Instructions for Missouri Cancer Registry
Melanoma Reporting Form
Patient Information
Please complete ALL demographics information, including address, DOB, SSN, race, etc.
Race: Check the box that describes the patient’s race. You may check more than one box for
multiracial patients. The following rules will help to select the appropriate box:
--White includes Mexican, Puerto Rican, Cuban, and all other Caucasians.
--African American includes the designation Black.
--Asian/Pacific Islander includes when place of birth is given as China, Japan, or the
Philippines.
Occupation: Record the patient’s usual occupation (that is, the kind of work performed during most
of the patient’s working life before diagnosis of this malignancy).
Cancer Identification
Date of Initial Diagnosis: This is the date this primary cancer was first diagnosed by a recognized
medical practitioner.
Primary Site of Cancer: Indicate if this is the original site of the tumor. If not, record the site of
original primary site. Be as specific as possible from the information available.
Information from the pathology report:
 Histology: Record the histology or tissue type of the primary tumor documented as the final
pathologic diagnosis (nodular melanoma, lentigo maligna melanoma, etc) or attach a copy
of the pathology report.
 Laterality: Indicate whether laterality is right or left.
 Ulceration: Indicate whether ulceration is present.
 Tumor size: Record tumor size in millimeters.
 Lymph Node involvement: Indicate any lymph node involvement.
 Clark’s Level: This is the depth of invasion.
 Breslow’s Information: This is the thickness of the tumor. This is not the same as the tumor
size.
SEER Staging of Disease: Describes the extent of the disease (non-invasive or in situ, localized,
regional or distant). You may also provide the TNM stage if known. If in doubt about stage, ask the
physician.
History of Previous Melanoma: Indicate if the patient has a history of previous melanoma(s) and
whether this is a recurrence or new primary.
Treatment
Surgery/procedure performed: Record information on any diagnostic or treatment procedure.
Date of procedure: Record date and type performed (shave, punch, excision, etc.).
Studies performed included: Indicate type of studies performed if any, including
lymphoscintigraphies and sentinel node biopsies.
Other performed/known treatments: This includes other surgical (e.g. wide excision, etc.) or nonsurgical (chemotherapy, etc.) treatments.
Other relevant information: Detail any other relevant information such as previous history of other
cancers or treatments not listed.
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