Download Cancer Registration Data set

Cancer Registration Dataset
Cancer Registration Dataset
(from Cancer Dataset Version 4.0)
This is an extract of the National Cancer Dataset, showing the data items required for the Cancer Registration Dataset.
1
1.1
1.2
Data Item
Description
Demographics
It is anticipated that some of the
demographic data items listed below will
be collected by every provider with which
the patient has contact.
NHS NUMBER
[NHS Number]
LOCAL PATIENT
IDENTIFIER
[Hospital Number]
Version 4.0
Issue Date: 11.08.03
Where this information is exchanged, the
appropriate data item name should be used
to identify the particular instance of the
data (See Description column).
The patient’s unique 10 digit new format
NHS Number
The local number by which the patient is
known at this hospital. This may be
hospital site specific i.e. there may be
different hospital numbers collected for the
patient at different points in the pathway.
Purpose
Codes and Classifications
Note: all dates should be held in format suitable for
date manipulations to take place, and should hold
four character years. The actual format held will
depend on the database being used.
Used for unique identification to match
records from different service providers.
Used for unique identification to link
events within a single service provider
NHS Data Dictionary
NHS Data Dictionary
Page 1 of 23
Cancer Registration Dataset
1.3
Data Item
ORGANISATION
CODE(CODE OF
PROVIDER)
[Provider Code]
1.4
CARE SPELL
IDENTIFIER
[Unique Care Spell
Number]
1.5
PATIENT FAMILY
OR SURNAME
[Surname]
Version 4.0
Issue Date: 11.08.03
Description
The organisation code of the Unit
providing the diagnosis or care to the
patient.
DSCN 22/2002 (Waiting Times) requires
collection of this data item at the following
points in the patient journey:
ORGANISATION CODE (PROVIDER
FIRST SEEN)
ORGANISATION CODE (PROVIDER
FIRST CANCER SPECIALIST)
ORGANISATION CODE (PROVIDER
FIRST DIAGNOSTIC TEST)
ORGANISATION CODE (PROVIDER
DECISION TO TREAT)
ORGANISATION CODE (PROVIDER
FIRST TREATMENT)
To link all activities for a patient to the
same care spell. It is envisaged that this
will be allocated on diagnosis, at the
organisation where the diagnosis takes
place, and will be communicated to all
organisations providing care to the patient.
The patient’s Surname
Note: it must be possible to provide
Cancer Registries with the patient’s
surname as at the date of diagnosis.
Purpose
To enable analysis by Provider Code.
Codes and Classifications
NHS Data Dictionary Supporting Information,
Administrative Codes, NHS Trust
Used to link all activities for the patient to
the same care spell.
Used for unique identification to link
records where the new NHS number is not
available (e.g. to previous tumours, genetic
requests, events carried out in private
hospitals). It should be possible to phase
out the use of surname once the use of
NHS number becomes universal.
NHS Data Dictionary
Page 2 of 23
Cancer Registration Dataset
Data Item
PATIENT
FORENAME OR
PERSONAL NAME
[Forenames]
Description
The patient’s Forenames
PATIENT USUAL
ADDRESS (AT
DIAGNOSIS)
[Address at Date of
Diagnosis]
POSTCODE OF
USUAL ADDRESS
(AT DIAGNOSIS)
[Postcode at Date of
Diagnosis]
SEX
[Sex]
ONS rules for completion of this field will
need to be followed.
1.10
1.12
1.6
1.7
1.8
1.9
Purpose
Used for unique identification to link
records where the new NHS number is not
available (e.g. to previous tumours, genetic
requests, events carried out in private
hospitals). It should be possible to phase
out the use of forename once the use of
NHS number becomes universal.
To derive and/or verify Postcode and for
flagging cancers at NHSCR/approved
‘medical research’ cohort studies/other
research
Codes and Classifications
NHS Data Dictionary
ONS rules for completion of this field will
need to be followed.
The address at diagnosis is used to enable
analysis by locality of patients.
NHS Data Dictionary
The patient’s sex
To enable analysis by sex.
BIRTH DATE
[Date of Birth]
The patient’s date of birth
CODE OF GP
PRACTICE
(REGISTERED GMP)
[GP Practice Code]
Practice with whom the patient is
registered
To enable age at diagnosis to be
established for epidemiological and
survival analyses. To enable analysis by
birth cohort and to assist linkage at
ONS/NHSCR (and registries) for women
who have changed their name on marriage
(or back on separation/divorce).
To enable analysis by GP Practice Code
NHS Data Dictionary
0 – Not known
1 – Male
2 – Female
9 – Not specified
Date format.
Version 4.0
Issue Date: 11.08.03
NHS Data Dictionary
NHS Data Dictionary Supporting Information,
Administrative codes, GP Practice (6 character
code allocated by PPA)
Page 3 of 23
Cancer Registration Dataset
1.13
1.14
Data Item
ORGANISATION
CODE
(RESPONSIBLE PCT)
[GP PCG/PCT Code]
(This need not be
collected directly by
clinical staff)
PATIENT FAMILY
OR SURNAME (AT
BIRTH)
[Surname at Birth]
Version 4.0
Issue Date: 11.08.03
Description
PCT corresponding to the GP Practice
Code
Purpose
To enable analysis by GP PCT Code
The patient’s surname at birth
Note: This is not usually readily available
from a hospital PAS system. It should be
collected prospectively on contact with the
patient.
Used for unique identification to link
previous records where the new NHS
number is not available (e.g. to previous
tumours, genetic requests). It should be
possible to phase out the use of surname at
birth once the use of NHS number
becomes universal.
Codes and Classifications
NHS Data Dictionary Supporting Information,
Administrative Codes (Primary Care Group, 5
character code starting with ‘4’, allocated by PPA).
Note: this can be derived from GP Practice Code.
Page 4 of 23
Cancer Registration Dataset
1.15
Data Item
ETHNIC CATEGORY
[Ethnic Category]
Description
The ethnic category of the patient, as
specified by the patient.
Purpose
To enable analysis by ethnicity.
Codes and Classifications
White
British A
Irish B
Any other white background C
Mixed
White and Black Caribbean D
White and Black African E
White and Asian F
Any other mixed background G
Asian or Asian British
Indian H
Pakistani J
Bangladeshi K
Any other Asian background L
Black or Black British
Caribbean M
African N
Any other black background P
Other Ethnic Groups
Chinese R
Any other ethnic group S
Not stated
Not stated Z
Version 4.0
Issue Date: 11.08.03
Page 5 of 23
Cancer Registration Dataset
2
Data Item
Referrals
2.13
CANCER STATUS
4
Diagnosis
Version 4.0
Issue Date: 11.08.03
Description
For ‘two-week wait’ referrals, only one
referral needs to be recorded. This will be
the referral to the consultant (or team) who
makes the actual diagnosis of cancer.
If the original GP referral was to a noncancer specialist, with subsequent referral
to a cancer specialist, then record all
referrals.
Where this information is exchanged, the
appropriate data item name should be used
to identify the particular instance of the
data (See Description column).
The Cancer Data Manual will detail
particular requirements for screening,
where the diagnosis takes place within
screening services and referral is for
treatment. Relevance of the data items in
this section to the screening services will
be investigated further.
The status of this referral
These fields should record the definitive
diagnosis as known to the hospital in
question, based on the information
available at the time the items were
completed. There will be only one
definitive diagnosis entry held.
Purpose
Codes and Classifications
The purpose of this item is to identify
urgent GP referrals for suspected cancer
who are subsequently diagnosed with
cancer. This item is used to flag records
that need data recorded on first definitive
treatment (cancer patients) and those who
do not (non-cancer patients).
1 - Suspected cancer (default)
2 - Diagnosis of cancer confirmed
3 - No cancer diagnosis identified by Trust
4 - No cancer diagnosis – determined automatically
Each tumour lead will be asked to decide if a
working diagnosis of cancer is useful for their site
and if there is a need for more than one diagnosis
entry to be collected.
Page 6 of 23
Cancer Registration Dataset
Data Item
DIAGNOSIS DATE
(CANCER)
[Date of diagnosis]
Description
This field records the date of diagnosis of
the tumour. It is required with the date of
birth to derive the age at diagnosis and is
used in the analysis of incidence trends
and in the calculation of survival rates. The
definition provided conforms to the
international requirements specified by the
European Network of Cancer Registries
(ENCR).
Purpose
To calculate annual incidence rates and to
determine the start date for survival
analysis.
4.2
PRIMARY
DIAGNOSIS (ICD)
[Primary Site]
The main cancer site for which the patient
is receiving care.
4.3
TUMOUR
LATERALITY
[Laterality]
The laterality of the primary tumour.
To differentiate tumours in paired organs.
To establish the numbers of various
cancers to enable calculation of annual
incidence rates.
To allow for an assessment of subsequent
treatment and outcome rates.
To differentiate tumours in paired organs.
4.1
Codes and Classifications
Order of declining priority:
1. Date of first histological or cytological
confirmation of this malignancy (with the exception
of histology or cytology at autopsy). This date
should be, in the following order:
a. date when the specimen was taken, or
b. date of receipt by the pathologist, or
c. date of the pathology report
2. Date of admission to hospital because of this
malignancy.
3. When evaluated at an out-patient clinic only:
date of first consultation at the out-patient clinic
because of this malignancy.
4. Date of diagnosis, other than 1, 2 or 3.
5. Date of death, if no information is available other
than the fact that the patient has died because of
malignancy.
6. Date of death, if the malignancy is discovered at
autopsy.
Mappable to ICD-10
Tumour leads will be asked to provide relevant
sites.
L - Left
R - Right
M - Midline
B - Bilateral
8 - Not applicable
9 – Not known
Tumour leads will be asked which of these are
relevant.
Version 4.0
Issue Date: 11.08.03
Page 7 of 23
Cancer Registration Dataset
4.4
Data Item
BASIS OF
DIAGNOSIS
(CANCER)
[Basis of diagnosis]
Version 4.0
Issue Date: 11.08.03
Description
This field records the eligibility of the
tumour for registration based on the best
source of information known to the Trust
and allows derivation of the degree of
certainty of diagnosis. It is therefore an
indicator of data quality, with microscopic
histological verification being viewed as
the ‘gold standard’ diagnosis. The
definition provided conforms with the
international requirements specified by the
European Network of Cancer Registries
(ENCR).
Purpose
To establish the certainty of diagnosis and
in particular the histological confirmation
rate for epidemiological analyses.
Codes and Classifications
Non-microscopic
0 - Death Certificate (The only information
available is from a death certificate)
1 – Clinical (Diagnosis made before death but
without the benefit of any of the following (2- 7))
2 - Clinical Investigation (Includes all diagnostic
techniques (e.g. X-rays, endoscopy, imaging,
ultrasound, exploratory surgery and autopsy)
without a tissue diagnosis)
4 - Specific Tumour Markers (Includes biochemical
and/or immunological markers which are specific
for a tumour site)
Microscopic
5 – Cytology (Examination of cells whether from a
primary or secondary site, including fluids aspirated
using endoscopes or needles. Also including
microscopic examination of peripheral blood films
and trephine bone marrow aspirates).
6 - Histology of a metastasis (Histological
examination of tissues from a metastasis, including
autopsy specimens)
7 - Histology of a primary tumour (Histological
examination of tissue from the primary tumour,
however obtained, including all cutting and bone
marrow biopsies. Also includes autopsy specimens
of a primary tumour)
9 – Not known (No information on how the
diagnosis has been made (e.g. PAS or HISS record
only))(Default)
Page 8 of 23
Cancer Registration Dataset
4.5
Data Item
HISTOLOGY
(SNOMED)
[Histology]
4.6
GRADE OF
DIFFERENTIATION
(AT DIAGNOSIS)
[Grade of
differentiation]
5
Cancer Care Plan
5.6
PLANNED CANCER
TREATMENT TYPE
[Management
modality]
Version 4.0
Issue Date: 11.08.03
Description
The cell type of the malignant disease
Note: This data item also appears in the
Pathology section. It is repeated here in
order to record the definitive
behaviour/histology of the tumour at the
point of diagnosis (there may be a number
of Pathology reports contributing to the
diagnosis).
Qualitative assessment of the
differentiation of the tumour expressed as
the extent to which a tumour resembles the
normal tissue at that site.
Note: This data item also appears in the
Pathology section. It is repeated here in
order to record the definitive grade of the
tumour at the point of diagnosis (there may
be a number of Pathology reports
contributing to the diagnosis).
There may be a number of cancer care
plans, on different dates.
What treatment(s) are planned for the
patient
DSCN 22/2002 (Waiting Times) requires
collection of this data item at the following
point in the patient journey:
PLANNED CANCER TREATMENT
TYPE (FIRST DEFINITIVE)
Purpose
To determine the incidence of tumours of
different histology and behaviour for
epidemiological analyses.
Codes and Classifications
Mappable to SNOMED which in turn maps to ICDO coding.
Tumour leads will be asked to provide relevant
histology descriptions.
To enable the effect of differentiation
grade on prognosis to be investigated.
Site specific, but generic definition:
GX - Grade of differentiation is not appropriate or
cannot be assessed
G1 - Well differentiated
G2 - Moderately differentiated
G3 - Poorly differentiated
G4 - Undifferentiated anaplastic
Tumour leads will be asked to provide information
on any site-specific grading system.
To determine the number of patients
undergoing each primary treatment.
To determine patterns of primary
treatment.
To enable analysis of discrete groups of
patients particularly where several
modalities are used.
The code ‘07’ in italics below is not specified in
DSCN 22/2002 i.e. is not applicable to waiting
times.
01 - Surgery
02 - Teletherapy
03 - Chemotherapy
04 - Hormone Therapy
05 - Specialist Palliative Care
06 - Brachytherapy
07 – Biological
08 – Other
09 – Active Monitoring
99 – Not known (default)
Page 9 of 23
Cancer Registration Dataset
Data Item
TREATMENT TYPE
SEQUENCE
(CANCER)
[Treatment type
sequence]
Description
The sequence of the treatment(s) above
6
Staging
These fields should be recorded at the time
that the first cancer care plan is agreed.
Cancer registries require the first pretreatment stage, i.e. the stage at diagnosis.
6.1
T CATEGORY
(FINAL
PRETREATMENT)
[Final pre-treatment T
category]
STAGING
CERTAINTY
FACTOR (T
CATEGORY)
[Certainty factor for T
category]
The ‘T’ part of the TNM classification
used to describe the clinical stage of the
tumour prior to treatment
To allow for pre-treatment T stage to be
taken into account in the analysis of
treatment and outcome.
UICC Coding
The validity of the T part of the TNM
classification according to the diagnostic
methods employed.
To provide a measure of the certainty with
which the pre-treatment T stage was
determined
UICC Coding
C1 - Evidence from standard diagnostic means (e.g.
inspection, palpation and standard radiography,
intraluminal endoscopy for tumours of certain
organs)
C2 - Evidence obtained by special diagnostic means
(e.g. radiographic imaging in special projections,
tomography, ultrasonography, lymphography,
angiography, scintigraphy, MRI, endoscopy, biopsy
and cytology)
C3 - Evidence from surgical exploration, including
biopsy and cytology
C4 - Evidence of the extent of disease following
definitive surgery and pathological examination of
the resected specimen
C5 - Evidence from autopsy
5.7
6.2
Version 4.0
Issue Date: 11.08.03
Purpose
To determine the number of patients
undergoing each primary treatment.
To determine patterns of primary
treatment.
To enable analysis of discrete groups of
patients particularly where several
modalities are used.
Codes and Classifications
1, 2, 3 etc.
Tumour leads will be asked to advise on need for
pre-surgical/surgical staging.
Tumour leads will be asked to advise whether
UICC coding is relevant to their particular site.
Page 10 of 23
Cancer Registration Dataset
6.3
6.4
6.5
6.6
6.7
6.8
Data Item
N CATEGORY
(FINAL
PRETREATMENT)
[Final pre-treatment N
category]
STAGING
CERTAINTY
FACTOR (N
CATEGORY)
[Certainty factor for N
category]
M CATEGORY
(FINAL
PRETREATMENT)
[Final pre-treatment M
category]
STAGING
CERTAINTY
FACTOR (M
CATEGORY)
[Certainty factor for M
category]
TNM CATEGORY
(FINAL
PRETREATMENT)
[Overall pre-treatment
stage group]
STAGING
CERTAINTY
FACTOR (TNM
CATEGORY)
[Certainty factor for
TNM stage]
Version 4.0
Issue Date: 11.08.03
Description
The ‘N’ part of the TNM classification
used to describe the clinical stage of the
tumour prior to treatment.
Note that micro-metastases should be
considered as positive.
The validity of the N part of the TNM
classification according to the diagnostic
methods employed.
Purpose
To allow for pre-treatment N stage to be
taken into account in the analysis of
treatment and outcome.
Codes and Classifications
UICC Coding
To provide a measure of the certainty with
which the pre-treatment N stage was
determined
UICC Coding
See Certainty factor for T Stage above
The ‘M’ part of the TNM classification
used to describe the clinical stage of the
tumour prior to treatment
To allow for pre-treatment M stage to be
taken into account in the analysis of
treatment and outcome.
UICC Coding
The validity of the M part of the TNM
classification according to the diagnostic
methods employed.
To provide a measure of the certainty with
which the pre-treatment M stage was
determined
UICC Coding
See Certainty factor for T Stage above
Overall clinical TNM stage of the tumour,
derived from each T, N, M component
prior to treatment
To allow for this factor to be taken into
account in the analysis of treatment and
outcome.
UICC Coding
The validity of the TNM classification
according to the diagnostic methods
employed.
To provide a measure of the certainty with
which the pre-treatment TNM stage was
determined
UICC Coding
See Certainty factor for T Stage above
Page 11 of 23
Cancer Registration Dataset
6.9
6.10
6.11
6.12
6.13
7
7.1
Data Item
SITE SPECIFIC
STAGING
CLASSIFICATION
[Site Specific
Classification]
TNM CATEGORY
(INTEGRATED)
[Overall Pathological
TNM stage grouping –
integrated stage]
T CATEGORY
(INTEGRATED
STAGE)
[Integrated stage - T
category]
N CATEGORY
(INTEGRATED
STAGE)
[Integrated stage – N
category]
M CATEGORY
(INTEGRATED
STAGE)
[Integrated stage - M
category]
Surgery and Other
Procedures
SITE CODE (OF
SURGERY)
[Hospital]
Version 4.0
Issue Date: 11.08.03
Description
Non-TNM staging system, which may or
may not map on to an equivalent TNM
stage. Coding system will be specified as
appropriate for each site.
Purpose
To allow for site specific classifications to
be taken into account in the analysis of
treatment and outcome.
The combination of pT (pathological) with
pN (pathological) and M (pre-treatment)
into stage groups that are more or less
homogeneous in respect of survival and for
which the survival rates are distinctive.
The ‘T’ part of the TNM classification
used to describe the integrated stage of the
tumour
To allow for the integrated TNM stage to
be taken into account in the analysis of
treatment and outcome.
The ‘N’ part of the TNM classification
used to describe the integrated stage of the
tumour.
Note that micro-metastases should be
considered as positive.
The ‘M’ part of the TNM classification
used to describe the integrated stage of the
tumour
This can be adapted for other procedures
including interventional radiology, laser
treatment, endoscopies etc. and photodynamic procedures. This also includes
procedures offered as supportive care.
The hospital at which the surgery takes
place.
Codes and Classifications
Site specific – e.g. Dukes for colorectal, NPI for
breast, “Limited’ or ‘Extensive’ stage disease for
Small Cell Lung Cancer
Tumour leads will be asked to advise on details
about any site-specific coding system used.
UICC
Tumour leads will be asked to comment on
relevance of UICC coding.
To allow for integrated T stage to be taken
into account in the analysis of treatment
and outcome.
UICC Coding
To allow for integrated N stage to be taken
into account in the analysis of treatment
and outcome.
UICC Coding
To allow for integrated M stage to be taken
into account in the analysis of treatment
and outcome.
UICC Coding
Required because different activities for a
patient may be carried out at different
service provider sites.
To enable reports and analysis by hospital
and/or cancer network.
NHS Data Dictionary Supporting Information,
Administrative Codes, NHS Trust Site (5 character
code, starts with ‘R’, allocated by OCS)
Page 12 of 23
Cancer Registration Dataset
7.2
7.4
7.9
7.10
7.11
8
Data Item
CONSULTANT
CODE
[Managing consultant
surgeon]
CANCER
TREATMENT
INTENT
[Treatment intent]
PROCEDURE DATE
[Date of surgery]
PRIMARY
PROCEDURE (OPCS)
[Main surgical
procedure]
PROCEDURE (OPCS)
[Sub-procedure]
Pathology Details
Version 4.0
Issue Date: 11.08.03
Description
The consultant in overall charge of the
patient’s treatment.
Purpose
To enable reports and analysis by
consultant.
Codes and Classifications
NHS Data Dictionary Supporting Information,
Administrative Codes (Practitioner Code for a
Consultant)
The purpose of the surgical procedure(s)
being carried out
To enable analysis by treatment intent
The date that the surgical procedure(s)
below started.
To determine the time interval between
referral/diagnosis by the specialist team
and start of surgical treatment.
D - Diagnostic
S - Staging
C – Curative
P – Palliative
9 – Not known (default)
Date format
DSCN 22/2002 (Waiting Times) requires
collection of this data item at the following
point in the patient journey:
CLINICAL INTERVENTION DATE
(FIRST DIAGNOSTIC TEST).
The main surgical procedure carried out
Any sub-procedure carried out
(This may occur more than once)
Note: it is expected that all the data items
on the minimum RCPath dataset will be
collected. The pathology data items below
are a subset of that dataset. A patient may
have any number of pathology reports, and
there may be more than one pathology
report per specimen. If the original report
is reviewed or revised, then a new
pathology module will need to be
completed and dated, with the data item
‘Second Opinion’ on the RCPath Dataset
marked as ‘Y’.
To determine type of surgery performed to
enable analysis of surgically related data.
Mappable to OPCS-4
Tumour leads will be asked to supply lists of
procedures.
To determine type of surgery performed to
enable analysis of surgically related data.
Mappable to OPCS-4
Tumour leads will be asked to supply lists of
procedures.
Tumour leads will be asked to comment on the
relevance of the generic data items below to their
particular site.
Page 13 of 23
Cancer Registration Dataset
8.1
8.2
8.4
8.5
8.6
8.7
Data Item
PATHOLOGY
INVESTIGATION
TYPE
[Report Type]
SAMPLE RECEIPT
DATE
[Date specimen
received]
CONSULTANT
CODE
(PATHOLOGIST)
[Authorising
pathologist]
ORGANISATION
CODE (OF
REPORTING
PATHOLOGY)
[Reporting
organisation]
PRIMARY
DIAGNOSIS (ICD)
[Primary diagnosis
(Site)]
TUMOUR
LATERALITY
[Laterality]
Version 4.0
Issue Date: 11.08.03
Description
Cytology, Biopsy or Excision
Purpose
To record the type of specimen reported
and hence the RCPath dataset items that
should be recorded.
The date that the specimen was received
by the pathology laboratory.
To enable the date of diagnosis to be
determined for epidemiological purposes
(annual incidence rates and survival
analyses)
To enable reports and analysis by
consultant
The code of the pathologist authorising the
report
Codes and Classifications
CY - Cytology sample
BX - Biopsy sample
EX - Excision sample
9 – Uncertain/other
Date format
NHS Data Dictionary Supporting Information,
Administrative Codes (Practitioner Code for a
Consultant)
The organisation at which the authorising
pathologist is based.
Required because different activities for a
patient may be carried out at different
service provider sites.
To enable reports and analysis by hospital
and/or cancer network.
NHS Data Dictionary Supporting Information,
Administrative Codes, NHS Trust Site (5 character
code, starts with ‘R’, allocated by OCS)
The topographical site of the tumour
To establish the numbers of various
cancers to enable calculation of annual
incidence rates.
To allow for an assessment of subsequent
treatment and outcome rates.
To differentiate tumours in paired organs.
To define the site of the Pathology
specimen.
Mappable to ICD10
Side
L - Left
R - Right
B - Bilateral
M - Midline
8 - Not applicable
9 - Not known
Page 14 of 23
Cancer Registration Dataset
Data Item
INVASIVE LESION
SIZE
[Tumour size –
maximum diameter]
Description
To record the size of the tumour
8.9
SYNCHRONOUS
TUMOUR
INDICATOR
[Synchronous tumour]
To record the presence of multiple tumours
for a tumour site.
8.10
HISTOLOGY
(SNOMED)
[Histology]
GRADE OF
DIFFERENTIATION
[Grade of
differentiation]
The cell type of the malignant disease
8.8
8.11
8.12
8.13
CANCER
VASCULAR OR
LYMPHATIC
INVASION
[Vascular/lymphatic
invasion]
EXCISION MARGIN
[Excision Margins]
Version 4.0
Issue Date: 11.08.03
Qualitative assessment of the
differentiation of the tumour expressed as
the extent to which a tumour resembles the
normal tissue at that site.
Purpose
To obtain information of prognostic value
that can (for some tumour sites) be used to
derive the pT component of the TNM
stage. Tumour size cannot be used to
calculate pT if the tumour has been
reduced in size by treatment undertaken
prior to surgery.
To enable complete reporting of separate
tumours diagnosed simultaneously at the
same primary site. With the exception of
bladder and prostate tumours, a separate
report form should be completed for each
synchronous tumour reported
To determine the incidence of tumours of
different histology and behaviour for
epidemiological purposes.
To enable the effect of differentiation
grade on prognosis to be investigated.
To record the presence of unequivocal
tumour in vascular spaces.
To provide information of prognostic
importance.
Whether all the excision margins were
clear of tumour.
To determine adequacy of excision.
Codes and Classifications
N - No, no synchronous tumours present
Y - Yes, synchronous tumours present
9 - Not known (default)
Mappable to SNOMed which in turn maps to ICDO coding
Site specific, but generic definition:
GX - Grade of differentiation is not appropriate or
cannot be assessed
G1 - Well differentiated
G2 - Moderately differentiated
G3 - Poorly differentiated
G4 - Undifferentiated anaplastic
N - No, vascular/lymphatic invasion not present
Y - Yes, vascular/lymphatic invasion present
U - Uncertain whether vascular invasion is present
or not
9 - Not known (default)
A - Margin involved
B < 1mm clear
C - 1-5 mm clear
D - > 5 mm clear
U - Uncertain
8 - Not applicable (default)
Page 15 of 23
Cancer Registration Dataset
8.14
8.15
Data Item
NODES EXAMINED
NUMBER
[Local/regional nodes
examined]
NODES POSITIVE
NUMBER
[Local/regional nodes
positive]
8.16
T CATEGORY
(PATHOLOGICAL)
[Pathological T
category]
8.17
N CATEGORY
(PATHOLOGICAL)
[Pathological N
category]
8.18
M CATEGORY
(PATHOLOGICAL)
[Pathological M
category]
TNM CATEGORY
(PATHOLOGICAL)
[Overall Pathological
TNM stage grouping]
SERVICE REPORT
STATUS
[Second opinion]
8.19
8.21
Version 4.0
Issue Date: 11.08.03
Description
The number of local/regional nodes
examined. Local/regional nodes are
defined by the UICC TNM Atlas and vary
with the primary cancer site
The number of local/regional nodes
reported as being positive for the presence
of tumour metastases. Local/regional
nodes are defined by the UICC TNM Atlas
and vary with the primary cancer site
The extent of the primary tumour after
excision or biopsy of the primary cancer.
This is derived from Local Invasion Tumour Extent and Structure (s) Invaded
data items on the Pathology dataset
The histological evidence of the absence or
presence and extent of regional lymph
node metastases. This is derived from
Local/Regional nodes positive, Other
Nodes positive and Marker lymph node 1
positive data items on the Pathology
dataset.
The histological evidence of the absence or
presence of distant metastases. This is
derived from the Distant Metastases data
item on the Pathology dataset.
The combination of pT with pN and pM
into stage groups that are more or less
homogeneous in respect of survival and for
which the survival rates are distinctive.
This field is a flag to indicate that the
report is a second opinion or
supplementary report on the tumour.
Purpose
To obtain information relating to the
quality of the diagnostic process.
Codes and Classifications
Detail of the nodes involved will be supplied in the
Cancer Data Manual.
To obtain information of prognostic value
that can be used to derive the pN
component of the TNM stage.
Detail of the nodes involved will be supplied in the
Cancer Data Manual.
To allow for the pathological T stage to be
taken into account in the analysis of
treatment and outcome.
UICC
Tumour leads will be asked to comment on
relevance of UICC coding.
To allow for the pathological N stage to be
taken into account in the analysis of
treatment and outcome.
UICC
Tumour leads will be asked to comment on
relevance of UICC coding.
To allow for the pathological M stage to be
taken into account in the analysis of
treatment and outcome.
UICC
Tumour leads will be asked to comment on
relevance of UICC coding.
To allow for the pathological TNM stage
to be taken into account in the analysis of
treatment and outcome.
UICC
Tumour leads will be asked to comment on
relevance of UICC coding.
1 – final (complete)
2 – preliminary (interim)
3 – test not available
4 - unspecified
5 – second opinion/supplementary report
Page 16 of 23
Cancer Registration Dataset
Data Item
SPECIMEN NATURE
[Nature of specimen]
Description
This field records the nature of the
specimen reported.
8.23
ORGANISATION
CODE (REQUESTED
BY)
[Organisation of
referral]
This field records the organization at
which the referring consultant/GP is based.
8.24
CARE
PROFESSIONAL
CODE (REQUESTED
BY)
[Referred by]
T CATEGORY
EXTENDED
(PATHOLOGICAL)
[Local invasion –
tumour extent]
M CATEGORY
EXTENDED
(PATHOLOGICAL)
[Distant metastases]
Chemotherapy and
other drugs
The consultant referring the specimen.
This is not required if the source of referral
is a GP.
8.22
8.25
8.26
9
Version 4.0
Issue Date: 11.08.03
The extent of the invasion of the tumour.
This is used to derive the pT component of
the pTpNpM stage. In some cases, more
than one code can be selected for a given
tumour.
The presence of metastatic deposits of the
primary tumour at distant metastatic sites.
The field is used to derive the pM
component of the pTpNpM stage.
Chemotherapy and/or other anti-Cancer
and/or Supportive drugs given to the
patient during their treatment.
Purpose
Codes and Classifications
1 - Primary tumour
2 - Re-excision of primary tumour
3 - Recurrence
4 - Nodes
5 - Metastatic site other than nodes
9 - Not known
For NHS institutions, this is the site’s organization
code
If the source of referral is a GP, the GP Practice
code is recorded.
Coding for voluntary organizations and private
hospitals will also be required.
Defaults:
V81999 Practice Code unknown
V81998 Practice Code of MOD Doctor
GMC Code of the consultant.
Defaults:
C9999998 – locum consultant code
C9999999 – consultant code unknown
UICC coding.
UICC Coding
Page 17 of 23
Cancer Registration Dataset
Data Item
SITE CODE (OF
CANCER DRUG
TREATMENT)
[Hospital]
Description
The hospital at which the drug treatment
takes place
CONSULTANT
CODE
[Managing consultant]
DRUG THERAPY
TYPE
[Drug therapy type]
The consultant in overall charge of the
patient’s drug treatment
The type of drug therapy administered
To establish patterns of drug therapy
treatment
9.8
DRUG TREATMENT
INTENT
[Treatment intent]
The intended outcome of treatment
9.10
START DATE (ANTICANCER DRUG
REGIMEN)
[Drug treatment start
date]
Radiotherapy
Radiotherapy
(teletherapy)
Record the date on which the first dose of
the drug is administered to the patient.
To establish the frequency of different
treatment intents.
To monitor treatment related outcomes. To
assess patterns of chemotherapy or other
drug therapy practice for comparison with
best practice guidelines
To enable the date of the first definitive
treatment to be recorded.
Cancer Registries only require the start
date of the first chemotherapy course
9.1
9.2
9.7
10
10
10.1
SITE CODE (OF
TELETHERAPY)
[Hospital]
10.2
CONSULTANT
CODE
[Managing consultant]
Version 4.0
Issue Date: 11.08.03
A course of teletherapy is defined as a
string of prescriptions which are
consecutive.
The hospital at which the teletherapy takes
place
The consultant in overall charge of the
patient’s teletherapy treatment
Purpose
Required because different activities for a
patient may be carried out at different
service provider sites.
To enable reports and analysis by hospital
and/or cancer network.
To enable reports and analysis by
consultant.
Required because different activities for a
patient may be carried out at different
service provider sites.
To enable reports and analysis by hospital
and/or cancer network.
To enable reports and analysis by
consultant.
Codes and Classifications
NHS Data Dictionary Supporting Information,
Administrative Codes, NHS Trust Site (5 character
code, starts with ‘R’, allocated by OCS)
NHS Data Dictionary Supporting Information,
Administrative Codes (Practitioner Code for a
Consultant)
C - Chemotherapy
H - Hormone/endocrine therapy
I - Immunotherapy
O - Other
C - Curative
P - Palliative
A - Adjuvant
N - Neoadjuvant
9 - Not known (default)
Date format
NHS Data Dictionary Supporting Information,
Administrative Codes, NHS Trust Site (5 character
code, starts with ‘R’, allocated by OCS)
NHS Data Dictionary Supporting Information,
Administrative Codes (Practitioner Code for a
Consultant)
Page 18 of 23
Cancer Registration Dataset
10.6
10.7
10.8
11
Data Item
CANCER
TREATMENT
INTENT
[Treatment intent]
RADIOTHERAPY
ANATOMICAL
TREATMENT SITE
[Anatomical treatment
site]
START DATE
(TELETHERAPY
TREATMENT
COURSE)
[Teletherapy start date]
Radiotherapy
(Brachytherapy)
11.1
SITE CODE (OF
BRACHYTHERAPY)
[Hospital]
11.2
CONSULTANT
CODE
[Managing consultant]
Version 4.0
Issue Date: 11.08.03
Description
Curative - any treatment where long-term
survival is the aim of a significant
proportion of patients
Palliative - any treatment where the clear
intention is to improve symptoms and
possibly prolong life but where long-term
survival is unlikely
Adjuvant - an adjunct to a potentially
ablative local treatment
Neoadjuvant - an adjuvant treatment given
prior to a potentially ablative local
treatment
Not known
The part of the body to which the
prescription is administered.
The date on which the first fraction of
teletherapy for this prescription is
administered to the patient.
A course of brachytherapy is defined as a
string of prescriptions which are
consecutive.
The hospital at which the brachytherapy
takes place
The consultant in overall charge of the
patient’s brachytherapy treatment
Purpose
To establish the frequency of each
treatment intent.
To monitor treatment related outcomes.
To assess patterns of teletherapy practice
for comparison with best practice
guidelines
Codes and Classifications
C - Curative
P - Palliative
A - Adjuvant
N - Neoadjuvant
9 - Not known (default)
To assess patterns of teletherapy practice
for comparison with best practice
guidelines.
OPCS ‘Z’ Codes
*To enable the measurement of the
interval from the date of decision to treat
to start of treatment, to monitor delays.
Required because different activities for a
patient may be carried out at different
service provider sites. To enable reports
and analysis by hospital and/or cancer
network.
To enable reports and analysis by
consultant.
NHS Data Dictionary Supporting Information,
Administrative Codes, NHS Trust Site (5 character
code, starts with ‘R’, allocated by OCS)
NHS Data Dictionary Supporting Information,
Administrative Codes (Practitioner Code for a
Consultant)
Page 19 of 23
Cancer Registration Dataset
11.6
11.7
11.8
11.9
15
15.1
Data Item
CANCER
TREATMENT
INTENT
[Treatment intent]
BRACHYTHERAPY
TYPE
[Type of
brachytherapy]
RADIOTHERAPY
ANATOMICAL
TREATMENT SITE
[Anatomical treatment
site]
START DATE
(BRACHYTHERAPY
TREATMENT
COURSE)
[Brachytherapy start
date]
Death Details
DEATH DATE
[Date of death]
Version 4.0
Issue Date: 11.08.03
Description
Curative - any treatment where long-term
survival is the aim of a significant
proportion of patients
Palliative - any treatment where the clear
intention is to improve symptoms and
possibly prolong life but where long-term
survival is unlikely
Adjuvant - an adjunct to a potentially
ablative local treatment
Neoadjuvant - an adjuvant treatment given
prior to a potentially ablative local
treatment
Not known
The type of brachytherapy being used
Purpose
To establish the frequency of each
treatment intent.
To monitor treatment related outcomes.
To assess patterns of brachytherapy
practice for comparison with best practice
guidelines
Codes and Classifications
C - Curative
P - Palliative
A - Adjuvant
N - Neoadjuvant
9 - Not known (default)
To assess patterns of brachytherapy
practice for comparison with best practice
guidelines
The part of the body to which the
prescription is administered.
To assess patterns of brachytherapy
practice for comparison with best practice
guidelines.
BI – Interstitial
BC - Intra-cavitary
BT – NOS
US - Unsealed sources
OPCS ‘Z’ Codes.
The date on which the first fraction of
brachytherapy for this prescription is
administered to the patient.
To enable the measurement of the interval
from the date of decision to treat to start of
treatment, to monitor delays.
The date the patient died. Left blank if the
patient is still alive.
To determine survival rates and mortality
rates
NHS Data Dictionary, Attribute DEATH DATE
Page 20 of 23
Cancer Registration Dataset
15.2
15.3
15.5
15.6
15.7
15.8
Data Item
DEATH LOCATION
TYPE (CANCER)
[Place of death]
Codes and Classifications
1 - Hospital
2 - NHS hospice/specialist palliative care unit
3 - Voluntary hospice/specialist palliative care unit
4 - Patient’s own home
5 - Care home
99 - Other
DEATH CAUSE
The source of the information about the
To provide an indication of the accuracy of
1 - death certificate
IDENTIFICATION
death of the patient
the cause of death.
2 - NHSCR Follow-up
METHOD
3 - hospital records
[How cause of death
4 - verbal communication
established]
5 - post-mortem
The data items shaded below will usually not be collected directly by the Trust; information would come from Cancer Registries.
DEATH CAUSE
As recorded on the death certificate. Will
To identify cancer-specific deaths
ICD-10 coding
CODE (IMMEDIATE)
be provided by Cancer Registry if death
[Cause of death –
did not take place in the Trust.
immediate]
DEATH CAUSE
As recorded on the death certificate. Will
To identify cancer-specific deaths
ICD-10 coding
CODE (CONDITION)
be provided by Cancer Registry if death
[Cause of death –
did not take place in the Trust.
condition giving rise to
death]
DEATH CAUSE
As recorded on the death certificate. Will
To identify cancer-specific deaths
ICD-10 coding
CODE
be provided by Cancer Registry if death
(UNDERLYING)
did not take place in the Trust.
[Cause of death underlying condition
leading to death]
DEATH CAUSE
As recorded on the death certificate. Will
To identify cancer-specific deaths
ICD-10 coding
CODE
be provided by Cancer Registry if death
(SIGNIFICANT)
did not take place in the Trust.
[Cause of death significant condition
not directly related to
death]
Version 4.0
Issue Date: 11.08.03
Description
Where the patient died
Purpose
To enable reports and analyses by place of
death.
Page 21 of 23
Cancer Registration Dataset
B.1
Data Item
DIAGNOSTIC
ROUTE
[Screening status]
Description
Purpose
Indicates the patient’s route to diagnosis.
B.7
ENDOCRINE
THERAPY TYPE
[Endocrine therapy
type]
The type of endocrine therapy given to the patient
B.8
MARKER LYMPH
NODE RESULT
[Marker lymph node 1
positive]
C.1
DIAGNOSTIC
ROUTE
[Screening status]
To record the presence or absence of metastases in a ‘marker lymph node’ that is of
therapeutic and prognostic importance.
This is site-specific:
For breast cancer this will be the sentinal node.
(Required for Cancer Registry purposes)
Indicates the patient’s route to diagnosis.
C.10
MARKER LYMPH
NODE RESULT
[Marker lymph node 1
positive]
Version 4.0
Issue Date: 11.08.03
To record the presence or absence of metastases in a ‘marker lymph node’ that is of
therapeutic and prognostic importance.
This is site-specific:
For colorectal cancer this will be the apical node.
(Required for Cancer Registry purposes)
Codes and Classifications
1 - cancers detected by national screening
programme
2 - interval cancers occurring in patients screened
by a national screening programme
3 - other cancers
9 - not known (default)
R - Radiotherapy ablation (e.g. radiation induced
menopause)
S - Surgical ablation (e.g. oophrectomy,
orchidectomy)
M - Medical ablation (e.g. LHRH analogues)
A - Adjuvant endocrine therapy (e.g. Tamoxifen +
surgery)
D - Definitive endocrine therapy (e.g. Tamoxifen
alone)
O -Other
N - No, marker lymph node 1 negative
Y - Yes, marker lymph node 1 positive present
9 - Status of marker lymph node 1 unknown
8 - Not applicable
1 - cancers detected by national screening
programme
2 - interval cancers occurring in patients screened
by a national screening programme
3 - other cancers
9 - not known (default)
N - No, marker lymph node 1 negative
Y - Yes, marker lymph node 1 positive present
9 - Status of marker lymph node 1 unknown
8 - Not applicable
Page 22 of 23
Cancer Registration Dataset
HN1
HN.2
HN.3
G.2
Data Item
PATIENT HISTORY
(CANCER
DIAGNOSIS)
[History of non-head
and neck cancer – site]
YEAR CANCER
DIAGNOSED
[History of non-head
and neck cancer - year
of diagnosis]
PREVIOUS
TREATMENT
ELSEWHERE
[Previous treatment for
head and neck cancer
elsewhere]
DIAGNOSTIC
ROUTE
[Screening status]
Version 4.0
Issue Date: 11.08.03
Description
Purpose
Any non head and neck primary malignancies that have occurred or subsequently occur
in the patient’s follow up.
Codes and Classifications
Any ICD-10 code.
99 Unknown
Year of either histological, cytological, radiological or clinical diagnosis of the cancer
above.
4 digit year.
Has the patient been treated for this current head and neck tumour elsewhere?
Y - Yes
N- No
9 – Not known (default)
Indicates the patient’s route to diagnosis.
1 - cancers detected by national screening
programme
2 - interval cancers occurring in patients screened
by a national screening programme
3 - other cancers
9 - not known (default)
Page 23 of 23