Q&A Session for Collecting Cancer Data: Prostate

Q&A Session for Collecting Cancer Data: Prostate

Thursday, May 05, 2011

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Q: AJCC 7th Edition chapter on prostate shows a different interpretation of Gleason Score for grade, i.e., Gleason 6 is shown as well differentiated. Which way should grade be coded?

A: The grade data item (NAACCR item # 440) should be coded using instructions from FORDS or the SEER Program Coding and Staging Manual, not the AJCC Cancer Staging Manual.

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Q: What do we use if the Gleason score for one core is 3+4 and the next is 4 +3?

A: Per instructions for coding CS SSF7 (Gleason’s Primary Pattern and Secondary Pattern Values on Needle Core Biopsy/TURP of Prostate) documented in the notes that precede the codes, assign code 043 based on Gleason 4 + 3 in the situation described.

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Q: Physician does a DRE and palpates one lobe and feels a firm nodule. Physician proceeds to take biopsy which shows that left and right lobes are positive for cancer. When you code extension, then the clinical stage is based on DRE not on the biopsy.

A: Yes. Note 3C in CS v02.03 preceding the CS Extension – Clinical Extension codes for prostate documents: “Codes 200 to 240 are used only for clinically/radiographically apparent tumor/nodule/mass which is palpable or visible by imaging. To decide among codes 200-240, use only physical exam or imaging information, and not biopsy information.” This is documented in Note 2C in CS v02.02 for prostate.

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Q: If we have a patient just being treated with hormonal therapy would you consider this disease free?

A: Responses to this question from webinar participants follow:

Participant1 response: According to radiation oncologist, PSA levels at virtually undetectable levels indicate that the patient is disease free.

Participant2 response:Hormone therapy is controlling the growth. It is not a cure. Therefore, there is still evidence of disease.

Participant3 response:If you can't measure the disease, the patient is NED (no evidence of disease). If PSA is 0 and there is no radiographic evidence of cancer, consider the person NED.

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Q: If brachytherapy is given first followed by external beam, would you code the brachytherapy as the boost even though it was given first?

A: Brachytherapy would be considered the boost. See the I&R below.

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Q: What if the patient had brachytherapy only? Do you still code that as a boost?

A: No. It would be coded as regional treatment modality.

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Q: If the code for multiplicity counter is 99, is the date of multiple tumors the date of the biopsy or unknown date?

A: In that situation, the date of multiple tumors should be the date of diagnosis. See page 341c of Multiple Primary and Histology Coding Rules (revised 11/5/2010).

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Q: Why was the EVAL code for prostatectomy assigned a "4" (instead of "3") which means autopsy in the standard table?

A: The codes for CS Tumor Size/Ext Eval are different from the codes in this data item for most other sites. For prostate, CS Tumor Size/Ext Eval is used to evaluate the coding of tumor size and extension as coded in both CS Extension - Clinical Extension AND Site-Specific Factor 3, Pathologic Extension.If prostatectomy is performed for prostate cancer and there was not neoadjuvant systemic or radiation treatment, assign code 4 for CS TS/Ext Eval.

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Q: What is a saturation biopsy? How does it differ from a TRUS biopsy?

A: Transperineal template guided saturation biopsy (TTSB) is a stereotactic prostate biopsy technique that typically produces 30-80 biopsies. It is used for some high risk patients including men with persistently elevated PSAs or atypia on prior biopsies or men with biopsies showing PIN.

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Q: There aresome discrepancies on whether or not to code thermal ablation of the prostate as cancer treatment. There is a code in FORDS; however, thermal ablation is usually only a treatment done for BPH. Are we supposed to record this as treatment or not?

A: Are you referring to a specific type of thermal ablation (laser, microwave, etc.)? From what I could find, there are different types of thermal treatment. SEER has specific instructions for some types such as microwave therapy. If the thermal ablation was used to treat the cancer, it should be coded. If it was performed solely for treatment of BPH, it should not be coded as cancer treatment.

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Q: If a nodule is palpated followed by positive biopsies in multiple locations of the prostate, how should multiplicity counter be coded?

A: I don't feel that a palpable nodule is enough to say there is only one tumor. I would assign code 99 to multiplicity counter.

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Q: When the operative report documents 34 biopsies taken but the path report documents 6 biopsies, how many biopsies are recorded in the SSF field?

A: Code the number of cores examined as documented in the pathology report in SSF13 for prostate as documented in Note 1 preceding the codes for SSF13 (Number of Cores Examined).

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Q: DRE: no nodules palpated. Ultrasound identifies a "lesion" in the prostate. Is the word lesion allowed to consider this clinically apparent?

A: Lesion is not one of the terms in the notes. Hopefully, the physician assigns a T value! If not, consider asking for clarification from the physician on whether or not it is a clinically apparent lesion.

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Q: If the biopsyinvolvement is more extensive than the DRE, why would you not code the biopsy as the site EVAL? You stated earlier that you would use the most extensive code for deriving stage?

A: The CS Extension – Clinical Extension code for prostate is based on what was found on DRE or TRUS, not on what was found on biopsy. Code 0 would be appropriate.

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Q: Please tell us where it is documented that the terms mass, tumor, and nodule may be used to infer that a prostate tumor is clinically apparent.

A: It is documented in the notes preceding the codes for CS Extension – Clinical Extension. Note 3A in CS v02.03 states: “A clinically inapparent tumor is one that is neither palpable nor reliably visible by imaging. A clinically apparent tumor is palpable or visible by imaging. If a clinician documents a "tumor", "mass", or "nodule", this can be inferred as apparent.”Note 2A in CS v02.02 states: “A clinically inapparent tumor is one that is neither palpable nor reliably visible by imaging. A clinically apparent tumor/nodule/mass is palpable or visible by imaging.”

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Q: Those words (tumor, mass, nodule) are specific to a DRE.Are we also to use the words tumor and nodule for imaging?

A: Yes. See notes preceding CS Extension – Clinical Extension referenced in the question and answer above.

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Q: If there is a nodule palpated on DRE, but prostate biopsy identifies extra prostatic extension, what is the correct extension code and CS Tumor Size/Ext Eval code?

A: I’m not sure. A similar question was asked on the CAnswer Forum and referred to the CS mapping team. It has not yet been answered.

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Q: If the number of core biopsies documented on ultrasound report is different than what is documented on the path report, which do you record?

A: Note 1 preceding the codes for SSF13 (Number of Cores Examined) states to record the number of prostate core biopsies examined for cancer documented in the pathology report.

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Q: In your example of two Gleason scores, 3 + 4 and 4 + 3, you say code highest primary and highest secondary, which would be 044, but you said 043. Was that an error?

A: No, it was not an error. In that situation the correct code would be 043. The following instructions are found in Note 3 preceding the codes for SSF7 in CS v02.03: “If different patterns equal the same high score, give priority to the highest primary pattern and then the highest secondary pattern. For example, both Gleason's 3, 4 and Gleason's 4, 3 equal Gleason's score 7; code 043. Do not mix patterns from multiple specimens.”

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Q: When a pathology lab reads the tissue and issues a report and then patient goes to a treatment facility and that facility sends out the slides for review and their review gives a different pattern or score, which does report has precedence?

A: That’s tricky, and I can’t find a rule for it. I would code the patterns and score from the report that is being used as the basis for the treatment plan.

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Q: If a patient has T2NOS N0M0 disease, what is the group stage? AJCC 6th Edition has a group stage for this, but 7th Edition does not.

A: In AJCC 7th Edition, you need PSA value and Gleason score along with T, N, and M values to determine stage group.

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Q: Is a clinician’s statement of "induration" or "firmness" found on DRE considered clinically apparent?

A: No. Only the terms tumor, mass, or nodule can be inferred as clinically apparent.

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Q: If the DRE is negative and the PSA is NOT elevated (<4), would you still code to CS Ext 150?

A: Yes. PSA is just given as an example of why the physician suspected prostate cancer. It does not have anything to do with the actual code.

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Q: What CS tumor Size/Ext Eval code should we assign for CS Extension code 300 without prostatectomy?

A: The code for CS Tumor Size/Ext Eval would be based on how the 300 code was derived. If it was based on needle biopsy, code a 1. If based on physician statement, assign code 0. 0 and 1 will both derive a clinical stage.

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Q: If a patient gets 3-4 months of hormonal therapy prior to radical prostatectomy to downsize prostate tumor prior to surgery, is this considered neoadjuvant treatment?

A: Yes. It would be considered neoadjuvant treatment. However, make sure the drug given to shrink the prostate is a hormone and not one of the drugs used for BPH.

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Q: What is the CS Extension – Clinical Extension for a case where the DRE is stated to be abnormal and PSA is elevated?

A: There is not enough information here to assign a specific code. However, the description of abnormal DRE cannot be used to infer that the tumor is clinically apparent.

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Q: If there is a physician statement of increased PSA for biopsy, can we code SSF 2 (PSA Interpretation) as 010 (elevated)?

A: No. Increased PSA level may not be abnormal. It may be a cause for concern and a reason to biopsy but not necessarily an elevated level.

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Q: Explain what a tertiary pattern measures?

A: Gleason primary pattern measures the most common pattern;secondary pattern the second most common pattern. If the pathologist sees another area with a different pattern, he/she would include it in the path report as tertiary pattern. Tertiary pattern is only documentedfor prostatectomy, not for core bioipsies. A physician would be concerned if the Gleason score was say a 3+3=6, but the pathologist identified an area of tumor that showed a pattern of 5. This would indicate an area of aggressive tumor, and the patient may be treated differently based on this information.

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Q: Just to clarify, for SSF2, if there is no clinician interpretation but a lab range is given, we CAN take the lab range? This seems to go against the purpose of the SSF and could be affected by race, age etc.

Priority:

A: Per a CAnswer Forum response, you can use the lab's interpretation of elevated. The question and answer from the CAnswer Forum follow:

Question: In the CS Manual Part I Section 2, p. 93, it states for PSA Interpretation: "Interpretation of the PSA value is a clinical judgment on the part of the physician. If there is no interpretation of the PSA value in the record, use code 999. Do not infer a code for this field based on the normal values listed for the PSA Value." This seems to be a change from CSv1. Is there a concern on the part of the CS Mapping Team that there will be an increase of code 999 (unknown)" in this SSF field for CSv2?

Response: By the new CS coding manual, registrars are allowed to interpret PSA value based on normal range listed in the lab report.Please see VERSION 02.03.02, Part 1, p80 ( "....In the absence of a physician's interpretation of the test, if the reference range for the lab is listed on the test report, the registrar may use that information to assign the appropriate code....".This new rule is different from that in previous version (v02.02).

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Q: Case 3 CS Lymph Nodes. Would you code as 999 as page 44, Part I, Section 1 states can use Inaccessible Lymph Nodes Rule if clinically low stage. Metastatic disease is not a low stage.

A: To me the scans done that identified the bone metastasis would suffice to say no lymph nodemetastasis.

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