This section applies to all neoplasms (including benign and borderline intracranial and CNS tumors) except hematopoietic and lymphoid neoplasms. For information regarding first course of therapy for hematopoietic and lymphoid neoplasms, refer to the NCI SEER Hematopoietic and Lymphoid Neoplasm Coding Manual.

Definitions

Active surveillance: A treatment plan that involves closely watching a patient’s condition but not giving any treatment unless there are changes in test results that show the condition is getting worse. Active surveillance may be used to avoid or delay the need for treatments such as radiation therapy or surgery, which can cause side effects or other problems. During active surveillance, certain exams and tests are done on a regular schedule. It may be used in the treatment of certain types of cancer, such as prostate cancer, urethral cancer, and intraocular (eye) melanoma. It is a type of expectant management. Also called active monitoring. (Source: http://www.cancer.gov/dictionary?CdrID=616060)
Cancer tissue: Proliferating malignant cells; an area of active production of malignant cells. Cancer tissue includes primary tumor and metastatic sites where cancer tissue grows. Cells in fluid such as pleural fluid or ascitic fluid are not “cancer tissue” because the cells do not grow and proliferate in the fluid.
Concurrent therapy: A treatment that is given at the same time as another.
           Example: Chemotherapy and radiation therapy
Deferred therapy: Closely watching a patient’s condition but not giving treatment unless symptoms appear or change, or there are changes in test results. Deferred therapy avoids problems that may be caused by treatments such as radiation or surgery. It is used to find early signs that the condition is getting worse. During deferred therapy, patients may be given certain exams and tests. It is sometimes used in prostate cancer. Also called expectant management. (Source: http://www.cancer.gov/dictionary?CdrID=667618)
Disease recurrence: For solid tumors, see the Solid Tumor Rules and for hematopoietic and lymphoid neoplasms see the Hematopoietic and Lymphoid Neoplasm Coding Manual and Database to determine disease recurrence.
Expectant management: Closely watching a patient’s condition but not giving treatment unless symptoms appear or change, or there are changes in test results. Expectant management avoids problems that may be caused by treatments such as radiation or surgery. It is used to find early signs that the condition is getting worse. During expectant management, patients may be given certain exams and tests. It is sometimes used in prostate cancer. Also called deferred therapy. (Source: http://www.cancer.gov/dictionary?CdrID=616061)
First course of therapy: All treatments administered to the patient after the original diagnosis of cancer in an attempt to destroy or modify the cancer tissue. See below for detailed information on timing and treatment plan documentation requirements.
Hospice: A program that provides special care for people who are near the end of life and for their families, either at home, in freestanding facilities, or within hospitals. Hospice care may include treatment that destroys or modifies cancer tissue. If performed as part of the first course, treatment that destroys or modifies cancer tissue is collected when given in a hospice setting. “Hospice, NOS” is not specific enough to be included as first course treatment.
Neoadjuvant therapy: Systemic therapy or radiation therapy given prior to surgery to shrink the tumor.

Palliative treatment: The World Health Organization describes palliative care as treatment that improves the quality of life by preventing or relieving suffering.
           Note: Palliative therapy is part of the first course of therapy only when it destroys or modifies cancer tissue.
           Example: The patient was diagnosed with stage IV cancer of the prostate with painful bone metastases. The patient starts radiation treatment intended to shrink the tumor in the bone and relieve the intense pain. The radiation treatments are palliative because they relieve the bone pain; the radiation is also first course of therapy because it destroys proliferating cancer tissue.
Surgical procedure: Any surgical procedure coded in the data items Surgery of Primary Site 2023, Scope of Regional Lymph Node Surgery (excluding code 1), or Surgical Procedure of Other Site.
Treatment: Procedures that destroy or modify primary (primary site) or secondary (metastatic) cancer tissue.
Treatment failure: The treatment modalities did not destroy or modify the cancer cells. The tumor either became larger (disease progression) or stayed the same size after treatment.
Watchful waiting: Closely watching a patient’s condition but not giving treatment unless symptoms appear or change. Watchful waiting is sometimes used in conditions that progress slowly. It is also used when the risks of treatment are greater than the possible benefits. During watchful waiting, patients may be given certain tests and exams. Watchful waiting is sometimes used in prostate cancer. It is a type of expectant management. (Source: http://www.cancer.gov/dictionary?CdrID=45942)

Treatment Timing

Use the following instructions in hierarchical order

      1. Use the documented first course of therapy (treatment plan) from the medical record. First course of therapy ends when the treatment plan is completed no matter how long it takes to complete the plan unless there is documentation of disease progression, recurrence, or treatment failure (see #2 below).

           Example: Hormonal therapy (e.g., Tamoxifen) after surgery, radiation, and chemotherapy. First course ends when hormonal therapy is completed, even if this takes years, unless there is documentation of disease progression, recurrence, or treatment failure (see #2 below).

2. First course of therapy ends when there is documentation of disease progression, recurrence, or treatment failure

           Example 1: The documented treatment plan for sarcoma is pre-operative (neoadjuvant) chemotherapy, followed by surgery, then radiation or chemotherapy depending upon the pathology from surgery. Scans show the tumor is not regressing after pre-operative chemotherapy. Plans for                                   surgery are cancelled, radiation was not administered, and a different type of chemotherapy is started. Code only the first chemotherapy as first course. Do not code the second chemotherapy as first course because it is administered after documented treatment failure.

           Example 2: The documented treatment plan for a patient with locally advanced breast cancer includes mastectomy, chemotherapy, radiation to the chest wall and axilla, and hormone therapy. The patient has the mastectomy and completes chemotherapy. During the course of radiation                                      therapy, the liver enzymes are rising. Workup proves liver metastases. The physician stops the radiation and does not continue with hormone therapy (the treatment plan is altered). The patient is placed on a clinical trial to receive Herceptin for metastatic breast cancer.  Code only                               the first chemotherapy as first course. Do not code the second chemotherapy as first course because it is administered after documented treatment failure.

Coding Instructions

      1. Code all treatment data items to 0 or 00 (Not done) when the physician opts for active surveillance, deferred therapy, expectant management, or watchful waiting. When the disease progresses or the patient becomes symptomatic, any prescribed treatment is second course.

            a. Code Treatment Status (RX Summ--Treatment Status) to 2

      2. Code the treatment as first course of therapy if the patient refuses treatment but changes his/her mind and the prescribed treatment is implemented less than one year from the date of diagnosis, AND there is no evidence of disease progression

      3. The first course of therapy is no treatment when the patient refuses all treatment. Code all treatment data items to Refused.

            a. Keep the refused codes even if the patient later changes his/her mind and decides to have the prescribed treatment

                  i. more than one year after diagnosis, or

                  ii. when there is evidence of disease progression before treatment is implemented

      4. Code all treatment that was started and administered, whether completed or not. Document treatment discontinuation in text fields.

            Example: The patient completed only the first dose of a planned 30-day chemotherapy regimen. Code chemotherapy as administered.

      5. Code the treatment on each abstract when a patient has multiple primaries and the treatment given for one primary also affects/treats another primary

            Example 1: The patient had prostate and bladder cancer. The bladder cancer was treated with a TURB. The prostate cancer was treated with radiation to the prostate and pelvis. The pelvic radiation includes the regional lymph nodes for the bladder. Code the radiation as treatment for both                                  the bladder and prostate cases.

            Example 2: The patient had a hysterectomy for ovarian cancer. The pathology report reveals a previously unsuspected microinvasive cancer of the cervix. Code the hysterectomy as surgical treatment for both the ovarian and cervix primaries.

      6. Code the treatments only for the site that is affected when a patient has multiple primaries and the treatment affects only one of the primaries

            Example: The patient has colon and tonsil primaries. The colon cancer is treated with a hemicolectomy and the tonsil primary is treated with radiation to the tonsil and regional nodes. Do not code the radiation for the colon. Do not code the hemicolectomy for the tonsil.

      7. Code the treatment given as first course even if the correct primary is identified later when a patient is diagnosed with an unknown primary

            Example: The patient is diagnosed with metastatic carcinoma, unknown primary site. After a full course of chemotherapy, the primary site is identified as prostate. Code the chemotherapy as first course of treatment.

      8. Do not code treatment as first course when it is added to the plan after the primary site is discovered. This is a change in the treatment plan.

            Example: The patient is diagnosed with metastatic carcinoma, unknown primary site. After a full course of chemotherapy, the primary site is identified as prostate. Hormonal treatment is started. Code the chemotherapy as first course of treatment. The hormone therapy is second course                                   because it was not part of the initial treatment plan.

      9. For information regarding first course of therapy for hematopoietic and lymphoid neoplasms, refer to the NCI SEER Hematopoietic and Lymphoid Neoplasm Coding Manual.


Treatment Plan

A treatment plan describes the type(s) of treatment(s) intended to modify, control, remove, or destroy the malignancy. The documentation confirming a treatment plan may be fragmented.  It is frequently found in several different sources, i.e., medical record, clinic record, consultation reports, and outpatient records. All cancer-directed treatments specified in the physician(s) treatment plan are a part of the first course of therapy.

A treatment plan may specify only one method of treatment (i.e., surgery) or any combination of therapies (i.e., surgery, radiation therapy, chemotherapy, hormone therapy, immunotherapy, or other therapy). A single regimen includes the combination of concurrent or adjuvant treatments. All treatments specified in the treatment plan and delivered to the patient are first course of therapy.


Definitive Treatment

Definitive treatment usually modifies, controls, removes, or destroys proliferating cancer tissue. Treatment may be directed toward either the primary or metastatic sites. Physicians administer the treatment(s) to minimize the size of tumor, or to delay the spread of disease.

NOTE: Only definitive therapy should be included in statistical analyses of treatment. Surgical codes 00-07, and Other treatment code 0 must be excluded. These codes are not considered definitive therapy.

Palliative treatment is treatment that improves the patient’s quality of life by preventing or relieving suffering. Palliative therapy may include definitive treatment procedures as well as non-definitive patient care procedures. For example: The patient was diagnosed with stage IV cancer of the prostate with painful bony metastases. The patient starts radiation treatment intended to shrink the tumor in the bone and relieve the intense pain. The radiation treatments are palliative because they relieve the bone pain; the radiation is also first course of therapy because it destroys proliferating cancer tissue. Record any palliative treatment that modifies or destroys cancer tissue as first course therapy.

Non-Definitive Treatment (Non-treatment patient care procedures)

Non-definitive treatments prolong the patient's life, make the patient comfortable, or prepare the patient for definitive therapy. These treatments are not tumor directed. They are not meant to reduce the size of the tumor or delay the spread of disease. Non-definitive procedures include diagnostic procedures and supportive care (treatments designed to relieve symptoms and minimize the effects of the cancer). Non-definitive therapies are generally not used in statistical analysis of treatment.

EXAMPLES:

 Surgical procedures:

                Incisional biopsies

                Exploratory procedures with or without biopsies

 Supportive care/relieving symptoms:

                Palliative care, including surgery, radiation, and chemotherapy for symptom relief only

                Pain medication

                Oxygen

                Antibiotics administered for an associated infection

                Transfusions*

                Intravenous therapy to maintain fluid or nutritional balance

                Laser therapy directed at relieving symptoms

*NOTE: Coding Treatment for Hematopoietic Diseases:  For many of the newly reportable hematopoietic diseases, the principal treatment is another type of treatment that does not meet the usual definition that treatment "modifies, controls, removes or destroys proliferating cancer tissue.” Such treatments include phlebotomy, transfusions, and aspirin. In order to document that patients with hematopoietic diseases did have some medical treatment, SEER and the Commission on Cancer have agreed to record these treatments as First Course "Other Treatment” (code 1) for the hematopoietic diseases ONLY. A complete description of the treatment plan should be recorded in the text field for "Other Treatment” on the abstract. For more details, consult the Hematopoietic Database.