When and What to Report
It is the responsibility of the original pathologist to report all cancer diagnoses. Any slide review, second opinion, report correction, addendums, etc. related to the original specimen diagnosis that either change the original incidence of cancer (i.e., reportable to non-reportable, or vice versa) or changes the histology and/or behavior of the original specimen is to be electronically transmitted to CCR by the original pathologist within 2 weeks of finalizing the revised pathology documentation.
What are the Reportable Diagnostic Criteria?
All reportable neoplasms meeting the criteria as outlined in the CCR Electronic Pathology Reporting Standards Implementation Guide should be transmitted to CCR. Neoplasms outlined under Non-Reportable Diagnoses do not need to be transmitted.
In the event an ambiguous term(s) precede a reportable cancer diagnoses, the case is to be considered reportable. Examples of ambiguous terminology include, but are not limited to the following: apparently, appear to, suspicious, likely or most likely, favors, comparable, consistent with, typical (of), probable, presumed, malignant appearing.
- Invasive malignancies
- In situ malignancies
- To see the terms within a pathology report that indicate in situ behavior and are reportable, please go to page 5 of the CCR Electronic Pathology Reporting Standard Implementation Guide
- Benign and borderline intracranial and/or central nervous system (CNS) tumors
- All hematopoietic and lymphoid neoplasms as outlined by SEER are reportable
- Carcinoid tumors, NOS of the appendix
- Severe or high-grade dysplasia, documented as being synonymous with carcinoma
- Neuroendocrine tumor when the diagnosis is insulinoma
- Cystic pancreatic endocrine neoplasm (CPEN)
- Cystic pancreatic endocrine specified as neourendorcrine tumor, grades 1 and 2
- Solid pseudopapillary neoplasm of pancreas
- Non-invasive mucinous cystic neoplasm (MCN) of pancreas with high-grade dysplasia
- Mature teratoma of the testes in adults
Pathology Report Types
The following types of pathology reports that provide information on reportable neoplasms should be transmitted to CCR:
- Surgical pathology reports:
- Biopsy (needle core, excisional, incisional, bone marrow aspirates)
- Surgical resection
- Surgical re-excision
- Cytology reports:
- Biopsy (fine-needle aspiration)
- Brushings (e.g., endoscopic evaluation of pancreas, PAP smear)
- Fluids (urine, peritoneal, pleural, cerebrospinal)
- Fluid, broncheoalveolar lavage
- Hematologic-specific reports
- Immunohistochemistry (IHC)
- Peripheral blood count flow cytometry
- Molecular reports, including:
- Molecular diagnosis PCR
- Sequencing (NGS, pyrosequencing, etc.)
- Gene array
- Slide reviews
- Biomarker results
- Pathology report addenda
Required Data Elements
All data elements listed in the CCR NAACCR Volume 5 Version 4.0 – HL7 2.5.1 Constraints Document (revised 02-10-2019) are required if accessible. These data elements include:
- Facilities information
- Ordering provider information
- Patient demographics
- Tumor-specific information
Facilities and ordering provider information is required in order to successfully match pathology information to existing records in CCR’s database and/or to match to the criteria for research studies and clinical trials. Patient demographic items are essential for epidemiological incidence and mortality research.
CCR recognizes that not all facility and patient information may be available to all pathologists. However, it is likely that facility/office electronic health record (EHR) systems will contain many of these data elements, so CCR recommends that laboratory information system (LIS) vendors work with ordering facilities/offices and their EHR vendors to enable these kinds of data elements to be transmitted to CCR.
Guidance on Reporting
To maintain high standards in reporting accuracy, please visit our Reporting Resources Library and also review the North American Association of Central Cancer Registries (NAACR) Pathology Laboratory Electronic Reporting Volume 5.
All pathology departments and laboratories should reference the CCR Electronic Pathology Reporting Standards Implementation Guide and review the reporting requirements to ensure the required data is being transmitted.
All pathologists are required to report cancer diagnoses electronically before January 1, 2019.
*Self-validation is used to test HL7 message structure. It does not validate content.