In a previous blog post, I shared some tips for getting started with the STORE manual (STandards for Oncology Registry Entry). This post will focus on the data collection changes that are part of STORE. As we know, some of the changes were expected; others have taken some cancer registrars by surprise. For a complete listing of updates, review Appendix A: STORE Updates for 2018.
Changes We Expected
- Comorbidities and Complications fields replaced by Secondary Diagnoses
Comorbidities and Complications were collected in ICD-9, which is no longer used, so Secondary Diagnoses are now captured in ICD-10. You can find the information in the same place in the electronic health record (EHR) and will still only collect 10. Because Secondary Diagnoses have been in place since 2013 with additions made in 2015, this isn’t really new and does not represent additional work, but it’s worth noting.
- Summary Stage Changes
Summary Stage 2018 uses the same concepts as Summary Stage 2000 with some changes and updates, but we’ve known about them since the draft was released in January 2018. The final manual was released in April 2018.
- TNM Stage Criteria in AJCC 8th Edition went into effect on January 1, 2018
The initial American Joint Committee on Cancer (AJCC) Eighth Edition of the Cancer Staging Manual, was published in October 2016; however, activation was delayed until January 1, 2018. According to the AJCC, “The delay of implementation to January 1, 2018 has given AJCC an opportunity to work with the surveillance community, the pathology community, and clinical decision support software developers … [and to] make improvements and clarifications that will help all audiences.” Get tips for using the AJCC eBook in my previous post.
- Grade of Disease coding has undergone major revisions
Grade of Disease coding has undergone major revisions and is now closely aligned with AJCC Stage. Most information for this field is found on the SEER website or in the NAACCR training page. This field is only difficult if you have to complete it manually because you have to select the correct grade schema ID. However, once your NAACCR V2018-compliant cancer registry database software is implemented, your software will preselect the grade schema ID for you and populate your drop down with only the appropriate choices. Therefore, the complexity of this field is only temporary, and it will be much easier once you can rely on your registry software.
- Site Specific Disease Items (SSDI) closely incorporated to AJCC Stage
Some SSDI’s are required for stage assignments. Others are not required for stage assignment BUT are still required fields. Your software will automatically load the correct fields for completion based on site and/or histology, as well as other factors. Many of the SSDI’s were already being reported as Site Specific Factors (SSF) and the information will be found in the same place in the EHR. They will just be recorded in a different place in your software and perhaps in a different format. There have been some new SSDI’s introduced that were not SSF.
- Solid Tumor Rules (STR) have been incorporated for a subset of site/histology combinations
For all diseases not included in the STR’s, registrars will continue to use Multiple Primary and Histology database (MPH). It is imperative that registrars use the correct criteria so become familiar with which cancers are coded using the STR and which use the MPH. The Hematopoietic and Lymphoid Neoplasm Database (Heme DB) is still in use for the appropriate diseases.
- Radiation Therapy data collection has undergone a dramatic change with only the date fields and the Radiation/Surgery Sequence field remaining unchanged.
I will admit, the new radiation therapy coding standards are scary, but registrars helped to write these standards, so we can handle them! Radiation Therapy data collection has undergone a dramatic change with only the date fields and the Radiation/Surgery Sequence field remaining unchanged. I recommend you take some time to become familiar with these new coding standards and if you need to gain a clearer understanding of radiation therapy, reach out to a knowledgeable radiation therapy practitioner, dosimetrist or radiation oncologist for guidance. Invest your time in educating yourself to provide the most accurate coding available in these challenging new fields.
Changes We Weren’t Expecting
- More precise coding of Lymphovascular Invasion
Lymphovascular Invasion has traditionally been a data collection field. This field is now being coded in a much more precise method using Schema ID’s. Although a very arduous process if done manually, your cancer registry database should automatically point you to the correct Schema ID. This is attached to AJCC Stage.
- Sentinel Lymph Node information being reported for Breast and Cutaneous Melanoma cases
Sentinel Lymph Node information is now being reported for Breast and Cutaneous Melanoma cases diagnosed January 1, 2018 and thereafter. These include Date of Sentinel Lymph Node Biopsy, Date of Sentinel Lymph Node Biopsy Flag, Sentinel Lymph Nodes Examined, and Sentinel Lymph Nodes Positive. This information is also tied to AJCC Staging for these 2 disease processes.
- Mets at Diagnosis – Other
Mets at Diagnosis – Other will be used to capture metastasis that is not collected in the Mets at Diagnosis – Bone, Mets at Diagnosis – Brain, Mets at Diagnosis – Liver, Mets at Diagnosis – Lung, and Mets at Diagnosis – Distant Lymph Nodes, as well as Carcinomatosis. This is also tied to AJCC Stage.
- Type of First Recurrence is marked as revised
The Type of First Recurrence is marked as revised. The revision is a minor change in the instructions for Coding to reference both the MPH and STR as applicable.
- Outcomes fields are required
Date of Last Cancer (tumor) Status and Date of Last Cancer (tumor) Status Flag fields are new and required. These new fields, along with the updated Cancer Status field will bring a higher level of detail to outcomes information. This will make NCDB data more relevant for clinicians as well as researchers.
- Extent of Disease (EOD) Stage
Extent of Disease Stage is a requirement only for Surveillance, Epidemiology, and End Results (SEER) registry areas. More information can be found at the SEER website.
- Case Administration Section
There are a couple of fields in the Case Administration section worth reviewing – Date Case Completed COD and RQRS NCDB Submission Flag. These will most likely be automated fields within your cancer registry database software.
This certainly doesn’t cover all the changes in the STORE manual, but this is a good start and should help you as you begin to apply the new standards. As Dr. Frederick Green, MD FACS says in his Foreword, STORE is the culmination of “a concerted effort to update and ensure [standards that] would have greater relevance to current oncologic practice and data collection.”
So don’t be afraid of STORE – welcome it – because as registrars, we play a large part in ensuring the collection of cancer data allows healthcare providers, researchers, and the surveillance community to work together to provide better care for all cancer patients.