Download NSSG Minimum Datasets and Policy for Collection

NHS England
Clinical Networks
Cancer NSSG Minimum Datasets and
Policy for Collection
Version 7 (June 2013)
Further information
This policy is subject to Annual Review.
For further information regarding this document, or to make comments on the
content, please contact:
Linda Wintersgill
Clinical Networks and Senate (Northern England)
Waterfront 4
Goldcrest Way
Newcastle Upon Tyne
NE15 8NY
email: [email protected]
Tel: 0191 275 4663
Version History
Version
Version 1
Version 2
Date
February 2009
July 2009
Version 3
July 2009
Version 4
July 2010
Version 5
Version 6
Version 7
June 2011
March 2012
May 2013
Change Summary
To reflect comments
from NSSG members
To reflect further
comments from
consultation
Reviewed by Cancer
Managers
Reviewed and updated
Reviewed
Reviewed and updated
2
Contents
Page
NSSG Minimum Datasets and Policy for Collection
4
a. Cancer Waiting Times Dataset
4
b. Cancer Outcomes and Services Dataset
5
c. National Audit Datasets
7
Appendix 1
Cancer Waiting Times Dataset
9
Appendix 2
COSD Core Data Items
11
Appendix 2a
Breast
15
Appendix 2b
Brain & CNS
16
Appendix 2c
Colorectal
17
Appendix 2d
CTYA
18
Appendix 2e
Gynaecology
21
Appendix 2f
Haematology
22
Appendix 2g
Head & Neck
23
Appendix 2h
Lung
24
Appendix 2i
Sarcoma
25
Appendix 2j
Skin
26
Appendix 2k
Upper GI
27
Appendix 2l
Urology
28
Appendix 2m
Others
29
Information Sharing Dataset
31
Appendix 3
3
NSSG Minimum Datasets and Policy for Collection
This agreed NSSG minimum dataset contains data items required for the
cancer waiting times, cancer registry and national cancer audits. Please see
the appendices for details of the data items included within these datasets.
Responsibilities for data collection
a.
Cancer Waiting Times Dataset
Cancer Waiting Times Dataset (Appendix 1)
Each team has responsibility for collecting the parts of the dataset that
apply to parts of the patient pathway under their direct management.
Each team also has responsibility for the transfer of information when a
patient is referred between multi-disciplinary teams (MDTs).
Cancer Executive Leads in each organisation have overall responsibility
for collection of the dataset supported by:
Cancer Unit Managers
Two Week Waits Booking staff
MDT Coordinators
Wider Information Teams
all of whom have responsibility for the collection of data items relevant to
their work area.
Information sharing arrangements and responsibilities are outlined in the
NECN Information Sharing Protocol. For Cancer Waiting Times (CWT)
Monitoring data collection is as close to real time as possible and in line
with DSCN 20/2008 and within the timetable outlined in the National
Contract for Acute Services.
The trust receiving an urgent GP referral for suspected cancer
(two week wait referral) or a referral for a patient with breast
symptoms (excluding for cosmetic reasons or family history clinics
without symptoms) is responsible for collecting and uploading the
CWT data items.
Trusts receiving referrals for patients from the screening
programme are responsible for collecting and uploading data
relating to them (until the point of onward referral if trusts are
referring elsewhere e.g. for treatment).
Trusts managing the pathways of patients upgraded onto the 62
day pathway are responsible for collecting and uploading
information relating to these patients (until the point of onward
referral if trusts are referring elsewhere e.g. for treatment).
4
Trusts are also responsible for collecting and uploading the
treatment data for all patients they provide a treatment for.
If a patient is referred on to another trust for treatment, the
referring trust must share diagnosis details to ensure targets can
be monitored.
Data items will be stored in trust wide databases for cancer
waiting times monitoring (a mixture of in-house and externally
supplied systems are in use across the network).
For tertiary referrals, referring trusts must share as a minimum the
data items detailed in the North of England Cancer Network
Information Sharing Protocol. A sample proforma, showing these
data items, is attached at Appendix 3.
Data collection is as close to real time as possible as each event on the
patient pathway occurs. Data is collected by MDT Co-ordinators, trackers
and Cancer Information staff. Cancer Information Teams have overall
responsibility for reviewing the data prior to upload. As outlined within the
NECN Information Sharing Protocol, the NECN upload deadline is in
advance of the national deadline to allow all trusts a chance to review the
data uploaded for shared patients, to ensure data uploaded is complete
and accurate.
b.
Cancer Outcomes and Services Dataset
The Cancer Outcomes and Services Dataset (COSD) is the new national
standard for reporting cancer in the NHS in England. It replaces the
National Cancer Dataset and the Cancer Registration Dataset (CRDS)
and includes additional site specific data items relevant to different
tumour types. It is aligned with other national cancer datasets, including
Cancer Waits (NCWTMDS); Radiotherapy (RTDS), Systemic Anti Cancer
Therapy (SACT) and Diagnostic Imaging (DID).
The COSD is applicable to all UK Association of Cancer Registries
(UKACR) registerable conditions – and relates to all new diagnoses from
1 January 2013. As a minimum pathology reports must be submitted.
For some high volume diseases, generally those which do not require
MDT discussion, no other information is required.
For all other cases as a minimum the core dataset should be completed,
including all applicable data items (Appendix 2). In addition to this core
dataset, most cases will also require a site specific dataset to be
completed – see Appendices 2a – 2l for details. Many of these site
specific items are clinical data and clinical teams are responsible for
ensuring that relevant data are available and accurately coded for upload
in accordance with submission timescales.
The dataset is mandated for phased submission from January 2013:
Core items plus site specific stage should be completed for all relevant
cases from January 2013
All other site specific clinical data (i.e. all site specific data excluding
site specific pathology sections) should be completed from July 2013.
5
The remaining site specific pathology sections should be completed
from January 2014
Submission of the full dataset in XML format from January 2015.
The Dataset is divided into Sections (e.g. CORE – IMAGING, LUNG
PATHOLOGY etc) and for each record a section can only be submitted if
the Mandatory items in that section are completed and comply with
validation criteria.
Some items will be collected from other sources such as ONS or are
submitted under other standards such as Cancer Waiting Times and
RTDS details of which can be found in Appendix 2m. But it should be
noted that for COSD these items are all extended to relate to all
registerable conditions. Definitions within these items for “primary cancer”
are therefore also extended to cover all registerable conditions
Data submissions from Providers may be submitted in separate files from
different Provider systems although most of the data items are likely to
be extracted from MDT software systems – and these are detailed in
individual Data Transfer Partnership Agreements (DTPA). Data from all
sources will be linked by the registries at patient level using NHS Number
to complete the full dataset.
The National Contract for Acute Services outlines timescales and
responsibilities for acute trusts for collection mandated datasets.
Providers are required to comply with the reporting requirements of SUS
and UNIFY and ensure that all mandatory datasets, including the Cancer
Outcomes and Services Dataset, are submitted in accordance with
agreed timescales.
Providers are responsible for the capture and submission data for the
sections of the pathway for which they are responsible. Registries will
‘match up’ data relating to a single patient where activity covers more
than one trust. It is imperative that all trusts include in their upload files
all data items relevant to this activity so that a complete registration
record can be compiled – especially the key ‘Linkage’ items which will
ensure robust compilation of data.
Each team has responsibility for collecting the parts of the dataset that
apply to parts of the patient pathway under their direct management.
Each team also has responsibility for the transfer of all relevant
information when a patient is referred between multi-disciplinary teams
(MDTs). This responsibility extends beyond cancer waiting times
conditions to all included in the List of Registerable conditions
Cancer Executive Leads have overall responsibility for collection of the
dataset supported by:
Cancer Unit Managers
MDT Coordinators
MDT Team Members
Wider Information Teams
Clinical staff
6
all of whom have responsibility for the collection of data items relevant to
their work area. In addition trusts must ensure that where patients are
managed across a number of trusts that all relevant information
pertaining to that activity is shared with other trusts in accordance with
the NECN Information Sharing Protocol.
c.
National Audit Datasets
Audit of cancer services is an essential element of service review and
quality improvement and is also a key component of peer review.
Participation in the National Audits is now mandated in the NHS
Standard Contract and hospital providers are required to make a
statement in their Quality Accounts about their participation in the
National Audits.
There are currently 4 national cancer audits in place:
Lung (LUCADA)
Bowel (NBoCAP)
Head & Neck (DAHNO)
Oesophago-Gastric
The national Mastectomy and Breast Reconstruction Audit (NMBRA) is
now closed.
All trusts in NECN participate in all current national audits. Improving
Outcomes: A Strategy for Cancer1 indicates that the current national
audits will be maintained and new audits will be introduced over time.
Each trust is responsible for the capture of national audit data items
relating to activity carried out in their own organisation and for
submission of that data. Each team will be responsible for the parts of
the datasets that apply to stages of the patient pathway under their direct
management and is also responsible for the transfer of all relevant
information where a patient is referred between multi-disciplinary teams
(MDTs).
Cancer Executive Leads have overall responsibility for the collection of
the datasets supported by:
Cancer Unit Managers
Audit staff
MDT Coordinators
Wider Information Teams
Clinical Staff
1
Improving Outcomes: A strategy for Cancer - DH January 2011
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_1
23394.pdf
7
all of whom have responsibility for the collection of data items relevant to
their work area. In addition trusts must ensure that where patients are
managed across a number of trusts that all relevant information
pertaining to that activity is shared with other trusts in accordance with
the NECN Information Sharing Protocol.
Audit data will be submitted by Trusts, in accordance with the timetables
and deadlines specific to each audit. In some cases, a single trust will
upload data on behalf of (a number of) other trusts. Trusts should ensure
that they have internal processes to share all relevant information to
support these audits which are designed to measure the quality of care
given and to stimulate service improvement.
Latest datasets for each of the national audits are available on the NECN
website – www.necn.nhs.uk
Reviewed by:
Cancer Unit Managers
Cancer Information Working Group
NSSG Chairs (Clinical Advisory Group)
June 2013
8
Appendix 1
Cancer Waiting Times Dataset
Data Item
The Health
Care Provider
where patient
first seen
following a
Referral
Request with
Priority Type
Code 'Two
Week Wait', or
the referral is
from a Cancer
Screening
service
The Health Care
Provider where
the patients
receives First
Definitive
Treatment for
cancer following
referral request
with Priority Type
Code 'Two Week
Wait', or referral
is from a Cancer
Screening
Service
The Health Care
Provider where
the patient
receives
second or
subsequent
treatment for
cancer following
referral with
Priority Type
code 'Two Week
Wait', or the
referral is from
Cancer
Screening
Service
The Health
Care
Provider
where the
patient
receives
first
definitive
treatment
for cancer
following
consultant
upgrade
onto a 62
day patient
pathway
The Health
Care
Provider
where the
patient
receives
second or
subsequent
treatment
for cancer
following a
consultant
upgrade
onto a 62
day patient
pathway
The Health
Care Provider
where the
patient
receives first
definitive
treatment for
cancer
following
referral request
from another
Source of
Referral for
Outpatients or
a different
Priority Type
Code
The Health Care
Provider where
the patient
receives second
or subsequent
treatment for
cancer following
referral request
from another
Source of
Referral for
Outpatients or a
different Priority
Type Code
NHS NUMBER
PATIENT PATHWAY IDENTIFIER
ORGANISATION CODE (PATIENT PATHWAY IDENTIFIER ISSUER)
M
M
M
M
M*
M*
M
M*
M*
M
M*
M*
M
M*
M*
M
M*
M*
M
M*
M*
DECISION TO REFER DATE (CANCER OR BREAST SYMPTOMS)
SOURCE OF REFERRAL FOR OUT-PATIENTS
PRIORITY TYPE
M*
M
M
N/A
N/A
N/A
N/A
N/A
N/A
N/A
M
M
N/A
N/A
N/A
O
O
O
N/A
N/A
N/A
CANCER REFERRAL TO TREATMENT PERIOD START DATE
TWO WEEK WAIT CANCER OR SYMPTOMATIC BREAST REFERRAL TYPE
M
M
M
N/A
N/A
N/A
O
N/A
N/A
N/A
O
O
N/A
N/A
CONSULTANT UPGRADE DATE
SITE CODE (PROVIDER CONSULTANT UPGRADE)
DATE FIRST SEEN
N/A
N/A
M
N/A
N/A
N/A
N/A
N/A
N/A
M
M
M
N/A
N/A
N/A
O
O
O
N/A
N/A
N/A
SITE CODE (PROVIDER FIRST SEEN)
WAITING TIME ADJUSTMENT (FIRST SEEN)
WAITING TIME ADJUSTMENT REASON (FIRST SEEN)
M
M*
M*
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
DELAY REASON COMMENT (FIRST SEEN)
DELAY REASON REFERRAL TO FIRST SEEN (CANCER OR BREAST
SYMPTOMS)
MULTIDISCIPLINARY TEAM DISCUSSION INDICATOR
MULTIDISCIPLINARY TEAM DISCUSSION DATE (CANCER)
M*
N/A
N/A
M*
N/A
N/A
N/A
M*
M*
M*
N/A
M*
M*
N/A
M*
M*
N/A
M*
M*
N/A
M*
M*
N/A
M*
M*
N/A
M*
M*
CANCER OR SYMPTOMATIC BREAST REFERRAL PATIENT STATUS
PRIMARY DIAGNOSIS (ICD)
TUMOUR LATERALITY
M
N/A
N/A
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
CANCER TREATMENT EVENT TYPE
N/A
M
M
M
M
M
M
9
Data Item
The Health
Care Provider
where patient
first seen
following a
Referral
Request with
Priority Type
Code 'Two
Week Wait', or
the referral is
from a Cancer
Screening
service
The Health Care
Provider where
the patients
receives First
Definitive
Treatment for
cancer following
referral request
with Priority Type
Code 'Two Week
Wait', or referral
is from a Cancer
Screening
Service
The Health Care
Provider where
the patient
receives
second or
subsequent
treatment for
cancer following
referral with
Priority Type
code 'Two Week
Wait', or the
referral is from
Cancer
Screening
Service
The Health
Care
Provider
where the
patient
receives
first
definitive
treatment
for cancer
following
consultant
upgrade
onto a 62
day patient
pathway
The Health
Care
Provider
where the
patient
receives
second or
subsequent
treatment
for cancer
following a
consultant
upgrade
onto a 62
day patient
pathway
METASTATIC SITE
SITE CODE (PROVIDER DECISION TO TREAT (CANCER))
N/A
M*
M*
M
M*
M
M*
M
CANCER TREATMENT PERIOD START DATE
TREATMENT START DATE (CANCER)
CANCER TREATMENT MODALITY
N/A
N/A
N/A
M
M
M
M
M
M
CANCER CARE SETTING (TREATMENT)
CLINICAL TRIAL INDICATOR
N/A
N/A
M
M
SITE CODE (PROVIDER TREATMENT START DATE (CANCER))
RADIOTHERAPY PRIORITY
RADIOTHERAPY INTENT
N/A
N/A
N/A
DELAY REASON COMMENT (DECISION TO TREATMENT)
DELAY REASON (DECISION TO TREATMENT)
WAITING TIME ADJUSTMENT (TREATMENT)
The Health Care
Provider where
the patient
receives second
or subsequent
treatment for
cancer following
referral request
from another
Source of
Referral for
Outpatients or a
different Priority
Type Code
M*
M
The Health
Care Provider
where the
patient
receives first
definitive
treatment for
cancer
following
referral request
from another
Source of
Referral for
Outpatients or
a different
Priority Type
Code
M*
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M
M*
M*
M
M*
M*
M
M*
M*
M
M*
M*
M
M*
M*
M
M*
M*
N/A
N/A
N/A
M*
M*
M*
M*
M*
M*
M*
M*
M*
M*
M*
M*
M*
M*
M*
M*
M*
M*
WAITING TIME ADJUSTMENT REASON (TREATMENT)
DELAY REASON COMMENT (REFERRAL TO TREATMENT)
N/A
N/A
M*
M*
M*
N/A
M*
M*
M*
N/A
M*
O*
M*
N/A
DELAY REASON REFERRAL TO TREATMENT (CANCER)
DELAY REASON COMMENT (CONSULTANT UPGRADE)
DELAY REASON (CONSULTANT UPGRADE)
N/A
N/A
N/A
M*
M*
M*
N/A
N/A
N/A
M*
M*
M*
N/A
N/A
N/A
O*
O*
O*
N/A
N/A
N/A
M*
M
(Source – CWT User Guide V8.0 DoH)
10
Appendix 2
Cancer Outcomes and Services Dataset - Core
Data
Data Item Name
Data Item Description
item No.
CORE – LINKAGE - These items are required for every record in order to link patient records. One occurrence of this group is required
CORE - PATIENT IDENTITY DETAILS
To carry patient identity details for linkage. One occurrence of this group is required.
CR0010
NHS NUMBER*
The NHS NUMBER, the primary identifier of a PERSON
CR0020
LOCAL PATIENT IDENTIFIER*
This is a number used to identify a PATIENT uniquely within a Health Care Provider.
CR1350
NHS NUMBER STATUS INDICATOR CODE
NHS NUMBER STATUS INDICATOR CODE indicates the verification status of the NHS number provided.
CR0100
PERSON BIRTH DATE
The date on which a PERSON was born.
CR0030
ORGANISATION CODE (CODE OF PROVIDER)
ORGANISATION CODE (CODE OF PROVIDER)
CORE - DIAGNOSTIC DETAILS
To carry diagnostic details for linkage. One occurrence of this group is required.
CR0370
PRIMARY DIAGNOSIS (ICD)
See DIAGNOSTIC CODING of primary diagnosis.
CR2030
DATE OF DIAGNOSIS (CLINICALLY AGREED)*
DATE OF RECURRENCE (CLINICALLY AGREED) is required as mandatory.
CR0440
DATE OF RECURRENCE (CLINICALLY AGREED)*
DATE OF RECURRENCE (CLINICALLY AGREED) is required as mandatory.
CORE – DEMOGRAPHICS - To carry the patient demographic details. It is anticipated that some of the demographic data items listed below will be collected by every provider with
which the patient has contact. Where this information is exchanged, the appropriate data item name should be used to identify the particular instance of the data. One occurrence of
this group is permitted
CR0050
PERSON FAMILY NAME
That part of a PERSON's name which is used to describe family.
CR0060
PERSON GIVEN NAME
The forename(s) or given name(s) of a PERSON.
CR0070
PATIENT USUAL ADDRESS (AT DIAGNOSIS)
PATIENT USUAL ADDRESS (AT DIAGNOSIS).
CR0080
POSTCODE OF USUAL ADDRESS (AT DIAGNOSIS)
POSTCODE OF USUAL ADDRESS (AT DIAGNOSIS).
CR0090
PERSON GENDER CODE (CURRENT)
A PERSON's gender currently.
CR0110
GENERAL MEDICAL PRACTITIONER (SPECIFIED)
The code of the GENERAL MEDICAL PRACTITIONER .
GENERAL MEDICAL PRACTICE CODE (PATIENT
CR0120
This is the code of the GP Practice that the PATIENT is registered with.
REGISTRATION)
CR0140
PERSON FAMILY NAME (AT BIRTH)
The PATIENT's surname at birth.
CR0150
ETHNIC CATEGORY
The ethnicity of a PERSON,
CORE - REFERRALS AND FIRST STAGE OF PATIENT PATHWAY - To carry patient referral details to the Trust that receives the first referral. These details include information
relating to the first stage of the Patient Pathway. One occurrence of this group is permitted
CR1600
SOURCE OF REFERRAL FOR OUT-PATIENTS
This identifies the source of referral of each Consultant Out-Patient Episode.
CR1580
REFERRAL TO TREATMENT PERIOD START DATE
The start date of a REFERRAL TO TREATMENT PERIOD.
CR0230
DATE FIRST SEEN
This is the date that the PATIENT is first seen.
CR0210
CONSULTANT CODE
A code uniquely identifying a CONSULTANT.
CR0220
CARE PROFESSIONAL MAIN SPECIALTY CODE
A unique code identifying each MAIN SPECIALTY
CR1410
ORGANISATION SITE CODE (PROVIDER FIRST SEEN)
The ORGANISATION SITE CODE of the Health Care Provider at the first contact with the PATIENT.
CR1360
DATE FIRST SEEN (CANCER SPECIALIST)
This is the date that the PATIENT is first seen by the appropriate specialist .
ORGANISATION SITE CODE (PROVIDER FIRST
CR1400
The ORGANISATION SITE CODE where the PATIENT is first seen by an appropriate cancer specialist
CANCER SPECIALIST)
CANCER OR SYMPTOMATIC BREAST REFERRAL
Recorded to enable tracking of the status of PATIENTS referred with a suspected cancer, or with breast
CR0270
PATIENT STATUS
symptoms with cancer not originally suspected.
11
CR2000
CANCER SYMPTOMS FIRST NOTED DATE
CORE - IMAGING
CR0310
SITE CODE (OF IMAGING)
CR0320
PROCEDURE DATE (CANCER IMAGING)
CR1610
IMAGING CODE (NICIP)*
CR0330
CANCER IMAGING MODALITY*
CR0340
IMAGING ANATOMICAL SITE*
CR3000
ANATOMICAL SIDE (IMAGING)*
CR0160
IMAGING REPORT TEXT
CR0350
LESION SIZE (RADIOLOGICAL)
CORE - DIAGNOSIS
CR0380
TUMOUR LATERALITY
CR0390
BASIS OF DIAGNOSIS (CANCER)
CR0400
MORPHOLOGY (SNOMED)*
CR0180
MORPHOLOGY (ICDO3)*
CR0480
TOPOGRAPHY (ICDO3)
CR0410
GRADE OF DIFFERENTIATION (AT DIAGNOSIS)
CR1590
METASTATIC SITE
CR0450
CANCER RECURRENCE CARE PLAN INDICATOR
Record the time when the symptoms were first noted - Year only - YYYY.
To carry imaging details Multiple occurrences of this data group are permitted
This is the ORGANISATION SITE CODE of the Organisation where the imaging took place.
The DATE the Cancer Imaging was carried out.
IMAGING CODE to identify both the test modality and body site of the test.
The type of imaging procedure used during an Imaging or Radiodiagnostic Event
A classification of the part of the body that is the subject of an Imaging Or Radiodiagnostic Event.
The side of the body that is the subject of an Imaging or Radiodiagnostic Event.
This is the full text provided in the imaging report.
The size in mm of the maximum diameter of the primary lesion, largest if more than one.
To carry diagnostic details. One occurrence of this group is permitted
Tumour laterality identifies the side of the body.
This is the method used to confirm the cancer.
This is the PATIENT DIAGNOSIS using the SNOMED code
The morphology code for the diagnosed cancer as defined by ICDO3.
The topographical site code for the tumour as defined by ICDO3.
The definitive grade of the Tumour at the time of PATIENT DIAGNOSIS.
The site of the metastatic disease, if any, at diagnosis.
An indication of whether a diagnosis of recurrence has been recorded for which a new Cancer Care Plan is
required. A new record should be completed for a recurrence.
To carry cancer care plan details. One occurrence of this group is permitted
An indication of whether the PATIENT's CARE PLAN was discussed at a Multidisciplinary Team Meeting.
CORE - CANCER CARE PLAN
CR0420
MULTIDISCIPLINARY TEAM DISCUSSION INDICATOR
MULTIDISCIPLINARY TEAM DISCUSSION DATE
CR0430
The date on which the PATIENTwas discussed at a MDT
(CANCER)
CR0460
CANCER CARE PLAN INTENT
The intention of a Cancer Care Plan developed .
Start of repeating item - Planned Cancer Treatment Type - Multiple occurrences of this item are permitted
CR0470
PLANNED CANCER TREATMENT TYPE
This is the clinically proposed treatment
End of repeating item - Planned Cancer Treatment Type
CR0490
NO CANCER TREATMENT REASON
The main reason why no active cancer treatment is specified within a Cancer Care Plan.
CR2060
ADULT COMORBIDITY EVALUATION - 27 SCORE
Overall Comorbidity Score
CR0510
PERFORMANCE STATUS (ADULT)
WHO status relating to activity / disability.
CR2050
CLINICAL NURSE SPECIALIST INDICATION CODE
Record if and when the patient saw a site specific CNS.
CORE - CLINICAL TRIALS - To carry clinical trial details for a patient who is eligible for a cancer clinical trial. Only one instance will be recorded for each diagnosis.
CR1290
PATIENT TRIAL STATUS (CANCER)
Is PATIENT eligible for a cancer CLINICAL TRIAL .
CR1260
CANCER CLINICAL TRIAL TREATMENT TYPE
The type of treatment covered by a cancer CLINICAL TRIAL.
CORE – STAGING - To carry the cancer staging details. - 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. One occurrence of this group is permitted
CR0520
T CATEGORY (FINAL PRETREATMENT)
UICC code which classifies the size and extent of the primary tumour before treatment.
UICC code which classifies the absence or presence and extent of regional lymph node metastases before
CR0540
N CATEGORY (FINAL PRETREATMENT)
treatment.
CR0560
M CATEGORY (FINAL PRETREATMENT)
UICC code which classifies the absence or presence of distant metastases pre treatment.
CR0580
TNM STAGE GROUPING (FINAL PRE TREATMENT)
Record the overall clinical TNM stage grouping of the tumour
12
CR0620
T CATEGORY (INTEGRATED STAGE)
UICC code which classifies the size and extent of the primary tumour after treatment
UICC code which classifies the absence or presence and extent of regional lymph node metastases after
CR0630
N CATEGORY (INTEGRATED STAGE)
treatment
CR0640
M CATEGORY (INTEGRATED STAGE)
UICC code which classifies the absence or presence of distant metastases after treatment
Record the overall TNM stage grouping of the tumour, derived from each T, N and M component after
CR0610
TNM STAGE GROUPING (INTEGRATED)
treatment.
CR2070
TNM EDITION NUMBER
The UICC edition number used for Tumour, Node and Metastasis (TNM) staging for cancer diagnosis
CORE - TREATMENT
To carry the cancer treatment details. Multiple occurrences of this data group are permitted
CR1340
CANCER TREATMENT EVENT TYPE
The stage of treatment reached during a Cancer PATIENT PATHWAY
CR1370
TREATMENT START DATE (CANCER)
Start Date of the first, second or subsequent cancer treatment
CR2040
CANCER TREATMENT MODALITY
The type of treatment or care which was delivered in a Cancer Treatment Period
ORGANISATION SITE CODE (PROVIDER TREATMENT The ORGANISATION SITE CODE of the ORGANISATION where the TREATMENT START DATE FOR
CR1450
START DATE (CANCER)
CANCER is recorded.
CR0660
CONSULTANT CODE
The Consultant code of the consultant responsible for the treatment of the patient
CR0670
CARE PROFESSIONAL MAIN SPECIALTY CODE
The main specialty code of the consultant responsible for the treatment of the patient
CORE - SURGERY AND OTHER PROCEDURES - To carry the surgery and other procedures details. This can be adapted for other procedures including interventional radiology,
laser treatment, endoscopies etc. and photo-dynamic procedures. This also includes procedures offered as supportive care. One occurrence of this data group is permitted per
treatment where applicable.
CR0680
CANCER TREATMENT INTENT
The original intention of the cancer treatment provided during a Cancer Care Spell.
CR0710
PROCEDURE DATE
The date the procedure was carried out.
CR0720
PRIMARY PROCEDURE (OPCS)
Primary procedure is the main procedure carried out.
Start of repeating item - Procedure (OPCS) Multiple occurrences of this item are permitted
CR0730
PROCEDURE (OPCS)
This is a procedure other than the PRIMARY PROCEDURE (OPCS)
End of repeating item - Procedure (OPCS)
CR0740
CR0750
DISCHARGE DATE (HOSPITAL PROVIDER SPELL)
DISCHARGE DESTINATION (HOSPITAL PROVIDER
SPELL)
The date a PATIENT was discharged from a Hospital Provider Spell.
This records the destination of a PATIENT on completion of the Hospital Provider Spell. It can also indicate
that the PATIENT died.
CORE – RADIOTHERAPY - To carry the radiotherapy details. A course of radiotherapy is defined as a string of prescriptions which are consecutive. One
occurrence of this data group is permitted per treatment where applicable.
CR1200
BRACHYTHERAPY TYPE
Type of Brachytherapy Treatment used.
CORE - ACTIVE MONITORING
To carry active monitoring details. One occurrence of this group is permitted per treatment where applicable.
CR1240
MONITORING INTENT
The purpose of monitoring a patient.
CORE - PATHOLOGY DETAILS - To carry the pathology details. It is expected that all the data items on the minimum RCPath dataset will be collected - pathology data items below
are a subset of that dataset. A patient may have any number of pathology reports, and more than one pathology report per specimen. Multiple occurrences of this group are permitted
CR0780
INVESTIGATION RESULT DATE
The date on which an investigation was concluded e.g. the date the result was authorised.
CR0950
SERVICE REPORT IDENTIFIER
A unique identifier of a SERVICE REPORT.
CR0960
SERVICE REPORT STATUS
The status of the SERVICE REPORT.
CARE PROFESSIONAL CODE (PATHOLOGY TEST
CR0990
The code of the CARE PROFESSIONAL who requests the pathology test.
REQUESTED BY)
ORGANISATION SITE CODE (PATHOLOGY TEST
ORGANISATION SITE CODE of the CARE PROFESSIONAL who requested the DIAGNOSTIC TEST
CR0980
REQUESTED BY)
REQUEST .
13
CR1010
CR0770
CR0790
CR0970
CR0530
CR0850
CR0810
CR0820
CR0760
CR1020
CR0830
CR0860
CR0870
CR0880
CR0840
CR0890
CR0900
SAMPLE COLLECTION DATE
SAMPLE RECEIPT DATE
ORGANISATION CODE (OF REPORTING
PATHOLOGIST)
CONSULTANT CODE (PATHOLOGIST)
SPECIMEN NATURE
TOPOGRAPHY (SNOMED)
MORPHOLOGY (SNOMED)
PRIMARY DIAGNOSIS (ICD PATHOLOGICAL)
TUMOUR LATERALITY (PATHOLOGICAL)
PATHOLOGY INVESTIGATION TYPE
PATHOLOGY REPORT TEXT
LESION SIZE (PATHOLOGICAL)
GRADE OF DIFFERENTIATION (PATHOLOGICAL)
CANCER VASCULAR OR LYMPHATIC INVASION
EXCISION MARGIN
SYNCHRONOUS TUMOUR INDICATOR
NUMBER OF NODES EXAMINED
NUMBER OF NODES POSITIVE
CR0910
T CATEGORY (PATHOLOGICAL)
CR0920
N CATEGORY (PATHOLOGICAL)
CR0930
M CATEGORY (PATHOLOGICAL)
CR0940
TNM STAGE GROUPING (PATHOLOGICAL)
CR0800
The date that a SAMPLE collection takes place .
Date of receipt of a SAMPLE by a LABORATORY.
This is the ORGANISATION CODE at which the authorising pathologist is based.
CONSULTANT CODE of the Pathologist who authorises the pathology report.
The nature of the specimen taken during a Clinical Investigation.
This is the topographical site of the tumour as categorised by SNOMED RT
This is the morphology of the tumour as categorised by SNOMED RT
PRIMARY DIAGNOSIS based on the evidence from a pathological examination.
Identifies the side of the body for a tumour relating to paired organs from a pathological examination.
The type of pathology investigation carried out.
The full text from the pathology report
The size in millimetres of the diameter of a lesion, largest if more than one
The definitive grade of the Tumour based on the evidence from a pathological examination.
An indication of the presence or absence of unequivocal tumour in lymphatic and/or vascular spaces.
An indication of whether the excision margin was clear of the tumour and if so, by how much.
An indicator of the presence of multiple tumours at a tumour site.
The number of local and regional nodes examined.
The number of local and regional nodes reported as being positive for the presence of Tumour metastases.
UICC code which classifies the size and extent of the primary Tumour based on the evidence from a
pathological examination.
UICC code which classifies the absence or presence and extent of regional lymph node metastases based
on the evidence from a pathological examination.
UICC code which classifies the absence or presence of distant metastases based on the evidence from a
pathological examination.
UICC code which classifies the combination of Tumour, node and metastases into stage groupings based on
the evidence from a pathological examination.
CR1000
NEOADJUVANT THERAPY INDICATOR
Indicator of whether the pathological stage was recorded after the patient had received neoadjuvant therapy.
CORE - CANCER RECURRENCE / SECONDARY CANCER
To carry cancer recurrence/secondary details. One occurrence of this group is permitted where applicable
CR0300
SOURCE OF REFERRAL FOR CANCER
This identifies the source of referral for a recurrence of cancer.
RECURRENCE
CR1540
KEY WORKER SEEN INDICATOR (CANCER
Record whether the patient was seen by a designated key worker
RECURRENCE)
CR1550
PALLIATIVE CARE SPECIALIST SEEN INDICATOR
Record whether the patient was seen by a palliative care specialist.
(CANCER RECURRENCE)
CORE - DEATH DETAILS - To carry the death details (not required for direct submission by Trusts) One occurrence of this group is permitted where applicable.
CR1270
PERSON DEATH DATE
The date on which a PERSON died or is officially deemed to have died.
CR1280
DEATH LOCATION TYPE
The type of LOCATION at which a PERSON died.
14
Appendix 2a
Breast
BREAST - REFERRALS
To carry referral details for breast cancer Multiple occurrences of this data group are permitted
BR4000
BR4010
BR4020
Date of clinical assessment of the breast for which a cancer is registered.
Provider code where clinical assessment of the breast for which a cancer is registered was carried out.
Result of the clinical assessment of the breast for which a cancer is registered.
DATE OF CLINICAL ASSESSMENT
ORGANISATION SITE CODE (OF CLINICAL ASSESSMENT)
CLINICAL ASSESSMENT RESULT (BREAST)
BREAST - IMAGING
To carry imaging mammogram, ultrasound and axilla ultrasound details for breast cancer
BREAST - IMAGING (MAMMOGRAM) Multiple occurrences of this data group are permitted
BR4030
BR4040
BR4050
PROCEDURE DATE (MAMMOGRAM)
ORGANISATION SITE CODE (MAMMOGRAM)
MAMMOGRAM RESULT
Date when mammography was carried out.
Provider code where mammography was carried out.
Result of the mammogram.
BREAST - IMAGING (ULTRASOUND) Multiple occurrences of this data group are permitted
BR4060
BR4070
BR4080
PROCEDURE DATE (BREAST ULTRASOUND)
ORGANISATION SITE CODE (BREAST ULTRASOUND)
BREAST ULTRASOUND EXAMINATION RESULT
Date when the ultrasound examination of the breast was carried out.
Provider code where ultrasound examination of the breast was carried out.
Result of the ultrasound examination of the breast.
BREAST - IMAGING (AXILLA ULTRASOUND) Multiple occurrences of this data group are permitted
BR4090
BR4100
BR4110
PROCEDURE DATE (AXILLA ULTRASOUND)
ORGANISATION SITE CODE (OF AXILLA ULTRASOUND)
AXILLA ULTRASOUND EXAMINATION RESULT
BREAST - CANCER CARE PLAN
BR4120
NPI SCORE
Date when the ultrasound examination of the axilla was carried out.
Provider code where ultrasound examination of the axilla was carried out.
Result of the ultrasound examination of the axilla.
To carry cancer care plan details for breast cancer One occurrence of this data group is permitted
Nottingham Prognostic Index Score (calculated from tumour size, grade and lymph node involvement)
BREAST - SURGERY & OTHER PROCEDURES
To carry surgery and other procedure details for breast cancer One occurrence of this data group is permitted
BR4130
The ASA physical status classification system for assessing the fitness of patients before surgery.
ASA SCORE
BREAST - PATHOLOGY
To carry pathology details for breast cancer Multiple occurrences of this data group are permitted
BR4320
BR4330
BR4140
BR4160
BR4170
BR4180
BR4190
BR4200
BR4210
BR4230
INVESTIGATION RESULT DATE
SERVICE REPORT IDENTIFIER
MULTIFOCAL TUMOUR INDICATOR (BREAST)
DCIS grade
INVASIVE GRADE (BREAST)
NON INVASIVE TUMOUR SIZE
WHOLE TUMOUR SIZE
METASTASIS EXTENT CODE
DISTANCE TO MARGIN
ER ALLRED SCORE
The date on which an investigation was concluded e.g. the date the result was authorised.
A unique identifier of a SERVICE REPORT.
Is there more than one discrete tumour identified in the same breast?
If ductal carcinoma in situ is present, record the DCIS grade.
The grade of the tumour as defined by modified Bloom and Richardson system
The size of the non invasive tumour in mm.
Whole size of tumour (invasive + surrounding DCIS if DCIS extends >1mm beyond invasive) (mm)
For single node positivity
Distance to closest relevant margin (mm).
ER Allred score (range 0, 2 -8)
BR4220
ER STATUS
Oestrogen Receptor (ER) status.
BR4300
PR ALLRED SCORE
Record the PR ALLRED score if ER status is negative.
BR4290
BR4280
BR4310
BR4240
BR4250
BR4260
BR4270
PR STATUS
HER2 STATUS
HER2 ISH STATUS
CYTOLOGY (BREAST)
CYTOLOGY (NODE)
CORE BIOPSY (BREAST)
CORE BIOPSY (NODE)
Progesterone Receptor Status. Record the PR status if ER status is negative.
HER2 Immunohistochemical status . Where the initial result of this test is "Borderline"
Record the result of the ISH test, only required if the initial HER2 status is "Borderline".
Cytology opinion (Breast)
Cytology opinion on axillary lymph node.
Needle core biopsy opinion.
Needle biopsy opinion on axillary lymph node.
15
Appendix 2b
Brain & CNS
CNS - IMAGING
To carry imaging details for CNS cancer One occurrence of this data group is permitted
BA3000
BA3020
BA3030
Location of lesion (largest lesion if more than one) or where centred.
Radiologically determined number of lesions
Est in mm of the maximum diameter of the tumour measured prior to treatment (largest lesion if more than one).
LESION LOCATION (RADIOLOGICAL)
NUMBER OF LESIONS (RADIOLOGICAL)
LESION SIZE (RADIOLOGICAL)
Start of repeating item - Features of Lesions (Radiological) Multiple occurrences of this item are permitted
BA3040
FEATURES OF LARGEST LESION (RADIOLOGICAL)
Features of the largest lesion such as density, necrosis recorded pre treatment.
End of repeating item - Features of Lesions (Radiological)
BA3050
PRINCIPAL DIAGNOSTIC IMAGING TYPE
CNS - CANCER CARE PLAN
Indicate the principal imaging procedure undertaken to diagnose the tumour.
To carry cancer care plan details for CNS cancer One occurrence of this data group is permitted
BA3060
PRIMARY DIAGNOSIS (ICD RADIOLOGICAL)
Based on radiological examination recorded pre treatment.
BA3080
MDT PROVISIONAL DIAGNOSIS (ICD)
Working diagnosis as defined at MDT where the first definitive treatment is agreed.
CNS - SURGERY & OTHER PROCEDURES
To carry surgery and other procedure details for CNS cancer One occurrence of this data group is permitted per
treatment
BA3130
ASA SCORE
The ASA system for assessing the fitness of patients before surgery.
BA3100
TUMOUR LOCATION (SURGICAL)
Surgically determined anatomical location of lesion(s) or where centred.
BA3140
EXCISION TYPE
Identify whether excision is Partial or Total
CNS - RADIOSURGERY
To carry radiosurgery details for CNS cancer One occurrence of this data group is permitted per treatment where
applicable
BA3110
BA3120
Did patient have radiosurgical treatment
Date of radiosurgical treatment
RADIOSURGERY PERFORMED INDICATOR
PROCEDURE DATE (RADIOSURGERY)
CNS - PATHOLOGY
To carry pathology details for CNS cancer Multiple occurrences of this data group are permitted
Start of repeating item - Molecular Diagnostics Code
BA3070
MOLECULAR DIAGNOSTICS CODE
End of repeating item - Molecular Diagnostics Code
Chromosomal or genetic markers associated with the brain tumour.
Start of repeating item - Immunohistochemistry Hormone Expression Type
BA3150
IMMUNOHISTOCHEMISTRY HORMONE EXPRESSION TYPE
Hormone expression by immunohistochemistry.
End of repeating item - Immunohistochemistry Hormone Expression Type
BA3160
WHO TUMOUR GRADE (CNS)
Grade using WHO classification for tumours of the central nervous system.
16
Appendix 2c
Colorectal
COLORECTAL - IMAGING
To carry imaging details for colorectal cancer One occurrence of this data group is permitted
CO5010
PROCEDURE DATE (FIRST CT SCAN)
CO5020
PROCEDURE DATE (FIRST MRI SCAN OF RECTUM)
CO5030
PROCEDURE DATE (SECOND MRI SCAN OF RECTUM)
CO5040
DATE OF ENDOANAL ULTRASOUND
COLORECTAL - DIAGNOSIS
Record the date on which the first staging CT was performed.
Date of first MRI scan of rectum pre treatment.
Date of MRI scan of rectum following neo adjuvant treatment and before surgical treatment.
Date of first pre-operative endoscopic ultrasound.
To carry diagnosis details for colorectal cancer One occurrence of this data group is permitted
CO5060
SYNCHRONOUS TUMOUR INDICATOR (CAECUM)
CO5070
SYNCHRONOUS TUMOUR INDICATOR (APPENDIX)
CO5080
SYNCHRONOUS TUMOUR INDICATOR (ASCENDING COLON)
CO5090
SYNCHRONOUS TUMOUR INDICATOR (HEPATIC FLEXURE)
CO5100
SYNCHRONOUS TUMOUR INDICATOR (TRANSVERSE COLON)
CO5110
SYNCHRONOUS TUMOUR INDICATOR (SPLENIC FLEXURE)
CO5120
SYNCHRONOUS TUMOUR INDICATOR (DESCENDING COLON )
CO5130
SYNCHRONOUS TUMOUR INDICATOR (SIGMOID COLON)
CO5140
SYNCHRONOUS TUMOUR INDICATOR (RECTOSIGMOID)
CO5150
SYNCHRONOUS TUMOUR INDICATOR (RECTUM)
CO5160
TUMOUR HEIGHT ABOVE ANAL VERGE
COLORECTAL - CANCER CARE PLAN
Record any synchronous tumours in the Caecum as identified by the clinician at presentation.
Record any synchronous tumours in the Appendix as identified by the clinician at presentation.
Record any synchronous tumours in the Ascending Colon as identified by the clinician at presentation.
Record any synchronous tumours in the Hepatic Flexure as identified by the clinician at presentation.
Record any synchronous tumours in the Transverse Colon as identified by the clinician at presentation.
Record any synchronous tumours in the Splenic Flexure as identified by the clinician at presentation.
Record any synchronous tumours in the Descending Colon as identified by the clinician at presentation.
Record any synchronous tumours in the Sigmoid Colon as identified by the clinician at presentation.
Record any synchronous tumours in the RectoSigmoid as identified by the clinician at presentation.
Record any synchronous tumours in the Rectum as identified by the clinician at presentation.
Record approximate height (cm) of lower limit of tumour above anal verge measured by rigid sigmoidoscopy only
To carry cancer care plan details for colorectal cancer One occurrence of this data group is permitted
CO5005
BODY MASS INDEX
COLORECTAL - STAGING
Estimate of a patient's Body Mass Index (BMI) at diagnosis.
To carry staging details for colorectal cancer One occurrence of this data group is permitted
CO5170
MODIFIED DUKES
COLORECTAL - SURGERY & OTHER PROCEDURES
CO5180
SURGICAL ACCESS
COLORECTAL - PATHOLOGY
Dukes' stage of disease at diagnosis
To carry details of surgery and other procedures for each surgery for colorectal cancer One occurrence of this
data group is permitted per treatment where applicable
The approach used to perform the main procedure.
To carry details of pathology for colorectal cancer Multiple occurrences of this data group are permitted
CO5320
CO5330
CO5190
CO5210
The date on which an investigation was concluded .
A unique identifier of a SERVICE REPORT.
Record whether the proximal or distal resection margins were involved.
Record the distance from the outer margin of the tumour to the closest non peritonealised resection margin in mm.
CO5230
INVESTIGATION RESULT DATE
SERVICE REPORT IDENTIFIER
POSITIVE PROXIMAL OR DISTAL RESECTION MARGIN
DISTANCE TO CIRCUMFERENTIAL MARGIN
DISTANCE BETWEEN LOWER END OF TUMOUR AND DISTAL
RESECTION MARGIN.
CO5250
PERFORATIONS OR SEROSAL INVOLVEMENT INDICATION CODE
CO5260
PLANE OF SURGICAL EXCISION
CO5270
DISTANCE FROM DENTATE LINE
CO5280
DISTANCE BEYOND MUSCULARIS PROPRIA
CO5290
CO5300
CO5310
RESPONSE TO PREOPERATIVE THERAPY
STATUS OF CIRCUMFERENTIAL EXCISION MARGIN
DISTANCE TO CIRCUMFERENTIAL EXCISION MARGIN
Record the distance between the lower end of the tumour and the distal resection margin in mm.
Is there continuity between the lumen of the bowel and the serosal surface or surgical resection margin through the
tumour.
This is the quality of the surgical excision as seen by the pathologist. This grades the resection on its worst plane.
For abdominoperineal excision specimens only. Record the distance of the tumour from the dentate line in mm
measured on the gross specimen.
Maximum distance of spread beyond muscularis propria in mm. If there is doubt about the sites of the muscularis
propria estimate the distance as accurately as possible.
If preoperative therapy was given what was the response
Record if the edge of the tumour is 1 mm or less from the circumferential resection margin (i.e. margin involved)
Record the distance from the tumour to the circumferential margin in mm.
17
Appendix 2d
Children, Teenage and Young Adult
CTYA - REFERRAL
To carry referrals details for CTYA One occurrence of this data group is permitted
CT6050
The specialty of person referring to Principal Treatment Centre or age specific Specialist TYA MDT.
SPECIALTY (REFERRER TO SPECIALIST)
CTYA - DIAGNOSIS
CT6060
PRIMARY DIAGNOSIS SUBSIDIARY COMMENT
To carry diagnosis details for CTYA One occurrence of this data group is permitted
(Optional) Additional comments on diagnosis where coding is difficult or imprecise.
Start of repeating item - Secondary Diagnosis (ICD)
CT6070
SECONDARY DIAGNOSIS (ICD)
Optional. Types (ICD10 codes) of other significant conditions (e.g. Down Syndrome, NF1, Fanconi anaemia) which may
predispose to cancer or influence treatment.
End of repeating item - Secondary Diagnosis (ICD)
CT6080
OTHER SIGNIFICANT DIAGNOSIS SUBSIDIARY COMMENT
CT6090
FAMILIAL CANCER SYNDROME
CT6100
FAMILIAL CANCER SYNDROME SUBSIDIARY COMMENT
CT6030
CONSULTANT SPECIALTY (AT DIAGNOSIS)
CT6040
CONSULTANT AGE SPECIALTY (AT DIAGNOSIS)
CTYA - CANCER CARE PLAN
(Optional) Additional comments on other significant conditions where coding is difficult or imprecise.
Indicate whether there is a possible or confirmed familial cancer syndrome
(Optional) Specifies or describes familial cancer syndrome where coded as "Yes" or "Possible".
The specialty of the consultant responsible for the patient at the time of diagnosis.
The age group specialty of the consultant responsible for the patient at the time of diagnosis.
To carry cancer care plan details for CTYA One occurrence of this data group is permitted
Start of repeating item - Multidisciplinary Team Age Category
CT6110
MULTIDISCIPLINARY TEAM AGE CATEGORY
End of repeating item - Multidisciplinary Team Age Category
Type(s) of MDT where care plan for patient was discussed. Possible multiple entries.
CTYA - STEM CELL TRANSPLANTATION
To carry stem cell transplantation details for CTYA Multiple occurrences of this data group are permitted
CT6150
STEM CELL INFUSION DATE
Date of stem cell infusion
CT6130
CT6140
STEM CELL INFUSION SOURCE
STEM CELL INFUSION DONOR
Source of stem cells for infusion
Donor for stem cell infusion.
CTYA - CHEMOTHERAPY
To carry chemotherapy details for CTYA One occurrence of this data group is permitted per treatment where applicable
CT6160
The age group specialty of the consultant responsible for prescription of chemotherapy.
SPECIALTY SUB CODE (CHEMOTHERAPY CONSULTANT)
CTYA - ACUTE LYMPHOCYTIC LEUKAEMIA and ACUTE MYELOID LEUKAEMIA - To carry Acute Lymphocytic Leukaemia and AML details for CTYA One occurrence of this data group is permitted
CT6210
EXTRAMEDULLARY DISEASE
Sites of disease identified outside bone marrow
CT6220
WHITE BLOOD CELL COUNT (HIGHEST PRE TREATMENT)
Highest white blood cell count pre treatment (x 10 to the power of 9 g per litre)
CT6230
CYTOGENETIC RISK CODE
Risk allocation based on cytogentic findings.
CT6240
CYTOGENETICS SUBSIDIARY COMMENT
(Optional) Description of cytogenetic findings.
CTYA - NON HODGKIN LYMPHOMA
To carry CTYA (NHL) details for CTYA One occurrence of this data group is permitted
CT6250
MURPHY (ST JUDE) STAGE
CT6260
ALK-1 STATUS FOR ALCL
CTYA - HODGKIN LYMPHOMA
CT6270
ANN ARBOR STAGE
CT6280
ANN ARBOR SYMPTOMS
CT6290
ANN ARBOR EXTRANODALITY
Separates patients on the basis of limited versus extensive disease. (http://www.cancer.gov/cancertopics/pdq/treatment/child-nonhodgkins/HealthProfessional/page3)
Activin Receptor-like Kinase 1 (ALK-1) is a gene expression protein which distinguishes prognostically important subsets of this
diagnosis.
To carry Hodgkin Lymphoma details for CTYA One occurrence of this data group is permitted
Staging based on location of detected disease.
Additional stage designation based on presence or absence of specific symptoms.
Additional staging designation based on extranodal involvement.
18
CTYA - NEUROBLASTOMA
CT6300
INTERNATIONAL NEUROBLASTOMA PATHOLOGIC
CLASSIFICATION
CT6310
CYTOGENETIC RISK CLASSIFICATION
(NEUROBLASTOMA)
CT6320
INTERNATIONAL NEUROBLASTOMA STAGING SYSTEM
CTYA - RENAL TUMOURS
To carry Neuroblastoma details for CTYA One occurrence of this data group is permitted
INPC system involves evaluation of tumour specimens
Risk allocation based on cytogentic findings
International Neuroblastoma Staging System. Children’s Oncology Group Neuroblastoma Risk Grouping.
http://www.cancer.gov/cancertopics/pdq/treatment/neuroblastoma/HealthProfessional/page3
To carry renal tumours details for CTYA One occurrence of this data group is permitted
CT6330
WILMS TUMOUR STAGE
Stage is determined by the results of the imaging studies and both the surgical and pathologic findings at nephrectomy.
RISK CLASSIFICATION (PATHOLOGICAL) AFTER
CT6680
Classification and timing of surgery determine histological risk.
IMMEDIATE NEPHRECTOMY
RISK CLASSIFICATION (PATHOLOGICAL) AFTER
CT6340
Classification after preoperative chemotherapy determines histological risk:
PREOPERATIVE CHEMOTHERAPY
CTYA - RHABDOMYOSARCOMA and OTHER SOFT TISSUE SARCOMAS - To carry Rhabdomyosarcoma and other Soft Tissue Sarcoma details for CTYA One occurrence of this data group is permitted
CT6350
CT6360
CT6370
IRS POST SURGICAL GROUP
CYTOGENETICS FOR ALVEOLAR RHABDOMYOSARCOMA
RHABDOMYOSARCOMA SITE PROGNOSIS CODE
SARCOMA TUMOUR SITE (SOFT TISSUE OTHER THAN
CT6380
RHABDOMYOSARCOMA)
SARCOMA TUMOUR SUBSITE (SOFT TISSUE) OTHER
CT6390
THAN RHABDOMYOSARCOMA
CTYA - OSTEOSARCOMA
IRS group defines the post surgical disease status at diagnosis.
Presence of a specific cytogenetic abnormality.
Grouping of anatomical sites which implies prognostic significance
CT6400
PRIMARY TUMOUR SIZE (Radiological)
Maximum dimension in mm recorded on diagnostic imaging as agreed at MDT
CT6410
EXTENT OF NECROSIS AFTER CHEMOTHERAPY
Pathologically assessed effect of chemotherapy on the resected tumour specimen as a percentage
Location of the soft tissue sarcoma within the body (more specific than ICD10/ICDO3 sites)
Sublocation of the soft tissue sarcoma within the tumour site.
To carry Osteosarcoma details for CTYA
One occurrence of this data group is permitted
CT6420
SARCOMA SURGICAL MARGIN ADEQUACY
CTYA - EWINGS
Pathological assessment of completeness of resection
To carry Ewings details for CTYA One occurrence of this data group is permitted
CT6450
Radiologically calculated estimate of tumour volume at diagnosis which has value in determining treatment
TUMOUR VOLUME AT DIAGNOSIS
CT6460
CYTOGENETICS FOR EWINGS SARCOMA
CTYA - OSTEOSARCOMA and EWINGS
Cytogenetic analysis
To carry Osteosarcoma and Ewings details for CTYA One occurrence of this data group is permitted
CT6470
Location of the bone sarcoma within the body (more specific than ICD10/ICDO3 sites)
SARCOMA TUMOUR SITE (BONE)
CT6440
SARCOMA TUMOUR SUBSITE (BONE)
CTYA - GERM CELL CNS TUMOURS
Sublocation of the bone sarcoma within the tumour site.
To carry Germ Cell CNS Tumours details for CTYA One occurrence of this data group is permitted
CT6530
Maximum level of alpha feto protein in the Cerebro Spinal Fluid at diagnosis. AFP units recorded in kU/l
ALPHA FETOPROTEIN (CEREBROSPINAL FLUID)
BETA HUMAN CHORIONIC GONADOTROPIN
CT6550
(CEREBROSPINAL FLUID)
CTYA - GERM CELL NON CNS TUMOURS
TNM STAGE GROUPING FOR NON CNS GERM CELL
CT6590
TUMOURS
CTYA - GERM CELL CNS and GERM CELL NON CNS TUMOURS
To carry Germ Cell Tumours details for CTYA One occurrence of this data group is permitted
CT6580
Maximum Serum level of HCG at diagnosis in IU/l
BETA HUMAN CHORIONIC GONADOTROPIN (SERUM)
Maximum CSF level of HCG at diagnosis in IU/l.
TNM classification for Germ Cell Non CNS Tumours.
To carry Germ cell CNS and Germ Cell non CNS Tumours details for CTYA One occurrence of this data group is permitted
CTYA - GERM CELL CNS, GERM CELL NON CNS TUMOURS, HEPATOBLASTOMA and HEPATOCELLULAR CERCINOMA - To carry Germ Cell CNS, erm Cell Non CNS Tumours, Hepatoblastoma and
Hepatocellular carcinoma details for CTYA One occurrence of this data group is permitted
19
CT6520
ALPHA FETOPROTEIN (SERUM )
CTYA - MEDULLOBLASTOMA
CT6560
CHANG STAGING FOR MEDULLOBLASTOMA
CTYA - HEPATOBLASTOMA
CT6500
PRETEXT STAGING SYSTEM STAGE
CT6510
PRETEXT STAGING OUTSIDE LIVER
CTYA - RENAL PATHOLOGY (Paediatric Kidney)
CT6690
INVESTIGATION RESULT DATE
CT6700
SERVICE REPORT IDENTIFIER
CT6610
TUMOUR RUPTURE
CT6620
ANAPLASTIC NEPHROBLASTOMA
CT6630
PERIRENAL FAT INVASION
CT6640
RENAL SINUS INVASION
CT6650
RENAL VEIN TUMOUR
CT6660
VIABLE TUMOUR
CT6670
TUMOUR LOCAL STAGE (PATHOLOGICAL)
Maximum Serum level of alpha feto protein at diagnosis.
To carry Medulloblastoma details for CTYA One occurrence of this data group is permitted
Chang stage for Medulloblastoma.
To carry Hepatoblastoma details for CTYA One occurrence of this data group is permitted
Pretext 1 – 4 refers to sectors of liver involved.
Additional Pretext staging used to describe disease outside the liver.
To carry Pathology details for CTYA Multiple occurrences of this data group are permitted
The date on which an investigation was concluded e.g. the date the result was authorised.
A unique identifier of a SERVICE REPORT.
Integrity of tumour margins based on pathologist's assessment.
Is there evidence of anaplasia, focal or diffused, based on established pathological classification
Are there areas of perirenal fat suspected for tumour infiltration
Is there evidence of invasion of renal sinus by tumour
Is there evidence of tumour thrombus in the renal vein
Is there evidence of viable tumour in the renal sinus
Local stage of the tumour as assessed by pathologist. (SIOP)
20
Appendix 2e
Gynaecology
GYNAECOLOGY - SURGERY & OTHER PROCEDURES
GY7000
SURGEON GRADE
GYNAECOLOGY - STAGING
GY7010
FINAL FIGO STAGE
GYNAECOLOGY - PATHOLOGY
GY7320
GY7430
GY7050
GY7120
GY7130
GY7100
INVESTIGATION RESULT DATE
SERVICE REPORT IDENTIFIER
FALLOPIAN TUBE INVOLVEMENT
OVARIAN INVOLVEMENT
SEROSAL INVOLVEMENT
OMENTAL INVOLVEMENT
To carry surgery and other procedure details for Gynae 1 occurrence of data group is permitted per treatment where applicable
Grade of senior surgeon present at operation
To carry staging details for Gynae One occurrence of this data group is permitted
The FIGO stage is generally confirmed at pathology review in MDT
To carry pathology details for Gynae Multiple occurrences of this data group are permitted
The date on which an investigation was concluded e.g. the date the result was authorised.
A unique identifier of a SERVICE REPORT.
For endometrial and epithelial/ovarian cancers, is there microscopic involvement of fallopian tubes
For endometrial and fallopian cancers, is there microscopic involvement of ovaries
For endometrial, epithelial/ovarian and fallopian cancers, is there microscopic involvement of uterine serosa
For endometrium, ovary, fallopian tube and primary peritoneum cancers, is there involvement of the omentum
GYNAECOLOGY - PATHOLOGY - FALLOPIAN TUBE, OVARIAN EPITHELIAL and PRIMARY PERITONEAL - One occurrence of this data group per pathology report where applicable
GY7140
GY7190
GY7150
GY7170
GY7180
CAPSULE STATUS
OVARIAN SURFACE INVOLVEMENT
TUMOUR GRADE
PERITONEAL CYTOLOGY
PERITONEAL INVOLVEMENT
GYNAECOLOGY - PATHOLOGY - ENDOMETRIAL
GY7210
GY7220
GY7240
GY7250
GY7260
GY7270
GY7280
BACKGROUND ENDOMETRIUM
DISTANCE TO SEROSA
INVOLVEMENT OF CERVICAL STROMA
INVOLVEMENT OF CERVICAL SURFACE OR GLANDS
MYOMETRIAL INVASION
PARAMETRIUM INVOLVEMENT
PERITONEAL WASHINGS
GYNAECOLOGY - PATHOLOGY - CERVICAL
GY7290
GY7300
GY7350
GY7310
GY7330
GY7340
GY7360
GY7370
CGIN GRADE
CIN GRADE
SMILE
EXCISION MARGIN (PRE INVASIVE)
INVASIVE THICKNESS
PARACERVICAL OR PARAMETRIAL INVOLVEMENT
THICKNESS UNINVOLVED STROMA
VAGINAL INVOLVEMENT
GYNAECOLOGY - PATHOLOGY - VULVAL
GY7390
INVASIVE THICKNESS
GYNAECOLOGY - PATHOLOGY - NODES
GY7020
GY7060
GY7080
GY7070
GY7090
GY7410
GY7420
GY7230
NODAL STATUS CERVICAL CANCER
NODES EXAMINED NUMBER (PARA-AORTIC)
NODES POSITIVE NUMBER (PARA-AORTIC)
NODES EXAMINED NUMBER (PELVIC)
NODES POSITIVE NUMBER (PELVIC)
NODES EXAMINED NUMBER (INGUINO-FEMORAL)
NODES POSITIVE NUMBER (INGUINO-FEMORAL)
EXTRANODAL SPREAD
Capsule status of ovaries (record the most severe)
Is there involvement of the surface of either ovary?
Specify the grade of the tumour.
Result of peritoneal cytology
Is there peritoneal involvement?
To carry pathology details for Gynae – Endometrial. 1 occurrence of this group is permitted per pathology report where applicable
Are abnormalities present in the background endometrium?
Specify the tumour free distance to the serosa
Is there microscopic involvement of cervical stroma?
Is there microscopic involvement of endocervical surface or crypt epithelium?
Is there microscopic evidence of myometrial invasion?
Is there microscopic involvement of parametrium?
Were peritoneal washings submitted and if so were malignant cells seen?
To carry pathology details for Gynae - Cervical 1 occurrence of this group is permitted per pathology report where applicable
Specify presence and grade of CGIN
Specify presence and grade of CIN
Specify presence of SMILE
Is there evidence of resection margin involvement by in situ/pre invasive disease (CIN, CGIN, SMILE)
The thickness or depth of the invasive lesion in mm
Is there evidence of paracervical and/or parametrial involvement?
Minimum thickness of uninvolved cervical stroma in mm
Is there evidence of microscopic vaginal involvement?
To carry pathology details for Gynae - Vulval 1 occurrence of this data group is permitted per pathology report where applicable
The thickness or depth of the invasive lesion in mm
To carry pathology details for Gynae - Nodes 1 occurrence of this data group is permitted per pathology report where applicable
FOR CERVICAL CANCERS ONLY.
The number of para-aortic nodes examined.
The number of para-aortic nodes reported as being positive for the presence of tumour metastases.
The number of pelvic nodes examined
The number of pelvic nodes reported as being positive for the presence of tumour metastases.
The number of inguino-femoral nodes examined.
The number of inguino-femoral nodes reported as being positive for the presence of tumour metastases.
Is there evidence of extranodal spread/extension?
21
Appendix 2f
Haematology
VARIOUS HAEMATOLOGY - LABORATORY RESULTS
To carry laboratory results for various haematological diseases, as specified. 1 occurrence of this group is permitted
9
PLATELET COUNT
HA8030
Level of platelets in blood as n x 10 per litre, to be collected at diagnosis.
9
WHITE BLOOD CELL COUNT (HIGHEST PRE TREATMENT)
HA8150
Highest White blood cell count pre-treatment (n x 10 per litre)
BLOOD HAEMOGLOBIN CONCENTRATION
HA8100
Blood haemoglobin concentration g/dl.
BONE MARROW KARYOTYPE
HA8110
Karyotype of marrow sample as classified by MDT from laboratory result of sample taken pre treatment.
BONE MARROW BLASTS PERCENTAGE
HA8120
Blast cells in bone marrow aspirate as percentage of all nucleated cells.
NEUTROPHIL COUNT
HA8130
Blood neutrophil count n/dl. (Cytopenia YES if less than 1.8)
ALBUMIN LEVEL
HA8550
Level in serum of albumin as g per litre measured pre-treatment
BETA2 MICROGLOBULIN LEVEL
HA8540
Level in serum of beta 2 microglobulin as mg per litre measured pre-treatment
BLOOD LYMPHOCTYE COUNT
HA8660
Number of lymphocytes in blood measured pre-treatment
LACTATE DEHYDROGENASE LEVEL
HA8350
Lactate Dehydrogenase level in serum measured pre-treatment.
BLOOD MYELOBLASTS PERCENTAGE
HA8040
Myeloblasts as percentage of total white cells
BLOOD BASOPHILS PERCENTAGE
HA8050
Basophils as percentage of total white cells
BLOOD EOSINOPHILS PERCENTAGE
HA8060
Eosinophils as percentage of total white cells
CYTOGENETIC GROUP (ACUTE MYELOID LEUKAEMIA)
HA8160
Cytogenetic analysis of bone marrow (preferably) or blood sample.
VARIOUS HAEMATOLOGY - CANCER CARE PLAN - To carry cancer care plan details, specifically Nodal details, for various haematological diseases, as specified. One occurrence of this data group is permitted
NUMBER OF ABNORMAL NODAL AREAS
HA8320
Number of abnormal nodal areas detected clinically and radiologically.
PRIMARY EXTRANODAL SITE
HA8330
Site of origin of lymphoma if believed to be outside lymph nodes as agreed by MDT based on clinical and radiological findings.
NUMBER OF EXTRANODAL SITES CODE
HA8420
Number of sites with Lymphoma outside lymph nodes (clinical assessment)
HAEMATOLOGY - CML CANCER CARE PLAN
To carry cancer care plan details specific to Chronic Myeloid Leukaemia (CML) One occurrence of this data group is permitted
SPLEEN CM BELOW COSTAL MARGIN
HA8000
Maximum distance from the costal margin in centimetres. Measured (not estimated) by person examining patient.
SOKAL INDEX (CHRONIC MYELOID LEUKAEMIA)
HA8010
Index derived from age, spleen size, platelet count, myeloblasts %.
HASFORD INDEX (CHRONIC MYELOID LEUKAEMIA)
HA8020
Index derived from age, spleen size, platelet count, myeloblasts % , eosinophils % , basophils %.
HAEMATOLOGY - MYELODYSPLASIA CANCER CARE PLAN
To carry cancer care plan details specific to Myelodysplasia One occurrence of this data group is permitted
IPSS (MYELODYSPLASIA)
HA8080
INTERNATIONAL PROGNOSTIC SCORING SYSTEM for myelodysplasia.
HAEMATOLOGY - CLL CANCER CARE PLAN
To carry cancer care plan details specific to CLL One occurrence of this data group is permitted
HEPATOMEGALY INDICATOR
HA8200
Liver enlargement identified from clinical examination.
SPLENOMEGALY INDICATOR
HA8210
Spleen enlargement identified from clinical examination.
NUMBER OF LYMPHADENOPATHY AREAS
HA8220
Number of enlarged lymph node areas (neck, axilla, groins) identified from clinical assessment.
RAI STAGE
HA8230
Prognostic index derived from platelet count, Hb, lymphadenopathy, hepatomegaly, splenomegaly
BINET STAGE
HA8240
Prognostic index derived from platelet count, Hb, lymphadenopathy, hepatomegaly, splenomegaly.
HAEMATOLOGY - FOLLICULAR CANCER CARE PLAN
To carry cancer care plan details specific to Follicular One occurrence of this data group is permitted
FLIPI INDEX SCORE
HA8360
Follicular Lymphoma International Prognostic Index Score (FLIPI)
HAEMATOLOGY - DLBCL CANCER CARE PLAN
To carry cancer care plan details specific to DLBCL One occurrence of this data group is permitted
(R)IPI INDEX for DLBCL SCORE
HA8450
Revised International Prognostic Index Score
HAEMATOLOGY - MYELOMA CANCER CARE PLAN
To carry cancer care plan details specific to Myeloma One occurrence of this data group is permitted
ISS STAGE for MYELOMA
HA8560
International staging system for Myeloma derived from Beta2 Microglobulin and Albumin lab results.
HAEMATOLOGY - HODGKIN CANCER CARE PLAN
To carry cancer care plan details specific to Hodgkin One occurrence of this data group is permitted
HASENCLEVER INDEX
HA8670
Index derived from age, gender, Hb, Albumin, white blood count, Lymphocyte count, Ann Arbor stage.
HAEMATOLOGY - ACUTE LYMPHOCYTIC LEUKAEMIA CANCER CARE PLAN - To carry cancer care plan details specific to Acute Lymphocytic Leukaemia One occurrence of this data group is permitted
EXTRAMEDULLARY DISEASE
HA8270
Sites of disease identified outside bone marrow
VARIOUS HAEMATOLOGY – STAGING - To carry staging details, specifically Ann Arbor staging details, for various haematological diseases, as specified. One occurrence of this data group is permitted
ANN ARBOR STAGE
HA8280
Staging based on location of detected disease.
ANN ARBOR SYMPTOMS
HA8290
Additional stage designation based on presence or absence of specific symptoms.
ANN ARBOR EXTRANODALITY
HA8300
Additional staging designation based on extranodal involvement.
ANN ARBOR BULK
HA8310
Additional staging designation based on presence of bulky disease.
22
Appendix 2g
Head & Neck
HEAD & NECK - PRE TREATMENT ASSESSMENT
HN9230
DATE HEIGHT MEASURED
HN9220
PERSON HEIGHT IN METRES
HN9210
DATE WEIGHT MEASURED
HN9200
PERSON OBSERVATION (WEIGHT)
HN9060
CANCER DENTAL ASSESSMENT DATE
HN9050
CARE CONTACT DATE (DIETICIAN INITIAL)
HN9140
PLANNED POST-OPERATIVE COMMUNICATION METHOD
HEAD & NECK - POST TREATMENT ASSESSMENT
To carry pre treatment assessment details for head and neck cancer One occurrence of this data group is permitted
Date the patient's height was measured.
Height of the patient, in metres to 2 decimal places (n.nn).
Date the patient's weight was measured.
Weight of the patient, in kilograms with up to three decimal places (nnn.nnn).
The date of the first dental assessment by a dentally qualified practitioner, which contributes to preparation for treatment.
The date that the patient was first assessed by a dietician.
(Only applicable prior to laryngectomy).The patient's proposed method of communication following laryngectomy.
To carry post treatment assessment details for head and neck cancer Multiple occurrences of this data group are permitted
HN9000
CLINICAL STATUS ASSESSMENT DATE (CANCER)
HN9220
PERSON HEIGHT IN METRES
HN9200
PERSON OBSERVATION (WEIGHT)
HN9010
PRIMARY TUMOUR STATUS
HN9020
NODAL STATUS
HN9030
METASTATIC STATUS
HN9150
SVR COMMUNICATION PRIMARY METHOD
HN9080
SPEECH & LANGUAGE ASSESSMENT DATE
HEAD & NECK - PATHOLOGY - GENERAL
HN9440
INVESTIGATION RESULT DATE
The date on which a clinical assessment was performed.
Height of the patient, in metres, to 2 decimal places (n.nn).
Weight of the patient, in kilograms with up to three decimal places (nnn.nnn).
The status of the primary tumour at this follow-up contact.
The status of the regional nodal metastases at this follow-up contact.
The status of the distant metastases at this follow-up contact.
(Only applicable following laryngectomy). The patients primary method of communication at post operative contact.
Record the date of contact where assessment swallowing occurs following completion of treatment.
To carry general pathology details for head and neck cancer Multiple occurrences of this group are permitted
The date on which an investigation was concluded e.g. the date the result was authorised.
HN9450
A unique identifier of a SERVICE REPORT.
SERVICE REPORT IDENTIFIER
HEAD & NECK - PATHOLOGY - VARIOUS
HN9300
MAXIMUM DEPTH OF INVASION
To carry pathology details for various head and neck cancer One occurrence of this data group is permitted per pathology report
where applicable
The maximum depth of invasion in mm. Record as "00" to indicate 'not applicable'.
HN9310
BONE INVASION
Is there evidence of invasion into bone
HN9320
CARTILAGE INVASION
Is there evidence of invasion into cartilage
HN9330
NECK DISSECTION LATERALITY
Identify laterality of neck dissection if performed
HEAD & NECK - PATHOLOGY - SALIVARY
HN9380
HISTOLOGICAL GRADE (SALIVARY TUMOUR)
HN9390
MACROSCOPIC EXTRAGLANDULAR EXTENSION
HEAD & NECK - PATHOLOGY - GENERAL and SALIVARY
HN9400
HN9410
HN9420
HN9430
POSITIVE NODES LATERALITY
LARGEST METASTASIS LEFT NECK
LARGEST METASTASIS RIGHT NECK
EXTRACAPSULAR SPREAD
To carry salivary pathology details for head and neck cancer One occurrence of this data group is permitted per pathology report
where applicable
Specify the histological grade of the tumour
Macroscopic extension of tumour outside the capsule of the salivary gland.
To carry general and salivary pathology details for head and neck cancer One occurrence of this data group is permitted per
pathology report where applicable
If nodes positive specify laterality
If Neck dissected on Left side, the size in mm of the largest metastasis
If Neck dissected on Right side, the size in mm of the largest metastasis
Invasion of metastatic tumour outside the capsule of a lymph node.
23
Appendix 2h
Lung
LUNG - IMAGING (CT SCAN)
To carry imaging (CT Scan) details for Lung Carcinoma Note this is non repeating One occurrence of this data group is permitted
LU10000
PROCEDURE DATE (CT SCAN)
Date CT scan was performed which informed management of patient at time of MDT
LU10020
SCAN PERFORMED INDICATOR (CT)
Was a CT scan performed on this patient?
LUNG - IMAGING (PET SCAN)
To carry imaging (PET Scan) details for Lung Carcinoma Note this is non repeating One occurrence of this data group is permitted
LU10010
PROCEDURE DATE (PET CT SCAN)
Date PET CT scan was performed which informed management of patient at time of MDT
LU10030
SCAN PERFORMED INDICATOR (PET)
Was a PET scan performed on this patient?
LUNG - CANCER CARE PLAN
To carry care plan details for Lung Carcinoma. One occurrence of this data group is permitted
LU10040
FEV1 PERCENTAGE
LU10050
FEV1 ABSOLUTE VALUE
LU10190
SMOKING STATUS
LU10060
MEDIASTINAL SAMPLING INDICATOR
LUNG - BRONCHOSCOPY
LU10070
PROCEDURE DATE BRONCHOSCOPY
LU10080
BRONCHOSCOPY PERFORMED INDICATOR
LUNG - BIOMARKERS
The Forced Expiratory Volume in the first second as a percentage of the predicted value
The absolute value of the patient's Forced Expiratory Volume in the first second in litres
Specify the current smoking status of the patient.
Has patient had a mediastinoscopy,mediastinotomy,open mediastinal sampling or other type of mediastinal biopsy
To carry Bronchoscopy details for Lung Carcinoma (which informed management of patient at time of MDT) One occurrence of
this data group is permitted
Date bronchoscopy was performed which informed management of patient at time of MDT
Was a bronchoscopy performed on this patient?
To carry Biomarker details for Lung Carcinoma One occurrence of this data group is permitted
LU10090
Epidermal Growth Factor Receptor Mutational Status
LU10200
LU10210
LU10100
LU10110
LU10120
LU10130
LU10140
LU10150
LU10160
LU10170
LU10180
Pathology details for Lung Carcinoma (Most items are only applicable where patients have surgical resection) Multiple occurrences
of this data group are permitted
The date on which an investigation was concluded e.g. the date the result was authorised.
A unique identifier of a SERVICE REPORT.
Is the tumour within 20mm of carina (if known) or more than 20mm from carina
Extent of atelectasis/obstructive pneumonitis
What is the extent of pleural invasion
Does the tumour invade the pericardium
Does the tumour invade the diaphragm
Does the tumour invade the great vessels (aorta, central pulmonary artery or vein)
Does the tumour invade the Atrium or Heart
Is there evidence of malignant pleural effusion?
Record the most distant location of separate tumour nodules
EPIDERMAL GROWTH FACTOR RECEPTOR MUTATIONAL
STATUS
LUNG - PATHOLOGY
INVESTIGATION RESULT DATE
SERVICE REPORT IDENTIFIER
PROXIMITY TO CARINA
EXTENT OF ATELECTASIS
EXTENT OF PLEURAL INVASION
PERICARDIAL INVASION
DIAPHRAGM INVASION
INVASION INTO GREAT VESSEL
INVASION INTO HEART
MALIGNANT PLEURAL EFFUSION
SATELLITE TUMOUR NODULES LOCATION
24
Appendix 2i
Sarcoma
SARCOMA - DIAGNOSIS
To carry diagnosis details for Sarcoma - for both Bone and Soft Tissue One occurrence of this data group is permitted
SA11000
SA11010
SA11080
SA11090
SA11025
SARCOMA -
SARCOMA TUMOUR SITE (BONE)
SARCOMA TUMOUR SUBSITE (BONE)
SARCOMA TUMOUR SITE (SOFT TISSUE)
SARCOMA TUMOUR SUBSITE (SOFT TISSUE)
MULTIFOCAL OR SYNCHRONOUS TUMOUR INDICATOR
PATHOLOGY
Location of the bone sarcoma within the body as defined by OPCS4 code
Sublocation of the bone sarcoma within the tumour site.
Location of the soft tissue sarcoma within the body as defined by OPCS4 code
Sublocation of the soft tissue sarcoma within the tumour site.
An indicator of the presence of tumours at multiple sites arising synchronously/concurrently.
To carry pathology details for Sarcoma - for both Bone and Soft Tissue Multiple occurrences of this data group are permitted
SA11200
SA11210
SA11120
SA11170
SARCOMA -
INVESTIGATION RESULT DATE
SERVICE REPORT IDENTIFIER
HISTOPATHOLOGICAL TUMOUR GRADE
GENETIC CONFIRMATION INDICATOR
PATHOLOGY - BONE
SA11130
SA11140
SA11160
SARCOMA -
EXTENT OF LOCAL SPREAD (BONE)
TUMOUR NECROSIS
TISSUE TYPE AT NEAREST MARGIN
PATHOLOGY - SOFT TISSUE
The date on which an investigation was concluded e.g. the date the result was authorised.
A unique identifier of a SERVICE REPORT.
Histopathological grade of tumour
Are there any cytogenetic or molecular genetic data confirming the histological diagnosis?
To carry pathology details for Sarcoma specific to Bone One occurrence of this data group is permitted per pathology report where
applicable
FOR MEDULLARY TUMOURS ONLY. Does the tumour breach the cortex.
Approximate percentage of tumour necrosis in response to pre-operative therapy
Type of tissue at nearest excision margin
To carry pathology details for Sarcoma specific to Soft Tissue One occurrence of this data group is permitted per pathology report
where applicable
Record the deepest tissue compartment where the tumour is located
SA11100
TUMOUR DEPTH
25
Appendix 2j
Skin
SKIN - STAGING
SK12510
AJCC STAGE GROUP
To carry staging details for Basal Cell Carcinoma (BCC), Squamous Cell Carcinoma (SCC), and Malignant Melanoma (MM) One
occurrence of this data group is permitted
This is the final integrated stage as agreed by MDT.
SKIN - GENERAL - BCC, SCC & MM
To carry general details for BCC, SCC, and MM. Multiple occurrences of this data group are permitted
SK12040
SK12050
SK12120
SK12010
SK12020
SK12030
INVESTIGATION RESULT DATE
SERVICE REPORT IDENTIFIER
SKIN CANCER LESION INDICATOR
GRADE OF CLINICIAN/SURGEON OPERATING
SITE CODE OF SPECIMEN
CLINICAL DIAGNOSIS (PRE-HISTOLOGICAL RESULT SKIN)
SKIN - PATHOLOGY - BCC & SCC
The date on which an investigation was concluded e.g. the date the result was authorised.
A unique identifier of a SERVICE REPORT.
This is the specimen number or letter used to identify the specimen within a report. .
The level of training reached of the actual operating Clinician or Surgeon, not necessarily the responsible Clinician.
This is the four digit ICD10 code of the skin specimen e.g. C445 =Skin of trunk
What is the clinical diagnosis of the patients lesion/rash.
SK12530
PERINEURAL INVASION
SK12537
LESION DIAMETER GREATER THAN 20MM INDICATOR
SK12650
DEEP INVASION INDICATOR FOR pT3
SK12660
DEEP INVASION INDICATOR FOR pT4
SKIN - PATHOLOGY - SCC
Invasion into perineurium of nerve bundles
Is the diameter of the lesion greater than 20mm?
For Stage pT3 Tumours only: Tumour with invasion of maxilla, mandible, orbit or temporal bone
Stage pT4 Tumours only: Tumour with invasion of skeleton (axial/appendicular) or perineural invasion of skull base.
To carry pathology details for SCC. One occurrence of this data group is permitted per pathology report where applicable
SK12545
SK12565
CLARKS LEVEL IV INDICATOR
LESION VERTICAL THICKNESS GREATER THAN 2MM
INDICATOR
SKIN - PATHOLOGY - MM
Greater than or equal to Clark's level IV.
Is the vertical thickness of the lesion greater than 2mm
SK12580
SK12590
SK12600
Loss of full thickness of epidermis associated with reactive changes (ulceration).
Mitotic rate per square mm
Is there evidence of Microsatellite or in transit metastases.
SK12620
SK12630
SK12430
SK12450
SK12460
SK12470
SK12480
SK12490
ULCERATION INDICATOR
MITOTIC RATE
MICROSATELLITE OR IN-TRANSIT METASTASIS
INDICATOR
TUMOUR REGRESSION INDICATOR
BRESLOW THICKNESS
TUMOUR INFILTRATING LYMPHOCYTES (TILS)
FINAL EXCISION MARGIN AFTER WIDE LOCAL EXCISION
SENTINEL NODES EXAMINED NUMBER
SENTINEL NODES POSITIVE NUMBER
POST SNB COMPLETION LYMPHADENECTOMY - NODES
SAMPLED NUMBER
POST SNB COMPLETION LYMPHADENECTOMY - NODES
POSITIVE NUMBER
To carry pathology details for BCC and SCC. One occurrence per pathology report where applicable
To carry pathology details for MM. One occurrence of this data group is permitted per pathology report where applicable
Area of loss of tumour associated with reactive changes.
Breslow thickness in mm to nearest 0.01mm
Type of TILS.
Record the final margin of excision after wide local excision procedure.
Number of sentinal nodes sampled.
Number of sentinal nodes positive.
Post SNB completion lymphadenectomy (not always done), number of nodes sampled.
Post SNB completion lymphadenectomy (not always done), number of nodes positive.
26
Appendix 2k
Upper GI
UPPER GI - CANCER CARE PLAN
To carry cancer care plan details for Upper GI cancer One occurrence of this data group is permitted
UG13293
BODY MASS INDEX
UPPER GI - CANCER CARE PLAN - LIVER METS
UG13630
NUMBER OF LIVER METASTASES (PRE-OPERATIVE
IMAGING)
UPPER GI - ENDOSCOPIC OR RADIOLOGICAL PROCEDURES
UG13030
PROCEDURE DATE (ENDOSCOPIC OR RADIOLOGICAL)
UG14410
ORGANISATION SITE CODE (PROVIDER ENDOSCOPIC OR
RADIOLOGICAL PROCEDURE)
UG13320
CONSULTANT CODE (ENDOSCOPIC OR RADIOLOGICAL
PROCEDURE)
Start of repeating item - Endoscopic Procedure Type
UG14290
ENDOSCOPIC PROCEDURE TYPE
End of repeating item - Endoscopic Procedure Type
UG13250
RADIOLOGICAL PROCEDURE TYPE
UG13070
INTENT FOR BILIARY STENT
UG13080
SUCCESS OF DEPLOYMENT
Start of repeating item - Endoscopic/Radiological Complications
UG13090
ENDOSCOPIC OR RADIOLOGICAL COMPLICATION TYPE
End of repeating item - Endoscopic/Radiological Complications
UPPER GI - SURGICAL PROCEDURES
Estimate of a patient's Body Mass Index (BMI) at diagnosis
To carry cancer care plan details for Liver METS One occurrence of this data group is permitted
Total number of liver metastases seen on preoperative imaging
UG13235
ASA SCORE
UG13100
STAGING LAPAROSCOPY PERFORMED
UG13110
SURGICAL ACCESS TYPE (ABDOMINAL)
UG14190
SURGICAL ACCESS (THORACIC)
UG13240
SURGICAL PALLIATION TYPE
UG13590
LIVER TRANSPLANTATION
Start of repeating item - Surgical complications
UG14210
SURGICAL COMPLICATIONS
A system for assessing the fitness of patients before surgery.
Record whether a staging laparoscopy was performed.
The approach used to perform the abdominal part of the main procedure.
The approach used to perform the thoracic part of the main procedure.
Type of surgical palliation performed if any e.g. Hepaticojejunostomy
Was a liver transplant performed?
To carry Endoscopic and Radiological procedures details for Upper GI, as specified One occurrence of this data group is permitted
The date that the first therapeutic endoscopic/radiological procedure was performed.
ORGANISATION SITE CODE of the unit providing endoscopic palliative therapy to the PATIENT.
The GMC code of the consultant responsible for the endoscopic or radiological procedure
The main endoscopic procedures carried out. More than one procedure can be entered. Repeating Item.
Type of stent or drain inserted by radiological procedure
Reason for biliary stent insertion
Whether or not the stent was deployed successfully
The types of complications that the patient experiences during the admission for the endoscopic procedure.
To carry surgical procedure details for Upper GI, as specified 1 occurrence of this group permitted per treatment where applicable
The types of post-operative complications that the patient experiences between the time of the operation, and his / her discharge
from hospital or death.
End of repeating item - Surgical complications
UG13150
UNPLANNED RETURN TO THEATRE INDICATOR
Whether or not the patient required a second (unplanned) operation during the same admission as the primary procedure
UG14230
POST OPERATIVE TUMOUR SITE (UPPER GI)
The main cancer site for which the patient is receiving care, as established in the resected specimen.
UG13810
PALLIATIVE TREATMENT REASON (UPPER GI)
Rationale for palliative treatment
UPPER GI - LIVER METS and LIVER HCC To carry other procedure details for LIVER METS and Liver HCC 1 occurrence of this group is permitted/ treatment where applicable
UG13560
ABLATIVE THERAPY TYPE
Describe type of ablative (i.e. locally destructive treatment) therapy used if any
UG13580
TRANS ARTERIAL CHEMOEMBOLISATION
Was Trans Arterial Chemoembolisation (TACE) carried out?
UPPER GI - PATHOLOGY - VARIOUS
To carry pathology details for various Upper GI cancers as shown Multiple occurrences of this data group are permitted
UG14500
INVESTIGATION RESULT DATE
The date on which an investigation was concluded e.g. the date the result was authorised.
UG14510
SERVICE REPORT IDENTIFIER
A unique identifier of a SERVICE REPORT.
UG14470
NUMBER OF COLORECTAL METASTASES IN LIVER CODE
Number of colorectal metastases identified in resected liver
UG14480
EXCISION MARGIN (PROXIMAL, DISTAL)
Identify whether either proximal or distal margin is involved.
UG14490
EXCISION MARGIN (CIRCUMFERENTIAL)
Identify whether circumferential margin is involved.
27
Appendix 2l
Urology
UROLOGY - CANCER CARE PLAN
ESTIMATED GLOMERULAR FILTRATION RATE
UR15000
HYDRONEPHROSIS
UR15010
NORMAL LDH
UR15020
S-CATEGORY
UR15030
S-CATEGORY AFP
UR15040
S-CATEGORY HCG
UR15050
S-CATEGORY LDH
UR15060
PSA (DIAGNOSIS)
UR15070
UROLOGY - STAGING - TESTICULAR
STAGE GROUPING (TESTICULAR)
UR15300
Start of repeating item - Extra-nodal metastases
EXTRANODAL METASTASES
UR15320
End of repeating item - Extra-nodal metastases
LUNG METASTASES SUB-STAGE GROUPING
UR15330
UROLOGY - TREATMENT - BLADDER
INTRAVESICAL CHEMOTHERAPY RECEIVED INDICATOR
UR15100
INTRAVESICAL IMMUNOTHERAPY RECEIVED INDICATOR
UR15110
UROLOGY - TREATMENT - PROSTATE
PSA (PRE TREATMENT)
UR15080
UROLOGY - PATHOLOGY - GENERAL
INVESTIGATION RESULT DATE
UR15340
SERVICE REPORT IDENTIFIER
UR15350
UROLOGY - PATHOLOGY - BLADDER
DETRUSOR MUSCLE PRESENCE INDICATOR
UR15120
UROLOGY - PATHOLOGY - KIDNEY
TUMOUR NECROSIS INDICATOR
UR15130
PERINEPHRIC FAT INVASION
UR15140
ADRENAL INVASION
UR15150
RENAL VEIN TUMOUR
UR15160
GEROTA'S FASCIA INVASION
UR15170
UROLOGY - PATHOLOGY - PENIS
CORPUS SPONGIOSUM INVASION
UR15180
CORPUS CAVERNOSUM INVASION
UR15190
URETHRA OR PROSTATE INVASION
UR15200
UROLOGY - PATHOLOGY - PROSTATE
GLEASON GRADE (PRIMARY)
UR15210
GLEASON GRADE (SECONDARY)
UR15220
GLEASON GRADE (TERTIARY)
UR15230
PERINEURAL INVASION
UR15240
ORGAN CONFINED
UR15250
SEMINAL VESICLES INVASION
UR15260
TURP TUMOUR PERCENTAGE
UR15270
UROLOGY - PATHOLOGY - BLADDER
TUMOUR GRADE (UROLOGY)
UR15290
UROLOGY - PATHOLOGY - TESTICULAR
RETE TESTES INVASION
UR15310
To carry the cancer care plan details for Urology cancer. One occurrence of this data group is permitted
RENAL ONLY. This is the estimated Glomerular Filtration Rate.
BLADDER ONLY, Consequence of reduced outflow of urine from Kidney.
TESTICULAR ONLY. This is the upper limit of normal for the LDH assay which is used to calculate S Category.
TESTICULAR ONLY. Based on serum tumour markers AFP, HCG and LDH.
TESTICULAR ONLY. Alpha Feto-Protein (AFP) is a serum tumour marker.
TESTICULAR ONLY. Human Chorionic Gonadotropin (HCG) is a serum tumour marker.
TESTICULAR ONLY. Serum Lactate Dehydrogenase (LDH) is a serum tumour marker.
PROSTATE ONLY. Prostate Specific Antigen blood level in ng/ml, measured at time of diagnosis.
To carry staging details for Urology (Testicular) One occurrence of this group is permitted.
TESTICULAR ONLY. Nationally agreed anatomical stage groupings as defined by The Royal Marsden Hospital
For testicular Stage 4 patients only). Indicate the extent of metastatic spread (multiple items can be selected)
(For testicular cancer only) Where lung metastases are identified, specify the RMH grouping.
To carry the cancer treatment details for Bladder. One occurrence of this data group is permitted per treatment where applicable
Either INTRAVESICAL CHEMOTHERAPY RECEIVED INDICATOR or INTRAVESICAL IMMUNOTHERAPY RECEIVED INDICATOR
Either INTRAVESICAL CHEMOTHERAPY RECEIVED INDICATOR or INTRAVESICAL IMMUNOTHERAPY RECEIVED INDICATOR
To carry the cancer treatment details for Prostate. One occurrence of this data group is permitted per treatment where applicable
PROSTATE ONLY. Prostate Specific Antigen blood level in ng/ml, measured before treatment (including 2nd and subs treatments).
To carry general pathology details for Urology cancer. Multiple occurrences of this group are permitted.
The date on which an investigation was concluded e.g. the date the result was authorised.
A unique identifier of a SERVICE REPORT.
To carry the cancer pathology details for Bladder. 1 occurrence of this group is permitted per pathology report where applicable
BLADDER ONLY Presence or absence of detrusor muscle in the specimen
To carry the cancer pathology details for Kidney. 1 occurrence of this group is permitted per pathology report where applicable
Is there evidence of coagulative tumour necrosis?
Is there evidence of perinephric fat invasion?
Is there evidence of direct adrenal invasion?
Is there evidence of tumour thrombus in the renal vein?
Is there evidence of invasion into Gerota's fascia?
To carry the cancer pathology details for Penis. 1 occurrence of this data group is permitted per pathology report where applicable
Is there evidence of invasion into corpus spongiosum?
Is there evidence of invasion into corpus cavernosum?
Is there evidence of invasion into the urethra or prostate?
To carry the cancer pathology details for Prostate 1 occurrence of this group is permitted per pathology report where applicable
What is the most extensive Gleason grade?
If additional grades are present, what is the highest grade (biopsy) or the second most extensive grade (TURP and radicals).
Is there a different third grade in addition the primary and secondary grades and what is its value?
Is there perineural invasion (PNI)?
If prostatectomy was performed, is the tumour confined to the prostate?
If prostatectomy was performed, is there invasion into Seminal Vesicles?
For TURP only, what percentage of tumour if clinically unsuspected tumour.
To carry the cancer pathology details for bladder 1 occurrence of this group is permitted per pathology report where applicable
BLADDER ONLY. Specify whether LOW, HIGH Grade or PUNLMP .
To carry the cancer pathology details for Testicular 1 occurrence of this group is permitted per pathology report where applicable
For Seminoma only, does the tumour invade the rete testis
28
Appendix 2m
Other Data Items
CORE - REFERRALS AND FIRST STAGE OF PATIENT PATHWAY To carry patient referral details to the Trust that receives the first referral.
PATIENT PATHWAY IDENTIFIER
CR1380
ORGANISATION CODE (PATIENT PATHWAY IDENTIFIER ISSUER)
CR1390
TWO WEEK WAIT CANCER OR SYMPTOMATIC BREAST REFERRAL TYPE
CR0260
DECISION TO REFER DATE (CANCER OR BREAST SYMPTOMS)
CR0190
PRIORITY TYPE CODE
CR2020
CANCER REFERRAL TO TREATMENT PERIOD START DATE
CR0200
CONSULTANT UPGRADE DATE
CR1620
ORGANISATION SITE CODE (PROVIDER CONSULTANT UPGRADE)
CR3010
WAITING TIME ADJUSTMENT (FIRST SEEN)
CR0280
WAITING TIME ADJUSTMENT REASON (FIRST SEEN)
CR0290
DELAY REASON COMMENT (FIRST SEEN)
CR0250
DELAY REASON REFERRAL TO FIRST SEEN (CANCER OR BREAST SYMPTOMS)
CR0240
CORE - TREATMENT To carry cancer treatment details.
ORGANISATION SITE CODE (PROVIDER DECISION TO TREAT CANCER)
CR1420
CANCER TREATMENT PERIOD START DATE
CR1430
CANCER CARE SETTING (TREATMENT)
CR1440
DELAY REASON COMMENT (DECISION TO TREATMENT)
CR1460
DELAY REASON (DECISION TO TREATMENT)
CR1470
WAITING TIME ADJUSTMENT (TREATMENT)
CR1480
WAITING TIME ADJUSTMENT REASON (TREATMENT)
CR1490
DELAY REASON COMMENT (REFERRAL TO TREATMENT)
CR1500
DELAY REASON REFERRAL TO TREATMENT (CANCER)
CR1510
DELAY REASON COMMENT (CONSULTANT UPGRADE)
CR1520
DELAY REASON (CONSULTANT UPGRADE)
CR1530
CLINICAL TRIAL INDICATOR
CR1250
CORE - RADIOTHERAPY
To carry the radiotherapy details. A course of radiotherapy is defined as a string of prescriptions which are consecutive.
RADIOTHERAPY PRIORITY
CR1560
RADIOTHERAPY INTENT
CR1570
ANATOMICAL TREATMENT SITE (RADIOTHERAPY)
CR1140
CORE - CHEMOTHERAPY AND OTHER DRUGS - To carry the details of chemotherapy and/or other anti- ancer and/or supportive drugs given to the patient during their treatment.. 1 occurrence of this group is permitted per
treatment where applicable.
DRUG TREATMENT INTENT
CR1070
DRUG REGIMEN ACRONYM
CR1080
CORE – DEMOGRAPHICS - To carry the patient demographic details. It is anticipated that some of the demographic data items listed below will be collected by every provider with which the patient has contact. Where this information is
exchanged, the appropriate data item name should be used to identify the particular instance of the data. One occurrence of this group is permitted
ORGANISATION CODE (RESPONSIBLE PCT)
CR0130
CORE - DIAGNOSIS
To carry diagnosis details. One occurrence of this group is permitted
DATE OF DIAGNOSIS (CANCER REGISTRATION)
CR0360
DATE OF RECURRENCE (CANCER REGISTRATION)
CR0170
CORE - RADIOTHERAPY DETAILS
To carry the death details (not required for direct submission by Trusts), One occurrence of this group is permitted per treatment where applicable.
RADIOTHERAPY TOTAL DOSE
CR2080
RADIOTHERAPY TOTAL FRACTIONS
CR2090
CORE - DEATH DETAILS
To carry the death details (not required for direct submission by Trusts). One occurrence of this group is permitted
PERSON DEATH DATE
CR1270
DEATH LOCATION TYPE
CR1280
DEATH CAUSE IDENTIFICATION METHOD
CR3020
DEATH CAUSE ICD CODE (IMMEDIATE)
CR1300
DEATH CAUSE ICD CODE (CONDITION)
CR1310
29
DEATH CAUSE ICD CODE (UNDERLYING)
CR1320
DEATH CAUSE ICD CODE (SIGNIFICANT)
CR1330
BREAST - REFERRALS
SCREENING STATUS FOR CANCER
BR4025
GYNAECOLOGY - REFERRAL
SCREENING STATUS FOR CANCER
GY7030
COLORECTAL - REFERRALS
SCREENING STATUS FOR CANCER
CO5000
To carry referral details for breast cancer. One occurrence of this group is permitted
To carry referral details for gynae cancer. One occurrence of this group is permitted
To carry referral details for colorectal cancer. One occurrence of this group is permitted
30
Appendix 3
Information Sharing Dataset
North of England Cancer Network Information Sharing Proforma
Information sharing should take place as soon as possible after the decision to refer on. As a minimum, trusts should share information twice a week but be working towards haring information more frequently.
This proforma details the minimum amount of information required for a receiving trust. All fields must be completed where applicable. Additional cancer dataset items should also be added if the information is held at the time of transfer.
Information sharing does not need to take place on this proforma. Trusts should explore building reports and extracts in local systems. However, information sharing file of all formats must contain the fields specified in the Information Sharing Protocol.
Trust referring information:
Trust to receive information:
Named contact referring information:
Named contact to receive information:
All fields are compulsory and must be completed if applicable to each patient. Not including all relevant fields is contrary to the agreed Information Sharing Protocol.
If subsequent treatment:
NHS Number Patient Pathway
Identifier
D.O.B
Source of
Referral
Cancer
Cancer
Referral
Referral
Priority Type Type
Pt on a 62 Cancer Referral Consultant Org Code Date First
day
Referral Request Upgrade (First Seen)
Seen
Date
pathway? Decision Received
(Y/N)
Date
Date
Clock Reason for
Pause
Clock
Date(s) Pauses
Cancer
Status
Primary Recurrence
Diagnosis
(Y/N)
ICD (4 digits)
Date of
Diagnosis
Date of Decision
to Treat
Planned Cancer
Treatment Type
1st Treatment
Decision to Treat
Date
1st Treatment
Start Date
1st Treatment Type
Date Patient Referred to
Receiving Organisation
Reason for Onward Team Referred To Reason for If diagnostics only - ECAD date agreed by clinical Organisation code (provider Delay reason comment
Delay reason
state
team
Referral After
Referral
decision to treat)
referral to treatment) comment (decision to
Timeline Point
(Investigations/ test/investigation
treatment)
Diagnostics
only, First
Treatment or
Subsequent
Treatment)
Delay reason referral to
treatment
Delay Comment
reason s e.g.
decision to delays &
treatment reasons,
tracking
comments
31