42028-1

LOINC code 42028-1 identifies "NAACCR ambiguous terminology as basis for diagnosis". Identifies cases for which an ambiguous term is the most definitive word or phrase used to establish a cancer diagnosis (i.e., to determine whether or not the case is reportable). Do not include cases where a definite statement of malignancy is made within two months following the original/initial diagnosis. (This does not include the use of ambiguous terminology from cancer screening followed by a positive cancer confirmation that is follow-up to the screening.) Cases include reportable cancer diagnoses (by any method including death certificate only and autopsy only) based only on ambiguous terminology. There is no conclusive diagnosis (positive clinical diagnosis, pathology, etc.) within two months of the original diagnosis that will further qualify the ambiguous term (no longer based on ambiguous terminology). Ambiguous terminology may originate from any source document, such as pathology report, radiology report, or from a clinical report. This data item is used only when ambiguous terminology is used to establish diagnosis. It is not used when ambiguous terminology is used to clarify a primary site, specific histology, histologic group, or stage of disease. Ambiguous terms that are reportable Apparent(ly) Appears (effective with cases diagnosed 1/1/1998 and later) Comparable with (effective with cases diagnosed 1/1/1998 and later) Compatible with (effective with cases diagnosed 1/1/1998 and later) Consistent with Favor(s) Malignant appearing (effective with cases diagnosed 1/1/1998 and later) Most likely Presumed Probable Suspect(ed) Suspicious (for) Typical (of) Follow-back to a physician or subsequent readmission (following the initial two month diagnosis period) may eventually confirm a cancer diagnosis (conclusive cancer diagnosis greater than two months after date of initial diagnosis that was based on ambiguous terminology). These cases should be excluded from case selection in research studies and from annual contact (i.e., follow-up) by registrars. Direct patient contact is not recommended for these cases. Cases with a reportable cancer diagnosis that has been established based only on reports that contain ambiguous terminology to describe final diagnostic findings cannot currently be identified. Multiple surveys have identified a lack of consensus in the interpretation and use of ambiguous terms across physician specialties. These cases may or may not have an actual cancer diagnosis based on clinician, radiologist, and pathologist review. Furthermore, the historical interpretation and use of ambiguous terms by cancer registrars and registries has not been consistent or compatible with physician use of these terms. This data item will identify specific primary sites where the ambiguous terminology is commonly used to describe or establish a cancer diagnosis. Data collected will be used as the basis for modifications to case inclusion and reportable rules following complete analysis and impact assessment. This data item will allow cases to be identified within an analysis file. It will also allow these cases to be identified and excluded from patient contact studies. .. NAACCR Data Standards and Data Dictionary Version 11

This code measures NAACCR ambiguous terminology as basis for diagnosis in Cancer.XXX. It belongs to the TUMRRGT class in the LOINC classification.

LOINC (Logical Observation Identifiers Names and Codes) is a universal standard for identifying laboratory and clinical observations. It is maintained by the Regenstrief Institute and used worldwide for health data exchange.