Missouri Cancer RegistryMissouri Department of
4/04, 6/28/04, 1/05 Health & Senior Services
Missouri Cancer Registry Melanoma Reporting Form
Patient First Name: ______Middle: ______Last Name: ______
DOB: ______SS#: ______Street: ______
City:______State:______Zip: ______
Marital Status: single married divorced widowed unk
Primary Payer: not insured, self pay insurance, nos Medicaid/Medicare military unk
Date Specimen Collected: ______Physician: ______
1.Procedure performed: Biopsy Excision Wide/re-excision
Site: ______Histology/path report attached: ______
Laterality: Right Left Ulceration: Yes No Tumor size: ______
2.Is this the Primary Site? Yes No, primary site was: ______
3.Please record Clark’s Level and Breslow’s Depth information:
______
4.SEER Staging of Disease:
In Situ Local Regional* Distant* Unknown*
* Describe: ______
5.Was there lymph node involvement? Yes No Unknown
Studies performed included:
Lymphoscintigraphy sentinel node bx other: ______
6.Other physicians/facilities involved in the care of this melanoma:
______
7.Other treatments received for this melanoma (include date):
______
8.Race:White African American Asian/Pac. Isl. Native American
Other: ______
9.Ethnicity:Hispanic/Spanish? Yes No Unknown
10.History of Previous Melanoma?
Yes, this is a recurrence. Yes, previous melanoma was at another location.
No history of previous melanoma. Unknown
11.Date of last contact: ______
12.Any other known history of cancer in this patient? Yes* No Unk
* Please list______
THANK YOU FOR TAKING THE TIME TO PROVIDE THIS VALUABLE INFORMATION!
PLEASE MAIL COMPLETED FORMS TO MISSOURI CANCER REGISTRY at POBOX 718, Columbia, MO65205 or FAX COMPLETED FORMS TO: 573-884-9655
Instructions for Completing
Missouri Cancer Registry Melanoma Reporting Form
- Procedure performed: Record the procedure type.
Site: Record the body location for this procedure (e.g., Skin of arm, skin of chest, etc.).
Histology/path report attached: Record the histology or tissue type listed on the pathology report (e.g. Nodular melanoma, lentigo maligna melanoma, etc.) OR simply attach a copy of the pathology report to the form.
Laterality: Describes left or right (e.g. left arm, right leg, right cheek, etc.). Ulceration: This may be mentioned either in the dermatologist’s description of the tumor or in the pathology report.
Tumor size: Record the actual tumor size in millimeters.
- Primary site: Record where the cancer first started. The biopsy may be of the abdomen, but the cancer started on the thigh. Thigh would be the primary site.
- Clark’s Level: This is the depth of invasion. Usually mentioned on the path report.
Breslow’s Depth: This is the exact measurement of the thickness of the tumor under the microscope. It is NOT the same as tumor size. Usually mentioned on the path report.
- SEER Staging: This term will describe the extent of the disease. In situ cancers are easily identified because the histology (or tissue type) also describes the extent of disease. Information for other stages will not be described on pathology reports. The physician will supply. You may also provide the TNM stage if it is mentioned.
- Lymph node involvement? Procedures: Record whether lymph nodes are involved and the procedures used to determine their involvement.
- Other physicians/facilities involved: Record the name of any physician/facility also involved in the patient’s treatment of this cancer.
- Other treatments received: This includes other surgical (e.g. wide excision, etc.) or non-surgical (chemotherapy, etc.) treatments.
- Race: Record specific race of patient.
- Ethnicity: Check “yes” if patient is of Hispanic/Spanish origin.
- History of Previous melanoma: This may be a new melanoma or it may be a recurrence of a previously diagnosed melanoma.
- Date of last contact
- History of Other cancers: Please list any other known cancers for the patient.