Context.—

Cancer registrars should work closely with pathologists to ensure compliance with reporting standards. Many registrars, however, have little contact with pathologists, resulting in a lack of “real-time” interaction that is essential for their professional activities and development.

Objective.—

To facilitate registrars' case management, as cancer biology becomes more complex, we developed the ATP (Ask the Pathologist) forum as a place to ask pathology-related questions about neoplasms, such as terminology, biology, histologic classification, extent of disease, molecular markers, and prognostic factors.

Design.—

Questions posted are reviewed by the ATP multidisciplinary oversight committee, which consists of 3 pathologists, 4 cancer registrars, 1 internal medicine physician, the pathology resident member of the College of American Pathologists Cancer Committee, and 2 medical technologists. The oversight committee may answer the question. Alternatively, the committee may forward the question to a content expert pathologist, determine that the question is better suited for another reference Web site, or both.

Results.—

Since September 2013, when the ATP forum became available, users have posted 284 questions, of which 48 (17%) related to gastrointestinal tumors, 43 (15%) to breast tumors, and 37 (13%) to general pathology. The average turnaround time, from question posted to response, is 11.1 days.

Conclusions.—

The ATP forum has had a positive impact in the daily activities of cancer registrars. Of 440 registrars surveyed, more than 90% considered that questions were answered satisfactorily, and one-third reported that ATP answers affected how they managed a given case.

The National Cancer Registrars Association (NCRA) defines a cancer registry as “an information system designed for the collection, management, and analysis of data on persons with the diagnosis of a malignant or neoplastic disease.”1  The collection and interpretation of relevant data are the responsibilities of cancer registrars, data information professionals trained in medical terminology, anatomy, physiology, biostatistics, epidemiology, data abstracting, database management, and cancer registry procedures. Cancer registrars maintain a cancer database with entries for each patient given a diagnosis of and/or treated for cancer within a health care institution or a defined population. Information captured by the registry includes: (1) demographic information, such as age, sex, race/ethnicity, birthplace, and residence; (2) medical history, such as physical findings, screening information, occupation, and any history of a previous cancer; (3) diagnostic findings, such as date of diagnosis, results of procedures used to diagnose cancer, location of the primary cancer, histologic type and grade, and clinical and pathologic stage; (4) therapy, such as surgery, radiation therapy, chemotherapy, hormone therapy, immunotherapy; and (5) follow-up, such as annual information about treatment, recurrences, date of last contact and patient, and disease status at last contact. Registrars report these data to various health care agencies, including the National Cancer Database (NCDB), a nationwide oncology outcomes database established in 1988 as a joint project of the American College of Surgeons Commission on Cancer (CoC) and the American Cancer Society (ACS).2  The information gathered is evaluated for completeness, validity, and timeliness, and is used to inform a wide variety of public health decisions.36 

Because of the nature of this work, cancer registrars should work closely with pathologists, treating clinicians, administrators, researchers, and health care planners to ensure compliance with reporting standards and support the development and success of cancer programs. Increasingly, nonhospital settings are sources of cancer diagnoses, but they often lack a cancer registry. Teleworking, centralization of registry functions, and lack of access to other members of the cancer care team, specifically pathologists, can result in misinterpretation of data and inaccurate reporting to the NCDB.7 

Through experiences with our region's cancer registrars, we learned that they had pathology-based questions that remained unanswered. We invited them to participate in a series of phone conferences, and in 2012 we gave lectures at the Florida Cancer Registrars Association annual meeting to explain some of these pathology topics.8,9  This approach was successful, and we envisioned expanding it to all cancer registrars nationwide so they would have an opportunity to interact with pathology content experts. To accomplish this, we created an ongoing, pathology-focused question and answer forum within the CAnswer forum developed by the CoC and already familiar to registrars. This idea was presented to the College of American Pathologists (CAP) Cancer Committee and the CAP Pathology Electronic Reporting Committee, and in September 2013, in collaboration with the CoC, we launched the discussion board entitled “Ask the Pathologist” (ATP) on the CAnswer forum.10 

The ATP forum serves as a place to ask pathology-related questions about neoplasms, such as terminology, biology, histologic classification, extent of disease, molecular markers, and prognostic laboratory tests (Figure 1). Once a question is posted, the pathology resident member of the CAP Cancer Committee reviews it and emails it to the ATP multidisciplinary oversight committee for advisement and opinion. The oversight committee consists of 3 pathologists, 4 cancer registrars, 1 internal medicine physician, the pathology resident member, and 2 medical technologists. One of the cancer registrars is a representative of the Surveillance, Epidemiology, and End Results Program (SEER). The oversight committee determines whether the question is appropriate for the ATP forum or whether the question is better suited to a different CoC forum or other reference Web site (Figure 2).

Figure 1

Example of the front page of the Ask The Pathologist (ATP) forum on the American College of Surgeons' Web site, with alternate sites for posting questions not directly related to ATP. Abbreviations: ACoS, American College of Surgeons; AJCC, American Joint Committee on Cancer; CoC, Commission on Cancer; NCI, National Cancer Institute; SEER, Surveillance, Epidemiology, and End Results. Used with permission from the American College of Surgeons Commission on Cancer.

Figure 1

Example of the front page of the Ask The Pathologist (ATP) forum on the American College of Surgeons' Web site, with alternate sites for posting questions not directly related to ATP. Abbreviations: ACoS, American College of Surgeons; AJCC, American Joint Committee on Cancer; CoC, Commission on Cancer; NCI, National Cancer Institute; SEER, Surveillance, Epidemiology, and End Results. Used with permission from the American College of Surgeons Commission on Cancer.

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Figure 2

Flowchart indicating the steps followed while processing a post. Abbreviations: ATP, Ask The Pathologist; SEER, Surveillance, Epidemiology, and End Results.

Figure 2

Flowchart indicating the steps followed while processing a post. Abbreviations: ATP, Ask The Pathologist; SEER, Surveillance, Epidemiology, and End Results.

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Once deemed appropriate for the ATP, the question can be answered by members of the oversight committee or can be assigned to the appropriate content expert on the CAP Cancer Committee. Content experts provide a definitive answer and often include literature references (Figure 3). The oversight committee then reviews the answer for completeness, and finally the resident posts the response to the forum. When a question is more appropriate for another CAnswer forum or other site, the resident returns the questions to the contributor with a recommendation and a Web link as to where to repost the question. Examples of sites where questions have been redirected are: the CoC Program Standards,11  the American Joint Committee on Cancer (AJCC) Cancer Staging Manual 7th edition,12  the National Cancer Institute (NCI) SEER “Ask a Registrar”13  for questions regarding coding, topography, histology, and multiple primaries, and the CAP site for questions regarding protocol standards or protocol content.14  On occasion, for more complex questions, the committee has both forwarded the question to the pathology content expert to address the pathology component(s) of the question and provide education, and suggested another site for further information regarding the rest of the question.

Figure 3

Example (shown as submitted) of question and answer with references. Abbreviations: ADH, antidiuretic hormone; NE, neuroendocrine; SCLC, small cell lung carcinoma; WHO, World Health Organization.

Figure 3

Example (shown as submitted) of question and answer with references. Abbreviations: ADH, antidiuretic hormone; NE, neuroendocrine; SCLC, small cell lung carcinoma; WHO, World Health Organization.

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Having presented initial descriptive data of various aspects of the forum,1517  we became aware that many potential users did not know of its existence. To increase awareness and reach more cancer registrars, we publicized the ATP forum nationally, via mails sent from the CoC, and in The Connection, the newsletter of the NCR.18  We then surveyed the 3000 registered users of the CAnswer forum who had “Certified Tumor Registrar (CTR)” in their profile information in order to evaluate the success of our announcements. The questions used in this survey are listed in Table 1. The same month, we surveyed the pathologist members of the CAP House of Delegates to evaluate their knowledge of cancer registries. The questions and answer choices used in this survey are listed in Table 2.

Table 1

Questions and Answers (Percent Responding) in the Survey of Cancer Registrars (n = 460)

Questions and Answers (Percent Responding) in the Survey of Cancer Registrars (n = 460)
Questions and Answers (Percent Responding) in the Survey of Cancer Registrars (n = 460)
Table 2

Questions and Answers (Percent Responding) in the Survey of Pathologists (n = 160)

Questions and Answers (Percent Responding) in the Survey of Pathologists (n = 160)
Questions and Answers (Percent Responding) in the Survey of Pathologists (n = 160)

Since the forum's inception in September 2013, users have posted 284 questions. The distribution of questions by quarter is shown in Figure 4, and by subforum in Figure 5. Of the 284 questions, 48 (17%) were posted to the Gastrointestinal subforum, 43 (15%) were posted to the Breast subforum, and 37 (13%) were general questions addressing various topics (see an example in Figure 6). Of these 284 questions, the ATP forum content experts answered 147 (52%) and referred 137 (48%) to other sites: 101 (74%) to the NCI/SEER “Ask a SEER Registrar” site (Figure 7), 23 (17%) to the AJCC 7th edition subforum of the CAnswer forum, and a small percentage to the Collaborative Staging and Facility Oncology Registry Data Standards (FORDS)/NCDB forums of the CAnswer forum. At the end of 2015, we added a purpose statement to the ATP forum front page that resulted in fewer inappropriate questions posted to the forum (Figure 7). The turnaround time in days from question posted to response posted is shown, in 3-month intervals, from quarter 4 of 2013 to quarter 1 of 2017, in Figure 8. The overall average turnaround time of 15.0 days improved to an average of 11.1 days after the fourth quarter of 2013, when logistic problems were identified and solved. The average turnaround time, since then, has been very stable.

Figure 4

Number of questions posted since the Ask the Pathologist forum's inception, distributed by quarter.

Figure 4

Number of questions posted since the Ask the Pathologist forum's inception, distributed by quarter.

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Figure 5

Percentage of questions distributed by subforum.

Figure 5

Percentage of questions distributed by subforum.

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Figure 6

Example (shown as submitted) of a general Ask The Pathologist forum question. Abbreviations: AJCC, American Joint Committee on Cancer; CAP, College of American Pathologists; DCIS, ductal carcinoma in situ; LN, lymph node; SLN, sentinel lymph node; T, tumor category in TNM (tumor, node, metastasis) staging system.

Figure 6

Example (shown as submitted) of a general Ask The Pathologist forum question. Abbreviations: AJCC, American Joint Committee on Cancer; CAP, College of American Pathologists; DCIS, ductal carcinoma in situ; LN, lymph node; SLN, sentinel lymph node; T, tumor category in TNM (tumor, node, metastasis) staging system.

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Figure 7

Percentage of questions referred to other sites distributed by quarter. The asterisk (*) marks the time (end of 2015) at which we added alternate sites to the front page of the Ask The Pathologist (ATP) forum for questions not specifically related to ATP's purpose. Thus, in 2016 the number of referrals to other sites decreased.

Figure 7

Percentage of questions referred to other sites distributed by quarter. The asterisk (*) marks the time (end of 2015) at which we added alternate sites to the front page of the Ask The Pathologist (ATP) forum for questions not specifically related to ATP's purpose. Thus, in 2016 the number of referrals to other sites decreased.

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Figure 8

Turnaround times (in days from question posted to response posted) by quarter.

Figure 8

Turnaround times (in days from question posted to response posted) by quarter.

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The distribution of responses to our survey is shown in Table 1. Of the 3000 users of the CAnswer forum who had registered as a Certified Tumor Registrar, 460 (15%) responded to the survey, and the number of responses ranged from 283 (question 8) to 460 (question 1). Of the total number of respondents, 322 (70%) found out about the ATP forum by visiting the CAnswer forum or from NCRA communications. Of the 103 who answered “Other” to question 1, 72 (70%) became aware of the ATP forum as a result of our survey, and most of the remaining respondents became aware of it by CoC email. Of the 283 who answered question 8, 263 (93%) reported that questions were addressed “well” or “excellent.” Of the 445 who answered question 7, 93 (33%) reported that the answers at the ATP forum made a difference in how they handled a case. Of the 440 who answered question 4, 317 (72%) reported that their communication with the pathologist(s) was at least very good. Only 57 of respondents (13%), however, had ever posted a question on the ATP forum.

When asked for open comments about how to improve the ATP forum, 179 (39%) responded with free-text comments that were straightforward and could be easily grouped by intent (data not shown). A total of 94 registrars (20%) stated that they had never used the forum or had not heard of it before this survey was presented to them, 47 (10%) said that no changes should be made to the forum because it was satisfactory as it was, 38 (8%) stated that they preferred communications with their pathologists rather than using the forum, and 33 (7%) considered the long turnaround time to be inappropriate. The responses of 19 registrars (4%) fell into 1 of 3 groups: dissatisfaction with the referral of questions to other sites, dissatisfaction with answers not specific to the question, and satisfaction with pathologists' input on the topics. Answers such as “forum too hard to use” and “too many answers given” could be related to the CAnswer forum as a whole, because the ATP forum posts only 1 answer from the content expert and is organized by tumor site.

The answers of pathologists to the 6 survey questions are shown in Table 2. The number of responses ranged from 157 (question 6) to 160 (question 5). The clear majority of pathologists were aware of what a cancer registry is and that survival data come from data collected by cancer registrars. Almost three-fourths of pathologists reported that they were associated with a CoC-accredited facility, and 139 (87%) reported regular attendance to tumor boards. Even though 54 (34%) knew the cancer registrars at their facility, only 18 (54%) of these respondents discussed pathology-related questions with them.

An essential aspect of individual cancer care is the accurate and complete collection of staging information and the identification of prognostic and/or therapeutic indicators. The comprehensive collection of epidemiologic cancer data across populations requires a broad national commitment. For this purpose, in 1992 Congress established the National Program of Cancer Registries (NPCR) by enacting the Cancer Registries Amendment Act (Public Law 102-515).19  The NPCR is administered by the Centers for Disease Control and Prevention (CDC), and since 1994 it has funded state cancer registries to collect population-based cancer incidence data.4  Furthermore, the Congressional Mandate Public Law 1998 Code 280e20  authorized the CDC to provide funds to improve existing cancer registries; plan and implement registries where they did not exist; develop model legislation and regulations for states to enhance the viability of registry operations; set standards for data completeness, timeliness, and quality; provide training for registry personnel; and develop software to make collecting and processing data more efficient and accurate for medical facilities and registries. Today, through the NPCR, the CDC supports central cancer registries in 45 states, the District of Columbia, Puerto Rico, and the US Pacific Island Jurisdictions, accounting for 96% of the US population.5,6 

Data elements used to establish disease stage are abstracted into the NCDB, the SEER database, and the NPCR. These data are published annually in the United States cancer statistics: incidence and mortality web-based report.21  The NCDB, the largest clinical registry in the world, collects data from more than 1500 CoC-accredited facilities tracking patients with malignant neoplasms, as well as their treatments and outcomes. More than 34 million historical records have been collected, and more than 1 million cancer case reports are received annually, accounting for more than 70% of newly diagnosed cancers nationwide. Also, since 1998 the CDC has collaborated with the NCI, the North American Association of Central Cancer Registries, and the American Cancer Society, to publish the Annual Report to the Nation on the Status of Cancer.22  This national aggregate of cancer data enables researchers, clinicians, policy makers, public health professionals, and members of the public to monitor the burden of cancer, evaluate the success of existing programs, and assess needs for future cancer prevention, and to control efforts at national, state, and local levels.

Pathology reports are an essential component of the medical record and need to be interpreted accurately by cancer registrars. In volume 3 of the Standards for Cancer Registries,23  it is stated that, “The Central Registry must designate medical advisors…physicians who agree to serve…to consult with the registry staff as needed on questions of medical data interpretation, diagnosis and management, and/or classification of issues…at least one pathologist and one clinical oncologist advisor.…Maintaining long-term relationships with the advisors is especially helpful in achieving continuity and consistency…”

With centralization of cancer registries, many registrars have little contact with pathologists, resulting in a lack of “real-time” interaction, essential for professional development and improvement. In fact, in 2013 the NCRA tested 1342 registrars as to their understanding of AJCC staging. Results showed significant gaps in knowledge, indicating the need for continuing education, even among experienced registrars.24 

The ATP forum was created in part to address the lack of accessibility to pathologists, the unanswered pathology-related questions, and the need for continuing education, as cancer biology and terminology become more complex because of medical advances in prognostic indicators and therapeutic modalities. The ATP forum has already had an impact, as shown in the cancer registrar survey where 93% of respondents reported that the questions posted were answered “at least well,” and 33% reported that the content expert's answer affected what they did with a particular case. Many of those who judged questions answered “at least well” were not the same as those who posted questions, because according to our survey, of the 460 respondents, only 59 (13%) had ever posted questions to the ATP forum. With increasing awareness among cancer registrars through this survey, national emails and announcements, and the occasional forum “browser” we envision more registrars not only reading the forum but also posting questions, thereby increasing overall participation and knowledge. We also expect more questions related to the recent release of the 8th edition of the AJCC Cancer Staging Manual.

Of interest is the fact that half of the cancer registrars reported that communications with their pathologists were fair to poor, and 54% of the pathologists surveyed answered that they did not know their cancer registrar, even though both groups largely reported attending tumor boards regularly. Tumor boards provide an excellent opportunity for interaction and education, but with increased off-site housing and teleworking, registrars lose this valuable opportunity.

To enhance the educational aspects of the forum, and in response to suggestions that we address more questions rather than just defer to other sites, we are now addressing the pathology-related portion of the question as well as referring the specific non-ATP portion of the question to the appropriate site (Figure 9). We will also continue to track our turnaround times to identify areas of improvement in the multistep process of review, assignment, and rereview.

Figure 9

Example (shown as submitted) of a question that addresses the pathology component of the question and suggests referral of coding and reportability aspects to another reference site. Abbreviations: NCI, National Cancer Institute; SEER, Surveillance, Epidemiology, and End Results; WHO, World Health Organization.

Figure 9

Example (shown as submitted) of a question that addresses the pathology component of the question and suggests referral of coding and reportability aspects to another reference site. Abbreviations: NCI, National Cancer Institute; SEER, Surveillance, Epidemiology, and End Results; WHO, World Health Organization.

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The ATP subforum, as shown by the survey results, has aided in the understanding of pathology terminology and tumor biology, thereby contributing to problem-solving and the overall education of cancer registrars across the country. Registrars continue to seek help from their own pathologists, but they are also able to gain further clarification, and query an expert, in the event their pathologist is not available or does not know the answer. To date, more than a third of cancer registrars report that their practice has changed because of the ATP subforum. We hope that interaction via this forum will continue to clarify concepts and reduce the possibility of errors in the interpretation of and data extraction from pathology reports.

An Internet-based forum cannot replace the direct interaction between cancer registrars and other health care providers, but as multidisciplinary volunteers with a vested interest in fostering the pathologist-registrar relationship, we hope to use the ATP forum as another avenue of dialogue between the 2 groups.

The authors gratefully acknowledge the following ATP oversight committee members: Margaret (Peggy) Adamo, BS, RHIT, CTR, AAS; Feriyl Bhaijee, MD; James Dvorak, MT (ASCP); Christine Gibson, CTR, CCRP; Alison Knutson, CCRP; Douglas A. Murphy, MT (ASCP); Wendy Scharber, RHIT, CTR; Samantha Spencer, MD; Rachel L. Stewart, DO, PhD; and Annika L. Windon, MD. We would also like to thank the CAP House of Delegates staff and Representatives Steve Hansen, MBA; James E. Richard, DO; and Nicole D. Riddle, MD, for their assistance with the pathologist survey, as well as the pathologist members for contributing their time to take the survey. Additionally, we thank Alison Knutson for her assistance in enabling us to survey the cancer registrar members of the CoC CAnswer forum. We extend our gratitude to the cancer registrars who participated in our survey and contribute to our ATP forum. Finally, we thank the expert content members of the CAP Cancer Committee and the resident members of the CAP Cancer Committee (Feriyl Bhaijee, MD, Rachel L. Stewart, DO, PhD, and Annika L. Windon, MD), without whom the ATP forum would not be possible.

1
National Cancer Registrars Association
.
Become a cancer registrar
. ,
2017
.
2
American College and Surgeons; American Cancer Society
.
National Cancer Database
. ,
2017
.
3
Wagner
G.
History of cancer registration
.
In
:
Jensen
OM
,
MacLennan
R
,
Skeet
RG
,
eds
.
Cancer Registration: Principles and Methods
.
Lyon, France
:
International Agency for Research in Cancer;
1991
:
3
6
.
IARC scientific publication 95.
4
Parkin
DM
.
The evolution of the population-based cancer registry
.
Nat Rev Cancer
.
2006
;
6
(
8
):
603
612
.
5
Wingo
PA
,
Howe
HL
,
Thun
MJ
, et al.
A national framework for cancer surveillance in the United States
.
Cancer Causes Control
.
2005
;
16
(
2
):
151
170
.
6
Parkin
DM
.
The role of cancer registries in cancer control
.
Int J Clin Oncol
.
2008
;
13
(
2
):
102
111
.
7
Winchester
DP
,
Stewart
AK
,
Bura
C
, et al.
The National Cancer Data Base: a clinical surveillance and quality improvement tool
.
J Surg Oncol
.
2004
;
85
(
1
):
1
3
.
8
Strickland-Marmol
LB
.
CAP protocol pointers
.
Paper presented at: 34th Annual Meeting of the Florida Cancer Registrars Association
;
July
25,
2012
;
St Petersburg Beach, FL
.
9
Foulis
PR
.
CAP protocols background
.
Paper presented at: 34th Annual Meeting of the Florida Cancer Registrars Association
;
July
25,
2012
;
St Petersburg Beach, FL
.
10
Commission on Cancer
.
CAnswer forum
. ,
2017
.
11
Commission on Cancer
.
Cancer program standards (2016 edition)
. ,
2017
.
12
American Joint Committee on Cancer
.
Cancer Staging Manual. 8th ed
. ,
2017
.
13
National Cancer Institute
.
The Surveillance, Epidemiology, and End Results (SEER) Program “Ask a SEER Registrar”
.
https://seer.cancer.gov/. Accessed November 16
,
2017
.
15
Bhaijee
F
,
Strickland-Marmol
L
,
Muro-Cacho
C
, et al.
Improving the pathological diagnoses in cancer registries
.
Paper presented at: 134th Annual Meeting of the Association of Clinical Scientists
;
May
2014
;
Amelia Island, FL
.
16
Strickland-Marmol
L
,
Bhaijee
F
,
Muro-Cacho
C
, et al.
“Ask the Pathologist”–establishing open lines of communication between pathologists and cancer registrars
.
Paper presented at: Annual National Meeting of the American Society of Clinical Pathologists
;
October 8–10,
2014
;
Tampa, FL
.
17
Stewart
R
,
Strickland-Marmol
L
,
Muro-Cacho
C
, et al.
Pathologist-cancer registrar forum improves cancer protocols
.
Paper presented at: Annual Meeting of the College of American Pathologists
;
September
2015
;
Las Vegas, NV
.
18
Gibson
C.
CAP Cancer Committee update
.
The Connection
.
Summer 2014.
,
2017
.
19
Cancer Registries Amendment Act, Pub L No. 102-515 (1992)
.
November
16,
2017
.
21
US Cancer Statistics Working Group
.
United States cancer statistics: 1999-2014 incidence and mortality web-based report
.
https://nccd.cdc.gov/uscs/. Accessed November 16
,
2017
.
22
National Cancer Institute
.
Annual report to the nation on the status of cancer, 1975-2014
. ,
2017
.
23
Liaison(s) with outside agencies and the medical community
.
In
:
Hofferkamp
J
,
ed
.
Standards for Completeness, Quality, Analysis, Management, Security and Confidentiality of Data
.
Springfield, IL
:
North American Association of Central Cancer Registries;
2008
:
14. Standards for Cancer Registries; vol 3.
24
American Joint Committee on Cancer; National Cancer Registrars Association
.
Results of the AJCC-NCRA Education Needs Assessment
. ,
2017
.

Author notes

The authors have no relevant financial interest in the products or companies described in this article.