This page is part of the HL7 FHIR Implementation Guide: minimal Common Oncology Data Elements (mCODE) Release 1 - US Realm | STU1 (v3.0.0-ballot: STU 3 Ballot 1) based on FHIR R4. The current version which supercedes this version is 2.1.0. For a full list of available versions, see the Directory of published versions

Extended Example

In addition to providing examples of mCODE profiles, this extended example demonstrates how to represent a clinically realistic scenario.

• When information in the scenario does not map on to mCODE profiles, we provide examples using USCore or standard FHIR resources.
• We condense some repeated patterns. For example, we only show one example of MedicationAdministration when in reality, there could be multiple cycles, the only difference being the day of the administration.

Patient description

Patient Jenny M. is a 55 year old non-Hispanic white female with a past medical history significant for depression, a 20-pack-year history of smoking (current smoker), anxiety, and hypertension. Her family history was significant for a maternal aunt with ovarian cancer at age 69, a sister with breast cancer at age 64, and deceased paternal uncle due to pancreatic cancer.

During a routine screening mammography in February 2018, an abnormality was detected as a possible mass and suspected breast cancer. The gynecologist performing the biopsy refers the patient to an oncologist for further workup. An ultrasound-guided biopsy was performed along with prognostic tumor marker tests with ER positive, PR negative, and HER2 negative. The patient is referred to an oncologist who clinically reviews the mammogram and tumor marker results, and clinical staged the cancer diagnosis as cT3N0.

Genetic counseling ordered a 7 gene panel, and the panel results revealed a pathogenic variant in PALB2 (c.3549C>A).¹

A partial mastectomy was performed, revealing a 2.5 cm tumor with no lymph-vascular invasion and negative margins of excision. Three sentinel lymph nodes were excised and were negative for metastatic carcinoma. The tumor specimen was sent to the pathologist. The pathology report revealed a 2.5cm malignant tumor histological grade 2 invasive ductal adenocarcinoma with prognostic tumor markers ER positive, PR negative, and HER2 negative. The patient is pathologically staged as pT3 pN0, stage group IIB.

A 21-gene RT-PCR assay yielded a recurrence score of 47.

Treatment options were discussed between the patient and the medical oncologist. With an ECOG performance score of 0, the patient agrees to receive an AC-T chemotherapy regimen. She received four cycles of doxorubicin (60 mg/m² IV) and cyclophosphamide (600 mg/m² IV) followed by paclitaxel (175 mg/m² IV) (AC-T), administered on a dose-dense schedule. She subsequently received whole breast radiation therapy with regional nodal irradiation.

One month following the completion of first-line therapy, the patient is evaluated and with her disease status improving. The patient will undergo surveillance imaging and monitoring.

A timeline of the narrative is illustrated in the following diagram:

FHIR instances from mCODE elements

FHIR instances from non-mCODE elements