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SEER Inquiry System - Report
Produced: 09/06/2025 3:49 PM
Question 20220004
Inquiry Details
References:
2022 SEER Manual, 158-161. First Course of Therapy
Question:
First Course Treatment/Cancer-directed Treatment: What information can registrars use to determine disease progression and whether treatment counts as first course treatment? See Discussion.
Discussion:
Is a physician’s statement of progressive disease adequate to determine disease progression in coding first vs. second course treatment? Can an increase in tumor burden (i.e., a change in overall stage) be used by the registrar to determine disease progression?
Often, determining disease progression is difficult as there are no guidelines in the SEER Manual related to this topic. It seems a physician’s statement of progressive disease should always be accepted. However, that statement is not always available. While it seems an increase in tumor size alone would not be “progressive disease” as tumors will continue to grow, can registrars use an increase in tumor burden to make this determination?
The instructions for coding first vs. second course treatment are clear when a treatment plan is changed, but determining whether there has been disease progression, recurrence, or treatment failure can be difficult without a physician’s assessment.
For example, a patient was diagnosed with a newly diagnosed resectable pancreatic cancer; the documented treatment plan was for upfront chemotherapy, followed by repeat staging, followed by pancreatectomy. The patient completed 3 cycles of FOLFIRINOX, but the physician noted that the CT scan shows progressive disease, and the plan was to start a new treatment regimen with Abraxane, Gemzar, and stereotactic body radiation (SBRT) (Cyberknife). The patient completed the additional chemotherapy, radiation, and proceeded to the initially planned surgery. The pathologist staged this as yp disease, but the surgery appears to be second course treatment, and we would not code the surgery, or collect the staging (yp staging) since the physician stated this was progressive disease. The classification as yp staging can be misleading, since the resection is technically after neoadjuvant treatment, but is not collected per our guidelines. In this case, is it correct to code first course treatment as FOLFIRINOX only?
Answer:
Determining first course treatment is based on knowing the treatment plan and its course as to whether it was completed as initially planned. Read the medical record, scans, labs, and physician notes. First course of therapy ends when the treatment plan is completed as planned. Alternatively, first course of therapy ends when there is documented disease progression, recurrence, or treatment failure. A change to a drug in a different group or a change to a different treatment modality indicates the end of the first course of treatment. While a physician/clinician statement of progression, additional imaging, or other procedures that assess treatment efficacy, or increase in tumor burden can be used to denote progression, recurrence, or failure, a change to the initial treatment plan is a signal to to the registrar to suspect the end of first course of therapy. Once the initial treatment plan is changed, everything after the change is subsequent treatment.
In the scenario provided, code FOLFIRINOX as first course of treatment. Based on the information provided, the Abraxane, Gemzar, and SBRT are second course and everything that followed that is second or subsequent course. The physician noted progressive disease and a new treatment regimen was started -- this is a clear indication of the end of the first course of treatment. The planned treatment course was FOLFINOX and surgery. Once that initial treatment plan is changed, everything after the change is no longer first course of treatment. Use text fields to document the details.
