Synoptic Reporting and the Cancer Registry

Pathology specimens, radiology reports, and surgical reports are medical record documents that contain vital information for data collection in the cancer registry. Tumor size, location of malignancy, type of malignancy, and extent of disease are among the items collected from these physician reports.

For effective use of these reports, communication is critical. If they aren’t dictated clearly by the physician, the cancer registrar and other medical professionals who might potentially use the report will have a difficult time determining specific disease characteristics.  

Synoptic Reporting Becoming More Widely Adopted in the Cancer Registry

Synoptic reporting provides a more streamlined process than narrative text format for entering medical information into the medical record. It uses specific formatting that allows the physician to communicate clearly and concisely the type of procedure, findings, and other important tumor characteristics.

Apart from synoptic reporting, natural language processing (NLP) has also been used to parse meaning from narrative text format. It has a marked disadvantage in that it will reproduce physician errors entered in the initial narrative text. Synoptic reporting prevents errors at the physician input stage.  

See More

How to Become a Contract Medical Coder

Synoptic reporting has been used with College of American Pathologist protocols in Commission on Cancer accredited pathology departments at least since 2012. “CAP” checklists, as they are called, provide an easy to use, streamlined method of collecting specimen information that aids cancer registrars in coding disease-specific data items as well as staging.

^{Get Started Today}

Synoptic reporting is also being explored in radiological reports. A trial implementation by Cancer Care Ontario (CCO) collecting radiological data using synoptic reporting was conducted at a facility within the CCO’s Lung Cancer Screening Pilot for People at High Risk.

As of January 1^st, 2023, the Commission on Cancer is requiring certain primary site data items to be recorded in synoptic format within the medical record. These include breast sentinel lymph node biopsy for curative intent, wide local excision of melanoma for curative intent, and tumor location of colon resection.

New data items will be collected within the registry for cases diagnosed in 2022 that will detail breast surgical procedures as well as immediate reconstruction techniques.  They include type of breast surgical procedure and reconstruction performed at the registrar’s home facility as well as breast surgical procedure and reconstruction performed elsewhere. These data items will aid in future synoptic reporting implementation as well as with creation of new Site-Specific Disease Factors.

In summary, synoptic reporting helps both the treating physician and cancer registry with more quality inputs. In turn, the cancer registry supports synoptic reporting guidelines in providing information on surgical procedures and tumor characteristics. This is just one of the ways the cancer registry can help streamline the data collection process within and outside its database to provide more accurate information that can improve the quality of cancer patient care.

References

Hewer, E., (2020). The Oncologist’s Guide to Synoptic Reporting: A Primer Oncology and Informatics – Review; 98:396 402. https://www.karger.com/Article/FullText/500884

College of American Pathologists. (2022). Cancer Protocol Templates, College of American Pathologists.  https://www.cap.org/protocols-and-guidelines/cancer-reporting-tools/cancer-protocol-templates

Goel, A., DiLella, D., Dotsikas, G., Hilts, M., Kwan, D., Paxton, L., (2019). Unlocking Radiology Reporting Data: An Implementation of Synoptic Radiology Reporting in Low-Dose CT Cancer Screening. National Library of Medicine, National Center for Biotechnology Information, 32(6): 1044–1051. doi: 10.1007/s10278-019-00214-2

American College of Surgeons (2019). Optimal Resources for Cancer Care, 2020 Standards, Effective January 2020, Updated April 2022 [Electronic Manual]. American College of Surgeons

American College of Surgeons. (2021). STORE Standards for Oncology Registry Entry, Released 2022 [Electronic Manual]. American College of Surgeons.

Search Revenue Cycle Jobs

Additional Revenue Cycle Resources:

• Cancer Registry: Learn about Cancer Registry careers and opportunities.
• Case Management Utilization Review: Join a team pairing decades of Revenue Cycle knowledge with the support of one of healthcare’s most trusted brands.
• Refer-a-Friend: Make up to $2,000 per referral.