It’s important for Claims Assessors to understand that diagnosing cancer is a complex process. A precise diagnosis helps to determine the best treatment plan for that cancer. This blog will review treatment modalities and claims considerations to help Claims Assessors better understand pathology reports and what comes next for the patient.
The Pathology Report
The pathology report is a complex medical report that describes the diagnosis based on the results of the blood work, diagnostic imaging and biopsy results. If cancer is diagnosed, the report will include specific information including the type of cancer, the histologic grade, lymph node status, stage and the presence of hormone receptors or biomarkers.
The results of a biomarker test could show the cancer has a certain biomarker that is targeted by a known treatment protocol. Or it could show that the cancer has a biomarker that may prevent a certain therapy from working. Off-label treatment (not FDA approved) may be recommended because the treatment is approved for a different type of cancer that has the same biomarker.1
A concise pathologic diagnosis provides important information for the oncology team regarding treatment decisions, risk of recurrence and prognosis.
The Treatment Plan and Prognosis
In the past, patients diagnosed with a particular type of cancer (brain, breast or pancreatic for example), received the same treatment as others with the same diagnosis. Over the past decade research in cancer biology led to advancements in biomarker detection and increased the knowledge and understanding of cancer at the molecular and cellular level, which provides defining diagnostic information to help guide treatment and predict responses to a particular therapy.
Challenging or unusual cancer cases may be discussed at the tumor board, a multi-disciplinary approach to treatment planning with doctors from different specialties, who determine the best possible treatment based on the diagnosis.
In addition to documenting the test results, the pathologic diagnosis and the treatment plan and dates, the oncologist will also document a performance status.
There are two widely used scales for performance status which measures the patient’s level of functioning for patients with cancer. There is the Eastern Cooperative Oncology Group (ECOG) scale and the Karnofsky Performance scale (KPS).
The KPS measures the ability to perform ordinary tasks. The ECOG measures the patient’s level of functioning in terms of their ability to care for themselves including daily activities and physical ability.
Barring any other factors impacting quality of life, the performance scale should correlate with physical performance and with survival. The performance scale also plays a role in determining treatment and prognosis.