Person with cancer—most valid basis of diagnosis of the first recurrence, code N
Identifying and definitional attributes
|Metadata item type:||Data Element|
|Short name:||Most valid basis of diagnosis of recurrence|
|Registration status:||Health, Standard 07/12/2011|
|Definition:||The most valid basis of diagnosis of the first recurrence of locoregional cancer or distant metastasis in a person with cancer, as represented by a code.|
|Data Element Concept:||Person with cancer—most valid basis of diagnosis of a cancer|
Value domain attributes
|Maximum character length:||1|
Collection and usage attributes
|Guide for use:|
CODES 1 - 4
CODES 5 - 8
|Comments:||In a hospital setting this metadata item should be collected on the most valid basis of diagnosis at this admission. If more than one diagnosis technique is used during an admission, select the higher code from 1 to 8.|
Data element attributes
Collection and usage attributes
|Guide for use:|
Record the most valid basis of diagnosis that identifies the first recurrence of locoregional cancer or a distant metastasis.
The term recurrence refers to the return, reappearance or metastasis of cancer of the same histology after a disease-free period. It may be locoregional or a distant metastasis.
The information is collected for the first recurrence of cancer at any site.
The coding system is based on that recommended by the International Agency for Research on Cancer (IARC) and the International Association of Cancer Registries (IACR). The value "3" is not represented.
If more than one investigation identifying the recurrence is conducted at the same time, select the higher number code from 1 to 8 reflecting the most definitive method of diagnosis. For example, if the patient has both imaging (Code 2) and histology of a primary tumour (Code 7) to verify the cancer, record Code 7 as the most valid basis of diagnosis.
When considering the most valid basis of diagnosis, the minimum requirement of a cancer registry is differentiation between neoplasms that are verified microscopically and those that are not. To exclude the latter group means losing valuable information; the feasibility of making a morphological (histological) diagnosis is dependent upon a variety of factors, such as the health and age of the patient, accessibility of the tumour, availability of medical services, and the beliefs and decisions of the patient.
A biopsy of the primary tumour should be distinguished from a biopsy of a metastasis, for example, at laparotomy; a biopsy of cancer of the head of the pancreas versus a biopsy of a metastasis in the mesentery. However, when insufficient information is available to determine whether the site of the biopsy is primary or metastatic, Code 8. Cytological and histological diagnoses should also be distinguished.
Morphological confirmation of the clinical diagnosis of malignancy depends on the successful removal of a piece of tissue that is cancerous. When using endoscopic procedures such as bronchoscopy, gastroscopy or laparoscopy, the clinician may miss the tumour with the biopsy forceps. These cases must be registered on the basis of endoscopic diagnosis and not excluded through lack of a morphological diagnosis.
Care must be taken in the interpretation and subsequent coding of autopsy findings, which may vary as follows:
(a) The post-mortem report includes the post-mortem histological diagnosis (in which case, one of the histology codes should be recorded instead);
(b) The autopsy is macroscopic only, histological investigations having been carried out only during life (in which case, one of the histology codes should be recorded instead);
(c) The autopsy findings are not supported by any histological diagnosis.
|Collection methods:||The information should be obtained from the patient's medical record.|
|Comments:||Information regarding the basis of diagnosis is important for determining how definitively the malignancy was confirmed and subsequently the reliability of cancer statistics.|
Source and reference attributes
|Submitting organisation:||Cancer Australia|
International Agency for Research on Cancer (IARC)International Association of Cancer Registries (IACR)
|Related metadata references:|
See also Patient—diagnosis date of first recurrence as distant metastasis, DDMMYYYY Health, Standard 07/12/2011
See also Patient—diagnosis date of first recurrence as locoregional cancer, DDMMYYYY Health, Standard 07/12/2011
See also Person with cancer—region of first recurrence as distant metastasis, topography code (ICD-O-3) ANN.N Health, Standard 07/12/2011
See also Person with cancer—region of first recurrence as locoregional cancer, topography code (ICD-O-3) ANN.N Health, Standard 07/12/2011
|Implementation in Data Set Specifications:|
All attributes +
Cancer (clinical) DSS Health, Superseded 08/05/2014
Cancer (clinical) DSS Health, Superseded 14/05/2015
Cancer (clinical) NBPDS Health, Standard 14/05/2015