Executive Summary

Pathologist macroscopic and microscopic assessment of excised (removed) tissue is the gold standard for cancer diagnosis.  For decades, the pathologist report was, and in many places still is, rendered as a narrative description of the observations and ultimate conclusions of the pathologist.  Over the past 20 years, pathology reporting has evolved in many countries to a synoptic format (i.e., defined questions and answers) that specifies the specific data elements for the pathology to capture and communicate in their pathology report. This implementation guide is designed to support implementors of structured, electronic and SNOMED CT encoded cancer datasets.