Ambiguous Terminology Lists: References of Last Resort
The purpose of this communication is to clarify the use of Ambiguous Terminology as listed in FORDS: Revised for 2016 for case reportability and staging in Commission on Cancer (CoC)-accredited programs. When abstracting, registrars are to use the “Ambiguous Terms at Diagnosis” list with respect to case reportability, and the “Ambiguous Terms Describing Tumor Spread” list with respect to tumor spread for staging purposes. However, these lists need to be used correctly.
The first and foremost resource for the registrar for questionable cases is the physician who diagnosed and/or staged the tumor. The ideal way to approach abstracting situations when the medical record is not clear is to follow up with the physician. If the physician is not available, the medical record, and any other pertinent reports (e.g., pathology, etc.) should be read closely for the required information. The purpose of the Ambiguous Terminology lists is so that in the case where wording in the patient record is ambiguous with respect to reportability or tumor spread and no further information is available from any resource, registrars will make consistent decisions. When there is a clear statement of malignancy or tumor spread (i.e., the registrar can determine malignancy or tumor spread from the resources available), they should not refer to the Ambiguous Terminology lists. Registrars should only rely on these lists when the situation is not clear and the case cannot be discussed with the appropriate physician/pathologist.
The CoC recognizes that not every registrar has access to the physician who diagnosed and/or staged the tumor, as a result, the Ambiguous Terminology lists continue to be used in CoC-accredited programs and maintained by CoC as "references of last resort".
Kathleen K. Thoburn, CTR
Manager, Information & Data Standards
National Cancer Data Base
For information on the NCDB Call for Data: