Complete Breast Cancer Diagnostic Procedures only if the breast screening results were abnormal and/or "Immediate Work-up" selected in the previous step.

Breast Cancer Diagnostic Procedures: Enter the date the diagnostic procedure was performed, not the date of the results.  If there are duplicate diagnostic procedures (e.g., two biopsies performed), enter the date of the most recent procedure. All dates should be entered using the following format: Month (MM)/Day (DD)/Year (CCYY). These dates must not be more than 30 days before the recipient’s certification date.

• Additional mammographic views: If additional views (e.g., spot compression, etc.) were performed, enter the date.
• Repeat Breast Exam/Surgical Consultation: If a repeat CBE or surgical consultation was performed, enter the date. If both were performed, enter the date of the surgical consultation.
• Ultrasound: If an ultrasound was performed, enter the date.
• Biopsy/Lumpectomy: If a biopsy or lumpectomy was performed, enter the date. If both were performed, enter the date of the procedure performed resulting in a final diagnosis.
• Fine needle/Cyst aspiration: If a fine needle aspiration or a cyst aspiration was performed, enter the date.
• Other procedure performed: If a diagnostic procedure not listed above was performed, enter the date.
• Specify: Enter a description of the other diagnostic procedure performed.
  • Enter only the following diagnostic procedures as an “Other Breast Diagnostic Procedure”:
    • MRI
    • CT scan
    • PET scan
    • Ductogram
    • Skin biopsy
    • Cannulization
    • C&S nipple discharge
    • CAD, chest X-ray
    • Galactogram
    • Bone scan
    • Sentinel lymph node biopsy
    • Other medical consults
  • Do not enter additional mammogram, CBE/surgical consult, ultrasound, biopsy/lumpectomy, fine needle/cyst aspiration or treatment as an “Other Breast Diagnostic Procedure.”
  • Please report any of the “Other Breast Diagnostic Procedures” even though they are not covered by Cancer Detection Programs: Every Woman Counts (CDP: EWC).

Complete Breast Cancer Diagnosis Status only if the breast screening results were abnormal and/or "Immediate Work-up" selected in the previous step.

Breast Cancer Diagnosis Status
(Select only one)

• Work-up complete: Select this if no immediate diagnostic procedures are needed to determine the diagnosis.  It is also appropriate to select "Work-up complete" if the recipient is advised to return for further evaluation (e.g., CBE, mammogram, etc.) in 3 to 6 months after current diagnostic procedures.
  • If work-up is complete, enter the date of this diagnostic status. Use the date of the diagnostic procedure used to complete the work-up.
  • In the next section, enter the Breast Cancer Final Diagnosis and date of the final diagnosis.
• Lost to follow-up (two phone calls and certified letter sent): Select this if the recipient is considered lost to follow-up before the definitive diagnostic procedures were performed. Three attempts must be made to contact the recipient.  The third contact attempt must be by certified letter.
• Work-up refused: Select this if the recipient refused to have diagnostic procedures performed, acquired insurance, moved out of the area, or changed PCP for any reason.
• Died before work-up completed: Select this if the recipient died before the diagnostic procedure(s) was performed.

If work-up was NOT complete (patient was Lost to Follow-up, Work-up Refused, or Died before work-up completed):

• Enter the date this was determined as the Date of this Diagnostic Status
• Enter the date this was determined as the Date of this Final Diagnosis.
• DO NOT select a Breast Cancer Final Diagnosis category. 

Date of this diagnostic status: Enter the date of the diagnostic status using the following format: Month (MM)/Day (DD)/Year (CCYY).  Use the date of the definitive diagnostic procedure as the date of this diagnostic status. This date must not be more than 30 days before the recipient’s certification date.

Complete Breast Cancer Final Diagnosis only if the breast screening results were abnormal and/or "Immediate Work-up" selected in the previous step.

Breast Cancer Final Diagnosis: A final diagnosis of breast cancer can only be determined by a pathology report from histologic examination of tissue/cells.  Select a final diagnosis if the Breast Cancer Diagnosis Status was “Work-up Complete.” 

• Not Cancer: Select this if cancer is not found during current diagnostic procedures.
• Cancer in situ (Ductal or Lobular not specified): Do not select Cancer in situ. If the pathology report indicates the diagnosis of breast cancer in situ, select lobular (LCIS) or ductal (DCIS) below. 
• Lobular Cancer in situ (LCIS) (AJCC Stage 0):  Select this if the pathology report indicates the diagnosis is lobular carcinoma in situ.
• Ductal Cancer in situ (DCIS) (AJCC Stage 0): Select this if the pathology report indicates the diagnosis is ductal carcinoma in situ.
  • Breast Cancer Treatment data is required for a final diagnosis of DCIS.
• Invasive Cancer: Select this if the pathology report indicates the diagnosis is invasive cancer. If the pathology report indicates both invasive and in-situ components, select “Invasive Cancer.” Select this also for Paget’s disease (of the nipple with no tumor).
  • Data for Invasive Breast Cancer Stage, Invasive Breast Cancer Tumor Size and Breast Cancer Treatment Status is required for a final diagnosis of Invasive Cancer.

Date of This Final Diagnosis: Enter the date of the diagnosis using the following format: Month (MM)/Day (DD)/Year (CCYY). This date must not be more than 30 days before the recipient’s certification date.

• Enter just the date of this final diagnosis for patients that are Lost to Follow-up, Refused service or Died before work-up completed.  Note:  A final diagnosis category is not required unless the Breast Cancer Diagnosis Status was “Work-up Complete.”

Complete Invasive Breast Cancer Stage only if the Breast Cancer Final Diagnosis is invasive breast cancer.

Invasive Breast Cancer Stage: Please refer to the National Cancer Institute Web site for the American Joint Committee on Cancer (AJCC) staging system:

Select one of the following AJCC stages if the woman has invasive breast cancer:

• AJCC Stage I
• AJCC Stage II
• AJCC Stage III
• AJCC Stage IV
• Stage unknown
  • Select “Stage unknown” if the pathology report indicates invasive cancer and the stage is not available from any source (e.g., surgeon, oncologist, pathologist, etc.). 
  • Select “Stage unknown” for diagnosis of malignant phyllodes.

Complete Breast Cancer Tumor Size only if the Breast Cancer Final Diagnosis is invasive breast cancer.

Invasive Breast Cancer Tumor Size: The tumor size is based on surgical reports, pathology reports, biopsy reports and clinical or radiologic exams.

• 0 to ≤ 1 cm: Select this if the tumor is no more than 1 cm in its greatest dimension.
• > 1 to ≤ 2 cm: Select this if the tumor is greater than 1 cm and less than or equal to 2 cm in its greatest dimension.
• > 2 to ≤ 5 cm: Select this if the tumor is greater than 2 cm and less than or equal to
  5 cm in its greatest dimension.
• > 5 cm: Select this if the tumor is greater than 5 cm in its greatest dimension.
• Unknown: Select this only if the tumor size is not available from any source.
  • Select "Unknown" tumor size for diagnosis of inflammatory breast cancer.

Complete Breast Cancer Treatment Status if Breast Cancer Final Diagnosis is invasive cancer or DCIS.

Breast Cancer Treatment Status

• Treatment initiated: Select this if the clinic staff can verify from the recipient or treatment facility that treatment has been initiated.
• Referred for treatment (pending): Do not select Referred for treatment. A referral for treatment is not sufficient confirmation that treatment has been initiated.  Data submission is not complete if "Referred for treatment" is selected. 
• Lost to follow-up (two phone calls and certified letter): Select this if the recipient did not begin treatment and the clinic staff cannot locate the recipient.  Three attempts must be made to contact the recipient.  The third attempt must be by certified letter.
• Treatment refused: Select this if the recipient refused treatment.  Select this if the recipient only received non-standard or alternative treatments. 
• Treatment not needed: Select this if the medical provider and recipient agree that treatment would adversely affect the woman’s quality of life (with late or end-stage cancers) and that treatment is not recommended or needed at this time.
• Died before entering treatment: Select this if the recipient died before beginning treatment.

Date of this treatment status: Enter the date when treatment was initiated or other treatment status was determined using the following format: Month (MM)/Day (DD)/Year (CCYY). This date must not be more than 30 days before the recipient’s certification date.