledge of Medical Terminology 

• The cancer abstractor must possess a good working knowledge of medical terminology in order to interpret medical reports which contain information on diagnostic procedures, a diagnosis of cancer and treatment information.

Good Verbal and Written Skills

• The cancer abstractor must possess good verbal and written skills. There will be occasions when an abstractor must communicate or interact closely with physicians or other cancer abstractors concerning the specifics of a particular cancer case. These skills will enable comfortable interaction with other healthcare professionals involved with the case. 

Good Reading Skills 

• The cancer abstractor must possess good reading skills. Proper identification of pertinent reports, data items and supporting text into the abstract will assure complete and accurate information is reported to the state registry.

For more information, visit the web sites:

SEER Training

• training.seer.cancer.gov

National Cancer Registrars Association (NCRA)

• www.ncra-usa.org

ACOS / Commission on Cancer CA Forum

• http://cancerbulletin.facs.org/forums/

The following books and publications also provide additional information.

• International Classification of Diseases for Oncology, Third Edition (ICD-O3)
• Tennessee Cancer Registry Manual
• Collaborative Staging Manual and Coding Instructions
• Facility Oncology Registry Data Standards (FORD)-Used by American
• College of Surgeons, Commission on Cancer, Approved Cancer Programs