Files > ONCOLOGY PRIMARY

name
ONCOLOGY PRIMARY
number
165.5
location
^ONCO(165.5,
description
Tumor-related data for Oncology patients is stored in this file. (Demographic and follow-up data is in the Oncology Patient File). File is populated in the field by using the abstracting options.
applicationGroups
ONCO
Fields
#NameLocationTypeDetailsIndexDescription
.01site/gp(+)0;1POINTER164.2B Enter the SITE/GP for this primary.
.0101primary site/gpCOMPUTEDA COMPUTED FIELD RECORDING THE PRIMARY SITE/GROUP FOR ONCOLOGY.
.015selected sitesCOMPUTEDThis COMPUTED field displays selected SITE/GP (165.5,.01) values.
.017systemsCOMPUTEDCOMPUTED FIELD RECORDING THE MAJOR BODY SYSTEMS, SUCH AS LYMPHATIC, GASTROINTESTINAL, GENITOURINARY, ETC.
.02patient name(+)0;2POINTER160CEnter Oncology Patient Name.
.022icdo-site(+)0;22POINTER164.08Listing of primary sites in accordance with ICDO-2 (1992).
.023primary site code prefixCOMPUTEDIdentifies the three-digit code prefix for the primary site.
.025patient idCOMPUTEDCOMPUTED FIELD FOR RECORDING THE PATIENT IDENTIFICATION NUMBER.
.03reporting facility(+)0;3POINTER160.19 REPORTING FACILITY identifies the facility reporting the case.
.04class of case0;4POINTER165.3 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.
.041class no.COMPUTEDComputed CLASS OF CASE code. It is derived from CLASS OF CASE (165.5,.04).
.042class category(+)0;20SET OF CODES0:NONANALYTIC
1:ANALYTIC
AGRecord the category of case, either Analytic or Nonanalytic.
.043analytic primary req followupCOMPUTED
.05accession number(+)0;5FREE TEXTAA 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.
.06sequence number0;6FREE TEXTIndicates 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.
.061acc/seq numberCOMPUTED ACC/SEQ NUMBER concatinates the ACCESSION NUMBER and SEQUENCE NUMBER values.
.07accession year(+)0;7FREE TEXTAY 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.
.08medical record numberCOMPUTEDRecords the medical record number usually assigned by the reporting facility's health information management (HIM) department. For further information see FORDS page 36.
.09social security numberCOMPUTEDRecords the patient's Social Security Number. For further information see FORDS page 37.
.091statusCOMPUTEDSTATUS IS EITHER ALIVE OR DEAD.
.093place of birth (state)COMPUTEDTHE STATE WHERE THE PATIENT WAS BORN.
.1sexCOMPUTED Code the patient's SEX.
.115stateCOMPUTEDTHE PATIENT'S STATE OF RESIDENCY AT THE TIME OF DIAGNOSIS.
.1157st-countyCOMPUTEDSTATE AND COUNTY COMPUTED FIELD.
.117countyCOMPUTEDTHE PATIENT'S RESIDENCE COUNTY AT THE TIME OF DIAGNOSIS.
.12raceCOMPUTED"Race" is analyzed with the data item Spanish/Hispanic origin. Both items must be recorded.
.13race-sexCOMPUTEDCOMPUTED FIELD COMBINING BOTH RACE AND SEX, USED IN CROSS TABULATIONS.
.14sex-raceCOMPUTEDThis is the combined race and sex code, used for cross tabulations.
1date of inpatient admission0;8DATE-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.
1.1date of inpatient discharge0;9DATE-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.
1.2type of reporting source0;10POINTER168 Code the source documents used to abstract the cancer being reported. This item is used by central registries.
2primary surgeon0;11POINTER165 Records the physician who performed the most definitive surgical procedure. For further information see FORDS page 77.
2.1following physician0;12POINTER165 Records the person currently responsible for the patient's medical care. For further information see FORDS page 76.
2.2managing physician0;13POINTER165 Identifies the physician who is responsible for the overall management of the patient during diagnosis and/or treatment of this cancer.
2.3physician #30;14POINTER165 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.
2.4physician #40;15POINTER165 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.
3date dx0;16DATE-TIMEADX Records the date of initial diagnosis by a physician for the tumor being reported. For further information see FORDS pages 89-90.
3.1diagnosis episode careCOMPUTEDRECORDS THE CARE THE PATIENT RECEIVED DURING THE CURRENT EPISODE OF TREATMENT AT DIAGNOSIS.
3.5year dxCOMPUTEDDATE DX (165.5,3) year
4age at dxCOMPUTEDRecords the age of the patient at his or her last birthday before diagnosis. For further information see FORDS page 58.
4.1dx age-gpCOMPUTEDDIAGNOSIS AGE GROUP WILL GROUP PATIENTS BY AGE.
5dx facility0;17POINTER160.19Record the name of the facility where diagnosis was first made.
6facility referred from0;18POINTER160.19Identifies the facility that referred the patient to the reporting facility. For further information see FORDS page 85.
7facility referred to0;19POINTER160.19Identifies the facility to which the patient was referred for further care after discharge from the reporting facility. For further information see FORDS page 86.
8patient address at dx1;1FREE TEXT Identifies the patient's address (number and street) at the time of diagnosis. For further information see FORDS page 42.
8.1city/town at dx1;12FREE 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.
8.2patient address at dx - supp1;13FREE 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.
9postal code at dx1;2FREE 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.
10county at dx1;3FREE 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).
11marital status at dx1;5SET OF CODES1: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.
12palliative care3.1;26SET OF CODES0: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.
13palliative care @fac3.1;27SET OF CODES0: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.
14readmission w/i 30 days/surg3.1;28SET OF CODES0: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.
15systemic/surgery sequence3.1;39SET OF CODES0: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.
16state at dx1;4POINTER5 Identifies the patient's state of residence at the time of diagnosis. For further information see FORDS page 45.
17suspense date1;10DATE-TIME This is the date on which the primary was added to the suspense file.
18primary payer at dx1;11POINTER160.3 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.
19staged by (clinical stage)3;32SET OF CODES0: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.
20primary site(+)2;1POINTER164EIdentifies the primary site. For further information see FORDS page 91.
20.1primary site codeCOMPUTEDIdentifies the primary site ICD-O topography code.
21casefinding source1;6POINTER166 This field codes the earliest source of identifying information.
21.5infra/supra(+)2;7SET OF CODESI: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.
21.51iris/ciliary body2;22SET OF CODESI:Iris
C:Ciliary body
This field is used to determine the appropriate TNM encoding for malignant melanomas of the uvea.
21.52upper/lower24;4SET OF CODESU: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.
22histology (icd-o-2)2;3POINTER164.1AH Record the histology using the ICD-O-2 codes.
22.1icdo histology-codeCOMPUTED 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.
22.2papillary/follicular2;4SET OF CODESP: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.
22.3histology (icd-o-3)2.2;3POINTER169.3 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.
23reconstruction/restoration3;33FREE 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.
24grade/differentiation2;5POINTER164.43 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.
24.1grade path system2.3;1SET OF CODES2: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.
24.2grade path value2.3;2SET OF CODES1: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.
25tnm form assigned7;7FREE TEXT Records the date on which the TNM form was assigned to the Managing Physician.
25.1tumor marker 124;2POINTER164.15 Record prognostic indicators.
25.2tumor marker 224;3POINTER164.15 Record prognostic indicators.
25.3tumor marker 324;7POINTER164.15 Record LDH prognostic indicators for testicular cancer.
26diagnostic confirmation2;6SET OF CODES1: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.
27histo-morphologyCOMPUTEDThis field displays the HISTOLOGY ICD-O-3 (165.5,22.3) value concatinated with the GRADE/DIFFERENTIATION (165.5,24) value.
28laterality2;8SET OF CODES0: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.
29tumor size2;9NUMERIC 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.
29.1tumor size/ext eval (cs)CS;1FREE TEXTRecords how the codes for the two items TUMOR SIZE (CS) and EXTENSION (CS) were determined, based on the diagnostic methods employed.
29.2tumor size (cs)CS1;10FREE TEXTFOR 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.
29.9extension list usedCOMPUTEDThis 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.
30extension2;10NUMERICSeer Extent of Disease coding schema.
30.1pathologic extension2.2;2NUMERIC Code the farthest documented pathologic extension of tumor from the prostate, either by contiguous extension or distant metastasis.
30.2extension (cs)CS;11FREE TEXTIdentifies contiguous growth (extension) of the primary tumor within the organ of origin or its direct extension into neighboring organs.
30.5peripheral blood involvement24;5SET OF CODESB0: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.
30.9lymph node list usedCOMPUTEDThis 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.
31lymph nodes2;11NUMERICRecord SEER lymph node involvement.
31.1lymph nodes (cs)CS;12FREE TEXTIdentifies the regional lymph nodes involved with cancer at the time of diagnosis.
32regional lymph nodes positive2;12NUMERIC 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.
32.1lymph nodes eval (cs)CS;2FREE TEXTRecords how the code for the item LYMPH NODES (CS) was determined, based on the diagnostic methods employed.
33regional lymph nodes examined2;13NUMERIC 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 examinedCOMPUTEDRECORD THE NUMBER OF LYMPH NODES EXAMINED BY PATHOLOGIST.
34site of distant metastasis #12;14SET OF CODES0: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.
34.1site of distant metastasis #22;15SET OF CODES0: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.
34.2site of distant metastasis #32;16SET OF CODES0: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.
34.3mets at dx (cs)CS;3FREE TEXTIdentifies the distant site(s) of metastatic involvement at time of diagnosis.
34.31mets at dx-boneCS1;20SET OF CODES0:None
1:Yes
8:NA
9:Unknown
Identifies the presence of distant metastatic involvement of bone at time of diagnosis.
34.32mets at dx-brainCS1;21SET OF CODES0:None
1:Yes
8:NA
9:Unknown
Identifies the presence of distant metastatic involvement of the brain at time of diagnosis.
34.33mets at dx-liverCS1;22SET OF CODES0:None
1:Yes
8:NA
9:Unknown
Identifies the presence of distant metastatic involvement of the liver at time of diagnosis.
34.34mets at dx-lungCS1;23SET OF CODES0:None
1:Yes
8:NA
9:Unknown
Identifies the presence of distant metastatic involvement of the lung at time of diagnosis.
34.4mets eval (cs)CS;4FREE TEXTRecords how the code for the item METS AT DX (CS) was determined based on the diagnostic methods employed.
35seer summary stage 20002;17SET OF CODES0: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.
35.1seer summary stage abbreviatedCOMPUTEDThis item abbreviates the SEER SUMMARY STAGE 2000 (165.5,35) output values for condensed display.
36ajcc staging basis2;18SET OF CODESC: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.
37tnm clinicalCOMPUTEDThis is the combined Clinical T, N, and M codes, formatted for display.
37.1clinical t2;25FREE TEXTEvaluates the primary tumor (T) and reflects the tumor size and/or extension of the tumor known prior to the start of any therapy.
37.2clinical n2;26FREE TEXTIdentifies 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.
37.3clinical m2;27FREE TEXTIdentifies the presence or absence of distant metastasis (M) of the tumor known prior to the start of any therapy.
37.9automatic staging overridden24;1BOOLEAN1:Yes
0:No
This field is set to 'Yes' by the abstracting option if the operator overrides automatic staging.
38stage group clinical2;20FREE 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.
38.1gp-i ajcc summary stageCOMPUTEDRECORD THE AJCC STAGE.
38.2gp-ii ajcc summary stageCOMPUTEDRECORD THE AJCC STAGE.
38.3gp-iii ajcc summary stageCOMPUTEDRECORD THE AJCC STAGE.
38.4gp-iv ajcc summary stageCOMPUTEDRECORD THE AJCC STAGE.
38.5stage grouping-ajcc2;28SET OF CODES0:0
I:I
II:II
III:III
IV:IV
U:Unk/Uns
NA:NA
ASGThis 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.
39other staging system2;21POINTER164.3 OTHER STAGING SYSTEM allows institutions the opportunity to collect additional staging classifications, for example, CDS, RAI, DS or FAB.
40stage group bestCOMPUTEDThis field displays the "best" stage group as determined by the clinical/pathological hierarchy rules.
40.1tnm bestCOMPUTEDThis field displays the "best" TNM string as determined by the clinical/pathological hierarchy rules.
40.2staged byCOMPUTED 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
41associated with hiv2;23SET OF CODES1:Yes
2:No
999:Unknown
Record the presence/absence of HIV.
42treatment abbreviatedCOMPUTED 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
43treatmentCOMPUTEDThe treatment given to a patient, either curative or palliative in nature.
44tnm form completed7;14FREE TEXT Records the date on which the TNM form was completed by the Managing Physician.
44.1ssf1CS;5FREE TEXTIdentifies additional information needed to generate stage, or prognostic factors that have an effect on stage or survival.
44.101ssf10CS2;4FREE TEXTIdentifies additional information needed to generate stage, or prognostic factors that have an effect on stage or survival.
44.11ssf11CS2;5FREE TEXTIdentifies additional information needed to generate stage, or prognostic factors that have an effect on stage or survival.
44.12ssf12CS2;6FREE TEXTIdentifies additional information needed to generate stage, or prognostic factors that have an effect on stage or survival.
44.13ssf13CS2;7FREE TEXTIdentifies additional information needed to generate stage, or prognostic factors that have an effect on stage or survival.
44.14ssf14CS2;8FREE TEXTIdentifies additional information needed to generate stage, or prognostic factors that have an effect on stage or survival.
44.15ssf15CS2;9FREE TEXTIdentifies additional information needed to generate stage, or prognostic factors that have an effect on stage or survival.
44.16ssf16CS2;10FREE TEXTIdentifies additional information needed to generate stage, or prognostic factors that have an effect on stage or survival.
44.17ssf17CS2;11FREE TEXTIdentifies additional information needed to generate stage, or prognostic factors that have an effect on stage or survival.
44.18ssf18CS2;12FREE TEXTIdentifies additional information needed to generate stage, or prognostic factors that have an effect on stage or survival.
44.19ssf19CS2;13FREE TEXTIdentifies additional information needed to generate stage, or prognostic factors that have an effect on stage or survival.
44.2ssf2CS;6FREE TEXTIdentifies additional information needed to generate stage, or prognostic factors that have an effect on stage or survival.
44.201ssf20CS2;14FREE TEXTIdentifies additional information needed to generate stage, or prognostic factors that have an effect on stage or survival.
44.21ssf21CS2;15FREE TEXTIdentifies additional information needed to generate stage, or prognostic factors that have an effect on stage or survival.
44.22ssf22CS2;16FREE TEXTIdentifies additional information needed to generate stage, or prognostic factors that have an effect on stage or survival.
44.23ssf23CS2;17FREE TEXTIdentifies additional information needed to generate stage, or prognostic factors that have an effect on stage or survival.
44.24ssf24CS2;18FREE TEXTIdentifies additional information needed to generate stage, or prognostic factors that have an effect on stage or survival.
44.25ssf25CS2;19FREE TEXTIdentifies additional information needed to generate stage, or prognostic factors that have an effect on stage or survival.
44.3ssf3CS;7FREE TEXTIdentifies additional information needed to generate stage, or prognostic factors that have an effect on stage or survival.
44.4ssf4CS;8FREE TEXTIdentifies additional information needed to generate stage, or prognostic factors that have an effect on stage or survival.
44.5ssf5CS;9FREE TEXTIdentifies additional information needed to generate stage, or prognostic factors that have an effect on stage or survival.
44.6ssf6CS;10FREE TEXTIdentifies additional information needed to generate stage, or prognostic factors that have an effect on stage or survival.
44.7ssf7CS2;1FREE TEXTIdentifies additional information needed to generate stage, or prognostic factors that have an effect on stage or survival.
44.8ssf8CS2;2FREE TEXTIdentifies additional information needed to generate stage, or prognostic factors that have an effect on stage or survival.
44.9ssf9CS2;3FREE TEXTIdentifies additional information needed to generate stage, or prognostic factors that have an effect on stage or survival.
45performance status2;24SET OF CODES100: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.
46cap protocol review7;19SET OF CODES0: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.
47cap text7;20FREE TEXT Records the reason for CAP (College of American Pathologists) Protocol non-compliance.
48other primary sitesCOMPUTEDSITES OTHER THAN THE COMMON CANCER SITES ARE LISTED.
49first course of treatment dateCOMPUTEDRecords 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.
49.1first treatment dt-date dxCOMPUTEDA computed field derives from FIRST COURSE OF TREATMENT DATE minus DATE DX.
50most definitive surg date3;1DATE-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.
50.1surgery hospital3;2POINTER160.19Record the name of the institution providing treatment.
50.2surgery of primary @fac (r)3.1;7FREE TEXT Records the surgical procedure(s) performed to the primary site at this facilty. For further information see ROADS page 190.
50.3most definitive surg @fac date3.1;8DATE-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.
51date radiation started3;4DATE-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.
51.1radiation hospital3;5POINTER160.19Record the name of the institution administering the therapy.
51.2radiation3;6SET OF CODES0: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.
51.3radiation/surgery sequence3;7SET OF CODES0: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.
51.4radiation @facility3.1;12SET OF CODES0: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.
51.5radiation @facility date3.1;13DATE-TIME Record the date that the first course of radiation therapy performed AT THIS FACILITY was started.
52radiation therapy to cns date3;8DATE-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.
52.1radiation therapy to cns hosp3;9POINTER160.19Record the name of the institution administering the therapy. This field is used only for LUNGS and LEUKEMIAS.
52.2radiation therapy to cns3;10SET OF CODES0: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.
53chemotherapy date3;11DATE-TIME Record the date first course of CHEMOTHERAPY was started.
53.1chemotherapy hospital3;12POINTER160.19 Record the name of the institution where CHEMOTHERAPY was given.
53.2chemotherapy3;13SET OF CODES00: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.
53.3chemotherapy @fac3.1;14SET OF CODES00: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.
53.4chemotherapy @fac date3.1;15DATE-TIME Record the date chemotherapy was administered as first course of treatment at this facility.
54hormone therapy date3;14DATE-TIME Record the date HORMONE THERAPY was started.
54.1hormone therapy hospital3;15POINTER160.19Record the name of the institution that administered the hormone therapy.
54.2hormone therapy3;16SET OF CODES00: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.
54.3hormone therapy @fac3.1;16SET OF CODES00: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.
54.4hormone therapy @fac date3.1;17DATE-TIME Records the date hormone therapy was administered as first course of treatment at this facility.
55immunotherapy date3;17DATE-TIME The date immunotherapy was started.
55.1immunotherapy hospital3;18POINTER160.19The ACOS number of the institution where immunotherapy was performed.
55.2immunotherapy3;19SET OF CODES00: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.
55.3immunotherapy @fac3.1;18SET OF CODES00: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.
55.4immunotherapy @fac date3.1;19DATE-TIME Records the date immunotherapy was administered as first course of treatment at this facility.
56number of txs to this volume3;20NUMERIC Records the total number of treatment sessions (fractions) administered during the first course of treatment. For further information see FORDS page 163.
57other treatment start date3;23DATE-TIME Records the date on which other treatment began at any facility. For further information see FORDS pages 184-185.
57.1other treatment hospital3;24POINTER160.19Record the name of the institution where other treatment was administered.
57.2other treatment3;25SET OF CODES0: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.
57.3other treatment @fac3.1;20SET OF CODES0: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.
57.4other treatment @facility date3.1;21DATE-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).
58reason no surgery of primary3;26SET OF CODES0: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.
58.1surgical dx/staging proc3;27FREE TEXT Identifies the surgical procedure(s) performed in an effort to diagnose and/or stage disease. For further information see FORDS pages 109-110.
58.2surgery of primary (r)3;38NUMERIC Records the surgical procedure(s) performed to the primary site. For further information see ROADS pages 187-189.
58.3surgical dx/staging proc date3;31DATE-TIME Records the date on which the surgical diagnostic and/or staging procedure was performed. For further information see FORDS pages 107-108.
58.4surg dx/staging proc @fac3.1;5FREE 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.
58.5surg dx/staging proc @fac date3.1;6DATE-TIME Records the date on which the surgical diagnostic and/or staging procedure was performed at this facility.
58.6surgery of primary (f)3.1;29FREE TEXT Records the surgical procedure(s) performed to the primary site. For further information see FORDS page 135.
58.7surgery of primary @fac (f)3.1;30FREE TEXT Records the surgical procedure(s) performed to the primary at this facility. For further information see FORDS page 136.
59surgical margins3;28SET OF CODES0: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.
60subsequent course of treatment4;0MULTIPLE165.51Enter subsequent therapy (therapy provided after completion of the first course of therapy).
61pid#COMPUTEDRECORD THE PATIENT'S IDENTIFICATION NUMBER.
62qa selected7;4BOOLEANY:YES
Field is stuffed if randomly selected for QA review.
63qa review7;8BOOLEANN:NO
Y:YES
Field only used if Abstract was randomly selected for QA Review.
64qa date7;9DATE-TIME Date of QA Review if done on this Abstract.
64.1qa reviewer7;18POINTER200 Select the name of the QA reviewer.
64.2qa findings28;0WORD-PROCESSING Enter the QA FINDINGS of the QA review. Please limit your findings to 3 lines of text.
65physician's stage7;10FREE TEXTRecords information regarding the physician's stage.
66physician staging7;11POINTER165 This is the name of the physician performing the staging.
67acos #COMPUTED ACOS # is the equivalent of the INSTITUTION ID NUMBER as recorded in the ONCOLOGY SITE PARAMETERS file.
68state hospital #COMPUTED This is the state identification number.
69multiple tumors2;31NUMERICThis 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.
69.1family history2;32BOOLEAN0: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.
69.2diffuse retinal involvement3;30BOOLEAN0: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.
69.3multimodality therapy (clin)7;16BOOLEANY: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.
69.4multimodality therapy7;17BOOLEANY: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.
70date of first recurrence5;1DATE-TIME Records the date of the first recurrence. For further information see FORDS pages 195-196.
71type of first recurrence5;2POINTER160.12 Identifies the type of first recurrence after a period of documented disease-free intermission or remission. For further information see FORDS pages 197-198.
71.1distant site 15;3SET OF CODES0: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.
71.2distant site 25;4SET OF CODES0: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.
71.3distant site 35;5SET OF CODES0: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.
71.4other type of first recurrence5;6POINTER160.12 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.
72subsequent recurrences23;0MULTIPLE165.572This multiple records information on subsequent recurrences of the tumor.
73tumor statusTS;0MULTIPLE165.573This 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.
74surgical approach (r)3;34NUMERIC 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.
75reason for no radiation3;35SET OF CODES0: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.
76reason for no chemotherapy3;36SET OF CODES0: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.
77reason for no hormone therapy3;37SET OF CODES0: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.
78converted24;6BOOLEANY: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.
79screening date0;24DATE-TIME Record the most recent date on which the patient participated in a screening program related to this primary cancer.
80radiation treatment6;0MULTIPLE165.52Record the type of radiation therapy.
81completed by7;12FREE TEXTRecord the initials of the person who completed the PCE.
82reviewed by cancer committee7;13FREE TEXTAs 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.
83afip/jpc submission0;21SET OF CODES0: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).
84pce indicator7;15SET OF CODESBLA: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.
85pathologic t2.1;1FREE TEXTEvaluates the primary tumor (T) and reflects the tumor size and/or extension of the tumor known following the completion of surgical therapy.
86pathologic n2.1;2FREE TEXTIdentifies 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.
87pathologic m2.1;3FREE TEXTIdentifies the presence or absence of distant metastasis (M) of the tumor known following the completion of surgical therapy.
88stage group pathologic2.1;4FREE 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.
89staged by (pathologic stage)2.1;5SET OF CODES0: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.
89.1tnm pathologicCOMPUTEDThis is the combined Pathologic T, N, and M codes, formatted for display.
90date case completed7;1DATE-TIME The date that: (1) the abstractor decided that the case report was complete, and (2) the case passed all edits that were applied.
91abstract status7;2SET OF CODES0:Incomplete
1:Minimal data
2:Partial
3:Complete
A:Accession only
ASEnter the status of the abstract data entry.
92abstracted by(+)7;3POINTER200Records the initials or assigned code of the individual abstracting the case. For further information see FORDS page 207.
93other t2.1;6FREE TEXT"Other T" evaluates the primary tumor and identifies tumor size and/or extension.
94reporting date7;5DATE-TIME Records automatically the default date as reporting date.
95last tumor status7;6POINTER164.42ACSThis field records the code that summarizes the cancer status.
95.1v status/last tumor statusCOMPUTEDThis COMPUTED field concatenates STATUS (160,15) and LAST TUMOR STATUS (165.5,95).
96psa datePRO2;50FREE TEXT Records the date on which the Prostate Specific Antigen (PSA) test was performed.
97abstract incompleteCOMPUTEDRECORD THE ABSTRACT STATUS AS INCOMPLETE WHEN DATA IS MISSING.
98other n2.1;7FREE TEXT"Other N" classifies the regional lymph nodes and describes the absence or presence and the extent of node metastases.
99other m2.1;8FREE TEXT"Other M" records the presence or absence of distant metastases. Choose the lower (less advanced) M category when there is any uncertainty.
100text-primary site title8;1FREE TEXT Text area for description of primary site in natural language.
101text-histology title8;2FREE TEXT Text area for description of histologic type, behavior, and grade in natural language.
102dre +/-24;10SET OF CODES0: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.
103text-dx proc-op9;0WORD-PROCESSINGFree text field.
104text-dx proc-pe10;0WORD-PROCESSING Text area for information from history and physical examinations.
105text-dx proc-x-ray/scan11;0WORD-PROCESSINGFree text field.
106text-dx proc-scopes12;0WORD-PROCESSINGFree text field.
107text-dx proc-path13;0WORD-PROCESSINGFree text field.
108rx text-surgery14;0WORD-PROCESSINGFree text field.
109rx text-radiation15;0WORD-PROCESSINGFree text field.
110rx text-radiation other16;0WORD-PROCESSINGFree text field.
111rx text-chemo17;0WORD-PROCESSINGFree text field.
112rx text-hormone18;0WORD-PROCESSINGFree text field.
113text-remarks19;0WORD-PROCESSINGFree text field.
114rx text-brm20;0WORD-PROCESSINGFree text field.
115rx text-other21;0WORD-PROCESSINGFree text field.
116text-dx proc-lab tests22;0WORD-PROCESSING Text area for information from laboratory examinations other than cytology and histopatholgy.
117other stage group2.1;9FREE TEXTRecord 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
118staged by (other stage)2.1;10SET OF CODES0: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.
119screening result0;25SET OF CODES0: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.
120presentation at cancer conf0;26SET OF CODES0: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.
121date of cancer conf0;27DATE-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.
122referral to support services0;28SET OF CODES0: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
123inpatient/outpatient status0;23SET OF CODES1: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.
124date of no treatment2.1;11DATE-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.
125radiation treatment volume3;21POINTER164.7 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.
126location of radiation tx3;22SET OF CODES0: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.
127intent of radiation3;29SET OF CODES0: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.
128radiation completion status3;39POINTER164.8 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.
129radiation auxiliary volume3.1;1POINTER164.7
130radiation auxiliary date3.1;2DATE-TIME
131radiation auxiliary text15.1;0WORD-PROCESSING
132radiation local control status3.1;3SET OF CODES0: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.
133year put on protocol3.1;4FREE TEXT Record the year in which the patient was entered into a protocol.
134clinical risk factors2.1;12SET OF CODES0: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.
135pathologic risk factors2.1;13SET OF CODES0: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.
136serum tumor markers24;8SET OF CODESSX: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.
137date of 1st positive biopsy2.2;1DATE-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.
138scope of ln surgery (r)3;40NUMERIC Record the scope of regional lymph node surgery. For further information see ROADS page 192.
138.1scope of ln surgery @fac (r)3.1;9FREE TEXT Record the scope of regional lymph node surgery done AT THIS FACILITY. For further information see ROADS page 190.
138.2scope of ln surgery date3.1;22DATE-TIME Record the date that SCOPE OF LN SURGERY was performed.
138.3scope of ln surgery @fac date3.1;23DATE-TIME Record the date that SCOPE OF LN SURGERY @FAC was performed.
138.4scope of ln surgery (f)3.1;31SET OF CODES0: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.
138.5scope of ln surgery @fac (f)3.1;32SET OF CODES0: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.
139surg proc/other site (r)3;41NUMERIC 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.
139.1surg proc/other site @fac (r)3.1;10FREE 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.
139.2surg proc/other site date3.1;24DATE-TIME Records the date of surgical removal of distant lymph nodes or other tissue(s)/organ(s) beyond the primary site.
139.3surg proc/other site @fac date3.1;25DATE-TIME Record the date that SURG PROC/OTHER SITE @FAC was performed.
139.4surg proc/other site (f)3.1;33SET OF CODES0: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.
139.5surg proc/other site @fac (f)3.1;34SET OF CODES0: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.
139.6mets site resected3.1;41SET OF CODES1: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.
139.7mets site resected date3.2;1DATE-TIMEThis is the date the Metastatic Site was resected. The date must be after or equal to the DATE DX (#3) field.
140number of ln removed (r)3;42NUMERIC 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.
140.1number of ln removed @fac (r)3.1;11FREE 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.
141biopsy procedure2.1;14NUMERIC Records the biopsy procedure if the primary site is breast or prostate.
142guidance2.1;15NUMERICRecords the guidance if the primary site is breast or prostate.
143palpability of primary2.1;16SET OF CODES0:Not palpable
1:Palpable
9:Not stated/death cert only
Records the palpability of primary if the primary site is breast.
144first detected by2.1;17SET OF CODES0: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.
145approach for biopsy of primary2.1;18SET OF CODES0: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.
146biopsy of other than primary2.1;19SET OF CODES0: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.
147census tract0;29FREE 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
148other cancer0;30SET OF CODES0:No
1:Yes
9:Unknown
Records if the patient has other reportable malignancies.
148.1cancer #10;31POINTER164.2 Records the 1st OTHER CANCER associated with this patient. If not applicable for this patient, choose NOT APPLICABLE.
148.2cancer #20;32POINTER164.2 Records the 2nd OTHER CANCER associated with this patient. If not applicable for this patient, choose NOT APPLICABLE.
148.3cancer #30;33POINTER164.2 Records the 3rd OTHER CANCER associated with this patient. If not applicable for this patient, choose NOT APPLICABLE.
148.4cancer #40;34POINTER164.2 Records the 4th OTHER CANCER associated with this patient. If not applicable for this patient, choose NOT APPLICABLE.
149lymph-vascular invasion (l)2;19SET OF CODES0: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.
150follow-up historyCOMPUTEDRECORDS ALL FOLLOW SUCCESSFULLY COMPLETED.
151venous invasion (v)2;29SET OF CODESX: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.
152date systemic therapy startedCOMPUTEDRecords 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.
153hema trans/endocrine proc3.1;36POINTER167 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.
153.1hema trans/endocrine proc date3.1;35DATE-TIME Records the date on which hematologic transplant and endocrine procedures were performed.
154pain assessment3.1;37SET OF CODES0: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.
155date of first contact0;35DATE-TIMEAFC 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.
156dre date24;11FREE TEXT Records the date on which the DRE (Digital Rectal Examination) was performed.
157elapsed days to completionCOMPUTEDComputes the time interval in days between DATE OF FIRST CONTACT (165.5,155) and DATE CASE COMPLETED (165.5,90).
157.1elapsed months to completionCOMPUTEDComputes the time interval in months between DATE OF FIRST CONTACT (165.5,155) and DATE CASE COMPLETED (165.5,90).
159ambiguous terminology dx24;12SET OF CODES0: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.)
160derived ajcc-6 tCS1;1FREE TEXTThis is the AJCC 6th edition "T" component that is derived from CS coded fields, using the CS algorithm, effective with 2004 diagnosis.
160.7derived ajcc-7 tCS1;13FREE TEXTThis is the AJCC 7th edition "T" component that is derived from CS coded fields, using the CS algorithm, effective with 2010 diagnosis.
161derived ajcc-6 t descriptorCS1;2SET OF CODESc: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.
161.7derived ajcc-7 t descriptorCS1;14SET OF CODESc: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.
162derived ajcc-6 nCS1;3FREE TEXTThis is the AJCC 6th edition "N" component that is derived from CS coded fields, using the CS algorithm, effective with 2004 diagnosis.
162.7derived ajcc-7 nCS1;15FREE TEXTThis is the AJCC 7th edition "N" component that is derived from CS coded fields, using the CS algoritm, effective with 2010 diagnosis.
163derived ajcc-6 n descriptorCS1;4SET OF CODESc: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.
163.7derived ajcc-7 n descriptorCS1;16SET OF CODESc: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.
164derived ajcc-6 mCS1;5FREE TEXTThis is the AJCC 6th edition "N" component that is derived from CS coded fields, using the CS algorithm, effective with 2004 diagnosis.
164.7derived ajcc-7 mCS1;17FREE TEXTThis is the AJCC 7th edition "N" component that is derived from CS coded fields, using the CS algorithm, effective with 2010 diagnosis.
165derived ajcc-6 m descriptorCS1;6SET OF CODESc: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.
165.7derived ajcc-7 m descriptorCS1;18SET OF CODESc: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.
166derived ajcc-6 stage groupCS1;7FREE TEXTThis 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.
166.7derived ajcc-7 stage groupCS1;19FREE TEXTThis 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.
167derived ss1977CS1;8SET OF CODES0: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.
168derived ss2000CS1;9SET OF CODES0: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.
169cs version derivedCS1;11FREE TEXTThis item indicates the Collaborative Staging (CS) version used most recently to derive the CS output fields.
169.1cs version input originalCS1;12FREE TEXTThis item indicates the number of the version initially used to code Collaborative Staging (CS) fields.
170date first surgical procedure3.1;38DATE-TIME Records the earliest date on which any first course surgical procedure was performed. For further information see FORDS pages 131-132.
171date of first symptoms2.2;4FREE 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.
172date start of workup ordered2.2;5FREE TEXT Records the date the physician placed consult to specialty clinic OR ordered diagnostic procedures or tests.
173date workup started2.2;6FREE TEXT Records the date when the patient was seen in the specialty clinic OR had diagnostic procedures or tests performed.
174blood in sputum per pt2.2;7SET OF CODES0:No
1:Yes
9:Unknown/Not documented
Record the presence of blood in the patient's sputum as reported by the patient.
174.1date of blood in sputum per pt2.2;18FREE TEXT Records the date of the presence of blood in the patient's sputum (as reported by the patient).
175chest x-ray2.2;8SET OF CODES0: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'.
175.1date of chest x-ray2.2;19FREE TEXT Records the date of the diagnostic test CHEST X-RAY.
176ct scan2.2;9SET OF CODES0: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'.
176.1date of ct scan2.2;20FREE TEXT Records the date of the diagnostic test CT SCAN.
177bronchoscopy2.2;10SET OF CODES0: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'.
177.1date of bronchoscopy2.2;21FREE TEXT Records the date of the diagnostic test BRONCHOSCOPY.
178mediastinoscopy2.2;11SET OF CODES0: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'.
178.1date of mediastinoscopy2.2;22FREE TEXT Records the date of the diagnostic test MEDIASTINOSCOPY.
179pet scan2.2;12SET OF CODES0: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'.
179.1date of pet scan2.2;23FREE TEXT Records the date of the diagnostic test PET SCAN.
180change in bowel habits per pt2.2;13SET OF CODES0:No
1:Yes
9:Unknown/not documented
Record all changes in bowel habits as reported by the patient.
180.1date of change in bowel habits2.2;24FREE TEXT Records the date of a change in bowel habits (as reported by the patient).
181fecal occult blood test (fobt)2.2;14SET OF CODES0: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'.
181.1date of fobt2.2;25FREE TEXT Records the date of the diagnostic test FECAL OCCULT BLOOD TEST (FOBT).
182barium enema2.2;15SET OF CODES0: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'.
182.1date of barium enema2.2;27FREE TEXT Records the results of the diagnostic test BARIUM ENEMA.
183sigmoidoscopy2.2;16SET OF CODES0: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'.
183.1date of sigmoidoscopy2.2;28FREE TEXT Records the date of the diagnostic test SIGMOIDOSCOPY.
184ct of abdomen/pelvis2.2;17SET OF CODES0: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'.
184.1date of ct of abdomen/pelvis2.2;31FREE TEXTRecords the date of the diagnostic test CT OF ABDOMEN/PELVIS.
185colonoscopy2.2;29SET OF CODES0: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'.
185.1date of colonoscopy2.2;30FREE TEXT Records the date of the diagnostic test COLONOSCOPY. If this test was not done, record a '0'.
186dyspnea2.2;32SET OF CODES0:No
1:Yes
9:Unknown/not documented
Record whether the patient experienced dyspnea.
186.1date of dyspnea2.2;33FREE TEXT Records the date on which the patient was affected by dyspnea.
187increased cough2.2;34SET OF CODES0:No
1:Yes
9:Unknown/not documented
Record whether the patient experienced increased coughing.
187.1date of increased cough2.2;35FREE TEXT Records the date on which the patient experienced increased coughing.
188fever2.2;36SET OF CODES0:No
1:Yes
9:Unknown/not documented
Record whether the patient experienced a fever.
188.1date of fever2.2;37FREE TEXT Records the date on which the patient experienced a fever.
189night sweats2.2;38SET OF CODES0:No
1:Yes
9:Unknown/not documented
Record whether the patient experienced night sweats.
189.1date of night sweats2.2;39FREE TEXT Records the date on which the patient experienced night sweats.
190weight loss per pt2.2;40SET OF CODES0:No
1:Yes
9:Unknown/not documented
Record weight loss as reported by the patient.
191ulcerative colitis (uc)2.2;41SET OF CODES0:No
1:Yes
9:Unknown/not documented
Record whether the patient was affected by ulcerative colitis (UC).
192sporadic polyps2.2;42SET OF CODES0: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.
193date of conclusive dx24;13FREE 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.
194mult tum rpt as one prim24;14POINTER169 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
195date of multiple tumors24;15FREE 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.
196multiplicity counter24;16FREE 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
197edits checksumEDITS;1FREE TEXTProvides 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).
197.1checksum versionEDITS;2FREE TEXTIdentifies the NAACCR version that was used to calculate EDITS CHECKSUM (165.5,197).
198date case last changed7;21DATE-TIMEAAEDate the case was last changed or updated.
199case last changed by7;22POINTER200Records the name of the individual who last changed the case.
200date last contactCOMPUTEDDate last contact with the patient - computed from file #160.
201survival daysCOMPUTEDCOMPUTED SURVIVAL DATA IN DAYS.
202survival monthsCOMPUTEDCOMPUTED SURVIVAL DATA IN MONTHS.
203survival (years)COMPUTEDCOMPUTED SURVIVAL DATA IN YEARS.
204weeks of follow-upCOMPUTEDFOLLOW UP IN WEEKS.
205over-ride age/site/morphOVRD;1SET OF CODES1: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.
206over-ride seqno/dxconfOVRD;2SET OF CODES1:Reviewed
This is one of the thirteen flags used to override certain interfield and interrecord edits defined by SEER.
207over-ride site/lat/seqnoOVRD;3SET OF CODES1:Reviewed
This is one of the thirteen flags used to override certain interfield and interrecord edits defined by SEER.
208over-ride surg/dxconfOVRD;4SET OF CODES1:Reviewed
This is one of the thirteen flags used to override certain interfield and interrecord edits defined by SEER.
209over-ride site/typeOVRD;5SET OF CODES1:Reviewed
This is one of the thirteen flags used to override certain interfield and interrecord edits defined by SEER.
210over-ride histologyOVRD;6SET OF CODES1: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.
211over-ride report sourceOVRD;7SET OF CODES1:Reviewed
This is one of the thirteen flags used to override certain interfield and interrecord edits defined by SEER.
212over-ride ill-define siteOVRD;8SET OF CODES1:Reviewed
This is one of the thirteen flags used to override certain interfield and interrecord edits defined by SEER.
213over-ride leuk,lymphomaOVRD;9SET OF CODES1:Reviewed
This is one of the thirteen flags used to override certain interfield and interrecord edits defined by SEER.
214over-ride site/behaviorOVRD;10SET OF CODES1:Reviewed
This is one of the thirteen flags used to override certain interfield and interrecord edits defined by SEER.
215over-ride site/eod/dx dtOVRD;11SET OF CODES1:Reviewed
This is one of the thirteen flags used to override certain interfield and interrecord edits defined by SEER.
216over-ride site/lat/eodOVRD;12SET OF CODES1:Reviewed
This is one of the thirteen flags used to override certain interfield and interrecord edits defined by SEER.
217over-ride site/lat/morphOVRD;13SET OF CODES1:Reviewed
This is one of the thirteen flags used to override certain interfield and interrecord edits defined by SEER.
218over-ride ss/nodesposOVRD;14SET OF CODES1:Reviewed
This is one of the flags used to override certain interfield and interrecord edits defined by NAACCR.
219over-ride ss/tnm-nOVRD;15SET OF CODES1:Reviewed
This is one of the flags used to override certain interfield and interrecord edits defined by NAACCR.
220over-ride ss/tnm-mOVRD;16SET OF CODES1:Reviewed
This is one of the flags used to override certain interfield and interrecord edits defined by NAACCR.
221over-ride ss/dismet1OVRD;17SET OF CODES1:Reviewed
This is one of the flags used to override certain interfield and interrecord edits defined by NAACCR.
222over-ride acsn/class/seqOVRD;18SET OF CODES1:Reviewed
This is one of the flags used to override certain interfield and interrecord edits defined by NAACCR.
223over-ride hospseq/dxconfOVRD;19SET OF CODES1:Reviewed
This is one of the flags used to override certain interfield and interrecord edits defined by NAACCR.
224over-ride coc-site/typeOVRD;20SET OF CODES1:Reviewed
This is one of the flags used to override certain interfield and interrecord edits defined by NAACCR.
225over-ride hospseq/siteOVRD;21SET OF CODES1:Reviewed
This is one of the flags used to override certain interfield and interrecord edits defined by NAACCR.
226over-ride site/tnm-stggrpOVRD;22SET OF CODES1:Reviewed
This is one of the flags used to override certain interfield and interrecord edits defined by NAACCR.
227performance status at dx1;7SET OF CODES0: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
228treatment guideline #124;17SET OF CODES0: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)
229treatment guideline #224;18SET OF CODES0: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)
230treatment guideline #324;19SET OF CODES0: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)
231treatment guideline location24;20FREE TEXT Identifies where the treatment guidelines used in treatment planning are documented in the medical record.
232treatment guideline doc date24;21DATE-TIME Records the date when treatment guidelines were documented in the medical record.
233inpatient status2.3;3SET OF CODES0: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.
234approach2.3;4SET OF CODES0: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.
235treatment status2.3;5SET OF CODES0: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.
236date case initiated2.3;6DATE-TIME Date the electronic abstract is initiated in the reporting facility's cancer registry database.
237fee basis2.3;7SET OF CODES0: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.
237.1fee basis location2.3;11FREE TEXTIn 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.
238outside slides reviewed2.3;8SET OF CODES0: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.
239mitotic rate2.3;9SET OF CODESL:Low <5/50 HPF
H:High >5/50 HPF
U:Unknown
Identifies the rate or speed of cell division.
240cs schema discriminatorCS3;1FREE 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.
241tnm clin descriptor24;22SET OF CODES1: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.
242tnm path descriptor24;23SET OF CODES1: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.
244initiated by2.3;10POINTER200The 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.
245neoadjuvant therapy3.1;40SET OF CODES0: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.
247cs review requiredCS3;2SET OF CODES0: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).
248note title25;1FREE TEXT Records the name of the note which documents cancer staging in the medical record.
249note date25;2DATE-TIME Records the date of the note which documents cancer staging in the medical record.
250gleason score (pathologic)25;3FREE 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.
251nslc stage 1-3 path ln stagingPM;1SET OF CODES0:No
1:Yes
8:NA (Stage 0 and 4)
9:Unknown
Documents if mediastinal lymph node staging was performed at the reporting facility.
252reason for no ln biopsyPM;2SET OF CODES1: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.
253date of surgery consultPM;3DATE-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.
254intent of surgeryPM;4SET OF CODES0: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.
255date oncology consult orderedPM;5DATE-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.
256date oncology consult donePM;6DATE-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.
257chemotherapy recommendedPM;7SET OF CODES0:No
1:Yes
9:Unknown/not documented
Records if there is documentation that chemotherapy was recommended.
258intent of chemotherapyPM;8SET OF CODES0: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.
259type of chemotherapyPM;9SET OF CODES0: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.
260reason radiation stoppedPM;10SET OF CODES0: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).
261doc for no plat-based chemoPM;11SET OF CODES0: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.
262multimodality radiation typePM;12SET OF CODES0: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.
263reason hormone therapy stoppedPM;28SET OF CODES0: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).
264date hospice consult initiatedPM;14DATE-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.
265date hospice consult completedPM;15DATE-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.
266date hospice care initiatedPM;16DATE-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.
267egfr mutation testingPM;17SET OF CODES0: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.
268egfr mutation 1PM;18SET OF CODES1: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.
269egfr mutation 2PM;19SET OF CODES1: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.
270preop obstructing lesionPM;13SET OF CODES0:No
1:Yes
8:NA (in situ lesion/non-invasive polyp)
9:Unknown/not documented
Records if a preoperative obstructing lesion was found.
271oncology referralPM;20SET OF CODES1: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.
272date chemotherapy recommendedPM;21DATE-TIME Records the date on which chemotherapy was recommended.
273anti-egfr moab therapyPM;22SET OF CODES0: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
274perirectal ln involvementPM;23SET OF CODES0:No
1:Yes
8:NA (no surgery)
9:Unknown/not documented
Records the detection of perirectal lymph node involvement.
275risk of recurrencePM;24SET OF CODES1:Low
2:Medium
3:High
8:NA
9:Unknown/not documented
Records the risk of recurrence after treatment as documented on the Progress Notes.
276androgen deprivation therapyPM;25SET OF CODES0: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
277date adt initiatedPM;26DATE-TIME Records the date on which ADT (Androgen Deprivation Therapy) was initiated.
278non-adt chemotherapyPM;27SET OF CODES0: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.
279clinical trials discussion25;4SET OF CODES0: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.
280clin tnm documentation pre-tx 25;5SET OF CODES1:Yes
2:No
8:NA
9:Unknown
Records whether this case had a clinical stage documented prior to treatment.
280.1cl tnm documentation location25;7FREE TEXT Records the location of pre-treatment clinical stage documentation.
280.2cl tnm documentation date25;8DATE-TIME Records the date of pre-treatment clinical stage documentation.
281tx guidelines discussion25;6SET OF CODES0: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.
282vaccr extract indicatorEDITS;3SET OF CODESN:New
U:Update
Records whether this case has been newly 'Completed' or is an update to an already 'Completed' case.
283cs field needing reviewCS3;3FREE TEXTRecords the CS (Collaborative Staging) item(s) which need manual review/recoding by a registrar after the CS conversion.
300patient referred for treatmentBLA1;1SET OF CODES1: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.
301length of stayBLA1;2NUMERICRecord 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).
302history of cervix ca (pt)BLA1;3SET OF CODES0: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.
303history of colon ca (pt)BLA1;4SET OF CODES0: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.
304history of bladder ca (pt)BLA1;5SET OF CODES0: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.
305history of head & neck ca (pt)BLA1;6SET OF CODES0: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.
306history of kidney ca (pt)BLA1;7SET OF CODES0: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.
307history of prostate ca (pt)BLA1;8SET OF CODES0: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.
308history of other ca (pt)BLA1;9SET OF CODES0: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.
309history of bladder ca (fam)BLA1;10SET OF CODES0: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).
310history of colon ca (fam)BLA1;11SET OF CODES0: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).
311history of lung ca (fam)BLA1;12SET OF CODES0: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).
312history of prostate ca (fam)BLA1;13SET OF CODES0: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).
313history of other ca (fam)BLA1;14SET OF CODES0: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).
314smoking historyBLA1;15NUMERICRecord 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).
315duration of smoking historyBLA1;16NUMERICRecord 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).
316duration of smoke free historyBLA1;17NUMERICIf 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).
317gross hematuriaBLA1;18SET OF CODES0:No
1:Yes
9:Unknown
Record whether the patient was presented with a clinical finding of gross hematuria. If not present, code 0 (no).
318microscopic hematuriaBLA1;19SET OF CODES0:No
1:Yes
9:Unknown
Record whether the patient was presented with a clinical finding of microscopic hematuria. If not present, code 0 (no).
319urinary frequencyBLA1;20SET OF CODES0:No
1:Yes
9:Unknown
Record whether the patient was presented with a clinical finding of urinary frequency. If not present, code 0 (no).
320bladder irritabilityBLA1;21SET OF CODES0:No
1:Yes
9:Unknown
Record whether the patient was presented with a clinical finding of bladder irritability. If not present, code 0 (no).
321dysuriaBLA1;22SET OF CODES0:No
1:Yes
9:Unknown
Record whether the patient was presented with a clinical finding of dysuria. If not present, code 0 (no).
322other clinical detectionsBLA1;23SET OF CODES0:No
1:Yes
9:Unknown
Record whether the patient was presented with other clinical findings. If not present, code 0 (no).
323onset of symptomsBLA1;24DATE-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.
324duration of gross hematuriaBLA1;25NUMERICRecord 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.
325duration of dysuriaBLA1;26NUMERICRecord 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.
326bimanaul exam of bladderBLA1;27SET OF CODES0: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).
327cystoscopy with biopsyBLA1;28SET OF CODES0: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).
328cystoscopy without biopsyBLA1;29SET OF CODES0: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).
329flow cytometryBLA1;30SET OF CODES0: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).
330intravenous pyelogram (bla)BLA1;31SET OF CODES0: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).
331urine cytologyBLA1;32SET OF CODES0: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).
332urinalysisBLA1;33SET OF CODES0: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).
333other diagnostic proceduresBLA1;34SET OF CODES0: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).
334specialty making diagnosisBLA1;35SET OF CODES0: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.
335abdominal ultrasoundBLA1;36SET OF CODES0:Not done
1:Done
9:Unknown
Record whether an abdominal ultrasound procedure was performed to stage this case.
336bone imagingBLA1;37SET OF CODES0:Not done
1:Done
9:Unknown
Record whether a bone imaging procedure was performed to stage this case.
337chest x-ray (bladder)BLA1;38SET OF CODES0:Not done
1:Done
9:Unknown
Record whether a chest x-ray was performed to stage this case.
338ct chest/lungBLA1;39SET OF CODES0:Not done
1:Done
9:Unknown
Record whether a CT chest/lung procedure was performed to stage this case.
339ct abdomen/pelvisBLA1;40SET OF CODES0:Not done
1:Done
9:Unknown
Record whether a CT abdomen/pelvis procedure was performed to stage this case.
340ct otherBLA1;41SET OF CODES0:Not done
1:Done
9:Unknown
Record whether other CT procedures were performed to stage this case.
341mri pelvis/abdomenBLA1;42SET OF CODES0:Not done
1:Done
9:Unknown
Record whether an MRI pelvis/abdomen procedure was performed to stage this case.
342mri otherBLA1;43SET OF CODES0:Not done
1:Done
9:Unknown
Record whether other MRI procedures were performed to stage this case.
343other staging proceduresBLA1;44SET OF CODES0:Not done
1:Done
9:Unknown
Record whether other staging procedures were performed to stage this case.
344presence of hydronephrosisBLA1;45SET OF CODES0: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).
345presence of multiple tumorsBLA1;46SET OF CODES0:No
1:Yes
9:Unknown
Record whether the presence of multiple primary bladder tumors was detected either clinically or pathologically.
346protocol eligibility statusBLA2;1SET OF CODES0: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.
347managing physician (primary)BLA2;2POINTER166.12Record 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).
348managing physician (secondary)BLA2;3POINTER166.12Record 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).
349tumor resection during turbBLA2;4SET OF CODES1: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).
350type of urinary diversionBLA2;5SET OF CODES1: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).
351pelvic lymph node dissect (bl)BLA2;6SET OF CODES0: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).
352bleeding requiring transfusionBLA2;7SET OF CODES0:No
1:Yes
9:Unknown
Record whether this surgical complication resulted from operation. If this complication did not occur, code 0 (none).
353deep venous thrombosisBLA2;8SET OF CODES0:No
1:Yes
9:Unknown
Record whether this surgical complication resulted from operation. If this complication did not occur, code 0 (none).
354myocardial infarction (mi)BLA2;9SET OF CODES0:No
1:Yes
9:Unknown
This field describes a patient's prior medical condition.
355pelvic abscessBLA2;10SET OF CODES0:No
1:Yes
9:Unknown
Record whether this surgical complication resulted from operation. If this complication did not occur, code 0 (none).
356pneumonia req antibioticsBLA2;11SET OF CODES0:No
1:Yes
9:Unknown
Record whether this surgical complication resulted from operation. If this complication did not occur, code 0 (none).
357post-operative deathBLA2;12SET OF CODES0:No
1:Yes
9:Unknown
Record whether this surgical complication resulted from operation. If this complication did not occur, code 0 (none).
358pulmonary embolism/thrombosisBLA2;13SET OF CODES0:No
1:Yes
9:Unknown
Record whether this surgical complication resulted from operation. If this complication did not occur, code 0 (none).
359reoperationBLA2;14SET OF CODES0:No
1:Yes
9:Unknown
Record whether this surgical complication resulted from operation. If this complication did not occur, code 0 (none).
360other surgical complicationsBLA2;15SET OF CODES0: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.
361date radiation endedBLA2;16DATE-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.
362total rad (cgy/rad) doseBLA2;17NUMERICRecord 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.
363regional treatment modalityBLA2;18POINTER166.13 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.
363.1boost treatment modality24;9POINTER166.13 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.
364urinary incontinenceBLA2;19SET OF CODES0: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).
365hematuriaBLA2;20SET OF CODES0: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).
366radiation bowel injuryBLA2;21SET OF CODES0: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).
367date chemotherapy endedBLA2;22DATE-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.
368route chemotherapy adminBLA2;23SET OF CODES0: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).
369adriamycinBLA2;24SET OF CODES0:No
1:Yes
9:Unknown
Record whether the chemotherapeutic agent, Adriamycin, was given. If no chemotherapy was given, code as 0 (no).
370carboplatinumBLA2;25SET OF CODES0:No
1:Yes
9:Unknown
Record whether the chemotherapeutic agent, Carboplatinum, was given. If no chemotherapy was given, code as 0 (no).
371cisplatinBLA2;26SET OF CODES0:No
1:Yes
8:NA, chemotherapy not administered
9:Unknown
This field describes one type of chemotherapeutic agent administered to the patient.
372cyclophosphamideBLA2;27SET OF CODES0:No
1:Yes
8:NA, chemotherapy not administered
9:Unknown
This field describes one type of chemotherapeutic agent administered to the patient.
3735-fluorouracilBLA2;28SET OF CODES0:No
1:Yes
9:Unknown
Record whether the chemotherapeutic agent, 5-fluorouracil, was given. If no chemotherapy was given, code as 0 (no).
374gallium nitrateBLA2;29SET OF CODES0:No
1:Yes
9:Unknown
Record whether the chemotherapeutic agent, Gallium Nitrate, was given. If no chemotherapy was given, code as 0 (no).
375ifosfamideBLA2;30SET OF CODES0:No
1:Yes
9:Unknown
Record whether the chemotherapeutic agent, Ifosfamide, was given. If no chemotherapy was given, code as 0 (no).
376methotrexateBLA2;31SET OF CODES0:No
1:Yes
8:NA, chemotherapy not administered
9:Unknown
This field describes one type of chemotherapeutic agent administered to the patient.
377taxolBLA2;32SET OF CODES0:No
1:Yes
9:Unknown
Record whether the chemotherapeutic agent, Taxol, was given. If no chemotherapy was given, code as 0 (no).
378thiotepaBLA2;33SET OF CODES0:No
1:Yes
9:Unknown
Record whether the chemotherapeutic agent, Thiotepa, was given. If no chemotherapy was given, code as 0 (no).
379vinblastineBLA2;34SET OF CODES0:No
1:Yes
9:Unknown
Record whether the chemotherapeutic agent, Vinblastine, was given. If no chemotherapy was given, code as 0 (no).
380other chemotherapeutic agentsBLA2;35SET OF CODES0:No
1:Yes
8:NA, no chemotherapy administered
9:Unknown
This field describes one type of chemotherapeutic agent administered to the patient.
381indication for admin of agentsBLA2;36SET OF CODES0: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).
382reason chemotherapy stoppedBLA2;41SET OF CODES0: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).
383bcgBLA2;37SET OF CODES0:No
1:Yes
9:Unknown
Record whether BCG immunotherapy was administered for the first course of therapy.
384interferonBLA2;38SET OF CODES0:No
1:Yes
8:NA, chemotherapy not administered
9:Unknown
This field describes one type of chemotherapeutic agent administered to the patient.
385interleukin-2BLA2;39SET OF CODES0:No
1:Yes
8:NA
9:Unknown
Record whether Interleukin-2 immunotherapy was administered for the first course of therapy.
386other type of immunotherapyBLA2;40SET OF CODES0:No
1:Yes
8:NA
9:Unknown
Record whether other immunotherapy was administered for the first course of therapy.
387type of 1st recurrence/bladderBLA2;42SET OF CODES0: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.
400history of thyroid ca (fam)THY1;1SET OF CODES0: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).
401history of lymphoma (pt)THY1;2SET OF CODES0:No
1:Yes
9:Unknown
Record whether the patient has a history of Lymphoma, including Hodgkin's Disease.
402history of childhood maligTHY1;3SET OF CODES0:No
1:Yes
9:Unknown
Record whether the patient has a history of childhood malignancies, other than lymphoma.
403prior exposure to radiationTHY1;4SET OF CODES0: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.
404history of goiter (pt)THY1;5SET OF CODES0:No
1:Yes
9:Unknown
Record history of enlarged thyroid gland for a period of greater than 5 years prior to diagnosis.
405history of goiter (fam)THY1;6SET OF CODES0:No
1:Yes
9:Unknown
Record any familial history of thyroid enlargement (goiter), Graves Disease or thyroiditis.
406history of graves disease (pt)THY1;7SET OF CODES0:No
1:Yes
9:Unknown
Record whether the patient has a history of Graves Disease, i.e., autoimmune hyperthyroidism with or withour eye symptoms.
407history of thyroiditis (pt)THY1;8SET OF CODES0: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.
408dysphagiaTHY1;9SET OF CODES0:No
1:Yes
9:Unknown
Record whether the sign/symptom 'DYSPHAGIA' was present at the time of diagnosis.
409hoarseness or voice changeTHY1;10SET OF CODES0:No
1:Yes
9:Unknown
Record whether the sign/symptom 'HOARSENESS OR VOICE CHANGE' was present at the time of diagnosis.
410neck nodal massTHY1;11SET OF CODES0:No
1:Yes
9:Unknown
Record whether the sign/symptom 'NECK NODAL MASS' was present at the time of diagnosis.
411pain, boneTHY1;12SET OF CODES0:No
1:Yes
9:Unknown
Record whether the sign/symptom 'PAIN, BONE' was present at the time of diagnosis.
412pain, neckTHY1;13SET OF CODES0:No
1:Yes
9:Unknown
Record whether the sign/symptom 'PAIN, NECK' was present at the time of diagnosis.
413pathologic fractureTHY1;14SET OF CODES0:No
1:Yes
9:Unknown
Record whether the sign/symptom 'PATHOLOGIC FRACTURE' was present at the time of diagnosis.
414stridor/difficulty breathingTHY1;15SET OF CODES0:No
1:Yes
9:Unknown
Record whether the sign/symptom 'STRIDOR OR DIFFICULTY BREATHING' was present at the time of diagnosis.
415thyroid massTHY1;16SET OF CODES0:No
1:Yes
9:Unknown
Record whether the sign/symptom 'THYROID MASS' was present at the time of diagnosis.
416weight lossTHY1;17SET OF CODES0:No
1:Yes
9:Unknown
Record whether the sign/symptom 'WEIGHT LOSS' was present at the time of diagnosis.
417other signs/symptomsTHY1;18SET OF CODES0:No
1:Yes
9:Unknown
Record whether any OTHER signs/symptoms were present at the time of diagnosis.
418bone scan (thyroid)THY1;19SET OF CODES0: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'.
419chest x-ray (thyroid)THY1;20SET OF CODES0: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'.
420ct scan of neck (thyroid)THY1;21SET OF CODES0: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'.
421ct scan of chestTHY1;22SET OF CODES0: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'.
422incisional biopsy of thyroidTHY1;23SET OF CODES0: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'.
423laryngoscopyTHY1;24SET OF CODES0: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'.
424neck x-ray (ap & lateral)THY1;25SET OF CODES0: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'.
425needle aspiration of neck nodeTHY1;26SET OF CODES0: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'.
426needle aspiration of thyroidTHY1;27SET OF CODES0: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'.
427mri of neckTHY1;28SET OF CODES0: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'.
428thyroid scanTHY1;29SET OF CODES0: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'.
429ultrasound of thyroidTHY1;30SET OF CODES0: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'.
430other diagnostic/surgical testTHY1;31SET OF CODES0: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'.
431blood vessel invasionTHY1;32SET OF CODES0: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.
432extra-thyroidal extensionTHY1;33SET OF CODES0: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.
433multifocalTHY1;34SET OF CODES0:No
1:Microscopic
2:Gross
3:Multifocal, NOS
9:Unknown
Record whether the tumor was multifocal. Pathologic confirmation is required.
434location of positive nodesTHY1;35SET OF CODES0: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.
435date most definitive surg disTHY1;36DATE-TIMESource 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.
436airway problemTHY1;37SET OF CODES0: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).
437bleeding/hematomaTHY1;38SET OF CODES0: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).
438hypocalcemiaTHY1;39SET OF CODES0: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).
439recurrent nerve injuryTHY1;40SET OF CODES0: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).
440wound infectionTHY1;41SET OF CODES0: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).
441postoperative deathTHY1;42SET OF CODES0: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).
442regional dose: cgyTHY1;43NUMERIC 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.
443boost dose: cgyTHY1;44NUMERIC 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.
444initial dose of radioiodineTHY1;45NUMERICRecord 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.
445second dose of radioiodineTHY1;46NUMERICRecord 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.
446adjuvant chemotherapy (thy)THY1;47SET OF CODES0: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.
500history of soft tis sarc (fam)STS1;1SET OF CODES0: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).
501history of any cancer (pt)STS1;2SET OF CODES0: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).
502angiogram of primarySTS1;3SET OF CODES0: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'.
503bone marrow aspirate or biopsySTS1;4SET OF CODES0: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'.
504bone scan (soft tis sarcoma)STS1;5SET OF CODES0: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'.
505chest x-ray (sts/nhl)STS1;6SET OF CODES0: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'.
506ct scan of chest (sts)STS1;7SET OF CODES0: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'.
507ct scan of primarySTS1;8SET OF CODES0: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'.
508liver function studies (sts)STS1;9SET OF CODES0: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'.
509lymphangiogramSTS1;10SET OF CODES0: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'.
510mri of primarySTS1;11SET OF CODES0: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'.
511mri of otherSTS1;12SET OF CODES0: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'.
512skeletal x-raySTS1;13SET OF CODES0: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'.
513sonogramSTS1;14SET OF CODES0: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'.
514cytogeneticsSTS1;15SET OF CODES0: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'.
515electron microscopySTS1;16SET OF CODES0: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'.
516immunohistochemistrySTS1;17SET OF CODES0: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'.
517in situ hybridizationSTS1;18SET OF CODES0: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'.
518outside confirmation requestedSTS1;19SET OF CODES0:No
1:Yes
8:Not applicable
9:Unknown
Record whether an outside confirmation of a biopsy was requested.
519subsiteSTS1;20POINTER166.3Record the appropriate subsite code.
520type of additional coding sysSTS1;21SET OF CODES1:1 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'.
521value of additional coding sysSTS1;22SET OF CODES1:1
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'.
522pathologic size of tumorSTS1;23NUMERICRecord 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.
523depth of tumorSTS1;24SET OF CODES1: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.
524consultations (med oncologist)STS1;25SET OF CODES0:No
1:Yes
9:Unknown
Enter whether there was a consultation with a medical oncologist.
525consultations (rad oncologist)STS1;26SET OF CODES0:No
1:Yes
9:Unknown
Enter whether there was a consultation with a radiation oncologist.
526treating surgeonSTS2;1SET OF CODES1: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.
527asa classSTS2;2SET OF CODES1: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.
528fine needle aspirationSTS1;27NUMERICEnter 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".
529core needle biopsySTS1;28NUMERICEnter 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".
530incisional biopsy (sts pce)STS1;29NUMERICEnter 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".
531excisional biopsySTS1;30NUMERICEnter 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".
532external beam radiationSTS2;3SET OF CODES0:No
1:Yes
9:Unknown
Record whether any external beam radiation therapy was performed.
533external beam rad fractionsSTS2;4NUMERICRecord the number of fractions for external beam radiation.
534external beam radiation energySTS2;5NUMERICRecord the units (MV) of radiation energy if external beam radiation was performed .
535intraoperative radiationSTS2;6SET OF CODES0:No
1:Yes
9:Unknown
Record whether intraoperative radiation was performed.
536intraoperative radiation doseSTS2;7NUMERICRecord 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.
537intraoperative radiation enerSTS2;8NUMERICRecord the units (MV) of intraoperative radiation energy if this was performed.
538brachytherapySTS2;9SET OF CODES0:No
1:Yes
9:Unknown
Record whether brachytherapy was performed.
539brachytherapy daysSTS2;10NUMERICRecord the number of days brachytherapy was given.
540brachytherapy radiation doseSTS2;11NUMERICRecord 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.
541date brachytherapy startedSTS2;12DATE-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.
542date brachytherapy endedSTS2;13DATE-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.
543cytoxanSTS2;14SET OF CODES0:No
1:Yes
9:Unknown
Record whether the chemotherapeutic agent, Cytoxan, was given. If no chemotherapy was given, code as 0.
544dticSTS2;15SET OF CODES0:No
1:Yes
9:Unknown
Record whether the chemotherapeutic agent, DTIC, was administered. If no chemotherapy was given, code as 0.
545doxorubicin (sts)STS2;16SET OF CODES0:No
1:Yes
9:Unknown
Record whether the chemotherapeutic agent, Doxorubicin, was administered. If no chemotherapy was given, code as 0.
546etoposideSTS2;17SET OF CODES0:No
1:Yes
9:Unknown
Record whether the chemotherapeutic agent, Etoposide, was administered. If no chemotherapy was given, code as 0.
547cisplatin method of deliverySTS2;18SET OF CODES1: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.
548cytoxan method of deliverySTS2;19SET OF CODES1: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.
549dtic method of deliverySTS2;20SET OF CODES1: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.
550doxorubicin method of deliverySTS2;21SET OF CODES1: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.
551etoposide method of deliverySTS2;22SET OF CODES1: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.
552ifosfamide method of deliverySTS2;23SET OF CODES1: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.
553cisplatin locationSTS2;24SET OF CODES1: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.
554cytoxan locationSTS2;25SET OF CODES1: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.
555dtic locationSTS2;26SET OF CODES1: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.
556doxorubicin locationSTS2;27SET OF CODES1: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.
557etoposide locationSTS2;28SET OF CODES1: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.
558ifosfamide locationSTS2;29SET OF CODES1: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.
559colony stimulating factorsSTS2;30SET OF CODES0:No
1:Yes
8:NA
9:Unknown
Record whether colony stimulating factors were used.
560protocol participationSTS2;31SET OF CODES00: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).
561other protocolSTS2;32SET OF CODES0: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.
562referred to rehab servicesSTS2;33SET OF CODES0:No
1:Yes
9:Unknown
Record whether the patient was referred to rehabilitation services.
563physical therapy/rehabiltationSTS2;34SET OF CODES0:No
1:Yes
9:Unknown
Record whether the patient was referred to physical therapy or rehabilitation service.
564transferred to rehabilitationSTS2;35SET OF CODES0:No
1:Yes
9:Unknown
Record whether the patient was transferred to a rehabilitation facility after being released from the hospital.
565number of hospitalizationsSTS2;36NUMERICRecord 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.
566total length of staysSTS2;37NUMERICAdd 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.
567date ext beam rad startedSTS2;38DATE-TIME Record the date external beam radiation therapy was started. Code 0's if not given. Code 9's if unknown.
600clinical dx with bone lesionPRO1;1SET OF CODES1: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.
601clinical dx by rectal examPRO1;2SET OF CODES1: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.
602cytologyPRO1;3SET OF CODES1:Yes
2:No
9:Unknown
Record whether the Method of Diagnosis: CYTOLOGY was used to diagnose this case of prostate cancer.
603incidental finding in turpPRO1;4SET OF CODES1: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.
604needle aspiration biopsyPRO1;5SET OF CODES1:Yes
2:No
9:Unknown
Record whether the Method of Diagnosis: NEEDLE ASPIRATION BIOPSY was used to diagnose this case of prostate cancer.
605needle biopsy, nosPRO1;6SET OF CODES1:Yes
2:No
9:Unknown
Record whether the Method of Diagnosis: NEEDLE BIOPSY, NOS was used to diagnose this case of prostate cancer.
606perineal biopsyPRO1;7SET OF CODES1:Yes
2:No
9:Unknown
Record whether the Method of Diagnosis: PERINEAL BIOPSY was used to diagnose this case of prostate cancer.
607transrectal biopsyPRO1;8SET OF CODES1:Yes
2:No
9:Unknown
Record whether the Method of Diagnosis: TRANSRECTAL BIOPSY was used to diagnose this case of prostate cancer.
608trusPRO1;9SET OF CODES1: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.
609transurethral resectionPRO1;10SET OF CODES1: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.
610other method of dx (prostate)PRO1;11SET OF CODES1:Yes
2:No
9:Unknown
Record whether the Method of Diagnosis: OTHER was used to diagnose this case of prostate cancer.
611bone marrow aspirationPRO1;12SET OF CODES1: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).
612bone scan (prostate)PRO1;13SET OF CODES1: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).
613bone x-rayPRO1;14SET OF CODES1: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).
614chest x-ray (prostate)PRO1;15SET OF CODES1: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).
615ct scan of primary sitePRO1;16SET OF CODES1: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).
616intravenous pyelogram (pro)PRO1;17SET OF CODES1: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).
617liver scanPRO1;18SET OF CODES1: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).
618mri (pro)PRO1;19SET OF CODES1: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).
619pelvic lymph node dissect (pr)PRO1;20SET OF CODES1: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).
620prostatic acid phosphatasePRO1;21SET OF CODES1: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).
621prostate specific antigenPRO1;22SET OF CODES1: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).
622other diagnostic informationPRO1;23SET OF CODES1: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).
623gleason score (clinical)PRO1;24FREE 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.
623.1predominant pattern (02-40)PRO2;43NUMERIC 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'.
623.2lesser pattern (02-40)PRO2;44NUMERIC 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'.
623.3gleason's score (50-70)PRO2;45FREE 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.
623.4predominant pattern (50-70)PRO2;46NUMERIC 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'.
623.5lesser pattern (50-70)PRO2;47NUMERIC 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'.
624research protocolPRO1;25SET OF CODES1:In-house
2:Cooperative group
3:Not in a protocol
9:Unknown
Record whether the patient was entered into a protocol.
625rad therapy planned/givenPRO1;26SET OF CODES1: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.
626interstitial rad planned/givenPRO1;27SET OF CODES1: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.
627iodine 125PRO1;28SET OF CODES0:No
1:Yes
9:Unknown
Record whether the isotope IODINE 125 was administered interstitially.
628gold 198PRO1;29SET OF CODES0:No
1:Yes
9:Unknown
Record whether the isotope GOLD 198 was administered interstitially.
629palladium 103PRO1;30SET OF CODES0:No
1:Yes
9:Unknown
Record whether the isotope PALLADIUM 103 was administered interstitially.
630iridium 192PRO1;31SET OF CODES0:No
1:Yes
9:Unknown
Record whether the isotope IRIDIUM 192 was administered interstitially.
631other interstitial, nosPRO1;32SET OF CODES0:No
1:Yes
9:Unknown
Record whether OTHER INTERSTITIAL, NOS isotopes were administered.
632external rad planned/givenPRO1;33SET OF CODES1: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.
633prostate region onlyPRO1;34SET OF CODES0:No, region/site not targeted
1:Yes
8:NA, external radiation not administered
9:Unknown
Record whether the PROSTATE REGION ONLY was irradiated.
634prostate and pelvic nodesPRO1;35SET OF CODES0:No, region/site not targeted
1:Yes
8:NA, external radiation not administered
9:Unknown
Record whether PROSTATE AND PELVIC NODES were irradiated.
635prostate & pelvic para-aorticPRO1;36SET OF CODES0: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.
636distant metastatic sitesPRO1;37SET OF CODES0:No, region/site not targeted
1:Yes
8:NA, external radiation not administered
9:Unknown
Record whether DISTANT METASTATIC SITES were irradiated.
637other external sites, nosPRO1;38SET OF CODES0:No, region/site not targeted
1:Yes
8:NA, external radiation not administered
9:Unknown
Record whether OTHER EXTERNAL SITES, NOS were irradiated.
638total rad dose (prostate)PRO1;39SET OF CODES1: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).
639total rad dose (pelvic nodes)PRO1;40SET OF CODES1: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).
640total rad dose (para-aortic)PRO1;41SET OF CODES1: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).
641research protocol (radiation)PRO1;42SET OF CODES1:In-house
2:Cooperative group
3:Not in a protocol
9:Unknown
Record the patient was entered into a protocol.
642hormone therapy planned/givenPRO1;43SET OF CODES1: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.
643estrogensPRO1;44SET OF CODES0:No
1:Yes
9:Unknown
2:No
Record all types of hormonal drugs given.
644antiandrogensPRO1;45SET OF CODES0:No
1:Yes
9:Unknown
2:No
Record all types of hormonal drugs given.
645progestational agentsPRO1;46SET OF CODES0:No
1:Yes
9:Unknown
2:No
Record all types of hormonal drugs given.
646luteinizing hormonesPRO1;47SET OF CODES0:No
1:Yes
9:Unknown
2:No
Record all types of hormonal drugs given.
647orchiectomyPRO1;48SET OF CODES1:Yes
2:No
9:Unknown
Record whether an ORCHIECTOMY was administered. Code 2 (No) if an ORCHIECTOMY was not given.
648other exogenous hormone agentsPRO1;49SET OF CODES0:No
1:Yes
9:Unknown
2:No
Record all types of hormonal drugs given.
649backache (1st recurrence)PRO1;50SET OF CODES1:Yes
2:No
9:Unknown
Record whether a BACKACHE was used to diagnose the first recurrence.
650bone scan (1st recurrence)PRO1;51SET OF CODES1:Yes
2:No
9:Unknown
Record if a BONE SCAN was used to diagnose the first recurrence.
651lethargyPRO1;52SET OF CODES1:Yes
2:No
9:Unknown
Record if LETHARGY was used to diagnose the first recurrence.
652rectal exam (1st recurrence)PRO1;53SET OF CODES1:Yes
2:No
9:Unknown
Record whether a RECTAL EXAMINATION FOLLOWED BY NEEDLE BIOPSY was used to diagnose the first recurrence.
653tumor marker (1st recurrence)PRO1;54SET OF CODES1:Yes
2:No
9:Unknown
Record whether TUMOR MARKER ELEVATION was used to diagnose the first recurrence.
654weight loss (1st recurrence)PRO1;55SET OF CODES1:Yes
2:No
9:Unknown
Record whether WEIGHT LOSS was used to diagnose the first recurrence.
655other methods (1st recurrence)PRO1;56SET OF CODES1:Yes
2:No
9:Unknown
Record whether OTHER methods were used to diagnose the first recurrence.
656reason for 2nd coursePRO1;57SET OF CODES1:Recurrence
2:Progression of disease
8:No therapy
9:Unknown
Record whether the patient received treatment for recurrence or progression of disease.
657fam hist of prostate ca (pr98)PRO2;1SET OF CODES0: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.
658hematuria (pr98)PRO2;2SET OF CODES0:No
1:Yes
9:Unknown
Record all symptoms specific to prostate cancer that were reported by the patient and included in the medical chart.
659lower back pain (pr98)PRO2;3SET OF CODES0:No
1:Yes
9:Unknown
Record all symptoms specific to prostate cancer that were reported by the patient and included in the medical chart.
660trouble urinating (pr98)PRO2;4SET OF CODES0:No
1:Yes
9:Unknown
Record all symptoms specific to prostate cancer that were reported by the patient and included in the medical chart.
661clin dx w/ bone lesion (pr98)PRO2;5SET OF CODES0: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.
662clin dx by rectal exam (pr98)PRO2;6SET OF CODES0: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.
663cytology (pr98)PRO2;7SET OF CODES0:No
1:Yes
9:Unknown
Record whether the Initial Method of Diagnosis: CYTOLOGY was performed to diagnose this case of prostate cancer.
664digital transrectal bio (pr98)PRO2;8SET OF CODES0:No
1:Yes
9:Unknown
Record whether the Initial Method of Diagnosis: DIGITAL TRANSRECTAL BIOPSY was performed to diagnose this case of prostate cancer.
665incidental find in turp (pr98)PRO2;9SET OF CODES0: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.
666needle biopsy, nos (pr98)PRO2;10SET OF CODES0:No
1:Yes
9:Unknown
Record whether the Initial Method of Diagnosis: NEEDLE BIOPSY, NOS was performed to diagnose this case of prostate cancer.
667perineal biopsy (pr98)PRO2;11SET OF CODES0:No
1:Yes
9:Unknown
Record whether the Initial Method of Diagnosis: PERINEAL BIOPSY was performed to diagnose this case of prostate cancer.
668psa method of diagnosis (pr98)PRO2;12SET OF CODES0: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.
669transrectal biopsy (pr98)PRO2;13SET OF CODES0: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.
670transurethral resection (pr98)PRO2;14SET OF CODES0: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.
671bone marrow aspiration (pr98)PRO2;15SET OF CODES0: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).
672bone scan (pr98)PRO2;16SET OF CODES0: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).
673bone x-ray (pr98)PRO2;17SET OF CODES0: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).
674chest x-ray (pr98)PRO2;18SET OF CODES0: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).
675ct scan of abdomen (pr98)PRO2;19SET OF CODES0: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).
676ct scan of pelvis (pr98)PRO2;20SET OF CODES0: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).
677intravenous pyelogram (pr98)PRO2;21SET OF CODES0: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).
678mri (pr98)PRO2;22SET OF CODES0: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).
679pelvic lymph nd dissect (pr98)PRO2;23SET OF CODES0: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).
680polymerase chain react (pr98)PRO2;24SET OF CODES0: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).
681prostatic acid phosph (pr98)PRO2;25SET OF CODES0: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).
682psa diagnostic eval (pr98)PRO2;26SET OF CODES0: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).
683ultrasound of abdomen (pr98)PRO2;27SET OF CODES0: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).
684psaPRO2;28FREE 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.
685watchful waiting (pr98)PRO2;29SET OF CODES0: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.
686length of stay (pr98)PRO2;30NUMERIC 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.
687laparoscopic (pr98)PRO2;31SET OF CODES0: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.
688open (pr98)PRO2;32SET OF CODES0: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.
689permanent rectal injury (pr98)PRO2;33SET OF CODES0: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.
690thromboembolism (pr98)PRO2;34SET OF CODES0: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.
691urethral stricture (pr98)PRO2;35SET OF CODES0: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.
692radiation facilityPRO2;36SET OF CODES1: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.
693route of interstitial radPRO2;37SET OF CODES1: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.
694type of radiation adminPRO2;38SET OF CODES1: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.
695gastrointestinal complicationsPRO2;39SET OF CODES0: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.
696gastrourinary complicationsPRO2;40SET OF CODES0: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.
697anorectal complicationsPRO2;41SET OF CODES0: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.
698chronic complicationsPRO2;42SET OF CODES0: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.
699urethral/bladder complicationsPRO2;48SET OF CODES0: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.
699.1date of orchiectomyPRO2;49DATE-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.
700history of colorectal ca (fam)COL1;1SET OF CODES0:No
1:Yes
9:Unknown
Record any familial history of colorectal cancer documented in the medical record.
701history of colorectal ca (pt)COL1;2SET OF CODES0:No
1:Yes
9:Unknown
Record and personal history of a previous colorectal cancer documented in the medical record prior to 1997.
702multiple colorectal primariesCOL1;3SET OF CODES0: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.
703history of breast ca (pt)COL1;4SET OF CODES0:No
1:Yes
9:Unknown
Record whether the patient has a history of breast cancer.
704history of lung ca (pt)COL1;5SET OF CODES0:No
1:Yes
9:Unknown
Record whether the patient has a history of lung cancer.
705history of ovarian ca (pt)COL1;6SET OF CODES0:No
1:Yes
9:Unknown
Record whether the patient has a history of ovarian cancer.
706history of ovarian carcinomaCOL1;7SET OF CODES0: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.
707history of stomach ca (pt)COL1;8SET OF CODES0:No
1:Yes
9:Unknown
Record whether the patient has a history of stomach cancer.
708history of thyroid ca (pt)COL1;9SET OF CODES0:No
1:Yes
9:Unknown
Record whether the patient has a history of thyroid cancer.
709history of uterus ca (pt)COL1;10SET OF CODES0:No
1:Yes
9:Unknown
Record whether the patient has a history of uterus cancer.
710previous tah/bsoCOL1;11SET OF CODES0:No
1:Yes
9:Unknown
TAH/BSO (Total abdominal hysterectomy/bilateral salpingo-oophorectomy) Record the appropriate code.
711familial adenomatous polypsCOL1;12SET OF CODES0:No
1:Yes
9:Unknown/not documented
Record whether the patient was affected by FAP (Familial adenomatous polyposis).
712hnpccCOL1;13SET OF CODES0:No
1:Yes
9:Unknown/not documented
Record whether the patient is affected by hereditary nonpolyposis colon cancer (HNPCC) syndrome.
713inflammatory bowel diseaseCOL1;14SET OF CODES0:No
1:Yes
9:Unknown/not documented
Record whether the patient was affected by inflammatory bowel disease (IBD).
714prior polypsCOL1;15SET OF CODES0:No
1:Yes
9:Unknown
Record the appropriate code for prior polyps.
715polypsCOL1;16NUMERICRecord number of adenomas. If no adenomas, record 88. If number of adenomas unknown, record 90. If unknown if adenomas, record 99.
716duration of anemiaCOL1;17NUMERICRecord 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).
717duration of bowel obstructionCOL1;18NUMERICRecord 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).
718duration of bowel habit changeCOL1;19NUMERICRecord 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).
719duration of emergency pres-obsCOL1;20NUMERICRecord 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).
720duration of jaundiceCOL1;21NUMERICRecord 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).
721duration of malaiseCOL1;22NUMERICRecord 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).
722duration of blood in stoolCOL1;23NUMERICRecord 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).
723duration of pain (abdominal)COL1;24NUMERICRecord 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).
724duration of pain (pelvic)COL1;25NUMERICRecord 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).
725duration of rectal bleedingCOL1;26NUMERICRecord 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).
726duration of otherCOL1;27NUMERICRecord 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).
727endoscopic methodCOL1;28SET OF CODES0:Not done
1:Done
9:Unknown if done
Record whether 'endoscopic' initial method of diagnosis was performed. If unknown, code a '9'.
728radiographic methodCOL1;29SET OF CODES0:Not done
1:Done
9:Unknown if done
Record whether 'radiographic' initial method of diagnosis was performed. If unknown, code a '9'.
729screening digital rectal examCOL1;30SET OF CODES0: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'.
730screening physical exam methodCOL1;31SET OF CODES0:Not done
1:Done
9:Unknown if done
Record whether 'screening physical exam' initial method of diagnosis was performed. If unknown, code a '9'.
731other initial methodCOL1;32SET OF CODES0:Not done
1:Done
9:Unknown if done
Record whether other initial method of diagnosis was performed. If unknown, code a '9'.
732reason leading to eventual dxCOL1;33SET OF CODES0: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'.
733barium enema, double contrastCOL1;34SET OF CODES0: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'.
734barium enema, single contrastCOL1;35SET OF CODES0: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'.
735barium enema, nosCOL1;36SET OF CODES0: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'.
736biopsy of primary siteCOL1;37SET OF CODES0: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'.
737biopsy of metastatic siteCOL1;38SET OF CODES0: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'.
738ct scan of liverCOL1;39SET OF CODES0: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'.
739ct scan of primary site (col)COL1;40SET OF CODES0: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'.
740carcinoembryonic antigen (cea)COL1;41SET OF CODES0: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'.
741chest roentgenogramCOL1;42SET OF CODES0: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'.
742colonoscopyCOL1;43SET OF CODES0: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'.
743digital rectal examCOL1;44SET OF CODES0: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'.
744flexible sigmoidoscopyCOL1;45SET OF CODES0: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'.
745intravenous pyelogram (col)COL1;46SET OF CODES0: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'.
746serum-liver function testCOL1;47SET OF CODES0: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'.
747mri (col)COL1;48SET OF CODES0: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'.
748proctoscopy (rigid)COL1;49SET OF CODES0: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'.
749stool guaiac (occult blood)COL1;50SET OF CODES0: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'.
750ultrasound, liver, abdomenCOL1;51SET OF CODES0: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'.
751ultrasound, endorectalCOL1;52SET OF CODES0: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'.
752tumor level-endoscopic examCOL2;1NUMERICRecord 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'.
753level of rectal tumorCOL2;2SET OF CODES0: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.
754proximal margin of resectionCOL2;3SET OF CODES0:Negative
1:Microscopically positive
2:Grossly positive
8:NA
9:Unknown, not described
Record the appropriate code for the Proximal margin of resection.
755distal margin of resectionCOL2;4SET OF CODES0:Negative
1:Microscopically positive
2:Grossly positive
8:NA
9:Unknown, not described
Record the appropriate code for the Distal margin of resection.
756radial margin of resectionCOL2;5SET OF CODES0:Negative
1:Microscopically positive
2:Grossly positive
8:NA
9:Unknown, not described
Record the appropriate code for the Radial margin of resection.
757dist to closest mucosal marginCOL2;6NUMERICRecord 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.
758dist to closest radial marginCOL2;7NUMERICRecord 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.
759blood vessel or lymphatic invCOL2;8SET OF CODES0:No
1:Yes
9:Unknown
Record the appropriate code for blood vessel or lymphatic invasion.
760extramural venous invasionCOL2;9SET OF CODES0:No
1:Yes
9:Unknown
Record the appropriate code for extramural venous invasion.
761prominent lymphoid infiltrateCOL2;10SET OF CODES0:No
1:Yes
9:Unknown
Record the appropriate code for prominent lymphoid infiltrate (Crohn's lymphoid follicle).
762phys providing def treatmentCOL2;11SET OF CODES1: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.
763additional surgical proceduresCOL2;12NUMERICEnter 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.
764laparoscopy used during cdsCOL2;13SET OF CODES0:No
1:Yes
8:NA
9:Unknown
Record whether a laparoscopic procedure was used during cancer- directed surgery. Record an '8' if not applicable.
765method of anastomosisCOL2;14SET OF CODES0: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.
766cm from anastomosis to dentateCOL2;15NUMERICRecord the distance in centimeters of anastomosis from dentate.
767colostomyCOL2;16SET OF CODES0:No
1:Yes
9:Unknown
Record whether a colonscopy was performed.
768oophorectomyCOL2;17SET OF CODES0: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.
769pathological statusCOL2;18SET OF CODES0: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).
770abdominal infectionCOL2;19SET OF CODES0: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).
771abscessCOL2;20SET OF CODES0: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).
772admission for neutropeniaCOL2;21SET OF CODES0: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).
773anastomotic dehiscenceCOL2;22SET OF CODES0: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).
774dehydrationCOL2;23SET OF CODES0: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).
775diarrheaCOL2;24SET OF CODES0: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).
776early bowel obstructionCOL2;25SET OF CODES0: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).
777perineal infectionCOL2;26SET OF CODES0: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).
778pneumonia (col)COL2;27SET OF CODES0: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).
779proctitisCOL2;28SET OF CODES0: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).
780pulmonary embolism (col)COL2;29SET OF CODES0: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).
781radiation enteritisCOL2;30SET OF CODES0: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).
782stoma complicationCOL2;31SET OF CODES0: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).
783urinary tract infectionCOL2;32SET OF CODES0: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).
784endocavitary radiation (ecrt)COL2;33SET OF CODES0: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.
785intra-operative rad therapyCOL2;34SET OF CODES0: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.
786primary tumor rad dose (cgy)COL2;35NUMERICRecord 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.
787number of radiation treatmentsCOL2;36NUMERICRecord the number of radiation treatments. If none, record 00. If given, but number unknown, record 88. If unknown if radiation given, record 99.
788adjuvant chemotherapy (col)COL2;37SET OF CODES0: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.
7895 fu (fluorouracil)COL2;38SET OF CODES0: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.
790leucovorinCOL2;39SET OF CODES0:No
1:Yes
9:Unknown
Record whether the adjuvant therapy Leucovorin was given. If it is unknown if it was given, record a 9.
791levamisoleCOL2;40SET OF CODES0: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.
792cpt 11COL2;41SET OF CODES0: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.
793other adjuvant therapyCOL2;42SET OF CODES0:No
1:Yes
9:Unknown
Record whether any other adjuvant therapy was given. If it is unknown if any was given, record a 9.
794duration of adjuvant therapyCOL2;43SET OF CODES0: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.
795completed duration of therapyCOL2;44SET OF CODES0: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.
796nutritional consultationCOL2;45SET OF CODES0:No
1:Yes
9:Unknown
Record whether the other referral, nutritional consultation was made. If unknown, record 9.
797occupational therapyCOL2;46SET OF CODES0:No
1:Yes
9:Unknown
Record whether the other referral, occupational therapy was made. If unknown, record 9.
798ostomy consultationCOL2;47SET OF CODES0:No
1:Yes
9:Unknown
Record whether the other referral, ostomy consultation was made. If unknown, record 9.
799psychosocialCOL2;48SET OF CODES0:No
1:Yes
9:Unknown
Record whether the other referral, psychosocial was made. If unknown, record 9.
800history of leukemia (fam)NHL1;1SET OF CODES0: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).
801history of non-hodgkin's lymphNHL1;2SET OF CODES0: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).
802history of hodgkin's lymphomaNHL1;3SET OF CODES0: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).
8031st primary siteNHL1;4POINTER164Record 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.
8041st primary histologyNHL1;5POINTER164.1Record 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.
8052nd primary siteNHL1;6POINTER164Record 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.
8062nd primary histologyNHL1;7POINTER164.1Record 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.
807organ transplantNHL1;8SET OF CODES0:No
1:Yes
9:Unknown
Record the appropriate code for whether an organ transplant was a pre-existing condition. If unknown, code 9.
808hiv positiveNHL1;9SET OF CODES0:No
1:Yes
9:Unknown
Record the appropriate code for whether being HIV positive was a pre-existing condition. If unknown, code 9.
809crohn's diseaseNHL1;10SET OF CODES0:No
1:Yes
9:Unknown/not documented
Record whether Crohn's disease was a pre-existing condition.
810hashimoto's thyroiditisNHL1;11SET OF CODES0:No
1:Yes
9:Unknown
Record the appropriate code for whether Hashimoto's thyroiditis was a pre-existing condition. If unknown, code 9.
811systemic lupus erythematosusNHL1;12SET OF CODES0:No
1:Yes
9:Unknown
Record the appropriate code for whether systemic lupus erythematosus was a pre-existing condition. If unknown, code 9.
812rheumatoid arthritisNHL1;13SET OF CODES0: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.
813pneumocystis cariniiNHL1;14SET OF CODES0:No
1:Yes
9:Unknown
Record the appropriate code for whether pneumocystis carinii was a pre-existing condition. If unknown, code 9.
814cmv infectionNHL1;15SET OF CODES0:No
1:Yes
9:Unknown
Record the appropriate code for whether CMV infection was a pre-existing condition. If unknown, code 9.
815tuberculosisNHL1;16SET OF CODES0:No
1:Yes
9:Unknown
Record the appropriate code for whether tuberculosis was a pre-existing condition. If unknown, code 9.
816mycobacterium aviumNHL1;17SET OF CODES0:No
1:Yes
9:Unknown
Record the appropriate code for whether mycobacterium avium was a pre-existing condition. If unknown, code 9.
817other parasitic infectionsNHL1;18SET OF CODES0: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.
818other congenital diseasesNHL1;19SET OF CODES0: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.
819opportunistic diseaseNHL1;20SET OF CODES0: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.
820previous chemotherapyNHL1;21SET OF CODES0:No
1:Yes
9:Unknown
Record the appropriate code for whether the patient received any previous chemotherapy. If unknown, code 9.
821previous radiation therapyNHL1;22SET OF CODES0:No
1:Yes
9:Unknown
Record the appropriate code for whether the patient received any previous radiation therapy. If unknown, code 9.
822aids risk categoryNHL1;23NUMERICRecord 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.
823ct scan of brainNHL1;24SET OF CODES0: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.
824ct scan of abdomen/pelvisNHL1;25SET OF CODES0: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.
825mri of brainNHL1;26SET OF CODES0: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.
826mri of chestNHL1;27SET OF CODES0: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.
827mri of abdomen/pelvisNHL1;28SET OF CODES0: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.
828gallium scanNHL1;29SET OF CODES0: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.
829pet scanNHL1;30SET OF CODES0: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.
830lumbar punctureNHL1;31SET OF CODES0: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.
831hemoglobin/hematocritNHL1;32SET OF CODES0: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'.
832white countNHL1;33SET OF CODES0: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'.
833platelet countNHL1;34SET OF CODES0: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'.
834lactic dehydrogenase (ldh)NHL1;35SET OF CODES0: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'.
835liver function studies (nhl)NHL1;36SET OF CODES0: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'.
836total protein/albuminNHL1;37SET OF CODES0: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'.
837gene rearrangementsNHL1;38SET OF CODES0: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'.
838review of pathology/other instNHL1;39SET OF CODES0: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.
839lymph node biopsyNHL1;40SET OF CODES0: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'.
840bone marrow biopsyNHL1;41SET OF CODES0: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'.
841csf cytologyNHL1;42SET OF CODES0: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'.
842other site biopsyNHL1;43SET OF CODES0: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'.
843systemic symptomsNHL1;44SET OF CODES1: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.
844cd4 countNHL1;45SET OF CODES0: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'.
845hiv viral loadsNHL1;46SET OF CODES0: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'.
846specific histologic infoNHL2;1SET OF CODES1: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.
847cell type of lymphomaNHL2;2SET OF CODES1: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'.
848patient status at diagnosisNHL2;3SET OF CODES0: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'.
849type of staging system (ped)NHL2;4POINTER164.6If recording a pediatric case, enter the type of staging system used to stage this patient. If not applicable, code '88'. If unknown, code '99'.
850pediatric stageNHL2;5FREE TEXTEnter the pediatric stage as specified in the pediatric staging system selected. If not applicable, code '88'. If the pediatric stage is unknown, code '99'.
851staged by (pediatric stage)NHL2;6SET OF CODES0: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'.
852extranodal site 1NHL2;7FREE TEXTProvide 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.
853extranodal site 2NHL2;8FREE TEXTProvide 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.
854extranodal site 3NHL2;9FREE TEXTProvide 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.
855extranodal site w/c-d surgeryNHL2;10FREE TEXTRecord 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.
856extranodal site surgical procNHL2;11NUMERICRecord 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'.
857lymph nodes above diaphragmNHL2;12SET OF CODES1: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.
858lymph nodes below diaphragmNHL2;13SET OF CODES1: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.
859brainNHL2;14SET OF CODES1: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.
860other extranodal site(s)NHL2;15SET OF CODES1: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.
861total bodyNHL2;16SET OF CODES1: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.
862radiation/chemo sequenceNHL2;17NUMERICRecord the appropriate code for radiation/chemotherapy sequence.
863protocolNHL2;18SET OF CODES0: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.
864systemic chemotherapyNHL2;19SET OF CODES0: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.
865systemic chemotherapy dateNHL2;20DATE-TIME Record the first date on which systemic chemotherapy was administered.
866systemic chemotherapy cyclesNHL2;21NUMERICRecord 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.
867chlorambucilNHL2;22SET OF CODES0: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.
868cyclophosphamide (nhl)NHL2;23SET OF CODES0: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.
869doxorubicin (nhl)NHL2;24SET OF CODES0: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.
870fludarabineNHL2;25SET OF CODES0: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.
871chopNHL2;26SET OF CODES0: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.
872cvpNHL2;27SET OF CODES0: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.
873comlaNHL2;28SET OF CODES0: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.
874macop-bNHL2;29SET OF CODES0: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.
875m-bacodNHL2;30SET OF CODES0: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.
876pro-mace-cyta bomNHL2;31SET OF CODES0: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.
877other systemic chemo agentsNHL2;32SET OF CODES0: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.
878high dose systemic chemoNHL2;33SET OF CODES0: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.
879intrathecal chemotherapyNHL2;34SET OF CODES0:None
1:Administered
9:Unknown if administered
Record the appropriate code for whether intrathecal chemotherapy was administered. If unknown if administered, code 9.
880purpose of intrathecal chemoNHL2;35SET OF CODES1: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.
881interferon (nhl)NHL2;36SET OF CODES0:No
1:Yes
9:Unknown
Record the appropriate code for whether this type of immunotherapy was performed. If unknown if performed, code 9.
882interleukin-2 (il-2) (nhl)NHL2;37SET OF CODES0:No
1:Yes
9:Unknown
Record the appropriate code for whether this type of immunotherapy was performed. If unknown if performed, code 9.
883monoclonal antibodiesNHL2;38SET OF CODES0:No
1:Yes
9:Unknown
Record the appropriate code for whether this type of immunotherapy was performed. If unknown if performed, code 9.
884vaccine therapyNHL2;39SET OF CODES0: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.
900daughter (br98)BRE1;1SET OF CODES0: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.
901maternal aunt (br98)BRE1;2SET OF CODES0: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.
902maternal grandmother (br98)BRE1;3SET OF CODES0: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.
903mother (br98)BRE1;4SET OF CODES0: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.
904one sister (br98)BRE1;5SET OF CODES0: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.
905more than one sister (br98)BRE1;6SET OF CODES0: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.
906father (br98)BRE1;7SET OF CODES0: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.
907brother (br98)BRE1;8SET OF CODES0: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.
908fam history breast ca (br98)BRE1;9SET OF CODES0: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.
909history of breast ca (br98)BRE1;10SET OF CODES0: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.
910synchronous breast ca (br98)BRE1;11SET OF CODES0: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.
911colon (br98)BRE1;12SET OF CODES0: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.
912ovary (br98)BRE1;13SET OF CODES0: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.
913uterus (br98)BRE1;14SET OF CODES0: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.
914prostate (br98)BRE1;15SET OF CODES0: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.
915other (br98)BRE1;16SET OF CODES0: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.
916hormone replacement tpy (br98)BRE1;17SET OF CODES0: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.
917hormone replacement yrs (br98)BRE1;18SET OF CODES1: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.
918unknown mammogram (br98)BRE1;19SET OF CODES0: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.
919unknown mammogram dt (br98)BRE1;20DATE-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.
920screening mammogram (br98)BRE1;21SET OF CODES0: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.
921screening mammogram dt (br98)BRE1;22DATE-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.
922diagnostic mammogram (br98)BRE1;23SET OF CODES0: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.
923diagnostic mammogram dt (br98)BRE1;24DATE-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.
924magnification mammogram (br98)BRE1;25SET OF CODES0: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.
925magnification mamm dt (br98)BRE1;26DATE-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.
926mammogram (br98)BRE1;27SET OF CODES0: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.
927ultrasound (br98)BRE1;28SET OF CODES0: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.
928most definitive mamm (br98)BRE1;29SET OF CODES0: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.
929date of pathologic dx (br98)BRE1;30DATE-TIME Record the date that this breast cancer was first pathologically diagnosed.
930dcsi also present (br98)BRE1;31FREE 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.
931architecture pattern (br98)BRE1;32SET OF CODES1: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.
932nuclear grade (br98)BRE1;33SET OF CODES1: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.
933skin involvement (br98)BRE1;34SET OF CODES0:No involvement
1:Involvement
9:Unknown
For male patients, record the extent of involvement of the skin. For female patients, leave this field blank.
934chest wall involvement (br98)BRE1;35SET OF CODES0: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.
935pectoral involvement (br98)BRE1;36SET OF CODES0: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.
936dermal/lymphatic inv (br98)BRE1;37SET OF CODES0:No involvement
1:Involvement
9:Unknown
For male patients, record the extent of dermal/lymphatic involvement. For female patients, leave this field blank.
937dna index/ploidy (br98)BRE1;38SET OF CODES0: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.
940androgen receptor (br98)BRE1;41SET OF CODES0: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.
941type of test (br98)BRE1;42SET OF CODES0: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.
942size of dcis tumor (mm) (br98)BRE1;43NUMERIC 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.
943sentinel node biopsyBRE1;44SET OF CODES0: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.
944sentinel nodes examined (br98)BRE1;45SET OF CODES0: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.
945sentinel nodes positive (br98)BRE1;46SET OF CODES0: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.
946sentinel nodes detected (br98)BRE1;47SET OF CODES1:Vital blue dye
2:Radionuclide
3:Combination
8:NA, not done
9:Method unknown
Record the method by which the sentinel node was detected.
947specimen radiograph (br98)BRE1;48SET OF CODES0: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.
948submitted to pathology (br98)BRE1;49SET OF CODES0:No
1:Yes
8:NA
9:Unknown
Record whether the entire specimen was submitted to pathology.
949margin distance (br98)BRE1;50SET OF CODES0: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).
950re-excision (br98)BRE1;51SET OF CODES0: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).
951microscopic status (br98)BRE1;52SET OF CODES0: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.
952pre-radiation mammogram (br98)BRE1;53SET OF CODES0: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.
953sites irradiated (br98)BRE1;54SET OF CODES0: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.
954cgy dose to breast (br98)BRE1;55NUMERIC 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.
955specific hormone thpy (br98)BRE1;56SET OF CODES0: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.
956chemotherapy regime (br98)BRE1;57SET OF CODES0: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.
993regional tx modality conv flag27;7BOOLEANY: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.
994type of first recur conv flag27;6BOOLEANY: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.
995staged by conv flag27;5BOOLEANY: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.
996surgical margins conv flag27;2BOOLEANY: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.
997stage flag27;1BOOLEANY:YES
N:NO
Staging conversion flag.
998scope of ln surgery conv flag27;3BOOLEANY: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
999surgical proc/other conv flag27;4BOOLEANY: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.
999.1date of diagnosis flag27;8NUMERICSource of Standard: NAACCR Item #: 391 This field is a flag that explains why no appropriate value is entered for DATE DX (#3) field.
999.11rx date surg disch flag27;17NUMERICSource 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.
999.12rx date-radiation flag27;18NUMERICSource of Standard: NAACCR Item #: 1211 This field is a flag that explains why no appropriate value is entered for DATE RADIATION STARTED (#51) field.
999.13rx date rad ended flag27;19NUMERICSource of Standard: NAACCR Item #: 3221 This field is a flag that explains why no appropriate value is entered for DATE RADIATION ENDED (#361) field.
999.14rx date systemic flag27;20NUMERICSource 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.
999.15rx date-chemo flag27;21NUMERICSource of Standard: NAACCR Item #: 1221 This field is a flag that explains why no appropriate value is entered for CHEMOTHERAPY DATE (#53) field.
999.16rx date-hormone flag27;22NUMERICSource of Standard: NAACCR Item #: 1231 This field is a flag that explains why no appropriate value is entered for HORMONE THERAPY DATE (#54) field.
999.17rx date-brm flag27;23NUMERICSource of Standard: NAACCR Item #: 1241 This field is a flag that explains why no appropriate value is entered for IMMUNOTHERAPY DATE (#55) field.
999.18rx date-other flag27;24NUMERICSource 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.
999.19rx date-dx/stg proc flag27;25NUMERICSource 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.
999.2date conclusive dx flag27;9NUMERICSource 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.
999.21recurrence date-1st flag27;26NUMERICSource 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.
999.22date of last contact flag27;27NUMERICSource 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.
999.23subsq rx 2nd crs date flag27;28NUMERICSource 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.
999.24subsq rx 3rd crs date flag27;29NUMERICSource 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.
999.25subsq rx 4th crs date flag27;30NUMERICSource 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.
999.26address at dx--state27;31FREE TEXTSource of Standard: NAACCR Item #: 80 This field is for the patient's State from their Address at time of Diagnosis.
999.27address at dx--country27;32FREE TEXTSource of Standard: NAACCR Item #: 102 This field is for the patient's Country from their Address at the time of diagnosis.
999.28address current--state27;33FREE TEXTSource of Standard: NAACCR Item #: 1820 This field is for the patient's State from their current Address.
999.29address current--country27;34FREE TEXTSource of Standard: NAACCR Item #: 1832 This field is for the patient's Country from their current Address.
999.3date of mult tumors flag27;10NUMERICSource 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.
999.4date of first contact flag27;11NUMERICSource 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.
999.5date of inpt adm flag27;12NUMERICSource 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.
999.6date of inpt disch flag27;13NUMERICSource 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.
999.7date 1st crs rx flag27;14NUMERICSource 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.
999.8rx date-surgery flag27;15NUMERICSource 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.
999.9rx date mst defn srg flag27;16NUMERICSource 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.
1000oral contraceptivesHEP1;1SET OF CODES0: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.
1001estrogen replacementHEP1;2SET OF CODES0: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.
1002tamoxifenHEP1;3SET OF CODES0: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.
1003other hormonesHEP1;4SET OF CODES0: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.
1004ascitesHEP1;5SET OF CODES0: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.
1005cirrhosisHEP1;6SET OF CODES0: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.
1006child's class aHEP1;7SET OF CODES0: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.
1007child's class bHEP1;8SET OF CODES0: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.
1008child's class cHEP1;9SET OF CODES0: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.
1009hepatitis bHEP1;10SET OF CODES0: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.
1010hepatitis cHEP1;11SET OF CODES0: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.
1011hemochromatosisHEP1;12SET OF CODES0: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.
1012alcohol consumptionHEP1;13FREE 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.
1013afp (iu/ml)HEP1;14FREE 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.
1014cea (mg/ml)HEP1;15FREE 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.
1015ca19.9 (u/ml)HEP1;16FREE 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.
1016protime (sec)HEP1;17FREE 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.
1017bilirubin (mg/ml)HEP1;18FREE 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.
1018albumin (g/dl)HEP1;19FREE 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.
1019ldh (u/i)HEP1;20FREE 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.
1020ct arterial port-performedHEP1;21SET OF CODES0: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.
1021ct arterial port-cirrhosisHEP1;22SET OF CODES0: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.
1022ct arterial port-vascular invHEP1;23SET OF CODES0: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.
1023ct arterial port-bilobar disHEP1;24SET OF CODES0: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.
1024ct arterial port-lymph nodesHEP1;25SET OF CODES0: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.
1025ct arterial port-size of tumorHEP1;26FREE 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.
1026ct arterial port-num 0f tumorsHEP1;27FREE 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.
1027spiral ct-performedHEP1;28SET OF CODES0: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.
1028spiral ct-cirrhosisHEP1;29SET OF CODES0: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.
1029spiral ct-vascular invHEP1;30SET OF CODES0: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.
1030spiral ct-bilobar disHEP1;31SET OF CODES0: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.
1031spiral ct-lymph nodesHEP1;32SET OF CODES0: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.
1032spiral ct-size of tumorHEP1;33FREE 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.
1033spiral ct-num of tumorsHEP1;34FREE 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.
1034incremental ct-performedHEP1;35SET OF CODES0: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.
1035incremental ct-cirrhosisHEP1;36SET OF CODES0: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.
1036incremental ct-vascular invHEP1;37SET OF CODES0: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.
1037incremental ct-bilobar disHEP1;38SET OF CODES0: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.
1038incremental ct-lymph nodesHEP1;39SET OF CODES0: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.
1039incremental ct-size of tumorHEP1;40FREE 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.
1040incremental ct-num 0f tumorsHEP1;41FREE 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.
1041ultrasound-performedHEP1;42SET OF CODES0: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.
1042ultrasound-cirrhosisHEP1;43SET OF CODES0: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.
1043ultrasound-vascular invHEP1;44SET OF CODES0: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.
1044ultrasound-bilobar disHEP1;45SET OF CODES0: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.
1045ultrasound-lymph nodesHEP1;46SET OF CODES0: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.
1046ultrasound-size of tumorHEP1;47FREE 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.
1047ultrasound-num 0f tumorsHEP1;48FREE 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.
1048mri-performedHEP1;49SET OF CODES0: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.
1049mri-cirrhosisHEP1;50SET OF CODES0: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.
1050mri-vascular invHEP1;51SET OF CODES0: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.
1051mri-bilobar disHEP1;52SET OF CODES0: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.
1052mri-lymph nodesHEP1;53SET OF CODES0: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.
1053mri-size of tumorHEP1;54FREE 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.
1054mri-num 0f tumorsHEP1;55FREE 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.
1055definitive diagnosisHEP1;56SET OF CODES1: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.
1056radio-frequency destructionHEP1;57SET OF CODES0: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.
1057ablation & resectionHEP1;58SET OF CODES00: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.
1058distance to closest marginHEP1;59SET OF CODES0: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.
1059ablationHEP1;60SET OF CODES0: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.
1060resectionHEP1;61SET OF CODES0: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.
1061cisplatinHEP1;62SET OF CODES0: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.
1062fudrHEP1;63SET OF CODES0: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.
10635-fuHEP1;64SET OF CODES0: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.
1064fu & leucovorinHEP1;65SET OF CODES0: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.
1065irinotecan (cpt-11)HEP1;66SET OF CODES0: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.
1066mitomycin cHEP1;67SET OF CODES0: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.
1067oxaliplatinHEP1;68SET OF CODES0: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.
1068gemcitabineHEP1;69SET OF CODES0: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.
1069route chemo adminHEP1;70SET OF CODES01: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.
1070chemotherapy/surgery sequenceHEP1;71SET OF CODES0: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.
1071arterial embolizationHEP1;72SET OF CODES0: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.
1072death w/i 30 days start txHEP1;73SET OF CODES0: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.
1100history of melanoma (pt)MEL1;1SET OF CODES0: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.
1101history of other cancer (pt)MEL1;2SET OF CODES0:No
1:Yes
9:Unknown
Record if the patient had any history of other types of cancer.
1102first site codeMEL1;3POINTER164 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.
1103first site diagnosis dateMEL1;4DATE-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.
1104second site codeMEL1;5POINTER164 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.
1105second site diagnosis dateMEL1;6DATE-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.
1106pregnancy at initial diagnosisMEL1;7SET OF CODES0:No
1:Yes
8:NA, male
9:Unknown
Record whether the patient was pregnant at the time of initial diagnosis.
1107exogenous hormonesMEL1;8SET OF CODES0: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
1108disease presentation locationMEL1;9SET OF CODES1: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.
1109type of biopsyMEL1;10SET OF CODES0: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.
1110extranodal extensionMEL1;11SET OF CODES0: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.
1111microsatellitosisMEL1;12SET OF CODES0: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.
1112number of satellite nodulesMEL1;13FREE 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.
1113location of in-transit nodulesMEL1;14SET OF CODES0: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.
1114breslow's thicknessMEL1;15FREE 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.
1115clark's level of invasionMEL1;16SET OF CODES1: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.
1116angiolymphatic invasionMEL1;17SET OF CODES0: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.
1117perineural invasionMEL1;18SET OF CODES0: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.
1118ulcerationMEL1;19SET OF CODES0: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.
1119clinically amelanoticMEL1;20SET OF CODES0: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.
1120margin distance (mel)MEL1;21FREE 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).
1121surgical closureMEL1;22SET OF CODES1: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.
1122pre-op lymphoscintigraphyMEL1;23SET OF CODES0: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.
1123sentinel nodes detected byMEL1;24SET OF CODES0: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.
1124sentinel nodes examined (mel)MEL1;25SET OF CODES0: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.
1125sentinel nodes positive (mel)MEL1;26SET OF CODES0: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.
1126method of pathologic examMEL1;27SET OF CODES0: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.
1127lymph node dissectionMEL1;28SET OF CODES0: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.
1128number of basins dissectedMEL1;29SET OF CODES0: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.
1129number of basins positiveMEL1;30SET OF CODES0: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.
1130intravenous therapyMEL1;31SET OF CODES1: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.
1131gene therapyMEL1;32SET OF CODES0:No
1:Yes
8:NA
9:Unknown
Record whether the patient received this adjuvant immunotherapy.
1132size of tumor (melanoma)MEL1;33NUMERIC 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.
1200handednessCNS1;1SET OF CODES1:Left handed
2:Right handed
3:Ambidextrous
9:Unknown
This field describes whether the patient is left handed, right handed or ambidextrous.
1201hypertensionCNS1;2SET OF CODES0:No
1:Yes
9:Unknown
This field describes a patient's prior medical condition.
1202multiple sclerosis (ms)CNS1;3SET OF CODES0:No
1:Yes
9:Unknown
This field describes a patient's prior medical condition.
1203diabetesCNS1;4SET OF CODES0:No
1:Yes
9:Unknown
This field describes a patient's prior medical condition.
1204cerebrovascular diseaseCNS1;5SET OF CODES0:No
1:Yes
9:Unknown
This field describes a patient's prior medical condition.
1205brainCNS1;6SET OF CODES0:No
1:Yes
9:Unknown
This field describes a patient's prior history of any cancers.
1206breastCNS1;7SET OF CODES0:No
1:Yes
9:Unknown
This field describes a patient's prior history of any cancers.
1207prostateCNS1;8SET OF CODES0:No
1:Yes
9:Unknown
This field describes a patient's prior history of any cancers.
1208malignant melanomaCNS1;9SET OF CODES0:No
1:Yes
9:Unknown
This field describes a patient's prior history of any cancers.
1209other skin cancerCNS1;10SET OF CODES0:No
1:Yes
9:Unknown
This field describes a patient's prior history of any cancers.
1210leukemiaCNS1;11SET OF CODES0:No
1:Yes
9:Unknown
This field describes a patient's prior history of any cancers.
1211colon or other gi cancersCNS1;12SET OF CODES0:No
1:Yes
9:Unknown
This field describes a patient's prior history of any cancers.
1212other personal history of caCNS1;13SET OF CODES0:No
1:Yes
9:Unknown
This field describes a patient's prior history of any cancers.
1213neurofibromatosisCNS1;14SET OF CODES0:No
1:Yes
9:Unknown
This field describes a patient's predispostion to brain/CNS tumors.
1214von hippel-lindau diseaseCNS1;15SET OF CODES0:No
1:Yes
9:Unknown
This field describes a patient's predispostion to brain/CNS tumors.
1215tuberous sclerosisCNS1;16SET OF CODES0:No
1:Yes
9:Unknown
This field describes a patient's predispostion to brain/CNS tumors.
1216turcot syndromeCNS1;17SET OF CODES0:No
1:Yes
9:Unknown
This field describes a patient's predispostion to brain/CNS tumors.
1217li-fraumeni syndromeCNS1;18SET OF CODES0:No
1:Yes
9:Unknown
This field describes a patient's predispostion to brain/CNS tumors.
1218kowden diseaseCNS1;19SET OF CODES0:No
1:Yes
9:Unknown
This field describes a patient's predispostion to brain/CNS tumors.
1219nevoid basal cell carcinomaCNS1;20SET OF CODES0:No
1:Yes
9:Unknown
This field describes a patient's predispostion to brain/CNS tumors.
1220headacheCNS1;21SET OF CODES0: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.
1221nausea/vomitingCNS1;22SET OF CODES0: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.
1222change in sense of smell/tasteCNS1;23SET OF CODES0: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.
1223altered alertnessCNS1;24SET OF CODES0: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.
1224fatigueCNS1;25SET OF CODES0: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.
1225speech disturbanceCNS1;26SET OF CODES0: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.
1226personality changesCNS1;27SET OF CODES0: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.
1227depressionCNS1;28SET OF CODES0: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.
1228memory lossCNS1;29SET OF CODES0: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.
1229lack of concentrationCNS1;30SET OF CODES0: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.
1230double visionCNS1;31SET OF CODES0: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.
1231other visual disturbanceCNS1;32SET OF CODES0: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.
1232decreased hearingCNS1;33SET OF CODES0: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.
1233vertigoCNS1;34SET OF CODES0: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.
1234tinnitusCNS1;35SET OF CODES0: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.
1235numbness/tinglingCNS1;36SET OF CODES0: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.
1236weakness or paralysisCNS1;37SET OF CODES0: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.
1237difficulty in coord/balanceCNS1;38SET OF CODES0: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.
1238generalized seizureCNS1;39SET OF CODES0: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.
1239focal seizureCNS1;40SET OF CODES0: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.
1240bladder incontinenceCNS1;41SET OF CODES0: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.
1241bowel incontinenceCNS1;42SET OF CODES0: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.
1242pain (other than headache)CNS1;43SET OF CODES0: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.
1243weight changeCNS1;44SET OF CODES0: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.
1244other symptomsCNS1;45SET OF CODES0: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.
1245alertnessCNS1;46SET OF CODES0:No
1:Yes
8:NA, examination not done
9:Unknown
Record all findings from the neurological examination that evaluated the status of the tumor.
1246speechCNS1;47SET OF CODES0:No
1:Yes
8:NA, examination not done
9:Unknown
Record all findings from the neurological examination that evaluated the status of the tumor.
1247personalityCNS1;48SET OF CODES0:No
1:Yes
8:NA, examination not done
9:Unknown
Record all findings from the neurological examination that evaluated the status of the tumor.
1248memory or judgementCNS1;49SET OF CODES0:No
1:Yes
8:NA, examination not done
9:Unknown
Record all findings from the neurological examination that evaluated the status of the tumor.
1249visual acuityCNS1;50SET OF CODES0:No
1:Yes
8:NA, examination not done
9:Unknown
Record all findings from the neurological examination that evaluated the status of the tumor.
1250visual fieldsCNS1;51SET OF CODES0:No
1:Yes
8:NA, examination not done
9:Unknown
Record all findings from the neurological examination that evaluated the status of the tumor.
1251eye movements (eom)CNS1;52SET OF CODES0:No
1:Yes
8:NA, examination not done
9:Unknown
Record all findings from the neurological examination that evaluated the status of the tumor.
1252facial sensationCNS1;53SET OF CODES0:No
1:Yes
8:NA, examination not done
9:Unknown
Record all findings from the neurological examination that evaluated the status of the tumor.
1253facial movementCNS1;54SET OF CODES0:No
1:Yes
8:NA, examination not done
9:Unknown
Record all findings from the neurological examination that evaluated the status of the tumor.
1254hearingCNS1;55SET OF CODES0:No
1:Yes
8:NA, examination not done
9:Unknown
Record all findings from the neurological examination that evaluated the status of the tumor.
1255gag reflexCNS1;56SET OF CODES0:No
1:Yes
8:NA, examination not done
9:Unknown
Record all findings from the neurological examination that evaluated the status of the tumor.
1256sternocleidomastoid/shld strCNS1;57SET OF CODES0:No
1:Yes
8:NA, examination not done
9:Unknown
Record all findings from the neurological examination that evaluated the status of the tumor.
1257articulation or enunciationCNS1;58SET OF CODES0:No
1:Yes
8:NA, examination not done
9:Unknown
Record all findings from the neurological examination that evaluated the status of the tumor.
1258papilledemaCNS1;59SET OF CODES0:No
1:Yes
8:NA, examination not done
9:Unknown
Record all findings from the neurological examination that evaluated the status of the tumor.
1259tongue fasciculations/atrophyCNS1;60SET OF CODES0:No
1:Yes
8:NA, examination not done
9:Unknown
Record all findings from the neurological examination that evaluated the status of the tumor.
1260decrease in sensation/any siteCNS1;61SET OF CODES0:No
1:Yes
8:NA, examination not done
9:Unknown
Record all findings from the neurological examination that evaluated the status of the tumor.
1261cortical sensory deficitCNS1;62SET OF CODES0:No
1:Yes
8:NA, examination not done
9:Unknown
Record all findings from the neurological examination that evaluated the status of the tumor.
1262weakness/atrophy/fasciculationCNS1;63SET OF CODES0:No
1:Yes
8:NA, examination not done
9:Unknown
Record all findings from the neurological examination that evaluated the status of the tumor.
1263ataxia of gaitCNS1;64SET OF CODES0:No
1:Yes
8:NA, examination not done
9:Unknown
Record all findings from the neurological examination that evaluated the status of the tumor.
1264truncal ataxiaCNS1;65SET OF CODES0:No
1:Yes
8:NA, examination not done
9:Unknown
Record all findings from the neurological examination that evaluated the status of the tumor.
1265dysmetriaCNS1;66SET OF CODES0:No
1:Yes
8:NA, examination not done
9:Unknown
Record all findings from the neurological examination that evaluated the status of the tumor.
1266rapid alternating movementsCNS1;67SET OF CODES0:No
1:Yes
8:NA, examination not done
9:Unknown
Record all findings from the neurological examination that evaluated the status of the tumor.
1267finger to finger nose testingCNS1;68SET OF CODES0:No
1:Yes
8:NA, examination not done
9:Unknown
Record all findings from the neurological examination that evaluated the status of the tumor.
1268heel to knee to shin testingCNS1;69SET OF CODES0:No
1:Yes
8:NA, examination not done
9:Unknown
Record all findings from the neurological examination that evaluated the status of the tumor.
1269deep tendon reflexes/upper extCNS1;70SET OF CODES0:No
1:Yes
8:NA, examination not done
9:Unknown
Record all findings from the neurological examination that evaluated the status of the tumor.
1270deep tendon reflexes/lower extCNS1;71SET OF CODES0:No
1:Yes
8:NA, examination not done
9:Unknown
Record all findings from the neurological examination that evaluated the status of the tumor.
1271babinski signCNS1;72SET OF CODES0:No
1:Yes
8:NA, examination not done
9:Unknown
Record all findings from the neurological examination that evaluated the status of the tumor.
1272hoffman reflexCNS1;73SET OF CODES0:No
1:Yes
8:NA, examination not done
9:Unknown
Record all findings from the neurological examination that evaluated the status of the tumor.
1273other abnormal reflexesCNS1;74SET OF CODES0:No
1:Yes
8:NA, examination not done
9:Unknown
Record all findings from the neurological examination that evaluated the status of the tumor.
1274angiographyCNS1;75SET OF CODES0: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.
1275computed tomography (ct) scanCNS1;76SET OF CODES0: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.
1276ct scan of spineCNS1;77SET OF CODES0: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.
1277electroencephalography (eeg)CNS1;78SET OF CODES0: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.
1278isotope brain scanCNS1;79SET OF CODES0: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.
1279positron emission tomographyCNS1;80SET OF CODES0: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.
1280spect scanCNS1;81SET OF CODES0: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.
1281mri of brainCNS1;82SET OF CODES0: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.
1282mri of spineCNS1;83SET OF CODES0: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.
1283functional mriCNS1;84SET OF CODES0: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.
1284myelographyCNS1;85SET OF CODES0: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.
1285magnetic res spectroscopyCNS1;86SET OF CODES0: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.
1286frontal lobeCNS2;1SET OF CODES0: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.
1287temporal lobeCNS2;2SET OF CODES0: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.
1288parietal lobeCNS2;3SET OF CODES0: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.
1289occipital lobeCNS2;4SET OF CODES0: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.
1290optic nervesCNS2;5SET OF CODES0: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.
1291pituitary glandCNS2;6SET OF CODES0: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.
1292pineal glandCNS2;7SET OF CODES0: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.
1293cerebellumCNS2;8SET OF CODES0: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.
1294brain stemCNS2;9SET OF CODES0: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.
1295skull baseCNS2;10SET OF CODES0: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.
1296other skullCNS2;11SET OF CODES0: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.
1297spinal cordCNS2;12SET OF CODES0: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.
1298cerebral spinal fluid (csf)CNS2;13SET OF CODES0: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.
1299cranial meningesCNS2;14SET OF CODES0: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.
1300spinal meningesCNS2;15SET OF CODES0: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.
1301other tumor loc/involvementCNS2;16SET OF CODES0: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.
1302leftCNS2;17SET OF CODES0: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.
1303rightCNS2;18SET OF CODES0: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.
1304midlineCNS2;19SET OF CODES0: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.
1305number of tumorsCNS2;20SET OF CODES1:One tumor only
2:Multiple tumors
9:Unknown
This field describes whether the tumor is singular or multiple.
1306date of first symptomsCNS2;21DATE-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.
1307date of pathologic diagnosisCNS2;22DATE-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.
1308who histological clCNS2;23POINTER164.9 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.
1309molecular markersCNS2;24SET OF CODES0: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.
1310tumor size (source)CNS2;25SET OF CODES0: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.
1311karnofsky's rating prior to txCNS2;26POINTER164.17 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.
1312protocol participation (cns)CNS2;27SET OF CODES00: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.
1313protocol phaseCNS2;28SET OF CODES0: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.
1314none, no non-ca dir surgeryCNS2;29SET OF CODES0: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.
1315ventriculostomy/ext vent drainCNS2;30SET OF CODES0: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.
1316csf shunt/ventriculoperitonealCNS2;31SET OF CODES0: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.
1317csf shunt/3rd ventriculostomyCNS2;32SET OF CODES0: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.
1318csf shunt/otherCNS2;33SET OF CODES0: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.
1319stereotactic biopsyCNS2;34SET OF CODES0: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.
1320open brain biopsyCNS2;35SET OF CODES0: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.
1321open bx of spincal cord tumorCNS2;36SET OF CODES0: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.
1322laminectomy w/o resect/duraCNS2;37SET OF CODES0: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.
1323laminectomy w/o resect w duraCNS2;38SET OF CODES0: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.
1324surgery, nosCNS2;39SET OF CODES0: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.
1325unknown if surgery doneCNS2;40SET OF CODES0: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.
1326surgical approach (cns)CNS2;41SET OF CODES0: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.
1327extent of surgical resectionCNS2;42SET OF CODES0: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.
1328size of residual tumorCNS2;43NUMERIC 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
1329size of res tumor (source)CNS2;44SET OF CODES0: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.
1330anesthetic problemCNS2;45SET OF CODES0: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.
1331hemorrhage at operative siteCNS2;46SET OF CODES0: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.
1332seizureCNS2;47SET OF CODES0: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.
1333infection(s)CNS2;48SET OF CODES0: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.
1334dvt (deep venous thrombosis)CNS2;49SET OF CODES0: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.
1335persistent neurol worseningCNS2;50SET OF CODES0: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.
1336total radiation dose (cgy)CNS2;51SET OF CODES0: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.
1337type of ext beam radiationCNS2;52SET OF CODES0: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.
1338interstitial rad/brachytherapyCNS2;53SET OF CODES0: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.
1339stereotactic radiosurgeryCNS2;54SET OF CODES0: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.
1340skin reactionsCNS2;55SET OF CODES0: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.
1341anorexiaCNS2;56SET OF CODES0: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.
1342nausea or vomitingCNS2;57SET OF CODES0: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.
1343fatigueCNS2;58SET OF CODES0: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.
1344neurologic worseningCNS2;59SET OF CODES0: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.
1345radiation therapyCNS2;60SET OF CODES0: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.
1346procarbazineCNS2;61SET OF CODES0:No
1:Yes
8:NA, chemotherapy not administered
9:Unknown
This field describes one type of chemotherapeutic agent administered to the patient.
1347ccnuCNS2;62SET OF CODES0:No
1:Yes
8:NA, chemotherapy not administered
9:Unknown
This field describes one type of chemotherapeutic agent administered to the patient.
1348vincristineCNS2;63SET OF CODES0:No
1:Yes
8:NA, chemotherapy not administered
9:Unknown
This field describes one type of chemotherapeutic agent administered to the patient.
1349hydroxyureaCNS2;64SET OF CODES0:No
1:Yes
8:NA, chemotherapy not administered
9:Unknown
This field describes one type of chemotherapeutic agent administered to the patient.
1350bcnuCNS2;65SET OF CODES0:No
1:Yes
8:NA, chemotherapy not administered
9:Unknown
This field describes one type of chemotherapeutic agent administered to the patient.
1351bcnu wafer implantCNS2;66SET OF CODES0:No
1:Yes
8:NA, chemotherapy not administered
9:Unknown
This field describes one type of chemotherapeutic agent administered to the patient.
1352vp-16CNS2;67SET OF CODES0:No
1:Yes
8:NA, chemotherapy not administered
9:Unknown
This field describes one type of chemotherapeutic agent administered to the patient.
1353carboplatinCNS2;68SET OF CODES0:No
1:Yes
8:NA, chemotherapy not administered
9:Unknown
This field describes one type of chemotherapeutic agent administered to the patient.
1354temozolomideCNS2;69SET OF CODES0:No
1:Yes
8:NA, chemotherapy not administered
9:Unknown
This field describes one type of chemotherapeutic agent administered to the patient.
1355cpt-11CNS2;70SET OF CODES0:No
1:Yes
8:NA, chemotherapy not administered
9:Unknown
This field describes one type of chemotherapeutic agent administered to the patient.
1356tamoxifenCNS2;71SET OF CODES0:No
1:Yes
8:NA, chemotherapy not administered
9:Unknown
This field describes one type of chemotherapeutic agent administered to the patient.
1357cytarabine (ara-c)CNS2;72SET OF CODES0:No
1:Yes
8:NA, chemotherapy not administered
9:Unknown
This field describes one type of chemotherapeutic agent administered to the patient.
1358chemotherapeutic routeCNS2;73SET OF CODES1: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.
1359hearing lossCNS2;74SET OF CODES0:No
1:Yes
8:NA, chemotherapy not administered
9:Unknown
This field describes one of the complications which resulted from the administration of chemotherapy.
1360infectionCNS2;75SET OF CODES0:No
1:Yes
8:NA, chemotherapy not administered
9:Unknown
This field describes one of the complications which resulted from the administration of chemotherapy.
1361nausea and vomitingCNS2;76SET OF CODES0:No
1:Yes
8:NA, chemotherapy not administered
9:Unknown
This field describes one of the complications which resulted from the administration of chemotherapy.
1362blood count drop/bleedingCNS2;77SET OF CODES0:No
1:Yes
8:NA, chemotherapy not administered
9:Unknown
This field describes one of the complications which resulted from the administration of chemotherapy.
1363peripheral neuropathyCNS2;78SET OF CODES0:No
1:Yes
8:NA, chemotherapy not administered
9:Unknown
This field describes one of the complications which resulted from the administration of chemotherapy.
1364renal failureCNS2;79SET OF CODES0:No
1:Yes
8:NA, chemotherapy not administered
9:Unknown
This field describes one of the complications which resulted from the administration of chemotherapy.
1365pulmonary toxicityCNS2;80SET OF CODES0:No
1:Yes
8:NA, chemotherapy not administered
9:Unknown
This field describes one of the complications which resulted from the administration of chemotherapy.
1366other chemo complicationsCNS2;81SET OF CODES0:No
1:Yes
8:NA, chemotherapy not administered
9:Unknown
This field describes one of the complications which resulted from the administration of chemotherapy.
1367karnofsky's rating @ dis/transCNS2;82POINTER164.17 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.
1368date of progressionCNS2;83DATE-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.
1369type of progressionCNS2;84SET OF CODES0: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.
1370recurrence/progression docCNS2;85SET OF CODES0: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
1371karnofsky's rating recurrenceCNS2;86POINTER164.17 This field describes the patient's physical status at the time that either recurrence or progression was noted.
1372type of 1st recurrence/cnsCNS2;87SET OF CODES0: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.
1373protocol participation (subtx)CNS2;88SET OF CODES00: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.
1374type of subsequent surgical txCNS2;89SET OF CODES0: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.
1375type of subsequent radiationCNS2;90SET OF CODES0: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.
1376procarbazine (sub tx)CNS3;1SET OF CODES0: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.
1377ccnu (sub tx)CNS3;2SET OF CODES0: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.
1378vincristine (sub tx)CNS3;3SET OF CODES0: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.
1379hydroxyurea (sub tx)CNS3;4SET OF CODES0: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.
1380methotrexate (sub tx)CNS3;5SET OF CODES0: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.
1381cisplatin (sub tx)CNS3;6SET OF CODES0: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.
1382bcnu (sub tx)CNS3;7SET OF CODES0: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.
1383bcnu wafer implant (sub tx)CNS3;8SET OF CODES0: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.
1384vp-16 (sub tx)CNS3;9SET OF CODES0: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.
1385carboplatin (sub tx)CNS3;10SET OF CODES0: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.
1386temozolomide (sub tx)CNS3;11SET OF CODES0: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.
1387cyclophosphamide (sub tx)CNS3;12SET OF CODES0: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.
1388cpt-11 (sub tx)CNS3;13SET OF CODES0: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.
1389tamoxifen (sub tx)CNS3;14SET OF CODES0: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.
1390interferon (sub tx)CNS3;15SET OF CODES0: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.
1391cytarabine (ara-c) (sub tx)CNS3;16SET OF CODES0: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.
1392other chemotherapy (sub tx)CNS3;17SET OF CODES0: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.
1393other subsequent treatmentCNS3;18SET OF CODES0: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.
1394tumor sizeCNS3;19NUMERIC 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
1400lng co-morbid condition 1LUN1;1POINTER80 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.
1400.1lng co-morbid condition 2LUN1;2POINTER80 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.
1400.2lng co-morbid condition 3LUN1;3POINTER80 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.
1400.3lng co-morbid condition 4LUN1;4POINTER80 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.
1400.4lng co-morbid condition 5LUN1;5POINTER80 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.
1400.5lng co-morbid condition 6LUN1;6POINTER80 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.
1400.6lng co-morbid condition y/n(+)LUN1;76BOOLEAN0: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.
1401lng duration of tobacco useLUN1;7FREE 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
1402lng date of first tissue dxLUN1;8DATE-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.
1403lng personal hist oth maligLUN1;9POINTER164 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
1404lng coughLUN1;10SET OF CODES1: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.
1404.1lng shortness of breathLUN1;11SET OF CODES1: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.
1404.2lng weight lossLUN1;12SET OF CODES1: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.
1404.3lng hemoptysisLUN1;13SET OF CODES1: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.
1404.4lng palpable lymph nodesLUN1;14SET OF CODES1: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.
1405lng chest x-rayLUN1;15SET OF CODES1: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.
1405.1lng ct scanLUN1;16SET OF CODES1: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.
1405.2lng bronchoscopyLUN1;17SET OF CODES1: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.
1406lng history and physicalLUN1;18SET OF CODES1: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.
1406.1lng bronchoscopy pre-therapyLUN1;19SET OF CODES1: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.
1406.2lng fnabLUN1;20SET OF CODES1: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.
1406.3lng mediastinoscopyLUN1;21SET OF CODES1: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.
1406.4lng thorocotomy/open biopsyLUN1;22SET OF CODES1: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.
1406.5lng vatsLUN1;23SET OF CODES1: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.
1407lng fvcLUN1;24NUMERIC 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.
1407.1lng fevLUN1;25NUMERIC 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.
1408lng liver function testsLUN1;26SET OF CODES1: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.
1409lng bone scanLUN1;27SET OF CODES1:Performed
2:Not performed
9:Requested, not documented if performed
This item records whether or not a bone scan was performed.
1409.1lng emphysema (bone scan)LUN1;28SET OF CODES1: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.
1409.2lng vascular inv (bone scan)LUN1;29SET OF CODES1: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.
1409.3lng mediastinal ln (bone scan)LUN1;30SET OF CODES1: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.
1409.4lng tumor size (bone scan)LUN1;31FREE TEXT Record the size in millimeters of the dominant (largest) tumor as detected by the bone scan.
1409.5lng num of tumors (bone scan)LUN1;32FREE TEXT Record the number of tumor nodules found (or identified) by the bone scan.
1409.6lng metastasis (bone scan)LUN1;33SET OF CODES1: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.
1410lng ct scan of chestLUN1;34SET OF CODES1:Performed
2:Not performed
9:Requested, not documented if performed
This item records whether or not a CT scan of the chest was performed.
1410.1lng emphysema (chest ct)LUN1;35SET OF CODES1: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.
1410.2lng vascular inv (chest ct)LUN1;36SET OF CODES1: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.
1410.3lng mediastinal ln (chest ct)LUN1;37SET OF CODES1: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.
1410.4lng tumor size (chest ct)LUN1;38FREE TEXT Record the size in millimeters of the dominant (largest) tumor as detected by the CT scan of the chest.
1410.5lng num of tumors (chest ct)LUN1;39FREE TEXT Record the number of tumor nodules found (or identified) by the CT scan of the chest.
1410.6lng metastasis (chest ct)LUN1;40SET OF CODES1: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.
1411lng ct scan of brainLUN1;41SET OF CODES1:Performed
2:Not performed
9:Requested, not documented if performed
This item records whether or not a CT scan of the brain was performed.
1411.1lng emphysema (brain ct)LUN1;42SET OF CODES1: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.
1411.2lng vascular inv (brain ct)LUN1;43SET OF CODES1: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.
1411.3lng mediastinal ln (brain ct)LUN1;44SET OF CODES1: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.
1411.4lng tumor size (brain ct)LUN1;45FREE TEXT Record the size in millimeters of the dominant (largest) tumor as detected by the CT scan of the brain.
1411.5lng num of tumors (brain ct)LUN1;46FREE TEXT Record the number of tumor nodules found (or identified) by the CT scan of the brain.
1411.6lng metastasis (brain ct)LUN1;47SET OF CODES1: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.
1412lng mri scan of chestLUN1;48SET OF CODES1:Performed
2:Not performed
9:Requested, not documented if performed
This item records whether or not a MRI scan of the chest was performed.
1412.1lng emphysema (chest mri)LUN1;49SET OF CODES1: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.
1412.2lng vascular inv (chest mri)LUN1;50SET OF CODES1: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.
1412.3lng mediastinal ln (chest mri)LUN1;51SET OF CODES1: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.
1412.4lng tumor size (chest mri)LUN1;52FREE TEXT Record the size in millimeters of the dominant (largest) tumor as detected by the MRI scan of the chest.
1412.5lng num of tumors (chest mri)LUN1;53FREE TEXT Record the number of tumor nodules found (or identified) by the MRI scan of the chest.
1412.6lng metastasis (chest mri)LUN1;54SET OF CODES1: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.
1413lng mri scan of brainLUN1;55SET OF CODES1:Performed
2:Not performed
9:Requested, not documented if performed
This item records whether or not a MRI scan of the brain was performed.
1413.1lng emphysema (brain mri)LUN1;56SET OF CODES1: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.
1413.2lng vascular inv (brain mri)LUN1;57SET OF CODES1: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.
1413.3lng mediastinal ln (brain mri)LUN1;58SET OF CODES1: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.
1413.4lng tumor size (brain mri)LUN1;59FREE TEXT Record the size in millimeters of the dominant (largest) tumor as detected by the MRI scan of the brain.
1413.5lng num of tumors (brain mri)LUN1;60FREE TEXT Record the number of tumor nodules found (or identified) by the MRI scan of the brain.
1413.6lng metastasis (brain mri)LUN1;61SET OF CODES1: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.
1414lng pet scanLUN1;62SET OF CODES1:Performed
2:Not performed
9:Requested, not documented if performed
This item records whether or not a PET (positron emission tomography) scan was performed.
1414.1lng emphysema (pet scan)LUN1;63SET OF CODES1: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.
1414.2lng vascular inv (pet scan)LUN1;64SET OF CODES1: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.
1414.3lng mediastinal ln (pet scan)LUN1;65SET OF CODES1: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.
1414.4lng tumor size (pet scan)LUN1;66FREE TEXT Record the size in millimeters of the dominant (largest) tumor as detected by the PET (positron emission tomography) scan.
1414.5lng num of tumors (pet scan)LUN1;67FREE TEXT Record the number of tumor nodules found (or identified) by the PET (positron emission tomography) scan.
1414.6lng metastasis (pet scan)LUN1;68SET OF CODES1: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.
1415lng x-ray of chestLUN1;69SET OF CODES1:Performed
2:Not performed
9:Requested, not documented if performed
This item records whether or not a chest x-ray was performed.
1415.1lng emphysema (chest xray)LUN1;70SET OF CODES1: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.
1415.2lng vascular inv (chest xray)LUN1;71SET OF CODES1: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.
1415.3lng mediastinal (chest xray)LUN1;72SET OF CODES1: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.
1415.4lng tumor size (chest xray)LUN1;73FREE TEXT Record the size in millimeters of the dominant (largest) tumor as detected by the X-ray of the chest.
1415.5lng num of tumors (chest xray)LUN1;74FREE TEXT Record the number of tumor nodules found (or identified) by the X-ray of the chest.
1415.6lng metastasis (chest xray)LUN1;75SET OF CODES1: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.
1416lng high mediastinal (pre-op)LUN2;1SET OF CODES1: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.
1416.1lng upper paratrach (pre-op)LUN2;2SET OF CODES1: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.
1416.2lng prevasc/retro (pre-op)LUN2;3SET OF CODES1: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.
1416.3lng lower paratrach (pre-op)LUN2;4SET OF CODES1: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.
1416.4lng subaortic (pre-op)LUN2;5SET OF CODES1: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.
1416.5lng paraortic (pre-op)LUN2;6SET OF CODES1: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.
1416.6lng subcarinal (pre-op)LUN2;7SET OF CODES1: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.
1416.7lng paraesophageal (pre-op)LUN2;8SET OF CODES1: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.
1416.8lng pulmonary lig (pre-op)LUN2;9SET OF CODES1: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.
1417lng frozen sectionLUN2;10SET OF CODES1: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.
1418lng vascular invasionLUN2;11SET OF CODES1:Structure not involved
2:Yes, structure involved
9:Not documented
This item describes any tumor invasion of the vascular structure.
1418.1lng lymphatics invasionLUN2;12SET OF CODES1:Structure not involved
2:Yes, structure involved
9:Not documented
This item describes any tumor invasion of the lymphatics structure.
1418.2lng pleura invasionLUN2;13SET OF CODES1:Structure not involved
2:Yes, structure involved
9:Not documented
This item describes any tumor invasion of the pleura structure.
1418.3lng chest wall invasionLUN2;14SET OF CODES1:Structure not involved
2:Yes, structure involved
9:Not documented
This item describes any tumor invasion of the chest wall.
1418.4lng other invasionLUN2;15SET OF CODES1:Structure not involved
2:Yes, structure involved
9:Not documented
This item describes any tumor invasion of any other structure.
1419lng high mediastinal (scope)LUN2;16SET OF CODES1: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.
1419.1lng upper paratracheal (scope)LUN2;17SET OF CODES1: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.
1419.2lng prevasc/retrotrach (scope)LUN2;18SET OF CODES1: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.
1419.3lng lower paratracheal (scope)LUN2;19SET OF CODES1: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.
1419.4lng subaortic (scope)LUN2;20SET OF CODES1: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.
1419.5lng paraortic (scope)LUN2;21SET OF CODES1: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.
1419.6lng subcarinal (scope)LUN2;22SET OF CODES1: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.
1419.7lng paraesophageal (scope)LUN2;23SET OF CODES1: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.
1419.8lng pulmonary ligament (scope)LUN2;24SET OF CODES1: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.
1420lng peri-operative blood repLUN2;25FREE 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.
1421lng peri-operative deathLUN2;26SET OF CODES1: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.
1422lng boost dose (cgy)LUN2;27FREE 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
1423chemotherapeutic agent #1LUN2;28POINTER164.18 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.
1423.1chemotherapeutic agent #2LUN2;29POINTER164.18 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.
1423.2chemotherapeutic agent #3LUN2;30POINTER164.18 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.
1423.3chemotherapeutic agent #4LUN2;44POINTER164.18 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.
1423.4chemotherapeutic agent #5LUN2;45POINTER164.18 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.
1424lng chemotherapeutic toxicityLUN2;31SET OF CODES1: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.
1425lng chemotherapy/surg sequenceLUN2;32SET OF CODES1: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.
1426lng complication #1LUN2;33POINTER80 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)
1426.1lng complication #2LUN2;34POINTER80 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)
1426.2lng complication #3LUN2;35POINTER80 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)
1426.3lng complication #4LUN2;36POINTER80 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)
1426.4lng complication #5LUN2;37POINTER80 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)
1426.5lng treatment complication y/n(+)LUN2;40BOOLEAN0: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.
1427lng case abstractor initialsLUN2;38FREE 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.
1428lng date case was abstractedLUN2;39DATE-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.
1429lng proximal marginLUN2;41FREE 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
1429.1lng distal marginLUN2;42FREE 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
1430lng hct val before transfusionLUN2;43NUMERIC 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
1500gas prior exposure to radGAS1;1SET OF CODES1: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.
1501gas alcohol comsumptionGAS1;2FREE 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
1502gas menopausal status/hor txGAS1;3SET OF CODES1: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.
1503gas h2 blocker/proton pumpGAS1;4SET OF CODES1: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).
1504gas family hist of gastric caGAS1;5SET OF CODES1: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).
1505gas h-pylori infectionGAS1;6SET OF CODES1: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
1506gas duodenal ulcerGAS1;7SET OF CODES1: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
1507gas gastric ulcerGAS1;8SET OF CODES1: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
1508gas heartburn (benign cond)GAS1;9SET OF CODES1: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
1509gas pernicious anemiaGAS1;10SET OF CODES1: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
1510gas polyps of stomachGAS1;11SET OF CODES1: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
1511gas polyposis of bowelGAS1;12SET OF CODES1: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
1512gas barret's esophagusGAS1;13SET OF CODES1: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
1513gas atrophic gastritisGAS1;14SET OF CODES1: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
1514gas gastric metaplasiaGAS1;15SET OF CODES1: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
1515gas antibioticsGAS1;16SET OF CODES1: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.
1516gas proton pump inhibitorsGAS1;17SET OF CODES1: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.
1517gas h2 blockersGAS1;18SET OF CODES1: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).
1518gas bismuth compoundsGAS1;19SET OF CODES1: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.
1519gas prior intra-abdominal surgGAS1;20SET OF CODES1: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.
1520gas year of gastric resectionGAS1;21FREE 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
1521gas performance status at dxGAS1;22SET OF CODES1: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.
1522gas heartburn (symptoms)GAS1;23SET OF CODES1: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.
1523gas fever/night sweatsGAS1;24SET OF CODES1: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.
1524gas acute hematemesisGAS1;25SET OF CODES1: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.
1525gas transfusions for bld lossGAS1;26SET OF CODES1: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.
1526gas melenaGAS1;27SET OF CODES1: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.
1527gas painGAS1;28SET OF CODES1: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.
1528gas early satietyGAS1;29SET OF CODES1: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.
1529gas ct scan of abdomenGAS1;30SET OF CODES1: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.
1530gas ct scan of chestGAS1;31SET OF CODES1: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.
1531gas ct pelvisGAS1;32SET OF CODES1: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.
1532gas chest x-rayGAS1;33SET OF CODES1: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.
1533gas gallium scanGAS1;34SET OF CODES1: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.
1534gas bipedal lymphangiogramGAS1;35SET OF CODES1: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.
1535gas mriGAS1;36SET OF CODES1: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.
1536gas pet scanGAS1;37SET OF CODES1: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.
1537gas laparoscopyGAS1;38SET OF CODES1: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.
1538gas eusGAS1;39SET OF CODES1: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.
1539gas peritoneal lavageGAS1;40SET OF CODES1: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.
1540gas ldh (iu/l)GAS1;41NUMERIC 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
1541gas cea (ng/ml)GAS1;42NUMERIC 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
1542gas ca125 (u/ml)GAS1;43NUMERIC 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
1543gas beta2 microglobulinGAS1;44NUMERIC 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
1544gas urinary 5-hiaa (mg/24hr)GAS1;45NUMERIC 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
1545gas clinical/visual examGAS1;46SET OF CODES1: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.
1545.1gas biopsyGAS1;47SET OF CODES1: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.
1546gas gastro-esophageal junctionGAS1;48SET OF CODES1: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.
1547gas stomachGAS1;49SET OF CODES1: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.
1547.1gas liverGAS1;50SET OF CODES1: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.
1547.2gas extra-abdominalGAS1;51SET OF CODES1: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.
1547.3gas lymph nodesGAS1;52SET OF CODES1: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.
1547.4gas peritoneumGAS1;53SET OF CODES1: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.
1548gas date of first tissue dxGAS1;54DATE-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.
1549gas lauren's classificationGAS1;55SET OF CODES1: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.
1550gas goseki's classificationGAS1;56SET OF CODES1: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.
1551gas gastrinGAS1;57SET OF CODES1: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.
1551.1gas 5-hiaaGAS1;58SET OF CODES1: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.
1551.2gas ceaGAS1;59SET OF CODES1: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.
1551.3gas ca125GAS1;60SET OF CODES1: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.
1551.4gas other molecular markerGAS1;61SET OF CODES1: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.
1552gas mitotic rateGAS1;62SET OF CODES1:< 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).
1553gas tumor necrosisGAS1;63SET OF CODES1: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.
1554gas flow cytometry/fresh tissGAS1;64SET OF CODES1: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.
1554.1gas immunohistochem/frozen tisGAS1;65SET OF CODES1: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.
1554.2gas immunohistochem/paraffinGAS1;66SET OF CODES1: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.
1554.3gas molecular geneticsGAS1;67SET OF CODES1: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.
1554.4gas polymerase chain reactionGAS1;68SET OF CODES1: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.
1554.5gas southern blot techniqueGAS1;69SET OF CODES1: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.
1555gas ann arbor stagingGAS1;70SET OF CODES1: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).
1556gas adherence of resected primGAS1;71SET OF CODES1: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.
1557gas margin stat of resect primGAS1;72SET OF CODES1: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.
1558gas proximal marginGAS1;73FREE 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
1558.1gas distal marginGAS1;74FREE 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
1559gas spleenGAS2;1SET OF CODES1: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.
1559.1gas transverse colonGAS2;2SET OF CODES1: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.
1559.2gas liverGAS2;3SET OF CODES1: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.
1559.3gas diaphragmGAS2;4SET OF CODES1: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.
1559.4gas pancreasGAS2;5SET OF CODES1: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.
1559.5gas abdominal wallGAS2;6SET OF CODES1: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.
1559.6gas adrenal glandGAS2;7SET OF CODES1: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.
1559.7gas kidneyGAS2;8SET OF CODES1: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.
1559.8gas small intestineGAS2;9SET OF CODES1: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.
1559.9gas retroperitoneumGAS2;10SET OF CODES1: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.
1560gas perigastric lymph nodesGAS2;11SET OF CODES2: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.
1560.1gas common hepatic lymph nodesGAS2;12SET OF CODES2: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.
1560.2gas celiac lymph nodesGAS2;13SET OF CODES2: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.
1560.3gas splenic lymph nodesGAS2;14SET OF CODES2: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.
1560.4gas other intra-abdominal ndesGAS2;15SET OF CODES2: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.
1561gas grossly involved reg lnGAS2;16SET OF CODES1: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.
1562gas hct val before transfusionGAS2;17NUMERIC 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
1563gas total operative blood replGAS2;18FREE TEXTThis 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
1564gas intra/peri-operative deathGAS2;19SET OF CODES1: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.
1565gas anastomatic leakGAS2;20SET OF CODES1: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.
1565.1gas stump leakGAS2;21SET OF CODES1: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.
1565.2gas bleedingGAS2;22SET OF CODES1: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.
1565.3gas wound infectionGAS2;23SET OF CODES1: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.
1565.4gas sepsisGAS2;24SET OF CODES1: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.
1565.5gas pancreatitisGAS2;25SET OF CODES1: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.
1565.6gas dead bowelGAS2;26SET OF CODES1: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.
1565.7gas other complicationsGAS2;27SET OF CODES1: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.
1566gas date of surgical dischargeGAS2;28DATE-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.
1567gas intra-operative radiationGAS2;29FREE 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
1568gas concurrent chemotherapyGAS2;30SET OF CODES1: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.
1569gas intraperitoneal cmxGAS2;31SET OF CODES1: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.
1570gas admin of interferonGAS2;32SET OF CODES1:Administered
2:Not administered
9:Not documented
This item describes whether the patient was administered Interferon to treat the primary tumor.
1571gas co-morbid condition 1GAS2;33POINTER80 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.
1571.1gas co-morbid condition 2GAS2;34POINTER80 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.
1571.2gas co-morbid condition 3GAS2;35POINTER80 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.
1571.3gas co-morbid condition 4GAS2;36POINTER80 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.
1571.4gas co-morbid condition 5GAS2;37POINTER80 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.
1571.5gas co-morbid condition 6GAS2;38POINTER80 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.
1572gas duration of tobacco useGAS2;39FREE 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
1573gas personal hist oth maligGAS2;40POINTER164 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
1574gas weight lossGAS2;41SET OF CODES1: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.
1575gas boost dose (cgy)GAS2;42FREE 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
1576gas chemotherapeutic agent #1GAS2;43POINTER164.18 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.
1576.1gas chemotherapeutic agent #2GAS2;44POINTER164.18 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.
1576.2gas chemotherapeutic agent #3GAS2;45POINTER164.18 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.
1577gas chemotherapeutic toxicityGAS2;46SET OF CODES1: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.
1578gas chemotherapy/surg sequenceGAS2;47SET OF CODES1: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.
1579gas complication #1GAS2;48POINTER80 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)
1579.1gas complication #2GAS2;49POINTER80 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)
1579.2gas complication #3GAS2;50POINTER80 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)
1579.3gas complication #4GAS2;51POINTER80 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)
1579.4gas complication #5GAS2;52POINTER80 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)
2000division(+)DIV;1POINTER4 DIVISION is the division to which this primary belongs.
3000class of case conversion flagCONV;1SET OF CODES1:Converted
Indicates that the CLASS OF CASE value has been converted to NAACCR v12.
3001state at dx conversion flagCONV;2SET OF CODES1:Converted
Indicates that the STATE AT DX value has been converted to NAACCR v12.

Referenced by 1 types

  1. COMPUTED PRIMARY (165.59) -- site/gp*