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Systemic Treatment for Multiple Primary Cancers


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Title: Systemic Treatment for Multiple Primary Cancers

Systemic Treatment for Multiple Primary Cancers
Arizona Cancer Registry
Why a Module on This Topic?
  • Occasionally, a patient will be diagnosed
    concurrently with multiple primaries, and receive
    systemic treatment for all of these malignancies.
  • This does not happen frequently, but when it does
    it can be a source of confusion.
  • The questions for the registrar are
  • How do you know which treatments are directed at
    which cancer?
  • What and where are the rules addressing these

First, a Few Definitions
  • Concurrent
  • Simply, happening at the same time
  • Multiple Primaries
  • Generally, primaries are separate if you have
  • Multiple lesions with the same histology
    occurring in different sites, unless a physician
    states that one is metastatic from the other
  • Multiple lesions with different histologies
    occurring in different sites
  • Multiple lesions with different histologies
    occurring in the same site
  • The issue of what constitutes multiple
    primaries is discussed extensively in FORDS
    Revised for 2004, pages 15-20. The three
    definitions given above are most relevant to this

Definitions, Continued
  • Systemic Therapy
  • Any treatment that circulates through the
    bloodstream is considered to be systemic,
    reaching and affecting cells all over the body.
  • An extensive discussion of systemic therapy can
    be found in FORDS Revised for 2004, pages 28F
    and 28G.

Types of Systemic Therapy
  • Systemic treatments of the same type, e.g.,
    chemotherapy, hormonal therapy, and immunotherapy
    can act on different targets.
  • Chemotherapy
  • Hormonal Therapy
  • Immunotherapy
  • Radioisotopes- In rare cases
  • Radioisotopes are usually cell-specific and
    therefore have particular targets.
  • Endocrine therapy
  • Orchiectomy for advanced prostate cancer
  • Prophylactic oophorectomy for breast cancer
  • Hematologic transplants

Therapy Not Considered Systemic
  • Radiation
  • Surgery
  • Topical antineoplastics
  • Drugs that are applied to the surface of the
    body, often for treatment of skin lesions
  • The common denominator of these treatment types
    is that they are intended for local control of

  • Radiosensitizers are drugs that make cells more
    sensitive to the effects of radiation
  • Examples include 5-FU, Broxuridine
  • Radiosensitizers are NOT coded as chemotherapy
  • They are used for the purpose of enhancing
    radiation treatment
  • They are listed as ancillary agents in the
    SEERRx database

  • Next, a brief discussion of the major types of
    systemic therapies

  • Causes cells to stop growing or to die by
    interrupting DNA synthesis and replication.
  • Alkylating agents such as Cytoxan and Leukeran
    interfere with DNA replication.
  • Antimetabolites change the function of enzymes
    used in cell metabolism and protein synthesis.
    Examples of antimetabolites include 5-FU and
  • Antitumor antibiotics interfere with nucleic acid
    (building blocks of DNA) synthesis. Adriamycin
    (Doxorubicin) and bleomycin are two antitumor
  • Alkaloids target the spindle proteins necessary
    for cell division, inhibiting mitosis. Examples
    include vincristine and vinblastine.

Hormone Therapy Definition and Types
  • Hormone Therapy
  • Seeks to slow or stop the proliferation of cancer
    cells that are dependent on hormonal action to
  • Major types of hormonal therapy
  • Hormone-releasing factors
  • Hormones
  • Antihormones
  • Selective Estrogen Receptor Modulators (SERMs)
  • Aromatase Inhibitors

Hormone-Releasing Factors
  • Hormone-releasing factors influence production of
  • specific hormones via a feedback loop.
  • e.g., Luteinizing-releasing hormone (LHRH) in
    the hypothalamus controls release of
    follicle-stimulating hormone and luteinizing
    hormone (LH) from the pituitary.
  • Agonists mimic the action of hormone-releasing
  • For instance, if a male receives chronic high
    doses of LHRH agonists, this results in
    decreased androgen levels by interfering with
    the production or action of LHRH or LH via the
    feedback loop.
  • e.g. Lupron and Zoladex

Hormones, Antihormones, and SERMs
  • Hormones- Androgens, estrogens, progestins,
  • Used to oppose the activity of other
    cancer-fueling hormones
  • e.g., Androgens can be used to counteract
    estrogens and slow the growth of an
    estrogen-dependent cancer (e.g.,
  • e.g., Prednisone is a corticosteroid.
  • Antihormones- Antiestrogens, antiandrogens,
    adrenal steroid inhibitors
  • Erect a chemical barrier between the hormone
    and its receptor on a cells surface
  • e.g. Tamoxifen, Casodex
  • Selective Estrogen Receptor Modulators (SERMs)
  • Act like estrogen in some organs and like an
    anti-estrogen in others
  • e.g., Raloxifene

Aromatase Inhibitors
  • Aromatase is an enzyme that converts androgens,
    produced by the adrenal glands, into estrogens.
  • Aromatase inhibitors block this conversion,
    resulting in decreased estrogen levels and slowed
    growth of estrogen-dependent tumors.
  • e.g., Armidex

Biologic Therapy Definition and Types
  • Manipulates immune system to target and/or
    destroy cancer cells also known as
  • Two basic types
  • Active immunotherapy Boosts the patients
    existing defenses immunization of patient with
    materials to elicit an immune reaction against
    the tumor. May be
  • Specific- Targets antigens on specific type of
    cancer cell
  • Non-specific- Elicits a more general immune
  • Passive immunotherapy Sometimes called adoptive
    immunotherapy gives the patient antibodies and
    other agents so that the patient adopts an immune
    response that has been developed in a test tube.

Active Immunotherapy Interferons
  • Naturally-occurring proteins that interfere with
    virus replication (hence the name interferon.)
  • Able to be used against cancer because of
    advances in recombinant DNA technology.
  • Mechanisms of action include
  • Enhancing antigens so that antibodies can seek
    out cancer cells more effectively
  • Inhibiting DNA and protein synthesis
  • e.g. Interferon alpha-2b is used against
    Kaposis sarcoma, hairy cell leukemia, follicular
    lymphoma and malignant melanoma.

Active Immunotherapy Interleukins
  • Proteins produced by leukocytes, monocytes, and
    other cells that regulate immune response
  • Work by boosting number and activity of
    lymphocytes, especially killer T-cells.
  • e.g.,Interleukin-2 is used for metastatic renal
    cell carcinoma.

Passive Immunotherapy Monoclonal Antibodies
  • Administered to the patient, as opposed to active
    immunotherapy which seeks to boost already
    existing defenses
  • Monoclonal antibodies- Lab-engineered products.
    Work by
  • Attaching to specific antigen sites on tumor
    cells to interfere with their growth and
    replication, OR
  • Marking cell for destruction by immune system
  • Two basic types
  • Naked- Used alone
  • Conjugated- Used in combination with other drugs,
    toxins, or radioactive substances the monoclonal
    antibody delivers the agent to the cell by
    identifying and tagging the antigen.
  • e.g. Rituxan for B-cell lymphoma, Herceptin for
    breast cancer

Endocrine Therapy
  • Utilizes surgery or radiation to remove source of
    hormones, which secondarily slows the growth of
    tumor by starving it of the hormones it needs to
  • E.g., Orchiectomy for advanced prostate cancer,
    oophorectomy for breast cancer
  • Endocrine therapy is not coded as hormonal
  • Endocrine therapy is coded in the field
    Hematologic Transplant and Endocrine Procedures

Hematologic Transplants
  • Bone marrow or stem cell transplants performed
    to protect patients from myelosuppression or bone
    marrow ablation associated with administration of
    high-dose chemotherapy or radiation. (FORDS
    Revised for 2004, p. 28F).
  • Stem cells are immature forms that have the
    potential to differentiate into WBC, RBCs, or
  • Types of hematologic transplants
  • Autologous bone marrow- Uses cells harvested from
    the patient, stored, and then infused back into
    the patient after high-dose chemo or radiation
  • Allogenic bone marrow- Uses cells harvested from
    a donor
  • Syngeneic bone marrow- Uses cells harvested from
    identical twin
  • Peripheral blood- Stem cells come from
    bloodstream as opposed to bone marrow
  • Like Endocrine Procedures, Hematologic
    Transplants are coded in the Hematologic
    Transplant and Endocrine Procedures item.

Why these therapies can pose a challenge for the
  • Unlike surgery and radiation therapy, the
    systemic therapies just described have the
    potential to impact a number of different
  • For this reason, you need to ask yourself two
    questions when coding therapy for multiple
  • How do you determine which systemic treatment is
    directed at which primary?
  • The bottom-line question then becomes Which
    agent has the potential to impact which primary?

Where Do You Find Info to Answer These Questions?
  • There are a large number of resources available
    on the World Wide Web.
  • Two of the more comprehensive sites include
  • SEERRx- Should be the first source you look to
  • National Cancer Institute
  • SEERRx and the NCI web site will be discussed in
    some detail here.

Additional Guidance is Provided In…
  • SEER Program Coding and Staging Manual 2004 (p.
    172) states
  • If a patient has multiple primaries and the
    treatment given for one primary also
    affects/treats the other primary, code the
    treatment for both primary sites.

Introducing SEERRx
  • Released July, 2005
  • Must be used in place of SEER Book 8,
    Antineoplastic Drugs, and its supplements for
    cases diagnosed 1/1/2005 and after.

How to Download SEERRx
  • Go to http//
  • Request a password using the online form.
  • After your user name and password are emailed to
    you, you can install the program by following the
    onscreen instructions.

Using SEERRx
  • Each entry contains information on
  • Generic name
  • Category (Chemotherapy, Hormone therapy, etc.)
  • Brand name
  • Subcategory
  • Antiangiogenic agent, antiestrogen are two
  • This field is useful for determining the family
    of drugs that an agent belongs to.
  • Abbreviations
  • Primary Sites

More on Using SEERRx
  • When you are coding treatment, the most relevant
    information will be found in the following
  • Generic Name
  • Brand Name
  • Sometimes a clinician will refer to a drug by one
    of several names
  • Category
  • Chemotherapy, Hormones and hormonal mechanisms
    Biologic Therapy, etc.
  • Useful for coding purposes
  • Primary Sites
  • Malignancies the agent is used for
  • Remarks
  • Miscellaneous info, including indicated usages,
    FDA-approved, off-label, and clinical trials
  • Refer to slide 29, Notes of Caution, for
    additional info.

Using SEERRx, continued
  • Remember…
  • If a chemotherapy drug that a patient is
    receiving is changed to another drug in the same
    family, it would not be considered subsequent
    treatment. However, if the new drug comes from a
    different category, then it would be considered
    subsequent treatment.
  • For example, a switch to Carboplatin from
    Cisplatin would not be considered subsequent
    treatment, since they are both alkylating agents
    and in the same subcategory of Miscellaneous
    agent in SEERRx
  • Code only the original agent (first course).
  • (Reference FORDS Revised for 2004, pages

Notes of Caution
  • SEERRx is subject to update as more current
    therapy information becomes available.
  • SEERRx is not exhaustive. If a site is not
    listed, it is still possible that the drug is
    being used to treat the cancer.
  • A patient can be treated off-label or
    off-protocol, which usually implies that the
    drug is not being used routinely for a particular
    disease, but that the drug may have shown some
    efficacy in clinical trials and therefore may
    have some effect on the cancer.
  • If you find only one of the primary sites for the
    case you are abstracting, it is a good idea to do
    additional research. If the site is not listed in
    the entry for a drug, and you find when you look
    further that the drug can be used as treatment
    for the site/histology in question, code as

More Notes of Caution
  • Do not consider treatment dates when trying to
    decide if SEERRx is an appropriate reference.
    Only consider the diagnosis date (1/1/2005 and
    later ).
  • Also, spelling needs to be correct. For instance,
    if you enter Tamoxifan it wont bring up
    Tamoxifen (the right spelling).
  • Alternatively, entering the first few letters of
    an agents name will bring up entries, e.g.,

National Cancer Institute http//
  • Web site contains a subsection with information
    about the treatments for all cancers. This
    subsection includes
  • General info about site/histology
  • Broad overview of therapies
  • Summaries of standard treatment options, as well
    as those under evaluation, according to stage
  • References

To Get There
  • http//
  • The Types of Cancer section in the middle of
    the page contains two links
  • Common Cancer Types
  • All Cancer Types
  • A to Z list of sites/histologies, including those
    listed under Common Cancer Types
  • Select the primary site

To Get There, continued
  • Selecting a link for the primary site will bring
    up a page containing a number of subsections,
    each with its own links.
  • Under the first option, Treatment, (Located in
    the center of the page), will be links for
    patients and health professionals. Follow the
    health professional link.

Navigating the Treatment Section of the NCI web
  • The left side of the Treatment page has a list of
    options, including
  • General Information
  • Cellular Classification
  • Stage Information
  • Treatment Option Overview
  • Stages
  • Discussion of therapy options by stage
  • Recurrent
  • Management of recurrences/progression
  • Changes to Summary (Date)
  • Updates as new information becomes available
  • More Information
  • Links to specific topics on the NCI web site,
    such as prevention, genetics, supportive care,
  • The most useful links will be Treatment Option
    Overview and the individual stages.

To Summarize Some Treatment Information Issues…
  • It may be worth your while to check these
    references first
  • http//
  • http//
  • Another option, if the above two references dont
    give you any answers, is to search on the agents
    nameManufacturers usually have a website that
    may contain helpful information.
  • Warning Manufacturers websites may not use
    the same terminology as the registrars
    websites. For instance, a manufacturer may
    refer to an agent as immunotherapy, but SEERRx
    may categorize it as something else.
  • Query the treating physician if you cant find
    answers using reference sources.

Medical Record Documentation
  • The way treatment is documented in the record is
    not necessarily how it is coded by the registrar.
    For instance
  • Ancillary drugs such as Epogen or Zometa are not
    coded as cancer-directed therapy, even though
    this may be the impression given in the

Documentation, continued
  • If a physician states that the patient was given
    an agent for one primary,
  • AND
  • You find that the drug is also effective against
    the second cancer,
  • THEN
  • Code the agent for both primaries. In this case,
    you may override what the physician states.

And Beware…
  • Of the diagnosis given on order sheets.
  • The diagnosis information recorded on an order
    sheet may not be comprehensive enough to use in
    coding treatment.
  • For instance, an order sheet may state that a
    chemotherapy regimen is being given for one
    primary, when it may in fact be effective against
    the other primary (ies) as well. An example given
    later in this module (Case 1) illustrates this

Agents Also Used for Non-Malignant Conditions
  • If a patient is undergoing systemic treatment for
    a non-malignant condition, and then develops a
    cancer, do not code the systemic treatment for
    the cancer.
  • For instance, a patient being treated with
    methotrexate for rheumatoid arthritis develops
    prostate cancer.
  • Do not code the methotrexate as treatment for the
    prostate cancer.

  • And Now for a Few Exercises

Case 1
  • Diagnosis
  • Sequence 01 C41.3, M9231/3, Myxoid
    chondrosarcoma of costal cartilage
  • Sequence 02 C50.5, M8530/3, Inflammatory
    carcinoma of breast
  • Both primaries diagnosed 5/05.
  • Treatment
  • 6/05 Ifosfamide, Mesna, Adriamycin, Cisplatin,
  • Diagnosis on order sheets Breast ca. and
  • 8/05 Partial sternectomy w/reconstruction
  • Modified radical mastectomy
  • 11/05 Doxorubicin, cyclophosphamide
  • Diagnosis on chemotherapy order sheet
    Breast ca.

Case 1
  • Question
  • Which primary should the Doxorubicin and
    Cyclophosphamide, given in 11/05, be coded to?
  • Breast
  • Breast and sarcoma
  • Remember Use your references.
  • Also, the therapy given in 11/05 would be
    considered subsequent therapy, which is not
    required to be reported to the Arizona Cancer
    Registry (ACR) this is for illustrative purposes

Case 1
  • Answer
  • B, Breast and sarcoma
  • Rationale
  • Doxorubicin (generic for Adriamycin) and
    cyclophosphamide are used for both breast
    carcinoma and sarcoma per the drugs entries in
    the SEERRx database.
  • Although the order sheet states the treatment is
    being given for breast cancer, the registrar in
    this case would need to review references to find
    out whether Doxorubicin and cyclophosphamide are
    also effective for sarcoma.

Case 2
  • Diagnosis
  • Sequence 01 C50.1 (L), M8522/3, Infiltrating
    duct and lobular carcinoma of breast
  • Sequence 02 C50.5 (R), M8500/3, Infiltrating
    duct carcinoma of breast
  • Both breast primaries were diagnosed in 2/05.
  • Sequence 03 C44.2, M8720/3, Malignant melanoma
    of external ear
  • Melanoma diagnosed 4/05
  • Treatment
  • 3/05 Bilateral modified radical mastectomies
  • 4/05 Wide excision of skin lesion
  • 5/05 Aromasin

Case 2
  • Question
  • Which primary should Aromasin be coded to?
  • Breast
  • Melanoma
  • Breast and melanoma

Case 2
  • Answer
  • A, Breast
  • Rationale
  • Aromasin is a hormone that, per SEERRx, is
    active against breast cancer.
  • Aromasin does not impact melanoma melanoma is
    not mentioned anyplace in the SEERRx entry.
  • Also, the Treatment Option Overview for
    melanoma on NCIs web site does not mention
    hormonal therapy as having a role in the
    treatment of melanoma. Treatment Option
    Overview provides a synopsis of the standard and
    experimental therapies used for each stage of
    disease. The overview was used in this example
    because there is no stage information for the
    melanoma. If extent of disease is documented,
    following the appropriate stage link will give
    you more detailed information.

Case 3
  • Diagnosis
  • Sequence 01 C16.0, M8140/3, Adenocarcinoma of
    gastroesophageal junction
  • Sequence 02 C64.9, M8310/3, Clear cell carcinoma
    of kidney
  • Both primaries were diagnosed in 10/05.
  • Physician noted that the kidney ca. would be
    addressed after treatment for the GE primary, as
    the GE junction cancer had a worse prognosis.
  • Treatment
  • 11/05 Continuous infusion 5-FU
  • Diagnosis on order sheets Gastroesophageal ca.
  • 11/05 Begins external beam radiation
  • 3/06 Transhiatal esophagogastrectomy and partial
  • No change in size of renal mass from date of
    diagnosis to
  • date of resection

Case 3
  • Question
  • Which primary should 5-FU be coded to?
  • Gastroesophageal junction
  • Kidney
  • Gastroesophageal junction and kidney

Case 3
  • Answer
  • A, Gastroesophageal junction
  • Rationale
  • According to the SEERRx Remarks entry, 5-FU is
    approved for use against GI adenocarcinoma.
  • Other types of cancers are not mentioned. The
    Treatment Option Overview in the kidney cancer
    section of NCIs web site states that Systemic
    therapy has demonstrated only limited

Case 4
  • Diagnosis
  • Sequence 01 C42.1, M9823/3, Chronic lymphocytic
  • Sequence 60 C75.1, M8272/0, Pituitary adenoma
  • Both primaries were diagnosed in 8/05.
  • Treatment
  • 9/05 Bromocriptine

Case 4
  • Question
  • Which primary should Bromocriptine be coded to?
  • Pituitary adenoma
  • CLL
  • Pituitary adenoma and CLL

Case 4
  • Answer
  • A, Pituitary adenoma
  • Rationale
  • The hormonal mechanism for bromocriptine is not
    the same as for prednisone or other hormonal
    treatments for CLL a review of the CLL Treatment
    section on NCIs web site does not mention this
    particular drug.
  • The bromocriptine entry in SEERRx does not
    mention pituitary adenomas. However, it briefly
    states that the drugs mechanism of action is the
    inhibition of prolactin secretion from the
  • Also, an examination of the Treatment Option
    Overview for pituitary adenomas on the NCI web
    site specifically states that this agent is used
    to treat prolactin-secreting pituitary adenomas.
  • This case would be a good example of the
    importance of learning to rely on multiple

Case 5
  • Diagnosis
  • Sequence 01 C25.0, M8140/3, Adenocarcinoma of
    head of pancreas, Diagnosed 4/05
  • Sequence 02 C18.4, M8140/3, Adenocarcinoma of
    transverse colon, Diagnosed 5/05
  • Treatment
  • 4/05 Whipple procedure
  • 5/05 External beam radiation to pancreatic tumor
  • 5-FU given as radiosensitizing agent
    Gemcitabine treatment continued through 6/05.

Case 5
  • Question
  • Which primary should the 5-FU and Gemcitabine be
    coded to?
  • Pancreas
  • Colon
  • Pancreas and colon

Case 5
  • Answer
  • A, Pancreas
  • Rationale
  • 5-FU is sometimes used as a sensitizing agent
    when given concurrently with radiation therapy.
    5-FU can also be used as chemotherapy, but if
    given as a radiosensitizer it is considered an
    ancillary drug and NOT coded.
  • Note If a patient is diagnosed with a new
    primary while undergoing first course treatment
    for a cancer diagnosed previously, and the
    drug(s) used for the initial cancer is/are
    potentially effective against the malignancy that
    is diagnosed later…
  • Do not include the regimen in planned first
    course of treatment, because obviously it had no
    effect on the growth of the new primary.
  • BUT… do mention the drug in a text field when you
    abstract the subsequent primary.

When Do These Guidelines Become Effective?
  • Coding Systemic Treatments Potentially Effective
    for gt 1 Primary Cancer
  • ACR polled participants from the 10/27/05
    teleconference and found that a majority were
    already coding according to these guidelines, but
    that a significant minority were coding strictly
    per the medical record documentation.
  • Therefore, the guidelines provided in this module
    apply to cases diagnosed on or after 1/1/2005.
  • Registrars who are already coding using the
    principles discussed above do not need to go back
    to identify and update applicable cases.

Identifying Applicable Cases
  • Cases diagnosed on or after 1/1/2005 must be
    reviewed in order to be corrected where
  • Specifics for identifying these cases in your
    database will vary somewhat depending on your
    software, but these general procedures could be
    utilized across the board
  • Create a subset based on
  • Diagnosis date
  • 1/1/2005 and later
  • Sequence number
  • gt 00
  • From the subset, create a listing using the
    following fields
  • Name
  • Medical record number
  • Sequence number
  • Diagnosis date
  • Date first course treatment
  • Use the info from this listing as a guide in
    determining which cases to review.

Dont Forget!
  • If you are making a change to a case that you
    already submitted to the ACR, complete a Critical
    Change Form and send it to the state…
  • Updates of first course of treatment fields are
    considered to be critical changes.

In Summary…
  • Some systemic therapies have demonstrated
    activity against more than one malignancy.
  • It is the job of the registrar to determine which
    agent(s) is(are) recorded in which abstract(s)
    when a patient is being concurrently treated for
    two or more cancers.
  • Fortunately, there are a number of resources that
    a registrar can utilize in order to tease out
    this info.

SEERRx Summarized
  • SEERRx
  • Database of agents active against cancer
  • Went live in July, 2005.
  • Can be downloaded free of charge with a username
    and password obtained from SEER.
  • Primary sites and Remarks fields will
    probably be the most useful when trying to
    determine if an agent is useful against a
    specific malignancy.
  • To be updated periodically with knowledge
  • Effective for cases diagnosed 1/1/2005 and after
    do not take treatment dates into consideration
    when determining if you can use SEERRx for a
  • Just because a cancer is not listed in the drug
    entry does NOT mean it isnt being used for that

NCIs Web Site in a Nutshell
  • http//
  • Provides an overview of treatment by stage for
    all cancer types.
  • Information more in-depth than that provided in
  • Web pages are updated as information about
    advances becomes available. View updates by
    following the Changes to this Summary link at
    the bottom of the treatment by AJCC stage
    summaries links.

And Remember…
  • The ACR must be notified about changes made to
    first-course treatment data on cases that have
    already been submitted.
  • Two options for reporting updates
  • Critical change form- Available on the ACR web
    site, http//
  • Print off abstract and highlight changes.

A Few More Helpful Resources
  • CancerConsultants - http//professional.cancercons
  • Online resource center for oncology
    professionals. Contains links to articles on
    treatment advances.
  • Can sign up for newsletter free of charge
  • SEERs Training Web Site - http//
  • Site-specific modules contain information on
    current treatments, including names of agents.
    Information tends to be general.
  • CA A Journal for Clinicians - http//caonline.amc
  • Published by American Cancer Society
  • Good source of information about treatments and
    advances (along with many other cancer-related
  • Free access to full-text articles
  • American Society of Clinical Oncology (ASCO) -
  • Society represents oncology physicians
  • Free access to article abstracts and some
    full-text articles

  • Given the vast amount of information available on
    the web, finding additional sources shouldnt be
  • BUT…
  • What may be a challenge is sifting through the
    material and finding quality information
  • that is relevant, up-to-date and accurate.

Questions? Comments? Additions?
  • ACR Contacts
  • Georgia Yee, BSW, CTR
  • Office Chief
  • (602) 542-7308
  • Brenda Smith, CTR
  • Operations Manager
  • (602) 542-7357
  • Kara Locketti, CTR
  • Training Manager
  • (602) 542-7592

  • Thanks to April Fritz and Louanne Currence for
  • providing guidance during the 10/05
  • teleconference and in the development of this
  • module.