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Reporting Data Item |
Business Justification |
Definition Note: Where ‘NHS Wales Data Dictionary’ the definition is as per the Data Dictionary. |
Permissible Values |
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4. DIAGNOSIS | ||||
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4.0 ENCDv4.5b (4.1)
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Date of diagnosis (cancer registry definition)
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To calculate annual incidence rates and to determine the start date for survival analysis by the cancer registry.
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The definition provided conforms with the international requirements specified by the European Network of Cancer Registries (ENCR). The date of the first event (of the six listed under permissible values) to occur chronologically should be chosen as the incidence date. If an event of higher priority occurs within three months of the date initially chosen, the date of the higher priority event should take precedence, this should also be reflected and updated in the ‘Basis of diagnosis’.
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Order of declining priority: 1 – Date of first histological or cytological confirmation of this malignancy (with the exception of histology or cytology at autopsy). This date should be, in the following order: a – date when the specimen was taken b – or date of receipt by the pathologist c – or date of the pathology report 2 – Date of admission to hospital because of this malignancy. 3 – When evaluated at an outpatient clinic only: date of first consultation at the outpatient clinic because of this malignancy. 4 – Date of diagnosis, other than 1, 2 or 3 5 – Date of death, if no information is available other than the fact that the patient has died because of malignancy. 6 – Date of death, if the malignancy is discovered at autopsy. |
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4.1 ENCDv4.5b (4.4)
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Basis of diagnosis
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To establish the validity of the date of diagnosis recorded. |
As a measure of validity, only the ‘most valid basis of diagnosis’ is required. The codes opposite are hierarchical, therefore the higher the number the more validity the basis holds. If an event of higher priority occurs within three months of the date of diagnosis, the basis of the higher priority event should take precedence. |
Non-microscopic 1 – Death Certificate (The only information available is from a death certificate) 2 – Clinical (Diagnosis made before death but without the benefit of any of the following (2- 7)) 3 – Clinical Investigation (Includes all diagnostic techniques (e.g. X-rays, endoscopy, imaging, ultrasound, exploratory surgery and autopsy) without a tissue diagnosis) 4 – Specific tumour markers (Includes biochemical and/or immunological markers which are specific for a tumour site) Microscopic 5 – Cytology (Examination of cells whether from a primary or secondary site, including fluids aspirated using endoscopes or needles. Also including microscopic examination of peripheral blood films and trephine bone marrow aspirates). 6 – Histology of a metastases (Histological examination of tissues from a metastasis, including autopsy specimens) 7 – Histology of a primary tumour (Histological examination of tissue from the primary tumour, however obtained, including all cutting and bone marrow biopsies. Also includes autopsy specimens of a primary tumour) 0 – Unknown (No information on how the diagnosis has been made (e.g. Patient Aadministration System (PAS) or Hospital Information Support System (HISS) record only) |
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4.2 ENCDv4.5b (4.2)
SPCDv1.0 (5.1) |
Primary cancer site
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To establish the numbers of various cancers to enable calculation of annual incidence rates. To allow for an assessment of subsequent treatment and outcome rates. |
The site of the primary cancer for which the patient is receiving care.
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Refer to the current version of the International Statistical Classification of Diseases and Health Related Problems (ICD10).
*Permissible values will be dependent upon the output specifications. |
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4.3
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Pre-treatment morphology
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To record the definitive behaviour/histology of the tumour at the point of diagnosis. |
Cell type of malignant disease determined before the start of treatment. |
NHS Wales Data Dictionary Refer to morphology code as in the extract of the International Classifications of Diseases for Oncology on “Morphology of neoplasm’s” in ICD10.
*Permissible values will be dependent upon the output specifications. |
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4.4 ENCDv4.5b (6.1)
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Pre-treatment staging agreed by the multi disciplinary team cT (clinical Tumour) stage
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To allow for the Final pre treatment staging by the multi disciplinary team to be taken into account in the analysis of treatment and outcome. |
The ‘T’ (tumour) part of the TNM (Tumour, Node and Metastasis) classification to describe the clinical stage of the tumour prior to treatment. Clinical classification (Pre-treatment clinical classification), designated cTNM. This is based on evidence acquired before treatment. Such evidence arises from physical examination, imaging, endoscopy, biopsy, surgical exploration and other relevant examinations.
If the malignancy is discovered only at autopsy, or via a death certificate, then no pre-treatment TNM stage will be recorded. |
Refer to UICC (International Union Against Cancer) TNM (Tumour, Node and Metastasis) Classifications of Malignant Tumours |
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4.5 ENCDv4.5b (6.3)
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Pre-treatment staging agreed by the multi disciplinary team cN (clinical Node) stage
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To allow for the Final pre treatment staging by the multi disciplinary team to be taken into account in the analysis of treatment and outcome. |
The ‘N’ (Node) part of the TNM (Tumour, Node and Metastasis) classification to describe the clinical stage of the tumour prior to treatment.
Clinical classification (Pre-treatment clinical classification), designated cTNM. This is based on evidence acquired before treatment. Such evidence arises from physical examination, imaging, endoscopy, biopsy, surgical exploration and other relevant examinations.
If the malignancy is discovered only at autopsy, or via a death certificate, then no pre-treatment TNM stage will be recorded. |
Refer to UICC (International Union Against Cancer) TNM (Tumour, Node and Metastasis) Classifications of Malignant Tumours |
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4.6 ENCDv4.5b (6.5)
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Pre-treatment staging agreed by the multi disciplinary team cM (clinical Metastasis) stage
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To allow for the Final pre treatment staging by the multi disciplinary team to be taken into account in the analysis of treatment and outcome. |
The ‘M’ (Metastasis) part of the TNM (Tumour, Node and Metastasis) classification to describe the clinical stage of the tumour prior to treatment.
Clinical classification (Pre-treatment clinical classification), designated cTNM. This is based on evidence acquired before treatment. Such evidence arises from physical examination, imaging, endoscopy, biopsy, surgical exploration and other relevant examinations.
If the malignancy is discovered only at autopsy, or via a death certificate, then no pre-treatment TNM stage will be recorded. |
Refer to UICC (International Union Against Cancer) TNM (Tumour, Node and Metastasis) Classifications of Malignant Tumours |