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COSD User Guide - Information Standards Board for Health and

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1. are EE DAE 111 6 2 GYNAECOLOGY cp icl c 111 6 3 GYNAECOLOGY PATHOLOGY oi cscccccetcetgaradcatecevisetganteceseestedahansdeetnesbadecheedeceshestaanchueevesspenvonschneseeestanteceche 115 6 4 GYNAECOLOGY PATHOLOGY FALLOPIAN TUBE OVARIAN EPITHELIAL and PRIMARY PERITONEAL 116 6 5 GYNAECOLOGY PATHOLOGY ENDOMETRIAL essen nennen nennen nnn ener rennen ens 117 6 6 GYNAECOLOGY PATHOLOGY entren nnn enne ens 119 6 7 GYNAECOLOGY PATHOLOGY nennen nnne ener innen ener nnn enne enne ens 120 6 8 GYNAECOLOGY PATHOLOGY en nennen enne nennen nennen 120 7 HAEMATOLOGY mp 123 OVERVIEW 123 7 1 5 E HM 123 Author NCIN 6 Cancer Outcomes and Services Dataset User Guide 7 2 ICD CODES AND WHO DISEASE tete tete tette tette noti 7 3 HAEMATOLOGY CLINICAL DATASETS AND APPLICABLE DATA ITEMS t 7 4 HAEMATOLOGY LABORATORY RESULTS VARIOUS eet ttt tette tetti 7 5 HAEMATOLOGY CANCER CARE PLAN VARIOUS
2. Neoplasms Description specific group Dataset Dataset Only Comment C10 3 Posterior wall of Head and Neck e oropharynx C10 4 Branchial cleft Head and Neck e C10 8 Overlapping lesion of Head and Neck oropharynx C10 9 Oropharynx Head and Neck unspecified C11 0 Superior wall of Head and Neck nasopharynx C11 1 Posterior wall of Head and Neck nasopharynx C11 2 Lateral wall of Head and Neck nasopharynx 11 3 Anterior wall of Head and Neck e nasopharynx C11 8 Overlapping lesion of Head and Neck e nasopharynx C11 9 Nasopharynx Head and Neck s unspecified C12 Malignant neoplasm Head and Neck s of pyriform sinus C13 0 Postcricoid region Head and Neck e C13 1 Aryepiglottic fold Head and Neck hypopharyngeal e aspect C13 2 Posterior wall of Head and Neck C13 8 Overlapping lesion of Head and Neck s hypopharynx C13 9 Hypopharynx Head and Neck unspecified C14 0 Pharynx unspecified Head and Neck C14 2 Waldeyer s ring Head and Neck e C14 8 Overlapping lesion of Head and Neck lip oral cavity and e pharynx C15 0 Cervical part of Upper Usually oesophagus Gastrointestinal treated by Head amp Neck MDT C15 1 Thoracic part of Upper oesophagus Gastrointestinal C15 2 Abdominal part of Upper b oesophagus Gastrointestinal 15 3 Upper third of Upper oesophagus Gastrointestinal Author NCIN 221 Cancer Outcom
3. ICD 10 4th Expected Dataset to be collected Edition All C Codes Core and are Cancer Waiting Site Malignant Times Site Specific Core Path Neoplasms Description specific group Dataset Dataset Only Comment C17 9 Small intestine Colorectal Usually unspecified treated by Upper GI MDT C18 0 Caecum Colorectal e C18 1 Appendix Colorectal e C18 2 Ascending colon Colorectal e C18 3 Hepatic flexure Colorectal e C18 4 Transverse colon Colorectal e C18 5 Splenic flexure Colorectal e C18 6 Descending colon Colorectal e C18 7 Sigmoid colon Colorectal e C18 8 Overlapping lesion of Colorectal colon C18 9 Colon unspecified Colorectal e C19 Malignant neoplasm Colorectal of rectosigmoid e junction C20 Malignant neoplasm Colorectal of rectum C21 0 Anus unspecified Colorectal e C21 1 Anal canal Colorectal C21 2 Cloacogenic zone Colorectal e C21 8 Overlapping lesion of Colorectal rectum anus and e anal canal C22 0 Liver cell carcinoma Upper Liver cell Gastrointestinal carcinoma is also known as HCC C22 1 Intrahepatic bile duct Upper carcinoma Gastrointestinal C22 2 Hepatoblastoma Upper e Gastrointestinal C22 3 Angiosarcoma of liver Upper Gastrointestinal C22 4 Other sarcomas of Upper liver Gastrointestinal C22 7 Other specified Upper carcinomas of liver Gastrointestinal C22 9 Liver unspecified Upper n Gastrointestinal C23 Malignant neoplasm Upper of gallbladder Gastrointestinal
4. C47 8 Overlapping lesion Brain Central of peripheral Nervous Usually treated nerves and System by Sarcoma autonomic nervous MDT system C47 9 Peripheral nerves Brain Central Usually treated and autonomic Nervous nervous system System by Sarcoma unspecified C69 0 Conjunctiva Brain Central Not normally Nervous treated by CNS System MDT C69 1 Cornea Brain Central Not normally Nervous treated by CNS System MDT C69 2 Retina Brain Central Not normally Nervous treated by CNS System MDT C69 3 Choroid Brain Central Not normally Nervous treated by CNS System MDT C69 4 Ciliary body Brain Central Not normally Nervous treated by CNS System MDT C69 5 Lachrymal gland Brain Central Not normally and duct Nervous treated by CNS System MDT C69 6 Orbit Brain Central Not normally Nervous treated by CNS System MDT Maybe treated by Sarcoma MDT C69 8 Overlapping lesion Brain Central Not normally of eye and adnexa Nervous treated by CNS System MDT C69 9 Eye unspecified Brain Central Not normally Nervous treated by CNS System MDT C70 0 Cerebral meninges Brain Central Nervous System C70 1 Spinal meninges Brain Central Nervous System C70 9 Meninges Brain Central unspecified Nervous System C71 0 Cerebrum except Brain Central lobes and Nervous ventricles System C71 1 Frontal lobe Brain Central Nervous System Author NCIN 65 Cancer Outcomes and Services
5. 175 11 1 SKIN GENERAL BASAL CELL CARCINOMA BCC SQUAMOUS CELL CARCINOMA SCC and MALIGNANT MELANOMA eae 180 11 2 SKIN PATHOLOGY BASAL CELL CARCINOMA BCC and SQUAMOUS CELL CARCINOMA SCC 181 une pu i b mU dii me tR RE ut Ren EU RS OR SMOD RAPIDE und RUE 182 11 4 SKIN PATHOLOGY SQUAMOUS CELL CARCINOMA SCC eene 183 11 5 SKIN PATHOLOGY MALIGNANT MELANOMA cette tentis 184 12 UPPER Boo indc dits dnb SION enon startin aeseusec dS dun UR uURd 186 186 1 10 186 12 1 UPPER CANCER CARE PLAN 189 12 2 UPPER GI CANCER CARE PLAN LIVER 189 12 3 UPPER GI STAGING c cccseccsssssssssssssssssssssssussssscsssssscssscssscsussssssssssssssssssssssssssusssssssssssssesssesssesssesseesssen 189 12 4 UPPER GI MAIN ENDOSCOPIC OR RADIOLOGICAL PROCEDURES te te 192 12 5 UPPER GI SURGICAL PROCEDURES 194 12 6 UPPER GI LIVER METASTASES and LIVER HEPATOCELLULAR CARCINOMA 197 12 7 UPPER GI 1 198 13 UROLOGY PRINT POR
6. Author NCIN 223 ICD 10 4th Edition All C Codes are Malignant Cancer Outcomes and Services Dataset User Guide Cancer Waiting Times Site Expected Dataset to be collected Core and Site Specific Core Path Neoplasms Description specific group Dataset Dataset Only Comment C24 0 Extrahepatic bile duct Upper e Gastrointestinal C24 1 Ampulla of Vater Upper A Gastrointestinal C24 8 Overlapping lesion of Upper biliary tract Gastrointestinal C24 9 Biliary tract Upper unspecified Gastrointestinal 25 0 Head of pancreas Upper Gastrointestinal C25 1 Body of pancreas Upper e Gastrointestinal C25 2 Tail of pancreas Upper Gastrointestinal C25 3 Pancreatic duct Upper Gastrointestinal C25 4 Endocrine pancreas Upper e Gastrointestinal C25 7 Other parts of Upper e pancreas Gastrointestinal C25 8 Overlapping lesion of Upper Gastrointestinal C25 9 Pancreas unspecified Upper s Gastrointestinal C26 0 Intestinal tract part Colorectal s unspecified C26 1 Spleen Colorectal e C26 8 Overlapping lesion of Colorectal digestive system C26 9 lll defined sites Colorectal within the digestive system C30 0 Nasal cavity Head and Neck e C30 1 Middle ear Head and Neck e C31 0 Maxillary sinus Head and Neck e C31 1 Ethmoidal sinus Head and Neck e C31 2 Frontal sinus Head and Neck e C31 3
7. 4 1 COLORECTAL IMAGING To carry imaging details for colorectal cancer The following data items may be collected through the DIDS This section will be recorded once Schema Data item Data Item Data Item Name Format specification M R O X Section 5010 COLORECTAL PROCEDURE DATE FIRST CT SCAN 10 ccyy IMAGING PROCEDURE DATE CT SCAN mm dd PROCEDURE DATE FIRST MRI SCAN OF COLORECTAL an10 ccyy CO5020 RECTUM IMAGING mm dd PROCEDURE DATE FIRST MRI SCAN Author NCIN 78 Cancer Outcomes and Services Dataset User Guide PROCEDURE DATE SECOND MRI SCAN OF COLORECTAL an10 ccyy 5030 RECTUM IMAGING mm dd PROCEDURE DATE SECOND MRI SCAN DATE OF ENDOANAL ULTRASOUND COLORECTAL an10 ccyy 5040 PROCEDURE DATE ENDOANAL IMAGING mm dd ULTRASOUND PROCEDURE DATE FIRST CT SCAN Record the date on which the first staging CT was performed PROCEDURE DATE FIRST MRI SCAN OF RECTUM RECTAL CANCERS ONLY Date of first MRI scan of rectum pre treatment PROCEDURE DATE SECOND MRI SCAN OF RECTUM RECTAL CANCERS ONLY Date of MRI scan of rectum following neo adjuvant treatment and before surgical treatment if performed DATE OF ENDOANAL ULTRASOUND RECTAL CANCERS ONLY Date of first pre operative endoscopic ultrasound If endoanal ultrasound performed then date must be specified 4 2 COLORECTAL DIAGNOSIS To carry diagnosis details for colorectal cancer Th
8. C43 2 Malignant Skin melanoma of ear and external auricular canal C43 3 Malignant Skin melanoma of other and unspecified parts of face C43 4 Malignant Skin melanoma of scalp e and neck C43 5 Malignant Skin melanoma of trunk 43 6 Malignant Skin melanoma of upper limb including shoulder C43 7 Malignant Skin melanoma of lower limb including hip C43 8 Overlapping Skin malignant melanoma of skin C43 9 Malignant Skin melanoma of skin e unspecified C44 0 Skin of lip Skin See the Skin chapter of the COSD User Guide Overview e e e Section for further information on the collection of this Skin disease C44 1 Skin of eyelid Skin See the Skin including canthus chapter of the COSD User Guide Overview e e e Section for further information on the collection of this Skin disease Author NCIN 176 Cancer Outcomes and Services Dataset User Guide C44 2 Skin of ear and external auricular canal Skin See the Skin chapter of the COSD User Guide Overview Section for further information on the collection of this Skin disease C44 3 Skin of other and unspecified parts of face Skin See the Skin chapter of the COSD User Guide Overview Section for further information on the collection of this Skin disease C44 4 Skin of scalp and neck Skin e e e See the Skin chapter of the COSD
9. KEY TO PATHWAY EVENTS TRIGGER DATA ITEMS NEW DIAGNOSIS DATE OF DIAGNOSIS CLINICALLY AGREED TREATMENT TREATMENT START DATE CANCER RECURRENCE DIAGNOSIS DATE OF RECURRENCE CLINICALLY AGREED CORE LINKAGE IF ANY OF THESES ITEMS CHANGE AFTER SUBMISSION CONTACT THE REGISTRY There is no requirement to combine data fields extracted from different systems prior to submission Extracts may be uploaded from different systems as long as the linkage items are included for each record and the Author NCIN 275 Cancer Outcomes and Services Dataset User Guide schema rules for Mandatory items in each section are adhered to Any problems with this should be discussed with the National Cancer Registration Service receiving the extracts Author NCIN 276 Cancer Outcomes and Services Dataset User Guide APPENDIX I PATIENTS DIAGNOSED PRIOR TO 2013 Additional information on Scenarios for patients diagnosed prior to Jan 2013 For patients with a diagnosis before 1st Jan 2013 the COSD is not applicable Providers should aim to complete the registration dataset for these patients by end of February 2013 Scenario 1 Patient diagnosed with Cancer pre Jan 2013 receiving first treatment for this primary cancer after Jan 1st 2013 COSD is not applicable Cancer Waiting Times record to be completed as per NCWTMDS guidance All other cancer datasets to be completed in accordance with specific gu
10. tette tette tetti 7 6 HAEMATOLOGY CANCER CARE PLAN CHRONIC MYELOID LEUKAEMIA 7 7 HAEMATOLOGY CANCER CARE PLAN MYELODYSPLASIA sssesssesssesssesssessseesssesseesseesssesseesseesseessseeseees 7 8 HAEMATOLOGY CANCER CARE PLAN CHRONIC LYMPHOCYTIC LEUKAEMIA 7 9 HAEMATOLOGY CANCER CARE PLAN FOLLICULAR LYMPHOMA ssssesssessseesseessesseesssessessessesseeseen 7 10 HAEMATOLOGY CANCER CARE PLAN DIFFUSE LARGE B CELL 1 7 11 HAEMATOLOGY CANCER CARE PLAN MYELOMA eete ttt tette tette tentent 7 12 HAEMATOLOGY CANCER CARE PLAN HODGKIN LYMPHOMA eeet etn 7 13 HAEMATOLOGY CANCER CARE PLAN ACUTE LYMPHOCYTIC 1 7 14 HAEMATOLOGY STAGING HODGKIN FOLLICULAR DLBCL OTHER LYMPHOMAS 8 HEAD and BUE IE TDI ODE ROREM Te NUTT TN RURSUM TO 8 1 HEAD amp NECK PRE TREATMENT ASSESSMENT sesssesssesssessseesseesseesseesssesssesssesseesssesssesssesseesseesseeeseeeseees 8 3 HEAD amp NECK STAGING acsi atis i ar d hr ob a o se RH 8 2 HEAD amp NECK POST TREATMENT ASSESSMENT ettet tette tette nct 8 3 HEAD amp NECK PATHOLOGY GENERAL i cantina tone ndi arn ax 8 4 HEAD amp NECK PATHOLOGY VARIOUS ettet ttt tette tette tete tetto 8 5 HEAD amp
11. Suspicious of malignancy u Highly suspicious of malignancy U1 U2 U3 U4 U5 PROCEDURE DATE AXILLA ULTRASOUND Date when the ultrasound examination of the axilla was carried out This will normally be the date of the first outpatient appointment at the breast clinic If the patient attends more than one breast clinic the date that each ultrasound examination of the axilla was undertaken should be recorded ORGANISATION SITE CODE OF AXILLA ULTRASOUND Provider code where ultrasound examination of the axilla was carried out This will normally be the site code of the first outpatient appointment at the breast clinic If the patient attends more than one breast clinic the site code of each breast clinic appointment where ultrasound examination of the axilla was carried out should be recorded see ORGANISATION SITE CODE AXILLA ULTRASOUND EXAMINATION RESULT Result of the ultrasound examination of the axilla This will normally be the result of the ultrasound examination of the axilla undertaken at the first outpatient appointment at the breast clinic If the patient attends more than one breast clinic the result of each ultrasound examination of the axilla should be recorded Normal Benen S O Indeterminate probablybenign U4 Suspicious of malignancy Highly suspicious of malignancy U1 U2 U3 U4 5 2 3 BREAST CANCER CARE PLAN To carry cancer care plan details for breast cancer
12. p T2 Tumour invades any of the following prostatic stroma corpus spongiosum periurethral muscle p T3 Tumour invades any of the following corpus cavernosum beyond prostatic capsule bladder neck extraprostatic extension p T4 Tumour invades other adjacent organs invasion of bladder Regional Lymph Nodes p Nx Regional lymph nodes cannot be assessed p NO No regional lymph node metastasis Author NCIN 209 Cancer Outcomes and Services Dataset User Guide p N1 Metastasis in a single lymph node 2 cm or less in greatest dimension p N2 Metastasis in a single lymph node more than 2 cm or multiple lymph nodes Distant Metastasis p MO No distant metastasis p M1 Distant metastasis 13 6 UROLOGY STAGING PROSTATE UICC ADENOCARCINOMA OF THE PROSTATE TNM STAGING SEVENTH EDITION Stage Grouping T Stage N Stage M Stage Stage T1 T1a T1b Tic T2a NO MO Stage 11 T2b T2c NO MO Stage III T3 T3a T3b N1 MO Stage IV n NO Mo ANYT N1 MO ANYT ANY N M1 Note p indicates also applicable for pathological stage Primary Tumour T1 Clinically inapparent tumour neither palpable nor visible by imaging 1 Tumour incidental histological finding 5 or less of tissue resected T1b Tumour incidental histological finding in more than 5 of tissue res
13. 200 OVERVIEW 200 ODE OEE 200 13 1 UROLOGY CANCER CARE PLAN catena cde tea Eu o Ceci eranl andae d 203 13 2 UROLOGY STAGING TESTICULAR sscssicssssseconecssutssessessesecssstensstvatanssagnscssshoseedenssnsenbstosdansuasueeasstoseesedeend 205 13 3 UROLOGY STAGING RENAL PELVIS AND URETER eerte 207 13 4 UROLOGY STAGING URINARY BLADDER ssssssseesssesssesssesssesssesssesssesssesssesssesssesssesssesssesssesssesssesssesuees 208 13 5 UROLOGY STAGING URETHRA csesssesssesssesssesssecssecssecsnecsuecssecsuessnecsuecsuessuessuessuessnessuesssesseessuesseessneeseess 209 13 6 UROLOGY STAGING PROSTATE 210 13 7 UROLOGY STAGING KIDNEY e tette tette 211 13 8 UROLOGY STAGING tentent nte tentent tonto toto toto to toto 212 13 9 UROLOGY TREATMENT BLADDER ettet tette 213 13 10 UROLOGY TREATMENT PROSTATE c sssssssssssssssssssssssssssssssssssssssesssscssssssssssssssssssssssesssesssesssesssesssesssen 213 13 11 UROLOGY PATHOLOGY GENERAL eerte ttt ttt ttt ttt ttes cts 214 13 12 UROLOGY PATHOLOGY ko ente ten a Fe atn dude dada 214 13 13 UROLOGY PATHOLOGY KIDNEY scsscsssssssssssssssssssesssssssssssssssssssssssssssssssssssssssssssssssssssssssssssssnsseenens 214 13 14
14. D39 0 Neoplasm of uncertain or unknown behaviour of Uterus Gynaecological Author NCIN 254 ICD 10 4th Edition All C Codes are Malignant Neoplasms D39 1 Cancer Outcomes and Services Dataset User Guide Description Neoplasm of uncertain or unknown behaviour of Ovary Cancer Waiting Times Site specific group Gynaecological Expected Dataset to be collected Core and Site Specific Dataset Core Dataset Path Only Comment D39 2 Neoplasm of uncertain or unknown behaviour of Placenta Gynaecological D39 7 Neoplasm of uncertain or unknown behaviour of Other female genital organs Gynaecological D39 9 Neoplasm of uncertain or unknown behaviour of Female genital organ unspecified Gynaecological D40 0 Neoplasm of uncertain or unknown behaviour of prostate Urological D40 1 Neoplasm of uncertain or unknown behaviour of testis Urological D40 7 Neoplasm of uncertain or unknown behaviour of other male genital organs Urological D40 9 Neoplasm of uncertain or unknown behaviour of male genital organs unspecifed Urological D41 0 Neoplasm of uncertain or unknown behaviour of kidney Urological Author NCIN 255 ICD 10 4th Edition All C Codes are Malignant Neoplasms D41 1 Cancer Outcomes and Services Dataset User Guide Descripti
15. 11 9 Nasopharynx Head and Neck unspecified 12 Malignant Head and Neck neoplasm of e pyriform sinus C13 0 Postcricoid region Head and Neck e C13 1 Aryepiglottic fold Head and Neck hypopharyngeal e aspect C13 2 Posterior wall of Head and Neck hypopharynx 1 8 Overlapping lesion Head and Neck of hypopharynx C13 9 Hypopharynx Head and Neck unspecified C14 0 Pharynx Head and Neck unspecified 14 2 Waldeyer s ring Head and Neck e C14 8 Overlapping lesion Head and Neck of lip oral cavity e and pharynx C15 0 Cervical part of Upper Usually oesophagus Gastrointestinal treated by Head amp Neck MDT C30 0 Nasal cavity Head and Neck e C30 1 Middle ear Head and Neck e C31 0 Maxillary sinus Head and Neck e C31 1 Ethmoidal sinus Head and Neck e Author NCIN 147 Cancer Outcomes and Services Dataset User Guide C31 2 Frontal sinus Head and Neck C31 3 Sphenoidal sinus Head and Neck C31 8 Overlapping lesion of accessory sinuses Head and Neck C31 9 Accessory sinus unspecified Head and Neck C32 0 Glottis Head and Neck C32 1 Supraglottis Head and Neck C32 2 Subglottis Head and Neck C32 3 Laryngeal cartilage Head and Neck C32 8 Overlapping lesion of larynx Head and Neck C32 9 Larynx unspecified Head and Neck C73 Malignant neoplasm of thyroid gland Head and Neck C77 0 Lymph nod
16. D04 4 Carcinoma in situ of Skin skin of scalp and e neck D04 5 Carcinoma in situ of Skin skin of trunk D04 6 Carcinoma in situ of Skin skin of upper limb e including shoulder D04 7 Carcinoma in situ of Skin skin of lower limb e including hip D04 8 Carcinoma in situ of Skin skin of other sites D04 9 Carcinoma in situ of Skin skin unspecified D48 5 Neoplasm of Skin uncertain or unknown behaviour of Skin Note Malignant neoplasm of the anus should be coded as e Margin C43 5 C44 5 e Skin C43 5 C44 5 e Perinal skin C43 5 C44 5 11 1 SKIN GENERAL BASAL CELL CARCINOMA BCC SQUAMOUS CELL CARCINOMA SCC and MALIGNANT MELANOMA MM To carry general details for Basal Cell Carcinoma Squamous Cell Carcinoma and Malignant Melanoma This section can be recorded more than once Schema Data item Data Item Section Data Item Name Format specification M R O X SKIN GENERAL an10 ccyy SK12040 INVESTIGATION RESULT DATE BCC SCC amp MM mm dd SK12050 SKIN GENERAL SERVICE REPORT IDENTIFIER maxanig Author NCIN 180 Cancer Outcomes and Services Dataset User Guide BCGSCC amp MM SCC amp MM EE GENERAL CANCER LESION INDICATOR SK12120 max an3 BCC SCC amp MM SKIN CANCER LESION NUMBER GRADE OF CLINICIAN SURGEON SKIN GENERAL OPERATING SK12010 an2 BCC SCC amp MM CARE PROFESSIONAL SURGEON GRADE CANC
17. UICC MALIGNANT MELANOMA OF UPPER AERODIGESTIVE TRACT TNM STAGING SEVENTH EDITION Stage Grouping T Stage N Stage M Stage Stage III T3 NO MO Stage IVA T4a NO MO T3 T4a N1 MO Stage IVB T4b Any N MO Stage IVC AnyT Any N M1 UICC MAJOR SALIVARY GLANDS TNM STAGING SEVENTH EDITION Stage Grouping T Stage N Stage M Stage Stage T1 NO MO Stage II T2 NO MO Stage Ill T3 NO MO T1 T2 T3 N1 MO Stage IVA T4a T4b NO N1 MO T1 T2 T3 T4a N2 MO Stage IVB T4b Any N MO Any T N3 MO Stage IVC Any T Any N M1 UICC THYROID GLAND PAPILLARY OR FOLLICULAR TNM STAGING SEVENTH EDITION Stage Grouping T Stage N Stage M stage under 45 years Stage Any T Any N MO Stage Il Any T Any N M1 45 Years and over Stage T1a T1b NO MO Stage Il T2 NO MO Stage III T3 NO MO T1 T2 T3 N1a MO Stage IVA T1 T2 T3 16 MO T4a NO N1 MO Stage IVB T4b Any N MO Stage IVC Any Any N M1 UICC THYROID GLAND MEDULLARY TNM STAGING SEVENTH EDITION Stage Grouping T Stage N Stage M Stage Stage I T1a T1b NO MO Stage Il T2 T3 NO MO Stage III T1 T2 T3 N1a MO Stage IVA T1 T2 T3 Nib MO T4a Any N MO Stage IVB T4b Any N MO Author NCIN 151 Cancer Outcomes and Services Dataset User Guide Stage IVC Any T Any N M1 UICC THYROID GLAND ANAPLASTIC CARCINOMA ALL ANAPLASTIC CARCINOMA TNM STA
18. of other sites D03 9 Melanoma in situ Skin unspecified D04 0 Carcinoma in situ Skin e of skin of lip D04 1 Carcinoma in situ Skin of skin of eyelid e including canthus D04 2 Carcinoma in situ Skin of skin of ear and e external auricular canal Author NCIN 250 Cancer Outcomes and Services Dataset User Guide ICD 10 4th Expected Dataset to be collected Edition Core All C Codes and are Site Malignant Cancer Waiting Times Specific Core Neoplasms Description Site specific group Dataset Dataset Path Only Comment D04 3 Carcinoma in situ Skin of skin of other and unspecified parts of face D04 4 Carcinoma in situ Skin of skin of scalp and e neck D04 5 Carcinoma in situ Skin of skin of trunk 004 6 Carcinoma in situ Skin of skin of upper limb including shoulder 04 7 Carcinoma situ Skin of skin of lower limb including hip D04 8 Carcinoma in situ Skin of skin of other sites D04 9 Carcinoma in situ Skin of skin unspecified D05 0 Lobular carcinoma Breast in situ D05 1 Intraductal Breast carcinoma in situ D05 7 Other carcinoma in Breast situ of breast D05 9 Carcinoma in situ Breast of breast e unspecified D06 0 carcinoma in situ Gynaecological of endocervix D06 1 carcinoma in situ Gynaecological of exocervix D06 7 carcinoma in situ Gynaecological of other parts of e cervix D06 9 carci
19. MXXXXXX see Haematology Section 7 2 TOPOGRAPHY ICDO3 OPTIONAL The topographical site code for the tumour as defined by ICDO3 This will normally be derived by Registries Format CXX X GRADE OF DIFFERENTIATION AT DIAGNOSIS is the definitive grade of the Tumour at the time of PATIENT DIAGNOSIS Note Required for all Urological cancers except prostate and testis cancer This data item is not applicable to CNS or Haematology diagnosis ifferenti Poorly differentiated Undifferentiated anaplastic METASTATIC SITE CWT The site of the metastatic disease if any at diagnosis Note that for Cancer Waits this item cannot be reported for first treatments unless that first treatment is a first treatment of a metastatic cancer following an unknown primary cancer for COSD this should be recorded for all cases where applicable at diagnosis Note This is not applicable for Haematological diagnosis Brain iver Author NCIN 35 Cancer Outcomes and Services Dataset User Guide Multiple metastatic sites 04 a Sn ooo 09 Distantlymphnodes o 9 Other metastatic site CANCER RECURRENCE CARE PLAN INDICATOR An indication of whether a diagnosis of recurrence has been recorded for which a new Cancer Care Plan is required A new record should be completed for a recurrence Yes including local recurrence Yes not including local recurrence NN No not recurrence 1 5 CORE CANCER
20. c 2 2 g gt a gt uv vu m 2 z 22 D Q o 5 lt lt 5 o 2 bw 2 o c pt c 3 o c 5 ct 2 D gt 5 oO 2 o x identified by the clinician at presentation Synchronous tumours are defined as discrete tumours apparently not in continuity with other primary cancers originating in the same site or tissue Note If Yes a separate registration is required Yes SYNCHRONOUS TUMOUR INDICATOR ASCENDING COLON Record any synchronous tumours in the Ascending Colon as identified by the clinician at presentation Synchronous tumours are defined as discrete tumours apparently not in continuity with other primary cancers originating in the same site or tissue Note If Yes a separate registration is required Y Yes apparently not in continuity with other primary cancers originating in the same site or tissue Note If Yes a separate registration is required Yes SYNCHRONOUS TUMOUR INDICATOR TRANSVERSE COLON Record any synchronous tumours the Transverse Colon as identified by the clinician at presentation Synchronous tumours are defined as discrete c 3 o c wn o D o 5 ct lt 3 za 3 5 zt 3 lt E pi a o 3 D lt O 5 eo e 9a 5 D ct E 5 ct 3 2 p m F
21. esses Author NCIN Cancer Outcomes and Services Dataset User Guide STOVER VIEW 87 BDAC DUO CO DES E 87 5 3 CTYA TABLES OF DATA ITEMS BE COMPLETED s ccceceeeeeesseaeceeeeeseeuaaeceeeeeseeuaaeeeeeceseeseaeeneeeeees 87 5 4 CTYA REFERRALS All cases ssssesseeseeeeer nennen enne enne nnne nennen ernst nnne rnit en sienne senes 91 5 5 CTYA DIAGNOSIS All cases nennst inae anana niione eisene aasia asiana RES 91 5 6 CTYA CANCER CARE retorno sana den eiae aisiais shine 93 5 7 CTYA STEM CELL TRANSPLANTATION en ennnnenrnn sten siet 93 5 8 CTYA 2 NS RURTE ERE TE REN SEN USE UBER PRSE UNIS HERUM 94 5 9 CTYA ACUTE LEUKAEMIA LYMPHOCYTIC and MYELOID eese enne enne enne enne nennen 94 5 10 CTYA NON HODGKIN LYMPHOMA 95 5 11 CTYA HODGKIN LYMPHOMA 96 5 12 CTYA NEUROBLASTOMI eterne repetere ete Era ra e sheep ien te Ree eve Ea Ee tee ven rhe eR Ue ean 97 5 13 CTYA RENAL TUMOURS noit entre
22. 3 Either INTRAVESICAL CHEMOTHERAPY RECEIVED INDICATOR or INTRAVESICAL IMMUNOTHERAPY RECEIVED INDICATOR is Mandatory for the schema 14 Either INTRAVESICAL IMMUNOTHERAPY RECEIVED INDICATOR or INTRAVESICAL CHEMOTHERAPY RECEIVED INDICATOR is Mandatory for the schema Author NCIN 213 Cancer Outcomes and Services Dataset User Guide PROSTATE PROSTATE SPECIFIC ANTIGEN n5 n1 PRE TREATMENT PSA PRE TREATMENT PROSTATE ONLY Prostate Specific Antigen blood level in ng ml measured before treatment including second and subsequent treatments This is the PSA taken prior to EACH treatment because some curative treatments may be delivered years after diagnosis 13 11 UROLOGY PATHOLOGY GENERAL To carry general pathology details for Urology cancer This section can be recorded more than once A Schema Data item No Data Item Section Data Item Name Format specification M R 0 X UR15340 UROLOGY PATHOLOGY INVESTIGATION RESULT an10 ccyy GENERAL DATE mm dd UROLOGY PATHOLOGY SERVICE REPORT UR15350 max an18 GENERAL IDENTIFIER INVESTIGATION RESULT DATE The date on which an investigation was concluded e g the date the result was authorised SERVICE REPORT IDENTIFIER A unique identifier of a SERVICE REPORT 13 12 UROLOGY PATHOLOGY BLADDER To carry the cancer pathology details for Bladder This section will be recorded once per pathology report where applicable Schema Data Item Section Data Item
23. B lymphoblastic leukaemia NOS C91 0 leukaemia ALL 7 B lymphoblastic lymphoma with Lymphoblastic diffuse 3812 3 A t 9 22 q34 q11 2 BCR ABL1 Fete lymphoma 7 lymphoblastic leukaemia with Acute lymphoblastic 3812 3 B t 9 22 q34 q11 2 BCR ABL1 en leukaemia ALL ate 7 lymphoblastic lymphoma with Lymphoblastic diffuse 9813 3 t v 11q23 MLL re arranged c83 lymphoma ALL d B lymphoblastic leukaemia with Acute lymphoblastic t v 11q23 MLL re arranged leukaemia ALL d B lymphoblastic lymphoma with Lymphoblastic diffuse NN t 12 21 p13 q22 ETV6 RUNX1 od lymphoma ALL 4 B lymphoblastic leukaemia with Acute lymphoblastic 9814 3 B t 12 21 p13 q22 ETV6 RUNX1 691 0 leukaemia ALL iin 9815 3 A B lymphoblastic lymphoma with C83 5 Lymphoblastic diffuse ALL 7 hyperdiploidy lymphoma B lymphoblastic leukaemia with Acute lymphoblastic SEIS hyperdiploidy C210 leukaemia ALL f B lymphoblastic lymphoma with Lymphoblastic diffuse 3816 34 hypodiploidy hypodiploid ALL ws lymphoma m lymphoblastic leukaemia with Acute lymphoblastic 9816 3 hypodiploidy hypodiploid ALL leukaemia ALL ALL 7 lymphoblastic lymphoma with Lymphoblastic diffuse 9817 3 t 5 14 q31 q32 IL3 IGH eo lymphoma ALL d B lymphoblastic leukaemia with Acute lymphoblastic 9817 3 B t 5 14 q31 q32 IL3 IGH on leukaemia ALL f B lymphoblastic lymphoma with Lymphoblastic diffuse 9818 3 A t 1 19 q23 p13 3 TCF3 PBX1 cone l
24. C53 0 Endocervix Gynaecological e C53 1 Exocervix Gynaecological C53 8 Overlapping lesion Gynaecological of cervix uteri C53 9 Cervix uteri Gynaecological unspecified 54 0 Isthmus uteri Gynaecological 54 1 Endometrium Gynaecological 54 2 Myometrium Gynaecological 54 3 Fundus uteri Gynaecological 54 8 Overlapping lesion Gynaecological of corpus uteri 54 9 Corpus uteri Gynaecological unspecified 55 Malignant Gynaecological neoplasm of uterus part unspecified C56 Malignant Gynaecological neoplasm of ovary C57 0 Fallopian tube Gynaecological e C57 1 Broad ligament Gynaecological e C57 2 Round ligament Gynaecological e C57 3 Parametrium Gynaecological e C57 4 Uterine adnexa Gynaecological unspecified 57 7 Other specified Gynaecological female genital organs Author NCIN 109 Cancer Outcomes and Services Dataset User Guide C57 8 Overlapping lesion of female genital organs Gynaecological C57 9 Female genital organ unspecified Gynaecological C58 Malignant neoplasm of placenta Gynaecological C79 6 Secondary malignant neoplasm of ovary Gynaecological Normally treated by MDT of site of primary tumour Only use if unable to code to specific primary site D06 0 carcinoma in situ of endocervix Gynaecological D06 1 carcinoma in situ of exocervix Gynaecological D06 7 carcinoma in situ of other par
25. IMAGING eese enne inen nennen 3 2 CENTRAL NERVOUS SYSTEM CANCER CARE nennen enne nennen enne enn 3 3 CENTRAL NERVOUS SYSTEM SURGERY amp OTHER 3 4 CENTRAL NERVOUS SYSTEM RADIOSURGERY ssssseeeeeeeeen enne 3 5 CENTRAL NERVOUS SYSTEM ener nennen enr A COLORECTAL OVERVIEW ICD 1O CODES 4 1 COLORECTAL IMAGING wie sescciccssscedcasescesessnncessesoscatansbicedsucedecvosceiddssoseassicesessndeedndisedenseiirtensosbeiaaseicedevsatentes 4 2 COLORECTAL DIAGNOSIS ss ssid coscsscsinsescnnectsncctestotcuienbstscesseetsebeocetasesossdsuscaectscioaddabsnbectedsetaedsssnieasshedsassdheptes 4 3 COLORECTAL CANCER CARE PLAN uicsisccscsscicescesntcessssoscetstcescossocetsessnsedsssassosssbeedassedeeseiieteesoioetaasoicedessttennss 4 A COLORECTAL 5 2 4 5 COLORECTAL SURGERY amp OTHER 4 6 COLORECTAL PATHOLOGY lt ririri reote tube aea eiaa anrasan 5 CHILDREN TEENAGERS AND YOUNG ADULTS
26. Associated Conditions to be recorded on Childhood Cancer Registration Forms The associated conditions in the patient should include any medical condition that could be related to aetiology of the child s cancer or could affect treatment or outcome The main categories that are likely to be of interest and should therefore be recorded are as follows listed by Chapter within ICD 10 ICD10 ICD 10 Conditions Examples Chapter Codes C00 C97 Malignant neoplasms Any malignancy diagnosed before the subject of the current registration DOO D48 Benign and unspecified Melanocytivc naevus neurofibroma neoplasms D50 D98 Diseases of blood Thalassaemia sickle cell disease or trait blood forming organs amp spherocytosis Diamond Blackfan anaemia Fanconi immune system anaemia aplastic anaemia Von Willebrand disease severe combined immune deficiency Wiskott Aldrich syndrome IV EOO E90 Endocrine nutritional amp Goitre diabetes congenital adrenal hyperplasia albinism metabolic diseases cystic fibrosis F80 F89 Disorders of Autism psychological development F90 F98 Early onset behavioural Attention deficit hyperactivity disorder amp emotional disorders G90 Autonomic nervous Horner syndrome system disorders momo J sims Author NCIN 263 Cancer Outcomes and Services Dataset User Guide ICD10 ICD 10 Conditions Examples Chapter Codes o mm NN eee _ POO P96 Conditions originating Extreme prematurity bir
27. Author NCIN 288
28. Not accessable Author NCIN 122 Cancer Outcomes and Services Dataset User Guide 7 HAEMATOLOGY OVERVIEW In order to ensure that all the data items can be collected it is essential to discuss the process with clinicians responsible for treating the patients For all haematology patients it is essential to record the ICD03 MORPHOLOGY CODE see Core Dataset 7 1 STAGE TNM Staging is not collected for Haematological cancers However the following staging data items are required for all relevant cases CLL Rai stage and Binet stage including all component data items This is to enable comparison as neither stage is used exclusively Both can be derived if components are recorded Myeloma 155 All Lymphomas Ann Arbor Stage Ann Arbor Symptoms Ann Arbor Extranodality and Ann Arbor Bulk Additionally the following prognostic indicators are also required CML Hasford Index and Sokal index including all component data items This is to enable comparison as neither index is used exclusively Both can be calculated if components are recorded Myelodysplasia IPSS Follicular lymphoma index DLBCL R IPI index Hodgkin Lymphoma Hasenclever index Only applicable to advanced Stage 3 and 4 disease 7 2 ICD CODES AND WHO DISEASE GROUPS The following table shows the full list of ICD10 codes which are applicable for Haematology mapped against the relevant ICDO3 codes as well as the dataset which should be complet
29. Dataset Comment C00 0 External upper lip Head and Neck e 00 1 External lower lip Head and Neck e C00 2 External lip Head and Neck unspecified C00 3 Upper lip inner Head and Neck aspect C00 4 Lower lip inner Head and Neck r aspect C00 5 Lip unspecified Head and Neck inner aspect C00 6 Commissure of lip Head and Neck e C00 8 Overlapping lesion of Head and Neck lip C00 9 Lip unspecified Head and Neck e C01 Malignant neoplasm Head and Neck of base of tongue C02 0 Dorsal surface of Head and Neck amp tongue C02 1 Border of tongue Head and Neck e C02 2 Ventral surface of Head and Neck tongue C02 3 Anterior two thirds Head and Neck of tongue part e unspecified C02 4 Lingual tonsil Head and Neck e C02 8 Overlapping lesion of Head and Neck tongue C02 9 Tongue unspecified Head and Neck e C03 0 Upper gum Head and Neck Author NCIN 219 ICD 10 4th Edition All C Codes are Malignant Cancer Outcomes and Services Dataset User Guide Cancer Waiting Times Site Expected Dataset to be collected Core and Site Specific Core Path Neoplasms Description specific group Dataset Dataset Only Comment C03 1 Lower gum Head and Neck e C03 9 Gum unspecified Head and Neck e C04 0 Anterior floor of Head and Neck mouth C04 1 Lateral floor of H
30. Less than or equal to half myometrial invasion More than half myometrial invasion Adnexal involvement ms Tumourinvades abdominal sues more than oneste Author NCIN 114 Cancer Outcomes and Services Dataset User Guide 6 3 GYNAECOLOGY PATHOLOGY To carry pathology details for Gynae This section can be recorded more than once Schema Data item Data Item Section Data Item Name Format specification No GYNAECOLOGY an10 ccyy GY7320 INVESTIGATION RESULT DATE PATHOLOGY mm dd GYNAECOLOGY GY7430 SERVICE REPORT IDENTIFIER max an18 PATHOLOGY FALLOPIAN TUBE INVOLVEMENT GYNAECOLOGY GY7050 MICROSCOPIC INVOLVEMENT PATHOLOGY INDICATION CODE FALLOPIAN TUBE M R O X SEROSAL INVOLVEMENT GYNAECOLOGY GY7130 MICROSCOPIC INVOLVEMENT PATHOLOGY INDICATOR SEROSA OMENTAL INVOLVEMENT GYNAECOLOGY GY7100 OMENTUM INVOLVEMENT a PATHOLOGY INDICATION CODE INVESTIGATION RESULT DATE The date on which an investigation was concluded e g the date the result was authorised SERVICE REPORT IDENTIFIER A unique identifier of a SERVICE REPORT ani OVARIAN INVOLVEMENT GYNAECOLOGY GY7120 MICROSCOPIC INVOLVEMENT an1 PATHOLOGY INDICATION CODE OVARIAN 1 n1 FALLOPIAN TUBE INVOLVEMENT For endometrial and epithelial ovarian cancers is there microscopic involvement of fallopian tubes Not involved Right involved Left involved Both involved Not assessable OVARIA
31. PROCEDURE DATE BRONCHOSCOPY Date bronchoscopy was performed which informed management of patient at time of MDT BRONCHOSCOPY PERFORMED INDICATOR Was a bronchoscopy performed on this patient Not known 9 6 LUNG BIOMARKERS To carry Biomarker details for Lung Carcinoma This section will be recorded once Author NCIN 162 Cancer Outcomes and Services Dataset User Guide Schema Data item Data Item Data Item Name Format specification M R O X Section No LUNG EPIDERMAL GROWTH FACTOR RECEPTOR LU10090 an1 BIOMARKERS MUTATIONAL STATUS EPIDERMAL GROWTH FACTOR RECEPTOR MUTATIONAL STATUS Epidermal Growth Factor Receptor Mutational Status This would be available on the results report Wild type 4 Not assessed 9 7 LUNG PATHOLOGY To carry Pathology details for Lung Carcinoma Most items are only applicable where patients have surgical resection This section can be recorded more than once Schema Data item Data Item eee Data Item Name Format specification M R O X LUNG an10 ccyy LU10200 INVESTIGATION RESULT DATE PATHOLOGY mm dd LUNG LU10210 SERVICE REPORT IDENTIFIER max 18 PATHOLOGY LUNG PROXIMITY TO CARINA LU10100 ani PATHOLOGY TUMOUR PROXIMITY TO CARINA LUNG LU10110 EXTENT OF ATELECTASIS PATHOLOGY LUNG LU10120 EXTENT OF PLEURAL INVASION PATHOLOGY No Section fo foe j PERICARDIAL INVASION LU10130 TUMOUR INVASION INDICATOR an1 PATHOLOGY
32. UICC TNM 7 Author NCIN 265 Cancer Outcomes and Services Dataset User Guide NASOPHARYNX UICC TNM 7 INTERNATIONAL NEUROBLASTOMA NEUROBLASTOMA STAGING SYSTEM NON HODGKINS LYMPHOMA ADULT ANN ARBOR NON HODGKINS LYMPHOMA CHILDREN MURPHY ST JUDE STAGING SYSTEM OESOPHAGUS INCLUDING OESOPHAGOGASTRIC JUNCTION CARCINOMA UICC TNM 7 OESOPHAGUS INCLUDING OESOPHAGOGASTRIC JUNCTION GIST UICC TNM 7 ORAL CAVITY UICC TNM 7 OROPHARYNX UICC TNM 7 OMENTUM AND MESENTERY GIST UICC TNM 7 OVARY AND PERITONEUM FIGO PANCREAS UICC TNM 7 PANCREAS NEUROENDOCRINE TUMOURS EUROPEAN NEUROENDOCRINE TUMOUR SOCIETY TNM PENIS UICC TNM 6 PLEURAL MESOTHELIOMA UICC TNM 7 PROSTATE UICC TNM 7 RENAL PELVIS AND URETER UICC TNM 7 RETINOBLASTOMA UICC TNM 7 SARCOMA OF ORBIT UICC TNM 7 SKIN MALIGNANT MELANOMA AJCC TNM 7 SKIN MERKEL CELL CARCINOMA AJCC TNM 7 SKIN OF EYELID CARCINOMA UICC TNM 7 SMALL INTESTINE GIST UICC TNM 7 SMALL INTESTINE NEUROENDOCRINE TUMOURS EUROPEAN NEUROENDOCRINE TUMOUR SOCIETY TNM SMALL INTESTINE CARCINOMA UICC TNM 7 SOFT TISSUE UICC TNM 7 STOMACH CARCINOMA UICC TNM 7 STOMACH GIST UICC TNM 7 STOMACH NEUROENDOCRINE TUMOURS EUROPEAN NEUROENDOCRINE TUMOUR SOCIETY TNM SUBGLOTTIS UICC TNM 7 SUPRAGLOTTIS UICC TNM 7 UICC TNM 7 amp ROYAL MARSD
33. e pner information on the collection of this Skin disease C44 9 Malignant neoplasm Skin See the Skin of skin unspecified chapter of the COSD User Guide Overview Section for e e e further information on the collection of this Skin disease C45 0 Mesothelioma of Lung pleura e C45 1 Mesothelioma of Lung peritoneum C45 2 Mesothelioma of Lung e pericardium C45 7 Mesothelioma of Lung other sites C45 9 Mesothelioma Lung iE e unspecified C46 0 Kaposi sarcoma of Sarcoma skin 46 1 Kaposi sarcoma of Sarcoma soft tissue C46 2 Kaposi sarcoma of Sarcoma m palate C46 3 Kaposi sarcoma of Sarcoma lymph nodes C46 7 Kaposi sarcoma of Sarcoma other sites C46 8 Kaposi sarcoma of Sarcoma multiple organs C46 9 Kaposi sarcoma Sarcoma amp unspecified Author NCIN 229 ICD 10 4th Edition Cancer Outcomes and Services Dataset User Guide Expected Dataset to be collected All C Codes Core and are Cancer Waiting Site Malignant Times Site Specific Core Path Neoplasms Description specific group Dataset Dataset Only Comment C47 0 Peripheral nerves of Brain Central Usually head face and neck Nervous System treated by Sarcoma MDT C47 1 Peripheral nerves of Brain Central Usually upper limb including Nervous System e treated by shoulder Sarcoma MDT 47 2 Peripheral nerves Brain Central Usually lower limb including Nervous System treated by hip Sarco
34. in order to enable new unlisted types of treatment to be captured This change affects e CANCER CLINICAL TRIAL TREATMENT TYPE Core dataset CR1260 Addition of the following new data items to pilot the feasibility and potential benefits of using SNOMED CT and to support the National Information Strategy These are only applicable for those taking part in the pilot study e MORPHOLOGY SNOMED CT Core dataset CR3030 e PRIMARY PROCEDURE SNOMED CT Core dataset CR3040 e PROCEDURE SNOMED CT Core dataset CR3050 e TOPOGRAPHY SNOMED CT Core dataset CR3060 e MORPHOLOGY SNOMED CT Core dataset CR3070 Addition of the following two new data items and subsequent removal of ORGANISATION CODE RESPONSIBLE PCT in order to reflect changes in organisational structure to Clinical Commissioning Groups CCGs Neither of these data items would be submitted by Providers e ORGANISATION CODE GP PRACTICE RESPONSIBILITY Reference Other Sources CR3080 e ORGANISATION CODE RESIDENCE RESPONSIBILITY Reference Other Sources CR3090 BREAST Change data item format to allow recording to 2 decimal places max nX max n2 in order to standardise measurement items and enable a greater degree of accuracy where applicable This change affects e NON INVASIVE TUMOUR SIZE Breast dataset BR4180 e WHOLE TUMOUR SIZE Breast dataset BR4190 CNS Change data item format to allow recording to 2 decimal places max nX max n2 in
35. with negative nodes Stage2 ll Tumour of any size with extension to adjacent perineal structures 1 3 lower urethra 1 3 lower vagina anus with negative nodes Stage III Tumour of any size with or without extension to adjacent perineal structures 1 3 lower urethra 1 3 lower vagina anus with positive inguino femoral lymph nodes i With 1 lymph node metastasis 25 mm IIAii ii 1 2 lymph node metastasis es 5 mm With 2 or more lymph node metastases gt 5 mm or 3 or more lymph node metastases lt 5 mm With positive nodes with extracapsular spread Stage IV Tumour invades other regional 2 3 upper urethra 2 3 upper vagina or distant structures IVAi Tumour invades any of the following upper urethral and or vaginal mucosa bladder mucosa rectal mucosa or fixed to pelvic bone or IVAii fixed or ulcerated inguino femoral lymph nodes IVB Any distant metastasis including pelvic lymph nodes CERVICAL FIGO Stage WT 9 Description Group Stage The carcinoma is strictly confined to the cervix extension to the corpus would be disregarded Stage IA Invasive carcinoma which can be diagnosed only by microscopy with deepest invasion lt 5mm and largest extension 27mm IA1 Measured stromal invasion lt 3 0mm in depth and extension of lt 7 0 1 2 Measured stromal invasion gt 3 0mm and not gt 5 0mm with an extension of of not gt 7 0mm Stage IB Clinically visible lesion confined to the cervix or pre cli
36. A MS 9 Not Known o DCIS GRADE If ductal carcinoma in situ is present record the DCIS grade This is the cytonuclear grade 96 7 X Not assessable INVASIVE GRADE BREAST The invasive histological grade of the tumour as defined by modified Bloom and Richardson system NON INVASIVE TUMOUR SIZE The size of the non invasive tumour in mm This is only required if there is no invasive component Note For COSD reporting purposes this data item is not required to be submitted to two decimal places WHOLE TUMOUR SIZE Whole size of tumour invasive surrounding DCIS if DCIS extends 1mm beyond invasive mm For tumours without a DCIS component this will be the same as INVASIVE LESION SIZE Note For COSD reporting purposes this data item is not required to be submitted to two decimal places METASTASIS EXTENT CODE For single node positivity specify micrometastatic status as follows Greater than 2mm Metastases 2mm to greater than 0 2mm Micrometastasis less than or equal to 0 2mm Isolated tumour cells Metastasis 3 Isolated tumour cells 9 Notknown 7 DISTANCE TO MARGIN Distance to closest relevant margin mm Distance to nearest margin whether invasive or non invasive ER ALLRED SCORE ER Allred score range O 2 8 ER STATUS Oestrogen Receptor ER status A positive score means that Estrogen is causing your tumour to grow and a negative score means that the tumour is not
37. ALPHA FETOPROTEIN S CATEGORY HCG UROLOGY CANCER UR15050 S CATEGORY HUMAN CHORIONIC CARE PLAN GONADOTROPIN S CATEGORY LDH UROLOGY CANCER UR15060 S CATEGORY LACTATE CARE PLAN DEHYDROGENASE PSA DIAGNOSIS UROLOGY CANCER UR15070 PROSTATE SPECIFIC ANTIGEN CARE PLAN DIAGNOSIS ESTIMATED GLOMERULAR FILTRATION RATE RENAL ONLY This is the estimated Glomerular Filtration Rate It is a measurement of kidney function in mls min 1 73m2 This is to be collected once at diagnosis Note that this should be recorded as part of standard renal function test Positive values Numerical value to be recorded categories can be derived from this at a later stage 0 99 HYDRONEPHROSIS HYDRONEPHROSIS CODE BLADDER ONLY Consequence of reduced outflow of urine from Kidney May be present in one or both kidneys Oo B Bilateral 8 Not Applicable No Kidneys 9 Not Known NORMAL LDH TESTICULAR ONLY This is the upper limit of normal for the LDH Lactate Dehydrogenase Level assay which is used to calculate S Category Range 0 999999 S CATEGORY TESTICULAR ONLY Based on serum tumour markers AFP HCG and LDH For Testicular Cancer S category is an additional prognostic factor See below for further details of values to be recorded Tumour marker studies not available or not performed Tumour marker levels within normal limits LDH 1 5 X Normal and HCG mlu ml 5000 and AFP ug ml 1000 LDH 1 5 10
38. HASFORD INDEX CHRONIC MYELOID LEUKAEMIA Index derived from age spleen size platelet count myeloblasts 96 eosinophils 96 basophils 96 Low less than 781 Intermediate 781 1480 High gt 1480 if lt 20 years Score agt n gt X years 0 0413 eosinophils 2039 basophils 0 0420 spleen size cm below costal region 0 0584 blasts Dif lt 1500 10 1 tif gt 1500 10 L Dif lt 3 if Lies lif 23 1000 7 7 HAEMATOLOGY CANCER CARE PLAN MYELODYSPLASIA To carry cancer care plan details specific to Myelodysplasia This section will be recorded once Schema Data Item Section Data Item Name Format specification M R O X Data item No IPSS MYELODYSPLASIA Hagogo HAEMATOLOGY CANCER CARE rr RNATIONAL PROGNOSTIC PLAN MYELODYSPLASIA SCORING SYSTEM SCORE IPSS MYELODYSPLASIA INTERNATIONAL PROGNOSTIC SCORING SYSTEM for myelodysplasia Index derived from BM blasts 96 Karyotype Platelet count Hb Neutrophils e Score for BM Blasts 96 less than 5 0 5 for 5 10 1 5 for 11 20 e Score 0 for Karyotype Good 0 5 for Intermediate 1 for Poor e Score 0 for 0 1 cytopenias 0 5 for 2 3 cytopenias e Cytopenia Yes if Platelet count less than 100 and Haemoglobin less than 100 and Neutrophils less than 1 8 e Score range 0 to 3 0 The use of IPSS will be reviewed in light of the recently published IPSS R scoring system IPS
39. Local and or regional spread of tumour Tumour invades the serosa of the corpus uteri and or adnexa IB Vaginal and or parametrial involvement Metastases to pelvic and or para aortic nodes 1 Positive pelvic nodes 2 Positive para aortic nodes with or without positive pelvic lymph nodes Stage IV Tumour invades bladder and or bowel mucosa IVA Tumour invasion of bladder and or bowel mucosa IVB Distant metastases including abdominal metastases and or inguinal lymph nodes OVARIAN FIGO Stage n Group Description IA Tumour limited to one ovary capsule intact no tumour on ovarian surface no malignant cells in ascites or peritoneal washings IB Tumour limited to both ovaries capsules intact no tumour on ovarian surface no malignant cells in ascites or peritoneal washings IC Tumour limited to one or both ovaries with any of the following capsule ruptured tumour on ovarian surface malignant cells in the ascites or positive peritoneal washings Extension and or implants on uterus and or tubes no malignant cells in the ascites peritoneal washings Extension to other pelvic organ no malignant cells in the ascites or peritoneal washings with malignant cells the ascites or positive peritoneal washings Microscopic peritoneal metastasis beyond the pelvis IB Macroscopic peritoneal metastasis beyond the pelvis 2 cm or less in greatest dimension Peritoneal metastasis beyond pelvis more than 2 cm in greate
40. NECK PATHOLOGY SALIVARY cette tette tte tete tete tonic 8 6 HEAD amp NECK PATHOLOGY GENERAL and SALIVARY ettet tette tette c erus MN dE MEE EE 9 1 LUNG IMAGING CT SCAN oneris eR ovatus tesaiiossevarioss anaana anaana nananana anaana anaana nananana naana nanana 9 2 LUNG IMAGING PET SCAN eet tette tetto toto toto toto to totos 9 3 LUNG CANCER CARE PLAN 2 Rocha ta nhan absenden tint CAEN E ST AGING adatta peers copo edet a c encanta pet pA Rn 9 5 LUNG BRONCHOSCOPY 9 610 BIO ARRERS rediere AER e Ltda ed cq 9 710 6 PATOL GY Ges idis duriter tba Hte T5 SARCOMA cetus cence Ferte eii be rd Mae a RE OVERVIEW MM 1 10 RNC 10 1 SARCOMA DIAGNOSIS cire entails umts etd dresden 10 2 SARCOMA STAGE eeeeeeetteeteetteetee tentent ettet ettet tetto ttes toto Author NCIN Cancer Outcomes and Services Dataset User Guide 10 3 SARCOMA PATHOLDOY asia oiii deoa ctn inniinn 172 10 4 SARCOMA PATHOLOGY 173 10 5 SARCOMA PATHOLOGY SOFT 0 ttt tentent ttt 173 MR CREE 175 OVERVIEW ate 175
41. Stage T1 NO MO Stage II T2 NO MO Stage IIIA T3 NO MO Stage IIIB T1 T2 T3 N1 MO Stage IVA T4 Any N MO Stage IV Any T Any N M1 UICC EXTRAHEPATIC BILE DUCTS PERIHILAR ICD 10 C24 0 TNM STAGING SEVENTH EDITION Stage Grouping T Stage N Stage M Stage Stage 1 MO Stage II T2a T2b NO MO Stage IIIA T3 NO MO Stage IIIB T1 T2 T3 N1 MO Stage IVA T4 NO N1 MO Stage IVB Any T Any N M1 UICC EXTRAHEPATIC BILE DUCTS DISTAL ICD 10 C24 0 TNM STAGING SEVENTH EDITION Stage Grouping T Stage N Stage M Stage Stage IA T1 NO MO Stage IB T2 NO MO Stage IIA T3 NO MO Stage IIB T1 T2 T3 1 MO Stage III T4 Any N MO Stage IV Any T Any N M1 UICC AMPULLA OF VATERS ICD 10 C24 1 TNM STAGING SEVENTH EDITION Stage Grouping T Stage N Stage M Stage Author NCIN 191 Cancer Outcomes and Services Dataset User Guide Stage IA 1 MO Stage IB T2 NO MO Stage IIA T3 NO MO Stage IIB T1 T2 T3 N1 MO Stage III T4 Any N MO Stage IV Any T Any N M1 UICC PANCREAS ICD 10 C25 TNM STAGING SEVENTH EDITION Stage Grouping T Stage N Stage M Stage Stage IA T1 NO MO Stage IB T2 NO MO Stage IIA T3 NO MO Stage IIB T1 T2 T3 N1 MO Stage III T4 Any N MO Stage IV Any T Any N M1 12 4 UPPER GI MAIN ENDOSCOPIC OR RADIOLOGICAL PROCEDURES To carry Endoscopic
42. TILS SK12430 PATHOLOGY MM TUMOUR INFILTRATING LYMPHOCYTE TYPE SKIN FINAL EXCISION MARGIN AFTER WIDE LOCAL SK12450 PATHOLOGY MM EXCISION SKIN SENTINEL NODES EXAMINED NUMBER SK12460 PATHOLOGY NUMBER OF SENTINEL NODES SAMPLED MM SKIN SENTINEL NODES POSITIVE NUMBER SK12470 max n2 M PATHOLOGY NUMBER OF SENTINEL NODES POSITIVE 184 Author NCIN Cancer Outcomes and Services Dataset User Guide _ c MND ee Jn eee POST SNB COMPLETION LYMPHADENECTOMY SKIN NODES SAMPLED NUMBER SK12480 PATHOLOGY NUMBER OF SENTINEL NODES SAMPLED POST max n2 MM SENTINEL NODE COMPLETION LYMPHADENECTOMY POST SNB COMPLETION LYMPHADENECTOMY SKIN NODES POSITIVE NUMBER SK12490 PATHOLOGY NUMBER OF SENTINEL NODES POSITIVE POST max n2 MM SENTINEL NODE COMPLETION LYMPHADENECTOMY ULCERATION INDICATOR Loss of full thickness of epidermis associated with reactive changes ulceration MITOTIC RATE SKIN Mitotic rate per square millimetres mm Note May also be known as Mitotic Index or Count MICROSATELLITE OR IN TRANSIT METASTASIS INDICATOR Is there evidence of Microsatellite or in transit metastases Yes TUMOUR REGRESSION INDICATOR Area of loss of tumour associated with reactive changes Yes BRESLOW THICKNESS Breslow thickness mm to nearest 0 01mm Note Breslow thickness should be measured to a minimum of one decimal place but at times to a greater degr
43. a separate registration is required Yes SYNCHRONOUS TUMOUR INDICATOR RECTOSIGMOID Record any synchronous tumours in the RectoSigmoid as identified by the clinician at presentation Synchronous tumours are defined as discrete tumours apparently not in continuity with other primary cancers originating in the same site or tissue Note If Yes a separate registration is required Yes SYNCHRONOUS TUMOUR INDICATOR RECTUM Record any synchronous tumours in the Rectum as identified by the clinician at presentation Synchronous tumours are defined as discrete tumours apparently not in continuity with other primary cancers originating in the same site or tissue Note If Yes a separate registration is required Yes He TUMOUR HEIGHT ABOVE ANAL VERGE Record the approximate height in centimetres of the lower limit of the tumour above anal verge as measured by rigid sigmoidoscopy only 4 3 COLORECTAL CANCER CARE PLAN To carry cancer care plan details for colorectal cancer This section will be recorded once Schema specification M R O X Data item No Data Item Section Data Item Name Format COLORECTAL 5005 BODY MASS INDEX 2 1 CANCER CARE PLAN BODY MASS INDEX Estimate of a patient s Body Mass Index BMI at diagnosis The Body Mass Index BMI can be derived by a calculation using the patient s height and weight This data item would be obtained at presentation either in the outpatient
44. ct D 2 m zx lt D D o ct D D 09 7 w t o 5 a iv a D o lt 2 e I 2 2 c o c o c 2 2 gt 2 uw v re m c m c 2 22 oO Q o I 2 lt o lt 2 2 2 o c a ct c 3 o c a 5 ct gt m WN 6 2 o Flexure as identified by the clinician at presentation Synchronous tumours are defined as discrete tumours apparently not in continuity with other primary cancers originating in the same site or tissue Note If Yes a Yes D y 2 et D 9a Uu ect c ct 2 2 a c E 2 SYNCHRONOUS TUMOUR INDICATOR DESCENDING COLON Record any synchronous tumours in the Descending Colon as identified by the clinician at presentation Synchronous tumours are defined as discrete tumours apparently not in continuity with other primary cancers originating in the same site or tissue Yes SYNCHRONOUS TUMOUR INDICATOR SIGMOID COLON Record any synchronous tumours in the Sigmoid Colon as identified by the clinician at presentation Synchronous tumours are defined as discrete tumours Author NCIN 80 Cancer Outcomes and Services Dataset User Guide apparently not in continuity with other primary cancers originating in the same site or tissue Note If Yes
45. e of breast C50 9 Breast unspecified Breast e D05 0 Lobular carcinoma Breast 2 in situ D05 1 Intraductal Breast carcinoma in situ D05 7 Other carcinoma in Breast e situ of breast D05 9 Carcinoma in situ of Breast ups e breast unspecified Author NCIN 55 Cancer Outcomes and Services Dataset User Guide D48 6 Neoplasm of Breast uncertain or unknown behaviour of Breast 2 1 BREAST REFERRALS To carry referral details for breast cancer This section can be recorded more than once within a referral Schema Data Item Name Format specification M R O X BREAST BR4000 REFERRALS DATE OF CLINICAL ASSESSMENT 10 ccyy mm dd DELE Data Item item No Section BREAST ORGANISATION SITE CODE OF CLINICAL Minimum length BR4010 REFERRALS ASSESSMENT an5 maximum M SITE CODE OF CLINICAL ASSESSMENT length an9 CLINICAL ASSESSMENT RESULT BR4020 C EFERRALS BREAST CLINICAL ASSESSMENT RESULT CODE BREAST CANCER DATE OF CLINICAL ASSESSMENT Date of clinical physical examination This will normally be the date of the first outpatient appointment at the breast clinic If the patient attends more than one breast clinic the date of each clinical examination undertaken should be recorded ORGANISATION SITE CODE OF CLINICAL ASSESSMENT Provider code where clinical physical examination was Carried out This will normally be the site code
46. of meninges System e unspecified D33 0 Benign neoplasm Brain Central Nervous of brain System e supratentorial D33 1 Benign neoplasm Brain Central Nervous of brain System e infratentorial D33 2 Benign neoplasm Brain Central Nervous of brain System e unspecified D33 3 Benign neoplasm Brain Central Nervous Author NCIN 252 ICD 10 4th Edition All C Codes are Malignant Neoplasms D33 4 Cancer Outcomes and Services Dataset User Guide Description Benign neoplasm of spinal cord Cancer Waiting Times Site specific group Brain Central Nervous System Expected Dataset to be collected Core and Site Specific Dataset Core Dataset Path Only Comment D33 7 Benign neoplasm of other specified parts of central nervous system Brain Central Nervous System D33 9 Benign neoplasm of central nervous system unspecified Brain Central Nervous System D35 2 Benign neoplasm of Pituitary gland Brain Central Nervous System D35 3 Benign neoplasm of Craniopharyngeal duct Other Usually classified as CNS D35 4 Benign neoplasm of Pineal gland Brain Central Nervous System D37 0 Neoplasm of uncertain or unknown behaviour of lip oral cavity and pharynx Head and Neck D37 1 Neoplasm of uncertain or unknown behaviour of Stomach Upper Gastrointestinal D37 2 Neoplasm of uncertain or unknown behaviour of Small intesti
47. peripheral nerves and autonomic nervous system or C69 eye and adnexa only the CORE dataset needs to be completed TNM Staging does not need to be collected for CNS cancers ICD 10 CODES Note That for Central Nervous System full details are required for benign and uncertain tumours as well as malignant diseases Key if applicable different dataset from CWT group specified Expected Dataset to be ICD 10 collected All C Codes Cancer are Waiting Malignant Times Site Core Path Neoplasms Description specific group Dataset Only Comment C47 0 Peripheral nerves Brain Central Usually treated of head face and Nervous by Sarcoma neck System MDT C47 1 Peripheral nerves Brain Central Usually treated of upper limb Nervous e by Sarcoma including shoulder System MDT 47 2 Peripheral nerves Brain Central Usually treated of lower limb Nervous by Sarcoma including hip System MDT C47 3 Peripheral nerves Brain Central Usually treated of thorax Nervous e by Sarcoma System MDT C47 4 Peripheral nerves Brain Central Usually treated of abdomen Nervous by Sarcoma System MDT C47 5 Peripheral nerves Brain Central Usually treated of pelvis Nervous e by Sarcoma System MDT C47 6 Peripheral nerves Brain Central Usually treated of trunk Nervous e by Sarcoma unspecified System MDT Author NCIN 64 Cancer Outcomes and Services Dataset User Guide
48. 1 3 CORE IMAGING To carry imaging details This section can be recorded more than once Imaging carried out post treatment should also be submitted as part of the treatment record Schema Data Item Name Format specification M R O X Foe tae meme em g RG C item Data Item Section CORE CANCER IMAGING 6 CORE IMAGING ANATOMICAL 7 CORE ANATOMICAL SIDE 8 CRO160 Pace IMAGING REPORT TEXT max an270000 IMAGING CORE LESION SIZE Note Image guided procedures e g Image guided biopsies should be recorded under surgery section SITE CODE OF IMAGING This is the ORGANISATION SITE CODE of the Organisation where the Imaging took place Note This is not applicable for Skin diagnoses PROCEDURE DATE CANCER IMAGING The DATE the Cancer Imaging was carried out Note This is not applicable for Skin diagnoses IMAGING CODE NICIP This is the National Interim Clinical Imaging Procedure Code Set code which is used to identify both the test modality and body site of the test More information on NICIP can be found at the following link http www isb nhs uk library standard 125 Note This is not applicable for Skin diagnoses 5 Either IMAGING CODE NICIP or a combination of CANCER IMAGING MODALITY IMAGING ANATOMICAL SITE and ANATOMICAL SIDE IMAGING is Mandatory for the schema 6 Either IMAGING CODE NICIP or a combination of CANCER IMAGING MODALITY IMAGING ANATOMICAL SITE and ANATOMICAL SID
49. 3 Acute panmyelosis with myelofibrosis C94 4 i CORE ONLY 5 myelofibrosis 9940 3 Hairy cell leukaemia C91 4 Hairy cell leukaemia CORE ONLY 9 9945 3 Chronic myelomonocytic leukaemia C93 1 Chronie myelomonoytie MDS 3 leukaemia 9946 3 Juvenile myelomonocytic leukaemia C93 3 Juvenile myelomonocytic MDS 3 leukaemia Acute leukaemia of 9948 3 Aggressive NK cell leukaemia C95 0 2 CORE ONLY 10 unspecified cell type 9950 3 Polycythaemia vera D45 Polycythaemia vera CORE ONLY 1 9960 3 Chronic myeloproliferative neoplasm D47 1 Chronic myeloproliferative CORE ONLY 1 disease 9961 3 Primary myelofibrosis D47 4 Osteomyelofibrosis CORE ONLY 1 9962 3 Essential Thrombocythaemia D47 3 haemorrhagic CORE ONLY 1 thrombocythaemia 9963 3 Chronic neutrophilic leukaemia D47 1 myeloproliferative CORE ONLY 1 disease Chronic eosinophilic 9964 3 Chronic eosinophilic leukaemia NOS D47 5 leukaemia hypereosinophilic CORE ONLY 1 syndrome Myeloid and hoid ith 9965 3 eed ee HOP ere C92 7 Other myeloid leukaemia CORE ONLY 2 PDGFRA re arrangement Author NCIN 130 Cancer Outcomes and Services Dataset User Guide ICD 10 WHO DISEASE ICD O 3 ICD O 3 WHO Description 4th ICD10 Description Clinical dataset GROUP Edition 9966 3 Myeloid neoplasms with PDGFRB C92 7 Other myeloid leukaemia CORE ONLY 2 9967 3 My loid anid neoplasms with C92 7 Other myeloid
50. 5 u lt D RENAL VEIN TUMOUR Is there evidence of tumour thrombus the renal vein Yes 9 a gt o m gt e P 2 lt gt 2 2 oO 6 6 t 2 o oO o 5 lt o 5 et o e oO v w QD a D Yes 13 14 UROLOGY PATHOLOGY PENIS To carry the cancer pathology details for Penis This section will be recorded once per pathology report where applicable Data item N Data Item Section Data Item Name Format specification M R O X anne CORPUS SPONGIOSUM INVASION UR15180 TUMOUR INVASION INDICATOR ani PATHOLOGY PENIS CORPUS SPONGIOSUM UR15190 UROLOGY CORPUS CAVERNOSUM INVASION ant O Author NCIN 215 Cancer Outcomes and Services Dataset User Guide PATHOLOGY PENIS TUMOUR INVASION INDICATOR CORPUS CAVERNOSUM UROLOGY URETHRA OR PROSTATE INVASION UR15200 TUMOUR INVASION INDICATOR an1 PATHOLOGY PENIS URETHRA OR PROSTATE CORPUS SPONGIOSUM INVASION Is there evidence of invasion into corpus spongiosum Yes CORPUS CAVERNOSUM INVASION Is there evidence of invasion into corpus cavernosum Yes URETHRA OR PROSTATE INVASION Is there evidence of invasion into the urethra or prostate Yes 13 15 UROLOGY PATHOLOGY PROSTATE To carry the cancer pathology details for Prostate This section will
51. 9 Biliary tract Upper unspecified Gastrointestinal C25 0 Head of pancreas Upper Gastrointestinal C25 1 Body of pancreas Upper Gastrointestinal C25 2 Tail of pancreas Upper Gastrointestinal C25 3 Pancreatic duct Upper Gastrointestinal C25 4 Endocrine Upper pancreas Gastrointestinal C25 7 Other parts of Upper pancreas Gastrointestinal C25 8 Overlapping Upper lesion of Gastrointestinal pancreas C25 9 Pancreas Upper unspecified Gastrointestinal C78 7 Secondary Upper Normally malignant Gastrointestinal treated by neoplasm of liver MDT of and intrahepetic site of bile duct primary tumour Only use if unable to code to specific primary site D00 1 Carcinoma in situ Upper of Oesophagus Gastrointestinal D00 2 Carcinoma in situ Upper of Stomach Gastrointestinal D01 5 Carcinoma in situ Upper of Liver Gastrointestinal gallbladder and bile ducts D37 1 Neoplasm of Upper uncertain or Gastrointestinal unknown behaviour of Stomach Author NCIN 188 Cancer Outcomes and Services Dataset User Guide D37 2 Neoplasm of Upper uncertain or Gastrointestinal unknown e behaviour of Small intestine D37 6 Liver gallbladder Upper and bile ducts Gastrointestinal 12 1 UPPER GI CANCER CARE PLAN To carry cancer care plan details for MAIN Upper GI This section will be recorded once Data item Wap Data Item Section Data Item Name Format specification M R O X No UPPER GI C
52. 9734 3 Extraosseous plasmacytoma C90 2 Extramedullary plasmacytoma CORE ONLY 9 9735 3 Plasmablastic lymphoma C83 3 Diffuse large B cell lymphoma alia 9 8 ymp Lymphomas 9737 3 ALK positive large B cell lymphoma C83 3 Diffuse large B cell lymphoma Other 9 p g ymp 8 ymp Lymphomas Author NCIN 126 Cancer Outcomes and Services Dataset User Guide ICD 10 WHO DISEASE ICD O 3 1 WHO Description 4th ICD10 Description Clinical dataset GROUP Edition Large B cell lymphoma arising in HHV8 Other 9738 3 associated multicentric Castleman C83 3 Diffuse large B cell lymphoma 9 Lymphomas disease Histiocytic and mast cell 9740 1 Cutaneous mastocytosis D47 0 tumours of uncertain and CORE ONLY 1 unknown behaviour Histiocytic and mast cell 9740 1B Extracutaneous mastocytoma D47 0 tumours of uncertain and CORE ONLY 1 unknown behaviour 9740 3 Mast Cell Sarcoma C96 2 Malignant mast cell tumour CORE ONLY 1 9741 3 Systemic Mastocytosis C96 2 Malignant mast cell tumour CORE ONLY 1 9742 3 Mast Cell Leukaemia C94 3 Mast cell leukaemia CORE ONLY 1 Multifocal and multisystemic Multifocal and multisystemic disseminated Langerhans 9751 34 disseminated Langerhans cell 935 0 cell histiocytosis Letterer CORE ONLY 12 histiocytosis Letterer Siwe disease Siwe disease Multifocal and unisystemic Multifocal and unisystemic 9751 3 B disseminated Langerhans cell ee
53. C75 3 Pineal gland Other Usually treated by CNS MDT C75 4 Carotid body Other e 75 5 Aortic body Other other paraganglia C75 8 Pluriglandular Other involvement unspecified C75 9 Endocrine gland Other unspecified C76 0 Head face and neck Other Other and ill defined use only if unable to code to specific primary site C76 1 Thorax Other Other and ill defined use only if unable to code to specific primary site C76 2 Abdomen Other Other and ill defined use only if unable to code to specific primary site C76 3 Pelvis Other Other and ill defined use only if unable to code to specific primary site C76 4 Upper limb Other Other and ill defined use only if unable to code to specific primary site C76 5 Lower limb Other Other and ill defined use only if unable to code to specific primary site Author NCIN 237 ICD 10 4th Edition All C Codes are Malignant Neoplasms C76 7 Cancer Outcomes and Services Dataset User Guide Description Other ill defined sites Cancer Waiting Times Site specific group Other Expected Dataset to be collected Core and Site Specific Dataset Path Only Core Dataset Comment Other and ill defined use only if unable to code to specific primary site C76 8 Overlapping lesion of other and ill defined sites Other Other and ill defined use only if unable to code to s
54. CARE PLAN To carry cancer care plan details where a treatment planning decision was made This section will be recorded once Schema Data Item Section Data Item Name Format specification M R O X Data item No CRO420 CORE CANCER CARE MULTIDISCIPLINARY TEAM am PLAN DISCUSSION INDICATOR CRO430 CORE CANCER CARE MULTIDISCIPLINARY TEAM an10 ccyy PLAN DISCUSSION DATE CANCER mm dd CRO460 SERES robe on CANCER CARE PLAN INTENT 1 Start of repeating item Planned Cancer Treatment CORE CANCER CARE PLANNED CANCER TREATMENT End of repeating item Planned Cancer Treatment Type croago CORE ea CARE NO CANCER TREATMENT REASON an2 CORE ADULT COMORBIDITY EVALUATION CR2060 CANCER CARE PLAN 27 SCORE ani crosio CORE a CARE PERFORMANCE STATUS ADULT 1 CLINICAL NURSE SPECIALIST CR2050 CANCER PLAN INDICATION CODE anz MULTIDISCIPLINARY TEAM DISCUSSION INDICATOR CWT Please see Cancer Waiting Times dataset for definition MULTIDISCIPLINARY TEAM DISCUSSION DATE CANCER CWT Please see Cancer Waiting Times dataset for definition CANCER CARE PLAN INTENT The intention of a Cancer Care Plan developed within a Cancer Care Spell This only needs to be recorded when the first care plan is agreed Non Curative Z NomCurative o y Author NCIN 36 Cancer Outcomes and Services Dataset User Guide No active treatment 91 PLANNED CANCER TREATMENT This
55. CORE ONLY 9 9764 3 Immunoproliferative small intestinal C88 3 Immunoproliferative small Other 9 disease intestinal disease Lymphomas Author NCIN 127 Cancer Outcomes and Services Dataset User Guide ICD 10 ICD O 3 ICD O 3 WHO Description ath ICD10 Description Clinical dataset WEO DRENGE GROUP Edition Other specified neoplasms of uncertain or unknown 9766 1 Lymphomatoid granulomatosis D47 7 behaviour of lymphoid CORE ONLY 9 haematopoetic and related tissue 9769 1 Primary Amyloidosis E85 9 Amyloidosis unspecified CORE ONLY 9 9800 3 Leukaemia NOS C95 9 Leukaemia unspecified CORE ONLY 9801 3 Acute undifferentiated leukaemia C95 0 Acute or AML 6 unspecified cell type Acute leukaemia of 9805 3 Mixed phenotype acute leukaemia NOS C95 0 e AML 6 unspecified cell type Mixed phenotype acute leukaemia with Acute leukaemia of 9806 3 t 9 22 q34 q11 2 BCR ABL1 eee unspecified cell type 5 Mixed phenotype acute leukaemia with Acute leukaemia of 2807 3 t v 11q23 MLL re arranged pm unspecified cell type AML Mixed phenotype acute leukaemia Acute leukaemia of 9808 3 B myeloid NOS En unspecified cell type B Mixed phenotype acute leukaemia Acute leukaemia of 9809 3 T myeloid NOS one unspecified cell type 6 9811 3 Blymphoblastic lymphoma NOS C83 5 Lymphoblastic diffuse ALL 7 lymphoma Acute lymphoblastic 9811 3
56. Core Path Neoplasms Description specific group Dataset Dataset Only Comment C17 0 Duodenum Colorectal Usually treated by Upper GI MDT C17 1 Jejunum Colorectal Usually e treated by Upper GI MDT C17 2 lleum Colorectal Usually e treated by Upper GI MDT C17 3 Meckel s Colorectal Usually diverticulum e treated by Upper GI MDT C17 8 Overlapping lesion Colorectal Usually of small intestine e treated by Upper GI MDT C17 9 Small intestine Colorectal Usually unspecified e treated by Upper GI MDT C18 0 Caecum Colorectal e C18 1 Appendix Colorectal e C18 2 Ascending colon Colorectal e C18 3 Hepatic flexure Colorectal e C18 4 Transverse colon Colorectal e C18 5 Splenic flexure Colorectal e C18 6 Descending colon Colorectal e C18 7 Sigmoid colon Colorectal e Author NCIN 76 Cancer Outcomes and Services Dataset User Guide C18 8 Overlapping lesion Colorectal of colon C18 9 Colon unspecified Colorectal C19 Malignant Colorectal neoplasm of rectosigmoid junction C20 Malignant Colorectal neoplasm of rectum C21 0 Anus unspecified Colorectal C21 1 Anal canal Colorectal C21 2 Cloacogenic zone Colorectal C21 8 Overlapping lesion Colorectal of rectum anus and anal canal C26 0 Intestinal tract Colorectal part unspecified C26 1 Spleen Colorectal C26 8 Overlapping lesion Colorectal of digestive system C26 9 Ill defined sites Colorectal within the digestive system C
57. D38 5 Neoplasm of Lung uncertain or unknown behaviour of Other respiratory organs D38 6 Neoplasm of Lung uncertain or unknown behaviour of Respiratory organ unspecified 9 1 LUNG IMAGING CT SCAN To carry imaging CT Scan details for Lung Carcinoma to be captured once only for each care pathway Note this is non repeating This section will be recorded once Author NCIN 159 Cancer Outcomes and Services Dataset User Guide Schema Data item No Data Item Section Data Item Name Format specification M R O X LUNG IMAGING CT an10 ccyy mm LU10000 PROCEDURE DATE CT SCAN SCAN dd LUNG IMAGING CT SCAN PERFORMED LU10020 SCAN INDICATOR CT PROCEDURE DATE CT SCAN Date CT scan was performed which informed management of patient at time of MDT SCAN PERFORMED INDICATOR CT Was a CT scan performed on this patient Not known 9 2 LUNG IMAGING PET SCAN To carry imaging PET Scan details for Lung Carcinoma to be captured once only for each care pathway Note this is non repeating This section will be recorded once _ Schema Data item Data Item Section Data Item Name specification M R O X PROCEDURE DATE PET CT LUNG IMAGING PET SCAN 10 ccyy SCAN PROCEDURE DATE PET mm dd SCAN LUNG IMAGING PET SCAN PERFORMED LU10030 SCAN INDICATOR PET PROCEDURE DATE PET CT SCAN Date PET CT scan was performed which informed management
58. D46 7 Other myelodysplastic syndromes Haematological D46 9 Myelodysplastic syndrome unspecified Haematological D47 0 Histiocytic and mast cell tumours of uncertain and unknown behaviour Haematological D47 1 Chronic myeloproliferative disease Haematological D47 3 Essential haemorrhagic thrombocythaemia Haematological D47 4 Osteomyelofibrosis Haematological D47 5 Chronic eosinophilic leukamia hypereosinophilic syndrome Haematological Expected Dataset to be collected Core and Site Specific Core Dataset Dataset Path Only Comment what is required to be submitted for these Haematology diseases Author NCIN 259 Cancer Outcomes and Services Dataset User Guide ICD 10 4th Expected Dataset to be collected Edition Core All C Codes and are Site Malignant Cancer Waiting Times Specific Core Neoplasms Description Site specific group Dataset Dataset Path Only Comment D47 7 Other specified Haematological neoplasms of uncertain or unknown behaviour of lymphoid haematopoietic and related tissue D47 9 Neoplasm of Haematological uncertain or unknown behaviour of lymphoid haematopoietic and related tissue unspecified D48 0 Neoplasm of Sarcoma uncertain or unknown behaviour of Bone and articular cartilage D48 1 Neoplasm of Sarcoma Only uncertain or applicable for unknown GISTs behaviour of Connective and ot
59. Dataset User Guide C71 2 Temporal lobe Brain Central Nervous System C71 3 Parietal lobe Brain Central Nervous System C71 4 Occipital lobe Brain Central Nervous System C71 5 Cerebral ventricle Brain Central Nervous System C71 6 Cerebellum Brain Central CTYA dataset Nervous e collected for System Meduloblastoma lt 25 71 7 Brain stem Brain Central Nervous System C71 8 Overlapping lesion Brain Central of brain Nervous e System C71 9 Brain unspecified Brain Central Nervous System C72 0 Spinal cord Brain Central Nervous System C72 1 Cauda equina Brain Central Nervous System C72 2 Olfactory nerve Brain Central Nervous System C72 3 Optic nerve Brain Central Nervous System C72 4 Acoustic nerve Brain Central Nervous System C72 5 Other and Brain Central unspecified cranial Nervous e nerves System C72 8 Overlapping lesion Brain Central of brain and other Nervous parts of central System nervous system C72 9 Central nervous Brain Central system Nervous unspecified System C75 1 Pituitary gland Other Usually treated by CNS MDT Author NCIN 66 Cancer Outcomes and Services Dataset User Guide C75 2 Craniopharyngeal Other Usually treated duct by CNS MDT C75 3 Pineal gland Other Usually treated by CNS MDT C79 3 Seco
60. Dataset User Guide ICD 10 4th Expected Dataset to be collected Edition All C Codes Core and are Cancer Waiting Site Malignant Times Site Specific Core Neoplasms Description specific group Dataset Dataset Comment C44 4 Skin of scalp and neck Skin See the Skin chapter of the COSD User Guide Overview Section for e e further information on the collection of this Skin disease C44 5 Skin of trunk Skin See the Skin chapter of the COSD User Guide Overview Section for e e further information on the collection of this Skin disease C44 6 Skin of upper limb Skin See the Skin including shoulder chapter of the COSD User Guide Overview Section for e e e further information on the collection of this Skin disease C44 7 Skin of lower limb Skin See the Skin including hip chapter of the COSD User Guide Overview Section for e e e further information on the collection of this Skin disease Author NCIN 228 ICD 10 4th Edition All C Codes are Malignant Cancer Outcomes and Services Dataset User Guide Cancer Waiting Times Site Expected Dataset to be collected Core and Site Specific Core Neoplasms Description specific group Dataset Dataset Comment C44 8 Overlapping lesion of Skin See the Skin skin chapter of the COSD User Guide Overview Section for e e
61. GRADE BREAST max BR4180 PATHOLOGY NON INVASIVE TUMOUR SIZE BREAST max BR4190 PATHOLOGY WHOLE TUMOUR SIZE nacen ani ani ani 5 nd BREAST BR4200 ogy METASTASIS EXTENT CODE BREAST BR4210 aria ney DISTANCE TO MARGIN max n2 PRX BREAST ER ALLRED SCORE PATHOLOGY ALLRED SCORE ESTROGEN RECEPTOR E BREAST ER STATUS PATHOLOGY ESTROGEN RECEPTOR STATUS EE PR ALLRED SCORE BR SDD ur acy ALLRED SCORE PROGESTERONE RECEPTOR BREAST PR STATUS one PATHOLOGY PROGESTERONE RECEPTOR STATUS and HER2 STATUS BRA280 HUMAN EPIDERMAL GROWTH FACTOR RECEPTOR STATUS HER2 ISH STATUS BR4310 HUMAN EPIDERMAL GROWTH FACTOR IN 1 SITU HYBRIDIZATION RECEPTOR STATUS ee BREAST CYTOLOGY BREAST on PATHOLOGY CYTOLOGY RESULT CODE BREAST Tm BREAST CYTOLOGY NODE PATHOLOGY CYTOLOGY RESULT CODE NODE BREAST CORE BIOPSY BREAST BR4260 PATHOLOGY CORE BIOPSY RESULT CODE BREAST BREAST CORE BIOPSY NODE BRIZO PATHOLOGY CORE BIOPSY RESULT CODE NODE dne INVESTIGATION RESULT DATE The date on which an investigation was concluded e g the date the result was authorised 2 2 SERVICE REPORT IDENTIFIER A unique identifier of a SERVICE REPORT Author NCIN 61 Cancer Outcomes and Services Dataset User Guide MULTIFOCAL TUMOUR INDICATOR BREAST Is there more than one discrete tumour identified in the same breast
62. IDENTIFIER ISSUER PATHWAY IDENTIFIER ISSUER TWO WEEK WAIT CANCER OR TWO WEEK WAIT CANCER OR CRO260 CORE REFERRALS SYMPTOMATIC BREAST CWT SYMPTOMATIC BREAST REFERRAL TYPE DECISION REFER DATE CRO190 CORE REFERRALS CANCER OR BREAST CWT SYMPTOMS CR2020 CORE REFERRALS PRIORITY TYPE CODE PRIORITY TYPE CODE CWT CANCER REFERRAL TO CRO0200 CORE REFERRALS GANGS SASL 1S US TREATMENT PERIOD START CWT PERIOD START DATE DE CR1620 CORE REFERRALS CONSULTANT UPGRADE DATE CONSULTANT UPGRADE DATE CWT ORGANISATION SITE CODE PROVIDER SITE CODE OF PROVIDER GRDO GORE REFERRALS CONSULTANT UPGRADE CONSULTANT UPGRADE WAITING TIME ADJUSTMENT FIRST WAITING TIME ADJUSTMENT CRO280 CORE REFERRALS SEEN E E CWT WAITING TIME ADJUSTMENT REASON WAITING TIME ADJUSTMENT enoo GORE REFERRALS FIRST SEEN REASON FIRST SEEN CRO250 CORE REFERRALS DELAY REASON COMMENT FIRST SEEN CWT DELAY REASON REFERRAL TO DELAY REASON REFERRAL TO FIRST CRO240 CORE REFERRALS FIRST SEEN CANCER OR CWT SEEN CANCER OR BREAST SYMPTOMS E NER UG CORE TREATMENT To carry cancer treatment details ORGANISATION CODE CR1420 CORE TREATMENT CO uui ONE eee PROVIDER DECISION TO CWT TREAT CANCER CANCER TREATMENT PERIOD START CANCER TREATMENT PERIOD CR1430 CORE TREATMENT DIE CWT CR1440 CORE TREATMENT CANCER CARE SETTING TREATMENT CWT DELAY REASON COMMENT DECISION TO DELAY REASON COMMENT TREATMENT DECIS
63. Langerhans cell histiocytosis 12 histiocytosis 9751 3 u C96 6 Unifacal Eangerans cell CORE ONLY 12 Unifocal Langerhans cell histiocytosis histiocytosis 9755 3 Histiocytic sarcoma C96 8 Histiocytic sarcoma CORE ONLY 12 9756 3 Langerhans cell sarcoma C96 4 Sarcoma of d ndritic cells CORE ONLY 12 accessory cells 9757 3 Interdigitating dendritic cell sarcoma C96 4 sarcoma er dendriticcells CORE ONLY 12 accessory cells 9757 3A Dendritic cell tumour NOS C96 4 Sarcoma of dendritic cells CORE ONLY 12 accessory cells 9758 3 Follicular dendritic cell sarcoma C96 4 sarcoma df CORE ONLY 12 accessory cells S f dendritic cell 9759 3 Fibroblastic reticular cell tumour C96 4 CORE ONLY 12 accessory cells Malignant 9760 3 Immunoproliferative disease NOS C88 9 immunoproliferative disease CORE ONLY 9 unspecified 9 WM isa Waldenstr m macroglobulinaemia subtype of LPL 9761 3 This should not have its own title as is C88 0 Waldenstr m Other Inote they have not a separate lymphoid disease but a macroglobulinaemia Lymphomas the same ICD O subgroup of LPL 3 code but different ICD10 codes 9762 3 Heavy chain disease C88 2 Other heavy chain disease CORE ONLY 9 9762 3 Alpha heavy chain disease C88 3 Imminoproliterative CORE ONLY 9 intestinal disease 9762 3 Gamma heavy chain disease C88 2 Other heavy chain disease CORE ONLY 9 9762 3C Mu heavy chain disease C88 2 Other heavy chain disease
64. Leukaemia amp AML CTYA Acute Lymphocytic Leukaemia amp AML EXTRAMEDULLARY DISEASE EXTRAMEDULLARY DISEASE SITE WHITE BLOOD CELL COUNT HIGHEST PRETREATMENT CYTOGENETIC RISK CODE CYTOGENETIC RISK CODE ACUTE LYMPHOCYTIC LEUKAEMIA AND ACUTE MYELOID LEUKAEMIA CYTOGENETICS SUBSIDIARY COMMENT CYTOGENETIC FINDINGS COMMENT 94 Cancer Outcomes and Services Dataset User Guide EXTRAMEDULLARY DISEASE Sites of disease identified outside bone marrow WHITE BLOOD CELL COUNT HIGHEST PRETREATMENT Highest white blood cell count pre treatment x 10 to the power of 9 g per litre range 0 0 to 999 9 CYTOGENETIC RISK CODE Risk allocation based on cytogenetic findings This should be available for the MDT discussion but will only apply to a small number of cases Favourable Intermediate CYTOGENETICS SUBSIDIARY COMMENT Optional Description of cytogenetic findings This field would not normally be completed It should only be completed where the current coding is unable to distinguish between diagnoses for which treatments and outcomes may vary For example Philadelphia positive ALL This is a subtype of ALL which cannot be coded separately but which has its own clinical trial and treatment protocol 5 10 CTYA NON HODGKIN LYMPHOMA To carry CTYA Non Hodgkin Lymphoma details for CTYA This section will be recorded once Schema Data Item Section Data Item Name Format specification M R O X D
65. MO G3 4 high grade Ill T3 NO MO Any G IVA Any T NO Mia Any G IVB Any T N1 Any M Any G Any T Any N M1b Any G UICC SOFT TISSUE SARCOMA 2 GRADE SYSTEM EDITION Stage Grouping T Stage N Stage M Stage Grade IA T1a or T1b NO MO G1 or G2 IB T2a NO MO G1 or G2 IIA T2b NO MO G1 or G2 1 or T1b NO MO G3 orG4 2 NO MO G3 orG4 Il T2b NO MO G3 orG4 IV Any T N1 MO Any G Any T Any N M1 Any G 10 3 SARCOMA PATHOLOGY To carry pathology details for Sarcoma for both Bone and Soft Tissue This section can be recorded more than once Schema Data item Data Item Section Data Item Name Format specification No M R O X SARCOMA an10 ccyy SA11200 INVESTIGATION RESULT DATE PATHOLOGY mm dd SARCOMA HISTOPATHOLOGICAL TUMOUR SA11120 1 PATHOLOGY GRADE SARCOMA GENETIC CONFIRMATION SA11170 an1 PATHOLOGY INDICATOR INVESTIGATION RESULT DATE The date on which an investigation was concluded e g the date the result was authorised SERVICE REPORT IDENTIFIER A unique identifier of a SERVICE REPORT SARCOMA SA11210 SERVICE REPORT IDENTIFIER max an18 PATHOLOGY HISTOPATHOLOGICAL TUMOUR GRADE Histopathological grade of tumour Author NCIN 172 Cancer Outcomes and Services Dataset User Guide GENETIC CONFIRMATION INDICATOR Are there any cytogenetic or molecular genetic data confirming the histological diagnosis Yes confirmed No
66. NEC 7069 Spine 7929 Other Note This is not applicable for Skin diagnoses ANATOMICAL SIDE IMAGING Note This is only required if NICIP is not available The side of the body that is the subject of an Imaging or Radiodiagnostic Event Note This is not applicable for Skin diagnoses beme Not applicable 9 NetKnwn o Author NCIN 32 Cancer Outcomes and Services Dataset User Guide IMAGING REPORT TEXT optional This is the full text provided in the imaging report and may be required by registries to derive final stage and diagnosis date for registration Note This is not applicable for Skin diagnoses LESION SIZE RADIOLOGICAL The size in millimetres of the maximum diameter of the primary lesion largest if more than one Note For COSD reporting purposes this data item is not required to be submitted to two decimal places Note This is not applicable for Skin diagnoses 1 4 CORE DIAGNOSIS To carry the diagnosis details This section will be agreed by the Multidisciplinary Team responsible for the patient and will probably be completed at the time the patient is discussed at the MDT meeting The details may be different from those which appear in the Pathology data items This section will be recorded once Note The three data items in the Diagnostic Details Section are required for linkage each time the record is submitted Schema Data I
67. Name Format specification M R O X Data item No DETRUSOR MUSCLE PRESENCE UROLOGY PATHOLOGY INDICATOR BLADDER DETRUSOR MUSCLE PRESENCE INDICATION CODE UR15120 DETRUSOR MUSCLE PRESENCE INDICATOR BLADDER ONLY Presence or absence of detrusor muscle in the specimen 13 13 UROLOGY PATHOLOGY KIDNEY To carry the cancer pathology details for Kidney This section will be recorded once is permitted per pathology report where applicable d Schema Data item Data Item Section Data Item Name Format specification M R O X No Author NCIN 214 Cancer Outcomes and Services Dataset User Guide UROLOGY PATHOLOGY UR15130 KIDNEY TUMOUR NECROSIS INDICATOR 1 PERINEPHRIC FAT INVASION UROLOGY PATHOLOGY UR15140 Wane TUMOUR INVASION INDICATOR 1 PERINEPHRIC FAT ADRENAL INVASION UROLOGY PATHOLOGY UR15150 KIDNEY TUMOUR INVASION INDICATOR an1 ADRENAL UROLOGY PATHOLOGY RENAL VEIN TUMOUR UR15160 an1 KIDNEY RENAL VEIN TUMOUR INDICATOR GEROTA S FASCIA INVASION UROLOGY PATHOLOGY UR15170 KIDNEY TUMOUR INVASION INDICATOR an1 GEROTAS FASCIA TUMOUR NECROSIS INDICATOR Is there evidence of coagulative tumour necrosis Yes u PERINEPHRIC FAT INVASION Is there evidence of perinephric fat invasion Yes gt x m z gt 2 lt gt 2 o ct zy m m lt 2 m 23 m O a 2 o 5 24 3 lt
68. PHASE 3 Continue Continue SITE SPECIFIC Start SITE CORE and Preparation Expand to full STAGE and SPECIFIC CLINICAL SITE SPECIFIC SITE SPECIFIC CLINICAL including test SITE SPECIFIC SITE SPECIFIC downloads STAGE and DATA ITEMS downloads CLINICAL CLINICAL and SITE Items already SITE SPECIFIC voluntary basis downloads SPECIFIC collected CLINICAL PATHOLOGY downloads downloads FULL COSD Expand to full SITE Continue SPECIFIC CORE and Start SITE Continue SITE PATHOLOGY SITE SPECIFIC Preparation SPECIFIC SPECIFIC Continue STAGE and SITE SPECIFIC including test PATHOLOGY PATHOLOGY CORE and SITE SPECIFIC PATHOLOGY DATA ITEMS downloads downloads downloads SITE SPECIFIC CLINICAL and SITE voluntary basis Items already Items already STAGE and SPECIFIC collected collected SITE SPECIFIC PATHOLOGY CLINICAL downloads downloads FULL COSD Author NCIN 272 Cancer Outcomes and Services Dataset User Guide SITE SPECIFIC STAGE ITEMS TO BE SUBMITTED FROM START OF IMPLEMENTATION COLORECTAL modified Dukes CTYA Murphy St Jude Stage Ann Arbor Stage Ann Arbor Symptoms Ann Arbor Extranodality International neuroblastoma staging system Wilms tumour stage TNM stage grouping for Non CNS Germ Cell Tumours Chang staging for medulloblastoma GYNAE Final FIGO stage Nodal status cervical cancer HAEMATOLOGY Rai stage Binet stage ISS stage for Myeloma Ann Arbor Stage Ann Arbor Symptoms An
69. POSTCODE OF USUAL ADDRESS of the PATIENT at the time of PATIENT DIAGNOSIS see POSTCODE PERSON GENDER CODE CURRENT A PERSON s current gender GENERAL MEDICAL PRACTITIONER SPECIFIED This is the code of the GENERAL MEDICAL PRACTITIONER specified by the PATIENT This GENERAL MEDICAL PRACTITIONER works within the General Medical Practitioner Practice with which the PATIENT is registered GENERAL MEDICAL PRACTICE CODE PATIENT REGISTRATION This is the code of the GP Practice that the PATIENT is registered with PERSON FAMILY NAME AT BIRTH The PATIENT s surname at birth ETHNIC CATEGORY The ethnicity of a PERSON as specified by the PERSON The 16 1 ethnic data categories defined in the 2001 census is the national mandatory standard for the collection and analysis of ethnicity The Office for National Statistics has developed a further breakdown of the group from that given which may be used locally OO A White British S C AnyotherWhitebacground S Oooo gt F WhiteandAsian S G Any other mixed background PN Africa S P AnyotherBlackbackground S y O R Chinese 99 Notknown S Note The default option for this item is 99 Not known Author NCIN 27 Cancer Outcomes and Services Dataset User Guide 1 2 CORE REFERRALS AND FIRST STAGE OF PATIENT PATHWAY To carry patient referral details for the Provider that receives the first referral These details include information relati
70. SPECIALIST SEEN CR1550 RECURRENCE INDICATOR CANCER 1 SECONDARY CANCER RECURRENCE SOURCE OF REFERRAL FOR CANCER RECURRENCE Recurrences only This identifies the source of referral for a recurrence of cancer Author NCIN 53 Cancer Outcomes and Services Dataset User Guide Note Either SOURCE OF REFERRAL FOR OUT PATIENTS or SOURCE OF REFERRAL FOR CANCER RECURRENCE can be recorded Initiated by the CONSULTANT responsible for the Consultant Out Patient Episode Following an emergency admission i Following a Domiciliary Consultation Following an Accident And Emergency Attendance including Minor Injuries Units and Walk In Centres RO3eferral from a GENERAL PRACTITIONER with a Special Interest GPwSI or dentist with a Special Interest DwSI Referral from an Accident And Emergency Department including Minor Injuries Units and Walk In Centres 6 Referral from a Specialist NURSE Secondary Care Referral from an Orthoptist Other not initiated by the CONSULTANT responsible for the Consultant Out Patient Episode KEY WORKER SEEN INDICATOR CANCER RECURRENCE Record whether the patient was seen by a designated key worker who was neither the clinical nurse specialist nor a palliative care specialist This applies specifically to a recurrence of cancer Not known not recorded PALLIATIVE CARE SPECIALIST SEEN INDICATOR CANCER RECURRENCE Record whether the patient was seen by a palliative care sp
71. UROLOGY PATHOLOGY 215 Author NCIN 8 Cancer Outcomes and Services Dataset User Guide 13 15 UROLOGY PATHOLOGY PROSTATE 216 13 16 UROLOGY PATHOLOGY BLADDER ccccccceeeeeeseenececeeeeeeeenaeeeceeeceseaaeeeceeeceseeaaeaeeeeesesteneaeeeeeeeeeeaaea 217 13 17 UROLOGY PATHOLOGY 218 APPENDIX A Cancer Waiting Times ICD10 Codes and Tumour Groups for Primary Diagnoses 219 APPENDIX B MANDATORY REGISTERABLE CONDITIONS c cccececesseseececececeeeeaeaececeeeseeeeaeeeeeeeseeseaeeeeeeeees 249 APPENDIX C WHO CLASSIFICATION OF TUMOURS OF HAEMATOPOETIC AND LYMPHOID TISSUE 262 APPENDIX D CTYA ASSOCIATED CONDITIONS ccccceceeeeseeneeeceeeeeeeeaeeeceeeeeseeaaeaeeeeeeeseesueaeeeeeeesnesneaeeeeeetees 263 APPENDIX E RECOMMENDED STAGING TO BE COLLECTED BY CANCER REGISTRIES 265 APPENDIX F SKIN DATASET AJCC STAGE GROUP ADDITIONAL INFORMATION 268 APPENDIX G TIMETABLE FOR IMPLEMENTATION 272 APPENDIX WHEN TO COMPLETE AND SUBMIT THE 274 APPENDIX PATIENTS DIAGNOSED PRIOR TO 2013 esssssssssesseeseeee enne 277 APPENDIX J REFERRAL SCEN
72. Urothelial Neoplasm of Low Maligant Potential 13 17 UROLOGY PATHOLOGY TESTICULAR To carry the cancer pathology details for Testicular This section will be recorded once per pathology report where applicable Schema Data item Data Item Section Data Item Name Format specification M R O X RETE TESTES INVASION UROLOGY PATHOLOGY UR15310 TUMOUR INVASION INDICATOR TESTICULAR RETE TESTIS RETE TESTES INVASION For Seminoma only does the tumour invade the rete testis Not applicable Author NCIN 218 Cancer Outcomes and Services Dataset User Guide APPENDIX A Cancer Waiting Times ICD10 Codes and Tumour Groups for Primary Diagnoses Applicable from April 2012 Notes The following table lists all the registerable diseases by ICD10 code together with the expected dataset to be completed and the potential stage This table provides general guidelines only as not all permutations can be covered and there will always be exceptions Local clinical input is essential to identify and complete the appropriate stage Further guidance is available from your local cancer registration service office Key if applicable different dataset from CWT group specified ICD 10 4th Edition All C Codes are Malignant Neoplasms Description Cancer Waiting Times Site specific group Expected Dataset to be collected Core and Site Specific Dataset Path Only Core
73. User Guide Other Treatment not Other treatment goes not 23 3 distinguish between active and non active treatment active for CWT reporting BIPHOSPHONAT Other Treatment 12 ES ES biphosponates NOT KNOWN 99 Not known 12 Cryotherapy OTHER Light Therapy including Photodynamic Therapy 18 and Psoralen Ultra Violet A PUVA Therapy Laser Treatment 20 including Argon Beam OTHER ACTIVE 10 Other Active therapy TREATMENTS Treatment Other Treatment active Other a not 23 treatment distinguish between active and non active for CWT reporting Radio Frequency 10 Ablation RFA OTHER High Intensity Focussed 11 Ultrasound HIFU OTHER SPECIALIST Specialist ae PALLIATIVE 5 palliative care 7 Specialist Palliative Care PALLIATIVE TREATMENTS TREATMENT No active Active Monitoring treatment 8 excluding non specialist PALLIATIVE Only record Palliative Care NON ATTIVE 11 planned Non specialist Palliative TREATMENT treatments as no g Care excluding Active PALLIATIVE active treatment if Monitoring only non active treatments are 98 All treatment declined DECLINED Author NCIN 39 Cancer Outcomes and Services Dataset User Guide currently planned Hyperbaric Oxygen 17 Therapy Only record OTHER here if there are no active treatments planne
74. and Adnexal carcinomas the AJCC Stage Group should also be recorded as specified in Section 11 3 For all skin cancers that do not require MDT discussion the minimum requirement is for the pathology report to be submitted Providers are encouraged to submit more complete datasets if possible Grade of Differentiation is not applicable for skin cancers other than SCC and therefore the two core dataset items GRADE OF DIFFERENTIATION AT DIAGNOSIS and GRADE OF DIFFERENTIATION PATHOLOGICAL are not applicable for Melanoma BCCs or Merkel Cell tumours For PATHOLOGY INVESTIGATION TYPE which is a Core dataset item the following site specific values should be used for skin Curettage Shave Biopsy Punch Biopsy Incisional Biopsy and Excision Note Non melanoma skin cancers include BCC e SCC Merkel Cell tumours Adnexal primary malignant adnexal carcinomas of eccrine apocrine follicular and sebaceous subtypes Other NMSC ICD 10 CODES Key if applicable different dataset from CWT group specified ICD 10 Expected Dataset to be collected All C Codes Core and are Cancer Waiting Site Malignant Times Site Specific Core Path Neoplasms Description specific group Dataset Dataset Only Comment C43 0 Malignant Skin melanoma of lip 43 1 Malignant Skin melanoma of e eyelid including canthus Author NCIN 175 Cancer Outcomes and Services Dataset User Guide
75. and Radiological procedures details for Upper GI as specified This section will be recorded once Data item UG13030 UG14410 UG13320 UG14290 Author NC Data Item Section UPPER GI MAIN ENDOSCOPIC OR RADIOLOGICAL PROCEDURES UPPER GI O G ENDOSCOPIC OR RADIOLOGICAL PROCEDURES UPPER GI MAIN ENDOSCOPIC OR RADIOLOGICAL PROCEDURES IN UPPER GI PANCREATIC and O G SURGERY amp OTHER PROCEDURES Data Item Name PROCEDURE DATE ENDOSCOPIC OR RADIOLOGICAL ORGANISATION SITE CODE PROVIDER ENDOSCOPIC OR RADIOLOGICAL PROCEDURE SITE CODE OF PROVIDER ENDOSCOPIC OR RADIOLOGICAL PROCEDURE CONSULTANT CODE ENDOSCOPIC OR RADIOLOGICAL PROCEDURE Format 10 ccyy mm dd minimum length an5 maximum length an9 Schema specification M R O X Start of repeating item Endoscopic Procedure Type End of repeating item Endoscopic Procedure Type ENDOSCOPIC PROCEDURE 1 an TYPE 192 Cancer Outcomes and Services Dataset User Guide UPPER GI LIVER CHOLANGIOCARCINOMA RADIOLOGICAL UG13250 1 ENDOSCOPIC OR RADIOLOGICAL PROCEDURE TYPE PROCEDURES UPPER GI LIVER INTENT FOR BILIARY CHOLANGIOCARCINOMA STENT UG13070 an1 ENDOSCOPIC OR RADIOLOGICAL BILIARY STENT PROCEDURES INSERTION REASON UPPER GI LIVER SUCCESS OF CHOLANGIOCARCINOMA DEPLOYMENT MERE ENDOSCOPIC OR RADIOLOGICAL STENT DEPLOYED PROCEDURES SUCCESS INDICATOR Start of repeating item Endosc
76. and extent of the primary tumour before treatment N CATEGORY FINAL PRETREATMENT This is the UICC code which classifies the absence or presence and extent of regional lymph node metastases before treatment M CATEGORY FINAL PRETREATMENT This is the UICC code which classifies the absence or presence of distant metastases before treatment TNM STAGE GROUPING FINAL PRE TREATMENT Record the overall clinical TNM stage grouping of the tumour derived from each T N and M component prior to treatment This classification is based on all the evidence available to the clinician s with responsibility for assessing the patient and for the patient s treatment plan Such evidence arises from physical examination imaging endoscopy biopsy surgical exploration and other relevant examinations The overall pre treatment TNM stage grouping indicates the tumour stage at the time the treatment plan was devised T CATEGORY INTEGRATED STAGE This is the UICC code which classifies the size and extent of the primary tumour after treatment and or after all available evidence has been collected N CATEGORY INTEGRATED STAGE This is the UICC code which classifies the absence or presence and extent of regional lymph node metastases after treatment and or after all available evidence has been collected M CATEGORY INTEGRATED STAGE This is the UICC code which classifies the absence or presence of distant metastases after treatment and or after all availa
77. and this will be registered as a new diagnosis by the cancer registries Please note that for the purpose of COSD MGUS monoclonal gammopathy of unknown significance is not a registerable disease and therefore amyloidosis associated with a paraprotein MGUS should be submitted for COSD and will be registered as a new diagnosis Amyloidosis as identified above should be recorded for COSD and coded as follows ICD10 code E85 9 Amyloidosis unspecified ICDO3 morphology code M9769 1 Primary Amyloidosis is composed of abnormal immunoglobulin light chains or rarely heavy chains which deposit either intact or in fragments in various tissues These form B pleated sheets AL amyloid that bind Congo Red dye with characteristic birefringence ICD 10 ICD O 3 ICD O 3 WHO Description 4th ICD10 Description Clinical dataset GROUP Edition 9591 3 Malignant lymphoma non Hodgkin 85 9 Non Hodgkin lymphoma Other No applicable NOS unspecified Lymphomas group i amp Other 9591 3 Hairy cell leukaemia variant C85 1 B cell lymphoma unspecified 9 Lymphomas 9591 3 B Splenic diffuse red pulp small B cell C85 1 Eee vn phai unspecified Other 9 lymphoma Lymphomas 9591 3 PRIN Bel lymphoma leukaemia C85 1 B cell lymphoma unspecified Other 9 unclassifiable Lymphomas 9591 3 D B cell lymphoma NOS C85 1 B cell lymphoma unspecified Other 9 ymp ymp Lymphomas B cell lymphoma interme
78. be recorded once per pathology report where applicable Schema Data item D Data Item Section Data Item Name Format specification M R O X No UROLOGY PATHOLOGY UR15210 GLEASON GRADE PRIMARY 1 M PROSTATE UROLOGY PATHOLOGY UR15220 GLEASON GRADE SECONDARY 1 UROLOGY PATHOLOGY UR15230 GLEASON GRADE TERTIARY 1 PERINEURAL INVASION UROLOGY PATHOLOGY UR15240 PERINEURAL INVASION INDICATOR ani PROSTATE UROLOGY UROLOGY PATHOLOGY ORGAN CONFINED UR15250 ani PROSTATE ORGAN CONFINED INDICATOR SEMINAL VESICLES INVASION UROLOGY PATHOLOGY UR15260 TUMOUR INVASION INDICATOR an1 PROSTATE SEMINAL VESICLES UROLOGY PATHOLOGY UR15270 TURP TUMOUR PERCENTAGE max n3 PROSTATE Format an1 used to align with Data Dictionary rules Applies to the next three data items Author NCIN 216 Cancer Outcomes and Services Dataset User Guide The Gleason Grading System is a system for CANCER STAGING The Gleason Grading System is used to help evaluate the prognosis of men with prostate cancer A pathologist assigns a Gleason grade to the most common tumour pattern in a biopsy specimen Primary Grade then the second most common Secondary Grade The grades are added together to give the Gleason Score Sometimes pathologists will also give a grade to a third component of the specimen Tertiary Grade although this recorded separately and is not added to th
79. but not more than 5cm in greatest dimension or 5 or fewer positive lymph nodes none more than 5cm in greatest dimension or evidence of extranodal extension of tumour N3 Metastasis with a lymph node mass more than 5cm in greatest dimension amp pN3 Distant Metastasis MO No distant metastasis Mia Non regional lymph nodes or lung M1b Other sites 13 3 UROLOGY STAGING RENAL PELVIS AND URETER UICC CARCINOMA OF THE RENAL AND URETER TNM STAGING SEVENTH EDITION Stage Grouping T Stage N Stage M Stage Stage 1 MO Stage Il T2 NO MO Stage III T3 NO MO Stage IV T4 NO MO Any T N1 N2 N3 MO Any T Any N M1 Note p indicates also applicable for pathological stage Primary Tumour p TO No evidence of primary tumour p Ta Non invasive papillary carcinoma p Tis Carcinoma in situ p T1 Tumour invades subepithelial connective tissue p T2 Tumour invades muscularis p T3 Renal pelvis Tumour invades beyond muscularis into peripelvic fat or renal parenchyma Ureter Tumour invades beyond muscularis into periureteric fat p T4 Tumour invades adjacent organs or through the kidney into perinephric fat Regional Lymph Nodes p NX Regional lymph nodes cannot be assessed p NO No regional lymph node metastasis p N1 Metastasis in a single lymph node 2 cm or less in greatest dimension p N2 Metastasis in a single lymph node more than 2 cm but n
80. by the relevant nursing staff when appropriate This will vary between specialties depending on patient pathway As one of the intentions is to identify patients not seen by the Clinical Nurse Specialist it may not be possible to collect at time of patient contact Yes including nurse present when patient given diagnosis Yes but nurse not present when patient given diagnosis N No patient not seen at all by nurse but nurse informed of diagnosis NN No patient not seen at all by nurse and nurse not informed of diagnosis Not known 1 6 CORE CLINICAL TRIALS To carry clinical trial details for a patient who is eligible for a cancer clinical trial Only one instance will be recorded for each diagnosis This section will be recorded once Schema Data Item Section Data Item Name Format specification M R O X Data item No CR1290 CORE CLINICAL PATIENT TRIAL STATUS CANCER an2 M TRIALS CORE CLINICAL CANCER CLINICAL TRIAL TREATMENT PATIENT TRIAL STATUS CANCER An indication of whether a PATIENT who is eligible for a cancer CLINICAL TRIAL is taking part in it Author NCIN 41 Cancer Outcomes and Services Dataset User Guide PATIENT eligible consented and entered trial PATIENT eligible declined trial CANCER CLINICAL TRIAL TREATMENT TYPE The type of treatment covered by a cancer CLINICAL TRIAL This is used to record the type s of treatment that are the subject of the cancer CLINICA
81. care transferred to Trust B for further investigations Trust A may legitimately leave the M stage blank if they have not received notification about the outcome of the investigations For the purposes of recording data within the Cancer Outcomes Dataset COSD M9 should be recorded in these circumstances to signify that M is intentionally being left blank Please note however in these circumstances Trust B would be expected to provide additional data about M stage Does the use of MX or M9 affect assigning a Stage Grouping Providers will not be able to provide a Stage Grouping when MX or M9 are used What should be recorded if the status of distant metastatic disease is uncertain because of indeterminate findings If the status of distant metastatic disease is indeterminate because interpretation of the clinical findings is uncertain for example a CT scan shows a liver lesion and the radiologist MDT is uncertain if it represents metastatic disease or a benign lesion then the TNM principle of applying the lower category should be used and MO should be recorded Author NCIN 287 Cancer Outcomes and Services Dataset User Guide What if an indeterminate lesion is later identified to be malignant Indeterminate lesions are often monitored by repeated imaging and can be identified as malignant if their characteristics change over time If such lesions are identified as malignant before the initiation of treatment both the pretreatment and integr
82. cell type Haematological C95 9 Leukaemia unspecified Haematological C96 0 Multifocal and multisystemic disseminated Langerhans cell histiocytosis Letterer Siwe disease Haematological C96 2 Malignant mast cell tumour Haematological C96 4 Sarcoma of dendritic cells accessory cells Haematological C96 5 Multifocal and unisystemic disseminated Langerhans cell histiocytosis Haematological C96 6 Unifocal Langerhans cell histiocytosis Haematological C96 7 Other specified malignant neoplasms of lymphoid haematopoietic and related tissue Haematological C96 8 Histiocytic sarcoma Haematological C96 9 Malignant neoplasms of lymphoid haematopoietic and related tissue unspecified Haematological Expected Dataset to be collected Core and Site Specific Dataset Core Dataset Path Only Comment Author NCIN 247 Cancer Outcomes and Services Dataset User Guide ICD 10 4th Expected Dataset to be collected Edition Core and are Cancer Waiting Site Malignant Times Site Specific Core Path Neoplasms Description specific group Dataset Dataset Only Comment C97 Malignant neoplasms Other of independent 3 primary multiple sites D05 0 Lobular carcinoma in Breast situ D05 1 Intraductal Breast carcinoma in situ D05 7 Other carcinoma in Breast e situ of
83. clear of the tumour and if so by how much Where there is more than one measurement record the closest or closest relevant margin Where actual measurements are not taken use options 01 05 or 06 06 _ a Not applicable Note This data item is not applicable for Haematology diagnosis NUMBER OF NODES EXAMINED The number of local and regional nodes examined Note This data item is not applicable for CNS Haematology or Lung diagnosis NUMBER OF NODES POSITIVE The number of local and regional nodes reported as being positive for the presence of Tumour metastases Note This data item is not applicable for CNS Haematology or Lung diagnosis Author NCIN 51 Cancer Outcomes and Services Dataset User Guide Note The COSD Core Staging data items mentioned below are not applicable for CNS Gynaecology Haematology Skin and most CTYA diagnosis Please see site specific datasets for further information on collecting these data item including the site specific values to be used T CATEGORY PATHOLOGICAL T CATEGORY PATHOLOGICAL is the Union for International Cancer Control UICC code which classifies the size and extent of the primary Tumour based on the evidence from a pathological examination N CATEGORY PATHOLOGICAL N CATEGORY PATHOLOGICAL is the Union for International Cancer Control UICC code which classifies the absence or presence and extent of regional lymph node metastases based on the evidence from a path
84. disease that is a constant threat to life A moribund patient who is not expected to survive without the operation A declared brain dead patient whose organs are being removed for donor purposes TUMOUR LOCATION SURGICAL Surgically determined anatomical location of lesion s or where centred 01 Frontal lobe 26 Pterygopalatine fossa Temporal lobe Anterior clinoid dura N 7 s o Third ventricle Cervical intradural m e Ww Author NCIN 72 Cancer Outcomes and Services Dataset User Guide _ ParasagitaVparatatine dure fosar a Wemeebew Sie e tembermadua idle cranittosse ratemporalfoss EXCISION TYPE Identify whether excision is Partial or Total Total macroscopic Extent uncertain 3 4 CENTRAL NERVOUS SYSTEM RADIOSURGERY To carry radiosurgery details for Central Nervous System cancer This section will be recorded once per treatment where applicable y Schema Data item M R O X CENTRAL NERVOUS SYSTEM RADIOSURGERY RADIOSURGERY RADIOSURGERY mm dd RADIOSURGERY PERFORMED INDICATOR Did patient have radiosurgical treatment This information only needs to be collected by the specialist centre where the radiosurgery was performed Data Item Section Data Item Name Format specification Not known Em Ee
85. is the clinically proposed treatment usually agreed at Multi Disciplinary Team Meeting and may not be the same as the treatment which is subsequently agreed with the patient More than one planned treatment type may be recorded and these may either be alternative or sequential treatments This only needs to be recorded when the first treatment planning decision is made Other Active Treatment No active treatment Biphosphonates Anti Cancer Drug Other Radiotherapy Other _ 225922 Mapping against actual treatment The following table shows how the treatment modality as defined in Cancer Waiting Times will map to these proposed treatment types CANCER TREATMENT PLANNED CANCER Overall treatment CODE TREATMENT TYPE CODE MODALITY Treatment Group as reported for type CWT SURGERY 1 Surgery 1 Surgery SURGERY Teletherapy Beam Teletherapy Radiation excluding RADIOTHERAPY Proton Therapy Chemoradiotherapy RADIOTHERAPY Do not record planned treatment under chemotherapy RADIOTHERAPY Radiotherapy Proton Therapy RADIOTHERAPY Other 19 Radioisotope Therapy Not recorded in Radiotherapy for including Radioiodine CWT reporting Not recorded in Radiotherapy for Anti cancer drug regimen 3 Chemotherapy 2 Cytotoxic DRUG TREATMENTS ANTI CANCER DRUGS Chemotherapy Author NCIN 37 Cancer Outcomes and Services Dataset User Guide Anti can
86. leukaemia CORE ONLY 2 FGFR1 abnormalities Neoplasm of uncertain or unknown behaviour of 9971 1 Early lesions plasmacytic hyperplasia D47 9 ivmphold Haemakapoleticnnd CORE ONLY 13 related tissue unspecified Neoplasm of uncertain or Early lesions infectious mononucleosis unknown behaviour of 9371 1 B like PTLD Dare lymphoid haematopoietic and COREONLY 13 related tissue unspecified Neoplasm of uncertain or unknown behaviour of 9971 3A Polymorphic PTLD D47 9 lymphoid haematopoietic and CORE ONLY 13 related tissue unspecified Neoplasm of uncertain or 9971 3 B Monomorphic PTLD B and T NK cell 047 9 Unknown behaviour of CORE ONLY 13 types lymphoid haematopoietic and related tissue unspecified Hodgkin lymphoma 9971 3C Classical Hodgkin lymphoma type PTLD C81 9 PR CORE ONLY 13 unspecified 9975 3 Myeloproliferative neoplasm 0471 Chronic myeloproliferative CORE ONLY 1 unclassifiable disease gt Myelodysplastic Myelodysplastic Myel liferat 9975 3 yelodysplastic 94 6 myeloproliferative disease CORE ONLY 3 neoplasm unclassifiable ge not elsewhere classified 9980 3 Refractory anaemia D46 4 Refractory MDS 4 unspecified Refractory anaemia with ring Refractory anaemia with 9982 3 sideroblasts Died ringed sideroblasts MDS 4 Refractory anaemia with ring amp 9982 3 sideroblasts associated with marked D46 1 y MDS 4 ringed sidero
87. marrow involvement in NHL is defined as gt 5 2596 malignant cells in an otherwise normal bone marrow 2596 malignant cells in the bone marrow is defined as leukaemia ALK 1 STATUS FOR ALCL Activin Receptor like Kinase 1 ALK 1 is a gene expression protein which distinguishes prognostically important subsets of this diagnosis This should be available for the MDT discussion but will only apply to a small number of cases ALK positive ALK negative 5 11 CTYA HODGKIN LYMPHOMA To carry Hodgkin Lymphoma details for CTYA This section will be recorded once Note This includes Nodular Lymphocyte Predominant Hodgkin Lymphoma ICDO3 code 9659 3 for which the staging is the same Schema Data Item Section Data Item Name Format specification is M R O X CTYA HODGKIN ELA gt LYMPHOMA ANN ARBOR SYMPTOMS INDICATOR LYMPHOMA ARBOR EXTRANODALITY INDICATOR ANN ARBOR STAGE Staging based on location and extent of detected disease It is essential to record the stage for this group of patients This information should be available to the MDT Data item One region of lymph nodes or spleen or thymus or Waldeyer s ring enlarged a disease outside lymph nodes eg liver bone marrow excludingE ANN ARBOR SYMPTOMS Additional stage designation based on presence or absence of specific symptoms A No Symptoms za Presence of any of the following unexplained persistent or recurrent fe
88. node biopsy and completion lymphadenectomy if performed 2 Macrometastases are defined as clinically detectable nodal metastases confirmed by therapeutic lymphadenectomy or when nodal metastasis exhibits gross extracapsular extension Author NCIN 271 Cancer Outcomes and Services Dataset User Guide APPENDIX TIMETABLE FOR IMPLEMENTATION Minimum requirement for all Providers July 2012 Dec 2012 Jan 2013 June 2013 PHASE 1 CORE DATA ITEMS Preparation including test downloads voluntary basis SITE SPECIFIC DATASETS STAGE DATA ITEMS Preparation including test downloads voluntary basis SITE SPECIFIC DATASETS CLINICAL DATA ITEMS Preparation including test downloads voluntary basis SITE SPECIFIC DATASETS PATHOLOGY DATA ITEMS Preparation including test downloads voluntary basis Additional requirement where currently collected electronically optional July 2013 Dec Jan 2014 2013 Dec 2014 Jan 2015 onwards PHASE 2 PHASE 3 Continue CORE Continue Continue and SITE SPECIFIC CORE and CORE and STAGE downloads SITE SPECIFIC SITE SPECIFIC STAGE and STAGE and SITE SPECIFIC SITE SPECIFIC CLINICAL CLINICAL and SITE downloads SPECIFIC PATHOLOGY downloads FULL COSD Jan 2013 June July 2013 Dec Jan 2014 July 2012 Dec 2012 2013 2013 Dec 2014 Jan 2015 onwards PHASE 1 PHASE 2
89. or platelet count lt 100 Notes on Rai Stage and Binet Stage calculations Platelet count gt 99 is more fully described as Platelet count gt 99 x 10 L Hb gt 109 is more fully described as Hb gt 109g L 7 9 HAEMATOLOGY CANCER CARE PLAN FOLLICULAR LYMPHOMA To carry cancer care plan details specific to Follicula Lymphoma This section will be recorded once Schema Data Item Section Data Item Name Format specification M R O X Data item No FLIPI INDEX SCORE HAEMATOLOGY CANCER FOLLICULAR LYMPHOMA CARE PLAN FOLLICULAR INTERNATIONAL PROGNOSTIC INDEX SCORE HA8360 FLIP INDEX SCORE Follicular Lymphoma International Prognostic Index Score FLIPI derived from age Hb number of nodal areas LDH Ann Arbor stage Score 1 for age gt 60 years Hb lt 120 g l more than 4 nodal areas LDH above normal Stage III or IV Range 0 5 7 10 HAEMATOLOGY CANCER CARE PLAN DIFFUSE LARGE B CELL LYMPHOMA To carry cancer care plan details specific to DLBCL This section will be recorded once Schema Data item Data Item Section Data Item Name Format specification M R O X Author NCIN 141 Cancer Outcomes and Services Dataset User Guide HAEMATOLOGY CANCER R IPI INDEX for DLBCL SCORE HA8450 REVISED INTERNATIONAL CARE PLAN DLBCI PROGNOSTIC INDEX SCORE R IPI INDEX for DLBCL SCORE Revised International Prognostic Index Score derived from Age perf
90. order to standardise measurement items and enable a greater degree of accuracy where applicable This change affects e LESION SIZE RADIOLOGICAL CNS dataset BA3030 COLORECTAL Author NCIN 11 Cancer Outcomes and Services Dataset User Guide Change data item format to allow recording to 2 decimal places max nX max n2 in order to standardise measurement items and enable a greater degree of accuracy where applicable This change affects e DISTANCE TO CIRCUMFERENTIAL MARGIN Colorectal dataset CO5210 e DISTANCE BETWEEN LOWER END OF TUMOUR AND DISTAL RESECTION MARGIN Colorectal dataset CO5230 e DISTANCE FROM DENTATE LINE Colorectal dataset CO5270 e DISTANCE BEYOND MUSCULARIS PROPRIA Colorectal dataset CO5280 e DISTANCE TO CIRCUMFERENTIAL EXCISION MARGIN Colorectal dataset CO5310 Change in data item format to max n4 max n2 in order to align to clinical practice This change affects e DISTANCE BETWEEN LOWER END OF TUMOUR AND DISTAL RESECTION MARGIN Colorectal dataset CO5230 Data item currently suspended due to it being a duplicate of DISTANCE TO CIRCUMFERENTIAL MARGIN CO5210 This suspension affects e DISTANCE TO CIRCUMFERENTIAL EXCISION MARGIN Colorectal dataset CO5310 CTYA Change data item format to allow recording to 2 decimal places max nX max n2 in order to standardise measurement items and enable a greater degree of accuracy where applicable This change affects e PRIMARY TUMOUR SIZE RADIO
91. specific fields are only currently applicable for Melanoma SCC and BCC 11 4 SKIN PATHOLOGY SQUAMOUS CELL CARCINOMA SCC To carry pathology details for Squamous Cell Carcinoma This section will be recorded once per pathology report where applicable Schema Data item Data Item Section Data Item Name Format specification M R O X SKIN PATHOLOGY SK12545 scc CLARKS LEVEL IV INDICATOR Author NCIN Cancer Outcomes and Services Dataset User Guide SKIN PATHOLOGY LESION VERTICAL THICKNESS GREATER SK12565 ani M SCC THAN 2MM INDICATOR CLARKS LEVEL IV INDICATOR Greater than or equal to Clark s level IV ON Nw LLL Not assessable LESION VERTICAL THICKNESS GREATER THAN 2MM INDICATOR Is the vertical thickness of the lesion greater than 2mm Yes Greater than 2mm No Less than or equal to 2mm Not known 11 5 SKIN PATHOLOGY MALIGNANT MELANOMA To carry pathology details for Malignant Melanoma This section will be recorded once per pathology report where applicable _ Schema Data item Data Item INE Data Item Name Format specification M R O X No Section SKIN SK12580 PATHOLOGY ULCERATION INDICATOR MM SKIN 5 12590 PATHOLOGY MITOTIC RATE SKIN MM SKIN MICROSATELLITE OR IN TRANSIT METASTASIS SK12600 PATHOLOGY MM INDICATOR SKIN SK12620 PATHOLOGY TUMOUR REGRESSION INDICATOR MM SKIN PATHOLOGY BRESLOW THICKNESS MM SKIN TUMOUR INFILTRATING LYMPHOCYTES
92. the International Statistical Classification of Diseases and Related Health Problems ICD and is a comprehensive classification of causes of morbidity and mortality The primary diagnosis is the main condition treated or investigated during the relevant episode of healthcare Note Where the ICD10 code only has 3 characters eg C01 please add X as a packing digit to meet the validation rules e g CO1 X CO7 X C73 X etc Format CXX X or DXX X DATE OF DIAGNOSIS CLINICALLY AGREED For linkage purposes this is required as mandatory This is now the only Diagnosis date which Providers are required to submit for new primary cancers Record the date where Cancer was confirmed or diagnosis agreed This will normally be the date of the authorised pathology report which confirms the cancer or if this is not available at the time it will be the date of the Multidisciplinary Team Meeting when the diagnosis was agreed Note This is not the same as DATE OF RECURRENCE CANCER REGISTRATION which is used for Cancer Registration Providers are no longer required to record as Registries will derive this date from information received DATE OF RECURRENCE CLINICALLY AGREED THIS DATA ITEM APPLIES TO RECURRENCES ONLY This is now the only Diagnosis date which Providers are required to record for recurrences Record the date where Cancer recurrence was confirmed or diagnosis of recurrence was agreed This will normally be the date of the authorised
93. the stent was deployed successfully OoN NE NE Y Not known ENDOSCOPIC OR RADIOLOGICAL COMPLICATION TYPE The types of complications that the patient experiences during the admission for the endoscopic procedure More than one option can be selected 00 No complications Perforation Haemorrhage 09 Pancreatitis Cholangitis Other 12 5 UPPER GI SURGICAL PROCEDURES To carry surgical procedure details for Upper Gl as specified This section will be recorded once per treatment where applicable p Schema Data item Data Item Section Data Item Name Format specification M R O X ASA SCORE ASA PHYSICAL STATUS UG13235 UPPERGI SURGICAL PROCEDURES an1 CLASSIFICATION SYSTEM CODE STAGING LAPAROSCOPY PERFORMED 0613100 UPPER SURGICAL PROCEDURES an1 M STAGING LAPAROSCOPY PERFORMED INDICATOR SURGICAL ACCESS TYPE 0613110 UPPER SURGICAL PROCEDURES an1 ABDOMINAL SURGICAL ACCESS THORACIC UPPER GI O G SURGICAL UG14190 SURGICAL ACCESS TYPE an2 PROCEDURES THORACIC UPPER GI LIVER CHOLANGIOCARCINOMA and UG13240 SURGICAL PALLIATION TYPE an1 PANCREATIC SURGICAL PROCEDURES LIVER TRANSPLANTATION UPPER GI LIVER HCC SURGICAL UG13590 LIVER TRANSPLANT an1 PROCEDURES PERFORMED INDICATOR Start of repeating item Surgical complications Author NCIN 194 Cancer Outcomes and Services Dataset User Guide SURGICAL COMPLICATIONS UPPER GI O G SURGICAL UG14210 SURGI
94. to specific primary site C79 4 Secondary malignant neoplasm of other and unspecified parts of nervous system Brain Central Nervous System Normally treated by MDT of site of primary tumour Only use if unable to code to specific primary site Author NCIN 241 Cancer Outcomes and Services Dataset User Guide ICD 10 4th Expected Dataset to be collected Edition All C Codes Core and are Cancer Waiting Site Malignant Times Site Specific Core Path Neoplasms Description specific group Dataset Dataset Only Comment C79 5 Secondary malignant neoplasm of bone and bone marrow Sarcoma Normally treated by MDT of site of primary tumour Only use if unable to code to specific primary site C79 6 Secondary malignant neoplasm of ovary Gynaecological Normally treated by MDT of site of primary tumour Only use if unable to code to specific primary site C79 7 Secondary malignant neoplasm of adrenal gland Other Normally treated by MDT of site of primary tumour Only use if unable to code to specific primary site C79 8 Secondary malignant neoplasm of other specified sites Other Normally treated by MDT of site of primary tumour Only use if unable to code to specific primary site C79 9 Secondary malignant neoplasm unspecified site Other Normally treated by MDT of site of primary tumour Only use if unable
95. to code to specific primary site C80 0 Malignant neoplasm primary site unknown so stated Other Only use if unable to code to specific primary site Author NCIN 242 Cancer Outcomes and Services Dataset User Guide ICD 10 4th Expected Dataset to be collected Edition All C Codes Core and are Cancer Waiting Site Malignant Times Site Specific Core Path Neoplasms Description specific group Dataset Dataset Only Comment C80 9 Malignant neoplasm Other Only use if unspecified unable to code to specific primary site C81 0 Nodular lymphocyte Haematological See the Haematology chapter of COSD User Guide predominant Hodgkin Section 7 2 for information regarding what is lymphoma required to be submitted for these Haematology C81 1 Nodular sclerosis Haematological diseases classical Hodgkin lymphoma C81 2 Mixed cellularity Haematological classical Hodgkin lymphoma C81 3 Lymphocytic Haematological depleted classical Hodgkin lymphoma C81 4 Lymphocyte rich Haematological classical Hodgkin lymphoma C81 7 Other classical Haematological Hodgkin lymphoma C81 9 Hodgkin lymphoma Haematological unspecified C82 0 Follicular lymphoma Haematological gradei C82 1 Follicular lymphoma Haematological grade ii C82 2 Follicular lymphoma Haematological grade iii unspecified C82 3 Follicular lymphoma Haematological grade iiia C82 4 Fo
96. 0 RM CELL COUNT HIGHEST PRE Lymphocytes HA8660 BLOOD LYMPHOCTYE COUNT Hasenclever index HA8670 HASENCLEVER INDEX 7 4 HAEMATOLOGY LABORATORY RESULTS VARIOUS To carry laboratory results for various haematological diseases as specified This section will be recorded once Schema Data Item Section Data Item Name Format specification M R O X HAEMATOLOGY LABORATORY PLATELET COUNT HA8030 RESULTS CML CLL PLATELETS COUNT max n4 MYELODYSPLASIA Data item No HA8150 HAEMATOLOGY LABORATORY WHITE BLOOD CELL COUNT max RESULTS AML ALL HODGKIN HIGHEST PRETREATMENT n3 n1 BLOOD HAEMOGLOBIN HAEMATOLOGY LABORATORY pU PEN HA8100 HAEMOGLOBIN max n3 i CONCENTRATION GRAMS PER LITRE Author NCIN 134 Cancer Outcomes and Services Dataset User Guide Schema Data Item Section Data Item Name Format specification M R O X HA8110 HAEMATOLOGY LABORATORY BONE MARROW KARYOTYPE me RESULTS MYELODYSPLASIA KARYOTYPE TEST OUTCOME BONE MARROW BLASTS HA8120 HAEMATOLOGY LABORATORY PERCENTAGE RESULTS MYELODYSPLASIA BONE MARROW BLAST CELLS PERCENTAGE HAEMATOLOGY LABORATORY max HAEMATOLOGY LABORATORY HAEMATOLOGY LABORATORY max HA8540 RESULTS MYELOMA BETA2 MICROGLOBULIN LEVEL HAEMATOLOGY LABORATORY max HAEMATOLOGY LABORATORY HA8350 RESULTS FOLLICULAR DLBCL Data item No OTHER LYMPHOMAS HAEMATOLOGY LABORATORY BLOOD MYELOBLA
97. 00 are recorded 5 22 CTYA MEDULLOBLASTOMA To carry Medulloblastoma details for CTYA This section will be recorded once Schema Data Item Section Data Item Name Format specification No M R O X CTYA CHANG STAGING FOR CT6560 MEDULLOBLASTOMA VAEDUEEOBEASTOMAE CHANG STAGING SYSTEM STAGE CHANG STAGING FOR MEDULLOBLASTOMA Chang stage for Medulloblastoma Data item No evidence of metastatic disease microscopic tumour cells found in CSF gross nodular seeding in spinal subarachnoid space M2 gross nodular seeding in cerebellum cerebral subarachnoid space or in the third or fourth ventricles Author NCIN 105 Cancer Outcomes and Services Dataset User Guide 5 23 CTYA HEPATOBLASTOMA To carry Hepatoblastoma details for CTYA This section will be recorded once Schema Data Item Section Data Item Name Format specification M R O X Data item No CT6500 PRETEXT STAGING SYSTEM STAGE 1 HEPATOBLASTOMA CTYA PRETEXT STAGING OUTSIDE LIVER CT6510 PRETEXT STAGING SYSTEM STAGE ani HEPATOBLASTOMA OUTSIDE LIVER PRETEXT STAGING SYSTEM STAGE Pretext 1 4 refers to sectors of liver involved Stage 1 tumour involves only 1 quadrant Stage 2 tumour involves 2 adjoining quadrants 2 adjoining sections free Stage 3 tumour involves 3 adjoining quadrants only 1 quadrant free or 2 non adjoining quadrants free Stage 4 tumour involves all 4 quadrants PRETEXT STAGING OUTSIDE LIVER
98. 11220 max n3 TISSUE SARCOMA TUMOUR DEPTH Record the deepest tissue compartment where the tumour is located Intradermal cutaneous Fascial subfascial MITOTIC RATE SARCOMA Mitotic rate per 5mm squared Also known as mitotic index and mitotic count Component used to stage GISTs ONLY APPLICABLE TO GISTs Author NCIN 174 Cancer Outcomes and Services Dataset User Guide 11 SKIN OVERVIEW As with all other tumour types pathology reports should be submitted for all skin cancers It is expected that by January 2014 the pathology reports will include the RCPath cancer data sets where published in line with the Royal College of Pathologists professional standards Where applicable the AJCC STAGE GROUP not the UICC TNM Stage Grouping should be collected for stageable skin cancers Therefore the TNM stage fields which are included in the core dataset are not generally applicable for skin cancers although basic TNM for skin cancer will still be included in Histopathology Reports Please see section 11 3 SKIN STAGING for further information on how to record AJCC Stage Group For Melanomas the full Core and Site Specific datasets must be submitted For SCCs and BCCs which require MDT discussion the full Core and Site Specific datasets must be submitted For other non melanoma cases which require MDT discussion only the Core dataset should be submitted Where stage is applicable for these cases e g Merkel Cell tumours
99. 16 1 C16 4 TNM STAGING SEVENTH EDITION Stage Grouping T Stage N Stage M Stage Stage IA T1 NO MO Stage IB T2 NO MO T1 N1 MO Stage IIA LE ng mo T2 N1 MO T1 N2 MO Stage IIB S i T3 N1 MO T2 N2 MO T1 N3 MO Stage IIIA 14a Ni Mo T3 N2 MO T2 N3 MO Stage IIIB T4b NO N1 MO T4a N2 MO T3 N3 MO Stage IIIC T4a N3 MO T4b N2 N3 MO Stage IV Any T Any N M1 UICC SMALL INTESTINE ICD 10 C17 TNM STAGING SEVENTH EDITION Stage grouping T Stage N stage M stage Stage T1 T2 NO MO Stage IIA T3 NO MO Stage IIIB T4 NO MO Stage IIIA Any T N1 MO Stage IIIB Any T N2 MO Stage IV Any T Any N M1 UICC LIVER HEPATOCELLULAR CARCINOMA ICD 10 C22 0 TNM STAGING SEVENTH EDITION Author NCIN Cancer Outcomes and Services Dataset User Guide Stage Grouping T Stage N stage M Stage Stage T1 NO MO Stage II T2 NO MO Stage IIIA T3a NO MO Stage IIIB T3b NO MO Stage IIIC T4 NO MO Stage IVA Any T N1 MO Stage IVB Any T Any N M1 UICC LIVER INTRAHEPATIC BILE DUCTS ICD 10 C22 1 TNM STAGING SEVENTH EDITION Stage Grouping T Stage N Stage M Stage Stage T1 NO MO Stage II T2 NO MO Stage III T3 NO MO Stage IVA T4 NO MO Any T N1 MO Stage IVB Any T Any N M1 UICC GALLBLADDER ICD 10 C23 TNM STAGING SEVENTH EDITION Stage Grouping T Stage N Stage M Stage
100. 4a Extension to chest wall does not include pectoralis muscle invasion only T4b Ulceration ipsilateral satellite skin nodules or skin oedema including peau d orange T4c Both T4a and T4b as above T4d Inflammatory carcinoma Regional Lymph Nodes NO No regional lymph node metastasis N1 Metastasis in movable ipsilateral Level 1 1 axillary lymph node s N2a Metastasis in axillary lymph node s fixed to one another matted or to other structures N2b Metastasis only in clinically detected internal mammary lymph node s and in absence of clinically evident axillary lymph node metastasis N3a Metastasis in infraclavicular lymph node s N3b Metastasis in internal mammary and axillary lymph nodes N3c Metastasis in supraclavicular lymph node s Distant Metastasis MO No distant metastasis M1 Distant metastasis Author NCIN 60 Cancer Outcomes and Services Dataset User Guide 2 6 BREAST PATHOLOGY To carry pathology details for breast cancer This section can be recorded more than once Schema Data Item Name Format specification M R O X Data item Data Item No Section BREAST an10 ccyy BR4320 PATHOLOGY INVESTIGATION RESULT DATE nimedd BREAST BR4330 PATHOLOGY SERVICE REPORT IDENTIFIER max an18 MULTIFOCAL TUMOUR INDICATOR BR4140 fep den BREAST MULTIFOCAL TUMOUR INDICATOR BREAST DCIS GRADE BR4160 PATHOLOGY DUCTAL CARCINOMA IN SITU GRADE ani BR4170 BREAST INVASIVE GRADE BREAST ai PATHOLOGY BREAST INVASIVE
101. 78 4 Secondary Colorectal Normally malignant treated by neoplasm of small MDT of site of intestine primary tumour Only use if unable to code to specific primary site C78 5 Secondary Colorectal Normally malignant treated by neoplasm of large MDT of site of intestine and primary rectum tumour Only use if unable to code to specific primary site C78 8 Secondary Colorectal Normally malignant treated by neoplasm of other MDT of site of and unspecified primary digestive organs tumour Only use if unable to code to specific primary site Author NCIN 77 Cancer Outcomes and Services Dataset User Guide 001 0 Carcinoma in situ Colorectal of Colon 001 1 Carcinoma in situ Colorectal of Rectosigmoid junction D01 2 Carcinoma in situ Colorectal of Rectum D01 3 Carcinoma in situ Colorectal of Anus and anal e canal D01 4 Carcinoma in situ Colorectal of Anus and anal e canal D01 7 Other specified Colorectal digestive organs 001 9 Carcinoma in situ Colorectal of Digestive organ e unspecified D37 3 Neoplasm of Colorectal uncertain or unknown behaviour of Appendix D37 4 Neoplasm of Colorectal uncertain or unknown behaviour of Colon D37 5 Neoplasm of Colorectal uncertain or unknown behaviour of Rectum D37 7 Other digestive Colorectal Upper organs Gastrointestinal D37 9 Digestive organ Colorectal Upper unspecified Gastrointestinal
102. ANCER CARE UG13293 PLAN BODY MASS INDEX n2 n1 BODY MASS INDEX Estimate of a patient s Body Mass Index BMI at diagnosis The Body Mass Index BMI can be derived by a calculation using the patient s height and weight This data item would be obtained at presentation either in the outpatient clinic or on the ward PERSON OBSERVATION BMI 12 2 UPPER GI CANCER CARE PLAN LIVER METASTASES To carry cancer care plan details for Liver Metastases This section will be recorded once Schema Data item Data Item Section Data Item Name Format specification M R O X No UPPER GI CANCER CARE NUMBER OF LIVER METASTASES UG13630 ani PLAN LIVER METS PRE OPERATIVE IMAGING NUMBER OF LIVER METASTASES PRE OPERATIVE IMAGING Total number of liver metastases seen on preoperative imaging 3 ues SSS SSS SS 1 12 3 UPPER GI STAGING UICC OESOPHAGUS INCLUDING OESOPHAGOGASTRIC JUNCTION ICD 10 C15 C16 TNM STAGING SEVENTH EDITION Author NCIN 189 Cancer Outcomes and Services Dataset User Guide Stage Grouping T Stage N Stage M Stage Stage IA 1 MO Stage IB T2 NO MO Stage IIA T3 MO MO Stage IIB T1 T2 1 MO Stage IIIA NU T3 N1 MO T1 T2 N2 MO Stage IIIB T3 N2 MO Stage T4a N1 N2 MO T4b Any N MO Any T N3 MO Stage IV Any T Any N M1 UICC STOMACH INCLUDING FUNDUS OF STOMACH BODY OF STOMACH PYLORIC ANTRUM AND PYLORUS ICD 10 C
103. ARIOS sssssssssseseeeseeeeeeneenee en en EEn EEE A e araea ni tene tn sten en 278 APPENDIX DATA ITEMS FROM OTHER STANDARDS FOR REFERENCE eren enne ens 280 APPENDIX L DATA ITEMS FROM OTHER SOURCES FOR REFERENCE essere enne nnne enne ns 282 APPENDIX M UNDERSTANDING CANCER ONLINE E LEARNING TRAINING eeeeeeeeeeeeee nennen 286 APPENDIX N A STATEMENT REGARDING THE USE OF MO AND MX IN THE STAGING OF CANCERS 287 Author NCIN 9 Cancer Outcomes and Services Dataset User Guide STATUS USER GUIDE Information for Implementation Stage Phase 3 Changes to dataset from April 2014 This User Guide version 2 1 is one of a suite of documents to aid Users in implementing the COSD Information Standard ISN ISB 1521 which was mandated from January 2013 It includes all the data items in COSD together with definitions formats codes and values and additional guidance on collection and implementation This revised version of the User Guide includes further guidance and some minor changes which have been identified during implementation It is aligned with and should be read in conjunction with version v1 2 of the dataset which is available to download on the NCIN website Other guidance and support documents including FAQ are also available on the NCIN website and we are continuing with plans to provide an online version of the Guide Ph
104. ATHOLOGY DETAILS CORE PATHOLOGY DETAILS CORE PATHOLOGY DETAILS CORE PATHOLOGY DETAILS CORE PATHOLOGY DETAILS CORE PATHOLOGY DETAILS CORE PATHOLOGY DETAILS CORE PATHOLOGY DETAILS CORE PATHOLOGY DETAILS CORE PATHOLOGY DETAILS CORE PATHOLOGY DETAILS CORE PATHOLOGY DETAILS CORE PATHOLOGY DETAILS CORE PATHOLOGY DETAILS CORE PATHOLOGY DETAILS CORE PATHOLOGY DETAILS Schema specification M R O X Format 48 Data Item Name PATHOLOGY INVESTIGATION TYPE SAMPLE COLLECTION DATE SAMPLE RECEIPT DATE INVESTIGATION RESULT DATE CONSULTANT CODE PATHOLOGIST ORGANISATION CODE OF REPORTING PATHOLOGIST PATHOLOGY REPORT TEXT PRIMARY DIAGNOSIS ICD PATHOLOGICAL TUMOUR LATERALITY PATHOLOGICAL LESION SIZE PATHOLOGICAL SYNCHRONOUS TUMOUR INDICATOR TOPOGRAPHY SNOMED TOPOGRAPHY SNOMED CT MORPHOLOGY SNOMED MORPHOLOGY SNOMED CT GRADE OF DIFFERENTIATION PATHOLOGICAL CANCER VASCULAR OR LYMPHATIC INVASION Cancer Outcomes and Services Dataset User Guide CORE CRO880 PATHOLOGY EXCISION MARGIN an2 DETAILS CORE CRO890 PATHOLOGY NUMBER OF NODES EXAMINED max n3 DETAILS CORE CRO900 PATHOLOGY NUMBER OF NODES POSITIVE max n3 DETAILS CORE CRO910 PATHOLOGY T CATEGORY PATHOLOGICAL max an5 DETAILS CORE CRO920 PATHOLOGY N CATEGORY PATHOLOGICAL max an5 DETAILS CORE CR0930 PATHOLOGY M CATEGORY PATHOLOGICAL max an5 DE
105. Additional Pretext staging used to describe disease outside the liver extension into the vena cava and or all three hepatic veins extension into the main and or both left and right branches of the portal vein extra hepatic disease presence of distant metastases 5 24 CTYA RENAL PATHOLOGY Paediatric Kidney To carry Pathology details for CTYA This section can be recorded more than once Schema Data Item Section Data Item Name Format specification No cte690 CTYA RENAL PATHOLOGY vestiGATION RESULT pate 2 10 Paediatric Kidney mm dd CT6700 CIVA DENAT PATHOLOGY SERVICE REPORT IDENTIFIER max an18 Paediatric Kidney CT6610 CTYA RENAL PATHOLOGY TUMOUR RUPTURE Paediatric Kidney TUMOUR RUPTURE INDICATOR Data item M R O X PERIRENAL FAT INVASION CTYA RENAL PATHOLOGY CT6630 ON ieu Pis TUMOUR INVASION INDICATOR y PERIRENAL FAT RENAL SINUS INVASION CT6640 TUMOUR INVASION INDICATOR a y RENAL SINUS Author NCIN ANAPLASTIC NEPHROBLASTOMA CT6620 GIYA RENAL PATHOLOGY ANAPLASTIC NEPHROBLASTOMA an Paediatric Kidney TYPE an n 1 1 1 1 106 Cancer Outcomes and Services Dataset User Guide RENAL VEIN TUMOUR CTA RENALPATHOLOGY Teva ven TUMOUR w INDICATOR eee Meascann maae rumoua moraro R _ Paediatric Kidney VIABLE TUMOUR INDICATOR TUMOUR LOCAL STAGE CT6670 e t PATHOLOGICAL anl y TUMOUR LOCAL STAGE INVESTIGATION RE
106. CAL COMPLICATION PROCEDURES TYPE End of repeating item Surgical complications UNPLANNED RETURN TO THEATRE INDICATOR UG13150 UPPER GI SURGICAL PROCEDURES UNPLANNED OPERATION INDICATOR POST OPERATIVE TUMOUR SITE UPPER GI UPPER GI O G SURGICAL UG14230 POST OPERATIVE TUMOUR PROCEDURES SITE UPPER GASTROINTESTINAL PALLIATIVE TREATMENT REASON UPPER GI 0613810 UPPER GI SURGICAL PROCEDURES PALLIATIVE TREATMENT REASON CODE UPPER GASTROINTESTINAL ASA SCORE The ASA physical status classification system is a system for assessing the fitness of patients before surgery A normal healthy patient A patient with mild systemic disease A patient with severe systemic disease A patient with severe systemic disease that is a constant threat to life A moribund patient who is not expected to survive without the operation 5c A declared brain dead patient whose organs are being removed for donor purposes STAGING LAPAROSCOPY PERFORMED Record whether a staging laparoscopy was performed This may include an intraoperative ultrasound which is performed at some centres SURGICAL ACCESS ABDOMINAL The approach used to perform the abdominal part of the main procedure For Oesophagectomy can have Open laparotomy abdomen and thoracoscopic chest Laparoscopic abdomen and open thoracotomy chest Laparoscopic abdomen and thoracoscopic chest Open operation Laparoscopic w
107. CD O 3 WHO Description 4th ICD10 Description Clinical dataset GROUP Edition Chronic Myelogenous Leukaemia Chronic myeloid leukaemia 9875 3 C92 1 CML 1 Chronic Phase CML BCR ABL positive Atypical chronic myeloid leukaemia Atypical chronic myeloid 9876 3 92 2 MDS 1 BCR ABL1 negative leukaemia BCR ABL negative 9891 3 Acute monoblastic and monocytic C93 0 Acute monoblastic monocytic AML 5 leukaemia leukaemia 9895 3 AML with myelodysplasia related C92 8 Acute myeloid leukaemia with AML 5 changes multilineage dysplasia AML with t 8 21 q22 q22 RUNX1 Acute myeloblastic leukaemia 9896 3 RUNX1T1 C92 0 AML AML 5 Acute myeloid leukaemia with 9897 3 AML with t 9 11 p22 q23 MLLT3 MLL C92 6 11423 AML 5 SE Chronic myeloproliferative 9898 1 Transient abnormal myelopoiesis D47 1 disease CORE ONLY 5 9898 3 Myeloid leukaemiaassociated with C92 7 Other myeloid leukaemia AML 5 Down syndrome 9910 3 Acute megakaryoblastic leukaemia C94 2 megakaryoblastic AML 5 leukaemia AML megakaryoblastic with Acute megakaryoblastic 9911 3 C94 2 AML 5 t 1 22 p13 q13 RBM15 MKL1 leukaemia 9920 3 C92 0 Acute myeloblastic leukaemia AML 5 AML Myelodysplastic and 9920 3 t MDS MPN C94 6 myeloproliferative disease MDS 5 not elsewhere classified 9920 3B t MDS pags Other my lodysplastic MDS 5 syndromes 9930 3 Myeloid sarcoma C92 3 Myeloid sarcoma CORE ONLY 5 P Acute panmyelosis with 9931
108. CIRCUMFERENTIAL EXCISION MARGIN Record if the edge of the tumour is 1 mm or less from the circumferential resection margin i e margin involved Circumferential margin refers to the completeness of the surgeon s resection margin in the opinion of the histopathologist In parts of the colon where it is completely surrounded by peritoneum recording of the circumferential resection margin CRM is not appropriate 0 Margin not involved Margin involved Pomm LL DISTANCE TO CIRCUMFERENTIAL EXCISION MARGIN This data item is currently suspended as it duplicates data item DISTANCE TO CIRCUMFERENTIAL MARGIN CO5210 It is expected that it will be removed from the COSD upon its next formal review Record the distance from the tumour to the circumferential margin in mm Note For COSD reporting purposes this data item is only required to be submitted to one decimal place Author NCIN 86 Cancer Outcomes and Services Dataset User Guide 5 CHILDREN TEENAGERS AND YOUNG ADULTS 5 1 OVERVIEW There is no nationally agreed standardised categorisation by age and the following groupings are used for COSD e Paediatric under 16 years at time of diagnosis e Teenage 16 18 years under 19 at time of diagnosis e Young Adult 19 24 at time of diagnosis For all patients under 25 more than one dataset may be required depending on the nature of the disease and the management of the patient The following guidelines are intend
109. COLORECTAL max 5270 DISTANCE FROM DENTATE LINE PATHOLOGY n3 max n2 COLORECTAL max CO5280 DISTANCE BEYOND MUSCULARIS PROPRIA PATHOLOGY n3 max n2 COS290 COLORECTAL RESPONSE TO PREOPERATIVE THERAPY 1 an PATHOLOGY PREOPERATIVE THERAPY RESPONSE TYPE STATUS OF CIRCUMFERENTIAL EXCISION COLORECTAL MARGIN CO5300 an1 PATHOLOGY MARGIN INVOLVED INDICATION CODE CIRCUMFERENTIAL MARGIN CO5310 COLORECTAL DISTANCE TO CIRCUMFERENTIAL EXCISION max PATHOLOGY MARGIN n3 max n2 INVESTIGATION RESULT DATE The date on which an investigation was concluded e g the date the result was authorised SERVICE REPORT IDENTIFIER A unique identifier of a SERVICE REPORT POSITIVE PROXIMAL OR DISTAL RESECTION MARGIN Record whether the proximal or distal resection margins were involved If the minimal distance from the cut margin is less than or equal to 1 mm the margin is considered involved 0 Margin not involved Margin involved DISTANCE TO CIRCUMFERENTIAL MARGIN Record the distance from the outer margin of the tumour to the closest non peritonealised circumferential resection margin in mm RECTAL CANCERS ONLY Note For COSD reporting purposes this data item is only required to be submitted to one decimal place DISTANCE BETWEEN LOWER END OF TUMOUR AND DISTAL RESECTION MARGIN Record the distance between the lower end of the tumour and the distal resection margin in mm ALL COLORECTAL CANCERS Note For COSD reporting purposes this d
110. CT6620 N PHROBLASTOMA CT6630 PERIRENAL FAT INVASION CT6640 RENAL SINUS INVASION CT6650 RENAL VEIN TUMOUR CT6660 VIABLE TUMOUR TUMOUR LOCAL STAGE CT6670 PATHOLOGICAL Author NCIN 90 Cancer Outcomes and Services Dataset User Guide Note This data item is also in the core for all pathology This is an additional use of this data item to enable the Renal dataset to be identified 5 4 CTYA REFERRALS All cases To carry referrals details for CTYA This section will be recorded once Schema Data Item Section Data Item Name Format specification M R O X Data item No mp SPECIALTY REFERRER TO SPECIALIST CT6050 REGERE CARE PROFESSIONAL MAIN SPECIALTY CODE CANCER REFERRAL SPECIALTY REFERRER TO SPECIALIST The specialty of the person referring to the patients Principal Treatment Centre or age specific Specialist TYA MDT Main Specialty and Treatment Function Codes 5 5 CTYA DIAGNOSIS All cases To carry diagnosis details for CTYA This section will be recorded once Schema Data Item Name Format specification M R O X CT6060 CTYA PRIMARY DIAGNOSIS SUBSIDIARY COMMENT DIAGNOSIS PRIMARY DIAGNOSIS CANCER COMMENT e Start of repeating item Secondary Diagnosis ICD CTYA End of repeating item Secondary Diagnosis ICD mo OTHER SIGNIFICANT DIAGNOSIS SUBSIDIARY m icem DIAGNOSIS 50 SECONDARY DIAGNOSIS CANCER COMMENT item Data
111. D End of repeating item Extra nodal metastases UROLOGY STAGING LUNG METASTASES SUB STAGE UR15330 an2 TESTICULAR GROUPING Author NCIN 205 Cancer Outcomes and Services Dataset User Guide STAGE GROUPING TESTICULAR TESTICULAR ONLY Nationally agreed anatomical stage groupings as defined by The Royal Marsden Hospital RMH 3A Stage 3A Supradiaphragmatic lymphadenopathy with abdominal ee ee a 3B Stage 3B Supradiaphragmatic lymphadenopathy with abdominal EE ee C NN 3C Stage 3C Supradiaphragmatic lymphadenopathy with abdominal O S EN n RN 4A Stage 4A Extralymphatic metastases with abdominal __ _ ET mesi km o 4B Stage 4B Extralymphatic metastases with abdominal BENE NN 4C Stage 4C Extralymphatic metastases with abdominal ENNIUS EXTRANODAL METASTASES FOR TESTICULAR STAGE 4 PATIENTS ONLY Indicate the extent of metastatic spread multiple items can be selected Note This data item only applies to a small cohort of patients 8 Wanmoeme SSCS Mediastinal involvement LUNG METASTASES SUB STAGE GROUPING FOR TESTICULAR CANCER ONLY Where lung metastases identified specify the RMH grouping Note This only applies to a very small sub group with Extra Nodal Metastases Less than or equal to 3 metastases Greater than 3 metastases Greater than 3 metastases one or more greater than or equal to 2cm diameter UICC CARCINOMA OF THE TESTIS TNM STAGING SEVENTH EDITION STAGE COMPONENTS ON
112. E IMAGING is Mandatory for the schema 7 Either IMAGING CODE NICIP or a combination of CANCER IMAGING MODALITY IMAGING ANATOMICAL SITE and ANATOMICAL SIDE IMAGING is Mandatory for the schema 8 Either IMAGING CODE NICIP or a combination of CANCER IMAGING MODALITY IMAGING ANATOMICAL SITE and ANATOMICAL SIDE IMAGING is Mandatory for the schema As IMAGING CODE NICIP is used for the Diagnostic Imaging Dataset this should now be available to most systems and should be used in preference Author NCIN 31 Cancer Outcomes and Services Dataset User Guide CANCER IMAGING MODALITY Note This is only required if NICIP is not available The type of imaging procedure used during an Imaging or Radiodiagnostic Event for a Cancer Care Spell Note This is not applicable for Skin diagnoses IMAGING ANATOMICAL SITE Note This is only required if NICIP is not available A classification of the part of the body that is the subject of an Imaging or Radiodiagnostic Event The coding frame used is the OPCS 4 Z coding plus two additional local codes e Whole body 2001 e Multiple sites CZ002 For the purposes of recording Imaging Site for COSD the following high level codes are sufficient although more detailed codes can be used if preferred 7921 Head 7923 Neck NEC 7924 Chest 7925 Back NEC 7926 Abdomen NEC 7927 Trunk 7899 7909 Leg NEC Z019 Brain
113. EAD amp NECK PRE HN9060 an10 ccyy DAHNO TREATMENT CANCER DENTAL ASSESSMENT DATE dd mm HN22 ASSESSMENT HN9050 HEAD amp NECK PRE CARE CONTACT DATE DIETICIAN an10 ccyy DAHNO TREATMENT INITIAL mm dd HN19 ASSESSMENT PLANNED POST OPERATIVE HN9140 HEAD amp NECK PRE COMMUNICATION METHOD DAHNO TREATMENT SURGICAL VOICE RESTORATION an1 SVR8 ASSESSMENT COMMUNICATION METHOD PLANNED POST OPERATIVE DATE HEIGHT MEASURED Date the patient s height was measured PERSON HEIGHT IN METRES Height of the patient in metres to 2 decimal places n nn DATE WEIGHT MEASURED Date the patient s weight was measured PERSON OBSERVATION WEIGHT Weight of the patient in kilograms with up to three decimal places nnn nnn CANCER DENTAL ASSESSMENT DATE The date of the first dental assessment by a dentally qualified practitioner which contributes to preparation for treatment This is a person who the Multi Disciplinary Team considers suitably qualified to carry out the pre treatment dental assessment of the patient CARE CONTACT DATE DIETICIAN INITIAL The date that the patient was first assessed by a dietician PLANNED POST OPERATIVE COMMUNICATION METHOD Only applicable to head and neck cancer prior to laryngectomy The patient s proposed method of communication following laryngectomy O PSVR Primary SVR OOS 0 o Oesophagealvoice SSS M Mouthing W Writing or AAC aid Aut
114. EFERRAL SCENARIOS Referral information is required once for each cancer diagnosis and is completed by the Provider which diagnosed the cancer This should therefore be recorded from the beginning of the referral pathway within the Provider which led to the cancer diagnosis It will normally begin at the referral to outpatients from primary care from emergency services or from another Provider Cancer Waiting Times only requires this information for 2ww and screening referrals but for COSD it is essential that details of the referral section of the pathway are recorded for all cases Data items from Referral to First Seen Date The following data items should be completed according to the scenarios following PRIORITY TYPE CODE SOURCE OF REFERRAL FOR OUTPATIENTS DATE FIRST SEEN CONSULTANT CODE ORGANISATION CODE PROVIDER FIRST SEEN SCENARIOS SCENARIO 1 2 WEEK WAIT AND SCREENING CASES details as covered by Cancer Waiting Times guidance SCENARIO 2 PATIENTS INITIALLY REFERRED TO OUTPATIENTS SOURCE OF REFERRAL FOR OUT PATIENTS will normally be referral from a GENERAL MEDICAL PRACTITIONER referral from a GENERAL DENTAL PRACTITIONER referral from a GENERAL PRACTITIONER with Special Interest Or if referred from another Hospital referral from a CONSULTANT other than in an Accident And Emergency Department Other referral sources listed may also be applicable SCENARIO 3 PATIENTS INITIALLY SEEN AS EMERGENCIES BUT THEN REFERRED TO AN
115. EN STAGING TESTIS SYSTEM THYROID UICC TNM 7 UPPER AERODIGESTIVE TRACT MALIGNANT MELANOMA UICC TNM 7 URETHRA UICC TNM 7 URINARY BLADDER UICC TNM 7 UTERUS ENDOMETRIUM FIGO UTERUS UTERINE SARCOMA FIGO UVEA MALIGNANT MELANOMA UICC TNM 7 VAGINA FIGO VULVA FIGO VULVA MALIGNANT MELANOMA AJCC TNM 7 Author NCIN 266 Cancer Outcomes and Services Dataset User Guide Note the use of which preferred staging systems should be used is under frequent review and are likely to change in the future These staging systems are recognised as currently being discussed and new guidance may be available soon _ Staging for merkel cell carcinoma of the skin has recently been added for collection in COSD if possible See Section 0 10 Stage of COSD User Guide for advice on how to record for COSD Author NCIN 267 Cancer Outcomes and Services Dataset User Guide APPENDIX F SKIN DATASET AJCC STAGE GROUP ADDITIONAL INFORMATION American Joint Committee on Cancer AJCC Additional Information AJCC STAGE GROUP AMERICAN JOINT COMMITTEE ON CANCER STAGE MELANOMA STAGING 7TH EDITION Clinical Staging Pathological Staging uere Tam nen em wn DeL ppp Dp e Stage III Any T gt N1 MO Stage IIIA Pee ee e oe Pee oe es 4a 1 pe poe wm ve EN XE Autho
116. ENTAGE BONE MARROW KARYOTYPE IPSS MYELODYSPLASIA ALBUMIN LEVEL BETA2 MICROGLOBULIN LEVEL ISS STAGE for MYELOMA ANN ARBOR STAGE ANN ARBOR SYMPTOMS ANN ARBOR EXTRANODALITY ANN ARBOR BULK NUMBER OF ABNORMAL NODAL AREAS PRIMARY EXTRANODAL SITE BLOOD HAEMOGLOBIN CONCENTRATION LACTATE DEHYDROGENASE LEVEL FLIPI INDEX SCORE 133 Cancer Outcomes and Services Dataset User Guide DATA ITEM Clinical Dataset SITE SPECIFIC DATA ITEM DLBCL Ann Arbor stage HA8280 ANN ARBOR STAGE Ann Arbor symptoms HA8290 ANN ARBOR SYMPTOMS Ann Arbor extranodality HA8300 ANN ARBOR EXTRANODALITY Ann Arbor Bulk HA8310 ANN ARBOR BULK Extranodal sites HA8420 NUMBER OF EXTRANODAL SITES CODE Primary Extranodal Site HA8330 PRIMARY EXTRANODAL SITE LDH HA8350 LACTATE DEHYDROGENASE LEVEL R IPI HA8450 R IPI INDEX for DLBCL SCORE Other Lymphomas Ann Arbor stage HA8280 ANN ARBOR STAGE Ann Arbor symptoms HA8290 ANN ARBOR SYMPTOMS Ann Arbor extranodality HA8300 ANN ARBOR EXTRANODALITY Ann Arbor Bulk HA8310 ANN ARBOR BULK Primary Extranodal Site HA8330 PRIMARY EXTRANODAL SITE LDH HA8350 LACTATE DEHYDROGENASE LEVEL Hodgkin Ann Arbor stage HA8280 ANN ARBOR STAGE Ann Arbor symptoms HA8290 ANN ARBOR SYMPTOMS Ann Arbor extranodality HA8300 ANN ARBOR EXTRANODALITY Ann Arbor Bulk HA8310 ANN ARBOR BULK Primary Extranodal Site HA8330 PRIMARY EXTRANODAL SITE Hb HA8100 BLOOD HAEMOGLOBIN CONCENTRATION Albumin HA8550 ALBUMIN LEVEL WBC HA815
117. EOPERATIVE CHEMOTHERAPY WILMS TUMOUR STAGE Stage is determined by the results of the imaging studies and both the surgical and pathologic findings at nephrectomy It is essential to record the stage for this group of patients and this information should be available to the MDT following treatment e Stage 1 tumour is limited to the kidney and completely resected e Stage 2 tumour is completely resected and there is no evidence of tumour at or beyond the margins of resection but the tumour extends beyond the kidney penetration of capsule invasion of blood vessels outside renal parenchyma e Stage 3 there is residual tumour following surgery that is confined to the abdomen Author NCIN 98 Cancer Outcomes and Services Dataset User Guide e Stage 4 there are distant metastases lung liver bone brain or lymph node metastases outside the abdominopelvic region e Stage 5 involvement of both kidneys is present at diagnosis RISK CLASSIFICATION PATHOLOGICAL AFTER IMMEDIATE NEPHRECTOMY Classification and timing of surgery determine histological risk This information should be available for the MDT discussion following treatment but will only apply to a small number of cases The following definitions are used e Favourable histology non anaplastic Wilms tumour all subtypes cystic partially differentiated nephroblastoma mesoblastic nephroma diffuse nephroblastomatosis e Unfavourable histology Anaplastic Wilms tumo
118. ER SKIN GENERAL SITE CODE OF SPECIMEN SK12020 an4 M BCC SCC amp MM SKIN SPECIMEN SITE CODE CLINICAL DIAGNOSIS PRE SKIN GENERAL SK12030 HISTOLOGICAL RESULT SKIN an2 BCC SCC amp MM SKIN CANCER LESION DIAGNOSIS INVESTIGATION RESULT DATE The date on which an investigation was concluded e g the date the result was authorised SERVICE REPORT IDENTIFIER A unique identifier of a SERVICE REPORT SKIN CANCER LESION INDICATOR This is the specimen number or letter used to identify the specimen within a report Where more than one primary skin cancer is reported on the same pathology report record the lesion number or letter as specified on the pathology report GRADE OF CLINICIAN SURGEON OPERATING This is the level of training reached of the actual operating Clinician or Surgeon and not necessarily the responsible Clinician This data item could be obtained from the MDT NURSE TRAINEE SPECIALIST DOCTOR CONSULTANT SURGEON CONSULTANT DERMATOLOGIST SITE CODE OF SPECIMEN This is the four digit ICD10 code of the skin specimen e g C445 Skin of trunk CLINICAL DIAGNOSIS PRE HISTOLOGICAL RESULT SKIN What is the clinical diagnosis of the patient s lesion rash Atypical mole Melanocytic tumour atypical tumour of unknown malignant potential S SSS 11 2 SKIN PATHOLOGY BASAL CELL CARCINOMA BCC and SQUAMOUS CELL CARCINOMA SCC To carry pathology details for Bas
119. FUSION DONOR STEM CELL INFUSION DONOR TYPE STEM CELL INFUSION DATE Date of stem cell infusion STEM CELL INFUSION SOURCE Source of stem cells for infusion 10 ccyy mm dd an1 Not known STEM CELL INFUSION DONOR Donor for stem cell infusion Autologous Allogeneic Sibling Author NCIN Cancer Outcomes and Services Dataset User Guide Allogeneic Haplo 4 Allogeneic Unrelated 9 Not Known 5 8 CTYA CHEMOTHERAPY To carry chemotherapy details for CTYA This section will be recorded once per treatment where applicable Schema specification M R O X Data item No CT6160 SPECIALTY SUB CODE CHEMOTHERAPY CONSULTANT The age group specialty of the consultant responsible for prescription of chemotherapy Data Item Section Data Item Name Format SPECIALTY SUB CODE CHEMOTHERAPY CONSULTANT CHILDREN TEENAGERS AND YOUNG ADULTS AGE CATEGORY CONSULTANT PRESCRIBING CHEMOTHERAPY CTYA MAIN CHEMOTHERAPY Paediatric 3 ij Teenage and Young Adult Adult Only 5 9 CTYA ACUTE LEUKAEMIA LYMPHOCYTIC and MYELOID To carry Acute Leukaemia Lymphocytic and Myeloid details for CTYA This section will be recorded once Schema specification M R O X Data Item Section DELE Format item No Data Item Name CTYA Acute Author NCIN Lymphocytic Leukaemia amp AML CTYA Acute Lymphocytic Leukaemia amp AML CTYA Acute Lymphocytic
120. G SYSTEM ADRENAL CORTEX TUMOURS UICC TNM 7 AMPULLA OF VATER CARCINOMA UICC TNM 7 AMPULLA OF VATER NEUROENDOCRINE TUMOURS EUROPEAN NEUROENDOCRINE TUMOUR SOCIETY TNM ANAL CANAL UICC TNM 7 APPENDIX CARCINOMA UICC TNM 7 APPENDIX NEUROENDOCRINE TUMOURS EUROPEAN NEUROENDOCRINE TUMOUR SOCIETY TNM BONE UICC TNM 7 BREAST UICC TNM 7 CERVIX FIGO AND N STAGE CHRONIC LYMPHOCYTIC LEUKAEMIA RAI AND BINET COLON AND RECTUM CARCINOMA UICC TNM 5 amp DUKES COLON AND RECTUM GIST UICC TNM 7 COLON AND RECTUM NEUROENDOCRINE TUMOURS EUROPEAN NEUROENDOCRINE TUMOUR SOCIETY TNM CONJUNCTIVA CARCINOMA UICC TNM 7 CONJUNCTIVA MELANOMA UICC TNM 7 CUTANEOUS SQUAMOUS CELL CARCINOMA AND OTHER CUTANEOUS CARCINOMA AJCC TNM 7 EXTRAHEPATIC BILE DUCT PERIHILAR UICC TNM 7 EXTRAHEPATIC BILE DUCTS DISTAL UICC TNM 7 FALLOPIAN TUBE FIGO GALLBLADDER UICC TNM 7 GLOTTIS UICC TNM 7 HODGKINS LYMPHOMA ANN ARBOR HYPOPHARYNX UICC TNM 7 KIDNEY UICC TNM 7 KIDNEY WILMS WILMS TUMOUR STAGE NWTSG LACRIMAL GLAND CARCINOMA UICC TNM 7 LIP UICC TNM 7 LIVER INTRAHEPATIC BILE DUCTS UICC TNM 7 LIVER HEPATOCELLULAR UICC TNM 7 LUNG UICC TNM 7 MAJOR SALIVARY GLANDS UICC TNM 7 MAXILLARY SINUS UICC TNM 7 MEDULLOBLASTOMA CHANG STAGING SYSTEM MYELOMA INTERNATIONAL STAGING SYSTEM ISS NASAL CAVITY AND PARANASAL SINUSES
121. GING SEVENTH EDITION Stage Grouping T Stage N Stage M Stage Stage IVA T4a Any N MO Stage IVB T4b Any N MO Stage IVC Any T Any N M1 8 2 HEAD amp NECK POST TREATMENT ASSESSMENT To carry post treatment assessment details for head and neck cancer This section can be recorded more than once The assessment information should be recorded 12 months post diagnosis as a minimum and annually thereafter if possible _ Schema Data item No Data Item Section Data Item Name Format specification M R O X DER ees EST CLINICAL STATUS ASSESSMENT DATE 10 an10 ccyy HNI990 TREATMENT id DAHNO 14 1 CANCER mm dd ASSESSMENT HEAD amp NECK POST TREATMENT PERSON HEIGHT IN METRES ASSESSMENT HEAD amp NECK POST HN9200 PERSON OBSERVATION WEIGHT max TREATMENT DAHNO D1 PERSON WEIGHT n3 max n3 ASSESSMENT HEAD amp NECK POST TREATMENT PRIMARY TUMOUR STATUS ASSESSMENT HEAD amp NECK POST TREATMENT NODAL STATUS ASSESSMENT HEAD amp NECK POST TREATMENT METASTATIC STATUS ASSESSMENT HN9220 DAHNO D3 HN9010 DAHNO 14 2 HN9020 DAHNO 14 3 HN9030 DAHNO 14 4 SVR COMMUNICATION PRIMARY HN9150 HEAD amp NECK POST METHOD DAHNO TREATMENT SURGICAL VOICE RESTORATION SVR9 ASSESSMENT COMMUNICATION METHOD PRIMARY SPEECH amp LANGUAGE ASSESSMENT HN9080 HEAD amp NECK POST DATE an10 ccyy TREATMENT SPEECH AND LANGUAGE mm dd ASSESSMENT ASSESSMENT DATE CLINICAL STATUS ASSES
122. IAL CHEMOEMBOLISATION UPPER GI LIVER UG13580 TRANS ARTERIAL CHEMOEMBOLISATION an1 METS and LIVER HCC PERFORMED INDICATOR ABLATIVE THERAPY TYPE Describe type of ablative i e locally destructive treatment therapy used if any This procedure would be performed in the endoscopy unit Please check local policies Other ablative treatment Not known LN R Radiofrequency ablation E WE 9 Author NCIN 197 Cancer Outcomes and Services Dataset User Guide TRANS ARTERIAL CHEMOEMBOLISATION Was Trans Arterial Chemoembolisation TACE carried out This procedure would be performed in the specialist centres Not known 12 7 UPPER GI PATHOLOGY To carry pathology details for various Upper GI cancers as shown This section can be recorded more than once Data item r Data Item Section Data Item Name Format specification No M R O X UPPER GI PATHOLOGY LIVER UG14500 METS INVESTIGATION RESULT DATE UPPER GI PATHOLOGY LIVER UG14510 SERVICE REPORT IDENTIFIER METS UG14470 UPPER GI PATHOLOGY LIVER NUMBER OF COLORECTAL METS METASTASES IN LIVER CODE EXCISION MARGIN PROXIMAL DISTAL UPPER GI PATHOLOGY UG14480 MARGIN INVOLVED INDICATION OESOPHAGEAL AND STOMACH CODE POSITIVE PROXIMAL OR DISTAL RESECTION MARGIN EXCISION MARGIN UPPER GI PATHOLOGY CIRCUMFERENTIAL OESOPHAGEAL OG JUNCTION UG14490 MARGIN INVOLVED INDICATION PANCREAS BILE DUCT LCC CODE CIRCU
123. IN OTHER LYMPHOMAS HODGKIN HES HAEMATOLOGY STAGING ANN ARBOR SYMPTOMS HA8290 FOLLICULAR DLBCL OTHER ANN ARBOR SYMPTOMS an1 LYMPHOMAS HODGKIN INDICATOR EN HAEMATOLOGY CANCER CARE ANN ARBOR BULK HA831 PLAN FOLLICULAR DLBCL i ANN ARBOR BULK INDICATOR ANN ARBOR STAGE Staging based on location of detected disease Author NCIN 143 Cancer Outcomes and Services Dataset User Guide One region of lymph nodes or spleen or thymus or Waldeyer s ring enlarged 2 regions of lymph nodes enlarged on same side of diaphragm Ill lymph nodes enlarged on both sides of diaphragm IV disease outside lymph nodes e g liver bone marrow excluding E No Symptoms Presence of any of the following unexplained persistent or recurrent fever greater than 38 C 101 5 F drenching night sweats unexplained weight loss of 1096 or more within the last 6 months ANN ARBOR EXTRANODALITY ANN ARBOR EXTRANODALITY INDICATOR Additional staging designation based on extranodal involvement For Primary Nodal lymphoma code E if there is involvement of a single extranodal site by contiguous spread ie directly adjoining from the known nodal group For Primary Extranodal lymphoma code E if there is a single extranodal lesion with or without lymphatic involvement in the draining area e g a thyroid lymphoma with draining cervical lymph node involvement The designation of Stage 4 for nodal disea
124. IN 168 Cancer Outcomes and Services Dataset User Guide C78 6 Secondary Sarcoma Normally malignant treated by neoplasm of MDT of site of retroperitoneum primary and peritoneum tumour Only use if unable to code to specific primary site 79 5 Secondary Sarcoma Normally malignant treated by neoplasm of bone MDT of site of and bone marrow primary tumour Only use if unable to code to specific primary site D48 0 Neoplasm of Sarcoma uncertain or unknown behaviour of Bone i and articular cartilage D48 1 Neoplasm of Sarcoma Only uncertain or applicable for unknown GISTs behaviour of Connective and other soft tissue 10 1 SARCOMA DIAGNOSIS To carry diagnosis details for Sarcoma for both Bone and Soft Tissue This section will be recorded once Schema Data Item Section Data Item Name Format specification M R O X SARCOMA SA11000 SARCOMA TUMOUR SITE BONE DIAGNOSIS SARCOMA SA11010 SARCOMA TUMOUR SUBSITE BONE an2 DIAGNOSIS Data item SARCOMA 11080 SARCOMA TUMOUR SITE SOFT TISSUE DIAGNOSIS SARCOMA SARCOMA TUMOUR SUBSITE SOFT SA11090 an2 DIAGNOSIS TISSUE SARCOMA MULTIFOCAL OR SYNCHRONOUS SA11025 an1 DIAGNOSIS TUMOUR INDICATOR SARCOMA TUMOUR SITE BONE Location of the bone sarcoma within the body as defined by OPCS4 code This is more specific than ICD10 ICDO3 sites Note Other Z codes may be used if they are felt more app
125. ION TO TREATMENT DELAY REASON DECISION TO DELAY REASON DECISION TO CR1470 CORE TREATMENT WENT RENE CWT 280 Cancer Outcomes and Services Dataset User Guide WAITING TIME ADJUSTMENT WAITING TIME ADJUSTMENT CR1480 CORE TREATMENT EUNT EE CWT WAITING TIME ADJUSTMENT REASON WAITING TIME ADJUSTMENT Cue GORE TREATMENT TREATMENT REASON TREATMENT DELAY REASON COMMENT REFERRAL DELAY REASON COMMENT Gu CORE Une MENT TREATMENT REFERRAL TO TREATMENT SHIT DELAY REASON REFERRAL TO DELAY REASON REFERRAL TO Cet GORE TREATMENT TREATMENT CANCER TREATMENT CANCER DELAY REASON COMMENT CONSULTANT DELAY REASON COMMENT Orisa GORE Dass etr UPGRADE CONSULTANT UPGRADE OW DELAY REASON CONSULTANT DELAY REASON CONSULTANT CR1530 CORE TREATMENT ERNE CWT CR1250 CORE TREATMENT CLINICAL TRIAL INDICATOR CLINICAL TRIAL INDICATOR CWT CORE RADIOTHERAPY To carry the radiotherapy details A course of radiotherapy is defined as a string of prescriptions which are consecutive CR1560 CORE RADIOTHERAPY RADIOTHERAPY PRIORITY RADIOTHERAPY PRIORITY Ede CR1570 CORE RADIOTHERAPY RADIOTHERAPY INTENT RADIOTHERAPY INTENT CWT ANATOMICAL TREATMENT SITE ANATOMICAL TREATMENT SITE CR1140 CORE RADIOTHERAPY ened ae Epson RDTS CORE CHEMOTHERAPY AND OTHER DRUGS To carry the details of chemotherapy and or other anti ancer and or supporti
126. Item Section senose t _ DIAGNOSIS FAMILIAL CANCER SYNDROME INDICATOR P FAMILIAL CANCER SYNDROME SUBSIDIARY DIAGNOSIS COMMENT an50 FAMILIAL CANCER SYNDROME COMMENT NA CONSULTANT SPECIALTY AT DIAGNOSIS CARE CT6030 PROFESSIONAL MAIN SPECIALTY CODE an3 DIAGNOSIS mos CONSULTANT AGE SPECIALTY AT DIAGNOSIS CT6040 DiAGNOsis CHILDREN TEENAGERS AND YOUNG ADULTS AGE an1 CATEGORY CONSULTANT AT DIAGNOSIS PRIMARY DIAGNOSIS SUBSIDIARY COMMENT Optional Additional comments on diagnosis where coding is difficult or imprecise Author NCIN 91 Cancer Outcomes and Services Dataset User Guide Examples of this would be papillary glioneuronal tumour or angiocentric glioma to specify recently described diagnoses which do not have ICD10 or ICD O 3 coding Anaplastic ependymoma or ependymoblastoma to distinguish between these two diagnoses which may have different treatment decisions or outcomes but which cannot be distinguished in ICD10 or ICD O 3 coding SECONDARY DIAGNOSIS ICD Optional Types ICD10 codes of other significant conditions e g Down Syndrome NF1 Fanconi anaemia which may predispose to cancer or influence treatment Possible multiple entries This information should be available for the MDT discussion but will only apply to a small number of cases See Appendix D for list of Associated Conditions to be Recorded on Childhood Cancer Regis
127. L To carry pathology details for Gynae for Cervical This section will be recorded once per pathology report where applicable Data item No Data Item Section GYNAECOLOGY PATHOLOGY CERVICAL GY7290 GYNAECOLOGY PATHOLOGY CERVICAL GY7300 GY7350 GYNAECOLOGY PATHOLOGY CERVICAL GY7310 GYNAECOLOGY PATHOLOGY CERVICAL GY7330 GYNAECOLOGY PATHOLOGY CERVICAL GY7340 GYNAECOLOGY PATHOLOGY CERVICAL GY7360 GYNAECOLOGY PATHOLOGY CERVICAL GY7370 Schema Data Item Name Format specification M R O X i m m o CGIN GRADE CERVICAL GLANDULAR INTRAEPITHELIAL NEOPLASIA PRESENCE AND GRADE CIN GRADE CERVICAL INTRAEPITHELIAL NEOPLASIA PRESENCE AND GRADE GYNAECOLOGY SMILE 1 an PATHOLOGY CERVICAL SMILE INDICATION CODE EXCISION MARGIN PRE INVASIVE RESECTION MARGIN INVOLVEMENT INDICATOR INVASIVE THICKNESS PARACERVICAL OR PARAMETRIAL INVOLVEMENT PARACERVICAL OR PARAMETRIAL INVOLVEMENT INDICATOR THICKNESS UNINVOLVED STROMA UNINVOLVED CERVICAL STROMA THICKNESS VAGINAL INVOLVEMENT MICROSCOPIC INVOLVEMENT INDICATOR VAGINAL CGIN GRADE Specify presence and grade of CGIN cervical glandular intraepithelial neoplasia Low High Not present Not assessable CIN GRADE Specify presence and grade of CIN cervical intra epithelial neoplasia NTR Not present Not assessable Ww SMILE Specify presence of SMILE Stratified M
128. L SITE Site of origin of lymphoma if believed to be outside lymph nodes as agreed by MDT based on clinical and radiological findings Blood Bone 9 Liver Marrow Muscle Author NCIN 137 Cancer Outcomes and Services Dataset User Guide Salivary gland NUMBER OF EXTRANODAL SITES CODE Number of sites with Lymphoma outside lymph nodes clinical assessment More than 1 7 6 HAEMATOLOGY CANCER CARE PLAN CHRONIC MYELOID LEUKAEMIA To carry cancer care plan details specific to Chronic Myeloid Leukaemia CML This section will be recorded once Schema Data Item Section Data Item Name Format specification M R O X Data item No HAEMATOLOGY HA8000 CANCER CARE PLAN SPLEEN CM BELOW COSTAL MARGIN CML nw SOKAL MYELOID a PLAN CHRONIC MYELOID LEUKAEMIA INDEX SCORE SOKAL eg HASFORD AE MYELOID HA8020 CANCER CARE PLAN a CIE CHRONIC MYELOID LEUKAEMIA INDEX SCORE HASFORD SPLEEN CM BELOW COSTAL MARGIN Maximum distance from the costal margin in centimetres Measured not estimated by person examining patient Range 0 50 cm SOKAL INDEX CHRONIC MYELOID LEUKAEMIA Index derived from age spleen size platelet count myeloblasts 96 Pire os 00716 Age in years 434 00345 Spleen sizein em below costal region 751 E ss 008770 Kk 21 e Author NCIN 138 Cancer Outcomes and Services Dataset User Guide
129. L TRIAL into which the patient has been entered and does not necessarily mean the treatment that the patient will actually receive which will be recorded only as part of the clinical trial documentation Where a trial covers more than one type of treatment eg chemotherapy compared with radiotherapy then the option for combined treatment should be selected Where the trial covers a treatment type not specified here e g biological therapies the data item should be left blank This data item will be reviewed post implementation 4__ immunotherapy S y Radiotherapy 6 Combination treatment L8 Jome o S 1 7 CORE STAGING To carry the cancer staging details Both pre treatment and integrated stage should be recorded in this section UICC coding should be used Please refer to site specific sections for details of applicable values The pre treatment stage fields are those on which the first treatment is based i e this final staging information available prior to first treatment Integrated stage fields should be recorded when all available information regarding stage has been assessed following surgical treatment and or final review of the case Note Arabic numerals should be used i e submit in the format 1 2a 4 etc NOT Tia Tii Do not include TNM prefixes The National Staging Panel for Cancer Registration wishes to propose a modification to TNM7 to be used in England and retain the use of MX in
130. LOGICAL CTYA dataset CT6400 GYNAECOLOGY Change data item format to allow recording to 2 decimal places max nX max n2 in order to standardise measurement items and enable a greater degree of accuracy where applicable This change affects e INVASIVE THICKNESS Gynaecology dataset GY7330 e THICKNESS UNINVOLVED STROMA Gynaecology dataset GY7360 e INVASIVE THICKNESS Gynaecology dataset GY7390 HAEMATOLOGY Change data item name description format and national code due to a change in clinical practice whereby this is now measured in g l rather than g dl in haematology laboratories This change in measurement means a change in format to max n3 and a range of 10 250 This change affects e BLOOD HAEMOGLOBIN CONCENTRATION GRAMS PER LITRE Haematology dataset HA8100 Change data item description in order to take into account the above mentioned change in blood haemoglobin concentration This change affects e IPSS MYELODYSPLASIA Haematology dataset HA8080 e RAI STAGE Haematology dataset HA8230 e BINET STAGE Haematology dataset HA8240 e FLIPI INDEX SCORE Haematology dataset HA8360 e HASENCLEVER INDEX Haematology dataset HA8670 SARCOMA Addition of the following new data item which is a component required for staging Gastrointestinal Stromal Tumours GISTs e MITOTIC RATE SARCOMA Sarcoma dataset SA11220 Author NCIN 12 Cancer Outcomes and Services Dataset User Guide SKIN Cha
131. LY TNM T Clinical Classification Apart for a pT4 where radical orchidectomy is not always necessary for classification purposes the extent of the primary tumour is classified after radical orchidectomy see pT below In other circumstances TX is used if no radical orchidectomy has been performed Primary Tumour pTO No evidence of primary tumour e g histological scar in testis pTis Intratubular germ cell neoplasia 1 Tumour limited to testis and epididymis without vascular lymphatic invasion tumour may invade tunica albuginea but not tunica vaginalis pT2 Tumour limited to testis and epididymis with vascular lymphatic invasion or tumour extending Author NCIN 206 Cancer Outcomes and Services Dataset User Guide through tunica albuginea with involvement of tunica vaginalis pT3 Tumour invades spermatic cord with or without vascular lymphatic invasion pT4 Tumour invades scrotum with or without vascular lymphatic invasion Regional Lymph Nodes NO amp No regional lymph node metastasis pNO N1 amp Metastasis with a lymph node mass 2cm or less in greatest dimension or 5 or fewer positive lymph pN1 nodes none more than 2cm in greatest dimension N2 Metastasis with a lymph node mass more than 2cm but not more than 5cm in greatest dimension or 5 or fewer positive lymph nodes none more than 5cm in greatest dimension pN2 Metastasis with a lymph node mass more than 2cm
132. MENT M M DE Data Item item No Section ORGANISATION SITE CODE PROVIDER TREATMENT START 2 CR1450 spe aTMENT DATE CANCER UE E SITE CODE OF PROVIDER CANCER 8 TREATMENT START DATE CORE CRO660 TREATMENT CONSULTANT CODE TREATMENT CORE CARE PROFESSIONAL MAIN CRO670 3 M cRo670 SPECIALTY CODE TREATMENT 2 CANCER TREATMENT EVENT CWT The stage of treatment reached during a Cancer PATIENT PATHWAY for primary recurrent or metastatic cancer For COSD these definitions are extended to apply to all registerable conditions However those conditions not covered by Cancer Waits will need to be excluded from CWT uploads 01 First Definitive Treatment for a new primary cancer 02 Second or subsequent treatment for a new primary cancer 03 Treatment for a local recurrence of a primary cancer 04 Treatment for a regional recurrence of cancer 05 Treatment for a distant recurrence of cancer metastatic disease 06 Treatment for multiple recurrence of cancer local and or regional and or distant 07 First treatment for metastatic disease following an unknown primary 08 Second or subsequent treatment for metastatic disease following an unknown primary 09 Treatment for relapse of primary cancer second or subsequent 10 Treatment for progression of primary cancer second or subsequent TREATMENT START DATE CANCER CWT This is the Start Date of the fi
133. MFERENTIAL LIVER HCC AND LIVER METS MARGIN INVESTIGATION RESULT DATE The date on which an investigation was concluded e g the date the result was authorised SERVICE REPORT IDENTIFIER A unique identifier of a SERVICE REPORT NUMBER OF COLORECTAL METASTASES IN LIVER CODE Number of colorectal metastases identified in resected liver Greater than 5 EXCISION MARGIN PROXIMAL DISTAL Identify whether either proximal or distal margin is involved Involved equals 1mm or less not involved equals greater than 1mm 0 Margin not involved Author NCIN 198 Cancer Outcomes and Services Dataset User Guide Margin involved EXCISION MARGIN CIRCUMFERENTIAL Identify whether circumferential margin is involved Involved equals 1mm or less not involved equals greater than 1mm 0 Margin not involved Margin involved Author NCIN 199 Cancer Outcomes and Services Dataset User Guide 13 UROLOGY OVERVIEW The site specific Urology dataset applies additionally to in situ Bladder cancers 009 0 and pTa Bladder cancers D41 4 although these are excluded from Cancer Waits Watchful Waiting and Active Surveillance A treatment CANCER TREATMENT MODALITY of Active Monitoring should be recorded for all patients who are largely asymptomatic and may progress to active treatment if the status of the disease progresses This covers all patients who are being monitored only and will include watchful waiting as us
134. N INVOLVEMENT For endometrial and fallopian cancers is there microscopic involvement of ovaries SEROSAL INVOLVEMENT For endometrial epithelial ovarian and fallopian cancers is there microscopic involvement of uterine serosa Not assessable Author NCIN 115 Cancer Outcomes and Services Dataset User Guide OMENTAL INVOLVEMENT For endometrium ovary fallopian tube and primary peritoneum cancers is there involvement of the omentum Involved deposit size not specified Involved deposit s 20mm or less Involved deposit s greater than 20mm 4 Not involved Not assessable not sent 6 4 GYNAECOLOGY PATHOLOGY FALLOPIAN TUBE OVARIAN EPITHELIAL and PRIMARY PERITONEAL To carry pathology details for Gynae for Fallopian Tube Ovarian Epithelial and Primary Peritoneal This section will be recorded once per pathology report where applicable Data item No GY7140 GY7190 GY7150 GY7170 GY7180 Data Item Section GYNAECOLOGY PATHOLOGY FALLOPIAN TUBE OVARIAN EPITHELIAL and PRIMARY PERITONEAL GYNAECOLOGY PATHOLOGY FALLOPIAN TUBE OVARIAN EPITHELIAL and PRIMARY PERITONEAL GYNAECOLOGY PATHOLOGY FALLOPIAN TUBE OVARIAN EPITHELIAL and PRIMARY PERITONEAL GYNAECOLOGY PATHOLOGY FALLOPIAN TUBE OVARIAN EPITHELIAL and PRIMARY PERITONEAL GYNAECOLOGY PATHOLOGY FALLOPIAN TUBE OVARIAN EPITHELIAL and PRIMARY PERITONEAL Schema Data Item Name Format X specificati
135. NCIN national cancer intelligence network Using information to improve quality amp choice CANCER OUTCOMES AND SERVICES DATASET COSD User Guide Version 2 1 Cancer Outcomes and Services Dataset User Guide VERSION CONTROL Version Date Brief Summary of Change Editor Draft 0 1 15 08 2011 Initial draft version produced Trish Stokes Shaun Gallagher Draft 0 2 15 09 2011 Updated following circulation to SSCRG Chairs Trish Stokes Shaun Gallagher Version 22 09 2011 Finalised for operational testing Trish 1 0 Stokes Shaun Gallagher Version 15 12 2011 Updated to include feedback from operational testing Trish 1 1 Stokes Shaun Gallagher Version 19 01 2012 Amendments made Trish 1 2 Stokes Shaun Gallagher Version 01 02 2012 Amendments made Trish 1 3 Stokes Shaun Gallagher Version 23 02 2012 Updated with finalised COSD version 0 5 0 Trish 1 4 Stokes Shaun Gallagher Version 24 02 2012 Finalised for draft ISB submission Trish 1 5 Stokes Shaun Gallagher Version 18 04 2012 Updated for full stage ISB submission Trish 1 6 Stokes Shaun Gallagher Version 11 05 2012 Updated post ISB submission Frozen for further consultation Trish 1 7 Stokes Shaun Gallagher Version 01 06 2012 Minor amendments specifically the inclusion of the SERVICE Trish 1 8 REPORT IDENTIFER data item to align with version 0 5 2 of the Stokes Shaun COSD Submitted to ISB f
136. NDOMETRIAL INDICATOR CERVICAL SURFACE OR GLANDS a n1 n1 n1 n1 Data Item Section Data Item Name Format specification M R O X GYNAECOLOGY MYOMETRIAL INVASION GY7260 PATHOLOGY MYOMETRIAL INVASION ENDOMETRIAL IDENTIFICATION CODE GYNAECOLOGY PARAMETRIUM INVOLVEMENT GY7270 PATHOLOGY MICROSCOPIC INVOLVEMENT a ENDOMETRIAL INDICATOR PARAMETRIUM Author NCIN 117 Cancer Outcomes and Services Dataset User Guide GYNAECOLOGY PERITONEAL WASHINGS GY7280 PATHOLOGY PERITONEAL WASHINGS IDENTIFIED ENDOMETRIAL BACKGROUND ENDOMETRIUM Are abnormalities present in the background endometrium Normal oN Abnormal Not assessable DISTANCE TO SEROSA Specify the tumour free distance to the serosa in millimetres mm s INVOLVEMENT OF CERVICAL STROMA Is there microscopic involvement of cervical stroma Not assessable INVOLVEMENT OF CERVICAL SURFACE OR GLANDS Is there microscopic involvement of endocervical surface or Not assessable MYOMETRIAL INVASION Is there microscopic evidence of myometrial invasion Less than 50 Greater than or equal to 50 PARAMETRIUM INVOLVEMENT Is there microscopic involvement of parametrium Not assessable PERITONEAL WASHINGS Were peritoneal washings submitted and if so were malignant cells seen Not sent Not assessable Author NCIN 118 Cancer Outcomes and Services Dataset User Guide 6 6 GYNAECOLOGY PATHOLOGY CERVICA
137. NE INVASION INDICATION CODE Is there evidence of invasion into bone This is not applicable to many sites as bone not resected Present Absent Not assessed Not applicable CARTILAGE INVASION Is there evidence of invasion into cartilage This is not applicable to many sites as cartilage is not resected 4 Not applicable NECK DISSECTION LATERALITY Identify laterality of neck dissection if performed Author NCIN 154 Cancer Outcomes and Services Dataset User Guide Right Bilateral Not performed Not applicable 8 5 HEAD amp NECK PATHOLOGY SALIVARY To carry salivary pathology details for head and neck cancer This section will be recorded once per pathology report where applicable Schema Data item Data Item Section Data Item Name Format specification M R O X HISTOLOGICAL GRADE SALIVARY HEAD amp NECK TUMOUR PATHOLOGY SALIVARY HISTOLOGICAL TUMOUR GRADE SALIVARY MACROSCOPIC EXTRAGLANDULAR HN9390 HEAD amp NECK EXTENSION PATHOLOGY SALIVARY MACROSCOPIC EXTRAGLANDULAR EXTENSION INDICATION CODE HISTOLOGICAL GRADE SALIVARY TUMOUR Specify the histological grade of the tumour Low High Not assessed HN9380 Not applicable MACROSCOPIC EXTRAGLANDULAR EXTENSION Macroscopic extension of tumour outside the capsule of the salivary gland Present Absent 8 6 HEAD amp NECK PATHOLOGY GENERAL and SALIVARY To carry general and salivary patho
138. OMA TUMOUR SITE SOFT TISSUE OTHER THAN RHABDOMYOSARCO Author NCIN 89 Data item No Cancer Outcomes and Services Dataset User Guide Data Item Name ALL Acute Lymphocytic Rhabdomyosarcoma and other Soft Tissue Sarcomas Leukaemia Hodgkin s Lymphoma Neuroblastoma AML NHL STS excluding Rhabdomyosarcoma Osteosarcoma Germ Cell CNS Germ Cell Non CNS Medulloblastoma Hepatoblastoma SARCOMA TUMOUR SUBSITE CT6390 SOFT TISSUE OTHER THAN RHABDOMYOSARCOMA PRIMARY TUMOUR SIZE 6400 RADIOLOGICAL v EXTENT OF NECROSIS AFTER CT6410 CHEMOTHERAPY v SARCOMA SURGICAL MARGIN CT6420 ADEQUACY TUMOUR VOLUME AT CT6450 DIAGNOSIS CYTOGENETICS FOR EWINGS CT6460 SARCOMA CT6470 SARCOMA TUMOUR SITE BONE SARCOMA TUMOUR SUBSITE CT6440 ONS ALPHA FETOPROTEIN CT6530 CEREBROSPINAL FLUID v BETA HUMAN CHORIONIC CT6550 GONADOTROPIN v CEREBROSPINAL FLUID TNM STAGE GROUPING FOR CT6590 NON CNS GERM CELL TUMOURS v BETA HUMAN CHORIONIC CT6580 GONADOTROPIN SERUM CT6520 ALPHA FETOPROTEIN SERUM Yu CHANG STAGING FOR CT6560 MEDULLOBLASTOMA Y PRETEXT STAGING SYSTEM CT6500 ERIE PRETEXT STAGING OUTSIDE PREN CT6690 INVESTIGATION RESULT DATE CT6610 TUMOUR RUPTURE ANAPLASTIC
139. OTHER CONSULTANT SOURCE OF REFERRAL FOR OUT PATIENTS will be either following an emergency admission following an Accident And Emergency Attendance including Minor Injuries Units and Walk In Centres Ba referral from an Accident And Emergency Department including Minor Injuries Units and Walk In Centres DATE FIRST SEEN will be the first outpatient appointment following the emergency presentation or the first consultation with the specialist if patient remained as an inpatient CONSULTANT CODE relates to Date First Seen so will be the consultant who the patient was referred to following the emergency presentation ORGANISATION CODE PROVIDER FIRST SEEN relates to the Date First Seen so will be the organisation the patient was referred to following the emergency presentation Author NCIN 278 Cancer Outcomes and Services Dataset User Guide SCENARIO 4 PATIENTS WHERE CANCER WAS INITIALLY DIAGNOSED AND FIRST TREATED AS AN EMERGENCY SOURCE OF REFERRAL FOR OUT PATIENTS will normally be one of the emergency codes above DATE FIRST SEEN will be the date of the emergency first treatment CONSULTANT CODE relates to Date First Seen so will be the consultant carrying out the first treatment ORGANISATION CODE PROVIDER FIRST SEEN relates to the Date First Seen so will be the organisation carrying out the first treatment SCENARIO 5 PATIENTS WHERE CANCER WAS AN INCIDENTAL FINDING OF ANOTHER TREATMENT OR PROCESS SOURCE OF REFERRAL FOR
140. OUT PATIENTS will be other initiated by the CONSULTANT responsible for the Consultant Out Patient Episode DATE FIRST SEEN will be the date of the incidental finding CONSULTANT CODE relates to Date First Seen so will be the consultant who made the incidental findings during another treatment or process ORGANISATION CODE PROVIDER FIRST SEEN relates to the Date First Seen so will be the organisation where the incidental findings were made Data items for Cancer Specialist The following data items should be completed according to the scenarios following FIRST SEEN BY SPECIALIST DATE CANCER ORGANISATION CODE PROVIDER FIRST CANCER SPECIALIST SCENARIO 1 PATIENT WAS FIRST SEEN BY THE APPROPRIATE CANCER SPECIALIST Use same details as DATE FIRST SEEN and ORGANISATION CODE PROVIDER FIRST SEEN SCENARIO 2 INITIAL REFERRAL WAS NOT TO THE APPROPRIATE CANCER SPECIALIST Record details for the first appointment with the appropriate cancer specialist to progress this cancer diagnosis Author NCIN 279 APPENDIX K DATA ITEMS FROM OTHER STANDARDS FOR REFERENCE CORE REFERRALS AND FIRST STAGE OF PATIENT PATHWAY To carry patient referral details to the Provider that receives the first referral CR1380 CORE REFERRALS PATIENT PATHWAY IDENTIFIER PATIENT PATHWAY IDENTIFIER CWT i ORGANISATION CODE PATIENT SITE CODE PATIENT Cines CORE c REFERRALS PATHWAY
141. Outcomes and Services Dataset User Guide INTRODUCTION What is the Cancer Outcomes and Services Dataset The Cancer Outcomes and Services Dataset COSD is the new national standard for reporting cancer in the NHS in England It replaces the National Cancer Dataset and the Cancer Registration Dataset and includes additional site specific data items relevant to the different tumour types It is aligned with other national cancer datasets including Cancer Waits NCWTMDS Radiotherapy RTDS Systemic Anti Cancer Therapy SACT and Diagnostic Imaging DID Why is it needed We needed to revise the National Cancer Dataset to ensure that we meet the current information requirements for the NHS The Cancer Reform Strategy 2007 identified better information and stronger commissioning as two of the key drivers to achieve the goal that cancer services in this country should be amongst the best in the world The subsequent Improving Outcomes A Strategy for Cancer January 2011 further supports this concept to demonstrate cancer outcomes using high quality data and intelligence for all stakeholders What is different from previous data collection The COSD clarifies the data items that need to be submitted electronically directly to the National Cancer Registration Service on a monthly basis Most Providers have been sending monthly data submissions directly to the registries from systems such as MDT Multi disciplinary Team software PAS Patien
142. PERICARDIUM ine DIAPHRAGM INVASION LU10140 TUMOUR INVASION INDICATOR 1 PATHOLOGY DIAPHRAGM one INVASION INTO GREAT VESSEL LU10150 TUMOUR INVASION INDICATOR 1 PATHOLOGY GREAT VESSELS m INVASION INTO HEART LU10160 TUMOUR INVASION INDICATOR an1 PATHOLOGY HEART sane MALIGNANT PLEURAL EFFUSION LU10170 MALIGNANT PLEURAL EFFUSION 1 PATHOLOGY INDICATOR Author NCIN 163 Cancer Outcomes and Services Dataset User Guide LUNG SATELLITE TUMOUR NODULES LU10180 an1 PATHOLOGY LOCATION INVESTIGATION RESULT DATE The date on which an investigation was concluded e g the date the result was authorised SERVICE REPORT IDENTIFIER A unique identifier of a SERVICE REPORT PROXIMITY TO CARINA Is the tumour within 20mm of carina if known or more than 20mm from carina lt 20mm EXTENT OF ATELECTASIS Extent of atelectasis obstructive pneumonitis None or less than the two other categories Involving hilar region but not whole lung Involving whole lung EXTENT OF PLEURAL INVASION What is the extent of pleural invasion Author NCIN 164 Cancer Outcomes and Services Dataset User Guide SATELLITE TUMOUR NODULES LOCATION Record the most distant location of separate tumour nodules Separate tumour nodules in same lobe Separate tumour nodules in a different ipsilateral lobe Separate tumour nodules in a contralateral lobe No separate tumour nodules LL Author NCIN 165 Cancer O
143. PROCEDURE DATE RADIOSURGERY Date of radiosurgical treatment This information only needs to be collected by the specialist centre where the radiosurgery was performed 3 5 CENTRAL NERVOUS SYSTEM PATHOLOGY To carry pathology details for Central Nervous System cancer This section can be recorded more than once Author NCIN 73 Cancer Outcomes and Services Dataset User Guide Schema DET item No Data Item Section Data Item Name Format specification M R O X CENTRAL NERVOUS an10 ccyy BA3170 SYSTEM INVESTIGATION RESULT DATE dd M mm PATHOLOGY CENTRAL NERVOUS BA3180 SYSTEM SERVICE REPORT IDENTIFIER max an18 PATHOLOGY Start of repeating item Molecular Diagnostics Code CENTRAL NERVOUS BA3070 SYSTEM MOLECULAR DIAGNOSTICS CODE PATHOLOGY End of repeating item Molecular Diagnostics Code Start of repeating item Immunohistochemistry Hormone Expression Type CENTRAL NERVOUS IMMUNOHISTOCHEMISTRY HORMONE BA3150 SYSTEM EXPRESSION TYPE PATHOLOGY HORMONE EXPRESSION TYPE End of repeating item Immunohistochemistry Hormone Expression Type CENTRAL NERVOUS WHO TUMOUR GRADE CNS SYSTEM WORLD HEALTH ORGANISATION CENTRAL PATHOLOGY NERVOUS SYSTEM TUMOUR GRADE INVESTIGATION RESULT DATE The date on which an investigation was concluded e g the date the result was authorised SERVICE REPORT IDENTIFIER A unique identifier of a SERVICE REPORT MOLECULAR DIAGNOSTICS CODE Chromosomal or genetic markers ass
144. S as described above will be retained until any changes are agreed Author NCIN 139 Cancer Outcomes and Services Dataset User Guide 7 8 HAEMATOLOGY CANCER CARE PLAN CHRONIC LYMPHOCYTIC LEUKAEMIA To carry cancer care plan details specific to Applicable to Chronic Lymphocytic Leukaemia This section will be recorded once Schema Data Item Section Data Item Name Format specification M R O X Data item No HAEMATOLOGY CANCER HA8200 CARE PLAN CLL HEPATOMEGALY INDICATOR HAEMATOLOGY CANCER HA8210 CARE PLAN CLL SPLENOMEGALY INDICATOR HAEMATOLOGY CANCER HA8230 CARE PLAN CLL RAI STAGE HAEMATOLOGY CANCER HA8240 CARE PLAN CLL BINET STAGE HEPATOMEGALY INDICATOR Liver enlargement identified from clinical examination CARE PLAN CLL LYMPHADENOPATHY AREAS ni SPLENOMEGALY INDICATOR Spleen enlargement identified from clinical examination NUMBER OF LYMPHADENOPATHY AREAS Number of enlarged lymph node areas neck axilla groins identified from clinical assessment Range 0 3 RAI STAGE Applicable to Chronic Lymphocytic Leukaemia Prognostic index derived from platelet count Hb lymphadenopathy hepatomegaly splenomegaly Note that immune cytopenias are not included when calculating the Stage ie if Platelet count is below 100 and or Haemoglobin levels are below 110 as a result of immune cytopenia Also please see note on calculations below Rai Stage and Binet Stage both solely rely on ph
145. SMENT DATE CANCER The date on which a clinical assessment was performed Author NCIN 152 Cancer Outcomes and Services Dataset User Guide PERSON HEIGHT IN METRES Height of the patient in metres to 2 decimal places n nn PERSON OBSERVATION WEIGHT Weight of the patient in kilograms with up to three decimal places nnn nnn PRIMARY TUMOUR STATUS The status of the primary tumour at this follow up contact Residual primary tumour No evidence of primary tumour Recurrent primary tumour NODAL STATUS The status of the regional nodal metastases at this follow up contact METASTATIC STATUS The status of the distant metastases at this follow up contact SVR COMMUNICATION PRIMARY METHOD Only applicable to head and neck cancer following laryngectomy The patient s primary method of communication at post operative contact e VP voie prosthesis professional changed _ SPEECH amp LANGUAGE ASSESSMENT DATE Record the date of contact where assessment swallowing occurs following completion of treatment Whilst ideally data is entered at each contact after completion of treatment key point of recording is at 6 months post cancer care plan agreed date Please note this is not the same data item as First SALT Contact Date which is included in the DAHNO dataset from November 2012 8 3 HEAD amp NECK PATHOLOGY GENERAL To carry general pathology details for head and neck ca
146. ST The CONSULTANT CODE of the Pathologist who authorises the pathology report ORGANISATION CODE OF REPORTING PATHOLOGIST This is the ORGANISATION CODE of the ORGANISATION at which the authorising pathologist is based See ORGANISATION CODE PATHOLOGY REPORT TEXT The full text from the pathology report which may be required by Registries to calculate diagnosis and staging details PRIMARY DIAGNOSIS ICD PATHOLOGICAL The PRIMARY DIAGNOSIS based on the evidence from a pathological examination Format CXX X or DXX X TUMOUR LATERALITY PATHOLOGICAL Tumour laterality identifies the side of the body for a tumour relating to paired organs within a PATIENT based on the evidence from a pathological examination Bilateral Not applicable LESION SIZE PATHOLOGICAL The size in millimetres of the diameter of a lesion largest if more than one if the histology of a SAMPLE proves to be invasive Note For COSD reporting purposes this data item is not required to be submitted to two decimal places Note This data item is not applicable for Haematology diagnosis Note Please see Skin site specific dataset for further information on collecting this data item including the site specific values to be used SYNCHRONOUS TUMOUR INDICATOR An indicator of the presence of multiple tumours at a tumour site No no synchronous tumours present Yes synchronous tumours present Note This data item is not applicable for Haematology dia
147. STS RESULTS CML PERCENTAGE HAEMATOLOGY LABORATORY BLOOD BASOPHILS RESULTS CML PERCENTAGE HAEMATOLOGY LABORATORY BLOOD EOSINOPHILS RESULTS CML PERCENTAGE CYTOGENETIC GROUP ACUTE MYELOID LEUKAEMIA HA8160 unc M CYTOGENETIC RISK CODE ACUTE MYELOID LEUKAEMIA HAEMATOLOGY PLATELET COUNT Level of platelets in blood as n x 10 per litre to be collected at diagnosis Normally provided by Haematology lab before transfusion treatment Range 0 5000 WHITE BLOOD CELL COUNT HIGHEST PRETREATMENT Highest White blood cell count pre treatment x 10 per litre Normally provided by Haematology lab before transfusion treatment Range 0 0 to 999 9 to 1dp BLOOD HAEMOGLOBIN CONCENTRATION GRAMS PER LITRE Blood haemoglobin concentration g l Normally provided by Haematology lab before transfusion treatment BONE MARROW KARYOTYPE Karyotype of marrow sample as classified by MDT from laboratory result of sample taken pre treatment From Cytogenetics laboratory maybe as part of integrated haematopathology report Classification coding may be done by the lab or the MDT Classify as e Good if normal Y del 5q del 20q Author NCIN 135 Cancer Outcomes and Services Dataset User Guide e Intermediate if any other abnormalities e if complex more than 2 abnormalities or chromosome7 abnormalities BONE MARROW BLASTS PERCENTAGE Blast cel
148. SULT DATE The date on which an investigation was concluded e g the date the result was authorised SERVICE REPORT IDENTIFIER A unique identifier of a SERVICE REPORT TUMOUR RUPTURE Integrity of tumour margins based on pathologist s assessment Yes Not stated ANAPLASTIC NEPHROBLASTOMA Is there evidence of anaplasia focal or diffused based on established pathological classification Focal Anaplasia D Diffused Anaplasia PERIRENAL FAT INVASION Are there areas of perirenal fat suspected for tumour infiltration NN aa RENAL SINUS INVASION Is there evidence of invasion of renal sinus by tumour RENAL VEIN TUMOUR Is there evidence of tumour thrombus in the renal vein ON NO VIABLE TUMOUR Is there evidence of viable tumour in the renal sinus LUN NO TUMOUR LOCAL STAGE PATHOLOGICAL Local stage of the tumour as assessed by pathologist Classification system used is International Society of Paediatric Oncology SIOP Stage III Author NCIN 107 Cancer Outcomes and Services Dataset User Guide 6 GYNAECOLOGY OVERVIEW The gynaecological site specific dataset covers all registerable conditions listed below including neoplasms of uncertain or unknown behaviour of the female genital organs D39 This is a more extensive list of conditions than is routinely required for Cancer Waiting Times submissions For in situ conditions 006 007 only the pathology report needs to be submitt
149. Sphenoidal sinus Head and Neck e C31 8 Overlapping lesion of Head and Neck accessory sinuses C31 9 Accessory sinus Head and Neck unspecified C32 0 Glottis Head and Neck e C32 1 Supraglottis Head and Neck C32 2 Subglottis Head and Neck Author NCIN 224 Cancer Outcomes and Services Dataset User Guide ICD 10 4th Expected Dataset to be collected Edition All C Codes Core and are Cancer Waiting Site Malignant Times Site Specific Core Path Neoplasms Description specific group Dataset Dataset Only Comment C32 3 Laryngeal cartilage Head and Neck e C32 8 Overlapping lesion of Head and Neck larynx C32 9 Larynx unspecified Head and Neck e C33 Malignant neoplasm Lung m of trachea C34 0 Main bronchus Lung e C34 1 Upper lobe bronchus Lung or lung C34 2 Middle lobe Lung bronchus or lung a C34 3 Lower lobe bronchus Lung or lung C34 8 Overlapping lesion of Lung bronchus and lung C34 9 Bronchus or lung Lung unspecified C37 Malignant neoplasm Lung of thymus C38 0 Heart Lung e C38 1 Anterior Lung e mediastinum C38 2 Posterior Lung e mediastinum C38 3 Mediastinum part Lung unspecified C38 4 Pleura Lung e C38 8 Overlapping lesion of Lung heart mediastinum e and pleura C39 0 Upper respiratory Lung tract part e unspecified C39 8 Overlapping lesion of Lung respiratory and e intrathoracic organs C39 9 Ill defined s
150. TAGE DEN Author NCIN 99 Cancer Outcomes and Services Dataset User Guide CTYA CT6370 RHABDOMYOSARCOMA and OTHER STS RHABDOMYOSARCOMA SITE PROGNOSIS CODE SARCOMA TUMOUR SITE SOFT TISSUE OTHER THAN RHABDOMYOSARCOMA SARCOMA TUMOUR SITE SOFT TISSUE SARCOMA TUMOUR SUBSITE SOFT CTYA TISSUE OTHER THAN CT6390 RHABDOMYOSARCOMA and RHABDOMYOSARCOMA OTHER STS SARCOMA TUMOUR SUBSITE SOFT TISSUE CTYA CT6380 RHABDOMYOSARCOMA and OTHER STS IRS POST SURGICAL GROUP IRS group defines the post surgical disease status at diagnosis This information should be available for the MDT discussion following treatment but will only apply to a small number of cases The following definitions are used Group 1 primary complete resection Group 2 microscopic residual disease or primary complete resection with completely resected lymph node involvement Group 3 macroscopic residual disease Group 4 distant metastases CYTOGENETICS FOR ALVEOLAR RHABDOMYOSARCOMA Presence of a specific cytogenetic abnormality This information should be available for the MDT discussion but will only apply to a small number of cases The following definitions are used P Fusion positive LLL N O Fusion negative X 9 Not known Not available RHABDOMYOSARCOMA SITE PROGNOSIS CODE Grouping of anatomical sites which imply prognostic significance This information should be available for the MDT discussion but will o
151. TAILS CORE TNM STAGE GROUPING CRO940 PATHOLOGY max an5 CORE CR1000 PATHOLOGY NEOADJUVANT THERAPY INDICATOR 1 DETAILS CORE CRO950 PATHOLOGY SERVICE REPORT IDENTIFIER max 18 DETAILS CORE CRO960 PATHOLOGY SERVICE REPORT STATUS 1 DETAILS CORE CR0970 PATHOLOGY SPECIMEN NATURE DETAILS CORE ORGANISATION SITE CODE minimum length PATHOLOGY TEST REQUESTED BY CRO980 PATHOLOGY SITE CODE OF PATHOLOGY TEST an5 maximum DETAILS REQUEST length an9 CORE CARE PROFESSIONAL CODE CRO990 PATHOLOGY PATHOLOGY TEST REQUESTED BY DETAILS PATHOLOGY INVESTIGATION TYPE The type of pathology investigation procedure carried out Note Please see Skin site specific dataset for further information on collecting this data item including the site specific values to be used Cytology Biopsy NOS Excision Partial Excision Radical Excision Further Excision Curettage Shave Biopsy PB Punch Biopsy jIndsonalBiopsy o Author NCIN 49 Cancer Outcomes and Services Dataset User Guide 99 Uncertain other SAMPLE COLLECTION DATE The date that a SAMPLE collection takes place or the start of a period for SAMPLE collection This is the same as the date the Sample is taken SAMPLE RECEIPT DATE Date of receipt of a SAMPLE by a LABORATORY INVESTIGATION RESULT DATE The date on which an investigation was concluded e g the date the result was authorised CONSULTANT CODE PATHOLOGI
152. TUMOUR SIZE Radiological Maximum dimension in mm recorded on diagnostic imaging as agreed at MDT This information should be available for the MDT discussion but will only apply to a small number of cases Author NCIN 101 Cancer Outcomes and Services Dataset User Guide Note For COSD reporting purposes this data item is not required to be submitted to two decimal places EXTENT OF NECROSIS AFTER CHEMOTHERAPY Pathologically assessed effect of chemotherapy on the resected tumour specimen as a percentage This information should be available for the MDT discussion following treatment but will only apply to a small number of cases SARCOMA SURGICAL MARGIN ADEQUACY Pathological assessment of completeness of resection This information should be available for the MDT discussion following treatment but will only apply to a small number of cases Wide Compartmental _ 9 Not known 5 16 CTYA EWINGS To carry Ewings details for CTYA This section will be recorded once Schema Data Item Name Format specification M R O X Data item Data Item No Section TUMOUR VOLUME AT DIAGNOSIS CT6450 CTYA EWINGS TUMOUR VOLUME AT DIAGNOSIS CODE CYTOGENETICS FOR EWINGS CT6460 CTYA EWINGS SARCOMA CYTOGENETIC ANALYSIS CODE TUMOUR VOLUME AT DIAGNOSIS Radiologically calculated estimate of tumour volume at diagnosis which has value in determining treatment This information should be available for
153. This section will be recorded once Author NCIN 58 Cancer Outcomes and Services Dataset User Guide Schema Data Item Section Data Item Name Format specification M R O X Data item No NPI SCORE BR4120 NOTTINGHAM PROGNOSTIC T INDEX SCORE NPI SCORE Nottingham Prognostic Index Score calculated from invasive tumour size grade and lymph node involvement Where Sis the maximum diameter of the index lesion in centimetres invasive carcinoma e Nis the number of axillary lymph nodes involved 0 nodes 1 1 3 nodes 2 gt 4 3 e Gisthe grade of tumour Grade 1 1 Grade 2 2 Grade 3 3 The index is calculated using the formula NPI 0 2xS N G Note It is important to record all relevant information to ensure that NPI following neoadjuvant therapy can be identified This includes NEOADJUVANT THERAPY INDICATOR in the core pathology section and use of y prefixes if appropriate in TNM stage fields 2 4 BREAST SURGERY AND OTHER PROCEDURES To carry surgery and other procedure details for breast cancer This section will be recorded once Schema Data Item Section Data Item Name Format specification M R O X Data item No ASA SCORE BR4130 rU ASA PHYSICAL STATUS CER PROCODER CLASSIFICATION SYSTEM CODE ASA SCORE The ASA physical status classification system is a system for assessing the fitness of patients before surgery You would expect to find this information in the pre opera
154. UROLOGY TREATMENT BLADDER To carry the cancer treatment details for Bladder This section will be recorded once per treatment where applicable Schema Data item No Data Item Section Data Item Name Format specification M R O X UROLOGY TREATMENT INTRAVESICAL CHEMOTHERAPY 13 UR15100 ani M BLADDER RECEIVED INDICATOR UROLOGY TREATMENT INTRAVESICAL IMMUNOTHERAPY 14 UR15110 1 BLADDER RECEIVED INDICATOR Note Either INTRAVESICAL CHEMOTHERAPY RECEIVED INDICATOR or INTRAVESICAL IMMUNOTHERAPY RECEIVED INDICATOR is required if applicable INTRAVESICAL CHEMOTHERAPY RECEIVED INDICATOR BLADDER ONLY Only required for patients having chemotherapy Record as YES for patients having intravesical chemotherapy to distinguish from intravenous This data items requires clinical involvement to ensure completeness Not known INTRAVESICAL IMMUNOTHERAPY RECEIVED INDICATOR BLADDER ONLY Only required for patients having immunotherapy Record as YES for patients having immunotherapy to distinguish from systemic This data items requires clinical involvement to ensure completeness Not known 13 10 UROLOGY TREATMENT PROSTATE To carry the cancer treatment details for Prostate This section will be recorded once per treatment where applicable Schema Data item Data Item Section Data Item Name Format specification M R O X UR15080 UROLOGY TREATMENT PSA PRE TREATMENT max M
155. User Guide Overview Section for further information on the collection of this Skin disease C44 5 Skin of trunk Skin e e e See the Skin chapter of the COSD User Guide Overview Section for further information on the collection of this Skin disease Author NCIN 177 Cancer Outcomes and Services Dataset User Guide C44 6 Skin of upper limb Skin See the Skin including shoulder chapter of the COSD User Guide Overview e e e Section for further information on the collection of this Skin disease C44 7 Skin of lower limb Skin See the Skin including hip chapter of the COSD User Guide Overview e e e Section for further information on the collection of this Skin disease C44 8 Overlapping lesion Skin See the Skin of skin chapter of the COSD User Guide Overview e e e Section for further information on the collection of this Skin disease C44 9 Malignant Skin See the Skin neoplasm of skin chapter of the unspecified COSD User Guide Overview e e e Section for further information on the collection of this Skin disease C51 0 Labium majus Gynaecological Gynaecology and Skin Datasets to be collected where applicable Author NCIN 178 Cancer Outcomes and Services Dataset User Guide C51 1 La
156. X Normal or HCG mlu ml 5000 50 000 or AFP ug ml 1000 10 000 LDH 10 X Normal or HCG mlu ml 50 000 or AFP ug ml 10 000 Author NCIN 204 Cancer Outcomes and Services Dataset User Guide S CATEGORY AFP TESTICULAR ONLY Alpha Feto Protein AFP is a serum tumour marker Where normal are values recorded this will be collected once at diagnosis by specialist MDT If abnormal at diagnosis the lowest measurement prior to chemotherapy or radiotherapy should be recorded If no chemotherapy or radiotherapy is given where markers are abnormal record lowest measurement post orchidectomy Range 0 999999 S CATEGORY HCG TESTICULAR ONLY Human Chorionic Gonadotropin HCG is a serum tumour marker Where normal values are recorded this will be collected once at diagnosis by specialist MDT If abnormal at diagnosis the lowest measurement prior to chemotherapy or radiotherapy should be recorded If no chemotherapy or radiotherapy is given where markers are abnormal record lowest measurement post orchidectomy To be collected once at diagnosis by specialist MDT Range 0 999999 S CATEGORY LDH TESTICULAR ONLY Serum Lactate Dehydrogenase LDH is a serum tumour marker Where normal values are recorded this will be collected once at diagnosis by specialist MDT If abnormal at diagnosis the lowest measurement prior to chemotherapy or radiotherapy should be recorded If no chemotherapy or radiotherapy is given where markers are abnormal record l
157. YNAECOLOGY PATHOLOGY NODES To carry pathology details for Gynae for Nodes This section will be recorded once per pathology report where applicable 3 Schema Data item No Data Item Section Data Item Name Format specification M R O X Author NCIN 120 Cancer Outcomes and Services Dataset User Guide GYNAECOLOGY NODAL STATUS CERVICAL CANCER GY7020 an2 PATHOLOGY NODES CERVICAL NODE STATUS NODES EXAMINED NUMBER GY7060 GYNAECOLOGY PARA AORTIC PATHOLOGY NODES NUMBER OF NODES EXAMINED PARA AORTIC NODES POSITIVE NUMBER PARA GYNAECOLOGY AORTIC GY7080 PATHOLOGY NODES NUMBER OF NODES POSITIVE PARA AORTIC NODES EXAMINED NUMBER east GYNAECOLOGY PELVIC PATHOLOGY NODES NUMBER OF NODES EXAMINED PELVIC NODES POSITIVE NUMBER PELVIC GYNAECOLOGY GY7090 NUMBER OF NODES POSITIVE PATHOLOGY NODES PELVIC NODES EXAMINED NUMBER TERP GYNAECOLOGY INGUINO FEMORAL PATHOLOGY NODES NUMBER OF NODES EXAMINED INGUINO FEMORAL NODES POSITIVE NUMBER GYNAECOLOGY INGUINO FEMORAL PATHOLOGY NODES NUMBER OF NODES POSITIVE INGUINO FEMORAL GY7230 GYNAECOLOGY EXTRANODAL SPREAD PATHOLOGY NODES EXTRANODAL SPREAD INDICATOR NODAL STATUS CERVICAL CANCER FOR CERVICAL CANCERS ONLY Only required for surgically staged early FIGO stage cancers Histological assessment of regional lymph nodes including surgical excision or fine needle GY7420 aspiration FIGO staging for cervica
158. al Cell Carcinoma and Squamous Cell Carcinoma Author NCIN 181 Cancer Outcomes and Services Dataset User Guide This section will be recorded once per pathology report where applicable Schema Data item Data Item Section Data Item Name Format specification No PERINEURAL INVASION SKIN PATHOLOGY SK12530 PERINEURAL INVASION INDICATOR BCC amp SCC SKIN M R O X SKIN PATHOLOGY LESION DIAMETER GREATER THAN SK12537 M BCC amp SCC 20MM INDICATOR SKIN PATHOLOGY DEEP INVASION INDICATOR FOR pT3 BCC amp SCC TUMOUR INVASION INDICATOR PT3 e SKIN PATHOLOGY DEEP INVASION INDICATOR FOR pT4 a BCC amp SCC TUMOUR INVASION INDICATOR PT4 PERINEURAL INVASION Invasion into perineurium of nerve bundles 1 1 n1 Yes Greater than 20mm No Less than or equal to 20mm DEEP INVASION INDICATOR FOR pT3 For Stage pT3 Tumours only Tumour with invasion of maxilla mandible orbit or temporal bone DEEP INVASION INDICATOR FOR pT4 For Stage pT4 Tumours only Tumour with invasion of skeleton axial or appendicular or perineural invasion of skull base Uncertain 11 3 SKIN STAGING Note TNM stage fields in the Core dataset will not be completed for skin cancers For Melanoma SCC and BCC the AJCC Stage Group 7th Edition is included in the site specific dataset For other skin cancers e g Merkel Cell tumours and Adnexal carcinomas the AJCC Stage Group field is th
159. al marginal zone lymphoma of NE R Other 9699 3 A mucosa associated lymphoid tissue C88 4 mw 9 MALT associated lymphoid tissue Lymphomas MALT lymphoma 9699 3 Nodal marginal zone lymphoma C83 0 Small cell B cell lymphoma orner 9 8 ymp ymp Lymphomas 9700 3 Mycosis fungoides C84 0 Mycosis fungoides 10 y 8 y 8 Lymphomas Author NCIN 125 Cancer Outcomes and Services Dataset User Guide ICD 10 WHO DISEASE ICD O 3 ICD O 3 WHO Description 4th ICD10 Description Clinical dataset GROUP Edition Other 9701 3 S zary syndrome C84 1 S zary disease lymphomas 10 Peripheral T cell lymphoma Other 9702 3 A Peripheral T cell lymphoma NOS C84 4 not elsewhere classified busiheifias 10 9702 3 B Anaplastic large cell lymphoma ALK 84 7 Anaplastic large cell Other 10 negative lymphoma ALK negative Lymphomas 9705 3 Angioimmunoblastic T cell lymphoma C86 5 Angioimmunoblastic T cell 10 lymphoma Lymphomas 9708 3 Subcutaneous panniculitis like T cell C863 Subcutaneous panniculitis like Other 10 lymphoma T cell lymphoma Lymphomas Primary cutaneous CD8 aggressive 9709 3 A epidermotropic cytotoxic T cell C84 8 cutanecus Tecellilyimphoma Other 10 unspecified Lymphomas lymphoma 9709 3 B Primary cutaneous CD4 positive C84 8 Cutaneous T cell lymphoma Other 10 small medium T cell lymphoma unspecified Lymphomas 9712 3 Intra
160. ancer One occurrence of this group is permitted COLORECTAL REFERRALS To carry referral details for colorectal cancer One occurrence of this group is permitted Author NCIN 284 Cancer Outcomes and Services Dataset User Guide Author NCIN 285 APPENDIX M UNDERSTANDING CANCER ONLINE E LEARNING TRAINING 4 I Institute of e Healthcare X Management nderstanding S amp S Cancer Cancer Oncology Training for NHS and Public Health non clinical staff Professionally Accredited by the Institute of Healthcare Management Launch date 2 April 2012 Key features include flexibility to work at your own pace from work or home ability to stop and resume at any point from any computer reference guides colourful images throughout glossary of terms learning objectives quizzes certificate of achievement What to do next For more information visit www ncin org uk You will be able to self register onto the learning space website ready for the launch on the 2nd April 2012 EastMidlands Cancer Network Unlocking better care network arg formation prove quay Who it is for and what you will learn This new e learning tool is aimed primarily at Multi disciplinary Team Co ordinators and Cancer Registration staff who need to know SEL about cancer medical terminology diagnostic tests and treatments SEL how cancer services are organised in t
161. aniopharyngeal duct D35 4 Benign neoplasm Brain Central of Pineal gland Nervous System D42 0 Neoplasm of Brain Central uncertain or Nervous unknown System behaviour of cerebral meninges D42 1 Neoplasm of Brain Central uncertain or Nervous unknown System behaviour of spinal meninges D42 9 Neoplasm of Brain Central uncertain or Nervous unknown System behaviour of meninges unspecified D43 0 Neoplasm of Brain Central uncertain or Nervous unknown System behaviour of brain supratentorial D43 1 Neoplasm of Brain Central uncertain or Nervous unknown System behaviour of brain infratentorial D43 2 Neoplasm of Brain Central uncertain or Nervous unknown System behaviour of brain unspecified D43 3 Neoplasm of Brain Central uncertain or Nervous unknown System behaviour of cranial nerves D43 4 Neoplasm of Brain Central uncertain or Nervous unknown System behaviour of spinal cord D43 7 Neoplasm of Brain Central uncertain or unknown behaviour of other parts of central nervous system Nervous System Author NCIN 68 Cancer Outcomes and Services Dataset User Guide D43 9 Neoplasm of Brain Central uncertain or Nervous unknown System behaviour of central nervous system unspecified D44 3 Neoplasm of Brain Central uncertain or Nervous unknown System behaviour of pituitary gland D44 4 Neoplasm of Brain Central uncertain or Nervous unknown Syste
162. ase 3 of implementation includes the submission of the site specific pathology items from January 2014 from which time the full dataset should be submitted In addition to this a small number of revisions included here will take effect from April 2014 The formal change notice to support these changes is due to be published in December 2013 Implementation of the Standard is being carried out by the National Cancer Registration Service NCRS and queries regarding implementation should initially be raised with the Data Liaison staff at the local offices of the NCRS We are very pleased to report that by the beginning of October 2013 all but one Provider was submitting COSD data and only three Providers had failed to sign and return a Data Transfer Partnership Agreement describing the files to be submitted All Providers have access to their current monthly position via the national COSD Conformance Monitoring Feedback Portal which has been established by the NCRS This currently provides feedback on files submitted and completion for some key data items where the files are submitted in the prescribed XML format Level 3 reports based upon post registered data have not been delivered as expected due to a range of issues of which the most significant has been the delays in migrating all legacy systems and normalising 11 million patient records on the national ENCORE platform This has been more complex and taken much longer than could have been antic
163. ata item No ETEdEG CTYA NON HODGKIN MURPHY ST JUDE STAGE Adi LYMPHOMA MURPHY ST JUDES STAGE CTYA NON HODGKIN ALK 1 STATUS FOR ALCL CT6260 1 MURPHY ST JUDE STAGE The St Jude Children s Research Hospital model Murphy Staging which separates patients on the basis of limited versus extensive disease http www cancer gov cancertopics pdg treatment child non hodgkins HealthProfessional page3 It is essential to record the disease specific stage for this group of patients This information should be available to the MDT The following definitions are used Stage 1 disease is limited to a single tumour or to one lymph node group e g neck axilla groin etc outside of the abdomen or mediastinum Stage 2 disease is limited to one tumour with local lymph node involvement or to two or more tumours or lymph node groups on the same side of the diaphragm or to a completely resected primary tumour of the gastrointestinal tract with without involvement of local lymph nodes Author NCIN 95 Cancer Outcomes and Services Dataset User Guide Stage 3 disease includes tumours or lymph node groups involved on both sides of the diaphragm or any primary intrathoracic tumour mediastinal pleural or thymic disease or extensive NHL within the abdomen or any paraspinal or epidural tumours Stage 4 disease involves the bone marrow and or central nervous system CNS with without other sites of involvement Bone
164. ata item is only required to be submitted to one decimal place PERFORATIONS OR SEROSAL INVOLVEMENT INDICATION CODE Is there continuity between the lumen of the bowel and the serosal surface or surgical resection margin through the tumour Author NCIN 85 Cancer Outcomes and Services Dataset User Guide Yes tumour perforation only B Yes bowel perforation but not through tumour Yes both bowel and tumour perforation N O No perforation PLANE OF SURGICAL EXCISION FOR RECTAL CANCERS ONLY This is the quality of the surgical excision as seen by the pathologist This grades the resection on its worst plane Mesorectal fascia Intramesorectal Muscularis propria DISTANCE FROM DENTATE LINE For abdominoperineal excision specimens only Record the distance of the tumour from the dentate line in mm measured on the gross specimen Note For COSD reporting purposes this data item is only required to be submitted to one decimal place DISTANCE BEYOND MUSCULARIS PROPRIA Maximum distance of spread beyond muscularis propria in mm If there is doubt about the sites of the muscularis propria estimate the distance as accurately as possible Note For COSD reporting purposes this data item is only required to be submitted to one decimal place RESPONSE TO PREOPERATIVE THERAPY If preoperative therapy was given what was the response No residual tumour cells mucous lakes only Minimal residual cancer No marked regression STATUS OF
165. ated stage should be recorded as M1 If such lesions are identified as malignant after the initiation of treatment the pretreatment stage should be recorded as as this reflects the decision making process that determined the treatment The integrated stage however should be recorded as M1 How will the cancer registries handle MX and will this hinder international comparisons of data It is important that data collected in the UK can be compared with international performance data If the Registry has received MDT data that include MX the Registry may convert this to MO when the data is to be used for international comparison This will allow robust international comparison It is important to note that Registry will only be able to do this when MX has been specifically selected in the integrated and or pretreatment stage submitted by the MD T M9 will not be converted to MO by the cancer registries Does the same logic apply to T and N components too TX and NX are still allowed in TNM7 so the issues are not the same as for the M component However the categories T9 and N9 will be added to COSD so that the definitions of X and 9 are consistent across the definitions So for each of the T N and M components X should be a clinical decision that the component cannot be assessed and 9 should be used in COSD submissions to indicate that the data is not available Author National Staging Panel for Cancer Registration Last updated 18 01 2013
166. be collected where applicable C51 2 Clitoris Gynaecological Gynaecology e and Skin Datasets to be collected where applicable C51 8 Overlapping lesion of Gynaecological vulva Gynaecology and Skin Datasets to be collected where applicable C51 9 Vulva unspecified Gynaecological T Gynaecology e and Skin Datasets to be collected where applicable C52 Malignant neoplasm Gynaecological of vagina C53 0 Endocervix Gynaecological C53 1 Exocervix Gynaecological e C53 8 Overlapping lesion of Gynaecological cervix uteri C53 9 Cervix uteri Gynaecological unspecified C54 0 Isthmus uteri Gynaecological e C54 1 Endometrium Gynaecological e C54 2 Myometrium Gynaecological e C54 3 Fundus uteri Gynaecological e Author NCIN 232 Cancer Outcomes and Services Dataset User Guide ICD 10 4th Edition Expected Dataset to be collected All C Codes Core and are Cancer Waiting Site Malignant Times Site Specific Core Path Neoplasms Description specific group Dataset Dataset Only Comment C54 8 Overlapping lesion of Gynaecological e corpus uteri C54 9 Corpus uteri Gynaecological e unspecified C55 Malignant neoplasm Gynaecological of uterus part e unspecified C56 Malignant neoplasm Gynaecological of ovary C57 0 Fallopian tube Gynaecological e C57 1 Broad ligament Gynaecological e C57 2 Round ligament Gyna
167. bium minus Gynaecological Gynaecology and Skin Datasets be collected where applicable C51 2 Clitoris Gynaecological Gynaecology and Skin Datasets be collected where applicable C51 8 Overlapping lesion Gynaecological Gynaecology of vulva and Skin Datasets to be collected where applicable C51 9 Vulva unspecified Gynaecological Gynaecology and Skin Datasets be collected where applicable C79 2 Secondary Skin Normally malignant treated by neoplasm of skin MDT of site of primary tumour Only use if unable to code to specific primary site D03 0 Melanoma in situ Skin of lip e D03 1 Melanoma in situ Skin of eyelid including e canthus D03 2 Melanoma in situ Skin of ear and external e auricular canal D03 3 Melanoma in situ Skin of other and unspecified parts of D03 4 Melanoma in situ Skin of scalp and neck DO3 5 Melanoma in situ Skin of trunk D03 6 Melanoma in situ Skin of upper limb e including shoulder D03 7 Melanoma in situ Skin of lower limb e including hip Author NCIN 179 Cancer Outcomes and Services Dataset User Guide D03 9 Melanoma in situ Skin unspecified D04 0 Carcinoma in situ of Skin skin of lip D04 1 Carcinoma in situ of Skin skin of eyelid e including canthus D04 2 Carcinoma in situ of Skin skin of ear and external auricular canal D04 3 Carcinoma in situ of Skin skin of other and unspecified parts of face
168. blasts thrombocytosis 9983 3 Refractory anaemia with excess blasts D46 2 Refractory anaemia with MDS 4 excess of blasts 9985 3 Refractory cytopenia with multilineage 046 5 Refractory anaemia with MDS A dysplasia multi lineage dysplasia 9985 3A Refractory cytopenia of childhood D46 5 Refractory anaemia Wh MDS 4 multi lineage dysplasia Myelodysplastic syndrome Myelodysplast d ted 9986 3 EE 046 6 with isolated del 5q MDS 4 with isolated del 5q chromosomal abnormality 9989 3 Myelodysplastic syndrome D46 9 Myelodysplastic syndrome MDS A unclassifiable unspecified Other Myelodysplasti 9991 3 Refractory neutropenia D46 7 ee DOYSEASUG MDS 4 syndromes Other Myelodysplasti 9992 3 Refractory thrombocytopenia D46 7 MDS 4 syndromes C817 Other classical Hodgkin Redundant lymphoma reclassified C82 5 Diffuse follicle centre Redundant lymphoma reclassified C827 Other types of follicular Redundant i lymphoma reclassified 33 9 Non follicular diffuse Redundant lymphoma unspecified reclassified Author NCIN 131 Cancer Outcomes and Services Dataset User Guide ICD 10 ICD O 3 ICD O 3 WHO Description 4th Edition ICD10 Description Other malignant immunoproliferative diseases Clinical dataset Redundant reclassified Other monocytic leukaemia Redundant reclassified Monocytic leukaemia unspecified Redundant reclassified Other s
169. ble evidence has been collected TNM STAGE GROUPING INTEGRATED Record the overall TNM stage grouping of the tumour derived from each T N and M component after treatment This classification is based on all the evidence available to the clinician s with responsibility for assessing the patient It will be determined on the basis of all the clinical imaging and pathological data available following the first surgical procedure s i e this is the integration of the pathological staging with the clinical staging The overall integrated TNM stage grouping indicates the tumour stage after treatment and or after all available evidence has been collected Note If the patient has had neoadjuvant therapy i e Chemotherapy or Radiotherapy before surgical treatment the integrated stage may be the same as the pre treatment stage TNM EDITION NUMBER The UICC edition number used for TNM staging for this cancer diagnosis This is only recorded once for all the staging for each cancer diagnosis It is expected that TNM EDITION will be consistent for all stage data for each diagnosis Author NCIN 43 Cancer Outcomes and Services Dataset User Guide 1 8 CORE TREATMENT To carry the cancer treatment details This section can be recorded more than once Schema Data Item Name Format specification M R O X CORE CR1370 CORE TREATMENT START DATE CANCER 10 ccyy mm dd M TREATMENT CR2040 CORE CANCER TREATMENT MODALITY an2 M TREAT
170. bmitted if the Mandatory items in that section are completed Items marked as X in the schema specification should not be submitted as part of the COSD data flow from Providers These items will be collected from other sources such as ONS See Appendix L or are submitted under other standards such as Cancer Waiting Times and RTDS See Appendix K Items that are shared specifically with the Cancer Waiting Times dataset NCWTMDS are marked as CWT in the relevant descriptions However for COSD these items are all extended to relate to all registerable conditions Definitions within these items for primary cancer are therefore also extended to cover all registerable conditions When should the data be submitted The deadline for first submitting a record is 25 working days after the end of month of Diagnosis All available relevant data items should be included and additional information or updates not available at the time should be uploaded with ensuing monthly submissions Treatments not submitted with the initial record should also be submitted within 25 working days of the end of month of the Treatment Start Date See Appendix H for further details Phased Implementation The dataset is mandated for phased submission from January 2013 The core and site specific stage should be completed for all relevant cases from that date All other site specific clinical data i e all site specific data excluding site specific pathology sections
171. breast D05 9 Carcinoma in situ of Breast ve e breast unspecified Author NCIN 248 Cancer Outcomes and Services Dataset User Guide APPENDIX B MANDATORY REGISTERABLE CONDITIONS MANDATORY REGISTERABLE CONDITIONS from the UKACR Library of Recommendations Further details to be provided regarding applicable data fields for each disease Notes The following table lists all the registerable diseases by ICD10 code together with the expected dataset to be completed and the potential stage This table provides general guidelines only as not all permutations can be covered and there will always be exceptions Local clinical input is essential to identify and complete the appropriate stage Further guidance is available from your local cancer registration service office ICD 10 4th Expected Dataset to be collected Edition Core All C Codes and are Site Malignant Cancer Waiting Times Specific Core Neoplasms Description Site specific group Dataset Dataset Path Only Comment C00 0 Malignant neoplasms See Appendix A for full list C97 D00 0 Carcinoma in situ Head and Neck of Lip oral cavity e and pharynx D00 1 Carcinoma in situ Upper of Oesophagus Gastrointestinal D00 2 Carcinoma in situ Upper of Stomach Gastrointestinal D01 0 Carcinoma in situ Colorectal of Colon DO1 1 Carcinoma in situ Colorectal of Rectosigmoid junction DO1 2 Carcinoma in situ Colorectal o
172. cal e C63 7 Other specified male Urological s genital organs C63 8 Overlapping lesion of Urological s male genital organs C63 9 Male genital organ Urological unspecified C64 Malignant neoplasm Urological of kidney except e renal pelvis C65 Malignant neoplasm Urological of renal pelvis C66 Malignant neoplasm Urological of ureter C67 0 Trigone of bladder Urological e C67 1 Dome of bladder Urological e C67 2 Lateral wall of Urological s bladder C67 3 Anterior wall of Urological bladder C67 4 Posterior wall of Urological bladder C67 5 Bladder neck Urological e C67 6 Ureteric orifice Urological C67 7 Urachus Urological e C67 8 Overlapping lesion of Urological e bladder C67 9 Bladder unspecified Urological e C68 0 Urethra Urological C68 1 Paraurethral glands Urological e Author NCIN 234 Cancer Outcomes and Services Dataset User Guide ICD 10 4th Expected Dataset to be collected Edition All C Codes Core and are Cancer Waiting Site Malignant Times Site Specific Core Path Neoplasms Description specific group Dataset Dataset Only Comment C68 8 Overlapping lesion of Urological urinary organs C68 9 Urinary organ Urological unspecified C69 0 Conjunctiva Brain Central Not normally Nervous System treated by CNS MDT C69 1 Cornea Brain Central Not normally Nervous System treated by CNS MDT C69 2 Retina Brain C
173. cer drug regimen 4 Hormone therapy 3 Hormone Therapy DRUG TREATMENTS 21 Therapies Not recorded in Anti Cancer Drug immnnotherapy treatments for CWT reporting 7 Biological 15 Anti cancer drug regimen DRUG TREATMENTS Immunotherapy Anti Cancer Drug Anti cancer drug regimen 13 Other 14 other DRUG TREATMENTS 12 Cryotherapy OTHER Light Therapy including Photodynamic Therapy 16 and Psoralen and Ultra Cres Violet A PUVA Therapy Laser Treatment 20 including Argon Beam OTHER ACTIVE 10 Other Active therapy TREATMENTS Treatment Other Treatment active Other neamen does 97 treatment distinguish between active and non active for CWT reporting Radio Frequency 10 Ablation RFA OTHER High Intensity Focussed a Ultrasound HIFU ee SPECIALIST 5 Specialist 7 Specialist Palliative Care PALLIATIVE TREATMENTS PALLIATIVE palliative care TREATMENT Active Monitoring 8 excluding non specialist PALLIATIVE Palliative Care Non specialist Palliative No active 9 iuis excluding Active PALLIATIVE treatment onitoring Only record 98 All treatment declined DECLINED NON ACTIVE 11 pede as no TREATMENT active treatment if only non active treatments are Hyperbaric Oxygen currently planned 47 Therapy Only record OTHER Author NCIN here if there are no active treatments planned 38 Cancer Outcomes and Services Dataset
174. clinic or on the ward PERSON OBSERVATION BMI 4 4 COLORECTAL STAGING UICC TNM CLASSIFICATION OF COLORECTAL TUMOURS FIFTH EDITION PATHOLOGY Primary Tumour pTX Primary tumour cannot be assessed pTO No evidence of primary tumour pT1 Tumour invades submucosa pT2 Tumour invades muscularis propria pT3 Tumour invades through muscularis propria into subserosa or non peritonealised pericolic or perirectal Author NCIN 81 Cancer Outcomes and Services Dataset User Guide tissues pT4 Tumour directly invades other organs pT4a and or involves the visceral peritoneum pT4b Regional Lymph Nodes pNX Regional lymph nodes cannot be assessed pNO No regional lymph node metastasis pN1 Metastasis in 1 to 3 regional lymph nodes pN2 Metastasis in 4 or more regional lymph nodes Distant Metastasis pMX Distant metastasis cannot be assessed pMO No distant metastasis pM1 Distant metastasis UICC TNM CLASSIFICATION OF APPENDIX SEVENTH EDITION CARCINOMA TUMOURS Note Stage data items for Appendix are not collected by NBOCAP Primary Tumour 1 Tumour invades submucosa 2 Tumour invades muscluaria propria T3 Tumour invades subserosa or mesoappendix T4 Tumour perforates visceral peritoneum including mucinous peritoneal tumour within the right lower quadrant and or directly invades
175. completed each time the record is submitted 0 15 Recording Recurrences A new record needs to be completed for a diagnosed recurrence metastatic or secondary linked to the primary diagnosis by the PRIMARY DIAGNOSIS ICD in the CORE DIAGNOSTIC DETAILS Section Ultimately a complete record should be submitted for every diagnosis of recurrence but at present only Breast recurrence records are required All pathology reports which relate to recurrences for any tumour site should also continue to be submitted CORE DATA ITEMS REQUIRED FOR RECURRENCE RECORD The following identifies the sections and items which are essential in order to register recurrences accurately Author NCIN 21 Cancer Outcomes and Services Dataset User Guide The REFERRALS CLINICAL TRIALS and STAGING Sections are not currently required for Recurrences but all other sections are applicable Author NCIN 22 Cancer Outcomes and Services Dataset User Guide SECTION Specific Fields Comments CORE PATIENT IDENTITY DETAILS ALL FIELDS including PRIMARY DIAGNOSIS ICD Linkage to any other records or submissions for this patient Note The Primary Diagnosis field should always contain the original diagnosis code unless the primary is unknown CORE DIAGNOSTIC DETAILS ALL FIELDS including DATE OF RECURRENCE CLINICALLY AGREED Linkage to primary record other submissions for this recurrence and any other recurrences o
176. ct we are proposing extending the scope of the COSD to include this The United Kingdom and Ireland Association of Cancer Registries UKIACR is currently considering its inclusion in the UKIACR Library of Recommendations Author NCIN 261 Cancer Outcomes and Services Dataset User Guide APPENDIX C WHO CLASSIFICATION OF TUMOURS OF HAEMATOPOETIC AND LYMPHOID TISSUE Group numbers have been assigned for ease of reference as used in Section 7 2 ICD Codes and WHO Disease Groups in the Haematology section of the User Guide WHO Classification does not distinguish Groups 7 amp 8 as separate disease groups GROUP Description GROUP 1 Myeloproliferative neoplasms Myeloid and lymphoid neoplasms with eosinophilia and abnormalities of PDGFRA GROUP 2 PDGFRB or FGFR1 GROUP 3 Myelodysplastic myeloproliferative neoplasms GROUP 4 Myelodysplastic syndromes GROUP 5 Acute myeloid leukaemia AML and related Precursor neoplasms GROUP 6 Acute leukaemias of ambiguous lineage GROUP 7 Precursor B lymphoid neoplasms GROUP 8 Precursor T lymphoid neoplasms GROUP 9 Mature B cell neoplasms GROUP 10 Mature T cell and NK cell neoplasms GROUP 11 Hodgkin lymphoma GROUP 12 Histiocytic and dendritic cell neoplasm GROUP 13 Post transplant lymphoproliferative disorders PTLD Author NCIN 262 Cancer Outcomes and Services Dataset User Guide APPENDIX CTYA ASSOCIATED CONDITIONS
177. d Other Treatment not orner oe does nar 23 distinguish between active active for CWT reporting BIPHOSPHONAT Other Treatment 2 ES biphosponates cee NOT KNOWN 99 Not known NO CANCER TREATMENT REASON The main reason why no active cancer treatment is specified within a Cancer Care Plan 6 Diedbeforetreatment ooo 9 Not known 000000 ACE 27 SCORE ADULT COMORBIDITY EVALUATION 27 SCORE Overall Comorbidity Score is defined according to the highest ranked single ailment except in the case where two or more Grade 2 ailments occur in different organ systems In this situation the overall comorbidity score should be designated Grade 3 Note ACE 27 scoring relates to co morbidities and not the condition Cancer being treated Note This is not applicable for Skin diagnoses Note This is currently undergoing pilot testing to see if it feasible appropriate to collect for all adult cancers This is currently optional for local use a Author NCIN 40 Cancer Outcomes and Services Dataset User Guide 9 Not known S y PERFORMANCE STATUS ADULT A World Health Organisation classification indicating a PERSON s status relating to activity disability This is the Performance Status agreed at the time that the treatment planning is carried out by the MDT This only need to be recorded once when the first treatment planning decision is ma
178. d if the patient had a mediastinoscopy mediastinotomy open Staging Grouping T Stage N Stage M Stage Stage IA T1a b NO MO Stage IB T2a NO MO Stage IIA T2b NO MO T1a b N1 MO T2a N1 MO Stage IIB T2b N1 MO T3 NO MO Stage IIIA T1a b T2a b N2 MO T3 N1 N2 MO T4 NO N1 MO Stage IIIB T4 N2 MO Any N3 MO Stage IV Any T Any N M1 mediastinal sampling or other type of mediastinal biopsy e g Endobronchial ultrasound or transbronchial needle aspiration biopsy This data item will be recorded by the specialist centres Author NCIN 161 Cancer Outcomes and Services Dataset User Guide 9 4 LUNG STAGING UICC LUNG TNM STAGING SEVENTH EDITION UICC PLEURAL MESOTHELIOMA TNM STAGING SEVENTH EDITION Stage Grouping T Stage N Stage M Stage Stage IA Tla NO MO Stage IB Tib NO MO Stage II T2 NO MO Stage III T1 T2 N1 MO 1 2 2 T3 NO N1 N2 MO Stage IV TA Any N MO Any T N3 MO Any T Any N M1 9 5 LUNG BRONCHOSCOPY To carry Bronchoscopy details for Lung Carcinoma which informed management of patient at time of MDT This section will be recorded once Data item No Data Item Section Data Item Name Format specification M R O X PROCEDURE DATE LUNG BRONCHOSCOPY an10 ccyy LU10070 BRONCHOSCOPY PROCEDURE DATE mm dd BRONCHOSCOPY LUNG BRONCHOSCOPY PERFORMED LU10080 1 BRONCHOSCOPY INDICATOR
179. de Note This data item is not applicable for Paediatric patients or Skin diagnosis except for melanoma stage 4 Able to carry out all normal activity without restriction Restricted in physically strenuous activity but able to walk and do light work 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 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 9 Not recorded Note Code 5 Dead is not a valid classification under the WHO coding system CLINICAL NURSE SPECIALIST INDICATION CODE Record if and when the patient saw an appropriate site specific clinical nurse specialist Note that this data item will enable several situations to be recorded e g whether the Clinical Nurse Specialist was present when the patient was given the diagnosis whether the Clinical Nurse Specialist saw the patient at all and whether the Clinical Nurse Specialist was aware of the patient s diagnosis Please therefore read all options in order to select the most appropriate code It is not as present possible to distinguish between Cancer Nurse Specialist and Clinical Nurse Specialist in the COSD Although included in the section on Cancer Care Plan this information will not necessarily be available at the meeting It would be expected that this would be completed
180. de N2 Metastasis in a single regional lymph node Distant Metastasis MO No distant metastasis M1 Distant metastasis Note Recording Kidney stage following preoperative drug therapy For cases of kidney cancer treated with surgery problems will be encountered where preoperative drug therapy usually biological targeted therapy is used TNM stage will be dependent on histological examination of the resected specimen together with information obtained from radiological imaging etc Wherever possible TNM with the y prefix NEOADJUVANT THERAPY INDICATOR should be used for pathology stage fields For all other cases where no operation is performed staging will have to be based Author NCIN 211 Cancer Outcomes and Services Dataset User Guide on radiological appearances either before or after preoperative drug therapy and an integrated TNM stage decided based on the radiological appearances 13 8 UROLOGY STAGING PENIS UICC CARCINOMA OF THE PENIS TNM STAGING SIXTH EDITION Stage Grouping T Stage N Stage M Stage Stage 0 Tis NO MO Stage 0 Ta NO MO Stage T1 NO MO T1a NO MO Stage Il T1b NO MO T2 NO MO T3 NO MO Stage IIIA T1 T2 T3 N1 MO Stage IIIB T1 T2 T3 N2 MO Stage IV T4 Any N MO Any N3 MO Any Any N M1 Primary Tumour Tis Carcinoma in situ Ta Non invasive verrucous carcinoma 1 Tumour invades subepithelial connective tissue without lymph
181. de This is essential for every cancer diagnosis in order to identify emergency presentations Please note that where patients first present as an emergency codes 01 10 or 04 are applicable Note Values in NBOCAP audit may differ Schema Initiated by the CONSULTANT responsible for the Consultant Out Patient Episode following an emergency admission following a Domiciliary Consultation Centres other initiated by the CONSULTANT responsible for the Consultant Out Patient Episode Author NCIN 28 EE following an Accident And Emergency Attendance including Minor Injuries Units and Walk In Cancer Outcomes and Services Dataset User Guide Not initiated by the CONSULTANT responsible for the Consultant Out Patient Episode referral from a GENERAL MEDICAL PRACTITIONER referral from a GENERAL DENTAL PRACTITIONER referral from a GENERAL PRACTITIONER with a Special Interest GPwSI or dentist with a Special Interest DwSI referral from an Accident And Emergency Department including Minor Injuries Units and Walk In Centres 96 self referral o O REFERRAL TO TREATMENT PERIOD START DATE CWT The start date of a REFERRAL TO TREATMENT PERIOD Date the initial referral which led to the cancer diagnoses was received by the Provider If patient presented as an emergency it will be the date of the referral following that emergency presentation This may be different from CANCER REFERRAL TO TREATMENT PERIOD START DATE if initial re
182. der neck p T4 Tumour invades other adjacent organs 15 Note Most verrucous carcinomas arise from penile skin rather than urethra readers are referred to the penile dataset for clarification Note Recording Urethra stage following neoadjuvant therapy For cases of bladder or urethral cancer treated by cystectomy problems will be encountered where neoadjuvant therapy is used TNM stage will be dependent on histological examination of the resected specimen together with information obtained from radiological imaging etc Wherever possible TNM with the y prefix NEOADJUVANT THERAPY INDICATOR should be used for pathology stage fields For all other cases where no operation is performed staging will have to be based on radiological appearances either before or after the neo adjuvant treatment and an integrated TNM stage decided based on the radiological appearances UICC TRANSITIONAL CELL CARCINOMA OF THE PROSTATE PROSTATIC URETHRA TNM STAGING SEVENTH EDITION Stage Grouping T Stage N Stage M Stage Stage 1 MO Stage 11 T2 NO MO Stage III T1 T2 1 MO T3 NO N1 MO Stage IV T4 NO N1 MO Any N2 MO Any Any N M1 Note p indicates also applicable for pathological stage Primary Tumour p Tis pu Carcinoma in situ involvement of prostatic urethra p Tis pd Carcinoma in situ involvement of prostatic ducts p T1 Tumour invades subepithelial connective tissue
183. diate between oa Other 9596 3 DLBCL Classical Hodgkins C85 1 B cell lymphoma unspecified lymphomas 9 9597 3 Primary cutaneous follicle centre C82 6 Cutaneous follicle centre Follicular 9 lymphoma lymphoma Hodgkin lymphoma 9650 3 Classical Hodgkin lymphoma C81 9 p Hodgkin 11 unspecified Author NCIN 124 Cancer Outcomes and Services Dataset User Guide ICD 10 ICD O 3 ICD O 3 WHO Description 4th ICD10 Description Clinical dataset WHO DISEASE GROUP Edition 9651 3 Lymphocyte rich classical Hodgkin C814 Lymphocyte rich classical Hodgkin 11 lymphoma Hodgkin lymphoma 9652 3 Mixed cellularity classical Hodgkin C812 Mixed cellularity classical Hodgkin 11 lymphoma Hodgkin lymphoma 9653 3 Lymphocyte depleted classical Hodgkin C81 3 Lymphocytic depleted Hodgkin 11 lymphoma classical Hodgkin lymphoma Nodular lymphocyte 9659 3 Nodular lymphocyte predorninant C81 0 predominant Hodgkin Hodgkin 11 Hodgkin lymphoma lymphoma 9663 3 Nodular sclerosis classical Hodgkin C811 Nodular sclerosis classical Hodgkin 11 lymphoma Hodgkin lymphoma 9671 3 Lymphoplasmacytic lymphoma C83 3 Diffuse large B cell lymphoma Other 9 ymphop ytic lymp 8 ymp Lymphomas 9673 3 Mantle cell lymphoma C83 1 Mantle cell lymphoma Other 9 ymp ymp Lymphomas 9678 3 Primary effusion lymphoma C83 3 Diffuse large B cell lymphoma Other 9 y ymp 8 Ymp Lymphomas 9679 3 Primary m
184. distinguished from the subsequent pathological diagnosis if it becomes available You may be able to identify this information at the MDT meeting during the imaging review Author NCIN 71 Cancer Outcomes and Services Dataset User Guide ICD 10 MDT PROVISIONAL DIAGNOSIS ICD Working diagnosis as defined at MDT where the first definitive treatment is agreed This is the clinical opinion which may also be informed by biopsy radiological and or other investigations ICD 10 3 3 CENTRAL NERVOUS SYSTEM SURGERY amp OTHER PROCEDURES To carry surgery and other procedure details for Central Nervous System cancer This section will be recorded once per treatment _ Schema Data item Data Item Section Data Item Name Format specification M R O X ASA SCORE CENTRAL NERVOUS SYSTEM BA3130 ASA PHYSICAL STATUS SURGERY amp OTHER PROCEDURES CLASSIFICATION SYSTEM CODE CENTRAL NERVOUS SYSTEM TUMOUR LOCATION BA3100 an2 SURGERY amp OTHER PROCEDURES SURGICAL CENTRAL NERVOUS SYSTEM BA3140 EXCISION TYPE an1 SURGERY amp OTHER PROCEDURES ASA SCORE ASA PHYSICAL STATUS CLASSIFICATION SYSTEM CODE The ASA physical status classification system is a system for assessing the fitness of patients before surgery 2 A normal healthy patient A patient with mild systemic disease A patient with severe systemic disease that limits function but is not incapacitating A patient with severe systemic
185. driven by estrogen Negative Not performed PR ALLRED SCORE Record the PR ALLRED score if known Range 2 8 PR STATUS Progesterone Receptor Status Record the PR status if known P Author NCIN 62 Cancer Outcomes and Services Dataset User Guide N Negative ooo Not performed HER2 STATUS HER2 Immunohistochemical status Human Epidermal Growth Factor Receptor 2 Where the initial result of this test is Borderline a further report will follow with result of the ISH test Le ON B Borderline HER2 ISH STATUS Record the result of the ISH in situ hybridization test This is only required if the initial HER2 status is Borderline P Positive o OE Negative CYTOLOGY BREAST Cytology opinion Breast ici Suspicious of malignancy CYTOLOGY NODE Cytology opinion on axillary lymph node ici Suspicious of malignancy CORE BIOPSY BREAST Needle core biopsy opinion CORE BIOPSY NODE Needle biopsy opinion on axillary lymph node Author NCIN 63 Cancer Outcomes and Services Dataset User Guide 3 CENTRAL NERVOUS SYSTEM CNS OVERVIEW For the COSD benign brain cancers are included in the Central Nervous System Dataset although they are excluded from Cancer Waits ICD 10 codes C47 and C69 are grouped under Brain Central Nervous System for Cancer Waits but are excluded from the COSD Central Nervous System dataset For diseases coded under C47
186. e TO Carcinoma in situ Bowen disease High grade Squamous Intraepithelial Lesion HSIL Anal Intraepithelial Neoplasia 11 111 AIN II III T1 Tumour 2cm or less in greatest dimension T2 Tumour more than 2cm but no more than 5cm in greatest dimension T3 Tumour more than 5cmin greatest dimension T4 Tumour of any size invades adjacent organ s e g vagina urethra bladder Regional Lymph Nodes NO Noregional lymph node metastasis N1 Metastasis in perirectal lymph node s N2 Metastasis in unilateral internal iliac and or unilateral inguinal lymph nodes s N3 Metastasis in perirectal and inguinal lymph nodes and or bilateral internal iliac and or bilateral inguinal lymph nodes Distant Metastasis MO No distant metastasis M1 Distant metastasis To carry staging details for colorectal cancer This section will be recorded once Schema Data item No Data Item Section Data Item Name Format specification M R O X MODIFIED DUKES COLORECTAL CO5170 MODIFIED DUKES CLASSIFICATION STAGING CODE MODIFIED DUKES MODIFIED DUKES CLASSIFICATION CODE Dukes stage of disease at diagnosis based on pathological evidence but upgraded to Stage D if there is clinical evidence of metastasis Stage D should be recorded if metastatic spread is identified either in the preoperative staging process e g on CT scanning MRI USS chest x ray or at the t
187. e 1 for each of Age 44 Male gender Hb 105 Albumin 40 White blood count 14 9 Lymphocyte count lt 0 6 or Lymphocyte percentage of white blood cells lt 8 Ann Arbor Stage IV Author NCIN 142 Cancer Outcomes and Services Dataset User Guide Note Hasenclever Index is only required for lymphomas with Ann Arbor Stage 3 or 4 Range 0 7 7 13 HAEMATOLOGY CANCER CARE PLAN ACUTE LYMPHOCYTIC LEUKAEMIA To carry cancer care plan details specific to Acute Lymphocytic Leukaemia s This section will be recorded once Schema Data Item Section Data Item Name Format specification M R O X Data item No EXTRAMEDULLARY HA8270 HAEMATOLOGY CANCER CARE PLAN DISEASE Acute Lymphocytic Leukaemia EXTRAMEDULLARY DISEASE SITE EXTRAMEDULLARY DISEASE EXTRAMEDULLARY DISEASE SITE Sites of disease identified outside bone marrow Testes 7 14 HAEMATOLOGY STAGING HODGKIN FOLLICULAR DLBCL OTHER LYMPHOMAS To carry staging details specifically Ann Arbor staging details for various haematological diseases as specified This section will be recorded once Schema Data item No Data Item Section Data Item Name Format specification M R O X HAEMATOLOGY STAGING HA8280 FOLLICULAR DLBCL OTHER ANN ARBOR STAGE LYMPHOMAS HODGKIN PREMIATO TONY CA VPET EARNE ANN ARBOR EXTRANODALITY HA8300 PLAN FOLLICULAR DLBCL ANN ARBOR EXTRA INDICATOR OTHER LYMPHOMAS HODGK
188. e Referral section of the Core dataset and should be completed for all under 25s 5 2 ICD 10 CODES Any applicable ICD10 code where the patient is under 25 at the time of diagnosis see Appendices A and B 5 3 CTYA TABLES OF DATA ITEMS TO BE COMPLETED 5 3 1 Data items applicable to all cases any diagnosis V to be completed for all cases V to be completed for all cases where applicable pala Data Item Name All cases item No CT6050 SPECIALTY REFERRER TO SPECIALIST vV CT6060 PRIMARY DIAGNOSIS SUBSIDIARY COMMENT v CT6070 SECONDARY DIAGNOSIS ICD V CT6080 OTHER SIGNIFICANT DIAGNOSIS SUBSIDIARY COMMENT V CT6090 FAMILIAL CANCER SYNDROME V Author NCIN 87 Cancer Outcomes and Services Dataset User Guide CT6100 FAMILIAL CANCER SYNDROME SUBSIDIARY COMMENT v CT6030 CONSULTANT SPECIALTY AT DIAGNOSIS 6040 CONSULTANT AGE SPECIALTY AT DIAGNOSIS 6110 MULTIDISCIPLINARY TEAM AGE CATEGORY CT6150 STEM CELL INFUSION DATE v CT6130 STEM CELL INFUSION SOURCE v CT6140 STEM CELL INFUSION DONOR v CT6160 SPECIALTY SUB CODE CHEMOTHERAPY CONSULTANT 5 3 2 Disease specific Data items The following table shows which data items are applicable to each specific diagnosis be completed for all disease specific cases V to be completed for all disease specific cases if applicable Rhabdomyosarcoma and oth
189. e only site specific item that needs to be recorded in addition to the Core dataset To carry staging details for Basal Cell Carcinoma Squamous Cell Carcinoma and Malignant Melanoma This section will be recorded once Author NCIN 182 Cancer Outcomes and Services Dataset User Guide Schema Data item Data Item Data Item Name Format specification M R O X No Section AJCC STAGE GROUP SK12510 SKIN STAGING AMERICAN JOINT COMMITTEE ON CANCER STAGE AJCC STAGE GROUP AMERICAN JOINT COMMITTEE ON CANCER STAGE American Joint Committee on Cancer staging of tumour at diagnosis This is the final integrated stage as agreed by MDT Format AJCC Stage Melanoma Non melanoma Merkel cell Group SCC BCC and Adnexal tumours 1 T1 NO MO 1A IA T1a NO MO T1 pNO MO 1B IB Tib NO MO T1 cNO MO T2a NO MO 2 II T2 NO MO T2b NO MO 2A T3a NO MO T2 3 pNO MO T3b NO MO 2B IIB T4a NO MO T2 3 cNO MO 2C T4b NO MO T4 NO Mo 3 T 3 NO MO 1 2 3 MO 1 4 N1a MO 3A T1 4a N2a MO Any T Nia MO T1 4b 1 MO T1 4b N2a MO 3B IIIB T1 4a N1a MO Any T N1b N2 Mo T1 4a N2b MO T1 4a N2c MO T1 4b N1b MO T1 4b N2b MO 2 e T1 4b N2c MO Any T N3 MO T1 2 3 N2 MO 4 IV Any Tany N M1 Any T N3 MO Any TAny N M1 Any M1 Note AJCC Stage Group to be recorded for all skin cancers where applicable The remaining site
190. e record submitted unless it contains completed Mandatory items in that section If there is other data in a section and the Mandatory items are not completed the record will not pass validation tests R Required This data item where applicable should be submitted as soon as possible but is not required to validate the submitted record Author NCIN 16 Cancer Outcomes and Services Dataset User Guide O Optional This item may be submitted at the discretion of the Provider It is either not currently required nationally or it will be obtained derived by the National Cancer Registration Service from other sources P For use in a pilot project only at present to study the feasibility and potential benefits of using SNOMED CT Please contact cosd ncin org uk for further details X Not applicable for schema This data item should not be included in the submission It will be obtained derived by the National Cancer Registration Service from other sources Note Data items shaded in grey in the User Guide and COSD Dataset do not need to be submitted directly by Providers for COSD 0 3 National Codes Where there is a defined list of values for a data item the code appears on the left of the table and the definition appears on the right as shown in the example below National Code Definition 1 1to3 2 4 or more U Number uncertain 0 4 Patient Pathway There should be one record for each primary cance
191. e score GLEASON GRADE PRIMARY What is the most extensive Gleason grade 1 5 Range 1 5 GLEASON GRADE SECONDARY If additional grades are present what is the highest grade biopsy or the second most extensive grade TURP and radicals If no additional grades are present primary and secondary grades are the same 1 5 Range 1 5 GLEASON GRADE TERTIARY Is there a different third grade in addition the primary and secondary grades and what is its value Note that this is only applicable to about 5 of prostate cases 1 5 Not applicable PERINEURAL INVASION Is there perineural invasion PNI ORGAN CONFINED If prostatectomy was performed is the tumour confined to the prostate NN LL SEMINAL VESICLES INVASION If prostatectomy was performed is there invasion into Seminal Vesicles X Not applicable TURP TUMOUR PERCENTAGE For TURP only what percentage of tumour if clinically unsuspected tumour Range 0 100 13 16 UROLOGY PATHOLOGY BLADDER To carry the cancer pathology details for bladder This section will be recorded once per pathology report where applicable Author NCIN 217 Cancer Outcomes and Services Dataset User Guide Schema Data item Data Item Section Data Item Name Format specification M R O X UROLOGY PATHOLOGY TUMOUR GRADE UR15290 BLADDER UROLOGY TUMOUR GRADE UROLOGY BLADDER ONLY Specify whether LOW HIGH Grade or PUNLMP Papillary
192. e used for pathology stage fields For all other cases where no operation is performed staging will have to be based on radiological appearances either before or after the neo adjuvant treatment and an integrated TNM stage decided based on the radiological appearances 13 7 UROLOGY STAGING KIDNEY UICC RENAL CELL CARCINOMA OF THE KIDNEY TNM STAGING SEVENTH EDITION Stage Grouping T Stage N Stage M Stage Stage 1 MO Stage 11 T2 NO MO Stage Ill T3 Any N MO T1 T2 T3 N1 M1 Stage IV T4 Any N MO Any Any N M1 Primary Tumour T1 Tumour 7cm or less in greatest dimension limited to the kidney T1a Tumour 4cm or less Tib Tumour more than 4cm but not more than 7cm T2a Tumour is more than 7cm in greatest dimension but not more than 10cm limited to the kidney T2b Tumour is more than 10cm in greatest dimension limited to the kidney T3a Tumour grossly extends into the renal vein or its segmental muscle containing branches or tumour invades perirenal and or renal sinus fat periplexic fat but not beyond Gerota fascia T3b Tumour grossly extends into vena cava below diaphragm T3c Tumour grossly extends into vena cava above diaphragm T4 Tumour invades beyond Gerota fascia including contiguous extension into the ipsilateral adrenal gland Regional Lymph Nodes NO No regional lymph node metastasis N1 Metastasis in a single regional lymph no
193. ead and Neck mouth C04 8 Overlapping lesion of Head and Neck floor of mouth C04 9 Floor of mouth Head and Neck unspecified 5 0 Hard palate Head and Neck C05 1 Soft palate Head and Neck e C05 2 Uvula Head and Neck C05 8 Overlapping lesion of Head and Neck palate C05 9 Palate unspecified Head and Neck e C06 0 Cheek mucosa Head and Neck e C06 1 Vestibule of mouth Head and Neck e C06 2 Retromolar area Head and Neck e C06 8 Overlapping lesion of Head and Neck other and unspecified parts of mouth C06 9 Mouth unspecified Head and Neck e C07 Malignant neoplasm Head and Neck of parotid gland C08 0 Submandibular gland Head and Neck C08 1 Sublingual gland Head and Neck e C08 8 Overlapping lesion of Head and Neck major salivary glands 8 9 Major salivary gland Head and Neck unspecified C09 0 Tonsillar fossa Head and Neck e C09 1 Tonsillar pillar Head and Neck anterior posterior C09 8 Overlapping lesion of Head and Neck tonsil C09 9 Tonsil unspecified Head and Neck e C10 0 Vallecula Head and Neck e C10 1 Anterior surface of Head and Neck epiglottis C10 2 Lateral wall of Head and Neck oropharynx Author NCIN 220 ICD 10 4th Edition All C Codes are Malignant Cancer Outcomes and Services Dataset User Guide Cancer Waiting Times Site Expected Dataset to be collected Core and Site Specific Core Path
194. ecialist This would be a member of the specialist palliative care team led by a consultant in palliative medicine This applies to specifically to a recurrence of cancer Not known not recorded Author NCIN 54 Cancer Outcomes and Services Dataset User Guide 2 BREAST OVERVIEW TNM Staging and NPI Score should both be collected for invasive breast cancers TNM stage is required to enable international comparisons As for Cancer Waits the breast cancer site specific dataset also includes in situ non invasive breast cancers D05 which are TNM Stage NPI score is not used for non invasive breast cancers Please also note that a separate record should be completed for each diagnosis of secondary metastatic breast cancer see Recording Recurrences section Using This Guide ICD 10 CODES Key if applicable different dataset from CWT group specified ICD 10 Expected Dataset to be collected All C Codes Cancer Core and are Waiting Site Malignant Times Site Specific Core Path Neoplasms Description specific group Dataset Dataset Only Comment C50 0 Nipple and areola Breast e C50 1 Central portion of Breast e breast C50 2 Upper inner Breast e quadrant of breast C50 3 Lower inner Breast quadrant of breast 50 4 Upper outer Breast quadrant of breast C50 5 Lower outer Breast e quadrant of breast C50 6 Axillary tail of Breast e breast C50 8 Overlapping lesion Breast
195. ecological e C57 3 Parametrium Gynaecological e C57 4 Uterine adnexa Gynaecological unspecified C57 7 Other specified Gynaecological b female genital organs C57 8 Overlapping lesion of Gynaecological female genital organs C57 9 Female genital organ Gynaecological unspecified C58 Malignant neoplasm Gynaecological of placenta C60 0 Prepuce Urological Urology and Skin Datasets to be collected where applicable C60 1 Glans penis Urological Urology and Skin Datasets to be collected where applicable C60 2 Body of penis Urological Urology and Skin Datasets to be collected where applicable C60 8 Overlapping lesion of Urological Urology penis and Skin Datasets to be collected where applicable Author NCIN 233 Cancer Outcomes and Services Dataset User Guide ICD 10 4th Expected Dataset to be collected Edition All C Codes Core and are Cancer Waiting Site Malignant Times Site Specific Core Path Neoplasms Description specific group Dataset Dataset Only Comment C60 9 Penis unspecified Urological Urology and Skin Datasets to be collected where applicable C61 Malignant neoplasm Urological of prostate C62 0 Undescended testis Urological e C62 1 Descended testis Urological e C62 9 Testis unspecified Urological e C63 0 Epididymis Urological e C63 1 Spermatic cord Urological e C63 2 Scrotum Urologi
196. ected Tic Tumour identified by needle biopsy e g because of elevated prostate specific antigen PSA p T2 Tumour confined within prostate p T2a Tumour involves one half of one lobe or less p T2b Tumour involves more than one half of one lobe but not both lobes p T2c Tumour involves both lobes p T3 Tumour extends through the prostatic capsule p T3a Extracapsular extension unilateral or bilateral including microscopic bladder neck involvement p T3b Tumour invades seminal vesicle s p T4 Tumour is fixed or invades adjacent structures other than seminal vesicles external sphincter rectum levator muscles and or pelvic wall Regional Lymph Nodes Regional lymph nodes cannot be assessed p NX p NO No regional lymph node metastasis p N1 Regional lymph node metastasis Distant Metastasis MO No distant metastasis p M1 Distant metastasis 1 Non regional lymph pM1b Bone s p M1c Other site s Note Recording Prostate stage following neoadjuvant therapy Author NCIN 210 Cancer Outcomes and Services Dataset User Guide For cases of prostate cancer treated by prostatectomy problems will be encountered where neoadjuvant therapy usually hormones is used TNM stage will be dependent on histological examination of the resected specimen together with information obtained from radiological imaging etc Wherever possible TNM with the y prefix NEOADJUVANT THERAPY INDICATOR should b
197. ectly from the pathology system Free text reports containing the pathological data items will currently be accepted as long as the linkage fields can be identified CORE CANCER RECURRENCE SOURCE OF REFERRAL FOR CANCER RECURRENCE KEY WORKER SEEN INDICATOR CANCER RECURRENCE PALLIATIVE CARE SPECIALIST SEEN INDICATOR CANCER RECURRENCE These fields are specific to recurrences and MUST be completed for all records submitted ADDITIONAL SITE SPECIFIC DATA ITEMS REQUIRED FOR BREAST RECURRENCE RECORD In addition to the CORE data items above the following should also be completed from the site specific Breast dataset SECTION Specific Fields Comments BREAST REFERRALS ALL FIELDS These fields relate to the assessment which led to the diagnosis of recurrence BREAST IMAGING MAMMOGRAM ALL FIELDS IF APPLICABLE Contribute to diagnosis and stage assessment where no treatment recorded BREAST IMAGING ULTRASOUND ALL FIELDS IF APPLICABLE Contribute to diagnosis and stage assessment where no treatment recorded BREAST IMAGING AXILLA ULTRASOUND ALL FIELDS IF APPLICABLE Contribute to diagnosis and stage assessment where no treatment recorded BREAST PATHOLOGY ALL FIELDS IF APPLICABLE All Site Specific Pathology details should be completed and should normally be submitted directly from the pathology system Free text reports containin
198. ed Clinical stage 1 T1 NO or Nx MO Clinical stage 2 T2 or T3 NO or Nx MO Clinical stage 3 T1 3 NO MO or T4 with any N MO NE WEM Clinical stage 4 All T with any N M1 5 20 CTYA GERM CELL CNS AND GERM CELL NON CNS TUMOURS To carry Germ cell CNS and Germ Cell non CNS Tumours details for CTYA This section will be recorded once Author NCIN 104 Cancer Outcomes and Services Dataset User Guide Schema Data Item Section Data Item Name Format specification M R O X DELE item No BETA HUMAN CHORIONIC CTYA GERM CELL CNS and GONADOTROPIN SERUM CT6580 GERM CELL NON CNS BETA HUMAN CHORIONIC TUMOURS GONADOTROPIN MAXIMUM AT DIAGNOSIS BETA HUMAN CHORIONIC GONADOTROPIN SERUM Maximum Serum level of HCG at diagnosis 10 1 measured only for CNS germ cell tumours 5 21 CTYA GERM CELL CNS GERM CELL NON CNS HEPATOBLASTOMA AND HEPATOCELLULAR CARCINOMA To carry Germ Cell CNS Germ Cell Non CNS Tumours Hepatoblastoma and Hepatocellular carcinoma details for CTYA This section will be recorded once Schema Data Item Section Data Item Name Format specification M R O X DE Y item No ALPHA FETOPROTEIN CTYA GERM CELL CNS GERM CELL NON SERUM CT6520 CNS HEPATOBLASTOMA and ALPHA FETOPROTEIN HEPATOCELLULAR CARCINOMA MAXIMUM AT DIAGNOSIS ALPHA FETOPROTEIN SERUM Maximum Serum level of alpha feto protein at diagnosis AFP units recorded in values gt 100 0
199. ed Neither Core nor site specific Gynae dataset is required at present TNM Staging does not need to be collected for Gynaecology cancers ICD 10 CODES Key if applicable different dataset from CWT group specified ICD 10 Expected Dataset to be collected All C Codes Core and are Cancer Waiting Site Malignant Times Site Specific Core Path Neoplasms Description specific group Dataset Dataset Only Comment C48 1 Specified parts of Sarcoma Sarcoma and peritoneum Gynaecology Datasets to be collected where applicable 48 2 Peritoneum Sarcoma Sarcoma and unspecified Gynaecology e Datasets to be collected where applicable C51 0 Labium majus Gynaecological Gynaecology and Skin Datasets to be collected where applicable C51 1 Labium minus Gynaecological Gynaecology and Skin Datasets to be collected where applicable Author NCIN 108 Cancer Outcomes and Services Dataset User Guide C51 2 Clitoris Gynaecological Gynaecology and Skin Datasets to be collected where applicable C51 8 Overlapping lesion Gynaecological Gynaecology of vulva and Skin Datasets to be collected where applicable C51 9 Vulva unspecified Gynaecological Gynaecology and Skin Datasets to be collected where applicable C52 Malignant Gynaecological neoplasm of vagina
200. ed clinically In order to distinguish between the above two groups of patients the field MONITORING INTENT should be completed as follows Active surveillance monitoring Use Code 1 Monitoring with future curative intent e Watchful waiting Use Code2 Monitoring with future palliative intent e f unable to distinguish use Code 3 Monitoring with unknown or uncertain future intent For symptomatic patients who are not receiving active treatment the selected treatment type CANCER TREATMENT MODALITY will be either Specialist Palliative Care or Non specialist Palliative Care depending on whether the patient is under the care of a specialist in palliative medicine ICD 10 CODES Key if applicable different dataset from CWT group specified ICD 10 Expected Dataset to be collected All C Codes Core and are Cancer Waiting Site Malignant Times Site Specific Core Path Neoplasms Description specific group Dataset Dataset Only Comment C60 0 Prepuce Urological Urology and Skin Datasets to be collected where applicable C60 1 Glans penis Urological Urology and Skin Datasets to be collected where applicable C60 2 Body of penis Urological Urology and Skin Datasets to be collected where applicable Author NCIN 200 Cancer Outcomes and Services Dataset User Guide C60 8 Overlappin
201. ed for each disease and the WHO Disease Group Please see Appendix C for Description of Disease Groups Changes from Version 1 9 of the User Guide are shown in red IMPORTANT NOTE Where a suffix has been added this should be used consistently as shown to ensure that diseases with the same ICDO3 code can be correctly distinguished To ensure that consistent coding continues to be applied nationally please advise the COSD team if you identify potential changes or additional coding requirements For visual clarity the ICDO3 codes in the table are formatted differently from the specification Records should be submitted according to the format in the specification either MXXXXX or MXXXXXX with suffix Where marked as CORE ONLY there is no disease specific dataset so only the core dataset will be completed Please also note that every record must include the relevant ICDO3 code LYMPHOBLASTIC LEUKAEMIA LYMPHOBLASTIC LYMPHOMA CODING Lymphoblastic lymphoma and lymphoblastic leukaemia are now known to be the same entity This is reflected in the latest ICDO3 coding update which assigns the same morphology code to both and uses the combined term lymphoblastic leukaemia lymphoma Historically different codes were assigned to lymphoblastic Author NCIN 123 Cancer Outcomes and Services Dataset User Guide lymphoma and leukaemia and ICD10 coding still distinguishes between these two groups The coding list below therefore retains the s
202. ed to support the decision on which datasets should be submitted Where the patient is discussed by an age specific paediatric or TYA MDT at a designated paediatric or TYA Principal Treatment Centre PTC the responsibility for completing the CTYA dataset rests with the PTC For patients of any age who are also discussed at a site specific MDT or where the disease is not specified in the CTYA dataset for example the diagnosis of a colorectal carcinoma the appropriate site specific dataset should also be completed by the relevant MDT National guidance offers TYA aged 19 24 years the option of referral to a TYA PTC although the guidance also indicates that all such patients should be discussed at a TYA MDT even if they are not referred to the PTC for treatment If despite this the patient is only discussed by a site specific MDT that team should complete the appropriate site specific dataset and the relevant additional non disease specific items in the CTYA dataset Where a disease is covered by both the CTYA and a site specific dataset such as some haematological diseases only one set of disease specific items needs to be completed either CTYA or site specific according to the speciality of the treating team The non disease specific items in the CTYA dataset should however be completed as per the preceding paragraphs Please note that CANCER SYMPTOMS FIRST NOTED DATE which records when symptoms were first noted is included in th
203. ediastinal thymic large B cell C85 2 Mediastinal thymic large B Other 9 lymphoma cell lymphoma Lymphomas 9680 3 ms large B cell lymphoma DLBCL C83 3 Diffuse large B cell lymphoma DLBCL 9 9680 3 A Primary DLBCL of the CNS C83 3 Diffuse large B cell lymphoma DLBCL 9 9680 3 B EBV positive DLBCL of the elderly C83 3 Diffuse large B cell lymphoma DLBCL 9 B cell lymphoma intermediate between 9680 3 DLBCL Burkitt lymphoma C83 3 Diffuse large B cell lymphoma DLBCL 9 9680 3 D Primary cutaneous DLBCL leg type C83 3 Diffuse large B cell lymphoma DBLCL 9 9680 3 E DEBEL C83 3 Diffuse large B cell lymphoma DLBCL 9 inflammation 9687 3 Burkitt lymphoma C83 7 Burkitt lymphoma Osher 9 ymp ymp Lymphomas 9688 3 T cell histiocyte rich large B cell C83 3 Diffuse large B cell lymphoma Other 9 lymphoma Lymphomas 9689 3 Splenic marginal zone lymphoma C83 0 Small cell B cell lymphoma Osher 9 8 ymp i ymp Lymphomas 9690 3 Follicular lymphoma C82 9 Follicular lymphoma Follicular 9 unspecified 9691 3 Follicular lymphoma Grade 2 C82 1 Follicular lymphoma grade II Follicular 9 9695 3 Follicular lymphoma Grade 1 C82 0 Follicular lymphoma grade Follicular 9 9698 3 Follicular lymphoma Grade 3 C82 2 lymphoma grade III Follicular 9 unspecified 9698 3A Follicular lymphoma Grade 3A C82 3 Follicular lymphoma grade Illa Follicular 9 9698 3 Follicular lymphoma Grade C82 4 Follicular lymphoma grade Follicular 9 Extranod
204. ee of precision as to allow accurate AJCC staging it is essential that the thickness in mm that is recorded in a database should accurately reflect the stated AJCC7 stage Dataset for the histological reporting of primary cutaneous malignant melanoma and regional lymph nodes 2nd edition November 2012 TUMOUR INFILTRATING LYMPHOCYTES TILS Type of TILS Tumour infiltrating lymphocytes TILS are white blood cells that have left the bloodstream and migrated into a tumour Non brisk Brisk Absent FINAL EXCISION MARGIN AFTER WIDE LOCAL EXCISION Record the final margin of excision in millimetres mm s after wide local excision procedure This is an amalgamation of clinical and histopathological data Note For COSD reporting purposes this data item is not required to be submitted to two decimal places SENTINEL NODES EXAMINED NUMBER Number of sentinal nodes sampled SENTINEL NODES POSITIVE NUMBER Number of sentinal nodes positive POST SNB COMPLETION LYMPHADENECTOMY NODES SAMPLED NUMBER Post SNB completion lymphadenectomy number of nodes sampled This procedure is not carried out in all cases POST SNB COMPLETION LYMPHADENECTOMY NODES POSITIVE NUMBER Post SNB completion lymphadenectomy number of nodes positive This procedure is not carried out in all cases Author NCIN 185 12 UPPER OVERVIEW Cancer Outcomes and Services Dataset User Guide ICD 10 codes C17 1 C17 2 C17 3 C17 8 and C17 9 are grouped und
205. eeecaeseeeeesnaeeeenees 14 WAY ISIE MECH ED 14 What is different from previous data 14 Other guidance documentation dices sesicraccesveosccecnasascovssericacnessassesuasiecaseassuunansdaasba snes sadaasveabacataasasscdsvenseaanaea de 14 Which diagnoses does COSD apply to oiiire a aa E aala AARRE 14 What data items should be completed cecesccccccsesessssececececseseeaeseeececseesaesesececeesasesesecsceesesesaeseeseeeseaeaeees 14 When should the data be submitted tette ete ee e eet ern bep a ER HERR EUR LUN RR Ro 15 Phased Implementation iur rerna eee eR ehh geek raa een eO RR eR RR Aa Ra Nun YR CERTE Ra d Sb Ri 15 Online TAMING 15 Feedback And QUOHOS REA 15 O USING THIS GUIDE ILLE 16 0 1 Layout ot the Usef G lde ii ates a Toda ceeds 16 0 2 Key to Data It m 16 OFS National CodeS ES 17 Q A Patient 17 0 5 DE MORAINES RERO 19 19 EPA SMS 19 08 20 0 9 Plai ends ccnig
206. entral Not normally Nervous System treated by CNS MDT C69 3 Choroid Brain Central Not normally Nervous System treated by CNS MDT C69 4 Ciliary body Brain Central Not normally Nervous System treated by CNS MDT C69 5 Lachrymal gland and Brain Central Not normally duct Nervous System treated by CNS MDT C69 6 Orbit Brain Central Not normally Nervous System treated by CNS MDT Maybe treated by Sarcoma MDT C69 8 Overlapping lesion of Brain Central Not normally eye and adnexa Nervous System treated by CNS MDT C69 9 Eye unspecified Brain Central Not normally Nervous System treated by CNS MDT C70 0 Cerebral meninges Brain Central Nervous System C70 1 Spinal meninges Brain Central Nervous System C70 9 Meninges Brain Central unspecified Nervous System C71 0 Cerebrum except Brain Central lobes and ventricles Nervous System C71 1 Frontal lobe Brain Central Nervous System C71 2 Temporal lobe Brain Central Nervous System C71 3 Parietal lobe Brain Central Nervous System Author NCIN 235 ICD 10 4th Edition All C Codes are Malignant Cancer Outcomes and Services Dataset User Guide Cancer Waiting Times Site Expected Dataset to be collected Core and Site Specific Core Path Neoplasms Description specific group Dataset Dataset Only Comment C71 4 Occipital lobe Brain Central e Nervous System C71 5 Cerebral ventricle Brain Cent
207. eparate ICD10 codes C83 5 and C91 0 but assigns the same ICDO3 codes to each pair of diseases Further detail can be provided if required RECORDING AMYLOIDOSIS FOR COSD The aim is to register patients presenting with symptoms referable to an underlying diagnosis of amyloidosis in the absence of a known registerable plasma cell or lymphoid neoplasm Amyloidosis may be associated with plasma cell neoplasms such as multiple myeloma other B cell neoplasms such as lymphoplasmacytic lymphoma or with paraproteinaemias which are not associated with identified myeloma or lymphoma i e MGUS If amyloidosis is identified in association with a registerable condition such as multiple myeloma plasmacytoma lymphoplasmacytic lymphoma Waldenstroms macroglobulinaemia etc only the data for the associated registerable condition should be submitted through COSD and this will be registered as a new diagnosis by the cancer registries Amyloidosis should not be submitted for COSD in these circumstances Amyloid deposition associated with chronic infection medullary carcinoma of the thyroid insulinoma prolactinoma Alzheimer disease prion diseases and other non AL types of amyloid is considered to be secondary amyloidosis and should not be submitted for COSD If amyloidosis is identified in the absence of a registerable condition or before the identification of a registerable condition then data for Primary Amyloidosis should be submitted for COSD
208. er Guide DATE OF CRO170 CORE DIAGNOSIS DATE OF RECURRENCE CANCER REGISTRATION RECURRENCE NEW mm dd CANCER REGISTRATION CORE RADIOTHERAPY DETAILS To carry the death details not required for direct submission by Trusts One occurrence of this group is permitted per treatment where applicable RADIOTHERAPY CR2080 CORE RADIOTHERAPY RADIOTHERAPY TOTAL DOSE max n3 n2 TOTAL DOSE RTDS RADIOTHERAPY CR2090 CORE RADIOTHERAPY RADIOTHERAPY TOTAL FRACTIONS max n2 TOTAL FRACTIONS RTDS CORE DEATH DETAILS To carry the death details not required for direct submission by Trusts One occurrence of this group is permitted CR1270 CORE DEATH DETAILS PERSON DEATH DATE ONS mm dd DATE CR1280 CORE DEATH DETAILS DEATH LOCATION TYPE ani P LOCATION ONS DEATH CAUSE CR3020 CORE DEATH DETAILS DEATH CAUSE IDENTIFICATION METHOD an1 IDENTIFICATION ONS METHOD DEATH CAUSE ICD CR1300 CORE DEATH DETAILS DEATH CAUSE ICD CODE IMMEDIATE an6 CODE IMMEDIATE ONS DEATH CAUSE ICD CR131 CORE DEATH DETAILS DEATH CAUSE ICD CODE NDITION NS 310 CAUSE ICD CODE ON an6 CODE IMMEDIATE Author NCIN 283 Cancer Outcomes and Services Dataset User Guide BREAST REFERRALS To carry referral details for breast cancer One occurrence of this group is permitted GYNAECOLOGY REFERRAL To carry referral details for gynae c
209. er Soft Tissue H E E 5 2 5 a 7 5 e E 2 E E a a o R c 5 zy gt E z 5 Ez S 5 z t 2 v a 5 9 ire K t S 7 7 2 i E o ala JEN Data Item E 2 s b 1 9 lt lt 2 I 2 won fo gt EXTRAMEDULLARY CT6210 DISEASE WHITE BLOOD CELL CT6220 COUNT HIGHEST v CYTOGENETIC RISK CT6230 Cone CYTOGENETICS CT6240 SUBSIDIARY MURPHY ST JUDE 6250 TAGE 1 1 STATUS FOR CT6260 vic CT6270 ANN ARBOR STAGE v ANN ARBOR CT6280 SYMPTOMS id ANN ARBOR CT6290 EXTRANODALITY y Author NCIN 88 Cancer Outcomes and Services Dataset User Guide CT6300 INTERNATIONAL NEUROBLASTOMA PATHOLOGIC CLASSIFICATION CT6310 CYTOGENETIC RISK CLASSIFICATION NEUROBLASTOMA CT6320 INTERNATIONAL NEUROBLASTOMA STAGING SYSTEM CT6330 WILMS TUMOUR STAGE CT6680 RISK CLASSIFICATION PATHOLOGICAL AFTER IMMEDIATE NEPHRECTOMY CT6340 RISK CLASSIFICATION PATHOLOGICAL AFT ER PREOPERATIVE CHEMOTHERAPY CT6350 IRS POST SURGICAL GROUP CT6360 CYTOGENETICS FOR ALVEOLAR RHABDOMYOSARCO MA CT6370 RHABDOMYOSARCO MA SITE PROGNOSIS CODE CT6380 SARC
210. er Upper GI for Cancer Waits but are excluded from the COSD Upper GI dataset For diseases coded under C17 1 C17 2 C17 3 C17 8 and C17 9 only the CORE dataset needs to be completed ICD 10 CODES Key if applicable different dataset from CWT group specified Expected Dataset to be ICD 10 collected Core and All C Codes are Cancer Waiting Site Malignant Times Site Specific Core Path Neoplasms Description specific group Dataset Dataset Only Comment C15 0 Cervical part of Upper Usually oesophagus Gastrointestinal treated by Head amp Neck MDT C15 1 Thoracic part of Upper oesophagus Gastrointestinal 15 2 Abdominal part Upper of oesophagus Gastrointestinal 15 3 Upper third of Upper oesophagus Gastrointestinal C15 4 Middle third of Upper oesophagus Gastrointestinal 15 5 Lower third of Upper oesophagus Gastrointestinal 15 8 Overlapping Upper lesion of Gastrointestinal oesophagus 15 9 Oesophagus Upper unspecified Gastrointestinal C16 0 Cardia Upper Gastrointestinal C16 1 Fundus of Upper stomach Gastrointestinal e C16 2 Body of stomach Upper Gastrointestinal s C16 3 Pyloric antrum Upper Gastrointestinal 16 4 Pylorus Upper Gastrointestinal Author NCIN 186 Cancer Outcomes and Services Dataset User Guide C16 5 Lesser curvature Upper of stomach Gast
211. erformance status prognostic factors and treatment options which are normally discussed at the MDT meeting Many of the site specific data items will be recorded at this point in the patient pathway See site specific sections for further details There will only be one Cancer Care Plan section completed for each record Most of the data items in this section will normally be available at the meeting at which the first definitive treatment was discussed Please note that some of the data items in the Care Plan sections of the site specific datasets will only be available after the initial treatment has been completed or at a subsequent MDT discussion The items in this section will not therefore necessarily relate to the date of the MDT recorded MULTIDISCIPLINARY TEAM DISCUSSION DATE CANCER 0 10 Stage This relates to the extent and spread of the tumour For COSD the stage may be recorded at three points in the patient pathway e Pre treatment usually assessed at the MDT meeting where the treatment options are agreed e Pathological stage recorded in the Pathology section e Integrated stage following surgical treatment and or final review of the case For most cancers TNM staging is used but see site specific sections for relevant TNM values and for other staging systems used Where p is shown in the staging tables this indicates that the code is also applicable for pathology The core staging section is not applicable to Haematolog
212. es and Services Dataset User Guide ICD 10 4th Expected Dataset to be collected Edition All C Codes Core and are Cancer Waiting Site Malignant Times Site Specific Core Path Neoplasms Description specific group Dataset Dataset Only Comment C15 4 Middle third of Upper oesophagus Gastrointestinal C15 5 Lower third of Upper oesophagus Gastrointestinal C15 8 Overlapping lesion of Upper oesophagus Gastrointestinal C15 9 Oesophagus Upper unspecified Gastrointestinal C16 0 Cardia Upper Gastrointestinal C16 1 Fundus of stomach Upper Gastrointestinal C16 2 Body of stomach Upper Gastrointestinal C16 3 Pyloric antrum Upper Gastrointestinal C16 4 Pylorus Upper Gastrointestinal C16 5 Lesser curvature of Upper stomach unspecified Gastrointestinal C16 6 Greater curvature of Upper stomach unspecified Gastrointestinal C16 8 Overlapping lesion of Upper stomach Gastrointestinal C16 9 Stomach unspecified Upper Gastrointestinal C17 0 Duodenum Colorectal Usually treated by Upper GI MDT C17 1 Jejunum Colorectal Usually treated by Upper GI MDT C17 2 Ileum Colorectal Usually treated by Upper GI MDT C17 3 Meckel s diverticulum Colorectal Usually treated by Upper GI MDT C17 8 Overlapping lesion of Colorectal Usually small intestine treated by Upper GI MDT Author NCIN 222 Cancer Outcomes and Services Dataset User Guide
213. es of head face and neck Head and Neck Secondary only use if unable to code to specific primary site D00 0 Carcinoma in situ of Lip oral cavity and pharynx Head and Neck D02 0 Carcinoma in situ of Larynx Head and Neck D09 3 carcinoma in situ of thyroid and other endocrine glands Head and Neck D37 0 Neoplasm of uncertain or unknown behaviour of lip oral cavity and pharynx Head and Neck D38 0 Neoplasm of uncertain or unknown behaviour of Larynx Head and Neck D44 0 Neoplasm of uncertain or unknown behaviour of thyroid gland Head and Neck 8 1 HEAD amp NECK PRE TREATMENT ASSESSMENT Author NCIN 148 Cancer Outcomes and Services Dataset User Guide To carry pre treatment assessment details for head and neck cancer This section will be recorded once Schema DELE item No HEAD amp NECK PRE DATE HEIGHT MEASURED an10 ccyy N9230 TREATMENT yy DAHNO D4 OBSERVATION DATE HEIGHT mm dd Data Item Section Data Item Name Format specification M R O X ASSESSMENT HEAD amp NECK PRE HNG220 TREATMENT PERSON HEIGHT IN METRES 1 n2 DAHNO D3 ASSESSMENT HEAD amp NECK PRE HN9210 DATE WEIGHT MEASURED an10 TREATMENT DAHNO D2 OBSERVATION DATE WEIGHT mm dd ASSESSMENT BERG Ee PERSON OBSERVATION WEIGHT max Neste TREATMENT DAHNO D1 PERSON WEIGHT n3 max n3 ASSESSMENT H
214. f Rectum D01 3 Carcinoma in situ Colorectal of Anus and anal canal D01 4 Carcinoma in situ Colorectal of Anus and anal canal D01 5 Carcinoma in situ Upper of Liver Gastrointestinal gallbladder and bile ducts 001 7 Other specified Colorectal digestive organs D01 9 Carcinoma in situ Colorectal of Digestive organ unspecified D02 0 Carcinoma in situ Head and Neck of Larynx Author NCIN 249 Cancer Outcomes and Services Dataset User Guide ICD 10 4th Expected Dataset to be collected Edition Core All C Codes and are Site Malignant Cancer Waiting Times Specific Core Neoplasms Description Site specific group Dataset Dataset Path Only Comment DO2 1 Carcinoma in situ Lung of Trachea D02 2 Carcinoma in situ Lung of Bronchus and e lung D02 3 Carcinoma in situ Lung of Other parts of e respiratory system D02 4 Carcinoma in situ Lung of Respiratory e system unspecified D03 0 Melanoma in situ Skin of lip D03 1 Melanoma in situ Skin of eyelid including e canthus D03 2 Melanoma in situ Skin of ear and external e auricular canal D03 3 Melanoma in situ Skin of other and unspecified parts of face D03 4 Melanoma in situ Skin of scalp and neck D03 5 Melanoma in situ Skin e of trunk D03 6 Melanoma in situ Skin of upper limb e including shoulder D03 7 Melanoma in situ Skin of lower limb e including hip D03 8 Melanoma in situ Other
215. f this cancer DATE OF RECURRENCE CLINICALLY AGREED is specific to recurrences and MUST be completed for all records submitted CORE DEMOGRAPHICS ALL RELEVANT FIELDS Patient details are essential for record matching and for data quality and assurance CORE IMAGING ALL FIELDS Pre post treatment To assist with staging and identification of regional recurrence CORE DIAGNOSIS ALL FIELDS including All fields should be completed if possible METASTATIC SITE and CANCER RECURRENCE CARE PLAN INDICATOR METASTATIC SITE and CANCER RECURRENCE CARE PLAN INDICATOR are used with Imaging and Pathology to identify local regional and distant recurrences where no treatment is received CORE CANCER CARE PLAN ALL APPLICABLE FIELDS including MULTIDISCIPLINARY TEAM DISCUSSION INDICATOR and CLINICAL NURE SPECIALIST INDICATION CODE To monitor service CORE TREATMENT ALL APPLICABLE FIELDS All treatment details should be completed including non active treatments such as specialist or non specialist palliative support CORE SURGERY AND OTHER PROCEDURES RADIOTHERAPY ACTIVE MONITORING ALL APPLICABLE FIELDS These sections should be completed if applicable Author NCIN 23 Cancer Outcomes and Services Dataset User Guide CORE PATHOLOGY ALL APPLICABLE FIELDS All Pathology details should be completed and should normally be submitted dir
216. ferral was not to the cancer services teams DATE FIRST SEEN CWT This is the date that the PATIENT is first seen in the Provider that receives the first referral which leads to the cancer diagnosis It is the date first seen in secondary care for this diagnosis CONSULTANT CODE FIRST SEEN A code uniquely identifying a CONSULTANT The CONSULTANT CODE is derived from either the GENERAL MEDICAL COUNCIL REFERENCE NUMBER for GENERAL MEDICAL PRACTITIONERS or the GENERAL DENTAL COUNCIL REGISTRATION NUMBER for GENERAL DENTAL PRACTITIONERS where the dentist doesn t have a GENERAL MEDICAL COUNCIL REFERENCE NUMBER This is the Code of the Consultant who is responsible for the appointment recorded under DATE FIRST SEEN CARE PROFESSIONAL MAIN SPECIALTY CODE FIRST SEEN A unique code identifying each MAIN SPECIALTY designated by Royal Colleges This is the same as the OCCUPATION CODES describing specialties Can be derived from consultant code Codes 501 Obstetrics and 502 Gynaecology should be used and not the combined code 500 Obstetrics and Gynaecology this is in common with the requirements for central returns including Hospital Episode Statistics See Main Specialty And Treatment Function Codes ORGANISATION CODE PROVIDER FIRST SEEN CWT The ORGANISATION SITE CODE of the Health Care Provider at the first contact with the PATIENT That is the Health Care Provider at the first Out Patient Attendance Consultant Imaging or Radiodiagno
217. filtration unresectable or by lymph node involvement The midline is defined as the vertebral column Tumours originating on 1 side and crossing the midline must infiltrate to or beyond the opposite side of the vertebral column e STAGE 4 Any primary tumour with dissemination to distant lymph nodes bone bone marrow liver skin and or other Organs except as defined for Stage 4S e STAGE 4S Localised primary tumour as defined for stage 1 2A or 2B with dissemination limited to skin liver and or bone marrow limited to infants younger than 1 year Marrow involvement should be minimal 1096 of total nucleated cells identified as malignant by bone biopsy or by bone marrow aspirate More extensive bone marrow involvement would be considered to be stage 4 disease The results of the MIBG scan if performed should be negative for disease in the bone marrow Stage 2A Stage 28 Stage 45 5 13 CTYA RENAL TUMOURS To carry renal tumours details for CTYA This section will be recorded once Schema Data Item Name Format specification Section M R O X No CTYA RENAL CT6330 TUMOURS WILMS TUMOUR STAGE 1 Data item Data Item RISK CLASSIFICATION PATHOLOGICAL AFTER ee CTYA RENAL IMMEDIATE NEPHRECTOMY ET TUMOURS PATHOLOGICAL RISK CLASSIFICATION CODE AFTER NEPHRECTOMY RISK CLASSIFICATION PATHOLOGICAL AFTER CTYA RENAL PREOPERATIVE CHEMOTHERAPY T TUMOURS PATHOLOGICAL RISK CLASSIFICATION CODE AFTER PR
218. g peritoneum C45 2 Mesothelioma of Lung pericardium C45 7 Mesothelioma of Lung other sites C45 9 Mesothelioma Lung unspecified C78 0 Secondary Lung Normally malignant treated by neoplasm of lung MDT of site of primary tumour Only use if unable to code to specific primary site C78 1 Secondary Lung Normally malignant treated by neoplasm of MDT of site of mediastinum primary tumour Only use if unable to code to specific primary site C78 2 Secondary Lung Normally malignant treated by neoplasm of pleura MDT of site of primary tumour Only use if unable to code to specific primary site Author NCIN 158 Cancer Outcomes and Services Dataset User Guide C78 3 Secondary Lung Normally malignant treated by neoplasm of other MDT of site of and unspecified primary respiratory organs tumour Only use if unable to code to specific primary site D02 1 Carcinoma in situ of Lung Trachea D02 2 Carcinoma in situ of Lung Bronchus and lung D02 3 Carcinoma in situ of Lung Other parts of respiratory system D02 4 Carcinoma in situ of Lung Respiratory system unspecified D38 1 Neoplasm of Lung uncertain or unknown behaviour of Trachea bronchus and lung D38 2 Neoplasm of Lung uncertain or unknown behaviour of Pleura D38 3 Neoplasm of Lung uncertain or unknown behaviour of Mediastinum D38 4 Neoplasm of Lung uncertain or unknown behaviour of Thymus
219. g lesion Urological Urology and of penis Skin Datasets to be collected where applicable C60 9 Penis unspecified Urological Urology and e Skin Datasets to be collected where applicable C61 Malignant Urological neoplasm of e prostate C62 0 Undescended testis Urological e C62 1 Descended testis Urological e C62 9 Testis unspecified Urological e C63 0 Epididymis Urological e C63 1 Spermatic cord Urological e C63 2 Scrotum Urological e C63 7 Other specified Urological male genital organs C63 8 Overlapping lesion Urological of male genital organs C63 9 Male genital organ Urological unspecified e C64 Malignant Urological neoplasm of kidney except renal pelvis C65 Malignant Urological neoplasm of renal e pelvis C66 Malignant Urological m neoplasm of ureter C67 0 Trigone of bladder Urological e C67 1 Dome of bladder Urological C67 2 Lateral wall of Urological bladder C67 3 Anterior wall of Urological bladder C67 4 Posterior wall of Urological bladder C67 5 Bladder neck Urological C67 6 Ureteric orifice Urological 67 7 Urachus Urological 67 8 Overlapping lesion Urological of bladder i Author NCIN 201 Cancer Outcomes and Services Dataset User Guide C67 9 Bladder unspecified Urological C68 0 Urethra Urological C68 1 Paraurethral glands Urological C68 8 Overlapping lesion of urinary organs Urological C68 9 Ur
220. g the pathological data items will currently be accepted as long as the linkage fields can be identified Author NCIN 24 Cancer Outcomes and Services Dataset User Guide 1 CORE ICD 10 CODES The core data items should be collected for all cancers and other registerable conditions where applicable See Appendix A to C for the full lists of ICD10 codes Note For diagnoses not included in the site specific datasets the core items only should be completed For some registerable conditions only pathology reports will be available at present CORE LINKAGE These items are required for every record in order to link patient records CORE PATIENT IDENTITY DETAILS NHS NUMBER and or LOCAL PATIENT IDENTIFIER NHS NUMBER STATUS INDICATOR CODE PERSON BIRTH DATE ORGANISATION CODE CODE OF PROVIDER See Core Demographics section for details CORE DIAGNOSTIC DETAILS PRIMARY DIAGNOSIS ICD DATE OF DIAGNOSIS CLINICALLY AGREED or DATE OF RECURRENCE CLINICALLY AGREED See Core Diagnosis for details 1 1 CORE DEMOGRAPHIC DETAILS To carry the patient demographic details It is anticipated that some of the demographic data items listed below will be collected by every provider with which the patient has contact Where this information is exchanged the appropriate data item name should be used This section will be recorded once Patient identity details are required for linkage each time the record is submit
221. g use future palliative intent for watchful waiting For Haematology this is applicable to most CLL some Follicular Lymphomas and Myelodysplasias 1 12 CORE PATHOLOGY To carry the pathology details The core dataset includes general pathological items which are applicable to all tumour sites unless otherwise stated Site specific pathology items relating to stage components are included in the site specific pathology sections These core and site specific items are a subset of the RCPath cancer data sets which have been approved as Professional Standards by the College Where structured reporting systems are not available for pathology it is expected that many of the relevant data items will be included in the free text pathology report Providers may also wish to submit these items from other structured systems such as MDT software however the original pathology report should always be submitted and there is no expectation for Providers to double enter these data unless they have chosen to do so for local purposes A patient may have any number of pathology reports and there may be more than one pathology report per specimen Author NCIN 47 Cancer Outcomes and Services Dataset User Guide This section can be recorded more than once BELE item No CR0760 CR1010 CR0770 CR0780 CR0790 CR3070 CR0850 CR3060 CRO860 CR0870 Author NCIN Data Item Section CORE PATHOLOGY DETAILS CORE P
222. gical myelomonocytic leukaemia C92 6 Acute myeloid Haematological leukaemia with 11q23 abnormality C92 7 Other myeloid Haematological leukaemia C92 8 Acute myeloid Haematological leukaemia with multilineage dysplasia C92 9 Myeloid leukaemia Haematological unspecified C93 0 Acute Haematological monoblastic monocy tic leukaemia C93 1 Chronic Haematological myelomonocytic leukaemia C93 3 Juvenile Haematological myelomonocytic leukaemia C93 7 Other monocytic Haematological leukaemia C93 9 Monocytic Haematological leukaemia unspecified C94 0 Acute erythroid Haematological leukaemia Expected Dataset to be collected Core and Site Specific Dataset Core Dataset Path Only Comment Author NCIN 246 ICD 10 4th Edition All C Codes are Malignant Neoplasms 94 2 Cancer Outcomes and Services Dataset User Guide Description Acute megakaryoblastic leukaemia Cancer Waiting Times Site specific group Haematological C94 3 Mast cell leukaemia Haematological C94 4 Acute panmyelosis with myelofibrosis Haematological C94 6 Myelodysplastic and myeloproliferative disease not elsewhere classified Haematological C94 7 Other specified leukaemias Haematological C95 0 Acute leukaemia of unspecified cell type Haematological C95 1 Chronic leukaemia of unspecified cell type Haematological C95 7 Other leukaemia of unspecified
223. gnosis TOPOGRAPHY SNOMED This is the topographical site of the tumour as categorised by SNOMED RT TOPOGRAPHY SNOMED CT This is the topographical site of the tumour as categorised by SNOMED CT Note For use in pilot project only at present Please contact cosd ncin org uk for further details MORPHOLOGY SNOMED This is the morphology of the tumour as categorised by SNOMED RT Format MXXXXX Author NCIN 50 Cancer Outcomes and Services Dataset User Guide MORPHOLOGY SNOMED This is the morphology of the tumour as categorised by SNOMED CT Note For use in pilot project only at present Please contact cosd ncin org uk for further details GRADE OF DIFFERENTIATION PATHOLOGICAL The definitive grade of the Tumour based on the evidence from a pathological examination so Poorly differentiated Undifferentiated anaplastic Note This data item is not applicable for CNS or Haematology diagnosis Note Please see Skin site specific dataset for further information on collecting this data item including the site specific values to be used although this data item is not used for Melanoma but is for Squamous Cell Carcinoma CANCER VASCULAR OR LYMPHATIC INVASION An indication of the presence or absence of unequivocal tumour in lymphatic and or vascular spaces 9 Not known o Note This data item is not applicable for Haematology diagnosis EXCISION MARGIN An indication of whether the excision margin was
224. h ulceration T4 gt 4 0 a w o ulceration b with ulceration REGIONAL LYMPH NODES NX Patients in whom the regional nodes cannot be assessed for example previously removed for another reason NO No regional metastases detected N1 3 Regional metastases based upon the number of metastatic nodes and presence or absence of intralymphatic metastases in transit or satellite metastases NOTE 1 3 and a c subcategories assigned as shown below N OF CLASSIFICATION No of METASTATIC NODES NODAL METASTATIC MASS N1 1 node a micrometastasis1 Author NCIN 270 Cancer Outcomes and Services Dataset User Guide b macrometastasis2 N2 2 3 nodes a micrometastasis1 b macrometastasis2 c in transit met s satellite s without metastatic nodes N3 4 or more metastatic nodes or matted nodes or in transit met s satellite s with metastatic node s Distant Metastatis M MO No detectable evidence of distant metastases 1 Metastases to skin subcutaneous or distant lymph nodes M1b Metastases to lung Mic Metastases to all other visceral sites or distant metastases to any site combined with an elevated serum LDH NOTE Serum LDH is incorporated into the M category as shown below M CLASSIFICATION SITE SERUM LDH Mia Distant skin subcutaneous or nodal mets Normal Mib Lung metastases Normal Mic All other visceral metastases Normal Any distant metastasis Elevated Notes 1 Micrometastases are diagnosed after sentinel lymph
225. he NHS SEL about cancer types key risks including causes risk factors signs and symptoms anatomy and physiology Other NHS staff can also use it to improve their understanding of cancer Module 2a Section 2 The cell cycle i by National Cancer Action Team Part of the National Cancer Programme http PH uni ncin org uk cancer eo tools training default aspx 286 Cancer Outcomes and Services Dataset User Guide APPENDIX N A STATEMENT REGARDING THE USE OF MO AND MX IN THE STAGING OF CANCERS Background TNM editions prior to TNM7 included the category MX to identify when distant metastases could not be assessed TNM7 removed this category because the overuse of the MX category meant that a large proportion of tumours was not staged a TNM group stage cannot be applied if MX is used According to the rules of TNM7 MO should be used if there is no positive evidence of distant metastases However clinical practice in the UK has persisted in using the MX category The National Staging Panel for Cancer Registration wishes to propose a modification to TNM7 to be used in England and retain the use of MX in specific circumstances When can MX be used MX may be used in the pretreatment or integrated stage when in normal circumstances further investigations would be deemed necessary to exclude distant metastases but these are not performed because either the patient has declined further investigation or the patien
226. he mammogram This will normally be the result of the mammogram taken at the first outpatient appointment at the breast clinic If the patient attends more than one breast clinic the result of each mammogram should be recorded Author NCIN 57 Cancer Outcomes and Services Dataset User Guide R5 PROCEDURE DATE BREAST ULTRASOUND Date when the ultrasound examination of the breast was carried out This will normally be the date of the first outpatient appointment at the breast clinic If the patient attends more than one breast clinic the date that each ultrasound examination of the breast was undertaken should be recorded ORGANISATION SITE CODE BREAST ULTRASOUND Provider code where ultrasound examination of the breast was carried out This will normally be the site code of the first outpatient appointment at the breast clinic If the patient attends more than one breast clinic the site code of each breast clinic where ultrasound examination of the breast was undertaken should be recorded see ORGANISATION SITE CODE BREAST ULTRASOUND EXAMINATION RESULT Result of the ultrasound examination of the breast This will normally be the result of the ultrasound examination of the breast undertaken at the first outpatient appointment at the breast clinic If the patient attends more than one breast clinic the result of each ultrasound examination of the breast should be recorded Indeterminate probably benign
227. her soft tissue D48 2 Neoplasm of Other uncertain or unknown behaviour of Peripheral nerves and autonomic nervous system D48 3 Neoplasm of Other uncertain or unknown behaviour of Retroperitoneum D48 4 Neoplasm of Other uncertain or unknown behaviour of Peritoneum D48 5 Neoplasm of Skin uncertain or unknown behaviour of Skin Author NCIN 260 Cancer Outcomes and Services Dataset User Guide ICD 10 4th Expected Dataset to be collected Edition Core All C Codes and are Site Malignant Cancer Waiting Times Specific Core Neoplasms Description Site specific group Dataset Dataset Path Only Comment D48 6 Neoplasm of Breast uncertain or unknown behaviour of Breast D48 7 Neoplasm of Other uncertain or unknown behaviour of Other specified sites D48 9 Neoplasm of Other uncertain or unknown behaviour unspecified 85 9 Amyloidosis Haematology See the Haematology chapter of COSD User unspecified Guide Section 7 2 for information regarding what is required to be submitted for these Haematology diseases 15 Although Primary amyloidosis E85 9 is listed as an E ICD code in the World Health Organisation WHO disease classification amongst clinicians it is widely acknowledged and subsequently treated as a cancer receiving Chemotherapy in cases Whilst we await the WHO disease classification being updated to reflect this fa
228. hor NCIN WBC Cytogenetics group WBC Extramedullary disease Spleen Platelets Blood Myeloblasts Blood Basophils Blood Eosinophils Hasford score Sokol score Hepatomegaly Splenomegaly Lymphadenopathy Hb Platelets Binet Rai Hb Platelets Neutrophils Marrow blasts Karyotype IPSS index Albumin Beta 2 microglobulin ISS Stage Ann Arbor stage Ann Arbor symptoms Ann Arbor extranodality Ann Arbor Bulk Nodal areas Primary Extranodal Site Hb LDH FLIPI DATA ITEM HA8150 HA8160 HA8150 HA8270 HA8000 HA8030 HA8040 HA8050 HA8060 HA8010 HA8020 HA8200 HA8210 HA8220 HA8100 HA8030 HA8240 HA8230 HA8100 HA8030 HA8130 HA8120 HA8110 HA8080 HA8550 HA8540 HA8560 HA8280 HA8290 HA8300 HA8310 HA8320 HA8330 HA8100 HA8350 HA8360 SITE SPECIFIC DATA ITEM WHITE BLOOD CELL COUNT HIGHEST PRE TREATMENT CYTOGENETIC GROUP ACUTE MYELOID LEUKAEMIA WHITE BLOOD CELL COUNT HIGHEST PRE TREATMENT EXTRAMEDULLARY DISEASE SPLEEN CM BELOW COSTAL MARGIN PLATELET COUNT BLOOD MYELOBLASTS BLOOD BASOPHILS PERCENTAGE BLOOD EOSINOPHILS PERCENTAGE SOKAL INDEX CHRONIC MYELOID LEUKAEMIA HASFORD INDEX CHRONIC MYELOID LEUKAEMIA HEPATOMEGALY INDICATOR SPLENOMEGALY INDICATOR NUMBER OF LYMPHADENOPATHY AREAS BLOOD HAEMOGLOBIN CONCENTRATION PLATELET COUNT BINET STAGE RAI STAGE BLOOD HAEMOGLOBIN CONCENTRATION PLATELET COUNT NEUTROPHIL COUNT BONE MARROW BLASTS PERC
229. hor NCIN 149 8 3 HEAD amp NECK STAGING Cancer Outcomes and Services Dataset User Guide UICC LIP AND ORAL CAVITY ICD 10 C00 C06 TNM STAGING SEVENTH EDITION Stage Grouping T Stage N Stage M Stage Stage 1 MO Stage 11 T2 NO MO Stage III T3 NO MO T1 T2 T3 N1 MO Stage IVA T4a NO N1 MO T1 T2 T3 T4a N2 MO Stage IVB Any T N3 MO T4b Any N MO Stage IVC Any T Any N M1 UICC PHARYNX TNM STAGING SEVENTH EDITION Stage Grouping T Stage N Stage M Stage Stage 1 MO Stage II T2 NO MO Stage III T3 NO MO T1 T2 T3 N1 MO Stage IVA T1 T2 T3 N2 MO T4a NO N1 N2 MO Stage IVB T4b Any N Mo Any T N3 MO Stage IVC Any T Any N M1 UICC LARYNX TNM STAGING SEVENTH EDITION Stage Grouping T Stage N Stage M Stage Stage 1 MO Stage Il T2 NO MO Stage III T1 T2 N1 MO T3 NO N1 MO Stage IVA T4a T4b NO N1 MO T1 T2 T3 N2 MO Stage IVB T4b Any N MO Any T N3 MO Stage IVC Any T Any N M1 UICC NASAL CAVITY AND PARANASAL SINUSES TNM STAGING SEVENTH EDITION Stage Grouping T Stage N Stage M Stage Stage 1 MO Stage 11 T2 NO MO Stage lll T3 NO MO T1 T2 T3 N1 MO Stage IVA T1 T2 T3 N2 MO T4a NO N1 N2 MO Author NCIN 150 Cancer Outcomes and Services Dataset User Guide Stage IVB T4b Any MO Any T N3 MO Stage IVC Any T Any N M1
230. ibule of mouth Head and Neck e C06 2 Retromolar area Head and Neck e C06 8 Overlapping lesion Head and Neck of other and unspecified parts of mouth C06 9 Mouth Head and Neck VES e unspecified C07 Malignant Head and Neck neoplasm of e parotid gland C08 0 Submandibular Head and Neck gland C08 1 Sublingual gland Head and Neck e C08 8 Overlapping lesion Head and Neck of major salivary e glands C08 9 Major salivary Head and Neck T e gland unspecified C09 0 Tonsillar fossa Head and Neck e C09 1 Tonsillar pillar Head and Neck anterior e posterior C09 8 Overlapping lesion Head and Neck m of tonsil C09 9 Tonsil unspecified Head and Neck e C10 0 Vallecula Head and Neck e Author NCIN 146 Cancer Outcomes and Services Dataset User Guide C10 1 Anterior surface of Head and Neck epiglottis C10 2 Lateral wall of Head and Neck oropharynx C10 3 Posterior wall of Head and Neck oropharynx s C10 4 Branchial cleft Head and Neck e C10 8 Overlapping lesion Head and Neck of oropharynx s 10 9 Head and Neck unspecified C11 0 Superior wall of Head and Neck nasopharynx C11 1 Posterior wall of Head and Neck nasopharynx 11 2 Lateral wall of Head and Neck nasopharynx C11 3 Anterior wall of Head and Neck nasopharynx 11 8 Overlapping lesion Head and Neck of nasopharynx
231. ich are consecutive Only Brachytherapy is included here as all other Radiotherapy details are collected from other sources This section will be recorded once per treatment where applicable Author NCIN 46 Cancer Outcomes and Services Dataset User Guide Schema specification M R O X Data item No Data Item Section Data Item Name Format CR1200 CORE RADIOTHERAPY BRACHYTHERAPY TYPE BRACHYTHERAPY TYPE The type of Brachytherapy Treatment Course being given B Interstitial Intra cavity Not otherwise specified Unsealed Source Note This data item is not applicable for Colorectal and Haematology diagnosis 1 11 CORE TREATMENT ACTIVE MONITORING To carry active monitoring details This section will be recorded once per treatment where applicable Schema specification M R O X Data item No Data Item Section Data Item Name Format CR1240 CORE ACTIVE MONITORING MONITORING INTENT MONITORING INTENT The purpose of monitoring a patient This may only be used for first definitive treatment Monitoring with future curative intent Monitoring with future palliative intent Monitoring with unknown or uncertain future intent Note This data item is not applicable for Gynaecology diagnosis although is particularly relevant to Urology Lung and some Haematology diagnosis For Urology future curative intent is equivalent to active monitoring active surveillance For Urology and Lun
232. idance eg SACT for patients treated with Chemotherapy RTDS for patient treated with Radiotherapy Scenario 2 Patient diagnosed with Cancer pre Jan 2013 receiving subsequent treatment for this primary cancer after Jan 1st 2013 COSD is not applicable Cancer Waiting Times record to be completed as per NCWTMDS guidance All other cancer datasets to be completed in accordance with specific guidance eg SACT for patients treated with Chemotherapy RTDS for patient treated with Radiotherapy Scenario 3 Patient diagnosed with Cancer pre Jan 2013 Diagnosed with a different cancer after 1st Jan 2013 COSD is applicable for the new cancer and relevant site specific and core data items should be completed Cancer Waiting Times record to be completed if applicable as per NCWTMDS guidance All other cancer datasets to be completed in accordance with specific guidance eg SACT for patients treated with Chemotherapy RTDS for patient treated with Radiotherapy Scenario 4 Patient diagnosed with Cancer pre Jan 2013 Diagnosed with a recurrence of this cancer after 1st Jan 2013 COSD is applicable for the recurrence Cancer Waiting Times record to be completed if applicable as per NCWTMDS guidance All other cancer datasets to be completed in accordance with specific guidance eg SACT for patients treated with Chemotherapy RTDS for patient treated with Radiotherapy Author NCIN 277 Cancer Outcomes and Services Dataset User Guide APPENDIX J R
233. ify a PATIENT uniquely within a Health Care Provider It may be different from the PATIENT s casenote number and may be assigned automatically by the computer system NHS NUMBER STATUS INDICATOR CODE The NHS NUMBER STATUS INDICATOR CODE indicates the verification status of the NHS number provided Number present and verified Number present but not traced Trace required Trace attempted No match or multiple match found 3 08 Trace needs to be resolved NHS Number or patient detail conflict Number not present and trace not required Trace postponed baby under six weeks old PERSON BIRTH DATE The date on which a PERSON was born or is officially deemed to have been born ORGANISATION CODE CODE OF PROVIDER The ORGANISATION CODE of the ORGANISATION acting as a Health Care Provider This is the three digit code of the organisation submitting the demographic details This will therefore normally be either the organisation where the referral is received or the treating organisation see ORGANISATION CODE PERSON FAMILY NAME That part of a PERSON s name which is used to describe family clan tribal group or marital association PERSON GIVEN NAME The forename s or given name s of a PERSON PATIENT USUAL ADDRESS AT DIAGNOSIS The PATIENT USUAL ADDRESS of the PATIENT at the time of PATIENT DIAGNOSIS Author NCIN 26 Cancer Outcomes and Services Dataset User Guide POSTCODE OF USUAL ADDRESS AT DIAGNOSIS The
234. ime of operation It is accepted that a small number of D cases are cured by further treatment such as liver resection but for COSD metastatic spread distant from the primary should always be recorded as D A Dukes A Tumour confined to wall of bowel nodes negative Tumour penetrates through the muscularis propria to involve extramural tissues nodes negative ex Dukes C1 Metastases confined to regional lymph nodes node s positive but apical node negative E Dukes C2 Metastases present in nodes at mesenteric artery ligature apical node positive Dukes D Metastatic spread outside the operative field Wim OCS Note Recording stage following neoadjuvant therapy For cases of rectal cancer particular problems will be encountered where neoadjuvant therapy is used As with other cases the modified Dukes stage will be dependent on histological examination of the resected specimen together with information obtained from radiological imaging etc There is no way of indicating using modified Dukes stage alone whether a patient has had neoadjuvant therapy although this can be identified from the NEOADJUVANT THERAPY INDICATOR and from the dates of treatments recorded Wherever possible TNM with the y prefix should be used for pathology stage fields For resected cases where there has been a complete pathological response a modified Dukes stage Author NCIN 83 Cancer Outcomes and Services Dataset User Guide can t be
235. inary organ unspecified Urological C79 0 Secondary malignant neoplasm of kidney and renal pelvis Urological Normally treated by MDT of site of primary tumour Only use if unable to code to specific primary site C79 1 Secondary malignant neoplasm of bladder and other and unspecified urinary organs Urological Normally treated by MDT of site of primary tumour Only use if unable to code to specific primary site D07 4 carcinoma in situ of penis Urological D07 5 carcinoma in situ of prostate Urological D07 6 carcinoma in situ of other and unspecified male genital organs Urological D09 0 Carcinoma in situ of Bladder Urological D09 1 carcinoma in situ of other and unspecified urinary organs Urological D40 0 Neoplasm of uncertain or unknown behaviour of prostate Urological D40 1 Neoplasm of uncertain or unknown behaviour of testis Urological D40 7 Neoplasm of uncertain or unknown behaviour of other male genital organs Urological Author NCIN 202 Cancer Outcomes and Services Dataset User Guide D40 9 Neoplasm of uncertain or unknown behaviour of male genital organs unspecifed Urological D41 0 Neoplasm of uncertain or unknown behaviour of kidney Urological D41 1 Neoplasm of uncertain or unknown behaviour of renal pelvis Urologica
236. ing microscopic examination of peripheral blood films and trephine bone marrow aspirates specimens Histology of a primary tumour Histological examination of tissue from the primary tumour 7 however obtained including all cutting and bone marrow biopsies Also includes autopsy specimens of a primary tumour 9 Unknown No information on how the diagnosis has been made e g PAS or HISS record only Histology of a metastasis Histological examination of tissues from a metastasis including autopsy Either MORPHOLOGY SNOMED or MORPHOLOGY ICDO3 should be submitted For linkage purposes MORPHOLOGY SNOMED and or MORPHOLOGY ICDO3 is required MORPHOLOGY ICD03 must be completed for all Haematology diagnoses Note Please see the Haematology Site Specific dataset for further details about collection this data item including site specific values to be used MORPHOLOGY SNOMED This is the PATIENT DIAGNOSIS for the cell type of the malignant disease recorded as part of a Cancer Care Spell This can be recorded as well as or instead of MORPHOLOGY ICDO3 Format MXXXXX MORPHOLOGY SNOMED This is the PATIENT DIAGNOSIS using the SNOMED CT code for the cell type of the malignant disease recorded as of a Cancer Care Spell Note For use in pilot project only at present Please contact cosd ncin org uk for further details MORPHOLOGY ICDO3 The morphology code for the diagnosed cancer as defined by ICDO3 Format MXXXXX
237. ipated but is now completed This has however provided the opportunity to review and improve the initial specification and the revised Level 3 reports are expected to be available during the first quarter of 2014 We would like to take this opportunity to thank all those who have been involved in the development and implementation of the Standard and encourage you to continue to send us your comments which help to identify necessary amendments and improvements Trish Stokes Datasets Programme Manager NCIN October 2013 Author NCIN 10 Cancer Outcomes and Services Dataset User Guide WHATS CHANGED SINCE VERSION 2 0 Below notes the significant changes that have occurred since the last version of the User Guide CORE Change data item name and description to clarify the point in the pathway when these items are recorded These changes affect e CONSULTANT CODE FIRST SEEN Core dataset CRO210 e CARE PROFESSIONAL MAIN SPECIALTY CODE FIRST SEEN Core dataset CRO220 e CONSULTANT CODE TREATMENT Core dataset CRO660 e CARE PROFESSIONAL MAIN SPECIALTY CODE TREATMENT Core dataset CRO670 Change data item format to allow recording to 2 decimal places max nX max n2 in order to standardise measurement items and enable a greater degree of accuracy where applicable This change affects e LESION SIZE RADIOLOGICAL Core dataset CRO350 e LESION SIZE PATHOLOGICAL Core dataset CRO830 Additional value Other
238. ired if the request comes from a GENERAL MEDICAL PRACTITIONER Author NCIN 52 Cancer Outcomes and Services Dataset User Guide 1 13 CORE DEATH DETAILS To carry death details not required for direct submission by Providers This section is recorded once Schema Data Item Section Data Item Name Format specification Data item M R O X No CORE DEATH an10 ccyy mm CORE DEATH DEATH LOCATION PERSON DEATH DATE The date on which a PERSON died or is officially deemed to have died DEATH LOCATION TYPE The type of LOCATION at which a PERSON died Patient s own home 1 14 CORE CANCER RECURRENCE SECONDARY CANCER THE FOLLOWING SECTION IS ONLY APPLICABLE WHERE A DIAGNOSIS OF RECURRENT SECONDARY METASTATIC CANCER HAS BEEN MADE THESE DETAILS ARE NOT APPLICABLE WHERE METASTATIC CANCER IS IDENTIFIED AT THE SAME TIME AS THE PRIMARY DIAGNOSIS A NEW RECORD IS REQUIRED FOR EACH RECURRENCE DIAGNOSIS To carry details of metastatic secondary cancer recurrence This section will be recorded once where applicable Schema Data Item Section Data Item Name Format specification M R O X CRO440 CORE DIAGNOSTIC DATE OF RECURRENCE an10 ccyy DETAILS CLINICALLY AGREED mm dd CORE CANCER RECURRENCE SOURCEOFREFERRALFOR SECONDARY CANCER Data item No eee KEY WORKER SEEN INDICATOR CR1540 RECURRENCE CANCER RECURRENCE 1 SECONDARY CANCER CORE CANCER PALLIATIVE CARE
239. is section will be recorded once Data item Data Item Section Data Item Name Format specification M R O X COLORECTAL SYNCHRONOUS TUMOUR INDICATOR CO5060 ani DIAGNOSIS CAECUM COLORECTAL SYNCHRONOUS TUMOUR INDICATOR CO5070 ani DIAGNOSIS APPENDIX COLORECTAL SYNCHRONOUS TUMOUR INDICATOR CO5080 ani DIAGNOSIS ASCENDING COLON COLORECTAL SYNCHRONOUS TUMOUR INDICATOR CO5090 ani DIAGNOSIS HEPATIC FLEXURE COLORECTAL SYNCHRONOUS TUMOUR INDICATOR CO5100 ani DIAGNOSIS TRANSVERSE COLON COLORECTAL SYNCHRONOUS TUMOUR INDICATOR CO5110 ani DIAGNOSIS SPLENIC FLEXURE COLORECTAL SYNCHRONOUS TUMOUR INDICATOR CO5120 ani DIAGNOSIS DESCENDING COLON COLORECTAL SYNCHRONOUS TUMOUR INDICATOR CO5130 ani DIAGNOSIS SIGMOID COLON COLORECTAL SYNCHRONOUS TUMOUR INDICATOR CO5140 ani DIAGNOSIS RECTOSIGMOID COLORECTAL SYNCHRONOUS TUMOUR INDICATOR CO5150 ani DIAGNOSIS RECTUM COLORECTAL CO5160 TUMOUR HEIGHT ABOVE ANAL VERGE max n2 DIAGNOSIS SYNCHRONOUS TUMOUR INDICATOR CAECUM Record any synchronous tumours in the Caecum as identified by the clinician at presentation Synchronous tumours are defined as discrete tumours apparently Author NCIN 79 Cancer Outcomes and Services Dataset User Guide not in continuity with other primary cancers originating in the same site or tissue Note If Yes a separate registration is required Yes o lt 2 O I 2 2 c o
240. ites Lung within the respiratory e system C40 0 Scapula and long Sarcoma bones of upper limb 40 1 Short bones of upper Sarcoma 7 limb 40 2 Long bones of lower Sarcoma limb C40 3 Short bones of lower Sarcoma limb Author NCIN 225 ICD 10 4th Edition All C Codes are Malignant Neoplasms C40 8 Cancer Outcomes and Services Dataset User Guide Description Overlapping lesion of bone and articular cartilage of limbs Cancer Waiting Times Site specific group Sarcoma Expected Dataset to be collected Core and Site Specific Core Path Dataset Dataset Only Comment C40 9 Bone and articular cartilage of limb unspecified Sarcoma C41 0 Bones of skull and face Sarcoma C41 1 Mandible Sarcoma C41 2 Vertebral column Sarcoma C41 3 Ribs sternum and clavicle Sarcoma C41 4 Pelvic bones sacrum and coccyx Sarcoma C41 8 Overlapping lesion of bone and articular cartilage Sarcoma C41 9 Bone and articular cartilage unspecified Sarcoma C43 0 Malignant melanoma of lip Skin C43 1 Malignant melanoma of eyelid including canthus Skin C43 2 Malignant melanoma of ear and external auricular canal Skin C43 3 Malignant melanoma of other and unspecified parts of face Skin C43 4 Malignant melanoma of scalp and neck Skin C43 5 Malignant melanoma
241. ith planned conversion to open surgery SURGICAL ACCESS THORACIC The approach used to perform the thoracic part of the main procedure Author NCIN 195 Cancer Outcomes and Services Dataset User Guide Thoracoscopic converted to open Thoracoscopic completed Not applicable SURGICAL PALLIATION TYPE Type of surgical palliation performed if any e g Hepaticojejunostomy gastric bypass biliary bypass gastric biliary bypass celiac plexus block Not known LIVER TRANSPLANTATION Was a liver transplant performed Yes SURGICAL COMPLICATIONS The types of post operative complications that the patient experiences between the time of the operation and his her discharge from hospital or death A complication is defined as a development of clinical significance that requires intervention i e alteration in the patient s management plan NB re operation radiological intervention or readmission to critical care is NOT required 00 No complications Pneumonia 02 Acute respiratory distress syndrome ARDS 03 Pulmonary embolism 04 Pleural effusion 05 Anastomotic leak 06 Chyle leak 07 Haemorrhage 08 O Cardiac complication 09 Acute renal failure Wound infection liver failure gastric outlet obstruction 98 99 pancreatic leak biliary leak gastric anastomotic leak pancreatic endocrine insufficiency pancreatic exocrine insufficiency early delayed gastric emptying Duode
242. l D41 2 Neoplasm of uncertain or unknown behaviour of ureter Urological D41 3 Neoplasm of uncertain or unknown behaviour of urethra Urological D41 4 Neoplasm of uncertain or unknown behaviour of bladder Urological D41 7 Neoplasm of uncertain or unknown behaviour of other urinary organs Urological D41 9 Neoplasm of uncertain or unknown behaviour of urinary organs unspecified Urological For tumours in unusual sites where there is overlap between a dataset based on anatomy and another based on the disease description it is recommended that both datasets are completed For example for a melanoma of the penis both the penile and the melanoma dataset should be completed 13 1 UROLOGY CANCER CARE PLAN To carry the cancer care plan details for Urology There may be a number of cancer care plans on different dates This section will be recorded once Author NCIN 203 Cancer Outcomes and Services Dataset User Guide Schema Data item M R O X Data Item Section Data Item Name Format specification No UROLOGY CANCER ESTIMATED GLOMERULAR FILTRATION UR15000 max n2 CARE PLAN RATE UROLOGY CANCER HYDRONEPHROSIS UR15010 an1 CARE PLAN HYDRONEPHROSIS CODE NORMAL LDH UROLOGY CANCER UR15020 LACTATE DEHYDROGENASE LEVEL CARE PLAN NORMAL UPPER LIMIT 1 UROLOGY CANCER S CATEGORY AFP CARE PLAN S CATEGORY
243. l cancer is clinical but nodal status may be an important prognostic factor and determinant of management options including the need for adjuvant therapy This could be derived from NODES EXAMINED NUMBER PELVIC and NODES POSITIVE NUMBER PELVIC but may also be entered separately Regional lymph nodes cannot be assessed No regional lymph node metastases Regional lymph node metastases NODES EXAMINED NUMBER PARA AORTIC The number of para aortic nodes examined Not applicable for vulval cancers Use 0 if nodes not sent NODES POSITIVE NUMBER PARA AORTIC The number of para aortic nodes reported as being positive for the presence of tumour metastases Not applicable for vulval cancers NODES EXAMINED NUMBER PELVIC The number of pelvic nodes examined Not applicable for vulval cancers Use 0 if nodes not sent NODES POSITIVE NUMBER PELVIC The number of pelvic nodes reported as being positive for the presence of tumour metastases Not applicable for vulval cancers NODES EXAMINED NUMBER INGUINO FEMORAL The number of inguino femoral nodes examined Only applicable to vulval cancers Use 0 if nodes not sent Author NCIN 121 Cancer Outcomes and Services Dataset User Guide NODES POSITIVE NUMBER INGUINO FEMORAL The number of inguino femoral nodes reported as being positive for the presence of tumour metastases Only applicable to vulval cancers EXTRANODAL SPREAD Is there evidence of extranodal spread extension
244. lip Head and Neck e C00 2 External lip Head and Neck unspecified C00 3 Upper lip inner Head and Neck aspect C00 4 Lower lip inner Head and Neck aspect C00 5 Lip unspecified Head and Neck inner aspect C00 6 Commissure of lip Head and Neck C00 8 Overlapping lesion Head and Neck of lip C00 9 Lip unspecified Head and Neck C01 Malignant Head and Neck neoplasm of base of tongue C02 0 Dorsal surface of Head and Neck tongue C02 1 Border of tongue Head and Neck C02 2 Ventral surface of Head and Neck tongue C02 3 Anterior two thirds Head and Neck of tongue part unspecified C02 4 Lingual tonsil Head and Neck C02 8 Overlapping lesion Head and Neck of tongue Author NCIN 145 Cancer Outcomes and Services Dataset User Guide C02 9 Tongue Head and Neck a unspecified C03 0 Upper gum Head and Neck e C03 1 Lower gum Head and Neck e C03 9 Gum unspecified Head and Neck C04 0 Anterior floor of Head and Neck mouth C04 1 Lateral floor of Head and Neck mouth C04 8 Overlapping lesion Head and Neck e of floor of mouth C04 9 Floor of mouth Head and Neck unspecified C05 0 Hard palate Head and Neck e C05 1 Soft palate Head and Neck C05 2 Uvula Head and Neck e C05 8 Overlapping lesion Head and Neck of palate 5 9 Palate unspecified Head and Neck 6 0 Cheek mucosa Head and Neck C06 1 Vest
245. llicular lymphoma Haematological grade iiib C82 5 Diffuse follicle centre Haematological lymphoma C82 6 Cutaneous follicle Haematological centre lymphoma C82 7 Other types of Haematological follicular lymphoma C82 9 Follicular lymphoma Haematological unspecified C83 0 Small cell B cell Haematological lymphoma C83 1 Mantle cell Haematological lymphoma C83 3 Diffuse large B cell Haematological lymphoma Author NCIN 243 Cancer Outcomes and Services Dataset User Guide ICD 10 4th Expected Dataset to be collected Edition All C Codes Core and are Cancer Waiting Site Malignant Times Site Specific Core Path Neoplasms C83 5 Description Lymphoblastic diffuse lymphoma specific group Dataset Dataset Only Comment Haematological C83 7 Burkitt lymphoma Haematological C83 8 Other non follicular lymphoma Haematological C83 9 Non follicular diffuse lymphoma unspecified Haematological C84 0 Mycosis fungoides Haematological C84 1 Sez ry disease Haematological C84 4 Peripheral T cell lymphoma not elsewhere classified Haematological C84 5 Other mature T NK cell lymphomas Haematological C84 6 Anaplastic large cell lymphoma ALK positive Haematological C84 7 Anaplastic large cell lymphoma ALK negative Haematological C84 8 Cutaneous T cell lymphoma unspecified Haematological C84 9 Ma
246. logy details for head and neck cancer This section will be recorded once per pathology report where applicable Schema Data item No Data Item Section Data Item Name Format specification M R O X POSITIVE NODES LATERALITY HEAD amp NECK PATHOLOGY HN9400 ANATOMICAL SIDE POSITIVE GENERAL and SALIVARY NODES Author NCIN 155 Cancer Outcomes and Services Dataset User Guide LARGEST METASTASIS LEFT HEAD amp NECK PATHOLOGY NECK GENERAL and SALIVARY LARGEST METASTASIS LEFT NECK LARGEST METASTASIS RIGHT HEAD amp NECK PATHOLOGY NECK HANSAEN GENERAL and SALIVARY LARGEST METASTASIS RIGHT NECK EXTRACAPSULAR SPREAD HEAD amp NECK PATHOLOGY HN9430 EXTRACAPSULAR SPREAD GENERAL and SALIVARY INDICATION CODE POSITIVE NODES LATERALITY If nodes positive specify laterality Not applicable LARGEST METASTASIS LEFT NECK If Neck dissected on Left side the size in mm of the largest metastasis LARGEST METASTASIS RIGHT NECK If Neck dissected on Right side the size in mm of the largest metastasis EXTRACAPSULAR SPREAD Invasion of metastatic tumour outside the capsule of a lymph node Present Absent Not assessable Author NCIN 156 Cancer Outcomes and Services Dataset User Guide 9 LUNG OVERVIEW Some items in the Lung site specific dataset may not be available until sometime after the initial record has been uploaded For surgery patients treatment record and pa
247. ls in bone marrow aspirate as percentage of all nucleated cells Normally taken from laboratory report on diagnostic bone marrow Range 0 20 NEUTROPHIL COUNT Blood neutrophil count n dl Normally provided by Haematology lab before transfusion treatment Range 0 0 to 999 9 to 1dp Range 10 to 80 ALBUMIN LEVEL Level in serum of albumin as g per litre measured pre treatment Normally provided from Biochemistry laboratory before treatment BETA2 MICROGLOBULIN LEVEL Level in serum of beta 2 microglobulin as mg per litre measured pre treatment Normally provided from Biochemistry laboratory before treatment Range 0 0 to 99 9 to 1dp BLOOD LYMPHOCYTE COUNT Number of lymphocytes in blood measured pre treatment Normally provided by Haematology lab before transfusion treatment Range 0 0 to 99 9 to 1dp LACTATE DEHYDROGENASE LEVEL Lactate Dehydrogenase level in serum measured pre treatment Normally provided from Biochemistry laboratory before treatment Above normal Not above normal Test not done BLOOD MYELOBLASTS PERCENTAGE Myeloblasts as percentage of total white cells Normally provided by Haematology lab before transfusion treatment Range 0 100 BLOOD BASOPHILS PERCENTAGE Basophils as percentage of total white cells Normally provided by Haematology lab before transfusion treatment Range 100 BLOOD EOSINOPHILS PERCENTAGE Eosinophils as percentage of total white cells Normall
248. m behaviour of Craniopharyngeal duct D44 5 Neoplasm of Brain Central uncertain or Nervous unknown System behaviour of pineal gland 3 1 CENTRAL NERVOUS SYSTEM IMAGING To carry imaging details for Central Nervous System cancer This section will be recorded once _ Schema Data item Data Item Section Data Item Name Format specification No M R O X CENTRAL NERVOUS LESION LOCATION BA3000 an2 SYSTEM IMAGING RADIOLOGICAL CENTRAL NERVOUS NUMBER OF LESIONS BA3020 max n2 SYSTEM IMAGING RADIOLOGICAL CENTRAL NERVOUS max BA3030 LESION SIZE RADIOLOGICAL SYSTEM IMAGING n3 max n2 Start of repeating item Features of Lesions Radiological FEATURES OF LARGEST LESION CENTRAL NERVOUS RADIOLOGICAL SYSTEM IMAGING LARGEST LESION FEATURES RADIOLOGICAL BA3040 End of repeating item Features of Lesions Radiological CENTRAL NERVOUS PRINCIPAL DIAGNOSTIC IMAGING BA3050 an1 SYSTEM IMAGING TYPE LESION LOCATION RADIOLOGICAL Radiologically determined anatomical location of lesion largest lesion if more than one or where centred This is recorded prior to treatment Frontal lobe Author NCIN 69 Cancer Outcomes and Services Dataset User Guide s i T 5 i T i i T n 2 5 7 2 x T 2 5 x 7 x x 0 n D 5 a Author NCIN 70 Cancer Outcomes and Services Dataset User Guide 39 99 ees NUMBER OF LESIONS RADIOLOGICAL Radiol
249. m and Sarcoma clavicle C41 4 Pelvic bones Sarcoma sacrum and coccyx Author NCIN 166 Cancer Outcomes and Services Dataset User Guide C41 8 Overlapping lesion Sarcoma of bone and articular cartilage C41 9 Bone and articular Sarcoma cartilage unspecified C46 0 Kaposi sarcoma of Sarcoma skin C46 1 Kaposi sarcoma of Sarcoma soft tissue C46 2 Kaposi sarcoma of Sarcoma palate C46 3 Kaposi sarcoma of Sarcoma lymph nodes C46 7 Kaposi sarcoma of Sarcoma other sites C46 8 Kaposi sarcoma of Sarcoma multiple organs C46 9 Kaposi sarcoma Sarcoma unspecified C47 0 Peripheral nerves of Brain Central Usually head face and neck Nervous treated by System Sarcoma MDT C47 1 Peripheral nerves of Brain Central Usually upper limb Nervous treated by including shoulder System Sarcoma MDT C47 2 Peripheral nerves of Brain Central Usually lower limb Nervous treated by including hip System Sarcoma MDT C47 3 Peripheral nerves of Brain Central Usually thorax Nervous treated by System Sarcoma MDT C47 4 Peripheral nerves of Brain Central Usually abdomen Nervous treated by System Sarcoma MDT C47 5 Peripheral nerves of Brain Central Usually pelvis Nervous treated by System Sarcoma MDT C47 6 Peripheral nerves of Brain Central Usually trunk unspecified Nervous treated by System Sarcoma MDT 47 8 Overlapping lesion Brain Central Usually of pe
250. ma MDT C47 3 Peripheral nerves of Brain Central Usually thorax Nervous System treated by Sarcoma MDT C47 4 Peripheral nerves of Brain Central Usually abdomen Nervous System treated by Sarcoma MDT 47 5 Peripheral nerves Brain Central Usually pelvis Nervous System treated by Sarcoma MDT C47 6 Peripheral nerves of Brain Central Usually trunk unspecified Nervous System e treated by Sarcoma MDT C47 8 Overlapping lesion of Brain Central Usually peripheral nerves and Nervous System treated by autonomic nervous Sarcoma system MDT C47 9 Peripheral nerves and Brain Central Usually autonomic nervous Nervous System treated by system unspecified Sarcoma MDT C48 0 Retroperitoneum Sarcoma Usually treated by Sarcoma MDT C48 1 Specified parts of Sarcoma Sarcoma peritoneum and Gynaecology Datasets to be collected where applicable Author NCIN 230 Cancer Outcomes and Services Dataset User Guide ICD 10 4th Expected Dataset to be collected Edition All C Codes Core and are Cancer Waiting Site Malignant Times Site Specific Core Path Neoplasms Description specific group Dataset Dataset Only Comment C48 2 Peritoneum Sarcoma Sarcoma unspecified and Gynaecology Datasets to be collected where applicable C48 8 Overlapping lesion of Sarcoma retroperitoneum and peritoneum 49 0 Connective and soft Sarc
251. mary site C78 1 Secondary malignant Lung Normally neoplasm of treated by mediastinum MDT of site of primary e tumour Only use if unable to code to specific primary site C78 2 Secondary malignant Lung Normally neoplasm of pleura treated by MDT of site of primary e tumour Only use if unable to code to specific primary site C78 3 Secondary malignant Lung Normally neoplasm of other treated by and unspecified MDT of site respiratory organs of primary e tumour Only use if unable to code to specific primary site Author NCIN 239 Cancer Outcomes and Services Dataset User Guide ICD 10 4th Expected Dataset to be collected Edition All C Codes Core and are Cancer Waiting Site Malignant Times Site Specific Core Path Neoplasms Description C78 4 Secondary malignant neoplasm of small intestine specific group Colorectal Only Comment Normally treated by MDT of site of primary tumour Only use if unable to code to specific primary site C78 5 Secondary malignant neoplasm of large intestine and rectum Colorectal Normally treated by MDT of site of primary tumour Only use if unable to code to specific primary site C78 6 Secondary malignant neoplasm of retroperitoneum and peritoneum Sarcoma Normally treated by MDT of site of primary tumour Only use if unable to code to specific primary site C78 7 Secondary malignant neoplasm
252. meters Note This should be available for the MDT discussion but will only apply to a small number of cases Favourable Unfavourable CYTOGENETIC RISK CLASSIFICATION NEUROBLASTOMA Risk allocation based on cytogentic findings Favourable Unfavourable Other Non informative Not known INTERNATIONAL NEUROBLASTOMA STAGING SYSTEM International Neuroblastoma Staging System Children s Oncology Group Neuroblastoma Risk Grouping http www cancer gov cancertopics pdg treatment neuroblastoma HealthProfessional page3 STAGE 1 Localised tumour with complete gross excision with or without microscopic residual disease representative ipsilateral lymph nodes negative for tumour microscopically nodes attached to and removed with the primary tumour may be positive Author NCIN 97 Cancer Outcomes and Services Dataset User Guide e STAGE 2A Localised tumour with incomplete gross excision representative ipsilateral nonadherent lymph nodes negative for tumour microscopically e STAGE 2B Localised tumour with or without complete gross excision with ipsilateral nonadherent lymph nodes positive for tumour Enlarged contralateral lymph nodes must be negative microscopically e STAGE 3 Unresectable unilateral tumour infiltrating across the midline with or without regional lymph node involvement or localised unilateral tumour with contralateral regional lymph node involvement or midline tumour with bilateral extension by in
253. n Arbor Extranodality Ann Arbor Bulk SKIN AJCC Stage group UROLOGY Stage group Testicular Author NCIN 273 Cancer Outcomes and Services Dataset User Guide APPENDIX WHEN TO COMPLETE AND SUBMIT THE DATA The following table shows the point in the pathway event when the different sections of the dataset are expected to be completed and submitted Once the relevant Pathway Event Trigger has occurred the related field see Key to Pathway Events should be completed along with other applicable data items in the sections noted Data items marked as Mandatory in the relevant section of the dataset must be submitted for the record to pass validation rules Items marked Required should be submitted where applicable and as soon as possible after the initial record is uploaded Once the trigger event has occurred the record should be sent in the next submission 25 working days after month end Every effort should be made to complete all the applicable items in that section before submission where possible Any missing items should ideally be completed and submitted within three months of diagnosis or of subsequent treatment however the final deadline for completion of relevant items is six months after month of diagnosis or subsequent treatment Although the final deadline for completion of relevant items is six months after month of diagnosis or subsequent treatment the English National Cancer Registration Service follows
254. n renas eraan esna E e as ea aE Esa iea nst 1 11 CORE TREATMENT ACTIVE MONITORING sees nnns 112 CORE PATHOLOGY irsinin 1 13 CORE DEATH DETAILS sccesccistuscccsnecvecestcnepsosnateudeabtebesucnervesechetetantnewcudeshrabocuegaviycashanstcagesunadestartesastactucsahede 1 14 CORE CANCER RECURRENCE SECONDARY CANCER c cesceseeseesceseeeeeeecaeeaecueeeeceaeceeeaecaeseesneeereaeeaseaeeas 2 H ein CD 1O CODES i Em 2 1 BREAST REFERRALS REN RES EER ESE ELSNER AEE IAES REESE a pA iWxEEuccm M 2 3 BREAST CANCER CARE PLAN inar E een oes p Rau nh ee ey hu eR AER REY REB ERR EREEREER 2 4 BREAST SURGERY AND OTHER PROCEDURES essen enn nennen 2 5 BREAST STAGING c EEEE SEESE 2 6 BREAST PATHOLOGY isisisi grinneis aannaaien toran aiar Eran ES E ADEN EEEE KESE E ERE EEEa 3 CENTRAL NERVOUS SYSTEM CNS cescceseceecesecececaeecseeeaeeeesseeeeeesecsaeceaeceaecaaecaeecaeseaeseaeeeaeerseeeeeaeseaeeeaeenaes OVERVIEW NETESE RAES EENES SEA ICD TO CODES ET 3 1 CENTRAL NERVOUS SYSTEM
255. n to PROCEDURE OPCS Note For use in pilot project only at present Please contact cosd ncin org uk for further details DISCHARGE DATE HOSPITAL PROVIDER SPELL The date a PATIENT was discharged from a Hospital Provider Spell DISCHARGE DESTINATION HOSPITAL PROVIDER SPELL This records the destination of a PATIENT on completion of the Hospital Provider Spell It can also indicate that the PATIENT died Usual place of residence unless listed below for example a private dwelling whether owner occupied or owned by local authority housing association or other landlord This includes wardened accommodation but not residential accommodation where health care is provided It also includes PATIENTS with no fixed abode Temporary place of residence when usually resident elsewhere includes hotel residential educational establishment Repatriation from high security psychiatric accommodation in an NHS Hospital Provider NHS Provider Penal establishment or police station High Security Psychiatric Hospital Scotland Not applicable PATIENT died or still birth Non NHS run hospital Non NHS other than Local Authority run Hospice Default Codes Not applicable hospital provider spell not finished at episode end i e not discharged or current episode unfinished i i i i i i 66 1 10 CORE TREATMENT RADIOTHERAPY To carry the radiotherapy details A course of radiotherapy is defined as a string of prescriptions wh
256. nal suture line leak Anastomotic stricture Other Not known UNPLANNED RETURN TO THEATRE INDICATOR Whether or not the patient required a second unplanned operation during the same admission as the primary procedure Author NCIN 196 Cancer Outcomes and Services Dataset User Guide Not known POST OPERATIVE TUMOUR SITE UPPER The main cancer site for which the patient is receiving care as established in the resected specimen Please note that Cardia should no longer be used to describe adenocarcinomas located at the gastro oesophageal junction Instead these tumours should be described by the appropriate Siewert type 01 02 03 04 05 Oesophagus upper third Oesophagus middle third Oesophagus lower third Siewert 1 Siewert 2 Siewert 3 Fundus Body of stomach Antrum Pylorus PALLIATIVE TREATMENT REASON UPPER Gl Rationale for palliative treatment Extensive intrahepatic disease Widespread disease Both extensive intrahepatic and widespread disease Le Biliary obstruction Gastric outlet obstruction 12 6 UPPER GI LIVER METASTASES and LIVER HEPATOCELLULAR CARCINOMA To carry other procedure details for Liver Metastases and Liver Carcinoma This section will be recorded once per treatment where applicable Schema Data item A Data Item Section Data Item Name Format specification M R O X No UPPER GI LIVER UG13560 ABLATIVE THERAPY TYPE an1 M METS and LIVER HCC TRANS ARTER
257. ncer This section can be recorded more than once Data item Data Item Section Data Item Name Format specification o M R 0 X HN9440 HEAD amp NECK PATHOLOGY INVESTIGATION RESULT 10 ccyy Author NCIN 153 Cancer Outcomes and Services Dataset User Guide HEAD amp NECK PATHOLOGY SERVICE REPORT HN9450 max 18 GENERAL IDENTIFIER INVESTIGATION RESULT DATE The date on which an investigation was concluded e g the date the result was authorised SERVICE REPORT IDENTIFIER A unique identifier of a SERVICE REPORT 8 4 HEAD amp NECK PATHOLOGY VARIOUS To carry pathology details for various head and neck cancer This section will be recorded once per pathology report where applicable Schema Data item Su Data Item Section Data Item Name Format specification No M R O X HEAD amp NECK PATHOLOGY MAXIMUM DEPTH OF HN9300 max n3 VARIOUS INVASION BONE INVASION HEAD amp NECK PATHOLOGY HN9310 BONE INVASION INDICATION an1 VARIOUS CODE CARTILAGE INVASION HEAD amp NECK PATHOLOGY HN9320 CARTILAGE INVASION an1 VARIOUS INDICATION CODE NECK DISSECTION LATERALITY HEAD amp NECK PATHOLOGY HN9330 ANATOMICAL SIDE NECK an1 VARIOUS DISSECTION MAXIMUM DEPTH OF INVASION The maximum depth of invasion in mm Record as 00 to indicate not applicable This is not applicable for nasopharynx hypopharynx nasal cavity or sinuses BONE INVASION BO
258. ndary Brain Central Normally malignant Nervous treated by MDT neoplasm of brain System of site of and cerebral primary tumour meninges Only use if unable to code to specific primary site C79 4 Secondary Brain Central Normally malignant Nervous treated by MDT neoplasm of other System of site of and unspecified primary tumour parts of nervous Only use if system unable to code to specific primary site D32 0 benign neoplasm Brain Central of cerebral Nervous meninges System D32 1 benign neoplasm Brain Central of spinal meninges Nervous System D32 9 benign neoplasm Brain Central of meninges Nervous unspecified System D33 0 Benign neoplasm Brain Central of brain Nervous supratentorial System D33 1 Benign neoplasm Brain Central of brain Nervous infratentorial System D33 2 Benign neoplasm Brain Central of brain Nervous unspecified System D33 3 Benign neoplasm Brain Central of cranial nerves Nervous System D33 4 Benign neoplasm Brain Central of spinal cord Nervous System D33 7 Benign neoplasm Brain Central of other specified Nervous parts of central System nervous system D33 9 Benign neoplasm Brain Central of central nervous Nervous system System unspecified D35 2 Benign neoplasm Brain Central of Pituitary gland Nervous System Author NCIN 67 Cancer Outcomes and Services Dataset User Guide D35 3 Benign neoplasm Other Usually treated of by CNS MDT Cr
259. ne Upper Gastrointestinal D37 3 Neoplasm of uncertain or unknown behaviour of Appendix Colorectal D37 4 Neoplasm of uncertain or unknown behaviour of Colon Colorectal D37 5 Neoplasm of uncertain or unknown behaviour of Rectum Colorectal Author NCIN 253 ICD 10 4th Edition All C Codes are Malignant Neoplasms D37 6 Cancer Outcomes and Services Dataset User Guide Description Liver gallbladder and bile ducts Cancer Waiting Times Site specific group Upper Gastrointestinal Expected Dataset to be collected Core and Site Specific Dataset Core Dataset Path Only Comment D37 7 Other digestive organs Colorectal Upper Gastrointestinal D37 9 Digestive organ unspecified Colorectal Upper Gastrointestinal D38 0 Neoplasm of uncertain or unknown behaviour of Larynx Head and Neck D38 1 Neoplasm of uncertain or unknown behaviour of Trachea bronchus and lung Lung D38 2 Neoplasm of uncertain or unknown behaviour of Pleura Lung D38 3 Neoplasm of uncertain or unknown behaviour of Mediastinum Lung D38 4 Neoplasm of uncertain or unknown behaviour of Thymus Lung D38 5 Neoplasm of uncertain or unknown behaviour of Other respiratory organs Lung D38 6 Neoplasm of uncertain or unknown behaviour of Respiratory organ unspecified Lung
260. ng to the first stage of the Patient Pathway Note This section will only be completed for Primary cancer diagnoses For Recurrent cancers the section labelled CANCER RECURRENCE SECONDARY CANCER will be completed instead SOURCE OF REFERRAL FOR OUT PATIENTS or SOURCE OF REFERRAL FOR CANCER RECURRENCE can be recorded This section will be recorded once See Appendix J for Referral scenarios Data Data Item Data Item Format specification item No Section M R O X CORE SOURCE OF REFERRAL FOR OUT cus CORE REFERRAL TREATMENT PERIOD CR1580 REFERRALS START DATE ARID eyy iaa M CR0230 CORE DATE FIRST SEEN an10 ccyy mm dd M REFERRALS yy CRO210 Pore CONSULTANT CODE FIRST SEEN M REFERRALS CORE CARE PROFESSIONAL MAIN CRO220 REFERRALS SPECIALTY CODE FIRST SEEN M ORGANISATION SITE CODE CR1410 CORE PROVIDER FIRST SEEN minimum length an5 REFERRALS SITE CODE OF PROVIDER FIRST maximum length an9 SEEN CORE DATE FIRST SEEN CANCER CR1360 REFERRALS SPECIALIST arcade ORGANISATION SITE CODE PROVIDER FIRST CANCER CR1400 SPECIALIST TUE SITE CODE OF PROVIDER FIRST 8 CANCER SPECIALIST CORE CANCER OR SYMPTOMATIC CRO270 REFERRALS BREAST REFERRAL PATIENT STATUS CORE CANCER SYMPTOMS FIRST NOTED CR2000 REFERRALS DATE max an10 ccyy mm dd DEBE SOURCE OF REFERRAL FOR OUT PATIENTS CWT This identifies the source of referral of each Consultant Out Patient Episo
261. nge data item format to allow recording to 2 decimal places max nX max n2 in order to standardise measurement items and enable a greater degree of accuracy where applicable This change affects e FINAL EXCISION MARGIN AFTER WIDE LOCAL EXCISION Skin dataset SK12450 Change data item format from max n2 to max n3 and remove range restriction in order to capture actual value recorded Change of data item name to MITOTIC RATE SKIN in order to differentiate it from item in the Sarcoma dataset These changes affect e MITOTIC RATE Skin dataset SK12590 UPPER GI Deletion of value Cardia 11 national code as it is no longer used This change affects e POST OPERATIVE TUMOUR SITE UPPER GI Upper GI dataset UG14230 APPENDIX A e Missing D codes 005 0 005 1 D05 7 and 005 9 added to Cancer Waiting Times ICD10 Codes and Tumour Groups for Primary Diagnoses APPENDIX B Although Primary amyloidosis E85 9 is listed as an E ICD code in the World Health Organisation WHO disease classification amongst clinicians it is widely acknowledged and subsequently treated as a cancer receiving Chemotherapy in cases Whilst we await the WHO disease classification being updated to reflect this fact we are proposing extending the scope of the COSD to include this The United Kingdom and Ireland Association of Cancer Registries UKIACR is currently considering its inclusion in the UKIACR Library of Recommendations Author NCIN 13 Cancer
262. nical cancers greater than stage IA IB1 Clinically visible lesion lt 4 0cm in greatest dimension IB2 Clinically visible lesion 24 0cm in greatest dimension Stage ll Cervical carcinoma invades beyond the uterus but not to pelvic wall or to lower third of vagina Stage IIA Without parametrial invasion HAL Clinically visible lesion lt 4 0cm in greatest dimension 2 Clinically visible lesion gt 4 0cm in greatest dimension IIB Tumour with parametrial invasion Stage III Tumour extends to pelvic wall and or involves lower third of vagina and or causes hydronephrosis or non functioning kidney Tumour involves lower third of vagina with no extension to the pelvic wall Author NCIN 112 Cancer Outcomes and Services Dataset User Guide IIB Tumour extends to pelvic wall and or hydronephrosis or non functioning kidney Stage IV The carcinoma has extended beyond the true pelvis or has involved biopsy proven the mucosa of the bladder or rectum A bullous edema as such does not permit a case to be allotted to Stage IV IVA Spread of the tumour to adjacent organs IVB Spread to distant organs ENDOMETRIAL pre Description Stage Tumour confined to corpus uteri IA No or lt half myometrial invasion IB Invasion equal to or more than half of the myometrium Il Tumour invades cervical stroma but does not extend beyond uterus Stage III
263. nly apply to a small number of cases The following definitions are used Favourable sites Orbit genitourinary Non Bladder Prostate Non Parameningeal Head and Neck Unfavourable sites All other sites of disease Favourable Unfavourable i SARCOMA TUMOUR SITE SOFT TISSUE OTHER THAN RHABDOMYOSARCOMA Location of the soft tissue sarcoma within the body more specific than ICD10 ICDO3 sites 2272 2301 2459 2533 Peritoneum 7891 Shoulder Author NCIN 100 Cancer Outcomes and Services Dataset User Guide SARCOMA TUMOUR SUBSITE SOFT TISSUE OTHER THAN RHABDOMYOSARCOMA Sublocation of the soft tissue sarcoma within the tumour site This is additional detail to enable a more precise localisation of the tumour site RP Retroperitoneal subsite of 253 3 __ ooo IP Intraperitoneal subsite of 53 3 o y O EB tlbow substeofZ89 8 o y O PO jPosteior substeof2903 amp 7904 y Lateral subsite of 290 3 amp 790 4 Not Known Not Applicable 5 15 CTYA OSTEOSARCOMA To carry Osteosarcoma details for CTYA This section will be recorded once Schema Data Item Section Data Item Name Format specification M R O X No CT6400 CTYA PRIMARY TUMOUR SIZE max n3 max OSTEOSARCOMA Radiological n2 Data item E EXTENT OF NECROSIS AFTER CT6410 CHEMOTHERAPY max n3 OSTEOSARCOMA TUMOUR NECROSIS me SARCOMA SURGICAL MARGIN CT6420 ADEQUACY an1 OSTEOSARCOMA SARCOMA SURGICAL MARGIN PRIMARY
264. noma in situ Gynaecological of cervix e unspecified D07 0 carcinoma in situ Gynaecological of endometrium D07 1 carcinoma in situ Gynaecological b of vulva D07 2 carcinoma in situ Gynaecological of vagina Author NCIN 251 Cancer Outcomes and Services Dataset User Guide ICD 10 4th Edition All C Codes are Malignant Neoplasms Description D07 3 carcinoma in situ of other and Cancer Waiting Times Site specific group Gynaecological Expected Dataset to be collected Core and Site Specific Dataset Core Dataset Path Only Comment of cranial nerves System unspecified female genital organs DO7 4 carcinoma in situ Urological of penis D07 5 carcinoma in situ Urological of prostate D07 6 carcinoma in situ Urological of other and unspecified male genital organs D09 0 Carcinoma in situ Urological of Bladder D09 1 carcinoma in situ Urological of other and unspecified urinary organs DO9 2 carcinoma in situ Other of eye D09 3 carcinoma in situ Head and Neck of thyroid and e other endocrine glands D09 7 carcinoma in situ Other of other specified e sites 009 9 carcinoma in situ Other unspecified D32 0 benign neoplasm Brain Central Nervous of cerebral System meninges D32 1 benign neoplasm Brain Central Nervous T of spinal meninges System D32 9 benign neoplasm Brain Central Nervous
265. nosis This will be defined by the MDT Teenage and Young Adult Author NCIN 92 Cancer Outcomes and Services Dataset User Guide 5 6 CTYA CANCER CARE PLAN To carry cancer care plan details for CTYA One occurrence of this data group is permitted Schema specification M R O X Data Data Item N Format item No Section Data Item Name Start of repeating item Multidisciplinary Team Age Category MULTIDISCIPLINARY TEAM AGE CATEGORY CHILDREN TEENAGERS AND YOUNG ADULTS AGE CATEGORY MULTIDISCIPLINARY TEAM Start of repeating item Multidisciplinary Team Age Category CTYA CANCER CARE PLAN CT6110 MULTIDISCIPLINARY TEAM AGE CATEGORY Type s of MDT where the care plan for the patient was discussed More than one option can be recorded This field defines the nature of each MDT at which the patient s care plan is discussed Paediatric Teenage and Young Adult Adult 5 7 CTYA STEM CELL TRANSPLANTATION To carry stem cell transplantation details for CTYA This section can be recorded more than once Schema specification M R O X Format item No Data Item Section Data Item Name STEM CELL INFUSION DATE CTYA MAIN STEM CELL TRANSPLANTATION CT6150 CT6130 CT6140 CTYA MAIN STEM CELL TRANSPLANTATION CTYA MAIN STEM CELL TRANSPLANTATION PROCEDURE DATE STEM CELL INFUSION STEM CELL INFUSION SOURCE STEM CELL INFUSION SOURCE CODE STEM CELL IN
266. not confirmed Test not done 10 4 SARCOMA PATHOLOGY BONE To carry pathology details for Sarcoma specific to Bone This section will be recorded once per pathology report where applicable Data item Data Item Section Data Item Name Format specification M R O X EXTENT OF LOCAL SPREAD SARCOMA PATHOLOGY SA11130 BONE BONE TUMOUR BREACH IDENTIFIER SARCOMA PATHOLOGY SA11140 TUMOUR NECROSIS max n3 BONE SARCOMA PATHOLOGY TISSUE TYPE AT NEAREST SA11160 ani BONE MARGIN EXTENT OF LOCAL SPREAD BONE TUMOUR BREACH IDENTIFIER FOR MEDULLARY TUMOURS ONLY Does the tumour breach the cortex The extent of local spread will determine whether the tumour is intracompartmental or extracompartmental Intracompartmental Extracompartmental TUMOUR NECROSIS Approximate percentage of tumour necrosis in response to pre operative therapy TISSUE TYPE AT NEAREST MARGIN Type of tissue at nearest excision margin Normal tissue Tumour 10 5 SARCOMA PATHOLOGY SOFT TISSUE To carry pathology details for Sarcoma specific to Soft Tissue This section will be recorded once per pathology report where applicable Schema Data item BER Data Item Section Data Item Name Format specification M R O X Author NCIN 173 Cancer Outcomes and Services Dataset User Guide SARCOMA PATHOLOGY SOFT 5411100 TISSUE TUMOUR DEPTH 1 SARCOMA PATHOLOGY SOFT MITOTIC RATE SA
267. nseascasubecsextdastedsantaavsdesdstdeaslevteatesgdbededteniusssuantanysbeviteiaibdasdacdanSacssiadsans 20 SCAG E o ea ac jes ausleasatataasatandeadag assidsuatestaieesattabaetdatandicatag snddciabsuseasanstacciaeartedtas 20 OTL TREATIMONE PRETIO RITTER III 21 Os DP PALM Ol ORY EORR 21 OLTS DOSEN E E 21 0 14 LINKAGE 21 0 15 Recording RECUFFENCES eter eere renean testae nen ee anno e Ar redeas emnes edes 21 co RU 25 IED 1O CODES 25 CORETINKAGE es tee tiende A 25 1 1 CORE DEMOGRAPHIC DETAI S en ree 25 1 2 CORE REFERRALS AND FIRST STAGE OF PATIENT 28 TS CORE IMAGIN E EEAS E A E EA E A E AE 31 Author NCIN 4 Cancer Outcomes and Services Dataset User Guide im EeosnidobhiBpi isi siei TS CORE CANCER CARE PLAN 1 6 CORE CLINICAL TRIALS 1 7 CORE pice 1 8 CORE TREATMENT M 1 9 CORE TREATMENT SURGERY AND OTHER PROCEDURES 3 10 CORE TREATMENT RADIOTHERAPY seerias neer
268. nt Haematological immunoproliferative disease unspecified C90 0 Multiple myeloma Haematological C90 1 Plasma cell Haematological leukaemia C90 2 Extramedullary Haematological plasmacytoma C90 3 Solitary Haematological plasmacytoma C91 0 Acute lymphoblastic Haematological leukaemia ALL 91 1 Chronic lymphocytic Haematological leukaemia of B cell type C91 3 Prolymphocytic Haematological leukaemia of B cell type C91 4 Hairy cell leukaemia Haematological C91 5 Adult T cell Haematological lymphoma leukaemi a HTLV 1 associated C91 6 Prolymphocytic Haematological leukaemia of T cell type Expected Dataset to be collected Core and Site Specific Dataset Core Dataset Path Only Comment Author NCIN 245 Cancer Outcomes and Services Dataset User Guide ICD 10 4th Edition All C Codes are Cancer Waiting Malignant Times Site Neoplasms Description specific group C91 7 Other lymphoid Haematological leukaemia C91 8 Mature B cell Haematological leukaemia Burkitt type C91 9 Lymphoid leukaemia Haematological unspecified C92 0 Acute myeloid Haematological leukaemia AML C92 1 Chronic myeloid Haematological leukaemia CML BCR ABL positive C92 2 Atypical chronic Haematological myeloid leukaemia BCR ABL negative C92 3 Myeloid sarcoma Haematological C92 4 Acute promyelocytic Haematological leukaemia PML C92 5 Acute Haematolo
269. obturator external iliac or presacral N3 Metastasis in a common iliac lymph node s Distant Metastasis MO No distant metastasis M1 Distant metastasis Note Recording Bladder stage following neoadjuvant therapy For cases of bladder or urethral cancer treated by cystectomy problems will be encountered where neoadjuvant therapy is used TNM stage will be dependent on histological examination of the resected specimen together with information obtained from radiological imaging etc Wherever possible TNM with the y prefix NEOADJUVANT THERAPY INDICATOR should be used for pathology stage fields For all other cases where no operation is performed staging will have to be based on radiological appearances either before or after the neo adjuvant treatment and an integrated TNM stage decided based on the radiological appearances Author NCIN 208 Cancer Outcomes and Services Dataset User Guide 13 5 UROLOGY STAGING URETHRA UICC CARCINOMA OF THE URETHRA MALE AND FEMALE TNM STAGING SEVENTH EDITION Note p indicates also applicable for pathological stage p Ta Non invasive papillary polypoid or verrucous carcinoma p Tis Carcinoma in situ p T1 Tumour invades subepithelial connective tissue p T2 Tumour invades any of the following corpus spongiosum prostate periurethral muscle p T3 Tumour invades any of the following corpus cavernosum beyond prostatic capsule anterior vagina blad
270. ociated with the brain tumour This may involve selection of more than one value for each tumour Evidence of IDH1 or IDH2 mutation Evidence of methylation of the MGMT gene CpG island Evidence of total loss of 1p and 19q Evidence of KIAA 1549 BRAF fusion gene Other IMMUNOHISTOCHEMISTRY HORMONE EXPRESSION TYPE HORMONE EXPRESSION TYPE Hormone expression by immunohistochemistry FOR PITUITARY ADENOMAS ONLY Multiple values may be recorded 0 Non functioning 1 ACTH H FSH Alpha subunit TSH Prolactin Growth Hormone Author NCIN 74 Cancer Outcomes and Services Dataset User Guide WHO TUMOUR GRADE CNS WORLD HEALTH ORGANISATION CENTRAL NERVOUS SYSTEM TUMOUR GRADE The grade of the tumour using WHO classification for tumours of the central nervous system FOR INTRA AXIAL AND EXTRA AXIAL ONLY Author NCIN 75 Cancer Outcomes and Services Dataset User Guide 4 COLORECTAL OVERVIEW TNM Staging needs to be collected for Colorectal cancers Please note that there are different editions of TNM Stage used for different disease sites see section 4 4 Colorectal Staging Site specific data items have been aligned between the COSD and the National Bowel Cancer Audit ICD 10 CODES Key if applicable different dataset from CWT group specified Expected Dataset to be collected All C Codes Core and are Cancer Waiting Site Malignant Times Site Specific
271. of uncertain or unknown behaviour of Craniopharyngeal duct Brain Central Nervous System D44 5 Neoplasm of uncertain or unknown behaviour of pineal gland Brain Central Nervous System D44 6 Neoplasm of uncertain or unknown behaviour of carotid body Other D44 7 Neoplasm of uncertain or unknown behaviour of aortic body and other paraganglia body Other D44 8 Neoplasm of uncertain or unknown behaviour of pluriglandular involvement Other D44 9 Neoplasm of uncertain or unknown behaviour of endocrine gland unspecified Other D45 Polycythaemia vera Haematological See the Haematology chapter of COSD User Guide Section 7 2 for information regarding Author NCIN 258 ICD 10 4th Edition All C Codes are Malignant Neoplasms D46 0 Cancer Outcomes and Services Dataset User Guide Description Refractory anaemia without ringed sideroblasts so stated Cancer Waiting Times Site specific group Haematological D46 1 Refractory anaemia with ringed sideroblasts Haematological D46 2 Refractory anaemia with excess of blasts Haematological D46 4 Refractory anaemia unspecified Haematological D46 5 Refractory anaemia with multi lineage dysplasia Haematological D46 6 Myelodysplastic syndrome with isolated del 5q chromosomal abnormality Haematological
272. of liver and intrahepetic bile duct Upper Gastrointestinal Normally treated by MDT of site of primary tumour Only use if unable to code to specific primary site C78 8 Secondary malignant neoplasm of other and unspecified digestive organs Colorectal Normally treated by MDT of site of primary tumour Only use if unable to code to specific primary site Author NCIN 240 Cancer Outcomes and Services Dataset User Guide ICD 10 4th Expected Dataset to be collected Edition All C Codes Core and are Cancer Waiting Site Malignant Times Site Specific Core Path Neoplasms Description specific group Dataset Dataset Only Comment C79 0 Secondary malignant neoplasm of kidney and renal pelvis Urological Normally treated by MDT of site of primary tumour Only use if unable to code to specific primary site C79 1 Secondary malignant neoplasm of bladder and other and unspecified urinary organs Urological Normally treated by MDT of site of primary tumour Only use if unable to code to specific primary site C79 2 Secondary malignant neoplasm of skin Skin Normally treated by MDT of site of primary tumour Only use if unable to code to specific primary site C79 3 Secondary malignant neoplasm of brain and cerebral meninges Brain Central Nervous System Normally treated by MDT of site of primary tumour Only use if unable to code
273. of patient at time of MDT SCAN PERFORMED INDICATOR PET Was a PET scan performed on this patient LU10010 Not known 9 3 LUNG CANCER CARE PLAN To carry care plan details for Lung Carcinoma Only one per diagnosis This section will be recorded once Schema Data item N Data Item Section Data Item Name Format specification M R O X Author NCIN 160 Cancer Outcomes and Services Dataset User Guide FEV1 PERCENTAGE LUNG CANCER LU10040 CARE BEAN FORCED EXPIRATORY VOLUME IN 1 SECOND max n3 PERCENTAGE FEV1 ABSOLUTE VALUE LUNG CANCER LU10050 CAREEBLAN FORCED EXPIRATORY VOLUME IN 1 SECOND n1 n2 ABSOLUTE AMOUNT LUNG CANCER SMOKING STATUS LU10190 an1 CARE PLAN SMOKING STATUS CODE LUNG CANCER LU10060 MEDIASTINAL SAMPLING INDICATOR an1 CARE PLAN FEV1 PERCENTAGE The Forced Expiratory Volume in the first second as a percentage of the predicted value Must be an integer in the range of 1 to 150 FEV1 ABSOLUTE VALUE The absolute value of the patient s Forced Expiratory Volume in the first second in litres Must be numeric in the range of 0 10 to 9 99 SMOKING STATUS Specify the current smoking status of the patient This data item could be collected at presentation either in the outpatients or on the ward Current smoker Ex smoker Non smoker history unknown Never smoked Not Stated PERSON asked but declined to provide a response MEDIASTINAL SAMPLING INDICATOR Recor
274. of the first outpatient appointment at the breast clinic If the patient attends more than one breast clinic the site code of each breast clinic where a clinical physical examination was undertaken should be recorded see ORGANISATION SITE CODE CLINICAL ASSESSMENT RESULT BREAST Result of the clinical physical examination of the breast for which a cancer is registered This will normally be the result of an assessment of a patient s clinical history and physical examination undertaken at the first outpatient appointment at the breast clinic If the patient attends more than one breast clinic the result of each clinical physical examination undertaken should be recorded P2 Benign Suspicious Malignant P2 Benign o Oe Suspicious o O P5 Malignant y O 2 2 BREAST IMAGING To carry imaging mammogram ultrasound and axilla ultrasound details for breast cancer These sections can be recorded more than once Author NCIN 56 Cancer Outcomes and Services Dataset User Guide Schema Data Item Section Data Item Name Format specification M R O X BREAST IMAGING MAMMOGRAM Multiple occurrences of this data group are permitted BREAST IMAGING PROCEDURE DATE ORGANISATION SITE CODE BREAST IMAGING MAMMOGRAM MAMMOGRAM SITE CODE OF MAMMOGRAM MAMMOGRAM RESULT BR4050 BREAST IMAGING MAMMOGRAM RESULT MAMMOGRAM CODE BREAST IMAGING ULTRASOUND Multiple occurrences of this data group are pe
275. of trunk Skin C43 6 Malignant melanoma of upper limb including shoulder Skin C43 7 Malignant melanoma of lower limb including hip Skin C43 8 Overlapping malignant melanoma of skin Skin C43 9 Malignant melanoma of skin unspecified Skin Author NCIN 226 ICD 10 4th Edition All C Codes are Malignant Neoplasms C44 0 Cancer Outcomes and Services Dataset User Guide Expected Dataset to be collected Core and Cancer Waiting Site Times Site Specific Core Description specific group Dataset Dataset Comment Skin of lip Skin See the Skin chapter of the COSD User Guide Overview Section for e e e pner information on the collection of this Skin disease C44 1 Skin of eyelid Skin See the Skin including canthus chapter of the COSD User Guide Overview Section for e e further information on the collection of this Skin disease C44 2 Skin of ear and Skin See the Skin external auricular chapter of canal the COSD User Guide Overview Section for e e e further information on the collection of this Skin disease C44 3 Skin of other and Skin See the Skin unspecified parts of chapter of face the COSD User Guide Overview Section for e e e further information on the collection of this Skin disease Author NCIN 227 Cancer Outcomes and Services
276. ogically determined number of lesions LESION SIZE RADIOLOGICAL Radiological estimate in millimetres mm of the maximum diameter of the tumour measured prior to treatment largest lesion if more than one Record as to indicate not assessable for diffuse tumours e g gliomatosis cerebri Note For COSD reporting purposes this data item is not required to be submitted to two decimal places FEATURES OF LARGEST LESION RADIOLOGICAL Radiologically identified features of the largest lesion such as density necrosis recorded pre treatment This may involve selection of more than one value mereces o 9 o PRINCIPAL DIAGNOSTIC IMAGING TYPE Indicate the principal imaging procedure undertaken to diagnose the tumour Please note that the value PET Scan includes PET CT Scan CT Scan MRI Scan PET Scan 3 2 CENTRAL NERVOUS SYSTEM CANCER CARE PLAN To carry cancer care plan details for Central Nervous System cancer This section will be recorded once T Schema Data item Data Item Section Data Item Name Format specification M R O X CENTRAL NERVOUS BA3060 SYSTEM CANCER CARE PLAN CENTRAL NERVOUS BA3080 SYSTEM CANCER CARE PLAN PRIMARY DIAGNOSIS ICD RADIOLOGICAL MDT PROVISIONAL DIAGNOSIS ICD PROVISIONAL DIAGNOSIS ICD PRIMARY DIAGNOSIS ICD RADIOLOGICAL Primary diagnosis based on imaging In many cases this will be the definitive clinical diagnosis but needs to be
277. ological examination M CATEGORY PATHOLOGICAL The Union for International Cancer Control UICC code which classifies the absence or presence of distant metastases based on the evidence from a pathological examination TNM STAGE GROUPING PATHOLOGICAL The Union for International Cancer Control UICC code which classifies the combination of Tumour node and metastases into stage groupings based on the evidence from a pathological examination NEOADJUVANT THERAPY INDICATOR Indicator of whether the pathological stage was recorded after the patient had received neoadjuvant therapy i e chemotherapy or radiotherapy prior to surgery Note If this is Yes the pathology stage fields should be prefixed with the letter y SERVICE REPORT IDENTIFIER A unique identifier of a SERVICE REPORT SERVICE REPORT STATUS The status of the SERVICE REPORT Supplementary second opinion Further excision of primary tumour Regional Lymph Nodes Metastatic site other than regional lymph nodes Where none of the above options are applicable Not known maybe selected ORGANISATION SITE CODE PATHOLOGY TEST REQUESTED BY The ORGANISATION SITE CODE of the ORGANISATION at which the CARE PROFESSIONAL who requested the DIAGNOSTIC TEST REQUEST for suspected cancer is based See ORGANISATION SITE CODE CARE PROFESSIONAL CODE PATHOLOGY TEST REQUESTED BY The code of the CARE PROFESSIONAL who requests the pathology test This is not requ
278. oma tissue of head face and neck 49 1 Connective and soft Sarcoma tissue of upper limb including shoulder 49 2 Connective and soft Sarcoma tissue of lower limb including hip 49 3 Connective and soft Sarcoma tissue of thorax 49 4 Connective and soft Sarcoma tissue of abdomen C49 5 Connective and soft Sarcoma e tissue of pelvis C49 6 Connective and soft Sarcoma tissue of trunk e unspecified C49 8 Overlapping lesion of Sarcoma connective and soft e tissue C49 9 Connective and soft Sarcoma tissue unspecified C50 0 Nipple and areola Breast e C50 1 Central portion of Breast e breast C50 2 Upper inner Breast e quadrant of breast C50 3 Lower inner Breast e quadrant of breast C50 4 Upper outer Breast e quadrant of breast C50 5 Lower outer Breast e quadrant of breast C50 6 Axillary tail of breast Breast e C50 8 Overlapping lesion of Breast breast C50 9 Breast unspecified Breast e Author NCIN 231 Cancer Outcomes and Services Dataset User Guide ICD 10 4th Expected Dataset to be collected Edition All C Codes Core and are Cancer Waiting Site Malignant Times Site Specific Core Path Neoplasms Description specific group Dataset Dataset Only Comment C51 0 Labium majus Gynaecological Gynaecology and Skin Datasets to be collected where applicable C51 1 Labium minus Gynaecological Gynaecology and Skin Datasets to
279. on M R O X CAPSULE STATUS OVARIAN SURFACE INVOLVEMENT OVARY SURFACE INVOLVEMENT INDICATOR TUMOUR GRADE TUMOUR GRADE GYNAECOLOGY PERITONEAL CYTOLOGY PERITONEAL CYTOLOGY RESULT CODE PERITONEAL INVOLVEMENT PERITONEAL INVOLVEMENT INDICATOR CAPSULE STATUS Capsule status of ovaries record the most severe Intact Disrupted Involved Not assessable Not assessable Author NCIN 116 Cancer Outcomes and Services Dataset User Guide TUMOUR GRADE Specify the grade of the tumour For serous tumours specify whether High or Low grade clear cell carcinomas and carcinosarcomas are all high grade for all other tumours use three tier grading system PERITONEAL CYTOLOGY Result of peritoneal cytology PERITONEAL INVOLVEMENT Is there peritoneal involvement 6 5 GYNAECOLOGY PATHOLOGY ENDOMETRIAL To carry pathology details for Gynae for Endometrial This section will be recorded once per pathology report where applicable J Schema Data item No GYNAECOLOGY BACKGROUND ENDOMETRIUM GY7210 PATHOLOGY BACKGROUND ENDOMETRIUM an1 ENDOMETRIAL ABNORMALITY INDICATION CODE GYNAECOLOGY GY7220 PATHOLOGY DISTANCE TO SEROSA max n2 ENDOMETRIAL GYNAECOLOGY INVOLVEMENT OF CERVICAL STROMA GY7240 PATHOLOGY MICROSCOPIC INVOLVEMENT ENDOMETRIAL INDICATOR CERVICAL STROMA a INVOLVEMENT OF CERVICAL SURFACE GYNAECOLOGY OR GLANDS GY7250 PATHOLOGY MICROSCOPIC INVOLVEMENT a E
280. on Neoplasm of uncertain or unknown behaviour of renal pelvis Cancer Waiting Times Site specific group Urological Expected Dataset to be collected Core and Site Specific Dataset Core Dataset Path Only Comment D41 2 Neoplasm of uncertain or unknown behaviour of ureter Urological D41 3 Neoplasm of uncertain or unknown behaviour of urethra Urological D41 4 Neoplasm of uncertain or unknown behaviour of bladder Urological D41 7 Neoplasm of uncertain or unknown behaviour of other urinary organs Urological D41 9 Neoplasm of uncertain or unknown behaviour of urinary organs unspecified Urological D42 0 Neoplasm of uncertain or unknown behaviour of cerebral meninges Brain Central Nervous System D42 1 Neoplasm of uncertain or unknown behaviour of spinal meninges Brain Central Nervous System D42 9 Neoplasm of uncertain or unknown behaviour of meninges unspecified Brain Central Nervous System Author NCIN 256 ICD 10 4th Edition All C Codes are Malignant Neoplasms D43 0 Cancer Outcomes and Services Dataset User Guide Description Neoplasm of uncertain or unknown behaviour of brain supratentorial Cancer Waiting Times Site specific group Brain Central Nervous System Expected Dataset to be collected Core and Site Specific Dataset Core Dataset Path Onl
281. on Data Item Name Format specification M R O X Data item No eee e CNS TUMOURS FLUID eso cowoomomw csessmanum CNS TUMOURS GONADOTROPIN CEREBROSPINAL FLUID ALPHA FETOPROTEIN CEREBROSPINAL FLUID Maximum level of alpha feto protein in the Cerebro Spinal Fluid at diagnosis AFP units recorded in kU I values 100 000 are recorded Measured only for CNS germ cell tumours BETA HUMAN CHORIONIC GONADOTROPIN CEREBROSPINAL FLUID Maximum CSF level of HCG at diagnosis in 10 1 Measured only for CNS germ cell tumours 5 19 CTYA GERM CELL NON CNS TUMOURS To carry Germ Cell Non CNS Tumours details for CTYA Non CNS germ cell tumours are defined as ICD10 00 0 69 9 C73 C75 0 C75 4 C80 9 D00 0 D31 9 D34 D35 1 D35 5 D41 9 D44 0 D44 2 D44 6 D48 9 combined with Morphology 9060 9104 This section will be recorded once Schema Data Item Section Data Item Name Format specification M R O X Data item No TNM STAGE GROUPING FOR NON CNS GERM CELL TUMOURS TNM STAGE GROUPING NON CENTRAL NERVOUS SYSTEM GERM CELL TUMOURS CTYA GERM CELL NON CNS TUMOURS TNM STAGE GROUPING FOR NON CNS GERM CELL TUMOURS TNM classification for Germ Cell Non CNS Tumours This information should be available for the MDT discussion but will only apply to a small number of cases Staging is an important prognostic and outcomes analysis factor The following definitions are us
282. opic Radiological Complications ENDOSCOPIC OR UPPER GI MAIN ENDOSCOPIC UG13090 RADIOLOGICAL OR RADIOLOGICAL PROCEDURES COMPLICATION TYPE End of repeating item Endoscopic Radiological Complications PROCEDURE DATE ENDOSCOPIC OR RADIOLOGICAL The date that the first therapeutic endoscopic radiological procedure was performed ORGANISATION SITE CODE PROVIDER ENDOSCOPIC OR RADIOLOGICAL PROCEDURE SITE CODE OF PROVIDER ENDOSCOPIC OR RADIOLOGICAL PROCEDURE is the ORGANISATION SITE CODE of the unit providing endoscopic palliative therapy to the PATIENT see ORGANISATION SITE CODE CONSULTANT CODE ENDOSCOPIC OR RADIOLOGICAL PROCEDURE The GMC code of the consultant responsible for the endoscopic or radiological procedure CONSULTANT CODE ENDOSCOPIC PROCEDURE TYPE The main endoscopic procedures carried out More than one procedure can be entered Repeating Item For pancreas only values 1 4 and 8 are valid The OG National Audit definition the main endoscopic techniques performed as part of the first therapeutic endoscopic procedure T ehe RADIOLOGICAL PROCEDURE TYPE Type of stent or drain inserted by radiological procedure plastic stent metal stent external biliary drain INTENT FOR BILIARY STENT Reason for biliary stent insertion Bridge to surgery Palliation Author NCIN 193 Cancer Outcomes and Services Dataset User Guide UL SUCCESS OF DEPLOYMENT Whether or not
283. or full stage submission Board Gallagher Version 20 07 2012 Haematology codes list updated Additional minor amendments Trish 1 9 User Guide published on the NCIN website Stokes Shaun Gallagher Version 18 01 2013 Update to ICD10 table to include 4 Edition amendments and Trish 2 0 clarification of the Dataset required for each disease Stokes Shaun Updated Haematology table to include further amendments to Gallagher ICDO3 codes and additional coding levels for specific morphologies General guidance on the expected staging system by tumour type Amended to include changes identified in version 1 1 of the COSD Correction to a number of minor errors identified Author NCIN Cancer Outcomes and Services Dataset User Guide Version 2 1 23 10 2013 Updated to include a number of COSD data changes See What s updated since version 2 0 below for further information Trish Stokes Shaun Gallagher Author NCIN Cancer Outcomes and Services Dataset User Guide CONTENTS 4 SAS USER 10 WHATS CHANGED SINCE VERSION 2 0 haa sien en nnne 11 INTRODUCTION ER 14 What is the Cancer Outcomes and Services Dataset 00 ceeccecesceeececsneceeececseeeeeeeecaeeeeeeecaeeee
284. ormance status LDH extranodal sites Ann Arbor Stage Score 1 for each of age gt 60 PS gt 2 LDH above Normal gt 1 extranodal site stage III or IV Range 0 5 Either R IPI or IPI may currently be used as prognostic indicators However the scores calculated as above apply to both indices and can be grouped to provide either the IPI or the R IPI Groupings 7 11 HAEMATOLOGY CANCER CARE PLAN MYELOMA To carry cancer care plan details specific to Myeloma This section will be recorded once Schema Data Item Section Data Item Name Format specification M R O X Data item No ISS STAGE for MYELOMA HA8560 MSN CARE INTERNATIONAL STAGING SYSTEM STAGE ISS STAGE for MYELOMA International Staging System for Myeloma derived from Beta2 Microglobulin and Albumin lab results Stage 1 Beta 2 M less than 3 5 and Albumin greater than 34 Stage 3 Beta 2 M greater than 5 5 Stage 2 Beta 2 M less than 3 5 and albumin less than 35 OR Beta 2 M 3 5 5 5 7 12 HAEMATOLOGY CANCER CARE PLAN HODGKIN LYMPHOMA To carry cancer care plan details specific to Hodgkin This section will be recorded once Schema Data Item Section Data Item Name Format specification M R O X Data item No HASENCLEVER INDEX HA8670 HAEMATOLOGY CANCER CARE PLAN HASENCLEVER INDEX HODGKIN SCORE HASENCLEVER INDEX Index derived from age gender Hb Albumin white blood count Lymphocyte count Ann Arbor stage Scor
285. ot more than 5 cm in greatest dimension Author NCIN 207 Cancer Outcomes and Services Dataset User Guide or multiple lymph nodes none more than 5 cm in greatest dimension p N3 Metastasis in a lymph node more than 5 cm in greatest dimension Distant Metastasis MO No distant metastasis p M1 Distant metastasis 13 4 UROLOGY STAGING URINARY BLADDER UICC CARCINOMA OF THE URINARY BLADDER TNM STAGING SEVENTH EDITION Stage Grouping T Stage N Stage M Stage Stage 1 MO Stage 11 T2a b NO MO Stage III T3a b NO MO T4a NO MO Stage IV T4b NO MO Any T N1 N2 N3 MO Any T Any N M1 Primary Tumour Ta Non invasive papillary carcinoma Tis Carcinoma in situ flat tumour T1 Tumour invades subepithelial connective tissue T2a Tumour invades superficial muscle inner half T2b Tumour invades deep muscle outer half T3a Tumour invades perivesical tissue Microscopically T3b Tumour invades perivesical tissue Macroscopically extravesical mass T4a Tumour invades prostate stroma seminal vesicles uterus or vagina T4b Tumour invades pelvic wall or abdominal wall Regional Lymph Nodes NO No regional lymph node metastasis N1 Metastasis in a single lymph node in the true pelvis hypogastric obturator external iliac or presacral N2 Metastasis in multiple lymph nodes in the true pelvis hypogastric
286. other organs or structures T4a Tumour perforates visceral peritoneum including mucinous peritoneal tumour within the right lower quardrant T4b Tumour directly invades other organs or structures Please note Direct invasion in T4 includes invasion of other intestinal segments by way of the serosa e g invasion of ileum Tumour that is adherent to other organs or structures macroscopically is classified T4b However if no tumour is present in the adhesion microscopically the classification should be pT1 2 or 3 Regional Lymph Nodes NO No regional lymph nodes metastasis N1 Metastasis in 1 3 regional lymph nodes N2 Metastasis in 4 or more regional lymph nodes Note A satellite peritumoural nodule in the periappendiceal adipose tissue of a primary carcinoma without histological evidence of residual lymph nodule may represent discontinuous spread T3 venous invasion with extravascular spread T3 V1 2 or a totally replaced lymph node N1 2 Distant Metastasis MO Nodistant M1 Distant metastasis 1 Intraperitonel metastasis beyond the right lower quadrant including pseudomyxoma peritone 16 Non peritoneal metastasis UICC TNM CLASSIFICATION OF ANAL SEVENTH EDITION Note Stage data items for Anal cancers are not collected by NBOCAP Primary Tumour Author NCIN 82 Cancer Outcomes and Services Dataset User Guid
287. ovascular invasion or is poorly differentiated or undifferentiated T1b Tumour invades subepithelial connective tissue with lymphovascular invasion or is poorly differentiated or undifferentiated T2 Tumour invades corpus spongiosum or caverneosum T3 Tumour invades urethra T4 Tumour invades adjacent structures Regional Lymph Nodes NO No palpable or visibly enlarges inguinal lymph nodes N1 Palpable mobile unilateral inguinal lymph node N2 Palpable mobile multiple or bilateral inguinal lymph nodes N3 Fixed inguinal lymph nodal mass or pelvic lymphadenopathy unilateral or bilateral Distant Metastasis MO No distant metastasis M1 Distant metastasis Note Recording Penis stage following neoadjuvant therapy For cases of penis cancer treated with surgery problems will be encountered where preoperative chemotherapy is used TNM stage will be dependent on histological examination of the resected specimen together with information obtained from radiological imaging etc Wherever possible TNM with the y prefix NEOADJUVANT THERAPY INDICATOR should be used for pathology stage fields For all other cases Author NCIN 212 Cancer Outcomes and Services Dataset User Guide where no operation is performed staging will have to be based on radiological appearances either before or after the preoperative chemotherapy and an integrated TNM stage decided based on the radiological appearances 13 9
288. owest measurement post orchidectomy Range 0 999999 PSA DIAGNOSIS PROSTATE ONLY Prostate Specific Antigen blood level in ng ml measured at time of diagnosis 13 2 UROLOGY STAGING TESTICULAR For testicular cancer ideally RMH stage grouping and TNM stage components should both be collected UICC stage groupings should not be used as they do not map to RMH stage Pre treatment TNM Stage components are optional S category should be collected separately First CT Scan performed usually after orchidectomy prior to chemotherapy radiotherapy should be reported in the Core Imaging section Note Although International Germ Cell Consensus IGCC Prognostic Groupings largely supersedes RHM Staging for testicular cancer except for seminomas the NCIN Urology SSRCG has agreed that RHM Staging should continue to be used for staging testicular cancer for the near future Further consideration on how stage is collected for testicular cancers in the future will be considered again when the COSD is next reviewed To carry staging details for Testicular This section will be recorded once Data item Data Item Section Data Item Name Format specification M R O X STAGE GROUPING TESTICULAR UROLOGY STAGING UR15300 STAGE GROUPING TESTICULAR M TESTICULAR CANCER Start of repeating item Extra nodal metastases UR15320 UROLOGY STAGING EXTRANODAL METASTASES i an TESTICULAR EXTENT OF METASATIC SPREA
289. pathology report which confirms the recurrence or if this is not available at the time it will be the date of the Multidisciplinary Team Meeting when the diagnosis of recurrence was agreed Note This is not the same as DATE OF RECURRENCE CANCER REGISTRATION which is used for Cancer Registration TUMOUR LATERALITY CWT Identifies the side of the body for a tumour relating to paired organs within a PATIENT This refers to the side of the body on which the cancer originates For the Central Nervous System the definition for bilateral is evidence that the tumour is crossing the midline Left ight Ru idline gn Sa 9 Bilateral Not applicable Not known BASIS OF DIAGNOSIS CANCER This is the method used to confirm the cancer Non microscopic Death Certificate The only information available is from a death certificate Clinical Diagnosis made before death but without the benefit of any of the following 2 7 Clinical Investigation Includes all diagnostic techniques e g X rays endoscopy imaging Author NCIN 34 Cancer Outcomes and Services Dataset User Guide 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 Cytology Examination of cells whether from a primary or secondary site including fluids aspirated 5 using endoscopes or needles Also includ
290. pecific primary site C77 0 Lymph nodes of head face and neck Head and Neck Secondary only use if unable to code to specific primary site 77 1 Intrathoracic lymph nodes Other Secondary only use if unable to code to specific primary site C77 2 Intra abdominal lymph nodes Other Secondary only use if unable to code to specific primary site C77 3 Axillary and upper limb lymph nodes Other Secondary only use if unable to code to specific primary site C77 4 Inguinal and lower limb lymph nodes Other Secondary only use if unable to code to specific primary site C77 5 Intrapelvic lymph nodes Other Secondary only use if unable to code to specific primary site Author NCIN 238 Cancer Outcomes and Services Dataset User Guide ICD 10 4th Expected Dataset to be collected Edition All C Codes Core and are Cancer Waiting Site Malignant Times Site Specific Core Path Neoplasms Description specific group Dataset Dataset Only Comment C77 8 Lymph nodes of Other Secondary multiple regions only use if unable to code to specific primary site C77 9 Lymph node Other Secondary unspecified only use if unable to code to specific primary site C78 0 Secondary malignant Lung Normally neoplasm of lung treated by MDT of site of primary e tumour Only use if unable to code to specific pri
291. pecified leukaemias Redundant reclassified Chronic leukaemia of unspecified cell type Redundant reclassified Other leukaemia of unspecified cell type Redundant reclassified Other specified malignant neoplasms of lymphoid haematopoietic and related tissue Redundant reclassified Malignant neoplasms of lymphoid haematopoietic and related tissue unspecified Redundant reclassified not used in ICD O 3 D46 4 used instead Refractory anaemia without ringed sideroblasts so stated Redundant reclassified Neoplasm of uncertain or unknown behaviour of lymphoid haematopoietic and related tissue unspecified Redundant reclassified WHO DISEASE GROUP There is a behaviour discrepancy between the ICD10 site code and the new ICD O 3 morphology code although these diseases are now coded with a behaviour code of 3 they are still recorded with a D code in ICD10 Redundant disease has been reclassified under other codes Author NCIN 132 Cancer Outcomes and Services Dataset User Guide 7 3 HAEMATOLOGY CLINICAL DATASETS AND APPLICABLE DATA ITEMS The following table shows which of the site specific data items are applicable to each clinical dataset Note There are also some core data items which are used to calculate some of the indices e g Age gender performance status Clinical Dataset Myelodysplasia MDS Follicular Aut
292. principles and procedures defined internationally which advise that registrations are obtained from a variety of multiple sources and can be updated continuously and in a systematic manner IARC 1991 For this reason any information made available to the Cancer Registration Service will always be used to update a record even if this is made after the date that a registration is declared complete for analytical purposes or for submission to ONS Author NCIN 274 Cancer Outcomes and Services Dataset User Guide PATHWAY EVENT TRIGGER KEY x je i E n e Must be submitted for this event E zm 4 OShould be submitted for this event if available applicable 2 amp 4 x ui ui o CORE LINKAGE IF ANY OF THESES ITEMS CHANGE AFTER bh B g 2 e le SUBMISSION CONTACT THE REGISTRY a s S e Bs le la la IS g 8 SRERS Y g le lt ui 2 gt a G E lg amp 2EZEO cz IE E t a BE Eseseols LS E tc ui ui o9 o o 5 SECTION zu la e e e 4 e e e e e e e e e e e e e e e e e e CORE DEATH DETAILS e
293. r NCIN 268 Cancer Outcomes and Services Dataset User Guide Notes 1 Clinical staging includes microstaging of the primary melanoma and clinical radiologic evaluation for metastases By convention it should be used after complete excision of the primary melanoma with clinical assessment for regional and distant metastases 2 Pathologic staging includes microstaging of the primary melanoma and pathologic information about the regional lymph nodes after partial or complete lymphadenectomy Pathologic Stage O or Stage IA patients are the exception they do not require pathologic evaluation of their lymph nodes 3 Histological measures of high risk differ between SCC and BCC and are fully covered by the RCPath data sets which are therefore recommended AJCC STAGE GROUP AMERICAN JOINT COMMITTEE ON CANCER STAGE NON MELANOMA STAGING BCC AND SCC 7TH EDITION Stage T High risk features i No distant metastases T1 Tumor lt 2 cm in gt 2mm No Nodes No distant greatest dimension with thickness metastases lt 2 high risk features Clarks level gt 4 Perineural invasion SCC site ear SCC site lip Poorly or un differentiated T2 Tumor gt 2 cm in gt 2mm No Nodes No distant greatest dimension thickness metastases or Tumor any size with Clarks level gt 4 22 high risk features Perineural invasion SCC site ear SCC site lip Poorly or un differentiated T3 Tumor with invasion No Nodes No distant of maxilla mandible metasta
294. r diagnosis or a diagnosis of secondary or metastatic cancer recurrence Providers are responsible for completing any sections of the patient pathway which were carried out by them and should agree with other organisations in the patient pathway as to who is responsible for submitting data items for different sections The diagnosis will normally trigger the registration record so details prior to diagnosis may be completed retrospectively The patient pathway may take several months and the record may not therefore be complete at the first submission Providers should ensure that all details are submitted as soon as available and any updates to the records should be submitted monthly Cancer Patient s Pathway for a New Primary Diagnosis The diagram below illustrates the main sections of the cancer patient s pathway which need to be completed for a new primary diagnosis The sections highlighted in purple may be collected more than once 1 Currently only Breast recurrences are required Author NCIN 17 Cancer Outcomes and Services Dataset User Guide DEMOGRAPHICS e g NHS Number Date of Birth etc REFERRAL e g Source of Referral Date First Seen etc IMAGING PRE TREATMENT e g Cancer Imaging Modality Imaging Anatomical Site etc PATHOLOGY PRE TREATMENT e g Investigation Date Investigation Type etc DIAGNOSIS e g Primary Diagnosis Basis of Diagnosis etc CARE PLAN e g Multidisciplinary Team Disc
295. r ne en eet rex ee ta nerunt epe eau gone erp gri ven pee tud 98 5 14 CTYA RHABDOMYOSARCOMA and OTHER SOFT TISSUE SARCOMAS 99 5 15 CTYA OSTEOSARCOMA RAERR E GXREPSEUCIQNES EE 101 5A 6 CTYA EWINGS id rr ERR ODER REI rH SEE EIAS NOE SII Du E od EA pH rM Ee ears 102 5 17 OSTEOSARCOMA and EWINGS eessssseeseeeeeeen eene nennen nere nensis 102 5 18 CTYA CNS TUM UQODURS tino rt etre eee SEHR nea E HR ERE 104 5 19 CTYA GERM CELL NON CNS TUMOURS sirenen sociis karan 104 5 20 CTYA GERM CELL CNS AND GERM CELL NON CNS TUMOURS sss enne 104 5 21 CTYA GERM CELL CNS GERM CELL NON CNS HEPATOBLASTOMA AND HEPATOCELLULAR CARCINOMA qc E NE AREE 105 5 22 CTYA MEDUEPEOBLDASTO MA 5 return tne ot on ena orare Ree npa e RN a e Lea d Rn eU S ER ee RE deum Deka ux 105 5 23 CTYA HEPATOBLEASTOMA neon si ha ek RSS an PR AR e a e o Rn ba NER eR RE nen SURE 106 5 24 CTYA RENAL PATHOLOGY Paediatric Kidney eese ener enne nnns 106 soMidsele co ie 108 OVERVIEW 108 CODES PEE 108 GYNAECOLOGY SURGERY nerit
296. ral A Nervous System C71 6 Cerebellum Brain Central CTYA dataset Nervous System e collected for Meduloblast oma patients under 25 C71 7 Brain stem Brain Central Nervous System C71 8 Overlapping lesion of Brain Central A brain Nervous System C71 9 Brain unspecified Brain Central b Nervous System C72 0 Spinal cord Brain Central Nervous System C72 1 Cauda equina Brain Central Nervous System C72 2 Olfactory nerve Brain Central s Nervous System C72 3 Optic nerve Brain Central e Nervous System C72 4 Acoustic nerve Brain Central e Nervous System C72 5 Other and Brain Central unspecified cranial Nervous System e nerves C72 8 Overlapping lesion of Brain Central brain and other parts Nervous System P of central nervous system C72 9 Central nervous Brain Central m system unspecified Nervous System C73 Malignant neoplasm Head and Neck of thyroid gland C74 0 Cortex of adrenal Other gland C74 1 Medulla of adrenal Other gland C74 9 Adrenal gland Other unspecified C75 0 Parathyroid gland Other e C75 1 Pituitary gland Other Usually treated by CNS MDT C75 2 Craniopharyngeal Other Usually duct treated by CNS MDT Author NCIN 236 Cancer Outcomes and Services Dataset User Guide ICD 10 4th Expected Dataset to be collected Edition are Cancer Waiting Site Malignant Times Site Specific Core Path Neoplasms Description specific group Dataset Dataset Only Comment
297. ripheral nerves Nervous and autonomic System ieoten dy Sarcoma MDT nervous system C47 9 Peripheral nerves Brain Central and autonomic Nervous nervous system System e d Sarcoma MDT unspecified C48 0 Retroperitoneum Sarcoma Usually treated by Sarcoma MDT Author NCIN 167 Cancer Outcomes and Services Dataset User Guide C48 1 Specified parts of Sarcoma Sarcoma and peritoneum Gynaecology Datasets be collected where applicable C48 2 Peritoneum Sarcoma Sarcoma and unspecified Gynaecology Datasets to be collected where applicable 48 8 Overlapping lesion Sarcoma of retroperitoneum and peritoneum C49 0 Connective and soft Sarcoma tissue of head face e and neck C49 1 Connective and soft Sarcoma tissue of upper limb including shoulder 49 2 Connective and soft Sarcoma tissue of lower e limb including hip 49 3 Connective soft Sarcoma tissue of thorax C49 4 Connective and soft Sarcoma tissue of abdomen e C49 5 Connective and soft Sarcoma tissue of pelvis C49 6 Connective and soft Sarcoma tissue of trunk e unspecified C49 8 Overlapping lesion Sarcoma of connective and e soft tissue C49 9 Connective and soft Sarcoma tissue unspecified C69 6 Orbit Brain Central Nervous System Not normally treated by CNS treated by Sarcoma MDT Author NC
298. rmitted BREAST IMAGING PROCEDURE DATE BREAST ORGANISATION SITE CODE BREAST IMAGING BREAST ULTRASOUND ULTRASOUND SITE CODE OF BREAST ULTRASOUND BREAST ULTRASOUND BREAST IMAGING EXAMINATION RESULT ULTRASOUND BREAST ULTRASOUND RESULT CODE BREAST IMAGING AXILLA ULTRASOUND Multiple occurrences of this data group are permitted BREAST IMAGING PROCEDURE DATE AXILLA ORGANISATION SITE CODE BREAST IMAGING OF AXILLA ULTRASOUND AXILLA ULTRASOUND SITE CODE OF AXILLA ULTRASOUND AXILLA ULTRASOUND BREAST IMAGING EXAMINATION RESULT AXILLA ULTRASOUND AXILLA ULTRASOUND RESULT CODE Minimum length an5 maximum length an9 BR4040 Minimum length an5 maximum length an9 BR4070 BR4080 Minimum length an5 maximum length an9 BR4100 BR4110 PROCEDURE DATE MAMMOGRAM Date when mammography was carried out This will normally be the date of the first outpatient appointment at the breast clinic If the patient attends more than one breast clinic the date that each mammogram was undertaken should be recorded ORGANISATION SITE CODE MAMMOGRAM Provider code where mammography was carried out This will normally be the site code of the first outpatient appointment at the breast clinic If the patient attends more than one breast clinic the site code of each breast clinic appointment where a mammogram was taken should be recorded see ORGANISATION SITE CODE MAMMOGRAM RESULT Result of t
299. rointestinal unspecified C16 6 Greater curvature Upper of stomach Gastrointestinal unspecified C16 8 Overlapping Upper lesion of stomach Gastrointestinal C16 9 Stomach Upper unspecified Gastrointestinal C17 0 Duodenum Colorectal Usually treated by Upper GI MDT C17 1 Jejunum Colorectal Usually treated by Upper GI MDT C17 2 Ileum Colorectal Usually treated by Upper GI MDT C17 3 Meckel s Colorectal Usually diverticulum treated by Upper GI MDT C17 8 Overlapping Colorectal Usually lesion of small treated by intestine Upper GI MDT C17 9 Small intestine Colorectal Usually unspecified treated by Upper GI MDT C22 0 Liver cell Upper Liver cell carcinoma Gastrointestinal carcinoma is also known as HCC C22 1 Intrahepatic bile Upper duct carcinoma Gastrointestinal C22 2 Hepatoblastoma Upper Gastrointestinal C22 3 Angiosarcoma of Upper liver Gastrointestinal C22 4 Other sarcomas Upper of liver Gastrointestinal C22 7 Other specified Upper carcinomas of Gastrointestinal liver C22 9 Liver unspecified Upper Gastrointestinal Author NCIN 187 Cancer Outcomes and Services Dataset User Guide C23 Malignant Upper neoplasm of Gastrointestinal gallbladder C24 0 Extrahepatic bile Upper duct Gastrointestinal C24 1 Ampulla of Vater Upper Gastrointestinal C24 8 Overlapping Upper lesion of biliary Gastrointestinal tract C24
300. ropriate Author NCIN 169 Cancer Outcomes and Services Dataset User Guide Note Use Cranium 2639 for instances of Sarcoma of the Skull SARCOMA TUMOUR SUBSITE BONE Sub location of the bone sarcoma within the tumour site This gives a more details location of the tumour and should be recorded by specialist centres treating the patient DP Diaphyseal Middle otter Author NCIN 170 Cancer Outcomes and Services Dataset User Guide SARCOMA TUMOUR SITE SOFT TISSUE Location of the soft tissue sarcoma within the body as defined by OPCS4 code This is more specific than ICD10 ICDOS3 sites Note Other Z codes may be used if they are felt more appropriate SARCOMA TUMOUR SUBSITE SOFT TISSUE Sub location of the soft tissue sarcoma within the tumour site This gives a more details location of the tumour and should be recorded by specialist centres treating the patient Posterior MULTIFOCAL OR SYNCHRONOUS TUMOUR INDICATOR An indicator of the presence of tumours at multiple sites arising synchronously concurrently Author NCIN 171 Cancer Outcomes and Services Dataset User Guide 10 2 SARCOMA STAGE UICC BONE SARCOMA 2 GRADE SYSTEM SEVENTH EDITION Stage Grouping T Stage N Stage M Stage Grade IA T1 NO MO G1 2 low grade IB T2 NO MO G1 2 low grade T1 NO MO G3 4 high grade T2 NO
301. rst second or subsequent cancer treatment given to a PATIENT who is receiving care for a cancer condition Applicable to all registered cases but see Cancer Waiting Times for definition CANCER TREATMENT MODALITY CWT Applicable to all registered cases but see Cancer Waiting Times for definition and values Applicable for active and non active treatments and to record where a patient declines treatment Applies to all treatments at all stages in the patient pathway including both primary cancer and recurrence ORGANISATION SITE CODE PROVIDER TREATMENT START DATE CANCER CWT Applicable to all registered cases but see Cancer Waiting Times for definition and values Author NCIN 44 Cancer Outcomes and Services Dataset User Guide CONSULTANT CODE TREATMENT The Consultant code of the consultant responsible for the treatment of the patient CARE PROFESSIONAL MAIN SPECIALTY CODE TREATMENT The main specialty code of the consultant responsible for the treatment of the patient Codes 501 Obstetrics and 502 Gynaecology should be used and not the combined code 500 Obstetrics and Gynaecology this is in common with the requirements for central returns including Hospital Episode Statistics See Main Specialty and Treatment Function Codes for the full list of valid codes 1 9 CORE TREATMENT SURGERY AND OTHER PROCEDURES To carry the surgery and other procedures details This can be adapted for other procedures including in
302. se implies disseminated disease involving distant extranodal sites Multiple extranodal deposits should be considered Stage IV and E should not be used However by convention involvement of the bone marrow liver lung pleura and CSF are always considered Stage 4 even if the disease is isolated to that organ E Extranodal involvement ANN ARBOR BULK Additional staging designation based on presence of bulky disease Code X if there is presence of bulky disease that is a nodal mass whose greatest dimension is more than 10 centimetres in size and or a widening of the mediastinum middle chest by more than one third X Yes bulky disease present Author NCIN 144 Cancer Outcomes and Services Dataset User Guide 8 HEAD and NECK OVERVIEW In the first phase of implementing the COSD the site specific Head and Neck data items will be collected once pre treatment and at least once post treatment The assessment information should be recorded 12 months post diagnosis as a minimum and annually thereafter if possible ICD 10 CODES Key if applicable different dataset from CWT group specified ICD 10 Expected Dataset to be collected All C Codes Core and are Cancer Waiting Site Malignant Times Site Specific Core Path Neoplasms Description specific group Dataset Dataset Only Comment C00 0 External upper lip Head and Neck e 00 1 External lower
303. ses orbit or temporal bone T1 20r3 Metastasis in a single ipsilateral lymph No distant node lt 3 cm in greatest dimension metastases IV T1 T2 or T3 Metastasis in a single ipsilateral lymph No distant node gt 3 cm but lt 6 cm in greatest metastases dimension or in multiple ipsilateral lymph nodes lt 6 cm in greatest dimension or in bilateral or contralateral lymph nodes lt 6 Author NCIN 269 Cancer Outcomes and Services Dataset User Guide cm in greatest dimension Metastasis in a lymph node gt 6 cm in No distant greatest dimension metastases Tumor with invasion of Any nodal status No distant skeleton axial or metastases appendicular or perineural invasion of skull base Any tumour status Any nodal status Distant metastases PRIMARY TUMOR T TX Primary tumor cannot be assessed for example curettaged or severely regressed melanoma TO No evidence of primary tumor Tis Melanoma in situ T1 Melanomas 1 0 mm or less in thickness T2 Melanomas 1 01 2 0 mm Melanomas 2 01 4 0 mm T4 Melanomas more than 4 0 mm Note a and b subcategories of T are assigned based on ulceration and number of mitoses per mm2 as shown below THICKNESS CLASSIFICATION mm ULCERATION STATUS MITOSES T1 lt 1 0 a w o ulceration and mitosis lt 1 mm2 b with ulceration or mitoses 21 mm2 T2 1 01 2 0 a w o ulceration b with ulceration T3 2 01 4 0 a w o ulceration b wit
304. should be completed from July 2013 The remaining site specific pathology sections should be completed from January 2014 See Appendix G and COSD Specification for further details Online Training A free online training course aimed primarily at non clinical staff is available to support those involved in collecting the data See Appendix M for further details Feedback and Queries Feedback and questions relating to the COSD are welcomed and should be emailed to cosd ncin org uk The COSD Project Team would like to express their thanks to all those who have participated and continue to provide support and guidance in the development of this information standard Trish Stokes COSD Programme Manager NCIN Author NCIN 15 Cancer Outcomes and Services Dataset User Guide 0 USING THIS GUIDE This User Guide provides additional information to support the COSD Specification and should also be used in conjunction with the COSD Dataset Implementation and Technical Guidance documents are also available for further information on the NCIN website 0 1 Layout of the User Guide The COSD Dataset and User Guide are structured to reflect the patient pathway Each of the core and site specific datasets is divided into sections along the pathway Each of these sections contains the data items relevant to that section and these data items are likely to be collected at that point in the pathway The Guide includes a Generic chapter for Core datase
305. sion Size etc 0 5 Demographics Demographic details are required for every record in order to ensure that the correct patient can be identified and information can be correctly linked The Demographics section should be completed by every Provider the first time a record is submitted There will only be one Demographics section completed for each record Demographic linkage items will be required each time the record is submitted Almost all patients should have an NHS Number and this should always be included where available For those who do not have an NHS Number the hospital number LOCAL PATIENT IDENTIFIER must be provided 0 6 Referrals This section includes details from referral up to the first appointment and is therefore to be recorded once for each cancer diagnosis For some cases this is already recorded and submitted for Cancer Waiting Times For the COSD this information is required for all cases This is essential to support analysis for outcomes and work on presentation and routes to diagnosis Further guidance on how various scenarios should be recorded is included in Appendix J There will only be one Referral section completed for each record 0 7 Imaging Imaging procedures carried out to diagnose or stage the cancer are included in this section Most of the fields in this section are also extracted for the Diagnostic Imaging Dataset DIDS Generic core imaging data may be provided through alternative methods and sho
306. specific circumstances Please see Appendix N for further guidance This section will be recorded once This section is not applicable for Haematology or Skin Please see site specific sections for other relevant staging Note Where the pathological stage was recorded after the patient had received neoadjuvant therapy i e chemotherapy or radiotherapy prior to surgery the integrated stage may be the same as the pre treatment stage Schema Data Item Name Format specification M R O X Data Item Data Item No Section CORE CR0520 STAGING T CATEGORY FINAL PRETREATMENT max an5 i CR0540 PORE N CATEGORY FINAL PRETREATMENT max an5 STAGING Author NCIN 42 Cancer Outcomes and Services Dataset User Guide CORE M CATEGORY FINAL ummER _ CORE TNM STAGE GROUPING FINAL PRE Pose mus m mum mms o Deme ums remm 3 STAGING Dee us 3 STAGING CORE CRO640 CATEGORY INTEGRATED STAGE max 5 71 CORE TNM STAGE GROUPING mage STAGING INTEGRATED marana pk CR2070 CORES TNM EDITION NUMBER max an2 STAGING Note The COSD Core Staging data items mentioned below are not applicable for CNS Gynaecology Haematology Skin and most CTYA diagnosis Please see site specific datasets for further information on collecting this data item including the site specific values to be used T CATEGORY FINAL PRETREATMENT This is the UICC code which classifies the size
307. st dimension and or regional lymph node metastasis IV Distant metastasis beyond the peritoneal cavity excludes peritoneal metastasis Author NCIN 113 Cancer Outcomes and Services Dataset User Guide FALLOPIAN TUBE Description IA Tumour limited to one tube without penetrating the serosal surface IB Tumour limited to both tubes without penetrating the serosal surface IC Tumour limited to one or both tubes with extension onto through the tubal serosa or with malignant cells in the ascites or positive peritoneal washings Extension and or metastasis to uterus and or ovaries Extension to other pelvic structures Pelvic extension with malignant cells in the ascites or positive peritoneal washings Microscopic peritoneal metastasis outside the pelvis Macroscopic peritoneal metastasis outside the pelvis 2 or less in greatest dimension Peritoneal metastasis more than 2 in greatest dimension and or positive regional lymph nodes IV Distant metastasis beyond the peritoneal cavity excludes peritoneal metastasis LEIOMYOSARCOMAS AND ENDOMETRIAL STROMAL SARCOMAS FIGO Stage Group 18 Tumour imited to uterus and greater than Semin greatest dimensions 18 is umour invades abdominal tissues more than neste ADENOSARCOMAS FIGO Stage P Description Group Tumour limited to endometrium endocervix with no myometrial invasion B
308. stic Event CLINICAL INTERVENTION Hospital Provider Spell Accident and Emergency Attendance or Screening Test whichever is the earlier SERVICE related to the initial REFERRAL REQUEST It is the date first seen in secondary care for this diagnosis See ORGANISATION SITE CODE DATE FIRST SEEN CANCER SPECIALIST This is the date that the PATIENT is first seen by the appropriate specialist for cancer care within a Cancer Care Spell This is the PERSON or PERSONS who are most able to progress the diagnosis of the primary tumour If patient s first appointment is with the appropriate cancer specialist this will be the same as DATE FIRST SEEN Author NCIN 29 Cancer Outcomes and Services Dataset User Guide ORGANISATION CODE PROVIDER FIRST CANCER SPECIALIST The ORGANISATION SITE CODE of the ORGANISATION acting as Health Care Provider where the PATIENT is first seen by an appropriate cancer specialist on the DATE FIRST SEEN CANCER SPECIALIST If patient s first appointment is with the appropriate cancer specialist this will be the same as ORGANISATION CODE PROVIDER FIRST SEEN See ORGANISATION SITE CODE CANCER OR SYMPTOMATIC BREAST REFERRAL PATIENT STATUS CWT This is recorded to enable tracking of the status of REFERRAL REQUESTS for PATIENTS referred with a suspected cancer or referred with breast symptoms with cancer not originally suspected For COSD these definitions are extended to apply to all registerable conditions However
309. t Administration Systems and Pathology The COSD includes updated definitions and values for these items Many other items in the COSD are already submitted through standard NHS routes such as Cancer Waits and apart from key items these do not need to be resent Most of the remaining items in the COSD are site specific and are required for patient management and clinical care These also need to be submitted directly to the registries The data which Providers send to the registries directly may be submitted in separate files from different Provider systems although most of the data items are likely to be extracted from MDT software systems Data from all sources will be linked by the registries at patient level using NHS Number to complete the full dataset This User Guide contains all data items which need to be included in the monthly submission by NHS Providers of Cancer Services to the National Cancer Registration Service The Guide provides a description of the data items the tumour sites or disease types to which they apply and any further information needed to collect them Other guidance documentation Technical Guidance and Implementation Guidance is provided separately Which diagnoses does COSD apply to The COSD is applicable to all UK Association of Cancer Registries UKACR registerable conditions see Appendix B It relates to all new diagnoses from 1 January 2013 For the purposes of COSD the term cancer is used throughou
310. t Gynaecologist not sub specialist Sub Specialty Fellow Associate Specialist Staff Grade 5 5 3 sHO STiorsT2 General Surgeon other surgical specialty 6 2 GYNAECOLOGY STAGING To carry staging details for Gynae This section will be recorded once Schema specification M R O X Data item No Data Item Section Data Item Name Format GY7010 GYNAECOLOGY STAGING FINAL FIGO STAGE maxas FINAL FIGO STAGE The FIGO stage is generally confirmed at pathology review in MDT meetings following surgery for uterine and vulval malignancies and for ovarian malignancies undergoing primary surgery For ovarian malignancies planned to undergo neoadjuvant chemotherapy and for cases of cervical cancer which is staged clinically the final FIGO stage is determined at the time of review of clinical findings imaging cytology and biopsy histology at the MDT meeting FIGO Stage groups for gynaecological cancers are as follows Author NCIN 111 Cancer Outcomes and Services Dataset User Guide VULVAL FIGO Stage M 9 Description Group Stage Tumour confined to the vulva IA Lesions lt 2 cm in size confined to the vulva or perineum and with stromal invasion lt 1 0 mmf no nodal metastasis IB Lesions gt 2 cm in size or with stromal invasion gt 1 0 mm confined to the vulva or perineum
311. t followed by individual chapters for each of the site specific datasets applicable to each Tumour Group Each chapter is laid out similarly and arranged as follows O Overview ICD 10 codes for the Tumour Group O Sections as per the COSD Dataset each including m Table of data items W Details of the data items description codes and values MEANING OF NOT KNOWN VALUE Not known includes both not recorded and for example test not done This is usually coded 9 or 99 depending on the data item format LIST OF REGISTERABLE DISEASES The ICD10 disease codes lists for all registerable conditions C amp D codes are provided in Appendices A and B The Haematology ICDO3 codes list can be found in Section 7 2 ICD CODES AND WHO DISEASE GROUPS 0 2 Key to Data Item Tables All data items are listed as follows The reference number for the COSD data item Data Item The section in which the data item appears Section Data Item The name of the data item This is followed by the DATA DICTIONARY ITEM NAME if Name different Format required for submission of the data item Schema The detailed schema for submission of the data is included in the Technical Guidance specification M R O X P This column identifies whether items are required for the extract to pass validation rules when submitted in XML format Note that all applicable data should be submitted as soon as possible M Mandatory A section cannot be included in th
312. t has co morbidities that preclude staging investigations or the prognosis and treatment would be unaffected by further knowledge about distant metastases MX may also be used in radiological reports where the radiologist wishes to indicate that they have been unable to assess or have no information about distant metastases Pathologists are typically unable to comment on the status of distant metastases if the specimen does not include appropriate material In such circumstances it is appropriate for MX to be recorded When should MX not be used MX should not be used in either the pretreatment or integrated stage when there is no evidence of distant metastatic disease and further investigations to look for metastatic disease are deemed inappropriate because the clinical risk is low For example a patient with small breast tumour without nodal metastases T1 T2 NO is clinically unlikely to have distant metastatic disease and will not routinely have cross sectional imaging Such patients are considered to have been clinically assessed as cMO and therefore MO should be recorded in both the pretreatment and integrated stage fields MX must not be used as a default entry and must only be selected in the specific circumstances highlighted above Can the M stage just be left blank M9 in COSD The M stage should only be left blank when the result of investigations is not known for example the patient has been diagnosed at Trust A but has their
313. t the documentation to apply to all these registerable conditions What data items should be completed All registerable conditions should be reported as defined in Appendices A and B This includes submitting all pathology reports for these cases For some high volume diseases generally those which do not require MDT discussion only pathology reports are required and no other information needs to be submitted for COSD Author NCIN 14 Cancer Outcomes and Services Dataset User Guide For all other cases as a minimum the core dataset should be completed including all applicable data items In addition to the core dataset most cases will also require a site specific dataset to be completed For under 25s there may be two site specific datasets completed CTYA and disease specific depending on the nature of the disease and where the patient is treated Please see CTYA section 5 1 of this Guide for further details Appendices A and B provide further details by tumour type PLEASE NOTE ALL ITEMS IN THE DATASET except those marked X in the schema specification and those in the greyed out sections of the COSD Dataset ARE MANDATORY WHERE APPLICABLE UNLESS STATED OTHERWISE IN THE DESCRIPTIONS THIS INCLUDES ALL ITEMS MARKED AS BOTH MANDATORY M AND REQUIRED R IN THE SCHEMA SPECIFICATION The Dataset is divided into Sections e g CORE IMAGING LUNG PATHOLOGY etc and for each record a section can only be su
314. tated NPM1 C92 0 TAM myeloblastic leukaemia yc 5 9861 3C Acute myeloid leukaemia NOS 92 0 leukaemia AML 5 9865 3 AML with t 6 9 p23 q34 DEK NUP214 C92 0 oes myeloblastic leukaemia ay 5 Acute promyelocytic leukaemia with Acute promyelocytic 9866 3 t 15 17 q22 q12 PML RARA mud leukaemia PML AME 5 9867 3 Acute myelomonocytic leukaemia C92 5 myelormonocyti AML 5 leukaemia AML with inv 3 q21q26 2 or Acute myeloblastic leukaemia 9869 3 103 3 921 126 2 RPRNI EVIL c92 0 tamy AME 9870 3 Acute basophilic leukaemia C92 7 Other myeloid leukaemia AML 5 AML with inv 16 p13 1 q22 or Acute myelomonocytic 9871 3 t 16 16 p13 1 q22 11 leukaemia AME 9872 3 AMLwith minimal differentiation C92 0 TAM myelblasticle kaeriiai ii 5 9873 3 AML without maturation 92 0 myeloblastie leukaeria AML 5 9874 3 AML with maturation C92 0 myeloblastie leukaemia 5 Chronic Myelogenous Leukaemia BCR Chronic myeloid leukaemia 9875 3 ABL1 positive CML BCR ABL positive eM 1 Chronic Myelogenous Leukaemia Chronic myeloid leukaemia 9875 3 A Accelerated Phase CML BCR ABL positive CML Chronic Myelogenous Leukaemia Chronic myeloid leukaemia 9875 3 B Blastic Phase CML BCR ABL positive Author NCIN 129 Cancer Outcomes and Services Dataset User Guide ICD 10 WHO DISEASE ICD O 3 I
315. ted Schema Data item n No Data Item Section Data Item Name Format specification i M R O X CORE PATIENT CORE PATIENT CRO020 IDENTITY DETAILS LOCAL PATIENT IDENTIFIER CORE PATIENT an10 ccyy mm CRO100 IDENTITY DETAILS PERSON BIRTH DATE CORE PATIENT ORGANISATION CODE CODE OF STOUN IDENTITY DETAILS PROVIDER 3 A combination of NHS NUMBER and or LOCAL PATIENT IDENTIFIER is Mandatory for the schema CORE PATIENT NHS NUMBER STATUS CR1350 IDENTITY DETAILS INDICATOR CODE anz O A combination of LOCAL PATIENT IDENTIFIER and or NHS NUMBER is Mandatory for the schema Author NCIN 25 Cancer Outcomes and Services Dataset User Guide CORE max 35 CORE max 35 CROO70 CORE PATIENT USUAL ADDRESS AT an175 5 lines M DEMOGRAPHICS DIAGNOSIS each an35 CORE POSTCODE OF USUAL ADDRESS CORE PERSON GENDER CODE CRO090 1 M DEMOGRAPHICS CURRENT an CORE GENERAL MEDICAL DEMOGRAPHICS PRACTITIONER SPECIFIED PE CORE GENERAL MEDICAL PRACTICE 3 DEMOGRAPHICS CODE PATIENT REGISTRATION CORE PERSON FAMILY NAME AT max 35 DEMOGRAPHICS BIRTH characters CORE CRO150 ETHNIC CATEGORY an2 NHS NUMBER The NHS NUMBER is a unique identifier for a PATIENT within the NHS in England and Wales This will not vary by any ORGANISATION of which a PERSON is a PATIENT LOCAL PATIENT IDENTIFIER For linkage purposes NHS NUMBER and or LOCAL PATIENT IDENTIFIER are required This is a number used to ident
316. tem Name Format specification M R O X CORE DATE OF DIAGNOSIS CLINICALLY CR2030 CORE AGREED 10 M DIAGNOSTIC DATE OF DIAGNOSIS CANCER mm dd CLINICALLY AGREED DATE OF RECURRENCE CLINICALLY CR0440 AGREED an10 ccyy 2 DIAGNOSTIC DATE OF RECURRENCE CANCER mm dd CLINICALLY AGREED Data item Data Item No Section CORE emm _ Fao semen m _ DIAGNOSIS DIAGNOSIS em meme cm _ DIAGNOSIS DIAGNOSIS MORPHOLOGY ICD O an7 COE E DIAGNOSIS TOPOGRAPHY ICD O an7 CORE GRADE OF DIFFERENTIATION AT COR Either DATE OF DIAGNOSIS CLINICALLY AGREED DATE OF RECURRENCE CLINICALLY AGREED is Mandatory for the schema 10 Either DATE OF DIAGNOSIS CLINICALLY AGREED or DATE OF RECURRENCE CLINICALLY AGREED is Mandatory for the schema Either MORPHOLOGY SNOMED and or MORPHOLOGY ICDO3 is Mandatory for the schema Either MORPHOLOGY SNOMED and or MORPHOLOGY ICDO3 is Mandatory for the schema Author NCIN 33 Cancer Outcomes and Services Dataset User Guide CORE CR1590 DIAGNOSIS METASTATIC SITE DEBE CORE CANCER RECURRENCE CARE PLAN DIAGNOSIS INDICATOR PRIMARY DIAGNOSIS ICD See DIAGNOSTIC CODING for details on coding and PRIMARY DIAGNOSES for the standardised definition of primary diagnosis The primary diagnosis is normally agreed at the MDT Meeting where the patient is discussed ICD10 is
317. tem is used the values should be recorded in the generic TNM stage fields in the core dataset The TNM EDITION NUMBER should be recorded as E 0 11 Treatment The initial record is completed up to the first treatment but all subsequent treatments are also required Treatments are also reported for cases covered by Cancer Waiting Times although some additional details are included in COSD in both generic core and site specific sections There may be more than one Treatment section completed for each record 0 12 Pathology Pathological diagnosis and grade where applicable are recorded on biopsies and may be amended after surgical resection if appropriate when pathological staging should also be available Full text pathology reports should be submitted to include these data items if structured coded extracts are not available There may be more than one Pathology section completed for each record 0 13 Death Details of death are obtained by the National Cancer Registration Service from ONS but may be submitted by Providers where available There may only be one Death section completed for each record 0 14 Linkage Data Items In order to ensure that records submitted can be linked appropriately some key data fields must be completed for each record submitted These are shown at the start of the Core Dataset Section and further details are included in the relevant Demographics and Diagnosis sections There will be one linkage section
318. terventional radiology laser treatment endoscopies etc and photo dynamic procedures This also includes procedures offered as supportive care This section will be recorded once per treatment where applicable Schema Data Item Section Data Item Name Format specification M R O X Data item No red ta ee DISCHARGE DATE HOSPITAL an10 ccyy OTHER PROCEDURES PROVIDER SPELL mm dd OTHER PROCEDURES HOSPITAL PROVIDER SPELL CANCER TREATMENT INTENT The original intention of the cancer treatment provided during a Cancer Care Spell c 5 Palliative PROCEDURE DATE The date the procedure was carried out PRIMARY PROCEDURE OPCS Primary procedure is the main procedure carried out Author NCIN 45 Cancer Outcomes and Services Dataset User Guide PRIMARY PROCEDURE SNOMED Primary procedure is the main procedure carried out using SNOMED CT This maybe recorded in addition to PRIMARY PROCEDURE OPCS Note For use in pilot project only at present Please contact cosd ncin org uk for further details PROCEDURE OPCS This is a procedure other than the PRIMARY PROCEDURE OPCS carried out and recorded for CDS or Hospital Episode Statistics purposes This may occur more than once PROCEDURE SNOMED CT This is a procedure other than the PRIMARY PROCEDURE carried out and recorded for CDS or Hospital Episode Statistics purposes This may occur more than once This maybe recorded in additio
319. th asphyxia congenital rubella in perinatal period syndrome neonatal jaundice congenital hydrocele Congenital Coloboma aniridia cardiac defects cleft lip or palate malformations Hirschsprung disease cryptorchism hypospadias pseudo hermaphroditism congenital malformations of kidney neurofibromatosis tuberous sclerosis hemihypertrophy Beckwith Wiedmann syndrome Constitutional Down syndrome Turner syndrome Klinefelter syndrome chromosomal gonadal dysgenesis fragile X chromosome abnormalities The list given above is not meant to be exhaustive Where examples are given these are simply the most frequent or important conditions within a given category The overriding rule should be that if it is believed that a condition might be relevant to aetiology produce significant comorbidity or otherwise affect treatment or prognosis and then it should be recorded In particular it is suggested that any heritable condition included in Online Mendelian Inheritance in Man OMIM http www ncbi nlm nih gov omim should be recorded Author NCIN 264 Cancer Outcomes and Services Dataset User Guide APPENDIX E RECOMMENDED STAGING TO BE COLLECTED BY CANCER REGISTRIES The National Staging Panel for Cancer Registration recommends that the staging systems recorded by the cancer registries follow the guidance issued by the Royal College of Pathologists and the Cancer Outcomes Services Dataset TUMOUR TYPE STAGIN
320. the MDT discussion but will only apply to a small number of cases The following definitions are used Less than 200ml 200ml or greater CYTOGENETICS FOR EWINGS SARCOMA Cytogenetic analysis This information should be available for the MDT discussion but will only apply to a small number of cases The following definitions are used t 11 22 Variant Translocation Negative Not Available 5 17 CTYA OSTEOSARCOMA and EWINGS To carry Osteosarcoma and Ewings details for CTYA This section will be recorded once Author NCIN 102 Cancer Outcomes and Services Dataset User Guide Schema Data Item Section Data Item Name Format specification M R O X Data item No CTYA OSTEOSARCOMA and SARCOMA TUMOUR SITE CTYA OSTEOSARCOMA and SARCOMA TUMOUR SUBSITE SARCOMA TUMOUR SITE BONE Location of the bone sarcoma within the body more specific than ICD10 ICDOS sites E2746 SARCOMA TUMOUR SUBSITE BONE Sublocation of the bone sarcoma within the tumour site PR Proximal ooo DP Diaphyseal Middle Other 000000 Author NCIN 103 Cancer Outcomes and Services Dataset User Guide 5 18 CTYA GERM CELL CNS TUMOURS To carry Germ Cell CNS Tumours details for CTYA CNS germ cell tumours are defined as ICD10 C70 0 C72 9 C75 1 C75 3 D32 0 D33 9 D35 2 D35 4 D42 0 D43 9 D44 3 D44 5 combined with Morphology 9060 9104 This section will be recorded once Schema Data Item Secti
321. thology details may be completed by a different Provider from the First Seen Provider Site specific data items have been aligned between the COSD and the National Lung Cancer Audit ICD 10 CODES Key if applicable different dataset from CWT group specified ICD 10 Expected Dataset to be collected All C Codes Core and are Cancer Waiting Site Malignant Times Site Specific Core Path Neoplasms Description specific group Dataset Dataset Only Comment C33 Malignant Lung neoplasm of trachea C34 0 Main bronchus Lung e C34 1 Upper lobe Lung e bronchus or lung C34 2 Middle lobe Lung e bronchus or lung C34 3 Lower lobe Lung e bronchus or lung C34 8 Overlapping lesion Lung of bronchus and e lung C34 9 Bronchus or lung Lung NS e unspecified C37 Malignant Lung neoplasm of e thymus C38 0 Heart Lung e C38 1 Anterior Lung e e mediastinum C38 2 Posterior Lung UP e mediastinum C38 3 Mediastinum part Lung unspecified C38 4 Pleura Lung e Author NCIN 157 Cancer Outcomes and Services Dataset User Guide C38 8 Overlapping lesion Lung of heart mediastinum and pleura C39 0 Upper respiratory Lung tract part unspecified C39 8 Overlapping lesion Lung of respiratory and intrathoracic organs C39 9 Ill defined sites Lung within the respiratory system C45 0 Mesothelioma of Lung pleura C45 1 Mesothelioma of Lun
322. those conditions not covered by Cancer Waits will need to be excluded from CWT uploads Suspected primary cancer Under investigation following symptomatic referral cancer not suspected breast referrals only see note 1 No new cancer diagnosis identified by the Healthcare Provider Diagnosis of new cancer confirmed first treatment not yet planned Diagnosis of new cancer confirmed English NHS first treatment planned Diagnosis of cancer confirmed no English NHS treatment planned First treatment commenced English NHS only Diagnosis of new cancer confirmed subsequent English NHS treatment planned Diagnosis of recurrent cancer confirmed subsequent English NHS treatment planned 08 CANCER SYMPTOMS FIRST NOTED DATE MANDATORY FOR CTYA OPTIONAL FOR ALL OTHERS Record the time when the symptoms were first noted related to this diagnosis as agreed between the consultant and the patient This will normally be recorded by the consultant first seeing the patient in secondary care Depending on the length of time this should normally include at least the month and year The day should also be included if known If symptoms have been present for a long time then it may only be possible to record the year In these various circumstances the Format Length will be e DATE including year month and day CCYY MM DD e YEAR AND MONTH YYYY MM e YEAR ONLY YYYY Author NCIN 30 Cancer Outcomes and Services Dataset User Guide
323. tive notes or the Anaesthetist review section 1 normal healthy patient 3 A patient with mild systemic disease 3 A patient with severe systemic disease that limits function but is not incapacitating 4 A patient with severe systemic disease that is a constant threat to life 5 moribund patient who is not expected to survive without the operation 6 A declared brain dead patient whose organs are being removed for donor purposes Author NCIN 59 Cancer Outcomes and Services Dataset User Guide 2 5 BREAST STAGING UICC CLASSIFICATION OF BREAST TNM STAGING SEVENTH EDITION Stage Grouping T Stage N Stage M Stage Stage T1 NO MO TO T1 N1 MO Stage Il TO T1 N1 MO T2 NO MO T2 N1 MO T3 NO MO Stage III TO T1 T2 N2 MO T3 N1 N2 MO T4 NO N1 N2 MO Any N3 MO Stage IV Any T Any N M1 Primary Tumour Tis Tumour in situ DCIS ductal carcinoma in situ LCIS lobular carcinoma in situ Timi Microinvasion is 0 1cm or less in greatest dimension 1 Tumour is more than 0 1 but not more than 0 5cm in greatest dimension Tib Tumour is more than 0 5cm but not more than 1cm in greatest dimension 1 Tumour is more than 1cm but more than 2 in greatest dimension T2 Tumour more than 2cm but not more than 5cm in greatest dimension T3 Tumour more than 5cm in greatest dimension T
324. tration Forms OTHER SIGNIFICANT DIAGNOSIS SUBSIDIARY COMMENT Optional Additional comments on other significant conditions where coding is difficult or imprecise For example NF1 or NF2 to distinguish between these two distinct conditions which may have different treatment decisions or outcomes but cannot be coded separately This information should be available for the MDT discussion but will only apply to a small number of cases FAMILIAL CANCER SYNDROME Indicate whether there is a possible or confirmed familial cancer syndrome This information should be available for the MDT discussion but will only apply to a small number of cases The following definitions are used Y NES AO OoN P Possible o Oe 9 Not Known S FAMILIAL CANCER SYNDROME SUBSIDIARY COMMENT Optional Where Familial Cancer Syndrome is coded as Yes or Possible this field can be used to provide further details For example Li Fraumeni Rhabdoid tumour predisposition syndrome or Biallelic PMS2 mutation to identify distinct syndromes which may have different treatment decisions or outcomes but cannot be coded separately CONSULTANT SPECIALTY AT DIAGNOSIS The specialty of the consultant responsible for the patient at the time of diagnosis Main Specialty and Treatment Function Codes CONSULTANT AGE SPECIALTY AT DIAGNOSIS The age group specialty of the consultant responsible for the patient at the time of diag
325. ts of cervix Gynaecological D06 9 carcinoma in situ of cervix unspecified Gynaecological D07 0 carcinoma in situ of endometrium Gynaecological D07 1 carcinoma in situ of vulva Gynaecological D07 2 carcinoma in situ of vagina Gynaecological D07 3 carcinoma in situ of other and unspecified female genital organs Gynaecological D39 0 Neoplasm of uncertain or unknown behaviour of Uterus Gynaecological D39 1 Neoplasm of uncertain or unknown behaviour of Ovary Gynaecological D39 2 Neoplasm of uncertain or unknown behaviour of Placenta Gynaecological Author NCIN 110 Cancer Outcomes and Services Dataset User Guide D39 7 Neoplasm of Gynaecological uncertain or unknown behaviour of Other female genital organs D39 9 Neoplasm of Gynaecological uncertain or unknown behaviour of Female genital organ unspecified 6 1 GYNAECOLOGY SURGERY To carry surgery and other procedure details for Gynae This section will be recorded once per treatment where applicable Schema Data item No Data Item Section Data Item Name Format specification M R O X SURGEON GRADE GYNAECOLOGY GY7000 G RGERY CARE PROFESSIONAL SENIOR OPERATING SURGEON GRADE CANCER SURGEON GRADE Grade of senior surgeon present at operation Sub specialist Gynaecological Oncologist Consultan
326. ture T NK cell lymphoma unspecified Haematological C85 1 B cell lymphoma unspecified Haematological C85 2 Mediastinal thymic large B cell lymphoma Haematological C85 7 Other specified types of non Hodgkin lymphoma Haematological C85 9 Non Hodgkin lymphoma unspecified Haematological C86 0 Extranodal NK T cell lymphoma nasal type Haematological C86 1 Hepatosplenic T cell lymphoma Haematological C86 2 Enteropathy type intestinal T cell lymphoma Haematological C86 3 Subcutaneous panniculitis like T cell lymphoma Haematological Author NCIN 244 ICD 10 4th Edition All C Codes are Malignant Cancer Outcomes and Services Dataset User Guide Cancer Waiting Times Site Neoplasms Description specific group C86 4 Blastic N K cell Haematological lympthoma C86 5 Angioimmunoblastic Haematological T cell lymphoma C86 6 Primary cutaneous Haematological CD30 positive T cell proliferations C88 0 Waldenstr m Haematological macroglobulinaemia C88 2 Other heavy chain Haematological disease C88 3 Immunoproliferative Haematological small intestinal disease C88 4 Extranodal marginal Haematological zone B cell lymphoma of mucosa associated lymphoid tissue MALT lymphoma C88 7 Other malignant Haematological immunoproliferative diseases C88 9 Maligna
327. ucin Producing Intra Epithelial Lesion Author NCIN 119 Cancer Outcomes and Services Dataset User Guide Absent Not assessable EXCISION MARGIN PRE INVASIVE Is there evidence of resection margin involvement by in situ pre invasive disease CIN CGIN and SMILE INVASIVE THICKNESS The thickness or depth of the invasive lesion in millimetres mm Note For COSD reporting purposes this data item is not required to be submitted to two decimal places PARACERVICAL OR PARAMETRIAL INVOLVEMENT Is there evidence of paracervical and or parametrial involvement X Not assessable THICKNESS UNINVOLVED STROMA Minimum thickness of uninvolved cervical stroma in millimetres mm minimum tumour free rim Note For COSD reporting purposes this data item is not required to be submitted to two decimal places VAGINAL INVOLVEMENT Is there evidence of microscopic vaginal involvement 8 6 7 GYNAECOLOGY PATHOLOGY VULVAL To carry pathology details for Gynae for Vulval This section will be recorded once per pathology report where applicable Schema Data item n ANE Data Item Section Data Item Name Format specification No M R O X GY7390 GYNAECOLOGY PATHOLOGY INVASIVE max n2 max VULVAL THICKNESS n2 INVASIVE THICKNESS The thickness or depth of the invasive lesion in millimetre s mm s Note For COSD reporting purposes this data item is not required to be submitted to two decimal places 6 8 G
328. uld be discussed with the local office of the NCRS Details of specific imaging procedures and outcomes required for specific disease groups are included in the appropriate site specific sections and must be included in monthly submissions There may be more than one Imaging section completed for each record Note Imaging carried out post treatment should also be available Author NCIN 19 Cancer Outcomes and Services Dataset User Guide 0 8 Diagnosis Diagnosis details in the linkage section are required for every record in order to ensure that the correct record can be identified and information can be correctly linked The full diagnosis details section enables the disease to be correctly registered All registerable conditions should be recorded see Appendix B Recording an applicable diagnosis including a Date of Diagnosis triggers inclusion of the record in the submission Please refer to site specific sections for applicable ICD10 and or ICDO3 codes This information will normally be confirmed by the Multidisciplinary Team at their MDT Meeting Both ICD10 codes and Morphology SNOMED and or ICDO3 must be completed for all cases ICD03 Topography Codes do not need to be completed by Providers There will only be one Diagnosis section completed for each record Diagnosis linkage items will be required each time the record is submitted 0 9 Cancer Care Plan This section includes details applicable to care planning including p
329. ur focal and diffuse malignant rhabdoid tumour of kidney clear cell sarcoma of the kidney renal cell carcinoma FAVOURABLE UNFAVOURABLE RISK CLASSIFICATION PATHOLOGICAL AFTER PREOPERATIVE CHEMOTHERAPY Classification after preoperative chemotherapy determines histological risk This information should be available for the MDT discussion following treatment but will only apply to a small number of cases The following definitions are used Low risk cystic partially differentiated nephroblastoma completely necrotic nephroblastoma mesoblastic nephroma diffuse nephroblastomatosis Intermediate risk nephroblastoma type epithelial stromal mixed regressive focal anaplasia High risk nephroblastoma blastemal type nephroblastoma with anaplasia malignant rhabdoid tumour of the kidney clear cell sarcoma of the kidney renal cell carcinoma Low Intermediate H High 5 14 CTYA RHABDOMYOSARCOMA and OTHER SOFT TISSUE SARCOMAS To carry Rhabdomyosarcoma and other Soft Tissue Sarcoma details for CTYA This section will be recorded once I XU mom item No Data Item Section Data Item Name Format specification M R O X IRS POST SURGICAL GROUP pA INTERGROUP RHABDOMYOSARCOMA CT6350 RHABDOMYOSARCOMA and CYTOGENETICS FOR ALVEOLAR RHABDOMYOSARCOMA CYTOGENETIC PRESENCE TYPE RHABDOMYOSARCOMA CTYA CT6360 RHABDOMYOSARCOMA and OTHER STS OTHER STS STUDY POST SURGICAL GROUPING ani SYSTEM S
330. used Similarly for those cases where no surgery is undertaken a modified Dukes stage can only be used where metastatic spread has been identified and hence allocated to Modified Dukes stage D For all other cases where no operation is performed staging will have to be based on radiological appearances either before or after the neo adjuvant treatment and an integrated TNM stage decided based on the radiological appearances 4 5 COLORECTAL SURGERY amp OTHER PROCEDURES To carry details of surgery and other procedures for each surgery for colorectal cancer This section will be recorded once per treatment where applicable Schema Data item No Data Item Section Data Item Name Format specification M R O X SURGICAL ACCESS COLORECTAL SURGERY amp OTHER CO5180 SURGICAL ACCESS PROCEDURES TYPE SURGICAL ACCESS Approach to surgery laparoscopic open or converted Record the access used to perform the operation Recording the surgical access is standard clinical practice and should be obtained from the operational notes Open operation Excision of the tumour via a laparotomy with no use of a laparoscope Laparoscopic with planned conversion to open surgery Excision of the tumour after targeted laparoscopic assessment and or part of the treatment being completed laparoscopically Laparoscopy with unplanned conversion to open surgery Inability to complete the intra abdominal dissection laparoscopically
331. ussion Date Planned Cancer Treatment Type etc STAGE PRE TREATMENT e g TNM Stage Grouping Final Pre Treatment TNM Edition Number etc TREATMENT e g Treatment Start Date Treatment Modality etc IMAGING POST TREATMENT e g Cancer Imaging Modality Imaging Anatomical Site etc PATHOLOGY POST TREATMENT e g TNM Stage Grouping Pathological Lesion Size etc POST TREATMENT STAGE i e TNM Stage Grouping Integrated DEATH DETAILS i e Person Death Date and Death Location Type Not Required for Trust submission Cancer Patient s Pathway for a Recurrence A new record is required for each recurrence The diagram below illustrates the main sections of the cancer patient s pathway which need to be completed for a recurrence as detailed in COSD The sections highlighted in purple may be collected more than once The sections highlighted in green include different data items from the primary diagnosis record 2 Currently only Breast recurrences are required Author NCIN 18 Cancer Outcomes and Services Dataset User Guide DEMOGRAPHICS e g NHS Number Date of Birth etc only Source of Referral for Cancer Recurrence is collected found in the Cancer Recurrence section of the dataset TREATMENT e g Treatment Start Date Treatment Modality etc IMAGING POST TREATMENT e g Cancer Imaging Modality Imaging Anatomical Site etc PATHOLOGY POST TREATMENT e g TNM Stage Grouping Pathological Le
332. usually but not always requires the use of a larger incision than that required to extract the specimen Laparoscopic completed Laparoscopic dissection with small incision to extract the specimen Open operation Laparoscopic with planned conversion to open surgery Laparoscopic with unplanned conversion to open surgery Laparoscopic completed 4 6 COLORECTAL PATHOLOGY To carry details of pathology for colorectal cancer This section can be recorded more than once Schema Data Data Item Data Item Name Format specification M R O X item No Section COLORECTAL an10 ccyy 5320 INVESTIGATION RESULT DATE PATHOLOGY mm dd COLORECTAL 5330 SERVICE REPORT IDENTIFIER max an18 PATHOLOGY Author NCIN 84 Cancer Outcomes and Services Dataset User Guide POSITIVE PROXIMAL OR DISTAL RESECTION MARGIN COLORECTAL 5190 MARGIN INVOLVED INDICATION CODE 1 PATHOLOGY POSITIVE PROXIMAL OR DISTAL RESECTION MARGIN DISTANCE TO CIRCUMFERENTIAL MARGIN COLORECTAL max 5210 DISTANCE TO CLOSEST NON PERITONEALISED PATHOLOGY n2 max n2 RESECTION MARGIN DISTANCE BETWEEN LOWER END OF TUMOUR COLORECTAL max 5230 AND DISTAL RESECTION MARGIN PATHOLOGY n4 max n2 DISTANCE TO DISTAL RESECTION MARGIN COLORECTAL PERFORATIONS OR SEROSAL INVOLVEMENT 5250 1 PATHOLOGY INDICATION CODE COLORECTAL PLANE OF SURGICAL EXCISION 5260 1 PATHOLOGY PLANE OF SURGICAL EXCISION TYPE
333. utcomes and Services Dataset User Guide 10 SARCOMA OVERVIEW Sarcomas are a rare form of cancer which account for approximately 1 of all malignancies However these tumours can arise within any site of the body implying that some sarcomas will not be included within the ICD 10 site codes listed below The Cancer Waiting Times and COSD datasets have consistent inclusion criteria for sarcomas although the COSD also includes C78 6 Secondary malignant neoplasm of retroperitoneum and peritoneum As much information as possible is required in order to accurately reflect the sarcoma subsite For tumours coded under the C46 ICD 10 codes only the CORE dataset needs to be completed ICD 10 CODES Key if applicable different dataset from CWT group specified ICD 10 Expected Dataset to be collected All C Codes Core and are Cancer Waiting Site Malignant Times Site Specific Core Path Neoplasms Description specific group Dataset Dataset Only Comment 40 0 Scapula and long Sarcoma bones of upper limb C40 1 Short bones of Sarcoma upper limb s C40 2 Long bones of Sarcoma lower limb C40 3 Short bones of Sarcoma lower limb T C40 8 Overlapping lesion Sarcoma of bone and articular cartilage e of limbs C40 9 Bone and articular Sarcoma cartilage of limb e unspecified C41 0 Bones of skull and Sarcoma face 41 1 Mandible Sarcoma e C41 2 Vertebral column Sarcoma e C41 3 Ribs sternu
334. vascular large B cell lymphoma C83 3 Diffuse large B cell lymphoma EET 9 8 ymp i E ymp Lymphomas 9714 3 Anaplastic large cell lymphoma ALK C84 6 Anaplastic large cell Other 10 positive lymphoma ALK positive Lymphomas Hepatosplenic T cell Other 9716 3 Hepatosplenic T cell lymphoma C86 1 lymphoma Lymphomas 10 9717 3 Enteropathy associated T cell C86 2 Enteropathy type intestinal Other 10 lymphoma T cell lymphoma Lymphomas 9718 3 Primary cutaneous anaplastic large cell C86 6 Primary cutaneous CD30 Other 10 lymphoma positive T cell proliferations Lymphomas 9719 3 Extranodal NK T cell lymphoma nasal C86 0 Extranodal NK T cell Other 10 type lymphoma nasal type Lymphomas 9719 3 T NK cell lymphoma C84 9 Mature T NK cell lymphoma CORE 10 unspecified Systemic EBV positive T cell 9724 3 lymphoproliferative disease of C84 5 Sedi Ad V NN 10 childhood TR PU 9725 3 Hydroa vacciniforme like lymphoma C84 5 Other mature T NK cell Other 10 lymphomas Lymphomas 9726 3 Primary cutaneous gamma delta T cell C84 5 Other mature T NK cell Other 10 lymphoma lymphomas Lymphomas 9727 3 Blastic plasmacytoid dendritic cell 86 4 Blastic NK cell lymphoma Other 5 neoplasm Lymphomas 9729 3 T lymphoblastic lymphoma C83 5 Lymphoblastic diffuse ALL 8 lymphoma 9731 3 Solitary plasmacytoma of bone C90 3 Solitary plasmacytoma CORE ONLY 9 9732 3 Plasma cell myeloma C90 0 Multiple myeloma Myeloma 9 9733 3 Plasma cell leukaemia C90 1 Plasma cell leukaemia Myeloma 9
335. ve drugs given to the patient during their treatment One occurrence of this data group is permitted per treatment where applicable cR1070 CORE dau en AND DRUG TREATMENT INTENT DRUG TREATMENT INTENT SACT cR1080 CORE pd AND CN DRUG REGIMEN ACRONYM DRUG REGIMEN ACRONYM SACT Author NCIN 281 Cancer Outcomes and Services Dataset User Guide APPENDIX L DATA ITEMS FROM OTHER SOURCES FOR REFERENCE Current Schema Collecti Specific on ation CORE DEMOGRAPHICS To carry the patient demographic details It is anticipated that some of the demographic data items listed below will be collected by every provider with which the patient has contact Where this information is exchanged the appropriate data item name should be used to identify the particular instance of the data One occurrence of this group is permitted ORGANISATION CR3080 CORE DEMOGRAPHICS an3 CODE GP PRACTICE NEW X RESPONSIBILITY ORGANISATION CR3090 CORE DEMOGRAPHICS ORGANISATION CODE RESIDENCE RESPONSIBILITY an3 CODE RESIDENCE NEW X RESPONSIBILITY CORE DIAGNOSIS To carry diagnosis details One occurrence of this group is permitted SEINE DATE OF DIAGNOSIS ns CR0360 CORE DIAGNOSIS DATE OF DIAGNOSIS CANCER REGISTRATION CANCER X mm dd REGIST REGISTRATION RY Author NCIN 282 Cancer Outcomes and Services Dataset Us
336. ver greater than 38 C 101 5 F drenching night sweats unexplained weight loss of 10 or more within the last 6 months Author NCIN 96 Cancer Outcomes and Services Dataset User Guide ANN ARBOR EXTRANODALITY Additional staging designation based on extranodal involvement Code E if there is involvement of a single extranodal site that directly adjoins or is next to the known nodal group E E Extranodal involvement 5 12 CTYA NEUROBLASTOMA To carry Neuroblastoma details for CTYA This section will be recorded once Schema Data Item Section Data Item Name Format specification M R O X INTERNATIONAL NEUROBLASTOMA CTYA PATHOLOGIC CLASSIFICATION NEUROBLASTOMA INTERNATIONAL NEUROBLASTOMA CT6300 PATHOLOGY CLASSIFICATION CODE CTYA CYTOGENETIC RISK CLASSIFICATION CT6310 NEUROBLASTOMA 1 NEUROBLASTOMA CYTOGENETIC RISK CODE NEUROBLASTOMA INTERNATIONAL NEUROBLASTOMA STAGING CTYA SYSTEM max an2 NEUROBLASTOMA INTERNATIONAL NEUROBLASTOMA STAGING SYSTEM STAGE CT6320 INTERNATIONAL NEUROBLASTOMA PATHOLOGIC CLASSIFICATION The International Neuroblastoma Pathologic Classification INPC system involves evaluation of tumour specimens obtained prior to therapy for the amount of stromal development the degree of neuroblastic maturation and the mitosis karyorrhexis index of the neuroblastic cells Favourable and unfavourable prognoses are defined on the base of these histologic para
337. y Comment D43 1 Neoplasm of uncertain or unknown behaviour of brain infratentorial Brain Central Nervous System D43 2 Neoplasm of uncertain or unknown behaviour of brain unspecified Brain Central Nervous System D43 3 Neoplasm of uncertain or unknown behaviour of cranial nerves Brain Central Nervous System D43 4 Neoplasm of uncertain or unknown behaviour of spinal cord Brain Central Nervous System D43 7 Neoplasm of uncertain or unknown behaviour of other parts of central nervous system Brain Central Nervous System D43 9 Neoplasm of uncertain or unknown behaviour of central nervous system unspecified Brain Central Nervous System D44 0 Neoplasm of uncertain or unknown behaviour of thyroid gland Head and Neck D44 1 Neoplasm of uncertain or unknown behaviour of adrenal gland Other Author NCIN 257 ICD 10 4th Edition All C Codes are Malignant Neoplasms D44 2 Cancer Outcomes and Services Dataset User Guide Description Neoplasm of uncertain or unknown behaviour of parathyroid gland Cancer Waiting Times Site specific group Other Expected Dataset to be collected Core and Site Specific Dataset Core Dataset Path Only Comment D44 3 Neoplasm of uncertain or unknown behaviour of pituitary gland Brain Central Nervous System D44 4 Neoplasm
338. y or Skin diagnoses however relevant staging data items are included in the Haematology and Skin datasets There will only be one Staging section completed for each record Pathological stage may be recorded more than once General guidance on the expected staging system by tumour type is included in Appendix E Use of MX and MO TNM editions prior to TNM7 included the category MX to identify when distant metastases could not be assessed TNM7 removed this category because the overuse of the MX category meant that a large proportion of tumours was not staged a TNM group stage cannot be applied if MX is used According to the rules of TNM7 MO should be used if there is no positive evidence of distant metastases However clinical practice in the UK has persisted in using the MX category Author NCIN 20 Cancer Outcomes and Services Dataset User Guide The National Staging Panel for Cancer Registration wishes to propose a modification to TNM7 to be used in England and retain the use of MX in specific circumstances and to introduce M9 Please see Appendix N for further guidance Note Where the pathological stage was recorded after the patient had received neoadjuvant therapy i e chemotherapy or radiotherapy prior to surgery the integrated stage may be the same as the pre treatment stage Neuroendocrine Tumours These are currently staged using the EUROPEAN NEUROENDOCRINE TUMOUR SOCIETY TNM Staging System Where this staging sys
339. y provided by Haematology lab before transfusion treatment 96 Range 100 CYTOGENETIC GROUP ACUTE MYELOID LEUKAEMIA Cytogenetic analysis of bone marrow preferably or blood sample From Cytogenetics laboratory maybe as part of integrated haematopathology report Classification coding may be done by the lab or the MDT Classify as Author NCIN 136 Cancer Outcomes and Services Dataset User Guide e Favourable if t 8 21 t 15 17 inv 16 irrespective of other abnormalities e Adverse if monosomy 5 monosomy 7 del 5q abnormality of 3q more than 4 abnormalities e Intermediate if any other abnormality or normal karyotype Favourable Adverse Intermediate No result Note No Result includes Test not done 7 5 HAEMATOLOGY CANCER CARE PLAN VARIOUS To carry cancer care plan details specifically Nodal details for various haematological diseases as specified This section will be recorded once Data item No HA8320 HAEMATOLOGY CANCER CARE PLAN HA8330 FOLLICULAR DLBCL OTHER LYMPHOMAS HODGKIN HA8420 Data Item Section HAEMATOLOGY FOLLICULAR HAEMATOLOGY CANCER CARE PLAN DLBCL Schema specification M R O X Data Item Name Format NUMBER OF ABNORMAL NODAL AREAS PRIMARY EXTRANODAL SITE NUMBER OF EXTRANODAL SITES CODE NUMBER OF ABNORMAL NODAL AREAS Number of abnormal nodal areas detected clinically and radiologically PRIMARY EXTRANODA
340. ymphoma A T B lymphoblastic leukaemia with Acute lymphoblastic 9818 38 t 1 19 q23 p13 3 TCF3 PBX1 910 leukaemia ALL AL d Author NCIN 128 Cancer Outcomes and Services Dataset User Guide ICD 10 ICD O 3 ICD O 3 WHO Description 4th ICD10 Description Clinical dataset WHO DISEASE GROUP Edition 9823 3 Chronic lymphocytic leukaemia small C911 Chronic lymphocytic CLL 9 lymphocytic lymphoma leukaemia of B cell type 9826 3 Burkitt cell leukaemia C91 8 proeleukaemia ALL 9 Burkitt type Adult T cell Other 9827 3 Adult T cell leukaemia lymphoma C91 5 lymphoma leukaemia HTLV 10 Lymphomas 1 associated 9831 3 TEM large granular lymphocytic C91 7 Other lymphoid leukaemia CORE ONLY 10 leukaemia 9831 3 ds lymphoproliferative disorderof Other lymphoid leukaemia CORE ONLY 10 9833 3 B cell prolymphocytic leukaemia C91 3 Prolymphocyticleukaemiaof CORE ONLY 9 B cell type Prol hocytic leuk ia of 9834 3 T cell prolymphocytic leukaemia C91 6 CORE ONLY 10 T cell type 9837 3 T lymphoblastic leukaemia C91 0 Acute lymphoblastie ALL 8 Ymp leukaemia ALL 9840 3 Acute erythroid leukaemia C94 0 Acute erythroid leukaemia AML 5 9860 3 Myeloid leukaemia NOS C92 9 Myeloid leukaemia CORE ONLY unspecified 9861 3A AML with mutated CEBPA C92 0 TAM myel blastie leukaemia Wl ait 5 9861 3 AML with mu
341. ysical examination and standard laboratory tests and do not require ultrasound computed tomography or magnetic resonance imaging http www ncbi nlm nih gov pmc articles PMC2972576 tool pubmed Stage 0 if Platelet count 99 and Hb gt 109 and no lymphadenopathy hepatomegaly or splenomegaly Stage if Platelet count gt 99 and Hb gt 109 and any lymphadenopathy Stage Il if hepatomegaly or splenomegaly Stage III if Hb lt 110 Author NCIN 140 Cancer Outcomes and Services Dataset User Guide Stage IV if platelet count lt 100 BINET STAGE Applicable to Chronic Lymphocytic Leukaemia Prognostic index derived from platelet count Hb lymphadenopathy hepatomegaly splenomegaly Note that immune cytopenias are not included when calculating the Stage ie if Platelet count is below 100 and or Haemoglobin levels are below 110 as a result of immune cytopenia Also please see note on calculations below Rai Stage and Binet Stage both solely rely on physical examination and standard laboratory tests and do not require ultrasound computed tomography or magnetic resonance imaging http www ncbi nlm nih gov pmc articles PMC2972576 tool pubmed A Stage A if Platelet count gt 99 and Hb gt 99 and 1or 2 areas of organ enlargement number of lymph node groups plus score 1 for hepatomegaly 1 for splenomegaly Stage B if Platelet count 99 and Hb gt 99 and 3 4 5 areas of organ enlargement Stage C if Hb lt 100

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