Self Instructional Manual for Cancer Registrars - SEER - National ...

SECTION
C
ABSTRACTING THE MEDICAL RECORD: WHAT, WHEN, AND HOW TO ABSTRACT
WHAT CASES TO ABSTRACT
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 so 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 carcinomasr sarcomas, melanomas, leukemias, and lymphomas, all
malignancies with a behavior code of 2 or higher in the International Classification of Diseases for Oncolog),,
Second Edition, (ICD-O-2).
Inconclusive
diagnosis
When the diagnosis is vague or inconclusive, such as probable carcinoma of the lung, the following terms
indicate involvement:
compatible with suspect consistent with
suspicious probable most likely
The following terms are not to be interpreted as involvement:
equivocal suggests possible
worrisome
questionable
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 as 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, histology, and extent of disease as
information becomes more complete.
Benign tumors and borderline malignancies (behavior codes 0 and 1) also may be listed in the registry.
These diagnoses are referred to as "reportable-by-agreement" cases.
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