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SEER Inquiry System - Report
Produced: 07/27/2024 7:59 AM
Question 20240045
Inquiry Details
References:
2024 SEER Manual, 18-21. Reportability
Question:
Reportability/Ambiguous Terminology--Prostate: Should cases be reported and abstracted based on ambiguous terminology, e.g., suspicious for prostate cancer, when the physician is not treating the case as malignant? See Discussion.
Discussion:
Please comment on these specific scenarios.
- A prostate biopsy is suspicious for adenocarcinoma, but the urologist is not considering this malignant, nor is the urologist treating for malignancy, but there is no clear statement from the physician that this is not reportable. Should this case be abstracted?
- A prostate biopsy is suspicious for adenocarcinoma, and there is a statement by the physician that this is not yet malignant. Should this case be abstracted?
- Prostate MRI with PIRADS 4 or 5; however, the treating urologist does not call this malignant and is not treating patient for prostate cancer. [Example: 2024 Prostate MRI - PI-RADS 4. Follow up with Urologist states patient to repeat Prostate MRI in 1 year and continue with yearly PSA levels and there is no mention of prostate cancer other than the PI-RADS score]. Should this case be abstracted?
Answer:
For each of your scenarios, the medical record information indicates that the case is not reportable based on physician opinion. Do not abstract these cases.
Remember that the ambiguous terms list is to be used as a last resort. The ideal way to approach abstracting situations when the medical record is not clear is to follow up with the physician. If the physician is not available, the medical record, and any other pertinent reports (e.g., pathology, etc.) should be read closely for the required information. See page 19 in the SEER Manual, https://seer.cancer.gov/manuals/2024/SPCSM_2024_MainDoc.pdf
