1. Mignon Dryden, CTR April 11, 2018 Region 5 Educational Meeting
2018 Data Changes
Mignon Dryden, CTR
April 11, 2018
Region 5 Educational Meeting

2. What we’ll cover: EOD Summary Staging 2018
SSDI – Site Specific Data Items
New Grade Codes

3. EOD – Extent of Disease History of EOD EOD 2018 Structure & Schemas
General Coding Guidelines/Instructions
Core Data Items

4. History of EOD
EOD Developed by NCI-SEER and in use between 1977 – 2003
Original data items:
Tumor Size
Extension (included mets)
Lymph Nodes (included distant LNs)
Previously collected by SEER registries prior to CS

5. History of EOD
SEER EOD was used as the foundation of Collaborative Stage
Result of concerted efforts to create a crosswalk between TNM/EOD/SS2000
EOD coding schemes built into CS
CS used complex algorithms to derive values for each system
CS was implemented in 2004 and EOD was discontinued
CS in use 2004 to 2015 (some SEER registries continued to collect until 2017

6. EOD and TNM
AJCC Staging is used as a clinical tool and, as such, is continually undergoing changes and adjustments to reflect the most current medical knowledge.
Each TNM edition includes sections on how the new improved edition reflects a better understanding of tumor characteristics and factors that are prognostically related.
SEER EOD has been an epidemiological tool used to track cancer incidence, particularly in specified populations. SEER EOD was carefully developed and remained constant so that studies can look at data over time, and tumor characteristics could be compared over time.

7. EOD Timing Rules
EOD should include all information available within 4 months of diagnosis in the absence of disease progression or through completion of surgeries in first course of treatment, whichever is longer.
Mets known to have developed after EOD was established should be excluded.

8. EOD Timing Rules
EOD Timing Rules do not necessarily line up with the rules for first course of treatment.
First course of therapy is coded independently of EOD/Staging. Different guidelines apply.
Planned treatment is counted as first course therapy, even if the disease progresses before the planned therapy is completed.

9. EOD Timing Rules and First Course of TX
Example: Breast cancer case was staged as confined to breast at the time EOD was established in July 2017 and radiation therapy to chest wall was planned. Subsequently, brain metastasis was found in August. Radiation therapy to the chest wall was administered in October.

10. EOD Timing Rules and First Course of TX
The chest wall irradiation carried out in October is counted as first course treatment because it was planned.
If radiation therapy to the brain mets is administered, that would be a change in the therapy plan and the radiation therapy would be counted as second course of therapy.

11. EOD General Rules
EOD schemas apply to ALL primary sites and specified histologies.
Most schemas are based on primary site.
Some schemas are based on histology alone.

12. EOD General Guidelines
Gross observations at surgery are particularly important when all malignant tissue is not removed.
For example, a colon cancer resection may transect the tumor. It is important to observe any tumor tissue that may still be remaining at the end of the procedure, for example, tumor tissue adherent to the abdominal wall.
EOD Extension is coded accordingly.
In the event of a discrepancy between path and op report findings concerning excised tissue, priority is given to path report.

13. EOD General Guidelines
EOD information obtained after neoadjuvant treatment has started may be used, but would only be used if it was greater than pre-treatment clinical findings.

14. EOD General Guidelines
Clinical information, such as description of skin involvement for breast cancer and distant lymph nodes for any site, can change the EOD stage.
If the op/path information disproves the clinical information, use the op/path information.

15. Non-Definitive Ambiguous Terminology
TNM Staging information can be used to code EOD 2018 when it is the only information available.
Use the medical record documentation to assign EOD when there is a discrepancy between TNM information and the documentation in the medical record.
EOD 2018, unlike Collaborative Stage, does not offer the TNM, NOS, options for coding. For example, there is no option for:
“Stated as T2 with no other information on extension.”

16. EOD General Guidelines
EOD Schema-Specific guidelines take precedence over general guidelines
(just as in SEER Summary Stage and TNM Staging)

17. EOD Data Items
Primary Tumor
Regional Lymph Nodes
Metastases

18. EOD Primary Tumor
EOD Primary tumor is used to classify contiguous growth (extension) of the primary tumor within the organ of origin or its direct extension into neighboring organs.
Code the farthest documented extension of tumor away from the primary site.
A “localized, NOS” code is provided for those cases in which the only description is “localized with no further information.” “NOS” codes should be used only after an exhaustive search for more specific information.

19. EOD Primary Tumor In situ : Assign code 000
Exception: For some schemas , e.g., breast, there may be multiple categories of in situ codes.
Example:
Breast Primary Tumor
000 In situ : noninfiltrating; intraductal
050 Paget disease of nipple without underlying tumor
070 Paget disease of nipple with underlying DCIS

20. EOD Primary Tumor
In the past, if only in situ tumor was identified in the primary site, but there was met involvement, we assumed that the area of invasion had been missed and we assigned a code that represented localized disease.
SEER EOD 2018:
In the case of an in-situ primary tumor with met involvement –assign EOD primary tumor as in situ and code EOD Mets appropriately.

21. EOD Primary Tumor For cases in which no primary tumor is found:
Use code 800: No evidence of primary tumor

22. EOD Regional Lymph Node
EOD Regional Node is used to classify the regional lymph nodes involved with cancer at the time of diagnosis.
Record the specific involved regional lymph node chain(s) farthest from the primary site. Regional lymph nodes are listed for each schema.

23. EOD Regional Lymph Node
Lymph node chains categorized as regional lymph nodes in EOD 2018 match the categories described by AJCC Staging.
Lymph nodes categorized as regional in EOD 2018 do not necessarily match the regional lymph node groups described in previous versions of EOD ( ).
They also do not match the site-specific regional lymph node groups described in SEER Summary Stage 2000.

24. EOD Regional Lymph Node
Example: For breast cancer cases,
In EOD 2018, supraclavicular lymph nodes are counted as regional lymph nodes.
In SEER Summary Stage 2000 and previous SEER EOD schemes, supraclavicular lymph nodes are not counted as regional lymph nodes. They are categorized as distant lymph nodes.

25. EOD Regional Lymph Node
Isolated Tumor cells (ITCs):
For some schemas, ITCs are counted as positive regional nodes, while other schemas count them as negative.
See the individual schemas to determine how to code ITCs.

26. EOD Metastases
EOD Metastases is used to classify the distant site(s) of metastatic involvement at time of diagnosis.
Determination of EOD Mets requires only a History and Physical Exam. Imaging of distant organs is not required. In other words, the registrar can infer that there are no distant metastases based solely on PE documentation.

27. EOD Metastases
For a few schemas such as Breast, Lung, Kidney, and Ovary, the EOD Mets category may include direct extension of the primary tumor into distant organs or tissues.
If the structure involved by direct extension is not listed in EOD Primary Tumor, look for the structure in EOD Mets.

28. EOD Metastases
For a few schemas such as Breast, Lung, Kidney, and Ovary, the EOD Mets category may include direct extension of the primary tumor into distant organs or tissues.
If the structure involved by direct extension is not listed in EOD Primary Tumor, look for the structure in EOD Mets.
Example: Breast
SEER EOD Mets:
70 Skin over axilla
Contralateral breast
Sternum
Upper abdomen

29. Site Specific EOD
Some of the data elements included in the previous versions of SEER EOD were pulled out and recorded as Site Specific Factors in Collaborative Stage.
They have been added back and are now included in EOD fields.
Example: Lung
In Collaborative Stage:
CS Site Specific Factor 1 described
Separate Tumor Nodules in the Ipsilateral Lung

30. Site Specific EOD In EOD 2018:
Separate tumor nodules in the ipsilateral lung are coded under Primary Tumor Extension
EOD Primary Tumor Note 4: Separate ipsilateral tumor nodules are coded either 500 (same lobe) or 700 (different ipsilateral lobe)

31. Summary Stage 2018

32. Summary Stage 2018
Summary Stage is the most basic way of categorizing how far a cancer has spread from its point of origin.
The 2018 version of Summary Stage applies to every anatomic site, including lymphomas and leukemias.

33. Summary Stage 2018
Timeframe: includes all information available through completion of surgery(ies) in the first course of treatment or within four months of diagnosis in the absence of disease progression, whichever is longer.
Based on combined clinical and operative/pathological assessment.

34. Summary Stage 2018
Code
Definition
In situ 1
Localized only 2
Regional by direct extension only 3
Regional lymph nodes only 4
Regional by BOTH direction extension AND lymph node involvement 5
Regional, NOS (Not Otherwise Specified) 7
Distant site(s)/node(s) involved 8
Benign/borderline* 9
Unknown if extension or metastasis (unstaged, unknown, or unspecified)
Death certificate only case
Applicable for the following SSS2018 schemas: Brain, CNS Other, Intracranial Gland

35. In Situ
An in situ diagnosis can only be made microscopically, because a pathologist must identify the basement membrane and determine that it has not been penetrated.
Pathologists have many ways of describing in situ cancer, such as non- invasive, pre-invasive, non-infiltrating, intra-epithelial, Stage 0, intraductal, intracystic, no stromal invasion, and no penetration below the basement membrane.
Organs and tissues that have no epithelial layer cannot be staged as in situ, since they do not have a basement membrane (e.g., soft tissues, connective tissue).

36. Localized Limited to the site of origin
Has spread no farther than the site of origin in which it started
Important to know and recognize the names of different structures within the organ (such as lamina propria, myometrium, muscularis) so that a description of invasion or involvement of these structures will not be interpreted as regional spread.
A localized cancer is a malignancy limited to the site of origin; it has spread no farther than the site of origin in which it started. There is infiltration past the basement membrane of the epithelium into the functional part of the organ, but there is no spread beyond the boundaries of the organ. A tumor can be widely invasive or even show metastases within the organ itself and still be considered “confined to organ of origin” or localized in summary stage.

37. Regional by Direct Extension Only
For primary sites that have “walls” (e.g. colon, rectum) invasion through entire wall of organ into surrounding organs and/or adjacent tissues, direct extension or contiguous spread. For those primary sites without defined walls when the tumor has spread beyond the primary site or capsule into adjacent structures.

38. Regional by Lymph Nodes Only
Regional lymph nodes are listed for each schema/site.
For lymphomas, any mention of lymph nodes is indicative of involvement and is used to determine the number and location of lymph node chains involved (see Lymphoma scheme).
For solid tumors, the terms “fixed” or “matted” and “mass in the mediastinum, retroperitoneum, and/or mesentery” (with no specific information as to tissue involved) are considered involvement of lymph nodes.

39. Regional to Lymph Nodes Only
Terms such as “palpable”, “visible swelling”, and “shotty” should be ignored. Look for a statement of involvement, either clinical or pathological. Terms such as “palpable,” “enlarged,” “visible swelling,” “shotty,” or “lymph- adenopathy” may be used to include involvement IF there is a statement of involvement by the clinician, or patient was treated as though regional nodes were involved. If these terms are used and there is no treatment to indicate lymph nodes are involved, then code none (000).

40. Regional by Lymph Nodes Only
The terms “homolateral” and “ipsilateral” are used interchangeably. Any unidentified nodes included with the resected primary site specimen are to be considered as “Regional Lymph Nodes, NOS.”

41. Regional by Lymph Nodes Only
If the only indication of lymph node involvement in the record is the physician’s statement of an N category from the TNM staging system or a stage from a site-specific staging system, use that information to code regional lymph node involvement.
If there is a discrepancy between documentation in the medical record and the physician’s assignment of TNM, the documentation takes precedence. Cases of this type should be discussed with the physician who assigned the TNM.

42. Reginal by Lymph Nodes Only
If there is a discrepancy between documentation in the medical record and the physician’s assignment of TNM, the documentation takes precedence. Cases of this type should be discussed with the physician who assigned the TNM.

43. Regional by Lymph Nodes Only
Note: Regional lymph nodes are not palpable for inaccessible sites such as bladder, kidney, prostate, esophagus, stomach, lung, liver, corpus uteri and ovary. The best description concerning regional lymph nodes will be the surgeon’s evaluation at the time of exploratory surgery or definitive surgery.

44. Regional by Direct Extension & LN’s
A combination of direct extension and regional lymph node involvement.

45. Regional NOS Regional, NOS (Not Otherwise Specified).
Used when it is unclear whether the tissues are involved by direct extension or lymph nodes, or when the other categories are not applicable, such as for staging Non-Hodgkin and Hodgkin lymphoma of more than one lymph node region.
Regional, NOS is used for very few schemas, some of which include lymphomas, melanoma skin, brain, and CNS other.

46. Distant
Distant metastases are tumor cells that have broken away from the primary tumor, have travelled to other parts of the body, and have begun to grow at the new location.
Distant stage is also called remote, diffuse, disseminated, metastatic, or secondary disease. The point is that in most cases there is no continuous trail of tumor cells between the primary site and the distant site.

47. Distant
Cancer cells can travel from the primary site in any of four ways:
Extension from primary organ beyond adjacent tissue into next organ; for example, from the lung through the pleura into bone or nerve.
Travel in lymph channels beyond the first (regional) drainage area.
Hematogenous or blood-borne metastases.
Spread through fluids in a body cavity. Also called implantation or seeding metastases.
Invasion of blood vessels within the primary tumor (veins are more susceptible to invasion than thicker-walled arteries) allows escape of tumor cells or tumor emboli which are transported through the blood stream to another part of the body where it lodges in a capillary or arteriole. At that point the tumor penetrates the vessel wall and grows back into the surrounding tissue.
Example: malignant cells rupture the surface of the primary tumor and are released into the thoracic or peritoneal cavity. They float in the fluid and can land on and begin to grow on any tissue reached by the fluid. This type of spread is also called implantation or seeding metastases. Some tumors form large quantities of fluid called ascites that can be removed, but the fluid rapidly re-accumulates. However, the presence of fluid or ascites does not automatically indicate dissemination. There must be cytologic evidence of malignant cells.

48. Example: liver involvement from a primary in the gallbladder.
Distant
Common sites of distant spread are liver, lung, brain, and bones, but they are not listed specifically for each scheme.
However, if the primary site is adjacent to the liver, lung, brain or bone, it is important to review the summary stage scheme for the primary site to assure that the stage is not regional by direct extension.
Example: liver involvement from a primary in the gallbladder.
This is likely regional by direct extension rather than distant stage, since the gallbladder is adjacent to liver. Read the diagnostic imaging reports to determine whether the cancer involves the surface of the secondary organ, which would be regional by direct extension, or whether the cancer is inside the secondary organ.
These organs receive blood flow from all parts of body and thus are a target for distant metastases.

49. Distant
Hematopoietic, reticuloendothelial, immunoproliferative, and myeloproliferative neoplasms are considered distant except as noted in the stage scheme.

50. Benign/Borderline
Benign/borderline neoplasms are collected only for Brain, CNS Other and Intracranial Gland schemas. No other schemas include a code 8.

51. Unknown
If the primary site is unknown (C809), then summary stage must be unknown.
There will be cases for which sufficient evidence is not available to adequately assign a stage.
Examples:
the patient expires before workup is completed,
a patient refuses a diagnostic or treatment procedure,
there is limited workup due to the patient’s age or a simultaneous contraindicating condition.
Death Certificate Only cases

52. SSDI – Site Specific Data Items

53. SSDI – Site Specific Data Items
Discontinue current SSF approach
Develop SSDIs
More flexibility
Different data item lengths
Coding actual data item
Easier to retrieve data for researchers
The final decision was to discontinue the SSF approach and make SSDIs for each.
There were several reasons for this decision, but the main ones are:
More flexibility. No longer will all data items need to be 3 digits. Some may be shorter, others may be longer. It will also allow us to collecting lab values with the decimal point as part of the code.
Other advantages include the data item name being collected instead of a SSF. For example, your software will ask for ER instead of SSF #1 for breast.
Also, it will be easier for people to retrieve data. Instead of remembering that SSF#1 is for PSA in Prostate, they’ll be able to look in the database for PSA.

54. What is a SSDI? Site-Specific Data Item
Previously called site-specific factors
Now have own data item/data number
NAACCR “custodian” of these data items
What is a SSDI? It simply is a site-specific data item. “Site” in this instance is based on the primary site or the AJCC chapter. Previously these were called site-specific factors, which were first introduced in 2004 with CSv1, and then went through major revisions in 2010 with CSv2.
Now that the SSFs have been moved over to SSDIs, they have their own data item number and can be applied to as many sites as needed. The site specific data item taskforce is the group that is in charge of these SSDIs and is responsible for reviewing the SSFs and developing/updating them as needed.

55. SSDI: 2018 Data Collection
SSDIs go into effect for cases diagnosed 1/1/2018+
SSDIs items cannot be coded for any cases with diagnosis date PRIOR to 1/1/2018
REMEMBER: SSDIs are based on date of diagnosis, NOT date case abstracted
All the SSFs will be retained for cases diagnosed This means that the SSFs go strictly on the date of diagnosis, not the year that the case is abstracted. This is a change from what was done with the CS updates. You are to follow your standard setter’s requirements for the year when the case was diagnosed, not the year the case is abstracted.
Example, if you are abstracting a 2017 case in 2018, you are to code the applicable/required SSFs for that site, not the SSDIs

56. SSDI: 2018 Data Collection Data items different lengths
Data items can include decimal points
Different coding conventions used to document
Recording of actual values, percentages, ranges
Recording different definitions of unknown
The general changes include: data items are different lengths. There will no longer be a standard 3 digit data item. For some data items, mostly lab values, decimals will be part of the code. Also, depending on the data item, different coding conventions may be used to record actual values, percentages and ranges. And there will be some changes to coding unknown.

57. SSDI: 2018 Data Collection SSFs being combined when possible
Example: Perineural Invasion
Collected in several different schemas, not always the same SSF.
Will be one SSDI

58. SSDI Example: Perineural Invasion
The biggest change to this data item is going to 1 digit long, instead of the standard 3 digits from CS.
In this data item, you will see code 2, which is “Cannot be determined.” This is based on the CAP protocol. Sometimes a physician will indicate cannot be determined because the specimen is not adequate to determine the level of perineural invasion. It should only be used when this selection is noted on the CAP protocol/pathology report.
Code 2: It should only be used when this selection is noted on the CAP protocol/pathology report.

59. SSDI: 2018 Data Collection
SEER has developed a staging tool referred to as SEER*RSA that provides information (primary site/histology/other factors defined) about each cancer schema.

60. New Grade Codes

61. Grade Codes
Grade is a measure of the aggressiveness of the tumor and an important prognostic indicator for many tumors.
Historically, grade in cancer registries has been collected based on a generic 4-grade classification with the following categories.
The same categories were collected for all reportable primary tumors, and categories from systems using two or three grades were converted to the four-grade values.

62. Grade Codes
Beginning with cases diagnosed in 2018, the definition of grade has been expanded, and classification of grade now varies by tumor site and/or histology. The grading system for a cancer type may have two, three, or four grades. No longer will all grades be converted to a four-grade system.

63. Grade Codes Grade is defined in many chapters of the AJCC manual.
Based on the chapter, the generic cancer registry grade categories or another definition of grade may be used.
Registry software can display the appropriate grade table based on what the registrar enters for primary site, histology and, where applicable, a schema discriminator.
The recommended AJCC grade is required to assign stage group (clinical, pathological and post-therapy) for certain tumors. If the recommended AJCC grade is not available, use the generic cancer registry grade categories or another definition of grade. When the recommended AJCC grade is not available, it may not be possible to determine the AJCC stage group.

64. Grade Codes Code Grade Description 1 2 3 4 5 A B C D E 9
Grade Group 1: Gleason score < 6 2
Grade Group 2: Gleason score 7 Gleason pattern 3+4 3
Gleason score 7 Gleason pattern 4+3 4
Gleason score 8 5
Grade Group 5: Gleason score 9 or 10 A
Well Differentiated B
Moderately Differentiated C
Poorly Differentiated D
Undifferentiated, anaplastic E
Stated as “Gleason score 7” with no patterns documented or Any Gleason patterns = 7 not in 2 or 3 9
Grade cannot be assessed; Unknown
Example: Prostate
Use this table to assign grade which is required in order to assign stage group. The following AJCC chapters require grade, using the grade table indicated in the parentheses, to assign stage group. Other sites are Esophagus, Appendix, Bone, Breast, Soft Tissue and GIST.

65. Grade - Clinical
Record the grade of a solid primary tumor before any treatment, whether surgical resection or initiation of any treatment including neoadjuvant.
For those cases that are eligible for AJCC staging, the recommended grading system is specified in the AJCC Chapter. The AJCC Chapter-specific grading systems (codes 1-5) take priority over the generic grade definitions (codes A- E, L, H, 9). For those cases that are not eligible for AJCC staging, if the recommended grading system is not documented, the generic grade definitions would apply.

66. Grade - Clinical
Note 1: Clinical grade is recorded for cases where a histological (microscopic) exam is done and tissue is available and grade is recorded. This includes FNA, biopsy, needle core biopsy, etc.
Note 2: Clinical grade must not be blank.
Note 3: Assign the highest grade from the primary tumor assessed during the clinical time frame.
Note 4: Code 9 (unknown) when:
Grade is not documented.
Clinical staging is not applicable (for example, cancer is an incidental finding during surgery for another condition).
Grade checked “not applicable” on CAP Protocol (if available) and no other grade information is available.
If there is only one grade available and it cannot be determined if it is clinical or pathological, assign the clinical grade appropriately and code unknown (9) for pathological grade, and blank for post-therapy grade.

67. Grade - Pathological
Record the grade of a solid primary tumor that has been resected and for which no neoadjuvant therapy was administered. If AJCC pathological staging is being assigned, the tumor must have met the surgical resection requirements in the AJCC manual. This may include the grade from the clinical workup.

68. Grade - Pathological
Note 1: Pathological grade is recorded for cases where a surgical resection has been done.
Note 2: Pathological grade must not be blank.
Note 3: Assign the highest grade from the primary tumor. If the clinical grade is the highest grade identified, use the grade that was identified during the clinical time frame for both the clinical grade and the pathological grade.
Note 4: Code 9 (unknown) when:
Grade not documented.
No resection of the primary site.
Neoadjuvant therapy followed by a resection (see post-therapy grade).
Clinical case only (see clinical grade).
There is only one grade available and it cannot be determined if it is clinical or pathological.
Grade checked “not applicable” on CAP Protocol (if available) and no other grade information is available.

69. Grade – Post Therapy
Record the grade of a solid primary tumor that has been resected following neoadjuvant therapy. If AJCC post-therapy staging is being assigned, the tumor must have met the surgical resection requirements for yp in the AJCC manual.
This data item corresponds to the yp staging period only.
Record the highest grade documented from the surgical treatment resection specimen of the primary site following neoadjuvant therapy.

70. Grade – Post Therapy Note 1: Leave post-therapy grade blank when:
No neoadjuvant therapy.
Clinical or pathological case only.
There is only one grade available and it cannot be determined if it is clinical, pathological or post-therapy.
Note 2: Assign the highest grade from the resected primary tumor assessed after the completion of neoadjuvant therapy.
Note 3: Code 9 when:
Surgical resection is done after neoadjuvant therapy and grade from the primary site is not documented.
Grade checked “not applicable” on CAP Protocol (if available) and no other grade information is available.

71. Grade – Generic Table
Code Grade Description
1 Site-specific grade system category
2 Site-specific grade system category
3 Site-specific grade system category
4 Site-specific grade system category
5 Site-specific grade system category
L Low grade
H High grade
M Site-specific grade system category
S Site-specific grade system category
A Well differentiated
B Moderately differentiated
C Poorly differentiated
D Undifferentiated and anaplastic
8 Not applicable (Hematopoietic neoplasms only)
9 Grade cannot be assessed; Unknown
Blank (Post-therapy only)
Codes 1-5 are applicable for the AJCC-recommended grading systems. Not all grade tables will have five codes; most will have three or four. Categories L and H are used for “low grade” and “high grade” for those cancers for which these are used (e.g. urinary cancers with urothelial histologies).
Codes A-D are the generic grade categories (definitions) that have been used by the cancer surveillance community for many years. Codes A-D are not available for all cancers since although many AJCC chapters continue to use the generic grade terms, many of the chapters now use a three-grade system, instead of the traditional four-grade system.

72. Resources: CRGC Website http://crgc-cancer.org/registrar-education/
NAACCR 2018 Implementation Web page
SEER*Educate
SEER*RSA
SEER*RSA Use the information on this site to:
Code EOD 2018 data items
Code Summary Stage 2018
Code Site-Specific Data Items (SSDIs)
Code TNM or CS data items, as appropriate, for 2017 and prior cases

73. 8th Edition Resources NCRA's Online Catalog of 8th Edition Training
NCRA has prepared a special online training catalog to help registrars easily find 8th edition training. The catalog includes relevant sessions from the conference and the archived webinars from the popular 2017 fall webinar series entitled Site Anatomy and 8th Edition Staging. NCRA also offers a Cancer Case Studies Workbook that includes 50 cases to practice 8th edition staging and has updated its online case studies. 
 Learn more about NCRA's 8th Edition Training Catalog at: 

74. Acknowledgements: Jennifer Ruhl, MSHCA, RHIT, CCS, CTR, NCI SEER
Christina Schwarz, BA, CTR, Greater Bay Area Cancer Registry
Donna Hansen, CTR, California Cancer Registry