NPCR Education and Training Series NETS Module 6: Gynecological Malignancies Part 3

1
Advanced Abstracting Gynecologic Cancers
III. STAGE OF DISEASE TNM and Collaborative
Staging
2
AJCC TNM Stage

• T, N and M based on extent of cancer
• Stage groupings based on prognosis
• Evidence based
• Correlated with FIGO

3
AJCC Staging Benefit

• Strict criteria allow comparisons of cases
• With similar characteristics
• Among facilities
• Over time
• Preferred staging for clinical research

4
AJCC Staging Disadvantages

• Restrictions of staging criteria frequently
  prevent assigning stages to some tumors
• Changes in new editions of staging criteria limit
  comparisons over time

5
AJCC Staging Documentation

• AJCC staging by managing physicians required by
  CoC for approved programs
• Registrars should also determine AJCC stage
  independently
• Helpful in resolving discrepancies between
  assigned and derived AJCC stages
• Facilitates QA
• May be saved on separate field in abstract

6
Sixth Edition Changes in TNM

• Major change addition of scoring risk factors
  for GTT
• Text descriptions clarified

7
Staging GTT

• Clinical and pathologic not discussed
• Prognosis dependant on risk factors
• T category
• T1 Confined to uterus
• T2 Other GYN by mets or direct extension
• No regional nodes (N)
• M category
• M1a lung mets
• M1b all other distant mets

8
GTT Risk Scoring Table
Seven risk factors are included on the table
below. Previous failed chemotherapy was omitted
for lack of space
Note Score of 7 or less is low risk score of 8
or more is high risk
9
SEER Summary Stage

• Required by central registries
• Used for historical comparisons
• Simpler concepts than TNM
• Applicable to more tumors than TNM
• May not correlate with TNM
• Derived by CS algorithm

10
SEER Summary Stages

• 0 Non-invasive
• 1 Local
• Regional
• 2 By direct extension
• 3 By regional LN involvement
• 4 By direct extension and LN involvement
• 5 Regional, NOS
• 7 Distant
• 9 Unknown stage

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Collaborative Staging (CS)

• Collects
• Basic elements used for staging
• How coding elements assessed clinically or
  pathologically
• Derives
• Mixed or best stage
• TNM and Summary stages
• Algorithm can be changed as needed

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CS Logical Assumptions

• If status of regional nodes not mentioned, but
  treatment is appropriate for local disease,
  assume nodes not involved
• If status of regional nodes not mentioned, but
  primary lesion is in situ, assume nodes not
  involved.
• If status of distant metastases not mentioned but
  treatment is appropriate for local disease,
  assume no distant mets

13
CS Cautions GYN

• Some histologies have their own schema
• Lymphoma
• Kaposis sarcoma
• Skin of vulva
• Melanoma uses melanoma schema
• Mycosis fungoides and Sezary disease use their
  own schema
• Other skin histologies use vulva schema
• GTT of non-placenta site uses schema for site

14
Other GYN CS Schemas

• Specified sites (C57.1-C57.4)
• Broad and round ligaments
• Parametrium
• Uterine adnexa
• Other and unspecified sites (C57.7-C57.9)
• Other specified sites not previously named
• Overlapping lesion of GYN organs
• Female genital tract, NOS

15
CS Evaluation Size/Extension

• Evaluation based on
• 0 Clinical information only
• 1 Clinical and biopsy and/or surgical
  observations
• 2 Autopsy (cancer suspected/dxd prior to death)
• 3 Resection without pre-operative treatment
• 5 Pre-op tx, coding based on clinical
  information
• 6 Pre-op tx, coding based on pathological
  information
• 8 Autopsy (cancer not suspected prior to death)
• 9 Unknown if done, not documented

16
CS Evaluation LNs and Mets

• Codes 5, 6 similar to TS/Ext Eval
• Lymph nodes
• Code 1 states FNA instead of biopsy
• At least one LN must be removed to use code 3
• Mets
• Code 1 excludes any biopsy
• Code 3 requires only tissue be examined

17
CS Extension

• Extension of the primary site
• Note Code as local if in situ lesion with
  involved lymph nodes
• Direct extension into adjacent organs
• Ovarian cancer discontinuous extension
• Farthest extension clinical or pathological

18
CS Lymph Nodes

• Terms that mean clinical LN involvement
• Fixed or matted
• Mass in node bearing area
• LNs may be regional or distant depending on GYN
  site
• GTT placenta no regional LNs
• Code farthest LNs even if clinical

19
CS Mets at Dx

• Code farthest metastases
• Disregard metastases arising after dx
• Code mets 00
• If treatment standard for early stage disease
• If MD stage does not indicate mets

20
CS Site-Specific Factors

• None applicable for most GYN sites
• SSF 1 applicable for two sites
• Ovary CA-125 testing
• Placenta low/high risk score
• SSF 2 6 are not used for any GYN site
• Code as 888

21
CS Valuable for QA

• Compare CS derived TNM stage to TNM stage
  assigned by MD
• Caution
• CS mixes clinical and pathological
• Assigned TNM must be one or the other
• Check your work first
• Work with MD to resolve differences

22
Fixing Collaborative Stages

• Dont change data just to get a match
• If CS stage unexpected, look for reasons
• Review stages in appropriate manuals
• Review each CS data item you entered
• Change data ONLY if a true error

23
CS Manual Updates

• Examples
• CS Mets at Dx
• Tumor size for multifocal primary
• Clarifications
• Use the correct version of all manuals

24
CS Update Mets at Dx

• Code Mets at Dx as 00 when treatment is
  appropriate for early-stage disease
• Code Mets at Dx as 99 when reason to doubt tumor
  is localized

25
CS Update Multi-focal

• Do not add several foci or tumors together to get
  size
• Use largest focus of a multifocal tumor to
  determine tumor size
• Use largest tumor to determine tumor size when
  multiple tumors are being reported as a single
  primary

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CS Update Clarifications

• Tumor size note revision for incisional bx, code
  999 in absence of clinical size
• Core biopsy was added to aspiration for regional
  LN positive and regional LN examined code 95
• Phrasing was clarified in several areas

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Advanced Abstracting Gynecologic Cancers
IV. TREATMENT
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Treatment Issues

• Determining timing of therapy
• Initial therapy
• Subsequent therapy
• Deciding how much data to collect
• Basic required data set
• Extended data set
• Additional special data items

29
Treatment First Course

• Initial plan of therapy
• Best chance for cure
• Best chance for long-term control
• Frequently an algorithm

30
End of First Course Treatment

• Completion of initial plan
• Note Ovarian Ca may include a 2nd surgery
• Cancer progresses on treatment
• Therapy changed to other type Modality not in
  initial algorithm
• Drug with different type of activity

31
Treatment Subsequent

• Begins after first course ends
• Not included in initial treatment algorithm
• A planned change in treatment is not subsequent
  treatment
• Subsequent treatment may still result in cure

32
Q. 1 Is it subsequent treatment?

• The radiation oncologist had planned to use
  photons to treat lymph nodes but decided to use
  electrons instead.
• No, it is still first-course

33
Q. 2 Is it subsequent treatment?

• Chemo was changed from one type, Platinol, to
  another type, Taxol, because the patient didnt
  respond as much as expected.
• Yes, treatment is subsequent

34
Q. 3 Is it subsequent treatment?

• The surgeon had planned a local excision but the
  cancer extended deeper than expected and she had
  to do a reexcision to get clear margins.
• No, it is still first-course

35
Amount of Data Basic

• Required (basic) data set
• NPCR-required data set
• COC Approved programs require additional data
• OK for facilities with minimum data needs
• Still provides useful and interesting graphs

36
Amount of Data Extended

• Used by research and teaching facilities
• Support higher outcomes data demand
• Common non required data items
• Names of drugs and regimens
• Types of radioisotopes
• Family history of cancer

37
Amount of Data Special Data Items

• Collected for a specific purpose
• Track surgical populations over time
• Evaluate a unique service or procedure
• Collected for a limited time
• Special studies
• Track usage of new equipment

38
Surgery

• Many GYN sites require surgery
• Extent of surgery depends on stage
• Intent of surgery depends on stage
• Often part of multi-modality treatment

39
Radiation Therapy

• Adjuvant
• Neoadjuvant
• Brachytherapy
• Intracavitary
• Interstitial
• Primary

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Chemotherapy

• Adjuvant
• Neoadjuvant
• Both

Image source National Cancer Institute
Taxol Molecule
41
SEERRx Interactive Drug Database

• Excellent source of chemo information
• Download free from SEER
• http//seer.cancer.gov/tools/seerrx
• Keep on desktop for quick access

42
Hormone Therapy

• Little used in GYN cancers
• Caution do not code estrogen replacement as
  hormonal treatment

43
Treatment Vulva

• Localized
• Wide excision for early malignancies
• Radical vulvectomy with bilateral lymph node
  dissection (LND) or RT to nodes
• Regional
• Radical vulvectomy with bilateral LND
• Primary RT with or without chemotherapy
• Distant
• Radical vulvectomy and pelvic exenteration
• Neo-adjuvant or adjuvant RT with or without
  chemotherapy

44
Treatment Vagina

• In situ and VAIN III
• Laser therapy or intravaginal chemo
• Localized
• Surgery or brachytherapy or intravaginal chemo
• Regional
• Brachytherapy and external beam radiation therapy
  (EBRT)
• Distant
• Brachytherapy and EBRT

45
Treatment Cervix

• In situ lesions and minimal invasion
• Limited surgery
• Localized
• Radical hysterectomy with or without LND
• Intracavitary brachytherapy
• Regional
• Brachytherapy and EBRT and chemo
• Distant
• Brachytherapy and EBRT and chemo

46
Treatment Endometrium

• Localized
• TAH-BSO with or without adjuvant EBRT
• Neoadjuvant brachytherapy and EBRT with TAH-BSO
  for deeper or high-grade tumors
• Regional
• Surgery and adjuvant EBRT
• Intracavitary brachytherapy and EBRT
• Distant
• Pelvic tumor Intracavitary brachytherapy and
  EBRT
• Distant mets hormone therapy

47
Treatment Sarcoma of Corpus

• Localized
• TAH-BSO and lymphadenectomy and adjuvant pelvic
  RT
• TAH-BSO and adjuvant chemotherapy
• EBRT alone
• Regional
• Same as for localized but with resection of all
  gross disease
• Distant
• Clinical trials (no standard therapy)

48
Treatment Ovary

• Localized
• TAH-BSO or TAH-USO and omentectomy
• Exploration of peritoneal cavity
• Regional
• TAH-BSO, omentectomy, cytoreduction and
  intraperitoneal chemotherapy
• Intraperitoneal radioisotope or EBRT
• Distant
• TAH-BSO, omentectomy, cytoreduction, debulking
  and chemotherapy

49
Prophylactic OophorectomyHigh-Risk Patients

• Code the surgery only if removed at same time as
  involved ovary
• Ovaries removed as preventive measure
• Unilateral or bilateral
• Not involved with cancer
• Slight risk of primary peritoneal carcinoma

50
Treatment GTT

• Local
• Single-agent chemotherapy
• TAH an option
• Metastaticlow-risk score
• Single-agent chemotherapy
• TAH and single-agent chemotherapy
• Metastatichigh-risk score
• Multi-agent chemotherapy and radiation to CNS
  mets (if any)

51
Palliative Care

• Intended to relieve symptoms
• May use cancer-treatment modalities
• Surgery
• Radiation
• Chemotherapy
• May require coding in more than one data field
• Code pain management only in palliative care field

52
Advanced Abstracting Gynecologic Cancers
V. FOLLOW-UP AND OUTCOMES
53
Follow-up

• Plan ahead
• Anticipate future health care needs
• Collect contact information
• Anticipate data needs
• Determine amount of data to collect

54
Plan Follow-up

• Set up follow-up when abstracting
• Identify likely contacts
• Collect list of helpful Web sites
• Make notes in abstract

55
Collect Follow-up Contacts

• Complete patient address
• Spouse name and work number
• Identify healthcare surrogate
• Other family
• Other contacts

56
Protect Patients Privacy

• HIPAA requirements
• Facilitys privacy policy
• Be careful
• Watch what you say and to whom
• Fax rather than email

57
Health Care Contacts

• Following physicians
• Other facilities that treated patient
• Home health care agencies if appropriate
• Hospice if appropriate

58
Anticipate Data Needs

• Survival and outcomes studies
• Recurrences
• Requirements for CoC approval
• Your facilitys needs

59
Amount of Data to Collect

• Abstract now for data requests
• Determine data needs
• Facility
• Physicians
• Research
• Determine amount of data to meet needs

60
Facility Data Needs

• Cancer site distributions
• Top cancer sites
• Trends over time
• Demographic distributions

61
Physician Data Needs

• Number of certain procedures
• Numbers of cancers by GYN site
• Outcomes on certain therapies
• Outcomes on certain stages
• Other

62
Research Data Needs

• Know what data your facility needs
• Teaching hospitals do research
• Hospitals participate in clinical trials
• Studies required for CoC-approval
• Special studies not limited to your facility

63
Recurrences

• Used for calculating disease-free survival
• Per MPH rules, GYN cancers more than one year
  apart are multiple primaries
• New occurrences within one year are same primary
• Assumes same site or metastatic site
• Assumes same histology and behavior

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Recurrences

• Invasive cancer following an in situ
• MPH Other sites rule M18
• Diagnosed within 60 days
• Single invasive primary one abstract
• MPH Other sites rule M15
• Diagnosed more than 60 days apart
• Two primaries two abstracts

65
Types of Recurrences

• Long list
• First match may not be best match
• Some specific to original behavior
• Some specific to recurrence site
• Check entire list until familiar w/ choices

66
Status at Last Contact

• Cancer status
• Was cancer present at last contact?
• Used to calculate disease-free survivals
• Vital status
• Was the patient alive or not?
• Used to calculate life-time survivals

67
Outcomes

• USE the data youve collected!
• Outcomes studies are required by CoC

68
QA Right Away

• Review as soon as you abstract
• Did you enter what you thought?
• Does it make sense?
• Run edit checks

69
Resources Used

• NCCN Clinical Practice Guidelines in Oncology,
  NCCN (nccn.org)
• Facts Figures 2007 and Cancer Reference
  Information, American Cancer Society
  (www.cancer.org)
• Cancer Topics, National Cancer Institute
  (www.cancer.gov)
• Cancer Stat Fact Sheets, SEER web site
  (seer.cancer.gov/statfacts)
• SEER Self Instructional Manual for Cancer
  Registrars Book Four, National Cancer Institute
  SEER Program
• AJCC Cancer Staging Manual, 6th ed., AJCC
• FORDS, Commission on Cancer
• ICD-O-3, World Health Organization

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Additional Resources

• Images
• A.D.A.M. Interactive Anatomy 4, A.D.A.M., Inc.,
  2004. Used with licensed permission.
• AJCC Cancer Staging Illustrations in PowerPoint
  from the AJCC Cancer Staging Atlas, sixth edition
  (2002). Springer-New York, 2007. Used with
  permission.

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• The findings and conclusions in this
  presentation are those of the authors and do not
  necessarily represent the views of the Centers
  for Disease Control and Prevention.

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• For information about CDCs
• Cancer Prevention and Control Programs
• and the
• National Program of Cancer Registries
• Please visit www.cdc.gov/cancer/npcr