# | Name | Location | Type | Details | Index | Description |
---|---|---|---|---|---|---|
.01 | site/gp(+) | 0;1 | POINTER | 164.2 | B | Enter the SITE/GP for this primary. |
.0101 | primary site/gp | COMPUTED | A COMPUTED FIELD RECORDING THE PRIMARY SITE/GROUP FOR ONCOLOGY. | |||
.015 | selected sites | COMPUTED | This COMPUTED field displays selected SITE/GP (165.5,.01) values. | |||
.017 | systems | COMPUTED | COMPUTED FIELD RECORDING THE MAJOR BODY SYSTEMS, SUCH AS LYMPHATIC, GASTROINTESTINAL, GENITOURINARY, ETC. | |||
.02 | patient name(+) | 0;2 | POINTER | 160 | C | Enter Oncology Patient Name. |
.022 | icdo-site(+) | 0;22 | POINTER | 164.08 | Listing of primary sites in accordance with ICDO-2 (1992). | |
.023 | primary site code prefix | COMPUTED | Identifies the three-digit code prefix for the primary site. | |||
.025 | patient id | COMPUTED | COMPUTED FIELD FOR RECORDING THE PATIENT IDENTIFICATION NUMBER. | |||
.03 | reporting facility(+) | 0;3 | POINTER | 160.19 | REPORTING FACILITY identifies the facility reporting the case. | |
.04 | class of case | 0;4 | POINTER | 165.3 | CLASS OF CASE reflects the facility's role in managing the cancer, whether the cancer is required to be reported by CoC, and whether the case was diagnosed after the program's Reference Date. CLASS OF CASE divides cases into two groups. Analytic cases (codes 00-22) are those that are required by CoC to be abstracted because of the program's primary responsibility in managing the cancer. Analytic cases are grouped according to the location of diagnosis and first course of treatment. Nonanalytic cases (codes 30-49 and 99) may be abstracted by the facility to meet central registry requirements or in response to a request by the facility's cancer program. Nonanalytic cases are grouped according to the reason a patient who received care at the facility is nonanalytic, or the reason a patient who never received care at the facility may have been abstracted. | |
.041 | class no. | COMPUTED | Computed CLASS OF CASE code. It is derived from CLASS OF CASE (165.5,.04). | |||
.042 | class category(+) | 0;20 | SET OF CODES | 0:NONANALYTIC 1:ANALYTIC | AG | Record the category of case, either Analytic or Nonanalytic. |
.043 | analytic primary req followup | COMPUTED | ||||
.05 | accession number(+) | 0;5 | FREE TEXT | AA | Provides a unique identifier for the patient consisting of the year in which the patient was first seen at the reporting facility and the consecutive order in which the patient was abstracted. For further information see FORDS page 33. | |
.06 | sequence number | 0;6 | FREE TEXT | Indicates the sequence of malignant and non-malignant neoplasms over the lifetime of the patient. Codes 00-59 and 99 indicate neoplasms of in situ or malignant behavior (Behavior equals 2 or 3). Codes 60-88 indicate neoplasms of non-malignant behavior (Behavior equals 0 or 1). Code 00 only if the patient has a single malignant primary. If the patient develops a subsequent malignant or in situ primary tumor, change the code for the first tumor from 00 to 01, and number subsequent tumors sequentially. Code 59 for the fifty-ninth of fifty-nine independent malignant or in situ primaries. Code 99 for an unspecified malignant or in situ sequence number or unknown. Code 60 only if the patient has a single non-malignant primary. If the patient develops a subsequent non-malignant primary, change the code for the first tumor from 60 to 61, and assign codes to subsequent non-malignant tumors sequentially. Code 87 for the twenty-seventh of twenty-seven independent non- malignant primaries. Code 88 for an unspecified number of neoplasms in this category. For further information see FORDS pages 34-35. | ||
.061 | acc/seq number | COMPUTED | ACC/SEQ NUMBER concatinates the ACCESSION NUMBER and SEQUENCE NUMBER values. | |||
.07 | accession year(+) | 0;7 | FREE TEXT | AY | ACCESSION YEAR (aka YEAR FIRST SEEN FOR THIS PRIMARY) is the year the patient was first seen at the reporting institution for diagnosis and/ or treatment of this primary. It is NOT the year that the registrar accession the case. ACCESSION YEAR relates only to one primary tumor. A patient with multiple primaries can have a different ACCESSION YEAR on each abstract. This data item is used to produce an accession register. The accession register identifies all primaries first treated or seen at the reporting institution for a given year. | |
.08 | medical record number | COMPUTED | Records the medical record number usually assigned by the reporting facility's health information management (HIM) department. For further information see FORDS page 36. | |||
.09 | social security number | COMPUTED | Records the patient's Social Security Number. For further information see FORDS page 37. | |||
.091 | status | COMPUTED | STATUS IS EITHER ALIVE OR DEAD. | |||
.093 | place of birth (state) | COMPUTED | THE STATE WHERE THE PATIENT WAS BORN. | |||
.1 | sex | COMPUTED | Code the patient's SEX. | |||
.115 | state | COMPUTED | THE PATIENT'S STATE OF RESIDENCY AT THE TIME OF DIAGNOSIS. | |||
.1157 | st-county | COMPUTED | STATE AND COUNTY COMPUTED FIELD. | |||
.117 | county | COMPUTED | THE PATIENT'S RESIDENCE COUNTY AT THE TIME OF DIAGNOSIS. | |||
.12 | race | COMPUTED | "Race" is analyzed with the data item Spanish/Hispanic origin. Both items must be recorded. | |||
.13 | race-sex | COMPUTED | COMPUTED FIELD COMBINING BOTH RACE AND SEX, USED IN CROSS TABULATIONS. | |||
.14 | sex-race | COMPUTED | This is the combined race and sex code, used for cross tabulations. | |||
1 | date of inpatient admission | 0;8 | DATE-TIME | Record the date of the inpatient admission to the facility for the most definitive surgery. If the patient does not have surgery, use the inpatient admission date for any other cancer-directed therapy. If the patient has no cancer-directed therapy, use the date of inpatient admission for diagnostic evaluation. | ||
1.1 | date of inpatient discharge | 0;9 | DATE-TIME | Record the date of the inpatient discharge from the facility for the most definitive sugery. If the patient did not have surgery, use the inpatient discharge date for any other cancer-directed therapy. If the patient has no cancer-directed therapy, use the date of inpatient discharge for diagnostic evaluation. | ||
1.2 | type of reporting source | 0;10 | POINTER | 168 | Code the source documents used to abstract the cancer being reported. This item is used by central registries. | |
2 | primary surgeon | 0;11 | POINTER | 165 | Records the physician who performed the most definitive surgical procedure. For further information see FORDS page 77. | |
2.1 | following physician | 0;12 | POINTER | 165 | Records the person currently responsible for the patient's medical care. For further information see FORDS page 76. | |
2.2 | managing physician | 0;13 | POINTER | 165 | Identifies the physician who is responsible for the overall management of the patient during diagnosis and/or treatment of this cancer. | |
2.3 | physician #3 | 0;14 | POINTER | 165 | Records another physician involved in the care of the patient. The Commission on Cancer recommends that this data item identify the physician who performed the most definitive radiation therapy. For further information see FORDS page 78. | |
2.4 | physician #4 | 0;15 | POINTER | 165 | Records another physician involved in the care of the patient. The Commission on Cancer recommends that this data item identify the physician who gives the most definitive systemic therapy. For further information see FORDS page 79. | |
3 | date dx | 0;16 | DATE-TIME | ADX | Records the date of initial diagnosis by a physician for the tumor being reported. For further information see FORDS pages 89-90. | |
3.1 | diagnosis episode care | COMPUTED | RECORDS THE CARE THE PATIENT RECEIVED DURING THE CURRENT EPISODE OF TREATMENT AT DIAGNOSIS. | |||
3.5 | year dx | COMPUTED | DATE DX (165.5,3) year | |||
4 | age at dx | COMPUTED | Records the age of the patient at his or her last birthday before diagnosis. For further information see FORDS page 58. | |||
4.1 | dx age-gp | COMPUTED | DIAGNOSIS AGE GROUP WILL GROUP PATIENTS BY AGE. | |||
5 | dx facility | 0;17 | POINTER | 160.19 | Record the name of the facility where diagnosis was first made. | |
6 | facility referred from | 0;18 | POINTER | 160.19 | Identifies the facility that referred the patient to the reporting facility. For further information see FORDS page 85. | |
7 | facility referred to | 0;19 | POINTER | 160.19 | Identifies the facility to which the patient was referred for further care after discharge from the reporting facility. For further information see FORDS page 86. | |
8 | patient address at dx | 1;1 | FREE TEXT | Identifies the patient's address (number and street) at the time of diagnosis. For further information see FORDS page 42. | ||
8.1 | city/town at dx | 1;12 | FREE TEXT | Identifies the name of the city or town in which the patient resides at the time the tumor is diagnosed and treated. For further information see FORDS page 44. | ||
8.2 | patient address at dx - supp | 1;13 | FREE TEXT | Provides the ability to store additional adress information such as the name of a place or facility (ie, a nursing home or name of an apartment complex) at the time of diagnosis. For further information see FORDS page 43. | ||
9 | postal code at dx | 1;2 | FREE TEXT | Identifies the postal code of the patient's address at diagnosis. For U.S. residents, record the patient's five-digit postal code at the time of diagnosis and treatment. For Canadian residents, record the six-character postal code. | ||
10 | county at dx | 1;3 | FREE TEXT | Identifies the county of the patient's residence at the time the reportable tumor is diagnosed. The COUNTY AT DX value will be triggered by the entry of a valid U. S. POSTAL CODE AT DX value. Canadian POSTAL CODE AT DX values will not trigger a COUNTY AT DX value. If unknown, enter 99998 (Outside state/county code unknown) or 99999 (County unknown). | ||
11 | marital status at dx | 1;5 | SET OF CODES | 1:Single (never married) 2:Married (including common law) 3:Separated 4:Divorced 5:Widowed 6:Unmarried or Domestic Partner 9:Unknown | This is the patient's marital status at the time of diagnosis for the reportable tumor. If the patient has multiple tumors, marital status may be different for each tumor. | |
12 | palliative care | 3.1;26 | SET OF CODES | 0:No palliative care 1:Surgery 2:Radiation 3:Systemic tx 4:Pain management 5:Surg, rad, and/or systemic tx w/o pain mgt 6:Surg, rad, and/or systemic tx w pain mgt 7:Palliative care, type unknown 9:Unknown, not stated | Identifies any care provided in an effort to palliate or alleviate symptoms. Palliative care is performed to relieve symptoms and may include surgery, radiation therapy, systemic therapy (chemotherapy, hormone therapy, or other systemic drugs), and/or pain management therapy. For further information see FORDS pages 189-190. | |
13 | palliative care @fac | 3.1;27 | SET OF CODES | 0:No palliative care 1:Surgery 2:Radiation 3:Systemic tx 4:Pain management 5:Surg, rad, and/or systemic tx w/o pain mgt 6:Surg, rad, and/or systemic tx w pain mgt 7:Palliative care, type unknown 9:Unknown, not stated | Identifies care provided at this facility in an effort to palliate or alleviate symptoms. Palliative care is performed to relieve symptoms and may include surgery, radiation therapy, systemic therapy (chemotherapy, hormone therapy, or other systemic drugs), and/or other pain management therapy. For further information see FORDS page 191. | |
14 | readmission w/i 30 days/surg | 3.1;28 | SET OF CODES | 0:No surgery/not readmitted 1:Unplanned readmission 2:Planned readmission 3:Planned and unplanned readmission 9:Unknown if surgery or readmission | Records a readmission to the same hospital within 30 days of discharge following a hospitalization for surgical resection of the primary site. For further information see FORDS page 146. | |
15 | systemic/surgery sequence | 3.1;39 | SET OF CODES | 0:No systemic and/or surgery 2:Systemic before surgery 3:Systemic after surgery 4:Systemic before and after surgery 5:Intraoperative systemic 6:Intraoperative/other before or after surgery 9:Sequence unknown | Records the sequencing of systemic therapy and surgical procedures given as part of the first course of treatment. | |
16 | state at dx | 1;4 | POINTER | 5 | Identifies the patient's state of residence at the time of diagnosis. For further information see FORDS page 45. | |
17 | suspense date | 1;10 | DATE-TIME | This is the date on which the primary was added to the suspense file. | ||
18 | primary payer at dx | 1;11 | POINTER | 160.3 | Identifies the patient's primary payer/insurance carrier at the time of initial diagnosis and/or treatment. For further information see FORDS pages 67-68. | |
19 | staged by (clinical stage) | 3;32 | SET OF CODES | 0:Not staged 1:Managing MD 2:Pathologist 3:Pathologist & managing MD 4:Committee chair, liaison MD, registry advisor 5:Registrar 6:Registrar & MD 7:Another facility 8:NA 9:Unknown | Identifies the person who recorded the clinical AJCC staging elements and the stage group in the patient's medical record. For futher information see FORDS page 117. | |
20 | primary site(+) | 2;1 | POINTER | 164 | E | Identifies the primary site. For further information see FORDS page 91. |
20.1 | primary site code | COMPUTED | Identifies the primary site ICD-O topography code. | |||
21 | casefinding source | 1;6 | POINTER | 166 | This field codes the earliest source of identifying information. | |
21.5 | infra/supra(+) | 2;7 | SET OF CODES | I:INFRATENTORIAL S:SUPRATENTORIAL | For brain tumors, enter 'I' or 'S' according to whether the tumor is infratentorial or supratentorial. This field does not apply to tumors other than brain tumors. | |
21.51 | iris/ciliary body | 2;22 | SET OF CODES | I:Iris C:Ciliary body | This field is used to determine the appropriate TNM encoding for malignant melanomas of the uvea. | |
21.52 | upper/lower | 24;4 | SET OF CODES | U:Upper 2/3 L:Lower 1/3 | This field is used to determine the appropriate N coding for tumors of the vagina. Enter U or L according to whether the regional lymph node metastasis relates to the upper two-thirds or lower one-third of the vagina. | |
22 | histology (icd-o-2) | 2;3 | POINTER | 164.1 | AH | Record the histology using the ICD-O-2 codes. |
22.1 | icdo histology-code | COMPUTED | Display the Histology Code value, based on the primary's date DX: If Date DX is before 2001 use the HISTOLOGY (ICD-O-2) value, if it is a 2001 or later case use the HISTOLOGY (ICD-O-3) value. | |||
22.2 | papillary/follicular | 2;4 | SET OF CODES | P:PAPILLARY F:FOLLICULAR | This code assists in the characterization of tumors of the thyroid gland. It is only significant for patients 45 years and over. If the tumor is neither papillary nor follicular, leave this field blank. | |
22.3 | histology (icd-o-3) | 2.2;3 | POINTER | 169.3 | Identifies the microscopic anatomy of cells for primaries diagnosed in 2001 or later. This field also contains the BEHAVIOR CODE which records the behavior of the tumor being reported. The fifth digit of the morphology code is the behavior code. For further information see FORDS pages 93-95. | |
23 | reconstruction/restoration | 3;33 | FREE TEXT | RECONSTRUCTIVE/RESTORATION is a surgical procdure that improves the shape and appearance or function of body structures that are missing, defective, damaged or misshapen by cancer or its treatment. RECONSTRUCTION/RESTORATION is limited to procedures started during the first course of treatment. For further information see ROADS page 195. | ||
24 | grade/differentiation | 2;5 | POINTER | 164.43 | Describes the tumor's resemblance to normal tissue. Well differentiated (Grade 1) is the most like normal tissue, and undifferentiated (Grade 4) is the least like normal tissue. Grades 5-8 define particular cell lines for lymphomas and leukemias. For further information see FORDS 2010 pages 112-113. | |
24.1 | grade path system | 2.3;1 | SET OF CODES | 2:Two-Grade System 3:Three-Grade System 4:Four-Grade System | Indicates whether a two, three or four grade system was used in the pathology report. Leave blank if no GRADE PATH SYSTEM is noted on the pathology report. | |
24.2 | grade path value | 2.3;2 | SET OF CODES | 1:Recorded as Grade I or 1 2:Recorded as Grade II or 2 3:Recorded as Grade III or 3 4:Recorded as Grade IV or 4 | Describes the grade assigned according to the grading system in GRADE PATH SYSTEM. Leave blank if no GRADE PATH SYSTEM is noted on the pathology report. | |
25 | tnm form assigned | 7;7 | FREE TEXT | Records the date on which the TNM form was assigned to the Managing Physician. | ||
25.1 | tumor marker 1 | 24;2 | POINTER | 164.15 | Record prognostic indicators. | |
25.2 | tumor marker 2 | 24;3 | POINTER | 164.15 | Record prognostic indicators. | |
25.3 | tumor marker 3 | 24;7 | POINTER | 164.15 | Record LDH prognostic indicators for testicular cancer. | |
26 | diagnostic confirmation | 2;6 | SET OF CODES | 1:Positive histology 2:Positive cytology 3:Pos hist + pos immunophenotyping + pos genetic 4:Positive microscopic 5:Positive lab test 6:Direct visual 7:Rad/other imaging 8:Clinical dx only 9:Unknown | Records the best method of diagnostic confirmation of the cancer being reported at any time in the patient's history. For further information see FORDS 2010 pages 117-119. | |
27 | histo-morphology | COMPUTED | This field displays the HISTOLOGY ICD-O-3 (165.5,22.3) value concatinated with the GRADE/DIFFERENTIATION (165.5,24) value. | |||
28 | laterality | 2;8 | SET OF CODES | 0:Not a paired site 1:Right 2:Left 3:One side involved, right/left not specified 4:Bilateral involvement, side of origin unknown 5:Paired site, midline tumor 9:Paired site, no laterality information | Identifies the side of a paired organ or the side of the body on which the reportable tumor originated. This applies to the primary site only. For further information see FORDS page 92. | |
29 | tumor size | 2;9 | NUMERIC | Describes the largest dimension of the diameter of the primary tumor in millimeters (mm). Code the exact size of the primary tumor in millimeters (mm). EXCEPTION: For melanomas of the skin (C44.0-C44.9), vulva (C51.0-C51.9), penis (C60.0-C60.9), scrotum (C63.3), and conjunctiva (C69.0): - code the depth of invasion in HUNDRETHS of millimeters. - code 989 for melanomas which are 9.89 mm or greater in depth. Code 998 when the following terms describe tumor involvement in these specific sites: Esophagus (C15.0-C15.9): Entire circumference Stomach (C16.0-C16.9): Diffuse, widespread, 3/4 or more, linitis plastica Colorectal (C18.0-C20.9): Familial/multiple polyposis Lung (C34.0-C34.9): Diffuse, entire lobe of lung Breast (C50.0-C50.9): Inflammatory carcinoma; diffuse, widespread, 3/4 or more of breast Code 999, unknown, if only one size is given for a mixed in situ and invasive tumor. Code 999 if the size of the tumor is unknown or the tumor size is not documented in the patient record. Code 999 for histologies or sites where size in not applicable: Unknown or ill-defined primary (C76.0-C76.8, C80.9) Hematopoietic, reticuloendothelial, immunoproliferative or myeloproliferative disease Multiple myeloma (9732) Letterer-Siwe disease (9754) For further information see FORDS pages 100-101. | ||
29.1 | tumor size/ext eval (cs) | CS;1 | FREE TEXT | Records how the codes for the two items TUMOR SIZE (CS) and EXTENSION (CS) were determined, based on the diagnostic methods employed. | ||
29.2 | tumor size (cs) | CS1;10 | FREE TEXT | FOR MALIGNANT MELANOMA: Record the size of the tumor in TUMOR SIZE (CS), not depth or thickness. Depth or thickness is recorded in SITE-SPECIFIC FACTOR 1 (CS). Records the largest dimension or diameter of the primary tumor, and is always recorded in millimeters. To convert centimeters to millimeters, multiply the dimension by 10. If tumor size is given in tenths of millimeters, round down if between .1 and .5 mm, and round up if between .6 and .9 mm. | ||
29.9 | extension list used | COMPUTED | This is a brief description of the SEER extension code list that was selected by the system for this primary. It is used for audit by print template ONCO PRIMARY EXTENT CODE AUDIT. | |||
30 | extension | 2;10 | NUMERIC | Seer Extent of Disease coding schema. | ||
30.1 | pathologic extension | 2.2;2 | NUMERIC | Code the farthest documented pathologic extension of tumor from the prostate, either by contiguous extension or distant metastasis. | ||
30.2 | extension (cs) | CS;11 | FREE TEXT | Identifies contiguous growth (extension) of the primary tumor within the organ of origin or its direct extension into neighboring organs. | ||
30.5 | peripheral blood involvement | 24;5 | SET OF CODES | B0:Absence of significant involvement, 5% or less atypical B0a:Clone negative B0b:Clone positive B1:Low blood tumor burden, > 5% atypical B1a:Clone negative B1b:Clone positive B2:High blood tumor burden | Identifies the percentage of circulating atypical cells of T-cell lymphoma. This information may be found as part of a blood smear differential. It is only associated with an histology of Mycosis fungoides or Sezary syndrome. | |
30.9 | lymph node list used | COMPUTED | This is a brief description of the SEER lymph node code list that was selected by the system for this primary. It is used for audit by print template ONCO PRIMARY EXTENT CODE AUDIT. | |||
31 | lymph nodes | 2;11 | NUMERIC | Record SEER lymph node involvement. | ||
31.1 | lymph nodes (cs) | CS;12 | FREE TEXT | Identifies the regional lymph nodes involved with cancer at the time of diagnosis. | ||
32 | regional lymph nodes positive | 2;12 | NUMERIC | Records the exact number of regional lymph nodes examined by the pathologist and found to contain metastases. 00 All nodes examined are negative. 01-89 1-89 nodes are positive. (Code exact number of nodes positive) 90 90 or more nodes are positive. 95 Positive aspiration of lymph node(s) was performed. 97 Positive nodes are documented, but the number is unspecified. 98 No nodes were examined. 99 It is unknown whether nodes are positive; not applicable; not stated in patient record. For further information see FORDS page 103. | ||
32.1 | lymph nodes eval (cs) | CS;2 | FREE TEXT | Records how the code for the item LYMPH NODES (CS) was determined, based on the diagnostic methods employed. | ||
33 | regional lymph nodes examined | 2;13 | NUMERIC | Records the total number of regional lymph nodes examined by the pathologist. 00 No nodes were examined. 01-89 1-89 nodes were examined. (Code the exact number of regional lymph nodes examined.) 90 90 or more nodes were examined. 95 No regional nodes were removed, but aspiration of regional nodes was performed. 96 Regional lymph node removal was documented as a sampling, and the number of nodes is unknown/not stated. 97 Regional lymph node removal was documented as a dissection, and the number of nodes is unknown/not stated. 98 Regional lymph nodes were surgically removed, but the number of lymph nodes is unknown/not stated and not documented as a sampling or dissection; nodes were examined but the number is unknown. 99 It is unknown whether nodes were examined; not applicable or negative; not stated in patient record. For further information see FORDS page 102. | ||
33.1 | #nodes examined | COMPUTED | RECORD THE NUMBER OF LYMPH NODES EXAMINED BY PATHOLOGIST. | |||
34 | site of distant metastasis #1 | 2;14 | SET OF CODES | 0:None 1:Peritoneum 2:Lung 3:Pleura 4:Liver 5:Bone 6:Central nervous system 7:Skin 8:Lymph nodes (distant) 9:Other/Gen/Carcinomatosis/Unkn | Code only the site(s) of distant metastasis identified during initial diagnosis and workup. For further information see ROADS pages 131-132. | |
34.1 | site of distant metastasis #2 | 2;15 | SET OF CODES | 0:None 1:Peritoneum 2:Lung 3:Pleura 4:Liver 5:Bone 6:Central nervous system 7:Skin 8:Lymph nodes (distant) 9:Other/Gen/Carcinomatosis/Unkn | Code the second site of distant metastasis identified during initial diagnosis and workup. For further information see ROADS pages 133-134. | |
34.2 | site of distant metastasis #3 | 2;16 | SET OF CODES | 0:None 1:Peritoneum 2:Lung 3:Pleura 4:Liver 5:Bone 6:Central nervous system 7:Skin 8:Lymph nodes (distant) 9:Other/Gen/Carcinomatosis/Unkn | Code the third site of distant metastasis identified during initial diagnosis and workup. For further information see ROADS pages 135-136. | |
34.3 | mets at dx (cs) | CS;3 | FREE TEXT | Identifies the distant site(s) of metastatic involvement at time of diagnosis. | ||
34.31 | mets at dx-bone | CS1;20 | SET OF CODES | 0:None 1:Yes 8:NA 9:Unknown | Identifies the presence of distant metastatic involvement of bone at time of diagnosis. | |
34.32 | mets at dx-brain | CS1;21 | SET OF CODES | 0:None 1:Yes 8:NA 9:Unknown | Identifies the presence of distant metastatic involvement of the brain at time of diagnosis. | |
34.33 | mets at dx-liver | CS1;22 | SET OF CODES | 0:None 1:Yes 8:NA 9:Unknown | Identifies the presence of distant metastatic involvement of the liver at time of diagnosis. | |
34.34 | mets at dx-lung | CS1;23 | SET OF CODES | 0:None 1:Yes 8:NA 9:Unknown | Identifies the presence of distant metastatic involvement of the lung at time of diagnosis. | |
34.4 | mets eval (cs) | CS;4 | FREE TEXT | Records how the code for the item METS AT DX (CS) was determined based on the diagnostic methods employed. | ||
35 | seer summary stage 2000 | 2;17 | SET OF CODES | 0:In situ 1:Localized 2:Regional by direct extension 3:Regional to lymph nodes 4:Regional by extension & to nodes 5:Regional, NOS 7:Distant metastasis/systemic disease 8:NA 9:Unknown | Provides a site-specific description of the extent of disease at diagnosis. For futher information see FORDS page 124. | |
35.1 | seer summary stage abbreviated | COMPUTED | This item abbreviates the SEER SUMMARY STAGE 2000 (165.5,35) output values for condensed display. | |||
36 | ajcc staging basis | 2;18 | SET OF CODES | C:Clinical-diagnostic P:Pathological (Post-surgical) R:Retreatment Staging A:Autopsy S:Surgical Evaluative | Record the most appropriate code to reflect the basis on which the case was staged. Clinical-diagnostic staging is used for those sites that are accessible, i.e. cervix, oral cavity, larynx, and for those organs where evaluation of extent must be made only on the basis of clinical-diagnostic findings. Clinical-diagnostic staging is based on the physical examination, diagnostic imaging, clinical pathology, and biopsy of the primary. Postsurgical pathological staging is a combination of all findings - clinical-diagnostic, surgical-evaluative, and postsurgical retreatment-pathological. | |
37 | tnm clinical | COMPUTED | This is the combined Clinical T, N, and M codes, formatted for display. | |||
37.1 | clinical t | 2;25 | FREE TEXT | Evaluates the primary tumor (T) and reflects the tumor size and/or extension of the tumor known prior to the start of any therapy. | ||
37.2 | clinical n | 2;26 | FREE TEXT | Identifies the absence or presence of regional lymph node (N) metastasis and describes the extent of regional lymph node metastasis of the tumor known prior to the start of any therapy. | ||
37.3 | clinical m | 2;27 | FREE TEXT | Identifies the presence or absence of distant metastasis (M) of the tumor known prior to the start of any therapy. | ||
37.9 | automatic staging overridden | 24;1 | BOOLEAN | 1:Yes 0:No | This field is set to 'Yes' by the abstracting option if the operator overrides automatic staging. | |
38 | stage group clinical | 2;20 | FREE TEXT | Identifies the anatomic extent of disease based on the T , N, and M elements as recorded by the physician. For futher information see FORDS page 115. | ||
38.1 | gp-i ajcc summary stage | COMPUTED | RECORD THE AJCC STAGE. | |||
38.2 | gp-ii ajcc summary stage | COMPUTED | RECORD THE AJCC STAGE. | |||
38.3 | gp-iii ajcc summary stage | COMPUTED | RECORD THE AJCC STAGE. | |||
38.4 | gp-iv ajcc summary stage | COMPUTED | RECORD THE AJCC STAGE. | |||
38.5 | stage grouping-ajcc | 2;28 | SET OF CODES | 0:0 I:I II:II III:III IV:IV U:Unk/Uns NA:NA | ASG | This field is set by either the CLINCICAL STAGE GROUP (38) or PATHOLOGIC STAGE GROUP (88) field depending on which takes precedence. It consists of the more general stage group values of 0, I, II, III, IV, Unk/Uns or NA. |
39 | other staging system | 2;21 | POINTER | 164.3 | OTHER STAGING SYSTEM allows institutions the opportunity to collect additional staging classifications, for example, CDS, RAI, DS or FAB. | |
40 | stage group best | COMPUTED | This field displays the "best" stage group as determined by the clinical/pathological hierarchy rules. | |||
40.1 | tnm best | COMPUTED | This field displays the "best" TNM string as determined by the clinical/pathological hierarchy rules. | |||
40.2 | staged by | COMPUTED | Choose from: 0 Not staged 1 Managing MD 2 Pathologist 3 Pathologist & managing MD 4 Committee chair, liaison MD, registry advisor 5 Registrar 6 Registrar & MD 7 Another facility 8 NA 9 Unknown | |||
41 | associated with hiv | 2;23 | SET OF CODES | 1:Yes 2:No 999:Unknown | Record the presence/absence of HIV. | |
42 | treatment abbreviated | COMPUTED | TREATMENT ABBREVIATED lists the type(s) of therapies intended to modify or control the malignancy. All cancer-directed therapies specified in TREATMENT ABBREVIATED are a part of the FIRST COURSE OF TREATMENT. The therapies have been abbreviated to a 1-character designation: S - SURGERY OF PRIMARY SITE (F) R - RADIATION P - RADIATION THERAPY TO CNS C - CHEMOTHERAPY H - HORMONE THERAPY B - IMMUMOTHERAPY O - OTHER TREATMENT E - HEMA TRANS/ENDOCRINE PROC | |||
43 | treatment | COMPUTED | The treatment given to a patient, either curative or palliative in nature. | |||
44 | tnm form completed | 7;14 | FREE TEXT | Records the date on which the TNM form was completed by the Managing Physician. | ||
44.1 | ssf1 | CS;5 | FREE TEXT | Identifies additional information needed to generate stage, or prognostic factors that have an effect on stage or survival. | ||
44.101 | ssf10 | CS2;4 | FREE TEXT | Identifies additional information needed to generate stage, or prognostic factors that have an effect on stage or survival. | ||
44.11 | ssf11 | CS2;5 | FREE TEXT | Identifies additional information needed to generate stage, or prognostic factors that have an effect on stage or survival. | ||
44.12 | ssf12 | CS2;6 | FREE TEXT | Identifies additional information needed to generate stage, or prognostic factors that have an effect on stage or survival. | ||
44.13 | ssf13 | CS2;7 | FREE TEXT | Identifies additional information needed to generate stage, or prognostic factors that have an effect on stage or survival. | ||
44.14 | ssf14 | CS2;8 | FREE TEXT | Identifies additional information needed to generate stage, or prognostic factors that have an effect on stage or survival. | ||
44.15 | ssf15 | CS2;9 | FREE TEXT | Identifies additional information needed to generate stage, or prognostic factors that have an effect on stage or survival. | ||
44.16 | ssf16 | CS2;10 | FREE TEXT | Identifies additional information needed to generate stage, or prognostic factors that have an effect on stage or survival. | ||
44.17 | ssf17 | CS2;11 | FREE TEXT | Identifies additional information needed to generate stage, or prognostic factors that have an effect on stage or survival. | ||
44.18 | ssf18 | CS2;12 | FREE TEXT | Identifies additional information needed to generate stage, or prognostic factors that have an effect on stage or survival. | ||
44.19 | ssf19 | CS2;13 | FREE TEXT | Identifies additional information needed to generate stage, or prognostic factors that have an effect on stage or survival. | ||
44.2 | ssf2 | CS;6 | FREE TEXT | Identifies additional information needed to generate stage, or prognostic factors that have an effect on stage or survival. | ||
44.201 | ssf20 | CS2;14 | FREE TEXT | Identifies additional information needed to generate stage, or prognostic factors that have an effect on stage or survival. | ||
44.21 | ssf21 | CS2;15 | FREE TEXT | Identifies additional information needed to generate stage, or prognostic factors that have an effect on stage or survival. | ||
44.22 | ssf22 | CS2;16 | FREE TEXT | Identifies additional information needed to generate stage, or prognostic factors that have an effect on stage or survival. | ||
44.23 | ssf23 | CS2;17 | FREE TEXT | Identifies additional information needed to generate stage, or prognostic factors that have an effect on stage or survival. | ||
44.24 | ssf24 | CS2;18 | FREE TEXT | Identifies additional information needed to generate stage, or prognostic factors that have an effect on stage or survival. | ||
44.25 | ssf25 | CS2;19 | FREE TEXT | Identifies additional information needed to generate stage, or prognostic factors that have an effect on stage or survival. | ||
44.3 | ssf3 | CS;7 | FREE TEXT | Identifies additional information needed to generate stage, or prognostic factors that have an effect on stage or survival. | ||
44.4 | ssf4 | CS;8 | FREE TEXT | Identifies additional information needed to generate stage, or prognostic factors that have an effect on stage or survival. | ||
44.5 | ssf5 | CS;9 | FREE TEXT | Identifies additional information needed to generate stage, or prognostic factors that have an effect on stage or survival. | ||
44.6 | ssf6 | CS;10 | FREE TEXT | Identifies additional information needed to generate stage, or prognostic factors that have an effect on stage or survival. | ||
44.7 | ssf7 | CS2;1 | FREE TEXT | Identifies additional information needed to generate stage, or prognostic factors that have an effect on stage or survival. | ||
44.8 | ssf8 | CS2;2 | FREE TEXT | Identifies additional information needed to generate stage, or prognostic factors that have an effect on stage or survival. | ||
44.9 | ssf9 | CS2;3 | FREE TEXT | Identifies additional information needed to generate stage, or prognostic factors that have an effect on stage or survival. | ||
45 | performance status | 2;24 | SET OF CODES | 100:NORMAL 90:MINOR SYMTOMS 80:ACTIVITY W EFFORT 70:NO WORK/SELF CARE 60:OCCASIONAL ASSIST 50:CONSIDERABLE ASSIST 40:DISABLED/SPECIAL CARE 30:SEVERLY DISABLED/HOSP 20:VERY SICK/HOSP 10:MORIBUND 0:DEAD | This is the performance status of the patient. | |
46 | cap protocol review | 7;19 | SET OF CODES | 0:Failed 1:Complied 9:NA or exempt | The ACS (American College of Surgeons) requires CAP (College of American Pathologists) Protocol Review of cases with surgical resection only. Biopsy only cases are exempt from review. Records whether this case failed, complied with or was exempt from CAP Protocol Review. To use code 1 (Complied), ALL elements of the CAP Cancer Protocol Checklist must be documented on the pathology report. | |
47 | cap text | 7;20 | FREE TEXT | Records the reason for CAP (College of American Pathologists) Protocol non-compliance. | ||
48 | other primary sites | COMPUTED | SITES OTHER THAN THE COMMON CANCER SITES ARE LISTED. | |||
49 | first course of treatment date | COMPUTED | Records the date on which treatment (surgery, radiation, systemic, or other therapy) of the patient begain at any facility. For further information see FORDS pages 129-130. | |||
49.1 | first treatment dt-date dx | COMPUTED | A computed field derives from FIRST COURSE OF TREATMENT DATE minus DATE DX. | |||
50 | most definitive surg date | 3;1 | DATE-TIME | Records the date of the most definitive surgical resection of the primary site performed as part of the first course of treatment. For further information see FORDS pages 133-134. | ||
50.1 | surgery hospital | 3;2 | POINTER | 160.19 | Record the name of the institution providing treatment. | |
50.2 | surgery of primary @fac (r) | 3.1;7 | FREE TEXT | Records the surgical procedure(s) performed to the primary site at this facilty. For further information see ROADS page 190. | ||
50.3 | most definitive surg @fac date | 3.1;8 | DATE-TIME | Records the date of the most definitive surgical resection of the primary site performed as part of the first course of treatment at this facility. | ||
51 | date radiation started | 3;4 | DATE-TIME | Records the date on which radiation therapy began at any facility that is part of the first course of treatment. For further information see FORDS pages 148-149. | ||
51.1 | radiation hospital | 3;5 | POINTER | 160.19 | Record the name of the institution administering the therapy. | |
51.2 | radiation | 3;6 | SET OF CODES | 0:None 1:Beam radiation 2:Radioactive implants 3:Radioisotopes 4:Beam + implants or radioisotopes 5:Radiation, NOS 7:Refused radiation 8:Recommended, unknown if given 9:Unknown if administered | Record the type of radiation administered to the primary site or any metastatic site. Include all procedures that are part of the first course of treatment, whether delivered at the reporting institution or at other institutions. | |
51.3 | radiation/surgery sequence | 3;7 | SET OF CODES | 0:No rad and/or surgery 2:Rad before surgery 3:Rad after surgery 4:Rad both before/after surgery 5:Intraoperative rad 6:Intraoperative rad w rad before/after surgery 9:Sequence unknown | Records the sequencing of radiation and surgical procedures given as part of the first course of treatment. For further information see FORDS pages 164-165. | |
51.4 | radiation @facility | 3.1;12 | SET OF CODES | 0:None 1:Beam radiation 2:Radioactive implants 3:Radioisotopes 4:Beam + implants or radioisotopes 5:Radiation, NOS 7:Refused radiation 8:Recommended, unknown if given 9:Unknown if administered | Record the type of radiation administered to the primary site or any metastatic site AT THIS FACILITY. Include all procedures that are part of the first course of treatment. | |
51.5 | radiation @facility date | 3.1;13 | DATE-TIME | Record the date that the first course of radiation therapy performed AT THIS FACILITY was started. | ||
52 | radiation therapy to cns date | 3;8 | DATE-TIME | FOR LUNG AND LEUKEMIA ONLY: record the date radiation therapy to the brain and CNS was initiated. ALL OTHER SITES: not a valid entry. | ||
52.1 | radiation therapy to cns hosp | 3;9 | POINTER | 160.19 | Record the name of the institution administering the therapy. This field is used only for LUNGS and LEUKEMIAS. | |
52.2 | radiation therapy to cns | 3;10 | SET OF CODES | 0:No radiation to CNS 1:Radiation 7:Patient refused radiation 8:Radiation recommended, unk if admin 9:Unknown/NA | These data are being kept for historical purposes. Do not code for cases diagnosed as of January 1, 1996. Case diagnosed on or after January 1, 1996 should be coded in the field RADIATION. Radiation treatment to the central nervous system (CNS) codes 0-8 are valid only for patients with lung or leukemia primaries. Code 9 (Unknown/NA) for all other cases. | |
53 | chemotherapy date | 3;11 | DATE-TIME | Record the date first course of CHEMOTHERAPY was started. | ||
53.1 | chemotherapy hospital | 3;12 | POINTER | 160.19 | Record the name of the institution where CHEMOTHERAPY was given. | |
53.2 | chemotherapy | 3;13 | SET OF CODES | 00:None 01:Chemotherapy, NOS 02:Single-agent 03:Multiagent 82:Not administered/contraindicated 85:Pt died prior to tx 86:Recommended, not admin, no reason given 87:Refusal 88:Recommended, unknown if admin 99:Unknown | Records the type of chemotherapy administered as first course of treatment at this and at all other facilities. If chemotherapy was not administered, then this item records the reason it was not administered to the patient. Chemotherapy consists of a group of anticancer drugs that inhibit the reproduction of cancer cells by interfering with DNA synthesis and mitosis. For further information see FORDS pages 171-172. | |
53.3 | chemotherapy @fac | 3.1;14 | SET OF CODES | 00:None 01:Chemotherapy, NOS 02:Single-agent 03:Multiagent 82:Not administered/contraindicated 85:Pt died prior to tx 86:Recommended, not admin, no reason given 87:Refusal 88:Recommended, unknown if admin 99:Unknown | Records the type of chemotherapy administered as first course of treatment at this facility. If chemotherapy was not administered, then this item records the reason it was not administered to the patient. Chemotherapy consists of a group of anticancer drugs that inhibit the reproduction of cancer cells by interfering with DNA synthesis and mitosis. For further information see FORDS pages 173-174. | |
53.4 | chemotherapy @fac date | 3.1;15 | DATE-TIME | Record the date chemotherapy was administered as first course of treatment at this facility. | ||
54 | hormone therapy date | 3;14 | DATE-TIME | Record the date HORMONE THERAPY was started. | ||
54.1 | hormone therapy hospital | 3;15 | POINTER | 160.19 | Record the name of the institution that administered the hormone therapy. | |
54.2 | hormone therapy | 3;16 | SET OF CODES | 00:None 01:Hormone therapy 82:Not administered/contraindicated 85:Pt died prior to tx 86:Recommended, not admin, no reason given 87:Refusal 88:Recommended, unknown if admin 99:Unknown | Records the type of hormone therapy administered as first course treatment at this and all other facilities. If hormone therapy was not administered, then this item records the reason it was not administered to the patient. Hormone therapy consists of a group of drugs that may affect the long-term control of a cancer's growth. It is not usually used as a curative measure. For further information see FORDS pages 175-176. | |
54.3 | hormone therapy @fac | 3.1;16 | SET OF CODES | 00:None 01:Hormone therapy 82:Not administered/contraindicated 85:Pt died prior to tx 86:Recommended, not admin, no reason given 87:Refusal 88:Recommended, unknown if admin 99:Unknown | Records the type of hormone therapy administered as first course treatment at this facility. If hormone therapy was not administered, then this item records the reason it was not administered to the patient. Hormone therapy consists of a group of drugs that may affect the long-term control of a cancer's growth. It is not usually used as a curative measure. For further information see FORDS pages 177-178. | |
54.4 | hormone therapy @fac date | 3.1;17 | DATE-TIME | Records the date hormone therapy was administered as first course of treatment at this facility. | ||
55 | immunotherapy date | 3;17 | DATE-TIME | The date immunotherapy was started. | ||
55.1 | immunotherapy hospital | 3;18 | POINTER | 160.19 | The ACOS number of the institution where immunotherapy was performed. | |
55.2 | immunotherapy | 3;19 | SET OF CODES | 00:None 01:Immunotherapy 82:Not administered/contraindicated 85:Pt died prior to tx 86:Recommended, not admin, no reason given 87:Refusal 88:Recommended, unknown if admin 99:Unknown | Records the type of immunotherapy administered as first course treatment at this and all other facilities. If immunotherapy was not administered, then this item records the reason it was not administered to the patient. Immunotherapy consists of biological or chemical agents that alter the immune system or change the host's response to the tumor cells. For further information see FORDS pages 179-180. | |
55.3 | immunotherapy @fac | 3.1;18 | SET OF CODES | 00:None 01:Immunotherapy 82:Not administered/contraindicated 85:Pt died prior to tx 86:Recommended, not admin, no reason given 87:Refusal 88:Recommended, unknown if admin 99:Unknown | Records the type of immunotherapy administered as first course treatment at this facility. If immunotherapy was not administered, then this item records the reason it was not administered to the patient. Immunotherapy consists of biological or chemical agents that alter the immune system or change the host's response to the tumor cells. For further information see FORDS page 181. | |
55.4 | immunotherapy @fac date | 3.1;19 | DATE-TIME | Records the date immunotherapy was administered as first course of treatment at this facility. | ||
56 | number of txs to this volume | 3;20 | NUMERIC | Records the total number of treatment sessions (fractions) administered during the first course of treatment. For further information see FORDS page 163. | ||
57 | other treatment start date | 3;23 | DATE-TIME | Records the date on which other treatment began at any facility. For further information see FORDS pages 184-185. | ||
57.1 | other treatment hospital | 3;24 | POINTER | 160.19 | Record the name of the institution where other treatment was administered. | |
57.2 | other treatment | 3;25 | SET OF CODES | 0:None 1:Other 2:Other - Experimental 3:Other - Double Blind 6:Other - Unproven 7:Refusal 8:Recommended, unknown if administered 9:Unknown | Identifies other treatment that cannot be defined as surgery, radiation, or systemic therapy according to the defined data elements in the FORDS manual. For further information see FORDS page 186. | |
57.3 | other treatment @fac | 3.1;20 | SET OF CODES | 0:None 1:Other 2:Other - Experimental 3:Other - Double Blind 6:Other - Unproven 7:Refusal 8:Recommended, unknown if administered 9:Unknown | Identifies other treatment given at this facility that cannot be defined as surgery, radiation, or systemic therapy according to the defined data elements in the FORDS manual. For further information see FORDS page 187. | |
57.4 | other treatment @facility date | 3.1;21 | DATE-TIME | Record the month, day, and year first course of other treatment performed AT THIS FACILITY was started. Collecting dates for each treatment modality allows sequencing of multiple treatments and aids evaluation of time intervals (from diagnosis to treatment and from treatment to recurrence). | ||
58 | reason no surgery of primary | 3;26 | SET OF CODES | 0:Surgery performed 1:Not part of 1st course 2:Contraindicated 5:Pt died prior to surgery 6:Recommended, not performed, no reason given 7:Refusal 8:Recommended, unknown if performed 9:Unknown | Records the reason that no surgery was performed on the primary site. For further information see FORDS page 147. | |
58.1 | surgical dx/staging proc | 3;27 | FREE TEXT | Identifies the surgical procedure(s) performed in an effort to diagnose and/or stage disease. For further information see FORDS pages 109-110. | ||
58.2 | surgery of primary (r) | 3;38 | NUMERIC | Records the surgical procedure(s) performed to the primary site. For further information see ROADS pages 187-189. | ||
58.3 | surgical dx/staging proc date | 3;31 | DATE-TIME | Records the date on which the surgical diagnostic and/or staging procedure was performed. For further information see FORDS pages 107-108. | ||
58.4 | surg dx/staging proc @fac | 3.1;5 | FREE TEXT | Identifies the surgical procedure(s) performed in an effort to diagnose and/or stage disease at this facility. For further information see FORDS page 111. | ||
58.5 | surg dx/staging proc @fac date | 3.1;6 | DATE-TIME | Records the date on which the surgical diagnostic and/or staging procedure was performed at this facility. | ||
58.6 | surgery of primary (f) | 3.1;29 | FREE TEXT | Records the surgical procedure(s) performed to the primary site. For further information see FORDS page 135. | ||
58.7 | surgery of primary @fac (f) | 3.1;30 | FREE TEXT | Records the surgical procedure(s) performed to the primary at this facility. For further information see FORDS page 136. | ||
59 | surgical margins | 3;28 | SET OF CODES | 0:No residual tumor 1:Residual tumor, NOS 2:Microscopic residual tumor 3:Macroscopic residual tumor 7:Margins not evaluable 8:No primary site surgery 9:Unknown or NA | Records the final status of the surgical margins after resection of the primary tumor. For further information see FORDS 2010 page 224. | |
60 | subsequent course of treatment | 4;0 | MULTIPLE | 165.51 | Enter subsequent therapy (therapy provided after completion of the first course of therapy). | |
61 | pid# | COMPUTED | RECORD THE PATIENT'S IDENTIFICATION NUMBER. | |||
62 | qa selected | 7;4 | BOOLEAN | Y:YES | Field is stuffed if randomly selected for QA review. | |
63 | qa review | 7;8 | BOOLEAN | N:NO Y:YES | Field only used if Abstract was randomly selected for QA Review. | |
64 | qa date | 7;9 | DATE-TIME | Date of QA Review if done on this Abstract. | ||
64.1 | qa reviewer | 7;18 | POINTER | 200 | Select the name of the QA reviewer. | |
64.2 | qa findings | 28;0 | WORD-PROCESSING | Enter the QA FINDINGS of the QA review. Please limit your findings to 3 lines of text. | ||
65 | physician's stage | 7;10 | FREE TEXT | Records information regarding the physician's stage. | ||
66 | physician staging | 7;11 | POINTER | 165 | This is the name of the physician performing the staging. | |
67 | acos # | COMPUTED | ACOS # is the equivalent of the INSTITUTION ID NUMBER as recorded in the ONCOLOGY SITE PARAMETERS file. | |||
68 | state hospital # | COMPUTED | This is the state identification number. | |||
69 | multiple tumors | 2;31 | NUMERIC | This field documents the existence and (if known) number of multiple tumors at an anatomic site. If there are NOT multiple tumors at this site, leave this field BLANK. If there ARE multiple tumors at this site, enter the exact number of tumors here if known, or a 1 if the exact number if not known. | ||
69.1 | family history | 2;32 | BOOLEAN | 0:No 1:Yes | If there is a known family history for this case, enter a 1. Otherwise, enter a 0 or leave blank. This field only applies to cancers of the retina. | |
69.2 | diffuse retinal involvement | 3;30 | BOOLEAN | 0:No 1:Yes | If there is diffuse retinal involvement without the formation of discrete masses, enter a 1. Otherwise, enter a 0 or leave blank. This field applies only to cancers of the retina. | |
69.3 | multimodality therapy (clin) | 7;16 | BOOLEAN | Y:Yes N:No | The first method of therapy is other than cancer-directed surgery. The patient is first treated with radiation therapy, chemotherapy, hormone therapy, immunotherapy, "other" therapy, or any combination of these therapies. The stage is based on a pathologic resection of the primary done after at least one of the other therapies has started. The other therapy may or may not be complete. This stage should supplement the clinical AJCC stage, not replace it. | |
69.4 | multimodality therapy | 7;17 | BOOLEAN | Y:Yes N:No | MULTIMODALITY THERAPY determines whether the pTNM category will have a "y Prefix" (eg yT1 N0 M0). The "y Prefix" indicates those cases in which classification is performed during or following initial multimodality therapy. The ypTNM categorizes the extent of tumor actually present at the time of that examination. The "y" category is not an estimate of the extent of tumor prior to multimodality therapy. | |
70 | date of first recurrence | 5;1 | DATE-TIME | Records the date of the first recurrence. For further information see FORDS pages 195-196. | ||
71 | type of first recurrence | 5;2 | POINTER | 160.12 | Identifies the type of first recurrence after a period of documented disease-free intermission or remission. For further information see FORDS pages 197-198. | |
71.1 | distant site 1 | 5;3 | SET OF CODES | 0:None 1:Peritoneum 2:Lung 3:Pleura 4:Liver 5:Bone 6:Central Nervous System 7:Skin 8:Lymph Nodes (Distant) 9:Other/Generalized/NOS | Record the first site of distant recurrence. | |
71.2 | distant site 2 | 5;4 | SET OF CODES | 0:None 1:Peritoneum 2:Lung 3:Pleura 4:Liver 5:Bone 6:Central Nervous System 7:Skin 8:Lymph Nodes (Distant) 9:Other/Generalized/NOS | Record the second site of distant recurrence. | |
71.3 | distant site 3 | 5;5 | SET OF CODES | 0:None 1:Peritoneum 2:Lung 3:Pleura 4:Liver 5:Bone 6:Central Nervous System 7:Skin 8:Lymph Nodes (Distant) 9:Other/Generalized/NOS | Record the third site of distant recurrence. | |
71.4 | other type of first recurrence | 5;6 | POINTER | 160.12 | Record the OTHER TYPE OF FIRST RECURRENCE. The term "recurrence" means the return or reappearance of the cancer after a disease-free intermission or remission. The patient may have more than one site of recurrence (i.e., both regional and distant metastases). Code regional in the data field TYPE OF FIRST RECURRENCE, and distant in this field. If the patient has only one site of recurrence or has been disease-free since treatment, code 00. | |
72 | subsequent recurrences | 23;0 | MULTIPLE | 165.572 | This multiple records information on subsequent recurrences of the tumor. | |
73 | tumor status | TS;0 | MULTIPLE | 165.573 | This multiple is populated by the Post/Edit Follow-Up option of the Follow-Up Menu. It contains the date of each follow-up for this patient, and the tumor status at each follow-up. | |
74 | surgical approach (r) | 3;34 | NUMERIC | SURGICAL APPROACH describes the method used to approach the organ of origin and/or primary tumor. Code the approach for surgery of the primary site only. If no primary site surgical procedure was done (SURGERY OF PRIMARY SITE is coded 00), SURGICAL APPROACH must be coded 0. If the field SURGERY OF PRIMARY SITE is 99 (Unknown if surgery performed; death certificate ONLY), code SURGICAL APPROACH 9 (Unknown; not stated; death certificate ONLY). For further information see ROADS page 186. | ||
75 | reason for no radiation | 3;35 | SET OF CODES | 0:Radiation administered 1:Not part of 1st course 2:Contraindicated 5:Pt died prior to tx 6:Recommended, not admin, no reason given 7:Refusal 8:Recommended, unknown if admin 9:Unknown | Records the reason that no regional radiation therapy was administered to the primary site. For further information see FORDS page 168. | |
76 | reason for no chemotherapy | 3;36 | SET OF CODES | 0:Chemo administered 1:Chemo not recommended 2:Contraindicated, autopsy-only cases 6:Reason unk 7:Pt refused chemo 8:Chemo recommended, unk if administered 9:Unk if administered, death cert-only cases | Record the reason the patient did not receive chemotherapy. REASON FOR NO CHEMOTHERAPY is useful in survival analysis. It is a quality assurance monitor of appropriateness of treatment. | |
77 | reason for no hormone therapy | 3;37 | SET OF CODES | 0:HT administered 1:HT not recommended 2:Contraindicated, autopsy-only cases 6:Reason unk 7:Pt refused HT 8:HT recommended, unk if administered 9:Unk if administered, death cert-only cases | The reason the patient did not receive hormone therapy. | |
78 | converted | 24;6 | BOOLEAN | Y:YES N:NO | If this field is "YES" it means that the primary has had the pointers in fields 5,6,7,50.1,51.1,52.1,53.1,54.1,55.1,56.1,57.1 and 60 subfield 2 converted from pointers to the ONCOLOGY CONTACT File (165) to pointers to the new ACOS NUMBER file (160.19) already, and should not try to convert. | |
79 | screening date | 0;24 | DATE-TIME | Record the most recent date on which the patient participated in a screening program related to this primary cancer. | ||
80 | radiation treatment | 6;0 | MULTIPLE | 165.52 | Record the type of radiation therapy. | |
81 | completed by | 7;12 | FREE TEXT | Record the initials of the person who completed the PCE. | ||
82 | reviewed by cancer committee | 7;13 | FREE TEXT | As a method of quality control, it is recommended that a member of the cancer committee review the abstract for accuracy prior to the submission of data to the Commission on Cancer. Record the initials of the chairman or member of the cancer committee who reviewed the completed PCE. | ||
83 | afip/jpc submission | 0;21 | SET OF CODES | 0:No 1:Yes 9:Unknown | AFIP/JPC SUBMISSION records whether the case was sent to the Armed Forces Institute of Pathology (AFIP) or Joint Pathology Center (JPC) for a second opinion. Effective April 1, 2011, all consultation cases must be sent to the Joint Pathology Center (JPC). | |
84 | pce indicator | 7;15 | SET OF CODES | BLA:Bladder THY:Thyroid STS:Soft Tissue Sarcoma PRO:Prostate (1992) COL:Colorectal NHL:Non-Hodgkins Lymphoma BRE:Breast PRO2:Prostate (1998) MEL:Melanoma HEP:Hepatocellular CNS:Intracranial/CNS GAS:Gastric LNG:Lung | APCE | This field indicates the existence of a PCE (Patient Care Evaluation) study. |
85 | pathologic t | 2.1;1 | FREE TEXT | Evaluates the primary tumor (T) and reflects the tumor size and/or extension of the tumor known following the completion of surgical therapy. | ||
86 | pathologic n | 2.1;2 | FREE TEXT | Identifies the absence or presence of regional lymph node (N) metastasis and describes the extent of regional lymph node metastasis of the tumor known following the completion of surgical therapy. | ||
87 | pathologic m | 2.1;3 | FREE TEXT | Identifies the presence or absence of distant metastasis (M) of the tumor known following the completion of surgical therapy. | ||
88 | stage group pathologic | 2.1;4 | FREE TEXT | Identifies the anatomic extent of disease based on the T, N, and M elements as recorded by the physician. For futher information see FORDS page 121. | ||
89 | staged by (pathologic stage) | 2.1;5 | SET OF CODES | 0:Not staged 1:Managing MD 2:Pathologist 3:Pathologist & managing MD 4:Committee chair, liaison MD, registry advisor 5:Registrar 6:Registrar & MD 7:Another facility 8:NA 9:Unknown | Identifies the person who recorded the pathologic AJCC staging elements and the stage group in the patient's medical record. For futher information see FORDS page 123. | |
89.1 | tnm pathologic | COMPUTED | This is the combined Pathologic T, N, and M codes, formatted for display. | |||
90 | date case completed | 7;1 | DATE-TIME | The date that: (1) the abstractor decided that the case report was complete, and (2) the case passed all edits that were applied. | ||
91 | abstract status | 7;2 | SET OF CODES | 0:Incomplete 1:Minimal data 2:Partial 3:Complete A:Accession only | AS | Enter the status of the abstract data entry. |
92 | abstracted by(+) | 7;3 | POINTER | 200 | Records the initials or assigned code of the individual abstracting the case. For further information see FORDS page 207. | |
93 | other t | 2.1;6 | FREE TEXT | "Other T" evaluates the primary tumor and identifies tumor size and/or extension. | ||
94 | reporting date | 7;5 | DATE-TIME | Records automatically the default date as reporting date. | ||
95 | last tumor status | 7;6 | POINTER | 164.42 | ACS | This field records the code that summarizes the cancer status. |
95.1 | v status/last tumor status | COMPUTED | This COMPUTED field concatenates STATUS (160,15) and LAST TUMOR STATUS (165.5,95). | |||
96 | psa date | PRO2;50 | FREE TEXT | Records the date on which the Prostate Specific Antigen (PSA) test was performed. | ||
97 | abstract incomplete | COMPUTED | RECORD THE ABSTRACT STATUS AS INCOMPLETE WHEN DATA IS MISSING. | |||
98 | other n | 2.1;7 | FREE TEXT | "Other N" classifies the regional lymph nodes and describes the absence or presence and the extent of node metastases. | ||
99 | other m | 2.1;8 | FREE TEXT | "Other M" records the presence or absence of distant metastases. Choose the lower (less advanced) M category when there is any uncertainty. | ||
100 | text-primary site title | 8;1 | FREE TEXT | Text area for description of primary site in natural language. | ||
101 | text-histology title | 8;2 | FREE TEXT | Text area for description of histologic type, behavior, and grade in natural language. | ||
102 | dre +/- | 24;10 | SET OF CODES | 0:Clinically normal 1:Clinically abnormal 9:Not done/not documented | A clinically inapparent tumor is one that is neither palpable nor reliably visible by imaging. An apparent tumor is palpable or visible by imaging. DO NOT INFER inapparent or apparent tumor based on the registrar's interpretation of terms in the DRE or imaging reports. A physician assignment of cT1C or cT2 is a clear statement of inapparent or apparent respectively. | |
103 | text-dx proc-op | 9;0 | WORD-PROCESSING | Free text field. | ||
104 | text-dx proc-pe | 10;0 | WORD-PROCESSING | Text area for information from history and physical examinations. | ||
105 | text-dx proc-x-ray/scan | 11;0 | WORD-PROCESSING | Free text field. | ||
106 | text-dx proc-scopes | 12;0 | WORD-PROCESSING | Free text field. | ||
107 | text-dx proc-path | 13;0 | WORD-PROCESSING | Free text field. | ||
108 | rx text-surgery | 14;0 | WORD-PROCESSING | Free text field. | ||
109 | rx text-radiation | 15;0 | WORD-PROCESSING | Free text field. | ||
110 | rx text-radiation other | 16;0 | WORD-PROCESSING | Free text field. | ||
111 | rx text-chemo | 17;0 | WORD-PROCESSING | Free text field. | ||
112 | rx text-hormone | 18;0 | WORD-PROCESSING | Free text field. | ||
113 | text-remarks | 19;0 | WORD-PROCESSING | Free text field. | ||
114 | rx text-brm | 20;0 | WORD-PROCESSING | Free text field. | ||
115 | rx text-other | 21;0 | WORD-PROCESSING | Free text field. | ||
116 | text-dx proc-lab tests | 22;0 | WORD-PROCESSING | Text area for information from laboratory examinations other than cytology and histopatholgy. | ||
117 | other stage group | 2.1;9 | FREE TEXT | Record the apparent extent of disease in accordance with AJCC staging requirements. Stage codes: 0 IB III IVB 0A IC IIIA IVC Occult II IIIB Not applicable 0is IIA IIIC Unknown I IIB IV IA IIC IVA | ||
118 | staged by (other stage) | 2.1;10 | SET OF CODES | 0:Not staged 1:Managing physician 2:Pathologist 3:Other physician 4:Any combination of 1, 2, or 3 5:Registrar 6:Any combination of 5 with 1, 2, or 3 7:Other 8:Staged, individual not specified 9:Unk if staged | "Staged By (Other Stage)" identifies the person who documented the other AJCC staging elements and the stage group. The Commission requires analytic cases to be staged by the managing physician. Compliance with Commission-approved program requirements can be analyzed using this data. | |
119 | screening result | 0;25 | SET OF CODES | 0:Within normal limits 1:Abnormal/not suggestive of cancer 2:Abnormal/suggestive of cancer 3:Equivocal/no followup necessary 4:Equivocal/evaluation recommended 8:NA 9:Unknown result, not specified | This item categorizes findings from the most recent screening(s), serves as a triage for patient notification, and acts as a tickler file to aid the institution in meeting patient notification requirements. | |
120 | presentation at cancer conf | 0;26 | SET OF CODES | 0:Not presented 1:Prospective (diagnostic) 2:Prospective (treatment) 3:Prospective (follow-up) 4:Prospective (combinations) 5:Prospective, NOS 6:Retrospective 7:Follow-up 8:Presentation, NOS 9:Unknown | This item documents case presentation at a cancer conference and the type or format of presentation. The number of cancer conferences, sites presented, and types of presentation can be analyzed and reported for administrative use, quality control, and survey preperation. | |
121 | date of cancer conf | 0;27 | DATE-TIME | Enter the date on which the case was first presented at a cancer conference. The number of cancer conferences, sites presented, types of presentations, and dates can be analyzed and reported for administration, quality control, and Commission on Cancer survey preparation. Update this item if a patient is presented at a subsequent cancer conference. | ||
122 | referral to support services | 0;28 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record if the patient was referred to any of the following services. Enterostomal/stomal therapy Home care Hospice Infusion/parenteral therapy Nutritionist Occupational therapy Other Patient services (American Cancer Society) Patient services (other) Patient support group (American Cancer Society) Patient support group (hospital operated) Patient support group (other organization/agency) Physical therapy Referral; service unspecified Rehabilitation facility Respiratory therapy Speech therapy Visiting nurse assistance | |
123 | inpatient/outpatient status | 0;23 | SET OF CODES | 1:Inpatient only 2:Outpatient only 3:In and outpatient 8:Other, including physician's office 9:Unknown | "Inpatient/Outpatient Status" allows the facility to identify points of access used to initially diagnose and/or treat the patient. | |
124 | date of no treatment | 2.1;11 | DATE-TIME | If, for any reason, the patient is not treated, record the date of this decision as the DATE OF NO TREATMENT. The physician may decide not to treat the patient because of comorbid conditions, advanced disease, or because the accepted management of the cancer is to observe until the disease progresses or until the patient becomes symptomatic. The patient may also refuse treatment. | ||
125 | radiation treatment volume | 3;21 | POINTER | 164.7 | Identifies the volume or anatomic target of the most clinically significant regional radiation therapy delivered to the patient during the first course of treatment. For further information see FORDS pages 151-154. | |
126 | location of radiation tx | 3;22 | SET OF CODES | 0:No radiation tx 1:All radiation tx at this fac 2:Regional tx at this fac, boost elsewhere 3:Boost at this fac, regional elsewhere 4:All radiation tx elsewhere 8:Other 9:Unknown | Identifies the location of the facility where radiation therapy was administered during the first course of treatment. For further information see FORDS page 150. | |
127 | intent of radiation | 3;29 | SET OF CODES | 0:No radiation 1:Curative (primary) 2:Curative (adjuvant) 4:Palliative (pain control) 5:Palliative (other, cosmetic) 6:Prophylactic (no symptoms, preventive) 8:Other, NOS 9:Unknown | Code the intent of radiation treatment. This item is useful in assessing the appropriateness of treatment and correlating outcome with original intent of the treatment. The choice in this data field is subjective. The responsible radiation oncologist is the best person to provide this information. | |
128 | radiation completion status | 3;39 | POINTER | 164.8 | RADIATION COMPLETION STATUS is useful in evaluating treatment outcomes and the appropriateness of the initial decision to treat. This field indicates whether the patient's radiation therapy was completed as outlined in the initial treatment plan. This information is generally available only in the radiation treatment chart. | |
129 | radiation auxiliary volume | 3.1;1 | POINTER | 164.7 | ||
130 | radiation auxiliary date | 3.1;2 | DATE-TIME | |||
131 | radiation auxiliary text | 15.1;0 | WORD-PROCESSING | |||
132 | radiation local control status | 3.1;3 | SET OF CODES | 0:No radiation 1:Tumor control status not evaluable 2:Tumor/symptoms controlled 3:Tumor/symptoms returned 4:Tumor/symptoms never controlled 8:Other, NOS 9:Unknown | RADIATION LOCAL CONTROL STATUS records the radiation treatment results in terms of disease control within the irradiated volume. The data may be used in quality assurance studies to assess the effectiveness of treatment. This is a dynamic data item. To be clinically useful, this data must be evaluated at each follow-up. | |
133 | year put on protocol | 3.1;4 | FREE TEXT | Record the year in which the patient was entered into a protocol. | ||
134 | clinical risk factors | 2.1;12 | SET OF CODES | 0:None 1:hCG > 100,000 IU/24-hour urine 2:Detection > 6 mo from term of pregnancy 3:Both U:Unknown L:Low risk H:High risk | For Gestational Trophoblastic Tumors FIGO added nonsurgical-pathologic prognostic risk factors to the classic anatomic staging system. These include B-hCG levels of greater than 100,000 and the detection of disease more than 6 months from termination of the antecedent pregnancy. These risk factors affect staging. | |
135 | pathologic risk factors | 2.1;13 | SET OF CODES | 0:None 1:hCG > 100,000 IU/24-hour urine 2:Detection > 6 mo from term of pregnancy 3:Both U:Unknown L:Low risk H:High risk | For Gestational Trophoblastic Tumors FIGO added nonsurgical-pathologic prognostic risk factors to the classic anatomic staging system. These include B-hCG levels of greater than 100,000 and the detection of disease more than 6 months from termination of the antecedent pregnancy. These risk factors affect staging. | |
136 | serum tumor markers | 24;8 | SET OF CODES | SX:Not available S0:Normal S1:LDH < 1.5XN, hCG < 5000 mIU/ml, AFP < 1000 ng/ml S2:LDH 1.5-10XN or hCG 5000-50,000 mIu/ml or AFP 1000-10,000 ng/ml S3:LDH > 10XN or hCG > 50,000 mIu/ml or AFP > 10,000 ng/ml | Serum Tumor Markers (S) SX Marker studies not available or not performed S0 Marker study levels within normal limits* S1 LDH < 1.5 X N AND hCG (mIU/ml) < 5000 AND AFP (ng/ml) < 1000 S2 LDH 1.5-10 X N OR hCG (mIu/ml) 5000-50,000 OR AFP (ng/ml) 1000-10,000 S3 LDH > 10 X N OR hCG (mIu/ml) > 50,000 OR AFP (ng/ml) > 10,000 N indicates the upper limit of normal for the LDH assay. * Check with your laboratory for normal limits values. | |
137 | date of 1st positive biopsy | 2.2;1 | DATE-TIME | Record the date of the first positive incisional or excisional biopsy. The biopsy may be taken from the primary or a secondary site. This data item refers to a tissue biopsy/positive histology only. The first positive biopsy may be at any time during the disease course. It may be non cancer-directed or cancer-directed surgery. | ||
138 | scope of ln surgery (r) | 3;40 | NUMERIC | Record the scope of regional lymph node surgery. For further information see ROADS page 192. | ||
138.1 | scope of ln surgery @fac (r) | 3.1;9 | FREE TEXT | Record the scope of regional lymph node surgery done AT THIS FACILITY. For further information see ROADS page 190. | ||
138.2 | scope of ln surgery date | 3.1;22 | DATE-TIME | Record the date that SCOPE OF LN SURGERY was performed. | ||
138.3 | scope of ln surgery @fac date | 3.1;23 | DATE-TIME | Record the date that SCOPE OF LN SURGERY @FAC was performed. | ||
138.4 | scope of ln surgery (f) | 3.1;31 | SET OF CODES | 0:None 1:Bx/aspiration, NOS 2:Sentinel Bx 3:Nodes removed, num unk 4:1-3 nodes removed 5:4 or more nodes removed 6:Sentinel + 3, 4 or 5, timing not stated 7:Sentinel + 3, 4, or 5, diff times 9:Unknown/NA | Identifies the removal, biopsy, or aspiration of regional lymph node(s) at the time of surgery of the primary site or during a separate surgical event. For further information see FORDS pages 138-139. | |
138.5 | scope of ln surgery @fac (f) | 3.1;32 | SET OF CODES | 0:None 1:Bx/aspiration, NOS 2:Sentinel Bx 3:Nodes removed, num unk 4:1-3 nodes removed 5:4 or more nodes removed 6:Sentinel + 3, 4 or 5, timing not stated 7:Sentinel + 3, 4, or 5, diff times 9:Unknown/NA | Identifies the removal, biopsy, or aspiration of regional lymph node(s) at the time of surgery of the primary site or during a separate surgical event at this facility. For further information see FORDS pages 140-141. | |
139 | surg proc/other site (r) | 3;41 | NUMERIC | Enter the code for surgery of other regional site(s), distant site(s) or distant lymph node(s). For further information see ROADS page 194. | ||
139.1 | surg proc/other site @fac (r) | 3.1;10 | FREE TEXT | Enter the code for surgery of other regional site(s), distant site(s) or distant lymph node(s) performed AT THIS FACILITY. For further information see ROADS page 190. | ||
139.2 | surg proc/other site date | 3.1;24 | DATE-TIME | Records the date of surgical removal of distant lymph nodes or other tissue(s)/organ(s) beyond the primary site. | ||
139.3 | surg proc/other site @fac date | 3.1;25 | DATE-TIME | Record the date that SURG PROC/OTHER SITE @FAC was performed. | ||
139.4 | surg proc/other site (f) | 3.1;33 | SET OF CODES | 0:None 1:Nonprimary surg proc performed 2:Nonprimary surg proc/other regional sites 3:Nonprimary surg proc/distant lymph node(s) 4:Nonprimary surg proc/distant site 5:Combination of codes 9:Unknown | Records the surgical removal of distant lymph nodes or other issue(s)/organ(s) beyond the primary site. For further information see FORDS page 142. | |
139.5 | surg proc/other site @fac (f) | 3.1;34 | SET OF CODES | 0:None 1:Nonprimary surg proc performed 2:Nonprimary surg proc/other regional sites 3:Nonprimary surg proc/distant lymph node(s) 4:Nonprimary surg proc/distant site 5:Combination of codes 9:Unknown | Records the surgical removal of distant lymph nodes or other tissue(s)/organ(s) beyond the primary site at this facility. For further information see FORDS page 143. | |
139.6 | mets site resected | 3.1;41 | SET OF CODES | 1:Peritoneum 2:Lung 3:Pleura 4:Liver 5:Bone 6:Brain 7:Skin 8:Distant LNS 9:Other | This is the Metastatic Site Resected for the First Course of Treatment. | |
139.7 | mets site resected date | 3.2;1 | DATE-TIME | This is the date the Metastatic Site was resected. The date must be after or equal to the DATE DX (#3) field. | ||
140 | number of ln removed (r) | 3;42 | NUMERIC | Record the number of regional lymph nodes that were microscopically examined and identified in the pathology report FOR THIS SURGICAL PROCEDURE ONLY. DO NOT add numbers of nodes removed during different surgical events. 00 for No nodes removed 01 for 1 node removed 02 for 2 nodes removed ... 90 for 90 or more nodes removed 95 for No nodes removed, aspiration performed 96 for Node removal as a sampling, number unknown 97 for Node removal as dissection, number unknown 98 for Nodes surgically removed, number unknown 99 for Unknown, not stated, death cert ONLY For further information see ROADS page 193. | ||
140.1 | number of ln removed @fac (r) | 3.1;11 | FREE TEXT | Record the number of regional lymph nodes that were microscopically examined and identified at this facility in the pathology report FOR THIS SURGICAL PROCEDURE ONLY. DO NOT add numbers of nodes removed during different surgical events. 00 for No nodes removed 01 for 1 node removed 02 for 2 nodes removed ... 90 for 90 or more nodes removed 95 for No nodes removed, aspiration performed 96 for Node removal as a sampling, number unknown 97 for Node removal as dissection, number unknown 98 for Nodes surgically removed, number unknown 99 for Unknown, not stated, death cert ONLY For further information see ROADS page 190. | ||
141 | biopsy procedure | 2.1;14 | NUMERIC | Records the biopsy procedure if the primary site is breast or prostate. | ||
142 | guidance | 2.1;15 | NUMERIC | Records the guidance if the primary site is breast or prostate. | ||
143 | palpability of primary | 2.1;16 | SET OF CODES | 0:Not palpable 1:Palpable 9:Not stated/death cert only | Records the palpability of primary if the primary site is breast. | |
144 | first detected by | 2.1;17 | SET OF CODES | 0:Not a breast primary 1:Patient felt lump/nipple discharge 2:Physician felt lump 3:Mammography - routine 4:Occult, incidental finding 9:Unknown | Records how it was first detected if the primary site is breast. | |
145 | approach for biopsy of primary | 2.1;18 | SET OF CODES | 0:No biopsy 1:Transrectal 2:Transperineal 3:Transurethral 4:Laparoscopic 5:Open (laparotomy) 9:Unknown/death cert only | Records the approach for biopsy of primary if the primary site is prostate. | |
146 | biopsy of other than primary | 2.1;19 | SET OF CODES | 0:None 1:Seminal vesicle(s), NOS 2:Unilateral 3:Bilateral 4:Other than seminal vesicle 5:4 + 1 6:4 + 2 7:4 + 3 9:Unknown/death cert only | Records the biopsy of other than primary site if the primary site is prostate. | |
147 | census tract | 0;29 | FREE TEXT | CENSUS TRACT identifies the patient's usual residence at the time the tumor was diagnosed. A CENSUS TRACT is a small statistical subdivision of a county. To code CENSUS TRACT, assume the decimal point is between the fourth and fifth positions of the field. Add zeros to fill all six positions. Example: CENSUS TRACT 409.6 would be coded 040960, and CENSUS TRACT 516.21 would be coded 051621. 000000 Area is not census tracted 999999 Area is census tracted, but census tract is not available | ||
148 | other cancer | 0;30 | SET OF CODES | 0:No 1:Yes 9:Unknown | Records if the patient has other reportable malignancies. | |
148.1 | cancer #1 | 0;31 | POINTER | 164.2 | Records the 1st OTHER CANCER associated with this patient. If not applicable for this patient, choose NOT APPLICABLE. | |
148.2 | cancer #2 | 0;32 | POINTER | 164.2 | Records the 2nd OTHER CANCER associated with this patient. If not applicable for this patient, choose NOT APPLICABLE. | |
148.3 | cancer #3 | 0;33 | POINTER | 164.2 | Records the 3rd OTHER CANCER associated with this patient. If not applicable for this patient, choose NOT APPLICABLE. | |
148.4 | cancer #4 | 0;34 | POINTER | 164.2 | Records the 4th OTHER CANCER associated with this patient. If not applicable for this patient, choose NOT APPLICABLE. | |
149 | lymph-vascular invasion (l) | 2;19 | SET OF CODES | 0:No lymphatic vessel invasion 1:Lymphatic vessel invasion 8:Not applicable 9:Unknown if lymph-vascular invasion present | LYMPH-VASCULAR INVASION records whether lymph-vascular invasion was involved. | |
150 | follow-up history | COMPUTED | RECORDS ALL FOLLOW SUCCESSFULLY COMPLETED. | |||
151 | venous invasion (v) | 2;29 | SET OF CODES | X:Venous invasion cannot be assessed 0:No venous invasion 1:Microscopic venous invasion 2:Macroscopic venous invasion | VENOUS INVASION records whether venous invasion was involved. | |
152 | date systemic therapy started | COMPUTED | Records the date of initiation for systemic therapy that is part of the first course of treatment. Systemic therapy includes the administration of chemotherapy agents, hormonal agents, biological response modifiers, bone marrow transplants, stem cell harvests, and surgical and/or radiation endocrine therapy. For further information see FORDS pages 169-170. | |||
153 | hema trans/endocrine proc | 3.1;36 | POINTER | 167 | Identifies systemic therapeutic procedures administered as part of the first course of treatment at this and all other facilities. If none of these procedures were administered, then this item records the reason they were not performed. These include bone marrow transplants, stem cell harvests, surgical and/or radiation endocrine therapy. For further information see FORDS pages 182-183. | |
153.1 | hema trans/endocrine proc date | 3.1;35 | DATE-TIME | Records the date on which hematologic transplant and endocrine procedures were performed. | ||
154 | pain assessment | 3.1;37 | SET OF CODES | 0:No pain assessment 1:No need for palliative care 2:Need for palliative care, no referral 3:Need for palliative care, referral 9:Unknown | Records whether or not a pain assessment was performed to determine the need for palliative care. For further information see FORDS page 188. | |
155 | date of first contact | 0;35 | DATE-TIME | AFC | Date of first contact with the reporting facility for diagnosis and/or treatment of this cancer. If this is an autopsy-only or death certificate-only case, then use the date of death. When it is unknown when the first patient contact occurred use 99/99/9999 or 99999999. 00/00/0000 is not allowed. For further information see FORDS page 87. | |
156 | dre date | 24;11 | FREE TEXT | Records the date on which the DRE (Digital Rectal Examination) was performed. | ||
157 | elapsed days to completion | COMPUTED | Computes the time interval in days between DATE OF FIRST CONTACT (165.5,155) and DATE CASE COMPLETED (165.5,90). | |||
157.1 | elapsed months to completion | COMPUTED | Computes the time interval in months between DATE OF FIRST CONTACT (165.5,155) and DATE CASE COMPLETED (165.5,90). | |||
159 | ambiguous terminology dx | 24;12 | SET OF CODES | 0:Conclusive term 1:Ambiguous term only 2:Ambiguous term followed by conclusive term 9:Unknown term | Identifies cases for which an ambiguous term is the most definitive word or phrase used to establish a cancer diagnosis (i.e., to determine whether or not the case is reportable). Do not include cases where a definite statement of malignancy is made within two months following the original/initial diagnosis. (This does not include the use of ambiguous terminology from cancer screening followed by a positive cancer confirmation that is follow-up to the screening.) | |
160 | derived ajcc-6 t | CS1;1 | FREE TEXT | This is the AJCC 6th edition "T" component that is derived from CS coded fields, using the CS algorithm, effective with 2004 diagnosis. | ||
160.7 | derived ajcc-7 t | CS1;13 | FREE TEXT | This is the AJCC 7th edition "T" component that is derived from CS coded fields, using the CS algorithm, effective with 2010 diagnosis. | ||
161 | derived ajcc-6 t descriptor | CS1;2 | SET OF CODES | c:clinical p:pathological a:autopsy only y:y prefix N:Not applicable 0:Not derived | This is the AJCC 6th edition "T Descriptor" component that is derived from CS coded fields, using the CS algorithm, effective with 2004 diagnosis. | |
161.7 | derived ajcc-7 t descriptor | CS1;14 | SET OF CODES | c:clinical p:pathological a:autopsy only y:yp prefix N:Not applicable 0:Not derived | This is the AJCC 7th edition "T Descriptor" component that is derived from CS coded fields, using the CS algorithm, effective with 2010 diagnosis. | |
162 | derived ajcc-6 n | CS1;3 | FREE TEXT | This is the AJCC 6th edition "N" component that is derived from CS coded fields, using the CS algorithm, effective with 2004 diagnosis. | ||
162.7 | derived ajcc-7 n | CS1;15 | FREE TEXT | This is the AJCC 7th edition "N" component that is derived from CS coded fields, using the CS algoritm, effective with 2010 diagnosis. | ||
163 | derived ajcc-6 n descriptor | CS1;4 | SET OF CODES | c:clinical p:pathological a:autopsy only y:y prefix N:Not applicable 0:Not derived | This is the AJCC 6th edition "N Descriptor" component that is derived from CS coded fields, using the CS algorithm, effective with 2004 diagnosis. | |
163.7 | derived ajcc-7 n descriptor | CS1;16 | SET OF CODES | c:clinical p:pathological a:autopsy only y:yp prefix N:Not applicable 0:Not derived | This is the AJCC 7th edition "N Descriptor" component that is derived from CS coded fields, using the CS algorithm, effective with 2010 diagnosis. | |
164 | derived ajcc-6 m | CS1;5 | FREE TEXT | This is the AJCC 6th edition "N" component that is derived from CS coded fields, using the CS algorithm, effective with 2004 diagnosis. | ||
164.7 | derived ajcc-7 m | CS1;17 | FREE TEXT | This is the AJCC 7th edition "N" component that is derived from CS coded fields, using the CS algorithm, effective with 2010 diagnosis. | ||
165 | derived ajcc-6 m descriptor | CS1;6 | SET OF CODES | c:clinical p:pathological a:autopsy only y:y prefix N:Not applicable 0:Not derived | This is the AJCC 6th edition "M Descriptor" component that is derived from CS coded fields, using the CS algorithm, effective with 2004 diagnosis. | |
165.7 | derived ajcc-7 m descriptor | CS1;18 | SET OF CODES | c:clinical p:pathological a:autopsy only y:yp prefix N:Not applicable 0:Not derived | This is the AJCC 7th edition "M Descriptor" component that is derived from CS coded fields, using the CS algorithm, effective with 2010 diagnosis. | |
166 | derived ajcc-6 stage group | CS1;7 | FREE TEXT | This is the AJCC 6th edition "Stage Group" component that is derived from the CS detailed site-specific codes, using the CS from the CS algorithm effective with 2004 diagnosis. | ||
166.7 | derived ajcc-7 stage group | CS1;19 | FREE TEXT | This is the AJCC 7th edition "Stage Group" component that is derived from the CS detailed site-specific codes, using the CS from the CS algorithm effective with 2010 diagnosis. | ||
167 | derived ss1977 | CS1;8 | SET OF CODES | 0:In situ 1:Localized 2:Regional, direct extension 3:Regional, lymph nodes only 4:Regional, extension and nodes 5:Regional, NOS 7:Distant 8:NA 9:Unknown/Unstaged | This is the derived "SEER Summary Stage 1977" from the CS algorithm (or EOD codes) effective with 2004 diagnosis. | |
168 | derived ss2000 | CS1;9 | SET OF CODES | 0:In situ 1:Localized 2:Regional, direct extension 3:Regional, lymph nodes only 4:Regional, extension and nodes 5:Regional, NOS 7:Distant 8:NA 9:Unknown/Unstaged | This is the derived "SEER Summary Stage 2000" from the CS algorithm (or EOD codes) effective with 2004 diagnosis. | |
169 | cs version derived | CS1;11 | FREE TEXT | This item indicates the Collaborative Staging (CS) version used most recently to derive the CS output fields. | ||
169.1 | cs version input original | CS1;12 | FREE TEXT | This item indicates the number of the version initially used to code Collaborative Staging (CS) fields. | ||
170 | date first surgical procedure | 3.1;38 | DATE-TIME | Records the earliest date on which any first course surgical procedure was performed. For further information see FORDS pages 131-132. | ||
171 | date of first symptoms | 2.2;4 | FREE TEXT | Records the date on which the patient was first seen with symptoms or had abnormal test results which began the workup which led to the diagnosis of cancer. This date would be before or equal to the DATE DX. | ||
172 | date start of workup ordered | 2.2;5 | FREE TEXT | Records the date the physician placed consult to specialty clinic OR ordered diagnostic procedures or tests. | ||
173 | date workup started | 2.2;6 | FREE TEXT | Records the date when the patient was seen in the specialty clinic OR had diagnostic procedures or tests performed. | ||
174 | blood in sputum per pt | 2.2;7 | SET OF CODES | 0:No 1:Yes 9:Unknown/Not documented | Record the presence of blood in the patient's sputum as reported by the patient. | |
174.1 | date of blood in sputum per pt | 2.2;18 | FREE TEXT | Records the date of the presence of blood in the patient's sputum (as reported by the patient). | ||
175 | chest x-ray | 2.2;8 | SET OF CODES | 0:Not done 1:Abnormal 2:Within normal limits 9:Unknown/not documented | Record the results of the diagnostic test CHEST X-RAY. If this test was not done, record a '0'. | |
175.1 | date of chest x-ray | 2.2;19 | FREE TEXT | Records the date of the diagnostic test CHEST X-RAY. | ||
176 | ct scan | 2.2;9 | SET OF CODES | 0:Not done 1:Abnormal 2:Within normal limits 9:Unknown/not documented | Record the results of the diagnostic test CT SCAN. If this test was not done, record a '0'. | |
176.1 | date of ct scan | 2.2;20 | FREE TEXT | Records the date of the diagnostic test CT SCAN. | ||
177 | bronchoscopy | 2.2;10 | SET OF CODES | 0:Not done 1:Abnormal 2:Within normal limits 9:Unknown/not documented | Record the results of the diagnostic test BRONCHOSCOPY. If this test was not done, record a '0'. | |
177.1 | date of bronchoscopy | 2.2;21 | FREE TEXT | Records the date of the diagnostic test BRONCHOSCOPY. | ||
178 | mediastinoscopy | 2.2;11 | SET OF CODES | 0:Not done 1:Abnormal 2:Within normal limits 9:Unknown/not documented | Record the results of the diagnostic test MEDIASTINOSCOPY. If this test was not done, record a '0'. | |
178.1 | date of mediastinoscopy | 2.2;22 | FREE TEXT | Records the date of the diagnostic test MEDIASTINOSCOPY. | ||
179 | pet scan | 2.2;12 | SET OF CODES | 0:Not done 1:Abnormal 2:Within normal limits 9:Unknown/not documented | Record the results of the diagnostic test PET SCAN. If this test was not done, record a '0'. | |
179.1 | date of pet scan | 2.2;23 | FREE TEXT | Records the date of the diagnostic test PET SCAN. | ||
180 | change in bowel habits per pt | 2.2;13 | SET OF CODES | 0:No 1:Yes 9:Unknown/not documented | Record all changes in bowel habits as reported by the patient. | |
180.1 | date of change in bowel habits | 2.2;24 | FREE TEXT | Records the date of a change in bowel habits (as reported by the patient). | ||
181 | fecal occult blood test (fobt) | 2.2;14 | SET OF CODES | 0:Not done 1:Positive (3-card sample) 2:Negative (3-card sample) 3:Positive (6-card sample) 4:Negative (6-card sample) 5:FIT Test 9:Unknown/not documented | Record the results of the diagnostic test FECAL OCCULT BLOOD TEST (FOBT). If this test was not done, record a '0'. | |
181.1 | date of fobt | 2.2;25 | FREE TEXT | Records the date of the diagnostic test FECAL OCCULT BLOOD TEST (FOBT). | ||
182 | barium enema | 2.2;15 | SET OF CODES | 0:Not done 1:Abnormal 2:Within normal limits 9:Unknown/not documented | Record the results of the diagnostic test BARIUM ENEMA. If this test was not done, record a '0'. | |
182.1 | date of barium enema | 2.2;27 | FREE TEXT | Records the results of the diagnostic test BARIUM ENEMA. | ||
183 | sigmoidoscopy | 2.2;16 | SET OF CODES | 0:Not done 1:Abnormal 2:Within normal limits 9:Unknown/not documented | Record the results of the diagnostic test SIGMOIDOSCOPY. If this test was not done, record a '0'. | |
183.1 | date of sigmoidoscopy | 2.2;28 | FREE TEXT | Records the date of the diagnostic test SIGMOIDOSCOPY. | ||
184 | ct of abdomen/pelvis | 2.2;17 | SET OF CODES | 0:Not done 1:Abnormal 2:Within normal limits 9:Unknown/not documented | Record the results of the diagnostic test CT OF ABDOMEN/PELVIS. If this test was not done, record a '0'. | |
184.1 | date of ct of abdomen/pelvis | 2.2;31 | FREE TEXT | Records the date of the diagnostic test CT OF ABDOMEN/PELVIS. | ||
185 | colonoscopy | 2.2;29 | SET OF CODES | 0:Not done 1:Abnormal 2:Within normal limits 9:Unknown/not documented | Record the results of the diagnostic test COLONOSCOPY. If this test was not done, record a '0'. | |
185.1 | date of colonoscopy | 2.2;30 | FREE TEXT | Records the date of the diagnostic test COLONOSCOPY. If this test was not done, record a '0'. | ||
186 | dyspnea | 2.2;32 | SET OF CODES | 0:No 1:Yes 9:Unknown/not documented | Record whether the patient experienced dyspnea. | |
186.1 | date of dyspnea | 2.2;33 | FREE TEXT | Records the date on which the patient was affected by dyspnea. | ||
187 | increased cough | 2.2;34 | SET OF CODES | 0:No 1:Yes 9:Unknown/not documented | Record whether the patient experienced increased coughing. | |
187.1 | date of increased cough | 2.2;35 | FREE TEXT | Records the date on which the patient experienced increased coughing. | ||
188 | fever | 2.2;36 | SET OF CODES | 0:No 1:Yes 9:Unknown/not documented | Record whether the patient experienced a fever. | |
188.1 | date of fever | 2.2;37 | FREE TEXT | Records the date on which the patient experienced a fever. | ||
189 | night sweats | 2.2;38 | SET OF CODES | 0:No 1:Yes 9:Unknown/not documented | Record whether the patient experienced night sweats. | |
189.1 | date of night sweats | 2.2;39 | FREE TEXT | Records the date on which the patient experienced night sweats. | ||
190 | weight loss per pt | 2.2;40 | SET OF CODES | 0:No 1:Yes 9:Unknown/not documented | Record weight loss as reported by the patient. | |
191 | ulcerative colitis (uc) | 2.2;41 | SET OF CODES | 0:No 1:Yes 9:Unknown/not documented | Record whether the patient was affected by ulcerative colitis (UC). | |
192 | sporadic polyps | 2.2;42 | SET OF CODES | 0:No 1:Yes 9:Unknown/not documented | Sporadic polyps can also develop in people with no family history of colon cancer. They are called "sporadic" to distinguish them from the familial kind. Certain types of sporadic polyps do increase the risk of colon cancer. These polyps, known as adenomas, often can be removed during a colonoscopic examination. Record the existence of sporadic polyps. | |
193 | date of conclusive dx | 24;13 | FREE TEXT | Documents the date when a conclusive cancer diagnosis (definite statement of malignancy) is made following an initial diagnosis that was based only on ambiguous terminology. The date of the conclusive diagnosis must be greater than two months following the initial (ambiguous terminology only) diagnosis. | ||
194 | mult tum rpt as one prim | 24;14 | POINTER | 169 | This data item is used to identify cases with multiple tumors that are abstracted ans reported as a single primary. Codes Description ----- ----------- 00 Single tumor 10 At least two benign tumors in same organ/primary site (Intracranial and CNS sites only) 11 At least two borderline tumors in the same organ/primary site (Intracranial and CNS sites only) 12 Benign and borderline tumors in the same organ/primary site (Intracranial and CNS sites only) 20 At least two in situ tumors in the same organ/primary site 30 One or more in situ and one or more invasive tumors in the same organ/primary site 31 One or more in situ/invasive adenocarcinoma in a polyp and one or more frank adenocarcinoma in one segment of colon 32 Familial polyposis with one or more in situ/invasive carcinoma 40 At least two invasive tumors in the same organ (Includes one or more invasive tumor with histology "NOS" and one or more separate invasive tumor with a more specific histology) 80 Multiple tumors present in the same organ/primary site, unknown if in situ or invasive 88 Information on multiple tumors not collected/not applicable for this site 99 Unknown | |
195 | date of multiple tumors | 24;15 | FREE TEXT | This data item is used to identify the month, day and year the patient is diagnosed with multiple tumors reported as a single primary. Use the multiple primary rules for that specific site to determine whether the tumors are a single primary or multiple primaries. | ||
196 | multiplicity counter | 24;16 | FREE TEXT | Records the number of tumors (multiplicity) reported as a single primary. Codes 00 No primary tumor identified 01 One tumor only 02 Two tumors present; bilateral ovaries involved with cystic carcinoma 03 Three tumors present .. .. 88 Information on multiple tumors not collected/not applicable for this site 89 Multicentric, multifocal, number unknown 99 Unknown if multiple tumors; not documented | ||
197 | edits checksum | EDITS;1 | FREE TEXT | Provides a checksum value for the NAACCR record associated with this abstract. This checksum will be used to detect changes to the NAACCR record once the ABSTRACT STATUS (165.5,91) has been set to 3 (Complete). | ||
197.1 | checksum version | EDITS;2 | FREE TEXT | Identifies the NAACCR version that was used to calculate EDITS CHECKSUM (165.5,197). | ||
198 | date case last changed | 7;21 | DATE-TIME | AAE | Date the case was last changed or updated. | |
199 | case last changed by | 7;22 | POINTER | 200 | Records the name of the individual who last changed the case. | |
200 | date last contact | COMPUTED | Date last contact with the patient - computed from file #160. | |||
201 | survival days | COMPUTED | COMPUTED SURVIVAL DATA IN DAYS. | |||
202 | survival months | COMPUTED | COMPUTED SURVIVAL DATA IN MONTHS. | |||
203 | survival (years) | COMPUTED | COMPUTED SURVIVAL DATA IN YEARS. | |||
204 | weeks of follow-up | COMPUTED | FOLLOW UP IN WEEKS. | |||
205 | over-ride age/site/morph | OVRD;1 | SET OF CODES | 1:Reviewed 2:Reviewed, Dx in utero 3:Reviewed, Codes 1 and 2 both apply | Used with CoC Metafile and the EDITS software to override the edit Age, Primary Site, Morphology (Coc) and/or the edit Age, Primary Site, Morphology ICD-O-3 (CoC). For further information see FORDS page 215. | |
206 | over-ride seqno/dxconf | OVRD;2 | SET OF CODES | 1:Reviewed | This is one of the thirteen flags used to override certain interfield and interrecord edits defined by SEER. | |
207 | over-ride site/lat/seqno | OVRD;3 | SET OF CODES | 1:Reviewed | This is one of the thirteen flags used to override certain interfield and interrecord edits defined by SEER. | |
208 | over-ride surg/dxconf | OVRD;4 | SET OF CODES | 1:Reviewed | This is one of the thirteen flags used to override certain interfield and interrecord edits defined by SEER. | |
209 | over-ride site/type | OVRD;5 | SET OF CODES | 1:Reviewed | This is one of the thirteen flags used to override certain interfield and interrecord edits defined by SEER. | |
210 | over-ride histology | OVRD;6 | SET OF CODES | 1:Reviewed - allow flags Morphology-Type & Behavior 2:Reviewed - allow flags Dx Conf, Behavior Code 3:Reviewed - conditions 1 & 2 both apply | This is one of the thirteen flags used to override certain interfield and interrecord edits defined by SEER. | |
211 | over-ride report source | OVRD;7 | SET OF CODES | 1:Reviewed | This is one of the thirteen flags used to override certain interfield and interrecord edits defined by SEER. | |
212 | over-ride ill-define site | OVRD;8 | SET OF CODES | 1:Reviewed | This is one of the thirteen flags used to override certain interfield and interrecord edits defined by SEER. | |
213 | over-ride leuk,lymphoma | OVRD;9 | SET OF CODES | 1:Reviewed | This is one of the thirteen flags used to override certain interfield and interrecord edits defined by SEER. | |
214 | over-ride site/behavior | OVRD;10 | SET OF CODES | 1:Reviewed | This is one of the thirteen flags used to override certain interfield and interrecord edits defined by SEER. | |
215 | over-ride site/eod/dx dt | OVRD;11 | SET OF CODES | 1:Reviewed | This is one of the thirteen flags used to override certain interfield and interrecord edits defined by SEER. | |
216 | over-ride site/lat/eod | OVRD;12 | SET OF CODES | 1:Reviewed | This is one of the thirteen flags used to override certain interfield and interrecord edits defined by SEER. | |
217 | over-ride site/lat/morph | OVRD;13 | SET OF CODES | 1:Reviewed | This is one of the thirteen flags used to override certain interfield and interrecord edits defined by SEER. | |
218 | over-ride ss/nodespos | OVRD;14 | SET OF CODES | 1:Reviewed | This is one of the flags used to override certain interfield and interrecord edits defined by NAACCR. | |
219 | over-ride ss/tnm-n | OVRD;15 | SET OF CODES | 1:Reviewed | This is one of the flags used to override certain interfield and interrecord edits defined by NAACCR. | |
220 | over-ride ss/tnm-m | OVRD;16 | SET OF CODES | 1:Reviewed | This is one of the flags used to override certain interfield and interrecord edits defined by NAACCR. | |
221 | over-ride ss/dismet1 | OVRD;17 | SET OF CODES | 1:Reviewed | This is one of the flags used to override certain interfield and interrecord edits defined by NAACCR. | |
222 | over-ride acsn/class/seq | OVRD;18 | SET OF CODES | 1:Reviewed | This is one of the flags used to override certain interfield and interrecord edits defined by NAACCR. | |
223 | over-ride hospseq/dxconf | OVRD;19 | SET OF CODES | 1:Reviewed | This is one of the flags used to override certain interfield and interrecord edits defined by NAACCR. | |
224 | over-ride coc-site/type | OVRD;20 | SET OF CODES | 1:Reviewed | This is one of the flags used to override certain interfield and interrecord edits defined by NAACCR. | |
225 | over-ride hospseq/site | OVRD;21 | SET OF CODES | 1:Reviewed | This is one of the flags used to override certain interfield and interrecord edits defined by NAACCR. | |
226 | over-ride site/tnm-stggrp | OVRD;22 | SET OF CODES | 1:Reviewed | This is one of the flags used to override certain interfield and interrecord edits defined by NAACCR. | |
227 | performance status at dx | 1;7 | SET OF CODES | 0:Score 0 1:Score 1 2:Score 2 3:Score 3 4:Score 4 5:Score 5 9:Unknown/not documented | Records an attempt to quantify the patient's general well-being. 0 - Asymptomatic (Fully active, able to carry on all predisease activities without restriction) 1 - Symptomatic but completely ambulatory (Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature. For example, light housework, office work) 2 - Symptomatic, <50% in bed during the day (Ambulatory and capable of all self care but unable to carry out any work activities. Up and about more than 50% of waking hours) 3 - Symptomatic, >50% in bed, but not bedbound (Capable of only limited self-care, confined to bed or chair 50% or more of waking hours) 4 - Bedbound (Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair) 5 - Death 9 - Unknown/not documented | |
228 | treatment guideline #1 | 24;17 | SET OF CODES | 0:None 1:NCCN 2:ASCO 3:ASH 4:AUA 5:PDQ 6:SSO 7:Other 8:NA 99:Unknown | Identifies the first guideline used to determine the first course of treatment. NCCN (National Comprehensive Cancer Network) ASCO (American Society of Clinical Oncology) ASH (American Society of Hematology) AUA (American Urologic Association) PDQ (Physician Data Query) SSO (The Society of Surgical Oncology) | |
229 | treatment guideline #2 | 24;18 | SET OF CODES | 0:None 1:NCCN 2:ASCO 3:ASH 4:AUA 5:PDQ 6:SSO 7:Other 8:NA 99:Unknown | Identifies the second guideline used to determine the first course of treatment. NCCN (National Comprehensive Cancer Network) ASCO (American Society of Clinical Oncology) ASH (American Society of Hematology) AUA (American Urologic Association) PDQ (Physician Data Query) SSO (The Society of Surgical Oncology) | |
230 | treatment guideline #3 | 24;19 | SET OF CODES | 0:None 1:NCCN 2:ASCO 3:ASH 4:AUA 5:PDQ 6:SSO 7:Other 8:NA 99:Unknown | Identifies the third guideline used to determine the first course of treatment. NCCN (National Comprehensive Cancer Network) ASCO (American Society of Clinical Oncology) ASH (American Society of Hematology) AUA (American Urologic Association) PDQ (Physician Data Query) SSO (The Society of Surgical Oncology) | |
231 | treatment guideline location | 24;20 | FREE TEXT | Identifies where the treatment guidelines used in treatment planning are documented in the medical record. | ||
232 | treatment guideline doc date | 24;21 | DATE-TIME | Records the date when treatment guidelines were documented in the medical record. | ||
233 | inpatient status | 2.3;3 | SET OF CODES | 0:Patient was never an inpatient 1:Patient was inpatient 9:Unknown if patient was an inpatient | This data item records whether there was an inpatient admission for the most definitive therapy, or in the absence of therapy, for diagnostic evaluation. | |
234 | approach | 2.3;4 | SET OF CODES | 0:No surgery/Dx at autopsy 1:Robotic assisted 2:Robotic converted to open 3:Endoscopic/Laparoscopic 4:Endoscopic/Laparoscopic converted to open 5:Open/Approach, NOS 9:Not stated/Death cert only | This item is used to describe the surgical method used to approach the primary site for patients undergoing surgery of the primary site at this facility. If the patient has multiple surgeries to the primary site, this item describes the approach used for the most invasive, definitive surgery. | |
235 | treatment status | 2.3;5 | SET OF CODES | 0:No treatment given 1:Treatment given 2:Active surveillance (watchful waiting) 9:Unknown if treatment was given | This data item summarizes whether the patient received any treatment or the tumor was under active surveillance. | |
236 | date case initiated | 2.3;6 | DATE-TIME | Date the electronic abstract is initiated in the reporting facility's cancer registry database. | ||
237 | fee basis | 2.3;7 | SET OF CODES | 0:No 1:Yes 9:Unknown | Indicates if the patient was referred to another facility for treatment or to a facility closer to the patient's residence either on a "Fee Basis" or via a CONTRACT with the reporting facility. | |
237.1 | fee basis location | 2.3;11 | FREE TEXT | In many cases the FACILITY REFERRED TO may not be the same place that the FEE BASIS treatment was performed. Therefore, this field enables facilities to track where the patient was referred to. This field is available to be displayed on ad hoc reports. Enter the name of the FEE BASIS LOCATION in free text. | ||
238 | outside slides reviewed | 2.3;8 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | Identifies if tissue slides diagnosed at another facility were reviewed at this facility. 0 (No) Outside tissue diagnosis done, slides not reviewed at this facility. 1 (Yes) Outside tissue diagnosis done, slides requested and reviewed at this facility. 8 (NA) Not applicable. No outside tissue diagnosis done. 9 (Unknown) Unknown if outside tissue diagnosis done. | |
239 | mitotic rate | 2.3;9 | SET OF CODES | L:Low <5/50 HPF H:High >5/50 HPF U:Unknown | Identifies the rate or speed of cell division. | |
240 | cs schema discriminator | CS3;1 | FREE TEXT | This case requires a CS SCHEMA DISCRIMINATOR to determine the correct tables for CSv2 (Collaborative Staging v2) calculations. For example, Melanomas of CILIARY BODY AND IRIS (C69.4) require a CS SCHEMA DISCRIMINATOR to discriminate between tumors arising in either ciliary body or iris, both coded C69.4 but requiring different CS schemas. For melanomas of the ciliary body CS SCHEMA DISCRIMINATOR should be coded 010. For melanomas of the Iris CS SCHEMA DISCRIMINATOR should be coded 020. CS SCHEMA DISCRIMINATOR values will be stuffed into SSF25 for use in CS calculations. | ||
241 | tnm clin descriptor | 24;22 | SET OF CODES | 1:E (Extranodal) 2:S (Spleen) 5:E & S (Extranodal and spleen) | Identifies the AJCC clinical stage (suffix) descriptor as recorded by the physician. AJCC stage descriptors identify special cases that need separate data analysis. The descriptors are adjuncts to and do not change the stage group. | |
242 | tnm path descriptor | 24;23 | SET OF CODES | 1:E (Extranodal) 2:S (Spleen) 5:E & S (Extranodal and spleen) | Identifies the AJCC clinical stage (suffix) descriptor as recorded by the physician. AJCC stage descriptors identify special cases that need separate data analysis. The descriptors are adjuncts to and do not change the stage group. | |
244 | initiated by | 2.3;10 | POINTER | 200 | The name of the person initiating the abstract in the reporting facility's cancer registry database. This field is stuffed with the user's DUZ when a new entry is added to this file. No user interaction is required and it may not be changed. | |
245 | neoadjuvant therapy | 3.1;40 | SET OF CODES | 0:Not recommended/NA 1:Radiation 2:Chemotherapy 3:Hormone therapy 4:Immunotherapy 5:Combination of neoadjuvant tx 7:Refusal 8:Recommended but not done 9:Unknown if recommended or done | Neoadjuvant therapy is the administration of therapeutic agents before the main treatment. This field documents if neoadjuvant therapy was performed for this patient and, if so, the type of neoadjuvant therapy performed. | |
247 | cs review required | CS3;2 | SET OF CODES | 0:Reviewed 1:Needs review | When a new version of Collaborative Staging (CS) is implemented some cases require manual review/conversion by the registrar. This field identifies cases for which Collaborative Staging review is either required or recommended in accordance with the Collaborative Staging Conversion Specifications. When the patch implementing the new CS version is installed the post-install program will flag any cases needing manual review by setting CS REVIEW REQUIRED to 1 (Needs review). Once a case has been reviewed by the registrar, the review flag can be cleared by setting CS REVIEW REQUIRED to 0 (Reviewed). | |
248 | note title | 25;1 | FREE TEXT | Records the name of the note which documents cancer staging in the medical record. | ||
249 | note date | 25;2 | DATE-TIME | Records the date of the note which documents cancer staging in the medical record. | ||
250 | gleason score (pathologic) | 25;3 | FREE TEXT | Record the pathologic Gleason Score. Gleason Score (pathologic) is obtained from a curative prostatectomy specimen. For cases where Gleason Score is unknown, not reported or not applicable, code 99. | ||
251 | nslc stage 1-3 path ln staging | PM;1 | SET OF CODES | 0:No 1:Yes 8:NA (Stage 0 and 4) 9:Unknown | Documents if mediastinal lymph node staging was performed at the reporting facility. | |
252 | reason for no ln biopsy | PM;2 | SET OF CODES | 1:Contraindicated 2:Patient declined 3:Patient transferred 4:Patient expired 8:NA 9:Unknown | Records the reason that mediastinal lymph nodes were not biopsied at the reporting facility. | |
253 | date of surgery consult | PM;3 | DATE-TIME | Records the surgery consult date. If NO surgery consult was ordered or not DONE, enter 00/00/0000; if UNKNOWN, enter 99/99/9999. | ||
254 | intent of surgery | PM;4 | SET OF CODES | 0:No surgery 1:Curative (primary) 2:Curative (adjuvant) 4:Palliative (pain control) 5:Palliative (other) 6:Prophylactic (no symptoms, preventive) 8:Other, NOS 9:Unknown | Code the intent of surgical treatment. This item is useful in assessing the appropriateness of treatment and correlating outcome with original intent of the treatment. | |
255 | date oncology consult ordered | PM;5 | DATE-TIME | Records the date the oncology consult was ordered. If NO oncology consult was ordered or not DONE, enter 00/00/0000; if UNKNOWN, enter 99/99/9999. | ||
256 | date oncology consult done | PM;6 | DATE-TIME | Records the date the oncology consult was done. If NO oncology consult was done, enter 00/00/0000; if UNKNOWN, enter 99/99/9999. | ||
257 | chemotherapy recommended | PM;7 | SET OF CODES | 0:No 1:Yes 9:Unknown/not documented | Records if there is documentation that chemotherapy was recommended. | |
258 | intent of chemotherapy | PM;8 | SET OF CODES | 0:No chemotherapy 1:Curative (primary) 2:Curative (adjuvant) 4:Palliative (pain control) 5:Palliative (other) 6:Prophylactic (no symptoms, preventive) 8:Other, NOS 9:Unknown | Code the intent of chemotherapy treatment. This item is useful in assessing the appropriateness of treatment and correlating outcome with original intent of the treatment. | |
259 | type of chemotherapy | PM;9 | SET OF CODES | 0:No chemotherapy 1:Adjuvant 2:Neoadjuvant 3:Concomitant or concurrent 4:Palliative 9:Unknown | Records the type of chemotherapy administered. Adjuvant - refers to additional treatment, usually given after surgery where all detectable disease has been removed, but where there remains a statistical risk of relapse due to occult disease. Neoadjuvant - in contrast to adjuvant therapy, is given prior to primary treatment, for example, before surgery to remove the tumor. The most common reason for neoadjuvant therapy is to reduce the size of the tumor so as to facilitate more effective surgery. Concomitant or concurrent - chemotherapy at the same time as other therapies, such as radiation. Palliative - chemotherapy given without expectation of a cure. | |
260 | reason radiation stopped | PM;10 | SET OF CODES | 0:Treatment completed, NA 1:Complications 2:Disease progression 3:Recommended but medically contraindicated 8:Other 9:Unknown | Record the reason radiation therapy was discontinued. If therapy ended when treatment was complete, or if the patient never received radiation therapy code 0 (treatment completed, NA). | |
261 | doc for no plat-based chemo | PM;11 | SET OF CODES | 0:No documentation 1:Documentation 8:NA 9:Unknown | Records if there is a documented reason in the Progress Notes stating why platinum-based chemotherapy was not recommended. | |
262 | multimodality radiation type | PM;12 | SET OF CODES | 0:No multimodality radiation therapy 1:Adjuvant 2:Neoadjuvant 3:Concomitant or concurrent 4:Palliative 9:Unknown | Records the type of radiation therapy administered. Adjuvant - refers to additional treatment, usually given after surgery where all detectable disease has been removed, but where there remains a statistical risk of relapse due to occult disease. Neoadjuvant - in contrast to adjuvant therapy, is given prior to primary treatment, for example, before surgery to remove the tumor. The most common reason for neoadjuvant therapy is to reduce the size of the tumor so as to facilitate more effective surgery. Concomitant or concurrent - radiation therapy at the same time as chemotherapy. Palliative - radiation therapy given without expectation of a cure. | |
263 | reason hormone therapy stopped | PM;28 | SET OF CODES | 0:Treatment completed, NA 1:Complications 2:Disease progression 3:Recommended but medically contraindicated 8:Other 9:Unknown | Record the reason hormone therapy was discontinued. If therapy ended when treatment was complete, or if the patient never received hormone therapy code 0 (treatment completed, NA). | |
264 | date hospice consult initiated | PM;14 | DATE-TIME | Records the date a hospice consult was initiated. If NO date a hospice consult was initiated or not DONE, enter 00/00/0000; if UNKNOWN, enter 99/99/9999. | ||
265 | date hospice consult completed | PM;15 | DATE-TIME | Records the date the hospice consult was created. If NO hospice consult created or DONE, enter 00/00/0000; if UNKNOWN, enter 99/99/9999. | ||
266 | date hospice care initiated | PM;16 | DATE-TIME | Records the date the patient entered hospice care. If there is NO date entered in hospice care or not DONE, enter 00/00/0000; if UNKNOWN, enter 99/99/9999. | ||
267 | egfr mutation testing | PM;17 | SET OF CODES | 0:No testing 1:EGFR mutation positive, NOS 2:EGFR mutation negative 8:NA 9:Unknown/not documented | Records if the Pathology Department performed an EGFR (Epidermal Growth Factor Receptor) mutation test and the results. | |
268 | egfr mutation 1 | PM;18 | SET OF CODES | 1:Wild type 2:G719 (exon 18) 3:Exon 19 deletion 4:Exon 20 insertion 5:T790M (exon 20) 6:L858R (exon 21) 7:L861Q (exon 21) 8:Other 9:Unknown | Records the first EGFR (Epidermal Growth Factor Receptor) mutation type. | |
269 | egfr mutation 2 | PM;19 | SET OF CODES | 1:Wild type 2:G719 (exon 18) 3:Exon 19 deletion 4:Exon 20 insertion 5:T790M (exon 20) 6:L858R (exon 21) 7:L861Q (exon 21) 8:Other 9:Unknown | Records the second EGFR (Epidermal Growth Factor Receptor) mutation type. | |
270 | preop obstructing lesion | PM;13 | SET OF CODES | 0:No 1:Yes 8:NA (in situ lesion/non-invasive polyp) 9:Unknown/not documented | Records if a preoperative obstructing lesion was found. | |
271 | oncology referral | PM;20 | SET OF CODES | 1:Referred 2:Not referred, no reason stated 3:Not referred, reason documented in notes 8:NA (in situ lesion/non-invasive polyp) 9:Unknown if referred | Records if the patient was referred to Oncology. | |
272 | date chemotherapy recommended | PM;21 | DATE-TIME | Records the date on which chemotherapy was recommended. | ||
273 | anti-egfr moab therapy | PM;22 | SET OF CODES | 0:No 1:Yes 8:NA (Stage < 4) 9:Unknown/not documented | For metastatic colorectal cancer, records if anti-EGFR (Epidermal Growth Factor Receptor) MoAb (monoclonal antibody) therapy was administered. e.g. Cetuximab/Panitumumab | |
274 | perirectal ln involvement | PM;23 | SET OF CODES | 0:No 1:Yes 8:NA (no surgery) 9:Unknown/not documented | Records the detection of perirectal lymph node involvement. | |
275 | risk of recurrence | PM;24 | SET OF CODES | 1:Low 2:Medium 3:High 8:NA 9:Unknown/not documented | Records the risk of recurrence after treatment as documented on the Progress Notes. | |
276 | androgen deprivation therapy | PM;25 | SET OF CODES | 0:ADT not administered 1:GnRH/LHRH agonist 2:Antiandrogen 3:CYP17 inhibitor 4:Combination 5:Orchiectomy 8:NA 9:Unknown/not documented | Records the type of ADT (Androgen Deprivation Therapy) administered. 1 GnRH/LHRH agonist Goserelin Acetate Leuprolide Acetate 2 Antiandrogen Bicalutamide Flutamide Nilutamide 3 CYP17 inhibitor Abiraterone acetate Ketoconazole 4 Combination 5 Orchiectomy | |
277 | date adt initiated | PM;26 | DATE-TIME | Records the date on which ADT (Androgen Deprivation Therapy) was initiated. | ||
278 | non-adt chemotherapy | PM;27 | SET OF CODES | 0:No non-ADT chemotherapy administered 1:Docetaxel 2:Cabazitaxel 3:Sipuleucel-T 4:Other 9:Unknown/not documented | Records whether non-ADT (Androgen Deprivation Therapy) chemotherapy was administered and, if so, what chemotherapeutic agent was used. | |
279 | clinical trials discussion | 25;4 | SET OF CODES | 0:NA (Not discussed) 1:With patient 2:With Tumor Board 3:With both patient and Tumor Board 9:Unknown | Records if clinical trials were discussed with the patient and/or the Tumor Board. | |
280 | clin tnm documentation pre-tx | 25;5 | SET OF CODES | 1:Yes 2:No 8:NA 9:Unknown | Records whether this case had a clinical stage documented prior to treatment. | |
280.1 | cl tnm documentation location | 25;7 | FREE TEXT | Records the location of pre-treatment clinical stage documentation. | ||
280.2 | cl tnm documentation date | 25;8 | DATE-TIME | Records the date of pre-treatment clinical stage documentation. | ||
281 | tx guidelines discussion | 25;6 | SET OF CODES | 0:NA (Not eligible) 1:Eligible 2:Eligible but not discussed 3:Discussed 9:Unknown | Records if this case was eligible for a treatment guidelines discussion. | |
282 | vaccr extract indicator | EDITS;3 | SET OF CODES | N:New U:Update | Records whether this case has been newly 'Completed' or is an update to an already 'Completed' case. | |
283 | cs field needing review | CS3;3 | FREE TEXT | Records the CS (Collaborative Staging) item(s) which need manual review/recoding by a registrar after the CS conversion. | ||
300 | patient referred for treatment | BLA1;1 | SET OF CODES | 1:Another hospital 2:Staff physician office 3:Non-staff physician office 4:Free standing facility 5:Other 8:Not applicable 9:Unknown | If the patient was referred elsewhere for part or all of the first course of therapy, record the type of facility to which the referral was made. | |
301 | length of stay | BLA1;2 | NUMERIC | Record the length of stay in days for inpatient cases only. If the patient has multiple inpatient stays, record the length of the admission for the most definitive treatment. If the patient was never an inpatient at your institution, record 888. If the length of stay cannot be determined, code as 999 (unknown). | ||
302 | history of cervix ca (pt) | BLA1;3 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether cervix cancer was diagnosed prior to the patient's bladder cancer or simultaneously with the bladder cancer. Simultaneous diagnosis is within six months of the diagnosis of bladder cancer. | |
303 | history of colon ca (pt) | BLA1;4 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether colon cancer was diagnosed prior to the patient's bladder cancer or simultaneously with the bladder cancer. Simultaneous diagnosis is within six months of the diagnosis of bladder cancer. | |
304 | history of bladder ca (pt) | BLA1;5 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether bladder cancer was diagnosed prior to the patient's bladder cancer or simultaneously with the bladder cancer. Simultaneous diagnosis is within six months of the diagnosis of bladder cancer. | |
305 | history of head & neck ca (pt) | BLA1;6 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether head and neck cancer was diagnosed prior to the patient's bladder cancer or simultaneously with the bladder cancer. Simultaneous diagnosis is within six months of the diagnosis of bladder cancer. | |
306 | history of kidney ca (pt) | BLA1;7 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether kidney cancer was diagnosed prior to the patient's bladder cancer or simultaneously with the bladder cancer. Simultaneous diagnosis is within six months of the diagnosis of bladder cancer. | |
307 | history of prostate ca (pt) | BLA1;8 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether prostate cancer was diagnosed prior to the patient's bladder cancer or simultaneously with the bladder cancer. Simultaneous diagnosis is within six months of the diagnosis of bladder cancer. | |
308 | history of other ca (pt) | BLA1;9 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether other cancer was diagnosed prior to the patient's bladder cancer or simultaneously with the bladder cancer. Simultaneous diagnosis is within six months of the diagnosis of bladder cancer. | |
309 | history of bladder ca (fam) | BLA1;10 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record any familial history of bladder cancer documented in the medical record. If the record does not mention familial history of bladder cancer, code 9 (unknown). | |
310 | history of colon ca (fam) | BLA1;11 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record any familial history of colon cancer documented in the medical record. If the record does not mention familial history of colon cancer, code 9 (unknown). | |
311 | history of lung ca (fam) | BLA1;12 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record any familial history of lung cancer documented in the medical record. If the record does not mention familial history of lung cancer, code 9 (unknown). | |
312 | history of prostate ca (fam) | BLA1;13 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record any familial history of prostate cancer documented in the medical record. If the record does not mention familial history of prostate cancer, code 9 (unknown). | |
313 | history of other ca (fam) | BLA1;14 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record any familial history of other cancer documented in the medical record. If the record does not mention familial history of other cancer, code 9 (unknown). | |
314 | smoking history | BLA1;15 | NUMERIC | Record the actual number of packs of cigarettes smoked per day. A zero must precede single-digit packs. If one or less packs per day are smoked, code as 01. If the patient was never a smoker, code 00. If the patient currently does not smoke, but did previously, code as 98. If the medical record does not mention tobacco use, code as 99 (unknown). | ||
315 | duration of smoking history | BLA1;16 | NUMERIC | Record the number of years the patient has smoked. A zero must precede single-digit years. If the patient never smoked, code 00. If the medical record does not mention duration of years, code 99 (unknown). | ||
316 | duration of smoke free history | BLA1;17 | NUMERIC | If the patient was a previous smoker and no longer smokes, record the number of years since his/her last cigarette. A zero must precede single- digit years. If the patient never smoked, code 00. If the patient never stopped smoking code 88 (not applicable). If the duration is unknown, code 99 (unknown). | ||
317 | gross hematuria | BLA1;18 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the patient was presented with a clinical finding of gross hematuria. If not present, code 0 (no). | |
318 | microscopic hematuria | BLA1;19 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the patient was presented with a clinical finding of microscopic hematuria. If not present, code 0 (no). | |
319 | urinary frequency | BLA1;20 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the patient was presented with a clinical finding of urinary frequency. If not present, code 0 (no). | |
320 | bladder irritability | BLA1;21 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the patient was presented with a clinical finding of bladder irritability. If not present, code 0 (no). | |
321 | dysuria | BLA1;22 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the patient was presented with a clinical finding of dysuria. If not present, code 0 (no). | |
322 | other clinical detections | BLA1;23 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the patient was presented with other clinical findings. If not present, code 0 (no). | |
323 | onset of symptoms | BLA1;24 | DATE-TIME | Record the date (mm/dd/ccyy) on which the symptoms were noted to begin. If the patient did not experience any symptoms, or if the documentation of symptoms was not recorded, enter date as 00/00/0000. If symptoms were present, but date of onset was unknown, record date as 99/99/9999. | ||
324 | duration of gross hematuria | BLA1;25 | NUMERIC | Record the duration (in months) of the patient's symptoms of gross hematuria prior to the diagnosis of cancer. If symptoms were not present, code 00. If symptoms were present and the duration unknown, code 99. | ||
325 | duration of dysuria | BLA1;26 | NUMERIC | Record the duration (in months) of the patient's symptoms of dysuria prior to the diagnosis of cancer. If symptoms were not present, code 00. If symptoms were present and the duration unknown, code 99. | ||
326 | bimanaul exam of bladder | BLA1;27 | SET OF CODES | 0:Not done 1:Done 9:Unknown if done | Record whether a bimanual examination of the bladder was used to diagnose the bladder cancer. If the procedure was not performed, code 0 (not done). | |
327 | cystoscopy with biopsy | BLA1;28 | SET OF CODES | 0:Not done 1:Done 9:Unknown if done | Record whether a cystoscopy with biopsy was used to diagnose the bladder cancer. If the procedure was not performed, code 0 (not done). | |
328 | cystoscopy without biopsy | BLA1;29 | SET OF CODES | 0:Not done 1:Done 9:Unknown if done | Record whether a cystoscopy without biopsy was used to diagnose the bladder cancer. If the procedure was not performed, code 0 (not done). | |
329 | flow cytometry | BLA1;30 | SET OF CODES | 0:Not done 1:Done 9:Unknown if done | Record whether a flow cytometry was used to diagnose this cancer. If the procedure was not performed, code 0 (not done). | |
330 | intravenous pyelogram (bla) | BLA1;31 | SET OF CODES | 0:Not done 1:Done 9:Unknown if done | Record whether an intravenous pyelogram was used to diagnose the bladder cancer. If the procedure was not performed, code 0 (not done). | |
331 | urine cytology | BLA1;32 | SET OF CODES | 0:Not done 1:Done 9:Unknown if done | Record whether a urine cytology was used to diagnose the bladder cancer. If the procedure was not performed, code 0 (not done). | |
332 | urinalysis | BLA1;33 | SET OF CODES | 0:Not done 1:Done 9:Unknown if done | Record whether a urinalysis was used to diagnose the bladder cancer. If the procedure was not performed, code 0 (not done). | |
333 | other diagnostic procedures | BLA1;34 | SET OF CODES | 0:Not done 1:Done 9:Unknown if done | Record whether other diagnostic procedures were used to diagnose the bladder cancer. If no other procedure was performed, code 0 (not done). | |
334 | specialty making diagnosis | BLA1;35 | SET OF CODES | 0:Internal Medicine 1:Family Practice 2:General Surgeon 3:Surgical Oncologist 4:Urologist 5:Urologic Oncologist 6:Medical Oncologist 7:Radiation Oncologist 8:Other 9:Unknown | Provide the specialty of the practitioner (other than the pathologist) who diagnosed this case of bladder cancer. | |
335 | abdominal ultrasound | BLA1;36 | SET OF CODES | 0:Not done 1:Done 9:Unknown | Record whether an abdominal ultrasound procedure was performed to stage this case. | |
336 | bone imaging | BLA1;37 | SET OF CODES | 0:Not done 1:Done 9:Unknown | Record whether a bone imaging procedure was performed to stage this case. | |
337 | chest x-ray (bladder) | BLA1;38 | SET OF CODES | 0:Not done 1:Done 9:Unknown | Record whether a chest x-ray was performed to stage this case. | |
338 | ct chest/lung | BLA1;39 | SET OF CODES | 0:Not done 1:Done 9:Unknown | Record whether a CT chest/lung procedure was performed to stage this case. | |
339 | ct abdomen/pelvis | BLA1;40 | SET OF CODES | 0:Not done 1:Done 9:Unknown | Record whether a CT abdomen/pelvis procedure was performed to stage this case. | |
340 | ct other | BLA1;41 | SET OF CODES | 0:Not done 1:Done 9:Unknown | Record whether other CT procedures were performed to stage this case. | |
341 | mri pelvis/abdomen | BLA1;42 | SET OF CODES | 0:Not done 1:Done 9:Unknown | Record whether an MRI pelvis/abdomen procedure was performed to stage this case. | |
342 | mri other | BLA1;43 | SET OF CODES | 0:Not done 1:Done 9:Unknown | Record whether other MRI procedures were performed to stage this case. | |
343 | other staging procedures | BLA1;44 | SET OF CODES | 0:Not done 1:Done 9:Unknown | Record whether other staging procedures were performed to stage this case. | |
344 | presence of hydronephrosis | BLA1;45 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the patient was noted at any time to have hydronephrosis. If the medical record does not mention hydronephrosis, code as 9 (unknown). | |
345 | presence of multiple tumors | BLA1;46 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the presence of multiple primary bladder tumors was detected either clinically or pathologically. | |
346 | protocol eligibility status | BLA2;1 | SET OF CODES | 0:Not available 1:On protocol 2:Ineligible (age,stage,etc.) 3:Ineligible (comorbidity, preexist cond) 4:Entered but withdrawn 6:Eligible, not entered 7:Eligible, refused 8:Not recommended 9:Unknown | Record the eligibility status of the patient to be entered into a protocol. Analysis of protocol eligibility status assists program planning. | |
347 | managing physician (primary) | BLA2;2 | POINTER | 166.12 | Record the specialty of the primary-care physician who managed the patient upon discharge. If it cannot be determined who the primary managing physician is, code 99 (unknown). | |
348 | managing physician (secondary) | BLA2;3 | POINTER | 166.12 | Record the specialty of the secondary-care physician who managed the patient upon discharge. If it cannot be determined who the secondary managing physician is, code 99 (unknown). | |
349 | tumor resection during turb | BLA2;4 | SET OF CODES | 1:Visibly complete resection 2:Visibly incomplete resection 8:Not applicable 9:Unknown | For all bladder cases undergoing a transurethral resection of the bladder (code 10) for the first course of treatment, record whether or not a tumor was grossly visible or not after resection. This information should be found in the operative report. For primary tumors of the prostatic utricle (C68.0), code 8 (not applicable). | |
350 | type of urinary diversion | BLA2;5 | SET OF CODES | 1:Ileoconduit 2:Continent cutaneous 3:Neobladder 8:Not applicable 9:Unknown | If cancer-directed surgery codes 20-70 are reported, code the type of urinary diversion performed. This information should be found in the operative report. For primary tumors of the prostatic utricle (C68.0), code 8 (not applicable). | |
351 | pelvic lymph node dissect (bl) | BLA2;6 | SET OF CODES | 0:Not done 1:Done 8:Not applicable 9:Unknown | If cancer-directed surgery code 70 is reported, code whether a pelvic lymph node dissection for radical surgery was performed. This information should be obtained from the operative and pathology reports. If the patient had a type of cancer-directed surgery other than a code 70, code 8 (not applicable). | |
352 | bleeding requiring transfusion | BLA2;7 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether this surgical complication resulted from operation. If this complication did not occur, code 0 (none). | |
353 | deep venous thrombosis | BLA2;8 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether this surgical complication resulted from operation. If this complication did not occur, code 0 (none). | |
354 | myocardial infarction (mi) | BLA2;9 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes a patient's prior medical condition. | |
355 | pelvic abscess | BLA2;10 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether this surgical complication resulted from operation. If this complication did not occur, code 0 (none). | |
356 | pneumonia req antibiotics | BLA2;11 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether this surgical complication resulted from operation. If this complication did not occur, code 0 (none). | |
357 | post-operative death | BLA2;12 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether this surgical complication resulted from operation. If this complication did not occur, code 0 (none). | |
358 | pulmonary embolism/thrombosis | BLA2;13 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether this surgical complication resulted from operation. If this complication did not occur, code 0 (none). | |
359 | reoperation | BLA2;14 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether this surgical complication resulted from operation. If this complication did not occur, code 0 (none). | |
360 | other surgical complications | BLA2;15 | SET OF CODES | 0:No 1:Yes 8:NA, surgery not performed 9:Unknown | This field describes a complication or event that occurred after surgery of the primary site and before the date of patient discharge from the hospital. | |
361 | date radiation ended | BLA2;16 | DATE-TIME | The date on which the patient completes or receives the last radiation treatment at any facility. For further information see FORDS pages 166-167. | ||
362 | total rad (cgy/rad) dose | BLA2;17 | NUMERIC | Record the total external rad dose and brachytherapy dosage given to all sites treated, including boost dosage. If the patient did not receive radiation therapy, code 00000. If it is known that the patient received radiation therapy but the amount is unknown, code 99999. | ||
363 | regional treatment modality | BLA2;18 | POINTER | 166.13 | Records the dominant modality of radiation therapy used to deliver the most clinically significant regional dose to the primary volume of interest during the first course of treatment. For further information see FORDS pages 155-157. | |
363.1 | boost treatment modality | 24;9 | POINTER | 166.13 | Records 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. This is accomplished with external beam fields of reduced size (relative to the regional treatment fields), implants, stereotactic radiosurgery, conformal therapy, or IMRT. External beam boosts may consist of two or more successive phases with progressively smaller fields generally coded as a single entry. For further information see FORDS pages 159-161. | |
364 | urinary incontinence | BLA2;19 | SET OF CODES | 0:None 1:Yes 8:Not applicable 9:Unknown | Record whether the patient experienced any urinary incontinence as a result of radiation therapy. If the patient did not receive radiation therapy, code 8 (not applicable). | |
365 | hematuria | BLA2;20 | SET OF CODES | 0:None 1:Yes 8:Not applicable 9:Unknown | Record whether the patient experienced any hematuria as a result of radiation therapy. If the patient did not receive radiation therapy, code 8 (not applicable). | |
366 | radiation bowel injury | BLA2;21 | SET OF CODES | 0:None 1:Yes 8:Not applicable 9:Unknown | Record whether the patient experienced a radiation bowel injury as a result of radiation therapy. If the patient did not receive radiation therapy, enter 8 (not applicable). | |
367 | date chemotherapy ended | BLA2;22 | DATE-TIME | Record the date on which the entire first course of chemotherapy was completed. If chemotherapy was not given, code date as 00/00/0000. | ||
368 | route chemotherapy admin | BLA2;23 | SET OF CODES | 0:No chemotherapy 1:Systemic 2:Intravesicle 9:Unknown | Record the route by which the chemotherapy was administered. If the patient did not receive chemotherapy, code 0 (no chemotherapy). | |
369 | adriamycin | BLA2;24 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the chemotherapeutic agent, Adriamycin, was given. If no chemotherapy was given, code as 0 (no). | |
370 | carboplatinum | BLA2;25 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the chemotherapeutic agent, Carboplatinum, was given. If no chemotherapy was given, code as 0 (no). | |
371 | cisplatin | BLA2;26 | SET OF CODES | 0:No 1:Yes 8:NA, chemotherapy not administered 9:Unknown | This field describes one type of chemotherapeutic agent administered to the patient. | |
372 | cyclophosphamide | BLA2;27 | SET OF CODES | 0:No 1:Yes 8:NA, chemotherapy not administered 9:Unknown | This field describes one type of chemotherapeutic agent administered to the patient. | |
373 | 5-fluorouracil | BLA2;28 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the chemotherapeutic agent, 5-fluorouracil, was given. If no chemotherapy was given, code as 0 (no). | |
374 | gallium nitrate | BLA2;29 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the chemotherapeutic agent, Gallium Nitrate, was given. If no chemotherapy was given, code as 0 (no). | |
375 | ifosfamide | BLA2;30 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the chemotherapeutic agent, Ifosfamide, was given. If no chemotherapy was given, code as 0 (no). | |
376 | methotrexate | BLA2;31 | SET OF CODES | 0:No 1:Yes 8:NA, chemotherapy not administered 9:Unknown | This field describes one type of chemotherapeutic agent administered to the patient. | |
377 | taxol | BLA2;32 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the chemotherapeutic agent, Taxol, was given. If no chemotherapy was given, code as 0 (no). | |
378 | thiotepa | BLA2;33 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the chemotherapeutic agent, Thiotepa, was given. If no chemotherapy was given, code as 0 (no). | |
379 | vinblastine | BLA2;34 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the chemotherapeutic agent, Vinblastine, was given. If no chemotherapy was given, code as 0 (no). | |
380 | other chemotherapeutic agents | BLA2;35 | SET OF CODES | 0:No 1:Yes 8:NA, no chemotherapy administered 9:Unknown | This field describes one type of chemotherapeutic agent administered to the patient. | |
381 | indication for admin of agents | BLA2;36 | SET OF CODES | 0:No agents administered, NA 1:Metastatic disease 2:Adjuvant therapy 3:Neoadjuvant therapy 8:Other 9:Unknown | Record the reason for chemotherapy. If the patient never received chemotherapy, code 0 (no agents administered, na). | |
382 | reason chemotherapy stopped | BLA2;41 | SET OF CODES | 0:Treatment completed, NA 1:Complications 2:Disease progression 3:Recommended but medically contraindicated 8:Other 9:Unknown | Record the reason chemotherapy was discontinued. If therapy ended when treatment was complete, or if the patient never received chemotherapy, code 0 (treatment completed, NA). | |
383 | bcg | BLA2;37 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether BCG immunotherapy was administered for the first course of therapy. | |
384 | interferon | BLA2;38 | SET OF CODES | 0:No 1:Yes 8:NA, chemotherapy not administered 9:Unknown | This field describes one type of chemotherapeutic agent administered to the patient. | |
385 | interleukin-2 | BLA2;39 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | Record whether Interleukin-2 immunotherapy was administered for the first course of therapy. | |
386 | other type of immunotherapy | BLA2;40 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | Record whether other immunotherapy was administered for the first course of therapy. | |
387 | type of 1st recurrence/bladder | BLA2;42 | SET OF CODES | 0:No recurrence 1:Bladder, superficial 2:Bladder, muscle invasion 3:Bladder, NOS 4:Pelvis 5:Distant 8:Never disease-free 9:Unknown | Record the type of the first recurrence. "Pelvic recurrence" is tumor that has invaded any of the following sites: prostate, uterus, vagina, pelvic wall, or abdominal wall. "Distant recurrence" occurs in a site considered distant from the organ or origin as presented in most staging schemes. | |
400 | history of thyroid ca (fam) | THY1;1 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record any familial history of thyroid cancer documented in the medical record. If the record does not mention familial history of thyroid cancer, code 9 (unknown). | |
401 | history of lymphoma (pt) | THY1;2 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the patient has a history of Lymphoma, including Hodgkin's Disease. | |
402 | history of childhood malig | THY1;3 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the patient has a history of childhood malignancies, other than lymphoma. | |
403 | prior exposure to radiation | THY1;4 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes a patient's known prior radiation exposure. Exposure to fluoroscopy, exposure to radioactive isotopes, or actual radiation treatments should be considered prior radiation exposure. Do not consider routine chest or dental x-rays as prior radiation exposure. | |
404 | history of goiter (pt) | THY1;5 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record history of enlarged thyroid gland for a period of greater than 5 years prior to diagnosis. | |
405 | history of goiter (fam) | THY1;6 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record any familial history of thyroid enlargement (goiter), Graves Disease or thyroiditis. | |
406 | history of graves disease (pt) | THY1;7 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the patient has a history of Graves Disease, i.e., autoimmune hyperthyroidism with or withour eye symptoms. | |
407 | history of thyroiditis (pt) | THY1;8 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the patient has a history of Hashimoto's thyroiditis or any other type of thyroiditis. Thyroiditis is often associated with hypothyroidism. | |
408 | dysphagia | THY1;9 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the sign/symptom 'DYSPHAGIA' was present at the time of diagnosis. | |
409 | hoarseness or voice change | THY1;10 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the sign/symptom 'HOARSENESS OR VOICE CHANGE' was present at the time of diagnosis. | |
410 | neck nodal mass | THY1;11 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the sign/symptom 'NECK NODAL MASS' was present at the time of diagnosis. | |
411 | pain, bone | THY1;12 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the sign/symptom 'PAIN, BONE' was present at the time of diagnosis. | |
412 | pain, neck | THY1;13 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the sign/symptom 'PAIN, NECK' was present at the time of diagnosis. | |
413 | pathologic fracture | THY1;14 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the sign/symptom 'PATHOLOGIC FRACTURE' was present at the time of diagnosis. | |
414 | stridor/difficulty breathing | THY1;15 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the sign/symptom 'STRIDOR OR DIFFICULTY BREATHING' was present at the time of diagnosis. | |
415 | thyroid mass | THY1;16 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the sign/symptom 'THYROID MASS' was present at the time of diagnosis. | |
416 | weight loss | THY1;17 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the sign/symptom 'WEIGHT LOSS' was present at the time of diagnosis. | |
417 | other signs/symptoms | THY1;18 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether any OTHER signs/symptoms were present at the time of diagnosis. | |
418 | bone scan (thyroid) | THY1;19 | SET OF CODES | 0:Test not done 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Procedure attempted and incomplete 8:Test done, results unknown 9:Unknown if test done | Record the results of the Diagnostic/Surgical Work-up 'BONE SCAN', if it was performed to evaluate this Thyroid cancer. If this test was not done record a '0'. | |
419 | chest x-ray (thyroid) | THY1;20 | SET OF CODES | 0:Test not done 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Procedure attempted and incomplete 8:Test done, results unknown 9:Unknown if test done | Record the results of the Diagnostic/Surgical Work-up 'CHEST X-RAY', if it was performed to evaluate this Thyroid cancer. If this test was not done record a '0'. | |
420 | ct scan of neck (thyroid) | THY1;21 | SET OF CODES | 0:Test not done 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Procedure attempted and incomplete 8:Test done, results unknown 9:Unknown if test done | Record the results of the Diagnostic/Surgical Work-up 'CT SCAN OF NECK', if it was performed to evaluate this Thyroid cancer. If this test was not done record a '0'. | |
421 | ct scan of chest | THY1;22 | SET OF CODES | 0:Test not done 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Procedure attempted and incomplete 8:Test done, results unknown 9:Unknown if test done | Record the results of the Diagnostic/Surgical Work-up 'CT SCAN OF CHEST', if it was performed to evaluate this cancer. If this test was not done record a '0'. | |
422 | incisional biopsy of thyroid | THY1;23 | SET OF CODES | 0:Test not done 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Procedure attempted and incomplete 8:Test done, results unknown 9:Unknown if test done | Record the results of the Diagnostic/Surgical Work-up 'INCISIONAL BIOPSY OF THYROID', if it was performed to evaluate this Thyroid cancer. If this test was not done record a '0'. | |
423 | laryngoscopy | THY1;24 | SET OF CODES | 0:Test not done 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Procedure attempted and incomplete 8:Test done, results unknown 9:Unknown if test done | Record the results of the Diagnostic/Surgical Work-up 'LARYNGOSCOPY', if it was performed to evaluate this Thyroid cancer. If this test was not done record a '0'. | |
424 | neck x-ray (ap & lateral) | THY1;25 | SET OF CODES | 0:Test not done 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Procedure attempted and incomplete 8:Test done, results unknown 9:Unknown if test done | Record the results of the Diagnostic/Surgical Work-up 'NECK X-RAY (AP & LATERAL)', if it was performed to evaluate this Thyroid cancer. If this test was not done record a '0'. | |
425 | needle aspiration of neck node | THY1;26 | SET OF CODES | 0:Test not done 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Procedure attempted and incomplete 8:Test done, results unknown 9:Unknown if test done | Record the results of the Diagnostic/Surgical Work-up 'NEEDLE ASPIRATION OF NECK NODE', if it was performed to evaluate this Thyroid cancer. If this test was not done record a '0'. | |
426 | needle aspiration of thyroid | THY1;27 | SET OF CODES | 0:Test not done 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Procedure attempted and incomplete 8:Test done, results unknown 9:Unknown if test done | Record the results of the Diagnostic/Surgical Work-up 'NEEDLE ASPIRATION OF THYROID', if it was performed to evaluate this Thyroid cancer. If this test was not done record a '0'. | |
427 | mri of neck | THY1;28 | SET OF CODES | 0:Test not donw 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Procedure attempted and incomplete 8:Test done, results unknown 9:Unknown if test done | Record the results of the Diagnostic/Surgical Work-up 'MRI OF NECK', if it was performed to evaluate this Thyroid cancer. If this test was not done record a '0'. | |
428 | thyroid scan | THY1;29 | SET OF CODES | 0:Test not done 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Procedure attempted and incomplete 8:Test done, results unknown 9:Unknown if test done | Record the results of the Diagnostic/Surgical Work-up 'THYROID SCAN', if it was performed to evaluate this Thyroid cancer. If this test was not done record a '0'. | |
429 | ultrasound of thyroid | THY1;30 | SET OF CODES | 0:Test not done 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Procedure attempted and incomplete 8:Test done, results unknown 9:Unknown if test done | Record the results of the Diagnostic/Surgical Work-up 'ULTRASOUND OF THYROID', if it was performed to evaluate this Thyroid cancer. If this test was not done record a '0'. | |
430 | other diagnostic/surgical test | THY1;31 | SET OF CODES | 0:Test not done 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Procedure attempted and incomplete 8:Test done, results unknown 9:Unknown if other test done | Record the results of any OTHER Diagnostic/Surgical Work-ups done, if any were performed to evaluate this Thyroid cancer. If other test were not done record a '0'. | |
431 | blood vessel invasion | THY1;32 | SET OF CODES | 0:No invasion 1:Yes 8:No surgery, not applicable 9:Unknown | Record the presence of blood vessel invasion. NOTE: This refers to the presence of tumor cells inside blood vessels of a caliber larger than capil- laries, located in the tumor capsule or beyond. The tumor cells should be attached to the vessel wall. | |
432 | extra-thyroidal extension | THY1;33 | SET OF CODES | 0:No extension 1:Esophagus 2:Trachea 3:Larynx 4:Strap muscles 5:Soft tissue 6:Multiple sites 7:Extension, NOS 8:Not applicable, no surgery 9:Unknown | Record any gross or microscopic extension beyond thyroid capsule. NOTE: Do not code invasion of the tumor capsule around a follicular cancer as an extra-thyroidal extension. | |
433 | multifocal | THY1;34 | SET OF CODES | 0:No 1:Microscopic 2:Gross 3:Multifocal, NOS 9:Unknown | Record whether the tumor was multifocal. Pathologic confirmation is required. | |
434 | location of positive nodes | THY1;35 | SET OF CODES | 0:No positive nodes 1:Perithyroid only 2:Lateral neck only 3:Mediastinum only 4:Multiple regions 5:Other 8:Not applicable 9:Unknown | Record the location of regional nodes if they are positive. | |
435 | date most definitive surg dis | THY1;36 | DATE-TIME | Source of Standard: NAACCR Item #: 3180 This is the date the patient was discharged following primary site surgery. The date must be after or equal to the DATE DX (#3) field. The date corresponds to the event recorded in SURGERY OF PRIMARY (F) (#58.6) and MOST DEFINITIVE SURG DATE (#50) fields. For further information see FORDS pages 144-145. | ||
436 | airway problem | THY1;37 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | Record whether the patient had the surgical complication 'AIRWAY PROBLEM REQUIRING TRACHEOSTOMY', which resulted from cancer-directed surgery. If no cancer-directed surgery was performed, code 8 (not applicable). | |
437 | bleeding/hematoma | THY1;38 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | Record whether the patient had the surgical complication 'BLEEDING HEMATOMA', which resulted from cancer-directed surgery. If no cancer-directed surgery was performed, code 8 (not applicable). | |
438 | hypocalcemia | THY1;39 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | Record whether the patient had the surgical complication 'HYPOCALCEMIA (NEEDS ORAL CALCIUM', which resulted from cancer-directed surgery. If no cancer- directed surgery was performed, code 8 (not applicable). | |
439 | recurrent nerve injury | THY1;40 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | Record whether the patient had the surgical complication 'RECURRENT NERVE INJURY (OR VOCAL CORD PARESIS)', which resulted from cancer-directed surgery. If no cancer-directed surgery was performed, code 8 (not applicable). | |
440 | wound infection | THY1;41 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | Record whether the patient had the surgical complication 'WOUND INFECTION', which resulted from cancer-directed surgery. If no cancer-directed surgery was performed, code 8 (not applicable). | |
441 | postoperative death | THY1;42 | SET OF CODES | 0:No 1:Yes 8:Not applicable, no surgery 9:Unknown | Record operative death occurring within 30 days of the cancer-directed surgery. If no cancer-directed surgery was performed, code 8 (not applicable). | |
442 | regional dose: cgy | THY1;43 | NUMERIC | Records the dominant or most clinically significant total dose of regional radiation therapy delivered to the patient during the first course of treatment. The unit of measure is centiGray (cGy). Code 88888 (NA, brachytherapy/radioisotopes administered) if not applicable or when brachytherapy or radioisotopes were administered to the patient. For further information see FORDS page 248. | ||
443 | boost dose: cgy | THY1;44 | NUMERIC | Records the additional boost dosage delivered to that part of the treatment volume encompassed by the boost fields or devices. The unit of measure is centiGray (cGy). Code 88888 (NA, brachytherapy/radioisotopes administered) if not applicable or when brachytherapy or radioisotopes were administered to the patient. For further information see FORDS page 252. | ||
444 | initial dose of radioiodine | THY1;45 | NUMERIC | Record the total Millicuries (mCi) of radioiodine given as part of initial therapy, whether for the purpose of ablation or therapy. If none received, code 00000. If unknown, code 99999. | ||
445 | second dose of radioiodine | THY1;46 | NUMERIC | Record the total Millicuries (mCi) of radioiodine given as second dose within the next 6 months after date of diagnosis. If none received, code 00000. If unknown, code 99999. | ||
446 | adjuvant chemotherapy (thy) | THY1;47 | SET OF CODES | 0:No concomitant treatment 1:Radiation treatment and concomitant adjuvant chemotherapy 9:Unknown if therapy concomitant | Record the Adjuvant Chemotherapy with Concomitant External Beam Radiation. If patient receives chemotherapy at any time during radiation as a radio- sensitizing agent, code 1. If chemotherapy is stopped more than 2 days prior to radiation therapy and not given until external beam therapy is completed, code 0. If unknown, code 9. | |
500 | history of soft tis sarc (fam) | STS1;1 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record any familial history of soft tissue sarcoma documented in the medical record. If the record does not mention familial history of soft tissue sarcoma, code 9 (unknown). | |
501 | history of any cancer (pt) | STS1;2 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record the personal history of any cancer documented in the medical record. If the record does not mention personal history of any cancer, code 9 (unknown). | |
502 | angiogram of primary | STS1;3 | SET OF CODES | 0:Test not done 1:Positive for cancer 2:Negative for cancer 3:Equivocal, suggestive of cancer 7:Test attempted but not completed 8:Test done, results unknown 9:Unknown if test done | Record the results of the Diagnostic Workup 'Angiogram for Primary', if it was performed to evaluate this soft tissue sarcoma. If this test was not done, record a '0'. | |
503 | bone marrow aspirate or biopsy | STS1;4 | SET OF CODES | 0:Test not done 1:Positive for cancer 2:Negative for cancer 3:Equivocal, suggestive of cancer 7:Test attempted but not completed 8:Test done, results unknown 9:Unknown if test done | Record the results of the Diagnostic Workup 'Bone marrow aspirate and/or Biopsy', if it was performed to evaluate this soft tissue sarcoma. If this test was not done, record a '0'. | |
504 | bone scan (soft tis sarcoma) | STS1;5 | SET OF CODES | 0:Test not done 1:Positive for cancer 2:Negative for cancer 3:Equivocal, suggestive of cancer 7:Test attempted but not completed 8:Test done, results unknown 9:Unknown if test done | Record the results of the Diagnostic Workup 'Bone scan', if it was performed to evaluate this soft tissue sarcoma. If this test was not done, record a '0'. | |
505 | chest x-ray (sts/nhl) | STS1;6 | SET OF CODES | 0:Test not done 1:Positive for cancer 2:Negative for cancer 3:Equivocal, suggestive of cancer 7:Test attempted but not completed 8:Test done, results unknown 9:Unknown if test done | Record the results of the Diagnostic Workup 'Chest X-RAY', if it was performed to evaluate this primary. If this test was not done, record a '0'. | |
506 | ct scan of chest (sts) | STS1;7 | SET OF CODES | 0:Test not done 1:Positive for cancer 2:Negative for cancer 3:Equivocal, suggestive of cancer 7:Test attempted but not completed 8:Test done, results unknown 9:Unknown if test done | Record the results of the Diagnostic Workup 'CT scan of chest', if it was performed to evaluate this soft tissue sarcoma. If this test was not done, record a '0'. | |
507 | ct scan of primary | STS1;8 | SET OF CODES | 0:Test not done 1:Positive for cancer 2:Negative for cancer 3:Equivocal, suggestive of cancer 7:Test attempted but not completed 8:Test done, results unknown 9:Unknown if test done | Record the results of the Diagnostic Workup 'CT scan of primary', if it was performed to evaluate this soft tissue sarcoma. If this test was not done, record a '0'. | |
508 | liver function studies (sts) | STS1;9 | SET OF CODES | 0:Test not done 1:Positive for cancer 2:Negative for cancer 3:Equivocal, suggestive of cancer 7:Test attempted but not completed 8:Test done, results unknown 9:Unknown if test done | Record the results of the Diagnostic Workup 'Liver Function Studies', if it was performed to evaluate this soft tissue sarcoma. If this test was not done, record a '0'. | |
509 | lymphangiogram | STS1;10 | SET OF CODES | 0:Test not done 1:Positive for cancer 2:Negative for cancer 3:Equivocal, suggestive of cancer 7:Test attempted but not completed 8:Test done, results unknown 9:Unknown if test done | Record the results of the Diagnostic Workup 'Lymphangiogram', if it was performed to evaluate this soft tissue sarcoma. If this test was not done, record a '0'. | |
510 | mri of primary | STS1;11 | SET OF CODES | 0:Test not done 1:Positive for cancer 2:Negative for cancer 3:Equivocal, suggestive of cancer 7:Test attempted but not completed 8:Test done, results unknown 9:Unknown if test done | Record the results of the Diagnostic Workup 'MRI of primary', if it was performed to evaluate this soft tissue sarcoma. If this test was not done, record a '0'. | |
511 | mri of other | STS1;12 | SET OF CODES | 0:Test not done 1:Positive for cancer 2:Negative for cancer 3:Equivocal, suggestive of cancer 7:Test attempted but not completed 8:Test done, results unknown 9:Unknown if test done | Record the results of the Diagnostic Workup 'MRI of other', if it was performed to evaluate this soft tissue sarcoma. If this test was not done, record a '0'. | |
512 | skeletal x-ray | STS1;13 | SET OF CODES | 0:Test not done 1:Positive for cancer 2:Negative for cancer 3:Equivocal, suggestive of cancer 7:Test attempted but not completed 8:Test done, results unknown 9:Unknown if test done | Record the results of the Diagnostic Workup 'Skeletal X-RAY', if it was performed to evaluate this soft tissue sarcoma. If this test was not done, record a '0'. | |
513 | sonogram | STS1;14 | SET OF CODES | 0:Test not done 1:Positive for cancer 2:Negative for cancer 3:Equivocal, suggestive of cancer 7:Test attempted but not completed 8:Test done, results unknown 9:Unknown if test done | Record the results of the Diagnostic Workup 'Sonogram', if it was performed to evaluate this soft tissue sarcoma. If this test was not done, record a '0'. | |
514 | cytogenetics | STS1;15 | SET OF CODES | 0:Not done 1:Done 9:Unknown if done | Record whether the 'Cytogenetics' test was performed to evaluate this primary. If this test was not done, record a '0'. | |
515 | electron microscopy | STS1;16 | SET OF CODES | 0:Not done 1:Done 9:Unknown if done | Record whether the Histologic Workup 'Electron microscopy' was performed to evaluate this soft tissue sarcoma. If this test was not done, record a '0'. | |
516 | immunohistochemistry | STS1;17 | SET OF CODES | 0:Not done 1:Done 9:Unknown if done | Record whether the 'Immunohistochemistry/Tumor Surface Marker' test was performed to evaluate this primary. If this test was not done, record a '0'. | |
517 | in situ hybridization | STS1;18 | SET OF CODES | 0:Not done 1:Done 9:Unknown if done | Record whether the Histologic Workup 'In situ hybridization' was performed to evaluate this soft tissue sarcoma. If this test was not done, record a '0'. | |
518 | outside confirmation requested | STS1;19 | SET OF CODES | 0:No 1:Yes 8:Not applicable 9:Unknown | Record whether an outside confirmation of a biopsy was requested. | |
519 | subsite | STS1;20 | POINTER | 166.3 | Record the appropriate subsite code. | |
520 | type of additional coding sys | STS1;21 | SET OF CODES | 1:1 to 3 system 2:1 to 2 or high/low system 8:Not applicable 9:Unknown | If your institution uses an additional grade coding system, record the additional system that is used. Code '1' if the coding system is a 1 to 3 scale. Code '2' if the coding system is a 1 to 2 or high/low scale. If not applicable code '8', and if unknown, code '9'. | |
521 | value of additional coding sys | STS1;22 | SET OF CODES | 1:1 2:2 3:3 5:Low 6:High 8:Not applicable 9:Unknown | Enter the numeric (1,2 or 3) value from the additional coding system. If code is 'low', code '5'; if code is 'high', code 6. If not applicable code '8', and if unknown, code '9'. | |
522 | pathologic size of tumor | STS1;23 | NUMERIC | Record the largest diameter of the primary tumor in milimeters (1 cm = 10 mm) as specified in the pathology report. If there is more than one tumor in the same primary site (multifocal), record the largest diameter of the largest tumor. Do not use size of the entire specimen for tumor size. In cases where the tumor diameter is not specified in the pathology report, size of tumor should be obtained from the operative report, followed by x-rays, or physical examinations. | ||
523 | depth of tumor | STS1;24 | SET OF CODES | 1:Superficial (above muscle fascia) 2:Deep (all else) 8:Not applicable 9:Unknown | Tumor depth is applicable for extremity, trunk and head and neck lesions. Code 8 if not applicable and 9 if unknown. | |
524 | consultations (med oncologist) | STS1;25 | SET OF CODES | 0:No 1:Yes 9:Unknown | Enter whether there was a consultation with a medical oncologist. | |
525 | consultations (rad oncologist) | STS1;26 | SET OF CODES | 0:No 1:Yes 9:Unknown | Enter whether there was a consultation with a radiation oncologist. | |
526 | treating surgeon | STS2;1 | SET OF CODES | 1:General surgeon 2:Orthopedic surgeon 3:Urologist 4:Gynecologist 5:ENT (ear, nose and throat) 6:Other 8:Not applicable, no surgery 9:Unknown | Record the appropriate code for the type of treating surgeon. | |
527 | asa class | STS2;2 | SET OF CODES | 1:No systemic disturbance 2:Mild to moderate systemic disturbance 3:Severe systemic disturbance 4:Life-threatening disturbance 5:Moribund with little chance of survival 9:Class unknown or not applicable | Record appropriate code from anesthesiologist's report. If no organic, physiologic, biochemical or psychiatric disturbance, code 1. If not recorded or if the patient did not receive surgery, code 9. | |
528 | fine needle aspiration | STS1;27 | NUMERIC | Enter the morphology code for this biopsy if it was performed. The first 4 digits should represent the HISTOLOGY, the 5th digit should represent the BEHAVIOR, and the 6th digit should represent the GRADE. For example, if this biopsy was performed and the HISTOLOGY was '8693', the BEHAVIOR was '3' and the GRADE was '1', then enter "869331". This will display as "8693/3/1". If the biopsy was not done code 8's (ie - 888888), if it is unknown whether the biopsy was done code 9's (ie - 999999). If the biopsy was done but one or more items are unknown, code 7's where unknown. For example, if the HISTOLOGY is '8693' and the behavior is '3' , but the GRADE is unknown, then enter "869337". | ||
529 | core needle biopsy | STS1;28 | NUMERIC | Enter the morphology code for this biopsy if it was performed. The first 4 digits should represent the HISTOLOGY, the 5th digit should represent the BEHAVIOR, and the 6th digit should represent the GRADE. For example, if this biopsy was performed and the HISTOLOGY was '8693', the BEHAVIOR was '3' and the GRADE was '1', then enter "869331". This will display as "8693/3/1". If the biopsy was not done code 8's (ie - 888888), if it is unknown whether the biopsy was done code 9's (ie - 999999). If the biopsy was done but one or more items are unknown, code 7's where unknown. For example, if the HISTOLOGY is '8693' and the behavior is '3' , but the GRADE is unknown, then enter "869337". | ||
530 | incisional biopsy (sts pce) | STS1;29 | NUMERIC | Enter the morphology code for this biopsy if it was performed. The first 4 digits should represent the HISTOLOGY, the 5th digit should represent the BEHAVIOR, and the 6th digit should represent the GRADE. For example, if this biopsy was performed and the HISTOLOGY was '8693', the BEHAVIOR was '3' and the GRADE was '1', then enter "869331". This will display as "8693/3/1". If the biopsy was not done code 8's (ie - 888888), if it is unknown whether the biopsy was done code 9's (ie - 999999). If the biopsy was done but one or more items are unknown, code 7's where unknown. For example, if the HISTOLOGY is '8693' and the behavior is '3' , but the GRADE is unknown, then enter "869337". | ||
531 | excisional biopsy | STS1;30 | NUMERIC | Enter the morphology code for this biopsy if it was performed. The first 4 digits should represent the HISTOLOGY, the 5th digit should represent the BEHAVIOR, and the 6th digit should represent the GRADE. For example, if this biopsy was performed and the HISTOLOGY was '8693', the BEHAVIOR was '3' and the GRADE was '1', then enter "869331". This will display as "8693/3/1". If the biopsy was not done code 8's (ie - 888888), if it is unknown whether the biopsy was done code 9's (ie - 999999). If the biopsy was done but one or more items are unknown, code 7's where unknown. For example, if the HISTOLOGY is '8693' and the behavior is '3' , but the GRADE is unknown, then enter "869337". | ||
532 | external beam radiation | STS2;3 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether any external beam radiation therapy was performed. | |
533 | external beam rad fractions | STS2;4 | NUMERIC | Record the number of fractions for external beam radiation. | ||
534 | external beam radiation energy | STS2;5 | NUMERIC | Record the units (MV) of radiation energy if external beam radiation was performed . | ||
535 | intraoperative radiation | STS2;6 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether intraoperative radiation was performed. | |
536 | intraoperative radiation dose | STS2;7 | NUMERIC | Record the total intraoperative radiation dose given. If the patient did not receive this type of radiation therapy, code 0's. If it is known that the patient received this type of radiation therapy but the dose is not known, code 9's. | ||
537 | intraoperative radiation ener | STS2;8 | NUMERIC | Record the units (MV) of intraoperative radiation energy if this was performed. | ||
538 | brachytherapy | STS2;9 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether brachytherapy was performed. | |
539 | brachytherapy days | STS2;10 | NUMERIC | Record the number of days brachytherapy was given. | ||
540 | brachytherapy radiation dose | STS2;11 | NUMERIC | Record the total brachytherapy radiation dose given. If the patient did not receive this type of radiation therapy, code 0's. If it is known that the patient received this type of radiation therapy, but the dose is unknown, code 9's. | ||
541 | date brachytherapy started | STS2;12 | DATE-TIME | Record the date on which brachytherapy was started. If brachytherapy was not given, code the date as 00/00/00. If it is unknown code as 99/99/99. | ||
542 | date brachytherapy ended | STS2;13 | DATE-TIME | Record the date on which brachytherapy ended. If brachytherapy was not given, code the date as 00/00/00. If it is unknown code as 99/99/99. | ||
543 | cytoxan | STS2;14 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the chemotherapeutic agent, Cytoxan, was given. If no chemotherapy was given, code as 0. | |
544 | dtic | STS2;15 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the chemotherapeutic agent, DTIC, was administered. If no chemotherapy was given, code as 0. | |
545 | doxorubicin (sts) | STS2;16 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the chemotherapeutic agent, Doxorubicin, was administered. If no chemotherapy was given, code as 0. | |
546 | etoposide | STS2;17 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the chemotherapeutic agent, Etoposide, was administered. If no chemotherapy was given, code as 0. | |
547 | cisplatin method of delivery | STS2;18 | SET OF CODES | 1:Bolus 2:Infusion 8:Not applicable 9:Unknown | Record the method of delivery for this agent, bolus or infusion. If not applicable cade 8, and if unknown code 9. | |
548 | cytoxan method of delivery | STS2;19 | SET OF CODES | 1:Bolus 2:Infusion 8:Not applicable 9:Unknown | Record the method of delivery for this agent, bolus or infusion. If not applicable cade 8, and if unknown code 9. | |
549 | dtic method of delivery | STS2;20 | SET OF CODES | 1:Bolus 2:Infusion 8:Not applicable 9:Unknown | Record the method of delivery for this agent, bolus or infusion. If not applicable cade 8, and if unknown code 9. | |
550 | doxorubicin method of delivery | STS2;21 | SET OF CODES | 1:Bolus 2:Infusion 8:Not applicable 9:Unknown | Record the method of delivery for this agent, bolus or infusion. If not applicable cade 8, and if unknown code 9. | |
551 | etoposide method of delivery | STS2;22 | SET OF CODES | 1:Bolus 2:Infusion 8:Not applicable 9:Unknown | Record the method of delivery for this agent, bolus or infusion. If not applicable cade 8, and if unknown code 9. | |
552 | ifosfamide method of delivery | STS2;23 | SET OF CODES | 1:Bolus 2:Infusion 8:Not applicable 9:Unknown | Record the method of delivery for this agent, bolus or infusion. If not applicable cade 8, and if unknown code 9. | |
553 | cisplatin location | STS2;24 | SET OF CODES | 1:Intra-arterial 2:Intravenous 3:Oral 8:Not applicable 9:Unknown | Record the location of this agent, whether intra-arterial, intravenous or oral. If not applicable, code 8, and if unknown code 9. | |
554 | cytoxan location | STS2;25 | SET OF CODES | 1:Intra-arterial 2:Intravenous 3:Oral 8:Not applicable 9:Unknown | Record the location of this agent, whether intra-arterial, intravenous or oral. If not applicable, code 8, and if unknown code 9. | |
555 | dtic location | STS2;26 | SET OF CODES | 1:Intra-arterial 2:Intravenous 3:Oral 8:Not applicable 9:Unknown | Record the location of this agent, whether intra-arterial, intravenous or oral. If not applicable, code 8, and if unknown code 9. | |
556 | doxorubicin location | STS2;27 | SET OF CODES | 1:Intra-arterial 2:Intravenous 3:Oral 8:Not applicable 9:Unknown | Record the location of this agent, whether intra-arterial, intravenous or oral. If not applicable, code 8, and if unknown code 9. | |
557 | etoposide location | STS2;28 | SET OF CODES | 1:Intra-arterial 2:Intravenous 3:Oral 8:Not applicable 9:Unknown | Record the location of this agent, whether intra-arterial, intravenous or oral. If not applicable, code 8, and if unknown code 9. | |
558 | ifosfamide location | STS2;29 | SET OF CODES | 1:Intra-arterial 2:Intravenous 3:Oral 8:Not applicable 9:Unknown | Record the location of this agent, whether intra-arterial, intravenous or oral. If not applicable, code 8, and if unknown code 9. | |
559 | colony stimulating factors | STS2;30 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | Record whether colony stimulating factors were used. | |
560 | protocol participation | STS2;31 | SET OF CODES | 00:Not on/NA 01:NSABP 02:GOG 03:RTOG 04:SWOG 05:ECOG 06:POG 07:CCG 08:CALGB 09:NCI 10:ACS 11:National protocol, NOS 12:Local protocol, NOS 99:Unknown | Record whether the patient was enrolled in and treated on a protocol. A physician may treat a patient following the guidelines of an established protocol; however, the patient is not enrolled into the protocol. For these patients, use code 00 (Not on/NA). | |
561 | other protocol | STS2;32 | SET OF CODES | 0:Not on protocol/not applicable 1:In house protocol 2:Non-cooperative, multi-institutional protocol 3:On protocol, type unknown 9:Unknown | Record whether therapy was given under another protocol. | |
562 | referred to rehab services | STS2;33 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the patient was referred to rehabilitation services. | |
563 | physical therapy/rehabiltation | STS2;34 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the patient was referred to physical therapy or rehabilitation service. | |
564 | transferred to rehabilitation | STS2;35 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the patient was transferred to a rehabilitation facility after being released from the hospital. | |
565 | number of hospitalizations | STS2;36 | NUMERIC | Record the number of hospitalizations for this patient, counting only overnight stays during the first six months after diagnosis. Do not count stays for 23 hour observation. If unknown, code 9's. | ||
566 | total length of stays | STS2;37 | NUMERIC | Add all days for each overnight hospitalization together to get a cumulative total for all stays during the first six months after diagnosis. Do not count stays for 23 hour observation. If unknown, code 9's. | ||
567 | date ext beam rad started | STS2;38 | DATE-TIME | Record the date external beam radiation therapy was started. Code 0's if not given. Code 9's if unknown. | ||
600 | clinical dx with bone lesion | PRO1;1 | SET OF CODES | 1:Yes 2:No 9:Unknown | Record whether the Method of Diagnosis: CLINICAL DIAGNOSIS WITH BONE LESION was used to diagnose this case of prostate cancer. | |
601 | clinical dx by rectal exam | PRO1;2 | SET OF CODES | 1:Yes 2:No 9:Unknown | Record whether the Method of Diagnosis: CLINICAL DIAGNOSIS BY RECTAL EXAM was used to diagnose this case of prostate cancer. | |
602 | cytology | PRO1;3 | SET OF CODES | 1:Yes 2:No 9:Unknown | Record whether the Method of Diagnosis: CYTOLOGY was used to diagnose this case of prostate cancer. | |
603 | incidental finding in turp | PRO1;4 | SET OF CODES | 1:Yes 2:No 9:Unknown | Record whether the Method of Diagnosis: INCIDENTAL FINDING IN TRANSURETHRAL RESECTION OF PROSTATE (TURP) FOR BENIGN DISEASE was used to diagnose this case of prostate cancer. | |
604 | needle aspiration biopsy | PRO1;5 | SET OF CODES | 1:Yes 2:No 9:Unknown | Record whether the Method of Diagnosis: NEEDLE ASPIRATION BIOPSY was used to diagnose this case of prostate cancer. | |
605 | needle biopsy, nos | PRO1;6 | SET OF CODES | 1:Yes 2:No 9:Unknown | Record whether the Method of Diagnosis: NEEDLE BIOPSY, NOS was used to diagnose this case of prostate cancer. | |
606 | perineal biopsy | PRO1;7 | SET OF CODES | 1:Yes 2:No 9:Unknown | Record whether the Method of Diagnosis: PERINEAL BIOPSY was used to diagnose this case of prostate cancer. | |
607 | transrectal biopsy | PRO1;8 | SET OF CODES | 1:Yes 2:No 9:Unknown | Record whether the Method of Diagnosis: TRANSRECTAL BIOPSY was used to diagnose this case of prostate cancer. | |
608 | trus | PRO1;9 | SET OF CODES | 1:Yes 2:No 9:Unknown | Record whether the Method of Diagnosis: TRANSRECTAL ULTRASONOGRAPHICALLY GUIDED BIOPSY (TRUS) was used to diagnose this case of prostate cancer. | |
609 | transurethral resection | PRO1;10 | SET OF CODES | 1:Yes 2:No 9:Unknown | Record whether the Method of Diagnosis: TRANSURETHRAL RESECTION OF PROSTATE, NOS was used to diagnose this case of prostate cancer. | |
610 | other method of dx (prostate) | PRO1;11 | SET OF CODES | 1:Yes 2:No 9:Unknown | Record whether the Method of Diagnosis: OTHER was used to diagnose this case of prostate cancer. | |
611 | bone marrow aspiration | PRO1;12 | SET OF CODES | 1:Normal 2:Abnormal/elevated 8:Test not done/unknown if done 9:Test done, results unknown | Record the results of the BONE MARROW ASPIRATION diagnostic test performed to evaluate the prostate tumor. If the study was done and the results cannot be determined, code 9 (Test done, results unknown). | |
612 | bone scan (prostate) | PRO1;13 | SET OF CODES | 1:Normal 2:Abnormal/elevated 8:Test not done/unknown if done 9:Test done, results unknown | Record the results of the BONE SCAN diagnostic test performed to evaluate the prostate tumor. If the study was done and the results cannot be determined, code 9 (Test done, results unknown). | |
613 | bone x-ray | PRO1;14 | SET OF CODES | 1:Normal 2:Abnormal/elevated 8:Test not done/unknown if done 9:Test done, results unknown | Record the results of the BONE X-RAY diagnostic test performed to evaluate the prostate tumor. If the study was done and the results cannot be determined, code 9 (Test done, results unknown). | |
614 | chest x-ray (prostate) | PRO1;15 | SET OF CODES | 1:Normal 2:Abnormal/elevated 8:Test not done/unknown if done 9:Test done, results unknown | Record the results of the CHEST X-RAY diagnostic test performed to evaluate the prostate tumor. If the study was done and the results cannot be determined, code 9 (Test done, results unknown). | |
615 | ct scan of primary site | PRO1;16 | SET OF CODES | 1:Normal 2:Abnormal/elevated 8:Test not done/unknown if done 9:Test done, results unknown | Record the results of the CT SCAN OF PRIMARY SITE diagnostic test performed to evaluate the prostate tumor. If a scan of the abdomen was performed by computed tomography (CT), record the results under CT SCAN OF PRIMARY SITE. If the study was done and the results cannot be determined, code 9 (Test done, results unknown). | |
616 | intravenous pyelogram (pro) | PRO1;17 | SET OF CODES | 1:Normal 2:Abnormal/elevated 8:Test not done/unknown if done 9:Test done, results unknown | Record the results of the INTRAVENOUS PYELOGRAM (IVP) diagnostic test performed to evaluate the prostate tumor. If the study was done and the results cannot be determined, code 9 (Test done, results unknown). | |
617 | liver scan | PRO1;18 | SET OF CODES | 1:Normal 2:Abnormal/elevated 8:Test not done/unknown if done 9:Test done, results unknown | Record the results of the LIVER SCAN diagnostic test performed to evaluate the prostate tumor. If the study was done and the results cannot be determined, code 9 (Test done, results unknown). | |
618 | mri (pro) | PRO1;19 | SET OF CODES | 1:Normal 2:Abnormal/elevated 8:Test not done/unknown if done 9:Test done, results unknown | Record the results of the MAGNETIC RESONANCE IMAGING (MRI) diagnostic test performed to evaluate the prostate tumor. If the study was done and the results cannot be determined, code 9 (Test done, results unknown). | |
619 | pelvic lymph node dissect (pr) | PRO1;20 | SET OF CODES | 1:Normal 2:Abnormal/elevated 8:Test not done/unknown if done 9:Test done, results unknown | Record the results of the PELVIC LYMPH NODE DISSECTION diagnostic test performed to evaluate the prostate tumor. If the study was done and the results cannot be determined, code 9 (Test done, results unknown). | |
620 | prostatic acid phosphatase | PRO1;21 | SET OF CODES | 1:Normal 2:Abnormal/elevated 8:Test not done/unknown if done 9:Test done, results unknown | Record the results of the PROSTATIC ACID PHOSPHATASE (PAP) diagnostic test performed to evaluate the prostate tumor. If the study was done and the results cannot be determined, code 9 (Test done, results unknown). | |
621 | prostate specific antigen | PRO1;22 | SET OF CODES | 1:Normal 2:Abnormal/elevated 8:Test not done/unknown if done 9:Test done, results unknown | Record the results of the PROSTATE SPECIFIC ANTIGEN (PSA) diagnostic test performed to evaluate the prostate tumor. If the study was done and the results cannot be determined, code 9 (Test done, results unknown). | |
622 | other diagnostic information | PRO1;23 | SET OF CODES | 1:Normal 2:Abnormal/elelvated 8:Test not done/unknown if done 9:Test done, results unknown | Record the results of OTHER diagnostic tests performed to evaluate the prostate tumor. If the study was done and the results cannot be determined, code 9 (Test done, results unknown). | |
623 | gleason score (clinical) | PRO1;24 | FREE TEXT | Record the clinical Gleason Score. Gleason Score (clinical) is obtained from a needle biopsy or TURP specimen. For cases where Gleason Score is unknown, not reported or not applicable, code 99. | ||
623.1 | predominant pattern (02-40) | PRO2;43 | NUMERIC | Record the predominant (primary) pattern of tumor for Biopsy, Local Resection, or Simple Prostatectomy, surgical codes 02-40. Gleason's grading system assigns histologic grade ranging from 1-5 to predominant pattern of tumor. Record the predominant pattern as stated in the pathology report. If the grade is not provided and only a Gleason score is available, enter a '0'. | ||
623.2 | lesser pattern (02-40) | PRO2;44 | NUMERIC | Record the lesser (secondary) pattern of tumor for Biopsy, Local Resection, or Simple Prostatectomy, surgical codes 02-40. Gleason's grading system assigns histologic grade ranging from 1-5 to lesser pattern of tumor. Record the lesser pattern as stated in the pathology report. If the grade is not provided and only a Gleason score is available, enter a '0'. | ||
623.3 | gleason's score (50-70) | PRO2;45 | FREE TEXT | Record the Gleason's score for Radical Prostatectomy, surgical codes 50-70. Gleason's grading system assigns histologic grade ranging from 1-5 to predominant (primary) and lesser (secondary) patterns of tumor. The grade numbers of the two patterns are added to obtain the Gleason score, which ranges from 02 to 10. Record the Gleason's score by adding the predominant and lesser patterns as stated in the pathology report. For example, if predominant pattern is 3 and lesser pattern is 4, then Gleason's score is 3 + 4 = 7. For cases where Gleason's score is unknown, not reported or not applicable, code 99. | ||
623.4 | predominant pattern (50-70) | PRO2;46 | NUMERIC | Record the predominant (primary) pattern of tumor for Radical Prostatectomy, surgical codes 50-70. Gleason's grading system assigns histologic grade ranging from 1-5 to predominant pattern of tumor. Record the predominant pattern as stated in the pathology report. If the grade is not provided and only a Gleason score is available, enter a '0'. | ||
623.5 | lesser pattern (50-70) | PRO2;47 | NUMERIC | Record the lesser (secondary) pattern of tumor for Radical Prostatectomy, surgical codes 50-70. Gleason's grading system assigns histologic grade ranging from 1-5 to lesser pattern of tumor. Record the lesser pattern as stated in the pathology report. If the grade is not provided and only a Gleason score is available, enter a '0'. | ||
624 | research protocol | PRO1;25 | SET OF CODES | 1:In-house 2:Cooperative group 3:Not in a protocol 9:Unknown | Record whether the patient was entered into a protocol. | |
625 | rad therapy planned/given | PRO1;26 | SET OF CODES | 1:Yes 2:No, not recommended 3:Patient refused radiation therapy 4:Radiation was planned, but not given 9:Unknown | Record whether the patient received radiation therapy. | |
626 | interstitial rad planned/given | PRO1;27 | SET OF CODES | 1:Yes 2:No, not recommended 3:Patient refused radiation therapy 4:Radiation was planned, but not given 9:Unknown | Record whether the patient received interstitial radiation. | |
627 | iodine 125 | PRO1;28 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the isotope IODINE 125 was administered interstitially. | |
628 | gold 198 | PRO1;29 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the isotope GOLD 198 was administered interstitially. | |
629 | palladium 103 | PRO1;30 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the isotope PALLADIUM 103 was administered interstitially. | |
630 | iridium 192 | PRO1;31 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the isotope IRIDIUM 192 was administered interstitially. | |
631 | other interstitial, nos | PRO1;32 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether OTHER INTERSTITIAL, NOS isotopes were administered. | |
632 | external rad planned/given | PRO1;33 | SET OF CODES | 1:Yes 2:No, not recommended 3:Patient refused external radiation 4:Radiation was planned, but not given 9:Unknown | Record whether the patient received external radiation. | |
633 | prostate region only | PRO1;34 | SET OF CODES | 0:No, region/site not targeted 1:Yes 8:NA, external radiation not administered 9:Unknown | Record whether the PROSTATE REGION ONLY was irradiated. | |
634 | prostate and pelvic nodes | PRO1;35 | SET OF CODES | 0:No, region/site not targeted 1:Yes 8:NA, external radiation not administered 9:Unknown | Record whether PROSTATE AND PELVIC NODES were irradiated. | |
635 | prostate & pelvic para-aortic | PRO1;36 | SET OF CODES | 0:No, region/site not targeted 1:Yes 8:NA, external radiation not administered 9:Unknown | Record whether PROSTATE AND PELVIC PARA-AORTIC NODES were irradiated. | |
636 | distant metastatic sites | PRO1;37 | SET OF CODES | 0:No, region/site not targeted 1:Yes 8:NA, external radiation not administered 9:Unknown | Record whether DISTANT METASTATIC SITES were irradiated. | |
637 | other external sites, nos | PRO1;38 | SET OF CODES | 0:No, region/site not targeted 1:Yes 8:NA, external radiation not administered 9:Unknown | Record whether OTHER EXTERNAL SITES, NOS were irradiated. | |
638 | total rad dose (prostate) | PRO1;39 | SET OF CODES | 1:Less than 1999 rad 2:2000-3000 rad 3:3001-4000 rad 4:4001-5000 rad 5:5001-6000 rad 6:6001-7000 rad 7:More than 7001 rad 8:Not given 9:Rad does unknown | Record the TOTAL (external) RAD DOSE given to the PROSTATE; this includes boost dosage. Do not include interstitial rad dose. If it is known that the patient received radiation therapy, but the amount given is unknown, code 9 (rad dose unknown). | |
639 | total rad dose (pelvic nodes) | PRO1;40 | SET OF CODES | 1:Less than 1999 rad 2:2000-3000 rad 3:3001-4000 rad 4:4001-5000 rad 5:More than 5001 rad 8:Not given 9:Rad dose unknown | Record the TOTAL (external) RAD DOSE given to the PELVIC NODES; this includes boost dosage. Do not include interstitial rad dose. If it is known that the patient received radiation therapy, but the amount given is unknown, code 9 (rad dose unknown). | |
640 | total rad dose (para-aortic) | PRO1;41 | SET OF CODES | 1:Less than 1999 rad 2:2000-3000 rad 3:3001-4000 rad 5:More than 5001 rad 8:Not given 9:Rad dose unknown | Record the TOTAL (external) RAD DOSE given to the PARA-AORTIC NODES; this includes boost dosage. Do not include interstitial rad dose. If it is known that the patient received radiation therapy, but the amount given is unknown, code 9 (rad dose unknown). | |
641 | research protocol (radiation) | PRO1;42 | SET OF CODES | 1:In-house 2:Cooperative group 3:Not in a protocol 9:Unknown | Record the patient was entered into a protocol. | |
642 | hormone therapy planned/given | PRO1;43 | SET OF CODES | 1:Yes 2:No, not recommended 3:Patient refused hormonal therapy 4:Hormonal therapy was planned, but not given 9:Unknown | Record whether the patient received hormonal therapy. | |
643 | estrogens | PRO1;44 | SET OF CODES | 0:No 1:Yes 9:Unknown 2:No | Record all types of hormonal drugs given. | |
644 | antiandrogens | PRO1;45 | SET OF CODES | 0:No 1:Yes 9:Unknown 2:No | Record all types of hormonal drugs given. | |
645 | progestational agents | PRO1;46 | SET OF CODES | 0:No 1:Yes 9:Unknown 2:No | Record all types of hormonal drugs given. | |
646 | luteinizing hormones | PRO1;47 | SET OF CODES | 0:No 1:Yes 9:Unknown 2:No | Record all types of hormonal drugs given. | |
647 | orchiectomy | PRO1;48 | SET OF CODES | 1:Yes 2:No 9:Unknown | Record whether an ORCHIECTOMY was administered. Code 2 (No) if an ORCHIECTOMY was not given. | |
648 | other exogenous hormone agents | PRO1;49 | SET OF CODES | 0:No 1:Yes 9:Unknown 2:No | Record all types of hormonal drugs given. | |
649 | backache (1st recurrence) | PRO1;50 | SET OF CODES | 1:Yes 2:No 9:Unknown | Record whether a BACKACHE was used to diagnose the first recurrence. | |
650 | bone scan (1st recurrence) | PRO1;51 | SET OF CODES | 1:Yes 2:No 9:Unknown | Record if a BONE SCAN was used to diagnose the first recurrence. | |
651 | lethargy | PRO1;52 | SET OF CODES | 1:Yes 2:No 9:Unknown | Record if LETHARGY was used to diagnose the first recurrence. | |
652 | rectal exam (1st recurrence) | PRO1;53 | SET OF CODES | 1:Yes 2:No 9:Unknown | Record whether a RECTAL EXAMINATION FOLLOWED BY NEEDLE BIOPSY was used to diagnose the first recurrence. | |
653 | tumor marker (1st recurrence) | PRO1;54 | SET OF CODES | 1:Yes 2:No 9:Unknown | Record whether TUMOR MARKER ELEVATION was used to diagnose the first recurrence. | |
654 | weight loss (1st recurrence) | PRO1;55 | SET OF CODES | 1:Yes 2:No 9:Unknown | Record whether WEIGHT LOSS was used to diagnose the first recurrence. | |
655 | other methods (1st recurrence) | PRO1;56 | SET OF CODES | 1:Yes 2:No 9:Unknown | Record whether OTHER methods were used to diagnose the first recurrence. | |
656 | reason for 2nd course | PRO1;57 | SET OF CODES | 1:Recurrence 2:Progression of disease 8:No therapy 9:Unknown | Record whether the patient received treatment for recurrence or progression of disease. | |
657 | fam hist of prostate ca (pr98) | PRO2;1 | SET OF CODES | 0:No 1:Yes, 1st degree relative 2:Yes, relative other than 1st degree 3:Yes, degree of relative unknown 9:Unknown | Record any familial history of prostate cancer documented in the medical record. First degree relatives include the patient's father, brother, or son. A grandfather, uncle, or cousin would not be considered a first degree relative. | |
658 | hematuria (pr98) | PRO2;2 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record all symptoms specific to prostate cancer that were reported by the patient and included in the medical chart. | |
659 | lower back pain (pr98) | PRO2;3 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record all symptoms specific to prostate cancer that were reported by the patient and included in the medical chart. | |
660 | trouble urinating (pr98) | PRO2;4 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record all symptoms specific to prostate cancer that were reported by the patient and included in the medical chart. | |
661 | clin dx w/ bone lesion (pr98) | PRO2;5 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the Initial Method of Diagnosis: CLINICAL DIAGNOSIS WITH BONE LESION was performed to diagnose this case of prostate cancer. | |
662 | clin dx by rectal exam (pr98) | PRO2;6 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the Initial Method of Diagnosis: CLINICAL DIAGNOSIS BY RECTAL EXAM was performed to diagnose this case of prostate cancer. | |
663 | cytology (pr98) | PRO2;7 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the Initial Method of Diagnosis: CYTOLOGY was performed to diagnose this case of prostate cancer. | |
664 | digital transrectal bio (pr98) | PRO2;8 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the Initial Method of Diagnosis: DIGITAL TRANSRECTAL BIOPSY was performed to diagnose this case of prostate cancer. | |
665 | incidental find in turp (pr98) | PRO2;9 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the Method of Diagnosis: INCIDENTAL FINDING IN TRANSURETHRAL RESECTION OF PROSTATE (TURP) FOR BENIGN DISEASE was performed to diagnose this case of prostate cancer. | |
666 | needle biopsy, nos (pr98) | PRO2;10 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the Initial Method of Diagnosis: NEEDLE BIOPSY, NOS was performed to diagnose this case of prostate cancer. | |
667 | perineal biopsy (pr98) | PRO2;11 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the Initial Method of Diagnosis: PERINEAL BIOPSY was performed to diagnose this case of prostate cancer. | |
668 | psa method of diagnosis (pr98) | PRO2;12 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the Initial Method of Diagnosis: PROSTATIC SPECIFIC ANTIGEN (PSA) was performed to diagnose this case of prostate cancer. | |
669 | transrectal biopsy (pr98) | PRO2;13 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the Initial Method of Diagnosis: TRANSRECTAL ULTRASONOGRAPHICALLY GUIDED BIOPSY (TRUS) was performed to diagnose this case of prostate cancer. | |
670 | transurethral resection (pr98) | PRO2;14 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the Initial Method of Diagnosis: TRANSURETHRAL RESECTION OF PROSTATE, NOS was performed to diagnose this case of prostate cancer. | |
671 | bone marrow aspiration (pr98) | PRO2;15 | SET OF CODES | 0:Test not done 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Procedure attempted and incomplete 8:Test done, results unknown 9:Unknown if test done | Record the results of the BONE MARROW ASPIRATION diagnostic test performed to evaluate the prostate tumor. If the study was done and the results cannot be determined, code 8 (Test done, results unknown). If it is unknown if the test was done code 9 (Unknown if test done). | |
672 | bone scan (pr98) | PRO2;16 | SET OF CODES | 0:Test not done 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Procedure attempted and incomplete 8:Test done, results unknown 9:Unknown if test done | Record the results of the BONE SCAN diagnostic test performed to evaluate the prostate tumor. If the study was done and the results cannot be determined, code 8 (Test done, results unknown). If it is unknown if the test was done code 9 (Unknown if test done). | |
673 | bone x-ray (pr98) | PRO2;17 | SET OF CODES | 0:Test not done 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Procedure attempted and incomplete 8:Test done, results unknown 9:Unknown if test done | Record the results of the BONE X-RAY diagnostic test performed to evaluate the prostate tumor. If the study was done and the results cannot be determined, code 8 (Test done, results unknown). If it is unknown if the test was done code 9 (Unknown if test done). | |
674 | chest x-ray (pr98) | PRO2;18 | SET OF CODES | 0:Test not done 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Procedure attempted and incomplete 8:Test done, results unknown 9:Unknown if test done | Record the results of the CHEST X-RAY diagnostic test performed to evaluate the prostate tumor. If the study was done and the results cannot be determined, code 8 (Test done, results unknown). If it is unknown if the test was done code 9 (Unknown if test done). | |
675 | ct scan of abdomen (pr98) | PRO2;19 | SET OF CODES | 0:Test not done 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Procedure attempted and incomplete 8:Test done, results unknown 9:Unknown if test done | Record the results of the CT SCAN OF ABDOMEN diagnostic test performed to evaluate the prostate tumor. If the study was done and the results cannot be determined, code 8 (Test done, results unknown). If it is unknown if the test was done code 9 (Unknown if test done). | |
676 | ct scan of pelvis (pr98) | PRO2;20 | SET OF CODES | 0:Test not done 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Procedure attempted and incomplete 8:Test done, results unknown 9:Unknown if test done | Record the results of the CT SCAN OF PELVIS diagnostic test performed to evaluate the prostate tumor. If the study was done and the results cannot be determined, code 8 (Test done, results unknown). If it is unknown if the test was done code 9 (Unknown if test done). | |
677 | intravenous pyelogram (pr98) | PRO2;21 | SET OF CODES | 0:Test not done 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Procedure attempted and incomplete 8:Test done, results unknown 9:Unknown if test done | Record the results of the INTRAVENOUS PYELOGRAM (IVP) diagnostic test performed to evaluate the prostate tumor. If the study was done and the results cannot be determined, code 8 (Test done, results unknown). If it is unknown if the test was done code 9 (Unknown if test done). | |
678 | mri (pr98) | PRO2;22 | SET OF CODES | 0:Test not done 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Procedure attempted and incomplete 8:Test done, results unknown 9:Unknown if test done | Record the results of the MAGNETIC RESONANCE IMAGING (MRI) diagnostic test performed to evaluate the prostate tumor. If the study was done and the results cannot be determined, code 8 (Test done, results unknown). If it is unknown if the test was done code 9 (Unknown if test done). | |
679 | pelvic lymph nd dissect (pr98) | PRO2;23 | SET OF CODES | 0:Test not done 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Procedure attempted and incomplete 8:Test done, results unknown 9:Unknown if test done | Record the results of the PELVIC LYMPH NODE DISSECTION diagnostic test performed to evaluate the prostate tumor. If the study was done and the results cannot be determined, code 8 (Test done, results unknown). If it is unknown if the test was done code 9 (Unknown if test done). | |
680 | polymerase chain react (pr98) | PRO2;24 | SET OF CODES | 0:Test not done 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Procedure attempted and incomplete 8:Test done, results unknown 9:Unknown if test done | Record the results of the POLYMERASE CHAIN REACTION ASSAY (PCR) diagnostic test performed to evaluate the prostate tumor. If the study was done and the results cannot be determined, code 8 (Test done, results unknown). If it is unknown if the test was done code 9 (Unknown if test done). | |
681 | prostatic acid phosph (pr98) | PRO2;25 | SET OF CODES | 0:Test not done 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Procedure attempted and incomplete 8:Test done, results unknown 9:Unknown if test done | Record the results of the PROSTATIC ACID PHOSPHATASE (PAP) diagnostic test performed to evaluate the prostate tumor. If the study was done and the results cannot be determined, code 8 (Test done, results unknown). If it is unknown if the test was done code 9 (Unknown if test done). | |
682 | psa diagnostic eval (pr98) | PRO2;26 | SET OF CODES | 0:Test not done 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Procedure attempted and incomplete 8:Test done, results unknown 9:Unknown if test done | Record the results of the PROSTATE SPECIFIC ANTIGEN (PSA) diagnostic test performed to evaluate the prostate tumor. If the study was done and the results cannot be determined, code 8 (Test done, results unknown). If it is unknown if the test was done code 9 (Unknown if test done). | |
683 | ultrasound of abdomen (pr98) | PRO2;27 | SET OF CODES | 0:Test not done 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Procedure attempted and incomplete 8:Test done, results unknown 9:Unknown if test done | Record the results of the ULTRASOUND OF ABDOMEN diagnostic test performed to evaluate the prostate tumor. If the study was done and the results cannot be determined, code 8 (Test done, results unknown). If it is unknown if the test was done code 9 (Unknown if test done). | |
684 | psa | PRO2;28 | FREE TEXT | Records the results of the highest pre-treatment Prostate Specific Antigen (PSA) test given within the last 12 months. If the first course of treatment was Watchful Waiting, the date the decision was made is considered the first course of treatment. Round the test result to the nearest single decimal point. Record 999.6 if PSA value was 999.6 or higher. Record 999.7 if no PSA test was performed. Record 999.8 if the test was done and results are unknown/not reported. Record 999.9 if it is unknown if the test was performed. | ||
685 | watchful waiting (pr98) | PRO2;29 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether or not the patient chose to forego surgery, radiation therapy, chemotherapy, and hormone therapy in favor of no immediate medical intervention. | |
686 | length of stay (pr98) | PRO2;30 | NUMERIC | Record the number of days the patient remained in the hospital following cancer-directed surgery. Include the day on which the patient was admitted to the hospital for treatment, and the day before the patient was discharged from the hospital. For example, if patient was admitted 1/12/98 and discharged 1/18/98, the length of stay is 6 days. If not applicable code, 88. If unknown, code 99. | ||
687 | laparoscopic (pr98) | PRO2;31 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | Record whether the LAPAROSCOPIC Type of Regional Lymph Node surgery was performed. If not applicable, code 8. If unknown, code 9. | |
688 | open (pr98) | PRO2;32 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | Record whether the OPEN Type of Regional Lymph Node surgery was performed. If not applicable, code 8. If unknown, code 9. | |
689 | permanent rectal injury (pr98) | PRO2;33 | SET OF CODES | 0:No 1:Yes 8:NA, no surgery 9:Unknown | Record whether permanent rectal injury was a surgical complication which was reported within 30 days of first course of treatment cancer- directed surgery. If not applicable, code 8. If unknown, code 9. | |
690 | thromboembolism (pr98) | PRO2;34 | SET OF CODES | 0:No 1:Yes 8:NA, no surgery 9:Unknown | Record whether thromboembolism was a surgical complication which was reported within 30 days of first course of treatment cancer- directed surgery. If not applicable, code 8. If unknown, code 9. | |
691 | urethral stricture (pr98) | PRO2;35 | SET OF CODES | 0:No 1:Yes 8:NA, no surgery 9:Unknown | Record whether urethral stricture was a surgical complication which was reported within 30 days of first course of treatment cancer- directed surgery. If not applicable, code 8. If unknown, code 9. | |
692 | radiation facility | PRO2;36 | SET OF CODES | 1:Reporting hospital 2:Other hospital 3:Freestanding facility 4:NOS 8:NA, radiation not administered 9:Unknown | Record whether radiation was administered at reporting hospital or administered elsewhere. Record 8 if no radiation administered. Record 9 if the radiation facility is unknown. | |
693 | route of interstitial rad | PRO2;37 | SET OF CODES | 1:Perineal 2:Open 8:NA, not administered 9:Unknown | Record the route by which interstitial radiation/brachytherapy was administered. Record 8 if not applicable. Record 9 if unknown. | |
694 | type of radiation admin | PRO2;38 | SET OF CODES | 1:Conformal therapy 2:Standard 8:NA 9:Unknown | Record the method by which external beam radiation was administered. Conformal therapy is a three dimensional radiation technique that minimizes exposure to normal tissue. Record 8 if not applicable. Record 9 if unknown. | |
695 | gastrointestinal complications | PRO2;39 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | Record whether or not acute gastrointestinal complications were reported within 90 days of the start of radiation therapy. Record 8 if not applicable. Record 9 if unknown. | |
696 | gastrourinary complications | PRO2;40 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | Record whether or not acute gastrourinary complications were reported within 90 days of the start of radiation therapy. Record 8 if not applicable. Record 9 if unknown. | |
697 | anorectal complications | PRO2;41 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | Record whether or not anorectal complications were reported within 90 days of the start of radiation therapy. Record 8 if not applicable. Record 9 if unknown. | |
698 | chronic complications | PRO2;42 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | Record whether or not chronic complications requiring surgery or prolonged hospitalization were reported within 90 days of the start of radiation therapy. Record 8 if not applicable. Record 9 if unknown. | |
699 | urethral/bladder complications | PRO2;48 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | Record whether or not urethral or bladder complications were reported within 90 days of the start of radiation therapy. Record 8 if not applicable. Record 9 if unknown. | |
699.1 | date of orchiectomy | PRO2;49 | DATE-TIME | Record the date of the orchiectomy. If no orchiectomy was performed, code 00/00/0000. If an orchiectomy was performed, but the month, day or year is unknown, code the unknown item with 9's. | ||
700 | history of colorectal ca (fam) | COL1;1 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record any familial history of colorectal cancer documented in the medical record. | |
701 | history of colorectal ca (pt) | COL1;2 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record and personal history of a previous colorectal cancer documented in the medical record prior to 1997. | |
702 | multiple colorectal primaries | COL1;3 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record if a second colorectal primary was diagnosed in addition to this reported cancer. If a patient has more than one colorectal primary and more than one record will be submitted, answer 'yes' on all records submitted for the patient. Note: If a second primary is accessioned late in the year, please remember to change the data item on any earlier records. | |
703 | history of breast ca (pt) | COL1;4 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the patient has a history of breast cancer. | |
704 | history of lung ca (pt) | COL1;5 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the patient has a history of lung cancer. | |
705 | history of ovarian ca (pt) | COL1;6 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the patient has a history of ovarian cancer. | |
706 | history of ovarian carcinoma | COL1;7 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the patient has a history of ovarian carcinoma, peritoneal site. Note: Ovarian carcinoma, peritoneal site does not refer to metastatic disease. It is a primary ovarian cancer arising in the peritoneum, not in the ovary. | |
707 | history of stomach ca (pt) | COL1;8 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the patient has a history of stomach cancer. | |
708 | history of thyroid ca (pt) | COL1;9 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the patient has a history of thyroid cancer. | |
709 | history of uterus ca (pt) | COL1;10 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the patient has a history of uterus cancer. | |
710 | previous tah/bso | COL1;11 | SET OF CODES | 0:No 1:Yes 9:Unknown | TAH/BSO (Total abdominal hysterectomy/bilateral salpingo-oophorectomy) Record the appropriate code. | |
711 | familial adenomatous polyps | COL1;12 | SET OF CODES | 0:No 1:Yes 9:Unknown/not documented | Record whether the patient was affected by FAP (Familial adenomatous polyposis). | |
712 | hnpcc | COL1;13 | SET OF CODES | 0:No 1:Yes 9:Unknown/not documented | Record whether the patient is affected by hereditary nonpolyposis colon cancer (HNPCC) syndrome. | |
713 | inflammatory bowel disease | COL1;14 | SET OF CODES | 0:No 1:Yes 9:Unknown/not documented | Record whether the patient was affected by inflammatory bowel disease (IBD). | |
714 | prior polyps | COL1;15 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record the appropriate code for prior polyps. | |
715 | polyps | COL1;16 | NUMERIC | Record number of adenomas. If no adenomas, record 88. If number of adenomas unknown, record 90. If unknown if adenomas, record 99. | ||
716 | duration of anemia | COL1;17 | NUMERIC | Record all anemia symptoms specific to the colorectal cancer that were reported by the patient and included in the medical chart. Round down to the nearest whole number if months fall into a range. For example, if the patient had symptoms for two to three months, record 02. If a symptom was not reported in the chart, code 99 (Unknown). | ||
717 | duration of bowel obstruction | COL1;18 | NUMERIC | Record all bowel obstruction symptoms specific to the colorectal cancer that were reported by the patient and included in the medical chart. Round down to the nearest whole number if months fall into a range. For example, if the patient had symptoms for two to three months, record 02. If a symptom was not reported in the chart, code 99 (Unknown). | ||
718 | duration of bowel habit change | COL1;19 | NUMERIC | Record all change in bowel habit symptoms specific to the colorectal cancer that were reported by the patient and included in the medical chart. Round down to the nearest whole number if months fall into a range. For example, if the patient had symptoms for two to three months, record 02. If a symptom was not reported in the chart, code 99 (Unknown). | ||
719 | duration of emergency pres-obs | COL1;20 | NUMERIC | Record all emergency presentation-obstruction symptoms specific to the colorectal cancer that were reported by the patient and included in the medical chart. Round down to the nearest whole number if months fall into a range. For example, if the patient had symptoms for two to three months, record 02. If a symptom was not reported in the chart, code 99 (Unknown). | ||
720 | duration of jaundice | COL1;21 | NUMERIC | Record all jaundice symptoms specific to the colorectal cancer that were reported by the patient and included in the medical chart. Round down to the nearest whole number if months fall into a range. For example, if the patient had symptoms for two to three months, record 02. If a symptom was not reported in the chart, code 99 (Unknown). | ||
721 | duration of malaise | COL1;22 | NUMERIC | Record all malaise symptoms specific to the colorectal cancer that were reported by the patient and included in the medical chart. Round down to the nearest whole number if months fall into a range. For example, if the patient had symptoms for two to three months, record 02. If a symptom was not reported in the chart, code 99 (Unknown). | ||
722 | duration of blood in stool | COL1;23 | NUMERIC | Record all occult blood in stool symptoms specific to the colorectal cancer that were reported by the patient and included in the medical chart. Round down to the nearest whole number if months fall into a range. For example, if the patient had symptoms for two to three months, record 02. If a symptom was not reported in the chart, code 99 (Unknown). | ||
723 | duration of pain (abdominal) | COL1;24 | NUMERIC | Record all abdominal pain symptoms specific to the colorectal cancer that were reported by the patient and included in the medical chart. Round down to the nearest whole number if months fall into a range. For example, if the patient had symptoms for two to three months, record 02. If a symptom was not reported in the chart, code 99 (Unknown). | ||
724 | duration of pain (pelvic) | COL1;25 | NUMERIC | Record all pelvic pain symptoms specific to the colorectal cancer that were reported by the patient and included in the medical chart. Round down to the nearest whole number if months fall into a range. For example, if the patient had symptoms for two to three months, record 02. If a symptom was not reported in the chart, code 99 (Unknown). | ||
725 | duration of rectal bleeding | COL1;26 | NUMERIC | Record all rectal bleeding symptoms specific to the colorectal cancer that were reported by the patient and included in the medical chart. Round down to the nearest whole number if months fall into a range. For example, if the patient had symptoms for two to three months, record 02. If a symptom was not reported in the chart, code 99 (Unknown). | ||
726 | duration of other | COL1;27 | NUMERIC | Record all other symptoms specific to the colorectal cancer that were reported by the patient and included in the medical chart. Round down to the nearest whole number if months fall into a range. For example, if the patient had symptoms for two to three months, record 02. If a symptom was not reported in the chart, code 99 (Unknown). | ||
727 | endoscopic method | COL1;28 | SET OF CODES | 0:Not done 1:Done 9:Unknown if done | Record whether 'endoscopic' initial method of diagnosis was performed. If unknown, code a '9'. | |
728 | radiographic method | COL1;29 | SET OF CODES | 0:Not done 1:Done 9:Unknown if done | Record whether 'radiographic' initial method of diagnosis was performed. If unknown, code a '9'. | |
729 | screening digital rectal exam | COL1;30 | SET OF CODES | 0:Not done 1:Done 9:Unknown if done | Record whether 'screening digital rectal exam' initial method of diagnosis was performed. If unknown, code a '9'. | |
730 | screening physical exam method | COL1;31 | SET OF CODES | 0:Not done 1:Done 9:Unknown if done | Record whether 'screening physical exam' initial method of diagnosis was performed. If unknown, code a '9'. | |
731 | other initial method | COL1;32 | SET OF CODES | 0:Not done 1:Done 9:Unknown if done | Record whether other initial method of diagnosis was performed. If unknown, code a '9'. | |
732 | reason leading to eventual dx | COL1;33 | SET OF CODES | 0:General screening (endoscopy, hemocult) 1:Symptoms 2:Familial history 3:Genetic test 4:Other 9:Unknown | Record the appropriate code for the precipitating reason or procedure which eventually lead to diagnosing this patient with this cancer. If unknown, code a '9'. | |
733 | barium enema, double contrast | COL1;34 | SET OF CODES | 0:Test not done 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Procedure attempted and incomplete 8:Test done, results unknown 9:Unknown if test done | Record the results of the Diagnostic Test 'BARIUM ENEMA, DOUBLE CONTRAST', if it was performed to evaluate this cancer. If this test was not done record a '0'. | |
734 | barium enema, single contrast | COL1;35 | SET OF CODES | 0:Test not done 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Procedure attempted and incomplete 8:Test done, results unknown 9:Unknown if test done | Record the results of the Diagnostic Test 'BARIUM ENEMA, SINGLE CONTRAST', if it was performed to evaluate this cancer. If this test was not done record a '0'. | |
735 | barium enema, nos | COL1;36 | SET OF CODES | 0:Test not done 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Procedure attempted and incomplete 8:Test done, results unknown 9:Unknown if test done | Record the results of the Diagnostic Test 'BARIUM ENEMA, NOS', if it was performed to evaluate this cancer. If this test was not done record a '0'. | |
736 | biopsy of primary site | COL1;37 | SET OF CODES | 0:Test not done 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Procedure attempted and incomplete 8:Test done, results unknown 9:Unknown if test done | Record the results of the Diagnostic Test 'BIOPSY OF PRIMARY SITE', if it was performed to evaluate this cancer. If this test was not done record a '0'. | |
737 | biopsy of metastatic site | COL1;38 | SET OF CODES | 0:Test not done 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Procedure attempted and incomplete 8:Test done, results unknown 9:Unknown if test done | Record the results of the Diagnostic Test 'BIOPSY OF METASTATIC SITE', if it was performed to evaluate this cancer. If this test was not done record a '0'. | |
738 | ct scan of liver | COL1;39 | SET OF CODES | 0:Test not done 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Procedure attempted and incomplete 8:Test done, results unknown 9:Unknown if test done | Record the results of the Diagnostic Test 'CT SCAN OF LIVER', if it was performed to evaluate this cancer. If this test was not done record a '0'. | |
739 | ct scan of primary site (col) | COL1;40 | SET OF CODES | 0:Test not done 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Procedure attempted and incomplete 8:Test done, results unknown 9:Unknown if test done | Record the results of the Diagnostic Test 'CT SCAN OF PRIMARY SITE', if it was performed to evaluate this cancer. If this test was not done record a '0'. | |
740 | carcinoembryonic antigen (cea) | COL1;41 | SET OF CODES | 0:Test not done 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Procedure attempted and incomplete 8:Test done, results unknown 9:Unknown if test done | Record the results of the Diagnostic Test 'CARCINOEMBRYONIC ANTIGEN (CEA)', if it was performed to evaluate this cancer. If this test was not done record a '0'. | |
741 | chest roentgenogram | COL1;42 | SET OF CODES | 0:Test not done 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Procedure attempted and incomplete 8:Test done, results unknown 9:Unknown if test done | Record the results of the Diagnostic Test 'CHEST ROENTGENOGRAM', if it was performed to evaluate this cancer. If this test was not done record a '0'. | |
742 | colonoscopy | COL1;43 | SET OF CODES | 0:Test not done 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Procedure attempted and incomplete 8:Test done, results unknown 9:Unknown if test done | Record the results of the Diagnostic Test 'COLONOSCOPY', if it was performed to evaluate this cancer. If this test was not done record a '0'. | |
743 | digital rectal exam | COL1;44 | SET OF CODES | 0:Test not done 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Procedure attempted and incomplete 8:Test done, results unknown 9:Unknown if test done | Record the results of the Diagnostic Test 'DIGITAL RECTAL EXAM', if it was performed to evaluate this cancer. If this test was not done record a '0'. | |
744 | flexible sigmoidoscopy | COL1;45 | SET OF CODES | 0:Test not done 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Procedure attempted and incomplete 8:Test done, results unknown 9:Unknown if test done | Record the results of the Diagnostic Test 'FLEXIBLE SIGMOIDOSCOPY', if it was performed to evaluate this cancer. If this test was not done record a '0'. | |
745 | intravenous pyelogram (col) | COL1;46 | SET OF CODES | 0:Test not done 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Procedure attempted and incomplete 8:Test done, results unknown 9:Unknown if test done | Record the results of the Diagnostic Test 'INTRAVENOUS PYELOGRAM (IVP)', if it was performed to evaluate this cancer. If this test was not done record a '0'. | |
746 | serum-liver function test | COL1;47 | SET OF CODES | 0:Test not done 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Procedure attempted and incomplete 8:Test done, results unknown 9:Unknown if test done | Record the results of the Diagnostic Test 'SERUM-LIVER FUNCTION TEST', if it was performed to evaluate this cancer. If this test was not done record a '0'. | |
747 | mri (col) | COL1;48 | SET OF CODES | 0:Test not done 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Procedure attempted and incomplete 8:Test done, results unknown 9:Unknown if test done | Record the results of the Diagnostic Test 'MAGNETIC RESONANCE IMAGING (MRI)', if it was performed to evaluate this cancer. If this test was not done record a '0'. | |
748 | proctoscopy (rigid) | COL1;49 | SET OF CODES | 0:Test not done 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Procedure attempted and incomplete 8:Test done, results unknown 9:Unknown if test done | Record the results of the Diagnostic Test 'PROCTOSCOPY (RIGID)', if it was performed to evaluate this cancer. If this test was not done record a '0'. | |
749 | stool guaiac (occult blood) | COL1;50 | SET OF CODES | 0:Test not done 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Procedure attempted and incomplete 8:Test done, results unknown 9:Unknown if test done | Record the results of the Diagnostic Test 'STOOL GUAIAC (OCCULT BLOOD)', if it was performed to evaluate this cancer. If this test was not done record a '0'. | |
750 | ultrasound, liver, abdomen | COL1;51 | SET OF CODES | 0:Test not done 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Procedure attempted and incomplete 8:Test done, results unknown 9:Unknown if test done | Record the results of the Diagnostic Test 'ULTRASOUND, LIVER, ABDOMEN', if it was performed to evaluate this cancer. If this test was not done record a '0'. | |
751 | ultrasound, endorectal | COL1;52 | SET OF CODES | 0:Test not done 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Procedure attempted and incomplete 8:Test done, results unknown 9:Unknown if test done | Record the results of the Diagnostic Test 'ULTRASOUND, ENDORECTAL', if it was performed to evaluate this cancer. If this test was not done record a '0'. | |
752 | tumor level-endoscopic exam | COL2;1 | NUMERIC | Record the level of tumor from anal verge by endoscopic exam in centimeters if less than 61 centimeters. If greater than 60 centi- meters, record the appropriate code for tumor site in colon. If examination performed but tumor not visualized, record a '70'. If examination was performed, but results unknown, record '80'. If unknown whether examination was performed, record '99'. If this exam- ination was not performed code '00'. | ||
753 | level of rectal tumor | COL2;2 | SET OF CODES | 0:Not measured 1:Low (0-5 cm) 2:Medium (6-10 cm) 3:High (11-15 cm) 7:Measured but results unknown 8:NA, not a rectal tumor 9:Unknown if measured | Record the appropriate code for the level of rectal tumor. If level not measured, record '0'. If level measured, but results unknown, record '7'. If not applicable, record '8'. Record '9' if unknown if measured. | |
754 | proximal margin of resection | COL2;3 | SET OF CODES | 0:Negative 1:Microscopically positive 2:Grossly positive 8:NA 9:Unknown, not described | Record the appropriate code for the Proximal margin of resection. | |
755 | distal margin of resection | COL2;4 | SET OF CODES | 0:Negative 1:Microscopically positive 2:Grossly positive 8:NA 9:Unknown, not described | Record the appropriate code for the Distal margin of resection. | |
756 | radial margin of resection | COL2;5 | SET OF CODES | 0:Negative 1:Microscopically positive 2:Grossly positive 8:NA 9:Unknown, not described | Record the appropriate code for the Radial margin of resection. | |
757 | dist to closest mucosal margin | COL2;6 | NUMERIC | Record the distance in millimeters (mm) to the closest mucosal margin (or to dentate for abdominal perineal resection). This may also be described as the lateral or circumferential margin. Record the distance in millimeters. Record 88 if not applicable. If unknown, record 99. | ||
758 | dist to closest radial margin | COL2;7 | NUMERIC | Record the distance in millimeters (mm) to the closest radial margin (or to the base of excision, if polyp). Record the distance in millimeters. Record 88 if not applicable. If unknown, record 99. | ||
759 | blood vessel or lymphatic inv | COL2;8 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record the appropriate code for blood vessel or lymphatic invasion. | |
760 | extramural venous invasion | COL2;9 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record the appropriate code for extramural venous invasion. | |
761 | prominent lymphoid infiltrate | COL2;10 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record the appropriate code for prominent lymphoid infiltrate (Crohn's lymphoid follicle). | |
762 | phys providing def treatment | COL2;11 | SET OF CODES | 1:Colorectal board certified surgeon 2:Gastroenterologist 3:General surgeon 4:Radiation therapist 5:Other 9:Unknown | Record the appropriate code representing the physician that provided the definitive treatment. | |
763 | additional surgical procedures | COL2;12 | NUMERIC | Enter any modified or additional surgical procedures for primary rectosigmoid or rectal cancer. Record the appropriate code if any of the specified procedures were performed. Please note that these codes do not represent the procedures as defined for the required surgery codes. For this field, these codes identify only the specified procedures. Record 88 for not applicable, not performed. Record 99 for unknown if performed. | ||
764 | laparoscopy used during cds | COL2;13 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | Record whether a laparoscopic procedure was used during cancer- directed surgery. Record an '8' if not applicable. | |
765 | method of anastomosis | COL2;14 | SET OF CODES | 0:Not done 1:Staple 2:Created by hand 8:Method not recorded 9:Unknown if done | Record the appropriate code for the method of anastomosis. | |
766 | cm from anastomosis to dentate | COL2;15 | NUMERIC | Record the distance in centimeters of anastomosis from dentate. | ||
767 | colostomy | COL2;16 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether a colonscopy was performed. | |
768 | oophorectomy | COL2;17 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether an oophorectomy was performed. If an oophorectomy was performed, record the pathological status in the pathological status field. | |
769 | pathological status | COL2;18 | SET OF CODES | 0:Not involved 1:Involved 8:NA 9:Unknown | Record the appropriate code. If an oophorectomy was performed, then record the pathological status in this field. If not performed, code an '8' (NA). | |
770 | abdominal infection | COL2;19 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | Record whether the patient had the surgical complication 'BLEEDING/HEMATOMA', which resulted from treatment. If the complication did not occur, code a '0' (no). If no treatment was performed, code 8 (NA). | |
771 | abscess | COL2;20 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | Record whether the patient had the surgical complication 'ABSCESS', which resulted from treatment. If the complication did not occur, code a '0' (no). If no treatment was performed, code 8 (NA). | |
772 | admission for neutropenia | COL2;21 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | Record whether the patient had the surgical complication 'ADMISSION FOR NEUTROPENIA', which resulted from treatment. If the complication did not occur, code a '0' (no). If no treatment was performed, code 8 (NA). | |
773 | anastomotic dehiscence | COL2;22 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | Record whether the patient had the surgical complication 'ANASTOMOTIC DEHISCENCE', which resulted from treatment. If the complication did not occur, code a '0' (no). If no treatment was performed, code 8 (NA). | |
774 | dehydration | COL2;23 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | Record whether the patient had the surgical complication 'DEHYDRATION', which resulted from treatment. If the complication did not occur, code a '0' (no). If no treatment was performed, code 8 (NA). | |
775 | diarrhea | COL2;24 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | Record whether the patient had the surgical complication 'DIARRHEA', which resulted from treatment. If the complication did not occur, code a '0' (no). If no treatment was performed, code 8 (NA). | |
776 | early bowel obstruction | COL2;25 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | Record whether the patient had the surgical complication 'EARLY BOWEL OBSTRUCTION', which resulted from treatment. If the complication did not occur, code a '0' (no). If no treatment was performed, code 8 (NA). | |
777 | perineal infection | COL2;26 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | Record whether the patient had the surgical complication 'PERINEAL INFECTION', which resulted from treatment. If the complication did not occur, code a '0' (no). If no treatment was performed, code 8 (NA). | |
778 | pneumonia (col) | COL2;27 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | Record whether the patient had the surgical complication 'PNEUMONIA', which resulted from treatment. If the complication did not occur, code a '0' (no). If no treatment was performed, code 8 (NA). | |
779 | proctitis | COL2;28 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | Record whether the patient had the surgical complication 'PROCTITIS', which resulted from treatment. If the complication did not occur, code a '0' (no). If no treatment was performed, code 8 (NA). | |
780 | pulmonary embolism (col) | COL2;29 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | Record whether the patient had the surgical complication 'PULMONARY EMBOLISM', which resulted from treatment. If the complication did not occur, code a '0' (no). If no treatment was performed, code 8 (NA). | |
781 | radiation enteritis | COL2;30 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | Record whether the patient had the surgical complication 'RADIATION ENTERITIS', which resulted from treatment. If the complication did not occur, code a '0' (no). If no treatment was performed, code 8 (NA). | |
782 | stoma complication | COL2;31 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | Record whether the patient had the surgical complication 'STOMA COMPLICATION', which resulted from treatment. If the complication did not occur, code a '0' (no). If no treatment was performed, code 8 (NA). | |
783 | urinary tract infection | COL2;32 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | Record whether the patient had the surgical complication 'URINARY TRACT INFECTION', which resulted from treatment. If the complication did not occur, code a '0' (no). If no treatment was performed, code 8 (NA). | |
784 | endocavitary radiation (ecrt) | COL2;33 | SET OF CODES | 0:None 1:Yes 9:Unknown | Record the appropriate code for whether endocavitary radiation (ECRT) was given. ECRT refers to contact radiation delivered through the bowel lumen, usually proctoscopically, especially for rectal cancer. | |
785 | intra-operative rad therapy | COL2;34 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record the appropriate code for whether intra-operative radiation therapy (IORT) was given. IORT is beam radiation and/or radioactive implants and/or radioisotopes at time of surgery. | |
786 | primary tumor rad dose (cgy) | COL2;35 | NUMERIC | Record the primary tumor total rad dose (cGy) given, including boost. If the patient did not receive radiation therapy, code 00000. If it is known that the patient received radiation therapy but the dose is unknown, code 88888. If it is unknown if patient received radiation, code 99999. | ||
787 | number of radiation treatments | COL2;36 | NUMERIC | Record the number of radiation treatments. If none, record 00. If given, but number unknown, record 88. If unknown if radiation given, record 99. | ||
788 | adjuvant chemotherapy (col) | COL2;37 | SET OF CODES | 0:No concomitant treatment 1:Radiation and concomitant bolus chemo 2:Radiation and concomitant infusion chemo 9:Unknown if therapy concomitant | Record the Adjuvant Chemotherapy with Concomitant External Beam Radiation. If patient receives chemotherapy at any time during radiation as a radio- sensitizing agent, code 1. If chemotherapy is stopped more than 2 days prior to radiation therapy and not given until external beam therapy is completed, code 0. If unknown, code 9. | |
789 | 5 fu (fluorouracil) | COL2;38 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the adjuvant therapy 5 FU (Fluorouracil) was given. If it is unknown if it was given, record a 9. | |
790 | leucovorin | COL2;39 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the adjuvant therapy Leucovorin was given. If it is unknown if it was given, record a 9. | |
791 | levamisole | COL2;40 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | Record whether the adjuvant therapy Levamisole was given. If it is unknown if it was given, record a 9. | |
792 | cpt 11 | COL2;41 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the adjuvant therapy CPT 11 was given. If it is unknown if it was given, record a 9. | |
793 | other adjuvant therapy | COL2;42 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether any other adjuvant therapy was given. If it is unknown if any was given, record a 9. | |
794 | duration of adjuvant therapy | COL2;43 | SET OF CODES | 0:No adjuvant therapy 1:1 to 6 months 2:7 to 12 months 8:Therapy given but duration unknown 9:Unknown if therapy given | Record the appropriate code for the duration of adjuvant therapy. | |
795 | completed duration of therapy | COL2;44 | SET OF CODES | 0:No (0-1 cycle) 1:Yes (2 or more cycles) 7:No therapy planned, not applicable 8:Unknown if therapy completed 9:Unknown if therapy given | Record the appropriate code. If one or less than one cycle completed, record 0. If two or more cycles completed, record 1. If there was no adjuvant therapy planned, record 7. If therapy was given, but unknown if completed, record 8. If unknown if therapy given, record 9. | |
796 | nutritional consultation | COL2;45 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the other referral, nutritional consultation was made. If unknown, record 9. | |
797 | occupational therapy | COL2;46 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the other referral, occupational therapy was made. If unknown, record 9. | |
798 | ostomy consultation | COL2;47 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the other referral, ostomy consultation was made. If unknown, record 9. | |
799 | psychosocial | COL2;48 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the other referral, psychosocial was made. If unknown, record 9. | |
800 | history of leukemia (fam) | NHL1;1 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record any familial history of leukemia documented in the medical record. If the record does not mention familial history of cancer, code 9 (unknown). | |
801 | history of non-hodgkin's lymph | NHL1;2 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record any familial history of Non-Hodgkin's lymphoma documented in the medical record. If the record does not mention familial history of cancer, code 9 (unknown). | |
802 | history of hodgkin's lymphoma | NHL1;3 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record any familial history of Hodgkin's lymphoma documented in the medical record. If the record does not mention familial history of cancer, code 9 (unknown). | |
803 | 1st primary site | NHL1;4 | POINTER | 164 | Record the ICD-O-2 code for the first site of any personal history of cancer documented in the medical record. If not applicable record 8's. If record does not mention personal history of any cancer, record 9's. | |
804 | 1st primary histology | NHL1;5 | POINTER | 164.1 | Record the 5-digit histology (including behavior) code for the first histology of any personal history of cancer documented in the medical record. If not applicable record 8's. If record does not mention personal history of any cancer, record 9's. | |
805 | 2nd primary site | NHL1;6 | POINTER | 164 | Record the ICD-O-2 code for the second site of any personal history of cancer documented in the medical record. If not applicable record 8's. If record does not mention personal history of any cancer, record 9's. | |
806 | 2nd primary histology | NHL1;7 | POINTER | 164.1 | Record the 5-digit histology (including behavior) code for the second histology of any personal history of cancer documented in the medical record. If not applicable record 8's. If record does not mention personal history of any cancer, record 9's. | |
807 | organ transplant | NHL1;8 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record the appropriate code for whether an organ transplant was a pre-existing condition. If unknown, code 9. | |
808 | hiv positive | NHL1;9 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record the appropriate code for whether being HIV positive was a pre-existing condition. If unknown, code 9. | |
809 | crohn's disease | NHL1;10 | SET OF CODES | 0:No 1:Yes 9:Unknown/not documented | Record whether Crohn's disease was a pre-existing condition. | |
810 | hashimoto's thyroiditis | NHL1;11 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record the appropriate code for whether Hashimoto's thyroiditis was a pre-existing condition. If unknown, code 9. | |
811 | systemic lupus erythematosus | NHL1;12 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record the appropriate code for whether systemic lupus erythematosus was a pre-existing condition. If unknown, code 9. | |
812 | rheumatoid arthritis | NHL1;13 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record the appropriate code for whether rheumatoid arthritis, including Sjogren's syndrome was a pre-existing condition. If unknown, code 9. | |
813 | pneumocystis carinii | NHL1;14 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record the appropriate code for whether pneumocystis carinii was a pre-existing condition. If unknown, code 9. | |
814 | cmv infection | NHL1;15 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record the appropriate code for whether CMV infection was a pre-existing condition. If unknown, code 9. | |
815 | tuberculosis | NHL1;16 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record the appropriate code for whether tuberculosis was a pre-existing condition. If unknown, code 9. | |
816 | mycobacterium avium | NHL1;17 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record the appropriate code for whether mycobacterium avium was a pre-existing condition. If unknown, code 9. | |
817 | other parasitic infections | NHL1;18 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record the appropriate code for whether there were any other parasitic infections that were pre-existing conditions. If unknown, code 9. | |
818 | other congenital diseases | NHL1;19 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record the appropriate code for whether there were any other congenital diseases that were pre-existing conditions. If unknown, code 9. | |
819 | opportunistic disease | NHL1;20 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record the appropriate code for whether opportunistic disease was a pre-existing condition, ONLY IF IT WAS WITHIN THE LAST 2 YEARS. If unknown, code 9. | |
820 | previous chemotherapy | NHL1;21 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record the appropriate code for whether the patient received any previous chemotherapy. If unknown, code 9. | |
821 | previous radiation therapy | NHL1;22 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record the appropriate code for whether the patient received any previous radiation therapy. If unknown, code 9. | |
822 | aids risk category | NHL1;23 | NUMERIC | Record the appropriate code. The risk categories listed (1-8) only apply to those patients who are HIV positive. Record 0 if the patient is not HIV positive. Record 7 if the patient has more than one risk category (2-6). Record 8 if the patient's risk category is other or unknown. Record 9 if it is unknown if the patient is HIV positive. | ||
823 | ct scan of brain | NHL1;24 | SET OF CODES | 0:Test not done 1:Positive for cancer 2:Negative for cancer 3:Equivocal, suggestive of cancer 7:Test attempted but not completed 8:Test done, results unknown 9:Unknown if test done | Record the results of the CT SCAN OF BRAIN if the test was performed to evaluate this non-Hodgkin's Lymphoma. If the test was not done, code 0. Do not leave blank. | |
824 | ct scan of abdomen/pelvis | NHL1;25 | SET OF CODES | 0:Test not done 1:Positive for cancer 2:Negative for cancer 3:Equivocal, suggestive of cancer 7:Test attempted but not completed 8:Test done, results unknown 9:Unknown if test done | Record the results of the CT SCAN OF ABDOMEN/PELVIS if the test was performed to evaluate this non-Hodgkin's Lymphoma. If the test was not done, code 0. Do not leave blank. | |
825 | mri of brain | NHL1;26 | SET OF CODES | 0:Test not done 1:Positive for cancer 2:Negative for cancer 3:Equivocal, suggestive of cancer 7:Test attempted but not completed 8:Test done, results unknown 9:Unknown if test done | Record the results of the MRI OF BRAIN if the test was performed to evaluate this non-Hodgkin's Lymphoma. If the test was not done, code 0. Do not leave blank. | |
826 | mri of chest | NHL1;27 | SET OF CODES | 0:Test not done 1:Positive for cancer 2:Negative for cancer 3:Equivocal, suggestive of cancer 7:Test attempted but not completed 8:Test done, results unknown 9:Unknown if test done | Record the results of the MRI OF CHEST if the test was performed to evaluate this non-Hodgkin's Lymphoma. If the test was not done, code 0. Do not leave blank. | |
827 | mri of abdomen/pelvis | NHL1;28 | SET OF CODES | 0:Test not done 1:Positive for cancer 2:Negative for cancer 3:Equivocal, suggestive of cancer 7:Test attempted but not completed 8:Test done, results unknown 9:Unknown if test done | Record the results of the MRI OF ABDOMEN/PELVIS if the test was performed to evaluate this non-Hodgkin's Lymphoma. If the test was not done, code 0. Do not leave blank. | |
828 | gallium scan | NHL1;29 | SET OF CODES | 0:Test not done 1:Positive for cancer 2:Negative for cancer 3:Equivocal, suggestive of cancer 7:Test attempted but not completed 8:Test done, results unknown 9:Unknown if test done | Record the results of the GALLIUM SCAN if the test was performed to evaluate this non-Hodgkin's Lymphoma. If the test was not done, code 0. Do not leave blank. | |
829 | pet scan | NHL1;30 | SET OF CODES | 0:Test not done 1:Positive for cancer 2:Negative for cancer 3:Equivocal, suggestive of cancer 7:Test attempted but not completed 8:Test done, results unknown 9:Unknown if test done | Record the results of the PET SCAN if the test was performed to evaluate this non-Hodgkin's Lymphoma. If the test was not done, code 0. Do not leave blank. | |
830 | lumbar puncture | NHL1;31 | SET OF CODES | 0:Test not done 1:Positive for cancer 2:Negative for cancer 3:Equivocal, suggestive of cancer 7:Test attempted but not completed 8:Test done, results unknown 9:Unknown if test done | Record the results of the LUMBAR PUNCTURE if the test was performed to evaluate this non-Hodgkin's Lymphoma. If the test was not done, code 0. Do not leave blank. | |
831 | hemoglobin/hematocrit | NHL1;32 | SET OF CODES | 0:Test not done 1:Normal 2:Higher than normal 3:Lower than normal 8:Test done, results unknown 9:Unknown if test done | Record the appropriate code for the results of the hemoglobin/hematocrit laboratory test, if it was performed. If the test was not performed, record a '0'. | |
832 | white count | NHL1;33 | SET OF CODES | 0:Test not done 1:Normal 2:Higher than normal 3:Lower than normal 8:Test done, results unknown 9:Unknown if test done | Record the appropriate code for the results of the white count laboratory test, if it was performed. If the test was not performed, record a '0'. | |
833 | platelet count | NHL1;34 | SET OF CODES | 0:Test not done 1:Normal 2:Higher than normal 3:Lower than normal 8:Test done, results unknown 9:Unknown if test done | Record the appropriate code for the results of the platelet count laboratory test, if it was performed. If the test was not performed, record a '0'. | |
834 | lactic dehydrogenase (ldh) | NHL1;35 | SET OF CODES | 0:Test not done 1:Normal 2:Higher than normal 3:Lower than normal 8:Test done, results unknown 9:Unknown if test done | Record the appropriate code for the results of the lactic dehydrogenase (LDH) laboratory test, if it was performed. If the test was not performed, record a '0'. | |
835 | liver function studies (nhl) | NHL1;36 | SET OF CODES | 0:Test not done 1:Normal 2:Higher than normal 3:Lower than normal 8:Test done, results unknown 9:Unknown if test done | Record the appropriate code for the results of the liver function studies laboratory test, if it was performed. If the test was not performed, record a '0'. | |
836 | total protein/albumin | NHL1;37 | SET OF CODES | 0:Test not done 1:Normal 2:Higher than normal 3:Lower than normal 8:Test done, results unknown 9:Unknown if test done | Record the appropriate code for the results of the total protein/albumin laboratory test, if it was performed. If the test was not performed, record a '0'. | |
837 | gene rearrangements | NHL1;38 | SET OF CODES | 0:Not done 1:Done 9:Unknown if test done | Record whether the 'Gene rearrangements' test was performed to evaluate this primary. If this test was not done, record a '0'. | |
838 | review of pathology/other inst | NHL1;39 | SET OF CODES | 0:No 1:Yes 9:Unknown if done | Record the appropriate code for whether there was a review of pathology at another institution by another pathologist. | |
839 | lymph node biopsy | NHL1;40 | SET OF CODES | 0:Test not done 1:Positive for cancer 2:Negative for cancer 3:Equivocal, suggestive of cancer 7:Test attempted but not completed 8:Test done, results unknown 9:Unknown if test done | Record the appropriate code for lymph node biopsy, if it was performed. If this biopsy was not performed record a '0'. | |
840 | bone marrow biopsy | NHL1;41 | SET OF CODES | 0:Test not done 1:Positive for cancer 2:Negative for cancer 3:Equivocal, suggestive of cancer 7:Test attempted but not completed 8:Test done, results unknown 9:Unknown if test done | Record the appropriate code for bone marrow biopsy, if it was performed. If this biopsy was not performed record a '0'. | |
841 | csf cytology | NHL1;42 | SET OF CODES | 0:Test not done 1:Positive for cancer 2:Negative for cancer 3:Equivocal, suggestive of cancer 7:Test attempted but not completed 8:Test done, results unknown 9:Unknown if test done | Record the appropriate code for CSF cytology biopsy, if it was performed. If this biopsy was not performed record a '0'. | |
842 | other site biopsy | NHL1;43 | SET OF CODES | 0:Test not done 1:Positive for cancer 2:Negative for cancer 3:Equivocal, suggestive of cancer 7:Test attempted but not completed 8:Test done, results unknown 9:Unknown if test done | Record the appropriate code for other site biopsy, if it was performed. If this biopsy was not performed record a '0'. | |
843 | systemic symptoms | NHL1;44 | SET OF CODES | 1:A (no symptoms) 2:B (defined systemic symptoms) 9:Unknown whether A or B | Record whether the patient was category A (without defined systemic symptoms) or B (with defined systemic symptoms). These symptoms include unexplained weight loss of at least 10% within 6 months prior to diagnosis, unexplained fever above 38 C, and drenching night sweats. Neither pruritus alone or short febrile illness associated with infection qualify within these systemic symptoms. | |
844 | cd4 count | NHL1;45 | SET OF CODES | 0:Test not done 1:< 1,000 copies/ml 2:1,000 to 9,999 copies/ml 3:> or = to 10,000 copies/ml 8:Test done, results unknown 9:Unknown if test done | Record the appropriate code for CD4 count, a diagnostic test specifically related to HIV disease. If the test was not performed, record a '0'. | |
845 | hiv viral loads | NHL1;46 | SET OF CODES | 0:Test not done 1:< 10,000 copies/ml 2:> or = to 10,000 copies/ml 8:Test done, results unknown 9:Unknown if test done | Record the appropriate code for HIV viral loads, a diagnostic test specifically related to HIV disease. If the test was not performed, record a '0'. | |
846 | specific histologic info | NHL2;1 | SET OF CODES | 1:Mantle cell lymphoma 2:MALT lymphoma 3:Peripheral T-cell lymphoma 4:Anaplastic, large cell (Ki-1) lymphoma 8:NA, no additional histologies noted 9:Unknown if any histologies noted | This field is used to record any additional specific histologic data. For this field record the appropriate code (1-4) if any of the specified histologies were noted. (Please note that 1-Mantle cell lymphoma is not the same histology as mantle zone lymphoma which is listed in the ICD-0-2 code book as 9673). Record '8' for not applicable, if none of these listed were noted. Record '9' if unknown if any of these histologies were noted. | |
847 | cell type of lymphoma | NHL2;2 | SET OF CODES | 1:T cell 2:B cell 3:Null cell 4:N X cell (natural killer cell) 9:Cell type unknown | Record the appropriate code for the cell type of the lymphoma. If the cell type is unknown, record a '9'. | |
848 | patient status at diagnosis | NHL2;3 | SET OF CODES | 0:Bedridden < or = to 50% 1:Bedridden > 50% 9:Unknown | Record the appropriate code for the patient's status at diagnosis. If completely ambulatory, record a '0'. If unknown, record a '9'. | |
849 | type of staging system (ped) | NHL2;4 | POINTER | 164.6 | If recording a pediatric case, enter the type of staging system used to stage this patient. If not applicable, code '88'. If unknown, code '99'. | |
850 | pediatric stage | NHL2;5 | FREE TEXT | Enter the pediatric stage as specified in the pediatric staging system selected. If not applicable, code '88'. If the pediatric stage is unknown, code '99'. | ||
851 | staged by (pediatric stage) | NHL2;6 | SET OF CODES | 0:Not staged 1:Managing physician 2:Pathologist 3:Other physician 4:Any combination of 1,2 or 3 5:Registrar 6:Any combination of 5 w/ 1,2 or 3 7:Other 8:Staged, individual not specified 9:Unknown if staged | Record the appropriate code for the individual who staged this pediatric case. If the patient was not staged, code '0'. | |
852 | extranodal site 1 | NHL2;7 | FREE TEXT | Provide ICD-O-2 site codes for the 1st clinically and/or pathologically involved extranodal site (in addition to the primary site). If no 1st extranodal site, code 8's. If unknown, code 9's. | ||
853 | extranodal site 2 | NHL2;8 | FREE TEXT | Provide ICD-O-2 site codes for the 2nd clinically and/or pathologically involved extranodal site (in addition to the primary site). If no 2nd extranodal site, code 8's. If unknown, code 9's. | ||
854 | extranodal site 3 | NHL2;9 | FREE TEXT | Provide ICD-O-2 site codes for the 3rd clinically and/or pathologically involved extranodal site (in addition to the primary site). If no 3rd extranodal site, code 8's. If unknown, code 9's. | ||
855 | extranodal site w/c-d surgery | NHL2;10 | FREE TEXT | Record the ICD-O-2 site code for any extranodal cancer-directed surgery, other than the primary-site surgery. If no additional cancer-directed surgery to an extranodal site, code 8's. If unknown, code 9's. | ||
856 | extranodal site surgical proc | NHL2;11 | NUMERIC | Record the appropriate cancer-directed surgical code for the first extranodal site. If there is no additional cancer-directed surgical procedure to an extranodal site, code '00'. | ||
857 | lymph nodes above diaphragm | NHL2;12 | SET OF CODES | 1:Irradiated 2:Not irradiated 8:NA, unknown if radiation therapy given 9:Radiation given, unknown if irradiated | Record the appropriate code for whether the lymph nodes above the diaphragm were irradiated. Please see the "Lymph Node Location Relative to Diaphragm" handout for additional information. | |
858 | lymph nodes below diaphragm | NHL2;13 | SET OF CODES | 1:Irradiated 2:Not irradiated 8:NA, unknown if radiation therapy given 9:Radiation therapy administered, unknown if this field irradiated | Record the appropriate code for whether the lymph nodes below the diaphragm were irradiated. Please see the "Lymph Node Location Relative to Diaphragm" handout for additional information. | |
859 | brain | NHL2;14 | SET OF CODES | 1:Irradiated 2:Not irradiated 8:NA, unknown if radiation therapy given 9:Radiation therapy administered, unknown if this field irradiated | Record the appropriate code for whether the brain was irradiated. If it is unknown if radiation therapy was given, code 8. If radiation therapy was administered but it is unknown if the brain was irradiated, code 9. | |
860 | other extranodal site(s) | NHL2;15 | SET OF CODES | 1:Irradiated 2:Not irradiated 8:NA, unknown if radiation therapy given 9:Radiation therapy administered, unknown if this field irradiated | Record the appropriate code for whether other extranodal site(s) were irradiated. If it is unknown if radiation therapy was given, code 8. If radiation therapy was administered but it is unknown if other extranodal sites were irradiated, code 9. | |
861 | total body | NHL2;16 | SET OF CODES | 1:Irradiated 2:Not irradiated 8:NA, unknown if radiation therapy given 9:Radiation therapy administered, unknown if this field irradiated | Record the appropriate code for whether the total body was irradiated. If it is unknown if radiation therapy was given, code 8. If radiation therapy was administered but it is unknown if the total body was irradiated, code 9. | |
862 | radiation/chemo sequence | NHL2;17 | NUMERIC | Record the appropriate code for radiation/chemotherapy sequence. | ||
863 | protocol | NHL2;18 | SET OF CODES | 0:Not on protocol 1:Cancer cooperative group trial 2:Other investigative, IRB-approved protocol 9:Unknown if on protocol | Record the appropriate code for systemic and/or intrathecal chemotherapy. If unknown, code 9. | |
864 | systemic chemotherapy | NHL2;19 | SET OF CODES | 0:None 1:Systemic chemotherapy, NOS 2:Systemic chemotherapy, single agent 3:Systemic chemotherapy, multiple agents 9:Unknown if administered | Record the appropriate code for the administration of systemic chemotherapy. If unknown if administered, code 9. | |
865 | systemic chemotherapy date | NHL2;20 | DATE-TIME | Record the first date on which systemic chemotherapy was administered. | ||
866 | systemic chemotherapy cycles | NHL2;21 | NUMERIC | Record the number of planned cycles of systemic chemotherapy. If not applicable (no systemic chemotherapy given), code 88. If given, but number unknown, code 97. If no termination date assigned at onset of systemic chemotherapy, code 98. If unknown if systemic chemotherapy was administered, code 99. | ||
867 | chlorambucil | NHL2;22 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown if given | Record whether this chemotherapeutic agent was administered during systemic chemotherapy. If not applicable (chemotherapy not given), code 8. If unknown if given, code 9. | |
868 | cyclophosphamide (nhl) | NHL2;23 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown if given | Record whether this chemotherapeutic agent was administered during systemic chemotherapy. If not applicable (chemotherapy not given), code 8. If unknown if given, code 9. | |
869 | doxorubicin (nhl) | NHL2;24 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown if given | Record whether this chemotherapeutic agent was administered during systemic chemotherapy. If not applicable (chemotherapy not given), code 8. If unknown if given, code 9. | |
870 | fludarabine | NHL2;25 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown if given | Record whether this chemotherapeutic agent was administered during systemic chemotherapy. If not applicable (chemotherapy not given), code 8. If unknown if given, code 9. | |
871 | chop | NHL2;26 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown if given | Record whether the combination chemotherapy agents, CHOP were administered during systemic chemotherapy. If not applicable (chemotherapy not given), code 8. If unknown if given, code 9. | |
872 | cvp | NHL2;27 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown if given | Record whether the combination chemotherapy agents, CVP were administered during systemic chemotherapy. If not applicable (chemotherapy not given), code 8. If unknown if given, code 9. | |
873 | comla | NHL2;28 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown if given | Record whether the combination chemotherapy agents, COMLA were administered during systemic chemotherapy. If not applicable (chemotherapy not given), code 8. If unknown if given, code 9. | |
874 | macop-b | NHL2;29 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown if given | Record whether the combination chemotherapy agents, MACOP-B were administered during systemic chemotherapy. If not applicable (chemotherapy not given), code 8. If unknown if given, code 9. | |
875 | m-bacod | NHL2;30 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown if given | Record whether the combination chemotherapy agents, M-BACOD were administered during systemic chemotherapy. If not applicable (chemotherapy not given), code 8. If unknown if given, code 9. | |
876 | pro-mace-cyta bom | NHL2;31 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown if given | Record whether the combination chemotherapy agents, PRO-MACE-Cyta BOM were administered during systemic chemotherapy. If not applicable (chemotherapy not given), code 8. If unknown if given, code 9. | |
877 | other systemic chemo agents | NHL2;32 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown if given | Record whether any other combination chemotherapy agents were administered during systemic chemotherapy. If not applicable (chemotherapy not given), code 8. If unknown if given, code 9. | |
878 | high dose systemic chemo | NHL2;33 | SET OF CODES | 0:No 1:Yes 9:Unknown if given | Record the appropriate code for whether high dose systemic chemotherapy with stem cell rescue was done. If unknown if done, code 9. | |
879 | intrathecal chemotherapy | NHL2;34 | SET OF CODES | 0:None 1:Administered 9:Unknown if administered | Record the appropriate code for whether intrathecal chemotherapy was administered. If unknown if administered, code 9. | |
880 | purpose of intrathecal chemo | NHL2;35 | SET OF CODES | 1:Treatment 2:Prophylaxis 7:NA, not administered 8:Administered, purpose unknown 9:Unknown if administered | Record the appropriate code for the purpose of intrathecal chemotherapy. If not applicable, intrathecal chemetherapy not administered, code 7. If intrathecal chemotherapy administered, but purpose unknown, code 8. If unknown whether intrathecal chemotherapy administered, code 9. | |
881 | interferon (nhl) | NHL2;36 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record the appropriate code for whether this type of immunotherapy was performed. If unknown if performed, code 9. | |
882 | interleukin-2 (il-2) (nhl) | NHL2;37 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record the appropriate code for whether this type of immunotherapy was performed. If unknown if performed, code 9. | |
883 | monoclonal antibodies | NHL2;38 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record the appropriate code for whether this type of immunotherapy was performed. If unknown if performed, code 9. | |
884 | vaccine therapy | NHL2;39 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | Record the appropriate code for whether this type of immunotherapy was performed. If unknown if performed, code 9. | |
900 | daughter (br98) | BRE1;1 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | Record any familial history of breast cancer documented in the medical record. Record 8 if not applicable. Record 9 if unknown. | |
901 | maternal aunt (br98) | BRE1;2 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | Record any familial history of breast cancer documented in the medical record. Record 8 if not applicable. Record 9 if unknown. | |
902 | maternal grandmother (br98) | BRE1;3 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | Record any familial history of breast cancer documented in the medical record. Record 8 if not applicable. Record 9 if unknown. | |
903 | mother (br98) | BRE1;4 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | Record any familial history of breast cancer documented in the medical record. Record 8 if not applicable. Record 9 if unknown. | |
904 | one sister (br98) | BRE1;5 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | Record any familial history of breast cancer documented in the medical record. Record 8 if not applicable. Record 9 if unknown. | |
905 | more than one sister (br98) | BRE1;6 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | Record any familial history of breast cancer documented in the medical record. Record 8 if not applicable. Record 9 if unknown. | |
906 | father (br98) | BRE1;7 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | Record any familial history of breast cancer documented in the medical record. Record 8 if not applicable. Record 9 if unknown. | |
907 | brother (br98) | BRE1;8 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | Record any familial history of breast cancer documented in the medical record. Record 8 if not applicable. Record 9 if unknown. | |
908 | fam history breast ca (br98) | BRE1;9 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | Record any familial history of breast cancer documented in the medical record. Record 8 if not applicable. Record 9 if unknown. | |
909 | history of breast ca (br98) | BRE1;10 | SET OF CODES | 0:None 1:Invasive 2:Ductal carcinoma in situ 3:Lobular carcinoma in situ 4:Other histology 8:History of breast ca, type unknown 9:Unknown | For females, record any personal history of breast cancer not synchronous (diagnosed 6 months or more prior) with the current breast cancer. For males, leave this field blank. | |
910 | synchronous breast ca (br98) | BRE1;11 | SET OF CODES | 0:No 1:Ipsilateral 2:Contralateral 3:Both 8:Yes, but laterality unknown 9:Unknown | Record any synchronous breast cancer diagnosed up to but not including 6 months prior to current breast cancer. | |
911 | colon (br98) | BRE1;12 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | Record whether the patient had colon cancer diagnosed either prior to this breast cancer or at the same time that this breast cancer was diagnosed. | |
912 | ovary (br98) | BRE1;13 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | Record whether the patient had ovarian cancer diagnosed either prior to this breast cancer or at the same time that this breast cancer was diagnosed. If the patient is a male leave this field blank. | |
913 | uterus (br98) | BRE1;14 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | Record whether the patient had uterine cancer diagnosed either prior to this breast cancer or at the same time that this breast cancer was diagnosed. If the patient is a male leave this field blank. | |
914 | prostate (br98) | BRE1;15 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | Record whether the patient had prostate cancer diagnosed either prior to this breast cancer or at the same time that this breast cancer was diagnosed. If the patient is a female leave this field blank. | |
915 | other (br98) | BRE1;16 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | Record whether the patient had other cancer diagnosed either prior to this breast cancer or at the same time that this breast cancer was diagnosed. | |
916 | hormone replacement tpy (br98) | BRE1;17 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record whether the patient was/is on hormone replacement therapy (estrogen/progesterone). If the patient is a male leave this field blank. | |
917 | hormone replacement yrs (br98) | BRE1;18 | SET OF CODES | 1:Less than 5 years 2:5 to 9 years 3:10 years or more 8:NA 9:Unknown | Record the appropriate code for the number of years of hormone replacement therapy the patient had. If patient is not on this therapy, code 8, not applicable. If the patient is a male leave this field blank. | |
918 | unknown mammogram (br98) | BRE1;19 | SET OF CODES | 0:No 1:Yes 9:Unknown | For FEMALE patients ONLY, record the appropriate code for whether a mammogram was given, but the type was unknown. If the type is known then record a 0. If the patient is male, leave this field blank. | |
919 | unknown mammogram dt (br98) | BRE1;20 | DATE-TIME | For FEMALE patients ONLY, record the date the mammogram was given if the type of mammogram is unknown. Use the most recent date if this unknown type of mammogram was done more than once. Record 0's if this type of mammogram was not given. Record 9's if it is unknown if this type was given. If the patient is male, leave this field blank. | ||
920 | screening mammogram (br98) | BRE1;21 | SET OF CODES | 0:No 1:Yes 9:Unknown | For FEMALE patients ONLY, record the appropriate code for whether a screening mammogram was given. If the patient is male, leave this field blank. | |
921 | screening mammogram dt (br98) | BRE1;22 | DATE-TIME | For FEMALE patients ONLY, record the date the screening mammogram was given. Use the most recent date if screening mammogram was done more than once. Record 0's if screening mammogram was not given. Record 9's if it is unknown if screening mammogram was given. If the patient is male, leave this field blank. | ||
922 | diagnostic mammogram (br98) | BRE1;23 | SET OF CODES | 0:No 1:Yes 9:Unknown | For FEMALE patients ONLY, record the appropriate code for whether a diagnostic mammogram was given. If the patient is male, leave this field blank. | |
923 | diagnostic mammogram dt (br98) | BRE1;24 | DATE-TIME | For FEMALE patients ONLY, record the date the diagnostic mammogram was given. Use the most recent date if diagnostic mammogram was done more than once. Record 0's if diagnostic mammogram was not given. Record 9's if it is unknown if diagnostic mammogram was given. If the patient is male, leave this field blank. | ||
924 | magnification mammogram (br98) | BRE1;25 | SET OF CODES | 0:No 1:Yes 9:Unknown | For FEMALE patients ONLY, record the appropriate code for whether a magnification mammogram was given. A magnification mammogram can be identified by finding the word "magnification" or "compression" in the title or body of the report. If the patient is male, leave this field blank. | |
925 | magnification mamm dt (br98) | BRE1;26 | DATE-TIME | For FEMALE patients ONLY, record the date the magnification mammogram was given. Use the most recent date if magnification mammogram was done more than once. Record 0's if magnification mammogram was not given. Record 9's if it is unknown if magnification mammogram was given. If the patient is male, leave this field blank. | ||
926 | mammogram (br98) | BRE1;27 | SET OF CODES | 0:Test not done 1:Results positive for cancer 2:Results negative for cancer 8:Test done, results equivocal/unknown 9:Unknown if test done | For MALES ONLY, record the results of the mammogram performed to evaluate the extent of breast cancer. If the mammogram was done but the results cannot be determined, code 8. If it is unknown if a mammogram was performed, code 9. If no mammogram was done, code 0. | |
927 | ultrasound (br98) | BRE1;28 | SET OF CODES | 0:Test not done 1:Results positive for cancer 2:Results negative for cancer 8:Test done, results equivocal/unknown 9:Unknown if test done | Record the results of the ultrasound if one was performed to evaluate the extent of breast cancer. If the ultrasound was done but the results cannot be determined, code 8. If it is unknown if an ultrasound was performed, code 9. If no ultrasound was done, code 0. | |
928 | most definitive mamm (br98) | BRE1;29 | SET OF CODES | 0:Negative/no abnormality 1:Localized calcifications 2:Diffuse calcifications 3:Mass, no calcifications 4:Mass plus one quad calcification 5:Mass plus multiple quad calcifications 6:NOS 8:NA 9:Unknown | For FEMALES ONLY, record the results of the patient's most definitive mammogram in this field. If no mammogram was done record 8, not applicable. For males, leave this field blank. | |
929 | date of pathologic dx (br98) | BRE1;30 | DATE-TIME | Record the date that this breast cancer was first pathologically diagnosed. | ||
930 | dcsi also present (br98) | BRE1;31 | FREE TEXT | If invasive ductal carcinoma is reported (Behavior code = 3), code if ductal carcinoma in situ (DCIS) is also present. If DCIS is not present, code 0. If DCIS is also present as a separate, simultaneous tumor, record 1. If DCIS is also present as mixed histology (in situ/invasive) in one tumor, record 2. If DCIS is also present, both as a separate tumor and in a tumor with mixed histology, record 3. If DCIS is also present, but unknown whether as a separate tumor or mixed histology, record 4. If reported tumor is not invasive ductal carcinoma, record 8, not applicable. If unknown whether DCIS is also present, record 9. | ||
931 | architecture pattern (br98) | BRE1;32 | SET OF CODES | 1:Cribriform 2:Micro papillary 3:Comedo 4:Solid 5:Other 6:NOS 7:Mixed (any combination) 8:NA, not DCIS 9:Pattern unknown | Record the architecture pattern, if DCIS is present (either as the reported tumor, or as a separate tumor simultaneous with an invasive ductal carcinoma, or as a tumor with mixed histology - in situ/invasive ductal carcinoma). This information is found on the pathology report, often under the histology description, or it may be found in the diagnostic report. | |
932 | nuclear grade (br98) | BRE1;33 | SET OF CODES | 1:Low 2:Intermediate 3:High 4:NOS 8:NA 9:Unknown | Record the nuclear grade, if DCIS is present (either as the reported tumor, or as a separate tumor simultaneous with an invasive ductal carcinoma, or as a tumor with mixed histology - in situ/invasive ductal carcinoma). This information is found on the pathology report, often under the histology description, or it may be in the diagnostic report. It is identified by the terms low, intermediate and high. | |
933 | skin involvement (br98) | BRE1;34 | SET OF CODES | 0:No involvement 1:Involvement 9:Unknown | For male patients, record the extent of involvement of the skin. For female patients, leave this field blank. | |
934 | chest wall involvement (br98) | BRE1;35 | SET OF CODES | 0:No involvement 1:Involvement 9:Unknown | For male patients, record the extent of involvement of the chest wall. For female patients, leave this field blank. | |
935 | pectoral involvement (br98) | BRE1;36 | SET OF CODES | 0:No involvement 1:Involvement 9:Unknown | For male patients, record the extent of involvement of the pectoral muscles. For female patients, leave this field blank. | |
936 | dermal/lymphatic inv (br98) | BRE1;37 | SET OF CODES | 0:No involvement 1:Involvement 9:Unknown | For male patients, record the extent of dermal/lymphatic involvement. For female patients, leave this field blank. | |
937 | dna index/ploidy (br98) | BRE1;38 | SET OF CODES | 0:Test not done 1:Diploid 2:Non-diploid 8:Test done, results unknown 9:Unknown if test done | For male patients, record the DNA Index/Ploidy. This is usually determined by flow symmetry. For females, leave this field blank. | |
940 | androgen receptor (br98) | BRE1;41 | SET OF CODES | 0:Not done 1:Positive 2:Negative 3:Low borderline 7:NA 8:Test done, results unknown 9:Unknown if test done | For male patients, record the results of the androgen receptor protein test. The results of these tests are sometimes shown as percents. For females, leave this field blank. | |
941 | type of test (br98) | BRE1;42 | SET OF CODES | 0:Neither ERA nor PRA was done 1:Immunohistochemical test 2:Biochemical test 8:ERA or PSA was done, type of test unknown 9:Unknown if ERA/PRA was done | If possible to determine, indicate which type of test was used for the ERA/PRA. Answer for estrogen receptor protein (ERA) first, and if that was not done, then answer for progesterone receptor protein (PRA). If neither ERA or PRA tests were done, record 0. | |
942 | size of dcis tumor (mm) (br98) | BRE1;43 | NUMERIC | Record the size of DCIS tumor. If the tumor being reported is coded as invasive ductal carcinoma and ductal carcinoma in situ is also present either as a separate, simultaneous tumor or in a tumor with mixed histology (in situ/invasive), record the largest dimension or diameter of the DCIS tumor in millimeters. Do not guess the size of the tumor. Do not use specimen size. Use size as recorded in the pathology report, if it is present. If invasive ductal carcinoma is reported but DCIS is not present, record 000. If invasive ductal carcinoma is not reported, record 888, not applicable. If invasive ductal carcinoma is reported and DCIS is also present but its size is not known, record 988. If ductal carcinoma is reported but presence of DCIS is unknown, record 999. | ||
943 | sentinel node biopsy | BRE1;44 | SET OF CODES | 0:No 1:Yes, positive 2:Yes, negative 3:Yes, results unknown 4:Attempted, unsuccessful 8:NA, not done, ocular site 9:Unknown | Record whether a sentinel node biopsy was performed. The sentinel node is the first lymph node(s) in the axillary lymph node basin receiving the lymphatic drainage of the breast. There may be one or several sentinel nodes identified by radionuclide injection, dye injection, or combination of the two. If surgeon could not find a sentinel node, record 4 - attempted, unsuccessful. | |
944 | sentinel nodes examined (br98) | BRE1;45 | SET OF CODES | 0:None 1:1 node examined 2:2 nodes examined 3:3 nodes examined 4:4 nodes examined 5:5 nodes examined 6:6 nodes examined 7:7 or more nodes examined 8:Examined, number unknown 9:Unknown if examined | Enter the number of sentinel nodes examined. Record 0 if no sentinel nodes examined. Record 8 if nodes examined, but the number is unknown and record 9 if it is unknown if sentinel nodes were examined. | |
945 | sentinel nodes positive (br98) | BRE1;46 | SET OF CODES | 0:None positive 1:1 positive node 2:2 positive nodes 3:3 positive nodes 4:4 positive nodes 5:5 positive nodes 6:6 or more positive nodes 7:None examined 8:Positive, number unknown 9:Unknown if positive | Enter the number of sentinel nodes positive. Record 0 if none are positive. Record 7 if none were examined. Record 8 if the positive number is unknown, and record 9 if it is unknown if any were positive. | |
946 | sentinel nodes detected (br98) | BRE1;47 | SET OF CODES | 1:Vital blue dye 2:Radionuclide 3:Combination 8:NA, not done 9:Method unknown | Record the method by which the sentinel node was detected. | |
947 | specimen radiograph (br98) | BRE1;48 | SET OF CODES | 0:Not done 1:Calcification 2:Mass 3:Both calcification and mass 4:Radiograph done, results NOS 8:NA 9:Unknown | Record the results of the radiograph. The radiograph is a film of the excised specimen. | |
948 | submitted to pathology (br98) | BRE1;49 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | Record whether the entire specimen was submitted to pathology. | |
949 | margin distance (br98) | BRE1;50 | SET OF CODES | 0:Margins not free, involved 1:Less than 1 mm 2:1 to 2 mm 3:3 to 5 mm 4:Greater than 5 mm 8:NA 9:Unknown | If margins are free, record the distance in millimeters from the tumor to the edge of the specimen (margin). | |
950 | re-excision (br98) | BRE1;51 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | Record whether a re-excision was performed following examination of the margins. Record 8 if margins were clear, not applicable. (NOTE: A mastectomy after an excisional biopsy does not count as a re-excision). | |
951 | microscopic status (br98) | BRE1;52 | SET OF CODES | 0:Uninvolved 1:Involved 8:NA 9:Unknown | Record the microscopic status of final margin after re-excision. If re-excision was performed indicate the status. If re-excision was not done, record 8, not applicable. | |
952 | pre-radiation mammogram (br98) | BRE1;53 | SET OF CODES | 0:Not done 1:Done, and entire lesion removed 2:Done, and entire lesion not removed 8:Done, but status of lesion unknown 9:Unknown if done | Record whether there was a pre-radiation therapy mammogram of the patient. If unknown, record 9. | |
953 | sites irradiated (br98) | BRE1;54 | SET OF CODES | 0:No radiation 1:Breast only 2:Breast and regional lymphatics 3:Other 8:Radiation, sites unknown 9:Unknown if radiation | Record the sites which were irradiated. Regional lymphatics includes axilla, chest wall, internal mammary lymph nodes and supraclavicular lymph nodes. Breast refers to 'whole' or 'entire' breast. If radiation was given, but site(s) unknown, record 8. If it is unknown if radiation was given, record 9. | |
954 | cgy dose to breast (br98) | BRE1;55 | NUMERIC | For female patients ONLY, record the cGy dose (00001-88887) given to the whole breast or chest wall. Do not include boost dose. If the patient did not receive radiation therapy, code 00000. If it is known that the patient received radiation therapy, but the dose is unknown, code 88888. If it is unknown if the patient raceived radiation, code 99999. For male patients, leave this field blank. | ||
955 | specific hormone thpy (br98) | BRE1;56 | SET OF CODES | 0:None 1:Tamoxifen 2:Orchiectomy 3:Estrogen 4:Other 8:NA 9:Unknown | For male patients ONLY, record the specific hormone treatment. Estrogen includes Diethylstilbestrol. For females, leave blank. | |
956 | chemotherapy regime (br98) | BRE1;57 | SET OF CODES | 0:No 1:Yes 8:NA, no chemotherapy 9:Unknown | Record the chemotherapeutic regime containing doxorubicin. Doxorubicin includes Adriamycin, Adriamycin-TM, Adriblastina, FT-106, 14-hydroxy daunomycin and Rubex. | |
993 | regional tx modality conv flag | 27;7 | BOOLEAN | Y:YES | This field will flag this record as having its REGIONAL TREATMENT MODALITY values converted from ROADS TO FORDS. The purpose of this field is to avoid converting already converted values. | |
994 | type of first recur conv flag | 27;6 | BOOLEAN | Y:YES | This field will flag this record as having its TYPE OF FIRST RECURRENCE values converted from ROADS TO FORDS. The purpose of this field is to avoid converting already converted values. | |
995 | staged by conv flag | 27;5 | BOOLEAN | Y:YES | This field will flag this record as having its STAGED BY (CLINICAL STAGE and STAGED BY (PATHOLOGIC STAGE) values converted from ROADS to FORDS. The purpose of this field is to avoid converting already converted values. | |
996 | surgical margins conv flag | 27;2 | BOOLEAN | Y:YES | This field will flag this record as having its SURGICAL MARGINS value converted from ROADS to FORDS. The purpose of this field is to avoid converting already converted values. | |
997 | stage flag | 27;1 | BOOLEAN | Y:YES N:NO | Staging conversion flag. | |
998 | scope of ln surgery conv flag | 27;3 | BOOLEAN | Y:YES | This field will flag this record as having its SCOPE OF LYMPH NODE SURGERY and SCOPE OF LN SURG @FACILITY values converted from ROADS to FORDS. The purpose of this field is to avoid converting already | |
999 | surgical proc/other conv flag | 27;4 | BOOLEAN | Y:YES | This field will flag this record as having its SURGICAL PROC/OTHER SITE and SURGICAL PROC/OTHER SITE @FAC values converted from ROADS to FORDS. The purpose of this field is to avoid converting already converted values. | |
999.1 | date of diagnosis flag | 27;8 | NUMERIC | Source of Standard: NAACCR Item #: 391 This field is a flag that explains why no appropriate value is entered for DATE DX (#3) field. | ||
999.11 | rx date surg disch flag | 27;17 | NUMERIC | Source of Standard: NAACCR Item #: 3181 This field is a flag that explains why no appropriate value is entered for DATE MOST DEFINITIVE SURG DIS (#435) field. | ||
999.12 | rx date-radiation flag | 27;18 | NUMERIC | Source of Standard: NAACCR Item #: 1211 This field is a flag that explains why no appropriate value is entered for DATE RADIATION STARTED (#51) field. | ||
999.13 | rx date rad ended flag | 27;19 | NUMERIC | Source of Standard: NAACCR Item #: 3221 This field is a flag that explains why no appropriate value is entered for DATE RADIATION ENDED (#361) field. | ||
999.14 | rx date systemic flag | 27;20 | NUMERIC | Source of Standard: NAACCR Item #: 3231 This field is a flag that explains why no appropriate value is entered for DATE SYSTEMIC THERAPY STARTED (#152) field. | ||
999.15 | rx date-chemo flag | 27;21 | NUMERIC | Source of Standard: NAACCR Item #: 1221 This field is a flag that explains why no appropriate value is entered for CHEMOTHERAPY DATE (#53) field. | ||
999.16 | rx date-hormone flag | 27;22 | NUMERIC | Source of Standard: NAACCR Item #: 1231 This field is a flag that explains why no appropriate value is entered for HORMONE THERAPY DATE (#54) field. | ||
999.17 | rx date-brm flag | 27;23 | NUMERIC | Source of Standard: NAACCR Item #: 1241 This field is a flag that explains why no appropriate value is entered for IMMUNOTHERAPY DATE (#55) field. | ||
999.18 | rx date-other flag | 27;24 | NUMERIC | Source of Standard: NAACCR Item #: 1251 This field is a flag that explains why no appropriate value is entered for OTHER TREATMENT START DATE (#57) field. | ||
999.19 | rx date-dx/stg proc flag | 27;25 | NUMERIC | Source of Standard: NAACCR Item #: 1281 This field is a flag that explains why no appropriate value is entered for SURGICAL DX/STAGING PROC DATE (#58.3) field. | ||
999.2 | date conclusive dx flag | 27;9 | NUMERIC | Source of Standard: NAACCR ITEM #: 448 This field is a flag that explains why no appropriate value is entered for DATE OF CONCLUSIVE DX (#193) field. | ||
999.21 | recurrence date-1st flag | 27;26 | NUMERIC | Source of Standard: NAACCR Item #: 1861 This field is a flag that explains why no appropriate value is entered for DATE OF FIRST RECURRENCE (#70) field. | ||
999.22 | date of last contact flag | 27;27 | NUMERIC | Source of Standard: NAACCR Item #: 1751 This field is a flag that explains why no appropriate value is entered for the FOLLOW-UP (#400) multiple of the ONCOLOGY PATIENT (#160) file. | ||
999.23 | subsq rx 2nd crs date flag | 27;28 | NUMERIC | Source of Standard: NAACCR Item #: 1661 This field is a flag that explains why no appropriate value is entered for SUBSEQUENT COURSE OF TREATMENT (#60) multiple field. | ||
999.24 | subsq rx 3rd crs date flag | 27;29 | NUMERIC | Source of Standard: NAACCR Item #: 1681 This field is a flag that explains why no appropriate 2nd value is entered for SUBSEQUENT COURSE OF TREATMENT (#60) multiple field. | ||
999.25 | subsq rx 4th crs date flag | 27;30 | NUMERIC | Source of Standard: NAACCR Item #: 1701 This field is a flag that explains why no appropriate 3rd value is entered for SUBSEQUENT COURSE OF TREATMENT (#60) multiple field. | ||
999.26 | address at dx--state | 27;31 | FREE TEXT | Source of Standard: NAACCR Item #: 80 This field is for the patient's State from their Address at time of Diagnosis. | ||
999.27 | address at dx--country | 27;32 | FREE TEXT | Source of Standard: NAACCR Item #: 102 This field is for the patient's Country from their Address at the time of diagnosis. | ||
999.28 | address current--state | 27;33 | FREE TEXT | Source of Standard: NAACCR Item #: 1820 This field is for the patient's State from their current Address. | ||
999.29 | address current--country | 27;34 | FREE TEXT | Source of Standard: NAACCR Item #: 1832 This field is for the patient's Country from their current Address. | ||
999.3 | date of mult tumors flag | 27;10 | NUMERIC | Source of Standard: NAACCR Item #: 439 This field is a flag that explains why no appropriate value is entered for DATE OF MULTIPLE TUMORS (#195) field. | ||
999.4 | date of first contact flag | 27;11 | NUMERIC | Source of Standard: NAACCR Item #: 581 This field is a flag that explains why no appropriate value is entered for DATE OF FIRST CONTACT (#155) field. | ||
999.5 | date of inpt adm flag | 27;12 | NUMERIC | Source of Standard: NAACCR Item #: 591 This field is a flag that explains why no appropriate value is entered for DATE OF INPATIENT ADMISSION (#1) field. | ||
999.6 | date of inpt disch flag | 27;13 | NUMERIC | Source of Standard: NAACCR Item #: 601 This field is a flag that explains why no appropriate value is entered for DATE OF INPATIENT DISCHARGE (#1.1) field. | ||
999.7 | date 1st crs rx flag | 27;14 | NUMERIC | Source of Standard: NAACCR Item #: 1271 This field is a flag that explains why no appropriate value is entered for FIRST COURSE OF TREATMENT DATE (#49) field. | ||
999.8 | rx date-surgery flag | 27;15 | NUMERIC | Source of Standard: NAACCR Item #: 1201 This field is a flag that explains why no appropriate value is entered for DATE FIRST SURGICAL PROCEDURE (#170) field. | ||
999.9 | rx date mst defn srg flag | 27;16 | NUMERIC | Source of Standard: NAACCR Item #: 3171 This field is a flag that explains why no appropriate value is entered for MOST DEFINITIVE SURG DATE (#50) field. | ||
1000 | oral contraceptives | HEP1;1 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes whether the patient was receiving prescribed hormonal therapy at the time of diagnosis. This information can typically be found in either the patient's clinic chart or the managing physician's notes. | |
1001 | estrogen replacement | HEP1;2 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes whether the patient was receiving prescribed hormonal therapy at the time of diagnosis. This information can typically be found in either the patient's clinic chart or the managing physician's notes. | |
1002 | tamoxifen | HEP1;3 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes whether the patient was receiving prescribed hormonal therapy at the time of diagnosis. This information can typically be found in either the patient's clinic chart or the managing physician's notes. | |
1003 | other hormones | HEP1;4 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes whether the patient was receiving prescribed hormonal therapy at the time of diagnosis. This information can typically be found in either the patient's clinic chart or the managing physician's notes. | |
1004 | ascites | HEP1;5 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes all conditions relevant to liver cancer which were reported as occurring in the patient at the time of diagnosis. This information can typically be found in the managing physician's notes. | |
1005 | cirrhosis | HEP1;6 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes all conditions relevant to liver cancer which were reported as occurring in the patient at the time of diagnosis. This information can typically be found in the managing physician's notes. | |
1006 | child's class a | HEP1;7 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes all conditions relevant to liver cancer which were reported as occurring in the patient at the time of diagnosis. This information can typically be found in the managing physician's notes. | |
1007 | child's class b | HEP1;8 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes all conditions relevant to liver cancer which were reported as occurring in the patient at the time of diagnosis. This information can typically be found in the managing physician's notes. | |
1008 | child's class c | HEP1;9 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes all conditions relevant to liver cancer which were reported as occurring in the patient at the time of diagnosis. This information can typically be found in the managing physician's notes. | |
1009 | hepatitis b | HEP1;10 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes all conditions relevant to liver cancer which were reported as occurring in the patient at the time of diagnosis. This information can typically be found in the managing physician's notes. | |
1010 | hepatitis c | HEP1;11 | SET OF CODES | 0:Patient screened, negative results 1:Patient screened, positive results for Hep C 8:Patient refused 9:Unknown if patient screened | This field describes all conditions relevant to liver cancer which were reported as occurring in the patient at the time of diagnosis. This information can typically be found in the managing physician's notes. | |
1011 | hemochromatosis | HEP1;12 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes all conditions relevant to liver cancer which were reported as occurring in the patient at the time of diagnosis. This information can typically be found in the managing physician's notes. | |
1012 | alcohol consumption | HEP1;13 | FREE TEXT | This field describes the number of drinks (beer, wine, other alcohol) consumed by the patient per week. If the patient has never consumed alcohol, code 000. If the number of drinks per week is unknown, code 999. This information can typically be found in either the patient's clinic chart or the managing physician's notes. | ||
1013 | afp (iu/ml) | HEP1;14 | FREE TEXT | This field describes the absolute value of each tumor marker test administered to the patient prior to the start of the first course of treatment. Tumor markers considered in this study include: AFP (IU/ml); CEA (mg/ml); and CA19.9 (U/ml). This information can typically be found in either the patient's hospital chart or laboratory records. Record tumor markers as whole numbers, round decimals to the nearest integer; for example 12.5 would be rounded up to 13, and 4.4 would be rounded down to 4. If a particular tumor marker test was not administered code 00000. If a test was administered but the results is unknown, code 99999. | ||
1014 | cea (mg/ml) | HEP1;15 | FREE TEXT | This field describes the absolute value of each tumor marker test administered to the patient prior to the start of the first course of treatment. Tumor markers considered in this study include: AFP (IU/ml); CEA (mg/ml); and CA19.9 (U/ml). This information can typically be found in either the patient's hospital chart or laboratory records. Record tumor markers as whole numbers, round decimals to the nearest integer; for example 12.5 would be rounded up to 13, and 4.4 would be rounded down to 4. If a particular tumor marker test was not administered code 00000. If a test was administered but the results is unknown, code 99999. | ||
1015 | ca19.9 (u/ml) | HEP1;16 | FREE TEXT | This field describes the absolute value of each tumor marker test administered to the patient prior to the start of the first course of treatment. Tumor markers considered in this study include: AFP (IU/ml); CEA (mg/ml); and CA19.9 (U/ml). This information can typically be found in either the patient's hospital chart or laboratory records. Record tumor markers as whole numbers, round decimals to the nearest integer; for example 12.5 would be rounded up to 13, and 4.4 would be rounded down to 4. If a particular tumor marker test was not administered code 00000. If a test was administered but the results is unknown, code 99999. | ||
1016 | protime (sec) | HEP1;17 | FREE TEXT | This field describes the absolute value of each liver function test administered to the patient prior to the start of the first course of treatment. This information can typically be found in either the patient's hospital chart or laboratory records. Record test results as whole numbers, round decimals to the nearest integer; for example 12.5 would be rounded up to 13, and 4.4 would be rounded down to 4. If a particular test was not administered, code 00000. If a test was administered but the result unknown, code 99999. | ||
1017 | bilirubin (mg/ml) | HEP1;18 | FREE TEXT | This field describes the absolute value of each liver function test administered to the patient prior to the start of the first course of treatment. This information can typically be found in either the patient's hospital chart or laboratory records. Record test results as whole numbers, round decimals to the nearest integer; for example 12.5 would be rounded up to 13, and 4.4 would be rounded down to 4. If a particular test was not administered, code 00000. If a test was administered but the result unknown, code 99999. | ||
1018 | albumin (g/dl) | HEP1;19 | FREE TEXT | This field describes the absolute value of each liver function test administered to the patient prior to the start of the first course of treatment. This information can typically be found in either the patient's hospital chart or laboratory records. Record test results as whole numbers, round decimals to the nearest integer; for example 12.5 would be rounded up to 13, and 4.4 would be rounded down to 4. If a particular test was not administered, code 00000. If a test was administered but the result unknown, code 99999. | ||
1019 | ldh (u/i) | HEP1;20 | FREE TEXT | This field describes the absolute value of each liver function test administered to the patient prior to the start of the first course of treatment. This information can typically be found in either the patient's hospital chart or laboratory records. Record test results as whole numbers, round decimals to the nearest integer; for example 12.5 would be rounded up to 13, and 4.4 would be rounded down to 4. If a particular test was not administered, code 00000. If a test was administered but the result unknown, code 99999. | ||
1020 | ct arterial port-performed | HEP1;21 | SET OF CODES | 0:Not performed 1:Performed 9:Unknown | This field describes the findings from each type of radiological imaging technique utilized in the evaluation of the patient. Record four pieces of information, 1) whether the imaging technique was performed; 2) whether the presence of cirrhosis, bilobar disease, vascular invasion, or enlarged lymph nodes were noted; 3) record the size of the dominant (largest) tumor in millimeters, and 4) the number of tumor nodules present. This information can typically be found in either the patient's hospital chart, the managing physician's notes, or the managing radiologist's notes. | |
1021 | ct arterial port-cirrhosis | HEP1;22 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | This field describes the findings from each type of radiological imaging technique utilized in the evaluation of the patient. Record four pieces of information, 1) whether the imaging technique was performed; 2) whether the presence of cirrhosis, bilobar disease, vascular invasion, or enlarged lymph nodes were noted; 3) record the size of the dominant (largest) tumor in millimeters, and 4) the number of tumor nodules present. This information can typically be found in either the patient's hospital chart, the managing physician's notes, or the managing radiologist's notes. | |
1022 | ct arterial port-vascular inv | HEP1;23 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | This field describes the findings from each type of radiological imaging technique utilized in the evaluation of the patient. Record four pieces of information, 1) whether the imaging technique was performed; 2) whether the presence of cirrhosis, bilobar disease, vascular invasion, or enlarged lymph nodes were noted; 3) record the size of the dominant (largest) tumor in millimeters, and 4) the number of tumor nodules present. This information can typically be found in either the patient's hospital chart, the managing physician's notes, or the managing radiologist's notes. | |
1023 | ct arterial port-bilobar dis | HEP1;24 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | This field describes the findings from each type of radiological imaging technique utilized in the evaluation of the patient. Record four pieces of information, 1) whether the imaging technique was performed; 2) whether the presence of cirrhosis, bilobar disease, vascular invasion, or enlarged lymph nodes were noted; 3) record the size of the dominant (largest) tumor in millimeters, and 4) the number of tumor nodules present. This information can typically be found in either the patient's hospital chart, the managing physician's notes, or the managing radiologist's notes. | |
1024 | ct arterial port-lymph nodes | HEP1;25 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | This field describes the findings from each type of radiological imaging technique utilized in the evaluation of the patient. Record four pieces of information, 1) whether the imaging technique was performed; 2) whether the presence of cirrhosis, bilobar disease, vascular invasion, or enlarged lymph nodes were noted; 3) record the size of the dominant (largest) tumor in millimeters, and 4) the number of tumor nodules present. This information can typically be found in either the patient's hospital chart, the managing physician's notes, or the managing radiologist's notes. | |
1025 | ct arterial port-size of tumor | HEP1;26 | FREE TEXT | This field describes the findings from each type of radiological imaging technique utilized in the evaluation of the patient. Record four pieces of information, 1) whether the imaging technique was performed; 2) whether the presence of cirrhosis, bilobar disease, vascular invasion, or enlarged lymph nodes were noted; 3) record the size of the dominant (largest) tumor in millimeters, and 4) the number of tumor nodules present. This information can typically be found in either the patient's hospital chart, the managing physician's notes, or the managing radiologist's notes. The size of the dominant tumor describes the dimension or diameter of the largest identified tumor in millimeters (1 cm = 10 mm). If the tumor has multiple measurements, code the largest size. For example, if the dominant or largest tumor is reported as measuring 3x4.4x2.5 cm, then code as 044. | ||
1026 | ct arterial port-num 0f tumors | HEP1;27 | FREE TEXT | This field describes the findings from each type of radiological imaging technique utilized in the evaluation of the patient. Record four pieces of information, 1) whether the imaging technique was performed; 2) whether the presence of cirrhosis, bilobar disease, vascular invasion, or enlarged lymph nodes were noted; 3) record the size of the dominant (largest) tumor in millimeters, and 4) the number of tumor nodules present. This information can typically be found in either the patient's hospital chart, the managing physician's notes, or the managing radiologist's notes. | ||
1027 | spiral ct-performed | HEP1;28 | SET OF CODES | 0:Not performed 1:Performed 9:Unknown | This field describes the findings from each type of radiological imaging technique utilized in the evaluation of the patient. Record four pieces of information, 1) whether the imaging technique was performed; 2) whether the presence of cirrhosis, bilobar disease, vascular invasion, or enlarged lymph nodes were noted; 3) record the size of the dominant (largest) tumor in millimeters, and 4) the number of tumor nodules present. This information can typically be found in either the patient's hospital chart, the managing physician's notes, or the managing radiologist's notes. | |
1028 | spiral ct-cirrhosis | HEP1;29 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | This field describes the findings from each type of radiological imaging technique utilized in the evaluation of the patient. Record four pieces of information, 1) whether the imaging technique was performed; 2) whether the presence of cirrhosis, bilobar disease, vascular invasion, or enlarged lymph nodes were noted; 3) record the size of the dominant (largest) tumor in millimeters, and 4) the number of tumor nodules present. This information can typically be found in either the patient's hospital chart, the managing physician's notes, or the managing radiologist's notes. | |
1029 | spiral ct-vascular inv | HEP1;30 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | This field describes the findings from each type of radiological imaging technique utilized in the evaluation of the patient. Record four pieces of information, 1) whether the imaging technique was performed; 2) whether the presence of cirrhosis, bilobar disease, vascular invasion, or enlarged lymph nodes were noted; 3) record the size of the dominant (largest) tumor in millimeters, and 4) the number of tumor nodules present. This information can typically be found in either the patient's hospital chart, the managing physician's notes, or the managing radiologist's notes. | |
1030 | spiral ct-bilobar dis | HEP1;31 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | This field describes the findings from each type of radiological imaging technique utilized in the evaluation of the patient. Record four pieces of information, 1) whether the imaging technique was performed; 2) whether the presence of cirrhosis, bilobar disease, vascular invasion, or enlarged lymph nodes were noted; 3) record the size of the dominant (largest) tumor in millimeters, and 4) the number of tumor nodules present. This information can typically be found in either the patient's hospital chart, the managing physician's notes, or the managing radiologist's notes. | |
1031 | spiral ct-lymph nodes | HEP1;32 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | This field describes the findings from each type of radiological imaging technique utilized in the evaluation of the patient. Record four pieces of information, 1) whether the imaging technique was performed; 2) whether the presence of cirrhosis, bilobar disease, vascular invasion, or enlarged lymph nodes were noted; 3) record the size of the dominant (largest) tumor in millimeters, and 4) the number of tumor nodules present. This information can typically be found in either the patient's hospital chart, the managing physician's notes, or the managing radiologist's notes. | |
1032 | spiral ct-size of tumor | HEP1;33 | FREE TEXT | This field describes the findings from each type of radiological imaging technique utilized in the evaluation of the patient. Record four pieces of information, 1) whether the imaging technique was performed; 2) whether the presence of cirrhosis, bilobar disease, vascular invasion, or enlarged lymph nodes were noted; 3) record the size of the dominant (largest) tumor in millimeters, and 4) the number of tumor nodules present. This information can typically be found in either the patient's hospital chart, the managing physician's notes, or the managing radiologist's notes. The size of the dominant tumor describes the dimension or diameter of the largest identified tumor in millimeters (1 cm = 10 mm). If the tumor has multiple measurements, code the largest size. For example, if the dominant or largest tumor is reported as measuring 3x4.4x2.5 cm, then code as 044. | ||
1033 | spiral ct-num of tumors | HEP1;34 | FREE TEXT | This field describes the findings from each type of radiological imaging technique utilized in the evaluation of the patient. Record four pieces of information, 1) whether the imaging technique was performed; 2) whether the presence of cirrhosis, bilobar disease, vascular invasion, or enlarged lymph nodes were noted; 3) record the size of the dominant (largest) tumor in millimeters, and 4) the number of tumor nodules present. This information can typically be found in either the patient's hospital chart, the managing physician's notes, or the managing radiologist's notes. | ||
1034 | incremental ct-performed | HEP1;35 | SET OF CODES | 0:Not performed 1:Performed 9:Unknown | This field describes the findings from each type of radiological imaging technique utilized in the evaluation of the patient. Record four pieces of information, 1) whether the imaging technique was performed; 2) whether the presence of cirrhosis, bilobar disease, vascular invasion, or enlarged lymph nodes were noted; 3) record the size of the dominant (largest) tumor in millimeters, and 4) the number of tumor nodules present. This information can typically be found in either the patient's hospital chart, the managing physician's notes, or the managing radiologist's notes. | |
1035 | incremental ct-cirrhosis | HEP1;36 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | This field describes the findings from each type of radiological imaging technique utilized in the evaluation of the patient. Record four pieces of information, 1) whether the imaging technique was performed; 2) whether the presence of cirrhosis, bilobar disease, vascular invasion, or enlarged lymph nodes were noted; 3) record the size of the dominant (largest) tumor in millimeters, and 4) the number of tumor nodules present. This information can typically be found in either the patient's hospital chart, the managing physician's notes, or the managing radiologist's notes. | |
1036 | incremental ct-vascular inv | HEP1;37 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | This field describes the findings from each type of radiological imaging technique utilized in the evaluation of the patient. Record four pieces of information, 1) whether the imaging technique was performed; 2) whether the presence of cirrhosis, bilobar disease, vascular invasion, or enlarged lymph nodes were noted; 3) record the size of the dominant (largest) tumor in millimeters, and 4) the number of tumor nodules present. This information can typically be found in either the patient's hospital chart, the managing physician's notes, or the managing radiologist's notes. | |
1037 | incremental ct-bilobar dis | HEP1;38 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | This field describes the findings from each type of radiological imaging technique utilized in the evaluation of the patient. Record four pieces of information, 1) whether the imaging technique was performed; 2) whether the presence of cirrhosis, bilobar disease, vascular invasion, or enlarged lymph nodes were noted; 3) record the size of the dominant (largest) tumor in millimeters, and 4) the number of tumor nodules present. This information can typically be found in either the patient's hospital chart, the managing physician's notes, or the managing radiologist's notes. | |
1038 | incremental ct-lymph nodes | HEP1;39 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | This field describes the findings from each type of radiological imaging technique utilized in the evaluation of the patient. Record four pieces of information, 1) whether the imaging technique was performed; 2) whether the presence of cirrhosis, bilobar disease, vascular invasion, or enlarged lymph nodes were noted; 3) record the size of the dominant (largest) tumor in millimeters, and 4) the number of tumor nodules present. This information can typically be found in either the patient's hospital chart, the managing physician's notes, or the managing radiologist's notes. | |
1039 | incremental ct-size of tumor | HEP1;40 | FREE TEXT | This field describes the findings from each type of radiological imaging technique utilized in the evaluation of the patient. Record four pieces of information, 1) whether the imaging technique was performed; 2) whether the presence of cirrhosis, bilobar disease, vascular invasion, or enlarged lymph nodes were noted; 3) record the size of the dominant (largest) tumor in millimeters, and 4) the number of tumor nodules present. This information can typically be found in either the patient's hospital chart, the managing physician's notes, or the managing radiologist's notes. The size of the dominant tumor describes the dimension or diameter of the largest identified tumor in millimeters (1 cm = 10 mm). If the tumor has multiple measurements, code the largest size. For example, if the dominant or largest tumor is reported as measuring 3x4.4x2.5 cm, then code as 044. | ||
1040 | incremental ct-num 0f tumors | HEP1;41 | FREE TEXT | This field describes the findings from each type of radiological imaging technique utilized in the evaluation of the patient. Record four pieces of information, 1) whether the imaging technique was performed; 2) whether the presence of cirrhosis, bilobar disease, vascular invasion, or enlarged lymph nodes were noted; 3) record the size of the dominant (largest) tumor in millimeters, and 4) the number of tumor nodules present. This information can typically be found in either the patient's hospital chart, the managing physician's notes, or the managing radiologist's notes. | ||
1041 | ultrasound-performed | HEP1;42 | SET OF CODES | 0:Not performed 1:Performed 9:Unknown | This field describes the findings from each type of radiological imaging technique utilized in the evaluation of the patient. Record four pieces of information, 1) whether the imaging technique was performed; 2) whether the presence of cirrhosis, bilobar disease, vascular invasion, or enlarged lymph nodes were noted; 3) record the size of the dominant (largest) tumor in millimeters, and 4) the number of tumor nodules present. This information can typically be found in either the patient's hospital chart, the managing physician's notes, or the managing radiologist's notes. | |
1042 | ultrasound-cirrhosis | HEP1;43 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | This field describes the findings from each type of radiological imaging technique utilized in the evaluation of the patient. Record four pieces of information, 1) whether the imaging technique was performed; 2) whether the presence of cirrhosis, bilobar disease, vascular invasion, or enlarged lymph nodes were noted; 3) record the size of the dominant (largest) tumor in millimeters, and 4) the number of tumor nodules present. This information can typically be found in either the patient's hospital chart, the managing physician's notes, or the managing radiologist's notes. | |
1043 | ultrasound-vascular inv | HEP1;44 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | This field describes the findings from each type of radiological imaging technique utilized in the evaluation of the patient. Record four pieces of information, 1) whether the imaging technique was performed; 2) whether the presence of cirrhosis, bilobar disease, vascular invasion, or enlarged lymph nodes were noted; 3) record the size of the dominant (largest) tumor in millimeters, and 4) the number of tumor nodules present. This information can typically be found in either the patient's hospital chart, the managing physician's notes, or the managing radiologist's notes. | |
1044 | ultrasound-bilobar dis | HEP1;45 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | This field describes the findings from each type of radiological imaging technique utilized in the evaluation of the patient. Record four pieces of information, 1) whether the imaging technique was performed; 2) whether the presence of cirrhosis, bilobar disease, vascular invasion, or enlarged lymph nodes were noted; 3) record the size of the dominant (largest) tumor in millimeters, and 4) the number of tumor nodules present. This information can typically be found in either the patient's hospital chart, the managing physician's notes, or the managing radiologist's notes. | |
1045 | ultrasound-lymph nodes | HEP1;46 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | This field describes the findings from each type of radiological imaging technique utilized in the evaluation of the patient. Record four pieces of information, 1) whether the imaging technique was performed; 2) whether the presence of cirrhosis, bilobar disease, vascular invasion, or enlarged lymph nodes were noted; 3) record the size of the dominant (largest) tumor in millimeters, and 4) the number of tumor nodules present. This information can typically be found in either the patient's hospital chart, the managing physician's notes, or the managing radiologist's notes. | |
1046 | ultrasound-size of tumor | HEP1;47 | FREE TEXT | This field describes the findings from each type of radiological imaging technique utilized in the evaluation of the patient. Record four pieces of information, 1) whether the imaging technique was performed; 2) whether the presence of cirrhosis, bilobar disease, vascular invasion, or enlarged lymph nodes were noted; 3) record the size of the dominant (largest) tumor in millimeters, and 4) the number of tumor nodules present. This information can typically be found in either the patient's hospital chart, the managing physician's notes, or the managing radiologist's notes. The size of the dominant tumor describes the dimension or diameter of the largest identified tumor in millimeters (1 cm = 10 mm). If the tumor has multiple measurements, code the largest size. For example, if the dominant or largest tumor is reported as measuring 3x4.4x2.5 cm, then code as 044. | ||
1047 | ultrasound-num 0f tumors | HEP1;48 | FREE TEXT | This field describes the findings from each type of radiological imaging technique utilized in the evaluation of the patient. Record four pieces of information, 1) whether the imaging technique was performed; 2) whether the presence of cirrhosis, bilobar disease, vascular invasion, or enlarged lymph nodes were noted; 3) record the size of the dominant (largest) tumor in millimeters, and 4) the number of tumor nodules present. This information can typically be found in either the patient's hospital chart, the managing physician's notes, or the managing radiologist's notes. | ||
1048 | mri-performed | HEP1;49 | SET OF CODES | 0:Not performed 1:Performed 9:Unknown | This field describes the findings from each type of radiological imaging technique utilized in the evaluation of the patient. Record four pieces of information, 1) whether the imaging technique was performed; 2) whether the presence of cirrhosis, bilobar disease, vascular invasion, or enlarged lymph nodes were noted; 3) record the size of the dominant (largest) tumor in millimeters, and 4) the number of tumor nodules present. This information can typically be found in either the patient's hospital chart, the managing physician's notes, or the managing radiologist's notes. | |
1049 | mri-cirrhosis | HEP1;50 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | This field describes the findings from each type of radiological imaging technique utilized in the evaluation of the patient. Record four pieces of information, 1) whether the imaging technique was performed; 2) whether the presence of cirrhosis, bilobar disease, vascular invasion, or enlarged lymph nodes were noted; 3) record the size of the dominant (largest) tumor in millimeters, and 4) the number of tumor nodules present. This information can typically be found in either the patient's hospital chart, the managing physician's notes, or the managing radiologist's notes. | |
1050 | mri-vascular inv | HEP1;51 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | This field describes the findings from each type of radiological imaging technique utilized in the evaluation of the patient. Record four pieces of information, 1) whether the imaging technique was performed; 2) whether the presence of cirrhosis, bilobar disease, vascular invasion, or enlarged lymph nodes were noted; 3) record the size of the dominant (largest) tumor in millimeters, and 4) the number of tumor nodules present. This information can typically be found in either the patient's hospital chart, the managing physician's notes, or the managing radiologist's notes. | |
1051 | mri-bilobar dis | HEP1;52 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | This field describes the findings from each type of radiological imaging technique utilized in the evaluation of the patient. Record four pieces of information, 1) whether the imaging technique was performed; 2) whether the presence of cirrhosis, bilobar disease, vascular invasion, or enlarged lymph nodes were noted; 3) record the size of the dominant (largest) tumor in millimeters, and 4) the number of tumor nodules present. This information can typically be found in either the patient's hospital chart, the managing physician's notes, or the managing radiologist's notes. | |
1052 | mri-lymph nodes | HEP1;53 | SET OF CODES | 0:NO 1:Yes 8:NA 9:Unknown | This field describes the findings from each type of radiological imaging technique utilized in the evaluation of the patient. Record four pieces of information, 1) whether the imaging technique was performed; 2) whether the presence of cirrhosis, bilobar disease, vascular invasion, or enlarged lymph nodes were noted; 3) record the size of the dominant (largest) tumor in millimeters, and 4) the number of tumor nodules present. This information can typically be found in either the patient's hospital chart, the managing physician's notes, or the managing radiologist's notes. | |
1053 | mri-size of tumor | HEP1;54 | FREE TEXT | This field describes the findings from each type of radiological imaging technique utilized in the evaluation of the patient. Record four pieces of information, 1) whether the imaging technique was performed; 2) whether the presence of cirrhosis, bilobar disease, vascular invasion, or enlarged lymph nodes were noted; 3) record the size of the dominant (largest) tumor in millimeters, and 4) the number of tumor nodules present. This information can typically be found in either the patient's hospital chart, the managing physician's notes, or the managing radiologist's notes. The size of the dominant tumor describes the dimension or diameter of the largest identified tumor in millimeters (1 cm = 10 mm). If the tumor has multiple measurements, code the largest size. For example, if the dominant or largest tumor is reported as measuring 3x4.4x2.5 cm, then code as 044. | ||
1054 | mri-num 0f tumors | HEP1;55 | FREE TEXT | This field describes the findings from each type of radiological imaging technique utilized in the evaluation of the patient. Record four pieces of information, 1) whether the imaging technique was performed; 2) whether the presence of cirrhosis, bilobar disease, vascular invasion, or enlarged lymph nodes were noted; 3) record the size of the dominant (largest) tumor in millimeters, and 4) the number of tumor nodules present. This information can typically be found in either the patient's hospital chart, the managing physician's notes, or the managing radiologist's notes. | ||
1055 | definitive diagnosis | HEP1;56 | SET OF CODES | 1:Percutaneous biopsy 2:At definitive cancer-directed surgery 3:Incidental at liver transplantation 9:Unknown | This field describes whether the DEFINITIVE DIAGNOSIS was achieved by percutaneous biopsy; at the time of the definitive cancer-directed surgical procedure; or at the time of pathologic examination of an explanted liver specimen. This information can typically by found in either the patient's hospital or clinical chart, or operative note. | |
1056 | radio-frequency destruction | HEP1;57 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | This field describes cancer-directed surgery of the primary site which does not appear as part of the Commission on Cancer's required surgical codes. If SURGERY OF PRIMARY SITE (question 36) was coded 17 then record whether the patient received RADIO-FREQUENCY DESTRUCTION of the tumor. | |
1057 | ablation & resection | HEP1;58 | SET OF CODES | 00:Ablation & resection not administered 11:Photodynamic therapy 12:Electrocautery, fulguration 13:Cryosurgery 14:Laser 15:Alcohol 16:Heat 17:Radio-frequency 18:Other 88:NA 99:Ablation administered, type unknown | This field describes the combination of ablative surgery and resection administered to the primary site. If the patient received both ablation and resection, record the ablative surgical therapy administered. If the patient did not receive a combination of surgical ablation and resection, code 00. If no cancer-directed surgery was administered, code 88. | |
1058 | distance to closest margin | HEP1;59 | SET OF CODES | 0:Margins involved 1:Negative margins, < 1cm 2:Negative margins, 1cm - 2cm 3:Negative margins, > 2cm 8:NA 9:Unknown, not described | This field describes the distance from the resected tumor to the closest margin. Code distance of margin ONLY if the tumor was surgically resected, this includes tumors which were ablated and resected. If no cancer-directed surgery was administered, or if the tumor was surgically ablated only, code 8. | |
1059 | ablation | HEP1;60 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | This field describes the surgical treatment of either microscopic or macroscopic residual tumor remaining AFTER the most definitive surgery of the primary site. Record whether this remaining tumor was ablated and/or resected. Ablation includes: photodynamic therapy; electrocautery; fulguration; cryosurgery; laser; alcohol; heat; radio-frequency; ultra- sound; acetic acid. | |
1060 | resection | HEP1;61 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | This field describes the surgical treatment of either microscopic or macroscopic residual tumor remaining AFTER the most definitive surgery of the primary site. Record whether this remaining tumor was ablated and/or resected. Resection includes: wedge resection, NOS; segmental resection; lobectomy, NOS (simple and extended); total hepatectomy with transplant; hepatectomy, NOS. | |
1061 | cisplatin | HEP1;62 | SET OF CODES | 0:No 1:Yes 8:Recommended, not known if administered 9:Unknown if recommended or administered | This field describes whether this type of chemotherapeutic agent was administered. This information can typically be found in either the patient's hospital chart or the managing medical oncologist's notes. | |
1062 | fudr | HEP1;63 | SET OF CODES | 0:No 1:Yes 8:Recommended, not known if administered 9:Unknown if recommended or administered | This field describes whether this type of chemotherapeutic agent was administered. This information can typically be found in either the patient's hospital chart or the managing medical oncologist's notes. | |
1063 | 5-fu | HEP1;64 | SET OF CODES | 0:No 1:Yes 8:Recommended, not known if administered 9:Unknown if recommended or administered | This field describes whether this type of chemotherapeutic agent was administered. This information can typically be found in either the patient's hospital chart or the managing medical oncologist's notes. | |
1064 | fu & leucovorin | HEP1;65 | SET OF CODES | 0:No 1:Yes 8:Recommended, not known if administered 9:Unknown if recommended or administered | This field describes whether this type of chemotherapeutic agent was administered. This information can typically be found in either the patient's hospital chart or the managing medical oncologist's notes. | |
1065 | irinotecan (cpt-11) | HEP1;66 | SET OF CODES | 0:No 1:Yes 8:Recommended, not known if administered 9:Unknown if recommended or administered | This field describes whether this type of chemotherapeutic agent was administered. This information can typically be found in either the patient's hospital chart or the managing medical oncologist's notes. | |
1066 | mitomycin c | HEP1;67 | SET OF CODES | 0:No 1:Yes 8:Recommended, now known if administered 9:Unknown if recommended or administered | This field describes whether this type of chemotherapeutic agent was administered. This information can typically be found in either the patient's hospital chart or the managing medical oncologist's notes. | |
1067 | oxaliplatin | HEP1;68 | SET OF CODES | 0:No 1:Yes 8:Recommended, not known if administered 9:Unknown if recommended or administered | This field describes whether this type of chemotherapeutic agent was administered. This information can typically be found in either the patient's hospital chart or the managing medical oncologist's notes. | |
1068 | gemcitabine | HEP1;69 | SET OF CODES | 0:No 1:Yes 8:Recommended, not known if administered 9:Unknown if recommended or administered | This field describes whether this type of chemotherapeutic agent was administered. This information can typically be found in either the patient's hospital chart or the managing medical oncologist's notes. | |
1069 | route chemo admin | HEP1;70 | SET OF CODES | 01:Intrathecal 02:Intra-arterial, bolus 03:Intravenous inf 04:Hepatic inf 05:Intra-arterial chemoembolization 06:Intratumoral inj of alcohol 07:Portal inf 08:Orally 09:Intramuscular 88:NA 99:Chemo admin, route unk | This field describes the route/method by which chemotherapy was administered. This information can typically be found in either the patient's hospital chart or the managing medical oncologist's notes. | |
1070 | chemotherapy/surgery sequence | HEP1;71 | SET OF CODES | 0:No chemotherapy and/or no surgery 1:Chemotherapy before surgery 2:Chemotherapy after surgery 3:Chemotherapy before and after surgery 9:Chemotherapy and surgery, sequence unknown | This field describes the sequence in which chemotherapy and primary tumor cancer-directed surgery were administered. | |
1071 | arterial embolization | HEP1;72 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes whether the patient had their tumor embolized without chemotherapy. This procedure involves the embolizing or clotting of a portion of the hepatic artery to disrupt the blood flow to the tumor. Information about this treatment modality can be found in the Vascular/Interventional Radiology procedure notes. | |
1072 | death w/i 30 days start tx | HEP1;73 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes whether the patient died from any cause within 30 days of the start of cancer-directed therapy. | |
1100 | history of melanoma (pt) | MEL1;1 | SET OF CODES | 0:None 1:Yes, synchronous or <2 months 2:Yes, 2 months to <4 years 3:Yes, 4 years to <7 years 4:Yes, 7 years to <15 years 5:Yes, 15 years or more 6:Yes, time period unknown 9:Unk if history of melanoma exists | Record if patient had or currently has any personal history of other melanoma and, if so, how far back it occurred in relation to the present melanoma. | |
1101 | history of other cancer (pt) | MEL1;2 | SET OF CODES | 0:No 1:Yes 9:Unknown | Record if the patient had any history of other types of cancer. | |
1102 | first site code | MEL1;3 | POINTER | 164 | Record the primary site of the most recent other cancer with which the patient has been diagnosed, if any. If no previous cancer was diagnosed, code 000. If a previous cancer was diagnosed, but the site is unknown, code 888. If it is unknown whether a history of other cancers exists for the patient, code 999. | |
1103 | first site diagnosis date | MEL1;4 | DATE-TIME | Record the date on which the most recent other cancer was diagnosed. If no previous cancer was diagnosed, code the date with 0's. If a previous cancer was diagnosed, but the date is unknown, code the date with 8's. If it is unknown whether a history of other cancers exists for the patient, code the date with 9's. | ||
1104 | second site code | MEL1;5 | POINTER | 164 | Record the primary site of the second most recent other cancer with which the patient has been diagnosed, if any. If no previous cancer was diagnosed, code 000. If a previous cancer was diagnosed, but the site is unknown, code 888. If it is unknown whether a history of other cancers exists for the patient, code 999. | |
1105 | second site diagnosis date | MEL1;6 | DATE-TIME | Record the date on which the second most recent other cancer was diagnosed. If no previous cancer was diagnosed, code the date 00/00/00. If a previous cancer was diagnosed, but the date is unknown, code the date 88/88/88. If it is unknown whether a history of other cancers exists for the patient, code the date 99/99/99. | ||
1106 | pregnancy at initial diagnosis | MEL1;7 | SET OF CODES | 0:No 1:Yes 8:NA, male 9:Unknown | Record whether the patient was pregnant at the time of initial diagnosis. | |
1107 | exogenous hormones | MEL1;8 | SET OF CODES | 0:None 1:Yes, HRT (hormone replacement therapy) 2:Yes, OC (oral contraceptives) 3:Yes, both HRT and OC 4:Yes, type unknown 8:NA, male 9:Unknown | Record whether the patient was receiving prescribed exogenous therapy at the time of initial diagnosis and the number of years of therapy. For this question, exogenous hormones are estrogen | |
1108 | disease presentation location | MEL1;9 | SET OF CODES | 1:Solitary cutaneous/subcutaneous 2:Multiple cutaneous/subcutaneous 3:Nodal 4:Visceral 5:Other 8:NA, primary site known 9:Unknown | Record the location of the disease presentation. If the primary site is known, code as 8, not applicable. | |
1109 | type of biopsy | MEL1;10 | SET OF CODES | 0:No biopsy performed 1:Excisional 2:Punch 3:Incisional 4:Shave 5:Saucerization 6:Fine needle aspiration 8:NA, non-cutaneous melanoma 9:Unknown | Record the appropriate code for cutaneous melanomas only. Code 8, not applicable, for non-cutaneous sites. | |
1110 | extranodal extension | MEL1;11 | SET OF CODES | 0:None 1:Microscopic, 2mm or less 2:Gross, greater than 2mm 3:Present, size unknown 8:NA, no nodes examined 9:Unknown | Record whether extranodal extension was determined on gross (greater than 2mm) observation or microscopic (2mm or less) observation. | |
1111 | microsatellitosis | MEL1;12 | SET OF CODES | 0:No 1:Yes 8:NA, non-cutaneous melanoma 9:Unknown | Record the presence of microsatellitosis. They are visualized with the aid of a microscope and defined as discrete nests of melanoma cells >0.05mm, noncontiguous and clearly separated from the main body of the tumor by normal reticular dermal collagen or subcutaneous fat. | |
1112 | number of satellite nodules | MEL1;13 | FREE TEXT | Record the number of satellite nodules within 2 cm of the primary tumor. If there were no satellite nodules, microsatellitosis not present, record 00. If there were multiple nodules but an exact number is not stated, record 97. Record 98 if not applicable, non- cutaneous melanoma. Record 99 if it is unknown whether there were satellite nodules. | ||
1113 | location of in-transit nodules | MEL1;14 | SET OF CODES | 0:None 1:Regional 2:Distant 3:Other 4:Present, location unknown 8:NA, non-cutaneous melanoma 9:Unknown | Record the location of in-transit nodules that were farthest from the primary lesion but not beyond the site of primary lymph node drainage. | |
1114 | breslow's thickness | MEL1;15 | FREE TEXT | Record the thickness of the primary lesion in millimeters using Breslow's method to measure the depth of the invasion. Record from the pathology report. Record 997 if cutaneous melanoma, Breslow's thickness unknown. Record 998, not applicable if non-cutaneous melanoma. Record 999 if cutaneous melanoma, but the primary site is unknown. | ||
1115 | clark's level of invasion | MEL1;16 | SET OF CODES | 1:I 2:II 3:III 4:IV 5:V 8:NA, primary site unknown 9:Unknown | There are 5 levels of invasion. Convert level from Roman to Arabic numerals. Code 8, not applicable, if primary site unknown or non- cutaneous melanoma. Code 9 if Clark's level is unknown. 1. Level I: All tumor cells confined to the epidermis with no invasion through the basement membrane (in situ melanoma). 2. Level II: Tumor cells penetrating through the basement membrane into the papillary dermis but not extending to the reticular dermis. 3. Level III: Tumor cells filling the papillary dermis and abutting against the reticular dermis but not invading it. 4. Level IV: Extension of tumor cells between the bundles of collagen characteristic of the reticular dermis. 5. Level V: Invasion into the subcutaneous tissue. | |
1116 | angiolymphatic invasion | MEL1;17 | SET OF CODES | 0:No 1:Yes 8:NA, site unknown or ocular 9:Unknown | Record if this histologic feature was noted in the pathology report. Angiolymphatic invasion can be pathologically evaluated using either the whole tissue specimen or tissue taken from a core biopsy. Code 8, not applicable, in situations in which either there was no specimen, a specimen was not adequately large enough to determine these factors, or the primary site was unknown. | |
1117 | perineural invasion | MEL1;18 | SET OF CODES | 0:No 1:Yes 8:NA, site unknown or ocular 9:Unknown | Record if this histologic feature was noted in the pathology report. Perineural invasion can be pathologically evaluated using either the whole tissue specimen or tissue taken from a core biopsy. Code 8, not applicable, in situations in which either there was no specimen, a specimen was not adequately large enough to determine these factors, or the primary site was unknown. | |
1118 | ulceration | MEL1;19 | SET OF CODES | 0:No 1:Yes 8:NA, site unknown or ocular 9:Unknown | Record whether the primary site was ulcerated. Ulceration is defined as a microscopic interruption of the surface epithelium involved by tumor. This does not alter the staging procedure but is typically associated with a worse prognosis. Code 8, not applicable, if a primary site is mucosal, occular or unknown. | |
1119 | clinically amelanotic | MEL1;20 | SET OF CODES | 0:No 1:Yes 8:NA, site unknown or ocular 9:Unknown | Record whether the primary site was lacking in melanin. Frequently, terms such as brownish, black, blue or tan are used to describe a primary site with melanin. Primary sites lacking melanin may be described as non-pigmented or not dark. Primary sites which are reported to appear red or have redness should be considered amelanotic. Code 8, not applicable, if primary site is mucosal, ocular or unknown. | |
1120 | margin distance (mel) | MEL1;21 | FREE TEXT | If margins are free according to the operative report, record the shortest distance in millimeters from the tumor to the edge of specimen (margin). | ||
1121 | surgical closure | MEL1;22 | SET OF CODES | 1:Primary or suture closure 2:Split-thickness skin graft 3:Flap 4:Full-thickness skin graft 5:Other, NOS 8:NA, surgery not performed 9:Unknown | Record the type of surgical closure. Code 8, not applicable if surgery was not performed for this site. | |
1122 | pre-op lymphoscintigraphy | MEL1;23 | SET OF CODES | 0:No 1:Yes, unidirectional flow 2:Yes, multidirectional flow 3:Yes, flow unknown 8:NA, ocular site 9:Unknown | Record whether lymphoscintigraphy was performed, and if done, what was the flow. Unidirectional flow indicates that only one lynph node basin drained the site. Multidirectional flow indicates that more than one lymph node basin drained the site. | |
1123 | sentinel nodes detected by | MEL1;24 | SET OF CODES | 0:Not done 1:Vital blue die 2:Radiolabeled colloid 3:Combination of 1 and 2 4:Done, method unknown 8:NA, not done, ocular site 9:Unknown | Record the method of detecion of the sentinel node. | |
1124 | sentinel nodes examined (mel) | MEL1;25 | SET OF CODES | 0:No nodes 1:1 node 2:2 nodes 3:3 nodes 4:4 nodes 5:5 nodes 6:6 or more nodes 7:Nodes examined, number unknown 8:NA, not done, ocular site 9:Unknown | Enter the exact number of sentinel nodes examined. | |
1125 | sentinel nodes positive (mel) | MEL1;26 | SET OF CODES | 0:No nodes 1:1 node 2:2 nodes 3:3 nodes 4:4 nodes 5:5 nodes 6:6 or more nodes 7:Nodes positive, number unknown 8:NA, not done, no exam, ocular site 9:Unknown | Enter the exact number of sentinel nodes positive. | |
1126 | method of pathologic exam | MEL1;27 | SET OF CODES | 0:Not examined 1:Routine staining 2:Immunochemistry 3:Serial sectioning 4:PCR 5:Other 6:Any comb of 1,2,3,4 7:Examined, method unknown 8:NA, not done, ocular site 9:Unknown | Record the method of pathological examination of the sentinel node. | |
1127 | lymph node dissection | MEL1;28 | SET OF CODES | 0:No 1:Yes 8:NA, not done, no + nodes, ocular site 9:Unknown | If sentinel node(s) positive, record if a complete node dissection was performed. A complete node dissection is the dissection of all nodes found in a particular basin. | |
1128 | number of basins dissected | MEL1;29 | SET OF CODES | 0:No basins 1:1 basin 2:2 basins 3:3 basins 4:4 basins 5:5 basins 6:6 or more basins 7:Basins dissected, number unknown 8:NA, not done, no + nodes, ocular site Unknown:Unknown | If sentinel node(s) positive, record the number of basins dissected. | |
1129 | number of basins positive | MEL1;30 | SET OF CODES | 0:No basins 1:1 basin 2:2 basins 3:3 basins 4:4 basins 5:5 basins 6:6 or more basins 7:Basins positive, number unknown 8:NA, not done, no basins dissected, ocular 9:Unknown | If sentinel node(s) positive, record the number of basins positive. A positive basin is one in which at least one lymph node, other than the sentinel node, is determined to be positive. | |
1130 | intravenous therapy | MEL1;31 | SET OF CODES | 1:Yes, systemic 2:Yes, regional 3:Yes, combination of 1 and 2 7:Yes, type unknown 8:NA, chemotherapy not administered 9:Unknown if chemotherapy administered | Record how the intravenous therapy was given. | |
1131 | gene therapy | MEL1;32 | SET OF CODES | 0:No 1:Yes 8:NA 9:Unknown | Record whether the patient received this adjuvant immunotherapy. | |
1132 | size of tumor (melanoma) | MEL1;33 | NUMERIC | SIZE OF TUMOR (MELANOMA) is the largest dimension, or the diameter of the primary tumor, and is always recorded in millimeters. Record the largest diameter of the primary tumor for cutaneous melanomas. Record the tumor size for clinically diagnosed ocular melanoma. Record 998 for mucosal melanomas. Record 999 when the primary site is unknown or tumor size is not recorded or not available. IMPORTANT NOTE: Do NOT confuse this item with SIZE OF TUMOR in ROADS. For malignant melanoma SIZE OF TUMOR in ROADS records "depth of invasion" and is equivalent to PCE item #30 (BRESLOW'S THICKNESS). SIZE OF TUMOR (MELANOMA) records the largest dimension or diameter of the primary tumor. | ||
1200 | handedness | CNS1;1 | SET OF CODES | 1:Left handed 2:Right handed 3:Ambidextrous 9:Unknown | This field describes whether the patient is left handed, right handed or ambidextrous. | |
1201 | hypertension | CNS1;2 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes a patient's prior medical condition. | |
1202 | multiple sclerosis (ms) | CNS1;3 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes a patient's prior medical condition. | |
1203 | diabetes | CNS1;4 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes a patient's prior medical condition. | |
1204 | cerebrovascular disease | CNS1;5 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes a patient's prior medical condition. | |
1205 | brain | CNS1;6 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes a patient's prior history of any cancers. | |
1206 | breast | CNS1;7 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes a patient's prior history of any cancers. | |
1207 | prostate | CNS1;8 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes a patient's prior history of any cancers. | |
1208 | malignant melanoma | CNS1;9 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes a patient's prior history of any cancers. | |
1209 | other skin cancer | CNS1;10 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes a patient's prior history of any cancers. | |
1210 | leukemia | CNS1;11 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes a patient's prior history of any cancers. | |
1211 | colon or other gi cancers | CNS1;12 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes a patient's prior history of any cancers. | |
1212 | other personal history of ca | CNS1;13 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes a patient's prior history of any cancers. | |
1213 | neurofibromatosis | CNS1;14 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes a patient's predispostion to brain/CNS tumors. | |
1214 | von hippel-lindau disease | CNS1;15 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes a patient's predispostion to brain/CNS tumors. | |
1215 | tuberous sclerosis | CNS1;16 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes a patient's predispostion to brain/CNS tumors. | |
1216 | turcot syndrome | CNS1;17 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes a patient's predispostion to brain/CNS tumors. | |
1217 | li-fraumeni syndrome | CNS1;18 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes a patient's predispostion to brain/CNS tumors. | |
1218 | kowden disease | CNS1;19 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes a patient's predispostion to brain/CNS tumors. | |
1219 | nevoid basal cell carcinoma | CNS1;20 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes a patient's predispostion to brain/CNS tumors. | |
1220 | headache | CNS1;21 | SET OF CODES | 0:No 1:Yes 9:Unknown, not stated | This field describes one of the symptoms specific to the brain tumor as reported by the patient or recorded in the medical chart. | |
1221 | nausea/vomiting | CNS1;22 | SET OF CODES | 0:No 1:Yes 9:Unknown, not stated | This field describes one of the symptoms specific to the brain tumor as reported by the patient or recorded in the medical chart. | |
1222 | change in sense of smell/taste | CNS1;23 | SET OF CODES | 0:No 1:Yes 9:Unknown, not stated | This field describes one of the symptoms specific to the brain tumor as reported by the patient or recorded in the medical chart. | |
1223 | altered alertness | CNS1;24 | SET OF CODES | 0:No 1:Yes 9:Unknown, not stated | This field describes one of the symptoms specific to the brain tumor as reported by the patient or recorded in the medical chart. | |
1224 | fatigue | CNS1;25 | SET OF CODES | 0:No 1:Yes 9:Unknown, not stated | This field describes one of the symptoms specific to the brain tumor as reported by the patient or recorded in the medical chart. | |
1225 | speech disturbance | CNS1;26 | SET OF CODES | 0:No 1:Yes 9:Unknown, not stated | This field describes one of the symptoms specific to the brain tumor as reported by the patient or recorded in the medical chart. | |
1226 | personality changes | CNS1;27 | SET OF CODES | 0:No 1:Yes 9:Unknown, not stated | This field describes one of the symptoms specific to the brain tumor as reported by the patient or recorded in the medical chart. | |
1227 | depression | CNS1;28 | SET OF CODES | 0:No 1:Yes 9:Unknown, not stated | This field describes one of the symptoms specific to the brain tumor as reported by the patient or recorded in the medical chart. | |
1228 | memory loss | CNS1;29 | SET OF CODES | 0:No 1:Yes 9:Unknown, not stated | This field describes one of the symptoms specific to the brain tumor as reported by the patient or recorded in the medical chart. | |
1229 | lack of concentration | CNS1;30 | SET OF CODES | 0:No 1:Yes 9:Unknown, not stated | This field describes one of the symptoms specific to the brain tumor as reported by the patient or recorded in the medical chart. | |
1230 | double vision | CNS1;31 | SET OF CODES | 0:No 1:Yes 9:Unknown, not stated | This field describes one of the symptoms specific to the brain tumor as reported by the patient or recorded in the medical chart. | |
1231 | other visual disturbance | CNS1;32 | SET OF CODES | 0:No 1:Yes 9:Unknown, not stated | This field describes one of the symptoms specific to the brain tumor as reported by the patient or recorded in the medical chart. | |
1232 | decreased hearing | CNS1;33 | SET OF CODES | 0:No 1:Yes 9:Unknown, not stated | This field describes one of the symptoms specific to the brain tumor as reported by the patient or recorded in the medical chart. | |
1233 | vertigo | CNS1;34 | SET OF CODES | 0:No 1:Yes 9:Unknown, not stated | This field describes one of the symptoms specific to the brain tumor as reported by the patient or recorded in the medical chart. | |
1234 | tinnitus | CNS1;35 | SET OF CODES | 0:No 1:Yes 9:Unknown, not stated | This field describes one of the symptoms specific to the brain tumor as reported by the patient or recorded in the medical chart. | |
1235 | numbness/tingling | CNS1;36 | SET OF CODES | 0:No 1:Yes 9:Unknown, not stated | This field describes one of the symptoms specific to the brain tumor as reported by the patient or recorded in the medical chart. | |
1236 | weakness or paralysis | CNS1;37 | SET OF CODES | 0:No 1:Yes 9:Unknown, not stated | This field describes one of the symptoms specific to the brain tumor as reported by the patient or recorded in the medical chart. | |
1237 | difficulty in coord/balance | CNS1;38 | SET OF CODES | 0:No 1:Yes 9:Unknown, not stated | This field describes one of the symptoms specific to the brain tumor as reported by the patient or recorded in the medical chart. | |
1238 | generalized seizure | CNS1;39 | SET OF CODES | 0:No 1:Yes 9:Unknown, not stated | This field describes one of the symptoms specific to the brain tumor as reported by the patient or recorded in the medical chart. | |
1239 | focal seizure | CNS1;40 | SET OF CODES | 0:No 1:Yes 9:Unknown, not stated | This field describes one of the symptoms specific to the brain tumor as reported by the patient or recorded in the medical chart. | |
1240 | bladder incontinence | CNS1;41 | SET OF CODES | 0:No 1:Yes 9:Unknown, not stated | This field describes one of the symptoms specific to the brain tumor as reported by the patient or recorded in the medical chart. | |
1241 | bowel incontinence | CNS1;42 | SET OF CODES | 0:No 1:Yes 9:Unknown, not stated | This field describes one of the symptoms specific to the brain tumor as reported by the patient or recorded in the medical chart. | |
1242 | pain (other than headache) | CNS1;43 | SET OF CODES | 0:No 1:Yes 9:Unknown, not stated | This field describes one of the symptoms specific to the brain tumor as reported by the patient or recorded in the medical chart. | |
1243 | weight change | CNS1;44 | SET OF CODES | 0:No 1:Yes 9:Unknown, not stated | This field describes one of the symptoms specific to the brain tumor as reported by the patient or recorded in the medical chart. | |
1244 | other symptoms | CNS1;45 | SET OF CODES | 0:No 1:Yes 9:Unknown, not stated | This field describes one of the symptoms specific to the brain tumor as reported by the patient or recorded in the medical chart. | |
1245 | alertness | CNS1;46 | SET OF CODES | 0:No 1:Yes 8:NA, examination not done 9:Unknown | Record all findings from the neurological examination that evaluated the status of the tumor. | |
1246 | speech | CNS1;47 | SET OF CODES | 0:No 1:Yes 8:NA, examination not done 9:Unknown | Record all findings from the neurological examination that evaluated the status of the tumor. | |
1247 | personality | CNS1;48 | SET OF CODES | 0:No 1:Yes 8:NA, examination not done 9:Unknown | Record all findings from the neurological examination that evaluated the status of the tumor. | |
1248 | memory or judgement | CNS1;49 | SET OF CODES | 0:No 1:Yes 8:NA, examination not done 9:Unknown | Record all findings from the neurological examination that evaluated the status of the tumor. | |
1249 | visual acuity | CNS1;50 | SET OF CODES | 0:No 1:Yes 8:NA, examination not done 9:Unknown | Record all findings from the neurological examination that evaluated the status of the tumor. | |
1250 | visual fields | CNS1;51 | SET OF CODES | 0:No 1:Yes 8:NA, examination not done 9:Unknown | Record all findings from the neurological examination that evaluated the status of the tumor. | |
1251 | eye movements (eom) | CNS1;52 | SET OF CODES | 0:No 1:Yes 8:NA, examination not done 9:Unknown | Record all findings from the neurological examination that evaluated the status of the tumor. | |
1252 | facial sensation | CNS1;53 | SET OF CODES | 0:No 1:Yes 8:NA, examination not done 9:Unknown | Record all findings from the neurological examination that evaluated the status of the tumor. | |
1253 | facial movement | CNS1;54 | SET OF CODES | 0:No 1:Yes 8:NA, examination not done 9:Unknown | Record all findings from the neurological examination that evaluated the status of the tumor. | |
1254 | hearing | CNS1;55 | SET OF CODES | 0:No 1:Yes 8:NA, examination not done 9:Unknown | Record all findings from the neurological examination that evaluated the status of the tumor. | |
1255 | gag reflex | CNS1;56 | SET OF CODES | 0:No 1:Yes 8:NA, examination not done 9:Unknown | Record all findings from the neurological examination that evaluated the status of the tumor. | |
1256 | sternocleidomastoid/shld str | CNS1;57 | SET OF CODES | 0:No 1:Yes 8:NA, examination not done 9:Unknown | Record all findings from the neurological examination that evaluated the status of the tumor. | |
1257 | articulation or enunciation | CNS1;58 | SET OF CODES | 0:No 1:Yes 8:NA, examination not done 9:Unknown | Record all findings from the neurological examination that evaluated the status of the tumor. | |
1258 | papilledema | CNS1;59 | SET OF CODES | 0:No 1:Yes 8:NA, examination not done 9:Unknown | Record all findings from the neurological examination that evaluated the status of the tumor. | |
1259 | tongue fasciculations/atrophy | CNS1;60 | SET OF CODES | 0:No 1:Yes 8:NA, examination not done 9:Unknown | Record all findings from the neurological examination that evaluated the status of the tumor. | |
1260 | decrease in sensation/any site | CNS1;61 | SET OF CODES | 0:No 1:Yes 8:NA, examination not done 9:Unknown | Record all findings from the neurological examination that evaluated the status of the tumor. | |
1261 | cortical sensory deficit | CNS1;62 | SET OF CODES | 0:No 1:Yes 8:NA, examination not done 9:Unknown | Record all findings from the neurological examination that evaluated the status of the tumor. | |
1262 | weakness/atrophy/fasciculation | CNS1;63 | SET OF CODES | 0:No 1:Yes 8:NA, examination not done 9:Unknown | Record all findings from the neurological examination that evaluated the status of the tumor. | |
1263 | ataxia of gait | CNS1;64 | SET OF CODES | 0:No 1:Yes 8:NA, examination not done 9:Unknown | Record all findings from the neurological examination that evaluated the status of the tumor. | |
1264 | truncal ataxia | CNS1;65 | SET OF CODES | 0:No 1:Yes 8:NA, examination not done 9:Unknown | Record all findings from the neurological examination that evaluated the status of the tumor. | |
1265 | dysmetria | CNS1;66 | SET OF CODES | 0:No 1:Yes 8:NA, examination not done 9:Unknown | Record all findings from the neurological examination that evaluated the status of the tumor. | |
1266 | rapid alternating movements | CNS1;67 | SET OF CODES | 0:No 1:Yes 8:NA, examination not done 9:Unknown | Record all findings from the neurological examination that evaluated the status of the tumor. | |
1267 | finger to finger nose testing | CNS1;68 | SET OF CODES | 0:No 1:Yes 8:NA, examination not done 9:Unknown | Record all findings from the neurological examination that evaluated the status of the tumor. | |
1268 | heel to knee to shin testing | CNS1;69 | SET OF CODES | 0:No 1:Yes 8:NA, examination not done 9:Unknown | Record all findings from the neurological examination that evaluated the status of the tumor. | |
1269 | deep tendon reflexes/upper ext | CNS1;70 | SET OF CODES | 0:No 1:Yes 8:NA, examination not done 9:Unknown | Record all findings from the neurological examination that evaluated the status of the tumor. | |
1270 | deep tendon reflexes/lower ext | CNS1;71 | SET OF CODES | 0:No 1:Yes 8:NA, examination not done 9:Unknown | Record all findings from the neurological examination that evaluated the status of the tumor. | |
1271 | babinski sign | CNS1;72 | SET OF CODES | 0:No 1:Yes 8:NA, examination not done 9:Unknown | Record all findings from the neurological examination that evaluated the status of the tumor. | |
1272 | hoffman reflex | CNS1;73 | SET OF CODES | 0:No 1:Yes 8:NA, examination not done 9:Unknown | Record all findings from the neurological examination that evaluated the status of the tumor. | |
1273 | other abnormal reflexes | CNS1;74 | SET OF CODES | 0:No 1:Yes 8:NA, examination not done 9:Unknown | Record all findings from the neurological examination that evaluated the status of the tumor. | |
1274 | angiography | CNS1;75 | SET OF CODES | 0:Results -, no evidence of brain tumor 1:Results +, some indication of disease 2:Results unknown, equivocal/inconclusive 8:NA, test not done 9:Unknown if test done | This field describes the results of a neurodiagnostic study performed to evaluate the patient's tumor. | |
1275 | computed tomography (ct) scan | CNS1;76 | SET OF CODES | 0:Results -, no evidence of brain tumor 1:Results +, some indication of disease 2:Results unknown, equivocal/inconclusive 8:NA, test not done 9:Unknown if test done | This field describes the results of a neurodiagnostic study performed to evaluate the patient's tumor. | |
1276 | ct scan of spine | CNS1;77 | SET OF CODES | 0:Results -, no evidence of brain tumor 1:Results +, some indication of disease 2:Results unknown, equivocal/inconclusive 8:NA, test not done 9:Unknown if test done | This field describes the results of a neurodiagnostic study performed to evaluate the patient's tumor. | |
1277 | electroencephalography (eeg) | CNS1;78 | SET OF CODES | 0:Results -, no evidence of brain tumor 1:Results +, some indication of disease 2:Results unknown, equivocal/inconclusive 8:NA, test not done 9:Unknown if test done | This field describes the results of a neurodiagnostic study performed to evaluate the patient's tumor. | |
1278 | isotope brain scan | CNS1;79 | SET OF CODES | 0:Results -, no evidence of brain tumor 1:Results +, some indication of disease 2:Results unknown, equivocal/inconclusive 8:NA, test not done 9:Unknown if test done | This field describes the results of a neurodiagnostic study performed to evaluate the patient's tumor. | |
1279 | positron emission tomography | CNS1;80 | SET OF CODES | 0:Results -, no evidence of brain tumor 1:Results +, some indication of disease 2:Results unknown, equivocal/inconclusive 8:NA, test not done 9:Unknown if test done | This field describes the results of a neurodiagnostic study performed to evaluate the patient's tumor. | |
1280 | spect scan | CNS1;81 | SET OF CODES | 0:Results -, no evidence of brain tumor 1:Results +, some indication of disease 2:Results unknown, equivocal/inconclusive 8:NA, test not done 9:Unknown if test done | This field describes the results of a neurodiagnostic study performed to evaluate the patient's tumor. | |
1281 | mri of brain | CNS1;82 | SET OF CODES | 0:Results -, no evidence of brain tumor 1:Results +, some indication of disease 2:Results unknown, equivocal/inconclusive 8:NA, test not done 9:Unknown if test done | This field describes the results of a neurodiagnostic study performed to evaluate the patient's tumor. | |
1282 | mri of spine | CNS1;83 | SET OF CODES | 0:Results -, no evidence of brain tumor 1:Results +, some indication of disease 2:Results unknown, equivocal/inconclusive 8:NA, test not done 9:Unknown if test done | This field describes the results of a neurodiagnostic study performed to evaluate the patient's tumor. | |
1283 | functional mri | CNS1;84 | SET OF CODES | 0:Results -, no evidence of brain tumor 1:Results +, some indication of disease 2:Results unknown, equivocal/inconclusive 8:NA, test not done 9:Unknown if test done | This field describes the results of a neurodiagnostic study performed to evaluate the patient's tumor. | |
1284 | myelography | CNS1;85 | SET OF CODES | 0:Results -, no evidence of brain tumor 1:Results +, some indication of disease 2:Results unknown, equivocal/inconclusive 8:NA, test not done 9:Unknown if test done | This field describes the results of a neurodiagnostic study performed to evaluate the patient's tumor. | |
1285 | magnetic res spectroscopy | CNS1;86 | SET OF CODES | 0:Results -, no evidence of brain tumor 1:Results +, some indication of disease 2:Results unknown, equivocal/inconclusive 8:NA, test not done 9:Unknown if test done | This field describes the results of a neurodiagnostic study performed to evaluate the patient's tumor. | |
1286 | frontal lobe | CNS2;1 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes a location involved by the tumor. If more than one location is involved, record all locations involved by the tumor. | |
1287 | temporal lobe | CNS2;2 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes a location involved by the tumor. If more than one location is involved, record all locations involved by the tumor. | |
1288 | parietal lobe | CNS2;3 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes a location involved by the tumor. If more than one location is involved, record all locations involved by the tumor. | |
1289 | occipital lobe | CNS2;4 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes a location involved by the tumor. If more than one location is involved, record all locations involved by the tumor. | |
1290 | optic nerves | CNS2;5 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes a location involved by the tumor. If more than one location is involved, record all locations involved by the tumor. | |
1291 | pituitary gland | CNS2;6 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes a location involved by the tumor. If more than one location is involved, record all locations involved by the tumor. | |
1292 | pineal gland | CNS2;7 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes a location involved by the tumor. If more than one location is involved, record all locations involved by the tumor. | |
1293 | cerebellum | CNS2;8 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes a location involved by the tumor. If more than one location is involved, record all locations involved by the tumor. | |
1294 | brain stem | CNS2;9 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes a location involved by the tumor. If more than one location is involved, record all locations involved by the tumor. | |
1295 | skull base | CNS2;10 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes a location involved by the tumor. If more than one location is involved, record all locations involved by the tumor. | |
1296 | other skull | CNS2;11 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes a location involved by the tumor. If more than one location is involved, record all locations involved by the tumor. | |
1297 | spinal cord | CNS2;12 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes a location involved by the tumor. If more than one location is involved, record all locations involved by the tumor. | |
1298 | cerebral spinal fluid (csf) | CNS2;13 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes a location involved by the tumor. If more than one location is involved, record all locations involved by the tumor. | |
1299 | cranial meninges | CNS2;14 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes a location involved by the tumor. If more than one location is involved, record all locations involved by the tumor. | |
1300 | spinal meninges | CNS2;15 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes a location involved by the tumor. If more than one location is involved, record all locations involved by the tumor. | |
1301 | other tumor loc/involvement | CNS2;16 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes a location involved by the tumor. If more than one location is involved, record all locations involved by the tumor. | |
1302 | left | CNS2;17 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes which side of the brain the tumor is located. Some tumors typically involve midline structures, such as pineal and pituitary gland tumors, and extend to the left or right. For these tumors code midline yes and indicate the side of the brain into which the tumor extends. Bilateral tumors should be coded as left and right. | |
1303 | right | CNS2;18 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes which side of the brain the tumor is located. Some tumors typically involve midline structures, such as pineal and pituitary gland tumors, and extend to the left or right. For these tumors code midline yes and indicate the side of the brain into which the tumor extends. Bilateral tumors should be coded as left and right. | |
1304 | midline | CNS2;19 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes which side of the brain the tumor is located. Some tumors typically involve midline structures, such as pineal and pituitary gland tumors, and extend to the left or right. For these tumors code midline yes and indicate the side of the brain into which the tumor extends. Bilateral tumors should be coded as left and right. | |
1305 | number of tumors | CNS2;20 | SET OF CODES | 1:One tumor only 2:Multiple tumors 9:Unknown | This field describes whether the tumor is singular or multiple. | |
1306 | date of first symptoms | CNS2;21 | DATE-TIME | This field describes the date of the first onset of symptoms. This information can typically be found in the patient's history & physical. If the date can not be determined or is unknown, code 99999999. | ||
1307 | date of pathologic diagnosis | CNS2;22 | DATE-TIME | This field describes the month, day, and year that this cancer was first pathologically diagnosed. If no pathologic diagnosis was determined, code 00000000; if the date of pathologic diagnosis is unknown or cannot be determined, code 99999999. | ||
1308 | who histological cl | CNS2;23 | POINTER | 164.9 | This field describes the WHO histological classfication of the tumor. Report the appropriate WHO code that corresponds to the written description of the tumor appearing on the pathology report. | |
1309 | molecular markers | CNS2;24 | SET OF CODES | 0:No 1:Yes 8:NA, no pathologic diagnosis 9:Unknown if molecular markers used | This field describes whether molecular markers were used in the pathologic evaluation of the tumor. The most commonly used markers are GFAP, DNA analysis, and KI-67 (MIB antibody). If a pathologic diagnosis was not made, code 8. | |
1310 | tumor size (source) | CNS2;25 | SET OF CODES | 0:Size not recorded 1:CT scan w or w/o contrast 2:MRI w/o contrast 3:MRI w contrast 4:PET scan 5:SPECT scan 6:Operative report 7:Other 9:Size recorded, source unknown | This field describes the source of the data from which the reported size of tumor was documented. DO NOT use the pathology report to determine tumor size. | |
1311 | karnofsky's rating prior to tx | CNS2;26 | POINTER | 164.17 | This field describes the physical status of the patient prior to the beginning of intial treatment using Karnofsky's Rating. This is prior to any definitive therapy. If the rating is not recorded, assign a rating based upon the best available information. | |
1312 | protocol participation (cns) | CNS2;27 | SET OF CODES | 00:Not on 01:RTOG 02:SWOG 03:ECOG 04:POG 05:CCG 06:NCI 07:NABTT 08:NABTC 09:National protcol, NOS 10:Other institutional protocols | This field describes whether the patient was enrolled in and treated on a protocol. A physician may treat a patient following the guidelines of an established protocol but not enroll the patient. For these cases, code 00. | |
1313 | protocol phase | CNS2;28 | SET OF CODES | 0:Not on 1:Phase I 2:Phase I/II 3:Phase II 4:Phase III 9:On protocol, phase unknown | This field describes the phase of the protocol in which the patient is enrolled. If the patient is not enrolled into a protocol, code 0. | |
1314 | none, no non-ca dir surgery | CNS2;29 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes one of the surgical procedures performed to diagnose/ stage disease (exploratory) or for the relief of symptoms (palliative) which are non-cancer directed surgery. | |
1315 | ventriculostomy/ext vent drain | CNS2;30 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes one of the surgical procedures performed to diagnose/ stage disease (exploratory) or for the relief of symptoms (palliative) which are non-cancer directed surgery. | |
1316 | csf shunt/ventriculoperitoneal | CNS2;31 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes one of the surgical procedures performed to diagnose/ stage disease (exploratory) or for the relief of symptoms (palliative) which are non-cancer directed surgery. | |
1317 | csf shunt/3rd ventriculostomy | CNS2;32 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes one of the surgical procedures performed to diagnose/ stage disease (exploratory) or for the relief of symptoms (palliative) which are non-cancer directed surgery. | |
1318 | csf shunt/other | CNS2;33 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes one of the surgical procedures performed to diagnose/ stage disease (exploratory) or for the relief of symptoms (palliative) which are non-cancer directed surgery. | |
1319 | stereotactic biopsy | CNS2;34 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes one of the surgical procedures performed to diagnose/ stage disease (exploratory) or for the relief of symptoms (palliative) which are non-cancer directed surgery. | |
1320 | open brain biopsy | CNS2;35 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes one of the surgical procedures performed to diagnose/ stage disease (exploratory) or for the relief of symptoms (palliative) which are non-cancer directed surgery. | |
1321 | open bx of spincal cord tumor | CNS2;36 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes one of the surgical procedures performed to diagnose/ stage disease (exploratory) or for the relief of symptoms (palliative) which are non-cancer directed surgery. | |
1322 | laminectomy w/o resect/dura | CNS2;37 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes one of the surgical procedures performed to diagnose/ stage disease (exploratory) or for the relief of symptoms (palliative) which are non-cancer directed surgery. | |
1323 | laminectomy w/o resect w dura | CNS2;38 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes one of the surgical procedures performed to diagnose/ stage disease (exploratory) or for the relief of symptoms (palliative) which are non-cancer directed surgery. | |
1324 | surgery, nos | CNS2;39 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes one of the surgical procedures performed to diagnose/ stage disease (exploratory) or for the relief of symptoms (palliative) which are non-cancer directed surgery. | |
1325 | unknown if surgery done | CNS2;40 | SET OF CODES | 0:No 1:Yes 9:Unknown | This field describes one of the surgical procedures performed to diagnose/ stage disease (exploratory) or for the relief of symptoms (palliative) which are non-cancer directed surgery. | |
1326 | surgical approach (cns) | CNS2;41 | SET OF CODES | 0:None, no ca-directed surgery 1:Craniotomy/craniectomy, w/o stereotactic/image guidance 2:Craniotomy/craniectomy, w sterotactic/image guidance 3:Endoscopy 4:Laminectomy 5:Other 9:Surgical approach unknown | This field describes the method used to approach the organ of origin and/or primary tumor. Code the approach for cancer-directed surgery of the primary site only. Stereotactic image guidance, with regard to SURGICAL APPROACH, is not the same as stereotactic radiosurgery, a method of radiation therapy. Stereotactic radiosurgery is addressed in question 57. BCNU wafer implants are surgically placed following resection of tumor. Report whether a wafer implantation occurred in questions 63 & 64. | |
1327 | extent of surgical resection | CNS2;42 | SET OF CODES | 0:None, no surgery performed 1:Subtotal resection 2:Total or gross resection 3:Lobectomy 4:Surgery, NOS 9:Unknown if surgery performed | This field describes only surgeries of the primary site. Record the most definitive surgery performed to the primary site. Biospy procedures are addressed in question 42. Codes 0, 1, 2, 4 and 9 may apply to brain and spinal cord tumors. Code 3 applies to brain tumors only. | |
1328 | size of residual tumor | CNS2;43 | NUMERIC | This field describes the size of remaining primary tumor AFTER the most definitive therapy. Record the largest dimension or diameter of the residual primary tumor in millimeters (1 cm = 10 mm). If the residual tumor has multiple measurements, code the largest size. For example, a residual tumor measuring 3 x 4.4 x 2.5 cm is coded as 044. Use information from postoperative or follow-up imaging studies (MRI, CT, PET, SPECT) to determine tumor size. Do not guess at the size of tumor. 000-No residual tumor 995-Size not specified, tumor judged smaller 996-Size not specified, tumor judged unchanged 997-Size not specified, tumor judged larger 998-NA, surgical treatment not administered 999-Unknown, tumor not evaluated | ||
1329 | size of res tumor (source) | CNS2;44 | SET OF CODES | 0:Size not recorded 1:CT scan w or w/o contrast 2:MRI w/o contrast 3:MRI w contrast 4:PET scan 5:SPECT scan 6:Operative report 7:Other 9:Size recorded, source unknown | This field describes the source of the data from which the reported size of the residual tumor was documented. | |
1330 | anesthetic problem | CNS2;45 | SET OF CODES | 0:No 1:Yes 8:NA, surgery not performed 9:Unknown | This field describes a complication or event that occurred after surgery of the primary site and before the date of patient discharge from the hospital. | |
1331 | hemorrhage at operative site | CNS2;46 | SET OF CODES | 0:No 1:Yes 8:NA, surgery not performed 9:Unknown | This field describes a complication or event that occurred after surgery of the primary site and before the date of patient discharge from the hospital. | |
1332 | seizure | CNS2;47 | SET OF CODES | 0:No 1:Yes 8:NA, surgery not performed 9:Unknown | This field describes a complication or event that occurred after surgery of the primary site and before the date of patient discharge from the hospital. | |
1333 | infection(s) | CNS2;48 | SET OF CODES | 0:No 1:Yes 8:NA, surgery not performed 9:Unknown | This field describes a complication or event that occurred after surgery of the primary site and before the date of patient discharge from the hospital. | |
1334 | dvt (deep venous thrombosis) | CNS2;49 | SET OF CODES | 0:No 1:Yes 8:NA, surgery not performed 9:Unknown | This field describes a complication or event that occurred after surgery of the primary site and before the date of patient discharge from the hospital. | |
1335 | persistent neurol worsening | CNS2;50 | SET OF CODES | 0:No 1:Yes 8:NA, surgery not performed 9:Unknown | This field describes a complication or event that occurred after surgery of the primary site and before the date of patient discharge from the hospital. | |
1336 | total radiation dose (cgy) | CNS2;51 | SET OF CODES | 0:No radiation administered 1:Less than 3000 cGy 2:3000-3999 cGy 3:4000-4999 cGy 4:5000-5999 cGy 5:6000-6999 cGy 6:7000-7999 cGy 7:8000-8999 cGy 8:10000 or more cGy 9:Dose unknown | This field describes the total dose delivered to the primary volume of interest, include any boost doses. | |
1337 | type of ext beam radiation | CNS2;52 | SET OF CODES | 0:No radiation therapy 1:Cobalt 2:>=2 and <4 MV X-rays 3:>=4 and <6 MV X-rays 4:>=6 and <10 MV X-rays 5:>=10 MV X-rays 6:Protons 7:Neutrons 9:Unknown | This field describes the type of external beam radiation therapy delivered to the primary volume of interest. | |
1338 | interstitial rad/brachytherapy | CNS2;53 | SET OF CODES | 0:None, brachytherapy not given 1:Iodine-125 2:Iridium-192 3:Other 9:Unknown | This field describes any radioactive implant used to treat the patient. | |
1339 | stereotactic radiosurgery | CNS2;54 | SET OF CODES | 0:None, not administered 1:Gamma knife 2:Linear accelerator (linac) 3:Other 9:Unknown | This field describes the type of delivery of the external radiation dose. Stereotactic radiosurgery is a method by which the focus and target of the radiation beam is precisely directed, and is different from external beam radiation which is a less controlled means of radiation therapy delivery. | |
1340 | skin reactions | CNS2;55 | SET OF CODES | 0:No, not present 1:Present, no tx delay, not req medication 2:Present, no tx delay, req medication 3:Present, tx delay or cessation 8:NA, radiation tx not administered 9:Unknown | This field describes a complication that resulted during or subsequent to radiation therapy. | |
1341 | anorexia | CNS2;56 | SET OF CODES | 0:No, not present 1:Present, no tx delay, not req medication 2:Present, no tx delay, req medication 3:Present, tx delay or cessation 8:NA, radiation tx not administered 9:Unknown | This field describes a complication that resulted during or subsequent to radiation therapy. | |
1342 | nausea or vomiting | CNS2;57 | SET OF CODES | 0:No, not present 1:Present, no tx delay, not req medication 2:Present, no tx delay, req medication 3:Present, tx delay or cessation 8:NA, radiation tx not administered 9:Unknown | This field describes a complication that resulted during or subsequent to radiation therapy. | |
1343 | fatigue | CNS2;58 | SET OF CODES | 0:No, not present 1:Present, no tx delay, not req medication 2:Present, no tx delay, req medication 3:Present, tx delay or cessation 8:NA, radiation tx not administered 9:Unknown | This field describes a complication that resulted during or subsequent to radiation therapy. | |
1344 | neurologic worsening | CNS2;59 | SET OF CODES | 0:No, not present 1:Present, no tx delay, not req medication 2:Present, no tx delay, req medication 3:Present, tx delay or cessation 8:NA, radiation tx not administered 9:Unknown | This field describes a complication that resulted during or subsequent to radiation therapy. | |
1345 | radiation therapy | CNS2;60 | SET OF CODES | 0:None 1:Ext beam 2:RA implants (brachytherapy) 3:Radioisotopes 4:Stereotactic radiosurgery 5:Ext beam/RA implants or radioisotopes 6:Ext beam/stereotactic radiosurgery 7:Radiation, NOS 9:Unk, death cert cases only | This field describes the type of radiation administered to the primary site. Include all procedures that are part of the first course of treatment, whether delivered at the reporting institution or at other institutions. | |
1346 | procarbazine | CNS2;61 | SET OF CODES | 0:No 1:Yes 8:NA, chemotherapy not administered 9:Unknown | This field describes one type of chemotherapeutic agent administered to the patient. | |
1347 | ccnu | CNS2;62 | SET OF CODES | 0:No 1:Yes 8:NA, chemotherapy not administered 9:Unknown | This field describes one type of chemotherapeutic agent administered to the patient. | |
1348 | vincristine | CNS2;63 | SET OF CODES | 0:No 1:Yes 8:NA, chemotherapy not administered 9:Unknown | This field describes one type of chemotherapeutic agent administered to the patient. | |
1349 | hydroxyurea | CNS2;64 | SET OF CODES | 0:No 1:Yes 8:NA, chemotherapy not administered 9:Unknown | This field describes one type of chemotherapeutic agent administered to the patient. | |
1350 | bcnu | CNS2;65 | SET OF CODES | 0:No 1:Yes 8:NA, chemotherapy not administered 9:Unknown | This field describes one type of chemotherapeutic agent administered to the patient. | |
1351 | bcnu wafer implant | CNS2;66 | SET OF CODES | 0:No 1:Yes 8:NA, chemotherapy not administered 9:Unknown | This field describes one type of chemotherapeutic agent administered to the patient. | |
1352 | vp-16 | CNS2;67 | SET OF CODES | 0:No 1:Yes 8:NA, chemotherapy not administered 9:Unknown | This field describes one type of chemotherapeutic agent administered to the patient. | |
1353 | carboplatin | CNS2;68 | SET OF CODES | 0:No 1:Yes 8:NA, chemotherapy not administered 9:Unknown | This field describes one type of chemotherapeutic agent administered to the patient. | |
1354 | temozolomide | CNS2;69 | SET OF CODES | 0:No 1:Yes 8:NA, chemotherapy not administered 9:Unknown | This field describes one type of chemotherapeutic agent administered to the patient. | |
1355 | cpt-11 | CNS2;70 | SET OF CODES | 0:No 1:Yes 8:NA, chemotherapy not administered 9:Unknown | This field describes one type of chemotherapeutic agent administered to the patient. | |
1356 | tamoxifen | CNS2;71 | SET OF CODES | 0:No 1:Yes 8:NA, chemotherapy not administered 9:Unknown | This field describes one type of chemotherapeutic agent administered to the patient. | |
1357 | cytarabine (ara-c) | CNS2;72 | SET OF CODES | 0:No 1:Yes 8:NA, chemotherapy not administered 9:Unknown | This field describes one type of chemotherapeutic agent administered to the patient. | |
1358 | chemotherapeutic route | CNS2;73 | SET OF CODES | 1:Intrathecal 2:Intra-arterial 3:Intravenous 4:Orally 5:Intramuscular 6:BCNU wafer implant 8:NA, chemotherapy not administered 9:Unknown | This field describes the route or method used to administer the chemotherapy. | |
1359 | hearing loss | CNS2;74 | SET OF CODES | 0:No 1:Yes 8:NA, chemotherapy not administered 9:Unknown | This field describes one of the complications which resulted from the administration of chemotherapy. | |
1360 | infection | CNS2;75 | SET OF CODES | 0:No 1:Yes 8:NA, chemotherapy not administered 9:Unknown | This field describes one of the complications which resulted from the administration of chemotherapy. | |
1361 | nausea and vomiting | CNS2;76 | SET OF CODES | 0:No 1:Yes 8:NA, chemotherapy not administered 9:Unknown | This field describes one of the complications which resulted from the administration of chemotherapy. | |
1362 | blood count drop/bleeding | CNS2;77 | SET OF CODES | 0:No 1:Yes 8:NA, chemotherapy not administered 9:Unknown | This field describes one of the complications which resulted from the administration of chemotherapy. | |
1363 | peripheral neuropathy | CNS2;78 | SET OF CODES | 0:No 1:Yes 8:NA, chemotherapy not administered 9:Unknown | This field describes one of the complications which resulted from the administration of chemotherapy. | |
1364 | renal failure | CNS2;79 | SET OF CODES | 0:No 1:Yes 8:NA, chemotherapy not administered 9:Unknown | This field describes one of the complications which resulted from the administration of chemotherapy. | |
1365 | pulmonary toxicity | CNS2;80 | SET OF CODES | 0:No 1:Yes 8:NA, chemotherapy not administered 9:Unknown | This field describes one of the complications which resulted from the administration of chemotherapy. | |
1366 | other chemo complications | CNS2;81 | SET OF CODES | 0:No 1:Yes 8:NA, chemotherapy not administered 9:Unknown | This field describes one of the complications which resulted from the administration of chemotherapy. | |
1367 | karnofsky's rating @ dis/trans | CNS2;82 | POINTER | 164.17 | This field describes the physical status of the patient at the time of discharge or transfer from the treating facility following definitive therapy. In some cases, the patient may be discharged from the treating facility and transferred to another care facility; use codes 030 and 020 to describe these cases. If rating is not recorded, assign a rating based upon the best available information. | |
1368 | date of progression | CNS2;83 | DATE-TIME | This field describes the date the medical practitioner determines that the tumor has progressed and that the first course of therapy has failed, necessitating consideration of a subsequent course of treatment. Patients with tumor progression were never disease free following the first course of treatment. Record the month, day and year of the determined progression, based on the best available information. If the patient was disease free following the first course of treatment, code 00000000; if no progression was noted or first course of therapy was not administered, code 88888888; if the date of tumor progression is unknown, code 99999999. | ||
1369 | type of progression | CNS2;84 | SET OF CODES | 0:None, disease-free 1:Local 2:Regional, same hemisphere 3:Regional, opposite hemisphere 4:Distant, spine/spinal cord 5:Distant, abdomen 6:Distant, other 8:NA, no progression, or no 1st course 9:Unknown if progressed | This field describes the progression of the cancer after the completion of the first course of therapy. | |
1370 | recurrence/progression doc | CNS2;85 | SET OF CODES | 0:No recurrence/progression 1:Neurological or Karnofsky's deterioration 2:CT scan 3:MRI scan 4:Comb of 1 + 2, or 1 + 3 5:Other 9:Unknown | ||
1371 | karnofsky's rating recurrence | CNS2;86 | POINTER | 164.17 | This field describes the patient's physical status at the time that either recurrence or progression was noted. | |
1372 | type of 1st recurrence/cns | CNS2;87 | SET OF CODES | 0:None, disease free 1:Local 2:Regional, same hemisphere 3:Regional, opposite hemisphere 4:Distant, spine/spincal cord 5:Distant, abdomen 6:Distant, other 8:NA, never disease free 9:Unknown if recurred | This field describes the return or reappearance of the cancer after a disease free intermission or remission. Record the type of the first recurrence. If the patient has been disease-free since treatment, code 0. | |
1373 | protocol participation (subtx) | CNS2;88 | SET OF CODES | 00:Not on 01:RTOG 02:SWOG 03:ECOG 04:POG 05:CCG 06:NCI 07:NABTT 08:NABTC 09:National protcol, NOS 10:Other institutional protocols | This field describes whether the patient was enrolled in and treated on a protocol as part of their treatment for progression or recurrence of disease. A physician may treat a patient following the guidelines of an established protocol but not enroll the patient. For these cases, code 00. | |
1374 | type of subsequent surgical tx | CNS2;89 | SET OF CODES | 0:None, no subsequent surgery 1:Subtotal resection 2:Total or gross resection 3:Lobectomy 4:Surgery, NOS 9:Unknown if subsequent surgery performed | This field describes subsequent surgical treatment administered to the patient. Subsequent therapy begins after the first course of therapy is complete, stopped, or changed. | |
1375 | type of subsequent radiation | CNS2;90 | SET OF CODES | 0:None 1:Beam radiation 2:RA implants 3:Radioisotopes 4:Stereotactic radiosurgery 5:Beam rad/RA implants or radioisotopes 6:Beam rad/stereotactic radiosurgery 7:Radiation, NOS 9:Unknown if administered | This field describes subsequent radiation treatment administered to the patient. Subsequent therapy begins after the first course of therapy is complete, stopped, or changed. | |
1376 | procarbazine (sub tx) | CNS3;1 | SET OF CODES | 0:No 1:Yes 8:NA, chemotherapy not administered 9:Unknown | This field describes one type of subsequent chemotherapy administered to the patient. Subsequent therapy begins after the first course of therapy is complete, stopped, or changed. | |
1377 | ccnu (sub tx) | CNS3;2 | SET OF CODES | 0:No 1:Yes 8:NA, chemotherapy not administered 9:Unknown | This field describes one type of subsequent chemotherapy administered to the patient. Subsequent therapy begins after the first course of therapy is complete, stopped, or changed. | |
1378 | vincristine (sub tx) | CNS3;3 | SET OF CODES | 0:No 1:Yes 8:NA, chemotherapy not administered 9:Unknown | This field describes one type of subsequent chemotherapy administered to the patient. Subsequent therapy begins after the first course of therapy is complete, stopped, or changed. | |
1379 | hydroxyurea (sub tx) | CNS3;4 | SET OF CODES | 0:No 1:Yes 8:NA, chemotherapy not administered 9:Unknown | This field describes one type of subsequent chemotherapy administered to the patient. Subsequent therapy begins after the first course of therapy is complete, stopped, or changed. | |
1380 | methotrexate (sub tx) | CNS3;5 | SET OF CODES | 0:No 1:Yes 8:NA, chemotherapy not administered 9:Unknown | This field describes one type of subsequent chemotherapy administered to the patient. Subsequent therapy begins after the first course of therapy is complete, stopped, or changed. | |
1381 | cisplatin (sub tx) | CNS3;6 | SET OF CODES | 0:No 1:Yes 8:NA, chemotherapy not administered 9:Unknown | This field describes one type of subsequent chemotherapy administered to the patient. Subsequent therapy begins after the first course of therapy is complete, stopped, or changed. | |
1382 | bcnu (sub tx) | CNS3;7 | SET OF CODES | 0:No 1:Yes 8:NA, chemotherapy not administered 9:Unknown | This field describes one type of subsequent chemotherapy administered to the patient. Subsequent therapy begins after the first course of therapy is complete, stopped, or changed. | |
1383 | bcnu wafer implant (sub tx) | CNS3;8 | SET OF CODES | 0:No 1:Yes 8:NA, chemotherapy not administered 9:Unknown | This field describes one type of subsequent chemotherapy administered to the patient. Subsequent therapy begins after the first course of therapy is complete, stopped, or changed. | |
1384 | vp-16 (sub tx) | CNS3;9 | SET OF CODES | 0:No 1:Yes 8:NA, chemotherapy not administered 9:Unknown | This field describes one type of subsequent chemotherapy administered to the patient. Subsequent therapy begins after the first course of therapy is complete, stopped, or changed. | |
1385 | carboplatin (sub tx) | CNS3;10 | SET OF CODES | 0:No 1:Yes 8:NA, chemotherapy not administered 9:Unknown | This field describes one type of subsequent chemotherapy administered to the patient. Subsequent therapy begins after the first course of therapy is complete, stopped, or changed. | |
1386 | temozolomide (sub tx) | CNS3;11 | SET OF CODES | 0:No 1:Yes 8:NA, chemotherapy not administered 9:Unknown | This field describes one type of subsequent chemotherapy administered to the patient. Subsequent therapy begins after the first course of therapy is complete, stopped, or changed. | |
1387 | cyclophosphamide (sub tx) | CNS3;12 | SET OF CODES | 0:No 1:Yes 8:NA, chemotherapy not administered 9:Unknown | This field describes one type of subsequent chemotherapy administered to the patient. Subsequent therapy begins after the first course of therapy is complete, stopped, or changed. | |
1388 | cpt-11 (sub tx) | CNS3;13 | SET OF CODES | 0:No 1:Yes 8:NA, chemotherapy not administered 9:Unknown | This field describes one type of subsequent chemotherapy administered to the patient. Subsequent therapy begins after the first course of therapy is complete, stopped, or changed. | |
1389 | tamoxifen (sub tx) | CNS3;14 | SET OF CODES | 0:No 1:Yes 8:NA, chemotherapy not administered 9:Unknown | This field describes one type of subsequent chemotherapy administered to the patient. Subsequent therapy begins after the first course of therapy is complete, stopped, or changed. | |
1390 | interferon (sub tx) | CNS3;15 | SET OF CODES | 0:No 1:Yes 8:NA, chemotherapy not administered 9:Unknown | This field describes one type of subsequent chemotherapy administered to the patient. Subsequent therapy begins after the first course of therapy is complete, stopped, or changed. | |
1391 | cytarabine (ara-c) (sub tx) | CNS3;16 | SET OF CODES | 0:No 1:Yes 8:NA, chemotherapy not administered 9:Unknown | This field describes one type of subsequent chemotherapy administered to the patient. Subsequent therapy begins after the first course of therapy is complete, stopped, or changed. | |
1392 | other chemotherapy (sub tx) | CNS3;17 | SET OF CODES | 0:No 1:Yes 8:NA, chemotherapy not administered 9:Unknown | This field describes one type of subsequent chemotherapy administered to the patient. Subsequent therapy begins after the first course of therapy is complete, stopped, or changed. | |
1393 | other subsequent treatment | CNS3;18 | SET OF CODES | 0:No other tx 1:Ca-directed tx, NOS 2:Monoclonal antibodies 3:Other experimental ca-dir tx 4:Double-blind clin trial 6:Unproven tx 7:Patient refused tx 8:Other tx rec, unk if admin 9:Unk if administered | This field describes other types of subsequent treatment administered to the patient. Subsequent therapy begins after the first course of therapy is complete, stopped, or changed. | |
1394 | tumor size | CNS3;19 | NUMERIC | This field describes the largest dimension or diameter of the primary tumor in millimeters (1 cm = 10 mm). If the tumor has multiple measurements, code the largest size. For example, a tumor measuring 3 x 4.4 x 2.5 cm is coded as 044. If there are multiple tumors, code the size of the largest tumor. For example, if the first tumor measures 2 x .5 cm and the second measures 1 x .5 cm, code 020. See ROADS for instructions on converting centimeters to millimeters. Use information from preoperative imaging (MRI, CT, PET, SPECT) to determine TUMOR SIZE. DO NOT use the pathology report to determine TUMOR SIZE. DO NOT guess at the TUMOR SIZE. Code 999 if TUMOR SIZE cannot be determined. Codes: 001 thru 997 - tumor size (mm) 999 - Unknown, cannot be determined, not recorded | ||
1400 | lng co-morbid condition 1 | LUN1;1 | POINTER | 80 | This field records a pre-existing medical condition that was present at the time of diagnosis for this cancer or the patient was first seen at your facility following diagnosis. Report the ICD-CM code. Pre- existing conditions should be coded; do NOT code conditions which the patient acquired while being treated for this condition. Allowable Codes: 000.00 001.00 thru 994.90 (valid ICD-CM codes) If no co-morbid conditions were documented, answer "No" to the CO-MORBID CONDITIONS (YES/NO) prompt. | |
1400.1 | lng co-morbid condition 2 | LUN1;2 | POINTER | 80 | This field records a pre-existing medical condition that was present at the time of diagnosis for this cancer or the patient was first seen at your facility following diagnosis. Report the ICD-CM code. Pre- existing conditions should be coded; do NOT code conditions which the patient acquired while being treated for this condition. Allowable Codes: 001.00 thru 994.90 (valid ICD-CM codes) If there was only one co-morbid condition, leave this field blank. | |
1400.2 | lng co-morbid condition 3 | LUN1;3 | POINTER | 80 | This field records a pre-existing medical condition that was present at the time of diagnosis for this cancer or the patient was first seen at your facility following diagnosis. Report the ICD-CM code. Pre- existing conditions should be coded; do NOT code conditions which the patient acquired while being treated for this condition. Allowable Codes: 001.00 thru 994.90 (valid ICD-CM codes) If there was only one co-morbid condition, leave this field blank. | |
1400.3 | lng co-morbid condition 4 | LUN1;4 | POINTER | 80 | This field records a pre-existing medical condition that was present at the time of diagnosis for this cancer or the patient was first seen at your facility following diagnosis. Report the ICD-CM code. Pre- existing conditions should be coded; do NOT code conditions which the patient acquired while being treated for this condition. Allowable Codes: 001.00 thru 994.90 (valid ICD-CM codes) If there was only one co-morbid condition, leave this field blank. | |
1400.4 | lng co-morbid condition 5 | LUN1;5 | POINTER | 80 | This field records a pre-existing medical condition that was present at the time of diagnosis for this cancer or the patient was first seen at your facility following diagnosis. Report the ICD-CM code. Pre- existing conditions should be coded; do NOT code conditions which the patient acquired while being treated for this condition. Allowable Codes: 001.00 thru 994.90 (valid ICD-CM codes) If there was only one co-morbid condition, leave this field blank. | |
1400.5 | lng co-morbid condition 6 | LUN1;6 | POINTER | 80 | This field records a pre-existing medical condition that was present at the time of diagnosis for this cancer or the patient was first seen at your facility following diagnosis. Report the ICD-CM code. Pre- existing conditions should be coded; do NOT code conditions which the patient acquired while being treated for this condition. Allowable Codes: 001.00 thru 994.90 (valid ICD-CM codes) If there was only one co-morbid condition, leave this field blank. | |
1400.6 | lng co-morbid condition y/n(+) | LUN1;76 | BOOLEAN | 0:No 1:Yes | Are CO-MORBID CONDITIONS associated with this cancer (Yes/No)? This item records if there were pre-existing medical conditions present at the time of diagnosis for this cancer. Answering "Yes" will prompt you for CO-MORBID CONDITIONS #1-6. Answering "No" will code CO-MORBID CONDITION #1 with 000.00 and leave the remaining co-morbid fields blank. | |
1401 | lng duration of tobacco use | LUN1;7 | FREE TEXT | This item describes the number of known years the patient used some form of tobacco, even if the patient is not presently using tobacco. If the patient has never used tobacco, code 00. If the patient's tobacco use cannot be determined, or if the duration of use is not known, code 99. Allowable Codes: 00 - never used tobacco 01 thru 98 - one or more years of tobacco use 99 - duration of tobacco use not documented | ||
1402 | lng date of first tissue dx | LUN1;8 | DATE-TIME | This item describes the month, day, and year (MMDDCCYY) that this primary cancer was first diagnosed using a tissue sample to arrive at a positive histologic or cytologic evaluation of the tumor. If a positive histologic or cytologic evaluation was made but the date is unknown code 99/99/9999. | ||
1403 | lng personal hist oth malig | LUN1;9 | POINTER | 164 | This item describes the patient's prior history of other invasive malignancies. If the patient has a history of other malignancies report the ICD-O-3 site code for the most recently diagnosed disease. If the patient has no personal history of other cancer, code C88.8. If the patient's personal history of other invasive malignancies is not documented, code C99.9. Allowable Codes: C00.0 thru C80.9 - valid ICD-0-3 site (topography) codes C88.8 - no personal history of other cancer C99.9 - personal history of other cancer not documented | |
1404 | lng cough | LUN1;10 | SET OF CODES | 1:Present 2:Not present 9:Not documented if present | This item describes the presence of a cough specific to lung (NSCLC) cancer that was recorded in the medical chart. | |
1404.1 | lng shortness of breath | LUN1;11 | SET OF CODES | 1:Present 2:Not present 9:Not documented if present | This item describes the presence of shortness of breath specific to lung (NSCLC) cancer that was recorded in the medical chart. | |
1404.2 | lng weight loss | LUN1;12 | SET OF CODES | 1:Present 2:Not present 9:Not documented if present | This item describes the presence of weight loss specific to lung (NSCLC) cancer that was recorded in the medical chart. | |
1404.3 | lng hemoptysis | LUN1;13 | SET OF CODES | 1:Present 2:Not present 9:Not documented if present | This item describes the presence of hemoptysis specific to lung (NSCLC) cancer that was recorded in the medical chart. | |
1404.4 | lng palpable lymph nodes | LUN1;14 | SET OF CODES | 1:Present 2:Not present 9:Not documented if present | This item describes the presence of palpable lymph nodes specific to lung (NSCLC) cancer that was recorded in the medical chart. | |
1405 | lng chest x-ray | LUN1;15 | SET OF CODES | 1:Used 2:Not used 9:Not documented if used | This item identifies patients who are screened routinely or due to a high risk history of cardiac and/or pulmonary disease. Record whether a chest x-ray method was used. | |
1405.1 | lng ct scan | LUN1;16 | SET OF CODES | 1:Used 2:Not used 9:Not documented if used | This item identifies patients who are screened routinely or due to a high risk history of cardiac and/or pulmonary disease. Record whether a CT scan method was used. | |
1405.2 | lng bronchoscopy | LUN1;17 | SET OF CODES | 1:Used 2:Not used 9:Not documented if used | This item identifies patients who are screened routinely or due to a high risk history of cardiac and/or pulmonary disease. Record whether a bronchoscopy method was used. | |
1406 | lng history and physical | LUN1;18 | SET OF CODES | 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal results 8:Not performed, not mentioned in record 9:Done, results not documented | This item describes the methods and results of the history and physical performed to evaluate and or diagnose the primary tumor before definitive therapy. | |
1406.1 | lng bronchoscopy pre-therapy | LUN1;19 | SET OF CODES | 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal results 8:Not performed, not mentioned in record 9:Done, results not documented | This item describes the methods and results of the bronchoscopy performed to evaluate and or diagnose the primary tumor before definitive therapy. | |
1406.2 | lng fnab | LUN1;20 | SET OF CODES | 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal results 8:Not performed, not mentioned in record 9:Done, results not documented | This item describes the methods and results of the FNAB (fine needle aspiration biopsy) performed to evaluate and or diagnose the primary tumor before definitive therapy. | |
1406.3 | lng mediastinoscopy | LUN1;21 | SET OF CODES | 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal results 8:Not performed, not mentioned in record 9:Done, results not documented | This item describes the methods and results of the mediastinoscopy performed to evaluate and or diagnose the primary tumor before definitive therapy. | |
1406.4 | lng thorocotomy/open biopsy | LUN1;22 | SET OF CODES | 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal results 8:Not performed, not mentioned in record 9:Done, results not documented | This item describes the methods and results of the thorocotomy/open biopsy (open technique) performed to evaluate and or diagnose the primary tumor before definitive therapy. | |
1406.5 | lng vats | LUN1;23 | SET OF CODES | 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal results 8:Not performed, not mentioned in record 9:Done, results not documented | This item describes the methods and results of the VATS (visual assisted thorocotomy surgery) performed to evaluate and or diagnose the primary tumor before definitive therapy. | |
1407 | lng fvc | LUN1;24 | NUMERIC | This item describes the results of the FVC (forced vital capacity) pulmonary function test (PFT). Record the absolute value of the result in liters (L). Record results to the precision of 2 decimal points and record zeros in unused positions; for example 2.54L would be coded as 2.54; 1.2L would be coded as 1.20; 0.5L would be coded as 0.50. If a test was administered but the result is not documented, code 9.98; if it's not documented whether the test was administered, code 9.99. | ||
1407.1 | lng fev | LUN1;25 | NUMERIC | This item describes the results of the FEV (forced expiratory volume) pulmonary function test (PFT). Record the absolute value of the result in liters (L). Record results to the precision of 2 decimal points and record zeros in unused positions; for example 2.54L would be coded as 2.54; 1.2L would be coded as 1.20; 0.5L would be coded as 0.50. If a test was administered but the result is not documented, code 9.98; if it's not documented whether the test was administered, code 9.99. | ||
1408 | lng liver function tests | LUN1;26 | SET OF CODES | 1:Abnormal results, for at least one test 2:Normal results on all tests 8:Test(s) not performed, not mentioned 9:Test(s) done, results not documented | This item describes the results of any test performed to evaluate the patient's liver function. Liver function tests typically include protime, bilirubin, albumin and LDH. If ANY of these tests were performed and were documented with abnormal results, code 1. If ALL liver function tests had normal results, code 2. | |
1409 | lng bone scan | LUN1;27 | SET OF CODES | 1:Performed 2:Not performed 9:Requested, not documented if performed | This item records whether or not a bone scan was performed. | |
1409.1 | lng emphysema (bone scan) | LUN1;28 | SET OF CODES | 1:Present 2:Absent 8:NA, test not performed 9:Not documented | This item records the presence or absence of emphysema as detected in the bone scan. | |
1409.2 | lng vascular inv (bone scan) | LUN1;29 | SET OF CODES | 1:Present 2:Absent 8:NA, test not performed 9:Not documented | This item records the presence or absence of vascular invasion as detected in the bone scan. | |
1409.3 | lng mediastinal ln (bone scan) | LUN1;30 | SET OF CODES | 1:Present 2:Absent 8:NA, test not performed 9:Not documented | This item records the presence or absence of enlarged mediastinal lymph nodes as detected in the bone scan. | |
1409.4 | lng tumor size (bone scan) | LUN1;31 | FREE TEXT | Record the size in millimeters of the dominant (largest) tumor as detected by the bone scan. | ||
1409.5 | lng num of tumors (bone scan) | LUN1;32 | FREE TEXT | Record the number of tumor nodules found (or identified) by the bone scan. | ||
1409.6 | lng metastasis (bone scan) | LUN1;33 | SET OF CODES | 1:Present 2:Absent 8:NA, test not performed 9:Not documented | This item records the presence or absence of metastasis as detected in the bone scan. | |
1410 | lng ct scan of chest | LUN1;34 | SET OF CODES | 1:Performed 2:Not performed 9:Requested, not documented if performed | This item records whether or not a CT scan of the chest was performed. | |
1410.1 | lng emphysema (chest ct) | LUN1;35 | SET OF CODES | 1:Present 2:Absent 8:NA, test not performed 9:Not documented | This item records the presence or absence of emphysema as detected in the CT scan of the chest. | |
1410.2 | lng vascular inv (chest ct) | LUN1;36 | SET OF CODES | 1:Present 2:Absent 8:NA, test not performed 9:Not documented | This item records the presence or absence of vascular invasion as detected in the CT scan of the chest. | |
1410.3 | lng mediastinal ln (chest ct) | LUN1;37 | SET OF CODES | 1:Present 2:Absent 8:NA, test not performed 9:Not documented | This item records the presence or absence of enlarged mediastinal lymph nodes as detected in the CT scan of the chest. | |
1410.4 | lng tumor size (chest ct) | LUN1;38 | FREE TEXT | Record the size in millimeters of the dominant (largest) tumor as detected by the CT scan of the chest. | ||
1410.5 | lng num of tumors (chest ct) | LUN1;39 | FREE TEXT | Record the number of tumor nodules found (or identified) by the CT scan of the chest. | ||
1410.6 | lng metastasis (chest ct) | LUN1;40 | SET OF CODES | 1:Present 2:Absent 8:NA, test not performed 9:Not documented | This item records the presence or absence of metastasis as detected in the CT scan of the chest. | |
1411 | lng ct scan of brain | LUN1;41 | SET OF CODES | 1:Performed 2:Not performed 9:Requested, not documented if performed | This item records whether or not a CT scan of the brain was performed. | |
1411.1 | lng emphysema (brain ct) | LUN1;42 | SET OF CODES | 1:Present 2:Absent 8:NA, test not performed 9:Not documented | This item records the presence or absence of emphysema as detected in the CT scan of the brain. | |
1411.2 | lng vascular inv (brain ct) | LUN1;43 | SET OF CODES | 1:Present 2:Absent 8:NA, test not performed 9:Not documented | This item records the presence or absence of vascular invasion as detected in the CT scan of the brain. | |
1411.3 | lng mediastinal ln (brain ct) | LUN1;44 | SET OF CODES | 1:Present 2:Absent 8:NA, test not performed 9:Not documented | This item records the presence or absence of enlarged mediastinal lymph nodes as detected in the CT scan of the brain. | |
1411.4 | lng tumor size (brain ct) | LUN1;45 | FREE TEXT | Record the size in millimeters of the dominant (largest) tumor as detected by the CT scan of the brain. | ||
1411.5 | lng num of tumors (brain ct) | LUN1;46 | FREE TEXT | Record the number of tumor nodules found (or identified) by the CT scan of the brain. | ||
1411.6 | lng metastasis (brain ct) | LUN1;47 | SET OF CODES | 1:Present 2:Absent 8:NA, test not performed 9:Not documented | This item records the presence or absence of metastasis as detected in the CT scan of the brain. | |
1412 | lng mri scan of chest | LUN1;48 | SET OF CODES | 1:Performed 2:Not performed 9:Requested, not documented if performed | This item records whether or not a MRI scan of the chest was performed. | |
1412.1 | lng emphysema (chest mri) | LUN1;49 | SET OF CODES | 1:Present 2:Absent 8:NA, test not performed 9:Not documented | This item records the presence or absence of emphysema as detected in the MRI of the chest. | |
1412.2 | lng vascular inv (chest mri) | LUN1;50 | SET OF CODES | 1:Present 2:Absent 8:NA, test not performed 9:Not documented | This item records the presence or absence of vascular invasion as detected in the MRI scan of chest. | |
1412.3 | lng mediastinal ln (chest mri) | LUN1;51 | SET OF CODES | 1:Present 2:Absent 8:NA, test not performed 9:Not documented | This item records the presence or absence of enlarged mediastinal lymph nodes as detected in the MRI scan of the chest. | |
1412.4 | lng tumor size (chest mri) | LUN1;52 | FREE TEXT | Record the size in millimeters of the dominant (largest) tumor as detected by the MRI scan of the chest. | ||
1412.5 | lng num of tumors (chest mri) | LUN1;53 | FREE TEXT | Record the number of tumor nodules found (or identified) by the MRI scan of the chest. | ||
1412.6 | lng metastasis (chest mri) | LUN1;54 | SET OF CODES | 1:Present 2:Absent 8:NA, test not performed 9:Not documented | This item records the presence or absence of metastasis as detected in the MRI scan of the chest. | |
1413 | lng mri scan of brain | LUN1;55 | SET OF CODES | 1:Performed 2:Not performed 9:Requested, not documented if performed | This item records whether or not a MRI scan of the brain was performed. | |
1413.1 | lng emphysema (brain mri) | LUN1;56 | SET OF CODES | 1:Present 2:Absent 8:NA, test not performed 9:Not documented | This item records the presence or absence of emphysema as detected in the MRI of the brain. | |
1413.2 | lng vascular inv (brain mri) | LUN1;57 | SET OF CODES | 1:Present 2:Absent 8:NA, test not performed 9:Not documented | This item records the presence or absence of vascular invasion as detected in the MRI scan of the brain. | |
1413.3 | lng mediastinal ln (brain mri) | LUN1;58 | SET OF CODES | 1:Present 2:Absent 8:NA, test not performed 9:Not documented | This item records the presence or absence of enlarged mediastinal lymph nodes as detected in the MRI scan of the brain. | |
1413.4 | lng tumor size (brain mri) | LUN1;59 | FREE TEXT | Record the size in millimeters of the dominant (largest) tumor as detected by the MRI scan of the brain. | ||
1413.5 | lng num of tumors (brain mri) | LUN1;60 | FREE TEXT | Record the number of tumor nodules found (or identified) by the MRI scan of the brain. | ||
1413.6 | lng metastasis (brain mri) | LUN1;61 | SET OF CODES | 1:Present 2:Absent 8:NA, test not performed 9:Not documented | This item records the presence or absence of metastasis as detected in the MRI scan of the brain. | |
1414 | lng pet scan | LUN1;62 | SET OF CODES | 1:Performed 2:Not performed 9:Requested, not documented if performed | This item records whether or not a PET (positron emission tomography) scan was performed. | |
1414.1 | lng emphysema (pet scan) | LUN1;63 | SET OF CODES | 1:Present 2:Absent 8:NA, test not performed 9:Not documented | This item records the presence or absence of emphysema as detected in the PET (positron emission tomography) scan. | |
1414.2 | lng vascular inv (pet scan) | LUN1;64 | SET OF CODES | 1:Present 2:Absent 8:NA, test not performed 9:Not documented | This item records the presence or absence of vascular invasion as detected in the PET (positron emission tomography) scan. | |
1414.3 | lng mediastinal ln (pet scan) | LUN1;65 | SET OF CODES | 1:Present 2:Absent 8:NA, test not performed 9:Not documented | This item records the presence or absence of enlarged mediastinal lymph nodes as detected in the PET (positron emission tomography) scan. | |
1414.4 | lng tumor size (pet scan) | LUN1;66 | FREE TEXT | Record the size in millimeters of the dominant (largest) tumor as detected by the PET (positron emission tomography) scan. | ||
1414.5 | lng num of tumors (pet scan) | LUN1;67 | FREE TEXT | Record the number of tumor nodules found (or identified) by the PET (positron emission tomography) scan. | ||
1414.6 | lng metastasis (pet scan) | LUN1;68 | SET OF CODES | 1:Present 2:Absent 8:NA, test not performed 9:Not documented | This item records the presence or absence of metastasis as detected in the PET (positron emission tomography) scan. | |
1415 | lng x-ray of chest | LUN1;69 | SET OF CODES | 1:Performed 2:Not performed 9:Requested, not documented if performed | This item records whether or not a chest x-ray was performed. | |
1415.1 | lng emphysema (chest xray) | LUN1;70 | SET OF CODES | 1:Present 2:Absent 8:NA, test not performed 9:Not documented | This item records the presence or absence of emphysema as detected in the X-Ray of the chest. | |
1415.2 | lng vascular inv (chest xray) | LUN1;71 | SET OF CODES | 1:Present 2:Absent 8:NA, test not performed 9:Not documented | This item records the presence or absence of vascular invasion as detected in the X-ray of the chest. | |
1415.3 | lng mediastinal (chest xray) | LUN1;72 | SET OF CODES | 1:Present 2:Absent 8:NA, test not performed 9:Not documented | This item records the presence or absence of enlarged mediastinal lymph nodes as detected in the X-ray of the chest. | |
1415.4 | lng tumor size (chest xray) | LUN1;73 | FREE TEXT | Record the size in millimeters of the dominant (largest) tumor as detected by the X-ray of the chest. | ||
1415.5 | lng num of tumors (chest xray) | LUN1;74 | FREE TEXT | Record the number of tumor nodules found (or identified) by the X-ray of the chest. | ||
1415.6 | lng metastasis (chest xray) | LUN1;75 | SET OF CODES | 1:Present 2:Absent 8:NA, test not performed 9:Not documented | This item records the presence or absence of metastasis as detected in the X-ray of the chest. | |
1416 | lng high mediastinal (pre-op) | LUN2;1 | SET OF CODES | 1:No nodes sampled 2:Sampled, no evidence of positive nodes 3:Sampled, evidence of positive nodes 4:Node sampling not mentioned 5:Sampled, results not documented | This item describes whether the highest mediastinal (level 1) nodes were sampled prior to the first course of therapy and if so, whether any positive nodes were found. | |
1416.1 | lng upper paratrach (pre-op) | LUN2;2 | SET OF CODES | 1:No nodes sampled 2:Sampled, no evidence of positive nodes 3:Sampled, evidence of positive nodes 4:Node sampling not mentioned 5:Sampled, results not documented | This item describes whether the upper paratracheal (level 2) nodes were sampled prior to the first course of therapy and if so, whether any positive nodes were found. | |
1416.2 | lng prevasc/retro (pre-op) | LUN2;3 | SET OF CODES | 1:No nodes sampled 2:Sampled, no evidence of positive nodes 3:Sampled, evidence of positive nodes 4:Node sampling not mentioned 5:Sampled, results not documented | This item describes whether the prevascular and retrotracheal (level 3) nodes were sampled prior to the first course of therapy and if so, whether any positive nodes were found. | |
1416.3 | lng lower paratrach (pre-op) | LUN2;4 | SET OF CODES | 1:No nodes sampled 2:Sampled, no evidence of positive nodes 3:Sampled, evidence of positive nodes 4:Node sampling not mentioned 5:Sampled, results not documented | This item describes whether the lower paratracheal (level 4) nodes were sampled prior to the first course of therapy and if so, whether any positive nodes were found. | |
1416.4 | lng subaortic (pre-op) | LUN2;5 | SET OF CODES | 1:No nodes sampled 2:Sampled, no evidence of positive nodes 3:Sampled, evidence of positive nodes 4:Node sampling not mentioned 5:Sampled, results not documented | This item describes whether the subaortic (level 5) nodes were sampled prior to the first course of therapy and if so, whether any positive nodes were found. | |
1416.5 | lng paraortic (pre-op) | LUN2;6 | SET OF CODES | 1:No nodes sampled 2:Sampled, no evidence of positive nodes 3:Sampled, evidence of positive nodes 4:Node sampling not mentioned 5:Sampled, results not documented | This item describes whether the paraortic (level 6) nodes were sampled prior to the first course of therapy and if so, whether any positive nodes were found. | |
1416.6 | lng subcarinal (pre-op) | LUN2;7 | SET OF CODES | 1:No nodes sampled 2:Sampled, no evidence of positive nodes 3:Sampled, evidence of positive nodes 4:Node sampling not mentioned 5:Sampled, results not documented | This item describes whether the subcarinal (level 7) nodes were sampled prior to the first course of therapy and if so, whether any positive nodes were found. | |
1416.7 | lng paraesophageal (pre-op) | LUN2;8 | SET OF CODES | 1:No nodes sampled 2:Sampled, no evidence of positive nodes 3:Sampled, evidence of positive nodes 4:Node sampling not mentioned 5:Sampled, results not documented | This item describes whether the paraesophageal (level 8) nodes were sampled prior to the first course of therapy and if so, whether any positive nodes were found. | |
1416.8 | lng pulmonary lig (pre-op) | LUN2;9 | SET OF CODES | 1:No nodes sampled 2:Sampled, no evidence of positive nodes 3:Sampled, evidence of positive nodes 4:Node sampling not mentioned 5:Sampled, results not documented | This item describes whether the pulmonary ligament (level 9) nodes were sampled prior to the first course of therapy and if so, whether any positive nodes were found. | |
1417 | lng frozen section | LUN2;10 | SET OF CODES | 1:Surgery performed, no frozen section taken 2:Surgery performed, frozen section taken 8:NA, no surgery 9:Not documented | This item describes whether or not a frozen section was taken according to the pathology report. | |
1418 | lng vascular invasion | LUN2;11 | SET OF CODES | 1:Structure not involved 2:Yes, structure involved 9:Not documented | This item describes any tumor invasion of the vascular structure. | |
1418.1 | lng lymphatics invasion | LUN2;12 | SET OF CODES | 1:Structure not involved 2:Yes, structure involved 9:Not documented | This item describes any tumor invasion of the lymphatics structure. | |
1418.2 | lng pleura invasion | LUN2;13 | SET OF CODES | 1:Structure not involved 2:Yes, structure involved 9:Not documented | This item describes any tumor invasion of the pleura structure. | |
1418.3 | lng chest wall invasion | LUN2;14 | SET OF CODES | 1:Structure not involved 2:Yes, structure involved 9:Not documented | This item describes any tumor invasion of the chest wall. | |
1418.4 | lng other invasion | LUN2;15 | SET OF CODES | 1:Structure not involved 2:Yes, structure involved 9:Not documented | This item describes any tumor invasion of any other structure. | |
1419 | lng high mediastinal (scope) | LUN2;16 | SET OF CODES | 1:Nodes not sampled 2:Nodes sampled, but not removed en bloc 3:Nodes removed en bloc 9:Lymph node assessment not documented | This item describes the scope of operative mediastinal lymph node assessment during surgery of the primary site. Record whether the highest mediastinal (level 1) nodes were sampled or taken en bloc. | |
1419.1 | lng upper paratracheal (scope) | LUN2;17 | SET OF CODES | 1:Nodes not sampled 2:Nodes sampled, but not removed en bloc 3:Nodes removed en bloc 9:Lymph node assessment not documented | This item describes the scope of operative mediastinal lymph node assessment during surgery of the primary site. Record whether the upper paratracheal (level 2) nodes were sampled or taken en bloc. | |
1419.2 | lng prevasc/retrotrach (scope) | LUN2;18 | SET OF CODES | 1:Nodes not sampled 2:Nodes sampled, but not removed en bloc 3:Nodes removed en bloc 9:Lymph node assessment not documented | This item describes the scope of operative mediastinal lymph node assessment during surgery of the primary site. Record whether the prevascular & retrotracheal (level 3) nodes were sampled or taken en bloc. | |
1419.3 | lng lower paratracheal (scope) | LUN2;19 | SET OF CODES | 1:Nodes not sampled 2:Nodes sampled, but not removed en bloc 3:Nodes removed en bloc 9:Lymph node assessment not documented | This item describes the scope of operative mediastinal lymph node assessment during surgery of the primary site. Record whether the lower paratracheal (level 4) nodes were sampled or taken en bloc. | |
1419.4 | lng subaortic (scope) | LUN2;20 | SET OF CODES | 1:Nodes not sampled 2:Nodes sampled, but not removed en bloc 3:Nodes removed en bloc 9:Lymph node assessment not documented | This item describes the scope of operative mediastinal lymph node assessment during surgery of the primary site. Record whether the subaortic (level 5) nodes were sampled or taken en bloc. | |
1419.5 | lng paraortic (scope) | LUN2;21 | SET OF CODES | 1:Nodes not sampled 2:Nodes sampled, but not removed en bloc 3:Nodes removed en bloc 9:Lymph node assessment not documented | This item describes the scope of operative mediastinal lymph node assessment during surgery of the primary site. Record whether the paraortic (level 6) nodes were sampled or taken en bloc. | |
1419.6 | lng subcarinal (scope) | LUN2;22 | SET OF CODES | 1:Nodes not sampled 2:Nodes sampled, but not removed en bloc 3:Nodes removed en bloc 9:Lymph node assessment not documented | This item describes the scope of operative mediastinal lymph node assessment during surgery of the primary site. Record whether the subcarinal (level 7) nodes were sampled or taken en bloc. | |
1419.7 | lng paraesophageal (scope) | LUN2;23 | SET OF CODES | 1:Nodes not sampled 2:Nodes sampled, but not removed en bloc 3:Nodes removed en bloc 9:Lymph node assessment not documented | This item describes the scope of operative mediastinal lymph node assessment during surgery of the primary site. Record whether the paraesophageal (level 8) nodes were sampled or taken en bloc. | |
1419.8 | lng pulmonary ligament (scope) | LUN2;24 | SET OF CODES | 1:Nodes not sampled 2:Nodes sampled, but not removed en bloc 3:Nodes removed en bloc 9:Lymph node assessment not documented | This item describes the scope of operative mediastinal lymph node assessment during surgery of the primary site. Record whether the pulmonary ligament (level 9) nodes were sampled or taken en bloc. | |
1420 | lng peri-operative blood rep | LUN2;25 | FREE TEXT | This item describes the total number of units of blood transfused within 30 days of operation. If the patient was transfused but the number of units is unknown, code 98. | ||
1421 | lng peri-operative death | LUN2;26 | SET OF CODES | 1:Died within same hospitalization 2:Died within 30 days of surgery 3:Both 1 & 2 4:Discharged/alive 30 days after surgery 9:Unknown | This item describes whether or not the patient died peri-operatively. | |
1422 | lng boost dose (cgy) | LUN2;27 | FREE TEXT | This item describes the boost dose of radiation administered to the central tumor field of the patient. If radiation was administered but boost dose is unknown, code 99999. Allowable Codes: 00000 - no radiation boost dose administered 00001 thru 99998 - boost dose administered (cGy) 99999- boost dose administered, dose not documented | ||
1423 | chemotherapeutic agent #1 | LUN2;28 | POINTER | 164.18 | Records the first chemotherapeutic agent administered to the patient as part of the first course of therapy. Each chemotherapeutic agent is assigned a 6-digit NSC (National Service Center) number. | |
1423.1 | chemotherapeutic agent #2 | LUN2;29 | POINTER | 164.18 | Records the second chemotherapeutic agent administered to the patient as part of the first course of therapy. Each chemotherapeutic agent is assigned a 6-digit NSC (National Service Center) number. | |
1423.2 | chemotherapeutic agent #3 | LUN2;30 | POINTER | 164.18 | Records the third chemotherapeutic agent administered to the patient as part of the first course of therapy. Each chemotherapeutic agent is assigned a 6-digit NSC (National Service Center) number. | |
1423.3 | chemotherapeutic agent #4 | LUN2;44 | POINTER | 164.18 | Records the fourth chemotherapeutic agent administered to the patient as part of the first course of therapy. Each chemotherapeutic agent is assigned a 6-digit NSC (National Service Center) number. | |
1423.4 | chemotherapeutic agent #5 | LUN2;45 | POINTER | 164.18 | Records the fifth chemotherapeutic agent administered to the patient as part of the first course of therapy. Each chemotherapeutic agent is assigned a 6-digit NSC (National Service Center) number. | |
1424 | lng chemotherapeutic toxicity | LUN2;31 | SET OF CODES | 1:Chemo discontinued due to toxicity 2:No chemo toxicity 9:Not documented | This item describes whether the administration of chemotherapy was discontinued as a result of toxicity. | |
1425 | lng chemotherapy/surg sequence | LUN2;32 | SET OF CODES | 1:Chemo before surgery 2:Chemo after surgery 3:Chemo before and after surgery 8:Chemo administered, no surgery 9:Chemo and surgery, sequence unknown | This data item describes the sequence in which chemotherapy and surgery of the primary site were administered. | |
1426 | lng complication #1 | LUN2;33 | POINTER | 80 | This item describes the first medical complication acquired by the patient during or resulting from the first course of therapy. Record valid ICD-CM codes. Allowable Codes: 001.00 - 999.90 (valid ICD-CM codes) E930.0 - E949.7 (valid ICD-CM adverse effect codes) | |
1426.1 | lng complication #2 | LUN2;34 | POINTER | 80 | This item describes the second medical complication acquired by the patient during or resulting from the first course of therapy. Allowable Codes: 001.00 - 999.90 (valid ICD-CM codes) E930.0 - E949.7 (valid ICD-CM adverse effect codes) | |
1426.2 | lng complication #3 | LUN2;35 | POINTER | 80 | This item describes the third medical complication acquired by the patient during or resulting from the first course of therapy. Allowable Codes: 001.00 - 999.90 (valid ICD-CM codes) E930.0 - E949.7 (valid ICD-CM adverse effect codes) | |
1426.3 | lng complication #4 | LUN2;36 | POINTER | 80 | This item describes the fourth medical complication acquired by the patient during or resulting from the first course of therapy. Allowable Codes: 001.00 - 999.90 (valid ICD-CM codes) E930.0 - E949.7 (valid ICD-CM adverse effect codes) | |
1426.4 | lng complication #5 | LUN2;37 | POINTER | 80 | This item describes the fifth medical complication acquired by the patient during or resulting from the first course of therapy. Allowable Codes: 001.00 - 999.90 (valid ICD-CM codes) E930.0 - E949.7 (valid ICD-CM adverse effect codes) | |
1426.5 | lng treatment complication y/n(+) | LUN2;40 | BOOLEAN | 0:No 1:Yes | This item records if there were medical complications acquired by the patient during or resulting from first course of therapy for this cancer. If no complications are listed, answer "No". COMPLICATION #1 will be automatically coded 000.00 with the remaining complication fields left blank. | |
1427 | lng case abstractor initials | LUN2;38 | FREE TEXT | This item records the initials of the person responsible for abstracting this case and having reviewed all the special study items for completeness and validity. | ||
1428 | lng date case was abstracted | LUN2;39 | DATE-TIME | This item describes the month, day and year (in the MMDDCCYY format) that this case was reviewed for completeness and validity by the case abstractor. | ||
1429 | lng proximal margin | LUN2;41 | FREE TEXT | This item describes the distance of the closest proximal free margin in millimeters of the resected primary tumor specimen. This information can be obtained from the pathology report. If surgery of primary site was performed but the extent of the free margin is unknown, code 999. Allowable Codes: 000 - no free margins in this segment 001 thru 997 - distance of closest free margin (mm) 998 - NA, no surgery of primary site 999 - unknown, extent of free margin not documented | ||
1429.1 | lng distal margin | LUN2;42 | FREE TEXT | This item describes the distance of the closest distal free margin in millimeters of the resected primary tumor specimen. This information can be obtained from the pathology report. If surgery of primary site was performed but the extent of the free margin is unknown, code 999. Allowable Codes: 000 - no free margins in this segment 001 thru 997 - distance of closest free margin (mm) 998 - NA, no surgery of primary site 999 - unknown, extent of free margin not documented | ||
1430 | lng hct val before transfusion | LUN2;43 | NUMERIC | This item describes the percent (%) of hematocrit before the first transfusion. Record results to the precision of one decimal point, record zeros in unused positions; for example 9.5% would be coded as 09.5. If the patient was transfused but hematocrit value is not documented, code 99.9. Allowable Codes: 00.0 - no transfusion 00.1 thru 99.0 - % Hct 99.9 - transfusion, % Hct not documented | ||
1500 | gas prior exposure to rad | GAS1;1 | SET OF CODES | 1:Documented exposure 2:Documented no exposure 9:Not documented | This item describes a patient's known prior radiation exposure. Exposure to fluoroscopy, exposure to radioactive isotopes, or actual radiation treatments should be considered prior radiation exposure. Occupational exposure to radiation should be considered: radioisotope lab worker; radiation therapist; radiology technician; miner. Do not code routine chest or dental x-rays as prior radiation exposure. | |
1501 | gas alcohol comsumption | GAS1;2 | FREE TEXT | This item describes the number of drinks (beer, wine, other alcohol) consumed by the patient per week. If the patient has never consumed alcohol, code 00. If the number of drinks per week is not documented, code 99. This information can typically be found in either the patient's clinic chart or the managing physician's notes. Allowable Codes: 00 - never consumed alcohol 01 thru 96 - 1 or more drinks up to 96 drinks per week 97 - 97 or more drinks per week 98 - alcohol consumption, number of drinks unknown 99 - alcohol consumption not documented | ||
1502 | gas menopausal status/hor tx | GAS1;3 | SET OF CODES | 1:Menopause, no hormome tx 2:Menopause, hormone tx stopped before dx 3:Menopause, hormone tx at dx 8:NA, male patient 9:Menopause not documented | This item describes whether a female patient has experienced menopause and, if so, whether or not she was receiving prescribed hormone replacement therapy. Menopause may occur naturally or as a result of a hysterectomy. If the patient is male, code 8. If the woman's menopausal status can not be determined, code 9. This information can typically be found in either the patient's clinic chart or the managing physician's notes. | |
1503 | gas h2 blocker/proton pump | GAS1;4 | SET OF CODES | 1:H2 blocker 2:Proton pump inhibitor 3:Both 8:Neither 9:Not documented | This item describes whether the patient was either self-medicating or taking prescribed H2 blocker or proton pump inhibitor drugs to suppress gastric acidity and control reflux. Common drug names for H2 blocker include: Pepcid (famotidine), Tagamet (cimetidine), Zantac (ranitidine), and Axid (nizatidine). Common names for proton pump inhibitors include: Prilosec (omeprazole), Prevacid (lansoprazole), Protonix (pantaprazol), Aciphex (rebeprazol), and Nexium (es-omeprazole). | |
1504 | gas family hist of gastric ca | GAS1;5 | SET OF CODES | 1:No 1st or 2nd deg relatives 2:1 1st deg relative 3:2 1st deg relatives 4:3 or more 1st deg relatives 5:1 or more 2nd deg relatives 6:Both 1st and 2nd deg relatives 9:Familial history, relation not indicated | This item describes whether there is any familial history of gastric cancer. Record familial history of gastric cancer in first degree relatives (parent, siblings, and child) or 2nd degree relatives (1st cousins, aunt, uncle, grandparent, grandchild). | |
1505 | gas h-pylori infection | GAS1;6 | SET OF CODES | 1:Past history, present at dx 2:No past history, present at dx 3:Past history, not present at dx 4:Documented never present 9:Unknown, not documented | This item describes whether the patient had at any time the following associated benign gastric condition: Helicobacter pylori (H-pylori) infection | |
1506 | gas duodenal ulcer | GAS1;7 | SET OF CODES | 1:Past history, present at dx 2:No past history, present at dx 3:Past history, not present at dx 4:Documented never present 9:Unknown, not documented | This item describes whether the patient had at any time the following associated benign gastric condition: Duodenal ulcer | |
1507 | gas gastric ulcer | GAS1;8 | SET OF CODES | 1:Past history, present at dx 2:No past history, present at dx 3:Past history, not present at dx 4:Documented never present 9:Unknown, not documented | This item describes whether the patient had at any time the following associated benign gastric condition: Gastric ulcer | |
1508 | gas heartburn (benign cond) | GAS1;9 | SET OF CODES | 1:Past history, present at dx 2:No past history, present at dx 3:Past history, not present at dx 4:Documented never present 9:Unknown, not documented | This item describes whether the patient had at any time the following associated benign gastric condition: Heartburn | |
1509 | gas pernicious anemia | GAS1;10 | SET OF CODES | 1:Past history, present at dx 2:No past history, present at dx 3:Past history, not present at dx 4:Documented never present 9:Unknown, not documented | This item describes whether the patient had at any time the following associated benign gastric condition: Pernicious anemia | |
1510 | gas polyps of stomach | GAS1;11 | SET OF CODES | 1:Past history, present at dx 2:No past history, present at dx 3:Past history, not present at dx 4:Documented never present 9:Unknown, not documented | This item describes whether the patient had at any time the following associated benign gastric condition: Polyps of stomach | |
1511 | gas polyposis of bowel | GAS1;12 | SET OF CODES | 1:Past history, present at dx 2:No past history, present at dx 3:Past history, not present at dx 4:Documented never present 9:Unknown, not documented | This item describes whether the patient had at any time the following associated benign gastric condition: Polyposis of small or large bowel | |
1512 | gas barret's esophagus | GAS1;13 | SET OF CODES | 1:Past history, present at dx 2:No past history, present at dx 3:Past history, not present at dx 4:Documented never present 9:Unknown, not documented | This item describes whether the patient had at any time the following associated benign gastric condition: Barret's esophagus | |
1513 | gas atrophic gastritis | GAS1;14 | SET OF CODES | 1:Past history, present at dx 2:No past history, present at dx 3:Past history, not present at dx 4:Documented never present 9:Unknown, not documented | This item describes whether the patient had at any time the following associated benign gastric condition: Atrophic gastritis | |
1514 | gas gastric metaplasia | GAS1;15 | SET OF CODES | 1:Past history, present at dx 2:No past history, present at dx 3:Past history, not present at dx 4:Documented never present 9:Unknown, not documented | This item describes whether the patient had at any time the following associated benign gastric condition: Gastric metaplasia | |
1515 | gas antibiotics | GAS1;16 | SET OF CODES | 1:Regimen given 2:H-pylori present, regimen not given 8:H-pylori not present 9:Not documented | This item records the use of antibiotics for H-pylori infection prior to diagnosis of gastric cancer. Examples of antibiotics include: ampicillin, amoxicillin, clarithromycin, etc. | |
1516 | gas proton pump inhibitors | GAS1;17 | SET OF CODES | 1:Regimen given 2:H-pylori present, regimen not given 8:H-pylori not present 9:Not documented | This item records the use of proton pump inhibitors for H-pylori infection prior to diagnosis of gastric cancer. Examples of proton pump inhibitors include: omeprazole, lansoprazole, rabeprazole, pantoprazol, es-omeprazole. | |
1517 | gas h2 blockers | GAS1;18 | SET OF CODES | 1:Regimen given 2:H-pylori present, regimen not given 8:H-pylori not present 9:Not documented | This item records the use of H2 blockers for H-pylori infection prior to diagnosis of gastric cancer. Examples of H2 blockers include: ranitidine (Zantac), famotidine (Pepcid), nizatidine (Axid), cimetidine (Tagamet). | |
1518 | gas bismuth compounds | GAS1;19 | SET OF CODES | 1:Regimen given 2:H-pylori present, regimen not given 8:H-pylori not present 9:Not documented | This item records the use of bismuth compounds for H-pylori infection prior to diagnosis of gastric cancer. Examples of bismuth compounds include: Pepo Bismol, prescription bismuth drugs. | |
1519 | gas prior intra-abdominal surg | GAS1;20 | SET OF CODES | 1:Documented 2:Documented No 9:Not mentioned | This item describes whether the patient had undergone any intra- abdominal surgery including a prior gastric resection, before the diagnosis of this cancer. Do not record retroperitoneal or extraperitoneal procedures as intra-abdominal surgeries. | |
1520 | gas year of gastric resection | GAS1;21 | FREE TEXT | This item describes the year that the patient received a gastric resection prior to this diagnosis. If the patient has a documented prior abdominal surgical resection indicate whether that surgery included a gastric resection by coding the year the resection occurred. If the patient has received more than one gastric resection, code the earliest (first) year. Allowable Codes: 0000 - documented no prior gastric resection 1901 thru 2001 - year of prior gastric resection 9999 - not documented whether there was prior gastric resection | ||
1521 | gas performance status at dx | GAS1;22 | SET OF CODES | 1:Normal, no symptoms 2:Symptoms/ambulatory/min limits 3:Out of bed > 50% of day/mod limits 4:In bed > 50% of day/severe limits 5:Bedridden/moribund 9:Not documented | This item describes the performance status of the patient at initial diagnosis. The scale used in this study is widely known as the ECOG performance status. | |
1522 | gas heartburn (symptoms) | GAS1;23 | SET OF CODES | 1:Present 2:Not present 9:Not documented | This item describes the presence of heartburn specific to gastric cancer that was recorded in the medical chart. | |
1523 | gas fever/night sweats | GAS1;24 | SET OF CODES | 1:Present 2:Not present 9:Not documented | This item describes the presence of fever/night sweats specific to gastric cancer that was recorded in the medical chart. | |
1524 | gas acute hematemesis | GAS1;25 | SET OF CODES | 1:Present 2:Not present 9:Not documented | This item describes the presence of acute hematemesis specific to gastric cancer that was recorded in the medical chart. | |
1525 | gas transfusions for bld loss | GAS1;26 | SET OF CODES | 1:Present 2:Not present 9:Not documented | This item describes the presence of transfusions for blood loss specific to gastric cancer that were recorded in the medical chart. | |
1526 | gas melena | GAS1;27 | SET OF CODES | 1:Present 2:Not present 9:Not documented | This item describes the presence of melena specific to gastric cancer that was recorded in the medical chart. | |
1527 | gas pain | GAS1;28 | SET OF CODES | 1:Present 2:Not present 9:Not documented | This item describes the presence of pain specific to gastric cancer that was recorded in the medical chart. | |
1528 | gas early satiety | GAS1;29 | SET OF CODES | 1:Present 2:Not present 9:Not documented | This item describes the presence of early satiety specific to gastric cancer that was recorded in the medical chart. | |
1529 | gas ct scan of abdomen | GAS1;30 | SET OF CODES | 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Not performed 8:Performed, results not documented 9:Not documented | This item describes the results of a CT scan of abdomen performed to evaluate the primary tumor. | |
1530 | gas ct scan of chest | GAS1;31 | SET OF CODES | 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Not performed 8:Performed, results not documented 9:Not documented | This item describes the results of a CT scan of chest performed to evaluate the primary tumor. | |
1531 | gas ct pelvis | GAS1;32 | SET OF CODES | 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Not performed 8:Performed, results not documented 9:Not documented | This item describes the results of a CT pelvis performed to evaluate the primary tumor. | |
1532 | gas chest x-ray | GAS1;33 | SET OF CODES | 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Not performed 8:Performed, results not documented 9:Not documented | This item describes the results of a chest x-ray performed to evaluate the primary tumor. | |
1533 | gas gallium scan | GAS1;34 | SET OF CODES | 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Not performed 8:Performed, results not documented 9:Not documented | This item describes the results of a gallium scan performed to evaluate the primary tumor. | |
1534 | gas bipedal lymphangiogram | GAS1;35 | SET OF CODES | 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Not performed 8:Performed, results not documented 9:Not documented | This item describes the results of a bipedal lymphangiogram (LAB) performed to evaluate the primary tumor. | |
1535 | gas mri | GAS1;36 | SET OF CODES | 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Not performed 8:Performed, results not documented 9:Not documented | This item describes the results of an MRI performed to evaluate the primary tumor. | |
1536 | gas pet scan | GAS1;37 | SET OF CODES | 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Not performed 8:Performed, results not documented 9:Not documented | This item describes the results of a PET scan performed to evaluate the primary tumor. | |
1537 | gas laparoscopy | GAS1;38 | SET OF CODES | 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Not performed 8:Performed, results not documented 9:Not documented | This item describes the results of a laparoscopy performed to evaluate the primary tumor. | |
1538 | gas eus | GAS1;39 | SET OF CODES | 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Not performed 8:Performed, results not documented 9:Not documented | This item describes the results of an EUS (endoscopic ultrasound) performed to evaluate the primary tumor. | |
1539 | gas peritoneal lavage | GAS1;40 | SET OF CODES | 1:Abnormal, suggestive of cancer 2:Abnormal, not suggestive of cancer 3:Normal 4:Not performed 8:Performed, results not documented 9:Not documented | This item describes the results of a peritoneal lavage performed to evaluate the primary tumor. | |
1540 | gas ldh (iu/l) | GAS1;41 | NUMERIC | This item describes the absolute value of the LDH (IU/L) study administered to the patient prior to the start of the first course of treatment. This information can typically be found in either the patient's hospital chart or laboratory records. Record results to the precision of one decimal point; record zeros in unused positions; for example 12.5 would be coded as 0012.5, and 4.4 would be coded as 0004.4. If a particular test was not administered, code 0000.0; if a test was administered but the result is unknown, code 8888.8; if it is not documented whether a test is administered, code 9999.9. Allowable Codes: 0000.0 - test not administered 0000.1 thru 8888.7 - absolute value of test 8888.8 - test administered, results unknown 9999.9 - not documented if test administered | ||
1541 | gas cea (ng/ml) | GAS1;42 | NUMERIC | This item describes the absolute value of the Carcinoembryonic antigen, CEA (ng/ml) study administered to the patient prior to the start of the first course of treatment. This information can typically be found in either the patient's hospital chart or laboratory records. Record results to the precision of one decimal point; record zeros in unused positions; for example 12.5 would be coded as 0012.5, and 4.4 would be coded as 0004.4. If a particular test was not administered, code 0000.0; if a test was administered but the result is unknown, code 8888.8; if it is not documented whether a test is administered, code 9999.9. Allowable Codes: 0000.0 - test not administered 0000.1 thru 8888.7 - absolute value of test 8888.8 - test administered, results unknown 9999.9 - not documented if test administered | ||
1542 | gas ca125 (u/ml) | GAS1;43 | NUMERIC | This item describes the absolute value of the CA125 (U/ml) study administered to the patient prior to the start of the first course of treatment. This information can typically be found in either the patient's hospital chart or laboratory records. Record results to the precision of one decimal point; record zeros in unused positions; for example 12.5 would be coded as 0012.5, and 4.4 would be coded as 0004.4. If a particular test was not administered, code 0000.0; if a test was administered but the result is unknown, code 8888.8; if it is not documented whether a test is administered, code 9999.9. Allowable Codes: 0000.0 - test not administered 0000.1 thru 8888.7 - absolute value of test 8888.8 - test administered, results unknown 9999.9 - not documented if test administered | ||
1543 | gas beta2 microglobulin | GAS1;44 | NUMERIC | This item describes the absolute value of the Beta2 microglobulin (ng/ml) study administered to the patient prior to the start of the first course of treatment. This information can typically be found in either the patient's hospital chart or laboratory records. Record results to the precision of one decimal point; record zeros in unused positions; for example 12.5 would be coded as 0012.5, and 4.4 would be coded as 0004.4. If a particular test was not administered, code 0000.0; if a test was administered but the result is unknown, code 8888.8; if it is not documented whether a test is administered, code 9999.9. Allowable Codes: 0000.0 - test not administered 0000.1 thru 8888.7 - absolute value of test 8888.8 - test administered, results unknown 9999.9 - not documented if test administered | ||
1544 | gas urinary 5-hiaa (mg/24hr) | GAS1;45 | NUMERIC | This item describes the absolute value of the Urinary 5-HIAA (mg/24hr) study administered to the patient prior to the start of the first course of treatment. This information can typically be found in either the patient's hospital chart or laboratory records. Record results to the precision of one decimal point; record zeros in unused positions; for example 12.5 would be coded as 0012.5, and 4.4 would be coded as 0004.4. If a particular test was not administered, code 0000.0; if a test was administered but the result is unknown, code 8888.8; if it is not documented whether a test is administered, code 9999.9. Allowable Codes: 0000.0 - test not administered 0000.1 thru 8888.7 - absolute value of test 8888.8 - test administered, results unknown 9999.9 - not documented if test administered | ||
1545 | gas clinical/visual exam | GAS1;46 | SET OF CODES | 1:Results positive for cancer 2:Results negative for caner 8:Not performed 9:Not documented, exam type not mentioned | This item describes the most definitive results of a gastroscopic clinical/visual examination. | |
1545.1 | gas biopsy | GAS1;47 | SET OF CODES | 1:Results positive for cancer 2:Results negative for cancer 8:Not performed 9:Not documented, exam type not mentioned | This item describes the most definitive results of a gastrscopic biopsy. | |
1546 | gas gastro-esophageal junction | GAS1;48 | SET OF CODES | 1:Siewart II <= 2cm from squamocolunmar junc 2:Siewart III > 2cm from squamocolumnar junc 9:No documented Siewart type or distance | This item distinguishes tumors that clearly arise within the stomach (type III) from those that start at or near the esophageal gastric junction (type II). Siewert type I tumors are excluded from this study as these are considered esophageal (C15.0-C15.9). This information may be obtained from the pathology report. | |
1547 | gas stomach | GAS1;49 | SET OF CODES | 1:Site of initial histologic dx 2:Not site of initial histologic dx 9:Site not documented | This item describes the site(s) of the initial histologic diagnosis of this cancer. | |
1547.1 | gas liver | GAS1;50 | SET OF CODES | 1:Site of initial histologic dx 2:Not site of initial histologic dx 9:Site not documented | This item describes the site(s) of the initial histologic diagnosis of this cancer. | |
1547.2 | gas extra-abdominal | GAS1;51 | SET OF CODES | 1:Site of initial histologic dx 2:Not site of initial histologic dx 9:Site not documented | This item describes the site(s) of the initial histologic diagnosis of this cancer. | |
1547.3 | gas lymph nodes | GAS1;52 | SET OF CODES | 1:Site of initial histologic dx 2:Not site of initial histologic dx 9:Site not documented | This item describes the site(s) of the initial histologic diagnosis of this cancer. | |
1547.4 | gas peritoneum | GAS1;53 | SET OF CODES | 1:Site of initial histologic dx 2:Not site of initial histologic dx 9:Site not documented | This item describes the site(s) of the initial histologic diagnosis of this cancer. | |
1548 | gas date of first tissue dx | GAS1;54 | DATE-TIME | This item describes the month, day, and year (MMDDCCYY) that this primary cancer was first diagnosed using a tissue sample to arrive at a positive histologic or cytologic evaluation of the tumor. If a positive histologic or cytologic evaluation was made but the date is unknown code 99/99/9999. | ||
1549 | gas lauren's classification | GAS1;55 | SET OF CODES | 1:Diffuse 2:Intestinal 3:Mixed 4:Other 9:Not documented | This item describes Lauren's classification which divides gastric carcinoma into two main histologic types, diffuse or intestinal. Record the classification if it is stated in the pathology report. | |
1550 | gas goseki's classification | GAS1;56 | SET OF CODES | 1:Type I tubular diff well/mucin poor 2:Type II tubular diff well/mucin rich 3:Type III tubular diff poor/mucin poor 3:Type IV tubular diff poor/mucin rich 9:Not documented | This item describes Goseki's classification which divides gastric carcinoma into four histologic types, depending upon the degree of tubular differentiation and mucin content. It is thought that this classification scheme can aid in predicting a tumor's mode of extension, recurrence and conditions of metastasis. This information may not appear on the pathology report. Request assistance from the attending pathologist to determine the appropriate code. | |
1551 | gas gastrin | GAS1;57 | SET OF CODES | 1:Used in pathologic evaluation 2:Not used 8:NA, pathologic dx not made 9:Not documented if used | This item describes whether molecular marker gastrin was used in the pathologic evaluation of the tumor. If a pathologic diagnosis was not made, code 8. | |
1551.1 | gas 5-hiaa | GAS1;58 | SET OF CODES | 1:Used in pathologic evaluation 2:Not used 8:NA, pathologic dx not made 9:Not documented if used | This item describes whether molecular marker 5-HIAA was used in the pathologic evaluation of the tumor. If a pathologic diagnosis was not made, code 8. | |
1551.2 | gas cea | GAS1;59 | SET OF CODES | 1:Used in pathologic evaluation 2:Not used 8:NA, pathologic dx not made 9:Not documented if used | This item describes whether molecular marker CEA was used in the pathologic evaluation of the tumor. If a pathologic diagnosis was not made, code 8. | |
1551.3 | gas ca125 | GAS1;60 | SET OF CODES | 1:Used in pathologic evaluation 2:Not used 8:NA, pathologic dx not made 9:Not documented if used | This item describes whether molecular marker CA124 was used in the pathologic evaluation of the tumor. If a pathologic diagnosis was not made, code 8. | |
1551.4 | gas other molecular marker | GAS1;61 | SET OF CODES | 1:Used in pathologic evaluation 2:Not used 8:NA, pathologic dx not made 9:Not documented if used | This item describes whether other molecular markers were used in the pathologic evaluation of the tumor. If a pathologic diagnosis was not made, code 8. | |
1552 | gas mitotic rate | GAS1;62 | SET OF CODES | 1:< or equal to 2/10 HPF 2:> 2 and < 5/10 HPF 3:Equal to or > 5/10 HPF 9:Not documented | This item describes the number of mitoses per high power field (HPF). | |
1553 | gas tumor necrosis | GAS1;63 | SET OF CODES | 1:Frequent, larger areas 2:Few small areas (rare/scattered) 3:No tumor cell necrosis 9:Not documented | This item describes the presence and degree of tumor necrosis. | |
1554 | gas flow cytometry/fresh tiss | GAS1;64 | SET OF CODES | 1:Used 2:Not used 9:Not documented | This data item describes if the flow cytometry on fresh tissue phenotype modality was performed on the lymphoma tissue in this case. | |
1554.1 | gas immunohistochem/frozen tis | GAS1;65 | SET OF CODES | 1:Used 2:Not used 9:Not documented | This data item describes if the immunohistochemistry on frozen tissue phenotype modality was performed on the lymphoma tissue in this case. | |
1554.2 | gas immunohistochem/paraffin | GAS1;66 | SET OF CODES | 1:Used 2:Not used 9:Not documented | This data item describes if the immunohistochemistry on paraffin embedded tissue phenotype modality was performed on the lymphoma tissue in this case. | |
1554.3 | gas molecular genetics | GAS1;67 | SET OF CODES | 1:Used 2:Not used 9:Not documented | This data item describes if the molecular genetics phenotype modality was performed on the lymphoma tissue in this case. | |
1554.4 | gas polymerase chain reaction | GAS1;68 | SET OF CODES | 1:Used 2:Not used 9:Not documented | This data item describes if the polymerase chain reaction technique phenotype modality was performed on the lymphoma tissue in this case. | |
1554.5 | gas southern blot technique | GAS1;69 | SET OF CODES | 1:Used 2:Not used 9:Not documented | This data item describes if the Southern blot technique phenotype modality was performed on the lymphoma tissue in this case. | |
1555 | gas ann arbor staging | GAS1;70 | SET OF CODES | 1:Stage IE (stomach) 2:Stage IIEi (stomach/perigastric ln) 3:Stage IIEii (stomach/periaortic ln) 4:Stage III (spleen tumor) 5:Stage IV (distant/liver/bone marrow) 9:Not documented | Gastric lymphoma staging is performed differently than adenocarcinoma staging, using a modification of the Ann Arbor System with Stage IE confined to the stomach, Stage IIEi confined to the stomach and perigastric lymph nodes, Stage IIEii confined to stomach and periaortic lymph nodes, Stage III involvement of the spleen, tumor on both sides of diaphragm and Stage IV involvement of distant sites (liver, bone marrow). | |
1556 | gas adherence of resected prim | GAS1;71 | SET OF CODES | 1:No tumor adherence 2:Tumor adherence lysed w/o resection 3:Tumor adherence, adj organ resected en bloc 9:Not documented | This item evaluates adherence of the resected primary specimen to other structures. | |
1557 | gas margin stat of resect prim | GAS1;72 | SET OF CODES | 1:Negative proximal and distal 2:Positive proximal, negative distal 3:Negative proximal, positive distal 4:Positive proximal and distal 9:Not documented | This item evaluates the margin status of the resected primary specimen. | |
1558 | gas proximal margin | GAS1;73 | FREE TEXT | This item describes the extent of the proximal free margin around the resected primary tumor specimen. Record the extent of the closest free margin in millimeters. If surgery of primary site was performed but the extent of the free margin is not documented, code 999. This information can be obtained from the pathology report. Allowable Codes: 000 - no free margins in this segment 001 thru 997 - extent of free margin (mm) 999 - extent of free margin not documented | ||
1558.1 | gas distal margin | GAS1;74 | FREE TEXT | This item describes the extent of the distal free margin around the resected primary tumor specimen. Record the extent of the closest free margin in millimeters. If surgery of primary site was performed but the extent of the free margin is not documented, code 999. This information can be obtained from the pathology report. Allowable Codes: 000 - no free margins in this segment 001 thru 997 - extent of free margin (mm) 999 - extent of free margin not documented | ||
1559 | gas spleen | GAS2;1 | SET OF CODES | 1:Resected, tumor adherence 2:Resected, no tumor adherence 3:Not resected, tumor adherence 4:Not resected, no tumor adherence 9:Extent of resection not documented | This item describes the removal of an organ or lymph node structure beyond the stomach and if there was tumor adherence to this structure. This information should be obtained from both the surgical and pathology report. | |
1559.1 | gas transverse colon | GAS2;2 | SET OF CODES | 1:Resected, tumor adherence 2:Resected, no tumor adherence 3:Not resected, tumor adherence 4:Not resected, no tumor adherence 9:Extent of resection not documented | This item describes the removal of an organ or lymph node structure beyond the stomach and if there was tumor adherence to this structure. This information should be obtained from both the surgical and pathology report. | |
1559.2 | gas liver | GAS2;3 | SET OF CODES | 1:Resected, tumor adherence 2:Resected, no tumor adherence 3:Not resected, tumor adherence 4:Not resected, no tumor adherence 9:Extent of resection not documented | This item describes the removal of an organ or lymph node structure beyond the stomach and if there was tumor adherence to this structure. This information should be obtained from both the surgical and pathology report. | |
1559.3 | gas diaphragm | GAS2;4 | SET OF CODES | 1:Resected, tumor adherence 2:Resected, no tumor adherence 3:Not resected, tumor adherence 4:Not resected, no tumor adherence 9:Extent of resection not documented | This item describes the removal of an organ or lymph node structure beyond the stomach and if there was tumor adherence to this structure. This information should be obtained from both the surgical and pathology report. | |
1559.4 | gas pancreas | GAS2;5 | SET OF CODES | 1:Resected, tumor adherence 2:Resected, no tumor adherence 3:Not resected, tumor adherence 4:Not resected, no tumor adherence 9:Extent of resection not documented | This item describes the removal of an organ or lymph node structure beyond the stomach and if there was tumor adherence to this structure. This information should be obtained from both the surgical and pathology report. | |
1559.5 | gas abdominal wall | GAS2;6 | SET OF CODES | 1:Resected, tumor adherence 2:Resected, no tumor adherence 3:Not resected, tumor adherence 4:Not resected, no tumor adherence 9:Extent of resection not documented | This item describes the removal of an organ or lymph node structure beyond the stomach and if there was tumor adherence to this structure. This information should be obtained from both the surgical and pathology report. | |
1559.6 | gas adrenal gland | GAS2;7 | SET OF CODES | 1:Resected, tumor adherence 2:Resected, no tumor adherence 3:Not resected, tumor adherence 4:Not resected, no tumor adherence 9:Extent of resection not documented | This item describes the removal of an organ or lymph node structure beyond the stomach and if there was tumor adherence to this structure. This information should be obtained from both the surgical and pathology report. | |
1559.7 | gas kidney | GAS2;8 | SET OF CODES | 1:Resected, tumor adherence 2:Resected, no tumor adherence 3:Not resected, tumor adherence 4:Not resected, no tumor adherence 9:Extent of resection not documented | This item describes the removal of an organ or lymph node structure beyond the stomach and if there was tumor adherence to this structure. This information should be obtained from both the surgical and pathology report. | |
1559.8 | gas small intestine | GAS2;9 | SET OF CODES | 1:Resected, tumor adherence 2:Resected, no tumor adherence 3:Not resected, tumor adherence 4:Not resected, no tumor adherence 9:Extent of resection not documented | This item describes the removal of an organ or lymph node structure beyond the stomach and if there was tumor adherence to this structure. This information should be obtained from both the surgical and pathology report. | |
1559.9 | gas retroperitoneum | GAS2;10 | SET OF CODES | 1:Resected, tumor adherence 2:Resected, no tumor adherence 3:Not resected, tumor adherence 4:Not resected, no tumor adherence 9:Extent of resection not documented | This item describes the removal of an organ or lymph node structure beyond the stomach and if there was tumor adherence to this structure. This information should be obtained from both the surgical and pathology report. | |
1560 | gas perigastric lymph nodes | GAS2;11 | SET OF CODES | 2:Resected 4:Not resected 9:Extent of resection not documented | This item describes the removal of an organ or lymph node structure beyond the stomach and if there was tumor adherence to this structure. This information should be obtained from both the surgical and pathology report. | |
1560.1 | gas common hepatic lymph nodes | GAS2;12 | SET OF CODES | 2:Resected 4:Not resected 9:Extent of resection not documented | This item describes the removal of an organ or lymph node structure beyond the stomach and if there was tumor adherence to this structure. This information should be obtained from both the surgical and pathology report. | |
1560.2 | gas celiac lymph nodes | GAS2;13 | SET OF CODES | 2:Resected 4:Not resected 9:Extent of resection not documented | This item describes the removal of an organ or lymph node structure beyond the stomach and if there was tumor adherence to this structure. This information should be obtained from both the surgical and pathology report. | |
1560.3 | gas splenic lymph nodes | GAS2;14 | SET OF CODES | 2:Resected 4:Not resected 9:Extent of resection not documented | This item describes the removal of an organ or lymph node structure beyond the stomach and if there was tumor adherence to this structure. This information should be obtained from both the surgical and pathology report. | |
1560.4 | gas other intra-abdominal ndes | GAS2;15 | SET OF CODES | 2:Resected 4:Not resected 9:Extent of resection not documented | This item describes the removal of an organ or lymph node structure beyond the stomach and if there was tumor adherence to this structure. This information should be obtained from both the surgical and pathology report. | |
1561 | gas grossly involved reg ln | GAS2;16 | SET OF CODES | 1:Resected 2:Not resected 9:Resection not documented | This item describes whether regional nodes were grossly involved at surgical resection. This information should only be recorded from the operative report. Do not report pathologically involved nodes. | |
1562 | gas hct val before transfusion | GAS2;17 | NUMERIC | This item describes the percent (%) of hematocrit before the first transfusion. Record results to the precision of one decimal point, record zeros in unused positions; for example 9.5% would be coded as 09.5. If the patient was transfused but hematocrit value is not documented, code 99.9. Allowable Codes: 00.0 - no transfusion 00.1 thru 99.0 - % Hct 99.9 - transfusion, % Hct not documented | ||
1563 | gas total operative blood repl | GAS2;18 | FREE TEXT | This item describes the total number of units of blood transfused during the surgery of primary site and within 24 hours postoperatively. If the patient was transfused but the number of units is not documented, code 99. Allowable Codes: 00 - no transfusion performed 01 thru 97 - units transfused 98 - transfusion, # of units not documented 99 - not recorded if transfusion done | ||
1564 | gas intra/peri-operative death | GAS2;19 | SET OF CODES | 1:Pt died intra-operatively 2:Pt died w/i 30 days while hospitalized 3:Pt died > 30 days while hospitalized 4:Pt died w/i 30 days/discharged 5:Pt alive and discharged 30 days following 9:Not documented | This item describes whether or not the patient died intra-operatively or peri-operatively. | |
1565 | gas anastomatic leak | GAS2;20 | SET OF CODES | 1:Caused re-operation 2:Did not cause re-operation 3:Did not occur 9:Not documented | This item describes whether an anastomotic leak required re-operation during the same hospitalization. | |
1565.1 | gas stump leak | GAS2;21 | SET OF CODES | 1:Caused re-operation 2:Did not cause re-operation 3:Did not occur 9:Not documented | This item describes whether a stump leak required re-operation during the same hospitalization. | |
1565.2 | gas bleeding | GAS2;22 | SET OF CODES | 1:Caused re-operation 2:Did not cause re-operation 3:Did not occur 9:Not documented | This item describes whether bleeding required re-operation during the same hospitalization. | |
1565.3 | gas wound infection | GAS2;23 | SET OF CODES | 1:Caused re-operation 2:Did not cause re-operation 3:Did not occur 9:Not documented | This item describes whether a wound infection required re-operation during the same hospitalization. | |
1565.4 | gas sepsis | GAS2;24 | SET OF CODES | 1:Caused re-operation 2:Did not cause re-operation 3:Did not occur 9:Not documented | This item describes whether sepsis required re-operation during the same hospitalization. | |
1565.5 | gas pancreatitis | GAS2;25 | SET OF CODES | 1:Caused re-operation 2:Did not cause re-operation 3:Did not occur 9:Not documented | This item describes whether pancreatitis required re-operation during the same hospitalization. | |
1565.6 | gas dead bowel | GAS2;26 | SET OF CODES | 1:Caused re-operation 2:Did not cause re-operation 3:Did not occur 9:Not documented | This item describes whether a dead bowel required re-operation during the same hospitalization. | |
1565.7 | gas other complications | GAS2;27 | SET OF CODES | 1:Caused re-operation 2:Did not cause re-operation 3:Did not occur 9:Not documented | This item describes whether other complications required re-operation during the same hospitalization. | |
1566 | gas date of surgical discharge | GAS2;28 | DATE-TIME | The date of surgical discharge is used to calculate a patient's length of stay in the hospital and is the month, day, and year that the patient was discharged from the hospital following surgery of primary site. Surgical treatment is defined as the surgical event which corresponds to the procedure recorded in the ROADS data item "Date of Surgery and includes surgical procedures of the primary site, scope of regional lymph nodes, or surgery to other regional sites, distant sites or distant lymph nodes. | ||
1567 | gas intra-operative radiation | GAS2;29 | FREE TEXT | This item describes the intra-operative dose of radiation was administered to the patient. The intra-operative dose may not be the dominant or most clinically significant dose delivered (data item #38), record the intra-operative dose separately from the dose recorded in data item #38. If intra-operative radiation therapy was not administered, code 00000. If intra-operative radiation was administered but the dose is not documented, code 88888. Allowable Codes: 00000 - no intraoperative radiation therapy 00001 thru 99998 - intraoperative dose administered 88888 - intraoperative radiation administered, dose not documented 99999 - not documented if administered | ||
1568 | gas concurrent chemotherapy | GAS2;30 | SET OF CODES | 1:Chemo concurrent with radiation 2:Chemo not concurrent with radiation 8:No chemo/unknown if chemo administered 9:Timing of chemo not documented | This item describes whether radiation therapy and chemotherapy were administered to the patient at the same time during the first course of treatment. | |
1569 | gas intraperitoneal cmx | GAS2;31 | SET OF CODES | 1:Catheter, mitoycin 2:Catheter, 5-fluorouracil 3:Catheter, other 4:Portal vein, mitomycin 5:Portal vein, 5-fluorouracil 6:Portal vein, other 8:Administered, method not documented 9:Not documented | This item describes the method of intraperitoneal chemotherapy administration and the chemotherapy agent used. | |
1570 | gas admin of interferon | GAS2;32 | SET OF CODES | 1:Administered 2:Not administered 9:Not documented | This item describes whether the patient was administered Interferon to treat the primary tumor. | |
1571 | gas co-morbid condition 1 | GAS2;33 | POINTER | 80 | This field records a pre-existing medical condition that was present at the time of diagnosis for this cancer or the patient was first seen at your facility following diagnosis. Report the ICD-CM code. Pre- existing conditions should be coded; do NOT code conditions which the patient acquired while being treated for this condition. Allowable Codes: 000.00 001.00 thru 994.90 (valid ICD-CM codes) If no co-morbid conditions were documented, then code 000.00 in this field and leave the remaining co-morbid fields blank. | |
1571.1 | gas co-morbid condition 2 | GAS2;34 | POINTER | 80 | This field records a pre-existing medical condition that was present at the time of diagnosis for this cancer or the patient was first seen at your facility following diagnosis. Report the ICD-CM code. Pre- existing conditions should be coded; do NOT code conditions which the patient acquired while being treated for this condition. Allowable Codes: 000.00 001.00 thru 994.90 (valid ICD-CM codes) If no co-morbid conditions were documented, then code 000.00 in this field and leave the remaining co-morbid fields blank. | |
1571.2 | gas co-morbid condition 3 | GAS2;35 | POINTER | 80 | This field records a pre-existing medical condition that was present at the time of diagnosis for this cancer or the patient was first seen at your facility following diagnosis. Report the ICD-CM code. Pre- existing conditions should be coded; do NOT code conditions which the patient acquired while being treated for this condition. Allowable Codes: 000.00 001.00 thru 994.90 (valid ICD-CM codes) If no co-morbid conditions were documented, then code 000.00 in this field and leave the remaining co-morbid fields blank. | |
1571.3 | gas co-morbid condition 4 | GAS2;36 | POINTER | 80 | This field records a pre-existing medical condition that was present at the time of diagnosis for this cancer or the patient was first seen at your facility following diagnosis. Report the ICD-CM code. Pre- existing conditions should be coded; do NOT code conditions which the patient acquired while being treated for this condition. Allowable Codes: 000.00 001.00 thru 994.90 (valid ICD-CM codes) If no co-morbid conditions were documented, then code 000.00 in this field and leave the remaining co-morbid fields blank. | |
1571.4 | gas co-morbid condition 5 | GAS2;37 | POINTER | 80 | This field records a pre-existing medical condition that was present at the time of diagnosis for this cancer or the patient was first seen at your facility following diagnosis. Report the ICD-CM code. Pre- existing conditions should be coded; do NOT code conditions which the patient acquired while being treated for this condition. Allowable Codes: 000.00 001.00 thru 994.90 (valid ICD-CM codes) If no co-morbid conditions were documented, then code 000.00 in this field and leave the remaining co-morbid fields blank. | |
1571.5 | gas co-morbid condition 6 | GAS2;38 | POINTER | 80 | This field records a pre-existing medical condition that was present at the time of diagnosis for this cancer or the patient was first seen at your facility following diagnosis. Report the ICD-CM code. Pre- existing conditions should be coded; do NOT code conditions which the patient acquired while being treated for this condition. Allowable Codes: 000.00 001.00 thru 994.90 (valid ICD-CM codes) If no co-morbid conditions were documented, then code 000.00 in this field and leave the remaining co-morbid fields blank. | |
1572 | gas duration of tobacco use | GAS2;39 | FREE TEXT | This item describes the number of known years the patient used some form of tobacco, even if the patient is not presently using tobacco. If the patient has never used tobacco, code 00. If the patient's tobacco use cannot be determined, or if the duration of use is not known, code 99. Allowable Codes: 00 - never used tobacco 01 thru 98 - one or more years of tobacco use 99 - duration of tobacco use not documented | ||
1573 | gas personal hist oth malig | GAS2;40 | POINTER | 164 | This item describes the patient's prior history of other invasive malignancies. If the patient has a history of other malignancies report the ICD-O-3 site code for the most recently diagnosed disease. If the patient has no personal history of other cancer, code C88.8. If the patient's personal history of other invasive malignancies is not documented, code C99.9. Allowable Codes: C00.0 thru C80.9 - valid ICD-0-3 site (topography) codes C88.8 - no personal history of other cancer C99.9 - personal history of other cancer not documented | |
1574 | gas weight loss | GAS2;41 | SET OF CODES | 1:Present 2:Not present 9:Not documented | This item describes the presence of weight loss specific to gastric cancer that was recorded in the medical chart. | |
1575 | gas boost dose (cgy) | GAS2;42 | FREE TEXT | This item describes the boost dose of radiation administered to the central tumor field of the patient. If radiation was administered but boost dose is unknown, code 99999. Allowable Codes: 00000 - no radiation boost dose administered 00001 thru 99998 - boost dose administered (cGy) 99999- boost dose administered, dose not documented | ||
1576 | gas chemotherapeutic agent #1 | GAS2;43 | POINTER | 164.18 | This item records the first chemotherapeutic agent administered to the patient as part of the first course of therapy. If chemotherapy was administered but the type(s) of agent(s) are unknown, code 999999. Allowable Codes: Valid NSC (National Service Center) number for chemotherapeutic agents listed in the Self Instructional Manual for Tumor Registrars, Book 8, Surveillance, Epidemiology and End Results Program, National Cancer Institute. | |
1576.1 | gas chemotherapeutic agent #2 | GAS2;44 | POINTER | 164.18 | This item records the second chemotherapeutic agent administered to the patient as part of the first course of therapy. If chemotherapy was administered but the type(s) of agent(s) are unknown, code 999999. Allowable Codes: Valid NSC (National Service Center) number for chemotherapeutic agents listed in the Self Instructional Manual for Tumor Registrars, Book 8, Surveillance, Epidemiology and End Results Program, National Cancer Institute. | |
1576.2 | gas chemotherapeutic agent #3 | GAS2;45 | POINTER | 164.18 | This item records the third chemotherapeutic agent administered to the patient as part of the first course of therapy. If chemotherapy was administered but the type(s) of agent(s) are unknown, code 999999. Allowable Codes: Valid NSC (National Service Center) number for chemotherapeutic agents listed in the Self Instructional Manual for Tumor Registrars, Book 8, Surveillance, Epidemiology and End Results Program, National Cancer Institute. | |
1577 | gas chemotherapeutic toxicity | GAS2;46 | SET OF CODES | 1:Chemo discontinued due to toxicity 2:No chemo toxicity 9:Not documented | This item describes whether the administration of chemotherapy was discontinued as a result of toxicity. | |
1578 | gas chemotherapy/surg sequence | GAS2;47 | SET OF CODES | 1:Chemo administered, no surgery 2:Chemo administered before surgery 3:Chemo administered after surgery 4:Chemo administered before and after surgery 9:Chemo and surgery administered, seq unk | This data item describes the sequence in which chemotherapy and surgery of the primary site were administered. | |
1579 | gas complication #1 | GAS2;48 | POINTER | 80 | This item describes the first medical complication acquired by the patient during or resulting from the first course of therapy. Record valid ICD-CM codes. Allowable Codes: 001.00 - 999.90 (valid ICD-CM codes) E930.0 - E949.7 (valid ICD-CM adverse effect codes) | |
1579.1 | gas complication #2 | GAS2;49 | POINTER | 80 | This item describes the first medical complication acquired by the patient during or resulting from the first course of therapy. Record valid ICD-CM codes. Allowable Codes: 001.00 - 999.90 (valid ICD-CM codes) E930.0 - E949.7 (valid ICD-CM adverse effect codes) | |
1579.2 | gas complication #3 | GAS2;50 | POINTER | 80 | This item describes the first medical complication acquired by the patient during or resulting from the first course of therapy. Record valid ICD-CM codes. Allowable Codes: 001.00 - 999.90 (valid ICD-CM codes) E930.0 - E949.7 (valid ICD-CM adverse effect codes) | |
1579.3 | gas complication #4 | GAS2;51 | POINTER | 80 | This item describes the first medical complication acquired by the patient during or resulting from the first course of therapy. Record valid ICD-CM codes. Allowable Codes: 001.00 - 999.90 (valid ICD-CM codes) E930.0 - E949.7 (valid ICD-CM adverse effect codes) | |
1579.4 | gas complication #5 | GAS2;52 | POINTER | 80 | This item describes the first medical complication acquired by the patient during or resulting from the first course of therapy. Record valid ICD-CM codes. Allowable Codes: 001.00 - 999.90 (valid ICD-CM codes) E930.0 - E949.7 (valid ICD-CM adverse effect codes) | |
2000 | division(+) | DIV;1 | POINTER | 4 | DIVISION is the division to which this primary belongs. | |
3000 | class of case conversion flag | CONV;1 | SET OF CODES | 1:Converted | Indicates that the CLASS OF CASE value has been converted to NAACCR v12. | |
3001 | state at dx conversion flag | CONV;2 | SET OF CODES | 1:Converted | Indicates that the STATE AT DX value has been converted to NAACCR v12. |