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APPENDIX B
Clarification of Cancer Groupings Used in Reporting Results, with Correspondence to NIOSH Cause-of-Death Codes and ICD Codes for Cancers
For Update 2006, the Department of Veterans Affairs (VA) requested two refinements in the system used in previous Veterans and Agent Orange (VAO) updates to present conclusions about the adequacy of evidence concerning associations between cancer types and exposure to the herbicides sprayed in Vietnam. First, conclusions should be provided for the full range of cancer types; that is, the cancer groupings for which conclusions are drawn should be exhaustive. Second, it should be apparent into which groupings specific cancer diagnosis falls.
The explicitly stated cancer grouping reviewed in prior updates left a few gaps in the full range of cancer types (as indicated in italics in Table B-1). Those gaps represent quite specific types of cancer on which no data compatible with review had been found; the endpoint by default was in the “inadequate or insufficient evidence” category. The major portion of evidence compiled for review in this series comes from cohort studies, primarily of mortality but some of incidence. Other data have been generated by case–control studies, which follow the only design amenable to studying very infrequent or very specific health outcomes. How researchers are able to group, analyze, and report their findings is influenced by the distribution of cases that they observe, so the data that VAO committees have had available for review reflect mortality experience at a level of specificity concordant with statistical analysis.
Previous updates have referred to the International Classification of Diseases (ICD) system, which is used by physicians and researchers around the world to group related diseases and procedures so that morbidity and mortality information can be classified for statistical purposes in a standard form amenable to data storage and retrieval. It is a comprehensive hierarchic system that permits great detail, but that can be collapsed into broad categories. Codes mentioned in VAO reports are stated in terms of ICD, Version 9 (ICD-9). ICD-7, ICD-8, and ICD-9 were
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in effect for deaths that occurred in 1960–1967, 1968–1978, and 1979–1998, respectively; the differences among them are fairly subtle. Although ICD-10, which went into effect for coding causes of deaths that occurred from 1999 on, appears radically different from the earlier versions, it corresponds in large part to basically the same disease entities (see Table B-2). To date, most published epidemiologic studies have been related to health outcomes that occurred and were encoded before ICD-10 went into effect.
Since 1983, the National Institute for Occupational Safety and Health (NIOSH) has maintained software for generating standardized expectations, as derived from US mortality data assembled by the National Center for Health Statistics, for ICD-encoded mortality data sets. An article by Robinson et al. (2006) discusses revisions to that standard software to incorporate deaths coded according to ICD-10 and includes conversions and equivalencies between ICD-7, -8, -9, and -10 for 119 exhaustive categories for cause of death. Codes for malignant neoplasms span the ICD-9 range 140.0–208.9, NIOSH’s major categories 02–10, or NIOSH’s more specific minor categories 004–040.
The NIOSH death codes for neoplasms provide comprehensive scaffolding for organizing the committee’s reviews and conclusions by cancer type that is somewhat simpler than ICD classifications, but maps completely to the ICD system as it has evolved. Because the NIOSH system has been used to mediate analysis of many sets of cohort data, its groupings correspond quite closely with the published research findings available for VAO review. In general cohort studies, one is unlikely to encounter results on more specific groupings than NIOSH’s minor categories.
As discussed in Chapter 2, this committee has not framed its conclusions strictly in terms of ICD codes, but the ICD system has been a valuable tool for the work of VAO committees. There can be coding errors on hospital records or death certificates, but when researchers present their results labeled with ICD codes, there can be little ambiguity about what they intended. When their most definitive indication is something like “respiratory cancers,” however, there can be uncertainty about where the evidence should be considered. In such cases, the committee has done its best to follow the hierarchy laid out in Table B-1.
As indicated above, many of the studies reviewed by the committee use or were written at a time when ICD-9 was in place. Accordingly, ICD references in this report use that scheme. ICD-10 began to be implemented in the United States in 1999. It differs from ICD-9 in level of detail (about 8,000 categories versus about 5,000 in ICD-9) and nomenclature (alphanumeric versus the numeric codes of ICD-9); additions and modifications were also made with regard to some coding rules and the rules for selecting an underlying cause of death (Anderson et al., 2001). Table B-2 lists the ICD-9 and ICD-10 codes for the various forms of malignant neoplasm addressed in this report. In situ neoplasms, benign neoplasms, neoplasms of uncertain behavior, and neoplasms of unspecified behavior have separate codes in both schemes.
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TABLE B-1 Mapping of Groupings of Malignant Neoplasms That Are the Subjects of Conclusions in Update 2004 with ICD-9 Codes
NIOSH Category for Cause of Death
Major
Minor
NIOSH Groupings of Cancer Sites
Subsites “Update 2004 Characterization of Grouping”a
ICD-9 Codes (Gapsb in Italics)
02
Buccal cavity and pharynx
“Oral, nasal, and pharyngeal”
004
Lip
140
005
Tongue
141
006
Other parts of buccal cavity
Salivary glands
142
Floor of mouth
144
Gum and other mouth
143, 145
007
Pharynx
Oropharynx
146
Tonsil
146.0–146.2
Nasopharynx
147
Hypopharynx
148
Other buccal cavity and pharynx
149
(160 = nasal below)
03
Digestive organs and peritoneum
“Gastrointestinal”
008
Esophagus
150
009
Stomach
151
010
Intestine except rectum
Small intestine
152
Colon (large intestine)
153
011
Rectum
154
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NIOSH Category for Cause of Death
Major
Minor
NIOSH Groupings of Cancer Sites
Subsites “Update 2004 Characterization of Grouping”a
ICD-9 Codes (Gapsb in Italics)
012
Biliary passages, liver, and gall bladder
“Hepatobiliary”
Liver and intrahepatic bile ducts
155
Gallbladder and extrahepatic bile ducts
156
013
Pancreas
157
014
Retroperitoneum and other and unspecified digestive organs
158–159
04
Respiratory system
“Respiratory”
015
Larynx
161
016
Trachea, bronchus, and lung
162
Trachea
162.0 (there is no ICD 162.1)
Lung and bronchus
162.2–162.9
017
Pleura
163
018
Other respiratory
Nasal cavity, middle ear, and accessory sinuses Thymus, heart, and mediastinum
(160, above with oral and pharyngeal) 164 (164.0, below with endocrine;
164.1, below with soft-tissue sarcoma)
Other respiratory, unspecified
165
(discontinuity with ICD codes)
05
019
Breast (male and female)
“Breast”
174, 175
06
Female genital organs
“Female reproductive”
020
Cervix uteri
180
021
Other unspecified parts of uterus
179, 181, 182
Uterus, parts unspecified
179
Placenta
181
Body of uterus
182
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022
Ovary, fallopian tube, and broad ligament
183
Ovary
183.0 (there is no ICD 183.1)
Fallopian tube and other uterine adnexa
183.2–183.9
023
Other female genital organs
184
07
Male genital system
185, 186
024
Prostate
“Prostate”
185
025
Testis
“Testicular”
186
Penis and other male genital organs
[for NIOSH in minor group 036]
187
08
Urinary system
026
Kidney (including renal pelvis and ureter)
“Renal”
189.0–189.2
027
Bladder and other urinary organs
“Urinary bladder”
188, 189.3–189.9
Bladder
188
Urethra, paraurethral glands, other and unspecified urinary
189.3–189.9
(discontinuity with ICD codes)
09
Other and unspecified sites
028
Bone (“and articular cartilage” in ICD nomenclature)
“Bone and joint”
170
“Skin”
029
Melanoma
172
030
Other malignant skin neoplasm
173
031
Mesothelioma
No codes (new minor code)
032
Connective (“and other soft” in ICD nomenclature) tissue
“Soft-tissue sarcoma”
171
(heart)
(164.1)
033
Brain and other parts of nervous system (ICD “soft tissue” includes peripheral nerves and autonomic nervous system)
“Brain”
191–192
034
Eye
190
035
Thyroid
193
(thymus)
164.0
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NIOSH Category for Cause of Death
Major
Minor
NIOSH Groupings of Cancer Sites
Subsites “Update 2004 Characterization of Grouping”a
ICD-9 Codes (Gapsb in Italics)
036
Other and unspecified sites
Other endocrine cancers
194
Other and ill-defined sites
195
Stated or assumed to be secondary of specified sites
196–198
Site unspecified
199
10
Lymphatic and hematopoietic tissue
Lymphoma
037
Hodgkin’s disease
201
038
Non-Hodgkin’s lymphoma
200, 202 (excluding 202.4), 273.3
039
Multiple myeloma
203 (excluding 203.1)
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040
Leukemia and aleukemia
“Leukemia (other than CLL)”
204–208
Lymphocytic
Acute lymphocytic
204.0
Chronic lymphocytic
204.1
Other lymphocytic
202.4; 204.2–204.9
Myeloid (granulocytic)
Acute myeloid
Acute
205.0
Acute erythremia and erythroleukemia
207.0
Megakaryocytic leukemia
207.2
Chronic myeloid
205.1
Other myeloid
205.2–205.3, 205.8–205.9
Monocytic
Acute monocytic
206.0
Chronic monocytic
206.1
Other monocytic
206.2–206.9
Other leukemia
Other acute
208.0
Other chronic
207.1, 208.1
Aleukemic, subleukemia, and “not otherwise specified”
203.1, 207.2, 207.8, 208.2–208.9
a Boldface cancer (sub)site: most comprehensive grouping for which conclusion was drawn in Update 2004.
b Italicized cancer (sub)site: prior gap in coverage of cancers (not explicitly addressed in text).
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TABLE B-2 Surveillance, Epidemiology, and End Results (SEER) Program Malignant Neoplasm Site Groupings for ICD-9 and ICD-10
Cancer Site
ICD-9 Codes
ICD-10 Codes
Buccal cavity and pharynx
Lip
140.0–140.9
C00.0–C00.9
Tongue
141.0–141.9
C01, C02.1–C02.9
Salivary glands
142.0–142.9
C07, C08.0–C08.9
Floor of mouth
144.0–144.9
C04.0–C04.9
Gum and other mouth
143.0–143.9, 145.0–145.6, 145.8–145.9
C03.0–C03.9, C05.0–C05.9, C06.0–C06.9
Nasopharynx
147.0–147.9
C11.1–C11.9
Tonsil
146.0–146.2
C09.0–C09.9
Oropharynx
146.3–146.9
C10.1–C10.9
Hypopharynx
148.0–148.9
C12, C13.0–C13.9
Other buccal cavity and pharynx
149.0–149.9
C14.0–C14.9
Digestive system
Esophagus
150.0–150.9
C15.0–C15.9
Stomach
151.0–151.9
C16.0–C16.9
Small intestine
152.0–152.9
C17.0–C17.9
Colon excluding rectum
153.0–153.9, 159.0
C18.0–C18.9, C26.0
Rectum and rectosigmoid junction
154.0–154.1
C19, C20
Anus, anal canal, and anorectum
154.2–154.3, 154.8
C21.0–C21.9
Liver and intrahepatic bile duct Liver
155.0,155.2
C22.0, C22.2–C22.4, C22.7–C22.9
Intrahepatic bile duct
155.1
C22.1
Gallbladder
156.0
C23
Other biliary
156.1–156.9
C24.0–C24.9
Pancreas
157.0–157.9
C25.0–C25.9
Retroperitoneum
158.0
C48.0
Peritoneum, omentum, and mesentery
158.8–158.9
C48.1–C48.2
Other digestive organs
159.8–159.9
C26.8–26.9, C48.8
Respiratory system
Nasal cavity, middle ear, and accessory sinuses
160.0–160.9
C30.0, C30.1, C31.0–C31.9
Larynx
161.0–161.9
C32.0–C32.9
Lung and bronchus
162.2–162.9
C34.0–C34.9
Pleura
163.0–163.9
C38.4
Trachea, mediastinum, and other respiratory organs
162.0, 164.2–165.9
C33, C38.1–C38.3, C38.8, C39
Bones and joints
170.0–170.9
C40.0–C40.9, C41.0–C41.9
Soft tissue (including heart)
171.0–171.9, 164.1
C38.0, C47.0–C47.9, C49.0–C49.9
Skin
Malignant melanomas
172.0–172.9
C43.0–C43.9
Other malignant skin neoplasms
173.0–173.9
C44.0–C44.9
Breast (male and female)
174.0–174.9, 175
C50.0–C50.9
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Cancer Site
ICD-9 Codes
ICD-10 Codes
Female genital system
Cervix
180.0–180.9
C53.0–C53.9
Corpus
182.0–182.1, 182.8
C54.0–C54.9
Uterus, not otherwise specified
179
C55
Ovary
183.0
C56.0–C56.9
Vagina
184.0
C52
Vulva
184.1–184.4
C51.0–C51.9
Other female genital organs
181, 183.2–183.9, 184.8, 184.9
C57.0–C57.9, C58
Male genital system
Prostate
185
C61
Testis
186.0–186.9
C62.0–C62.9
Penis
187.1–187.4
C60.0–C60.9
Other male genital organs
187.5–187.9
C63.0–C63.9
Urinary system
Urinary bladder
188.0–188.9
C67.0–C67.9
Kidney and renal pelvis
189.0, 189.1
C64.0–C64.9, C65.0–C65.9
Ureter
189.2
C66.0–C66.9
Other urinary organs
189.3–189.4, 189.8–189.9
C68.0–C68.9
Eye and orbit
190.0–190.9
C69.0–C69.9
Brain and other nervous system
Brain
191.0–191.9
C71.0–C71.9
Meninges
192.1
C70.0–C70.9
Other nervous systema
192.0, 192.2–192.9
C72.0–C72.9
Endocrine system
Thyroid
193
C73
Other endocrine (including thymus)
164.0, 194.0–194.9
C37, C74.00–C74.92, C75.0–C75.9
Lymphomas
Hodgkin’s disease
201.0–201.9
C81.0–81.9
Non-Hodgkin’s lymphomas
200.0–200.8, 202.0–202.2, 202.8–202.9
C82.0–C82.9, C83.0–C83.9, C84.0–C84.5, C85.0–C85.9, C96.3
Multiple myeloma
203.0, 238.6
C90.0, C90.2
Leukemias
Lymphocytic
Acute lymphocytic
204.0
C91.0
Chronic lymphocytic
204.1
C91.1
Other lymphocytic
202.4, 204.2–204.9
C91.2-C91.4, C91.7, C91.9
Myeloid (granulocytic)
Acute myeloid
205.0, 207.0, 207.2
C92.0, C92.4–C92.5, C94.0, C94.2
Chronic myeloid
205.1
C92.1
Other myeloid
205.2–205.3, 205.8–205.9
C92.2–C92.3, C92.7, C92.9
Monocytic
Acute monocytic
206.0
C93.0
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Cancer Site
ICD-9 Codes
ICD-10 Codes
Chronic monocytic
206.1
C93.1
Other monocytic
206.2–206.9
C93.2, C93.7, C93.9
Other leukemia
Other acute
208.0
C94.4, C94.5, C95.0
Other chronic
207.1, 208.1
C94.1, C95.1
Aleukemic, subleukemic, and “not otherwise specified”
203.1, 207.2, 207.8, 208.2–208.9
C90.1, C91.5, C94.3, C94.7, C95.2, C95.7, C95.9
Miscellaneous malignant neoplasms
159.1, 195.0–195.8, 196.0– 196.9, 199.0–199.1, 202.3, 202.5–202.6, 203.8
C26.1, C76.0–C76.8, C77.0–C77.9, C78.0–C78.8, C79.0–C79.8, C80, C88.0–C88.9, C96.0–C96.2, C96.7, C96.9, C97
SOURCE: Adapted from Ries et al. (2003), Table A-4.
a Cancers of the peripheral nerves and the autonomic nervous system are classified as “soft tissue” in ICD.
REFERENCES
Anderson RN, Minino AM, Hoyert DL, Rosenberg HM. 2001. Comparability of cause of death between ICD-9 and ICD-10: preliminary estimates. National Vital Statistics Reports 49(2):1–32.
Ries LAG, Eisner MP, Kosary CL, Hankey BF, Miller BA, Clegg L, Mariotto A, Fay MP, Feuer EJ, Edwards BK (eds). 2003. SEER Cancer Statistics Review, 1975–2000, National Cancer Institute. Bethesda, MD.
Robinson CF, Schnorr TM, Cassinelli RT, Calvert GM, Steenland K, Gersic CM, Schubauer-Berigan MK. 2006. Tenth revision U.S. mortality rates for use with the NIOSH Life Table Analysis System. Journal of Occupational and Environmental Medicine 48(7):662–667.