The stage of a breast cancer. Different staging systems use different staging groups, so there are currently no terminology bindings associated with this class.

The base class, independent of context, for evaluations (measurements, tests, or questions) and a value containing the result (answer).

The subject of a finding can be the entire patient, or an entity such as a location body structure, intervention, or condition. Things observed about the subject can include social and behavioral factors, subjective and objective observations, and assessments.

CIMI Alignment: 1) In CIMI V0.0.4, LaboratoryTestResult.specimen is 0.. but that cardinality makes it impossible to map to FHIR Observation, where specimen is 0..1. The cardinality of Specimen has been changed to 0..1 to enable FHIR mapping. 2) In CIMI V0.0.4, Findings (including EvaluationResult and LaboratoryTestResult) do not have related ('has-member') observations, nor components (sub-observations). These features of FHIR Observations were found to be very useful in modeling breast cancer pathology, and are included here. This represents a significant departure from the CIMI model. CompoundClinicalStatement has not been used to represent panel-like findings, because of the complexity of mapping this class to FHIR. 3) In CIMI V0.0.4, allowable datatypes for result (aka Value) include EmbeddedContent, GpsLocation, Multimedia, ParsableContent, and other types not allowed in a FHIR Observation. To make mapping feasible, the types of Value were restricted to only the allowable FHIR datatypes. 4) ExceptionValue has been moved to the RecordedContext, because it is only relevant when a value is supposed to be recorded, but is not. 5) The cardinality of FindingMethod has been changed from 0.. to 0..1 to make it possible to map to FHIR, where Observation.method is 0..1. 6) The class PhysicalEvaluationResult has been united with this class, and the body location (AnatomicalLocation) has been added to this class. This is because bodySite is part of Observation, and it cannot be profiled out of EvaluationResult and then re-included in PhysicalEvaluationResult. 7) The cardinality of AnatomicalLocation has been changed from 0..* to 0..1 to make it possible to map to FHIR, where Observation.bodySite is 0..1. 8) The attribute evaluationDate has been moved to RecordedContext, because it only applies to evaluations that have been done. 9) The attributes device and evaluationProcedure have been removed for brevity, since they are not used in the current IG.

A set of codes drawn from different coding systems, representing the same concept.

The concept representing the finding or action that is the topic of the statement.

For action topics, the TopicCode represents the action being described. For findings, the TopicCode represents the 'question' or property being investigated. For evaluation result findings, the TopicCode contains a concept for an observable entity, such as systolic blood pressure. For assertion findings, the TopicCode contains a code representing the condition, allergy, or other item being asserted. In all cases, the TopicCode describes the topic independent of the context of the action or the finding.

CIMI Alignment: TopicCode is the new CIMI name for the attribute formerly called 'key' in CIMI V0.0.4.

Malignant Neoplasm of Breast Staging

unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

The identification of the code system that defines the meaning of the symbol in the code.

Need to be unambiguous about the source of the definition of the symbol.

The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.

The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.

Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

Need to refer to a particular code in the system.

A representation of the meaning of the code in the system, following the rules of the system.

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

Indicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays).

This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.

Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.

The technique used to create the finding; for example, the specific imaging technique, lab test code, or assessment vehicle.

CIMI Alignment: In CIMI V0.0.4, this attribute was called 'method'. The value set binding reflects CIMI's preference for LOINC codes.

A clinical interpretation of a finding.

CIMI Alignment: The value set binding has been chosen to align with FHIR. (Note: it is not clear if Interpretation belongs in FindingTopic, rather than a context class, but that is how CIMI has modeled it.)

A class or division of people or things having particular shared characteristics

Code representing a class or division of people or things having particular shared characteristics

A location or structure in the body, including tissues, regions, cavities, and spaces; for example, right elbow, or left ventricle of the heart.

CIMI Alignment: In CIMI V0.0.4, AnatomicalLocation has no parent class. This appears to have been an oversight, and the parent should have been Entity, as modeled here.

A specimen is a substance, physical object, or collection of objects, that the laboratory considers a single discrete, uniquely identified unit that is the subject of one or more steps in the laboratory workflow. A specimen may include multiple physical pieces as long as they are considered a single unit within the laboratory workflow. A specimen results from one to many specimen collection procedures, and may be contained in multiple specimen containers. Specimen may have one or more processing activities.

CIMI Alignment: This class has been cut down to parts relevant to the current oncology ballot. The attribute parentSpecimenIdentifier has been changed from an Identifier to a reference to a Specimen, to make it possible to map to FHIR.

Indicator of significant change (delta) from the last or previous measurement.

A description of the conditions or context of an observation; for example, under sedation, fasting or post-exercise.

Body position and body site are also qualifiers, but handled separately. A qualifier cannot modify the measurement type; for example, a fasting blood sugar is still a blood sugar.

The usual or acceptable range for a test result.

A simplified, non-separable evaluation consisting of a finding code (represented by the Concept), value (or exception value), reference range, and interpretation.

The subject of the evaluation component is the same as in the parent evaluation.

The size and extent of the primary tumor, based on criteria defined by the staging system being used.

The presence of metastases in regional lymph nodes, based on criteria defined by the staging system being used.

The presence of distant metastases, based on criteria defined by the staging system being used.

Context for an evaluation result, used to indicate an evaluation has been made.

For example, measurement of blood pressure that has been made simply exists (although the value can be present or absent, accurate or inaccurate). The RecordedContext indicates the information presented stands on its own as presented. It can also apply to clinical notes.

CIMI Alignment: The RecordedContext class did not exist in CIMI V0.0.4, but CIMI has recently added it.

An abstract class that represents an encounter class. This class has been stubbed out to limit the scope of this implementation guide to classes relevant to this ballot concerning breast cancer.

Members represent the elements of a group of a related but independent evaluations.

Examples are the measurements that compose a complete blood count (CBC), or the elements of a pathology report. Each member is an independent evaluation, but the grouping reflects a composite lab order, shared specimen, or a single report author. Typically the Category and Reason are not given for individual findings that are part of the panel, but rather given at the level of the panel itself. Although the proper place to define Members this might be in EvaluationResultTopic, it cannot be defined there because the value references EvaluationResultRecorded, which is a clinical statement class.

CIMI Alignment: CIMI V0.0.4 does not have this attribute and uses CompoundClinicalStatement to create panels. Compared to having a separate class, the current representation closer alignment with FHIR and greater flexibility (related observations can be added to any observation).

EvaluationResultRecorded representing members represent the elements of a group of a related but independent evaluations.

Examples are the measurements that compose a complete blood count (CBC), or the elements of a pathology report. Each member is an independent evaluation, but the grouping reflects a composite lab order, shared specimen, or a single report author. Typically the Category and Reason are not given for individual findings that are part of the panel, but rather given at the level of the panel itself. Although the proper place to define Members this might be in EvaluationResultTopic, it cannot be defined there because the value references EvaluationResultRecorded, which is a clinical statement class.

CIMI Alignment: CIMI V0.0.4 does not have this attribute and uses CompoundClinicalStatement to create panels. Compared to having a separate class, the current representation closer alignment with FHIR and greater flexibility (related observations can be added to any observation).

HER2 receptor status. HER2 is a member of the human epidermal growth factor receptor family of proteins and is encoded by the ERBB2 oncogene. HER2 is overexpressed in 20-30% of breast tumors,10 and is associated with an aggressive clinical course and poor prognosis. HER2 status (positive=present or overexpressed; negative=absent) is a factor in determining prognosis and treatment options.

We are seeking feedback if it is better to put the positive/negative status in Value or Interpretation. The current approach is that positive/negative designation is a value, even though that value is (in fact) an interpretation of evidence from HER2 by IHC and/or HER2 by ISH tests, not a direct observation.

Estrogen receptor alpha is the predominant estrogen receptor expressed in breast tissue and is overexpressed in around 50% of breast carcinomas. ER status (positive=present or overexpressed; negative=absent) is a factor in determining prognosis and treatment options.

We are seeking feedback if it is better to put the positive/negative status in Value or Interpretation. The current approach is that positive/negative designation is a value, even though that value is (in fact) an interpretation of evidence (NuclearPositivity and AverageStainingIntensity).

Progesterone receptor status is a factor in determining prognosis and treatment options. The value is the percentage of cells that test (stain) positive for the presence of a receptor. The interpretation of positive or negative (found in the interpretation property) is based on the staining percentage, and may take into account the staining intensity.

Based on discussion with Cancer Interoperability Group subject matter experts, there was insufficient rationale to include the following components in the data model: StainingControl, PrimaryAntibody, Allred Score (both total and component scores). We are seeking feedback on whether or not those components should be included in this model.

We are seeking feedback if it is better to put the positive/negative status in Value or Interpretation. The current approach is that positive/negative designation is a value, even though that value is (in fact) an interpretation of evidence (NuclearPositivity and AverageStainingIntensity).

An evaluation of the size and shape of the nucleus in tumor cells and the percentage of tumor cells that are in the process of dividing or growing. Cancers with low nuclear grade grow and spread less quickly than cancers with high nuclear grade.

The Elston Grade/Nottingham Score, representative of the aggressive potential of the tumor. Well differentiated cells (Grade 1) look similar to normal cells and are usually slow growing, while poorly differentiated cells (Grade 3) look very different than normal and are fast-growing.

Indicates when the staging was done, in terms of treatment landmarks.