THE SEER PROGRAM

CODING AND STAGING MANUAL 2004

CANCER STATISTICS BRANCH

SURVEILLANCE RESEARCH PROGRAM

DIVISION OF CANCER CONTROL AND POPULATION SCIENCES

NATIONAL INSTITUTES OF HEALTH

PUBLIC HEALTH SERVICE

US DEPARTMENT OF HEALTH AND HUMAN SERVICES

***Effective Date: Cases diagnosed January 1, 2004***

**NIH Publication Number 04-5581**

**U.S. Department of Health and Human Services**

**National Institutes of Health**

**National Cancer Institute**

**The SEER Program Coding and Staging Manual 2004**

Editor

Carol Hahn Johnson, BS, CTR

Acknowledgements

Margaret "Peggy" Adamo, RHIT, CTR, SEER, NCI

Patricia Andrews, MPH, CTR, Louisiana Tumor Registry

Jack Cunningham, CTR, Georgia Center for Cancer Statistics

Lois Dickie, CTR, New Mexico Tumor Registry

Lynda L. Douglas, CTR, Northern California Cancer Center

Cynthia Dryer, BA, CTR, State Health Registry of Iowa

April Fritz, BA, RHIT, CTR, SEER NCI

Lea G. Guidry, RHIA, CTR, Acadiana Tumor Registry

Karen Ledford, RHIA, CTR, Centers for Disease Control

Nancy Lozon, BS, CTR, Metropolitan Detroit Cancer Surveillance System

Jeannine Maxwell, BS, CTR, Alaska Native Tumor Registry

SuAnn McFadden, CTR, Utah Cancer Registry

Donna Morrell, CTR, Los Angeles Cancer Surveillance Program

Patrick Nicolin, BA, CTR, Metropolitan Detroit Cancer Surveillance
System

Steven Peace, BS, CTR, SEER, NCI

Jean Pirkey, CTR, Connecticut Tumor Registry

Linda D. Rego, BA, CTR, Hawai'i Tumor Registry

Lynn Ries, MS, SEER, NCI

Frances Ross, BA, CTR, Kentucky Cancer Registry

Mary Streeter, RHIT, CTR, Georgia Center for Cancer Statistics

Nancy Sullivan, RHIA, Seattle-Puget Sound

Cheryl Tatum, BA, CTR, California Cancer Registry

**Suggested Citation**:

Johnson CH (ed.), SEER Program Coding and Staging Manual 2004.  National
Cancer Institute, NIH Publication number 04-5581, Bethesda, MD  2004.

**Copyright Information**

All material in this manual is in the public domain and may be
reproduced or copied without permission. We do request that you use a
source citation.

**Table of Contents**

**Preface to the SEER Program Coding and Staging Manual** vi

**Introduction SEER Program** 1

SEER Coding and Staging Manual Contents 1

Reportability 1

Dates of Diagnosis/Residency 1

Reportable Diagnoses 1

In Situ and Malignant/Invasive Histologies 1

Benign/Non-Malignant Histologies 2

Cases Diagnosed Clinically Are Reportable 3

Ambiguous Terminology 3

How to Use Ambiguous Terminology for Case Ascertainment 4

Changing Information on the Abstract 5

Determining Multiple Primaries: Solid Malignant Tumors 7

Terms 7

Definitions 7

Same vs. Different Primary Site 8

Same vs. Different Histology 10

Multiple Primary Rules for Solid Tumors 10

Definitions 10

Rules for Single Tumor 10

Rules for Multiple Tumors 10

COC Data Item - Type of First Recurrence 12

Determining Multiple Primaries: Hematopoietic Primaries 18

Determining Multiple Primaries: Benign and Borderline Primary
Intracranial and CNS Tumors 18

**Section I -- Basic Record Identification** 21

SEER Participant 23

Patient ID Number 25

Record Type 26

Record Number 27

SEER Coding System \-- Original 28

SEER Coding System \-- Current 28a

**Section II -- Information Source** 29

Type of Reporting Source 31

**Section III -- Demographic Information** 33

Place of Residence at Diagnosis 35

Coding Priorities/Sources 35

Persons with More than One Residence 35

Persons with No Usual Residence 35

Temporary Residents of SEER Area 36

Persons in the Armed Forces and on Maritime Ships 36

County 37

Census Tract 2000 38

Census Tract Certainty 2000 39

Place of Birth 41

Date of Birth 42

Age at Diagnosis 44

Race 1 45

Race 2, 3, 4, 5 51

IHS Link 56a

Spanish Surname or Origin 57

Computed Ethnicity 58

Computed Ethnicity Source 59

NHIA Derived Hispanic Origin 60

Sex 61

Marital Status at Diagnosis 62

**Section IV -- Description of This Neoplasm** 63

Date of Diagnosis 65

Sequence Number-Central 69

Primary Site 73

Laterality 78

Diagnostic Confirmation 81

Morphology 83

Histologic Type ICD-O-3 84

Behavior Code 89

Grade, Differentiation or Cell Indicator 91

ICD-O-2 Conversion Flag 98

ICD-O-3 Conversion Flag 99

**Section V -- Collaborative Staging and Coding Instructions** 101

Introduction 103

Changes in Abstracting Rules 104

How the Collaborative Staging System Works 106

Mapping and the Computer Algorithm 106

How Mapping Was Determined 109

General Instructions for Using the Collaborative Staging System Codes
and Coding Instructions 111

General Guidelines 111

Structure and Format of Site/Histology-Specific Code Schemas 114

> Coding "None" Vs. "Unknown" in the Collaborative Staging System, TNM
> and Summary Stage 114

Choosing the Correct Coding Schema for a Case 115

Schemas Where Tumor Size is Necessary for AJCC Staging 115

Schemas That Do Not Use Tumor Size for AJCC Staging 118

Death Certificate Only Cases 120

> Use of Autopsy Information in Collaborative Staging 120

Definitions of Adjacent Tissues, Structures, and Organs 122

Ambiguous Terminology 122

Interpreting Ambiguous Terminology for Collaborative Staging 122

How to Code the Collaborative Staging System Data Elements 124

CS Tumor Size 126

CS Extension 130

CS Tumor Size/Ext Eval 133

CS Lymph Nodes 136

CS Reg Nodes Eval 143

Regional Nodes Positive 146

Regional Nodes Examined 148

CS Mets at DX 150

CS Mets at Eval 152

CS Site-Specific Factor 1 154

CS Site-Specific Factor 2 156

CS Site-Specific Factor 3 158

CS Site-Specific Factor 4 160

CS Site-Specific Factor 5 162

CS Site-Specific Factor 6 164

SEER Summary Stage 1977 166

SEER Summary Stage 2000 167

Determining Descriptive Tumor Size 168

**Section VI -- First Course of Therapy** 169

> Definitions 169
>
> Treatment Timing 170
>
> Coding Instructions 171
>
> First Course for Leukemia and Hematopoietic Diseases (diagnosed 1/2001
> and after) 172

Date Therapy Initiated 174

Surgery of Primary Site 177

Scope of Regional Lymph Node Surgery 179

Surgical Procedure of Other Site 181

Reason for No Surgery of Primary Site 182

Radiation 184

Radiation Sequence with Surgery 188

Chemotherapy 189

Hormone Therapy 192

Immunotherapy 194

Hematologic Transplant Endocrine Procedures 197

Other Therapy 200

**Section VII -- Follow up Information** 203

Date of Last Follow up or of Death 204

Vital Status 206

ICD Code Revision Used for Cause of Death 207

Underlying Cause Death 208

Type of Follow up 210

**Section VIII -- Administrative Codes** 211

Site/Type Interfield Review 212

Histology/Behavior Type Interfield Review 213

Age/Site/Histology Interfield Review 214

Sequence Number/Diagnostic Confirmation Interfield Review 215

Site/Histology/Laterality/Sequence Interrecord Review 216

Surgery/Diagnostic Confirmation Interfield Review 217

Type of Reporting Source/Sequence Number Interfield Review 218

Sequence Number Ill-Defined Site Interfield Review 219

Leukemia or Lymphoma Diagnostic Confirmation Interfield Review 220

Over-Ride Flag for Site/Behavior (IF39) 221

Over-Ride Flag for Site/EOD/Diagnosis Date (IF40) 222

Over-Ride Flag for Site/Laterality/EOD (IF41) 223

Over-Ride Flag for Site/Laterality/Morphology (IF42) 224

**Appendix A -- County Codes** A-1

**Appendix B -- SEER GEOCODES** B-1

**Appendix C -- Site-Specific Coding Modules** C-1

**Appendix D -- Race and Nationality Descriptions from the 2000 Census**

**and Bureau of Vital Statistics** D-1

**PREFACE TO THE SEER PROGRAM CODING AND STAGING MANUAL 2004**

The *Surveillance, Epidemiology and End Results (SEER) Program Coding
and Staging Manual 2004* is effective for cases diagnosed January 1,
2004 and forward. Previous editions of this manual are available on the
SEER website, CD, or may be ordered through the SEER website. This is a
major rewrite of the manual. The *SEER Program Coding and Staging Manual
2004* includes all errata and revisions that apply to cases diagnosed
January 1, 2004 and forward. The 2004 changes and additions include:
Replacing EOD with Collaborative Stage, changes in instructions and
definitions for the race coding field, and the addition of instructions
for collecting and abstracting the benign and borderline primary
intracranial and central nervous system tumors (CNS). All of the changes
incorporated into the manual were approved by the Uniform Data Standards
Committee of the North American Association of Central Cancer
Registries.

This manual includes data item descriptions, codes, and coding
instructions for all data items required by SEER for cases diagnosed
January 1, 2004 and forward.

Data items that are not required for 2004 diagnoses but were collected
in years prior to 2004 still must be transmitted to SEER. These data
items should be blank for 2004 and forward diagnoses. Descriptions of
historic data items, allowable codes, and coding rules can be found in
historic manuals, but are not included in this manual.

SEER regions may submit technical questions to SEER using the web-based
SINQ system at <http://seer.cancer.gov/seerinquiry/>. The general
questions and answers from the SINQ system will be incorporated into the
next edition of the SEER manual.

This manual may be downloaded in electronic format from the SEER website
<http://seer.cancer.gov/>.

We gratefully acknowledge the representatives from each of the SEER
registries who participated in an electronic review of this manual. The
participants are listed on the acknowledgement page and we appreciate
the time they spent reviewing the manual.

Send suggestions or revisions to:

> Carol Hahn Johnson, BS, CTR
>
> Manager, Quality Improvement
>
> Surveillance, Epidemiology and End Results Program
>
> Cancer Statistics Branch, Surveillance Research Program,
>
> Division of Cancer Control and Population Sciences
>
> National Cancer Institute
>
> 6116 Executive Blvd
>
> Suite 504
>
> Bethesda, MD 20892-8316
>
> Fax: (301) 496-9949
>
> Email: <johnsoca@mail.nih.gov>
>
> SEER website: [http://seer.cancer.gov](http://seer.cancer.gov/)

**RECORD NUMBER**

**Item Length: 2**

## NAACCR Item #: 2190

**NAACCR Name: SEER Record Number**

The Record Number is a unique sequential number. The highest number for
each patient identifies the number of records that have been submitted
to SEER for that particular patient. This data item is helpful in record
linkage.

The record number is generated by the computer system for each SEER
submission. The record numbers are sequential starting with the number
01. The highest number assigned represents the total number of records
submitted to SEER for that particular patient.

# Codes

1.  One or first of more than one record for person

2.  Second record for the person

..

..

nn Last of nn records for person

**SEER Coding System \-- Original**

Item Length: 1

## NAACCR Item #: 2120

## NAACCR Name: SEER Coding Sys\--Original

## 

SEER Coding System \-- Original records the SEER coding system best
describing the way the majority of SEER items in the record were
originally coded.

**Codes**

0 No SEER coding

1 1987 SEER Coding Manual

2 May 1988 SEER Coding Manual

3 January 1989 SEER Coding Manual

4 January 1992 SEER Coding Manual

5 January 1998 SEER Coding Manual

6 January 2003 SEER Coding Manual

7 January 2004 SEER Coding Manual

**SEER Coding System \-- Current**

## Item Length: 1

## NAACCR Item #: 2120

## NAACCR Name: SEER Coding Sys\--Current

## 

SEER Coding System \-- Current records the SEER coding system best
describing the majority of SEER items as they are in the record (after
conversion).

**Codes**

0 No SEER coding

1 1987 SEER Coding Manual

2 May 1988 SEER Coding Manual

3 January 1989 SEER Coding Manual

4 January 1992 SEER Coding Manual

5 January 1998 SEER Coding Manual

6 January 2003 SEER Coding Manual

7 January 2004 SEER Coding Manual

**This page left blank**

**Type of Reporting Source**

## Item Length: 1

## NAACCR Item #: 500

**NAACCR Name: Type of Reporting Source**

The Type of Reporting Source identifies the source documents used to
abstract the case. This is not necessarily the original document that
identified the case; rather, it is the source that

provided the best information.

**Codes**

**Codes**

1 Hospital inpatient; Managed health plans with comprehensive, unified
medical records (new code definition effective with diagnosis on or
after 1/1/2006)

2 Radiation Treatment Centers or Medical Oncology Centers
(hospital-affiliated or independent) (effective with diagnosis on or
after 1/1/2006)

3 Laboratory Only (hospital-affiliated or independent)

4 Physician's Office/Private Medical Practitioner (LMD)

5 Nursing/Convalescent Home/Hospice

6 Autopsy Only

7 Death Certificate Only

8 Other hospital outpatient units/surgery centers (effective with
diagnosis on or after 1/1/2006)

**Definitions**

> **Managed health plan**: HMO or other health plan (e.g. Kaiser,
> Veterans Administration, military facilities) in which all diagnostic
> and treatment information is maintained centrally (in a unit record)
> and is available to the abstractor.
>
> **Physician office:** Examinations, tests and limited surgical
> procedures may be performed in a physician office. If called a surgery
> center, but cannot perform surgical procedures under general
> anesthesia, code as a physician office.
>
> **Serial record**: The office or facility stores information
> separately for each patient encounter.
>
> **Surgery center:** Surgery centers are equipped and staffed to
> perform surgical procedures under [general anesthesia]{.underline}.
> Patient does not stay overnight.
>
> **Unit record:** The office or facility stores information for all of
> a patient's encounters in one record with one record number.
>
> **Code Definitions**

+----+---------------------+-----------------------------------+------+
| ** | **Label**           | **Source Documents**              | **Pr |
| Co |                     |                                   | iori |
| de |                     |                                   | ty** |
| ** |                     |                                   |      |
+----+---------------------+-----------------------------------+------+
| 1  | Hospital inpatient; | -   Hospital inpatient            | 1    |
|    | Managed             |                                   |      |
+----+---------------------+-----------------------------------+------+
|    | health plans with   | -   Offices/facilities with unit  |      |
|    | comprehensive,      |     record                        |      |
|    | unified medical     |                                   |      |
|    | records             | -   HMO physician office or group |      |
|    |                     |                                   |      |
|    |                     | -   HMO affiliated free-standing  |      |
|    |                     |     laboratory, surgery,          |      |
|    |                     |     radiation or oncology clinic  |      |
|    |                     |                                   |      |
|    |                     | Includes outpatient services of   |      |
|    |                     | HMOs and large multi-specialty    |      |
|    |                     | physician group practices with    |      |
|    |                     | unit record.                      |      |
+----+---------------------+-----------------------------------+------+
| 2  | Radiation Treatment | -   Facilities with serial record | 2    |
|    | Centers or Medical  |     (not a unit record)           |      |
|    | Oncology Centers    |                                   |      |
|    | (                   | -   Radiation treatment centers   |      |
|    | hospital-affiliated |                                   |      |
|    | or independent)     | -   Medical oncology centers      |      |
|    |                     |     (hospital affiliated or       |      |
|    |                     |     independent)                  |      |
|    |                     |                                   |      |
|    |                     | There were no source documents    |      |
|    |                     | from code 1.                      |      |
+----+---------------------+-----------------------------------+------+
| 3  | Laboratory Only     | -   Laboratory with serial record | 5    |
|    | (                   |     (not a unit record)           |      |
|    | hospital-affiliated |                                   |      |
|    | or independent)     |                                   |      |
+----+---------------------+-----------------------------------+------+
|    |                     | There were no source documents    |      |
|    |                     | from codes 1,                     |      |
+----+---------------------+-----------------------------------+------+
|    |                     | 2, 8, or 4.                       |      |
+----+---------------------+-----------------------------------+------+
| 4  | Physician's         | -   Physician's office that is    | 4    |
|    | Office/Private      |     NOT an HMO or large           |      |
|    | Medical             |     multi-specialty physician     |      |
|    | Practitioner (LMD ) |     group practice.               |      |
|    |                     |                                   |      |
|    |                     | There were no source documents    |      |
|    |                     | from codes                        |      |
+----+---------------------+-----------------------------------+------+
|    |                     | > 1, 2 or 8.                      |      |
+----+---------------------+-----------------------------------+------+
| 5  | N                   | -   Nursing or convalescent home  | 6    |
|    | ursing/Convalescent |     or a hospice.                 |      |
|    | Home/Hospice        |                                   |      |
|    |                     | There were no source documents    |      |
|    |                     | from codes                        |      |
+----+---------------------+-----------------------------------+------+
|    |                     | > 1, 2, 8, 4, or 3.               |      |
+----+---------------------+-----------------------------------+------+
| 6  | Autopsy Only        | -   Autopsy                       | 7    |
|    |                     |                                   |      |
|    |                     | The cancer was first diagnosed on |      |
|    |                     | autopsy.                          |      |
+----+---------------------+-----------------------------------+------+
|    |                     | > There are no source documents   |      |
|    |                     | > from codes 1,                   |      |
|    |                     | >                                 |      |
|    |                     | > 2, 8, 4, 3, or 5.               |      |
+----+---------------------+-----------------------------------+------+
| 7  | Death Certificate   | -   Death certificate             | 8    |
|    | Only                |                                   |      |
|    |                     | Death certificate is the only     |      |
|    |                     | source of information;            |      |
|    |                     | follow-back activities did not    |      |
+----+---------------------+-----------------------------------+------+
|    |                     | > identify source documents from  |      |
|    |                     | > codes 1, 2, 8, 4, 3, 5 or 6. If |      |
|    |                     | > another source document is      |      |
+----+---------------------+-----------------------------------+------+
|    |                     | > subsequently identified, the    |      |
|    |                     | > Type of Reporting Source code   |      |
|    |                     | > must be changed to the          |      |
+----+---------------------+-----------------------------------+------+
|    |                     | > appropriate code in the range   |      |
|    |                     | > of 1, 2, 8, 4, 3 or             |      |
+----+---------------------+-----------------------------------+------+
|    |                     | > 6\.                             |      |
+----+---------------------+-----------------------------------+------+
| 8  | Other hospital      | -   Other hospital outpatient     | 3    |
|    | outpatient          |     units/surgery centers.        |      |
|    | units/surgery       |                                   |      |
|    | centers             | Includes, but not limited to,     |      |
|    |                     | outpatient surgery and nuclear    |      |
|    |                     | medicine services.                |      |
|    |                     |                                   |      |
|    |                     | There are no source documents     |      |
|    |                     | from codes 1                      |      |
|    |                     |                                   |      |
|    |                     | or 2.                             |      |
+----+---------------------+-----------------------------------+------+

**Priority Order for Assigning Type of Reporting Source**

When multiple source documents are used to abstract a case, use the
following priority order to assign a code for Type of Reporting Source:

**Priority order of codes**

1, 2, 8, 4, 3, 5, 6, 7.

**Note**

> Beginning with cases diagnosed 1/1/2006, the definitions for this
> field have been expanded. Codes 2 and 8 were added to identify
> outpatient sources that were previously grouped under code 1.
> Laboratory reports now have priority over nursing home reports. The
> source
>
> facilities included in the previous code 1 (hospital inpatient and
> outpatient) are split between codes 1, 2, and 8.
>
> It is recommended that no changes be made to the field for cases
> already existing in the central cancer registry database diagnosed
> prior to January 1, 2006. Conversion of the old codes would be
> problematic and would require extensive and time-consuming review of
> original source documentation.

**This page left blank**

**CENSUS TRACT CERTAINTY 2000**

**Item Length: 1**

## NAACCR Item #: 365

**NAACCR Name: Census Tr Certainty 2000**

sindividual record. Most of the time, this information is provided by a
geocoding vendor service. Central registry staff should codes this field
manually when geocoding is not available through a vendor service. This
item is coded for cases diagnosed January 1, 1996 and forward.

**Codes**

1 Census tract based on complete and valid street address of residence

2 Census tract based on residence ZIP + 4

3 Census tract based on residence ZIP + 2

4 Census tract based on residence ZIP code only

5 Census tract based on ZIP code of post office box

6 Census tract/BNA based on residence city where city has only one
census tract, or based on residence ZIP code where ZIP code has only one
census tract

9 Unable to assign census tract based on available information

Blank Not applicable (e.g., census tracting not attempted); Census tract
Certainty information for 2000 not coded

**Coding Priority**

The codes are hierarchical with the numerically lower codes having
priority.

1.  Code 1 has priority over codes 2-5 and 9

2.  Code 2 has priority over codes 3-5 and 9

3.  Code 3 has priority over codes 4, 5, and 9

4.  Code 4 has priority over codes 5 and 9

5.  Code 5 has priority over code 9

Note: Codes 1-5 and 9 are usually assigned by a geocoding vendor, while
code 6 is usually assigned through a special effort by the central
registry.

**Coding Instructions**

1.  Code 1

    a.  Used when the census tract is assigned with certainty based on
        street address

    b.  May be assigned based on a computer match (geocoding software)

    c.  May be assigned based on a central registry's manual coding
        system

> Example 1*:* The registry used a complete and valid street address to
> assign the census tract.
>
> Example 2: The registry used a rural route number to assign the census
> tract, and has confirmed that the rural route lies completely within a
> single census tract.
>
> Example 3: The registry used an incomplete street address to assign
> the census tract, and has confirmed that the entire street lies within
> a single census tract.

2.  Codes 2-5

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a.  Assign when there is some uncertainty about the census tract
    assignment

b.  May be assigned based on a computer match (geocoding software)

c.  May be assigned based on a central registry manually appointed code

d.  Assign code 4 when

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```
i.  Street address is incomplete or invalid, but ZIP code is known

ii. Only rural route number is available, but ZIP code is known

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```
e.  Assign code 5 when the registry used a post office box and ZIP code
    to code the census tract

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```
3.  Code 9

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```
a.  ZIP code is missing OR

b.  The complete address of the patient is unknown or cannot be
    determined OR

c.  There is insufficient information to assign a census code .

> Note: Avoid using the post office box mailing address to code the
> census tract whenever possible.

**IHS Link**

> **Item Length: 1**
>
> **NAACCR Item #: 192**
>
> **NAACCR Name: IHS Link**

The NAACCR Indian Health Service Linkage (IHS) captures the results of
the linkage of the registry database with the Indian Health Service
patient registration database. The IHS linkage identifies cancer cases
among American Indians who were misclassified as non-Indian in the
registry database in order to improve the quality of cancer surveillance
data on American Indians in both the individual registries and in all
registries as a whole. The goal is to include cancer incidence data for
American Indians in the United States Cancer Statistics by use of this
variable as well as the race variable.

The computer program that is run to capture the result of the linkage
will automatically assign the code for this data item. SEER will require
the IHS Link for all years of diagnosis but the field will be blank
unless an attempt was made to link the case with the records from the
Indian Health Service. The results of the linkage will be used to
populate this field.

**Codes**

0 Record sent for linkage, no IHS match

1 Record sent for linkage, IHS match

Blank Record not sent for linkage or linkage result pending

**This page left blank**

> Terminology Conversion Table

+-------------------------------------------------+--------+----------+
| **Description**                                 | > **G  | **SEER** |
|                                                 | rade** |          |
|                                                 |        | **Code** |
+=================================================+========+==========+
| Differentiated, NOS                             | > I    | 1        |
+-------------------------------------------------+--------+----------+
| Well differentiated                             | > I    | 1        |
+-------------------------------------------------+--------+----------+
|                                                 | > []{  | [        |
|                                                 | .mark} | ]{.mark} |
+-------------------------------------------------+--------+----------+
| Fairly well differentiated                      | > II   | 2        |
+-------------------------------------------------+--------+----------+
| Intermediate differentiation                    | > II   | 2        |
+-------------------------------------------------+--------+----------+
| Low grade                                       | > I-II | 2        |
+-------------------------------------------------+--------+----------+
| Mid differentiated                              | > II   | 2        |
+-------------------------------------------------+--------+----------+
| Moderately differentiated                       | > II   | 2        |
+-------------------------------------------------+--------+----------+
| Moderately well differentiated                  | > II   | 2        |
+-------------------------------------------------+--------+----------+
| Partially differentiated                        | > II   | 2        |
+-------------------------------------------------+--------+----------+
| Partially well differentiated                   | > I-II | 2        |
+-------------------------------------------------+--------+----------+
| Relatively or generally well differentiated     | > II   | 2        |
+-------------------------------------------------+--------+----------+
|                                                 |        |          |
+-------------------------------------------------+--------+----------+
| Medium grade, intermediate grade                | >      | 3        |
|                                                 | II-III |          |
+-------------------------------------------------+--------+----------+
| Moderately poorly differentiated                | > III  | 3        |
+-------------------------------------------------+--------+----------+
| Moderately undifferentiated                     | > III  | 3        |
+-------------------------------------------------+--------+----------+
| Poorly differentiated                           | > III  | 3        |
+-------------------------------------------------+--------+----------+
| Relatively poorly differentiated                | > III  | 3        |
+-------------------------------------------------+--------+----------+
| Relatively undifferentiated                     | > III  | 3        |
+-------------------------------------------------+--------+----------+
| Slightly differentiated                         | > III  | 3        |
+-------------------------------------------------+--------+----------+
| Dedifferentiated                                | > III  | 3        |
+-------------------------------------------------+--------+----------+
|                                                 |        |          |
+-------------------------------------------------+--------+----------+
| High grade                                      | >      | 4        |
|                                                 | III-IV |          |
+-------------------------------------------------+--------+----------+
| Undifferentiated, anaplastic, not               | > IV   | 4        |
| differentiated                                  |        |          |
+-------------------------------------------------+--------+----------+
| Non-high grade                                  |        | 9        |
+-------------------------------------------------+--------+----------+

###### Two-Grade System

Some cancers are graded using a two-grade system, for an example, colon
cancer. If the grade is listed as 1/2 or as low grade, assign code 2. If
the grade is listed as 2/2 or as high grade, assign code 4.

Two-Grade Conversion Table

+----------------+-----------------------------+----------------------+
| **Grade**      | **Differentiation /**       | **SEER Code**        |
|                |                             |                      |
|                | **Description**             |                      |
+================+=============================+======================+
| 1/2, I/II      | Low grade                   | 2                    |
+----------------+-----------------------------+----------------------+
| 2/2, II/II     | High grade                  | 4                    |
+----------------+-----------------------------+----------------------+

# Three-Grade System 

There are several sites for which a three-grade system is used, such as
peritoneum, endometrium, fallopian tube, prostate, bladder and soft
tissue sarcoma. The patterns of cell growth are measured on a scale of
1, 2, and 3 (also referred to as low, medium, and high grade). This
system measures the proportion of cancer cells that are growing and
making new cells and how closely they resemble the cells of the host
tissue. Thus, it is similar to a four-grade system, but simply divides
the spectrum into 3 rather than 4 categories (see Three-Grade Conversion
Table below). The expected outcome is more favorable for lower grades.

If a grade is written as 2/3 that means this is a grade 2 of a
three-grade system. Do not simply code the numerator. Use the following
table to convert the grade to SEER codes:

**Three-Grade Conversion Table**

**Do not use for breast primaries**

**Breast Cancer**

**Priority Order for Coding Breast Cancer Grade**

Code grade in the following priority order:

1.  Bloom-Richardson scores 3-9 converted to grade (See following table)

2.  Bloom Richardson grade (low, intermediate, high)

3.  Nuclear grade only

4.  Terminology

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```
a.  Differentiation (well differentiated, moderately differentiated,
    etc).

```{=html}
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```
5.  Histologic grade

```{=html}
<!-- -->
```
a.  Grade 1/I/i, grade 2/II/ii, grade 3/III/iii, grade 4/IV/iv

> Breast Grading Conversion Table

+-------+-------------+----------+---------------+-----------+--------+
| **BR  | > **BR      | *        | **            | **H       | **SEER |
| Sco   | > Grade**   | *Nuclear | Terminology** | istologic | Code** |
| res** |             | Grade**  |               | Grade**   |        |
+-------+-------------+----------+---------------+-----------+--------+
| 3-5   | > Low       | 1/3; 1/2 | Well          | I/III;    | > 1    |
|       |             |          | d             | 1/3       |        |
|       |             |          | ifferentiated |           |        |
+-------+-------------+----------+---------------+-----------+--------+
| 6, 7  | > I         | 2/3      | Moderately    | II/III;   | > 2    |
|       | ntermediate |          | d             | 2/3       |        |
|       |             |          | ifferentiated |           |        |
+-------+-------------+----------+---------------+-----------+--------+
| 8, 9  | > High      | 2/2; 3/3 | Poorly        | III/III;  | > 3    |
|       |             |          | d             | 3/3       |        |
|       |             |          | ifferentiated |           |        |
+-------+-------------+----------+---------------+-----------+--------+

**Bloom-Richardson (BR)**

1.  **BR** may **also** be **called**: modified Bloom-Richardson,
    Scarff-Bloom-Richardson, SBR grading, BR grading, Elston-Ellis
    modification of Bloom Richardson score, the Nottingham modification
    of Bloom Richardson score, Nottingham-Tenovus, or Nottingham grade

2.  BR may be expressed in **scores** (range 3-9)

3.  The score is based on three morphologic features of "invasive
    no-special-type" breast cancers (degree of tubule
    formation/histologic grade, mitotic activity, nuclear pleomorphism
    of tumor cells).

4.  Use the Breast Grading Conversion Table to convert the score, grade
    or term into the SEER code

5.  BR may be expressed as a **grade** (low, intermediate, high)

6.  BR grade is derived from the BR score. Note that the conversion of
    low, intermediate, and high for breast is different from the
    conversion used for all other tumors.

**Table 1. Allowable Values and Format for Collaborative Staging Data
Items**

+------------+--------+-----+------------+--------+-------+--------+
| **INPUT    |        |     |            |        |       |        |
| ITEMS**    |        |     |            |        |       |        |
+============+========+=====+============+========+=======+========+
| **Data     | **     | **  | *          | *      | **Bl  | **     |
| Item       | NAACCR | Cha | *Allowable | *Right | anks: | NAACCR |
| Name**     | Data   | r-a | Values**   | Justif | Yes   | Ver    |
|            | Item   | cte |            | ied,** | or    | 10.1** |
|            | Nu     | r** | **(sit     |        | No**  |        |
|            | mber** |     | e-specific | **Zero |       | **     |
|            |        | *   | unless     | fi     |       | Column |
|            |        | *Le | otherwise  | lled** |       | \#**   |
|            |        | ngt | stated)**  |        |       |        |
|            |        | h** |            |        |       |        |
+------------+--------+-----+------------+--------+-------+--------+
| CS Tumor   | 2800   | 3   | 000-999    | Yes    | No    | 6      |
| Size       |        |     |            |        |       | 29-631 |
+------------+--------+-----+------------+--------+-------+--------+
| CS         | 2810   | 2   | 00-99      | Yes    | No    | 6      |
| Extension  |        |     |            |        |       | 32-633 |
+------------+--------+-----+------------+--------+-------+--------+
| CS Tumor   | 2820   | 1   | 0-9        | N/A    | No    | 6      |
| Size/Ext   |        |     |            |        |       | 34-634 |
| Eval       |        |     |            |        |       |        |
+------------+--------+-----+------------+--------+-------+--------+
| CS Lymph   | 2830   | 2   | 00-99      | Yes    | No    | 6      |
| Nodes      |        |     |            |        |       | 35-636 |
+------------+--------+-----+------------+--------+-------+--------+
| CS Reg     | 2840   | 1   | 0-9        | N/A    | No    | 6      |
| Nodes Eval |        |     |            |        |       | 37-637 |
+------------+--------+-----+------------+--------+-------+--------+
| Regional   | 830    | 2   | 00-90, 95, | Yes    | No    | 5      |
| Nodes      |        |     | 96, 97,    |        |       | 41-542 |
| Examined   |        |     | 98, 99     |        |       |        |
|            |        |     | (all       |        |       |        |
|            |        |     | sites)     |        |       |        |
+------------+--------+-----+------------+--------+-------+--------+
| Regional   | 820    | 2   | 00-90, 95, | Yes    | No    | 5      |
| Nodes      |        |     | 97, 98, 99 |        |       | 39-540 |
| Positive   |        |     | (all       |        |       |        |
|            |        |     | sites)     |        |       |        |
+------------+--------+-----+------------+--------+-------+--------+
| CS Mets At | 2850   | 2   | 00-99      | Yes    | No    | 6      |
| Dx         |        |     |            |        |       | 38-639 |
+------------+--------+-----+------------+--------+-------+--------+
| CS Mets    | 2860   | 1   | 0-9        | N/A    | No    | 6      |
| Eval       |        |     |            |        |       | 40-640 |
+------------+--------+-----+------------+--------+-------+--------+
| CS         | 2880   | 3   | 000-999    | Yes    | No    | 6      |
| Sit        |        |     |            |        |       | 41-643 |
| e-Specific |        |     |            |        |       |        |
| Factor 1   |        |     |            |        |       |        |
+------------+--------+-----+------------+--------+-------+--------+
| CS         | 2890   | 3   | 000-999    | Yes    | No    | 6      |
| Sit        |        |     |            |        |       | 44-646 |
| e-Specific |        |     |            |        |       |        |
| Factor 2   |        |     |            |        |       |        |
+------------+--------+-----+------------+--------+-------+--------+
| CS         | 2900   | 3   | 000-999    | Yes    | No    | 6      |
| Sit        |        |     |            |        |       | 47-649 |
| e-Specific |        |     |            |        |       |        |
| Factor 3   |        |     |            |        |       |        |
+------------+--------+-----+------------+--------+-------+--------+
| CS         | 2910   | 3   | 000-999    | Yes    | No    | 6      |
| Sit        |        |     |            |        |       | 50-652 |
| e-Specific |        |     |            |        |       |        |
| Factor 4   |        |     |            |        |       |        |
+------------+--------+-----+------------+--------+-------+--------+
| CS         | 2920   | 3   | 000-999    | Yes    | No    | 6      |
| Sit        |        |     |            |        |       | 53-655 |
| e-Specific |        |     |            |        |       |        |
| Factor 5   |        |     |            |        |       |        |
+------------+--------+-----+------------+--------+-------+--------+
| CS         | 2930   | 3   | 000-999    | Yes    | No    | 6      |
| Sit        |        |     |            |        |       | 56-658 |
| e-Specific |        |     |            |        |       |        |
| Factor 6   |        |     |            |        |       |        |
+------------+--------+-----+------------+--------+-------+--------+

**Table 1 continued. Allowable Values and Format for Collaborative
Staging Data Items**

+------------+--------+-----+------------+--------+-------+--------+
| **OUTPUT   |        |     |            |        |       |        |
| ITEMS**    |        |     |            |        |       |        |
+------------+--------+-----+------------+--------+-------+--------+
| **Data     | **     | **  | *          | *      | **Bl  | **     |
| Item       | NAACCR | Cha | *Allowable | *Right | anks: | NAACCR |
| Name**     | Data   | r-a | Values**   | Just   | Yes   | Ver    |
|            | Item   | cte |            | ified, | or    | 10.1** |
|            | Nu     | r** |            | Zero   | No**  |        |
|            | mber** |     |            | fi     |       | **     |
|            |        | *   |            | lled** |       | Column |
|            |        | *Le |            |        |       | \#**   |
|            |        | ngt |            |        |       |        |
|            |        | h** |            |        |       |        |
+------------+--------+-----+------------+--------+-------+--------+
| Derived    | 2940   | 2   | 00, 01,    | N/A    | N/A   | 6      |
| AJCC T     |        |     | 05, 06,    |        |       | 59-660 |
|            |        |     | 07, 10,    |        |       |        |
|            |        |     | 11, 12,    |        |       |        |
|            |        |     | 13, 14,    |        |       |        |
|            |        |     | 15, 16,    |        |       |        |
|            |        |     | 17, 18,    |        |       |        |
|            |        |     | 19, 20,    |        |       |        |
|            |        |     | 21, 22,    |        |       |        |
|            |        |     | 23, 29,    |        |       |        |
|            |        |     | 30, 31,    |        |       |        |
|            |        |     | 32, 33,    |        |       |        |
|            |        |     | 39, 40,    |        |       |        |
|            |        |     | 41, 42,    |        |       |        |
|            |        |     | 43, 44,    |        |       |        |
|            |        |     | 49, 88, 99 |        |       |        |
+------------+--------+-----+------------+--------+-------+--------+
| Derived    | 2960   | 2   | 00, 01,    | N/A    | N/A   | 6      |
| AJCC N     |        |     | 02, 03,    |        |       | 62-663 |
|            |        |     | 04, 09,    |        |       |        |
|            |        |     | 10, 11,    |        |       |        |
|            |        |     | 12, 13,    |        |       |        |
|            |        |     | 18, 19,    |        |       |        |
|            |        |     | 20, 21,    |        |       |        |
|            |        |     | 22, 23,    |        |       |        |
|            |        |     | 29, 30,    |        |       |        |
|            |        |     | 31, 32,    |        |       |        |
|            |        |     | 33, 39,    |        |       |        |
|            |        |     | 88, 99     |        |       |        |
+------------+--------+-----+------------+--------+-------+--------+
| Derived    | 2980   | 2   | 00, 10,    | N/A    | N/A   | 6      |
| AJCC M     |        |     | 11, 12,    |        |       | 65-666 |
|            |        |     | 13, 19,    |        |       |        |
|            |        |     | 88, 99     |        |       |        |
+------------+--------+-----+------------+--------+-------+--------+
| Derived    | 2950   | 1   | c, p, a, y | N/A    | N/A   | 6      |
| AJCC T     |        |     |            |        |       | 61-661 |
| Descriptor |        |     |            |        |       |        |
+------------+--------+-----+------------+--------+-------+--------+
| Derived    | 2970   | 1   | c, p, a, y | N/A    | N/A   | 6      |
| AJCC N     |        |     |            |        |       | 64-664 |
| Descriptor |        |     |            |        |       |        |
+------------+--------+-----+------------+--------+-------+--------+
| Derived    | 2990   | 1   | c, p, a, y | N/A    | N/A   | 6      |
| AJCC M     |        |     |            |        |       | 67-667 |
| Descriptor |        |     |            |        |       |        |
+------------+--------+-----+------------+--------+-------+--------+
| Derived    | 3000   | 2   | 00, 01,    | N/A    | N/A   | 6      |
| AJCC Stage |        |     | 02, 10,    |        |       | 68-669 |
| Group      |        |     | 11, 12,    |        |       |        |
|            |        |     | 13, 14,    |        |       |        |
|            |        |     | 15, 16,    |        |       |        |
|            |        |     | 17, 18,    |        |       |        |
|            |        |     | 19, 20,    |        |       |        |
|            |        |     | 21, 22,    |        |       |        |
|            |        |     | 23, 24,    |        |       |        |
|            |        |     | 30, 31,    |        |       |        |
|            |        |     | 32, 33,    |        |       |        |
|            |        |     | 34, 35,    |        |       |        |
|            |        |     | 36, 37,    |        |       |        |
|            |        |     | 38, 39,    |        |       |        |
|            |        |     | 40, 41,    |        |       |        |
|            |        |     | 42, 43,    |        |       |        |
|            |        |     | 50, 51,    |        |       |        |
|            |        |     | 52, 53,    |        |       |        |
|            |        |     | 54, 55,    |        |       |        |
|            |        |     | 56, 57,    |        |       |        |
|            |        |     | 58, 59,    |        |       |        |
|            |        |     | 60, 61,    |        |       |        |
|            |        |     | 62, 63,    |        |       |        |
|            |        |     | 70, 71,    |        |       |        |
|            |        |     | 72, 73,    |        |       |        |
|            |        |     | 74, 88,    |        |       |        |
|            |        |     | 90, 99     |        |       |        |
+------------+--------+-----+------------+--------+-------+--------+
| Derived    | 3030   | 1   | Blank, 1,  | N/A    | Yes   | 6      |
| AJCC Flag  |        |     | 2          |        |       | 72-672 |
+------------+--------+-----+------------+--------+-------+--------+
| Derived    | 3010   | 1   | Blank, 0,  | N/A    | Yes   | 6      |
| SS1977     |        |     | 1, 2, 3,   |        |       | 70-670 |
|            |        |     | 4, 5, 7,   |        |       |        |
|            |        |     | 8, 9       |        |       |        |
+------------+--------+-----+------------+--------+-------+--------+

> ***Example:*** Liver palpated and reported as normal during laparotomy
> for stomach cancer (Eval code 1). CT scan of brain shows multiple
> metastatic nodules (Eval code 0).
>
> Code CS Mets Eval as 0; the brain would be reported as involved but
> the liver would not be reported as involved.

2\. For primary sites/histologies where there is no TNM schema (Table
6), this field may be coded as 9 (not applicable).

3\. Select the code that best explains how the information in the CS
Metastases field was determined.

> a\. If the patient had no examination of metastatic tissue, use code
> 0, 1, or 9.
>
> ***Example 1:*** Patient has diagnosis of colon cancer by biopsy. CT
> scan shows liver metastasis.
>
> Code this field as 0. Staging algorithm will indicate information is
> clinical (c).
>
> ***Example 2**:* Lung cancer with endoscopy of contralateral lung
> showing involvement of contralateral mainstem bronchus. Code this
> field as 1. Staging algorithm will indicate information is clinical
> (c).
>
> ***Example 3:*** Prostate cancer with enlarged scalene node confirmed
> as cancer on needle biopsy.
>
> Code this field as 3. Staging algorithm will indicate information is
> pathologic (p), since the biopsy of the metastatic site confirms M1
> disease.
>
> b\. If the patient had removal of presumed metastatic tissue (even
> though the pathology report was negative), use code 3.
>
> c\. Code the method of evaluation for the site(s) farthest from the
> primary.
>
> ***Example:*** Colon cancer patient has CT scan showing normal lungs.
> During the resection, the surgeon palpates the liver and finds it to
> be normal. Code this field as 0, since the CT scan shows that
> potential metastatic sites outside the surgical field are negative.
>
> d\. If the patient had an autopsy, use code 2 if the diagnosis was
> known or suspected prior to death. Use code 8 if the malignancy was
> not known or suspected prior to death.

4\. If the patient receives preoperative (neoadjuvant) systemic therapy
(chemotherapy, hormone therapy, immunotherapy) or radiation therapy, the
clinical status of metastases at diagnosis takes precedence (code 5).

5\. If the patient has biopsies of some metastases while others are
visible only on imaging, use code 6 to indicate if, after preoperative
treatment, the biopsy is negative for metastasis but there is still
evidence of clinical metastasis.

6\. Code 0 includes imaging studies such as standard radiography,
special radiographic projections, tomography, computerized tomography
(CT), ultrasonography, lymphography, angiography, scintigraphy (nuclear
scans), ultrasonography, magnetic resonance imaging (MRI), positron
emission tomography (PET) scans, spiral scanning (CT or MRI) and other
non-invasive methods of examining tissues.

7\. Any positive biopsy or resection of distant metastasis meets the
requirement for pathologic staging basis and should be coded to CS Mets
Eval code 3.

8\. Code 1 includes endoscopy and observations at surgery, such as
abdominal exploration at the time of a colon resection, where distant
metastasis is not biopsied.

**CS SITE-SPECIFIC FACTOR 1**

**Item Length: 3**

## NAACCR Item #: 2880

**NAACCR Name: CS Site-Specific Factor1**

Identifies additional information needed to generate stage, or
prognostic factors that have an effect on stage or survival.

+-----+----------------------------------------------------------------+
| **  | **Description**                                                |
| Cod |                                                                |
| e** |                                                                |
+-----+----------------------------------------------------------------+
| 000 | None                                                           |
+-----+----------------------------------------------------------------+
|     | **SITE/HISTOLOGY-SPECIFIC CODES**                              |
+-----+----------------------------------------------------------------+
| 999 | Unknown; \[site-specific title\] cannot be assessed;           |
|     |                                                                |
|     | Not documented in patient record                               |
+-----+----------------------------------------------------------------+

**For schemas that do not use this site-specific factor:**

  ---------- ----------------------------------------------------------------
  **Code**   **Description**

  888        Not applicable for this site
  ---------- ----------------------------------------------------------------

**INSTRUCTIONS FOR CODING**

1\. If there is no site/histology-specific factor for a schema, code
888.

2\. The following primary sites/histologies use Site Specific Factor 1
to code information. See the site-specific schemas for acceptable codes
and their definitions.

**[Site/Histology]{.underline} [Factor]{.underline}**

> Head and neck\* Size of Lymph Nodes
>
> Colon Carcinoembryonic Antigen (CEA)
>
> Rectosigmoid, rectum Carcinoembyronic Antigen (CEA)
>
> Liver Alpha Fetoprotein (AFP)
>
> Pleura Pleural Effusion

Malignant Melanoma of Skin,

> Vulva, Penis, Scrotum Measured Thickness (Depth), Breslow=s
> Measurement
>
> Mycosis Fungoides Peripheral Blood Involvement
>
> Breast Estrogen Receptor Assay (ERA)
>
> Ovary Carbohydrate Antigen 125 (CA-125)
>
> Placenta Prognostic Scoring Index
>
> Prostate Prostate Specific Antigen (PSA) Lab Value
>
> Testis Alpha Fetoprotein (AFP)
>
> Thyroid Solitary vs. Multifocal

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

3\. Code 000 Not done is used when there is a statement in the record
that a test was not performed.

> a\. If there is no report of a lab test in the health record, code as
> 999 Unknown; Not documented in patient record.

**For Head And Neck Sites Only:**

4\. Use code 9 only when it is unknown if lymph nodes are involved.
Within the Site-Specific Factors, do not code 9 in some positions and 0
or 1 in other positions. If specific information is available about the
positive or negative status of some but not all nodes in any one level
or group, assume that the rest of the nodes in the same Site-Specific
Factor are negative and code accordingly.

5\. When the only information available is ARegional nodes, NOS@ or
ACervical nodes, NOS@ or AInternal jugular lymph nodes, NOS@ or ALymph
nodes, NOS,@ code 0 in all digits of Site-Specific Factors 3-6.

6\. See ACoding Regional Lymph Nodes for Head and Neck Sites@ under CS
Lymph Nodes for further information about the regional nodes of the head
and neck, including definitions of the levels.

**SEER SUMMARY STAGE 1977**

> **Item Length: 1**
>
> **NAACCR Item #: 760**
>
> **NAACCR Name: SEER SUMMARY STAGE 1977**

For SEER registries who elect to have SEER submit their date to NAACCR,
only. Tumors diagnosed before January 1, 2001, should be assigned a
summary stage according to *SEER* *Summary Staging Guide*.

SEER Summary Stage 1977 is limited to information available within 2
months of the date of diagnosis.

***Note**:* See also the data item Derived SS21977 \[NAACCR Item #3010\]
for the value of SEER Summary Stage 1977 as generated by the
Collaborative Staging algorithm.

Data may be submitted using either manually entered SEER Summary Stage
1977 code or Collaborative Stage generated code.

**Codes**

0 In situ

1 Localized

2 Regional, direct extension only

3 Regional, regional lymph nodes only

4 Regional, direct extension and regional lymph nodes

5 Regional, NOS

7 Distant

8 Not appplicable

9 Unstaged

> **SEER SUMMARY STAGE 2000**
>
> **Item Length: 1**
>
> **NAACCR Item #: 759**
>
> **NAACCR Name: SEER SUMMARY STAGE 2000**

For SEER registries who elect to have SEER submit their date to NAACCR,
only. Tumors diagnosed January 1, 2001 or after, should be assigned a
summary stage according to *SEER* *Summary Staging Manual 2000*.

Summary stage should include all information available through
completion of surgery(ies) in the first course of treatment or within 4
months of diagnosis in the absence of disease progression, whichever is
longer.

***Note**:* See also the data item Derived SS2000 \[NAACCR Item #3020\]
for the value of SEER Summary Stage 2000 as generated by the
Collaborative Staging algorithm.

Data may be submitted using either manually entered SEER Summary Stage
2000 code or Collaborative Stage generated code.

**Codes**

0 In situ

1 Localized

2 Regional, direct extension only

3 Regional, regional lymph nodes only

4 Regional, direct extension and regional lymph nodes

5 Regional, NOS

7 Distant

8 Not applicable

9 Unstaged

**Determining Descriptive Tumor Size**

**Millimeter Equivalents for Descriptive Terms**

[Fruits]{.underline} [mm]{.underline}

Apple 070

Apricot 040

Cherry 020

Date 040

Fig (dried) 040

Grape 020

Grapefruit 100

Kumquat 050

Lemon 080

Olive 020

Orange 090

Peach 060

Pear 090

Plum 030

Tangerine 060

[Nuts]{.underline}

Almond 030

Chestnut 040

Chestnut, horse 040

Hazel 020

Hickory 030

Peanut 010

Pecan 030

Walnut 030

[Vegetables]{.underline}

Bean 010

Bean, lima 020

Pea 991

Pea, split 991

[Miscellaneous Food]{.underline} [mm]{.underline}

Doughnut 090

Egg 050

Bantam 040

Goose 070

Hen 030

Pigeon 030

Robin 020

Lentil 991

Millet 991

[Money]{.underline}

Dime 010

Dollar, half 030

Dollar, silver 040

Nickel 020

Penny 010

Quarter 020

[Other]{.underline}

Ball, golf 040

Ball, ping‑pong 030

Ball, tennis 060

Baseball 070

Eraser on pencil 991

Fist 090

Marble 010

Matchhead 991

Microscopic focus 990

Described as less than 1 cm. 991

Described as between 1 and 2 cm 992

Described as between 2 and 3 cm 993

Described as between 3 and 4 cm 994

Described as between 4 and 5 cm 995

### 

### SIZES IN CENTIMETERS, MILLIMETERS, INCHES

10 millimeters (mm) = 1 centimeter (cm)

1 millimeter (mm) = 1/10 centimeter (cm)

2.5 centimeters (cm) = 1 inch (in)

1 centimeter (cm) = .394 inch (in)

**Coding Instructions**

1.  When physician decides to do watchful waiting for a patient who has
    prostate cancer, the first course of therapy is no treatment. Code
    all of the treatment fields to 00, not done. When the disease
    progresses and the patient is symptomatic; any prescribed treatment
    is second course.

2.  When the patient refuses treatment the first course of therapy is no
    treatment. Code the treatment fields to refused. If the patient
    later changes his/her mind and decides to have the prescribed
    treatment code:

    a.  Code the treatment as first course of therapy if it has been
        less than one year since the cancer was diagnosed and there has
        been no documented disease progression.

    b.  Code the treatment as second course of therapy if it has been
        more than one year since the original cancer was diagnosed or if
        there has been documented disease progression.

3.  Code all treatment that was started and administered.

> Example: The patient completed only the first dose of a planned 30 day
> chemotherapy regimen. Code chemotherapy as administered.

4.  If a patient has multiple primaries and the treatment given for one
    primary also affects/treats the other primary, code the treatment
    for both primary sites.

> Example 1*:* The patient had prostate and bladder cancer. The bladder
> cancer was treated with a TURB. The prostate cancer was treated with
> radiation to the prostate and pelvis. The pelvic radiation includes
> the regional lymph nodes for the bladder. Code the radiation as
> treatment for both the bladder and prostate cases.
>
> Example 2: The patient had a hysterectomy for ovarian cancer. The
> pathology report reveals a previously unsuspected microinvasive cancer
> of the cervix. Code the hysterectomy as surgical treatment for both
> the ovarian and cervix primaries.

5.  primaries, code the treatments only on the site that is affected.

> Example: The patient has colon and tonsil primaries. The colon cancer
> is treated with a hemicolectomy and the tonsil primary is treated with
> radiation to the tonsil and regional nodes. Do not code the radiation
> for the colon. Do not code the hemicolectomy for the tonsil.

6.  If a patient is diagnosed with an unknown primary, code the
    treatment given as first course even if the correct primary is
    identified later.

> ***Example:*** The patient is diagnosed with metastatic carcinoma,
> unknown primary site. After a full course of chemotherapy, the primary
> site is identified as prostate. Hormonal treatment is started. Code
> the chemotherapy as first course of treatment. The hormone therapy is
> second course.

**First Course for Leukemia and Hematopoietic Diseases (diagnosed 1/2001
and after)**

**Leukemia**

> Leukemia is grouped or typed by how quickly the disease develops and
> gets worse. **Chronic** leukemia gets worse **slowly**. **Acute**
> leukemia gets worse **quickly**.
>
> Leukemias are also grouped by the **type** of **white blood cell**
> that is affected. The groupings are: **lymphoid** leukemia and
> **myeloid** leukemia.

**Definitions**

> **Consolidation:** Repetitive cycles of chemotherapy given immediately
> after the remission.
>
> **Induction:** Initial intensive course of chemotherapy.
>
> **Maintenance:** Chemotherapy given for a period of months or years to
> maintain remission.
>
> **Remission**: The bone marrow is normocellular with less than 5%
> blasts, there are no signs or symptoms of the disease, no signs or
> symptoms of central nervous system leukemia or other extramedullary
> infiltration, and all of the following laboratory values are within
> normal limits: white blood cell count and differential,
> hematocrit/hemoglobin level, and platelet count.

**Treatment** for leukemia is divided into **three phases**:

1.  Remission induction (chemotherapy and/or biologic response
    modifiers)

2.  CNS prophylaxis or consolidation (irradiation to brain,
    chemotherapy)

3.  Remission continuation or maintenance (chemotherapy or bone marrow
    transplants).

**Coding First Course of Therapy for Leukemia and Hematopoietic
Diseases:**

1.  If a patient has a partial or complete **remission** during the
    first course of therapy:

    a.  Code all therapy that is "remission-inducing" as first course.

    b.  Code all therapy that is "consolidation" as first course.

    c.  Code all therapy that is "remission-maintaining" as first
        course.

> ***Note**:* Do not record treatment given after the patient relapses
> (is no longer in remission).
>
> **Surgery of Primary Site**

**Item Length: 2**

**NAACCR Item #: 1290**

**NAACCR Name: RX Summ\--Surg Prim Site**

Surgery of Primary Site describes a surgical procedure that removes
and/or destroys tissue of the primary site performed as part of the
initial work-up or first course of therapy. Site-specific surgery codes
are included under Appendix C of this manual.

**General Coding Structure** (See Appendix C for site-specific codes)

00 None; no surgical procedure of primary site; diagnosed at autopsy
only

10-19 Site-specific codes. Tumor destruction; no pathologic specimen or
unknown whether there is a pathologic specimen

20-80 Site-specific codes. Resection; pathologic specimen

90 Surgery, NOS. A surgical procedure to the primary site was done, but
no information on the type of surgical procedure is provided.

98 Special codes for hematopoietic, reticuloendothelial,
immunoproliferative, myeloproliferative diseases; ill-defined sites; and
unknown primaries (See site-specific codes for the sites and
histologies), except death certificate only

99 Unknown if surgery performed; death certificate only

**Coding Instructions**

1.  Code 00 if **no surgery** is performed on the primary site or if
    case was diagnosed at **autopsy, and would not be otherwise coded to
    98.**

2.  Use the site-specific coding scheme corresponding to the coded
    primary site.

3.  Code the most **invasive, extensive, or definitive** surgery if the
    patient has multiple surgical procedures of the primary site even if
    there is no tumor found in the pathologic specimen. The codes in the
    range of 00-80 are **listed** in hierarchical but not necessarily
    numerical order. When more than one surgical procedure is performed,
    code the procedure listed furthest down the list within the codes
    10-80.

> Example: Patient has a needle biopsy of prostate that is positive for
> adenocarcinoma. The patient chooses to have a radical prostatectomy.
> The pathologic examination of the prostatectomy specimen shows no
> residual tumor. Code the radical prostatectomy.

4.  Code an **excisional biopsy,** even when documented as
    **incisional**, when:

    a.  All disease is removed (**margins free**) OR

    b.  All gross disease is removed and there is only **microscopic
        residual at the margin**

> Note: Do not code an excisional biopsy when there is macroscopic
> residual disease.

5.  Code **total removal of the primary site** when a previous procedure
    resected a portion of the site and the current surgery removed the
    rest of the organ. The previous procedure may have been cancer
    directed or non-cancer directed surgery.

6.  Code the removal of regional or distant **tissue/organs** when they
    are resected in continuity with the primary site (**en bloc)**.
    Specimens from an en bloc resection may be submitted to pathology
    separately.

> Example: Code an en bloc removal when the patient has a hysterectomy
> and an omentectomy.

7.  Code surgery for extra-lymphatic lymphoma using the site-specific
    surgery coding scheme (not lymph node scheme) for the primary site.

8.  Code **80** or **90** only when there is no specific information.

9.  Code **98** for the following sites unless the case is death
    certificate only:

    a.  Hematopoietic, reticuloendothelial, immunoproliferative, or
        myeloproliferative disease

        i.  Primary sites: C420, C421, C423, or C424 (all histologies)

        ii. Histologies: 9750, 9760-9764, 9800-9820, 9826, 9831-9920,
            9931-9964, 9980-9989 (all sites)

        iii. Unknown or ill-defined sites (C760-C768, C809) (all
             histologies)

10. Assign **code 99** for death certificate only (DCO) cases

**Scope of Regional Lymph Node Surgery**

**Item Length: 1**

**NAACCR Item #: 1292**

**NAACCR Name: RX Summ\--Scope Reg LN Sur**

Scope of Regional Lymph Node Surgery describes the procedure of removal,
biopsy, or aspiration of **regional** lymph nodes performed during the
initial work-up or first course of therapy.

**Codes**

0 No regional lymph nodes removed or aspirated; diagnosed at autopsy.

1 Biopsy or aspiration of regional lymph node, NOS

2 Sentinel lymph node biopsy \[only\]

3 Number of regional lymph nodes removed unknown, not stated; regional
lymph nodes removed, NOS

4 1 to 3 regional lymph nodes removed

5 4 or more regional lymph nodes removed

6 Sentinel node biopsy and code 3, 4, or 5 at same time or timing not
noted

7 Sentinel node biopsy and code 3, 4, or 5 at different times

9 Unknown or not applicable; death certificate only

**Coding Instructions**

1.  Code 0 when regional lymph node removal procedure was not performed.

2.  Code regional lymph node procedures in this data item. Record
    distant lymph node removal in Surgical Procedure of Other Site.

3.  Codes 1-7 are **hierarchical**. Code the procedure that is
    numerically higher.

4.  The regional lymph node surgical procedure(s) may be done to
    **diagnose** cancer, **stage** the disease, or as a part of the
    initial **treatment**. Record all surgical procedures that remove,
    biopsy, or aspirate regional lymph node(s) whether or not there were
    any surgical procedures of the primary site.

> Example: Patient has a sentinel node biopsy of a single lymph node.
> Assign code 2 (Sentinel lymph node biopsy \[only\]).

5.  The Scope of Regional Lymph Node field is **cumulative**; add the
    number of all of the lymph nodes removed during each surgical
    procedure performed as part of the first course of treatment.

> Example: Patient has a positive cervical node biopsy. The pathology
> report from a subsequent node dissection identifies three cervical
> nodes. Assign code 5 (4 or more regional lymph nodes removed).

6.  If the operative report lists a lymph node dissection, but **no
    nodes were found by the pathologist,** code the Scope of Regional
    Lymph Node Surgery to 0 (No lymph nodes removed)

7.  If the patient has **two primaries with common regional lymph
    nodes**, code the removal of regional nodes for both primaries.

> Example: Patient has a cystoprostatectomy and pelvic lymph node
> dissection for bladder cancer. Pathology identifies prostate cancer as
> well as the bladder cancer and 4/21 nodes positive for metastatic
> adenocarcinoma. Code Scope of Regional Lymph Node Surgery to 5 (4 or
> more regional lymph nodes removed) for both primaries.

8.  Assign **code 9** for

    a.  Primary sites

        i.  Brain (C700-C709) OR

        ii. Spinal cord (C710-C719) OR

        iii. Cranial nerves and other parts of the central nervous
             system (C720-C729)

    b.  Lymphoma with primary site in lymph nodes (C770-C779) AND
        histology

        i.  9590-9596 OR

        ii. 9650-9719 OR

        iii. 9727-9729

    c.  Hematopoietic, reticuloendothelial, immunoproliferative, or
        myeloproliferative disease

        i.  Primary sites: C420, C421, C423, or C424 (all histologies)

        ii. Histologies: 9750, 9760-9764, 9800-9820, 9826, 9831-9920,
            9931-9964, 9980-9989 (all sites)

        iii. Unknown or ill-defined sites (C760-C768, C809) (all
             histologies)

**Definitions**

> **Types of immunotherapy**
>
> **Cancer Vaccines:** Cancer vaccines are still in the experimental
> phase and are not coded in this data item. They may be coded in the
> field Other Therapy. Currently clinical trials use cancer vaccines for
> brain, breast, colon, kidney, lung, melanoma and ovary.
>
> **Interferons:** Interferons belong to a group of proteins called
> cytokines. They are produced naturally by the white blood cells in the
> body. Interferon-alpha is able to slow tumor growth directly as well
> as activate the immune system. It is used for a number of cancers
> including multiple myeloma, chronic myelogenous leukemia (CML), hairy
> cell leukemia, and malignant melanoma.
>
> **Interleukins** (IL-2) are often used to treat kidney cancer and
> melanoma.
>
> **Monoclonal Antibodies:** Monoclonal antibodies (Mab) are produced in
> a laboratory. The artificial antibodies are used in a variety of ways
> in systemic therapy.  Some are injected into the patient to seek out
> and disrupt cancer cell activities, such as rituximab (Rituxan) for
> lymphoma and trastuzumab (Herceptin) for breast.  When the monoclonal
> antibody disrupts tumor growth, it is coded as chemotherapy.  Other
> Mabs are linked to radioisotopes (conjugated monoclonal antibodies). 
> The Mab finds and attaches to the target tumor cells and brings with
> it the radioisotope that actually kills the tumor cell.  The
> monoclonal antibody itself does nothing to enhance the immune
> system.  Conjugated monoclonal antibodies such as tositumomab (Bexxar)
> or ibritumomab (Zevalin) are coded to the part of the drug that
> actually kills the cells, usually radioisotopes.  A third function of
> Mabs is to enhance the immune response against the cancer, either by
> identifying tumor cells that are mimicking normal cells, or by
> boosting the body\'s natural defenses that destroy foreign cells.  At
> the present time (2006), there are no FDA-approved monoclonal
> antibodies that are pure immunotherapy for cancer.   Consult SEER\*Rx
> for the treatement category in which each monoclonal antibody should
> be coded.

**Coding Instructions**

1.  Assign **code 00**

    a.  When there is no information in the patient's medical record
        about immunotherapy AND

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i.  It is known that radiation is not usually performed for this type
    and/or stage of cancer OR

ii. There is no reason to suspect that the patient would have had
    immunotherapy.

    b.  If the treatment plan offered multiple treatment options and the
        patient selected treatment that did not include immunotherapy

    c.  Patient elects to pursue no treatment following the discussion
        of immunotherapy. Discussion does not equal a recommendation.

    d.  Only information available is that the patient was referred to
        an oncologist. Referral does not equal a recommendation.

    e.  Watchful waiting (prostate)

    f.  Patient diagnosed at autopsy

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2.  Assign **code 87**

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a.  If the patient refused recommended immunotherapy.

b.  If the patient made a blanket refusal of all recommended treatment.

c.  If the patient refused all treatment before any was recommended.

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3.  Assign **code 99**

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a.  When there is no documentation that immunotherapy was recommended or
    performed

b.  Death certificate only.

**Hematologic Transplant and Endocrine Procedures**

**Item Length: 2**

**NAACCR Item #: 3250**

**NAACCR Name: RX Summ\--Transplnt/Endocr**

This data item records systemic therapeutic procedure administered as
part of the first course of treatment. These procedures include bone
marrow transplants (BMT) and stem cell harvests with rescue (stem cell
transplant), endocrine surgery and/or radiation performed for hormonal
effect (when cancer originates at another site), as well as combination
of transplants and endocrine therapy.

**Codes**

00 None, transplant procedure or endocrine therapy was not a part of the
first course of therapy; not customary therapy for this cancer;
diagnosed at autopsy only.

10 Bone marrow transplant, NOS. A bone marrow transplant procedure was
administered as first course therapy, but the type was not specified.

> 11 Bone marrow transplant autologous
>
> 12 Bone marrow transplant allogeneic

20 Stem cell harvest (stem cell transplant) and infusion as first course
therapy.

30 Endocrine surgery and/or endocrine radiation therapy as first course
therapy.

40 Combination of transplant procedure with endocrine surgery and/or
endocrine radiation (Code 30 in combination with 10, 11, 12, or 20) as
first course therapy.

82 Transplant procedure and/or endocrine therapy was not
recommended/administered because it was contraindicated due to patient
risk factors (comorbid conditions, advanced age, etc.).

85 Transplant procedures and/or endocrine therapy were not administered
because the patient died prior to planned or recommended therapy.

86 Transplant procedures and/or endocrine therapy were not administered;
it was recommended by the patient's physician, but was not administered
as part of first course therapy. No reason was noted in the patient
record.

87 Transplant procedures and/or endocrine therapy were not administered;
this treatment was recommended by the patient's physician but was
refused by the patient, a patient's family member, or the patient's
guardian. The refusal was noted in the patient record.

88 Transplant procedures and/or endocrine therapy was recommended, but
it is unknown if it was administered.

99 It is unknown if a transplant procedure or endocrine therapy was
recommended or administered because it is not stated in patient record;
death certificate only cases.

**Definitions**

> **Bone marrow transplant (BMT):** Procedure used to restore stem cells
> that were destroyed by chemotherapy and/or radiation. Replacing the
> stem cells allows the patient to undergo higher doses of chemotherapy.
>
> **BMT Allogeneic:** Receives bone marrow or stem cells from a donor.
>
> **BMT Autologous:** Uses the patient's own bone marrow and/or stem
> cells. The tumor cells are filtered out and the purified blood and
> stem cells are returned to the patient.
>
> ***Note:*** Used for breast cancer, lymphoma, leukemia, aplastic
> anemia, myeloma, germ cell tumors, ovarian cancer, and small cell lung
> cancer.
>
> **Conditioning:** High-dose chemotherapy with or without radiation
> administered prior to transplants such as BMT and stem cell to kill
> cancer cells. This conditioning also destroys normal bone marrow cells
> so the normal cells need to be replaced (rescue). The high dose
> chemotherapy is coded in the Chemotherapy field.
>
> **Hematopoietic Growth Factors:** A group of substances that support
> hematopoietic (blood cell) colony formation. The group includes
> erythropoietin, interleukin-3, and colony-stimulating factors (CSFs).
> The growth-stimulating substances are ancillary drugs and not coded.
>
> **Non-Myeloablative Therapy:** Uses immunosuppressive drugs pre- and
> post-transplant to ablate the bone marrow. These are not recorded as
> therapeutic agents.
>
> **Peripheral Blood Stem Cell Transplantation (PBSCT):** Rescue that
> replaces stem cells after conditioning.
>
> **Rescue:** Rescue is the actual BMT or stem cell transplant done
> after conditioning.
>
> **Stem Cells:** Immature cells found in bone marrow, blood stream and
> umbilical cords. The stem cells mature into blood cells.

**Coding Instructions**

1.  Assign **code 00**

    a.  When there is no information in the patient's medical record
        about transplant procedure or endocrine therapy AND

        i.  It is known that transplant procedure or endocrine therapy
            is not usually performed for this type and/or stage of
            cancer OR

        ii. There is no reason to suspect that the patient would have
            had transplant procedure or endocrine therapy.

    b.  If the treatment plan offered multiple treatment options and the
        patient selected treatment that did not include transplant
        procedure or endocrine therapy

    c.  Patient elects to pursue no treatment following the discussion
        of transplant procedure or endocrine therapy. Discussion does
        not equal a recommendation.

    d.  Only information available is that the patient was referred to
        an oncologist. Referral does not equal a recommendation.

    e.  Watchful waiting (CLL)

    f.  Patient diagnosed at autopsy

> Note: Hyperbaric oxygen has been used to treat cancer in clinical
> trials, but it is also used to promote tissue healing following head
> and neck surgeries. Do not code the administration of hyperbaric
> oxygen to promote healing as an experimental treatment.

4.  Assign **code 3** when the patient is enrolled in a double blind
    clinical **trial**. When the trial is complete and the code is
    broken, review and recode the therapy.

5.  Assign **code 6** for **unconventional** methods whether they are
    the single therapy or given

> in combination with conventional therapy. Use **code 6** for
> **alternative** therapy ONLY if
>
> the patient receives no other type of treatment.

6.  Assign **code 8** When other therapy was recommended by the
    physician but there is no information that the treatment was given.

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7.  Assign **code 9**

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a.  When there is no documentation that other therapy was recommended or
    performed

b.  Death certificate only.

The following explanations and definitions are quoted from the website
for the National Center for Complimentary and Alternative Medicine
(NCCAM). Complementary and alternative medicine, as defined by NCCAM, is
a group of diverse medical and health care systems, practices, and
products that are not presently considered to be part of conventional
medicine. While some scientific evidence exists regarding some CAM
therapies, for most there are key questions that are yet to be answered
through well-designed scientific studies\--questions such as whether
they are safe and whether they work for the diseases or medical
conditions for which they are used.

-   **Complementary** medicine is used **together with** conventional
    medicine. An example of

> a complementary therapy is using aromatherapy to help lessen a
> patient\'s discomfort
>
> following surgery.

-   **Alternative** medicine is used **in place of** conventional
    medicine. An example of an alternative therapy is using a special
    diet to treat cancer instead of undergoing surgery, radiation, or
    chemotherapy that has been recommended by a conventional doctor.

> See complete information on types of complementary and alternative
> medicine at <http://nccam.nih.gov/health/whatiscam/>

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