California Cancer Reporting System Standards Volume I: Abstracting and Coding Procedures
Enter codes, dates, and written summaries to reflect the first course of treatment.
Enter the date treatment was started for each modality.
For instructions about entering dates, see Section Entering Dates.
If the treatment was administered in courses (as in a radiation therapy series) or included different procedures (for example, excisional biopsy and a resection), enter the date the first procedure was performed.
The Date of Systemic Therapy will be generated from Date of Chemotherapy, Date of Hormone, Date of Immunotherapy, and Date of Transplant/Endocrine Procedures effective with cases diagnosed 1/1/2003 and forward.
See First Course of Treatment - Special Situations for additional information on special situations to consider while coding first course of treatment.
Text is the abstractor’s supporting documentation obtained from the medical record that validates codes entered in the abstract.
In the text fields, describe the treatment as briefly as possible.
If more than one procedure was performed, describe each one in chronological order.
Indicate where the procedure was performed, unless it was at the reporting facility.
The text field may be left blank when the type of treatment was not provided. But if no cancer-directed surgery is performed, record the reason in the text field for surgery.
Note: There is no text field for bone marrow transplant and endocrine procedures. Record text information regarding bone marrow transplants and endocrine procedures in the immunotherapy text field.
Numeric codes summarize each modality of treatment (surgery, radiation, chemotherapy, etc.). For each modality except surgery, code a summary of the entire first course of treatment. See Section First Course of Treatment - Surgery Introduction for coding each surgery field.
Refer to the most current Hematopoietic and Lymphoid Database and the Hematopoietic & Lymphoid Neoplasm Coding Manual for coding instructions on entering first course of therapy for hematopoietic and lymphoid neoplasms. This applies to cases diagnosed January 1, 2010 and forward.
Treatment given by a physician on the medical staff of a facility should not be recorded as treatment given at that reporting facility, effective with cases diagnosed January 1, 1998 and forward.
In the field provided, assign a separate code to that portion of the treatment administered at the reporting facility.
The codes for the reason no surgery, reason no radiation, reason no chemotherapy and reason no hormone therapy have been incorporated into each respective treatment modality field.
The codes for surgical procedures have one or two digits.
Other codes have two digits, with a 00 always meaning no procedure performed for that type of treatment.
Code all treatment fields to 00 (Not done) when physician decides to do active surveillance (aka watchful waiting) for a patient who has prostate cancer. The first course of therapy is no treatment. When the disease progresses or the patient becomes symptomatic, any prescribed treatment is second course.
Cases coded to 00 based on active surveillance must also be coded to 2 in the RX Summ-Treatment Status field.
Code the treatment as first course of therapy if the patient refuses treatment but changes his/her mind and the prescribed treatment is implemented less than one year from the date of diagnosis, AND there is no evidence of disease progression.
The first course of therapy is no treatment when the patient refuses treatment. Code the treatment fields to Refused.
Keep the refused codes, even if the patient later changes his/her mind and decides to have the prescribed treatment in the following scenario:
More than one year after diagnosis, or when there is evidence of disease progression before treatment is implemented.
Use code 87 in the respective treatment field if the patient or patient's guardian refuses that modality and record the fact in the text field.
If the patient or patient's guardian refuses surgery to the primary site, enter code 7 in the Reason for No Surgery field.
Note: Prior to January 1, 2010, referral does not equal a recommendation.
Code all treatment that was started and administered, whether completed or not.
Code the treatment on both abstracts when a patient has multiple primaries and the treatment given for one primary also affects/treats the other primary.
Code the treatments only for the site that is affected when a patient has multiple primaries and the treatment affects only one of the primaries.
Code the treatment given as first course even if the correct primary is identified later when a patient is diagnosed with an unknown primary.
Do not code treatment added to the plan when the primary site is discovered as first course. This is a change in the treatment plan.
Example: The patient is diagnosed with metastatic carcinoma, unknown primary site. After a full course of chemotherapy, the primary site is identified as prostate. Hormonal treatment is started. Code the chemotherapy as first course of treatment. The hormone therapy is second course because it was not part of the initial treatment plan.
Code 99 or 9 (unknown) is to 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: 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 At This Hospital fields with code 00.
Note: For cases diagnosed January 1, 2010 and forward, referral to a specialist is considered a recommendation.