Breast cancer (cancer registries) DSS Metadata Online Registry (METeOR)

Description

Patient—diagnosis date of cancer, DDMMYYYY Identifying and definitional attributes Short name: Date of diagnosis of cancer METeOR identifier: 416129 Registration status: Health, Standard 07/12/2011 Definition: The date on which the patient was first diagnosed with cancer (whether at its primary site or as a metastasis), expressed as DDMMYYYY. Data Element Concept: Patient—diagnosis date of cancer Value domain attributes Representational attributes Representation class: Date Data type: Date/Time Format: DDMMYYYY Maximum character length: 8 Data element attributes Collection and usage attributes Guide for use: Date of diagnosis must be: · Greater than or equal to date of birth · Less than or equal to date of death Diagnosis of cancer after death: If the patient is first diagnosed with the cancer in an autopsy report the date of diagnosis is the date of death as stated on the patient's death certificate. Incidental diagnosis of cancer: If a patient is admitted for another condition (for example a broken leg or pregnancy), and a cancer is diagnosed incidentally then the date of diagnosis is the date the cancer was diagnostically determined, not the admission date. Collection methods: Reporting rules: The date of diagnosis is the date of the pathology report, if any, that first confirmed the diagnosis of cancer. This date may be found attached to a letter of referral or a patient's medical record from another institution or hospital. If this date is unavailable, or if no pathological test was done, then the date may be determined from one of the sources listed in the following sequence: · Date of the consultation at, or admission to, the hospital, clinic or institution when the cancer was first diagnosed. Note: DO NOT use the admission date of the current admission if the patient had a prior diagnosis of this cancer. · Date of first diagnosis as stated by a recognised medical practitioner or dentist. Note: This date may be found attached to a letter of referral or a patient's medical record from an institution or hospital. · Date the patient states they were first diagnosed with cancer. Note: This may be the only date available in a few cases (for example, patient was first diagnosed in a foreign country). If components of the date are not known, an estimate should be provided with an estimated date flag to indicate that it is estimated. If an estimated date is not possible, a standard date of 15 June 1900 should be used with a flag to indicate the date is not known. Additionally, a date accuracy indicator should be recorded in conjunction with the estimated date. Comments: Patient administration system, cancer notification system, population cancer statistics, research. Source and reference attributes Submitting organisation: Cancer Australia Origin: International Agency for Research on Cancer World Health Organization International Association of Cancer Registries Reference documents: Modified from the definition presented by the New South Wales Inpatient Statistics Collection Manual 2000/2001 Relational attributes Related metadata references: See also Cancer staging—date of cancer staging, DDMMYYYY Health, Standard 04/02/2015 Supersedes Patient—diagnosis date (cancer), DDMMYYYY Health, Superseded 07/12/2011 See also Person with cancer—date of initial primary health care consultation, DDMMYYYY Health, Standard 04/02/2015 Implementation in Data Set Specifications: Bowel cancer diagnosed cluster Health, Standard 29/08/2014 Breast cancer (cancer registries) DSS Health, Standard 01/09/2012 Cancer (clinical) DSS Health, Standard 14/05/2015 Implementation in Indicators: Used as numerator National Bowel Cancer Screening Program: PI 06b-Positive predictive value of diagnostic assessment for detecting colorectal cancer Health, Standard 29/08/2014 National Bowel Cancer Screening Program: PI 07-Interval cancer rate Health, Standard 29/08/2014

Data type

date

Alias

UMLS CUI [1,1]

C2316983

UMLS CUI [1,2]

C0006826

Description

Person with cancer—distant metastasis status, M stage (UICC TNM Classification of Malignant Tumours, 7th ed) code X[XX] Identifying and definitional attributes Short name: Cancer staging—M stage code METeOR identifier: 403720 Registration status: Health, Standard 07/12/2011 Definition: The absence or presence of distant metastasis in a person with cancer, as represented by a code. Data Element Concept: Person with cancer—distant metastasis status Value domain attributes Representational attributes Classification scheme: International Union against Cancer (UICC) TNM Classification of Malignant Tumours 7th edition Representation class: Code Data type: String Format: X[XX] Maximum character length: 3 Supplementary values: Value Meaning 997 Not applicable 998 Unknown 999 Not stated/inadequately described Collection and usage attributes Guide for use: Valid M codes from the current edition of the UICC TNM Classification of Malignant Tumours. Refer to the TNM Supplement: A commentary on uniform use, 3rd Edition for coding rules. Source and reference attributes Reference documents: Wittekind C et al (Editors) 2003. International Union Against Cancer (UICC): TNM supplement: A commentary on uniform use, 3rd edition. Wiley-Blackwell. Data element attributes Collection and usage attributes Guide for use: Record the absence or presence of distant metastasis at the time of diagnosis of the cancer. TNM staging applies to solid tumours excluding brain tumours. Choose the lower (less advanced) M category when there is any uncertainty. The current edition of the AJCC Cancer Staging Manual provides an equivalent and alternative source of M stage codes. Staging classification systems other than the TNM classification system are recorded separately. Collection methods: This information should be obtained from the patient's medical record. Comments: Cancer stage is an important determinant of treatment and prognosis, and is used to evaluate new treatments and analyse outcomes. Survival analysis is adjusted by stage at diagnosis and distribution of cancer cases by type and stage. Source and reference attributes Submitting organisation: Cancer Australia Origin: International Union Against Cancer (UICC) Commission on Cancer, American College of Surgeons Reference documents: Sobin LH, Gospodarowicz MK, Wittekind C (Editors) 2009. International Union Against Cancer (UICC): TNM Classification of Malignant Tumours, 7th edition. Wiley-Blackwell American Joint Committee on Cancer 2010. AJCC Cancer Staging Manual, 7th edition. New York: Springer American College of Surgeons 2002. Facility Oncology Registry Data Standards (FORDS), 2009 revision. Commission on Cancer Relational attributes Related metadata references: See also Cancer staging—staging basis of cancer, code A Health, Superseded 07/12/2011 See also Cancer staging—staging basis of cancer, code A Health, Standard 07/12/2011 Supersedes Person with cancer—distant metastasis status, M stage (UICC TNM Classification of Malignant Tumours, 6th edn) code XX Health, Superseded 07/12/2011 See also Person with cancer—extent of primary cancer, TNM stage (UICC TNM Classification of Malignant Tumours, 7th ed) code X[XX] Health, Standard 07/12/2011 See also Person with cancer—primary tumour status, T stage (UICC TNM Classification of Malignant Tumours, 7th ed) code X[XXX] Health, Standard 07/12/2011 See also Person with cancer—regional lymph node metastasis status, N stage (UICC TNM Classification of Malignant Tumours, 7th ed) code X[XX] Health, Standard 07/12/2011 Implementation in Data Set Specifications: Breast cancer (cancer registries) DSS Health, Standard 01/09/2012 Cancer (clinical) DSS Health, Standard 14/05/2015

Data type

text

Alias

UMLS CUI [1,1]

C0456533

Description

Person with cancer—extent of primary cancer, TNM stage (UICC TNM Classification of Malignant Tumours, 7th ed) code X[XX] Identifying and definitional attributes Short name: Cancer staging—TNM stage grouping code METeOR identifier: 403726 Registration status: Health, Standard 07/12/2011 Definition: The anatomical extent of disease in a person with cancer based on the previously coded T, N and M stage categories, as represented by a code. Data Element Concept: Person with cancer—extent of primary cancer Value domain attributes Representational attributes Classification scheme: International Union against Cancer (UICC) TNM Classification of Malignant Tumours 7th edition Representation class: Code Data type: String Format: X[XX] Maximum character length: 3 Supplementary values: Value Meaning 997 Not applicable 998 Unknown 999 Not stated/inadequately described Collection and usage attributes Guide for use: Record the stage in Arabic numerals and the appropriate upper or lower case alphabetic character omitting the prefix "stage". For example, record Stage IIA2 for cancer of the cervix uteri as "2A2". Valid stage grouping codes from the current edition of the UICC TNM Classification of Malignant Tumours. Refer to the TNM Supplement: A Commentary on Uniform Use, 3rd Edition for coding rules. Source and reference attributes Reference documents: Wittekind C et al (Editors) 2003. International Union Against Cancer (UICC): TNM supplement: A commentary on uniform use, 3rd edition. Wiley-Blackwell. Data element attributes Collection and usage attributes Guide for use: Record the extent of the primary cancer at the time of diagnosis of the cancer. TNM staging applies to solid tumours excluding brain tumours. The current edition of the American Joint Committee on Cancer (AJCC) Cancer Staging Manual provides an equivalent and alternative source of TNM stage grouping codes. Stage groupings using classification systems other than the TNM classification system are recorded separately. Collection methods: This information should be obtained from the patient's medical record. Comments: Cancer stage is an important determinant of treatment and prognosis, and is used to evaluate new treatments and analyse outcomes. Survival analysis is adjusted by stage at diagnosis and distribution of cancer cases by type and stage. Source and reference attributes Submitting organisation: Cancer Australia Reference documents: Sobin LH, Gospodarowicz MK, Wittekind C (Editors) 2009. International Union Against Cancer (UICC): TNM Classification of Malignant Tumours, 7th edition. Wiley-Blackwell American Joint Committee on Cancer 2010. AJCC Cancer Staging Manual, 7th edition. New York: Springer American College of Surgeons 2002. Facility Oncology Registry Data Standards (FORDS), 2009 revision. Commission on Cancer Relational attributes Related metadata references: See also Cancer staging—staging basis of cancer, code A Health, Superseded 07/12/2011 See also Cancer staging—staging basis of cancer, code A Health, Standard 07/12/2011 See also Person with cancer—distant metastasis status, M stage (UICC TNM Classification of Malignant Tumours, 7th ed) code X[XX] Health, Standard 07/12/2011 Supersedes Person with cancer—extent of primary cancer, TNM stage (UICC TNM Classification of Malignant Tumours, 6th ed) code XXXX{[X]XX} Health, Superseded 07/12/2011 See also Person with cancer—primary tumour status, T stage (UICC TNM Classification of Malignant Tumours, 7th ed) code X[XXX] Health, Standard 07/12/2011 See also Person with cancer—regional lymph node metastasis status, N stage (UICC TNM Classification of Malignant Tumours, 7th ed) code X[XX] Health, Standard 07/12/2011 Implementation in Data Set Specifications: Bowel cancer diagnosed cluster Health, Standard 29/08/2014 Breast cancer (cancer registries) DSS Health, Standard 01/09/2012 Cancer (clinical) DSS Health, Standard 14/05/2015 Implementation in Indicators: Used as numerator National Bowel Cancer Screening Program: PI 08-Cancer clinico-pathological stage distribution Health, Standard 29/08/2014

Data type

text

Alias

UMLS CUI [1]

C1302362

Description

Person with cancer—histopathological grade, code N Identifying and definitional attributes Short name: Histopathological grade METeOR identifier: 422555 Registration status: Health, Standard 07/12/2011 Definition: The histopathological grade or differentiation in a person with cancer, as represented by a code. Data Element Concept: Person with cancer—histopathological grade Value domain attributes Representational attributes Representation class: Code Data type: Number Format: N Maximum character length: 1 Permissible values: Value Meaning 1 Grade 1: Low grade; well differentiated, differentiated, NOS 2 Grade 2: Intermediate grade, moderately differentiated, moderately well differentiated, intermediate differentiation 3 Grade 3: High grade, poorly differentiated 4 Grade 4: Undifferentiated, anaplastic Supplementary values: 9 Grade or differentiation not determined, not stated or not applicable Data set specification specific attributes Breast cancer (cancer registries) DSS DSS specific information: Breast cancer coding rules: Use the Nottingham grade (Elston-Ellis modification of Bloom-Richardson grading system). This classification only uses grades 1-3, 9. For an invasive tumour with an in situ component, record the grade for the invasive component only. If the grade of the invasive component is not reported, record the grade as unknown. Data element attributes Collection and usage attributes Guide for use: Histopathological grade or differentiation describes how little the tumour resembles the normal tissue from which it arose. Only malignant tumours are graded and only one code can be recorded. When more than one grade is documented for the primary tumour within the same specimen report, use the highest grade. For example, if grade 2-3 is documented, record the grade as 3. If the grades differ on multiple pathology reports for the same tumour, use the value from the larger specimen (for example, the grade from a surgical excision specimen would be used over the grade from a specimen from a diagnostic biopsy). Breast cancer coding rules: Use the Nottingham grade (Elston-Ellis modification of Bloom-Richardson grading system). This classification only uses grades 1-3, 9. For an invasive tumour with an in situ component, record the grade for the invasive component only. If the grade of the invasive component is not reported, record the grade as unknown. Collection methods: Cancer registry use: Collection of this data item should only be from notification and pathology reports relating to initial diagnosis and not for recurrent or metastatic disease. Only malignant tumours are graded. Source and reference attributes Origin: World Health Organization Commission on Cancer American College of Surgeons Reference documents: Fritz A et al. 2000. International Classification of Diseases for Oncology, Third edition (ICD-O), 3rd edition. Geneva: World Health Organization American College of Surgeons 1998. Standards of the Commission on Cancer Registry Operations and Data Standards (ROADS), Volume II, Commission on Cancer Johnson CH & Adamo M (Editors) 2007. SEER Program Coding and Staging Manual 2007. MD 2007. Bethesda: National Cancer Institute, NIH Publication number 07-5581 Relational attributes Related metadata references: Supersedes Person with cancer—histopathological grade, code N Health, Superseded 07/12/2011 Implementation in Data Set Specifications: Breast cancer (cancer registries) DSS Health, Standard 01/09/2012 Cancer (clinical) DSS Health, Standard 14/05/2015

Data type

integer

Alias

UMLS CUI [1,1]

C0475753

Description

Person with cancer—human epidermal growth factor receptor-2 test result, code N Identifying and definitional attributes Short name: Human epidermal growth factor receptor-2 test result Synonymous names: HER2 test result METeOR identifier: 370572 Registration status: Health, Standard 06/03/2009 Definition: The result of a person's human epidermal growth factor receptor-2 (HER2) test, as represented by a code. Data Element Concept: Person with cancer—human epidermal growth factor receptor-2 test result Value domain attributes Representational attributes Representation class: Code Data type: Number Format: N Maximum character length: 1 Permissible values: Value Meaning 1 Positive 2 Negative 3 Equivocal Supplementary values: 7 Unknown (test results not available) 8 Not applicable (test not done) Collection and usage attributes Guide for use: Record the reported conclusion of the HER2. If no conclusion is reported use the following guidelines (from the National Breast and Ovarian Cancer Centre and Australian Cancer Network’s pathology reporting guide (3rd ed.) for breast cancer): CODE 1 Positive · For in situ hybridisation: Result is more than 6 copies of the HER2 gene per nucleus OR a ratio of HER2 gene signals to chromosome 17 signals of more than 2.2. · For Immunochemistry: Result is described as 3+ or +++ OR >30% of cancer cells show strong complete membrane staining without cytoplasmic staining and without staining of normal tissue. CODE 2 Negative · For in situ hybridisation: Result is less than 4 copies of the HER2 gene per nucleus OR a ratio of HER2 gene signals to chromosome 17 signals of less than 1.8. · For Immunochemistry: Result described as 0, 1+ or + OR <10% of cancer cells show staining. CODE 3 Equivocal · For in situ hybridisation: Result is an average of between 4 and 6 HER2 gene copies per nucleus with a single probe OR a ratio of HER2 gene signals to chromosome 17 signals in the range of 1.8-2.2. · For Immunochemistry: Result described as 2+ or ++ OR <10% of cancer cells show strong complete membrane staining (rare) OR 10-30% of cancer cells show weak to moderate complete membrane staining OR Strong cytoplasmic staining is present, making assessment of membrane staining difficult. Supplementary codes CODE 7 Unknown (test results not available) Use this code when the test has been performed but the results are not yet available for analysis. CODE 8 Not applicable (test not done) This code is used as a validation measure, to show that the reason for the lack of results is due to the test not being performed. Data element attributes Collection and usage attributes Collection methods: For cancer registries, collection of this data item should only be from notification and pathology reports relating to initial diagnosis and not for recurrent or subsequent metastatic disease. Where different values are available from multiple specimens, the appropriate values to enter are selected according to the following hierarchy of rules: When multiple HER2 values are available, the value established by the most accurate test is used as per the hierarchy: FISH > CISH/SISH > IHC. (See Person with cancer—HER2 test type, code N) If the HER2 values differ on multiple pathology reports for the same tumour, use the value from the larger specimen. For multifocal tumours, use the HER2 value from the largest focus or from a metastatic deposit; e.g. Lymph node metastasis. A smaller focus that is HER2 positive may in fact be the source of a metastasis and in this setting the patient would derive benefit from the therapy offered as a result of HER2 positive status. Comments: Human epidermal growth factor receptor-2 (HER2) promotes the growth of cancer cells. HER2 is also known as c-erB-2 and Her2/neu. Tumours that are HER2-positive tend to grow more quickly than other types of cancer. HER2 status is an important prognostic marker and predicts the response to several therapies. Source and reference attributes Origin: National Breast and Ovarian Cancer Centre (NBOCC) Australasian Association of Cancer Registries (AACR) Australian Institute of Health and Welfare (AIHW) Reference documents: National Breast and Ovarian Cancer Centre and Australian Cancer Network. The Pathology reporting of breast cancer. A guide for pathologists, surgeons, radiologists and oncologists (3rd edition). National Breast and Ovarian Cancer Centre, Surry Hills, NSW, 2008. Relational attributes Implementation in Data Set Specifications: Breast cancer (cancer registries) DSS Health, Standard 01/09/2012

Data type

integer

Alias

UMLS CUI [1,1]

C1429315

UMLS CUI [1,2]

C0456984

Description

Person with cancer—human epidermal growth factor receptor-2 test type, code N Identifying and definitional attributes Short name: Human epidermal growth factor receptor-2 test type Synonymous names: HER2 test type METeOR identifier: 370607 Registration status: Health, Standard 06/03/2009 Definition: The type of test used to determine the results of human epidermal growth factor receptor-2 (HER2) at the time of diagnosis of the primary tumour, as represented by a code. Data Element Concept: Person with cancer—human epidermal growth factor receptor-2 test type Value domain attributes Representational attributes Representation class: Code Data type: Number Format: N Maximum character length: 1 Permissible values: Value Meaning 1 Fluorescence in situ hybridisation (FISH) 2 Brightfield in situ hybridisation 3 Immunochemistry (IHC) 8 Other Supplementary values: 9 Test type not stated or unknown Collection and usage attributes Guide for use: CODE 2 Brightfield in situ hybridisation Includes Chromogenic in situ hybridisation (CISH) and Silver in situ hybridisation (SISH). Data element attributes Collection and usage attributes Guide for use: Record the test type corresponding to the test result recorded in 'Person with Cancer - human epidermal growth factor receptor-2 test result'. Comments: Immunochemistry (IHC) measures how much HER2 protein is present in the tumour sample. Fluorescence in situ hybridisation (FISH), chromogenic in situ hybridisation (CISH) and silver in situ hybridisation (SISH) measure the amount of amplification of the gene responsible for HER2. The type of HER2 test used to determine HER2 status affects the accuracy of the information. Source and reference attributes Origin: National Breast and Ovarian Cancer Centre (NBOCC) Australasian Association of Cancer Registries (AACR) Australian Institute of Health and Welfare (AIHW) Relational attributes Implementation in Data Set Specifications: Breast cancer (cancer registries) DSS Health, Standard 01/09/2012

Data type

integer

Alias

UMLS CUI [1,1]

C1429315

UMLS CUI [1,2]

C0449570

Description

Person with cancer—laterality of primary cancer, code A Identifying and definitional attributes Short name: Laterality of primary cancer METeOR identifier: 422769 Registration status: Health, Standard 07/12/2011 Definition: The side of a paired organ that is the origin of the primary cancer in a person with cancer, as represented by a code. Data Element Concept: Person with cancer—laterality of primary cancer Value domain attributes Representational attributes Representation class: Code Data type: String Format: A Maximum character length: 1 Permissible values: Value Meaning R Right L Left B Bilateral Supplementary values: N Not applicable U Unknown Data element attributes Collection and usage attributes Guide for use: Record the appropriate code at the time of diagnosis. Definitions Right: Origin of primary site is on the right side of a paired organ. Left: Origin of primary site is on the left side of a paired organ. Bilateral: Origin of primary site is on both sides of a paired organ. (When tumours of the same morphology are diagnosed simultaneously in both sides of a paired organ.) Includes organs that are bilateral as a single primary (e.g. bilateral retinoblastoma (M9510/3, C69.2), (M9511/3, C69.2), (M9512/3, C69.2), (C69.6, C48.0), bilateral Wilms tumours (C64.9, M8960/3)) Note: Bilateral cancers are very rare. Unknown: It is unknown whether, for a paired organ the origin of the cancer was on the left or right side of the body. Paired organs and structures The valid International Classification of Diseases for Oncology values for paired organs are provided in the list below: C02.4 Lingual tonsil C07.9 Parotid gland C08.0 Submandibular gland C08.1 Sublingual gland C09.0 Tonsillar fossa C09.1 Tonsillar pillar C09.8 Overlapping lesion of tonsil C09.9 Tonsil, NOS C11.1 Posterior wall of nasopharynx C30.0 Nasal cavity (excluding nasal cartilage and nasal septum) C30.1 Middle ear C31.0 Maxillary sinus C31.2 Frontal sinus C34.0 Main bronchus (excluding carina) C34.1-C34.9 Lung C38.4 Pleura C40.0 Long bones of upper limb and scapula C40.1 Short bones of upper limb C40.2 Long bones of lower limb C40.3 Short bones of lower limb C41.3 Rib and clavicle (excluding sternum) C41.4 Pelvic bones (excluding sacrum, coccyx and symphysis pubis) C44.1 Skin of eyelid C44.2 Skin of external ear C44.3 Skin of other and unspecified parts of face C44.5 Skin of trunk C44.6 Skin of upper limb and shoulder C44.7 Skin of lower limb and hip C47.1 Peripheral nerves and autonomic nervous system of upper limb and shoulder C47.2 Peripheral nerves and autonomic nervous system of lower limb and hip C49.1 Connective, subcutaneous and other soft tissues of upper limb and shoulder C49.2 Connective, subcutaneous and other soft tissues of lower limb and hip C50.0-C50.9 Breast C56.9 Ovary C57.0 Fallopian tube C62.0-C62.9 Testis C63.0 Epididymis C63.1 Spermatic cord C64.9 Kidney, NOS C65.9 Renal pelvis C66.9 Ureter C69.0-C69.9 Eye and lacrimal gland C70.0 Cerebral meninges, NOS C71.0 Cerebrum C71.1 Frontal lobe C71.2 Temporal lobe C71.3 Parietal lobe C71.4 Occipital lobe C72.2 Olfactory nerve C72.3 Optic nerve C72.4 Acoustic nerve C72.5 Cranial nerve, NOS C74.0-C74.9 Adrenal gland C75.0 Parathyroid glands C75.4 Carotid body C76.4 Upper limb, NOS C76.5 Lower limb, NOS C77.3 Lymph nodes of axilla or arm C77.4 Lymph nodes of inguinal region or leg Collection methods: This information should be obtained from the patient's medical record and pathology report. Comments: The laterality of the primary tumour may have implications for treatment and prognosis, and can be of assistance to cancer registries for the coding of subsequent tumours in paired organs. Source and reference attributes Origin: World Health Organization Reference documents: American College of Surgeons 2002. Facility Oncology Registry Data Standards (FORDS), 2010 revision. Commission on Cancer Fritz A et al. 2000. International Classification of Diseases for Oncology (ICD-O), 3rd edition. Geneva: World Health Organization Relational attributes Related metadata references: Supersedes Person with cancer—laterality of primary cancer, code [N] Health, Superseded 07/12/2011 Implementation in Data Set Specifications: Breast cancer (cancer registries) DSS Health, Standard 01/09/2012 Cancer (clinical) DSS Health, Standard 14/05/2015

Data type

text

Alias

UMLS CUI [1,1]

C0925205

UMLS CUI [1,2]

C1306459

Description

Person with cancer—lymphovascular invasion, code N Identifying and definitional attributes Short name: Lymphovascular invasion METeOR identifier: 370618 Registration status: Health, Standard 06/03/2009 Definition: The presence or absence of the invasion of cancer cells into blood vessel(s) and/or the lymphatic system, as represented by a code. Data Element Concept: Person with cancer—lymphovascular invasion Value domain attributes Representational attributes Representation class: Code Data type: Number Format: N Maximum character length: 1 Permissible values: Value Meaning 1 Present 2 Absent 3 Suspicious Supplementary values: 9 Not stated or unknown Data element attributes Collection and usage attributes Guide for use: The presence of lymphovascular invasion should be recorded as Code 1, regardless of whether the extent of the invasion is described or not. Collection methods: For cancer registries, collection of this data item should only be from notification and pathology reports relating to initial diagnosis and not for recurrent or metastatic disease. If pathology report pertaining to initial diagnosis is for a metastasis, and not the primary tumour, record as 9. Comments: Invasion of the lymphatics or blood vessels by cancer cells is an important prognostic factor that indicates that the tumour is likely to spread. This item is included in data items defined for reporting in the pathology reporting guidelines as prepared by the National Breast and Ovarian Cancer Centre and Australian Cancer Network. Source and reference attributes Origin: National Breast and Ovarian Cancer Centre (NBOCC) Australasian Association of Cancer Registries (AACR) Australian Institute of Health and Welfare (AIHW) Reference documents: National Breast and Ovarian Cancer Centre and Australian Cancer Network. The Pathology reporting of breast cancer. A guide for pathologists, surgeons, radiologists and oncologists (3rd edition). National Breast and Ovarian Cancer Centre, Surry Hills, NSW, 2008. Relational attributes Implementation in Data Set Specifications: Breast cancer (cancer registries) DSS Health, Standard 01/09/2012

Data type

integer

Alias

UMLS CUI [1]

C1708790

Description

Person with cancer—morphology of cancer, code (ICD-O-3) NNNN/N Identifying and definitional attributes Short name: Morphology of cancer METeOR identifier: 399491 Registration status: Health, Standard 07/12/2011 Definition: The histological classification of the cancer tissue (histopathological type) in a person with cancer, and a description of the course of development that a tumour is likely to take: benign or malignant (behaviour), as represented by a code. Data Element Concept: Person with cancer—morphology of cancer Value domain attributes Representational attributes Classification scheme: International Classification of Diseases for Oncology 3rd edition Representation class: Code Data type: Number Format: NNNN/N Maximum character length: 5 Collection and usage attributes Guide for use: ICD-O morphology describes histology and behaviour as separate variables, recognising that there are a large number of possible combinations. In ICD-O, morphology is a 4-digit number ranging from 8000 to 9989, and behaviour is a single digit which can be 0, 1, 2, 3, 6 or 9. When the morphology is unknown, record 8000 and the appropriate behaviour code. For example, a tumour of unknown morphology with a behaviour code of "3" for a malignant primary site tumour would be recorded as 8000/3. Source and reference attributes Origin: International Classification of Diseases for Oncology, Third Edition (ICD-O-3) Data element attributes Collection and usage attributes Guide for use: Tumour morphology refers to the type of cell (histology) that has become neoplastic and its biologic activity (behaviour). Record the tumour morphology for patients who have been diagnosed with cancer. Record the tumour morphology relating to the initial diagnosis and not for recurrent disease. Record morphology codes in accordance with ICD-O-3 coding standards. Use the 5th-digit to record behaviour. Refer to the coding guidelines for morphology in ICD-O-3, pp 27-34. If the morphology differs on multiple pathology reports for the same tumour, use the value from the most representative tumour specimen examined. For example, if the tumour is described as ductal on core biopsy but undifferentiated carcinoma on the excision specimen, the morphology would be coded as undifferentiated carcinoma (a lower code) which has a less favourable diagnosis. Collection methods: This information should be obtained from the patient's pathology reports or, in the case of cancer registries, from the notification reports. Comments: The information is collected so that tumours can be classified into clinically relevant groups based on their primary site and morphology. This provides a basis for staging and the determination of treatment options. The morphology of the cancer also affects the course of the disease and prognosis. Source and reference attributes Submitting organisation: Cancer Australia Origin: World Health Organization New South Wales Health Department State and Territory Cancer Registries Reference documents: New South Wales Inpatient Statistics Collection Manual. 2000/2001 Esteban D, Whelan S, Laudico A, Parkin DM (Editors) 1995. World Health Organization and International Association of Cancer Registries: Manual for cancer registry personnel, IARC Technical Report No 10. Lyon: International Agency for Research on Cancer Fritz A et al. 2000. International Classification of Diseases for Oncology (ICD-O), 3rd edition. Geneva: World Health Organization Relational attributes Related metadata references: Supersedes Person with cancer—morphology of cancer, code (ICDO-3) NNNN/N Health, Superseded 07/12/2011 Implementation in Data Set Specifications: Breast cancer (cancer registries) DSS Health, Standard 01/09/2012 Cancer (clinical) DSS Health, Standard 14/05/2015 Implementation in Indicators: Used as numerator National Healthcare Agreement: PI 02-Incidence of selected cancers, 2015 Health, Standard 14/01/2015

Data type

integer

Alias

UMLS CUI [1,1]

C0332437

UMLS CUI [1,2]

C0027651

Description

Person with cancer—most valid basis of diagnosis of a cancer, code N Identifying and definitional attributes Short name: Most valid basis of diagnosis of cancer METeOR identifier: 422772 Registration status: Health, Standard 07/12/2011 Definition: The most valid basis of diagnosis in a person with cancer, as represented by a code. Data Element Concept: Person with cancer—most valid basis of diagnosis of a cancer Value domain attributes Representational attributes Representation class: Code Data type: Number Format: N Maximum character length: 1 Permissible values: Value Meaning 0 Death certificate only: Information provided is from a death certificate 1 Clinical: Diagnosis made before death, but without any of the following (codes 2-7) 2 Clinical investigation: All diagnostic techniques, including x-ray, endoscopy, imaging, ultrasound, exploratory surgery (e.g. laparotomy), and autopsy, without a tissue diagnosis 4 Specific tumour markers: Including biochemical and/or immunological markers that are specific for a tumour site 5 Cytology: Examination of cells from a primary or secondary site, including fluids aspirated by endoscopy or needle; also includes the microscopic examination of peripheral blood and bone marrow aspirates 6 Histology of metastasis: Histological examination of tissue from a metastasis, including autopsy specimens 7 Histology of a primary tumour: Histological examination of tissue from primary tumour, however obtained, including all cutting techniques and bone marrow biopsies; also includes autopsy specimens of primary tumour 8 Histology: either unknown whether of primary or metastatic site, or not otherwise specified Supplementary values: 9 Unknown. Collection and usage attributes Guide for use: CODES 1 - 4 Non-microscopic. CODES 5 - 8 Microscopic. CODE 9 Other. Comments: In a hospital setting this metadata item should be collected on the most valid basis of diagnosis at this admission. If more than one diagnosis technique is used during an admission, select the higher code from 1 to 8. Data element attributes Collection and usage attributes Guide for use: The most valid basis of diagnosis may be the initial histological examination of the primary site, or it may be the post-mortem examination (sometimes corrected even at this point when histological results become available). In a cancer registry setting, this metadata item should be revised if later information allows its upgrading. When considering the most valid basis of diagnosis, the minimum requirement of a cancer registry is differentiation between neoplasms that are verified microscopically and those that are not. To exclude the latter group means losing valuable information; the feasibility of making a morphological (histological) diagnosis is dependent upon a variety of factors, such as the health and age of the patient, accessibility of the tumour, availability of medical services, and the beliefs and decisions of the patient. A biopsy of the primary tumour should be distinguished from a biopsy of a metastasis, for example, at laparotomy; a biopsy of cancer of the head of the pancreas versus a biopsy of a metastasis in the mesentery. However, when insufficient information is available, Code 8 should be used for any histological diagnosis. Cytological and histological diagnoses should be distinguished. Morphological confirmation of the clinical diagnosis of malignancy depends on the successful removal of a piece of tissue that is cancerous. Especially when using endoscopic procedures (bronchoscopy, gastroscopy, laparoscopy, etc.), the clinician may miss the tumour with the biopsy forceps. These cases must be registered on the basis of endoscopic diagnosis and not excluded through lack of a morphological diagnosis. Care must be taken in the interpretation and subsequent coding of autopsy findings, which may vary as follows: a) the post-mortem report includes the post-mortem histological diagnosis (in which case, one of the histology codes should be recorded instead); b) the autopsy is macroscopic only, histological investigations having been carried out only during life (in which case, one of the histology codes should be recorded instead); c) the autopsy findings are not supported by any histological diagnosis. Comments: Knowledge of the basis of the diagnosis underlying a cancer code is one of the most important elements in assessing the reliability of cancer statistics. Source and reference attributes Origin: International Agency for Research on Cancer International Association of Cancer Registries Relational attributes Related metadata references: Supersedes Person with cancer—most valid basis of diagnosis of a cancer, code N Health, Superseded 07/12/2011 Implementation in Data Set Specifications: Breast cancer (cancer registries) DSS Health, Standard 01/09/2012 Cancer (clinical) DSS Health, Standard 14/05/2015

Data type

integer

Alias

UMLS CUI [1,1]

C1550351

UMLS CUI [1,2]

C0006826

Description

Person with cancer—neoadjuvant therapy indicator, code N Identifying and definitional attributes Short name: Neo-adjuvant therapy METeOR identifier: 370014 Registration status: Health, Standard 06/03/2009 Definition: Whether a person with a solid tumour has received neoadjuvant therapy, as represented by a code. Data Element Concept: Person with cancer—neoadjuvant therapy indicator Value domain attributes Representational attributes Representation class: Code Data type: Boolean Format: N Maximum character length: 1 Permissible values: Value Meaning 1 Yes 2 No Data element attributes Collection and usage attributes Guide for use: To be reported when therapy is received after a diagnosis of cancer and prior to primary surgical treatment. This data item is used to flag cases in which tumour descriptors, for example solid tumour size, may be inaccurate due to shrinkage from neoadjuvant therapy. Yes - indicates that the client has received neo-adjuvant therapy after a diagnosis of cancer and prior to primary surgical treatment No - indicates that the client did not receive neo-adjuvant therapy after a diagnosis of cancer and prior to primary surgical treatment For invasive breast cancer: Information is obtained from · Clinical notes on pathology report mentions that patient underwent chemotherapy prior to surgery · Microscopy section of pathology report describes tumour changes as a result of neoadjuvant therapy (coder may be alerted to look for this detail by a long interval between biopsy and wider excision) · Hospital notification indicates that admission if for chemotherapy only (and admission date is before that for surgery) Comments: Preoperative chemotherapy and/or radiotherapy may be received after a diagnosis of cancer but before surgical treatment. The effects of chemotherapy and/or radiotherapy prior to surgery will shrink the tumour and so the size of the tumour found from the subsequent surgical excision will be smaller than the original size of the tumour at the time of diagnosis. This impacts on the TNM-T and staging classification, and is important to take into account for analysis and research. Source and reference attributes Origin: National Breast and Ovarian Cancer Centre (NBOCC) Australasian Association of Cancer Registries (AACR) Australian Institute of Health and Welfare (AIHW) Reference documents: Johnson CH, Adamo M (eds.), SEER Program Coding and Staging Manual 2007. National Cancer Institute, NIH Publication number 07-5581, Bethesda, MD 2007. Relational attributes Implementation in Data Set Specifications: Breast cancer (cancer registries) DSS Health, Standard 01/09/2012

Data type

boolean

Alias

UMLS CUI [1,1]

C0600558

Description

Person with cancer—number of positive regional lymph nodes, total N[N] Identifying and definitional attributes Short name: Regional lymph nodes positive METeOR identifier: 415959 Registration status: Health, Standard 07/12/2011 Definition: The total number of regional lymph nodes reported to contain tumour in a person with cancer. Data Element Concept: Person with cancer—number of positive regional lymph nodes Value domain attributes Representational attributes Representation class: Total Data type: Number Format: N[N] Maximum character length: 2 Supplementary values: Value Meaning 99 Not stated/inadequately described Data element attributes Collection and usage attributes Guide for use: A list of which lymph nodes are defined as regional lymph nodes for each cancer site may be found in the current edition of the TNM Classification of Tumours, UICC (International Union Against Cancer) and the AJCC (American Joint Committee on Cancer) Cancer Staging Manual. The number includes all positive nodes regardless of whether they were removed and examined at a single or multiple procedures. For example, for breast cancer, record the sum of positive nodes detected in node sampling/sentinel node biopsy and those removed at axillary clearance. Collection methods: The information should be obtained from the patient's medical record. For cancer registries, collection of this data item should only be from notification and pathology reports relating to initial diagnosis and not for recurrent or metastatic disease. Source and reference attributes Origin: Australian Cancer Network Commission on Cancer American College of Surgeons Reference documents: American College of Surgeons 1998. Standards of the Commission on Cancer: Registry Operations and Data Standards (ROADS), Volume II, Commission on Cancer American Joint Committee on Cancer 2010. AJCC Staging Manual, 7th edition. New York: Springer Australian Cancer Network 2001. The pathology reporting of breast cancer: A guide for pathologists, surgeons and radiologists, 2nd Edition. Sydney: Australian Cancer Network Johnson CH & Adamo M (Editors) 2007. SEER Program Coding and Staging Manual 2007, MD 2008 revision. Bethesda: National Cancer Institute, NIH Publication number 07-5581 Sobin LH, Gospodarowicz MK, Wittekind C (Editors) 2009. International Union Against Cancer (UICC): TNM Classification of Malignant Tumours, 7th edition. Wiley-Blackwell Relational attributes Related metadata references: See also Number of regional lymph nodes examined Health, Standard 07/12/2011 Supersedes Person with cancer—number of positive regional lymph nodes, total N[N] Health, Superseded 07/12/2011 See also Person with cancer—number of regional lymph nodes examined, total N[N] Health, Standard 07/12/2011 Implementation in Data Set Specifications: Breast cancer (cancer registries) DSS Health, Standard 01/09/2012 Cancer (clinical) DSS Health, Standard 14/05/2015

Data type

integer

Alias

UMLS CUI [1,1]

C0807729

Description

Person with cancer—number of positive sentinel lymph nodes, total code N[NN] Identifying and definitional attributes Short name: Number of positive sentinel lymph nodes METeOR identifier: 370549 Registration status: Health, Standard 06/03/2009 Definition: The total number of sentinel lymph nodes reported as containing tumour after examination by a pathologist. Data Element Concept: Person with cancer—number of positive sentinel lymph nodes Value domain attributes Representational attributes Representation class: Total Data type: Number Format: N[NN] Maximum character length: 3 Supplementary values: Value Meaning 997 Number of lymph nodes unknown Data element attributes Collection and usage attributes Collection methods: For cancer registries: Collection of this data item should only be from notification and pathology reports relating to initial diagnosis and not for recurrent or metastatic disease. Comments: Sentinel lymph nodes are the first nodes that filter fluid draining away from the area of cancer. The number of lymph nodes with metastasis is important for cancer staging Source and reference attributes Origin: National Breast and Ovarian Cancer Centre (NBOCC) Australasian Association of Cancer Registries (AACR) Australian Institute of Health and Welfare (AIHW) Reference documents: Johnson CH, Adamo M (eds.), SEER Program Coding and Staging Manual 2007. National Cancer Institute, NIH Publication number 07-5581, Bethesda, MD 2007. Relational attributes Implementation in Data Set Specifications: Breast cancer (cancer registries) DSS Health, Standard 01/09/2012

Data type

integer

Alias

UMLS CUI [1,1]

C1522495

UMLS CUI [1,2]

C0746319

UMLS CUI [1,3]

C0449788

Description

Person with cancer—number of regional lymph nodes examined, total N[N] Identifying and definitional attributes Short name: Number of regional lymph nodes examined METeOR identifier: 415971 Registration status: Health, Standard 07/12/2011 Definition: The total number of regional lymph nodes examined by a pathologist in a person with cancer. Data Element Concept: Person with cancer—number of regional lymph nodes examined Value domain attributes Representational attributes Representation class: Total Data type: Number Format: N[N] Maximum character length: 2 Supplementary values: Value Meaning 99 Not stated/inadequately described Data set specification specific attributes Breast cancer (cancer registries) DSS DSS specific information: Breast cancer: Regional lymph nodes include all ipsilateral axillary, ipsilateral infraclavicular/subclavicular, ipsilateral internal mammary and ipsilateral supraclavicaular nodes. All other nodes (including contralateral internal mammary nodes) are considered to be distant metastases and should not be recorded in this data item. Definitions from UICC TNM Classification of Malignant Tumours 6th Edition. Data element attributes Collection and usage attributes Guide for use: A list of which lymph nodes are defined as regional lymph nodes for each cancer site may be found in the current edition of the TNM Classification of Tumours, UICC (International Union Against Cancer) or the AJCC (American Joint Committee on Cancer) Cancer Staging Manual. The number includes all nodes examined regardless of whether they were removed and examined at a single or multiple procedures. For example, for breast cancer, record the sum of regional lymph nodes examined from node sampling, sentinel node biopsy and axillary clearance. The number of regional lymph nodes is cumulative from all procedures that removed lymph nodes through the completion of surgeries for the initial treatment of the cancer. The initial course of treatment includes all treatments administered to the patient from diagnosis and before disease progression or recurrence. Breast cancer: Regional lymph nodes include all ipsilateral axillary nodes (levels 1, 2 and 3), ipsilateral internal mammary nodes, supraclavicular nodes and intramammary lymph nodes. All other nodes (including contralateral axillary, contralateral internal mammary nodes and cervical nodes) are considered to be distant metastases and should not be recorded in this data item. Definitions are from the UICC TNM Classification of Malignant Tumours, 7th Edition. Collection methods: For cancer registries, collection of this data item should only be from notification and pathology reports relating to initial diagnosis and not for recurrent or metastatic disease. Source and reference attributes Origin: Australian Cancer Network Commission on Cancer American College of Surgeons Reference documents: American College of Surgeons 1998. Standards of the Commission on Cancer: Registry Operations and Data Standards (ROADS), Volume II, Commission on Cancer American Joint Committee on Cancer 2010. AJCC Cancer Staging Manual, 7th edition. New York: Springer Australian Cancer Network & National Breast and Ovarian Cancer Network 2001. The pathology reporting of breast cancer: A guide for pathologists, surgeons, radiologists and oncologists, 3rd edition. Sydney: Australian Cancer Network & National Breast and Ovarian Cancer Network Johnson CH & Adamo M (Editors) 2007. SEER Program Coding and Staging Manual 2007, MD 2008 revision. Bethesda: National Cancer Institute, NIH Publication number 07-5581 Sobin LH, Gospodarowicz MK, Wittekind C (Editors) 2009. International Union Against Cancer (UICC): TNM Classification of Malignant Tumours, 7th edition. Wiley-Blackwell Relational attributes Related metadata references: See also Person with cancer—number of positive regional lymph nodes, total N[N] Health, Standard 07/12/2011 Supersedes Person with cancer—number of regional lymph nodes examined, total code N[N] Health, Superseded 07/12/2011 Implementation in Data Set Specifications: Breast cancer (cancer registries) DSS Health, Standard 01/09/2012 Cancer (clinical) DSS Health, Standard 14/05/2015

Data type

integer

Alias

UMLS CUI [1,1]

C0582103

UMLS CUI [1,2]

C0024204

UMLS CUI [1,3]

C0205147

UMLS CUI [1,4]

C0449788

Description

Person with cancer—number of sentinel lymph nodes examined, total code N[NN] Identifying and definitional attributes Short name: Number of sentinel lymph nodes examined METeOR identifier: 370558 Registration status: Health, Standard 06/03/2009 Definition: The total number of a person's sentinel lymph nodes examined by the pathologist. Data Element Concept: Person with cancer—number of sentinel lymph nodes examined Value domain attributes Representational attributes Representation class: Total Data type: Number Format: N[NN] Maximum character length: 3 Supplementary values: Value Meaning 997 Number of lymph nodes unknown Data element attributes Collection and usage attributes Collection methods: For cancer registries, collection of this data item should only be from pathology reports relating to initial diagnosis and not for recurrent or metastatic tumour. Comments: Sentinel lymph nodes are the first nodes that filter fluid draining away from the area of cancer. The presence of cancer cells in the lymph nodes indicates that cancer cells have already spread outside the primary site and may have spread to other areas of the body. This is important for cancer staging and treatment options. Source and reference attributes Origin: National Breast and Ovarian Cancer Centre (NBOCC) Australasian Association of Cancer Registries (AACR) Australian Institute of Health and Welfare (AIHW) Reference documents: Johnson CH, Adamo M (eds.), SEER Program Coding and Staging Manual 2007. National Cancer Institute, NIH Publication number 07-5581, Bethesda, MD 2007. Relational attributes Implementation in Data Set Specifications: Breast cancer (cancer registries) DSS Health, Standard 01/09/2012

Data type

integer

Alias

UMLS CUI [1]

C2733493

Description

Person with cancer—oestrogen receptor assay result, code N Identifying and definitional attributes Short name: Oestrogen receptor assay result METeOR identifier: 370036 Registration status: Health, Standard 06/03/2009 Definition: The result of oestrogen receptor assay at the time of diagnosis of the primary breast tumour, as represented by a code. Data Element Concept: Person with cancer—oestrogen receptor assay result Value domain attributes Representational attributes Representation class: Code Data type: Number Format: N Maximum character length: 1 Permissible values: Value Meaning 1 Positive 2 Negative 3 Equivocal Supplementary values: 7 Unknown (test results not available) 8 Not applicable (test not done) Collection and usage attributes Guide for use: Supplementary codes CODE 7 Unknown (test results not available) Use this code when the test has been performed but the results are not yet available for analysis. CODE 8 Not applicable (test not done) This code is used as a validation measure, to show that the reason for the lack of results is due to the test not being performed. Data element attributes Collection and usage attributes Guide for use: Where the pathologist has stated the test result in the conclusion of the pathology report as being positive, negative or equivocal this value should be coded. If the report does not specifically state the test result, this should be interpreted from the reported % nuclei stained positive. If => 1% of nuclei are reported as stained regardless of stain intensity (weak, intermediate or high/strong) the result is positive. If % nuclei stained is <1% the result is negative. Definitions from NBOCC & ACN Pathology Reporting Guidelines. Collection methods: For cancer registries: Collection of this data item should only be from notification and pathology reports relating to initial diagnosis and not for recurrent or subsequent metastatic disease. Where there are multiple reports relating to the primary breast tumour (from different specimens), the 'most positive' value is chosen according to the following hierarchy: Positive > Equivocal > Negative> Test done but results not known > Test not done. If oestrogen receptor assay tests are completed for invasive tumours with an in situ component, use the values from the invasive tumour. Do not record oestrogen receptor values for in situ tumours. For multifocal tumours, use the oestrogen receptor value from the largest focus or from a metastatic deposit, e.g. Lymph node metastasis. A smaller focus that is ER positive may in fact be the source of a metastasis and in this setting the patient would derive benefit from the therapy offered as a result of hormone receptor positive status. Comments: Hormone receptor status is an important prognostic indicator for breast cancer. The Australian Cancer Network Working Party established to develop guidelines for the pathology reporting of breast cancer recommends that hormone receptor assays be performed on all cases of invasive breast carcinoma. The report should include · the percentage of nuclei staining positive and the predominant staining intensity (low, medium, high) and · a conclusion as to whether the assay is positive or negative. Source and reference attributes Origin: Royal College of Pathologists of Australasia Australian Cancer Network Commission on Cancer American College of Surgeons Reference documents: Royal College of Pathologists of Australasia Manual of Use and Interpretation of Pathology Tests: Third Edition Sydney (2001) Australian Cancer Network Working Party The pathology reporting of breast cancer. A guide for pathologists, surgeons and radiologists Second Edition Sydney (2001) Commission on Cancer, Standards of the Commission on Cancer Registry Operations and Data Standards (ROADS) Volume II (1998) Relational attributes Related metadata references: Supersedes Person with cancer—oestrogen receptor assay results, code N Health, Superseded 06/03/2009 Implementation in Data Set Specifications: Breast cancer (cancer registries) DSS Health, Standard 01/09/2012

Data type

integer

Alias

UMLS CUI [1,1]

C0201553

Description

Person with cancer—primary site of cancer, topography code (ICD-O-3) ANN.N Identifying and definitional attributes Short name: Primary site of cancer (ICD-O-3 code) METeOR identifier: 396090 Registration status: Health, Standard 07/12/2011 Definition: The site in which the tumour originated in a person with cancer, as opposed to the secondary or metastatic sites, as represented by a code. Data Element Concept: Person with cancer—primary site of cancer Value domain attributes Representational attributes Classification scheme: International Classification of Diseases for Oncology 3rd edition Representation class: Code Data type: String Format: ANN.N Maximum character length: 5 Collection and usage attributes Guide for use: Record all four alphanumeric characters of the topography code. The number after the decimal point represents the subsite or subcategory. Data element attributes Collection and usage attributes Guide for use: Record the primary site of cancer, if known, for patients who have been diagnosed with cancer. When the primary site is unknown, record C80.9. The primary site of the tumour is the site of origin, as opposed to the secondary or metastatic site. Record all four alphanumeric characters of the topography code. The number after the decimal point represents the subsite or subcategory. Refer to the coding guidelines for topography in ICD-O-3, pp 23-26. Refer to the coding guidelines for multiple tumours in ICD-O-3, pp 35-37. If the patient is diagnosed with more than one primary tumour, record the site of each primary separately. If the primary site differs on multiple pathology or other notification reports for the same tumour, use the most specific value. For example, one report may state the breast (C50.9) is the site of the primary while another report records the lower-inner quadrant of the breast (C50.3) as the primary site; record C50.3 here as the primary site. Collection methods: This information should be obtained from the patient's medical record. Comments: The information is collected so that tumours can be classified into clinically relevant groups based on their primary site and histological type. This provides a basis for staging and the determination of treatment options. The primary site of the cancer also affects the course of the disease and prognosis. Source and reference attributes Submitting organisation: Cancer Australia Origin: World Health Organization Reference documents: Fritz A et al. 2000. International Classification of Diseases for Oncology (ICD-O), 3rd edition. Geneva: World Health Organization Relational attributes Related metadata references: Supersedes Person with cancer—primary site of cancer, code (ICDO-3) ANN{.N[N]} Health, Superseded 07/12/2011 Implementation in Data Set Specifications: Bowel cancer diagnosed cluster Health, Standard 29/08/2014 Breast cancer (cancer registries) DSS Health, Standard 01/09/2012 Cancer (clinical) DSS Health, Standard 14/05/2015 Implementation in Indicators: Used as numerator National Healthcare Agreement: PI 02-Incidence of selected cancers, 2015 Health, Standard 14/01/2015

Data type

text

Alias

UMLS CUI [1]

C0475447

Description

Person with cancer—primary tumour status, T stage (UICC TNM Classification of Malignant Tumours, 7th ed) code X[XXX] Identifying and definitional attributes Short name: Cancer staging—T stage code METeOR identifier: 403564 Registration status: Health, Standard 07/12/2011 Definition: The size and extent of the primary tumour in a person with cancer, as represented by a code. Data Element Concept: Person with cancer—primary tumour status Value domain attributes Representational attributes Classification scheme: International Union against Cancer (UICC) TNM Classification of Malignant Tumours 7th edition Representation class: Code Data type: String Format: X[XXX] Maximum character length: 4 Supplementary values: Value Meaning 9997 Not applicable 9998 Unknown 9999 Not stated/inadequately described Collection and usage attributes Guide for use: Valid T codes from the current edition of the UICC TNM Classification of Malignant Tumours. Record the stage in Arabic numerals and the appropriate upper or lower case alphabetic character omitting the prefix "T". For example, record stage T2a for lung cancer as "2a". Record if the T stage value has a prefix of “c” or “p”; for example, record retinoblastoma T stage pT2b as “p2b”. Refer to the TNM Supplement: A Commentary on Uniform Use, 3rd Edition for coding rules. Source and reference attributes Reference documents: Wittekind C et al (Editors) 2003. International Union Against Cancer (UICC): TNM supplement: A commentary on uniform use, 3rd edition. Wiley-Blackwell. Data element attributes Collection and usage attributes Guide for use: Record the size and extent of the primary tumour at the time of diagnosis of the cancer. TNM staging applies to solid tumours excluding brain tumours. Choose the lower (less advanced) T category when there is any uncertainty. The T stage value is derived from the size of the tumour and its relationship (extension) to other structures. The size is reflected in the value of data element Person with cancer—solid tumour size (at diagnosis), total millimetres NNN; the usage attributes provide additional detail. The extent of the primary cancer at diagnosis is usually recorded. An exception is malignant melanoma of the skin; by convention T stage is recorded after tumour excision and is based on tumour thickness with T subcategories based on ulceration and the number of mitoses seen. Ovarian cancer is also surgically/pathologically staged. The current edition of the American Joint Committee on Cancer (AJCC) Cancer Staging Manual provides an equivalent and alternative source of T stage codes. Staging classification systems other than the TNM classification system are recorded separately. Collection methods: This information should be obtained from the patient's medical record. Comments: Cancer stage is an important determinant of treatment and prognosis, and is used to evaluate new treatments and analyse outcomes. Survival analysis is adjusted by stage at diagnosis and distribution of cancer cases by type and stage. Source and reference attributes Submitting organisation: Cancer Australia Reference documents: Sobin LH, Gospodarowicz MK, Wittekind C (Editors) 2009. International Union Against Cancer (UICC): TNM Classification of Malignant Tumours, 7th edition. Wiley-Blackwell American Joint Committee on Cancer 2010. AJCC Cancer Staging Manual, 7th edition. New York: Springer American College of Surgeons 2002. Facility Oncology Registry Data Standards (FORDS), 2009 revision. Commission on Cancer Relational attributes Related metadata references: See also Cancer staging—staging basis of cancer, code A Health, Superseded 07/12/2011 See also Cancer staging—staging basis of cancer, code A Health, Standard 07/12/2011 See also Person with cancer—distant metastasis status, M stage (UICC TNM Classification of Malignant Tumours, 7th ed) code X[XX] Health, Standard 07/12/2011 See also Person with cancer—extent of primary cancer, TNM stage (UICC TNM Classification of Malignant Tumours, 7th ed) code X[XX] Health, Standard 07/12/2011 Supersedes Person with cancer—primary tumour status, T stage (UICC TNM Classification of Malignant Tumours, 6th ed) code XX[X] Health, Superseded 07/12/2011 See also Person with cancer—regional lymph node metastasis status, N stage (UICC TNM Classification of Malignant Tumours, 7th ed) code X[XX] Health, Standard 07/12/2011 See also Person with cancer—solid tumour size (at diagnosis), total millimetres NNN Health, Superseded 07/12/2011 Implementation in Data Set Specifications: Breast cancer (cancer registries) DSS Health, Standard 01/09/2012 Cancer (clinical) DSS Health, Standard 14/05/2015

Data type

text

Alias

UMLS CUI [1]

C0475455

Description

Person with cancer—regional lymph node metastasis status, N stage (UICC TNM Classification of Malignant Tumours, 7th ed) code X[XX] Identifying and definitional attributes Short name: Cancer staging—N stage code METeOR identifier: 403661 Registration status: Health, Standard 07/12/2011 Definition: The absence or presence and extent of regional lymph node metastasis in a person with cancer, as represented by a code. Data Element Concept: Person with cancer—regional lymph node metastasis status Value domain attributes Representational attributes Classification scheme: International Union against Cancer (UICC) TNM Classification of Malignant Tumours 7th edition Representation class: Code Data type: String Format: X[XX] Maximum character length: 3 Supplementary values: Value Meaning 997 Not applicable 998 Unknown 999 Not stated/inadequately described Collection and usage attributes Guide for use: Valid N codes from the current edition of the UICC TNM Classification of Malignant Tumours. Record the stage in Arabic numerals and the appropriate upper or lower case alphabetic character omitting the prefix "N". For example, record stage N1b for malignant melanoma of the skin as "1b". Record if the N stage value has a prefix of “c” or “p”. For example, record retinoblastoma N stage pN1 as “p1”. Refer to the TNM Supplement: A Commentary on Uniform Use, 3rd Edition for coding rules. Source and reference attributes Reference documents: Wittekind C et al (Editors) 2003. International Union Against Cancer (UICC): TNM supplement: A commentary on uniform use, 3rd edition. Wiley-Blackwell. Data element attributes Collection and usage attributes Guide for use: Record the absence or presence and extent of regional lymph node metastasis at the time of diagnosis of the cancer. TNM staging applies to solid tumours excluding brain tumours. Choose the lower (less advanced) N category when there is any uncertainty. The current edition of the AJCC (American Joint Committee on Cancer) Cancer Staging Manual provides an equivalent and alternative source of N stage codes. Staging classification systems other than the TNM classification system are recorded separately. Collection methods: This information should be obtained from the patient's medical record. Comments: Cancer stage is an important determinant of treatment and prognosis, and is used to evaluate new treatments and analyse outcomes. Survival analysis is adjusted by stage at diagnosis and distribution of cancer cases by type and stage. Source and reference attributes Submitting organisation: Cancer Australia Reference documents: Sobin LH, Gospodarowicz MK, Wittekind C (Editors) 2009. International Union Against Cancer (UICC): TNM Classification of Malignant Tumours, 7th edition. Wiley-Blackwell American Joint Committee on Cancer 2010. AJCC Cancer Staging Manual, 7th edition. New York: Springer American College of Surgeons 2002. Facility Oncology Registry Data Standards (FORDS), 2009 revision. Commission on Cancer Relational attributes Related metadata references: See also Cancer staging—staging basis of cancer, code A Health, Standard 07/12/2011 See also Cancer staging—staging basis of cancer, code A Health, Superseded 07/12/2011 See also Person with cancer—distant metastasis status, M stage (UICC TNM Classification of Malignant Tumours, 7th ed) code X[XX] Health, Standard 07/12/2011 See also Person with cancer—extent of primary cancer, TNM stage (UICC TNM Classification of Malignant Tumours, 7th ed) code X[XX] Health, Standard 07/12/2011 See also Person with cancer—primary tumour status, T stage (UICC TNM Classification of Malignant Tumours, 7th ed) code X[XXX] Health, Standard 07/12/2011 Supersedes Person with cancer—regional lymph node metastasis status, N stage (UICC TNM Classification of Malignant Tumours, 6th ed) code XX Health, Superseded 07/12/2011 Implementation in Data Set Specifications: Breast cancer (cancer registries) DSS Health, Standard 01/09/2012 Cancer (clinical) DSS Health, Standard 14/05/2015

Data type

text

Alias

UMLS CUI [1]

C0456532

Description

Person with cancer—solid tumour size (at diagnosis), total millimetres NNN Identifying and definitional attributes Short name: Tumour size at diagnosis (solid tumours) METeOR identifier: 422642 Registration status: Health, Standard 07/12/2011 Definition: The largest dimension of a solid tumour, measured in millimetres. Data Element Concept: Person with cancer—solid tumour size Value domain attributes Representational attributes Representation class: Total Data type: String Format: NNN Maximum character length: 3 Supplementary values: Value Meaning 999 Unknown Unit of measure: Millimetre (mm) Collection and usage attributes Guide for use: Size in millimetres with valid values 001 to 997. Data element attributes Collection and usage attributes Guide for use: The reporting standard for the size of solid tumours is: · Breast cancer or other solid neoplasms - the largest tumour dimension, measured to a precision of 1mm · Round to the nearest millimetre, rounding up if size is ≥ .5 mm (e.g. 1.50mm, 1.54mm recorded as 2mm, 1.47mm recorded as 1mm). General coding rules: Recorded size: · Only record measured size if stated, otherwise record size as unknown. Do not attempt to estimate size from descriptions of the tumour, such as 'tumour occupying three quarters of tissue' · Do not take values for size from sources other than histopathology (such as imaging, mammography or clinical examination). Size reported for multiple specimens: · If tumour is removed in more than one procedure (e.g. biopsy and excision, local excision and re-excision) do not sum the sizes across multiple pathology reports but rather use the larger of the measured sizes from the separate pathology reports · If tumour is divided into several parts (in the same pathology report), do not sum sizes together but rather use the larger of the measured sizes. However, if the pathologist states an aggregate or composite size, record that size. Multifocal tumour: · If the tumour is multifocal, record the size of the largest measured focus. Do not attempt to sum sizes of different foci. Macroscopic size: · If only macroscopic size is given, record this value · If the macroscopic and microscopic measurements differ, the microscopic measurement should be recorded. Exclusions: · Size is not recorded for Phyllodes tumours, sarcomas, or lymphomas. Invasive breast cancer coding rules: Note: These rules are to be used only when the record pertains to an invasive breast cancer (as per Person with cancer-primary site of cancer, topography code (ICD-O-3) ANN.N. Invasive tumours with an in situ component: · When an invasive tumour contains an in situ component, only record the size of the invasive component as stated · If the size of the invasive tumour is not recorded separately to the in situ component, then record the total size of the tumour without any attempt to estimate the invasive component using percentage or size of the in situ component. Microinvasive tumour: · For microinvasive tumours, record size in millimetres if stated. If microinvasion is stated but no size is recorded, enter 990 in size field to enable these very small tumours to be differentiated from other tumours without measured sizes. Bilateral breasts tumours: · Bilateral tumours are recorded as two separate primary tumours each having their own size (and other data elements). Multifocal tumours with different morphology: · Foci with different morphology should be considered to be separate primary tumours each having their own size (and other data elements). The coder needs to ascertain whether two foci with differing morphology are separate primaries with different morphology or a single multifocal primary with a mixed histology. In the latter case the rule of taking the size from the larger focus would apply as stated. Collection methods: This information should be obtained from the patient's pathology reports. Comments: The diameter of the largest dimension of solid neoplasms is collected for patient management, population cancer statistics and research. Source and reference attributes Reference documents: Johnson CH & Adamo M (Editors) 2007. SEER Program Coding and Staging Manual 2007. MD 2007. Bethesda:National Cancer Institute, NIH Publication number 07-5581 National Breast and Ovarian Cancer Centre and Australian Cancer Network 2008. The pathology reporting of breast cancer: A guide for pathologists, surgeons, radiologists and oncologists, 3rd edition. Surry Hills, NSW: National Breast and Ovarian Cancer Centre Relational attributes Related metadata references: Supersedes Person with cancer—solid tumour size (at diagnosis), total millimetres NNN Health, Superseded 07/12/2011 Implementation in Data Set Specifications: Breast cancer (cancer registries) DSS Health, Standard 01/09/2012 Cancer (clinical) DSS Health, Standard 14/05/2015

Data type

text

Measurement units

• mm

Alias

UMLS CUI [1,1]

C0475440

UMLS CUI [1,2]

C0441942