Glossary

Enter the abstractor's initials, beginning in the left most space. If there are fewer than three initials, leave the trailing spaces blank.

This data item identifies the patient and the tumor. Each patient entered in a reporting facility registry is assigned a unique accession number, and each primary diagnosed for that patient is assigned a sequence number. The accession number never changes and is never reassigned, even if a patient is removed from the registry.  The accession number may be auto-generated by some abstracting vendors.

Accuracy is the extent to which the data submitted has been correctly coded and matches the information in the medical record and have been correctly coded. It encompasses accurate abstracting, correct application of coding rules, text documentation to support codes, and correct entry into and retrieval from the computer.

Enter the status of the reporting facility’s ACoS cancer program approval.

A treatment plan that involves closely watching a patient’s condition but not giving any treatment unless there are changes in test results that show the condition is getting worse. Active surveillance may be used to avoid or delay the need for treatments such as radiation therapy or surgery, which can cause side effects or other problems. During active surveillance, certain exams and tests are done on a regular schedule. It may be used in the treatment of certain types of cancer, such as prostate cancer, urethral cancer, and intraocular (eye) melanoma. It is a type of expectant management.

The address at diagnosis field is part of the patient’s demographic data and has multiple uses. It indicates referral patterns and allows for the analysis of cancer cluster concerns and other epidemiological studies. The main purpose of the address field is to identify the patient's residence at the time the cancer was first diagnosed, not the patient's current address.

This data field captures the age of the patient at the time of diagnosis.

AJCC TNM staging is based on the clinical, operative and pathologic assessment of the anatomic extent of disease. T, N, & M indicates primary tumor growth (T), spread to regional lymph nodes (N) and metastasis (M). The T, N and M are referred to as “categories”. The categories are then assigned to an anatomic/prognostic Stage Group.

An alias (also known as, or AKA) first name used by the patient.

An alias (also known as, or AKA) surname used by the patient, certain religious order names (See Religious Names), or the first part of a Chinese name that might appear as a last name on another report. (For example, Sun Yat sen might appear elsewhere as Sun, Yat sen or Yat sen Sun).

Enter the medical record number assigned to the patient at the reporting facility. For facilities using a serial numbering system, enter the latest number assigned at the time of abstracting. (This will not be updated.)

Vague or ambiguous terms are sometimes used by physicians to describe a tumor when its behavior is uncertain. This occurs primarily when there is no histologic diagnosis.

Physicians sometimes describe disease involvement with ambiguous terms. A list of these terms with rules for interpretation may differ depending on the staging system.

Applies to medications that prevent the development, maturation, or spread of cancer cells. Included are drugs for chemotherapy (see Section VI.4), hormonal treatment (see Section VI.5), and immunotherapy (see Section VI.6). For cases diagnosed 1/1/2005 forward, registrars must use SEER*Rx, for coding systemic treatment (i.e. chemotherapy, hormone therapy, and immunotherapy). SEER*Rx is the downloadable, interactive antineoplastic drug database that replaces SEER Self-Instructional Manual Book 8, Antineoplastic Drugs. The software can be downloaded from the SEER*Rx Web Site.

For information on this topic, please click the page link to the right.

Radiation is classified as beam when the source of radioactivity is outside the patient, as in a cobalt machine or linear accelerator. Examples of beam radiation are:

The Behavior Code describes the malignant potential of the tumor.  Codes range from /0-benign to /3-malignant (invasive). The fifth digit of the morphology code is the Behavior Code.

The Birthplace - Country is intended to collect information on the patient's country of birth.

Birthplace - State  is a two-digit field that is intended to collect information on the patient's birth state.

Receiving bone marrow or stem cells from a donor; including haploidentical (or half-matched) transplants.

Record the dominant modality of radiation therapy used to deliver the most clinically significant boost dose to the primary volume of interest during the first course of treatment. The CCR requires the collection of this data item.

For information on this topic, please click the page link to the right.

BR could also be referred to as:  Bloom-Richardson, modified Bloom-Richardson, BR, BR grading, Scarff- Bloom-Richardson, SBR grading, Elston-Ellis modification of Bloom-Richardson score, Nottingham modification of Bloom-Richardson score, Nottingham modification of Scarff-Bloom-Richardson, Nottingham-Tenovus grade, or Nottingham grade.

Proliferating malignant cells or an area of active production of malignant cells. Sometimes malignant cells are found in tissue in which they did not originate and are not reproducing. A procedure that removes cancer cells but does not attack a site of proliferation of the cells (thoracentesis, for example) is not considered cancer treatment.

Casefinding (case ascertainment): The process of identifying all reportable cases through review of sources documents and case listings. Casefinding covers a range of cases that need to be accessed to determine whether or not they are reportable.

This two-digit field indicates the source that identified the case.

Please refer to the reportability guide below for information on specific histologies and sites for tumors that are reportable or not reportable to the CCR.

A procedure in which the blood supply to the tumor is blocked surgically or mechanically and anticancer drugs are administered directly into the tumor. This permits a higher concentration of drug to be in contact with the tumor for a longer period of time.

Generic or trade names of the drugs used for chemotherapy must be recorded in the text field.

Chemotherapy is a drug treatment that utilizes powerful chemicals to kill fast-growing cancer cells.

Chemotherapy includes the use of any chemical to attack or treat cancer tissue, unless the chemical achieves its effect through change of the hormone balance or by affecting the patient's immune system.

Occupation and Industry specific information is required to be entered in the abstract for children as well as adults.  Follow the instructions below for Occupation and Industry if the patient is under 18 years of age.

Enter the patient’s city of residence.

Class of Case is divided into two basic categories: Analytic and Nonanalytic.

This field identifies the presence or absence of distant metastasis (M) of the tumor known prior to the start of any therapy.

This field identifies the presence or absence of regional lymph node (N) involvement and describes the extent of regional node involvement known prior to the start of any therapy.

This field isolates the clinical stage (prefix/suffix) descriptor of the tumor prior to the start of any therapy.  The stage descriptor identifies special cases that need separate analysis. These descriptors supplement but do not change the stage group.

This field identifies the extent of disease based on the combination of T, N, and M data items known prior to the start of any therapy.

Clinical staging documents the tumor size/extension of the tumor known prior to the start of any therapy.

This field evaluates the primary tumor (T) and reflects tumor size/extension of the tumor known prior to the start of any therapy.

Cell Indicator (Codes 5, 6, 7, 8) describes the lineage or phenotype of the cell. Codes 5, 6, 7, and 8 are used only for hematopoietic and lymphoid neoplasms. Code 9 indicates cell type not determined, not stated, or not applicable.

A list of helpful Coding Resources is provided here, for registrars to reference when abstracting.

Cancer registries use multiple coding applications and manuals to abstract data.  These coding applications direct how and what patient and cancer data is to be collected.

Efforts to transition away from The Collaborative Stage Data Collection System will occur, beginning with cases diagnosed January 1, 2016 and forward. However, in order to transition without losing valuable data, a continued collection of information regarding related biomarkers and prognostic factors will need to occur.

Comorbidities and Complications data fields 1-10 are designated to capture the patient's preexisting medical conditions, factors influencing health status, and/or complications during the patient's admission to the reporting facility for the treatment of the cancer using ICD-9-CM codes. These factors may affect treatment decisions and influence outcomes.

The California Health and Safety Code stipulates that the identity of patients whose cases are reported to the CCR must be held in the strictest confidence. Information that could be used to identify a patient may not be released to or discussed with anyone other than authorized personnel at the reporting facility or other reporting sources, unless prior informed consent is received from the patient. Section 100330 of the code states:

Repetitive cycles of chemotherapy given immediately after the remission.

Abstract reporting by facilities is not mandatory for reportable cases diagnosed by the pathology department on the basis of slides or specimens submitted from outside the reporting facility and cases seen for consultation only. However, the facility must notify the regional registry about these types of cases in order to verify that all reportable cases in the population have been recorded.

The Contact Name/Address File is for generating follow-up letters to the patient or designated contact(s).

Country at DX documents the country the patient lived in at the time of diagnosis.

County at DX documents the county the patient lived in at the time of diagnosis.

The Collaborative Stage (CS) Site-Specific Factor items are intended to code biomarkers and prognostic factors that have an effect on stage or survival.  This applies to cases diagnosed January 1, 2016 and forward.

Current status is defined as contact with the patient within 15 months of the date the follow-up is reported. Although current follow up information is preferred, any information, whether current or not, should still reported.

This data field captures the month, day, and year of the patient’s birth.

This data item is used to explain why there is no appropriate value in the corresponding date field.

Enter the date in which chemotherapy began at any facility as part of first course of treatment.

This data item is used to explain why there is no appropriate value in the corresponding date field.

This field captures the month day and year of the patient’s diagnosis. It serves as the basis for computing incidence, survival, and other statistics. Accurate recording of the date of the first diagnosis of a reportable neoplasm is especially important.

This data item is used to explain why there is no appropriate value in the corresponding date field.

As the CCR began reporting benign brain and CNS tumors prior to national reporting implementation, there are two sets of rules for establishing the Date of Diagnosis for benign and malignant brain tumors.

Enter the date of the earliest surgical diagnostic and/or staging procedure in this field.

This data item is used to explain why there is no appropriate value in the corresponding date field.

Per SEER Clarification, effective January 1, 2012 forward, date of first contact is the admission date when the patient was an inpatient or an outpatient at the reporting facility for:

This data item is used to explain why there is no appropriate value in the corresponding date field.

Enter the date in which hormone therapy began at any facility as part of first course of treatment.

This data item is used to explain why there is no appropriate value in the corresponding date field.

Enter the date in which immunotherapy began at any facility as part of first course of treatment.

This data item is used to explain why there is no appropriate value in the corresponding date field. 

Enter the dates of "Inpatient Admission and Inpatient Discharge" to the reporting facility for the most definitive surgery.

This data item is used to explain why there is no appropriate value in the corresponding date field.

This data item is used to explain why there is no appropriate value in the corresponding date field.  

This field captures the date the patient was last seen, heard from, or the date of death. It is important for researchers to calculate survival and outcome studies.

This data item is used to explain why there is no appropriate value in the corresponding date field.

This field captures the date of the last information obtained on the primary (tumor) being followed. It is important because it collects the information on each tumor when the patient has multiple.

Enter the date in which Other Therapy began at any facility as part of first course treatment.

This data item is used to explain why there is no appropriate value in the corresponding date field.

Enter the date in which radiation therapy began at any facility as part of the first course treatment.

This data item is used to explain why there is no appropriate value in the corresponding date field.

Enter the date of surgery performed for each surgical procedure. There are three date fields available to be used in conjunction with each definitive procedure performed.

This data item is used to explain why there is no appropriate value in the corresponding date field.

Enter the date in which the transplant/endocrine procedure took place at any facility as part of the first course treatment.

Place of Death - Country is intended to collect information on the patient’s country of death.  Consult with your software vendor for possible auto-generation of this data item.

Closely watching a patient’s condition but not giving treatment unless symptoms appear or change, or there are changes in test results. Deferred therapy avoids problems that may be caused by treatments such as radiation or surgery. It is used to find early signs that the condition is getting worse. During deferred therapy, patients may be given certain exams and tests. It is sometimes used in prostate cancer. Synonym: expectant management.

Therapy that normally modifies, controls, removes, or destroys proliferating tumor tissue, whether primary or metastatic, even if it cannot be considered curative for a particular patient in view of the extent of disease, incompleteness of treatment, apparent lack of response, size of the dose administered, mortality during surgery, or other reason. The term excludes therapy that has no effect on malignant tissue. Procedures administered for the sole purpose of relieving symptoms are therefore not considered to be cancer treatment.

Deletions are cases that are to be, or have been deleted from the database.

Records the best method used to confirm the presence of the cancer being reported. The best method could occur at any time throughout the entire course of the disease. It is not limited to the confirmation at the time of initial diagnosis.

Record surgical procedures performed solely for establishing a diagnosis and or determining stage of disease. If there is more than one surgical diagnostic or staging procedure, record the first one performed.

Text documentation is an essential component of a complete electronic abstract and is heavily utilized for quality control and special studies. Text is needed to justify coded values and to document supplemental information not transmitted within coded values. High-quality text documentation facilitates consolidation of information from multiple reporting sources at the central registry. The length of the text fields are 1000 characters.

Vague or ambiguous terms are sometimes used by physicians to describe a tumor when its behavior is uncertain. This occurs primarily when there is no histologic diagnosis.

A continuous infiltration or growth from the primary site into other tissue or organs (compare to metastasis).

This item is required if available by the CCR. This field has been added for the purpose of tracking which cancer cases were first diagnosed via screening programs. If this information is not available, the field may be left blank. It is an existing optional data item as part of the Department of Defense Data Set and will be collected and transmitted from facilities completing the Department of Defense Data Set.

For solid tumors, see the Multiple Primary and Histology Coding Rules manual and for hematopoietic and lymphoid neoplams see the Hematopoietic and Lymphoid Neoplasm Case Reportability and Coding manual and the Hematopoietic Database to determine disease recurrence.

Record systemic therapeutic procedures administered as part of first course of treatment. For reporting purposes, endocrine surgery is defined as the total surgical removal of an endocrine gland (both glands or all of a remaining gland in the case of paired glands).

Dates transmitted between facility registries and central registries changed to improve the interoperability or communication of cancer registry data with other electronic record systems.  Registry software may display dates in the traditional manner or in the interoperable format. Consult your software vendor for specific data entry instructions.

The patient's name is used by reporting facilities as a patient identifier.

Closely watching a patient’s condition but not giving treatment unless symptoms appear or change, or there are changes in test results. Expectant management avoids problems that may be caused by treatments such as radiation or surgery. It is used to find early signs that the condition is getting worse. During expectant management, patients may be given certain exams and tests. It is sometimes used in prostate cancer. Synonym: deferred therapy.

For information on this topic, please click the page link to the right.

Extent of Disease (EOD) coding applies to cases diagnosed prior to January 1, 2004.  EOD staging was replaced by Collaborative Staging for cases diagnosed January 1, 2004 and forward.

The extra facility Information fields (also called user data) are provided for the convenience of the reporting facility, which determines how they are to be used. All the fields may be left blank. The information is not sent to the CCR.

This text field is designated for recording the final diagnosis (FDX) as determined by a recognized medical practitioner.

First course treatment is all treatments administered to the patient after the original diagnosis of cancer in an attempt to destroy or modify the cancer tissue.

Listed below are special conditions that may occur and must be taken into account when coding first course of treatment.

In abstracting surgical treatment, the total or partial removal (except an incisional biopsy) of tumor tissue must be recorded in the text field, whether from a primary or metastatic site.

The patient's name is used by reporting facilities as a patient identifier.

This field captures the person who will be the contact for follow up. This field is usually designated for the patient, however in some circumstances it may be a parent or guardian. It is where patient follow up letters are sent.

If available in the abstracting software, these follow up contact fields collect the other contacts the patient has listed in their chart (usually on the face sheet). These contacts are not the patient. They are relatives, friends, neighbors, etc.

Follow-up data items provide information about the outcome of cancers and the results of treatment. A patient's survival time is calculated on the basis of Date of Diagnosis and Date of Last Contact.

A function of the California cancer reporting system is annual monitoring of patients to ascertain survival rates. Therefore, if follow-up information is available before an abstract is submitted, include the follow-up information in the abstract.

Enter the name or code number of the attending physician—not a resident or intern—responsible for the patient. (For instructions about entering codes, see Section III.3.12.1)

Some follow-up data items are optional for reporting to the CCR but might be required by the ACoS, for shared follow-up involving other institutions, or by the reporting facility for in-house data.

For information on this topic, please click the page link to the right.

Grade is a measurement of how closely the tumor cells resemble the parent tissue (organ of origin).  For Hematopoietic and Lymphoid Neoplasms, Codes 5, 6, 7, and 8 describe the lineage or phenotype of the cell.  Code 9 indicates the cell type was not determined, not stated or not applicable.

Document the patient’s height in this field. This data item is required if available for cases diagnosed January 1, 2011 and forward.

Reportable hematopoietic diseases diagnosed January 1, 2010 and forward, use the current Hematopoietic Database and Manual to abstract hematopoietic cases.

Histology is the study of the minute structure of cells, tissues, and organs in relation to their functions. It is primarily through histological analysis that neoplasms are identified. Determination of the correct histology code can be one of the most difficult aspects of abstracting. Training and experience are essential for development of the ability to assign the correct code. The rules are taken from the SEER Program. They provide guidance, but no set of rules can cover all situations.

The morphology code indicates the type of cell that has become neoplastic (histology), its biologic activity (behavior), and the tumor grade or differentiation.

This page is a compilation of coding and staging manuals required by the California Cancer Registry since their January 1, 1988 reference date.

Record systemic therapeutic procedures administered as part of first course of treatment. For reporting purposes, endocrine surgery is defined as the total surgical removal of an endocrine gland (both glands or all of a remaining gland in the case of paired glands).

Hormone Therapy is a form of systemic therapy that works to add, block or remove hormones from the body to slow or stop the growth of cancer cells. Report the administration of hormones, anti-hormones, or steroids to attack cancer tissue by changing the patient's hormone balance.

Cancer-directed treatment with hormones and anti-hormones must be coded in the appropriate data field and must always have corresponding text documentation for all sites.

Use the following codes for recording hormone therapy in the Summary field.

This item indicates the coding system from which the Comorbidities and Complications codes are provided. This data item is not required by the CCR, but it is required for ACoS approved facilities. 

The morphology code indicates the type of cell that has become neoplastic (histology), its biologic activity (behavior), and the tumor grade or differentiation.

Primary site is the anatomic position of where the primary tumor developed. It is essential to identify the original (primary) site of a tumor rather than a metastatic (secondary) site.

Refer to the current Multiple Primary and Histology Rules to determine the number of primaries.  This applies to cases diagnosed January 1, 2007 forward.

Initial intensive course of chemotherapy.

Immunotherapy/Biological response modifier therapy (BRM) is a generic term covering everything done to the immune system to alter it or change the host response to a cancer (defense mechanism).

Enter the appropriate code below when coding immunotherapy in the Summary field.

The term "in situ" means a tumor that meets all microscopic criteria for malignancy, except invasion of basement membrane. For further discussion of "in situ", see Terms Indicating In Situ.

This instruction discusses how to code specific categories in instances where a specific primary site cannot be identified.

The usual (longest-held) occupation and industry of workers can reveal the national cancer burden by industry and occupation. Such information can also be used to help discover jobs that may have a high risk for cancer or other diseases and for which prevention efforts can be concentrated (or targeted).

Record the name or chemical symbol and method of administration of any radioactive material given orally, intracavitary, or by intravenous injection.

For information on this topic, please click the page link to the right.

Enter the findings from the laboratory tests or procedures used in establishing the diagnoses of neoplasms or metastases, such as serum protein electrophoresis for multiple myeloma or Waldenstrom's macroglobulinemia, serum alpha fetoprotein (AFP) for liver cancer, and other tumor marker studies.

The CCR assigned reporting facility code for the reporting facility or agency that provided the most recent follow-up information.

The patient's name is used by reporting facilities as a patient identifier.

This field captures the type of follow-up a patient has received.

This field is to be used to enter the code representing the source of the most recent information about the patient being followed.

This field is to be used to enter information representing the source of the most recent information on the tumor being followed.

Laterality describes the side of a paired organ or the side of the body on which the reportable tumor originated, which is not captured in topographic codes. This field applies only to the primary site. Its main purpose is to identify the origin of the tumor.

For information on this topic, please click the page link to the right.

Enter the code for the location of the facility in which radiation treatment was administered during first course of treatment.  This applies to cases diagnosed January 1, 2008 and forward.

For information on this topic, please click the page link to the right.

Lymph-vascular invasion identifies the presence or absence of tumor cells within blood vessels, lymphatic channels (not lymph nodes) or surrounding tissue within the primary tumor as noted microscopically by the pathologist.  Lymph-vascular invasion is an indicator of prognosis.

Reportable hematopoietic diseases diagnosed January 1, 2010 and forward, use the current Hematopoietic Database and Manual to abstract hematopoietic cases.

Cell Indicator (Codes 5, 6, 7, 8) describes the lineage or phenotype of the cell. Codes 5, 6, 7, and 8 are used only for hematopoietic and lymphoid neoplasms. Code 9 indicates cell type not determined, not stated, or not applicable.

Unspecified malignancies are those malignancies in which a specific histologic type has not been identified.

Malignant transformation occurs when a benign or borderline tumor transforms into a malignancy.

The patient's name is used by reporting facilities as a patient identifier.

Chemotherapy given for a period of month or years to MAINTAIN REMISSION.

Incidence of cancer and sites of cancer have shown correlations to marital status. These patterns are also different among races. Thus this data item is very important to researchers for the reportable neoplasm.

Enter the medical record number assigned to the patient at the reporting facility. For facilities using a serial numbering system, enter the latest number assigned at the time of abstracting. (This will not be updated.)

The dissemination of tumor cells from the primary site to a remote part of the body. It is important to distinguish metastatic lesions from new primaries. A metastatic lesion is not a primary tumor. Pathologic reports are usually the best source. The term "secondary" is sometimes used for a metastatic lesion. Since the lymphatic system is one of the main routes of metastasis, frequent reference will be found in examinations of the lymph nodes. Occurrence of a lesion in a lymph node ordinarily indicates metastasis.

A secondary tumor or growth formed from malignant cells that have broken away from the primary tumor, and have traveled to other parts of the body.

The Mets at Diagnosis – Bone data item captures whether bone is an involved metastatic site at the time of diagnosis.

The Mets at Diagnosis – Brain data item captures whether the brain is an involved metastatic site at the time of diagnosis.

The Mets at Diagnosis – Distant Lymph Node(s) data item captures whether distant lymph node(s) are an involved metastatic site at the time of diagnosis.

The Mets at Diagnosis – Liver data item captures whether the liver is an involved metastatic site at the time of diagnosis.

The Mets at Diagnosis – Lung data item captures whether lung is an involved metastatic site at the time of diagnosis.

The Mets at Diagnosis – Other data item captures any type of distant involvement not captured in the bone, brain, liver, lung, and distant lymph node fields where metastasis has occurred at the time of diagnosis.

The earliest stage of invasion—as malignant, not “in-situ”.

The earliest invasive stage. Applied to cervical cancer, describes a small cancer that has invaded the stroma to a limited extent. The FIGO stage is IA.

The patient's name is used by reporting facilities as a patient identifier.

The CCR now requires facilities to use the Modified Record instead of the former Update/Correction and Follow-Up Records to transmit data modifications for abstracts already submitted as New Case Records.

Some combinations of morphology and site codes are rejected because another site code more accurately reflects the tissue of origin.

Enter the pediatric patient’s mother’s first name in this field.

Follow the guidelines below for entering the patient’s name. Accurate patient information is important for matching data in the abstract with data about the patient received from other sources.

Reporting facilities must use the same rules for entering names, dates, and other information.  Although reporting facility systems may have different name-related data entry requirements, the CCR requires the following information and formatting for patient name.

A name suffix is a title that would follow the name in a letter such as Jr, Sr, III, or IV. It is frequently a generation identifier. It helps to distinguish between patients with the same name.

Vague or ambiguous terms are sometimes used by physicians to describe a tumor when its behavior is uncertain. This occurs primarily when there is no histologic diagnosis.

The CCR assigned reporting facility code of the hospital, facility, or agency responsible for the next follow-up of the patient.

Record the method of obtaining follow-up information about the patient for the next report.

Listed below are special conditions that may occur and must be taken into account when coding first course of treatment.

Not all abstracting requirements apply to free-standing radiation therapy centers and other cancer treatment centers that are not part of hospitals and do not have inpatient facilities. Usually, patients seen at these facilities have been hospitalized elsewhere previously, and the treatment center is not the primary source for detailed information about their diagnostic work-ups. However, case reports from such facilities afford a quality check on the hospitals' reports and, even more important, provide data that complete the information about the patient's first course of treatment. Without these reports, statewide data on patterns of care would not be accurate or clinically useful.

Enter the patient’s street number and street name at diagnosis.

This field records the total number of regional lymph nodes that were removed and examined by the pathologist. This field is also called Reg LN Exam.

This field records the exact number of regional lymph nodes examined by the pathologist and found to contain metastases. This field is also called Reg LN Pos.

The usual (longest-held) occupation and industry of workers can reveal the national cancer burden by industry and occupation. Such information can also be used to help discover jobs that may have a high risk for cancer or other diseases and for which prevention efforts can be concentrated (or targeted).

Enter findings from operative procedures performed during the diagnosis or treatment of the cancer.

Record the definitive cancer-directed treatment that cannot be assigned to any other category. Information on other therapy is used to describe and evaluate the quality of care and treatment practices.

This field captures other therapy administered to the patient as first course treatment.

In the remarks text field, record other reportable tumors/primary sites that the patient has or has had.

Effective with cases diagnosed January 1, 2016 and forward, this item is no longer reportable to the CCR.

This section identifies the sites that are considered paired. The ICD-O-3 site codes listed below are sites for which laterality must be entered. The requirement includes any subsite, except those specifically noted. See section V.2 for specific laterality coding.

Ordinarily means (1) non-curative, or (2) alleviation of symptoms.  If used for a procedure that is directed toward symptoms only, the therapy is not considered to be treatment (Examples: colostomy, removal of fluid—even if cancer cells are present—to ease pressure, neurosurgery to relieve pain).

This field identifies the presence or absence of distant metastasis (M) of the tumor known following the completion of surgical therapy.

This field identifies the presence or absence of regional lymph node (N) involvement and describes the extent of regional node involvement known following the completion of surgical therapy.

This field identifies the extent of disease based on the combination of T, N, and M data items known following the completion of surgical therapy.

Pathologic staging documents the tumor size/extension of the tumor known following the completion of surgical therapy.

This field evaluates the primary tumor (T) and reflects tumor size/extension of the tumor known following the completion of therapy.

The following data items have replaced the DXRX Report Identifiers as of January 1, 2010.

In this text field, enter the details needed to describe the information from the pathology or cytology reports.

Abstract reporting by facilities is not mandatory for reportable cases diagnosed by the pathology department on the basis of slides or specimens submitted from outside the reporting facility and cases seen for consultation only. However, the facility must notify the regional registry about these types of cases in order to verify that all reportable cases in the population have been recorded.

The following data items have replaced the DXRX Report Identifiers as of January 1, 2010.

These data items identify the patient’s insurance status at the time of initial diagnosis. It consists of three fields:

Pediatric protocols refer the specialized systems used to stage pediatric cancers. These systems are based on histologic type and/or primary site.

Pediatric staging refers to cancer staging that is specific to pediatric patients, which may differ in some instances from staging of adult cancers. Pediatric Stage includes patients who are younger than twenty (20) years of age.

Pediatric stage group refers to the stage group assigned for the pediatric cancer. This scheme is to be used for the purpose of entering the stage for pediatric patients only.

This field is to be used for entering the patient's current telephone number including the area code.

Enter findings from the physical examination performed by the physician.

Each reporting facility must maintain its own roster of physicians and their code or NPI numbers. The non-NPI numbers codes are based on the physicians' California license numbers.

Enter the physician’s license number.

If available; enter the physician NPI code, in the respective field. This is effective with cases diagnosed January 1, 2007 and forward. See Appendix X for further details.

Place of Death - Country is intended to collect information on the patient’s country of death.  Consult with your software vendor for possible auto-generation of this data item.

Place of Death - State is intended to collect information on the State of death.

If the case was not first diagnosed at the reporting facility, enter whatever is known about the place of diagnosis:

Primary site is the anatomic position of where the primary tumor developed. It is essential to identify the original (primary) site of a tumor rather than a metastatic (secondary) site.

Certain combinations of histology and primary site codes indicate errors in coding. The CCR data management system (Eureka) edits the data and rejects false combinations. False combinations (edit errors) must be corrected before the data management system can store the data and make it available for research.

For information on this topic, please click the page link to the right.

This field collects the patient’s participation in a Protocol Study.

The California Cancer Registry (CCR) and regional registries have procedures for assuring the quality of the data produced by the reporting system. Staff from the regional registry visit cancer reporting facilities to perform quality control audits and submit copies of their final reports to the CCR.

Enter the code that best characterizes the patient's quality of survival. This item is not required by the CCR.

Race and ethnicity are defined by specific physical, hereditary and cultural traditions, not necessarily by birthplace, place of residence, or citizenship. 'Origin' is defined by the Census Bureau as the heritage, nationality group, lineage, or in some cases, the country of birth of the person or the person's parents or ancestors before their arrival in the United States.

Record the dominant modality of radiation therapy used to deliver the most clinically significant boost dose to the primary volume of interest during the first course of treatment. The CCR requires the collection of this data item.

Record the dominant modality of radiation therapy used to deliver the most clinically significant regional RX Modality dose to the primary volume of interest during the first course of treatment. The CCR requires the collection of this data item.

Code the sequence in which radiation and surgical procedures were performed as part of the first course of treatment.

Use the following codes for recording radiation therapy in the summary field.

Enter the type and method of radiation therapy given to the patient as part of their first course treatment.

The principal types of radiation therapy are the external administration of radioactive beams, implantation of radioactive material, and the internal administration of radioisotopes by other than implantation.

Record the name or chemical symbol and method of administration of any radioactive material administered by implants, molds, seeds , needles, or intracavity applicators.

Tumor embolization combined with injection of small radioactive beads or coils into an organ or tumor.

Record the reason the patient did not undergo radiation treatment.

Record the reason the patient did not have surgery to the primary site. Reason for No Surgery only applies to the Surgery of the Primary Site field, not Scope of Regional Lymph Node Surgery or Surgery Other Regional/Distant Sites.

Recurrence occurs when a patient's primary tumor persisted after a period of complete remission. The following fields must be coded by American College of Surgeons-approved registries. The data items are optional for reporting to the California Cancer Registry.

Organs or tissues related to a site by physical proximity. Also applies to the first chain of lymph nodes draining the area of the site.

Use of the Regional Data fields is determined by the regional registry, which designates the codes to be entered.

This field records the exact number of regional lymph nodes examined by the pathologist and found to contain metastases. This field is also called Reg LN Pos.

Record the dominant modality of radiation therapy used to deliver the most clinically significant regional RX Modality dose to the primary volume of interest during the first course of treatment. The CCR requires the collection of this data item.

This field captures the patient's religion or creed.

Please use the following instructions as when entering religious names.

Textual information that does not fit into its designated field can be recorded in the Remarks area.

The bone marrow shows normal cellular characteristics (is normocellular), with less than 5% blasts, no signs or symptoms of the disease, no signs or symptoms of central nervous system leukemia or other extramedullary infiltration, and all of the following laboratory values within normal limits:  white blood cell count and differential, hematocrit/hemoglobin level, and platelet count.

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Vague or ambiguous terms are sometimes used by physicians to describe a tumor when its behavior is uncertain. This occurs primarily when there is no histologic diagnosis.

The reporting facility must report every reportable case first seen as an inpatient or outpatient, either with evidence of cancer or for cancer-directed treatment, on or after the date that mandatory reporting was declared for the region (the region's reference date). Refer to the Regional Registry Reference Date Guide for the specific date when mandatory reporting began in each region.

Enter the reporting facility's CCR assigned reporting facility code or the facility's name.

The CCR assigned reporting facility code for the facility or agency that has referred the patient to your facility.

The CCR assigned reporting facility code for the facility or agency that your reporting facility has referred the patient to.

The State of California has specific cancer reporting requirements.  An overview of California’s Health and Safety Code and related information is outlined below.

Some follow-up data items are optional for reporting to the CCR but might be required by the ACoS, for shared follow-up involving other institutions, or by the reporting facility for in-house data.

The following required data must be recorded in the Remarks section.

Many California hospitals have had their own cancer registries since the 1950's in accordance with guidelines established by the American College of Surgeons (ACoS) and its requirements for accreditation of oncology services. The main purpose of a hospital registry is to provide physicians with the data needed to maintain quality of care through peer review and to compare performance with recognized standards. However, a more comprehensive level of reporting is required by state law and that level is supported by the California Cancer Registry and its statewide database system, Eureka DMS.

This data item is used to summarize the status for all treatment modalities. It is used in conjunction with Date of Initial RX and/or Date of 1st Course RX-CoC and each modality of treatment with their respective date field to document whether treatment was given or not given, whether it is unknown if treatment was given, or whether treatment was given on an unknown date. Active surveillance (watchful waiting) is also documented. This data item is required by the CCR.

In the Scopes section of the abstract, record information for all scopes performed as part of the initial work-up of diagnosis.

This field is used to record surgeries performed on regional lymph nodes. Refer to the AJCC Staging Manual for nodes identified as regional by the AJCC. Record the removal of distant lymph node(s) in Surgical Procedure of Other Site.

Secondary Diagnosis data fields 1-10 are designed to capture the patient’s preexisting or secondary diagnosis, factors influencing health status, and/or complications during the admission to the reporting facility for the treatment of cancer using ICD-10-CM codes.  These factors may affect treatment decisions and influence outcomes.

Sequence refers to the chronological position of a patient's primary tumor among all the reportable tumors occurring during the patient's lifetime, whether they exist at the same or at different times and whether or not they are entered in the reporting facility's registry.

This field documents the sex (gender) of the patient.

In those cases where a patient is being followed by more than one reporting facility, the regional or the central registry may designate a facility responsible for follow-up in an effort to prevent physicians and patients from receiving requests for information from many sources.

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A patient's full social security number is critical for the identification of multiple reports of the same cancer so that they are not counted as separate cases.

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Pathologic examination determines the grade, or degree of differentiation, of the tumor. For these cancers, the grade is a measurement of how closely the tumor cells resemble the parent tissue (organ of origin). Well-differentiated tumor cells closely resemble the tissue from the organ of origin. Poorly differentiated and undifferentiated tumor cells are disorganized and abnormal looking; they bear little (poorly differentiated) or no (undifferentiated) resemblance to the tissue from the organ of origin. These similarities/differences may be based on pattern (architecture), cytology, nuclear (or nucleolar) features, or a combination of these elements, depending upon the grading system that is used. Some grading systems use only pattern, for example Gleason grading in prostate. Others use only a nuclear grade (usually size, amount of chromatin, degree of irregularity, and mitotic activity). Fuhrman’s grade for kidney is based only on nuclear features. Most systems use a combination of pattern and cytologic and nuclear features; for example Nottingham’s for breast combines numbers for pattern, nuclear size and shape, and mitotic activity. The information from this data item is useful for determining prognosis and treatment.

This data item is intended to record the data source from which comorbidities/complications was collected.  

Note: Source Comorbidity does not include data sources reflecting Secondary Diagnosis.

In order to completely capture all aspects of a patient’s surgical treatment, it is necessary to review multiple sources.  This instruction directs abstractors on where to obtain information regarding surgery.

This data item is used to identify patients with Spanish/Hispanic surname or of Spanish origin. Persons of Spanish or Hispanic surname/origin may be of any race.

Included in this data field are people whose native tongue is Spanish, who are nationals of a Spanish speaking Latin American country or Spain, and/or who identify with Spanish or Hispanic culture (such as Latinos living in the American Southwest).

Refer to the most current Multiple Primary and Histology Coding Rules for solid tumor coding instructions. This applies to cases diagnosed January 1, 2007 and forward.

Refer to the most current Hematopoietic and Lymphoid Database and the Hematopoietic & Lymphoid Neoplasm Coding Manual for Hematopoietic and Lymphoma coding instructions. This applies to cases diagnosed January 1, 2010 and forward.

Special rules for counting regional lymph nodes, gives guidance as to what to do when a core needle biopsy or aspiration is followed by a dissection.

Stage at Diagnosis is the established extent of disease determined at the conclusion of the diagnostic/staging workup for a new cancer.

This field identifies the person who assigned the cancer stage.

Record surgical procedures performed solely for establishing a diagnosis and or determining stage of disease. If there is more than one surgical diagnostic or staging procedure, record the first one performed.

Cancer “Staging” is a common language developed by medical professionals to communicate information about cancer to others. It describes the severity of an individual’s cancer based on the extent at the original tumor (the “site”), and how far the cancer has spread.

Staging Time Period refers to the time period allowable from which information can be used to determine the full extent of disease at diagnosis.

The State at Diagnosis data item identifies the patient's state of residence at time of diagnosis.

SEER Summary Stage is a basic way of categorizing how far a cancer has spread from the organ of origin.

Listed below are special conditions that may occur and must be taken into account when coding Summary Stage.

In abstracting surgical treatment, the total or partial removal (except an incisional biopsy) of tumor tissue must be recorded in the text field, whether from a primary or metastatic site.

This field refers to the surgical removal of sites other than the primary site. There are three one-character fields to be used to record removal of tissue other than the primary tumor or organ of origin. This would not include an en bloc resection.

This field refers to surgical procedures that are performed on the Primary Site. See Appendix Q.1 or Q.2 for Site-Specific Surgery Codes.

This field describes the final status of the surgical margins after resection of the primary tumor. It is used in staging, for quality assurance measures, and may be a prognostic factor in recurrence.

Synchronous Primaries are multiple histologically distinct tumors diagnosed simultaneously.  Outlined below are surgical coding instructions for synchronous primaries.

This field documents the sequence in which systemic therapy and surgical procedures were performed as part of the first course of treatment.

Vague or ambiguous terms are sometimes used by physicians to describe a tumor when its behavior is uncertain. This occurs primarily when there is no histologic diagnosis.

The text field for staging is used to document additional staging and diagnostic workup information not already entered in other text fields.

Timeliness involves how quickly the reporting facility submits a case to a regional registry or central registry after admission of the patient. Regional registries and the central registry monitor the timeliness of data submitted by facilities.

Submit all abstracts per agreement to the regional or central registry.

AJCC TNM staging is based on the clinical, operative and pathologic assessment of the anatomic extent of disease. T, N, & M indicates primary tumor growth (T), spread to regional lymph nodes (N) and metastasis (M). The T, N and M are referred to as “categories”. The categories are then assigned to an anatomic/prognostic Stage Group.

Stage classifications indicate the point in time and the basis/source of the information used to stage the case.

This field identifies the person(s) who assigned the clinical TNM staging items and stage group.

AJCC TNM Edition Number identifies the Cancer Staging Manual edition used to code the AJCC TNM Stage.

These fields record the patient's past or current use of tobacco.

The process for transmitting cases to the regional registry is specific to each region. Contact your regional registry for regional specific guidelines. General case transmission guidelines are outlined below.

Record systemic therapeutic procedures administered as part of first course of treatment. For reporting purposes, endocrine surgery is defined as the total surgical removal of an endocrine gland (both glands or all of a remaining gland in the case of paired glands).

Reporting requirements for cases diagnosed and treated elsewhere are less stringent than those for other cases. The reporting facility's medical record often does not contain the required data, or contains only secondhand data.

The CCR assigned reporting facility code for the reporting facility or agency that provided first course treatment.

The treatment modalities did not destroy or modify the cancer cells.  The tumor either became larger (disease progression) or stayed the same size after treatment.

Abstract reporting by facilities is not mandatory for reportable cases diagnosed by the pathology department on the basis of slides or specimens submitted from outside the reporting facility and cases seen for consultation only. However, the facility must notify the regional registry about these types of cases in order to verify that all reportable cases in the population have been recorded.

The intentional blockage of an artery or vein to stop the flow of blood through the desired vessel.

Tumor grade is the most important prognostic indicator for response to therapy and outcomes for brain and spinal cord tumors. According to the World Health Organization (WHO), the classification is more of a “malignancy scale” than a strict histologic grading system. Therefore, the WHO grade is different from the ICD-O grade/differentiation value that is stored with the morphology code.

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This field records the presence or absence of clinical evidence of the patient’s tumor as of the Date of Last Tumor Status (AKA – Date of Cancer Status). It is important because it can be used to gauge disease-free survival.

This field represents the type(s) of admission the patient had at the reporting facility.

Recurrence occurs when a patient's primary tumor persisted after a period of complete remission. The following fields must be coded by American College of Surgeons-approved registries. The data items are optional for reporting to the California Cancer Registry.

Type of Reporting Source codes the source documents used to abstract the majority of information on the tumor being reported.

Vague or ambiguous terms are sometimes used by physicians when indicating the primary site of a tumor. Interpretation of terms in this context is like their interpretation in a diagnosis of cancer itself.  See Section II.2.4.

Vague dates refers to those occasions where incomplete or vague date information exists in the medical record.  This instruction directs abstractors on how to enter vague dates.

This field records the vital status of the patient on the date of last follow-up.

Closely watching a patient’s condition but not giving treatment unless symptoms appear or change. Watchful waiting is sometimes used in conditions that progress slowly. It is also used when the risks of treatment are greater than the possible benefits. During watchful waiting, patients may be given certain tests and exams. Watchful waiting is sometimes used in prostate cancer. It is a type of expectant management.

Document the patient’s weight at diagnosis in this field. This data item is required if available for cases diagnosed January 1, 2011 and forward.

Tumor grade is the most important prognostic indicator for response to therapy and outcomes for brain and spinal cord tumors. According to the World Health Organization (WHO), the classification is more of a “malignancy scale” than a strict histologic grading system. Therefore, the WHO grade is different from the ICD-O grade/differentiation value that is stored with the morphology code.

Document X-Ray/Scan findings in this text field to capture relevant positive and negative findings on imaging or scans performed.

Year first seen is the year the patient was first seen for this reportable primary.

The data field Zip at DX identifies the postal code of the patient’s address at diagnosis.