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Updated December 2020
Reporting of Cancer Stage at Diagnosis by Regional Cancer Centres in Ontario
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Introduction
The appropriate management of a patient with cancer is not possible without knowledge of the extent or stage of the cancer. All clinicians must stage all cancer patients with AJCC staging schema as part of a routine assessment and treatment plan. Each treating facility is then responsible for ensuring processes are in place for accurate clinical documentation and collection of stage data.
Stage information constitutes one of the most important prognostic factors for cancer treatment. Reliable stage information supports healthcare providers, administrators, researchers and decision-makers in their planning, evaluation and quality improvement activities to enhance the patient experience and to advance patient outcomes.
Stage at Diagnosis is defined as the classification of patients with cancer into prognostically similar groups according to the extent of disease at the time of initial diagnosis. All patients undergoing diagnostic work-up for cancer are assigned a clinical stage in order to develop a treatment plan.
If the patient has definitive surgical treatment, the managing physician then assigns a pathological stage. If the patient receives neo-adjuvant* systemic treatment or radiation therapy, the managing physician assigns a post therapy stage in order to indicate the response to treatment. Only two of these three stage groups would be reported to CCO for any given case. i.e. clinical/pathological, clinical/post therapy.
From 2010-2017 two staging systems were in use in Ontario: American Joint Committee on Cancer (AJCC) Tumour Node Metastases (TNM) 7th edition and Collaborative Staging (CS) also based on the TNM 7th edition. Effective with patients diagnosed on January 1 2018, CS was discontinued in Canada and the AJCC TNM 8th edition was implemented. NB: Stage data captured using the Collaborative Stage Data Collection System (CS) will continue to be available for research purposes upon request.
*Neoadjuvant therapy: Treatment given as a first step to shrink a tumor before the main treatment, usually surgery, is given. Examples of neoadjuvant therapy include chemotherapy, radiation therapy, and hormone therapy. It is a type of induction therapy. (National Cancer Institute)
TNM Staging is reported centrally by the RCCs to Cancer Care Ontario (CCO) through CCO’s Data Book. Reporting is mandatory for all cancers with the exception of Breast, Cervix, Colorectal, Lung and Prostate. Those disease sites are currently reported within CCO by the Ontario Cancer Registry (OCR). In the future, a more collaborative effort between the RCCs and CCO is anticipated. Cancer centres that do report stage for these four cancers are encouraged to continue to do so.
Cancer Care Ontario owns and manages the Ontario Cancer Registry under the authority of Ontario’s Cancer Act and the Personal Health Information Protection Act. CCO has a mandate to collect stage data at a population level and to be in compliance with national standards. CCO is also required to provide Statistics Canada (Canadian Cancer Registry) with a TNM stage dataset that exceeds that currently submitted via Data Book. To meet this requirement, the OCR will continue to capture stage data for all new Breast, Colorectal, Lung and Prostate cancers regardless of where the patient is seen. Reporting of stage for these cancer sites is mandated at a national level by the Canadian Partnership Against Cancer (CPAC). Cervix will also be staged in support of the CCO screening program.
CCO also promotes the use of stage data in the development and reporting of cancer system indicators. Examples:
- To provide surveillance of prognostically similar groups of cancer
- To assess treatment pattern and guideline concordance
- To inform stage related decision making processes
- To support stage data quality improvement efforts
TNM Staging by Regional Cancer Centres
Accountability/Responsibility for RCC Reporting of TNM Staging
Information
The Regional Vice President is responsible for ensuring that TNM stage information is properly documented and reported to CCO through each RCC’s CCO Data Book process.
All RCCs should have a policy for the identification, collection and processing of cancer stage related data in their organization. Each centre will ensure compliance with that policy and that the stage information is of high quality.
CCO will assist RCCs by measuring completeness of stage information, monitoring standard setter stage education platforms, answering questions posed in the relevant ocrquestions and informatics mailboxes, provide expert technical staging support and ultimately generate stage data quality reporting. CCO will share data on stage data quality and completeness with RVPs and/or their delegates and through regular Regional Program processes.
Each RCC has a responsibility to monitor, on an on-going basis, the completeness and quality of stage data collected. Specific strategies to support quality monitoring should be implemented. These strategies may include regular review of incomplete cases, unknown stage cases, chart audits, and validation of stage by HIM staff, Cancer Registrars and/or Clinician experts.
Procedure for RCC Reporting of TNM Staging Information
All new analytic (see Appendix 1.16 in current Data Book) patients with a diagnosis of invasive or in-situ cancer, should be staged according to the 8th Edition of AJCC TNM Cancer Staging. Based on the guidelines from AJCC, the following cases should be excluded from staging as there is no corresponding AJCC staging schema:
Central Nervous System
Leukemias not listed in Chapter 79 (3rd printing) of AJCC 8th (Hodgkin and Non-Hodgkin Lyumphoma), where site=C421 (bone marrow) may now be used.
Primary unknown
Kaposi's Sarcoma
There are additional histologies that cannot be staged. Consult the lists of histologies in the AJCC manual by disease site.
Note that there is a new TNM staging schema for Cutaneous Lymphomas including Mycosis Fungoides and Sezary syndrome. Also, the Lugano staging system for Lymphomas has now been adopted by the AJCC.
The stage at diagnosis is to be recorded for all invasive and in-situ cancers with AJCC stage schema and submitted to CCO on a monthly basis via the CCO Data Book reporting process with exceptions as noted elsewhere in this document. Stage can be submitted up to 10 months from the date of diagnosis.
While CCO encourages all facilities to collect stage at diagnosis on as many cases as possible, the following stageable cases are excluded:
Non-reportable (to OCR) cases (see Appendix 1.16)
Non-analytic cases (see Appendix 1.16)
General Rules of the 8th Edition AJCC Cancer Staging Manual
AJCC 8th Edition Staging
The following rules and associated rationale are for the Eighth Edition AJCC Cancer Staging Manual. Note that these are general rules described in Chapter 1 of the AJCC Cancer Staging Manual. Please refer to relevant disease site chapters to learn more about specific allowable disease site differences to correctly stage such patients and that are necessary for appropriate medical care of the patient.
KEY TERMINOLOGY
Classifications: Describes the points in time of the care of the cancer patient. Criteria include:
Timeframe and Specific medical assessments and practices
Categories: T, N, M, and any nonanatomic factors needed to assign the stage group
Stage group: Easily communicated summary of categories, groups patients with similar prognosis
Assigning stage: AJCC stage is assigned by the managing physician based on data from all relevant sources including history, examination, laboratory studies, imaging, and surgical and pathology findings
CLINICAL STAGING CLASSIFICATION RULES
General: Clinical classification includes information from the date of cancer diagnosis until the start of definitive treatment (surgery, systemic or radiation therapy, active surveillance, or palliative care), or within four months, whichever is shorter, in the absence of disease progression
T category – includes information from clinical history, symptoms, physical exam, labs, imaging, endoscopy, biopsy, surgical exploration without resection
N category – physical exam, imaging, FNA or core needle biopsy, excisional biopsy, sentinel node biopsy
M category – clinical history, physical exam, imaging, FNA or biopsy
Rationale
Diagnostic biopsies of the primary site, regional nodes, and distant metastatic sites are included in clinical classification
Pathological exam of resected tissue (pathology report) does not necessarily make this pathological staging Clinical N category is cN even if based on lymph node biopsy
Clinical M category is cM if based on history, physical exam and imaging, pM1 if based on biopsy proven involvement
PATHOLOGICAL STAGING CLASSIFICATION RULES
General: includes all information from the date of cancer diagnosis (clinical stage), surgeon’s operative findings, and pathology report from resected specimen –must use all 3; without neo-adjuvant therapy (systemic or radiation) and in the absence of disease progression,
T category – must meet definitive surgical treatment specified in chapter
N category – microscopic assessment of at least one node required, include imaging and diagnostic biopsy
M category – history, physical exam, imaging, FNA or biopsy, resection
Rationale
Include all findings even if not microscopically proven, i.e., physical exam, imaging, operative findings Pathological staging is based on synthesis of all information and not solely on resected specimen pathology report – pathologist cannot assign final stage
Pathological M category is cM if based on physical exam and imaging, pM1 if based on biopsy proven involvement, “pM0” is NOT a valid category
POSTNEOADJUVANT THERAPY STAGING CLASSIFICATION RULES (effective 2019-2020)
yc Clinical: Includes physical exam and imaging assessment after neoadjuvant systemic/radiation therapy*
yp Pathological: includes all information from yc* staging, surgeon’s operative findings and pathology report from resected specimen
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No materials may be repurposed without the express written permission of the American Joint Committee on Cancer.
Permission requests may be submitted at cancerstaging.org
*Note: yc (Post-neoadjuvant Clinical) staging is not currently mandated for use in Canada and is not reported to CCO. However, yp (Post Therapy) is mandated by both when appropriate. To complete yp staging, the results of the neoadjuvant therapy must be taken into account (essentially using the yc information).
The clinical stage is essential to select and evaluate therapy, while the pathological stage provides the most precise data to estimate prognosis and calculate results.
If there is uncertainty regarding the T, N, or M classification to which a particular case should be assigned, i.e. there are two possible categories, then the lower (less advanced) category should be assigned. The same principle applies to the stage grouping. NB: This principle does NOT apply to Unknown or Missing information.
In the case of multiple, simultaneous tumours in one organ, the tumour with the highest T category is the one selected for classification and staging. For simultaneous bilateral cancers in paired organs, the tumours are classified separately as independent primary cancers in different organs, unless one is stated to be metastatic. In the case of tumours of the thyroid, liver, and ovary, multiplicity is a criterion of T classification. There are separate site-specific rules governing the T suffix field.
For specific rules regarding the use of X or assignment of Unknown refer to Chapter 1 of the AJCC TNM staging manual.
The date of diagnosis is the date a physician determines the patient has cancer. It may be the date of a diagnostic biopsy or other microscopic confirmation or of clear evidence on imaging. This rule varies by disease site.
All applicable stage categories and stage groups for a specific case should be submitted to CCO. There will be no more than two stage groups.
RCCs are instructed to refer directly to the AJCC TNM 8th edition staging manual for all disease site specific rules and instructions.
TNM Staging by Cancer Care Ontario
OCR staff within CCO currently stage all Breast, Lung, Colorectal, Prostate and Cervix cancer. RCCs are not required to submit stage for those cases.
Target for Reporting of CCO Stage Information
CCO must meet a minimum 90% completeness rate for reporting of valid and accurate TNM data elements for all Breast, Cervix, Colorectal, Lung and Prostate cancer cases.
Accountability/Responsibility for Reporting CCO Staging Information
CCO will work with Regional Cancer Centres throughout the province to secure access to cancer patient health records using remote technologies. Authorization for remote access is addressed in specific clauses of CCO annual funding agreements, i.e. Cancer Surgery Agreements and Quality Based Procedure Funding Agreements. CCO will also leverage the access it has to its own dataholdings including synoptic pathology reports in eMaRC and CIHI abstracts in order to fully stage each case using TNM 8th edition.
CCO will be responsible for a rigorous data quality monitoring program to measure the accuracy and completeness of its TNM data.
CCO Procedure for AJCC TNM 8th Edition Staging
CCO will identify the cancer cases for TNM stage data collection from the Ontario Cancer Registry (OCR) based on AJCC staging guidelines.
Demographic and disease information on newly identified cases for staging will be automatically extracted from the OCR and loaded into CDC Registry+ software, approximately 10 months after date of diagnosis (to ensure all treatment data have been received). Clinical and Pathological staging data elements will then be manually abstracted from the hospital patient record and from CCO data holdings.
Hospitals working with CCO to facilitate TNM staging will be responsible for providing CCO stage abstractors with remote access to the full electronic patient health record as technology permits. Where direct access is technically not feasible, hospitals may create an electronic workbasket or scan and upload patient health records to a secure CCO web portal.
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