Cancer Information Management
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BrownUnit4BreastAbstractCase1.docAbstracting II
CIM 220
Breast Abstract Form
Commission on Cancer Data Set
· Reference/Manuals needed: STORE, ICD-0-3, AJCC 8th Edition, Summary Stage, EOD, SSDI, STR, Grade
· PDF page numbers for the STORE manual (or other manual, as indicated) are listed to the right of each field below. When you are in the appropriate coding manual, enter the given PDF page number in the space at the top of the manual to be taken directly to the instructions for that field.
· Read the corresponding STORE (or other manual) instructions and examples for each data field to understand the exact data required for that field.
· Code EVERY field unless leaving the field blank is appropriate and blank is one of the choices in the coding instructions for that field.
· Be aware of how many spaces, characters, etc. are required for each field.
· For the fields containing codes, an answer will not be counted as correct unless it is in the correct format.
· Fill in the text fields at the end of the abstract. You will not be graded on this portion, but this is good practice for when you are abstracting real cases. If all pertinent information has been texted, you should be able to code all the fields in your abstract from your text.
· NOTE: If there is no date to code in a date field, you may either enter all 0’s (example: 00000000) or leave the field blank.
Case Number: 1
Cancer Identification
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STORE PDF Page |
Student Answer |
Instructor Notes |
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Class of Case |
118 |
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Date of First Contact |
124 |
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Date of Initial Diagnosis |
127 |
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You will also need your STR Manual and ICD-0-3 for Primary Site & Histology |
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Primary Site |
129 |
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Laterality |
131 |
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Histology |
132 |
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Behavior Code |
133 |
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Go to Grade manual for Grade fields |
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Grade PDF Page |
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Grade Clinical |
108 |
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Grade Pathological |
112 |
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Grade Post Therapy |
115 |
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Diagnostic Confirmation |
STORE PDF Page 137 |
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Stage of Disease at Diagnosis
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STORE PDF Page |
Student Answer |
Instructor Notes |
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Date of Surgical Diagnostic and Staging Procedure |
141 |
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Surgical Diagnostic and Staging Procedure |
143 |
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Lymphovascular Invasion |
147 |
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Date of`Sentinel Lymph Node Biopsy |
154 |
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Sentinel Lymph Nodes Examined |
155 |
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Sentinel Lymph Nodes Positive |
157 |
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Date Regional Lymph Node Dissection |
159 |
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Regional Lymph Nodes Examined |
160 |
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Regional Lymph Nodes Positive |
163 |
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Tumor Size and Mets
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Tumor Size Summary |
167 |
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Mets at Diagnosis - Bone |
172 |
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Mets at Diagnosis - Brain |
174 |
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Mets at Diagnosis – Distant Lymph Nodes |
176 |
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Mets at Diagnosis - Liver |
178 |
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Mets at Diagnosis - Lung |
180 |
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Mets at Diagnosis - Other |
182 |
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Summary Stage 2018
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Summary Stage manual PDF Page 228 |
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AJCC 8th Ed TNM Stage - Use AJCC manual for TNM and Stage Group
coding instructions & AJCC TNM and Stage Group Valid Codes (in Doc Sharing) and STORE for correct data entry format.
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AJCC TNM Clin T |
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AJCC TNM Clin T Suffix |
186 |
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AJCC TNM Clin N |
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AJCC TNM Clin N Suffix |
188 |
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AJCC TNM Clin M |
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AJCC TNM Clin Stage Group |
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AJCC TNM Path T |
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AJCC TNM Path T Suffix |
198 |
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AJCC TNM Path N |
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AJCC TNM Path N Suffix |
200 |
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AJCC TNM Path M |
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AJCC TNM Path Stage Group |
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AJCC TNM Post Therapy T |
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AJCC TNM Post Therapy T Suffix |
204 |
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AJCC TNM Post Therapy N |
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AJCC TNM Post Therapy N Suffix |
206 |
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AJCC TNM Post Therapy M |
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AJCC TNM Post Therapy Stage Group |
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GO to EOD breast schema
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EOD Primary Tumor |
EOD breast schema |
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EOD Regional Nodes |
EOD breast schema |
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EOD Mets |
EOD breast schema |
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Site-Specific Data Items
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Go SSDI Manual |
SSDI PDF Page |
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ER Summary |
202 |
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ER Percent Positive or Range |
204 |
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ER Total Allred Score |
206 |
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PR Summary |
208 |
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PR Percent Positive or Range |
210 |
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PR Total Allred Score |
212 |
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HER2 Overall Summary |
221 |
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Oncotype Dx Recurrence Score-DCIS |
237 |
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Oncotype Dx Risk Level-DCIS |
238 |
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Oncotype Dx Recurrence Score-Invasive |
239 |
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Oncotype Dx Risk Level-Invasive |
241 |
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Ki-67 |
242 |
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LN Positive Axillary Level I-II |
244 |
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Response to Neoadjuvant Therapy |
247 |
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Surgery Data Items
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STORE PDF Page |
Student Answer |
Instructor Notes |
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Date of Most Definitive Surgical Resection of the Primary Site |
219 |
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Surgical Procedure of the Primary Site |
220 |
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Surgical Margins of the Primary Site |
236 |
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Scope of Regional Lymph Node Surgery |
238 |
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Surgical Procedure/Other Site |
251 |
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Reason for No Surgery of Primary Site |
258 |
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Radiation Data Items (If radiation not given for this case, you may skip this section.)
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Date Radiation Started |
261 |
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Location of Radiation Treatment |
262 |
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Phase I Radiation Primary Treatment Volume |
264 |
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Phase I Radiation to Draining Lymph Nodes |
270 |
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Phase I Radiation Treatment Modality |
272 |
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Phase I External Beam Radiation Planning Technique |
274 |
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Phase I Dose per Fraction |
278 |
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Phase I Number of Fractions |
280 |
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Phase I Total Dose |
282 |
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Phase II Radiation Primary Treatment Volume |
264 |
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Phase II Radiation to Draining Lymph Nodes |
270 |
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Phase II Radiation Treatment Modality |
272 |
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Phase II External Beam Radiation Planning Technique |
274 |
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Phase II Dose per Fraction |
278 |
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Phase II Number of Fractions |
280 |
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Phase II Total Dose |
282 |
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Number of Phases of Radiation Treatment to this Volume |
284 |
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Radiation Treatment Discontinued Early |
285 |
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Total Dose |
287 |
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Radiation/Surgery Sequence |
289 |
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Date Radiation Ended |
291 |
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Reason for No Radiation |
292 |
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Systemic Therapy Data Items
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Date Chemotherapy Started |
297 |
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Chemotherapy |
299 |
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Date Hormone Therapy Started |
306 |
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Hormone Therapy |
308 |
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Date Immunotherapy Started |
313 |
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Immunotherapy |
315 |
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Systemic/Surgery Sequence |
321 |
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Outcomes
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STORE PDF Page |
Student Answer |
Instructor Notes |
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Cancer Status |
338 |
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Date of Last Contact or Death |
339 |
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Vital Status |
340 |
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Texting:
Along with the required Commission on Cancer (CoC) coded fields in the cancer abstract, there will also be texted information in the abstract. The CoC does not have specific requirements regarding text to be included in the cancer abstract. You may also need to adjust your texting for specific requirements of varying reporting agencies. In other words, the text required in your abstract will depend on where you work.
When texting you are providing documentation to backup all your coding. Your abstract should be able to “ stand alone” without the need to reference the patient’s chart.
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X-rays and Scans
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Scopes
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Labs
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History and Physical
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Operative Findings
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Pathology
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Surgery
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Radiation Therapy
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Chemotherapy
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Hormone Therapy
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Immunotherapy
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Remarks
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The end! (
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