Abstracting the Medical Records

A separate abstract is generally prepared for each independent cancer. Specific rules may modify that general rule for selected sites. For example, in the SEER Program, multiple neoplasms of the urinary bladder are represented by a single summary abstract since multiple tumors frequently occur in this site. Skin cancers are also handled in this manner. However, for most multiple primary tumors, each unrelated malignancy is abstracted on a separate form.

The registry number for patients with multiple primary tumors usually remains the same; a higher sequence number is assigned for each new primary cancer. Sequence number indicates the order in which a primary tumor is discovered in relation to the total number of primaries for a given patient. For example, the sequence number for the first of two primaries is 1; the sequence number for the second of two primaries is 2. Each primary is recorded on a separate abstract.

Hospitals with cancer programs approved by the Commission on Cancer of the American College of Surgeons are required to register all carcinomas, sarcomas, melanomas, leukemias, and lymphomas, i.e. all malignancies with a behavior code of 2 or higher in the International Classification of Diseases for Oncology, Third Edition, (ICD-O-3). In situ cancers of the cervix are not reportable. Skin cancer primaries with the following histology codes are also not reportable:

  • Malignant neoplasms (8000-8005).
  • Epithelial carcinoma (8010-8046).
  • Papillary and squamous cell carcinomas (8050-8084).
  • Basal and squamous cell cancers (8090-8110).

Benign tumors and borderline malignancies (behavior codes 0 and 1) also may be included in the registry. These diagnoses are referred to as " reportable-by-agreement" cases.

Inconclusive diagnosis

To assist with vague or inconclusive diagnostic terms, the following terms indicate involvement. For example, a probable carcinoma of the lung.

  • apparent(ly)
  • appears to
  • compatible with
  • consistent with
  • favor(s)
  • malignant appearing
  • most likely
  • presumed
  • probable
  • suspect(ed)
  • suspicious (for)
  • typical of

The following terms are not to be interpreted as involvement:

  • cannot be ruled out
  • equivocal
  • possible
  • potentially malignant
  • questionable
  • rule out
  • suggests
  • worrisome

For example, a diagnosis of probable carcinoma of the left lung would be abstracted as a lung primary. A diagnosis of questionable carcinoma of the left lung with brain metastasis would be abstracted, and the primary site would be coded to an unknown primary. A possible carcinoma is not reportable.

Changing the diagnosis

Over time, information may be added to the patient's medical chart that was missing in the original record. Therefore, it is the practice to accept the thinking and information about the case based on the latest or most complete information. Thus, it is acceptable to change the primary site and histology, as information becomes more complete, as long as the info is supplementing the original diagnosis ie: site, histology and stage are not changed as the tumor progresses.