California Cancer Reporting System Standards Volume I: Abstracting and Coding Procedures
Listed below are special conditions that may occur and must be taken into account when coding first course of treatment.
Beginning in 2009, the dates of diagnosis and treatment for tumors developed while in utero should reflect the dates on which they occur. In the past, these dates were assigned to the date the baby was born.
Diagnoses made in utero are reportable if the pregnancy results in a live birth. When a reportable diagnosis is confirmed prior to birth and disease is not evident at birth due to regression, accession the case based on the pre-birth diagnosis.
In the absence of documentation of stillbirth, abortion or fetal death, assume there was a live birth and report the case.
Record any part of the first course of treatment administered at another facility before the patient was admitted to the reporting facility or after discharge. Also record the name of the facility where the treatment was administered.
Leukemia and Hematopoietic Diseases
Refer to Hematopoietic and Lymphoid Neoplasm Case Reportability and Coding Manual and the Hematopoietic Database for leukemia and lymphoma cases diagnosed January 1, 2010 and forward.
Surgery:
If the patient or patient's guardian refuses surgery to the primary site:
Use code 7 in the Reason for No Surgery field.
Treatment Modalities:
If the patient or patient's guardian refuses any other treatment modality:
Use code 87 in the respective treatment field.
If a treatment that was originally refused was subsequently performed as part of the first course of treatment, enter the appropriate code for the procedure.
If a patient did not receive any of the treatments described in sections VI.2—VI.8:
The surgery summary code would be 00 and all the other treatment summary fields would contain a 00.
Example: The case might be Autopsy only, or the patient might have received only symptomatic or supportive therapy. Explain briefly why no definitive treatment was given (for example, "terminal," "deferred").
If definitive treatment was refused, see First Course of Treatment - Special Situations for coding instructions. A facility that is preparing initial case reports to only meet state mandatory reporting requirements may also use 00 if no treatment is documented in its medical records (code 99 should not be used in this situation).
The data item RX-Treatment Status was added to summarize the status of all treatment modalities. This data item is a summary of whether treatment was given, including an option that identifies active surveillance or watchful waiting.
Note: Referral to an oncology specialist is considered a recommendation. Registry personnel should follow up on these cases to determine whether treatment was administered or not, and code accordingly. This applies to cases diagnosed January 1, 2010 and forward.
If it is unknown whether or not the patient had treatment:
Code 99 or 9 (unknown) should generally be used only for cases in which the first course of treatment is unknown.
Enter 99 or 9 for each modality of treatment, leave the treatment date fields blank, and state briefly why the information is not available.
Do not use code 99 or 9 for a component part of the treatment summary.
Example: If surgical resection was performed and it is not known whether chemotherapy was administered, do not enter a 99 in the Chemotherapy field -- use code 00.
If specific treatment is recommended, but it is not known whether it was administered, enter a statement to this effect and code the appropriate summary fields for Immunotherapy and Other Therapy with code 88 (code 8 for Surgery) and Treatment at this reporting facility fields with code 00.
Note: Referral to a specialist is considered a recommendation. Registry personnel should follow up on these cases to determine whether treatment was administered or not, and code accordingly. This applies to cases diagnosed January 1, 2010 and forward.