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SEER Inquiry System - Report
Produced: 11/22/2024 7:13 AM
Question 20091123
Inquiry Details
References:
2007 SEER Manual, 3
Question:
Reportability: Is a tumor reportable if the pathology report indicates a non-reportable diagnosis at the time the specimen is removed but subsequent clinical statements state the patient had a reportable tumor? See Discussion.
Discussion:
The 2007 SEER Manual (page 3) states that cases diagnosed clinically are reportable. Exception 2 states if enough time has passed that it is reasonable to assume the physician has seen the negative pathology report, but the clinician continues to call this a reportable disease, accession the case.
SEER reporting guidelines state that severe dysplasia is not reportable, however, many clinicians regard it to be equivalent to carcinoma in situ.
Example 1: In 09-2007 the pathology report for excisional biopsy of right floor of mouth states the final diagnosis is severe dysplasia. At the time, the case is not accessioned based on non-reportable pathology. Patient is subsequently admitted in 3-09. According to the clinical history the patient was diagnosed with squamous cell carcinoma in 2007 and treated with laser. Is this reportable? If yes, how is behavior to be coded? How is "Ambiguous Terminology at Diagnosis" to be coded?
Example 2: In 2-08, the pathology report for a punch biopsy of a skin lesion states the final diagnosis is atypical melanocytic hyperplasia. In 3-08, patient is admitted for re-excision. The clinical diagnosis states re-excision being done for melanoma in situ.
Reference: SINQ 20061123
Answer:
A tumor that is non-reportable based on the pathology report diagnosis should not be accessioned if later clinician statements mistakenly refer to it as a reportable tumor. The exception in the 2007 SEER manual on page 3 is intended to allow the registrar to accession a case when the clinician actually disagrees with the pathology report and clinically diagnoses a reportable tumor.
