Reason for No Surgery [1340]

a. Assign code 1 when

i. Primary site is C420, C421, C423, C424, C760-C768, or C809

Note: Surgery is not standard treatment for these cases.

ii. There is no information in the patient’s medical record about surgery, AND

• It is known that surgery is not usually performed for this type and/or stage of cancer

OR

• There is no reason to suspect that the patient would have had surgery of primary site

Example: The patient would not be a surgical candidate because of advanced stage.

iii. The treatment plan offered multiple treatment options and the patient selected treatment that did not include surgery of the primary site

Example: Prostate cancer patient is offered three treatment options: a. Radical prostatectomy, b. Radiation therapy, or c. Hormone therapy. The patient chose to have radiation therapy. Assign code 1. Surgery of the primary site was not performed because it was not part of the planned first course of treatment. The treatment plan was for the patient to receive ONE of three treatment modality options: surgery, OR radiation, OR hormone therapy. At no time did the physician recommend that the patient have surgery AND radiation therapy AND hormone therapy. The patient chose radiation. This does not mean he refused surgery because at no time did the treatment plan include both radiation AND surgery. Recording that a patient refused the treatment modality means that the patient refused recommended therapy. This is a quality control check explaining why the patient did not receive the expected treatment for their cancer (patient’s choice versus physician’s choice, or facility’s lack of providing quality care).

iv. Surgery was part of the first course of treatment but was cancelled due to complete response to radiation and/or systemic therapy

v. Patient elected to pursue no treatment following the discussion of surgery. Discussion does not equal a recommendation. Patient's decision not to pursue surgery is not a refusal of surgery in this situation.

vi. Active surveillance/watchful waiting is the first course (e.g., prostate)

b. Assign code 2 when surgery of the primary site is contraindicated due to factors including, but not limited to, comorbid conditions, advanced age, and progression of tumor prior to planned surgery.

Example: Patient with metastatic cancer from the right kidney to the lung has a history of prior left nephrectomy with a current history of congestive heart disease and smoking. Surgery is not performed for the right kidney malignancy because the patient is considered a surgical risk.

c. Assign code 6 when

i. It is KNOWN that surgery was recommended

AND

ii. It is KNOWN that surgery was not performed

AND

iii. There is no documentation explaining why surgery was not done

Example: The medical record has a recommendation that the patient have surgery. No further admissions or documentation of surgery found; the primary care physician replies that the patient did NOT have surgery. No further information is given; it is unknown if the patient refused surgery or if there were co-morbid conditions that prevented the surgical procedure.

d. Assign code 7 when the patient

i. Refuses recommended surgery

OR

ii. Makes a blanket statement that he/she refused all treatment when surgery is a customary option according to NCCN guidelines and/or the NCI PDQ for the primary site/histology

• Assign code 1 when surgery is not normally performed for the site/histology

Note: Coding Reason for No Surgery of Primary Site as “refused” does not affect the coding of the other treatment data items (e.g., Radiation, Chemotherapy, Hormone Therapy, etc.). Code 7 means surgery is exactly what was recommended by the physician and the patient refused. If two treatment alternatives were offered and surgery was not chosen, code Reason for No Surgery of Primary Site as 1 [Surgery of the primary site was not performed because it was not part of the planned first-course treatment].

e. Assign code 8 when surgery is recommended, but it is unknown if the patient actually had the surgery

Example: There is documentation in the medical record that the primary care physician referred the patient to a surgical oncologist. Follow-back to the surgical oncologist and primary care physician yields no further information. Assign code 8, it is known that surgery was recommended but there is no information on whether or not the patient actually had the surgical procedure.

Note: Review cases coded 8 periodically for later confirmation of surgery.

a. When there is no documentation that surgery was recommended or performed

b. For death certificate only (DCO) cases

c. Autopsy only cases