Abstracting Guide

Standards for Cancer Registries

NAACCR Data Standards and Data Dictionary v23

NAACCR Recommended Abbreviation List

Ordered by Abbreviation Symbol

Context-Sensitive Abbreviations

The main principle is one should be able to enter abstract codes from one’s written text. Therefore, put the text in first and then code the abstract. If unable to code the data field from the text, refer back to the medical record and revise the text.

The second principle is to include only the text that is relevant to the specific cancer that is abstracted. For example, if the cancer is a lymphoma include information on HIV and B symptoms. This information is not relevant and should not be included in text for a breast cancer abstract. If a patient has more than one primary diagnosed at the same time, do not enter information for other primaries in the same abstract. Only include text information for the specific cancer that is coded on the abstract. It is tempting to put text in one abstract for both primaries and copy text to next tumor…. DON’T DO THIS!!!

The third principle is to Date all relative fields: all procedures and PE.

The following is a brief outline of relevant information and format to use for the basic text fields in an abstract.

PE: date and location of visit, age, sex, race, marital status, brief description of symptoms relevant to specific cancer, where patient resided at diagnosis, if not diagnosed at your facility, and patient’s previous history of reportable cancers, insurance.

Xray/Scans: date and location, type of scan, relevant findings of mass; size, position in organ, organs or structures within normal limits, impression with qualifying terms used to identify cancer. If nothing is found on scans, state Negative.

Labs: date and test type. Only information relative to tumor with ranges. Specifically: Breast ER, PR, Her2; Prostate: PSA; Colon & Rectum: CEA; Testis & Liver: AFP; Ovary: CA-125; Kaposi Sarcoma & Lymphoma: HIV/AIDS and B symptoms; Hematopoietic: blood work relevant to diagnosis. If the test is not done, text should state test name, not done with field coded appropriately as not done; if test is not in the medical record, state test name, not in MR and code appropriately as unknown in abstract field. Whatever code is entered in the abstract must have text documentation! Include text for applicable SSDIs.

Pathology report: date, path lab name if not your facility, path number, name of tissue, laterality, final diagnosis histology, grade, tumor size, number lymph nodes positive and negative, and margins. If more information is required to code lymph node information include this also, for example, extracapsular extension, size of involved lymph node for Head & Neck tumors. For all primaries, include information on tests to support coding for SSDIs.

Primary Site: specific site or subsite and laterality (for paired sites where the cancer arose). Do not code the biopsy site, if there are other areas of involvement and it is not stated that the biopsy site is the primary, particularly for head and necks tumors and lymphomas. Name the source that identified the H&N primary site using rules for determining primary site from Solid Tumor Rules, Head and Neck module.

Histology: histology name from most definitive surgical pathology final and highest grade from any specimen prior to treatment; if do not have path report, record physician’s diagnostic statement. For cases 2018 and later, follow the site specific Solid Tumor Rules.

Stage: give brief description of stage and document SEER Summary Stage and AJCC staging when possible. Always indicate physician staging when available.

Op Report: date and location, procedure name, pertinent information in report specific to cancer: location of tumor, size, if other organs and tissue in the area are mentioned as involved or normal.

Treatment: start date and location for all treatment (if estimated so state), and list surgery type, chemo/hormone/immunotherapy agents and radiation type, regional and boost modality and dose. For 2018 and later, refer to the latest version of the Standards for Oncology Registry Entry STORE Manual and the CTR Guide to Coding Radiation Therapy Treatment in the STORE, Version 4.0 for updated radiation coding instructions. Document physician name administering treatment.

Place of diagnosis: name the facility where patient was diagnosed. If diagnosed at your facility, state here.

Tumor Size Coded in Millimeters

General Codes for Tumor Size

Date of Diagnosis Estimation

GCR has reviewed the Revisions for 2010 SEER Program Coding and Staging Manual “Date of Diagnosis” document below. We have added more specific instructions (in bold type) to be followed by Georgia registrars.

We are requiring the year, month, and day of diagnosis for analytic cases. Please follow back with the physician to confirm a date or estimate as best as possible. Age at diagnosis and survival cannot be calculated without the complete YYYYMMDD diagnosis date known or estimated. This data element is critical for all analytical cases.

Please review the following document and note the more specific instructions

To: SEER Registries and other users of the SEER Program Coding and Staging Manual (SPCSM)

RE: Revisions for 2010 SEER Program Coding and Staging Manual, Section IV, NAACCR Item # 390, Date of Diagnosis, page 49

Effective Date: January 1, 2010

Revisions

Date of diagnosis must be transmitted in the YYYYMMDD format. Date of diagnosis may be recorded in the transmission format or recorded in the traditional format (MMDDYYYY) and converted electronically to the transmission format.

Regardless of the format, at least Year of diagnosis must be known or estimated for analytic cases. Year of diagnosis cannot be blank or unknown for analytic cases. Month and day cannot be blank or unknown for analytic cases.

Transmitting Dates

Transmit date fields in the year, month, day format (YYYYMMDD). Leave the month, day and/or year* blank when they cannot be estimated or are unknown.

Common Formats

Non-analytic cases only – Whenever possible, an attempt should be made to get an accurate diagnosis date from the physician or estimate the complete date. This is to be done especially for class of case 30: “reporting facility participated in diagnostic workup (consult only, staging workup after initial diagnosis elsewhere”.

Transmit Instructions

1. Transmit date fields in the year, month, day format (YYYYMMDD).
2. Leave the month, and/or day blank when they cannot be estimated or are unknown.
3. Most SEER registries collect the month, day, and year of diagnosis. When the full date (YYYYMMDD) is transmitted, the seventh and eighth digits (day) will be deleted when the data are received by SEER.

Definitions

Analytic case: Case for which the registry has information on the original diagnosis and/or the first course of treatment. For definition of first course treatment, see the 2023 SEER Program Coding and Staging Manual Section VII, First Course of Therapy.

Non-analytic case: All cases for which the registry does not have information on the original diagnosis and/or first course of treatment. Examples of those cases would be a patient who moved to your state after the original diagnosis and first course of treatment were complete and treatment was for persistent disease or metastatic disease; DCO with history of cancer, unknown when and where patient was diagnosed; follow-back gives no additional information. (Note: SEER instructions indicate an attempt at follow back should be made for non-analytic cases as well).

Instructions

Analytic cases

1. Follow-back must be done to obtain the date of diagnosis. If no information can be found, follow instruction 2.
2. Date of diagnosis must be estimated. See the SEER Program Coding and Staging Manual 2023, Date of Diagnosis, Coding Instructions, Coding instruction for estimating date of diagnosis.
3. For reports dated December or January of a given year code the month of the report or the month of admission (instruction 10a viii). Coding the month of the report or the month of admission results in a better estimate of the date of diagnosis than coding month as 99 and having the computer assign July as the month of diagnosis, for example.
4. When the diagnosis date is stated to be spring, summer, fall, or winter, follow instructions 10a i, ii, iii, and iv.

Non-Analytic Cases

Please refer to the Date of Diagnosis Estimation in the NAACCR Data Standard and Data Dictionary.

Class of Case 30 should have complete diagnosis date known or estimated.

Providing the diagnosis date at the time of reporting may positively impact the amount of your death clearance follow-back.

Consider getting your facility to update their patient information history page that a patient completes when seeing a physician or being admitted including Diagnosis of Cancer, site of cancer, date of diagnosis, where living at diagnosis (City and State)

Date of Diagnosis NAACCR Item # 390

Effective 2/1/2011
Records the date of initial diagnosis by a Health Care Professional for the tumor being reported.

Instructions for Coding

• Use the first date of diagnosis whether clinically or histologically confirmed.
• If the physician states that in retrospect the patient had cancer at an earlier date, use the earlier date as the date of diagnosis.
• Use the date therapy was started as the date of diagnosis if the patient receives a first course of treatment before a definitive diagnosis.
• The date of death is the date of diagnosis for a Class of Case 49.
• Avoid using code 9’s unknown for month, day, or year.
• Use all information in the medical record to estimate the date of diagnosis if the exact date cannot be determined. The date of initial diagnosis is the month, day, and year that this primary cancer was first diagnosed by a recognized medical practitioner. If estimated, clearly document in the text that the diagnosis date is estimated.

Class of Case (COC) 30, 31, 32, 33, 40, 41, 42, and 43 should have an accurate or estimated date of diagnosis using the following guidelines:

Diagnosis Date Estimation Guidelines