Diagnosis

Reporting Data Item

Business Justification

Definition

Note: Where ‘NHS Wales Data Dictionary’ the definition is as per the Data Dictionary.

Permissible Values

4. DIAGNOSIS

4.0

ENCDv4.5b (4.1)

DAHNO

HNCI

Date of diagnosis (cancer registry definition)

To calculate annual incidence rates and to determine the start date for survival analysis by the cancer registry.

The definition provided conforms with the requirements specified by the Cancer Registry. The date of the first event (of the seven 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’.

WCISU (Welsh Cancer Intelligence and Surveillance Unit) Cancer Registry

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 imaging x-ray or scan which confirms this malignancy

3 – Date of clinical diagnosis by consultant confirming malignancy

4 – Date of outpatient evaluation or in-patient hospital admission for a confirmed malignancy

5 – Date of diagnosis, other than 1 – 4, e.g. GP clinical diagnosis

6 – Date of death, if no information is available other than the fact that the patient has died because of malignancy.

7 – Date of death, if the malignancy is discovered at autopsy.

4.1

ENCDv4.5b (4.4)

DAHNO

Basis of diagnosis (cancer registry definition)

To establish the validity of the date of diagnosis recorded.

The definition provided conforms with the requirements specified by the Cancer Registry. 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.

WCISU (Welsh Cancer Intelligence and Surveillance Unit) Cancer Registry

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 Administration System (PAS) or Hospital Information Support System (HISS) record only)

4.2

ENCDv4.5b (4.2)

SPCDv1.0

(5.1)

DAHNO

HNCI

Primary cancer site

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.

Refer to the current version of the International Statistical Classification of Diseases and Health Related Problems (ICD10).

*Permissible grouped values and labels will be dependent upon the output specifications.

4.3

DAHNO

Pre-treatment morphology

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.

Refer to morphology code as in the extract of the International Classifications of Diseases for Oncology on “Morphology of neoplasms” in ICD10.

*Permissible grouped values and labels will be dependent upon the output specifications.

4.4

ENCDv4.5b (6.1)

DAHNO

Pre-treatment staging agreed by the multi disciplinary team

cT (clinical Tumour) stage

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

4.5

ENCDv4.5b (6.3)

DAHNO

Pre-treatment staging agreed by the multi disciplinary team

cN (clinical Node) stage

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

4.6

ENCDv4.5b (6.5)

DAHNO

Pre-treatment staging agreed by the multi disciplinary team

cM (clinical Metastasis) stage

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.

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

4.7

DAHNO

Integrated staging agreed by the multi disciplinary team

pT (pathological Tumour) stage

To allow for the integrated staging by the MDT to be taken into account in the analysis of treatment and outcome. Required for submission to the national clinical head & neck cancer audit.

The ‘T’ (Tumour) part of the TNM (Tumour, Node and Metastasis) classification used to describe the integrated stage of the tumour.

The combination of pT (pathological tumour) with pN (pathological node) and M (pre-treatment metastasis) into stage groups that are more or less homogeneous in respect of survival and for which the survival rates are distinctive.

Refer to UICC (International Union Against Cancer) TNM (Tumour, Node and Metastasis) Classifications of Malignant Tumours

4.8

DAHNO

Integrated staging agreed by the multi disciplinary team

pN (pathological Node) stage

To allow for the integrated staging by the MDT to be taken into account in the analysis of treatment and outcome. Required for submission to the national clinical head & neck cancer audit.

The ‘N’ (Node) part of the TNM (Tumour, Node and Metastasis) classification used to describe the integrated stage of the tumour.

Note that micro-metastases should be considered as positive.

Refer to UICC (International Union Against Cancer) TNM (Tumour, Node and Metastasis) Classifications of Malignant Tumours

4.9

DAHNO

Integrated staging agreed by the multi disciplinary team

cM (clinical Metastasis) stage

To allow for the integrated staging by the MDT to be taken into account in the analysis of treatment and outcome. Required for submission to the national clinical head & neck cancer audit.

The ‘M’ (Metastasis) part of the TNM (Tumour, Node and Metastasis) classification used to describe the integrated stage of the tumour.

Refer to UICC (International Union Against Cancer) TNM (Tumour, Node and Metastasis) Classifications of Malignant Tumours

4.10

DAHNO

Laterality of cancer

To enable analysis on pre-operative diagnosis results and outcomes. Required for submission to the national clinical head & neck cancer audit.

To differentiate tumours in paired organs; the laterality relates to the location of the organ in which the tumour is diagnosed.

Permissible values are agreed by the clinical steering groups and conform to the requirements of the reporting output specifications. Currently there is no explicit requirement to map to terminologies or classifications. This will be kept under review.

• Left

• Right

• Bilateral

4.11

DAHNO

Final pre-treatment stage grouping

To allow for the Final pre treatment stage groupings by the MDT to be taken into account in the analysis of treatment and outcome. Required for submission to the national clinical head & neck cancer audit.

The combination of cT (clinical tumour) with cN (clinical node) and cM (clinical metastasis) into stage groupings that are more or less homogeneous in respect of survival and for which the survival rates are distinctive. The stage groupings derived from cTNM (clinical Tumour, Node and Metastasis) once established must then remain unchanged.

Refer to UICC (International Union Against Cancer) TNM (Tumour, Node and Metastasis) Classifications of Malignant Tumours