Record male, female, hermaphrodite, transsexual, or unknown. In very rare instances, the sex cannot be determined. This information should be recorded.
Age at Diagnosis
This refers to years of age at time of initial diagnosis for the reported cancer. Record age at last birthday; do not round to the next birthday. The age of children less than 1 year old should be recorded as 000.
Record month, day, and year (including century) of patient's birth. If any of this information is unknown, record as NK (Not Known) or XX -- for instance, June, NK (or XX), 1925.
Place of Birth
Record state for patients born in the U.S. For foreign-born, record country. Some registries and registry systems have developed a code to record city, state, and country. If your registry utilizes such a code system, record the code as determined from your geographic location code. The SEER Program uses GSA (Government Services Administration) codes for birthplace.
Race / Ethnic Group
There may be some problems in classifying individuals of mixed (multi-cultural) heritage--for instance, a person with a Japanese mother and an African-American father. Record all the details. Abbreviations on medical records can be misleading. Black is often specified as "B," "C," or "NW"-- black, colored, or non-white. However, "C" may also be used to specify Caucasian or Chinese; and Japanese patients may also be classified as "NW." Hence, when abstracting hospital records which utilize abbreviations, be sure you know exactly what the abbreviations mean. It will be of use to note a general rule in trying to distinguish between Chinese and Japanese names: usually, Chinese names have only one syllable and Japanese names have two or more syllables. Chinese names end in consonants; Japanese in vowels. Latin American and Puerto Rican are designations for ethnic groups, not races. In many sections of the country, ethnic groups are of particular interest, and you will need to identify them -- for example, Spanish surname or origin, such as Mexican, Puerto Rican, or Cuban.
Select the appropriate alternative: single, married, divorced, separated, widowed. Do not assume that a person specified as Miss should be classified as single. Often women who have been separated or divorced use their maiden names. A patient whose only marriage has been annulled should be classified as single. Patients having "common law" marriages should be classified as married. There may be some instances in which this information is unknown, particularly with the more frequent use of "Ms."
Record the patient's usual or primary occupation and the industry in which the patient is currently or was previously employed. Also, note a secondary occupation if one is listed in the medical record. This is particularly important for determining possible carcinogenic exposure, for example, people working with asbestos or in the manufacture of polyvinyl chloride.
Record information on use of, or contact with, carcinogenic agents, such as history of smoking, drug usage, and drinking. Many also record the use of birth control pills or any other information which your Committee on Cancer requests.
- Previous Diagnosis of This Neoplasm
If the reported neoplasm was first diagnosed (whether clinically or histologically) in a physician's office or at another institution, record the name of the referring physician, the name of the facility where the diagnosis was made, the date of diagnosis, and the diagnosis (site and morphology).
- Previous Treatment for This Neoplasm
Indicate whether or not treatment was given for this neoplasm before entry to your institution.
Record the date and describe the nature of the treatment. This information may be contained in the referral letter or in the history section of the medical record. Copies of the diagnosis and treatment reports from the other institutions will frequently be appended to your hospital record.
When information concerning previous treatment is missing from the medical record, the registry or registry system should make every effort to contact institutions or physicians who have examined or treated the patient to obtain such information.
- Other Previous Neoplasms
Some registries prepare separate abstracts for each previously diagnosed primary mentioned in the patient's history. Other registries may elect only to record the fact that the patient has a history of one or more primary cancers if there is no evidence of these earlier cancers at time of admission. Your Cancer Committee will decide how your registry will handle previous neoplasms. Whether entered on a separate abstract or on the abstract of the neoplasm for which the patient is admitted. The date, site, type, and treatment of earlier diagnosis should be recorded in a uniform manner.
Record the date the patient was first admitted to your hospital for diagnosis and/or treatment of his or her malignancy. The patient may be readmitted many times for the same primary. Record only the date of the first admission. Sometimes the patient may be seen and treated only in an outpatient clinic or in the radiology department. For such cases, record the date the patient first appeared at the outpatient clinic or radiology department for diagnosis and/or treatment of this malignancy.
Record the first diagnosis of this cancer by a recognized medical practitioner. This may be a clinical diagnosis and may not ever be confirmed histologically. When the biopsy is histologically confirmed, the date of diagnosis is the date of the first clinical diagnosis and not the date of histologic confirmation.
Record the date the patient was discharged from the hospital following the first admission for this malignancy. For patient seen only as outpatients, leave blank.