2. Instructions and Reporting Requirements Module 2 Electronic Reporting For Facilities March 2014 North Carolina Central Cancer Registry State Center for Health Statistics Division of Public Health Department of Health and Human Services 1908 Mail Service Center Raleigh, NC 27699-1908 http://www.schs.state.nc.us/units/ccr/ http://www.schs.state.nc.us/units/ccr/ North Carolina Central Cancer Registry

3. Part II: Reporting Requirements

4. Section II.1: Reporting Procedures o MUST use the New Case Abstract Form to report an eligible case of cancer One for each independent primary tumor o A separate report must be completed and submitted for each primary tumor. o Example: If a patient is diagnosed with bladder cancer and a separate kidney cancer, a separate report must be submitted for each diagnosis. o Accuracy and thorough, complete reporting is necessary Please complete the form as ACCURATELY and COMPLETELY as possible. Once the report is free of errors and is successfully submitted, it is considered as having been reported to the NCCCR Copies of the medical record, paper version of the reporting form, or lists of reported patients are not required to be sent to the NCCCR.

5. Part II: Reporting Requirements Section II.1: Reporting Procedures - continued o Brief summary of steps required to report cases. Each step will be described in detail throughout the document and this training. 1.Obtain a Eureka account for each facility. 2.Obtain a Eureka user id and password for each staff person designated to report cases. Consider limiting this to two or three staff per facility. 3.Each user MUST have a personal user id and password. 4.Identify potential cases using the suggested casefinding procedures. 5.Determine if the case should be reported using the case eligibility criteria. 6.Access the electronic New Case Abstract form to enter and submit cases using the required data-entry specifications. 7.Track cases that have been reported to avoid duplicate reporting.

6. Part II: Reporting Requirements Section II.2: Cases Required to be Reported o All health care facilities and providers are required to report: Eligible cancer cases and Non-malignant Central Nervous System (CNS) tumors, including: o Brain, meninges and other CNS that are screened, diagnosed, treated or seen with evidence of cancer. Clinically diagnosed cases (not histologically confirmed )

7. Part II: Reporting Requirements Section II.2: Cases Required to be Reported o All health care facilities and providers are required to report: Clinically diagnosed cases (not histologically confirmed ) o Consider the following as equivalent: Tumor Mass Lesion Neoplasm

8. Part II: Reporting Requirements Section II.2: Cases Required to be Reported - continued o Reporting is required for all diagnoses that meet the following criteria - continued: Cell Type / Histology: o Any tumor/condition described as: Malignant Cancer Carcinoma (adenocarcinoma, transitional cell carcinoma, etc.) Sarcoma Melanoma Lymphoma Leukemia o Intraepithelial Neoplasia, Grade III (8077/2) of the following sites: Anal (AIN III) Vaginal (VAIN III) Vulvar (VIN III)

9. Part II: Reporting Requirements Section II.2: Cases Required to be Reported - continued o Reporting is required for all diagnoses that meet the following criteria - continued: Cell Type / Histology: o Squamous cell carcinoma originating in a mucoepidermoid site: Lip C00.1 – C00.9Vagina C52.9 Anus C21.0Prepuce C60.0 Labia C51.0 – C51.1Penis C60.1 – C60.9 Clitoris C51.2Scrotum C63.2 Vulva C51.9

10. Part II: Reporting Requirements Section II.2: Cases Required to be Reported - continued o Reporting is required for all diagnoses that meet the following criteria - continued: Behavior Code: Tumors that are invasive (ICD-O-3 Behavior code of /3) Tumors that are in-situ (ICD-O Behavior code of /2) If the usual behavior code is /0 (benign) or /1 (uncertain) but a pathologist designates the tumor as “in-situ” or “malignant,” these cases are reportable.

11. Part II: Reporting Requirements Section II.2: Cases Required to be Reported - continued o Reporting is required for all diagnoses that meet the following criteria - continued: Behavior Code - continued: o International Classification of Disease for Oncology, 3 rd Edition (ICD-O-3) Dual classification used principally in cancer registries with coding systems for both o Topography (site) and o Morphology(histology) Describes characteristics of the tumor itself, including its cell type and biologic activity Morphology axis on the diagram provides five-digit codes ranging from M-8000/0 to M-9992/3. First four digits indicate the specific histological term Fifth digit after the slash (/) is the behavior code o Indicated whether a tumor is malignant, benign, in situ, or uncertain (if benign or malignant) Separate one-digit code is provided for histologic grading (differentiation).

12. Part II: Reporting Requirements Section II.2: Cases Required to be Reported – continued Reporting is required for all diagnoses that meet the following criteria - continued: Diagnostic Confirmation (Method used to confirm the diagnosis) o Histologically confirmed cases Tissue examined and confirmed to be cancer o Cytologically confirmed cases Fluid examined and confirmed to be cancer

13. Part II: Reporting Requirements Section II.2: Cases Required to be Reported – continued Reporting is required for all diagnoses that meet the following criteria - continued: Diagnostic Confirmation (Method used to confirm the diagnosis) o Clinically diagnosed cases Confirmed by means other than microscopic examination o Such as positive radiology or laboratory results A diagnosis must be reported even if it has not been microscopically confirmed. o If the physician states the patient has cancer, the case is reportable o If the diagnosis could not be definitively confirmed but is being treated as a malignancy, the case is reportable.

14. Part II: Reporting Requirements Section II.3: Cases NOT Required to be Reported o The following types of cases are not required to be reported: Prostate Intraepithelial Neoplasia, Grade III (PIN III) 8148/2 Cervix Intraepithelial Neoplasia, Grade III (CIN III) 8077/2 Carcinoma in situ (CIS) of the cervix only. All other in situ cases are reportable. Basal and Squamous cell cancers (histology codes: 8000-8110) of the skin only (site code: C44._ only) are not reportable o Basal cell and squamous cell cancers of any other site are reportable o Skin of labia (C51.0), vulva (C51.9), penis (C60.9) and scrotum (C63.2) are reportable Patients seen only in consultation to provide a second opinion to confirm a diagnosis or a treatment plan. Patients in remission (there is no evidence of active disease) and not receiving prophylactic or adjuvant therapy.

15. Part II: Reporting Requirements Section II.3: o The NCCCR understands the scope of work required to meet these requirements for facilities. o Therefore, physician offices are not being asked to report cases that meet either of the following two criteria: It is documented that the patient was previously seen as an inpatient or outpatient at a hospital or cancer treatment facility in North Carolina for the diagnosis or treatment for this tumor. It is documented that the patient later went to a hospital or cancer treatment facility in North Carolina and it is known that the other facility provided management for the diagnosis or treatment of this tumor.

16. Part II: Reporting Requirements Section II.3 – continued: o Conditions of this situation: The other facility o Must be in North Carolina o Cannot be another physician’s office or treatment center not associated with a North Carolina facility o Must have provided cancer directed management of this tumor o If patient seen at another facility other than this tumor, or for reasons other than the direct management of this tumor, the case must be reported by the physician. o If in doubt if a diagnosis meets reportability criteria Submit a report Reduces the need to report these as missed cases later

17. Part II Reporting Requirements Completed