Figure 29: Breast Cancer Screening Cycle Data online form

Clinical Breast Exam (CBE)

CURRENT Breast Symptoms: Select the appropriate response from the drop-down list.

• Yes: Select if the recipient reports any breast symptoms.
• No: Select if the recipient does not report breast symptoms.
• Unknown: Select if (1) the recipient wasn’t asked; (2) the answer wasn’t recorded; (3) the recipient does not know; or (4) the recipient refused to answer.

Examples of breast symptoms include:

• Discrete mass/lump
• Non-cyclical breast pain
• Spontaneous unilateral nipple discharge
• Skin scaliness
• Skin dimpling or puckering
• Skin ulceration
• Skin inflammation

CURRENT CBE Results: Select the CBE result from the drop-down list that corresponds to the result of the CBE or reason if a CBE was not performed.

• Normal: Select if the CBE was performed and the finding was within normal limits.
• Benign findings: Select if the CBE revealed a finding not of concern for breast cancer.
• Abnormality, suspicious for cancer: Select if the CBE revealed a finding that is suspicious for breast cancer and requires an immediate diagnostic procedure, in addition to the initial mammogram, to rule out breast cancer.
• Not needed: Select if the recipient had a normal CBE within the last 12 months or per PCP discretion.
• Needed but not performed at this visit (includes refused);
  • Select if the recipient is due for a CBE but one was not performed.
  • Select if recipient refused examination or if due to other unknown reasons, the CBE was not performed.

Note: For a screening CBE with abnormal results and negative/benign mammogram result, complete and submit breast cancer diagnostic procedure(s), work-up status, final diagnosis and treatment status, as required.

Date of CURRENT CBE: Enter the date of the current CBE, using the following format: MM/DD/YYYY.

Current Results obtained from a non-CDP program provider: Select this box if the CBE results reported above have been obtained from a non-CDP provider (e.g., an outside provider and/or not paid by CDP: EWC).

Mammogram

PREVIOUS Mammogram: Select the appropriate response from the drop-down list.

• Yes – Date known: Select if the recipient has had a previous mammogram and date is known.
• Yes – Date unknown: Select if the recipient has had a previous mammogram and date is unknown.
• No: Select if the recipient has not had a previous mammogram.
• Unknown – The recipient doesn’t know: Select if the recipient does not know if she has had a previous mammogram.
• Unknown – The recipient wasn’t asked/recorded: Select if PCP did not ask the recipient or if recipient’s answer was not recorded.
• Unknown – The recipient refused to answer: Select if the recipient refused to answer the question.

Date of PREVIOUS Mammogram:

• Enter the month and year of the recipient’s initial mammogram from the prior cycle, using the following format: MM/YYYY.
• If the month of the previous mammogram is not known, enter the year only and leave the month blank.
• If the year of the previous mammogram is not known, select Yes - Date Unknown in the PREVIOUS Mammogram field.

• Reason for CURRENT Mammogram: Select the reason for starting a breast cancer screening cycle from the drop-down list.
• Routine screening mammogram: Select if the current mammogram was performed as part of a routine or annual screening schedule.
• Initial mammogram for symptoms, abnormal CBE, or previous abnormal mammogram: Select if the current mammogram was performed as evaluation of current symptoms or abnormal CBE finding or as additional evaluation of a recent mammogram prior to this cycle.
• No initial mammogram. CBE only or sent to other imaging or diagnostics: Select if the recipient received only a CBE; or if the current mammogram was not performed and recipient goes directly for diagnostic procedures. Select this if the recipient refuses to have a mammogram.
• Initial mammogram not paid by CDP. Client referred for diagnostics only: Select if the current mammogram was not paid by CDP: EWC (e.g., FPACT) and the recipient was enrolled into CDP: EWC for diagnostic procedures

Note: The initial mammogram could be a screening or diagnostic mammogram.

Breast Diagnostic Referral Date: If the current mammogram was not performed, enter the date of the CBE or first imaging/diagnostic procedure, whichever was done first. Enter the date using the following format: MM/DD/YYYY.

CURRENT Mammogram Result: Select the mammogram result that corresponds to the reported “Final Result” of the initial mammogram (screening or diagnostic) from the drop-down list.

• Negative (BI-RADS 1): Select if the assessment was negative.
• Benign (BI-RADS 2): Select if the assessment was benign.
• Probably Benign (BI-RADS 3): Select if the assessment was probably benign. Probably benign findings have a high probability of being benign. Further clinical evaluation must be completed for a probably benign mammogram.
  • If there is an immediate clinical evaluation:
    • Select Immediate Work-up as the Additional Procedures Needed to Complete Breast Cycle field.
    • Complete and submit breast cancer diagnostic procedure(s), work-up status, final diagnosis and treatment status, as required.
• Suspicious Abnormality (BI-RADS 4): Select if the assessment was suspicious abnormality. This indicates the findings do not have the characteristic morphology of breast cancer but do have a strong probability of being cancer.
  • Select Immediate Work-up as the Additional Procedures Needed to Complete Breast Cycle field.
  • Complete and submit breast cancer imaging and/or diagnostic procedure(s), work-up status, final diagnosis and treatment status, as required.
• Highly Suggestive of Malignancy (BI-RADS 5): Select if the assessment was highly suggestive of malignancy. These finding(s) have a high probability of being cancer.
  • Select Immediate Work-up in the Additional Procedures Needed to Complete Breast Cycle field.
  • Complete and submit breast cancer imaging and/or diagnostic procedure(s), work-up status, final diagnosis and treatment status, as required.
• Assessment is Incomplete (BI-RADS 0) – Needs more imaging: Select if the assessment was incomplete and requires additional imaging evaluation. No final assessment can be assigned due to incomplete radiologic work-up.
  • Select Immediate Work-up in the Additional Procedures Needed to Complete Breast Cycle field.
  • Complete and submit the breast cancer imaging and/or diagnostic procedure(s), work-up status, final diagnosis and treatment status, as required.
• Assessment is Incomplete (BI-RADS 0) – Needs film comparison: Select if the assessment was incomplete and requires review of prior mammograms. No final assessment can be assigned due to incomplete radiologic work-up.
  • Select Immediate Work-up in the Additional Procedures Needed to Complete Breast Cycle field.
  • Complete and submit the breast cancer imaging and/or diagnostic procedure(s), work-up status, final diagnosis and treatment status, as required.
• Unsatisfactory: Select this if the assessment was unsatisfactory.
  • Select Short Term Follow-Up in the Additional Procedures Needed to Complete Breast Cycle field.
  • After the repeat mammogram is completed, submit repeated mammogram using a new Breast Cancer Screening Cycle Data form.

Date of CURRENT Mammogram: Enter the date of the recipient’s initial mammogram using the following format: MM/DD/YYYY.

Additional Procedures Needed to Complete Breast Cycle

Additional Procedures Needed to Complete Breast Cycle: Select one from the drop-down list.

• Not needed or planned - Routine rescreen:
  • Select this when both the CBE and mammogram are normal/benign.
  • Submit next breast screening (CBE and mammogram) using a new Breast Cancer Screening Cycle Data form.
• Not needed or planned - Short-term follow-up:
  • Select this when additional diagnostic procedures/exams are required after a planned delay but within the next 12 months.
  • Submit next procedure(s)/exam(s) using a new Breast Cancer Screening Cycle Data form.
• Needed or planned – Immediate work-up:
  • Select this when additional diagnostic procedures are required without delay to rule out breast cancer.
  • Same-day ultrasound is considered an immediate work-up.
  • Complete and submit breast cancer diagnostic procedures, work-up status, final diagnosis and treatment status, as required.

Breast Imaging Procedures

Complete Breast Imaging and Diagnostic Procedures only if the breast screening results were abnormal and/or “Immediate Work-up” is selected in the Additional Procedures Needed to Complete Breast Cycle field.

Type of Procedure: Select procedure performed from the drop-down list.

Additional Mammographic Views: If additional views (e.g., spot compression, etc.) were performed, enter the date.

• Ultrasound: If an ultrasound was performed, enter the date.
• Film Comparison to evaluate an Assessment Incomplete: If comparison to previous mammogram performed, enter the date of the addendum report.

Date of Procedure: Enter the date the imaging procedure was performed, not the date of the results. All dates should be entered using the following format: MM/DD/YYYY.

Add: Double click the Add button after selecting each imaging procedure from the drop-down list and entering the date of imaging procedure. The procedure will not be saved if the Add button is not clicked.

Note: Report all imaging procedures performed. Multiple entries including the same procedure are allowed.

Remove: Highlight the procedure you would like to remove from the list, and click Remove button.

Final Imaging Outcome: Select the final imaging outcome from the drop-down list that corresponds to the reported final overall assessment based on all imaging procedures.

• Negative (BI-RADS 1)
• Benign Finding (BI-RADS 2)
• Probably Benign (BI-RADS 3)
• Suspicious Abnormality (BI-RADS 4)
• Highly Suggestive of Malignancy (BI‑RADS 5)
• Unsatisfactory – Radiologist could not read; no final outcome

Date of Final Imaging Outcome: Enter the date of the final imaging outcome using the following format: MM/DD/YYYY. Use the date of the last diagnostic procedure as the date of this final imaging outcome.

Note: If MRI provides the definitive final imaging outcome, please enter results of MRI as the Final Imaging Outcome, using the date of the MRI as the Date of Final Imaging Outcome.  Also, select MRI in Other Breast Procedure Performed.

Breast Diagnostic Procedures

Complete Breast Imaging and Diagnostic Procedures only if the breast screening results were abnormal and/or “Immediate Work-up” is selected in the Additional Procedures Needed to Complete Breast Cycle field.

Type of Procedure: Select type of diagnostic procedure performed from the drop-down list.

• Repeat Breast Exam: If a repeat CBE was performed, enter the date.
• Surgical Consultation: If a surgical consultation 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.

Date of Procedure: Enter the date the diagnostic procedure was performed, not the date of the results. All dates should be entered using the following format: MM/DD/YYYY.

Add: Double click the Add button after selecting each diagnostic procedure from the drop-down list and entering date of diagnostic procedure. The procedure will not be saved if the Add button is not clicked.

Note: Report all diagnostic procedures performed. Multiple entries including the same procedure are allowed.

Remove: Highlight the procedure you would like to remove from the list and click Remove.

Other Breast Procedure Performed: Select only one diagnostic procedure, which can provide a diagnosis of cancer or not cancer as an “Other Breast Diagnostic Procedure.”

If a diagnostic procedure not listed in the Type of Procedure drop-down list was performed, select applicable option below. Select procedure performed, even if not covered by CDP: EWC.

• MRI
• Skin Biopsy
• Other medical consults
• Other – Please specify

Note: If MRI provides the definitive final imaging outcome, please enter results of MRI as the Final Imaging Outcome and use the date of the MRI as the Date of Final Imaging Outcome.

Date of Other Procedure: Enter the date the other diagnostic procedure was performed, not the date of the results. All dates should be entered using the following format: MM/DD/YYYY.

Specify “Other” Procedure: Enter a description of the other diagnostic procedure performed.

• Please report an “Other Breast Diagnostic Procedure” even though it may not be covered by CDP: EWC.
• Do not enter the following as “Other Breast Diagnostic Procedure,” as they are already listed on the form:
• additional mammogram
• repeat CBE
• surgical consult
• ultrasound
• biopsy/lumpectomy
• fine needle/cyst aspiration
• Do not enter the following as “Other Breast Diagnostic Procedure:”
• CT scan
• PET scan
• Ductogram
• Chest X-Ray
• Galactogram
• DEXA scan
• Bone scan
• Radical or simple mastectomy
• Stereotactic localization
• Sentinel lymph node biopsy
• Nipple discharge cytology
• Prolactin level checks
• Cannulization
• Ultrasound to rule out metastases

Breast Work-up Status and Final Diagnosis Information

Complete Breast Work-up Status only if the breast screening results were abnormal and/or “Immediate Work-up” is selected in the Additional Procedures Needed to Complete Breast Cycle field.

Work-up Status: Select the work-up status from the drop-down list.

• 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 work-up status. Use the date of the imaging/diagnostic procedure used to complete the work-up and not the date of the report or of data entry.
• Lost to Follow-up: Select this if the recipient is considered lost to follow-up before the definitive imaging/diagnostic procedures were performed. Three attempts must be made to contact the recipient (two phone calls and certified letter sent). The third contact attempt must be by certified letter. Attempts to contact the recipient must be documented in her medical record.
• Work-up Refused: Select this if the recipient refused to have imaging/diagnostic procedures performed, acquired insurance, moved out of the area, or changed PCP for any reason.
• Died before Work-up Complete: Select this if the recipient died before the imaging/diagnostic procedure(s) was performed.

Note: If work-up was not complete (recipient was Lost to Follow-up, Work-up Refused, or Died before work-up complete), enter the date this was determined as the Date of this Work-up Status.

Date of Work-up Status: Enter the date of the work-up status using the following format: MM/DD/YYYY. Use the date of the final imaging/diagnostic procedure as the date of this work-up status.

Complete Breast Final Diagnosis only when the Work-up Status is Work-up Complete.

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 from the drop-down list if the Breast Cancer Work-up Status was “Work-up Complete.”

• No Breast Cancer/Benign – resume annual screening: Select this if cancer is not found during current diagnostic procedures. Resume annual screening. 
• No Breast Cancer/Benign – short-term follow-up: Select this if cancer is not found during current diagnostic procedures and short-term follow-up will be needed.
• Lobular Carcinoma In Situ (LCIS): Select this if the pathology report indicates the diagnosis is lobular carcinoma in situ or lobular neoplasia.
• Ductal Carcinoma In Situ (DCIS): Select this if the pathology report indicates the diagnosis is ductal carcinoma in situ.
  Note: Data for Breast Cancer Treatment Status is required.
• Invasive Breast Cancer: Select this if the pathology report indicates any of the following:
  • Invasive or infiltrating ductal or lobular carcinoma
  • Both invasive and in-situ components
  • Paget’s disease (of the nipple with no tumor).
    Note: Data for Breast Cancer Treatment Status is required.

Date of Final Diagnosis: Enter the date of the final diagnosis using the following format: MM/DD/YYYY.   Use the date of the definitive diagnostic procedure performed as the date of the final diagnosis.

Note:  If only diagnostic imaging procedure(s) performed, use the date of the final imaging outcome as the date of the final diagnosis.

Breast Cancer Treatment Information

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

Treatment Status: Select the appropriate treatment status from the drop-down list.

• Treatment started: Select this if the clinic staff can verify from the recipient or treatment facility that treatment has been initiated regardless of recipient’s insurance status.
• Lost to follow-up: 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 (two phone calls and certified letter sent). The third attempt must be by certified letter. Attempts to contact recipient must be documented in her medical record.
• Treatment refused: Select this if the recipient refused treatment or 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 recipient’s quality of life (with late or end-stage cancers) and that treatment is not recommended or needed at this time.
• Died before treatment started: Select this if the recipient died before beginning treatment.

Date of Treatment Status: Enter the date when treatment was initiated or other treatment status was determined using the following format: MM/DD/YYYY.

Patient enrolled in BCCTP. Check ONLY when you have completed the BCCTP enrollment process: See DETEC help or Recipient Eligibility form for a list of BCCTP qualifying diagnoses. If the breast diagnosis is not listed on the drop-down list, contact a BCCTP manager at 1-800-824-0088 for information on how to proceed.

Print

Click the Print button at the bottom of the online DETEC – Breast Cancer Screening Cycle form to print a copy of it. When you click the Print button the following message will pop-up:

Note: The information below reflects only data that has been saved. Be sure to save/submit the recipient information before printing.

Note: The Print button prints only what is visible on the screen. There is a Print button on every DETEC screen. Use the Print button found on bottom of this screen to print Breast Cancer Screening Cycle form.