California Cancer Reporting System Standards Volume I: Abstracting and Coding Procedures for Hospitals
Vague or ambiguous terms are sometimes used by physicians to describe a tumor when its behavior is uncertain. This occurs primarily when there is no histologic diagnosis.
The terms listed below are reportable when they are used with a term such as cancer, carcinoma, sarcoma, etc.
Ambiguous terms that are reportable (used to determine reportability):
Apparent(ly) (malignant)
Appears to*
Comparable with*
Compatible with (a malignancy)*
Consistent with (a malignancy)
Favor (a malignancy)
Malignant appearing*
Most likely (malignant)
Presumed (malignant)
Probable (malignancy)
Suspect or suspected (malignancy)
Suspicious (of malignancy)
Typical (of/for malignancy)
*Effective for cases diagnosed January 1, 1988 and forward.
Ambiguous terms not listed above are NOT reportable and are NOT to be abstracted.
Ambiguous terms may be located in any source document, such as pathology, operative, radiology, or clinical reports. This does not include tumor marker reports.
Do not report a case when cytology, biopsy, excision, resection, or physician’s statement proves the ambiguous diagnosis is not reportable.
Do not substitute synonyms such as “supposed” for presumed or “equal” for comparable. Do not substitute “likely” for “most likely.”
Report the case when there are reportable and non-reportable ambiguous terms within the medical record.
Report the case when there is a single report and it has a reportable term and a term not listed on the reportable list.
Do not report if the original source document used a non-reportable ambiguous term and later documents refer to a history of cancer.
If cytology is reported as “suspicious,” do not interpret this as a diagnosis of cancer. Abstract the case if a positive biopsy or a physician’s clinical impression of cancer supports the cytology findings.
In addition, a cytologically confirmed case with a negative biopsy must be evaluated carefully. If the biopsy rules out the presence of cancer, do not report the case. But if a negative biopsy does not rule out the presence of cancer, the case is considered to be cytologically confirmed and is reportable. See Section IV.2 Diagnostic Confirmation.
A urine cytology positive for malignancy is reportable. Report these cases when they are encountered. This is effective with cases diagnosed 1/1/2013 and forward. Do not implement new/additional casefinding methods to capture these cases.
Exception: When a subsequent biopsy of a urinary site is negative, do not report the case.
Code the primary site to C689 in the absence of any other information.
As always, do not report cytology cases with ambiguous terminology.
Benign and borderline primary intracranial and CNS tumors:
Use the above “Ambiguous terms that are reportable” list to identify benign and borderline primary intracranial and CNS tumors that are reportable.
If any of the reportable ambiguous terms precede either the word “tumor” or the word “neoplasm”, report the case.