Download National Cancer Data Set - Site specific items

DSC Notice: 54/2002
Date of Issue: January 2003
Subject:
NHS Information
Standards Board
Data Standards:
National Cancer Data Set - Site Specific
data items
Implementation Date: Immediate
DATA SET CHANGE CONTROL PROCEDURE
This paper gives notification of changes to be included in the NHS Data Dictionary Version.2 and the
NHS CDS Manual as appropriate. These will be consolidated into the publications in due course.
Summary of Changes:
This DSCN introduces data items into the NHS Data Dictionary Version.2, to support
Version 1.3_ISB of the National Cancer data set for additional site specific data items.
These cover seven types of cancer: Breast, Colorectal, Lung, Head & Neck,
Urological, Upper Gastro-Intestinal and Gynaecological.
Change Proposal
Reference No: CP 44/02
The NHS Information Standards Board (NHS ISB) is responsible for approving information standards.
The NHS ISB is supported by the Management Information Standards Board, the Clinical Information
Standards Board and the Technical Standards Board.
The packaging of standards document is under review. Any changes will be notified in due course.
Please note that the website address has changed, and that Data Set Change Notices are now
located at:
http://www.nhsia.nhs.uk/dscn/pages/default.asp and on the NHSnet at:
http://nww.nhsia.nhs.uk/dscn/pages/default.asp
DATA SET CHANGE NOTICE 54/2002
Reference:
CP 44/02 - DG1039/11/02 v2.6
Subject:
National Cancer Data Set - Site Specific items: Breast,
Colorectal, Lung, Head & Neck, Urological, Upper GastroIntestinal and Gynaecological
Type of Change:
Revision of NHS data standards
Effective Date:
Immediate
Reason for Change:
Integration of the National Cancer Data Set Site Specific
data items into the NHS Data Dictionary Version.2
Background:
The National Cancer Data Set Project, run by the NHS Information Authority, has
produced a set of data items relating to the diagnosis and management of cancer.
The purpose of the National Cancer Minimum Data Set is to advise organisations
within the National Health Service on a transferable set of data. These data will meet
the needs of clinical audit, assist in the generation of National Performance Indicators
and will allow outcome assessment.
Data Standards to support parts of the National Cancer Data Set have been released
earlier in the following DSCNs:
10/2002 Data Standards: Radiotherapy Treatments
23/2002 Data Standards: Chemotherapy HRGs
30/2002 Data Standards: change to Monitoring of the Cancer Waiting Times
More information about the project and the Data Set can be found at:
http://www.nhsia.nhs.uk/cancer/pages/default.asp
DSCN 53/2002 defines NHS Data standards to support Version 1.3_ISB core data set,
and this DSCN defines NHS data standards to support Version 1.3_ISB additional site
specific data items for seven types of cancer: Breast, Colorectal, Lung, Head & Neck,
Urological, Upper Gastro-Intestinal and Gynaecological.
DSCN 54/2002
Page 2 of 41
Summary of Changes:
Entity Definitions
A+E PATIENT DIAGNOSIS
BREAST CANCER CARE SPELL
CANCER CARE SPELL
Change entity type description
New entity type
Change entity type attributes and
relationships
CLINICAL CLASSIFICATION
Change entity type relationships
CLINICAL CLASSIFICATION FOR PERSON Change entity type name and
relationships
CLINICAL INTERVENTION
Change entity type relationships
CLINICAL SIGN OR SYMPTOM OF New entity type
PERSON
COLORECTAL CANCER CARE SPELL
New entity type
DRUG DOSAGE AND ADMINISTRATION
Change entity type description
and attributes
ENDOCRINE THERAPY
New entity type
GYNAECOLOGICAL CANCER CARE New entity type
SPELL
HEAD AND NECK CANCER CARE SPELL
New entity type
HEALTH CARE PROFESSIONAL
Change entity type attributes
LUNG CANCER CARE SPELL
New entity type
LUNG CAPACITY
New entity type
PATHOLOGY LABORATORY Change entity type attributes
INVESTIGATION
PATIENT
Change entity type attributes and
relationships
PATIENT DIAGNOSIS
Change entity type description
PATIENT PROCEDURE
Change entity type attributes and relationships
PERSON RELATIONSHIP
Change entity type attributes and relationships
REFERRAL FOR BREAST ASSESSMENT
Change entity type attributes and
relationships
TOBACCO USAGE
New entity type
UPPER GI CANCER CARE SPELL
New entity type
UROLOGICAL CANCER CARE SPELL
New entity type
Attribute Definitions
ALCOHOL STATUS
BREAST CARE NURSE SEEN
CIGARETTES PER DAY
CLINICAL EXAMINATION FINDINGS
CLINICAL SIGN OR SYMPTOM
COLONOSCOPY INCOMPLETE REASON
COLORECTAL OR STOMA NURSE SEEN DSCN 54/2002
Page 3 of 41
New attribute
New attribute
New attribute
New attribute
New attribute
New attribute
New attribute
DATE
COPD PRESENT
DATE STOPPED SMOKING
DIAGNOSTIC ROUTE
DRUG ROUTE OF ADMINISTRATION
ENDOCRINE THERAPY TYPE
FEV1 ABSOLUTE AMOUNT
FEV1 PERCENTAGE
GRADE OF RESPONSIBLE HCP
GYNAECOLOGICAL ONCOLOGY ACCREDITATION
LMP DATE
MARKER LYMPH NODE RESULT
MENSTRUAL STATUS
NUMBER OF YEARS SMOKED
NUTRITIONAL SUPPORT PROVIDED TYPE
OPERATIVE PATIENT PROCEDURE INDICATOR
PATIENT PROCEDURE RESULT
POSSUM SCORE (AFTER SURGERY)
POSSUM SCORE (AT DIAGNOSIS)
PREVIOUS TREATMENT ELSEWHERE
QUALITY OF LIFE
RELATION WITH CANCER
RELATIONSHIP TO PERSON
S CATEGORY FINAL PRETREATMENT
SERUM TUMOUR MARKER PSA
SMOKING STATUS
SURGICAL URGENCY
SYMPTOMS FIRST NOTED DATE
TOBACCO CHEWING HISTORY
TOBACCO USAGE TYPE
New attribute
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New attribute
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Data Item Notes
ALCOHOL STATUS
BREAST CANCER NURSE SEEN
CLINICAL EXAMINATION FINDINGS (BREAST CANCER)
CLINICAL SIGN OR SYMPTOM (ICD)
CODE OF RESPONSIBLE HCP (OPCS)
COLONOSCOPY INCOMPLETE REASON
COLORECTAL NURSE OR STOMA THERAPIST SEEN
COLORECTAL OR STOMA NURSE SEEN DATE
CO-MORBIDITY (ICD)
CONTACT DATE (DIETITIAN INITIAL)
COPD PRESENT
DSCN 54/2002
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New data item note
New data item note
New data item note
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New data item note
New data item note
New data item note
New data item note
New data item note
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New data item note
DIAGNOSTIC CODING
DIAGNOSTIC ROUTE DRUG ROUTE OF ADMINISTRATION
ENDOCRINE THERAPY TYPE
ESTIMATED PACK YEARS
FAMILY OR SURNAME OF RELATION WITH CANCER
FEV1 ABSOLUTE AMOUNT
FEV1 PERCENTAGE
GRADE OF RESPONSIBLE HCP GYNAECOLOGICAL ONCOLOGY ACCREDITATION
LMP DATE
MARKER LYMPH NODE RESULT
MENSTRUAL STATUS
NUTRITIONAL PROCEDURE (OPCS)
NUTRITIONAL PROCEDURE COMPLICATION (ICD)
NUTRITIONAL SUPPORT PROVIDED (CANCER)
NUTRITIONAL SUPPORT PROVIDED TYPE
(CANCER)
PATIENT HISTORY (CANCER DIAGNOSIS)
PATIENT PROCEDURE RESULT
(COLONOSCOPY)
POSSUM SCORE (AFTER SURGERY)
POSSUM SCORE (AT DIAGNOSIS)
PREVIOUS TREATMENT ELSEWHERE
PRIMARY DIAGNOSIS OF RELATION (ICD)
PROCEDURE CODING
QUALITY OF LIFE (AT DIAGNOSIS)
RELATIONSHIP TO PERSON
S CATEGORY FINAL PRETREATMENT
SERUM TUMOUR MARKER PSA
SMOKING STATUS
SURGICAL URGENCY (OPCS) SYMPTOMS FIRST NOTED DATE
THEATRE CASE START TIME
TOBACCO CHEWING HISTORY
TOBACCO USAGE TYPE
YEAR CANCER DIAGNOSED
YEAR STOPPED SMOKING
DSCN 54/2002
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Change data item note description
New data item note
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description
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CHANGES
Change Type:
Change entity type description
A+E PATIENT DIAGNOSIS
A type of CLINICAL CLASSIFICATION DIAGNOSIS FOR PERSON.
The remaining description, attributes and relationships are unchanged
Change Type:
New entity type
BREAST CANCER CARE SPELL
A type of CANCER CARE SPELL.
A continuous period of care, including assessment for care, for a PATIENT who has
been diagnosed as suffering from breast cancer.
References:
National Cancer Data Set Version 1.3_ISB October 2002
Attributes of this entity type are:
BREAST CARE NURSE SEEN
O LMP DATE
if not postmenopausal
MENSTRUAL STATUS
Each BREAST CANCER CARE SPELL
may be the result of one and only one REFERRAL FOR BREAST
ASSESSMENT
Change Type:
Change entity type attributes and relationships
CANCER CARE SPELL
The description is unchanged
Attributes of this entity type are:
QUALITY OF LIFE
O SYMPTOMS FIRST NOTED DATE
O DIAGNOSTIC ROUTE
DSCN 54/2002
Page 6 of 41
The remaining attributes are unchanged
Each CANCER CARE SPELL
may be associated with one or more PATIENT PROCEDURES
may be associated for endocrine therapy with one or more CLINICAL
INTERVENTIONS
The remaining relationships are unchanged
Change Type:
Change entity type relationships
CLINICAL CLASSIFICATION
The description and attributes are unchanged
Each CLINICAL CLASSIFICATION
may be classification of a cancer site for one or more PERSON
RELATIONSHIP
may be the classifier of one or more CLINICAL CLASSIFICATIONS
DIAGNOSES FOR PERSON
may be the classifier of one or more CLINICAL SIGNS OR SYMPTOMS OF
PERSON
The remaining relationships are unchanged
Change Type:
Change entity type name
CLINICAL CLASSIFICATION DIAGNOSIS FOR PERSON
The description and attributes are unchanged
Each CLINICAL DIAGNOSIS FOR PERSON
may be a complication arising from one and only one PATIENT
PROCEDURE
The remaining relationships are unchanged
Change Type:
Change entity type relationships
CLINICAL INTERVENTION
The description and attributes are unchanged
Each CLINICAL CARE INTERVENTION
may be endocrine therapy for one and only one CANCER CARE SPELL
DSCN 54/2002
Page 7 of 41
The remaining relationships are unchanged
Change Type:
New entity type
CLINICAL SIGN OR SYMPTOM OF PERSON
A type of PERSON OBSERVATION.
Signs or symptoms of a PERSON’s condition or disease. This could be either an
objective indication of the existence of a disease or condition as perceptible to the
examiner (sign) or the subjective evidence of a disease or condition as reported by the
PERSON (symptom). This includes signs and symptoms such as weight loss,
jaundice, abdominal pain, headaches, dysphagia, vomiting and anaemia.
References:
National Cancer Data Set Version 1.3_ISB October 2002
Attributes of this entity type are:
CLINICAL SIGN OR SYMPTOM
Each CLINICAL SIGN OR SYMPTOM OF PERSON
may be classified by one and only one CLINICAL CLASSIFICATION
Change Type:
New entity type
COLORECTAL CANCER CARE SPELL
A type of CANCER CARE SPELL.
A continuous period of care, including assessment for care for a PATIENT who has
been diagnosed as suffering from colorectal cancer.
References:
National Cancer Data Set Version 1.3_ISB October 2002
Attributes of this entity type are:
COLORECTAL OR STOMA NURSE SEEN DATE
This entity type has no relationships.
Change Type:
Change entity type description and attributes
DRUG DOSAGE AND ADMINISTRATION
The description is unchanged
References:
DSCN 54/2002
Page 8 of 41
National Cancer Data Set Version 1.3_ISB October 2002
Attributes of this entity type are:
DRUG ROUTE OF ADMINISTRATION
for the delivery of chemotherapy/immunotherapy treatment only
The remaining attributes are unchanged
The relationships are unchanged
Change Type:
New entity
ENDOCRINE THERAPY
A type of CLINICAL INTERVENTION.
A record of the type of endocrine therapy given to the PATIENT as part of a
CANCER CARE SPELL.
References:
National Cancer Data Set Version 1.3_ISB October 2002
Attributes of this entity type are:
ENDOCRINE THERAPY TYPE
This entity type has no relationships.
Change Type:
New entity type
GYNAECOLOGICAL CANCER CARE SPELL
A type of CANCER CARE SPELL.
A continuous period of care, including assessment for care for a PATIENT who has
been diagnosed as suffering from gynaecological cancer.
References:
National Cancer Data Set Version 1.3_ISB October 2002
This entity type has no attributes or relationships.
Change Type:
New entity type
HEAD AND NECK CANCER CARE SPELL
A type of CANCER CARE SPELL.
DSCN 54/2002
Page 9 of 41
A continuous period of care, including assessment for care for a PATIENT who has
been diagnosed as suffering from head or neck cancer.
References:
National Cancer Data Set Version 1.3_ISB October 2002
Attributes of this entity type are:
O NUTRITIONAL SUPPORT PROVIDED TYPE
if nutritional support given
PREVIOUS TREATMENT ELSEWHERE
This entity type has no relationships.
Change Type:
Change entity type attributes
HEALTH CARE PROFESSIONAL
The description is unchanged.
Attributes of this entity type are:
O GRADE OF RESPONSIBLE HCP
O GYNAECOLOGICAL ONCOLOGY ACCREDITATION
The remaining attributes are unchanged
The relationships are unchanged
Change Type:
New entity type
LUNG CANCER CARE SPELL
A type of CANCER CARE SPELL.
A continuous period of care, including assessment for care, for a PATIENT who has
been diagnosed as suffering from lung cancer.
References:
National Cancer Data Set Version 1.3_ISB October 2002
Attributes of this entity type are:
COPD PRESENT
Each LUNG CANCER CARE SPELL
may be associated with one or more LUNG CAPACITIES
Change Type:
New entity type
DSCN 54/2002
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LUNG CAPACITY
A type of PERSON OBSERVATION.
The lung capacity of a PERSON.
References:
National Cancer Data Set Version 1.3_ISB October 2002
Attributes of this entity type are:
FEV1 ABSOLUTE AMOUNT
FEV1 PERCENTAGE
Each LUNG CAPACITY
may be associated with one and only one LUNG CANCER CARE SPELL
Change Type:
Change entity type attributes
PATHOLOGY LABORATORY INVESTIGATION
The description is unchanged
Attributes of this entity type are:
O MARKER LYMPH NODE RESULT
The remaining attributes and relationships are unchanged
Change Type:
Change entity type attributes and relationships
PATIENT
The description is unchanged
Attributes of this entity type are:
ALCOHOL STATUS
Each PATIENT
may be associated with one or more TOBACCO USAGES
The remaining relationships are unchanged
Change Type:
Change entity type description
PATIENT DIAGNOSIS
A type of CLINICAL CLASSIFICATION DIAGNOSIS FOR PERSON.
DSCN 54/2002
Page 11 of 41
The remaining description, attributes and relationships are unchanged
Change Type:
Change entity type attributes and relationships
PATIENT PROCEDURE
The description is unchanged
Attributes of this entity type are:
O COLONOSCOPY INCOMPLETE REASON
if procedure is colonoscopy
OPERATIVE PATIENT PROCEDURE INDICATOR
O PATIENT PROCEDURE RESULT
if procedure is colonoscopy or other for cancer detection
O SURGICAL URGENCY
for operative procedures only
The remaining attributes are unchanged
Each PATIENT PROCEDURE
may be performed as treatment during one and only one CANCER CARE SPELL
may be the cause of complications recorded as one or more CLINICAL
DIAGNOSES FOR PERSON
The remaining relationships are unchanged
Change Type:
Change entity type attributes and relationships
PERSON RELATIONSHIP
The description is unchanged
Attributes of this entity type are:
O RELATIONSHIP TO PERSON
O RELATION WITH CANCER
Each PERSON RELATIONSHIP
may be related to a cancer site classified by one and only one CLINICAL
CLASSIFICATION
The remaining relationships are unchanged
Change Type:
Change entity type attributes and relationships
REFERRAL FOR BREAST ASSESSMENT
DSCN 54/2002
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The description is unchanged
Attributes of this entity type are:
CLINICAL EXAMINATION FINDINGS
The remaining attributes are unchanged
Each REFERRAL FOR BREAST ASSESSMENT
may be resultant in one or more BREAST CANCER CARE SPELLS
The remaining relationships are unchanged
Change Type:
New entity type
TOBACCO USAGE
The history of a PATIENT’s tobacco usage.
References:
National Cancer Data Set Version 1.3_ISB October 2002
Attributes of this entity type are:
K
START DATE
K
TOBACCO USAGE TYPE
O CIGARETTES PER DAY
if current or ex-smoker
O NUMBER OF YEARS SMOKED
if current or ex-smoker
SMOKING STATUS
O TOBACCO CHEWING HISTORY
O DATE STOPPED SMOKING
if ex-smoker
Each TOBACCO USAGE
must be the usage of one and only one PATIENT
Change Type:
New entity type
UPPER GI CANCER CARE SPELL
A type of CANCER CARE SPELL.
A continuous period of care, including assessment for care for a PATIENT who has
been diagnosed as suffering from upper gastro-intestinal cancer, which includes
stomach and gastro-oesophageal cancers.
References:
National Cancer Data Set Version 1.3_ISB October 2002
DSCN 54/2002
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Attributes of this entity type are:
POSSUM SCORE (AT DIAGNOSIS)
POSSUM SCORE (AFTER SURGERY)
This entity type has no relationships.
Change Type:
New entity type
UROLOGICAL CANCER CARE SPELL
A type of CANCER CARE SPELL.
A continuous period of care, including assessment for care for a PATIENT who has
been diagnosed as suffering from urological cancer.
References:
National Cancer Data Set Version 1.3_ISB October 2002
Attributes of this entity type are:
O SERUM TUMOUR MARKER PSA
for prostate cancer only
O S CATEGORY FINAL PRETREATMENT
for testis cancer only
This entity type has no relationships.
Change Type:
New attribute
ALCOHOL STATUS
The alcohol status of the PATIENT at the time the ALCOHOL USAGE is recorded.
National Codes:
1 Current heavy
2 Heavy in the past
3 Current light
4 Never
References:
National Cancer Data Set Version 1.3_ISB October 2002
Change Type:
New attribute
BREAST CANCER NURSE SEEN
DSCN 54/2002
Page 14 of 41
An indicator of whether the PATIENT has seen a specialist breast care nurse during a
BREAST CANCER CARE SPELL.
National Codes:
Y Yes
N No
References:
National Cancer Data Set Version 1.3_ISB October 2002
Change Type:
New attribute
CIGARETTES PER DAY
The number of cigarettes smoked by the patient where they are a current or exsmoker.
Change Type:
New attribute
CLINICAL EXAMINATION FINDINGS
The findings from the clinical examination performed on the PATIENT at the start of
a BREAST CANCER CARE SPELL.
National Codes:
P1 Normal
P2 Benign
P3 Uncertain
P4 Suspicious
P5 Malignant
References:
National Cancer Data Set Version 1.3_ISB October 2002
Change Type:
New attribute
CLINICAL SIGN OR SYMPTOM
An objective indication of the existence of a disease or condition as perceptible to the
examiner (sign) or the subjective evidence of a disease or condition as reported by the
PERSON (symptom). This includes signs and symptoms such as weight loss,
jaundice, abdominal pain, headaches, dysphagia, vomiting and anaemia.
References:
National Cancer Data Set Version 1.3_ISB October 2002
DSCN 54/2002
Page 15 of 41
Change Type:
New attribute
COLONOSCOPY INCOMPLETE REASON
The reason that a colonoscopy was incomplete.
National Codes:
1 Obstructing tumour
2 Poor bowel presentation
3 Patient intolerance/technical reasons
4 Other
References:
National Cancer Data Set Version 1.3_ISB October 2002
Change Type:
New attribute
COLORECTAL OR STOMA NURSE SEEN DATE
The date when the PATIENT first saw the colorectal nurse or stoma therapist during a
COLORECTAL CANCER CARE SPELL.
References:
National Cancer Data Set Version 1.3_ISB October 2002
Change Type:
New attribute
COPD PRESENT
An indication of evidence of Chronic Obstructive Pulmonary Disease in a PATIENT
with a LUNG CANCER CARE SPELL.
National Codes:
Y
Yes
N
No
References:
National Cancer Data Set Version 1.3_ISB October 2002
Change Type:
New attribute
DATE STOPPED SMOKING
The date on which the PATIENT stopped smoking where they are an ex-smoker. If
the exact date is not known the year should be recorded.
DSCN 54/2002
Page 16 of 41
Change Type:
New attribute
DIAGNOSTIC ROUTE
An indication of a PATIENT’S route to diagnosis of cancer for a CANCER CARE
SPELL.
National Codes:
1 Cancers detected by national screening programme
2 Interval cancers occurring in patients screened by a national screening
programme
3 Other route
References:
National Cancer Data Set Version 1.3_ISB October 2002
Change Type:
New attribute
DRUG ROUTE OF ADMINISTRATION
The method of delivery of the chemotherapy/immunotherapy treatment.
National Codes:
01 Intra-vesicular
97 Other
References:
National Cancer Data Set Version 1.3_ISB October 2002
Change Type:
New attribute
ENDOCRINE THERAPY TYPE
The type of ENDOCRINE THERAPY given to the PATIENT during a CANCER
CARE SPELL.
National Codes:
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
References:
National Cancer Data Set Version 1.3_ISB October 2002
DSCN 54/2002
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Change Type:
New attribute
FEV1 ABSOLUTE AMOUNT
The forced expiratory volume of the lungs in 1 second measured in litres.
References:
National Cancer Data Set Version 1.3_ISB October 2002
Change Type:
New attribute
FEV1 PERCENTAGE
The forced expiratory volume of the lungs in 1 second as a percentage of the predicted
value.
References:
National Cancer Data Set Version 1.3_ISB October 2002
Change Type:
New attribute
GRADE OF RESPONSIBLE HCP
The grade of the operating surgeon.
National Codes:
1 Consultant
2 Associate Specialist
3 Staff grade/clinical assistant
4 Specialist Registrar (SPR)
5 Senior House Officer (SHO)
6 House Officer (HO)
7 Other
References:
National Cancer Data Set Version 1.3_ISB October 2002
Change Type:
New attribute
GYNAECOLOGICAL ONCOLOGY ACCREDITATION
An indicator of accreditation in Gynaecological Oncology for the HEALTH CARE
PROFESSIONAL.
National Codes:
Y Yes
DSCN 54/2002
Page 18 of 41
N No
References:
National Cancer Data Set Version 1.3_ISB October 2002
Change Type:
New attribute
LMP DATE
The date of the PATIENT’s last menstrual period (LMP) at the start of the BREAST
CANCER CARE SPELL.
References:
National Cancer Data Set Version 1.3_ISB October 2002
Change Type:
New attribute
MARKER LYMPH NODE RESULT
An indicator of the presence or absence of metastases in a marker lymph node that is
of therapeutic and prognostic importance relating to a CANCER CARE SPELL.
For breast cancer, the marker lymph node will be the sentinal node.
For colorectal cancer, the marker lymph node will be the apical node.
National Codes:
N Marker lymph node 1 negative
Y Marker lymph node 1 positive present
References:
National Cancer Data Set Version 1.3_ISB October 2002
Change Type:
New attribute
MENSTRUAL STATUS
The PATIENT’s menstrual status at the start of the BREAST CANCER CARE
SPELL.
National Codes:
1 Premenopausal
2 Perimenopausal
3 Postmenopausal
References:
National Cancer Data Set Version 1.3_ISB October 2002
DSCN 54/2002
Page 19 of 41
Change Type:
New attribute
NUMBER OF YEARS SMOKED
The number of years that a patient was smoking where they are a current or exsmoker. This is used with the CIGARETTES PER DAY to calculate the estimated
pack years of smoking
Change Type:
New attribute
NUTRITIONAL SUPPORT PROVIDED TYPE
The type of nutritional support that has been given during a HEAD AND NECK
CANCER CARE SPELL.
National Codes:
E Enteral (by the functioning gut)
P Parenteral (via intravenous feeding)
References:
National Cancer Data Set Version 1.3_ISB October 2002
Change Type:
New attribute
OPERATIVE PATIENT PROCEDURE INDICATOR
An indication of whether or not the PATIENT PROCEDURE is an operative
procedure.
National Codes:
N no
Y yes
Change Type:
New attribute
PATIENT PROCEDURE RESULT
The result of a procedure such as a colonoscopy.
National Codes:
1 Normal
2 Abnormal
3 Inadequate
4 Not done
DSCN 54/2002
Page 20 of 41
References:
National Cancer Data Set Version 1.3_ISB October 2002
Change Type:
New attribute
POSSUM SCORE (AFTER SURGERY)
The Physiological and Operative Severity Score for the enUmeration of Mortality and
morbidity after surgery for an UPPER GI CANCER CARE SPELL. Further
information can be found in the Upper GI Appendix on
http://nww.nhsia.nhs.uk/cancer/pages/dataset/datamanuals.asp
References:
National Cancer Data Set Version 1.3_ISB October 2002
Change Type:
New attribute
POSSUM SCORE (AT DIAGNOSIS)
The Physiological and Operative Severity Score for the enUmeration of Mortality and
morbidity at the point of diagnosis for an UPPER GI CANCER CARE SPELL.
Further information can be found in the Upper GI Appendix on
http://nww.nhsia.nhs.uk/cancer/pages/dataset/datamanuals.asp
References:
National Cancer Data Set Version 1.3_ISB October 2002
Change Type:
New attribute
PREVIOUS TREATMENT ELSEWHERE
An indicator of whether the PATIENT has had previous treatment for head and neck
cancer elsewhere, as another HEAD AND NECK CANCER CARE SPELL.
National Codes:
Y Yes
N No
References:
National Cancer Data Set Version 1.3_ISB October 2002
Change Type:
New attribute
QUALITY OF LIFE
DSCN 54/2002
Page 21 of 41
A quality of life measurement at the time of diagnosis for a CANCER CARE SPELL
for Head & Neck cancers only. The measurement tool is the UW-QOL (University of
Washington Quality of Life) head and neck questionnaire. Further information can be
found in the Head & Neck Appendix on
http://nww.nhsia.nhs.uk/cancer/pages/dataset/datamanuals.asp
References:
National Cancer Data Set Version 1.3_ISB October 2002
Change Type:
New attribute
RELATION WITH CANCER
An indicator of whether the second PERSON in the PERSON RELATIONSHIP has
had cancer.
National Codes:
Y Yes
N No
References:
National Cancer Data Set Version 1.3_ISB October 2002
Change Type:
New attribute
RELATIONSHIP TO PERSON
The relationship of the second PERSON to the first PERSON. Note that this is a
limited list.
National Codes:
A Aunt
B Brother
C Child unspecified
D Daughter
F Father
G Grandparent
H Husband
K Cousin
M Mother
N Nephew/niece
P Parent unspecified
S Sister
U Uncle
W Wife
X Grandchild unspecified
Z Son
DSCN 54/2002
Page 22 of 41
References:
National Cancer Data Set Version 1.3_ISB October 2002
Change Type:
New attribute
S CATEGORY FINAL PRETREATMENT
The final pre-treatment measure of the stage based on the serum tumour marker for
testis cancer only. This is coded according to the UICC (Union Internationale Contre
le Cancer) coding (5th Edition, 1997) guidelines. Further information can be found in
the Urology Appendix on:
http://nww.nhsia.nhs.uk/cancer/pages/dataset/datamanuals.asp
References:
National Cancer Data Set Version 1.3_ISB October 2002
Change Type:
New attribute
SERUM TUMOUR MARKER PSA
The serum tumour marker elevation of Prostate Specific Antigen for prostate cancer
recorded at the time of diagnosis for a UROLOGICAL CANCER CARE SPELL.
References:
National Cancer Data Set Version 1.3_ISB October 2002
Change Type:
New attribute
SMOKING STATUS
The smoking status of the PATIENT at the time their TOBACCO USAGE is
recorded.
National Codes:
1 Current smoker
2 Ex-smoker
3 Non-smoker – history unknown
4 Never smoked
9 Unknown
References:
National Cancer Data Set Version 1.3_ISB October 2002
Change Type:
New attribute
DSCN 54/2002
Page 23 of 41
SURGICAL URGENCY
The surgical urgency relating to an operative procedure. A classification based on the
National Confidential Enquiry into Perioperative Deaths (NCEPOD) classification of
operation urgency. Used for local surgical and anaesthesia audits.
National Codes:
01 Elective – operation pre-planned at a time to suit both patient and surgeon
02 Scheduled – an early operation usually within 3 weeks. Often applicable to
cancer surgery
03 Urgent – operation as soon as possible and usually within 24hrs
04 Immediate – requires immediate surgery without time for preparation or
resuscitation
References:
National Cancer Data Set Version 1.3_ISB October 2002
Change Type:
New attribute
SYMPTOMS FIRST NOTED DATE
The month and year that the PATIENT first noted any symptoms related to the site of
cancer recorded as part of a CANCER CARE SPELL.
Change Type:
New attribute
TOBACCO CHEWING HISTORY
The PATIENT’s history of tobacco chewing as part of their TOBACCO USAGE.
National Codes:
1 Current
2 Ex
3 Never
References:
National Cancer Data Set Version 1.3_ISB October 2002
Change Type:
New attribute
TOBACCO USAGE TYPE
The type of a PATIENT’s TOBACCO USAGE.
National Codes:
G Cigarettes
P Pipe
DSCN 54/2002
Page 24 of 41
W Chewing
References:
National Cancer Data Set Version 1.3_ISB October 2002
Change Type:
New data item note
ALCOHOL STATUS
Format/length:
HES item:
National Codes:
Default Codes:
Change Type:
n1
Press Definition button for the National Codes
9 – Not known
New data item note
BREAST CANCER NURSE SEEN
Format/length:
HES item:
National Codes:
Default Codes:
Change Type:
an1
Press Definition button for the National Codes
9 – Not known
New data item note
CLINICAL EXAMINATION FINDINGS (BREAST CANCER)
Format/length:
HES item:
National Codes:
Default Codes:
an2
CLINICAL EXAMINATION FINDINGS (BREAST CANCER) is the same as
attribute CLINICAL EXAMINATION FINDINGS.
Change Type:
New data item note
CLINICAL SIGN OR SYMPTOM (ICD)
Format/length:
HES item:
an6
DSCN 54/2002
Page 25 of 41
National Codes:
Default Codes:
CLINICAL SIGN OR SYMPTOM classified using ICD coding.
See DIAGNOSTIC CODING for details of coding.
Change Type:
New data item note
CODE OF RESPONSIBLE HCP (OPCS)
Format/length:
HES item:
National Codes:
Default Codes:
an8
See Table below
C9999998 – Consultant, GMC code not known
D9999998 – Dentist, DPB code not known
G9999998 – General Medical Practitioner, GMP Code not
known
H9999998 – Other health care professional
M9999998 – Midwife
N9999998 – Nurse
P9999998 – Non-consultant doctor, GMC code not known
CODE OF RESPONSIBLE HCP (OPCS) is the GMC, DPB or other professional
registration code for the HEALTH CARE PROFESSIONAL undertaking the OPCS-4
classified operative PATIENT PROCEDURE. This will usually, but not exclusively,
be the lead health care professional or a junior member of the same team.
Where the actual professional registration code is unknown or the professional is not a
doctor or a dentist, the appropriate default code should be used.
Change Type:
New data item note
COLONOSCOPY INCOMPLETE REASON
Format/length:
HES item:
National Codes:
Default Codes:
Change Type:
n1
Press Definition button for the National Codes
New data item note
COLORECTAL NURSE OR STOMA THERAPIST SEEN
DSCN 54/2002
Page 26 of 41
Format/length:
HES item:
National Codes:
Default Codes:
an1
This is derived from the presence of COLORECTAL OR STOMA NURSE SEEN
DATE.
National codes:
Y – Yes
N – No
Change Type:
New data item note
COLORECTAL OR STOMA NURSE SEEN DATE
Format/length:
HES item:
National Codes:
Default Codes:
Change Type:
ccyymmdd
Press Definition button for the National Codes
New data item note
CO-MORBIDITY (ICD)
Format/length:
HES item:
National Codes:
Default Codes:
an6
99 Not known
This is PATIENT DIAGNOSIS with a PATIENT DIAGNOSIS CODING
SIGNIFICANCE of not ‘Primary’.
This is primarily to record whether the patient has Pancreatitis or Diabetes and if so
what type, when used for a CANCER CARE SPELL.
See DIAGNOSTIC CODING for details on coding.
Change Type:
New data item note
CONTACT DATE (DIETITIAN INITIAL)
DSCN 54/2002
Page 27 of 41
Format/length:
HES item:
National Codes:
Default Codes:
ccyymmdd
This is the CONTACT DATE of the INITIAL CONTACT with a PROFESSIONAL
STAFF GROUP TYPE c. ‘Dietetics’.
Change Type:
New data item note
COPD PRESENT
Format/length:
HES item:
National Codes:
Default Codes:
Change Type:
an1
Press Definition button for the National Codes
9 - Not known
Change data item note description
DIAGNOSTIC CODING
Format/length:
annnaa for ICD-10 (see ICD 10th Revision), an7 for
Clinical Terms (The Read Codes)
DIAGNSIS
HES item:
National Codes:
Default Codes:
This is a DIAGNOSIS.
See Clinical Coding for International Classification of Diseases (ICD-10) and Read
Coded Clinical Terms.
The remaining description is unchanged.
Change Type:
New data item note
DIAGNOSTIC ROUTE
Format/length:
HES item:
National Codes:
Default Codes:
n1
Press Definition button for the National Codes
9 – Not known
DSCN 54/2002
Page 28 of 41
Change Type:
New data item note
DRUG ROUTE OF ADMINISTRATION
Format/length:
HES item:
National Codes:
Default Codes:
Change Type:
n2
Press Definition button for the National Codes
New data item note
ENDOCRINE THERAPY TYPE
Format/length:
HES item:
National Codes:
Default Codes:
Change Type:
an1
Press Definition button for the National Codes
New data item note
ESTIMATED PACK YEARS
Format/length:
HES item:
National Codes:
Default Codes:
n3
ESTIMATED PACK YEARS is the estimated number of pack years of smoking. This
is the average number of cigarettes smoked per day divided by 20 (a pack) multiplied
by the number of years smoked. This is calculated from the CIGARETTES PER DAY
and NUMBER OF YEARS SMOKED.
For example: 20 cigarettes smoked per day for 20 years equals 20 pack years and 10
cigarettes per day for 20 years equals 10 pack years.
References:
National Cancer Data Set Version 1.3_ISB October 2002
Change Type:
New data item note
DSCN 54/2002
Page 29 of 41
FAMILY OR SURNAME OF RELATION WITH CANCER
Format/length:
HES item:
National Codes:
Default Codes:
This is the PERSON NAME WORD TYPE b. ‘Family or Surname’ of the PERSON
who is a RELATION WITH CANCER to the PERSON with a CANCER CARE
SPELL.
Change Type:
New data item note
FEV1 ABSOLUTE AMOUNT
Format/length:
HES item:
National Codes:
Default Codes:
Change Type:
n.nn
Press Definition button for the National Codes
New data item note
FEV1 PERCENTAGE
Format/length:
HES item:
National Codes:
Default Codes:
Change Type:
nn.nn
Press Definition button for the National Codes
New data item note
GRADE OF RESPONSIBLE HCP
Format/length:
HES item:
National Codes:
Default Codes:
Change Type:
n1
Press Definition button for the National Codes
9 – Not known
New data item note
DSCN 54/2002
Page 30 of 41
GYNAECOLOGICAL ONCOLOGY ACCREDITATION
Format/length:
HES item:
National Codes:
Default Codes:
Change Type:
an1
Press Definition button for the National Codes
9 - Not known
New data item note
LMP DATE
Format/length:
HES item:
National Codes:
Default Codes:
Change Type:
ccyymmdd
Press Definition button for the National Codes
New data item note
MARKER LYMPH NODE RESULT
Format/length:
HES item:
National Codes:
Default Codes:
Change Type:
an1
Press Definition button for the National Codes
8 – Not applicable
9 – Not known
New data item note
MENSTRUAL STATUS
Format/length:
HES item:
National Codes:
Default Codes:
Change Type:
n1
Press Definition button for the National Codes
9 – Not known
New data item note
NUTRITIONAL PROCEDURE (OPCS)
Format/length:
HES item:
an4
DSCN 54/2002
Page 31 of 41
National Codes:
Default Codes:
This is the code for the PATIENT PROCEDURE that has been performed on the
PATIENT to enable nutritional support as part of the HEAD AND NECK CANCER
CARE SPELL.
See PROCEDURE CODING for details on coding.
Change Type:
New data item note
NUTRITIONAL PROCEDURE COMPLICATION (ICD)
Format/length:
HES item:
National Codes:
Default Codes:
an6
This is the CLINICAL DIAGNOSIS FOR PERSON to describe a complication
arising from a NUTRITIONAL PROCEDURE (OPCS).
See DIAGNOSTIC CODING for details on coding.
Change Type:
New data item note
NUTRITIONAL SUPPORT PROVIDED (CANCER)
Format/length:
HES item:
National Codes:
Default Codes:
an1
This is derived from the presence of NUTRITIONAL SUPPORT PROVIDED TYPE.
National Codes:
Y Yes
N No
References:
National Cancer Data Set Version 1.3_ISB October 2002
Change Type:
New data item note
NUTRITIONAL SUPPORT PROVIDED TYPE (CANCER)
DSCN 54/2002
Page 32 of 41
Format/length:
HES item:
National Codes:
Default Codes:
an1
9 – Not known
NUTRITIONAL SUPPORT PROVIDED TYPE (CANCER) is the same as attribute
NUTRITIONAL SUPPORT PROVIDED TYPE.
Change Type:
New data item note
PATIENT HISTORY (CANCER DIAGNOSIS)
Format/length:
HES item:
National Codes:
Default Codes:
an6
PATIENT HISTORY (CANCER DIAGNOSIS) is the primary cancer of a previous or
subsequent CANCER CARE SPELL. It is the PATIENT DIAGNOSIS that defines
the CANCER CARE SPELL
It is similar to data item note PRIMARY DIAGNOSIS (ICD).
Change Type:
New data item note
PATIENT PROCEDURE RESULT (COLONOSCOPY)
Format/length:
HES item:
National Codes:
Default Codes:
n1
9 - Not known
PATIENT PROCEDURE RESULT (COLONOSCOPY) is the same as attribute
PATIENT PROCEDURE RESULT.
Change Type:
New data item note
POSSUM SCORE (AFTER SURGERY)
Format/length:
HES item:
n3
DSCN 54/2002
Page 33 of 41
National Codes:
Default Codes:
Change Type:
Press Definition button for the National Codes
New data item note
POSSUM SCORE (AT DIAGNOSIS)
Format/length:
HES item:
National Codes:
Default Codes:
Change Type:
n3
Press Definition button for the National Codes
New data item note
PREVIOUS TREATMENT ELSEWHERE
Format/length:
HES item:
National Codes:
Default Codes:
Change Type:
an1
Press Definition button for the National Codes
9 – Not known
New data item note
PRIMARY DIAGNOSIS OF RELATION (ICD)
Format/length:
HES item:
National Codes:
Default Codes:
an6
This is the PRIMARY DIAGNOSIS (ICD) related to the CANCER CARE SPELL of
the second PERSON in the PERSON RELATIONSHIP who is a RELATION WITH
CANCER.
Change Type:
Change data item note definition
PROCEDURE CODING
Format/length:
HES item:
annn for OPCS-4, an7 for Clinical Terms (The Read
Codes)
OPERATN
DSCN 54/2002
Page 34 of 41
National Codes:
Default Codes:
X998 - Out-patient procedure carried out but no
appropriate OPCS-4 code available
X999 - No out-patient procedure carried out
This is a CLINICAL CLASSIFICATION CODE.
See Clinical Coding for Classification of Surgical Operations and Procedures (OPCS-
4) and Read Coded Clinical Terms.
The remaining description is unchanged
Change Type:
New data item note
QUALITY OF LIFE (AT DIAGNOSIS)
Format/length:
HES item:
National Codes:
Default Codes:
n4
QUALITY OF LIFE (AT DIAGNOSIS) is the same as attribute QUALITY OF LIFE.
Change Type:
New data item note
RELATIONSHIP TO PERSON
Format/length:
HES item:
National Codes:
Default Codes:
Change Type:
an1
Press Definition button for the National Codes
New data item note
S CATEGORY FINAL PRETREATMENT
Format/length:
HES item:
National Codes:
Default Codes:
Change Type:
an2
Press Definition button for the National Codes
New data item note
DSCN 54/2002
Page 35 of 41
SERUM TUMOUR MARKER PSA
Format/length:
HES item:
National Codes:
Default Codes:
Change Type:
nnnn.n
Press Definition button for the National Codes
New data item note
SMOKING STATUS
Format/length:
HES item:
National Codes:
Default Codes:
Change Type:
n1
Press Definition button for the National Codes
9 – Not known
New data item note
SURGICAL URGENCY
Format/length:
HES item:
National Codes:
Default Codes:
n2
Press Definition button for the National Codes
99 – Urgency not known
The SURGICAL URGENCY for each of the recorded operative PATIENT
PROCEDURE (OPCS). An operative PATIENT PROCEDURE is identified by the
OPERATIVE PATIENT PROCEDURE INDICATOR Y ‘yes’.
Change Type:
New data item note
SYMPTOMS FIRST NOTED DATE
Format/length:
HES item:
National Codes:
Default Codes:
Change Type:
ccyymm
Press Definition button for the National Codes
New data item note
DSCN 54/2002
Page 36 of 41
THEATRE CASE START TIME
Format/length:
HES item:
National Codes:
Default Codes:
Change Type:
hh:mm
Press Definition button for the National Codes
New data item note
TOBACCO CHEWING HISTORY
Format/length:
HES item:
National Codes:
Default Codes:
Change Type:
n1
Press Definition button for the National Codes
9 – Not known
New data item note
TOBACCO USAGE TYPE
Format/length:
HES item:
National Codes:
Default Codes:
Change Type:
an1
Press Definition button for the National Codes
New data item note
YEAR CANCER DIAGNOSED
Format/length:
HES item:
National Codes:
Default Codes:
ccyy
YEAR CANCER DIAGNOSED is derived from DIAGNOSIS DATE (CANCER) for
the primary cancer of a previous or subsequent CANCER CARE SPELL.
Change Type:
New data item note
DSCN 54/2002
Page 37 of 41
YEAR STOPPED SMOKING
Format/length:
HES item:
National Codes:
Default Codes:
ccyy
YEAR STOPPED SMOKING is derived from DATE STOPPED SMOKING.
It is the year that the PATIENT stopped smoking as part of TOBACCO USAGE.
Please address enquiries about this DSCN to:­
Data Standards Team
NHS Information Authority
Aqueous II
Aston Cross
Rocky Lane
Birmingham
B6 5RQ
Tel: 0121 333 0333
DSCN 54/2002
Page 38 of 41
REFERRAL FOR
BREAST
ASSESSMENT
PATIENT
CARE SPELL
CANCER CARE SPELL
COLORECTAL
CANCER CARE
SPELL
BREAST CANCER
CARE SPELL
CLINICAL INTERVENTION
ENDOCRINE
THERAPY
DSCN 54/2002
Page 39 of 41
PERSON ROLE IN
ORGANISATION
CLINICAL
CLASSIFICATION
PERSON
RELATIONSHIP
PATIENT
TOBACCO
USAGE
CARE SPELL
CANCER CARE SPELL
HEAD AND
NECK CANCER
CARE SPELL
LUNG CANCER
CARE SPELL
PERSON
OBSERVATION
PATIENT
PROCEDURE
LUNG CAPACITY
DSCN 54/2002
Page 40 of 41
PERSON
PERSON ROLE IN
ORGANISATION
PATIENT
CLINICAL
CLASSIFICATION
PERSON
OBSERVATION
CLINICAL SIGN
OR SYMPTOM OF
PERSON
CARE SPELL
CANCER CARE SPELL
GYNAECOLOGICAL
UROLOGICAL
CANCER CARE
CANCER CARE
SPELL
SPELL
UPPER GI
CANCER CARE
SPELL
DSCN 54/2002
Page 41 of 41