Organization

Field Name

ID

Required

KCR

Ambiguous Terminology (AmbiguousTerminologyDx)

30450

no

NAACCR

Ambiguous Terminology DX

442

no


Item Length:  1

This data item is optional effective with 01/01/2013 diagnoses, but remain required for diagnoses in 2007-2012.

This data item is collected effective with diagnoses on or after January 1, 2007.  It identifies all cases, including DCO and autopsy only, which are accessioned based only on ambiguous terminology.  Registrars are required to collect cases based on ambiguous terminology in the diagnosis and it is advantageous to be able to identify those cases in the database.

Definitions

Phrase

Definition

Examples

Ambiguous terminology

Terms which have been mandated as reportable when used in a diagnosis.  See page 3 of the FORDS Manual for detailed instructions on how to use the list.

Clinical:  a physician’s statement that the patient most likely has lung cancer.

Laboratory tests:  A CBC suspicious for leukemia.

Pathology:  A prostate biopsy compatible with adenocarcinoma.

Conclusive terminology

A clear and definite statement of cancer.  The statement may be from a physician (clinical diagnosis), or may be from a laboratory test, autopsy, cytologic findings, and/or pathology.

Clinical:  a physician’s statement that the patient has lung cancer.

Laboratory tests:  A CBC diagnostic of acute leukemia.

Cytologic findings:  A FNA (fine needle aspiration) with findings of infiltrating duct carcinoma of the breast.

Pathology:  A colon biopsy showing adenocarcinoma.

List of Ambiguous Terms

Apparent(ly)                 Most likely

Appears                       Presumed

Comparable with          Probable

Compatible with           Suspect(ed)

Consistent with             Suspicious (for)

Favor(s)                       Typical (of)

Malignant appearing

Code

Label

Definition

Time Frame

0

Conclusive term

There was a conclusive diagnosis within 60 days of the original diagnosis.  Case was accessioned based on conclusive terminology.  Includes all diagnostic methods such as clinical diagnosis, cytology, pathology, etc.

Within 60 days of the date of initial diagnosis

1

Ambiguous term only

The case was accessioned based only on ambiguous terminology.  There was not conclusive terminology during the first 60 days following the initial diagnosis.  Includes all diagnostic methods except cytology.

Note:  Cytology is excluded because registrars are not required to collect cases with ambiguous terms describing a cytology diagnosis.

N/A

2

Ambiguous term followed by conclusive term

The case was originally assigned a code 1 (was accessioned based only on ambiguous terminology).  More than 60 days after the initial diagnosis, the information is being updated to show that a conclusive diagnosis was made by any diagnostic method including clinical diagnosis, cytology, pathology, autopsy, etc.

60 days or more after the date of diagnosis

9

Unknown term

There is no information about ambiguous terminology.

N/A

Coding Instructions

1.  Use code 0 when a case is accessioned based on conclusive terminology.  The diagnosis includes clear and definite terminology describing the malignancy within 60 days of the original diagnosis. 

     Note:  Usually the patient undergoes a diagnostic work-up because there is a suspicion of cancer (ambiguous  terminology).  For example, a mammogram may show calcifications suspicious for intraductal carcinoma; the date of the mammogram is the date of initial diagnosis.  When there is a clear and definite diagnosis within 60 days of that mammogram (date of initial diagnosis), such as the pathology from an excisional biopsy showing intraductal carcinoma, assign code 0.

2.  Use code 1 when a case is accessioned based on ambiguous terminology and there is no clear and definite terminology used to describe the malignancy within 60 days of the date of initial diagnosis.  The diagnosis may be from a pathology report, a radiology report, an imaging report, or in the medical record.

3.  Use code 2 when a case is accessioned based on ambiguous terminology followed by clear and definite more than 60 days after the initial diagnosis. 

4.  Follow back to a physician or subsequent readmission (following the initial 60 day period) may eventually confirm cancer (conclusive cancer term more than 60 days after ambiguous term).  Assign code 2.

5.  Leave this data item blank for cases diagnosed prior to 1/1/2007. 

6.  Cases accessioned based on ambiguous terminology (code 1) should be excluded from case selection in research studies.  Direct patient contact is not recommended.