California Cancer Reporting System Standards Volume I: Abstracting and Coding Procedures
This page was created to capture terms and definitions often used in abstracting.
Active Surveillance/Deferred Therapy/Expectant Management/Watchful Waiting: These are terms that denote 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.
Allograft/Homograft: A tissue transplant from one person to another. This can include bone, tendons, ligaments, skin and heart valves. Allograft and homograft are synonymous.
Antineoplastic Drugs: 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.
Autograft: A graft of tissue from one point to another of the same individual’s body. This can include bone, tendons, ligaments, skin and heart valves.
Bone Marrow Transplant (BMT): Receiving bone marrow or stem cells from a donor.
Allogeneic: Bone marrow from a donor (includes haploidentical)
Haploidentical: Bone marrow that is half-matched
Syngeneic: Bone marrow from an identical twin
Common Law Marriage: a couple living together for a period of time and declaring themselves as married to friends, family and the community, having never gone through a formal ceremony or obtained a marriage license.
Conditioning: High-dose chemotherapy with or without radiation administered prior to transplant such as BMT and stem cells to kill cancer cells. This conditioning also destroys normal bone marrow cells so the normal cells need to be replaced (rescued). The high dose chemotherapy is coded in the Chemotherapy field and the radiation is coded in the Radiation field.
Consolidation Chemotherapy: Repetitive cycles of chemotherapy given immediately after the remission.
Definitive Cancer Treatment: 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.
Direct Extension: A continuous infiltration or growth from the primary site into other tissue or organs (compare to metastasis).
Disease Recurrence: For solid tumors, see the Multiple Primary and Histology Coding Rules manual and for hematopoietic and lymphoid neoplasm see the Hematopoietic and Lymphoid Neoplasm Case Reportability and Coding manual and the Hematopoietic Database to determine disease recurrence.
Hematopoietic Growth Factors: A group of substances that support hematopoietic (blood cell) colony formation. The group includes erythropoietin, interleukin-3 and colony-stimulating factors (CSFs). The growth-stimulating substances are ancillary drugs and not coded.
Induction Chemotherapy: Initial intensive course of chemotherapy.
Intersex: A person born with ambiguous reproductive or sexual anatomy; chromosomal genotype and sexual genotype other than XY-male and XX-female.
Invasion: Local spread of a neoplasm by infiltration into or destruction of adjacent tissue.
Maintenance Chemotherapy: Chemotherapy given for a period of month or years to MAINTAIN REMISSION.
Metastasis: 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.
Microinvasion: The earliest stage of invasion—as malignant, not “in-situ”.
Microinvasive: 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.
Non-myeloablative Therapy: Uses immunosuppressive drugs pre- and post-transplant to ablate (destroy) the bone marrow. These are not recorded as therapeutic agents.
Palliative Treatment: Treatment that may improve the quality of life by preventing or relieving suffering. Palliative treatment is non-curative or alleviates 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).
Peripheral Blood Stem Cell Transplantation (PBSCT): Rescue that uses peripheral blood stem cells to replace stem cells after conditioning.
Regional: 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.
Remission: 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.
Rescue: Rescue is the actual BMT or PBSCT done after conditioning.
Stem Cells: Immature cells found in bone marrow, blood stream, placenta and umbilical cords. The stem cells mature into blood cells.
Stem Cell Transplant: Procedure to replenish supply of healthy blood-forming cells. Also known as bone marrow transplant, depending on the source of the stem cells.
Suspicious Cytology: A cytology report diagnosis that uses an ambiguous term which may constitute a diagnosis. See: Ambiguous Diagnostic Reportable Terms
Targeted Therapy: Targeted cancer therapies are drugs or other substances that block the growth and spread of cancer by interfering with specific molecules that are involved in the growth, progression and spread of cancer. Targeted cancer therapies are sometimes called “molecularly targeted drugs”, “molecularly targeted therapies”, “precision medicines” or similar names.
Transgender: A person who identifies with or expresses a gender identity that differs from the one which corresponds to the person’s sex at birth.
Transgendered Person: A person who identifies with or expresses a gender identity that differs from the one which corresponds to the person’s sex at birth.
Transsexual: A person who has undergone (or is in the process of) surgical alteration to achieve gender opposite to their sex at birth, i.e. surgically altered gender.
Treatment Failure: 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.
Tumor Embolization: The intentional blockage of an artery or vein to stop the flow of blood through the desired vessel.
Chemoembolization: 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.
Radioembolization: Tumor embolization combined with injection of small radioactive beads or coils into an organ or tumor.
Tumor Markers: A tumor marker is a substance found in the blood, urine, or body tissues that can be elevated in cancer, among other tissue types. There are many different tumor markers, each indicative of a particular disease process, and they are used in oncology to help detect the presence of cancer.
Umbilical Cord Stem Cell Transplant: treatment with stem cells harvested from umbilical cord blood.