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APPENDIX B Clariï¬cation 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 reï¬nements in the system used in previous Veterans and Agent Orange (VAO) updates to present conclusions about the adequacy of evidence concerning asso- ciations 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 speciï¬c 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 speciï¬c types of cancer on which no data compatible with review had been found; the endpoint by default was in the âinadequate or insuf- ï¬cient evidenceâ 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 caseâcontrol studies, which fol- low the only design amenable to studying very infrequent or very speciï¬c health outcomes. How researchers are able to group, analyze, and report their ï¬ndings is inï¬uenced by the distribution of cases that they observe, so the data that VAO committees have had available for review reï¬ect mortality experience at a level of speciï¬city concordant with statistical analysis. Previous updates have referred to the International Classiï¬cation 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 classiï¬ed for statistical purposes in a standard form amenable to data stor- age 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 707
708 VETERANS AND AGENT ORANGE: UPDATE 2006 in effect for deaths that occurred in 1960â1967, 1968â1978, and 1979â1998, 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 Sta- tistics, for ICD-encoded mortality data sets. An article by Robinson et al. (2006) discusses revisions to that standard software to incorporate deaths coded accord- ing 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 140.0â208.9, NIOSHâs major categories 02â10, or NIOSHâs more speciï¬c minor categories 004â040. The NIOSH death codes for neoplasms provide comprehensive scaffold- ing for organizing the committeeâs reviews and conclusions by cancer type that is somewhat simpler than ICD classiï¬cations, 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 ï¬ndings available for VAO review. In general cohort stud- ies, one is unlikely to encounter results on more speciï¬c groupings than NIOSHâs 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 certiï¬cates, but when researchers present their results labeled with ICD codes, there can be little ambiguity about what they intended. When their most deï¬nitive indication is something like ârespiratory cancers,â 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 modiï¬cations 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 neo- plasms, neoplasms of uncertain behavior, and neoplasms of unspeciï¬ed behavior have separate codes in both schemes.
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 Subsites âUpdate 2004 Characterization of Major Minor NIOSH Groupings of Cancer Sites Groupingâa ICD-9 Codes (Gapsb in Italics) 02 Buccal cavity and pharynx âOral, nasal, and pharyngealâ 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 146.0â146.2 Nasopharynx 147 Hypopharynx 148 Other buccal cavity and pharynx 149 (160 nasal below) 03 Digestive organs and peritoneum âGastrointestinalâ 008 Esophagus 150 009 Stomach 151 010 Intestine except rectum Small intestine 152 Colon (large intestine) 153 011 Rectum 154 709 continued
TABLE B-1 Continued 710 NIOSH Category for Cause of Death Subsites âUpdate 2004 Characterization of Major Minor NIOSH Groupings of Cancer Sites Groupingâa ICD-9 Codes (Gapsb in Italics) 012 Biliary passages, liver, and gall bladder âHepatobiliaryâ Liver and intrahepatic bile ducts 155 Gallbladder and extrahepatic bile ducts 156 013 Pancreas 157 014 Retroperitoneum and other and unspeciï¬ed 158â159 digestive organs 04 Respiratory system âRespiratoryâ 015 Larynx 161 016 Trachea, bronchus, and lung 162 Trachea 162.0 (there is no ICD 162.1) Lung and bronchus 162.2â162.9 017 Pleura 163 018 Other respiratory Nasal cavity, middle ear, and accessory sinuses (160, above with oral and pharyngeal) Thymus, heart, and mediastinum 164 (164.0, below with endocrine; 164.1, below with soft-tissue sarcoma) Other respiratory, unspeciï¬ed 165 (discontinuity with ICD codes) 05 019 Breast (male and female) âBreastâ 174, 175 06 Female genital organs âFemale reproductiveâ 020 Cervix uteri 180 021 Other unspeciï¬ed parts of uterus 179, 181, 182 Uterus, parts unspeciï¬ed 179 Placenta 181 Body of uterus 182
022 Ovary, fallopian tube, and broad ligament 183 Ovary 183.0 (there is no ICD 183.1) Fallopian tube and other uterine adnexa 183.2â183.9 023 Other female genital organs 184 07 Male genital system 185, 186 024 Prostate âProstateâ 185 025 Testis âTesticularâ 186 Penis and other male genital organs [for NIOSH in minor group 036] 187 08 Urinary system 026 Kidney (including renal pelvis and ureter) âRenalâ 189.0â189.2 027 Bladder and other urinary organs âUrinary bladderâ 188, 189.3â189.9 Bladder 188 Urethra, paraurethral glands, other and 189.3â189.9 unspeciï¬ed urinary (discontinuity with ICD codes) 09 Other and unspeciï¬ed sites 028 Bone (âand articular cartilageâ in ICD âBone and jointâ 170 nomenclature) âSkinâ 029 Melanoma 172 030 Other malignant skin neoplasm 173 031 Mesothelioma No codes (new minor code) 032 Connective (âand other softâ in ICD âSoft-tissue sarcomaâ 171 nomenclature) tissue (heart) (164.1) 033 Brain and other parts of nervous system (ICD âBrainâ 191â192 âsoft tissueâ includes peripheral nerves and autonomic nervous system) 034 Eye 190 035 Thyroid 193 (thymus) 164.0 711 continued
712 TABLE B-1 Continued NIOSH Category for Cause of Death Subsites âUpdate 2004 Characterization of Major Minor NIOSH Groupings of Cancer Sites Groupingâa ICD-9 Codes (Gapsb in Italics) 036 Other and unspeciï¬ed sites Other endocrine cancers 194 Other and ill-deï¬ned sites 195 Stated or assumed to be secondary of speciï¬ed 196â198 sites Site unspeciï¬ed 199 10 Lymphatic and hematopoietic tissue Lymphoma 037 Hodgkinâs disease 201 038 Non-Hodgkinâs lymphoma 200, 202 (excluding 202.4), 273.3 039 Multiple myeloma 203 (excluding 203.1)
040 Leukemia and aleukemia âLeukemia (other than CLL)â 204â208 Lymphocytic Acute lymphocytic 204.0 Chronic lymphocytic 204.1 Other lymphocytic 202.4; 204.2â204.9 Myeloid (granulocytic) Acute myeloid Acute 205.0 Acute erythremia and erythroleukemia 207.0 Megakaryocytic leukemia 207.2 Chronic myeloid 205.1 Other myeloid 205.2â205.3, 205.8â205.9 Monocytic Acute monocytic 206.0 Chronic monocytic 206.1 Other monocytic 206.2â206.9 Other leukemia Other acute 208.0 Other chronic 207.1, 208.1 Aleukemic, subleukemia, and ânot otherwise 203.1, 207.2, 207.8, 208.2â208.9 speciï¬edâ 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). 713
714 VETERANS AND AGENT ORANGE: UPDATE 2006 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 140.0â140.9 C00.0âC00.9 Tongue 141.0â141.9 C01, C02.1âC02.9 Salivary glands 142.0â142.9 C07, C08.0âC08.9 Floor of mouth 144.0â144.9 C04.0âC04.9 Gum and other mouth 143.0â143.9, 145.0â145.6, C03.0âC03.9, C05.0âC05.9, 145.8â145.9 C06.0âC06.9 Nasopharynx 147.0â147.9 C11.1âC11.9 Tonsil 146.0â146.2 C09.0âC09.9 Oropharynx 146.3â146.9 C10.1âC10.9 Hypopharynx 148.0â148.9 C12, C13.0âC13.9 Other buccal cavity and pharynx 149.0â149.9 C14.0âC14.9 Digestive system Esophagus 150.0â150.9 C15.0âC15.9 Stomach 151.0â151.9 C16.0âC16.9 Small intestine 152.0â152.9 C17.0âC17.9 Colon excluding rectum 153.0â153.9, 159.0 C18.0âC18.9, C26.0 Rectum and rectosigmoid 154.0â154.1 C19, C20 junction Anus, anal canal, and anorectum 154.2â154.3, 154.8 C21.0âC21.9 Liver and intrahepatic bile duct Liver 155.0,155.2 C22.0, C22.2âC22.4, C22.7âC22.9 Intrahepatic bile duct 155.1 C22.1 Gallbladder 156.0 C23 Other biliary 156.1â156.9 C24.0âC24.9 Pancreas 157.0â157.9 C25.0âC25.9 Retroperitoneum 158.0 C48.0 Peritoneum, omentum, and 158.8â158.9 C48.1âC48.2 mesentery Other digestive organs 159.8â159.9 C26.8â26.9, C48.8 Respiratory system Nasal cavity, middle ear, and 160.0â160.9 C30.0, C30.1, C31.0âC31.9 accessory sinuses Larynx 161.0â161.9 C32.0âC32.9 Lung and bronchus 162.2â162.9 C34.0âC34.9 Pleura 163.0â163.9 C38.4 Trachea, mediastinum, and other 162.0, 164.2â165.9 C33, C38.1âC38.3, C38.8, respiratory organs C39 Bones and joints 170.0â170.9 C40.0âC40.9, C41.0âC41.9 Soft tissue (including heart) 171.0â171.9, 164.1 C38.0, C47.0âC47.9, C49.0âC49.9 Skin Malignant melanomas 172.0â172.9 C43.0âC43.9 Other malignant skin neoplasms 173.0â173.9 C44.0âC44.9 Breast (male and female) 174.0â174.9, 175 C50.0âC50.9
APPENDIX B 715 TABLE B-2 Continued Cancer Site ICD-9 Codes ICD-10 Codes Female genital system Cervix 180.0â180.9 C53.0âC53.9 Corpus 182.0â182.1, 182.8 C54.0âC54.9 Uterus, not otherwise speciï¬ed 179 C55 Ovary 183.0 C56.0âC56.9 Vagina 184.0 C52 Vulva 184.1â184.4 C51.0âC51.9 Other female genital organs 181, 183.2â183.9, 184.8, C57.0âC57.9, C58 184.9 Male genital system Prostate 185 C61 Testis 186.0â186.9 C62.0âC62.9 Penis 187.1â187.4 C60.0âC60.9 Other male genital organs 187.5â187.9 C63.0âC63.9 Urinary system Urinary bladder 188.0â188.9 C67.0âC67.9 Kidney and renal pelvis 189.0, 189.1 C64.0âC64.9, C65.0âC65.9 Ureter 189.2 C66.0âC66.9 Other urinary organs 189.3â189.4, 189.8â189.9 C68.0âC68.9 Eye and orbit 190.0â190.9 C69.0âC69.9 Brain and other nervous system Brain 191.0â191.9 C71.0âC71.9 Meninges 192.1 C70.0âC70.9 Other nervous systema 192.0, 192.2â192.9 C72.0âC72.9 Endocrine system Thyroid 193 C73 Other endocrine (including 164.0, 194.0â194.9 C37, C74.00âC74.92, thymus) C75.0âC75.9 Lymphomas Hodgkinâs disease 201.0â201.9 C81.0â81.9 Non-Hodgkinâs lymphomas 200.0â200.8, 202.0â202.2, C82.0âC82.9, C83.0âC83.9, 202.8â202.9 C84.0âC84.5, C85.0âC85.9, 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, 204.2â204.9 C91.2-C91.4, C91.7, C91.9 Myeloid (granulocytic) Acute myeloid 205.0, 207.0, 207.2 C92.0, C92.4âC92.5, C94.0, C94.2 Chronic myeloid 205.1 C92.1 Other myeloid 205.2â205.3, 205.8â205.9 C92.2âC92.3, C92.7, C92.9 Monocytic Acute monocytic 206.0 C93.0 continued
716 VETERANS AND AGENT ORANGE: UPDATE 2006 TABLE B-2 Continued Cancer Site ICD-9 Codes ICD-10 Codes Chronic monocytic 206.1 C93.1 Other monocytic 206.2â206.9 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 203.1, 207.2, 207.8, C90.1, C91.5, C94.3, C94.7, ânot otherwise speciï¬edâ 208.2â208.9 C95.2, C95.7, C95.9 Miscellaneous malignant 159.1, 195.0â195.8, 196.0â C26.1, C76.0âC76.8, neoplasms 196.9, 199.0â199.1, C77.0âC77.9, C78.0âC78.8, 202.3, 202.5â202.6, C79.0âC79.8, C80, 203.8 C88.0âC88.9, C96.0âC96.2, 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 classiï¬ed as âsoft tissueâ in ICD. REFERENCES Anderson RN, Minino AM, Hoyert DL, Rosenberg HM. 2001. Comparability of cause of death be- tween ICD-9 and ICD-10: preliminary estimates. National Vital Statistics Reports 49(2):1â32. 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, 1975â2000, 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):662â667.