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National Cancer Data Base - Data Dictionary PUF 2013

Surgery

Scope of Regional LN Surgery 2012

DD_category: 
PUF Data Item Name: 
RX_SUMM_SCOPE_REG_LN_2012
NAACCR Item #: 
1292
length: 
1
Allowable values: 
0, 1, 2, 3, 4, 5, 6, 7, 9

Beginning in 2016, the Participant Use File (PUF) will include the revised scope of the regional lymph node surgery field for cases diagnosed on and after January 1, 2012. Scope of Regional Lymph Node Surgery was found to under-report Sentinel Lymph Node Biopsy (SLNBx) procedures, either alone or with Axillary Dissection (ALND).

Surgery at This Facility

DD_category: 
PUF Data Item Name: 
RX_HOSP_SURG_PRIM_SITE
NAACCR Item #: 
670
length: 
2
Allowable values: 
00, 10-80, 90, 98, 99
Description: 
This item records the surgical procedure performed to the primary site at the facility that submitted this record.
Registry Coding Instructions: 

·      Site-specific codes for this data item are found in Surgery of the Primary Site Codes.
·      If registry software allows only one procedure to be collected, document the most invasive surgical procedure for the primary site.
·      If registry software allows multiple procedures to be recorded, this item refers to the most invasive surgical procedure of the primary site.
·      For codes 00 through 79, the response positions are hierarchical by position (not necessarily numerically). Last-listed responses take precedence over responses written above. Code 98 takes precedence over code 00. Use codes 80 and 90 only if more precise information about the surgery is not available.
·      Biopsies that remove all of the tumor and/or leave only microscopic margins are to be coded in this item.
·      Surgery to remove regional tissue or organs is coded in this item only if the tissue/organs are removed in continuity with the primary site, except where noted in the site-specific Surgery of the Primary Site Codes.
·      If a previous surgical procedure to remove a portion of the primary site is followed by surgery to remove the remainder of the primary site, then code the total or final results.

NCDB System Code Assignments: 

Code

Label

Definition

00

None

No surgical procedure of primary site. Diagnosed at autopsy.

10-19

Site-specific codes; tumor destruction

Tumor destruction, no pathologic specimen produced. Refer to Surgery of the Primary Site Codes for the correct site-specific code for the procedure.

20-80

Site-specific codes; resection

Refer to Surgery of the Primary Site Codes for the correct site-specific code for the procedure.

90

Surgery, NOS

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

98

Site-specific codes; special

Special code. Refer to Surgery of the Primary Site Codes for the correct site-specific code for the procedure.

99

Unknown

Patient record does not state whether a surgical procedure of the primary site was performed and no information is available. Death certificate only.

 

Analytic Note: 

This item is available only for diagnosis years 2003 and later.   
 
CoC cancer programs are required to identify treatment their patients received from all sources.  Surgical treatment may have occurred at any facility, or at multiple facilities, not limited to the one whose report is included in this file.  This refers to the final surgery of the primary site, cumulative for all procedures, for the cancer by the reporting facility. Additional surgery, or prior surgery, may have been performed elsewhere.  The item RX_SUMM_SURG_PRIM_SITE describes the cumulative primary site surgery performed on the patient at any facility.
 

Surgical Approach

DD_category: 
PUF Data Item Name: 
RX_HOSP_SURG_APPR_2010
NAACCR Item #: 
668
length: 
1
Allowable values: 
0 - 5, 9
Description: 
This item is used to monitor patterns and trends in the adoption and utilization of minimally-invasive surgical techniques.
Registry Coding Instructions: 

This item may be left blank for cases diagnosed prior to 2010.
If the patient has multiple surgeries of the primary site, this item describes the approach used for the most invasive, definitive surgery.
For ablation of skin tumors, assign code 3.
Assign code 2 or 4 if the surgery began as robotic assisted or endoscopic and was converted to open.
If both robotic and endoscopic or laparoscopic surgery are used, code to robotic (codes 1 or 2).

NCDB System Code Assignments: 

0 = No surgical procedure of primary site at this facility.
1 = Robotic assisted.
2 = Robotic converted to open.
3 = Endoscopic or laparoscopic.
4 = Endoscopic or laparoscopic converted to open.
5 = Open or approach unspecified.
9 = Unknown whether surgery was performed at this facility.

Analytic Note: 

This item was first used for 2010 diagnoses.

First Surgical Procedure, Days from Dx

DD_category: 
PUF Data Item Name: 
DX_SURG_STARTED_DAYS
length: 
4
Allowable values: 
0 - 9999
Description: 
The number of days between the date of diagnosis (NAACCR Item #390) and the date the first treatment surgery was performed (NAACCR Item #1200). The surgery may be primary site surgery (NAACCR Item #1290), regional lymph node surgery (NAACCR Item #1292) or other regional or distant surgery (NAACCR Item #1294). Incisional biopsies are not coded as treatment surgery.
Registry Coding Instructions: 

None.

Analytic Note: 

CoC cancer programs are required to identify treatment their patients received from all sources.  Surgical treatment may have occurred at any facility, or at multiple facilities, not limited to the one whose report is included in this file.  This refers to the first surgical procedure for the cancer by any facility. 

Code

Reason for No Surgery

DD_category: 
PUF Data Item Name: 
REASON_FOR_NO_SURGERY
NAACCR Item #: 
1340
length: 
1
Allowable values: 
0-2, 5-9
Description: 
Records the reason that no surgery was performed on the primary site.
Registry Coding Instructions: 

·If Surgical Procedure of Primary Site (NAACCR Item #1290) is coded 00, then record the reason based on documentation in the patient record.

·Code 1 if the treatment plan offered multiple options and the patient selected treatment that did not include surgery of the primary site, or if the option of "no treatment" was accepted by the patient.

·Code 1 if Surgical Procedure of Primary Site (NAACCR Item #1290) is coded 98.

·Code 7 if the patient refused recommended surgical treatment, made a blanket refusal of all recommended treatment, or refused all treatment before any was recommended.

·Cases coded 8 should be followed and updated to a more definitive code as appropriate.

·Code 9 if the treatment plan offered multiple choices, but it is unknown which treatment, if any was provided.

Analytic Note: 

This item is reported using the FORDS manual for diagnosis years 2003 and later. 
 

Code

Readmission Within 30 Days of Surgical Discharge

DD_category: 
PUF Data Item Name: 
READM_HOSP_30_DAYS
NAACCR Item #: 
3190
length: 
1
Allowable values: 
0-3, 9
Description: 
Records a readmission to the same hospital, for the same illness, within 30 days of discharge following hospitalization for surgical resection of the primary site.
Registry Coding Instructions: 

·         Consult patient record or information from the billing department to determine if a readmission to the same hospital occurred within 30 days of the date recorded in the item Date of Surgical Discharge (NAACCR Item #3180).
·         Only record a readmission related to the treatment of this cancer.
·         Review the treatment plan to determine whether the readmission was planned.
·         If there was an unplanned admission following surgical discharge, check for an ICD-9-CM "E" code and record it, space allowing, as an additional ICD-9-CM Comorbidities and Complications item (NAACCR #3110, 3120, 3130, 3140, 3150, 3160, 3161, 3162, 3163, 3164).
 

Analytic Note: 

This item is only reported using the FORDS manual for diagnosis years 2003 and later. 
 

Code

Surgical Inpatient Stay, Days from Surgery

DD_category: 
PUF Data Item Name: 
SURG_DISCHARGE_DAYS
length: 
4
Allowable values: 
0 – 9999
Description: 
The number of days between the date the most definitive surgical procedure was performed on the primary site (NAACCR Item #3170) and the date the patient was discharged following primary site surgery (NAACCR Item #3180).
Registry Coding Instructions: 

None.

Analytic Note: 

Both the Date of Most Definitive Surgery of the Primary Site and the Date of Surgical Discharge were added to FORDS in 2003, so this item is not defined before that.

Code

Surgery Other Site

DD_category: 
PUF Data Item Name: 
RX_SUMM_SURG_OTH_REGDIS
NAACCR Item #: 
1294
length: 
1
Allowable values: 
0-5, 9
Description: 
Records the surgical removal of distant lymph nodes or other tissue(s)/organ(s) beyond the primary site.
Registry Coding Instructions: 

·Assign the highest numbered code that describes the surgical resection of distant lymph node(s) and/or regional/distant tissue or organs.

·Incidental removal of tissue or organs is not recorded as a Surgical Procedure/Other Site.

·Code 1 if any surgery is performed to treat tumors of unknown or ill-defined primary sites (C76.0-C76.8, C80.9) or for hematopoietic, reticuloendothelial, immunoproliferative, or myeloproliferative disease (C42.0, C42.1, C42.3, C42.4 or any site with hematopoietic histologies).

·If the procedure coded in this item was provided to prolong a patient’s life by controlling symptoms, to alleviate pain, or to make the patient more comfortable, then also record this surgery in the item Palliative Care (NAACCR Item #3270).

 

Analytic Note: 

This item was reported as a site-specific item using the ROADS manual for diagnosis years 1998 - 2002.  It has been converted to FORDS form by NCDB.  For cases diagnosed on or after January 1, 2003, the surgery of other regional or distant sites, or distant lymph nodes was reported using the FORDS manual; it is no longer specific to the organ of origin.

Code

Scope of Regional LN Surgery

DD_category: 
PUF Data Item Name: 
RX_SUMM_SCOPE_REG_LN_SUR
NAACCR Item #: 
1292
length: 
1
Allowable values: 
0-1, 9
Description: 
Identifies the removal, biopsy, or aspiration of regional lymph node(s) at the time of surgery of the primary site or during a separate surgical event.
Registry Coding Instructions: 

The scope of regional lymph node surgery is collected for each surgical event even if surgery of the primary site was not performed.

Record surgical procedures which aspirate, biopsy, or remove regional lymph nodes in an effort to diagnose or stage disease in this data item. Record the date of this surgical procedure in data item Date of First Course of Treatment (NAACCR Item #1270) and/or Date of First Surgical Procedure (NAACCR Item #1200) as appropriate.

For primaries of the meninges, brain, spinal cord, cranial nerves, and other parts of the central nervous system (C70.0-C70.9, C71.0-C71.9, C72.0-C72.9), code 9.

For lymphomas with a lymph node primary site (C77.0-C77.9), code 9.

For an unknown or ill-defined primary (C76.0-C76.8, C80.9) or for hematopoietic, reticuloendothelial, immunoproliferative, or myeloproliferative disease regardless of site, code 9.

Do not code distant lymph nodes removed during surgery to the primary site for this data item. Distant nodes are coded in the data field Surgical Procedure/Other Site (NAACCR Item #1294).

Refer to the applicable AJCC Cancer Staging Manual for site-specific identification of regional lymph nodes.

If the procedure coded in this item was provided to prolong a patient’s life by controlling symptoms, to alleviate pain, or to make the patient more comfortable, then also record this surgery in the item Palliative Care (NAACCR Item #3270).

 

NCDB System Code Assignments: 

0 = No regional lymph node surgery
1 = Regional lymph node surgery
9 = Unknown if there was any regional lymph node surgery

Analytic Note: 

This item was reported as a site-specific item under the ROADS manual for diagnosis years 1998 - 2002. Those cases were converted to FORDS form by NCDB.  For cases diagnosed on or after January 1, 2003, the scope of regional lymph node surgery is no longer specific to the organ of origin.
 
Sentinel Lymph Nodes:  Data on Scope of Regional Lymph Node Surgery have been found to under-report Sentinel Lymph Node Biopsy (SLNBx) procedures either alone or with Axillary Dissection (ALND). Reviews by the Commission on Cancer (CoC), the Centers for Disease Control and Prevention's National Program of Cancer Registries (CDC/NPCR), and the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) Program (NCI SEER) all confirmed mis-coding of this data element. Revised coding rules and associated instructions were developed that put emphasis on securing information from the operative report in contrast to the pathology report. These revised coding instructions were implemented for cases diagnosed January 1, 2012 and later. All population based and facility based cancer registry programs are coordinating implementation through shared materials, communications, training, and quality assessments. Therefore, CoC use of the item “Scope of Regional Lymph Node Surgery” is curtailed in all data years prior to 2012 contained in the PUF. The item is used only to identify whether or not a patient underwent regional lymph node surgery, effectively removing any distinction between the type or extent of surgical intervention. For all sites, codes for this item are limited to 0, 1 and 9.

Starting with the 2013 PUF, an expanded version of this variable is available for cases diagnosed in 2012 to the most recent diagnosis year in the PUF. This item, Scope of Regional LN Surgery 2012, can be found here: http://ncdbpuf.facs.org/node/417.

Surgical Margins

DD_category: 
PUF Data Item Name: 
RX_SUMM_SURGICAL_MARGINS
NAACCR Item #: 
1320
length: 
1
Allowable values: 
0-3, 7-9
Description: 
Records the final status of the surgical margins after resection of the primary tumor.
Registry Coding Instructions: 

·Record the margin status as it appears in the pathology report.

·Codes 0-3 are hierarchical; if two codes describe the margin status, use the numerically higher code.

·If no surgery of the primary site was performed, code 8.

·For lymphomas with a lymph node primary site (C77.0-C77.9), code 9.

·For an unknown or ill-defined primary (C76.0-C76.8, C80.9) or for hematopoietic, reticuloendothelial, immunoproliferative, or myeloproliferative disease, code 9.

·For Brain and CNS sites, the NCDB converts codes 0, 1, 2, 3, and 7 to code 9 for this item due to unreliability.

Code

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