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Introduction to the Tennessee Cancer Registry for Cancer Care Abstractors

Module 2: Reporting

Medical FilesThis module consists of 4 units. Unit 2.1 provides basic information about which healthcare facilities are responsible for reporting cancer cases and maintaining confidentiality. Unit 2.2 refers users to the International Classification of Diseases for Oncology, Third Edition (ICD-O-3): the list source for reportable tumors. Unit 2.3 categorizes the information collected by cancer registrars. Unit 2.4 offers a basic list of medical record reports from which cancer registrars can find patient and cancer information.

After completing this module, cancer abstractors will be able to:

  • Recognize if a healthcare facility is responsible for reporting a case.
  • Know where to find the list of reportable tumors.
  • Know which categories of cancer information to collect.
  • Know where to find this cancer information.

Unit 2.1: Who Reports the Information?

Healthcare Facilities

  • Hospitals
  • Outpatient Surgery Centers
  • Labs
  • Diagnostic & Treatment Centers

Healthcare Practitioners

  • Diagnose or Treat Cancer

By law, all cancer cases diagnosed and/or treated at these type facilities are required to be reported to the Tennessee Cancer Registry. (See Tennessee Cancer Reporting Act.)

Cancer data are highly confidential. Therefore, one of the most important responsibilities of cancer registry professionals is to protect the confidentiality of cancer patient information. (See HIPAA Privacy Rule.)

Unit 2.2: Reportable Malignancies

The reportable tumors are those that are listed in the International Classification of Diseases for Oncology, Third Edition (ICD-O-3) which have a behavior defined as in situ (behavior code = /2) or invasive (behavior code = /3). Beginning with Jan 1, 2004, all benign CNS tumors are also required to be reported.

Unit 2.3: What Information Is Reported?

The information collected by cancer registries can be placed into different categories:

Patient Information:

  • Demographics: name, date of birth, gender, race ethnicity, place of birth, etc. This information identifies the cancer patient and helps to prevent duplicate reporting.
  • Risks: Occupation and Industry.

Cancer Information:

  • Primary Site Identification: Breast / Lung / Colon / Prostate, etc.
  • Histology (Cell Type): Adenocarcinoma, Squamous Cell Carcinoma, etc.
  • Stage: Extent of Disease – local , regional, distant
  • Treatment: surgery, radiation therapy, chemotherapy, hormone, immunotherapy, etc.

Administrative Information

  • Reporting Facility – important for Quality Assurance(QA) follow-back
  • Abstractor – important for QA follow-back
  • Attending Physician – important for QA follow-back
     

Unit 2.4: Where Is The Information Found?

Cancer information is found in the medical record

  • Face Sheet
  • H & P
  • Imaging
  • Operative Report
  • Pathology Report
  • Consult Reports

Diagnostic and clinical findings, dates, surgical procedures, and treatment information can be identified by analyzing documents in the medical record.

Cancer data collection is a time and labor-intensive effort, but the great value of its product, cancer statistics, makes all of the hard work worthwhile.

Module 2: Review & Quiz

Review for Module 2

Cancer data is placed into different categories:

  • Demographic information relates personal facts about the patient e.g. name, date of birth, gender, race ethnicity, place of birth, etc.
  • Cancer information relates specific information about the type of cancer and the extent of disease e.g. primary site identification, histology (cell type), local regional or distant spread of disease.
  • Treatment information identifies the methods utilized to eradicate or control the disease e.g. surgery, radiation therapy, chemotherapy, hormone, immunotherapy, etc.
  • Administrative information is used to run reports and for registry specific purposes.

 
The collection of data begins with the diagnosis of cancer. Facilities that diagnose and/or treat cancer patients are required by law, the Tennessee Cancer Reporting Act of 1983, to report cases and provide cancer data to the Tennessee Cancer Registry.

To protect the confidentiality of cancer patients, physicians, and health care facilities, relevant regulations, policies, and laws are strictly implemented to standardize the handling of information in cancer registries.

Quiz for Module 2

Click here to take the  Module 2 Quiz.