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Understanding EOD Changes and Guidelines in Cancer Staging

EOD, developed by NCI-SEER, was a key tool in cancer staging from 1977 to 2003, capturing tumor size, extension, and lymph node involvement. The transition to Collaborative Stage in 2004 brought changes, with SEER EOD serving as an epidemiological tool. This summary covers EOD timing rules, general guidelines, and schema-specific instructions for coding primary tumors, lymph nodes, and metastases.

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Understanding EOD Changes and Guidelines in Cancer Staging

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  1. 2018 Data Changes Mignon Dryden, CTR April 11, 2018 Region 5 Educational Meeting

  2. What we’ll cover:  EOD  Summary Staging 2018  SSDI – Site Specific Data Items  New Grade Codes

  3. EOD – Extent of Disease  History of EOD  EOD 2018 Structure & Schemas  General Coding Guidelines/Instructions  Core Data Items

  4. History of EOD EOD Developed by NCI-SEER and in use between 1977 – 2003  Original data items: Tumor Size Extension (included mets) Lymph Nodes (included distant LNs)  Previously collected by SEER registries prior to CS

  5. History of EOD  SEER EOD was used as the foundation of Collaborative Stage Result of concerted efforts to create a crosswalk between TNM/EOD/SS2000 EOD coding schemes built into CS CS used complex algorithms to derive values for each system  CS was implemented in 2004 and EOD was discontinued  CS in use 2004 to 2015 (some SEER registries continued to collect until 2017

  6. EOD and TNM  AJCC Staging is used as a clinical tool and, as such, is continually undergoing changes and adjustments to reflect the most current medical knowledge.  Each TNM edition includes sections on how the new improved edition reflects a better understanding of tumor characteristics and factors that are prognostically related.  SEER EOD has been an epidemiological tool used to track cancer incidence, particularly in specified populations. SEER EOD was carefully developed and remained constant so that studies can look at data over time, and tumor characteristics could be compared over time.

  7. EOD Timing Rules  EOD should include all information available within 4 months of diagnosis in the absence of disease progression or through completion of surgeries in first course of treatment, whichever is longer.  Mets known to have developed after EOD was established should be excluded.

  8. EOD Timing Rules  EOD Timing Rules do not necessarily line up with the rules for first course of treatment.  First course of therapy is coded independently of EOD/Staging. Different guidelines apply.  Planned treatment is counted as first course therapy, even if the disease progresses before the planned therapy is completed.

  9. EOD Timing Rules and First Course of TX  Example: Breast cancer case was staged as confined to breast at the time EOD was established in July 2017 and radiation therapy to chest wall was planned. Subsequently, brain metastasis was found in August. Radiation therapy to the chest wall was administered in October.

  10. EOD Timing Rules and First Course of TX  The chest wall irradiation carried out in October is counted as first course treatment because it was planned.  If radiation therapy to the brain mets is administered, that would be a change in the therapy plan and the radiation therapy would be counted as second course of therapy.

  11. EOD General Rules  EOD schemas apply to ALL primary sites and specified histologies.  Most schemas are based on primary site.  Some schemas are based on histology alone.

  12. EOD General Guidelines  Gross observations at surgery are particularly important when all malignant tissue is not removed.  For example, a colon cancer resection may transect the tumor. It is important to observe any tumor tissue that may still be remaining at the end of the procedure, for example, tumor tissue adherent to the abdominal wall.  EOD Extension is coded accordingly.  In the event of a discrepancy between path and op report findings concerning excised tissue, priority is given to path report.

  13. EOD General Guidelines  EOD information obtained after neoadjuvant treatment has started may be used, but would only be used if it was greater than pre-treatment clinical findings.

  14. EOD General Guidelines  Clinical information, such as description of skin involvement for breast cancer and distant lymph nodes for any site, can change the EOD stage.  If the op/path information disproves the clinical information, use the op/path information.

  15. Non-Definitive Ambiguous Terminology  TNM Staging information can be used to code EOD 2018 when it is the only information available.  Use the medical record documentation to assign EOD when there is a discrepancy between TNM information and the documentation in the medical record.  EOD 2018, unlike Collaborative Stage, does not offer the TNM, NOS, options for coding. For example, there is no option for:  “Stated as T2 with no other information on extension.”

  16. EOD General Guidelines  EOD Schema-Specific guidelines take precedence over general guidelines  (just as in SEER Summary Stage and TNM Staging)

  17. EOD Data Items  Primary Tumor  Regional Lymph Nodes  Metastases

  18. EOD Primary Tumor  EOD Primary tumor is used to classify contiguous growth (extension) of the primary tumor within the organ of origin or its direct extension into neighboring organs.  Code the farthest documented extension of tumor away from the primary site.  A “localized, NOS” code is provided for those cases in which the only description is “localized with no further information.” “NOS” codes should be used only after an exhaustive search for more specific information.

  19. EOD Primary Tumor  In situ : Assign code 000  Exception: For some schemas , e.g., breast, there may be multiple categories of in situ codes.  Example:  Breast Primary Tumor  000 In situ : noninfiltrating; intraductal  050 Paget disease of nipple without underlying tumor  070 Paget disease of nipple with underlying DCIS

  20. EOD Primary Tumor  In the past, if only in situ tumor was identified in the primary site, but there was met involvement, we assumed that the area of invasion had been missed and we assigned a code that represented localized disease.  SEER EOD 2018:  In the case of an in-situ primary tumor with met involvement –assign EOD primary tumor as in situ and code EOD Mets appropriately.

  21. EOD Primary Tumor  For cases in which no primary tumor is found:  Use code 800: No evidence of primary tumor

  22. EOD Regional Lymph Node  EOD Regional Node is used to classify the regional lymph nodes involved with cancer at the time of diagnosis.  Record the specific involved regional lymph node chain(s) farthest from the primary site. Regional lymph nodes are listed for each schema.

  23. EOD Regional Lymph Node  Lymph node chains categorized as regional lymph nodes in EOD 2018 match the categories described by AJCC Staging.  Lymph nodes categorized as regional in EOD 2018 do not necessarily match the regional lymph node groups described in previous versions of EOD (1977- 2003).  They also do not match the site-specific regional lymph node groups described in SEER Summary Stage 2000.

  24. EOD Regional Lymph Node  Example: For breast cancer cases,  In EOD 2018, supraclavicular lymph nodes are counted as regional lymph nodes.  In SEER Summary Stage 2000 and previous SEER EOD schemes, supraclavicular lymph nodes are not counted as regional lymph nodes. They are categorized as distant lymph nodes.

  25. EOD Regional Lymph Node  Isolated Tumor cells (ITCs):  For some schemas, ITCs are counted as positive regional nodes, while other schemas count them as negative.  See the individual schemas to determine how to code ITCs.

  26. EOD Metastases  EOD Metastases is used to classify the distant site(s) of metastatic involvement at time of diagnosis.  Determination of EOD Mets requires only a History and Physical Exam. Imaging of distant organs is not required. In other words, the registrar can infer that there are no distant metastases based solely on PE documentation.

  27. EOD Metastases  For a few schemas such as Breast, Lung, Kidney, and Ovary, the EOD Mets category may include direct extension of the primary tumor into distant organs or tissues.  If the structure involved by direct extension is not listed in EOD Primary Tumor, look for the structure in EOD Mets.

  28. EOD Metastases  For a few schemas such as Breast, Lung, Kidney, and Ovary, the EOD Mets category may include direct extension of the primary tumor into distant organs or tissues.  If the structure involved by direct extension is not listed in EOD Primary Tumor, look for the structure in EOD Mets.  Example: Breast  SEER EOD Mets:  70 Skin over axilla Contralateral breast Sternum Upper abdomen

  29. Site Specific EOD  Some of the data elements included in the previous versions of SEER EOD were pulled out and recorded as Site Specific Factors in Collaborative Stage.  They have been added back and are now included in EOD fields.  Example: Lung  In Collaborative Stage:  CS Site Specific Factor 1 described  Separate Tumor Nodules in the Ipsilateral Lung

  30. Site Specific EOD  In EOD 2018:  Separate tumor nodules in the ipsilateral lung are coded under Primary Tumor Extension  EOD Primary Tumor Note 4: Separate ipsilateral tumor nodules are coded either 500 (same lobe) or 700 (different ipsilateral lobe)

  31. Summary Stage 2018

  32. Summary Stage 2018  Summary Stage is the most basic way of categorizing how far a cancer has spread from its point of origin.  The 2018 version of Summary Stage applies to every anatomic site, including lymphomas and leukemias.

  33. Summary Stage 2018  Timeframe: includes all information available through completion of surgery(ies) in the first course of treatment or within four months of diagnosis in the absence of disease progression, whichever is longer.  Based on combined clinical and operative/pathological assessment.

  34. Summary Stage 2018 Code 0 1 2 3 4 5 7 8 9 Definition In situ Localized only Regional by direct extension only Regional lymph nodes only Regional by BOTH direction extension AND lymph node involvement Regional, NOS (Not Otherwise Specified) Distant site(s)/node(s) involved Benign/borderline* Unknown if extension or metastasis (unstaged, unknown, or unspecified) Death certificate only case

  35. In Situ  An in situ diagnosis can only be made microscopically, because a pathologist must identify the basement membrane and determine that it has not been penetrated.  Pathologists have many ways of describing in situ cancer, such as non- invasive, pre-invasive, non-infiltrating, intra-epithelial, Stage 0, intraductal, intracystic, no stromal invasion, and no penetration below the basement membrane.  Organs and tissues that have no epithelial layer cannot be staged as in situ, since they do not have a basement membrane (e.g., soft tissues, connective tissue).

  36. Localized  Limited to the site of origin  Has spread no farther than the site of origin in which it started  Important to know and recognize the names of different structures within the organ (such as lamina propria, myometrium, muscularis) so that a description of invasion or involvement of these structures will not be interpreted as regional spread.

  37. Regional by Direct Extension Only  For primary sites that have “walls” (e.g. colon, rectum) invasion through entire wall of organ into surrounding organs and/or adjacent tissues, direct extension or contiguous spread. For those primary sites without defined walls when the tumor has spread beyond the primary site or capsule into adjacent structures.

  38. Regional by Lymph Nodes Only  Regional lymph nodes are listed for each schema/site.  For lymphomas, any mention of lymph nodes is indicative of involvement and is used to determine the number and location of lymph node chains involved (see Lymphoma scheme).  For solid tumors, the terms “fixed” or “matted” and “mass in the mediastinum, retroperitoneum, and/or mesentery” (with no specific information as to tissue involved) are considered involvement of lymph nodes.

  39. Regional to Lymph Nodes Only  Terms such as “palpable”, “visible swelling”, and “shotty” should be ignored. Look for a statement of involvement, either clinical or pathological. Terms such as “palpable,” “enlarged,” “visible swelling,” “shotty,” or “lymph- adenopathy” may be used to include involvement IF there is a statement of involvement by the clinician, or patient was treated as though regional nodes were involved. If these terms are used and there is no treatment to indicate lymph nodes are involved, then code none (000).

  40. Regional by Lymph Nodes Only  The terms “homolateral” and “ipsilateral” are used interchangeably. Any unidentified nodes included with the resected primary site specimen are to be considered as “Regional Lymph Nodes, NOS.”

  41. Regional by Lymph Nodes Only  If the only indication of lymph node involvement in the record is the physician’s statement of an N category from the TNM staging system or a stage from a site-specific staging system, use that information to code regional lymph node involvement.  If there is a discrepancy between documentation in the medical record and the physician’s assignment of TNM, the documentation takes precedence. Cases of this type should be discussed with the physician who assigned the TNM.

  42. Reginal by Lymph Nodes Only  If there is a discrepancy between documentation in the medical record and the physician’s assignment of TNM, the documentation takes precedence. Cases of this type should be discussed with the physician who assigned the TNM.

  43. Regional by Lymph Nodes Only  Note: Regional lymph nodes are not palpable for inaccessible sites such as bladder, kidney, prostate, esophagus, stomach, lung, liver, corpus uteri and ovary. The best description concerning regional lymph nodes will be the surgeon’s evaluation at the time of exploratory surgery or definitive surgery.

  44. Regional by Direct Extension & LN’s  A combination of direct extension and regional lymph node involvement.

  45. Regional NOS  Regional, NOS (Not Otherwise Specified).  Used when it is unclear whether the tissues are involved by direct extension or lymph nodes, or when the other categories are not applicable, such as for staging Non-Hodgkin and Hodgkin lymphoma of more than one lymph node region.  Regional, NOS is used for very few schemas, some of which include lymphomas, melanoma skin, brain, and CNS other.

  46. Distant  Distant metastases are tumor cells that have broken away from the primary tumor, have travelled to other parts of the body, and have begun to grow at the new location.  Distant stage is also called remote, diffuse, disseminated, metastatic, or secondary disease. The point is that in most cases there is no continuous trail of tumor cells between the primary site and the distant site.

  47. Distant  Cancer cells can travel from the primary site in any of four ways:  Extension from primary organ beyond adjacent tissue into next organ; for example, from the lung through the pleura into bone or nerve.  Travel in lymph channels beyond the first (regional) drainage area.  Hematogenous or blood-borne metastases.  Spread through fluids in a body cavity. Also called implantation or seeding metastases.

  48. Distant  Common sites of distant spread are liver, lung, brain, and bones, but they are not listed specifically for each scheme.  However, if the primary site is adjacent to the liver, lung, brain or bone, it is important to review the summary stage scheme for the primary site to assure that the stage is not regional by direct extension.  Example: liver involvement from a primary in the gallbladder.  This is likely regional by direct extension rather than distant stage, since the gallbladder is adjacent to liver. Read the diagnostic imaging reports to determine whether the cancer involves the surface of the secondary organ, which would be regional by direct extension, or whether the cancer is inside the secondary organ.

  49. Distant  Hematopoietic, reticuloendothelial, immunoproliferative, and myeloproliferative neoplasms are considered distant except as noted in the stage scheme.

  50. Benign/Borderline  Benign/borderline neoplasms are collected only for Brain, CNS Other and Intracranial Gland schemas. No other schemas include a code 8.

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