California Cancer Reporting System Standards Volume I: Abstracting and Coding Procedures for Hospitals
Abstract reporting by facilities is not mandatory for malignancies diagnosed by the pathology department on the basis of slides or specimens submitted from outside the hospital, cases seen only by the hospital's tumor board, and cases seen for consultation only. However, the facility must notify the regional registry about these types of cases in order to verify that all cancers in the population have been recorded.
Regional registries establish alternative reporting mechanisms for use when an abstract is not prepared -- for example, submission of a copy of the pathology report or the DHS's "Confidential Morbidity Report" (CMR form).
In the interest of ensuring complete information about the incidence of cancer, the CCR requests hospitals to report a first diagnosis even if the patient is not seen at the hospital (for example, a biopsy performed in a doctor's office). But a confirmation diagnosis -- that is, review of a diagnosis already made at another hospital -- need not be reported.
It is sometimes difficult to identify a consultation only case, especially at a large teaching hospital. As a guideline, the CCR recommends determination of who is ultimately responsible for treatment decisions and follow-up of the patient.
If the reporting hospital is responsible, an abstract should be submitted.
If the reporting hospital is confirming a diagnosis made elsewhere, rendering a second opinion, or recommending treatment to be delivered and managed elsewhere, an abstract is not required, although the regional registry must be notified of the case using one or both of the following methods:
Submit the patient's pathology report.
Submit a completed Confidential Morbidity Report (CMR) form.
Note: When in doubt about whether or not to submit a report either consult the regional registry or report the case using a CMR form.