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Change History |
Title |
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To remove all references to 'Health Solutions Wales', 'Business Services Centre' and 'Information Products Unit' and replace with 'NHS Wales Informatics Service' | |
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All Wales Breast Cancer Minimum Reporting Requirements v5.0 including Core Reporting Items v5.0 |
Data Items Breast Cancer Minimum Reporting Requirements
Summary Table of Reporting Requirements
The following tables outline the matrix of data items against reporting requirements.
ALL WALES BREAST CANCER MINIMUM REPORTING REQUIREMENT V5.0
Key: ENCDv4.5b = English National Cancer Dataset version 4.5b; matched data item
SPCDv1.0 = Specialist Palliative Care Dataset version 1.0; matched data item
WBCCA = Welsh Breast Cancer Clinical Audit
BCI = Breast Clinical Indicator
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Summary of Reporting Data Items: |
Minimum Reporting Requirements | ||||
|
Core |
Breast Site Specific | ||||
|
National Cancer Standards |
WCISU: Cancer Registry |
AOF: CWT |
WBCCA |
Breast Clinical Indicators | |
|
Section 1: Identification of Patient | |||||
|
NHS Number |
ü |
ü |
ü |
ü |
|
|
Birth date |
ü |
ü |
|
ü |
ü |
|
Sex |
ü |
ü |
|
ü |
ü |
|
GP practice code |
ü |
ü |
|
|
|
|
Ethnic group |
ü |
ü |
|
|
|
|
Case record number |
ü |
ü |
|
ü |
|
|
Patient’s name(s) |
ü |
ü |
|
|
|
|
Patient’s address at date of diagnosis |
ü |
ü |
|
|
|
|
Patient’s postcode at date of diagnosis |
ü |
ü |
|
ü |
|
|
Section 2: Referral | |||||
|
Source of (cancer) referral |
ü |
|
|
ü |
ü |
|
Organisation code (referred to) |
ü |
|
|
ü |
|
|
Consultant code (referred to) |
ü |
|
|
ü |
|
|
Date of receipt of cancer referral |
ü |
|
|
ü |
|
|
Presentation of disease at referral |
ü |
ü |
ü |
ü |
|
|
Section 3: Key Investigations | |||||
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Cancer imaging modality |
ü |
ü |
|
ü |
|
|
Date of investigation |
ü |
ü |
|
ü |
|
|
Cancer sampling modality – breast |
|
|
|
ü |
|
|
Cancer sampling modality – axilla |
|
|
|
ü |
|
|
Breast investigated |
|
|
|
ü |
|
|
Mammogram findings |
|
|
|
ü |
|
|
Ultrasound findings |
|
|
|
ü |
|
|
Clinical fine needle aspiration findings |
|
|
|
ü |
|
|
Guided fine needle aspiration findings |
|
|
|
ü |
|
|
Clinical core biopsy findings |
|
|
|
ü |
|
|
Guided core biopsy findings |
|
|
|
ü |
|
|
Smear (nipple discharge cytology) findings |
|
|
|
ü |
|
|
Other procedure findings |
|
|
|
ü |
|
|
Section 4: Diagnosis | |||||
|
Date of diagnosis (cancer registry definition) |
ü |
ü |
|
ü |
|
|
Basis of diagnosis (cancer registry definition) |
ü |
ü |
|
ü |
|
|
Primary cancer site |
ü |
ü |
|
ü |
|
|
Pre-treatment morphology |
ü |
ü |
ü |
ü |
ü |
|
Pre-treatment staging agreed by the multi disciplinary team cT (clinical Tumour) stage |
ü |
ü |
|
ü |
|
|
Pre-treatment staging agreed by the multi disciplinary team cN (clinical Node) stage |
ü |
ü |
|
ü |
|
|
Pre-treatment staging agreed by the multi disciplinary team cM (clinical Metastasis) stage |
ü |
ü |
|
ü |
|
|
Section 5: Multi Disciplinary Team Outcomes | |||||
|
Treatment plan discussed by the multi disciplinary team |
ü |
|
|
|
|
|
Multi disciplinary meeting identifier |
ü |
|
|
|
|
|
Date treatment plan discussed by the multi disciplinary team |
ü |
|
|
|
|
|
Cancer treatment plan intent |
ü |
|
|
|
|
|
Reason for no specific anti-cancer treatment |
ü |
|
|
|
|
|
Final pre-treatment performance status agreed by the multi disciplinary team |
ü |
ü |
|
|
|
|
Planned cancer treatment type |
ü |
|
|
|
|
|
Treatment type sequence |
ü |
|
|
|
|
|
Section 6: Surgery | |||||
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Surgical intent |
|
ü |
|
ü |
|
|
Date on which surgical procedure(s) carried out |
|
ü |
|
ü |
ü |
|
Surgical procedure(s) carried out |
|
ü |
|
ü |
ü |
|
Site code (of surgery) |
|
ü |
|
ü |
|
|
Consultant code (Surgeon) |
|
ü |
|
ü |
|
|
Section 7: Pathology | |||||
|
Date specimen taken |
|
ü |
|
|
|
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Histological diagnosis |
|
ü |
|
ü |
ü |
|
Grade of differentiation |
|
ü |
|
ü |
|
|
T (Tumour) category (pathological) |
|
ü |
|
ü |
|
|
N (Node) category (pathological) |
|
ü |
|
ü |
|
|
M (Metastasis) category (pathological) |
|
ü |
|
ü |
|
|
DCIS (Ductal Carcinoma In Situ) grade |
|
|
|
ü |
|
|
Invasive lesion size |
|
|
|
ü |
|
|
Whole size of tumour including DCIS (Ductal Carcinoma In Situ) |
|
|
|
ü |
|
|
Multifocal indicator |
|
|
|
ü |
|
|
Cancer vascular or lymphatic invasion |
|
|
|
ü |
|
|
Excision margin(s) status |
|
|
|
ü |
|
|
Local / regional nodes examined |
|
|
|
ü |
ü |
|
Local / regional nodes positive |
|
|
|
ü |
ü |
|
ER (Oestrogen Receptor) status |
|
ü |
|
ü |
ü |
|
PgR (Progesterone Receptor) status |
|
ü |
|
ü |
|
|
HER-2 (Human Epidermal growth factor Receptor 2) status |
|
ü |
|
ü |
|
|
Section 8: Drug Therapy | |||||
|
Date treatment started (drug therapy) |
|
ü |
|
ü |
ü |
|
Treatment intent (drug therapy) |
|
ü |
|
ü |
|
|
Drug therapy type |
|
ü |
|
ü |
|
|
Section 9: Radiotherapy | |||||
|
Date treatment started (radiotherapy) |
|
ü |
|
ü |
ü |
|
Treatment intent (radiotherapy) |
|
ü |
|
|
|
|
Radiotherapy type |
|
ü |
|
|
|
|
Anatomical treatment site (radiotherapy) |
|
|
|
ü |
|
|
Section 10: Palliative Care | |||||
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Member of specialist palliative care team seen |
|
ü |
|
|
|
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Section 11: Clinical Status Assessment | |||||
|
Date of death |
|
ü |
ü |
ü |
|
|
Date of recurrence |
|
|
|
ü |
|
|
Type of recurrence |
|
|
|
ü |
|
|
Section 12: AOF: Cancer Waiting Times | |||||
|
Priority of referral |
|
|
ü |
|
|
|
Date of decision to treat |
|
|
ü |
|
|
|
Date of start of first definitive procedure |
|
|
ü |
|
|
|
First procedure |
|
|
ü |
|
|
|
Suspension start date |
|
|
ü |
|
|
|
Suspension end date |
|
|
ü |
|
|
|
Reason for breach |
|
|
ü |
|
|
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Total number of data items: 81 | |||||