The diagnosis of cancer must be established based on the signs, symptoms and laboratory findings. The site of the primary cancerous tumor must be documented, as well as sites of recurrent cancer and cancer that has spread to other parts of the body to produce secondary tumors (metastatic tumors). If surgery has been done, the SSA requires a copy of the operative note that the surgeon dictates about the procedure, as well as a report on the gross visual and microscopic examination of any surgical specimens removed from the patient. Microscopic examination of tissue specimens by a pathologist is critical to the accurate diagnosis of cancer. If these documents are not obtainable by the SSA, then the summary of hospitalization or a report from the treating doctor must include details of the findings at surgery and the results of the pathologist's gross and microscopic examination of the tissues. However, the SSA much prefers the actual reports of the surgeon and pathologist.

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