Information Specification

The data items required for National Cancer Data Standards for Wales – Site Specific – Skin and their equivalent labels in COSD V9.0, where there is an equivalent, are listed below.

Where the specification cites NHS Wales Data Dictionary, please refer to the Dictionary for the relevant guidance i.e. definition, format, or code list.

For consistency, all dates listed in the Specification are standardised as ccyymmdd.

Where D is denoted in Status, this indicates that the information should be derived from another data item. This typically occurs with data items that are simply text representations of their code counterparts. Other Status codes are M (Mandatory), R (Required) – the data item should be recorded where applicable and O (Optional).

Core data items should be collected for all cancers. To reduce replication of information, Core data items have not been listed in this site-specific Standard and users should refer to National Cancer Data Standards for Wales – (1. National Cancer Data Set - Full list DSCNs.xlsx (live.com) for a list of Core requirements. However, in some cases, the site-specific application of Core data items may differ e.g. a particular tumour site may require additional or fewer codes to those already published in Core, or perhaps have additional business rules as to how the Core data item should be coded. Where this occurs, the Core data item will be replicated in the site-specific Standard with the respective additional site-specific detail. These are flagged in the following table with an * next to the data item name.

For data items used in the National Cancer Data Standards for Wales that already exist within the NHS Wales Data Dictionary. These data items have been flagged with an † next to the data item name, as whilst this introduces a change to an existing information standard, the immediate use of this mandate will be used as a framework for the development of the CIS, therefore service/data providers should continue with ‘business as usual’ in terms of the data being collected and reported.

Every new melanoma (as per CWT) will require a Core and Skin site-specific completion. Where a patient has multiple surgeries for that melanoma they should be recorded as such.

Every new cSCC (as per CWT) will require a Core and Skin site-specific completion.

Only the first BCC should be recorded. Any subsequent occurrences, irrespective of skin location, should be added to the original (first BCC). Therefore, only one Core and Skin site-specific completion is required, however there may be multiple surgeries/paths included in that one completion to reflect subsequent lesions.

Reporting Data Item	Definition	Format	Code List (Code)	Code List (Text)	Status	COSD
Skin – Clinical Examination – Malignant Melanoma. To record staging of malignant melanoma of skin
Size of Tumour (Largest Diameter)	Record the size of the tumour (largest diameter) as determined by the Clinician after a physical examination. Measure in centimetres (cms)	max n2.n2	N/A	N/A	R	N/A
Date Draining Lymph Node Basins Examined	Record the date that relevant draining lymph node basins were clinically examined (palpated in clinic) before WLE. Where it has been documented that the patient has no regional disease, no lymphadenopathy, or no palpable lymph nodes then this is confirmation that relevant draining lymph node basins have been examined	ccyymmdd	N/A	N/A	R	N/A
Skin – Diagnostic Procedures – Malignant Melanoma. To carry cancer diagnostic details for malignant melanoma of skin. (Multiple occurrences per core diagnostic procedure group)
Grade of Clinician/Surgeon (Diagnostic Procedure)	This is the level of training reached of the actual Clinician* or Surgeon performing the diagnostic procedure (excision or partial biopsy), and not necessarily the responsible clinician	Code List	NU	Nurse	R	N/A
			TS	Trainee Specialist Doctor
			CS	Consultant Surgeon (other than Plastic Surgeon/ENT Surgeon/OMF Surgeon )
			CD	Consultant Dermatologist
			CPS	Consultant Plastic Surgeon
			ENT	Consultant ENT Surgeon
			OMF	Oral Maxillofacial (OMF) Surgeon
			HP	Hospital Practitioner/Specialty & Associate Specialist (SAS)
			SI	GP with Special Interest
			GP	General Practitioner
			OO	Other Care Professional
Biopsy Type	Record the type of diagnostic biopsy that the patient has undergone	Code List	E	Excision Biopsy	R	N/A
			P	Partial Biopsy
			NB	No Biopsy
			9	Not known
Skin – Treatment – Surgery and Other Procedures – Malignant Melanoma. To carry additional surgery details for malignant melanoma of skin. (One Occurrence per Surgical episode - all data items within this section are required)
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. Note: Of the adjacent codes (i) Consultant ENT Surgeon and Oral Maxillofacial (OMF) Surgeon are not present in COSD. These have been added here to provide greater granularity. (ii) Consultant Surgeon (other than Plastic Surgeon/ENT Surgeon/OMF Surgeon ) and Hospital Practitioner/Specialty & Associate Specialist (SAS) contain additional text in the descriptor to those provided in COSD.	Code List	NU	Nurse	R	Grade of Clinician/Surgeon Operating (SK12010)
			TS	Trainee Specialist Doctor
			CS	Consultant Surgeon (other than Plastic Surgeon/ENT Surgeon/OMF Surgeon )
			CD	Consultant Dermatologist
			CPS	Consultant Plastic Surgeon
			ENT	Consultant ENT Surgeon
			OMF	Oral Maxillofacial (OMF) Surgeon
			HP	Hospital Practitioner/Specialty & Associate Specialist (SAS)
			SI	GP with Special Interest
			GP	General Practitioner
			OO	Other Care Professional
Member of Specialist MDT	Is the actual operating Clinician or Surgeon a member of the Specialist MDT	Code List	Y	Yes	R	Member of Specialist MDT (SK12700)
			N	No
			9	Not known
Depth of Excision	At the time of definitive surgery, record the extent of the deep excision margin in terms of tissue layers. Note: This should be recorded by the operating surgeon on the operation notes or in the clinical notes relating to the specimen from the final definitive surgery. This will be confirmed later by microscopic examination and the result can be found on the pathology report.	Code List	1	Less than deep fascia	R	N/A
			2	Down to deep fascia
			8	Not applicable
			9	Not recorded
Smallest Clinical Margin of Excision	At the time of definitive surgery, record the smallest clinically measured and documented distance to the edge of the visible component of the excision scar/tumour from the resection margin (in centimetres) Note: For patients that do not have further surgery following their diagnostic excision biopsy, record as Not applicable	Code List	1	<1cm	R	N/A
			2	1- <2cm
			3	2- <3cm
			4	>/= 3cm
			8	Not applicable
			9	Not recorded
Clinical Margin	Record the clinical margin at the time of excisional bx prior to WLE (in millimetres). Note: This will be clinically measured and documented at the time of each surgical procedure and can be found on either the pathology report or surgical operation note. For patients that do not have surgery or full excision not performed (sample biopsy), record as Not applicable	Code List	1	<2mm	R	N/A
			2	2mm
			3	>2mm
			8	Not applicable
			9	Not recorded
Skin – MDT – Malignant Melanoma. To carry additional MDT details for malignant melanoma of skin
Tumour Resectable	Record the decision made in MDT meeting on whether the tumour is resectable or not. Note: Unresectable melanoma is such that all sites of melanoma tumours cannot be completely removed surgically. It should be documented in MDT summary and should not be deduced. Where the origin of the primary lesion is not identifiable this would be classed as unresectable	Code List	Y	Yes- resectable	R	N/A
			N	No – unresectable
			8	Not applicable
			9	Not recorded
Skin – Treatment – Further Surgery and Other Procedures – Malignant Melanoma
Wide Local Excision	Has the patient undergone a wide local excision of the initial diagnostic biopsy site	Code List	Y	Yes	R	N/A
			N	No
			8	Not applicable
			9	Not known/not recorded
Pathology – Malignant Melanoma. To carry pathology details for malignant melanoma of skin. (One occurrence per Path 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.	Max an3	N/A	N/A	R	Skin Cancer Lesion Indicator (pSK12120)
Ulceration Indicator	Loss of full thickness of epidermis associated with reactive changes (ulceration)	Code List	Y	Yes	R	Ulceration Indicator (pSK12580)
			N	No
			U	Uncertain
			X	Cannot be assessed
			9	Not Known
Mitotic Rate (Skin)	Mitotic Rate per square millimetres (mm)	max n3	N/A	N/A	R	Mitotic Rate (Skin) (pSK12590)
Microsatellite or In-transit Metastasis Indicator	Is there evidence of Microsatellite or in transit metastases (Intralymphatic metastatic cells separate from main tumour)	Code List	Y	Yes	R	Microsatellite or In-transit Metastasis Indicator (pSK12600)
			N	No
			U	Uncertain
			X	Cannot be assessed
			9	Not Known
Tumour Regression Indicator	Area of loss of tumour associated with reactive changes	Code List	Y	Yes	R	Tumour Regression Indicator (pSK12620)
			N	No
			U	Uncertain
			X	Cannot be assessed
			9	Not Known
Breslow Thickness	Breslow Thickness in mm, can be recorded to nearest 0.01mm where clinically appropriate	max n2.max n2	N/A	N/A	R	Breslow Thickness (pSK12630)
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	Code List	N	Non-brisk	R	Tumour Infiltrating Lymphocytes (TILS) (pSK12430)
			B	Brisk
			A	Absent
Sentinel Nodes Examined Number	Number of sentinel nodes sampled	max n2	N/A	N/A	R	Sentinel Nodes Examined Number (pSK12460)
Sentinel Nodes Positive Number	Number of sentinel nodes positive	max n2	N/A	N/A	R	Sentinel Nodes Positive Number (pSK12470)
Post SNB Completion Lymphadenectomy – Nodes Sampled Number	Post Sentinel Node Biopsy (SNB) completion lymphadenectomy, number of nodes sampled. This procedure is not carried out in all cases	max n2	N/A	N/A	R	Post SNB Completion Lymphadenectomy – Nodes Sampled Number (pSK12480)
Post SNB Completion Lymphadenectomy – Nodes Positive Number	Post Sentinel Node Biopsy (SNB) completion lymphadenectomy, number of nodes positive. This procedure is not carried out in all cases	max n2	N/A	N/A	R	Post SNB Completion Lymphadenectomy – Nodes Positive Number (pSK12490)
Histopathology Report Complete	Record if all information required in the pathology report is complete. Note: Full information required as defined by the RCPath Cutaneous Malignant Melanoma Dataset (Please refer to User Guide for details)	Code List	1	Complete	R	N/A
			2	Not Complete
			8	Not Applicable
			9	Not Recorded
Skin – Molecular and Biomarkers – Somatic Testing for Targeted Therapy and Personalised Therapy – Malignant Melanoma
BRAF V600 mutation analysis of primary lesion, at diagnosis	Record the result of BRAF V600 mutation analysis of the primary lesion at the time of diagnosis	Code List	1	Positive	R	N/A
			2	Negative
			3	Indeterminate/Test Failed
			8	Not Applicable (Not Tested)
			9	Not Known
BRAF V600 mutation analysis of metastatic tissue	Record the result of BRAF V600 mutation analysis of metastatic tissue	Code List	1	Positive	R	N/A
			2	Negative
			3	Indeterminate/Test Failed
			8	Not Applicable (Not Tested)
			9	Not Known

Reporting Data Item	Definition	Format	Code List (Code)	Code List (Text)	Status	COSD
Skin - Clinical Examination - Cutaneous Squamous Cell Carcinoma. To record staging of cutaneous squamous cell carcinoma
Date Draining Lymph Node Basins Examined	Record the date that relevant draining lymph node basins were clinically examined (palpated in clinic) before standard surgical excision. Where it has been documented that the patient has no regional disease, no lymphadenopathy, or no palpable lymph nodes then this is confirmation that relevant draining lymph node basins have been examined	ccyymmdd	N/A	N/A	R	N/A
Skin - Treatment - Surgery and Other Procedures - Cutaneous Squamous Cell Carcinoma. To carry additional surgery details for cSCC. (One Occurrence per Surgical episode - all data items within this section are required)
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. Note: Of the adjacent codes (i) Consultant ENT Surgeon and Oral Maxillofacial (OMF) Surgeon are not present in COSD. These have been added here to provide greater granularity. (ii) Consultant Surgeon (other than Plastic Surgeon/ENT Surgeon/OMF Surgeon ) and Hospital Practitioner/Specialty & Associate Specialist (SAS) contain additional text in the descriptor to those provided in COSD.	Code List	NU	Nurse	R	Grade of Clinician/Surgeon Operating (SK12010)
			TS	Trainee Specialist Doctor
			CS	Consultant Surgeon (other than Plastic Surgeon/ENT Surgeon/OMF Surgeon )
			CD	Consultant Dermatologist
			CPS	Consultant Plastic Surgeon
			ENT	Consultant ENT Surgeon
			OMF	Oral Maxillofacial (OMF) Surgeon
			HP	Hospital Practitioner/Specialty & Associate Specialist (SAS)
			SI	GP with Special Interest
			GP	General Practitioner
			OO	Other Care Professional
Member of Specialist MDT	Is the actual operating Clinician or Surgeon a member of the Specialist MDT	Code List	Y	Yes	R	Member of Specialist MDT (SK12700)
			N	No
			9	Not known
Smallest Clinical Margin of Excision	At the time of definitive surgery, record the smallest clinically measured and documented distance to the edge of the visible component of the excision scar/tumour from the resection margin (in centimetres) Note: For patients that do not have further surgery following their diagnostic excision biopsy, record as Not applicable	Code List	1	<1cm	R	N/A
			2	1- <2cm
			3	2- <3cm
			4	>/= 3cm
			8	Not applicable
			9	Not recorded
Skin - Diagnostic Procedures - Cutaneous Squamous Cell Carcinoma. To carry cancer diagnostic and prognostic details for cutaneous squamous cell carcinoma
Risk Category	Record the assigned risk category of patients with primary cSCC	Code List	1	Low risk	R	N/A
			2	High risk
			3	Very high risk
			9	Not known
Pathology - cSCC. To carry pathology details for cutaneous Squamous Cell Carcinoma. (One occurrence per Path 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.	max an3	N/A	N/A	R	Skin Cancer Lesion Indicator (pSK12120)
Perineural Invasion	Is there perineural invasion (invasion into perineurium of nerve bundles- PNI)	Code List	Y	Yes	R	Perineural Invasion (pSK12530)
			N	No
			X	Cannot be assessed
			9	Not Known
Lesion Diameter Greater than 20mm Indicator	Is the diameter of the lesion greater than 20mm?	Code List	Y	Yes (Greater than 20mm)	R	Lesion Diameter Greater than 20mm Indicator (pSK12537)
			N	(Less than or equal to 20mm)
			U	Uncertain
			X	Cannot be assessed
			9	Not Known
Clarks Level IV Indicator	Greater than or equal to Clarks level IV	Code List	Y	Yes	R	Clarks Level IV Indicator (pSK12545)
			N	No
			U	Uncertain
			X	Cannot be assessed
Lesion Vertical Thickness Greater than 4mm Indicator	Is the vertical thickness of the lesion greater than 4 mm Note: (i) The name of the Data Item differs to that in COSD. This has been changed to align with BAD cSCC guidelines (ii) Codes Yes (Greater than 4 mm) and No (Greater than 2 mm but less than or equal to 4 mm) have been introduced, and differ to COSD, to support the revised alignment	Code List	Y	Yes (Greater than 4 mm)	R	Lesion Vertical Thickness Greater than 2mm Indicator (pSK12565)
			N1	No (Less than or equal to 2 mm)
			N2	No (Greater than 2 mm but less than or equal to 4 mm)
			U	Uncertain
			X	Cannot be assessed
			9	Not Known
Histopathology Report Complete (cSCC)	Record if all information required in the pathology report is complete. Note: Full information required as defined by the RCPath Primary Invasive Cutaneous Squamous Cell Carcinoma Dataset (Please refer to User Guide for details)	Code List	1	Complete	R	N/A
			2	Not Complete
			8	Not Applicable
			9	Not Recorded
Skin - Post Treatment Follow Up - Cutaneous Squamous Cell Carcinoma
Follow Up Schedule	Record if the patient is scheduled to receive post treatment (surgical) follow up appropriate to their risk category Please refer to the User Guide for details of the follow up schedule for each risk category	Code List	Y	Yes	R	N/A
			N	No
			9	Not known/not recorded

Reporting Data Item	Definition	Format	Code List (Code)	Code List (Text)	Status	COSD
Skin - Diagnosis. To carry additional tumour diagnosis details for Skin. (Multiple occurrences per core diagnostic procedure group)
Skin - Diagnosis - Basal Cell Carcinoma
Anatomical Site of Lesion	This is the region of the body where the lesion is present	Code List	1	Peri-Ocular	R	N/A
			2	Head and Neck
			3	Trunk
			4	Limbs
Skin - Treatment - Surgery and Other Procedures - Basal Cell Carcinoma. To carry additional surgery details for BCC
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. Note: Of the adjacent codes (i) Consultant ENT Surgeon and Oral Maxillofacial (OMF) Surgeon are not present in COSD. These have been added here to provide greater granularity. (ii) Consultant Surgeon (other than Plastic Surgeon/ENT Surgeon/OMF Surgeon ) and Hospital Practitioner/Specialty & Associate Specialist (SAS) contain additional text in the descriptor to those provided in COSD.	Code List	NU	Nurse	R	Grade of Clinician/Surgeon Operating (SK12010)
			TS	Trainee Specialist Doctor
			CS	Consultant Surgeon (other than Plastic Surgeon/ENT Surgeon/OMF Surgeon )
			CD	Consultant Dermatologist
			CPS	Consultant Plastic Surgeon
			ENT	Consultant ENT Surgeon
			OMF	Oral Maxillofacial (OMF) Surgeon
			HP	Hospital Practitioner/Specialty & Associate Specialist (SAS)
			SI	GP with Special Interest
			GP	General Practitioner
			OO	Other Care Professional
Member of Specialist MDT	Is the actual operating Clinician or Surgeon a member of the Specialist MDT	Code List	Y	Yes	R	Member of Specialist MDT (SK12700)
			N	No
			9	Not known
Pathology - BCC. To carry pathology details for Basal Cell Carcinoma. (One occurrence per Path 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.	max an3	N/A	N/A	R	Skin Cancer Lesion Indicator (pSK12120)
Perineural Invasion	Is there perineural invasion (invasion into perineurium of nerve bundles- PNI)	Code List	Y	Yes	R	Perineural Invasion (pSK12530)
			N	No
			X	Cannot be assessed
			9	Not Known
Lesion Diameter Greater than 20mm Indicator	Is the diameter of the lesion greater than 20mm?	Code List	Y	Yes (Greater than 20mm)	R	Lesion Diameter Greater than 20mm Indicator (pSK12537)
			N	(Less than or equal to 20mm)
			U	Uncertain
			X	Cannot be assessed
			9	Not Known