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CAP/CS Aligned Data Standard Change Log Previous Revision: New Revision: CAP CS Aligned Data Standard FINAL 20080029.xls CAP CS Aligned Data Standard FINAL 20080226xls Implementation changes HL7 Format Tab; Row 33 Incorrect ORU statement and HL7 version shown in the message BEFORE MSH|^~\&|ISIS-REGISTRAR|111|PIMS|CCO-OCR|20050901111110||OCR^ORU|11111111111|P|1.1|||||| AFTER MSH|^~\&|ISIS-REGISTRAR|111|PIMS|CCO-OCR|20050901111110||ORU^OR1|11111111111|P|2.3|||||| Please note that ISIS-REGISTRAR is the name of CCO’s application. The name that should appear here from the hospital’s perspective is the name of your LIS application Endometrium: missing HL7 solution for how to report mixed case carcinomas Mixed case carcinoma tab of file named: HL7 multiple specs_mixed case carcinomas final AFTER METHOD: Treat entire free-text as single value, with no delimiters OBX|3|CWE|^histologic_type^||^mixed_carcinoma_serous_cystadenocarcinoma_14_endometrioid_adenocarcinoma_with_squamous_metaplasia_20_endometrioid_adenocarcinoma_secretory_45^| Breast tab: Row 90 Lung tab: Row 59 Endometrium tab: Row 50 Prostate tab: Row 57 Colorectal tab: Row 53 Data definitions added for Clinical Metastasis values BEFORE AFTER Clinical Metatstasis clinical_metastasis Collaborative Staging: CS extension BEFORE All disease site: CS Extension AFTER All disease sites: Collaborative Staging Extension BEFORE Collaborative Staging Extension: options to select “Cannot be assessed” or “ No evidence of primary tumor” missing AFTER Options to select “Cannot be assessed” and “No evidence of primary tumor” added Added to Radical Prostatectomy tab: 62,63 Endometrium tab: 58,59 Breast tab: 95,96 Lung: tab 85,86 BEFORE Collaborative Staging Extension: options to select “Not Applicable” missing AFTER Options to select “Not Applicable” added Added to Colorectal resections tab: 64 Breast tab: 97 Lung: tab 87 ___ X unknown status of metastasis ___ 0 no metastasis found ___ 1 distant metastasis found X 0 1 Breast Row: 63 and 73 Underscore removed at the request of the hospitals as they found it confusing and were left unsure as to what to send to CCO. Data elements missing BEFORE Name of Closest Uninvolved Margin to Invasive carcinoma AFTER Name of Closest Uninvolved Margin to Invasive carcinoma closest_uninvolved_margin_invasive_carcinoma closest_uninvolved_margin_invasive_carcinoma *Specify which margin: ____ *** for margins uninvolved by invasive carcinoma ___ Surgical superior margin is closest uninvolved margin to malignant neoplasm (finding) ___ Surgical inferior margin is closest uninvolved margin to malignant neoplasm (finding) ___ Surgical medial margin is closest uninvolved margin to malignant neoplasm (finding) ___ Surgical lateral margin is closest uninvolved margin to malignant neoplasm (finding) ___ Surgical deep margin is closest uninvolved margin to malignant neoplasm (finding) ___ Other (specify): *Specify which margin: *** for margins uninvolved by invasive carcinoma ___ Surgical superior margin is closest uninvolved margin to malignant neoplasm (finding) ___ Surgical inferior margin is closest uninvolved margin to malignant neoplasm (finding) ___ Surgical medial margin is closest uninvolved margin to malignant neoplasm (finding) ___ Surgical lateral margin is closest uninvolved margin to malignant neoplasm (finding) ___ Surgical deep margin is closest uninvolved margin to malignant neoplasm (finding) ___ Other (specify): superior_margin inferior_margin medial_margin lateral_margin deep_margin other_********* BEFORE involved_margin_invasive_carcinoma involved_margin_DCIS Specify which margin(s): *** for margin(s) involved by invasive carcinoma (check all that apply) (check all that apply) ___ Surgical superior margin involved by malignant neoplasm (finding) superior_margin ___ Surgical inferior margin involved by malignant neoplasm (finding) inferior_margin ___ Surgical medial margin involved by malignant neoplasm (finding) medial_margin ___ Surgical lateral margin involved by malignant neoplasm (finding) lateral_margin ___ Surgical deep margin involved by malignant neoplasm (finding) ___ Other (specify): deep_margin other_********* Specify which margin(s): *** for margin(s) involved by DCIS (check all that apply) ___ Surgical superior margin involved by ductal carcinoma in situ (finding) (check all that apply) superior_margin ___ Surgical inferior margin involved by ductal carcinoma in situ (finding) inferior_margin ___ Surgical medial margin involved by ductal carcinoma in situ (finding) medial_margin ___ Surgical lateral margin involved by ductal carcinoma in situ (finding) lateral_margin ___ Surgical deep margin involved by ductal carcinoma in situ (finding) deep_margin ___ Other (specify): other_********* AFTER Margins involved by invasive carcinoma involved_margin_invasive_carcinoma Specify which margin(s): *** for margin(s) involved by invasive carcinoma (check all that apply) (check all that apply) ___ Surgical superior margin involved by malignant neoplasm (finding) superior_margin ___ Surgical inferior margin involved by malignant neoplasm (finding) inferior_margin ___ Surgical medial margin involved by malignant neoplasm (finding) medial_margin ___ Surgical lateral margin involved by malignant neoplasm (finding) lateral_margin ___ Surgical deep margin involved by malignant neoplasm (finding) ___ Other (specify): deep_margin other_********* Margins involved by DCIS involved_margin_DCIS Specify which margin(s): *** for margin(s) involved by DCIS (check all that apply) ___ Surgical superior margin involved by ductal carcinoma in situ (finding) (check all that apply) superior_margin ___ Surgical inferior margin involved by ductal carcinoma in situ (finding) inferior_margin ___ Surgical medial margin involved by ductal carcinoma in situ (finding) medial_margin ___ Surgical lateral margin involved by ductal carcinoma in situ (finding) lateral_margin ___ Surgical deep margin involved by ductal carcinoma in situ (finding) deep_margin ___ Other (specify): other_********* LUNG: Rows 35-26 Data elements missing BEFORE closest_uninvolved_margin_distance_carcinoma ___ Distance of invasive carcinoma from closest margin: ___ mm *** only if margins Uninvolved by Invasive Carcinoma ___ (numeric value in m closest_uninvolved_margin_carcinoma Specify margin: ___ (i.e. Margin closest to invasive carcinoma) *** only if margins Uninvolved by Invasive Carcinoma _____ (free text) AFTER Distance of invasive carcinomas from closest margin closest_uninvolved_margin_distance_carcinoma ___ Distance of invasive carcinoma from closest margin: ___ mm *** only if margins Uninvolved by Invasive Carcinoma ___ (numeric value in Margin closest to invasive carcinoma closest_uninvolved_margin_carcinoma Specify margin: ___ (i.e. Margin closest to invasive carcinoma) *** only if margins Uninvolved by Invasive Carcinoma _____ (free text) Endometrium Rows 26-28 Data elements missing BEFORE myometrial_thickness Specify myometrial thickness: ___ mm ___ (numeric value in mm) myometrial_invasion_percentage_gross ___ Less than 50% of myometrial invasion ___ Greater than 50% of myometrial invasion less_than_50_pct_myometrial_invasion greater_than_50_pct_myometrial_invasion AFTER Depth of Myometrial Invasion myometrial_invasion_depth Specify depth of invasion: ___ mm ___ (numeric value in mm) Myometrial Thickness myometrial_thickness Specify myometrial thickness: ___ mm ___ (numeric value in mm) Myometrial invasion percentage gross myometrial_invasion_percentage_gross ___ Less than 50% of myometrial invasion ___ Greater than 50% of myometrial invasion less_than_50_pct_myometrial_invasion greater_than_50_pct_myometrial_invasion Endometrium Row: 36-28 Data elements missing BEFORE closest_uninvolved_margin_distance_carcinoma *Distance of invasive carcinoma from closest margin: ___ mm *** only if margins Uninvolved by Invasive Carcinoma ___ (numeric value in mm) closest_uninvolved_margin_carcinoma *Specify margin: ________ *** only if margins Uninvolved by Invasive Carcinoma _____ (free text) name_of_involved_margins_carcinoma Specify margin(s): ________ *** only if margins Involved by Invasive Carcinoma _____ (free text) Closest uninvolved margin distance carcinoma closest_uninvolved_margin_distance_carcinoma *Distance of invasive carcinoma from closest margin: ___ mm *** only if margins Uninvolved by Invasive Carcinoma ___ (numeric value in mm) Closest uninvolved margin carcinoma closest_uninvolved_margin_carcinoma *Specify margin: ________ *** only if margins Uninvolved by Invasive Carcinoma _____ (free text) Name of involved margins carcinoma name_of_involved_margins_carcinoma Specify margin(s): ________ *** only if margins Involved by Invasive Carcinoma _____ (free text) AFTER HL7 multiple specimens_mixed case carcinoma document: multiple specimen tab: row 5 Further explanation and removal of the term primary cancer BEFORE 5) When a case includes multiple specimens, the primary cancer should be reported synoptically. All other specimens should be reported narratively for now. AFTER 5) When a case includes multiple specimens, the first specimen which is one of the CAP/CS aligned specimens should be reported to CCO synoptically in se each data element. All subsequent specimens should be send to CCO in one OBX segment using the FT data type. HL7 multiple specimens_mixed case carcinoma document: multiple specimen tab: row 75 Added example of NAACCR numbering format 4) All numeric value measurements (cm or mm) must be three-digit numbers, always with one implied decimal place. A numeric measurement of "203" in mm represents "20.3 mm", while a numeric measurement of "037" in cm represents "3.7 cm" and "190" in mm represents "19.0 mm". All other numeric values must be two-digit numbers, with no implied decimal places -- please left-pad with zeros if necessary to make it two-digit. e.g. Lymph nodes examined: 12 Lymph nodes involved: 03 Radical Prostatecomy tab: Row 16-17: 24-25 Data elements missing BEFORE tumor_greatest_dimension tumor_additional_dimensions *Tumor size (dominant nodule, if present): dimension: ___ cm *Greatest *Additional dimensions: ___ x ___ cm ___ (numeric value in cm) ___x___ (numeric values in cm) (If only one value is available, provide ___x second value empty) AFTER Tumor greatest dimension tumor_greatest_dimension tumor additional dimensions tumor_additional_dimensions *Tumor size (dominant nodule, if present): dimension: ___ cm *Greatest *Additional dimensions: ___ x ___ cm ___ (numeric value in cm) ___x___ (numeric values in cm) (If only one value is available, provide ___x second value empty) BEFORE AFTER focal_extension_site *** only if Extraprostatic Extension = Focal Present is true * Specify site(s): _____ ___ (free text) nonfocal_extension_site *** only if Extraprostatic Extension = Non-Focal Present is true * Specify site(s): _____ ___ (free text) focal extension site focal_extension_site *** only if Extraprostatic Extension = Focal Present is true * Specify site(s): _____ ___ (free text) nonfocal extension site nonfocal_extension_site *** only if Extraprostatic Extension = Non-Focal Present is true * Specify site(s): _____ ___ (free text) Colorectal tab: Rows 12-13 Data elements missing BEFORE tumor_greatest_dimension Greatest dimension: ___ cm *** choose only one between Tumor_size = cannot be determined Tumor_greatest_dimension = ___ (value) ___ (numeric value in cm) tumor_additional_dimensions *Additional dimensions: ___ x ___ cm ___x___ (numeric values in cm) (If only one value is available, provide ___x and leave th AFTER tumor greatest dimension tumor_greatest_dimension Greatest dimension: ___ cm *** choose only one between Tumor_size = cannot be determined Tumor_greatest_dimension = ___ (value) ___ (numeric value in cm) tumor additional dimensions tumor_additional_dimensions *Additional dimensions: ___ x ___ cm ___x___ (numeric values in cm) (If only one value is available, provide ___x and leave th Endometrium tab: Rows 10-11, 28, 34 Data elements missing BEFORE tumor_greatest_dimension Greatest dimension: ___ cm *** choose only one between - tumor_size = cannot be determined - tumor_greatest_dimension = ___ (numeric value) ___ (numeric value in cm) tumor_additional_dimensions *Additional dimensions: ___ x ___ cm ___x___ (numeric values in cm) (If only one value is available, provide ___x a second value empty) AFTER tumor greatest dimension tumor_greatest_dimension Greatest dimension: ___ cm *** choose only one between - tumor_size = cannot be determined - tumor_greatest_dimension = ___ (numeric value) ___ (numeric value in cm) tumor additional dimensions tumor_additional_dimensions *Additional dimensions: ___ x ___ cm ___x___ (numeric values in cm) (If only one value is available, provide ___x a second value empty) BEFORE myometrial_invasion_percentage Specify % of myometrium invasion: ___ ___ (numeric percentage value) myometrial_invasion_percentage Specify % of myometrium invasion: ___ ___ (numeric percentage value) distant_metastasis_site *Specify distant metastasis Site if known ________________ *** only if Distant Metastasis is pM1 _____ (free text) AFTER Myometrial invasion percentage BEFORE AFTER distant metastasis site distant_metastasis_site *Specify distant metastasis Site if known ________________ *** only if Distant Metastasis is pM1 _____ (free text) Breast tab: Rows 10-11, 15-16, 45, 55 Data elements missing BEFORE specimen_greatest_dimension Greatest dimension: ___ cm *** choose only one between - specimen_size = cannot be determined - specimen_greatest_dimension = ___ (numeric value)" ___ (numeric value in cm) specimen_additional_dimensions *Additional dimensions: ___ x ___ cm __x___ (numeric values in cm) (If only one value is available, provide ___x and leave the second value empty) invasive_component_greatest_dimension invasive_component_additional_dimensions mitotic_count_40x distant_metastasis_site Greatest dimension: ___ cm *** choose only one between - invasive_component_size = cannot be determined - invasive_component_greatest_dimension = ___ (numeric value)" *Additional dimensions: ___ x ___ cm For a 40x objective with a field area of 0.152 mm2 ___ 0 to 5 mitoses per 10 HPF (score = 1) ___ 6 to 10 mitoses per 10 HPF (score = 2) ___ Greater than 10 mitoses per 10 HPF (score = 3) ___ Not Applicable *** only one of mitotic_count_25x and mitotic_count_40x required *Specify site(s), if known: ____ *** use only if pM1: Distant metastasis ___ (numeric value in cm) ___x___ (numeric values in cm) (If only one value is available, provide ___x and leave the second value empty) score_1 score_2 score_3 not_applicable _____ (free text) AFTER specimen greatest dimension specimen_greatest_dimension Greatest dimension: ___ cm *** choose only one between - specimen_size = cannot be determined - specimen_greatest_dimension = ___ (numeric value)" ___ (numeric value in cm) specimen additional dimensions specimen_additional_dimensions *Additional dimensions: ___ x ___ cm __x___ (numeric values in cm) (If only one value is available, provide ___x and leave the second value empty) invasive component greatest dimension invasive_component_greatest_dimension invasive component additional dimensions invasive_component_additional_dimensions mitotic count 40x mitotic_count_40x Distant metastasis site distant_metastasis_site Greatest dimension: ___ cm *** choose only one between - invasive_component_size = cannot be determined - invasive_component_greatest_dimension = ___ (numeric value)" *Additional dimensions: ___ x ___ cm For a 40x objective with a field area of 0.152 mm2 ___ 0 to 5 mitoses per 10 HPF (score = 1) ___ 6 to 10 mitoses per 10 HPF (score = 2) ___ Greater than 10 mitoses per 10 HPF (score = 3) ___ Not Applicable *** only one of mitotic_count_25x and mitotic_count_40x required *Specify site(s), if known: ____ *** use only if pM1: Distant metastasis ___ (numeric value in cm) ___x___ (numeric values in cm) (If only one value is available, provide ___x and leave the second value empty) score_1 score_2 score_3 not_applicable _____ (free text) Lung tab: Row 11-12 BEFORE tumor_greatest_dimension Greatest dimension: ___ cm *** choose only one between - tumor_size = cannot be determined - tumor_greatest_dimension = ___ (numeric value) ___ (numeric value in cm) tumor_additional_dimensions *Additional dimensions: ___ x ___ cm ___x___ (numeric value in cm) (If only one value is available, provide ___x and leav AFTER tumor greatest dimension tumor_greatest_dimension Greatest dimension: ___ cm *** choose only one between - tumor_size = cannot be determined - tumor_greatest_dimension = ___ (numeric value) ___ (numeric value in cm) tumor additional dimensions tumor_additional_dimensions *Additional dimensions: ___ x ___ cm ___x___ (numeric value in cm) (If only one value is available, provide ___x and leav Lung tab: Row 35 Removed underscore BEFORE Distance of invasive carcinomas from closet margin closest_uninvolved_margin_distance_carcinoma __Distance of invasive carcinoma from closest margin: ___ mm *** only if margins Uninvolved by Invasive Carcinoma ___ (numeric value in mm) closest_uninvolved_margin_distance_carcinoma Distance of invasive carcinoma from closest margin: ___ mm *** only if margins Uninvolved by Invasive Carcinoma ___ (numeric value in mm) AFTER Distance of invasive carcinomas from closet margin Colorectal tab: Row 28 Removed underscore BEFORE Name of Closest Uninvolved Margin uninvolved_margin_carcinoma Specify margin __: ___ Surgical proximal margin is closest uninvolved margin to malignant neoplasm ___ Surgical distal margin is closest uninvolved margin to malignant neoplasm ___ Surgical circumferential margin is closest uninvolved margin to malignant neoplasm ___ Surgical mesenteric margin is closest uninvolved margin to malignant neoplasm *** only if ALL margins uninvolved by invasive carcinoma proximal_margin distal_margin circumferential_margin mesenteric_margin AFTER Name of Closest Uninvolved Margin uninvolved_margin_carcinoma Specify margin: ___ Surgical proximal margin is closest uninvolved margin to malignant neoplasm ___ Surgical distal margin is closest uninvolved margin to malignant neoplasm ___ Surgical circumferential margin is closest uninvolved margin to malignant neoplasm ___ Surgical mesenteric margin is closest uninvolved margin to malignant neoplasm *** only if ALL margins uninvolved by invasive carcinoma proximal_margin distal_margin circumferential_margin mesenteric_margin
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