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					       National Cancer Dataset                                                                                                                                           Waiting times




List of data items required for DSCN 22/2002
(Waiting Times)
This section lists the data items which are required for the collection of ‘Waiting Times’ information, as specified in DSCN 22/2002.

The Cancer Dataset has been designed with a ‘modular’ structure i.e. sections of the dataset can be collected at various points on the ‘patient pathway’. For instance, it is
expected that the ‘demographics’ section would be collected at various points of contact with the patient.

However, the Waiting Times DSCN and associated Data Standards have adopted a more linear approach and Data Standards mandate that a unique data item name is
required to identify the particular instance of the data.

The table below shows all the data items required for DSCN 22/2002.
Where a data item has exactly the same name and definition as a generic data item in the Cancer Dataset, then no further information is provided.
Where a data item is required to be collected at a particular point in the patient journey, the data item is listed with its description and also with a cross-reference to the
generic Cancer Dataset item.

         Data item                                                          Description                                         Cancer Dataset Item
1.1      NHS NUMBER                                                         as NCDS Core
         [NHS Number]
2.16     SOURCE OF REFERRAL FOR OUT-PATIENTS                                as NCDS Core

2.5      CANCER REFERRAL DECISION DATE                                      as NCDS Core
         [Date of decision to refer]
2.4      CANCER REFERRAL PRIORITY TYPE                                      as NCDS Core
         [Priority of referral]

2.6      REFERRAL REQUEST RECEIVED DATE                                     as NCDS Core
         [Date of receipt of referral]
2.12     URGENT CANCER REFERRAL TYPE                                        as NCDS Core

2.9      DATE FIRST SEEN                                                    as NCDS Core
         [Date first seen]
         ORGANISATION CODE (PROVIDER FIRST SEEN)                            The organisation code of the Unit at which the      1.3 ORGANISATION CODE (CODE OF
                                                                            patient is first seen.                              PROVIDER)
                                                                                                                                [Provider Code]




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      National Cancer Dataset                                                                                                        Waiting times




        Data item                                  Description                                           Cancer Dataset Item
2.2     REFERRING ORGANISATION CODE                as NCDS Core
        [Organisation of referral]

        ORGANISATION CODE (PROVIDER FIRST CANCER   The organisation code of the unit in which the        1.3 ORGANISATION CODE (CODE OF
        SPECIALIST)                                patient is first seen by an appropriate cancer        PROVIDER)
                                                   specialist.                                           [Provider Code]

        CANCER SPECIALIST REFERRAL DATE            The appropriate specialist is the person or           2.5 CANCER REFERRAL DECISION DATE
                                                   persons who are most able to progress the             [Date of decision to refer]
                                                   diagnosis of the primary tumour. For referrals
                                                   direct to the appropriate specialist, this will be
                                                   the same as cancer referral decision date.
                                                   Record:

                                                       ¨     The date on which the referral was
                                                       made.
                                                       ¨     Date of letter/fax from GP or other
                                                       hospital department.
                                                       ¨     Date of phone call from referring GP or
                                                       other hospital department.
                                                       ¨     Date of cross-referral where the patient
                                                       is already in hospital.
        FIRST SEEN BY SPECIALIST DATE (CANCER)     The appropriate specialist is the person or        2.9 DATE FIRST SEEN
                                                   persons who is/are most able to progress the       [Date first seen]
                                                   diagnosis of the primary tumour. This date
                                                   could be the same as date first seen if that
                                                   consultation was with an appropriate
                                                   specialist. Record:

                                                       ¨     The date of first out-patient
                                                       appointment with appropriate cancer
                                                       specialist.
                                                       ¨     The date of first diagnostic procedure if
                                                       this precedes the first out-patient
                                                       appointment.
                                                       ¨     The date first seen as an emergency, if
                                                       the patient was first seen as an emergency.




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       National Cancer Dataset                                                                                                          Waiting times




         Data item                                        Description                                      Cancer Dataset Item
                                                              ¨     The date the patient was first seen
                                                              following recall by screening unit.
2.14     WAITING TIME ADJUSTMENT (FIRST SEEN)             as NCDS Core
2.15     WAITING TIME ADJUSTMENT REASON (FIRST SEEN)      as NCDS Core
2.11     DELAY REASON COMMENT (FIRST SEEN)                as NCDS Core
2.10     DELAY REASON REFERRAL TO FIRST SEEN (CANCER)     as NCDS Core
         ORGANISATION CODE (PROVIDER FIRST DIAGNOSTIC     The organisation code of the unit in which the   1.3 ORGANISATION CODE (CODE OF
         TEST)                                            first diagnostic test takes place                PROVIDER)
                                                                                                           [Provider Code]

         CLINICAL INTERVENTION DATE (FIRST DIAGNOSTIC     The date of the first major diagnostic test. This 3.2 CLINICAL INTERVENTION DATE (CANCER
         TEST)                                            is the test that will move the level of suspicion of IMAGING)
                                                          cancer from "possible/probable" (based on            [Date of imaging]
                                                          history, clinical examination or blood count) to
                                                          "highly probable/certain". It does not refer to the
                                                          first test undergone, prior to referral to hospital,
                                                          such as a blood count, chest x-ray or blood tests
                                                          of liver function.

                                                          Depending on the diagnostic test this will be one 7.9 PROCEDURE DATE
                                                          of:                                               [Date of surgery]
                                                          3.2 – CLINICAL INTERVENTION DATE
                                                          (CANCER IMAGING)
                                                          [Date of imaging]
                                                          7.9 – PROCEDURE DATE
                                                          [Date of surgery]
5.1      MDT DISCUSSION INDICATOR                         as NCDS Core
5.2      MULTIDISCIPLINARY TEAM DISCUSSION DATE           as NCDS Core
2.13     CANCER STATUS                                    as NCDS Core
4.2      PRIMARY DIAGNOSIS (ICD)                          as NCDS Core
4.3      TUMOUR LATERALITY                                as NCDS Core
         ORGANISATION CODE (PROVIDER DECISION TO TREAT)   The organisation code of the Unit where the      1.3 ORGANISATION CODE (CODE OF
                                                          decision to treat is made                        PROVIDER)
                                                                                                           [Provider Code]




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         Data item                                       Description                                       Cancer Dataset Item
7.5      DECISION TO TREAT DATE (SURGERY)                as NCDS Core
9.4      DECISION TO TREAT DATE (ANTI-CANCER DRUG        as NCDS Core
         REGIMEN)
10.3     DECISION TO TREAT DATE (TELETHERAPY TREATMENT   as NCDS Core
         COURSE)
11.3     DECISION TO TREAT DATE (BRACHYTHERAPY           as NCDS Core
         TREATMENT COURSE)
12       DECISION TO TREAT DATE (SPECIALIST PALLIATIVE   as NCDS Core
         TREATMENT COURSE)
16.9     DECISION TO TREAT DATE (ACTIVE MONITORING)      as NCDS Core
         ORGANISATION CODE (PROVIDER FIRST TREATMENT)    The organisation code of the trust/provider at    1.3 ORGANISATION CODE (CODE OF
                                                         which the patient receives the first definitive   PROVIDER)
                                                         treatment.                                        [Provider Code]

         PLANNED CANCER TREATMENT TYPE (FIRST            This is the first definitive treatment type planned. 5.6 PLANNED CANCER TREATMENT TYPE
         DEFINITIVE)                                     This is the first intervention which is intended to [Management modality]
                                                         remove or shrink the tumour and/or to palliate
                                                         the effects of the cancer.                           Please note that code 07 – biological is not
                                                                                                              applicable to DSCN 22/2002 (waiting times).
7.8      START DATE (SURGERY HOSPITAL PROVIDER SPELL)    as NCDS Core
9.10     START DATE (ANTI-CANCER DRUG REGIMEN)           as NCDS Core
10.8     START DATE (TELETHERAPY TREATMENT COURSE)       as NCDS Core
11.9     START DATE (BRACHYTHERAPY TREATMENT COURSE)     as NCDS Core
12       START DATE (SPECIALIST PALLIATIVE TREATMENT     as NCDS Core
         COURSE)
16.10 START DATE (ACTIVE MONITORING)                     as NCDS Core
16.1     WAITING TIME ADJUSTMENT (DECISION TO TREAT)     as NCDS Core
16.3     WAITING TIME ADJUSTMENT REASON (DECISION TO     as NCDS Core
         TREAT)
16.2     WAITING TIME ADJUSTMENT (TREATMENT)             as NCDS Core
16.4     WAITING TIME ADJUSTMENT REASON (TREATMENT)      as NCDS Core
16.7     DELAY REASON COMMENT (REFERRAL TO TREATMENT) as NCDS Core




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         Data item                                      Description         Cancer Dataset Item
16.8     DELAY REASON COMMENT (DECISION TO TREATMENT)   as NCDS Core
16.5     DELAY REASON REFERRAL TO TREATMENT (CANCER)    as NCDS Core
16.6     DELAY REASON DECISION TO TREATMENT (CANCER)    as NCDS Core




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       National Cancer Dataset                                                                                                                           Cancer Registration




Subsets

    NATIONAL CANCER DATASET
      version 4.5             part 3 of 3

    SUBSETS
    Cancer Registration Dataset
     (from Cancer Dataset Version 4.5)
    This is an extract of the above, showing the data items required for the Cancer Registry dataset.

        Data Item                        Description                                      Purpose                               Codes and Classifications
                                                                                                                                Note: all dates should be held in format suitable
                                                                                                                                for date manipulations to take place, and should
                                                                                                                                hold four character years. The actual format
                                                                                                                                held will depend on the database being used.


                                         It is anticipated that some of the demographic data items listed below will be collected by every provider with which the
1       Demographics                     patient has contact.

                                         Where this information is exchanged, the appropriate data item name should be used to identify the particular instance of the
                                         data (See Description column).
1.1    NHS NUMBER                        as NCDS Core                                Used for unique identification to    NHS Data Dictionary
       [NHS Number]                                                                  match records from different service
                                                                                     providers.
1.2    LOCAL PATIENT IDENTIFIER as NCDS Core                                              Used for unique identification to link  NHS Data Dictionary
       Hospital Number]                                                                   events within a single service provider


1.3    ORGANISATION CODE                 as NCDS Core                                     To enable analysis by Provider Code. NHS Data Dictionary Supporting Information,
       (CODE OF PROVIDER)                                                                                                      Administrative Codes, NHS Trust
       [Provider Code]




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      Data Item                        Description      Purpose                                Codes and Classifications
1.4   CARE SPELL IDENTIFIER            as NCDS Core     Used to link all activities for the    NHS Data Dictionary
      [Unique Care Spell Number]                        patient to the same care spell.

1.5   PERSON FAMILY NAME               as NCDS Core     Used for unique identification to link NHS Data Dictionary
      [Surname]                                         records where the new NHS number
                                                        is not available (e.g. to previous
                                                        tumours, genetic requests, events
                                                        carried out in private hospitals). It
                                                        should be possible to phase out the
                                                        use of surname once the use of NHS
                                                        number becomes universal.


1.6   PERSON GIVEN NAME                as NCDS Core     Used for unique identification to link NHS Data Dictionary
      [Forenames]                                       records where the new NHS number
                                                        is not available (e.g. to previous
                                                        tumours, genetic requests, events
                                                        carried out in private hospitals). It
                                                        should be possible to phase out the
                                                        use of forename once the use of NHS
                                                        number becomes universal.


1.7   PATIENT USUAL ADDRESS            as NCDS Core     To derive and/or verify Postcode and NHS Data Dictionary
      (AT DIAGNOSIS)                                    for flagging cancers at
      [Address at Date of Diagnosis]                    NHSCR/approved ‘medical research’
                                                        cohort studies/other research


1.8   POSTCODE OF USUAL               as NCDS Core      The address at diagnosis is used to      NHS Data Dictionary
      ADDRESS (AT DIAGNOSIS)                            enable analysis by locality of patients.
      [Postcode at Date of Diagnosis]



1.9   SEX                              as NCDS Core     To enable analysis by sex.             NHS Data Dictionary
      [Sex]




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       Data Item                              Description      Purpose                               Codes and Classifications
1.10   PERSON BIRTH DATE                      as NCDS Core     To enable age at diagnosis to be         NHS Data Dictionary
       [Date of Birth]                                         established for epidemiological and      e-GIF Date Format "CCYY-MM-DD".
                                                               survival analyses. To enable analysis
                                                               by birth cohort and to assist linkage at
                                                               ONS/NHSCR (and registries) for
                                                               women who have changed their name
                                                               on marriage (or back on
                                                               separation/divorce).

1.11   GMP (CODE OF           as NCDS Core                     *To enable analysis by GP Code        NHS Data Dictionary
       REGISTEREDOR REFERRING
       GMP)
       [GP Code]                                               To enable derivation of GP Practice
                                                               Code and GP PCG/PCT code
       (This need only be collected by
       those sites who find it difficult to
       collect the GP Practice Code
       below)

1.12   CODE OF GP PRACTICE                    as NCDS Core     To enable analysis by GP Practice     NHS Data Dictionary Supporting Information,
       (REGISTERED GMP)                                        Code                                  Administrative codes, GP Practice (6 character
       [GP Practice Code]                                                                            code allocated by PPA)


1.13   ORGANISATION CODE                      as NCDS Core     To enable analysis by GP PCT Code     NHS Data Dictionary
       (RESPONSIBLE PCT)
       [GP PCG/PCT Code]
       (This need not be collected
       directly by clinical staff)




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       Data Item                     Description      Purpose                              Codes and Classifications
1.14   PERSON FAMILY NAME (AT        as NCDS Core     Used for unique identification to link NHS Data Dictionary
       BIRTH)                                         previous records where the new NHS
       [Surname at Birth]                             number is not available (e.g. to
                                                      previous tumours, genetic requests).
                                                      It should be possible to phase out the
                                                      use of surname at birth once the use
                                                      of NHS number becomes universal.



1.15   ETHNIC CATEGORY               as NCDS Core     To enable analysis by ethnicity.     NHS Data Dictionary
       [Ethnic Category]                                                                   White
                                                                                           A British
                                                                                           B Irish
                                                                                           C Any other white background

                                                                                           Mixed
                                                                                           D White and Black Caribbean
                                                                                           E White and Black African
                                                                                           F White and Asian
                                                                                           G Any other mixed background

                                                                                           Asian or Asian British
                                                                                           H Indian
                                                                                           J Pakistani
                                                                                           K Bangladeshi
                                                                                           L Any other Asian background

                                                                                           Black or Black British
                                                                                           M Caribbean
                                                                                           N African
                                                                                           P Any other black background

                                                                                           Other Ethnic Groups
                                                                                           R Chinese
                                                                                           S Any other ethnic group




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      Data Item                     Description                                   Purpose                               Codes and Classifications
                                    For ‘two-week wait’ referrals, only one referral needs to be recorded. This will be the referral to the consultant (or team) who
2      Referrals                    makes the actual diagnosis of cancer.

                             If the original GP referral was to a non-cancer specialist, with subsequent referral to a cancer specialist, then record all
                             referrals.
                             Where this information is exchanged, the appropriate data item name should be used to identify the particular instance of the
                             data (See Description column).
                             The Cancer Data Manual will detail particular requirements for screening, where the diagnosis takes place within screening
                             services and referral is for treatment. Relevance of the data items in this section to the screening services will be investigated
                             further.
2.1   SOURCE OF REFERRAL FOR as NCDS Core                                  *To identify patterns of referral.     NHS Data Dictionary
      CANCER
      [Source of Referral]

2.2   REFERRING ORGANISATION as NCDS Core                                         *To identify patterns of referral.    NHS Data Dictionary Supporting Information,
      CODE                                                                                                              Administrative Codes, NHS Trust Site (5
      [Organisation of Referral]                                                                                        character code starting with ‘R’) or GP Practice
                                                                                                                        (6 character code)


2.3   REFERRER CODE                 as NCDS Core                                  *To identify patterns of referral.    NHS Data Dictionary Supporting Information,
      [Referred by]                                                                                                     Administrative Codes, Practitioner Code (8
                                                                                                                        character code starting with ‘G’, allocated by the
                                                                                                                        PPA, for GPs. 8 character code, starting with C,
                                                                                                                        allocated by DoH, for consultants. 8 character
                                                                                                                        code, starting with D, allocated by DPB, for
                                                                                                                        General Dental Practitioners.)
                                                                                                                        A coding system for nurses is being
                                                                                                                        investigated.
                                                                                                                        A default code X9999998 can be used where
                                                                                                                        the referral is not from a consultant or GP e.g.
                                                                                                                        self-referral

2.4   CANCER REFERRAL               as NCDS Core                                  *For analysis of waiting times.       01 - Urgent referral for suspected cancer from a
      PRIORITY TYPE                                                                                                     General Medical Practitioner or General Dental
      [Priority of Referral]                                                                                            Practitioner
                                                                                                                        02 - Other referral source or urgency




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       Data Item                       Description       Purpose                                 Codes and Classifications
2.5    CANCER REFERRAL                 as NCDS Core      *To establish the date on which the          e-GIF Date Format "CCYY-MM-DD"
       DECISION DATE                                     referring clinician first initiates referral
       [Date of Decision to Refer]                       to the specialist involved in the
                                                         diagnostic process.

                                                         To identify length of delay in the
                                                         handling of referrals
2.6    REFERRAL REQUEST                as NCDS Core      *To establish the start date for the    e-GIF Date Format "CCYY-MM-DD"
       RECEIVED DATE                                     specialist-based diagnosis and
       [Date of Receipt of Referral]                     management process.
                                                         To identify length of delay in the
                                                         handling of referrals.
2.7    CONSULTANT CODE                 as NCDS Core      *To monitor the proportion of cancer    NHS Data Dictionary Supporting Information,
       [Referred to]                                     patients referred to a cancer site      Administrative Codes (Practitioner Code for a
                                                         specialist or a cancer site specific    Consultant)
                                                         team.
2.8    MAIN SPECIALTY CODE             as NCDS Core      *To monitor the proportion of cancer    NHS Data Dictionary Supporting Information,
       [Specialty Function Code]                         patients referred to a particular       Specialty function codes.
       (Can be derived from consultant                   specialty.
       code)

2.9    DATE FIRST SEEN                 as NCDS Core      *To measure any delay between           e-GIF Date Format "CCYY-MM-DD"
       [Date First Seen]                                 referral and first assessment by the
                                                         specialist team.

2.10   DELAY REASON REFERRAL           as NCDS Core      *For analysis of waiting times          01 - Clinic cancellation 1
       TO FIRST SEEN (CANCER)                                                                    02 – Out-patient capacity inadequate (i.e. no
                                                                                                 cancelled clinic, but not enough slots for this
                                                                                                 patient)
                                                                                                 03 - Administrative delay (e.g. failed to be
                                                                                                 rebook after DNA, lost referral, etc)
                                                                                                 04 – Not received within 24 hours
                                                                                                 99 - Other
2.11   DELAY REASON COMMENT            as NCDS Core      *To record the actual reason why a      Free text.
       (FIRST SEEN)                                      patient was not seen within the ‘two-
                                                         week- target.




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       National Cancer Dataset                                                                                             Cancer Registration




       Data Item                     Description       Purpose                                    Codes and Classifications
2.12   URGENT CANCER                 as NCDS Core      *To record, for waiting time purposes, 01 - Suspected breast cancer
       REFERRAL TYPE                                   the site of the suspected cancer. For 02 - Suspected children’s cancer
                                                       analysis purposes.                     03 - Suspected lung cancer
                                                                                              04 - Suspected haematological malignancies
                                                                                              excluding acute leukaemia
                                                                                              05 - Suspected acute leukaemia
                                                                                              06 - Suspected upper gastrointestinal cancers
                                                                                              07 - Suspected lower gastrointestinal cancers
                                                                                              08 - Suspected skin cancers
                                                                                              09 - Suspected gynaecological cancers
                                                                                              10 - Suspected brain/central nervous system
                                                                                              11 - Suspected urological cancers (excluding
                                                                                              testicular)
                                                                                              12 - Suspected testicular cancers
                                                                                              13 - Suspected head & neck cancers
                                                                                              14 - Suspected sarcomas
                                                                                              15 - Other suspected cancers


2.13   CANCER STATUS                 as NCDS Core      *The purpose of this item is to identify   1 - Suspected cancer (default)
                                                       urgent GP referrals for suspected          2 - Diagnosis of cancer confirmed
                                                       cancer who are subsequently                3 - No cancer diagnosis identified by Trust
                                                       diagnosed with cancer. This item is        4 - No cancer diagnosis – determined
                                                       used to flag records that need data        automatically
                                                       recorded on first definitive treatment
                                                       (cancer patients) and those who do
                                                       not (non-cancer patients).



2.14   WAITING TIME ADJUSTMENT as NCDS Core            *For analysis of waiting times             n3
       (FIRST SEEN)

2.15   WAITING TIME ADJUSTMENT as NCDS Core            For analysis of waiting times              Out-patient Services
       REASON (FIRST SEEN)
                                                                                                  1 - No adjustment to waiting time
                                                                                                  2 - Patient cancellation: A patient cancelled a
                                                                                                  booked out-patient appointment (giving
                                                                                                  advance warning)




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2.15    WAITING TIME ADJUSTMENT as NCDS Core          For analysis of waiting times
       National Cancer Dataset
        REASON (FIRST SEEN)                                                                                           Cancer Registration




       Data Item                     Description      Purpose                                Codes and Classifications
                                                                                             3 – DNA: a patient Did Not Attend an out-patient
                                                                                             appointment (no advance warning given).


                                                                                             4 - Patient choice: A patient refused an
                                                                                             appointment within two weeks before being
                                                                                             offered an appointment. These patients will be
                                                                                             excluded from two week wait monitoring but
                                                                                             included in monitoring of the treatment targets.


                                                                                             In-patient services
                                                                                             1 - No adjustment to waiting time
                                                                                               5 - Self deferral
                                                                                               6 - Suspension - medical reasons
                                                                                               7 - Suspension - patient reasons
2.16   SOURCE OF REFERRAL FOR as NCDS Core            For Analysis of Waiting Times.           National Codes:
       OUT-PATIENTS                                   The Waiting Times group needed a         The codes in italics below are specified in
                                                      different data item from 2.1 SOURCE DSCN 22/2002 as ‘not to be input’ as they
                                                      OF REFERRAL FOR CANCER,                  are not applicable to waiting times.
                                                      which has a wider description – the
                                                      definition here is for referrals to out-
                                                      patients only.

                                                                                             Initiated by the CONSULTANT responsible for
                                                                                             the CONSULTANT OUT-PATIENT EPISODE

                                                                                             01 - following an emergency admission
                                                                                             02 - following a domiciliary visit
                                                                                             10 - following an A&E attendance
                                                                                             11- other

                                                                                             Not initiated by the CONSULTANT responsible
                                                                                             for the CONSULTANT OUT-PATIENT
                                                                                             EPISODE

                                                                                             03 - referral from General Medical Practitioner
                                                                                             04 - referral from an A&E department




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      National Cancer Dataset                                                                                                                        Cancer Registration




      Data Item                     Description                                    Purpose                                  Codes and Classifications
                                                                                                                            05 referral from a Consultant, other than in an
                                                                                                                            A&E department
                                                                                                                            06 - self-referral
                                                                                                                            07 - referral from Prosthetist
                                                                                                                            92 - General Dental Practitioner
                                                                                                                            93 - Community Dental Service
                                                                                                                            08 - other source of referral

                                                                                                                            Note: The classification has been listed in
                                                                                                                            logical sequence rather than alphanumeric
                                                                                                                            order.

                                    This must be collected for all imaging performed to establish diagnosis and/or          Tumour leads will be asked to advise on
3      Imaging                      staging.                                                                                which follow-up imaging should be recorded
                                                                                                                            for their sites.
                                    ‘-oscopies’ should be entered as a procedure. Imaging performed as an
                                    intervention should be entered as a procedure e.g. imaging plus biopsy. Imaging
                                    relevant to a patient's cancer follow-up should be recorded. It is not intended to
                                    record imaging that is not considered to be relevant to cancer follow-up.

3.1   SITE CODE (OF IMAGING)        as NCDS Core                                   Required to bring together all           NHS Data Dictionary Supporting Information,
      [Hospital of imaging]                                                        activities for a patient, which may be   Administrative Codes, NHS Trust Site (5
                                                                                   carried out by different service         character code starting with ‘R’)
                                                                                   providers.
                                                                                   To enable reports and analysis by
                                                                                   hospital and/or cancer network.

3.2   CLINICAL INTERVENTION         as NCDS Core                                   To identify and calculate any delays.    e-GIF Date Format "CCYY-MM-DD"
      DATE (CANCER IMAGING)
      [Date of imaging]

3.3   CANCER IMAGING                The type of imaging technique/equipment used To identify that a patient has received    1 - Standard radiography
      MODALITY                      to produce the image e.g. Ultrasound,        a certain type of imaging e.g. barium      1A - Chest X-ray
      [Imaging Modality]            Mammography                                  enema, mammogram to enable                 1B - Sinus X-ray
                                                                                 monitoring of site specific guidelines.    1C - Mastoid views
                                                                                                                            1D - Orthopantomogram (OPG)
                                                                                                                            1E - Skull base X-rays
                                                                                                                            1F - Angiography
                                                                                                                            1G - Intravenous urography




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3.3    CANCER IMAGING               The type of imaging technique/equipment used To identify that a patient has received
       MODALITY                     to produce the image e.g. Ultrasound,        a certain type of imaging e.g. barium
      National Cancer Dataset
       [Imaging Modality]           Mammography                                  enema, mammogram to enable                                          Cancer Registration
                                                                                 monitoring of site specific guidelines.



      Data Item                     Description                                    Purpose                                 Codes and Classifications
                                                                                                                           1H - Retrograde urography
                                                                                                                           1J - Inferior vena cavography
                                                                                                                           1K - Bone angiography
                                                                                                                           1L - Soft tissue angiography
                                                                                                                           2A - CT Scan with contrast
                                                                                                                           2B - CT scan without contrast
                                                                                                                           3A - MRI scan with contrast
                                                                                                                           3B - MRI scan without contrast
                                                                                                                           3C - MRI cholangiography
                                                                                                                           4 - PET scan
                                                                                                                           5 - Ultrasound
                                                                                                                           5A - Tranabdominal ultrasound
                                                                                                                           5B - Transvaginal ultrasound
                                                                                                                           5C - Doppler ultrasound
                                                                                                                           5D - Transrectal ultrasound
                                                                                                                           5E - Endoscopic ultrasound
                                                                                                                           5F - Laparascopiuc ultrasound
                                                                                                                           6 - Nuclear Medicine imaging
                                                                                                                           6A - Bone scan
                                                                                                                           6B - Other isotope scan
                                                                                                                           6C - Ventilation/Perfusion scan
                                                                                                                           7 - Mammography
                                                                                                                           8 - Barium
                                                                                                                           8A - Barium enema
                                                                                                                           8B - Barium swallow
                                                                                                                           9 - Lymphoscintigraphy
                                                                                                                           99 - Other
                                                                                                                           Please note that this list is not comprehensive;
                                                                                                                           tumour leads will be asked to provide relevant
                                                                                                                           modalities.

3.4   ANATOMICAL EXAMINATION as NCDS Core                                          To identify that a patient has received an5
      SITE                                                                         the above type of image on this         OPCS ‘Z’ Coding.
      [Anatomical Site Examined]                                                   anatomical site, to enable monitoring
                                                                                   of site specific guidelines.




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      Data Item                     Description                                  Purpose                               Codes and Classifications
3.5   INVASIVE LESION SIZE          as NCDS Core                                                                       n3
      (RADIOLOGICAL                                                                                                    In millimeters.
      DETERMINATION)
      [Radiological size]

                                    These fields should record the definitive diagnosis as known to the hospital in    Each tumour lead will be asked to decide if a
4      Diagnosis                    question, based on the information available at the time the items were            working diagnosis of cancer is useful for
                                    completed. There will be only one definitive diagnosis entry held.                 their site and if there is a need for more than
                                                                                                                       one diagnosis entry to be collected.
4.1   DIAGNOSIS DATE (CANCER) as NCDS Core                                       To calculate annual incidence rates   e-GIF Date Format "CCYY-MM-DD" Order of
      [Date of diagnosis]                                                        and to determine the start date for   declining priority:
                                                                                 survival analysis.                    1. Date of first histological or cytological
                                                                                                                       confirmation of this malignancy (with the
                                                                                                                       exception of histology or cytology at autopsy).
                                                                                                                       This date should be, in the following order:
                                                                                                                       a. date when the specimen was taken, or
                                                                                                                       b. date of receipt by the pathologist, or
                                                                                                                       c. date of the pathology report
                                                                                                                       2. Date of admission to hospital because of this
                                                                                                                       malignancy.
                                                                                                                       3. When evaluated at an out-patient clinic only:
                                                                                                                       date of first consultation at the out-patient clinic
                                                                                                                       because of this malignancy.
                                                                                                                       4. Date of diagnosis, other than 1, 2 or 3.
                                                                                                                       5. Date of death, if no information is available
                                                                                                                       other than the fact that the patient has died
                                                                                                                       because of malignancy.
                                                                                                                       6. Date of death, if the malignancy is discovered
                                                                                                                       at autopsy.




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      Data Item                     Description       Purpose                               Codes and Classifications
4.2   PRIMARY DIAGNOSIS (ICD)       as NCDS Core      To establish the numbers of various   an6
      [Primary Site]                                  cancers to enable calculation of      Mappable to ICD-10
                                                      annual incidence rates.

                                                      To allow for an assessment of         Tumour leads will be asked to provide relevant
                                                      subsequent treatment and outcome      sites.
                                                      rates.


4.3   TUMOUR LATERALITY             as NCDS Core      To differentiate tumours in paired    L - Left
      [Laterality]                                    organs.                               R - Right
                                                                                            M - Midline
                                                                                            B - Bilateral
                                                                                            8 - Not applicable
                                                                                            9 – Not known
                                                                                            Tumour leads will be asked which of these are
                                                                                            relevant.




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      Data Item                     Description       Purpose                                  Codes and Classifications
4.4   BASIS OF DIAGNOSIS            as NCDS Core      To establish the certainty of diagnosis Non-microscopic
      (CANCER)                                        and in particular the histological
                                                                                              0 - Death Certificate (The only information
      [Basis of diagnosis]                            confirmation rate for epidemiological
                                                                                              available is from a death certificate)
                                                      analyses.
                                                                                              1 – Clinical (Diagnosis made before death but
                                                                                              without the benefit of any of the following (2- 7))


                                                                                               2 - Clinical Investigation (Includes all diagnostic
                                                                                               techniques (e.g. X-rays, endoscopy, imaging,
                                                                                               ultrasound, exploratory surgery and autopsy)
                                                                                               without a tissue diagnosis)


                                                                                               4 - Specific Tumour Markers (Includes
                                                                                               biochemical and/or immunological markers
                                                                                               which are specific for a tumour site)

                                                                                               Microscopic
                                                                                               5 – Cytology (Examination of cells whether from
                                                                                               a primary or secondary site, including fluids
                                                                                               aspirated using endoscopes or needles. Also
                                                                                               including microscopic examination of peripheral
                                                                                               blood films and trephine bone marrow
                                                                                               aspirates).

                                                                                               6 - Histology of a metastasis (Histological
                                                                                               examination of tissues from a metastasis,
                                                                                               including autopsy specimens)

                                                                                               7 - Histology of a primary tumour (Histological
                                                                                               examination of tissue from the primary tumour,
                                                                                               however obtained, including all cutting and
                                                                                               bone marrow biopsies. Also includes autopsy
                                                                                               specimens of a primary tumour)

                                                                                               9 – Not known (No information on how the
                                                                                               diagnosis has been made (e.g. PAS or HISS
                                                                                               record only))(Default)




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      Data Item                       Description                                 Purpose                                 Codes and Classifications
4.5   HISTOLOGY (SNOMED)              as NCDS Core                                To determine the incidence of           n18
      [Histology]                                                                 tumours of different histology and      Mappable to SNOMED which in turn maps to
                                                                                  behaviour for epidemiological           ICD-O coding.
                                                                                  analyses.
                                                                                                                          Tumour leads will be asked to provide relevant
                                                                                                                          histology descriptions.

4.6   GRADE OF                        as NCDS Core                                To enable the effect of differentiation an2    Site specific, but generic definition:
      DIFFERENTIATION                                                             grade on prognosis to be investigated.
      (AT DIAGNOSIS)                                                                                                      GX - Grade of differentiation is not appropriate
      [Grade of differentiation]                                                                                          or cannot be assessed

                                                                                                                          G1 - Well differentiated
                                                                                                                          G2 - Moderately differentiated
                                                                                                                          G3 - Poorly differentiated
                                                                                                                          G4 - Undifferentiated/ anaplastic
                                                                                                                          Tumour leads will be asked to provide
                                                                                                                          information on any site-specific grading system.

                                      There may be a number of cancer care plans, on different dates.
5      Cancer Care Plan

5.1   MDT DISCUSSION                as NCDS Core                                  To enable monitoring of statement in    Y - Yes; a Multidisciplinary Team Discussion
      INDICATOR                                                                   the Cancer Plan, para 6.11              Date recorded
      [Was this cancer care plan                                                                                          N - No; a Multidisciplinary Team Discussion
      discussed at an MDT meeting?]                                                                                       Date not recorded


5.2   MULTIDISCIPLINARY TEAM          as NCDS Core                                To enable monitoring of statement in    e-GIF Date Format "CCYY-MM-DD"
      DISCUSSION DATE                                                             the Cancer Plan, para 6.11
      [The date of the MDT meeting
      at which the cancer care plan
      was discussed].

5.3   CARE PLAN AGREED DATE           as NCDS Core                                To record the history of cancer care    e-GIF Date Format "CCYY-MM-DD"
      [Cancer care plan date]                                                     plans for this patient’s treatment.




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      Data Item                     Description       Purpose                                   Codes and Classifications
5.4   RECURRENCE INDICATOR          as NCDS Core      To enable tracking of events related Y- Yes, for a recurrence of the original primary
      [Recurrence indicator]                          to the original primary cancer and any tumour
                                                      subsequent recurrences.                N – No, for the original primary tumour


5.5   CANCER CARE PLAN INTENT as NCDS Core            To enable analysis of treatment           C – Curative
      [Cancer care plan intent]                       planned versus treatment given.           P – Palliative anti-cancer
                                                      To monitor the number of cancer           S - Supportive
                                                      patients who received no specific anti-   N - No specific cancer treatment
                                                      cancer treatment.                         9 – Not known (default)
                                                                                                Tumour leads will be asked for clear definitions
                                                                                                of ‘Curative’ and ‘Palliative’.




5.6   PLANNED CANCER                as NCDS Core      To determine the number of patients       The code ‘07’ in italics below is not specified in
      TREATMENT TYPE                                  undergoing each primary treatment.        DSCN 22/2002 i.e. is not applicable to waiting
      [Management modality]                                                                     times.
                                                      To determine patterns of primary
                                                      treatment.


                                                      To enable analysis of discrete groups 01 - Surgery
                                                      of patients particularly where several 02 - Teletherapy
                                                      modalities are used.                   03 - Chemotherapy
                                                                                             04 - Hormone Therapy
                                                                                             05 - Specialist Palliative Care
                                                                                             06 - Brachytherapy
                                                                                             07 – Biological
                                                                                             08 – Other
                                                                                             09 – Active Monitoring
                                                                                             99 – Not known (default)




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      Data Item                       Description       Purpose                                Codes and Classifications
5.7   TREATMENT TYPE                  as NCDS Core      To determine the number of patients    n3
      SEQUENCE (CANCER)                                 undergoing each primary treatment.
      [Treatment type sequence]                         To determine patterns of primary
                                                        treatment.



5.8   NO CANCER TREATMENT             as NCDS Core       To monitor the reasons why cancer     01 – Patient declined treatment
      REASON                                            patients received no specific anti-    02 - Unfit: poor performance status
      [Reason for no specific anti-                     cancer treatment.                      03 – Unfit: significant co-morbidity
      cancer treatment]                                                                        04 – Unfit: advanced stage cancer
                                                                                               05 - Unknown Primary Site
                                                                                               06 - Died before treatment
                                                                                               07 - No anti-cancer treatment available
                                                                                               08 – Other
                                                                                               09 – Watchful waiting
                                                                                               99 – Not known (default)

5.9   CO-MORBIDITY INDEX FOR          as NCDS Core      To allow co-morbidity to be taken into Investigations into the possible use of the ACE-
      ADULTS                                            account in the analysis of treatment   27 coding system are continuing.
      [Co-morbidity index]                              and outcome.

      Still under discussion




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       Data Item                      Description                                         Purpose                                 Codes and Classifications
5.10   PERFORMANCE STATUS             as NCDS Core                                        To allow for performance status to be Basically, coding as WHO Handbook (plus
       (ADULT)                                                                            taken into account in the analysis of code 5 added)
       [Performance status]                                                               treatment and outcome.
                                                                                                                                0 - Able to carry out all normal activity without
                                                                                                                                restriction
                                                                                                                                1 - Restricted in physically strenuous activity but
                                                                                                                                able to walk and do light work
                                                                                                                                2 - Able to walk and capable of all self care but
                                                                                                                                unable to carry out any work. Up and about
                                                                                                                                more than 50% of waking hours
                                                                                                                                  3 - Capable of only limited self care, confined
                                                                                                                                  to bed or chair more than 50% of waking hours

                                                                                                                                  4 - Completely disabled. Cannot carry on any
                                                                                                                                  self care. Totally confined to bed or chair

                                                                                                                                  5 - Not recorded

6      Staging                        These fields should be recorded at the time                                                 Tumour leads will be asked to advise on need
                                      that the first cancer care plan is agreed.                                                  for pre-surgical/surgical staging.
                                      Cancer registries require the first pre-treatment                                           Tumour leads will be asked to advise whether
                                      stage, i.e. the stage at diagnosis.                                                         UICC coding is relevant to their particular site.


6.1    T CATEGORY                       as NCDS Core                                      To allow for pre-treatment T stage to   an5
       (FINAL PRETREATMENT)                                                               be taken into account in the analysis   UICC Coding
       [Final pre-treatment T category]                                                   of treatment and outcome.




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      Data Item                      Description          Purpose                                 Codes and Classifications
6.2   STAGING CERTAINTY                 as NCDS Core      To provide a measure of the certainty an2
      FACTOR                                              with which the pre-treatment T stage UICC Coding
      (T CATEGORY)                                        was determined                        C1 - Evidence from standard diagnostic means
      [Certainty factor for T category]                                                         (e.g. inspection, palpation and standard
                                                                                                radiography, intraluminal endoscopy for
                                                                                                tumours of certain organs)

                                                                                                  C2 - Evidence obtained by special diagnostic
                                                                                                  means (e.g. radiographic imaging in special
                                                                                                  projections, tomography, ultrasonography,
                                                                                                  lymphography, angiography, scintigraphy, MRI,
                                                                                                  endoscopy, biopsy and cytology)


                                                                                                  C3 - Evidence from surgical exploration,
                                                                                                  including biopsy and cytology

                                                                                                  C4 - Evidence of the extent of disease following
                                                                                                  definitive surgery and pathological examination
                                                                                                  of the resected specimen

                                                                                                  C5 - Evidence from autopsy

6.3   N CATEGORY                       as NCDS Core       To allow for pre-treatment N stage to   an5
      (FINAL PRETREATMENT)                                be taken into account in the analysis   UICC Coding
      [Final pre-treatment N category]                    of treatment and outcome.


6.4   STAGING CERTAINTY                 as NCDS Core      To provide a measure of the certainty an2
      FACTOR                                              with which the pre-treatment N stage UICC Coding
      (N CATEGORY)                                        was determined
      [Certainty factor for N category]                                                         See Certainty factor for T Stage above


6.5   M CATEGORY                       as NCDS Core       To allow for pre-treatment M stage to an5
      (FINAL PRETREATMENT)                                be taken into account in the analysis UICC Coding
      [Final pre-treatment M category]                    of treatment and outcome.




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       Data Item                         Description       Purpose                                 Codes and Classifications
6.6    STAGING CERTAINTY                 as NCDS Core      To provide a measure of the certainty an2
       FACTOR (M CATEGORY)                                 with which the pre-treatment M stage UICC Coding
       [Certainty factor for M category]                   was determined
                                                                                                 See Certainty factor for T Stage above
6.7    TNM CATEGORY (FINAL               as NCDS Core      To allow for this factor to be taken into an5
       PRETREATMENT)                                       account in the analysis of treatment      UICC Coding
       [Overall pre-treatment stage                        and outcome.
       group]
6.8    STAGING CERTAINTY                as NCDS Core       To provide a measure of the certainty an2
       FACTOR (TNM CATEGORY)                               with which the pre-treatment TNM      UICC Coding
       [Certainty factor for TNM stage]                    stage was determined
                                                                                                 See Certainty factor for T Stage above

6.9    SITE SPECIFIC STAGING             as NCDS Core      To allow for site specific              n1
       CLASSIFICATION                                      classifications to be taken into        Site specific – e.g. Dukes for colorectal, NPI for
       [Site Specific Classification]                      account in the analysis of treatment    breast, “Limited’ or ‘Extensive’ stage disease for
                                                           and outcome.                            Small Cell Lung Cancer

                                                                                                   Tumour leads will be asked to advise on details
                                                                                                   about any site-specific coding system used.


6.10   TNM CATEGORY                      as NCDS Core      To allow for the integrated TNM stage an5
       (INTEGRATED)                                        to be taken into account in the       UICC
       [Overall Pathological TNM                           analysis of treatment and outcome.
       stage grouping – integrated                                                               Tumour leads will be asked to comment on
       stage]                                                                                    relevance of UICC coding.

6.11   T CATEGORY                        as NCDS Core      To allow for integrated T stage to be   an5
       (INTEGRATED STAGE)                                  taken into account in the analysis of   UICC Coding
       [Integrated stage - T category]                     treatment and outcome.




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       Data Item                         Description                                    Purpose                                Codes and Classifications
6.12   N CATEGORY                      as NCDS Core                                    To allow for integrated N stage to be   an5
       (INTEGRATED STAGE)                                                              taken into account in the analysis of   UICC Coding
       [Integrated stage – N category]                                                 treatment and outcome.



6.13   M CATEGORY                        as NCDS Core                                  To allow for integrated M stage to be   an5
       (INTEGRATED STAGE)                                                              taken into account in the analysis of   UICC Coding
       [Integrated stage - M category]                                                 treatment and outcome.

                                         This can be adapted for other procedures including interventional radiology, laser treatment, endoscopies etc. and photo-
7       Surgery and Other                dynamic procedures. This also includes procedures offered as supportive care.
        Procedures


7.1    SITE CODE                         as NCDS Core                                  Required because different activities   an5
       (OF SURGERY)                                                                    for a patient may be carried out at     NHS Data Dictionary Supporting Information,
       [Hospital]                                                                      different service provider sites.       Administrative Codes, NHS Trust Site (5
                                                                                       To enable reports and analysis by       character code, starts with ‘R’, allocated by
                                                                                       hospital and/or cancer network.         OCS)


7.2    CONSULTANT CODE                   as NCDS Core                                  To enable reports and analysis by       an8
       [Managing consultant surgeon]                                                   consultant.                             NHS Data Dictionary Supporting Information,
                                                                                                                               Administrative Codes (Practitioner Code for a
                                                                                                                               Consultant)
7.3    MAIN SPECIALTY CODE             The managing consultant’s specialty code        To enable reports and analysis by       n3
       [Specialty function code]                                                       consultant specialty.                   NHS Data Dictionary Supporting Information,
       (Can be derived from consultant                                                                                         Specialty function codes
       code)



7.4    CANCER TREATMENT                  The purpose of the surgical procedure(s) being *To enable analysis by treatment       A - Adjuvant
       INTENT                            carried out                                    intent                                 C – Curative
       [Treatment intent]                                                                                                      D - Diagnostic
                                                                                                                               N - Neoadjuvant
                                                                                                                               S - Staging




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7.4    CANCER TREATMENT                The purpose of the surgical procedure(s) being *To enable analysis by treatment
       INTENT                          carried out                                    intent
       [Treatment intent]
       Data Item                       Description                                    Purpose                                Codes and Classifications
                                                                                                                             P – Palliative
                                                                                                                             9 – Not known (default)

7.5    DECISION TO TREAT DATE          as NCDS Core                                  To define the delay between             e-GIF Date Format "CCYY-MM-DD"
       (SURGERY)                                                                     referral/diagnosis by the specialist
       [Date of decision to operate]                                                 team and definitive surgical treatment.


7.8    START DATE (SURGERY      as NCDS Core                                         To measure length of in-patient stay.   e-GIF Date Format "CCYY-MM-DD"
       HOSPITAL PROVIDER SPELL)
       [Date of admission]


7.9    PROCEDURE DATE                  as NCDS Core                                  To determine the time interval          e-GIF Date Format "CCYY-MM-DD"
       [Date of surgery]                                                             between referral/diagnosis by the
                                                                                     specialist team and start of surgical
                                                                                     treatment.
7.10   PRIMARY PROCEDURE               as NCDS Core                                  To determine type of surgery            an4
       (OPCS)                                                                        performed to enable analysis of         Mappable to OPCS-4
       [Main surgical procedure]                                                     surgically related data.
                                                                                                                             Tumour leads will be asked to supply lists of
                                                                                                                             procedures.

7.11   PROCEDURE (OPCS)                as NCDS Core                                  To determine type of surgery            an4
       [Sub-procedure]                                                               performed to enable analysis of         Mappable to OPCS-4
                                                                                     surgically related data.
                                                                                                                             Tumour leads will be asked to supply lists of
                                                                                                                             procedures.
7.12   DISCHARGE DATE                  as NCDS Core                                  To measure length of in-patient stay.   e-GIF Date Format "CCYY-MM-DD"
       (HOSPITAL PROVIDER
       SPELL)
       [Date of discharge]

7.13   DISCHARGE DESTINATION           as NCDS Core                                                                          See NHS Data Dictionary, attribute
       (HOSPITAL PROVIDER
       SPELL)                                                                                                                DISCHARGE DESTINATION
       [Discharge destination]




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      Data Item                     Description                                Purpose                                 Codes and Classifications
                                    Note: it is expected that all the data items on the minimum RCPath dataset will Tumour leads will be asked to comment on
8      Pathology Details            be collected. The pathology data items below are a subset of that dataset. A      the relevance of the generic data items
                                    patient may have any number of pathology reports, and there may be more than below to their particular site.
                                    one pathology report per specimen. If the original report is reviewed or revised,
                                    then a new pathology module will need to be completed and dated, with the data
                                    item ‘Second Opinion’ on the RCPath Dataset marked as ‘Y’.

8.1   PATHOLOGY INVESTIGATION as NCDS Core                                     To record the type of specimen          CY - Cytology
      TYPE                                                                     reported and hence the RCPath           BX - Biopsy
      [Report Type]                                                            dataset items that should be            EX - Excision
                                                                               recorded.                               9 – Uncertain/other

8.2   SAMPLE RECEIPT DATE           as NCDS Core                               To enable the date of diagnosis to be e-GIF Date Format "CCYY-MM-DD"
      [Date specimen received]                                                 determined for epidemiological
                                                                               purposes (annual incidence rates and
                                                                               survival analyses)

8.3   INVESTIGATION RESULT          as NCDS Core                                                                       e-GIF Date Format "CCYY-MM-DD"
      DATE
      [Date specimen reported]


8.4   CONSULTANT CODE               as NCDS Core                               To enable reports and analysis by       an8
      (PATHOLOGIST)                                                            consultant                              NHS Data Dictionary Supporting Information,
      [Authorising pathologist]                                                                                        Administrative Codes (Practitioner Code for a
                                                                                                                       Consultant)
8.5   ORGANISATION CODE (OF         as NCDS Core                               Required because different activities   NHS Data Dictionary Supporting Information,
      REPORTING PATHOLOGY)                                                     for a patient may be carried out at     Administrative Codes, NHS Trust Site (5
      [Reporting organisation]                                                 different service provider sites.       character code, starts with ‘R’, allocated by
                                                                               To enable reports and analysis by       OCS)
                                                                               hospital and/or cancer network.




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      Data Item                     Description       Purpose                               Codes and Classifications
8.6   PRIMARY DIAGNOSIS (ICD)       as NCDS Core      To establish the numbers of various   an6
      [Primary diagnosis (Site)]                      cancers to enable calculation of      Mappable to ICD10
                                                      annual incidence rates.
                                                      To allow for an assessment of
                                                      subsequent treatment and outcome
                                                      rates.


8.7   TUMOUR LATERALITY             as NCDS Core      To differentiate tumours in paired    L - Left
      [Laterality]                                    organs.
                                                      To define the site of the Pathology   R - Right
                                                      specimen.                             B - Bilateral
                                                                                            M - Midline
                                                                                            8 - Not applicable
                                                                                            9 - Not known

8.8   INVASIVE LESION SIZE          as NCDS Core      To obtain information of prognostic    n3
      [Tumour size – maximum                          value that can (for some tumour sites) mm
      diameter]                                       be used to derive the pT component
                                                      of the TNM stage. Tumour size
                                                      cannot be used to calculate pT if the
                                                      tumour has been reduced in size by
                                                      treatment undertaken prior to surgery.



8.9   SYNCHRONOUS TUMOUR            as NCDS Core      To enable complete reporting of       N - No, no synchronous tumours present
      INDICATOR                                       separate tumours diagnosed            Y - Yes, synchronous tumours present
      [Synchronous tumour]                            simultaneously at the same primary    9 - Not known (default)
                                                      site. With the exception of bladder
                                                      and prostate tumours, a separate
                                                      report form should be completed for
                                                      each synchronous tumour reported




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       Data Item                       Description       Purpose                                Codes and Classifications
8.10   HISTOLOGY (SNOMED)              as NCDS Core      To determine the incidence of          n18
       [Histology]                                       tumours of different histology and     Mappable to SNOMed which in turn maps to
                                                         behaviour for epidemiological          ICD-O coding
                                                         purposes.


8.11   GRADE OF                        as NCDS Core      To enable the effect of differentiation Site specific, but generic definition:
       DIFFERENTIATION                                   grade on prognosis to be investigated. GX - Grade of differentiation is not appropriate
       [Grade of differentiation]                                                                or cannot be assessed
                                                                                                 G1 - Well differentiated
                                                                                                 G2 - Moderately differentiated
                                                                                                 G3 - Poorly differentiated
                                                                                                 G4 - Undifferentiated/anaplastic

8.12   CANCER VASCULAR OR              as NCDS Core      To provide information of prognostic   N - No, vascular/lymphatic invasion not present
       LYMPHATIC INVASION                                importance.
       [Vascular/lymphatic invasion]                                                            Y - Yes, vascular/lymphatic invasion present
                                                                                                U - Uncertain whether vascular invasion is
                                                                                                present or not
                                                                                                9 - Not known (default)

8.13   EXCISION MARGIN                 as NCDS Core      To determine adequacy of excision.     01-Excision margins are clear (distance from
       [Excision Margins]                                                                       margin not stated)

                                                                                                02 - Excision margins are clear (tumour > 5mm
                                                                                                from the margin)
                                                                                                03 - Excision margins are clear (tumour greater
                                                                                                than 1mm from the margin but less than or
                                                                                                equal to 5 mm from the margin)
                                                                                                04 - Tumour is less than or equal to 1mm of
                                                                                                excision margin, but does not reach margin
                                                                                                05 - Tumour reaches tumour margin
                                                                                                06 - Uncertain
                                                                                                98 - Not applicable
                                                                                                99 - Not known




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       Data Item                         Description       Purpose                                 Codes and Classifications
8.14   NODES EXAMINED NUMBER as NCDS Core                  To obtain information relating to the   n2
       [Local/regional nodes                               quality of the diagnostic process.      Detail of the nodes involved will be supplied in
       examined]                                                                                   the Cancer Data Manual.


8.15   NODES POSITIVE NUMBER             as NCDS Core      To obtain information of prognostic     n2
       [Local/regional nodes positive]                     value that can be used to derive the    Detail of the nodes involved will be supplied in
                                                           pN component of the TNM stage.          the Cancer Data Manual.




8.16   T CATEGORY                        as NCDS Core      To allow for the pathological T stage   an5
       (PATHOLOGICAL)                                      to be taken into account in the         UICC
       [Pathological T category]                           analysis of treatment and outcome.
                                                                                                   Tumour leads will be asked to comment on
                                                                                                   relevance of UICC coding.


8.17   N CATEGORY                        as NCDS Core      To allow for the pathological N stage   an5
       (PATHOLOGICAL)                                      to be taken into account in the         UICC
       [Pathological N category]                           analysis of treatment and outcome.
                                                                                                   Tumour leads will be asked to comment on
                                                                                                   relevance of UICC coding.



8.18   M CATEGORY                        as NCDS Core      To allow for the pathological M stage   an5
       (PATHOLOGICAL)                                      to be taken into account in the         UICC
       [Pathological M category]                           analysis of treatment and outcome.
                                                                                                   Tumour leads will be asked to comment on
                                                                                                   relevance of UICC coding.
8.19   TNM CATEGORY                      as NCDS Core      To allow for the pathological TNM       an5
       (PATHOLOGICAL)                                      stage to be taken into account in the   UICC
       [Overall Pathological TNM                           analysis of treatment and outcome.
       stage grouping]                                                                             Tumour leads will be asked to comment on
                                                                                                   relevance of UICC coding.




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       Data Item                      Description         Purpose   Codes and Classifications
8.20   SERVICE REPORT                 as NCDS Core                  n18
       IDENTIFIER                                                   Numeric
       [Report number]


8.21   SERVICE REPORT STATUS          as NCDS Core                  1 – final (complete)
       [Second opinion]                                             2 – preliminary (interim)
                                                                    3 – test not available
                                                                    4 - unspecified
                                                                    5 – second opinion/supplementary report

8.22   SPECIMEN NATURE                as NCDS Core                  1 - Primary tumour
       [Nature of specimen]                                         2 - Re-excision of primary tumour
                                                                    3 - Recurrence
                                                                    4 - Nodes
                                                                    5 - Metastatic site other than nodes
                                                                    9 - Not known

8.23   ORGANISATION CODE              as NCDS Core                  For NHS institutions, this is the site’s
       (REQUESTED BY)                                               organization code
       [Organisation of referral]                                   If the source of referral is a GP, the GP Practice
                                                                    code is recorded.
                                                                    Coding for voluntary organizations and private
                                                                    hospitals will also be required.
                                                                    Defaults:
                                                                    V81999 Practice Code unknown
                                                                    V81998 Practice Code of MOD Doctor


8.24   CARE PROFESSIONAL CODE as NCDS Core                          an8       GMC Code of the consultant.
       (REQUESTED BY)
       [Referred by]                                                Defaults:
                                                                    C9999998 – locum consultant code
                                                                    C9999999 – consultant code unknown

8.25   T CATEGORY EXTENDED              as NCDS Core                an9
       (PATHOLOGICAL)                                               UICC coding.
       [Local invasion – tumour extent]




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       Data Item                         Description                                 Purpose                                 Codes and Classifications
8.26   M CATEGORY EXTENDED               as NCDS Core                                                                        an9
       (PATHOLOGICAL)                                                                                                        UICC coding.
       [Distant metastases]
                                         Chemotherapy and/or other anti-Cancer and/or Supportive drugs given to the patient during their treatment.
9       Chemotherapy
        and other drugs
9.1    SITE CODE (OF CANCER              as NCDS Core                                Required because different activities   an5
       DRUG TREATMENT)                                                               for a patient may be carried out at     NHS Data Dictionary Supporting Information,
       [Hospital]                                                                    different service provider sites.       Administrative Codes, NHS Trust Site (5
                                                                                                                             character code, starts with ‘R’, allocated by
                                                                                     To enable reports and analysis by       OCS)
                                                                                     hospital and/or cancer network.


9.2    CONSULTANT CODE                   as NCDS Core                                To enable reports and analysis by       an8
       [Managing consultant]                                                         consultant.                             NHS Data Dictionary Supporting Information,
                                                                                                                             Administrative Codes (Practitioner Code for a
                                                                                                                             Consultant)
9.3    MAIN SPECIALTY CODE            as NCDS Core                                   To enable reports and analysis by       n3
       [Specialty function code]                                                     consultant specialty.                   NHS Data Dictionary Supporting Information,
       Can be derived from consultant                                                                                        Specialty function codes
       code

9.4    DECISION TO TREAT DATE            as NCDS Core                                To enable the measurement of the        e-GIF Date Format "CCYY-MM-DD"
       (ANTI-CANCER DRUG                                                             interval from the date of decision to
       REGIMEN)                                                                      treat to start of treatment.
       [Date of decision to treat with
       drug therapy]                                                                 To monitor delays.

9.7    DRUG THERAPY TYPE                 as NCDS Core                                To establish patterns of drug therapy   C - Chemotherapy
       [Drug therapy type]                                                           treatment                               H - Hormone/endocrine therapy
                                                                                                                             I - Immunotherapy
                                                                                                                             O - Other




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       Data Item                     Description       Purpose                                 Codes and Classifications
9.8    DRUG TREATMENT INTENT         as NCDS Core      To establish the frequency of different C - Curative
       [Treatment intent]                              treatment intents.                      P - Palliative
                                                                                               A - Adjuvant
                                                       To monitor treatment related            N - Neoadjuvant
                                                       outcomes. To assess patterns of         9 - Not known (default)
                                                       chemotherapy or other drug therapy
                                                       practice for comparison with best
                                                       practice guidelines

9.9    DRUG REGIMEN ACRONYM          as NCDS Core      *To stratify patients by treatment      an35
       [Regimen Acronym]                               regime when calculating outcomes


9.10   START DATE                    as NCDS Core      To enable the date of the first         e-GIF Date Format "CCYY-MM-DD"
       (ANTI-CANCER DRUG                               definitive treatment to be recorded.
       REGIMEN)
       [Drug treatment start date]                     Cancer Registries only require the
                                                       start date of the first chemotherapy
                                                       course

10 Radiotherapy

10     Radiotherapy (teletherapy)    as NCDS Core

10.1   SITE CODE (OF                 as NCDS Core      Required because different activities   an5
       TELETHERAPY)                                    for a patient may be carried out at     NHS Data Dictionary Supporting Information,
       [Hospital]                                      different service provider sites.       Administrative Codes, NHS Trust Site (5
                                                       To enable reports and analysis by       character code, starts with ‘R’, allocated by
                                                       hospital and/or cancer network.         OCS)



10.2   CONSULTANT CODE               as NCDS Core      To enable reports and analysis by       an8
       [Managing consultant]                           consultant.                             NHS Data Dictionary Supporting Information,
                                                                                               Administrative Codes (Practitioner Code for a
                                                                                               Consultant)




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       Data Item                     Description      Purpose                                   Codes and Classifications
10.3   DECISION TO TREAT DATE      as NCDS Core       To enable the measurement of the          e-GIF Date Format "CCYY-MM-DD"
       (TELETHERAPY TREATMENT                         interval from the date of decision to
       COURSE)                                        treat to start of treatment, to monitor
       [Date of decision to treat]                    delays.




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       Data Item                     Description                                 Purpose                                   Codes and Classifications
10.6   CANCER TREATMENT              as NCDS Core                                To establish the frequency of each        C - Curative
       INTENT                                                                    treatment intent.
       [Treatment intent]
                                                                                 To monitor treatment related              P - Palliative
                                                                                 outcomes.
                                                                                 To assess patterns of teletherapy         A - Adjuvant
                                                                                 practice for comparison with best
                                                                                 practice guidelines
                                                                                                                           N - Neoadjuvant
                                                                                                                           9 - Not known (default)

10.7   RADIOTHERAPY                  as NCDS Core                                To assess patterns of teletherapy         OPCS ‘Z’ Codes
       ANATOMICAL TREATMENT                                                      practice for comparison with best
       SITE                                                                      practice guidelines.
       [Anatomical treatment site]

10.8   START DATE (TELETHERAPY as NCDS Core                                      *To enable the measurement of the         e-GIF Date Format "CCYY-MM-DD"
       TREATMENT COURSE)                                                         interval from the date of decision to
       [Teletherapy start date]                                                  treat to start of treatment, to monitor
                                                                                 delays.
                                     A course of brachytherapy is defined as a string of prescriptions which are consecutive.
11 Radiotherapy
   (Brachytherapy)
11.1   SITE CODE (OF                 as NCDS Core                                Required because different activities     an5
       BRACHYTHERAPY)                                                            for a patient may be carried out at       NHS Data Dictionary Supporting Information,
       [Hospital]                                                                different service provider sites. To      Administrative Codes, NHS Trust Site (5
                                                                                 enable reports and analysis by            character code, starts with ‘R’, allocated by
                                                                                 hospital and/or cancer network.           OCS)


11.2   CONSULTANT CODE               as NCDS Core                                To enable reports and analysis by         an8
       [Managing consultant]                                                     consultant.                               NHS Data Dictionary Supporting Information,
                                                                                                                           Administrative Codes (Practitioner Code for a
                                                                                                                           Consultant)




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       Data Item                     Description                                  Purpose                                   Codes and Classifications
11.3   DECISION TO TREAT DATE        as NCDS Core                                 *To enable the measurement of the         e-GIF Date Format "CCYY-MM-DD"
       (BRACHYTHERAPY                                                             interval from the date of decision to
       TREATMENT COURSE)                                                          treat to start of treatment, to monitor
       [Date of decision to treat]                                                delays

11.6   CANCER TREATMENT              as NCDS Core                                 To establish the frequency of each        C - Curative
       INTENT                                                                     treatment intent.
       [Treatment intent]                                                         To monitor treatment related              P - Palliative
                                                                                  outcomes.
                                                                                  To assess patterns of brachytherapy       A - Adjuvant
                                                                                  practice for comparison with best
                                                                                  practice guidelines


                                                                                                                            N - Neoadjuvant
                                                                                                                            9 - Not known (default)

11.7   BRACHYTHERAPY TYPE            as NCDS Core                                 To assess patterns of brachytherapy       BI – Interstitial
       [Type of brachytherapy]                                                    practice for comparison with best         BC - Intra-cavitary
                                                                                  practice guidelines                       BT – Not otherwise specified
                                                                                                                            US - Unsealed sources

11.8   RADIOTHERAPY                  as NCDS Core                                 To assess patterns of brachytherapy       OPCS ‘Z’ Codes.
       ANATOMICAL TREATMENT                                                       practice for comparison with best
       SITE                                                                       practice guidelines.
       [Anatomical treatment site]

11.9   START DATE                    as NCDS Core                                 To enable the measurement of the          e-GIF Date Format "CCYY-MM-DD"
       BRACHYTHERAPY                                                              interval from the date of decision to
       TREATMENT COURSE)                                                          treat to start of treatment, to monitor
       [Brachytherapy start date]                                                 delays.

                                     Note: the Palliative Care data items are in the process of being developed.
12 Palliative Care                   It is expected that this section will be completed whenever an intervention occurs that involves one face-to-face contact with
                                     the patient.
                                     It is expected that a Cancer Care Plan will also be completed for the Palliative Care Management Plan.




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       Data Item                           Description                                       Purpose                               Codes and Classifications
12.1   DECISION TO TREAT DATE              This is the date that the consultation between    For analysis of waiting times         e-GIF Date Format "CCYY-MM-DD"
       (SPECIALIST PALLIATIVE              the patient and the clinician took place and a
       TREATMENT COURSE)                   treatment plan for palliative care was agreed.
       [Date of decision to treat]
12.2   START DATE                          The date of the first treatment/support from      For analysis of waiting times         e-GIF Date Format "CCYY-MM-DD"
       (SPECIALIST PALLIATIVE              Specialist Palliative Care
       TREATMENT COURSE)
       [Specialist Palliative Care start
       date]
                                           Note: Clinical Trials information will be         Additional information corresponding to patients ineligible for a trial, or whether
13 Clinical Trials                         completed for every Clinical Trial in which       there is no trial available, can be recorded if required.
                                           the patient is involved.

13.1   PATIENT TRIAL STATUS                as NCDS Core                                      To assist in the measurement of the   EE – patient eligible, consented to and entered
       (CANCER)                                                                              percentage of patients entering       trial
       [Clinical trial status]                                                               clinical trials.
                                                                                                                                   ED – patient eligible, declined trial

13.2   CANCER CLINICAL TRIAL               as NCDS Core                                      To assist in the measurement of the   1 - Surgery
       TREATMENT TYPE                                                                        percentage of patients entering a     2 - Chemotherapy
       [Clinical trial type]                                                                 particular type of clinical trial.    3 - Hormone therapy
                                                                                                                                   4 - Immunotherapy
                                                                                                                                   5 - Radiotherapy
                                                                                                                                   6 - Combination treatment
15 Death Details
15.1   PERSON DEATH DATE                   as NCDS Core                                      To determine survival rates and       e-GIF Date Format "CCYY-MM-DD" NHS Data
       [Date of death]                                                                       mortality rates                       Dictionary, Attribute DEATH DATE
15.2   DEATH LOCATION TYPE                 as NCDS Core                                      To enable reports and analyses by     1 - Hospital
       (CANCER)                                                                              place of death.                       2 - NHS hospice/specialist palliative care unit
       [Place of death]
                                                                                                                                   3 - Voluntary hospice/specialist palliative care
                                                                                                                                   unit
                                                                                                                                   4 - Patient’s own home
                                                                                                                                   5 - Care home
                                                                                                                                   9 - Other
15.3   DEATH CAUSE                         as NCDS Core                                      To provide an indication of the       1 - death certificate
       IDENTIFICATION METHOD                                                                 accuracy of the cause of death.
       [How cause of death
       established]
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       Data Item                     Description       Purpose                           Codes and Classifications
15.3   DEATH CAUSE                   as NCDS Core      To provide an indication of the
       IDENTIFICATION METHOD                           accuracy of the cause of death.   2 - NHSCR Follow-up
       [How cause of death                                                               3 - hospital records
       established]                                                                      4 - verbal communication
                                                                                         5 - post-mortem




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       Data Item                           Description                                  Purpose                                   Codes and Classifications
The data items shaded below will usually not be collected directly by the Trust; information would come from Cancer Registries.
15.5   DEATH CAUSE CODE                    as NCDS Core                                 To identify cancer-specific deaths        ICD-10 coding
       (IMMEDIATE)
       [Cause of death – immediate]

15.6   DEATH CAUSE CODE                    as NCDS Core                                 To identify cancer-specific deaths        ICD-10 coding
       (CONDITION)
       [Cause of death – condition
       giving rise to death]
15.7   DEATH CAUSE CODE                    as NCDS Core                                 To identify cancer-specific deaths        ICD-10 coding
       (UNDERLYING)
       [Cause of death - underlying
       condition leading to death]

15.8   DEATH CAUSE CODE                    as NCDS Core                                 To identify cancer-specific deaths        ICD-10 coding
       (SIGNIFICANT)
       [Cause of death - significant
       condition not directly related to
       death]

B.1    DIAGNOSTIC ROUTE                    as NCDS Core                                                                           1 - cancers detected by national screening
       [Screening status]                                                                                                         programme
                                                                                                                                  2 - interval cancers occurring in patients
                                                                                                                                  screened by a national screening programme


                                                                                                                                  3 Other Route
                                                                                                                                  9 - not known (default)
B.7    ENDOCRINE THERAPY TYPE as NCDS Core                                                                                        R - Radiotherapy ablation (e.g. radiation
       [Endocrine therapy type]                                                                                                   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)




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[Endocrine therapy type]


National Cancer Dataset                                                 Cancer Registration




Data Item                     Description      Purpose   Codes and Classifications
                                                         O -Other




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      Data Item                        Description       Purpose   Codes and Classifications
B.8   MARKER LYMPH NODE                as NCDS Core                N - No, marker lymph node 1 negative
      RESULT                                                       Y - Yes, marker lymph node 1 positive present
      [Marker lymph node 1 positive]                               8 - Not applicable
                                                                   9 - Not known
C.1   DIAGNOSTIC ROUTE                 as NCDS Core                1 - cancers detected by national screening
      [Screening status]                                           programme
                                                                   2 - interval cancers occurring in patients
                                                                   screened by a national screening programme

                                                                   3 - other cancers
                                                                   9 - not known (default)

C.10 MARKER LYMPH NODE                 as NCDS Core                N - No, marker lymph node 1 negative
     RESULT
     [Marker lymph node 1 positive]                                Y - Yes, marker lymph node 1 positive present

                                                                   8 - Not applicable
                                                                   9 - Not known

HN1   PATIENT HISTORY                  as NCDS Core                an6
      (CANCER DIAGNOSIS)                                           Any ICD-10 code.
      [History of non-head and neck
      cancer – site]
HN.2 YEAR CANCER DIAGNOSED             as NCDS Core                4 digit year.
     [History of non-head and neck
     cancer - year of diagnosis]

HN.3 PREVIOUS TREATMENT                as NCDS Core                Y - Yes
     ELSEWHERE                                                     N- No
     [Previous treatment for head                                  9 – Not known (default)
     and neck cancer elsewhere]
G.2   DIAGNOSTIC ROUTE                 as NCDS Core                1 - cancers detected by national screening
      [Screening status]                                           programme




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G.2   DIAGNOSTIC ROUTE              as NCDS Core
      Data Item
      [Screening status]            Description       Purpose   Codes and Classifications
                                                                2 - interval cancers occurring in patients
                                                                screened by a national screening programme


                                                                3 - other route
                                                                9 - not known (default)




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DOCUMENT INFO
Description: Character Reference Letter for Pre Trial Investigation document sample