Complete Cervical Cancer Diagnostic Procedures if there were abnormal (*) cervical screening results and/or Immediate Work-up selected in the previous step.

Cervical Cancer Diagnostic Procedures: Enter the date the diagnostic procedure was performed, not the date of the results. 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.

• Colposcopy without biopsy (date): If a colposcopy without biopsy was performed, enter the date.
• Colposcopy directed biopsy (date): If a colposcopy directed biopsy was performed, enter the date.
• Other procedure performed (date): If a diagnostic procedure not listed above was performed, enter the date.
• Specify: Enter a description for the additional diagnostic procedure performed.
  • Enter only the following diagnostic procedures as an “Other Procedure”:
    • Endocervical curettage (ECC)
    • Excision of endocervical polyps
    • Endometrial biopsy (EMB)
    • Diagnostic conization
    • Biopsy of other structures such as the vagina and vulva
    • Cervicography
    • Loop electrocautery excision procedure (LEEP)
    • HPV testing

• Please report any of the procedures listed above even though they are not covered by Cancer Detection Programs: Every Woman Counts (CDP: EWC).
• Do not enter colposcopy without biopsy, colposcopy with biopsy, Pap smear test results or treatment (e.g., cryosurgery, hysterectomy, etc.) as an “Other Cervical Cancer Diagnostic Procedure.”  Pap smear test results should only be submitted using a Cervical Cancer Screen form.

Complete Cervical Cancer Diagnosis Status if there were abnormal (*) cervical screening results and/or Immediate Work-up selected in the previous step.

Cervical Cancer Diagnosis Status (Check One)

• Work-up complete: Select this if there are no further immediate diagnostic procedures 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., repeat Pap smear test) 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 Cervical Cancer Final Diagnosis and date of this diagnosis.
• Lost to follow-up (two phone calls and certified letter sent): Select this if the recipient did not follow-up before the definitive diagnostic procedures were performed.  Three attempts must be made to contact the recipient.  The third attempt must be by certified letter.
• Diagnostic 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 Cervical Cancer Final Diagnosis category. 

Date of this diagnostic status (date): Enter the date of this 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 Cervical Cancer Final Diagnosis if there were abnormal (*) cervical screening results and/or Immediate Work-up selected in the previous step.

Cervical Cancer Final Diagnosis (Check One): Select the diagnosis that most closely documents the reported result of the cervical final diagnosis. The final diagnosis of cervical cancer is usually determined by a pathology report from histologic examination of tissue/cells.  Select a Cervical Cancer Final Diagnosis if Cervical Cancer Diagnosis Status was “Work-up complete.”

Note: DO NOT submit a repeat Pap smear result on the Cervical Cancer Follow-up form.

• Normal/benign reaction:
  • Select this if the colposcopic examination is normal and the entire squamocolumnar junction is seen.
  • Select this if the biopsy results are negative and the endocervical curettage is negative. 
• HPV/condylomata/atypia: Select this when the cytology report notes cellular changes associated with the human papilloma virus (HPV) and no higher-grade atypia.
• CIN I (biopsy diagnosis): Select this when the pathology report notes findings consistent with a low-grade squamous intraepithelial lesion (LSIL) or cervical intraepithelial neoplasia (CIN I).
• CIN II (biopsy diagnosis): Select this if the pathology report indicates findings consistent with a high-grade squamous intraepithelial lesion (HSIL), moderate dysplasia or cervical intraepithelial neoplasia (CIN II).
  • Cervical Cancer Treatment data is required.
• CIN III/carcinoma in situ (biopsy diagnosis): Select this if the pathology report indicates findings consistent with severe dysplasia, cervical intraepithelial neoplasia (CIN III), or carcinoma in situ.
  • Cervical Cancer Treatment data is required.
• Invasive cervical carcinoma (biopsy diagnosis): Select this if the pathology report indicates invasive carcinoma.
  • Invasive Cervical Cancer Stage and Cervical Cancer Treatment data is required.

Complete Cervical Cancer Final Diagnosis if there were abnormal (*) cervical screening results and/or Immediate Work-up selected in the previous step.

• Other (specify): Select this if the pathology report indicates a different cancer or if the result is not listed above.  Enter a description of the result in the space provided.
  • Enter the following diagnoses as an “Other” Cervical Cancer Final Diagnosis:
    • HSIL (biopsy result)
    • LSIL (biopsy result)
    • Cervical polyps
    • Adenocarcinoma of the cervix
    • Vaginal intraepithelial neoplasia (VAIN)
    • Vulvar intraepithelial neoplasia (VIN)
    • Other cancers of the endometrium, vagina, ovaries or vulva (including primary and metastatic disease)
  • Do not submit a repeat Pap smear test result as an “Other” Cervical Cancer Final Diagnosis.

Date of the final diagnosis (date box): Enter the date of this 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.

Complete Invasive Cervical Cancer Stage only if the Cervical Cancer Final Diagnosis is invasive cervical carcinoma.

Please refer to the National Cancer Institute Web site for the American Joint Committee on Cancer (AJCC) or Federation Internationale de Gynecologie et d’Obstetrique (FIGO) staging system:

Select one of the AJCC/FIGO stages if the woman has invasive cervical carcinoma:

• AJCC Stage I/FIGO Stage 1
• AJCC Stage II/FIGO Stage 2
• AJCC Stage III/FIGO Stage 3
• AJCC Stage IV/FIGO Stage 4
• Stage unknown
  • Select "Stage unknown" only if the pathology report indicates invasive cervical carcinoma and the stage is not available from any source (e.g., surgeon, oncologist, pathologist, etc.). 

Complete Cervical Treatment Status if Cervical Cancer Final Diagnosis is CIN II, CIN III/carcinoma in situ, HSIL or invasive cancer.

Cervical Cancer Treatment Status (Check One):

• Treatment Initiated: Select this if the recipient accepted a referral for treatment and the clinic staff can verify from either 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.  If the recipient only receives non-standard or alternative treatments, select “Treatment refused.”
• 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.