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National Cancer Registration
Data Definitions
November 2016
Version 14.0
Document Control
Version
14.0
Date Issued
Author(s)
1
Cancer Registration Team
Related Documents
Staging definitions
Comments to
NSS.CancerReg @nhs.net
Document History
Comments
Version
Date
12.0
11.08.14
Version 12 complete with all amendments up to 2013 incidence date
13.0
07.11.16
Draft version 12.1 complete with all amendments up to 2016 incidence date
14.0
22.11.16
Final version 13.0 complete with all amendments up to 2016 incidence date.
Updates from version 12.0 have been marked in red.
Page | 2
Author(s)
A McD
K Smith
C Owers
K Smith
C Owers
CONTENTS
INTRODUCTION ......................................................................................................................... 4
PERSON RECORD ..................................................................................................................... 5
IDENTIFICATION AT DIAGNOSIS (Tumour level) .................................................................... 11
DIAGNOSIS DETAILS (TUMOUR LEVEL) ................................................................................ 14
STAGE DETAILS (TUMOUR LEVEL) ....................................................................................... 23
OTHER CONTRUBUTING FACTORS (TUMOUR LEVEL) ....................................................... 31
INITIAL TREATMENT (TUMOUR LEVEL) ................................................................................ 36
STATISTICAL & HISTORICAL DATA (TUMOUR LEVEL) ........................................................ 43
SYSTEM ADMINISTRATION DATA .......................................................................................... 45
SOURCE DATA– CLINICAL HISTORY RECORDS .................................................................. 47
Page | 3
INTRODUCTION
This document defines the data items that are collected or derived by the Cancer Registration computer system ‘SOCRATES’ (Scottish
Online Cancer Registration And Tumour Enumeration System).
The SOCRATES definitions are split into 7 sections:

PERSON RECORD (Person Level)

IDENTIFICATION AT DIAGNOSIS (Tumour Level)

DIAGNOSIS DETAILS (Tumour Level)

INITIAL TREATMENT (Tumour Level)

STATISTICAL & HISTORICAL DATA (Tumour Level)

SYSTEM ADMINISTRATION DATA (Person & tumour level)

SOURCE DATA - CLINICAL HISTORY RECORDS
Each definition is also broken into 5 sections:

FIELD NAME

FIELD LENGTH

FIELD PRIORITY

SOCRATES SCREEN LOCATION (where field can be located: P = Person, ID = ID at diagnosis, D = Diagnosis, St = Stage, OCF =
Other Contributing Factors, T = Treatment, A = Admin

Page | 4
DEFINITION WITH OPTIONS (if applicable)
PERSON RECORD
KEY:
L = field length
P = field priority: M = mandatory, O = optional, D= Derived
S = ‘Registration’ screen locations: P = Person, ID = ID at Diag, D = Diagnosis, St = Stage, OCF = Other Contributing Factors, S = Stats,
T = Treatment, A = Admin
Field
L
P
S
Definition and Options
Person Identifier
8
D
P
A unique number which will enable the unequivocal identification of individual cancer patients. It is a
sequential number allocated by the computer system SOCRATES (For historical data it will result from
person-based linkage). It uniquely identifies each person depending on person-based linkage and is
subject to change if linkage is reviewed.
20
D
P
Latest Surname from the last registration completed (if no previous registrations then name used for
provisional notification).
30
D
P
All surnames by which this person has been known. This includes maiden names, aliases or differences in
spelling.
30
D
P
Latest forename from the last registration completed.
30
D
P
All forenames by which this person has been known.
8
M
P
Patient’s full date of birth only. The date of birth at person & tumour level may not be the same. Therefore
this field is used for the DOB confirmed to be correct. i.e. the latest used or most commonly used if it is a
valid date. The main format inclusive of century is DD-MMM-YYYY e.g. 9th Feb 42 is 09-FEB-1942 this is
then saved onto the main oracle table as YYYYMMDD 19420242.
10
D
P
A Unique Patient Identifier (UPI) was determined to be the CHI number which was most current at the
time the indexes were linked ie. The record with the latest date of acceptance on a GP record. 10 digit
number consists of 6-digit DOB (DDMMYY) followed by 4 check digits (9th digit denotes sex. 1,3,5,7 or 9
=male, 2,4,6,8 or 0 =female). This field is automatically populated by ascertaining the derived UPI by
linking the CHI number held within the Registration Diagnosis screen directly to the CHI database. The
Socrates system is also automatically CHI seeded during production run linkage.
(P_ID)
Latest Surname
(P_SURNAME)
All Surnames
(P_SURNAME)
Latest Forename
(P_FORENAMES)
All Forenames
(P_FORENAMES)
Date of Birth
(P_DATE_OF_BIRTH)
Derived UPI
(P_DERIVED_UPI)
Page | 5
Pre-CHI
1
O
P
Pre-CHI is a tick box which can be used to break/remove bad UPI linkages.
1
M
ID
(Genetic) Sex of the patient. This should match with all sex fields of each tumour. Options:
(P_PRE_CHI)
Sex (Gender)
(P_SEX)
Code
1
2
9
Ethnic Group
(P_ETHNIC_GROUP)
2
M
P
Description
Male
Female
Not Specified
This field is collected for all registrations with an incidence date from 1.1.1997
These are used by NHS Scotland organisations for local and national return purposes.
It describes the patient’s perception of their Ethnic Group. For patients with more than one registration, the
Ethnic Group will be updated to reflect the most recent date option.
Originally these were based on the UK Dept. Of Health recommendations (Part of COPPISH SMR patient
ID section)
- From 1.1.1997 to 30.9.2005 incidence Ethnic Group 1 options:
Ethnic Group 1
Code
00
01
02
03
04
05
06
07
08
09
10
Description
White
Black Caribbean
Black African
Black Other
Indian
Pakistani
Bangladeshi
Chinese
Other Ethnic Group
Not Known
Refused
The following codes were created to reflect the Scottish Census 2001 categories and were used for a
short time in conjunction with the old codes.
- From 1.10.2005 to 31.3.2006 incidence. Ethnic Group 1 options OR Ethnic Group 2 options:
Page | 6
Ethnic Group
(contd)
Ethnic Group 2
2
M
P
Code
1A
1B
1C
1D
2A
3A
3B
3C
3D
3E
4A
4B
4C
5A
97
99
Description
White-Scottish
White-other British
White-Irish
Any other white background
Any mixed background
Indian
Pakistani
Bangladeshi
Chinese
Any other Asian background
Caribbean
African
Any other black background
Any other ethnic background
Refused/not provided by the patient
Not known
- From 1.4.2006 to 31.3.2010 incidence Ethnic Group 2 options only
- From 1.4.2010 to 30.9.2010 incidence Ethnic Group 2 options OR Ethnic Group 3 options:
Ethnic Group 3
Code
1A
1E
1F
1G
1H
1J
1K
IL
1Z
2A
Page | 7
Description
White-Scottish
White-English
White - Welsh
White-Northern Irish
White British
White-Irish
Gypsy/Traveller
Polish
Any other white ethnic background
Any mixed or multiple ethnic groups
Ethnic Group
(contd)
2
M
P
3F
3G
3H
3J
3Z
4D
4E
4F
4Z
5B
5X
98
99
Pakistani, Pakistani Scottish or Pakistani British
Indian, Indian Scottish or Indian British
Bangladeshi, Bangladeshi Scottish or Bangladeshi British
Chinese, Chinese Scottish or Chinese British
Other Asian
African, African Scottish or African British
Caribbean, Caribbean Scottish or Caribbean British
Black, Black Scottish or Black British
Other African, Caribbean or Black
Arab
Other Ethnic Group
Refused/not provided by the patient
Not known
- From 1.10.2010 to 30.9.2011 incidence. Ethnic Group 3 options only
Further changes have been made following a review of ethnicity recording in the 2011 Scottish Census.
- From 1.10.2011 to 31.3.2012 incidence. Ethnic Group 3 options OR Ethnic Group 4 options
Ethnic Group 4
Code
1A
1B
1C
1K
IL
1Z
2A
3F
3G
3H
3J
3Z
4D
4Y
Page | 8
Description
White-Scottish
White- Other British
Irish
Gypsy/Traveller
Polish
Any other white ethnic background
Any mixed or multiple ethnic groups
Pakistani, Pakistani Scottish or Pakistani British
Indian, Indian Scottish or Indian British
Bangladeshi, Bangladeshi Scottish or Bangladeshi British
Chinese, Chinese Scottish or Chinese British
Other Asian, Asian Scottish or Asian British
African, African Scottish or African British
Other African
Ethnic Group
(contd)
2
M
P
5C
5D
5B
5Y
6A
6Z
98
99
Caribbean, Caribbean Scottish or Caribbean British
Black, Black Scottish or Black British
Arab
Other Caribbean or Black
Arab, Arab Scottish or Arab British
Other Ethnic Group
Refused/not provided by the patient
Not known
- From 1.4.2012 incidence. Ethnic Group 4 options only
Date of Death
8
(P_DATE_OF_DEATH)
OOS (Out of
Scotland)
O/
P
Date of patient’s death may be entered by the Cancer Information Officer (CIO) or obtained through
linkage to the National Records of Scotland (NRS). The Cancer Registry receives death notifications from
various sources - NHSCR, CIO's directly view hospital systems, CHI, other cancer registries, genetic
clinics and NRS. Format DD-MMM-YYYY.
D
1
O
P
This should be ticked to indicate that a patient has died out with Scotland and we have been notified by
another Cancer Registry. Death will not be notified through the NRS linkage. This field may explain
discrepancy between SOCRATES and ISD warehouse data. This tick box was introduced in the
redeveloped SOCRATES.
1
O/
P
Living Status of Patient. Options:
(P_OOS)
Vital Status
(P_VITAL_STATUS)
Cause of Death 1
D
4
Code
1
2
3
6
9
D
P
Primary Cause of death. Obtained through NRS linkage and are be coded in ICD9 until 31.12.1999 (date
of death). Deaths from 1.1.2000 are coded in ICD10. The Cancer Registry receives death notifications
from various sources - NHSCR, CIO's directly view hospital systems, CHI, other cancer registries, genetic
clinics and NRS.
D
P
Secondary Cause of death x 3 indicates other causes of death. Obtained through NRS linkage and are
coded ICD9 until 31.12.1999 (date of death). Deaths from 1.1.2000 are coded in ICD10. The Cancer
(P_CAUSE_OF_DEATH_1)
Causes of Death 4 x7
2, 3, 4, 5, 6, 7 & 8
Page | 9
Description
Alive
Dead
Moved out of Scotland
Presumed deceased
Not Known
(P_CAUSE_OF_DEATH_2)
(P_CAUSE_OF_DEATH_3)
(P_CAUSE_OF_DEATH_4)
(P_CAUSE_OF_DEATH_5)
(P_CAUSE_OF_DEATH_6)
(P_CAUSE_OF_DEATH_7)
(P_CAUSE_OF_DEATH_8)
Death Record
Identifier
Information Officer (CIO) cannot fill this field in.
From 01.01.2013 Cause of death was increased to x7
8
D
P
*Death Record Identifier no longer recorded* This field now holds accession number – please see Source
Data – Clinical History Records section.
Death record identifier is a unique number which identifies the formal record of the patient’s death details
held by NRS. This is the number obtained after a record death link with NRS data. Not collected in
redeveloped SOCRATES.
8
O/
D
P
Date of leaving Scotland (or UK) may be entered by the Cancer Information Officer (CIO) or obtained
through nationwide NHSCR linkages.
200
0
O
P
Not validated but used to record information on the person not provided elsewhere.
(P_DEATH_RECORD_ID)
Embarkation
Date
(P_EMBARKATION_DATE)
Person
Comments
(N_NOTE)
Page | 10
IDENTIFICATION AT DIAGNOSIS (TUMOUR LEVEL)
KEY:
L = field length
P = field priority: M = mandatory, O = optional, D= Derived
S = ‘Registration’ screen locations: P = Person, ID = ID at Diag, D = Diagnosis, St = Stage, OCF = Other Contributing Factors, S = Stats,
T = Treatment, A = Admin.
Field
L
P
S
Definition and Options
Record Number
8
D
ID
Computer generated number given to all new provisional registrations & pre-97 registrations. The
confirmed registration will retain this number which uniquely and permanently identifies each tumour
registration. Note this is different from the person ID number.
8
D
ID
A unique number which will enable the unequivocal identification of individual cancer patients. It is a
sequential number allocated by the computer system SOCRATES (For historical data it will result from
person-based linkage).
20
M
ID
Surname of the patient on the incidence date. May include a hyphen or an apostrophe e.g. Wilmot-Brown
or O’Brien.
30
M
ID
Forenames or initials of the patient on the incidence date. May include a hyphen or an apostrophe, e.g.
Mary-Jane or T’Pau. Each forename/initial to be separated by a space.
30
D
ID
All surnames by which this person has been known. This includes maiden names, aliases or differences
in spelling. The Cancer Information Officer (CIO) cannot amend this field.
8
M
P
See Person screen definitions.
8
O/
D
P
See Person screen definitions.
2
M
ID
Marital Status has been recorded since registration began, the options originally part of the COPPISH
SMR patient ID section. Options:
(R_ID)
Person Identifier
(R_P_ID)
Surname at
Diagnosis
(R_SURNAME)
Forenames at
Diagnosis
(R_FORENAMES)
All Surnames
(R_SURNAME)
Date of Birth
(P_DATE_OF_BIRTH)
Date of Death
(P_DATE_OF_DEATH)
Marital Status
(R_MARITAL_STATUS_ID)
Page | 11
Option 1
Marital Status
Code
01
02
03
08
09
(contd)
Description
Never married (single)
Married (includes separated)
Widowed
Other (includes divorced)
Not Known
To take account of the Scottish Government Core Survey Question relating to “Legal Marital Status”, this
field has been reviewed.
From 1.4.2012 to 31.3.2013 incidence date, registrations may be recorded with Option 1 or Option 2:
Option 2
Code
A
B
C
D
E
F
G
H
J
Y
Z
Description
Never married nor registered civil partnership
Married
Registered civil partnership
Separated, but still married
Separated, but still in civil partnership
Divorced
Dissolved civil partnership
Widowed
Surviving civil partner
Other
Not Known
From 1.4.2013 incidence, all registrations must use the new coding option.
Ethnic Group
2
M
P
See Person screen definitions.
5
O
ID
Practice code of patient’s GP (Part of COPPISH SMR patient ID section). Each GP practice in Scotland
is identified by a unique code. The practice code is a four digit code plus a check digit with ranges of
code allocated to each Health Board. This field is collected for all registrations with an incidence date
from 1.1.1997
10
O
ID
The Community Health Index (CHI) is a population register which is used for health care purposes. The
CHI number uniquely identifies a person on the index. Prior to January 1997, there were 8 indexes, each
covering a defined geographical area, which together covered most of Scotland. A person may have
(P_ETHNIC_GROUP)
GP Practice Code
(R_PR_CODE)
CHI Number
(R_CHI_NO)
Page | 12
CHI Number
been registered on more than one index. From January 1997, all 8 Scottish databases were linked via a
search index, thus allowing a User in one Health Board area to access records in all other Health Board
areas. A Unique Patient Identifier (UPI) was determined to be the CHI number which was most current at
the time the indexes were linked ie. The record with the latest date of acceptance on a GP record. 10
digit number consists of 6-digit DOB (DDMMYY) followed by 4 check digits (9th digit denotes sex. 1,3,5,7
or 9 =male, 2,4,6,8 or 0 =female)
(contd)
Sex (Gender)
1
M
ID
See Person screen definitions.
10
0
M
ID
Usual full address of residence of the person on the incidence date i.e. the residence at which the person
resides for the majority of time. Must be within Scottish boundaries. This field is collected for all
registrations with an incidence date from 1.1.1997.
8
M
ID
Postcode for the usual place of residence of the person on the incidence date. Must be Scottish
postcode according to ISD postcode reference files.
16
O
ID
National Health Service (NHS) number is the identifier allocated to an individual to enable unique
identification within the UK for NHS health care purposes. (Part of COPPISH SMR patient ID section).
10
O
D
Hospital Patient Health Record Identifier was previously Case Reference Number and refers to the Case
Ref. No. from the institution of diagnosis. Part of COPPISH SMR patient ID section & is combined with
Health Records System Identifier to make up the ‘Patient Record Identifier’ which is used to uniquely
identify a patient within a health register or health records system such as PAS.
(P_SEX)
Address at
Diagnosis
(R_ADDRESS)
Postcode at
Diagnosis
(R_POSTCODE)
NHS Number
(R_NHS_NO)
Case Reference
(Hospital Record
ID)
(R_CASE_REF_NO)
Page | 13
DIAGNOSIS DETAILS (TUMOUR LEVEL)
KEY:
L = field length
P = field priority: M = mandatory, O = optional, D= Derived
S = ‘Registration’ screen locations: P = Person, ID = ID at Diag, D = Diagnosis, St = Stage, OCF = Other Contributing Factors, S = Stats,
T = Treatment, A = Admin.
Field
L
P
S
Definition and Options
Incidence Date
8
M
D
Incidence date is the date that the cancer in question becomes formally known to NHS Scotland.
Previously known as ‘date treatment commenced’. Can be termed “date of diagnosis”
(A) For patients seen as outpatients and/or day cases and/or inpatients (other than long stay or
residential), it is the earliest available date from the following:
- Date of first consultation as an outpatient.
- Date of first pathology report confirming diagnosis
- Date of admission to hospital.
- Date of hospital-initiated treatment
If none of the above dates apply or can be established, the date of diagnosis (or best estimate) should
be used.
(B) For long stay or residential patients, or patients receiving care at home, it is the date of diagnosis
(or best estimate).
(C) For death certificate only cases (when follow-up attempts have been unsuccessful), and for cases
first diagnosed at autopsy (unsuspected during life), it is the date of death.
8
D
D
The date the Cancer Information Officer confirms a registration on the SOCRATES cancer registration
database, having passed all validation checks. This is automatically allocated by the Socrates system.
30
D
D
The code identifies the Cancer Information Officer (CIO) who first confirms the registration. This field
remains unchanged regardless of any subsequent amendments by other staff. This is automatically
allocated by the Socrates system.
1
M
D
Death certificate initiated indicates that the case has FIRST come to light ONLY as a result of a death,
as assessed from the source records available at the time of confirming the registration. However,
subsequent evidence may be discovered ‘out in the field’. Options:
(R_INCIDENCE_DATE)
Date of Registration
(R_CONFIRMED_DATE_FIRST
)
CIO of Registration
(R_CONFIRMED_BY_FIRST)
Death Certificate
Initiated
(R_DEATH_CERTIFICATE
_INITIATED)
Page | 14
Death Certificate
Initiated
Code
0
1
(contd)
Death Certificate
Only
1
M
D
(R_DEATH_CERTIFICATE
_ONLY)
This indicates that the case has been registered from the death certificate only, since no other evidence
of the tumour can be found. i.e. No information from medical records, and no source records other than
the death record. Options:
Code
0
1
Diagnostic code ICD9 Code
M
D
ICD9 – International Classification of Diseases (9th revision). All registrations with an incidence date up
to and including 31.12.1996 should be classified according to the ICD9 classification. This field should
also be completed for all “Death Certificate Only” (DCO) cases with an incidence date up to and
including 31.12.1999.
6
M
D
ICDO - International Classification of Diseases for Oncology. Tumour type indicates the morphology
(histology) of the tumour and comprises the first four digits of the ICD-O morphology code and a fifth
digit which denotes behaviour of the tumour.
All registrations with an incidence date up to and including 31.12.1996 should be classified according to
the ICDO classification.
5th digit options:
(R_MORPHOLOGY_CODE_
ICDO)
Code
0
1
2
3
6
9
Diagnostic code ICD10
(R_SITE_CODE_ICD10)
Page | 15
Description
No
Yes
6
(R_SITE_CODE_ICD9)
Tumour Type ICDO Code
Description
No
Yes
6
M
D
Description
Benign
Uncertain whether benign or malignant
Carcinoma in situ
Malignant- primary site
Malignant- metastatic site or secondary site
Malignant- uncertain whether primary or metastatic site
ICD10 – International Classification of Diseases (10th revision). All registrations with an incidence date
from 1.1.1997 onwards should be completed with an ICD10 (version 3) site code. Registrations with an
incidence date from 1.1.2014 will be taking into account the modified version of ICD10 (version 4) and
using these codes in line with other NHS Scotland organisations for local and national return purposes.
Tumour Site –
ICDO(2) / ICDO(3)
Code
6
M
D
ICDO(2) - International Classification of Diseases for Oncology (2nd revision). Similar to ICD10 site
code, but there are differences in the site code ranges. ICDO(2) does not include type specific codes
such as lymphomas (C82-C85) or Kaposi’s sarcoma (C46), but has the ability to code such neoplasms
more precisely to their site of origin. All registrations should now be completed with an ICDO(2) site
code, regardless of incidence. This field is collected for all registrations with an incidence date from
1.1.1997. With the introduction of ICDO(3), it should be noted that there is no change in the codes for
SITE from ICDO(2) to ICDO(3).
6
M
D
ICDO(2) - International Classification of Diseases for Oncology (2nd revision). Tumour type indicates
the morphology (histology) of the tumour and comprises the first four digits of the ICDO(2) morphology
code and a fifth digit which denotes behaviour. All registrations with an incidence date from 1.1.1997 to
31.12.2005 should now be completed with an ICD(O)2 morphology code. There are some differences
between ICDO and ICDO(2) including the change in behaviour of certain tumour types from one
classification to the other.
6
M
D
ICDO(3) - International Classification of Diseases for Oncology (3rd revision). Tumour type indicates
the morphology (histology) of the tumour and comprises the first four digits of the ICDO(3) morphology
code and a fifth digit which denotes behaviour.
5th digit options:
(R_SITE_CODE_ICDO2)
Tumour Type ICDO(2) Code
(R_MORPHOLOGY_CODE_
ICDO2)
Tumour Type ICDO(3) Code
(R_MORPHOLOGY_CODE_
ICDO3)
Code
Description
0
Benign
1
Uncertain whether benign or malignant
2
Carcinoma in situ
3
Malignant- primary site
6
Malignant- metastatic site or secondary site
9
Malignant- uncertain whether primary or metastatic site
Please note there are some differences between ICDO(2) and ICDO(3) including the change in
behaviour of certain tumour types from one classification to the other. This field will be completed for all
registrations with an incidence date from 1.1.2006. Registrations with an incidence date from 1.1.2012
onwards, will adopt the 2011 updated version of codes for ICDO3.
Grade Classification
Used
(R_GRADE_CLASSIFICATION_
CODE)
Page | 16
1
M
D
Indicates the classification system used for grading tumour.
Options:
Code
1
2
Description
Grading for breast cancer (ICD10 C50 and D05).
ICD-O/UICC
3
4
5
6
7
8
9
Gleason Score (Prostate only – ICD10 C61)
Bloom and Richardson (Breast only) *NOW OBSOLETE*
Fuhrman nuclear grade/ISUP (VANCOUVER) (Renal cell carcinomas of kidney – ICD10
C64
WHO grade (Brain and CNS only - ICD10 C70-C72, D32 – D33, D35.2 – D35.4, D42 –
D43, D44.3 – D44.5
GIST only C15*, C16*, C17*, C18*, C20*, C25*, C269, C48.1, C762, C80* and
morphology 89363
Other
Not determined/not stated/not applicable
For code 1 note:
The Nottingham grading system (previously option 1) and the Bloom and Richardson grading system
(previously option 4) have been combined, as one is essentially a modification of the other. The new
Grading for breast cancer (option 1) will be used from the introduction in October 2010 of the newly
developed Socrates version and should be completed for all cases of breast cancer. Option 4 is now
obsolete. All previously registered cases of Bloom and Richardson Grade have been electronically
amended to record the new option 1.
For code 5 note:
Fuhrman nuclear grade was introduced as an option in Socrates in 2006. Previously, this classification
was recorded under [8] Other. ISUP (VANCOUVER) was introduced as an option in Socrates in 2014.
For code 6 note:
This was previously recorded under [8] Other with a note of grade in the Admin screen. To be collected
for records from 1.1.2006 incidence onwards.
For code 7 note:
This was introduced for 2016 registrations.
For most other cancers, the ICD-O/UICC grading system is used. If the grade of differentiation is
explicitly enumerated in the pathology report it should be recorded as such. If it is not explicitly stated, it
may be derived from the text of the pathology report according to the definition options stated for Grade
below. Grade is recorded every time this information is available except when T or B cell origin is
provided for lymphomas & leukaemias. In this event, the T or B - cell origin has priority and also has
options stated in Grade definition below.
This field is collected for all registrations with an incidence date from 1.1.1997.
Page | 17
Grade or Cell type
(R_GRADE_CELL_TYPE)
2
M
D
Grade or cell type indicates the degree of differentiation of malignant tumours or the T-cell & B-cell
designation for lymphomas and leukaemias and is sometimes recorded as the sixth digit of the ICDO
morphology code, although this is not recorded on SOCRATES.
Breast options:
Code
Description
1
Grade 1 / low grade
2
Grade 2 / intermediate grade
3
Grade 3 / high grade
9
Not Known
Prostate -‘Gleason Score’ Options: 2 -10 or 0 (Not known).
Up to incidence date 31.12. 2010, the Gleason score will be recorded as the sum of the Gleason Major
score and Gleason Minor score. From 1.1.2011 incidence date onwards, the Grade or Cell type field
will contain the Gleason Major, Minor and Tertiary score separately. Options: 1 - 5 or 9 (Not known).
To be completed for all prostate cases with an ICD10 code of C61.
Kidney – ‘Fuhrman’/ISUP (VANCOUVER) Options:
Code
Description
1
Grade I
2
Grade II
3
Grade III
4
Grade IV
9
Not Known
WHO (Brain and CNS) Options:
Code
Description
1
Grade I
2
Grade II
3
Grade III
4
Grade IV
9
Not Known
GIST (sarcoma GIST tumours only) Options:
Code
Description
Page | 18
Grade or Cell type
(contd)
GX
G1
G2
Grade cannot be assessed
Low grade; mitotic rate 5/50 per high-power field (HPF) or less
High grade; mitotic rate > 5/50 HPF
ICD-O/UICC Options:
Code
Description
1
(Well) differentiated
2
Moderately (well) differentiated
3
Poorly differentiated
4
Undifferentiated, anaplastic
5
T-Cell (inc. T-precursor)
6
B-Cell (inc. Pre-B, B-precursor)
7
Null Cell ( Non T-non B, leukaemias only)
8
Natural killer (NK) Cell
9
Grade/Cell type or differentiation not determined, not stated or not applicable.
To be used for all diagnostic sites other than those above.
This field is collected for all registrations with an incidence date from 1.1.1997.
Gleason Major
1
M
D
(R_GRADE_CELL_TYPE_
MAJOR)
This field is collected for all registrations with an incidence date from 1.1.2011 onwards.
Options:
Code
1
2
3
4
5
9
Gleason Minor
(R_GRADE_CELL_TYPE_
MINOR)
Page | 19
1
M
D
Description
Major 1
Major 2
Major 3
Major 4
Major 5
Not Known
Previously, this was recorded as a combined Gleason score with the Gleason Minor component. (See
above). These are now recorded separately.
To be completed for all prostate cases with an ICD10 code of C61.
This field is collected for all registrations with an incidence date from 1.1.2011 onwards.
Options:
Code
1
2
3
4
5
9
Description
Minor 1
Minor 2
Minor 3
Minor 4
Minor 5
Not Known
Previously, this was recorded as a combined Gleason score with the Gleason Major component. (See
above). These are now recorded separately.
To be completed for all prostate cases with an ICD10 code of C61.
Gleason Tertiary
1
M
D
(R_GRADE_CELL_TYPE_
TERTIARY)
This field is collected for all registrations with an incidence date from 1.1.2011.
Options:
Code
1
2
3
4
5
9
Description
Tertiary 1
Tertiary 2
Tertiary 3
Tertiary 4
Tertiary 5
Not Known
The tertiary component of the Gleason score was previously not recorded but indicates a generally
more aggressive pattern of the tumour and in some cases may be preferred as a measure with the
Gleason Major to derive a Gleason score.
To be completed for all prostate cases with an ICD10 code of C61.
Side (Laterality)
(R_SIDE)
Page | 20
1
M
D
This indicates the side or laterality of origin (i.e. left or right) in the case of paired organs. (e.g. breast,
kidney, limb, lung, ovary, testis). Acceptable SIDE is based on the current UKACR table of Laterality.
Tumours existing in both sides of a paired organ should be registered twice for Left and Right. The only
paired organs to be treated as a single site (bilateral) are tumours of the ovary and Wilms tumour of the
kidney or nephroblastoma. (ICDO(3) 8960/3)
Options:
Side (Laterality)
Code
0
1
2
3
9
(contd)
Description
Not applicable (non paired organs)
Right
Left
Bilateral
Not Known
This field is collected for all registrations with an incidence date from 1.1.1997.
Method of First
Detection
1
M
D
Method of first detection indicates how the tumour was first detected.
Options:
Code
1
2
3
4
5
8
9
(R_METHOD_FIRST_DETEC
TION)
Description
Screening examination
Incidental finding (on examination or at surgery for an unrelated reason)
Clinical presentation (with relevant symptoms)
Incidental finding at autopsy (previously unsuspected)
Interval cancer
Other
Not Known
Interval cancer is an option introduced in the redeveloped SOCRATES in 2006. It describes when a
primary tumour with histological confirmation is diagnosed in the interval following a negative screening
episode and before the next scheduled screening examination. The "interval" relates to the interval
between screenings rather than the interval between separate tumour occurrences.
This field is collected for all registrations with an incidence date from 1.1.1997.
Most Valid Basis of
Diagnosis
(R_MVB_DIAGNOSIS)
1
M
D
Most Valid Basis of diagnosis indicates the method judged to have best provided or validated the
diagnosis during the course of the illness.
Options:
Code
1
2
3
4
Page | 21
Description
Clinical only
Clinical investigation (including x-ray, ultrasound, etc.)
Exploratory surgery/endoscopy/autopsy (without concurrent or previous histology)
Specific biochemical and/or immunological tests (e.g. Prostate Specific Antigen (PSA)
- for prostate cancer or Bence Jones Protein (BJP) - for Myeloma)
Most Valid Basis of
Diagnosis
5
6
7
8
9
10
(contd)
Cytology (including blood film or bone marrow aspirate)
Histology of metastasis
Histology of primary
Autopsy (with concurrent or previous histology)
Not Known
Death certificate only
The methods of diagnosis are listed in essentially ascending order of validity, microscopic methods
having greater validity than non-microscopic methods.
This field is collected for all registrations with an incidence date from 1.1.1997.
Histological
Verification
1
M
D
(R_HISTOLOGY_VERIFIED)
Histological Verification is microscopic confirmation of the histological or cytological diagnosis (including
examination of peripheral blood film). For post-97 registrations, HV-verified should correspond with
Most Valid Basis Of Diagnosis options 5-8.
NOTE - CIN 3 should only be registered if the diagnosis is based on histology, not cytology alone.
Options:
Code
1
2
Microinvasive
(R_MICROINVASIVE)
1
M
D
Description
Verified
Not verified
Microinvasive is used to describe a degree of invasion which is not associated with any risk of nodal
metastasis and is sufficiently small to treat by local or conservative means.
Options:
Code
Description
0
No
1
Yes
9
Not Known
This field is collected for all registrations with an incidence date from 1.1.2005
Page | 22
STAGE DETAILS (TUMOUR LEVEL)
KEY:
L = field length
P = field priority: M = mandatory, O = optional, D= Derived
S = ‘Registration’ screen locations: P = Person, ID = ID at Diag, D = Diagnosis, St = Stage, OCF = Other Contributing Factors, S = Stats,
T = Treatment, A = Admin.
Clinical extent of 1
disease (Lung
only)
(R_CLINICAL_EXTE
NT_OF_DISEASE)
M for
lung
from
2005
St
Options:
Code
1
2
3
4
Description
Localised
Regional spread
Distant metastasis
Not Known
This field will be collected for all malignant lung tumours (C34*) registered with an incidence date from
1.1.2005 to 31.12.2012
TNM
AJCC
(Melanoma)
(R_AJCC)
4
O
(M for
melano
ma)
St
Please refer to staging document
St
AJCC – American Joint Committee on Cancer indicates the extent of disease progression of invasive
melanoma tumours.
AJCC is collected for malignant melanomas of the skin (ICD10 C43*) with an incident date from
1.1.2015
Options are:
Code
IA
IB
IIA
IIB
IIC
III
IIIA
Page | 23
IIIB
IIIC
IV
X
Staging Group
Testicular
4
(R_TESTICULAR_ST
AGING_GROUP)
O
(M for
testicula
r)
St
This staging group indicates the extent of disease progression of invasive testicular tumours.
(ICD10 C43*) with an incident date from 1.1.2015.
Options are:
Code
I
IA
IB
II
IIA
IIB
IIC
III
IIIA
IIIB
IIIC
IS
NK
FIGO Stage –
Before Surgery
(Cervix only)
(R_FIGO_BEFORE_
SURGERY)
3
O
(M for
cervix)
St
FIGO Stage indicates the extent of spread of the invasive primary tumour for cervix at diagnosis in
terms of the pathological and/or clinical findings for Socrates. FIGO stage has been collected for
malignant tumours of the cervix (ICD10 C53*) with an incidence date from 1.1.1997 onwards.
This is a new field to record stage before surgery if possible, and will be collected for all malignant
tumours of the cervix (C53*) from 1.1.2005.
See also FIGO stage after surgery. Options are the same for before or after surgery.
Options for cervix:
Code
Description
1
Tumour strictly confined to cervix (extension to the corpus uteri should be
disregarded)
Page | 24
FIGO Stage –
Before Surgery
2
(contd)
3
4
9
Tumour extends beyond the cervix/uterus but not as far as pelvic wall or lower third of
the vagina
Tumour extends to the pelvic wall or lower third of the vagina (includes all cases with
hydronephrosis or non-functioning kidney or both)
Tumour has invaded or spread beyond the true pelvis, bone, or has clinically involved
the mucosa (lining) of the bladder or rectum (bullous oedema as such does not permit
a case to be allotted to stage IV)
Not Known
FIGO Stage classification change and from 1.1.2014. See also FIGO stage after surgery. Options are
the same for before or after surgery. Options:
Code
Description
1
The carcinoma is strictly confined to the cervix (extension to the corpus would be
disregarded).
1a
Invasive carcinoma which can be diagnosed only by microscopy. All macroscopically
visible lesions - even with superficial invasion - are allotted to Stage Ib carcinomas.
Invasion is limited to a measured stromal invasion with a maximal depth of 5.0 mm and a
horizontal extension of not > 7.0 mm. Depth of invasion should not be > 5.0 mm taken
from the base of the epithelium of the original tissue - superficial or glandular. The
involvement of vascular spaces should not change the stage allotment.
1a1
Measured stromal invasion of not > 3.0 mm in depth and extension of not > 7.0 mm.
1a2
Measured stromal invasion of > 3.0 mm and not > 5.0 mm with an extension of not > 7.0
mm.
1b
Clinically visible lesions limited to the cervix uteri or preclinical cancers greater than
Stage IA.
1b1
Clinically visible lesions not > 4.0 cm.
1b2
Clinically visible lesions > 4.0 cm.
2
Cervical carcinoma invades beyond the uterus, but not to the pelvic wall or to the lower
third of the vagina.
2a
No obvious parametrial involvement.
2a1
Clinically visible lesion <=4.0 cm in greatest dimension
2a2
Clinically visible lesion >4.0 cm in greatest dimension
2b
Obvious parametrial involvement.
3
The carcinoma has extended to the pelvic wall. On rectal examination, there is no
cancer-free space between the tumour and the pelvic wall. The tumour involves the
lower-third of the vagina. All cases with hydronephrosis or non-functioning kidney are
Page | 25
FIGO Stage –
Before Surgery
3a
3b
4
(contd)
4a
4b
9
FIGO Stage –
Before Surgery
(Ovary only)
(R_FIGO_BEFORE_
SURGERY)
3
O
(M for
ovary)
St
included, unless they are known to be due to other causes.
Tumour involves lower-third of the vagina, with no extension to the pelvic wall.
Extension to the pelvic wall and/or hydronephrosis or non-functioning kidney
The carcinoma has extended beyond the true pelvis, or has involved (biopsy-proven) the
mucosa of the bladder or rectum. A bullous oedema, as such, does not permit a case to
be allotted to Stage IV.
Spread of the growth to adjacent organs.
Spread to distant organs.
Not known
FIGO Stage will be collected for malignant tumours of the ovary (ICD10 C56*) with an incidence date
from 1.1.2005 onwards. As with cervix, this is a new field.
See also FIGO stage after surgery. Options are the same for before or after surgery.
Code
1a
2a
2b
2c
3a
Description
Tumour limited to one ovary; capsule intact, no mal cells in ascites or peritoneal
washings
Both ovaries; capsule intact, no mal cells in ascites or peritoneal washings
One or both ovaries; capsule ruptured, tumour on surface, mal cells in ascites or
peritoneal washings
Extension to uterus; no mal cells in ascites or peritoneal washings
Extension to other pelvic tissues; no mal cells in ascites or peritoneal washings
Pelvic extension with mal cells in ascites or peritoneal washings
Microscopic peritoneal metastasis beyond pelvis
3b
Macroscopic peritoneal metastasis beyond pelvis 2cm or less in greatest dimension
3c
Peritoneal metastasis beyond pelvis more than 2cm in greatest dimension and/or
regional lymph node metastasis
Distant metastasis (excludes peritoneal metastasis)
Not Known
1b
1c
4
9
FIGO Stage classification change and from 1.1.2014 the options are:
See also FIGO stage after surgery. Options are the same for before or after surgery.
Page | 26
FIGO Stage –
Before Surgery
(contd)
Code
1
1a
1b
1c
1c1
1c2
1c3
2
2a
2b
3
3a
3a1
3a2
3b
3c
4
4a
4b
9
Page | 27
Description
Tumour confined to ovaries
Tumour in one ovary, capsule intact, no tumour on ovarian surface; no malignant cells
in the ascites or peritoneal washings
Tumour involves both ovaries, capsule intact, no tumour on ovarian surface; no
malignant cells in the ascites or peritoneal washings
Tumour limited to one or both ovaries
Tumour limited to one or both ovaries with surgical spill
Tumour limited to one or both ovaries with capsule rupture before surgery or tumour
on ovarian surface
Tumour limited to one or both ovaries with malignant cells in the ascites or peritoneal
washings
Tumour involves one or both ovaries with pelvic extension (below the pelvic brim) or
primary peritoneal cancer
Spread to the ovary(ies) and / or the uterus. No malignant ascites or peritoneal
washings (can have benign ascites)
Spread to other parts of the pelvis. No malignant ascites or peritoneal washings
Tumour involves one or both ovaries with cytologically or histologically confirmed
spread to the peritoneum outside the pelvis and/or metastasis to the retroperitoneal
lymph nodes
Positive retroperitoneal lymph nodes and/or microscopic metastasis beyond the pelvis
Positive retroperitoneal lymph nodes only (i) Metastasis less than or equal to 10mm
(ii) Metastasis >10mm
Microscopic, extrapelvic (above the brim) peritoneal involvement ± positive
retroperitoneal lymph nodes
Macroscopic, extrapelvic, peritoneal metastasis less than or equal to 2cm ± positive
retroperitoneal lymph nodes. Includes extension to capsule of liver/spleen
Macroscopic, extrapelvic, peritoneal metastasis greater than or equal to 2cm ±
positive retroperitoneal lymph nodes. Includes extension to capsule of liver/spleen
Distant metastasis excluding peritoneal metastasis.
Pleural effusion with positive cytology
Hepatic and/or splenic parenchymal metastasis, metastasis to extra-abdominal
organs (including inguinal lymph nodes and lymph nodes outside of the abdominal
cavity)
Not known
FIGO StageBefore Surgery
(Corpus Uteri
only)
3
O
(M for
Corpus
Uteri)
St
(R_FIGO_BEFORE_
SURGERY)
FIGO StageBefore Surgery
(Fallopian Tube)
(R_FIGO_BEFORE_
SURGERY)
FIGO Stage indicates the extent of spread of the invasive primary tumour for Corpus Uteri (C54#) at
diagnosis in terms of the pathological and/or clinical findings for Socrates.
FIGO Stage classification change from 1.1.2014 to include Corpus Uteri
See also FIGO stage after surgery. Options are the same for before or after surgery.
Code
1
1a
1b
2
3
3a
3b
3c
3c1
3c2
4
4a
4b
9
3
O
(M for
Fallopia
n Tube)
St
FIGO Stage will be collected for malignant tumours of the Fallopian Tube (ICD10 C57*) with an
incidence date from 1.1.2005 onwards.
FIGO Stage classification change from 1.1.2014
See also FIGO stage after surgery. Options are the same for before or after surgery
Code
1
1a
1b
1c
1c1
1c2
Page | 28
Description
Tumour contained to corpus uteri
No or less than half myometrial invasion
Invasion equal to or more than half of the myometrium
Tumour invades the cervical stroma but does not extend beyond the uterus
Local and/or regional spread of tumour
Tumour invades the serosa of the corpus uteri and/or adnexas
Vaginal and/or parametrial involvement
Metastases to pelvis and/or para-aortic lymph nodes
Spread of the growth to adjacent organs.
Positive para-aortic lymph nodes with or without positive pelvic lymph nodes
Tumour invades into bladder and/or bowel mucosa and/or distant metastasis
Tumour invasion bladder and/or bowel
Distant metastases including intra-abdominal and/or inguinal lymph nodes
Not known
Description
Tumour confined to fallopian tube(s)
Limited to lining of one fallopian tube (intra-luminal); no tumour on fallopian tube
surface; no malignant cells in the ascites or peritoneal washings
Limited to inner linings of both fallopian tubes (intra-luminal); no tumour on fallopian
tube surface; no malignant cells in the ascites or peritoneal washings
Tumour limited to one or both fallopian tube(s)
Tumour limited to one or both fallopian tube(s) with surgical spill
Tumour limited to one or both fallopian tube(s) with capsule rupture before surgery or
tumour on fallopian tube surface
FIGO Stage –
Before Surgery
1c3
(contd)
2
2a
2b
3
3a
3a1
3a2
3b
3c
4
4a
4b
9
FIGO StageAfter Surgery
(Cervix only)
3
O
(M for
cervix)
St
FIGO Stage indicates the extent of spread of the invasive primary tumour for cervix at diagnosis in
terms of the pathological and/or clinical findings for Socrates.
Previously this field was known as FIGO Stage, and was collected for all malignant tumours of the
cervix (ICD10 C53*) from 1.1.1997 onwards. All tumours recorded with a FIGO stage from 1.1.1997 to
31.12.2004 will exist on the SOCRATES database with a FIGO stage in the After Surgery field.
FIGO Stage classification change from 1.1.2014
See also FIGO stage before surgery. Options are the same for before or after surgery
3
O
(M for
St
FIGO Stage will be collected for malignant tumours of the ovary (ICD10 C56*) with an incidence date
from 1.1.2005 onwards.
(R_FIGO_AFTER_SU
RGERY)
FIGO StageAfter Surgery
Page | 29
Tumour limited to one or both fallopian tube(s) with malignant cells in the ascites or
peritoneal washings
Tumour involves one or both fallopian tube(s) with pelvic extension (below the pelvic
brim) or primary peritoneal cancer
Spread to the fallopian tube(s) and / or the uterus. No malignant ascites or peritoneal
washings (can have benign ascites)
Spread to other parts of the pelvis. No malignant ascites or peritoneal washings
Tumour involves one or both fallopian tube(s) with cytologically or histologically
confirmed spread to the peritoneum outside the pelvis and/or metastasis to the
retroperitoneal lymph nodes
Positive retroperitoneal lymph nodes and/or microscopic metastasis beyond the pelvis
Positive retroperitoneal lymph nodes only (i) Metastasis less than or equal to 10mm
(ii) Metastasis > 10mm
Microscopic, extrapelvic (above the brim) peritoneal involvement ± positive
retroperitoneal lymph nodes
Macroscopic, extrapelvic, peritoneal metastasis less than or equal to 2cm ± positive
retroperitoneal lymph nodes. Includes extension to capsule of liver/spleen
Macroscopic, extrapelvic, peritoneal metastasis greater than or equal to 2cm ±
positive retroperitoneal lymph nodes. Includes extension to capsule of liver/spleen
Distant metastasis excluding peritoneal metastasis
Pleural effusion with positive cytology
Hepatic and/or splenic parenchymal metastasis, metastasis to extra-abdominal
organs (including inguinal lymph nodes and lymph nodes outside of the abdominal
cavity
Not known
(Ovary only)
ovary)
FIGO Stage classification change from 1.1.2014
See also FIGO stage before surgery. Options are the same for before or after surgery
(R_FIGO_AFTER_SU
RGERY)
FIGO StageAfter Surgery
(Corpus Uteri
only)
3
O
(M for
Corpus
Uteri)
St
FIGO Stage will be collected for malignant tumours of the Corpus Uteri (ICD10 C54*) with an incidence
date from 1.1.2005 onwards.
FIGO Stage classification change from 1.1.2014
See also FIGO stage before surgery. Options are the same for before or after surgery
3
O
(M for
Fallopia
n Tube)
St
FIGO Stage will be collected for malignant tumours of the Fallopian Tube (ICD10 C57*) with an
incidence date from 1.1.2005 onwards.
FIGO Stage classification change from 1.1.2014
See also FIGO stage before surgery. Options are the same for before or after surgery
2
O
(M for
colorecta
l
tumours)
St
Stage (Colorectal) indicates the extent of spread of the invasive tumour at diagnosis in terms of the
pathological and/or clinical findings for Socrates. Extent of Primary tumour for Colorectal cancer Dukes’ staging is primarily based on histological findings.
Dukes’ Staging Classification Options:
(R_FIGO_AFTER_SU
RGERY)
FIGO StageAfter Surgery
(Fallopian Tube)
(R_FIGO_AFTER_SU
RGERY)
Dukes’ Stage
(Colorectal only)
(R_STAGE_COLORE
CTAL)
Code
A
B
C1
C2
D
9
Description
Tumour limited to muscularis propria (muscle coat), regional lymph nodes negative
Tumour invades through muscularis propria into serosa/subserosa or through
peritoneum but regional lymph nodes negative
Regional lymph nodes positive but apical node negative
Regional lymph nodes positive, apical lymph node positive
Distant metastases (e.g. liver)
Not Known
Note: Dukes’ stage D was not included in the original Dukes’ classification
Note: Regional lymph nodes are the pericolic and perirectal and those located along the ileocolic, right
colic, middle colic, left colic, inferior mesenteric and superior rectal (haemorrhoidal) arteries
This field is collected for all registrations with an incidence date from 1.1.1997 onwards for all malignant
colorectal (ICD10 C18 – C20) and anal (ICD10 C21) tumours.
Page | 30
OTHER CONTRUBUTING FACTORS (TUMOUR LEVEL)
KEY: L = field length
P = field priority: M = mandatory, O = optional, D= Derived
S = ‘Registration’ screen locations: P = Person, ID = ID at Diag, D = Diagnosis, St = Stage, OCF = Other Contributing Factors, S = Stats,
T = Treatment, A = Admin
Field
L
P
Breslow
thickness size
(mm)
4
O
(M for
cutaneous
melanoma
)
(R_MELANOMA_SKI
N_BRESLOW_SIZE)
Clarks level
2
(R_MELANOMA_SKI
N_CLARKS_LEVEL)
Pathological
Tumour Size
(mm)
3
(R_TUMOUR_SIZE)
Clinical Tumour
Size
(mm)
Page | 31
3
O (M for
cutaneo
us
melano
ma)
O
(M for
breast
and
testis)
O
(M for
liver)
S
Definition and Options
OCF
Breslow thickness (in mm, to 2 decimal places or 99.99 (Not known) will be recorded for all cutaneous
melanomas (C43*) with an incidence date from 1.1.2005.
OCF
Clarks level is a measure of the depth of invasion into the skin and will be recorded for all cutaneous
melanomas (C43*) with an incidence date from 1.1.2005.
Clarks level options:
Code
I
II
III
IV
V
9
OCF
OCF
Description
Clarks I
Clarks II
Clarks III
Clarks IV
Clarks V
Not Known
Pathological tumour size is the maximum diameter in mm of the invasive component of the tumour in
the fresh or fixed state on the histological preparation. If the two measurements are discrepant then
that obtained from the histological (fixed) section(s) should be recorded. The tumour (not the excised
specimen) with the greatest diameter should be used. Option range: 000-999 or NK - not known.
This field is collected for all malignant tumours of the breast (ICD10 C50*) with an incidence date from
1.1.1997 and all malignant tumours of testis (ICD10 C62*) from 1.1.2015
Clinical tumour size is the maximum diameter in mm of the invasive component of the tumour, or where
multiple tumours exist, the maximum diameter in mm of the largest tumour. Option range: 000-999 or
NK - not known
(R_TUMOUR_SIZE)
Nodes
Examined
(Breast)
This field is collected for all malignant hepatocellular tumours of the liver (ICD10 C220) with an
incidence date from 1.1.2014
1
O
(M for
breast)
OCF
(R_NODES_EXAMIN
ED)
Pathological nodal status -Indicates if the regional lymph nodes were examined. Associated with
invasive breast cancer only.
Options:
Code
0
1
2
9
Description
No
Yes, a sample
Yes, axillary node clearance
Not Known
This field is collected for all malignant tumours of the breast (ICD10 C50*) with an incidence date from
1.1.1997 to 31.12.2012
Regional Lymph
nodes
assessment
1
(R_NODES_EXAMIN
ED)
O
(M for
head
and
neck,
colorect
al, lung,
melano
ma or
breast)
OCF
Pathological nodal status -Indicates what regional lymph nodes were examined. Associated with
invasive head and neck, colorectal, lung, melanoma or breast cancer.
Options:
Code
Description
0
No regional lymph nodes removed or aspirated
1
Aspiration or biopsy of regional lymph node
2
Sentinel lymph node biopsy
3
Regional lymph node dissection
9
Not Known
This field is collected for all malignant tumours (ICD10 C00# - C14# or C18# - C21# or C30# - C34# or
C43# or C50# or C760 with an incidence date from 1.1.2013
Number
examined/Total
number
examined (head
and neck,
colorectal, lung,
melanoma or
breast)
(R_NO_OF_NODES_
Page | 32
2
O
(M for
head
and
neck,
colorect
al, lung,
melano
ma or
OCF
Pathological nodal status - Indicates how many regional lymph nodes were examined.
Options: 0-99 or NK - not known
Recoded for invasive breast only from 1.1.1997 and for invasive head and neck, colorectal, lung,
melanoma or breast from 1.1.2013
EXAMINED)
Positive
Nodes/Nodes
involved (head
and neck,
colorectal, lung,
melanoma or
breast)
1
(R_POSITIVE_NODE
S)
Number
Positive/Total
number
involved/Positiv
e (head and
neck, colorectal,
lung, melanoma
or breast)
(R_NO_POSITIVE_N
2
ODES)
Oestrogen
Receptor Status
(Breast only)
(R_OESTROGEN_R
ECEPTOR_STATUS)
1
breast)
O
(M for
(head
and
neck,
colorect
al, lung,
melano
ma or
breast)
O
(M for
head
and
neck,
colorect
al, lung,
melano
ma or
breast)
O
(M for
breast)
OCF
Pathological nodal status -Indicates if any of the regional lymph nodes were positive/involved
Options:
Code
Description
0
No
1
Yes
9
Not Known
This field is collected for invasive breast only from 1.1.1997 and for invasive head and neck, colorectal,
lung, melanoma or breast from 1.1.2013
OCF
Pathological nodal status -Indicates how many of the regional lymph nodes were positive/involved Options: 0-99 or NK - not known
Recoded for invasive breast only from 1.1.1997 and for invasive head and neck, colorectal, lung,
melanoma or breast from 1.1.2013
OCF
Oestrogen Receptor Status (or ER status) should be available for breast cases (ICD10 C50 or D05)
diagnosed histologically. i.e. confirmed from biopsy, surgical excision or histology of nodes or
metastases. Receptor status tests are usually performed on the biopsy specimen and generally issued
as a supplementary report after the initial reporting of the biopsy.
Record status regardless of any qualifying statements e.g. weakly positive.
Options:
Code
0
1
9
Description
Negative
Positive
Not Known
There are several different scoring systems but the recommended and usual method for both ER and
PR testing is the Quick (Allred) score.
Allred score: The scores are summed to give a maximum of 8. Generally reports will state results of
Page | 33
ER/PR status as positive or negative for example - “ER status: positive 5/8” but some may only provide
scores which can be referenced to known positive and negative ranges.
A score of 0-1 indicates negative result
A score of 2–3 positive (weak)
A score of 4–6 positive (moderate)
A score of 7–8 positive (strong)
Oestrogen
Receptor Status
(contd)
ER status may also be recorded as a value from which the status can be derived as shown below:
Method (assay)
DCC
EIA
ERICA
ER positive
> or = 20 fmols ER/mg protein
> or = 20 fmols ER/mg protein
> or = 10% positive staining
ER negative
< 20 fmols ER/mg protein
< 20 fmols ER/mg protein
< 10% positive staining
This field is collected for all registrations of malignant breast tumours (C50) with an incidence date from
1.1.1997 and additionally for all in situ breast tumours with an incidence date from 1.1.2009.
Note: This field was moved from the Diagnosis screen in Socrates to the Stage screen in October
2010.
Progesterone
Receptor Status
(Breast only)
(R_PROGESTERON
E_RECEPTOR_STA
TUS)
1
O
(M for
breast)
OCF
Progesterone Receptor Status (PR or PgR status) should be available for all breast cases (ICD10 C50
or D05) diagnosed histologically. i.e. confirmed from biopsy, surgical excision or histology of nodes or
metastases. Receptor status tests are usually performed on the biopsy specimen and generally issued
as a supplementary report after the initial reporting of the biopsy. See method of testing as in
Oestrogen Receptor Status.
Options:
Code
0
1
9
Description
Negative
Positive
Not Known
If positive (PgR+ or PR+), the cancer should respond well to hormone suppression treatments. If the
score is negative (PgR- or PR-), then the tumour will not be driven by progesterone, and HER2 status
may well be sought to determine the most effective treatment.
Page | 34
HER2 status
(Breast only)
(R_HER2)
1
O
(M for
breast)
This field is collected for all registrations of malignant or in situ breast tumours (C50 or D05) with an
incidence date from 1.1.2009.
There are two tests available to measure over-expression of HER2 receptors in a tumour cell.
OCF
a) Immunochemistry HER2 receptor test (IHC) shows how much of the HER2 protein is present in
a tumour cell.
b) Fluorescence in-situ hybridisation (FISH).If the HER2 test results are borderline this additional
more accurate test, will be carried out to confirm a positive or negative result.
Options:
Code
0
1
9
Description
Negative
Positive
Not Known
This field is collected for all registrations of malignant or in situ breast tumours (C50* or D05*) with an
incidence date from 1.1.2009
Page | 35
INITIAL TREATMENT (TUMOUR LEVEL)
KEY: L = field length
P = field priority: M = mandatory, O = optional, D= Derived
S = ‘Registration’ screen locations: P = Person, ID = ID at Diag, D = Diagnosis, St = Stage, OCF = Other Contributing Factors, S = Stats,
T = Treatment, A = Admin
Field
L
P
S
Definition and Options
Hospital / GP of
diagnosis
5
M
T
Hospital of diagnosis denotes the location (institution) code of the hospital in which the diagnosis was first
made. This may also be a GP surgery code if an initial biopsy was taken by a GP.
This field is collected for all registrations with an incidence date from 1.1.1997. For registrations with an
incidence date up to 31.12.1996, see Old Hosp Code field on Stats screen.
1
O
T
Tick box to indicate if the patient was diagnosed at home.
1
M
T
Surgery -there are 4 options for this treatment field:
Code
Description
0
No - no surgery OR exploratory surgery only with or without diagnostic biopsy [e.g.
diagnostic laparotomy with or without incisional biopsy (‘open and close’), needle
biopsy, and diagnostic endoscopy with or without incisional biopsy
1
Yes - partial or total resection of primary and/or metastases (including endoscopic
resection or biopsy where there is intent to remove all or bulk of macroscopic
neoplastic tissue, e.g., excision biopsy or cone biopsy). Surgery should also include
palliative procedures e.g. to bypass obstructive lesions or surgical procedures
intended to manipulate hormone levels e.g. by the removal of ovaries or testicles
7
Planned - surgery is planned at a later date
9
Not Known - there are no indications of any past or planned surgical procedures
relating to the neoplasm concerned
(T_FIRST_LOCATIO
N_CODE)
Hospital at
Home
(TBC)
Surgery
(T_STATUS)
This field is collected for all registrations with an incidence date from 1.1.1997.
Type of surgery
(T_SURGERY_TYPE
)
Page | 36
1
O/M
if
surge
T
This option is only available when Surgery = 1 – Yes.
ry is
1
Code
1
2
Date of First
Surgery
Description
Radical – this is when the procedure involves removal, part removal or destruction of
the primary tumour eg excision, resection or laser treatment.
Palliative – this is when the procedure is carried out to relieve the effects of the
tumour but not to remove tumour eg by-pass, stent insertion, dilatation, cosmesis
(breast cancer)
Please refer to OPSC codes for which treatments fall under the radical and palliative categories.
Date of first surgical treatment DD-MMM-YYYY (if applicable)
8
O
T
5
O
T
Institution code/practice code of Hospital/GP practice where a surgical treatment was first carried out (if
applicable)
1
O
T
Tick box to indicate if the patient was diagnosed at home.
1
M
T
Referred to a Clinical Oncologist (Radiotherapist) or Medical Oncologist. Options:
(T_FIRST_DATE)
Hospital/GP
Practice of First
Surgery
(T_FIRST_LOCATIO
N_CODE)
Hospital at
Home
(TBC)
Referred to
Oncologist
(T_STATUS)
Code
0
1
7
9
Description
No
Yes
Planned to refer
Not Known
This field is collected for all registrations with an incidence date from 1.1.1997.
Treated with
Radiotherapy
(T_STATUS)
Page | 37
1
M
T
Indicates if patient has been treated with radiotherapy. Radiotherapy is either external beam, or the
radioactive source can be introduced directly into the patient’s body. Radiotherapy may be used for:
curative treatment e.g. early seminomas, palliative treatment to contain the tumour & control symptoms
e.g. metastatic breast cancer, in combination with other curative treatments e.g. for tumours of the cervix,
and to sites other than the primary or metastases e.g. organ ablation or prophylaxis.
Options:
Code
0
1
7
9
Description
No
Yes
Planned
Not Known
This field is collected for all registrations with an incidence date from 1.1.1997.
Type of
radiotherapy
1
(T_RADIOTHERAPY
_TYPE)
Radiotherapy to
Primary
1
O/M
T
if
radiot
herap
y is 1
Type of radiotherapy administered. Options:
M
T
Radiotherapy treatment to Primary site. Options:
T
Code
Description
0
No
1
Yes
9
Not Known
Radiotherapy treatment to Metastases. Options:
(T_STATUS)
Radiotherapy to
Metastases
1
M
(T_STATUS)
Radiotherapy
Other
(T_STATUS)
Page | 38
Code
1
2
3
4
9
Code
0
1
9
1
M
T
Description
Brachytherapy
External beam/Teletherapy
Proton beam therapy
Radioisotope therapy
Not Known
Description
No
Yes
Not Known
Radiotherapy treatment to Other (such as organ ablation or prophylaxis). Options:
Code
Description
0
No
1
Yes
9
Not Known
Date of First
Radiotherapy
8
O
T
Date of first Radiotherapy treatment DD-MMM-YYYY (if applicable)
5
O
T
Institution code of Hospital where Radiotherapy was first carried out (if applicable)
1
O
T
Tick box to indicate if the patient was diagnosed at home.
1
M
T
Indicates if patient has had Systemic chemotherapy treatment.
Chemotherapy literally means treatment with drugs but is conventionally used to describe the use of
chemical agents to treat cancer. These agents may be used alone, or in conjunction with surgery and/or
radiotherapy. Options:
(T_FIRST_DATE)
Hospital/GP
Practice of First
Radiotherapy
(T_FIRST_LOCATIO
N_CODE)
Hospital at
Home
(TBC)
Treated with
Chemotherapy
(T_STATUS)
8
O
T
Code
Description
0
No
1
Yes
7
Planned
9
Not Known
This field is collected for all registrations with an incidence date from 1.1.1997.
Date of first Chemotherapy DD-MMM-YYYY (if applicable)
5
O
T
Institution code/practice code of Hospital/GP practice of first Chemotherapy (if applicable)
Hospital at
Home
(TBC)
1
O
T
Tick box to indicate if the patient had chemotherapy at home
Treated with
hormone
therapy
1
M
T
Indicates if patient has had Hormone treatment. Hormone therapy is the use of hormones to treat cancer.
Hormones are 'chemical messengers' released by the organs and dispersed by the blood to produce
effects on target organs e.g. oestrogens. Most likely to apply to Breast, Prostate, Endometrial (uterus) and
to a lesser extent, hypernephroma of kidney. Options:
Date of First
Chemotherapy
(T_FIRST_DATE)
Hospital/GP
Practice of First
Chemotherapy
(T_FIRST_LOCATIO
N_CODE)
(T_STATUS)
Page | 39
Code
Description
0
No
1
Yes
7
Planned
9
Not Known
This field is collected for all registrations with an incidence date from 1.1.1997.
Date of First
Hormone
Therapy
8
O
T
Date of first Hormone Therapy DD-MMM-YYYY (if applicable)
5
O
T
Institution code/practice code of Hospital/GP practice initiating Hormone Therapy (if applicable)
1
O
T
Tick box to indicate if the patient had hormone therapy at home
1
M
T
Indicates if patient has had Biological/Immunotherapy. Biological therapies are treatments that act on
processes in cells. They may: stop cancer cells from dividing and growing; seek out cancer cells and kill
them; encourage the immune system to attack cancer cells. There are many different types of biological
therapies including immunotherapy. Options:
(T_FIRST_DATE)
Hospital/GP
Practice of First
Hormone
Therapy
(T_FIRST_LOCATIO
N_CODE)
Hospital at
Home
(TBC)
Treated with
Biological/Immu
notherapy
(T_STATUS)
Code
0
1
7
9
Description
No
Yes
Planned
Not Known
This field is collected for all registrations with an incidence date from 1.1.2016
Date of First
Biological/Immu
notherapy
(T_FIRST_DATE)
Page | 40
8
O
T
Date of first Hormone Therapy DD-MMM-YYYY (if applicable)
Hospital/GP
Practice
of First
Biological/Immu
notherapy
5
O
T
Institution code/practice code of Hospital/GP practice initiating Hormone Therapy (if applicable)
1
O
T
Tick box to indicate if the patient had biological/immunotherapy at home
1
M
T
Other Therapy. Options:
Code
Description
0
No
1
Yes
7
Planned
9
Not Known
This field is collected for all registrations with an incidence date from 1.1.1997.
2
O
T
Indicates the type of Other Therapy treatment carried out. Options:
Code
Description
1
Anagrelide
2
Anti-Helicobacter/H.pylori treatment/eradication therapy
3
Bisphosphonate
4
Botox injection
5
Corticosteroids
6
Dopamine agonist therapy
7
Helmet/Electric Helmet
8
Hyperbaric oxygen therapy
9
Supportive Care/Best Supportive Care
10
Venesection
11
Watchful Wait/Active Surveillance
(T_FIRST_LOCATIO
N_CODE)
Hospital at
Home
(TBC)
Treated with
other therapy
(T_STATUS)
Type of other
therapy
(T_DESCRIPTION)
This field was previously text only and was collected for all registrations with an incidence date from
1.1.1997.
This field changed to a dropdown option for registrations from 1.1.2016
Page | 41
Date of First
Other Therapy
8
O
T
Date of first Other Therapy DD-MMM-YYYY (if applicable)
5
O
T
Institution code/practice code of Hospital/GP surgery where Other Therapy was first carried out (if
applicable)
1
O
T
Tick box to indicate if the patient had hormone therapy at home
1
M
T
Intent is most likely to be curative in early stage of disease e.g. microinvasive, or non invasive, in situ
disease, T1 or T2 N0 M0 , node negative breast cancer, Dukes’ A colorectal cancer, FIGO I cervical
cancer. Intent unlikely to be curative in advanced disease e.g. M1 breast cancer, Dukes’ D, FIGO IV.
Options:
(T_FIRST_DATE)
Hospital/GP
Practice of
Other Therapy
(T_FIRST_LOCATIO
N_CODE)
Hospital at
Home
(TBC)
Therapy
Objectives
(T_THERAPY_OBJE
CTIVES)
Code
1
2
9
Description
Curative intent
Non-curative intent (Palliative)
Not Known
This field is collected for all registrations with an incidence date from 1.1.1997.
Entered into
Clinical Trial
(T_CLINICAL_TRIAL)
Page | 42
1
M
T
Formerly Treatment Protocol Used This indicates whether the patient has been recruited into a specific
clinical trial. Only use the Not Known option if you feel you do not have an adequate set of medical
records on which to base your assessment.
Options:
Code
Description
0
No
1
Yes
9
Not Known
This field is collected for all registrations with an incidence date from 1.1.1997.
STATISTICAL & HISTORICAL DATA (TUMOUR LEVEL)
KEY: L = field length
P = field priority: M = mandatory, O = optional, D= Derived
S = ‘Registration’ screen locations: P = Person, ID = ID at Diag, D = Diagnosis, St = Stage, OCF = Other Contributing Factors, S = Stats,
T = Treatment, A = Admin
Field
L
P
S
Definition and Options
HISTORICAL DATA (1950-1996 registrations only)
Old Can Reg
No.
Old Registry
6
O/D
S
Sequential number allocated by each regional registry computer system (not unique)
2
M
Pre97
S
This uniquely identifies which one of the five Scottish regional registries has made the registration.
Mandatory for Pre-97 tumours.
Code
0
2
3
4
5
Old Hospital
code
5
Old GRO(S)
Flag
Social Class
Description
North (Inverness)
North-East (Aberdeen)
East (Dundee)
South-East (Edinburgh)
West (Glasgow)
S
Institution code of institution of registration - Mandatory for Pre-97 tumours.
1
M
Pre97
D
S
Indicates if a GRO(S) match has been made to update record
1
D
S
Social Class - Derived from the occupation code of the patient on the incidence date
Occupation
3
D
S
Occupation of patient at time of registration. This is a 3 digit code according to OPCS classifications.
Range: 001-350, 666 &777. Only collected on pre-SOCRATES data.
Parish code
5
D
S
Parish area - Derived from the postcode of the patient on the incidence date
Old Alt Case
No.
10
D
S
Other case ref. numbers used (pre 1997)
Page | 43
Old Batch
Number
4
D
S
Batch numbers allocated to data prior to DTC 1997
STATISTICAL DATA (used for all registrations)
NOTE: postcode-derived variables are of uncertain reliability and are due to be further developed.
Output areas are the smallest geographical unit for which Census data are available There were 42,604
output areas at the 2001 Census with a mean population size of 119 people. The smallest output area
represented 50 people and the largest 2,357 people. This wide variation was due to a few large output
areas with populations in communal establishments. However, the population sizes have become
increasingly variable in the years since the 2001 Census due to population migration.
As above
Output Area
2001
10
D
S
Output Area
1991
HB Residence
cypher
HB Residence
number
Local Govt
District
Grid Ref Easting
7
D
S
1
D
S
2
D
S
A letter (cypher) relating to the locale, of the resident population, represented as one of 15 Scottish Health
Board Areas
Number designated to HB of Residence (1 – 15)
2
D
S
Local government district (1 – 68)
6
D
S
Grid Ref
Northing
Local Council
Area
Urban / Rural
Part
Constituency
7
D
S
2
D
S
1
2
D
D
S
S
ED Grid Reference - Derived from the Enumeration District of the patient on the incidence date. The
easting with the origin based in the Scilly isles.
ED Grid Reference - Derived from the Enumeration District of the patient on the incidence date. The
northing with the origin based in the Scilly isles.
The local government council area, as defined by the reorganisation of 1 April 1996, where the patient
normally resides. This information is derived directly from the patient's postcode of residence.
Urban/Rural Status Indicator – Derived from the Postcode of the patient on the incidence date
Derived from the Postcode of the patient on the incidence date
Note: There is a Geography Hierarchy:
Postcode
Output area
Data Zone
Intermediate geography
Local Council Area
Page | 44
SYSTEM ADMINISTRATION DATA
KEY: L = field length
P = field priority: M = mandatory, O = optional, D= Derived
S = ‘Registration’ screen locations: P = Person, ID = ID at Diag, D = Diagnosis, St = Stage, OCF = Other Contributing Factors, S = Stats
T = Treatment, A = Admin
Field
L
P S
Definition and Options
Hospital Code
5
O A
Hospital code is allocated by the system according to the data source where it is presumed the medical
records with the most information on the patient will be available. Once this code has been allocated the
CRO(s) who work with that institution or area will be able see these provisional records in their batch.
This code will usually be associated with the provisional notification before registration, and may not
correspond to the registered hospital of diagnosis & Case Ref. no.
If transferred to another hospital batch this field will indicate where the provisional registration was last
transferred from
(R_HB_CODE)
/
D
Previous
Hospital
5
D A
8
D A
Date provisional registration was last transferred
8
D A
Date the record was last updated
30
D A
Code denoting the last Cancer Information Officer (CIO) who made an amendment to the registration
1
D A
Indicates if the record is a provisional registration, a validated / confirmed registration, or a previously
deleted registration
8
D A
The initial date the provisional registration was inserted into the hospital batch for the Cancer Information
Officer (CIO) to work with
2
D A
SOCRATES Grouping for similar tumour site families
(R_HOSPITAL_BATC
H_TRANS_FROM)
Transfer Date
(R_TRANSFER_DAT
E)
Last Updated
Date
(R_UPDATED_DATE
)
Last Updated
By
(R_UPDATED_BY)
Confirmed,
Provisional or
Deleted
(R_STATUS)
Date into Batch
(R_INTO_BATCH_D
ATE)
Subcluster
Code
(R_SUBCLUSTER_C
ODE)
Page | 45
Berg
Morphology
2
D A
‘Berg’ grouping for similar morphological families
1
O A
Tick box to indicate that a registration has been considered to be an independent primary tumour,
regardless of the existence of other registrations with a similar diagnosis.
2
O A
8
O A
Indicates that a particular quality check has been completed for a particular record. There are a growing
number of options due to the development of a more comprehensive quality assurance programme in
Cancer Registration.
Indicates that a haematological transformation has occurred recorded for incidence year 2013 onwards
4
O A
ICD10 – International Classification of Diseases (10th revision) recorded for haematological
transformations which have occurred since 01.01.2013
5
O A
500
O A
/
D
ICDO(3) - International Classification of Diseases for Oncology (3rd revision). Tumour type indicates the
morphology (histology) of the tumour and comprises the first four digits of the ICDO(3) morphology code
and a fifth digit which denotes behavior. This is recorded for haematological transformations which have
occurred since 01.01.2013
Derived from Quality Checks. Indicates date and description of check. Options:
(R_BERG_CODE)
Independent
Primary Tumour
(R_INDEPENDENT_
PRIMARY)
Quality Checks
(CR_QUALITY_CHE
CKS)
Transformation
Date
(R_TRANSFORMATI
ON_DATE)
Transformation
ICD10
(R_TRANSFORMATI
ON_ICD10)
Transformation
ICDO3
(R_TRANSFORMATI
ON_ICD03)
Checks
Page | 46
Code
1
2
3
4
5
6
7
8
9
10
11
Description
Duplicate tumour
IARC
Eurocim
Others
GRO record postcode checked
Death before incidence date checked
More than one death record checked
Cancer screening
Cancer audit
Non-specific morphology
18QA
Latest Note
2000
O A
(CR_NOTE)
Latest comment to be added regarding the tumour. There is a List Notes button available to view
previous notes.
SOURCE DATA– CLINICAL HISTORY RECORDS
KEY: L = field length
P = field priority: M = mandatory, O = optional, D= Derived
SD = ‘Source Data‘ screen locations: ID = ID, Ad = Address, O = Other, D = Diagnosis, T = Treatment, Sys = System, , Desc = Description
Field
L
P
SD Definition and Options
Load num
8
D
ID
Production run load number. Indicates when source data record was processed
Int link
6
D
ID
Not used
SOC link
6
D
ID
Socrates link weight
2
D
AL
L
Record Type of data. Options:
(CH_ID)
(CH_LINK_WEIGH
T)
Type
(CH_RECORD_TY
PE)
Surname
(CH_SURNAME)
Page | 47
Code
10
20-24, 27
30, 32, 51
34, 39
52
60-62
90
98
20
D
ID
Description
SMR01
Pathology
Oncology
Radiotherapy
Prescribing
Screening
NRS death notification - quarterly
NRS death notification - annual
As defined previously
Previous
Name
20
D
ID
As defined previously
30
D
ID
As defined previously
1
D
ID
As defined previously
10
D
ID
As defined previously
10
D
ID
As defined previously
Derived CHI
11
D
ID
As defined previously
Marital Status
1
D
ID
As defined previously
2
D
ID
As defined previously
200
D
Ad
As defined previously
8
D
Ad
As defined previously
40
D
O
Consultant code, Clinician certifying death on GRO records, Hospital areas on Pathology reports etc
20
D
O
Ward number if available
5
D
O
GP Practice code
2
D
O
Staging information if available
18
D
O
TNM information if available
(CH_SURNAME_A
T_BIRTH)
Forenames
(CH_FORENAMES)
Sex
(CH_SEX)
Date Of Birth
(CH_DATE_OF_BI
RTH)
CHI
(CH_CHI_NO)
(CH_MARITAL_ST
ATUS_ID)
Ethnic Group
(CH_ETHNIC_GR
OUP)
Address
(CH_ADDRESS)
Postcode
(CH_POSTCODE)
Sent By
(CH_SENT_BY)
Ward
(CH_WARD)
GP Code
(CH_G_CODE)
Stage
(CH_STAGE)
TNM
(CH_TNM)
Page | 48
Size
2
D
O
Tumour size if available
8
D
O
Date of death if available at source
16
D
O
As defined previously
12
D
O
Local ref. no such as lab no
10
D
O
(Hospital Patient ID) As defined previously
2
D
D
Subcluster Code grouping of cancer site codes - used for the elimination of similar notifications.
6
D
D
Converted to ICD-10 code from SNOMED and ICD-9 codes
7
D
D
Site code used for notifications before any conversions.
6
D
D
Site code used for notifications before any conversions.
6
D
D
Site code used for notifications before any conversions.
6
D
D
Site code used for notifications before any conversions.
6
D
D
Site code used for notifications before any conversions.
6
D
D
Site code used for notifications before any conversions.
(CH_SIZE)
Source DOD
(CH_SOURCE_DO
D)
NHS Number
(CH_NHS_NO)
Local Patient
ID
(CH_LOCAL_PATI
ENT_ID)
Case Ref No
(CH_HOSPITAL_P
ATIENT_ID)
Sub Code
(CH_SUBCLUSTE
R_CODE)
ICD-10 Conv.
Site
(CH_SITE_CODE_I
CD10)
Unconverted
Site 1
(CH_DIAGNOSIS_1)
Unconverted
Site 2
(CH_DIAGNOSIS_2)
Unconverted
Site 3
(CH_DIAGNOSIS_3)
Unconverted
Site 4
(CH_DIAGNOSIS_4)
Unconverted
Site 5
(CH_DIAGNOSIS_5)
Unconverted
Site 6
(CH_DIAGNOSIS_6)
Page | 49
Unconverted
Site 7
6
D
D
Site code used for notifications before any conversions.
6
D
D
Site code used for notifications before any conversions.
5
D
D
Converted from SNOP codes (WGH radiotherapy) or eg M-80003 to 80003
7
D
D
Type code used for notifications before any conversions.
2
D
D
Berg morphology type grouping code used to eliminate multiple primary/duplicate notifications
6
D
D
Indicates the creation rule decision (NEW – new tumour, MP1 – different at sub cluster code etc)
8
D
D
As defined previously.
4
D
T
Operation or procedure code used for notifications from SMR01.
4
D
T
Operation or procedure code used for notifications from SMR01.
4
D
T
Operation or procedure code used for notifications from SMR01.
4
D
T
Operation or procedure code used for notifications from SMR01.
4
D
T
Operation or procedure code used for notifications from SMR01.
4
D
T
Operation or procedure code used for notifications from SMR01.
(CH_DIAGNOSIS_7)
Unconverted
Site 8
(CH_DIAGNOSIS_8)
Converted
Morphology
(CH_MORPHOLOGY
_CODE_ICDO2)
Unconverted
Morphology
(CH_MORPHOLOGY
_CODE_UNCONVER
TED)
Berg Group
(CH_BERG_CODE)
Create Point
(CH_CREATEPOINT)
Incidence
Date
(CH_DATE_OF_ADM
ISSION)
Procedures OP1
(CH_PROCEDURE_1)
Procedures OP2
(CH_PROCEDURE_2)
Procedures –
OP3
(CH_PROCEDURE_3)
Procedures –
OP4
(CH_PROCEDURE_4)
Procedures –
OP5
(CH_PROCEDURE_5)
Procedures –
OP6
(CH_PROCEDURE_6)
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Procedures –
OP7
4
D
T
Operation or procedure code used for notifications from SMR01.
4
D
T
Operation or procedure code used for notifications from SMR01.
2
D
T
Specialty for SMR01 data & Request Type for pathology data e.g. A for autopsy
5
D
T
Hospital code converted from text input if pathology data or 3 digit code if WGH radiotherapy data
5
D
T
Original code or text received from source data.
8
D
T
(SMR01) Hospital admission date
8
D
Sys
Unique number generated for CDP (Cancer Data Processing) for all notifications.
1
D
Sys
Describes the outcome of the addition of a source data record. Options:
(CH_PROCEDURE_7)
Procedures –
OP8
(CH_PROCEDURE_8)
Specialty or
Req Type
(CH_SPECIALTY_CO
DE)
Hospital
Converted
(CH_CONV_INSTITU
TION)
Hospital
Unconverted
(CH_REFERRING_
HOSPITAL_CODE)
Date of
Admission
(CH_DATE_OF_ADM
ISSION)
Accession
Number
(CH_S_ID)
New Data
(CH_PROCESSING_
STATUS)
Data Source
(CH_DATA_PROVID
ER_CODE)
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7
D
Code
Description
D
Non-cancer death for unknown person
E
Error has been caused by this record
J
Duplicate data
M
Data rejected by multiple primary rules
P
Data used to create provisional record
S
Data rejected by secondary rules
X
Supplementary data added to an open provisional record
Sys Main source of notification e.g. GRO-S, SMR01 or source location code of hospital of
pathology/radiotherapy
Site – short
desc
130
D
De
sc
Additional information from the Pathology text i.e. site of tumour/excision/substance
130
D
De
sc
Additional information from the Pathology text i.e. type of excision
From Community Prescribing data this displays the prescribed drug.
130
D
De
sc
Morphology description
10,00
0
D
De
sc
Full pathology text.
(CH_SITE_DESC_
SHORT)
Site – long
desc
(CH_SITE_DESC_LO
NG)
Morphology
desc
(CH_MORPH_DESC)
Pathology
(CH_PATHOLOGY
_REPORT)
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