Documenting Cancer Registry

1. What is the cancer diagnosis being abstracted (primary site, histology)? (Default: [VERIFY])
2. What is the date of diagnosis per STORE manual rules? (Default: determine from first pathologic confirmation or clinical diagnosis)
3. Is this case reportable per state registry rules? (Default: verify reportability)
4. What class of case is this (analytic vs. non-analytic)? (Default: determine per CoC definitions)
5. Is this a single primary or are there multiple primaries requiring separate abstracts? (Default: apply SEER multiple primary rules)
6. What staging system applies (AJCC TNM, Ann Arbor, other disease-specific)? (Default: AJCC 8th edition for solid tumors)
7. Has first course treatment been completed or is it ongoing? (Default: document all treatments in first course)
8. What is the patient's current vital status? (Default: alive at last contact)

Documents to Request

• Pathology reports (all biopsies, surgical specimens, cytology)
• Operative reports for all cancer surgeries
• Radiology imaging reports (CT, MRI, PET/CT, bone scan)
• Chemotherapy administration records (agents, dates, doses)
• Radiation therapy summary (fields, dose, fractionation, dates)
• Death certificate if applicable
• Consultation notes from all treating physicians
• Molecular/biomarker testing results
• Clinical trial enrollment documentation if applicable
• Discharge summaries for cancer-related hospitalizations

Step 1: Determine Reportability and Case Eligibility

Reportable conditions per NAACCR/STORE standards:

• All invasive cancers (behavior code /3 in ICD-O-3)
• In situ cancers (behavior code /2) except in situ cervix (CIN III is not reportable as cancer)
• Benign and borderline CNS tumors (behavior codes /0 and /1 for brain and CNS)
• Pilocytic astrocytoma and other specific borderline neoplasms per site-specific rules

Non-reportable: Basal cell carcinoma of skin, squamous cell carcinoma of skin (except genital sites and select other sites per state rules), most benign tumors outside CNS.

Class of case determination:

• Class 00: Diagnosed at this facility, no treatment here or elsewhere
• Class 10: Diagnosed at this facility, all treatment here
• Class 11–14: Diagnosed at this facility, treatment partially or fully elsewhere
• Class 20–22: Diagnosed elsewhere, treatment partially or fully at this facility
• Analytic cases (classes 00–22) count toward CoC metrics; non-analytic cases (classes 30+) are abstracted but do not count toward quality measures.

Step 2: Code Primary Site and Histology

ICD-O-3 Topography (site) coding:

• Use the most specific subsite code available (e.g., C50.4 for upper-outer quadrant of breast, not C50.9 NOS)
• When the subsite is not documented, use the NOS (.9) code for the site
• For overlapping lesions, use the .8 (overlapping) code when applicable

ICD-O-3 Morphology (histology) coding:

• Four-digit histology code + one-digit behavior code (e.g., 8140/3 = adenocarcinoma, malignant)
• Use the most specific histology term from the pathology report
• When multiple biopsies show different histologies at the same site, code the highest-grade or most specific histology
• Grade: 1 = well differentiated, 2 = moderately differentiated, 3 = poorly differentiated, 4 = undifferentiated, 9 = not determined

Multiple primary rules (SEER/CoC):

• Apply site-specific multiple primary and histology coding rules published by SEER
• Generally: different histologic groups at the same site = separate primaries; same histology at different sites = separate primaries
• Same histology at paired organs (bilateral breast) within specific time rules may be single or multiple primaries per site-specific guidelines

Step 3: Abstract Required Data Elements

NAACCR required data elements (core set):

Collaborative staging / AJCC staging data items:

• For each staging data item, record the value from the medical record using the NAACCR-defined coding scheme
• Clinical T, N, M values and pathologic T, N, M values are recorded separately
• Document the staging basis and any site-specific factors required by AJCC (e.g., PSA, Gleason for prostate; ER/PR/HER2 for breast)

Step 4: Code First Course Treatment

First course of treatment includes all cancer-directed therapy administered before disease progression or recurrence:

Surgery coding:

• Use site-specific surgery codes (NAACCR Item #1290)
• Document surgical approach, extent of resection, margin status
• Code "no surgery" when only biopsy performed (biopsy is not treatment)

Systemic therapy coding:

• Chemotherapy: code as single-agent or multi-agent; record specific agents when possible
• Hormonal therapy: code separately from chemotherapy (e.g., tamoxifen, aromatase inhibitors)
• Immunotherapy: code checkpoint inhibitors, vaccines, and other immune-based treatments
• Targeted therapy: code per current NAACCR definitions (may be classified under chemotherapy or other treatment)

Radiation therapy coding:

• Record treatment modality (external beam, brachytherapy, radioisotopes)
• Document total dose, number of fractions, treatment dates
• Regional vs. distant radiation (palliative to metastatic site)

Step 5: Complete Follow-Up Documentation

• Date of last contact: Most recent documented patient encounter
• Vital status: Alive, dead (document source: death certificate, medical record, obituary)
• Cancer status at last contact: No evidence of disease, alive with disease, dead of this cancer, dead of other cause
• Recurrence information: Document date, type (local, regional, distant), and site of first recurrence
• Follow-up schedule: Annual follow-up required per CoC standards; 90% follow-up rate required for accreditation

Checkpoint B: Post-Draft Alignment (Mandatory)

1. Is the case reportable per NAACCR/state registry rules?
2. Are ICD-O-3 topography and morphology codes accurate and specific?
3. Have SEER multiple primary rules been applied correctly?
4. Is staging documented per AJCC 8th edition with all required site-specific factors?
5. Does the first course treatment coding capture all modalities administered before progression?

Quality Audit

• Case reportability confirmed per NAACCR/state rules
• Class of case correctly assigned (analytic vs. non-analytic)
• ICD-O-3 topography code at most specific subsite level
• ICD-O-3 morphology code matches pathology report histology
• Behavior code correct (/2 for in situ, /3 for invasive)
• SEER multiple primary rules applied for patients with multiple cancers
• AJCC 8th edition staging complete with clinical and pathologic T, N, M
• Site-specific staging factors coded (ER/PR/HER2, PSA, Gleason, etc.)
• Date of diagnosis assigned per STORE manual rules
• First course treatment coded completely for all modalities
• Treatment dates documented for each modality
• Follow-up data current (date of last contact, vital status)
• Abstract completeness rate meets CoC standard (≥90% within 6 months of diagnosis)
• Data quality review performed before submission

Guidelines

• Date of diagnosis is defined by STORE manual rules — it is NOT always the pathology report date. It may be the date of first clinical diagnosis if pathologic confirmation comes later.
• Always use the most specific ICD-O-3 code available — NOS codes should be used only when the medical record lacks specificity
• Multiple primaries are determined by published SEER rules, not clinical judgment — follow the algorithm exactly
• First course treatment ends at disease progression or recurrence, not at an arbitrary time cutoff
• Abstracts for analytic cases should be completed within 6 months of diagnosis per CoC standards
• Annual follow-up must achieve ≥90% completeness rate for CoC accreditation
• Registry data is used for national cancer statistics — coding accuracy affects public health policy and research
• When medical record documentation is ambiguous, consult with the treating physician before coding — do not infer treatment intent from incomplete records