Reporting Data Item

Definition

Format

Code List
(Code)

Code List (Text)

Status

COSD

Colorectal - Diagnosis. To carry diagnostic details for Colorectal cancer (One occurrence per core diagnosis group)

Synchronous Tumour Indicator

Record any synchronous tumours in the 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.

To establish the frequency of multiple cancers. 

More than one synchronous cancer may be recorded.

Code List

01

Caecum

R

Synchronous Tumour Indicator (CO5400)

02

Appendix

03

Ascending Colon

04

Hepatic Flexure

05

Transverse Colon

06

Splenic Flexure

07

Descending Colon

08

Sigmoid Colon

09

Rectosigmoid

10

Rectum

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.

Note:
I. For rectal cancers only
ii. Do not use 0 for Not Known, instead leave field blank

max n2
Range 0-15

N/A

N/A

R

Tumour Height Above Anal Verge (CO5160)

Pre-habilitation Programme Status

Did the patient undergo a formal pre-habilitation programme

Code List

Y

Yes

R

N/A

N

No

9

Not Known

Cardiopulmonary Test Type

Indicate which cardiopulmonary test was used

Note: This is a COSD data item but in COSD relates to Lung only. It has been added here as it is a requirement in Wales for the Colorectal site-specific standard.

Code List

1

Incremental shuttle walk test (ISWT)

R

Cardiopulmonary Test Type (LU10420)

2

Oxygen consumption (VO2)

Cardiopulmonary Exercise Test Result

The Cardiopulmonary Exercise Test result

Note: This is a COSD data item but in COSD relates to Lung only. It has been added here as it is a requirement in Wales for the Colorectal site-specific standard.

max n3
% predicted. Range 0 - 200

N/A

N/A

R

Cardiopulmonary Exercise Test Result (NLCA) (LU10370)

Cardiopulmonary Exercise Testing (CPEX) Anaerobic Threshold

Record the anaerobic threshold

max n2.max n1
Range 0-99

N/A

N/A

R

N/A

Mismatch Repair Proteins

An indication of the presence or absence of mismatch repair proteins in the cancer

Note: Only required for completion if Microsatellite Instability (MSI) / Mismatch Repair Analysis is recorded for Core data item Gene or Stratification Biomarker Analysed

Code List

1

Deficient

R

N/A

2

Proficient

Colorectal - Clinical Nurse Specialist. To carry details of Clinical Nurse Specialist Type (Multiple occurrences as per Core - CNS & Risk Factor Group)

Clinical Nurse Specialist Type

The type of clinical Nurse Specialist assigned to the patient during their treatment pathway

Code List

1

Clinical Nurse Specialist

R

Clinical Nurse Specialist Type (CO5180)

2

Stoma Nurse Specialist

8

Other

9

Not Known

Colorectal - Surgery. To carry additional surgery details for Colorectal cancer (One occurrence per core surgery group)

Reason for No Surgical Treatment

The reason why surgical treatment was not carried out

Code List

1

Patient unfit due to a pre-diagnosed medical condition

R

N/A

2

Patient refused treatment

3

Advanced disease

7

Other 

Reason for No Surgical Treatment - 'Other' 

If Other is recorded for data item Reason for No Surgical Treatment, please specify the reason why surgical treatment was not carried out

max an100

N/A

N/A

R

N/A

Consultant Code - Surgical Treatment

The GMC code for the Consultant who was actually in overall charge of the patient’s surgical treatment during the time the patient was in hospital undergoing surgery

Note: Refer to NHS Wales Data Dictionary definition for Consultant Code for further information on the code's format

an8

N/A

N/A

R

N/A

Surgical Admission Type *

Record the mode of surgery performed

Note: The codes Scheduled/Expedited and Urgent are not present in Core but have been added here as a site-specific requirement.

Code List

1

Elective

R

Surgical Admission Type (CR8500)

2

Emergency

3

Scheduled/Expedited

4

Urgent

9

Not Known

Surgical Access Type *

Approach to surgery (laparoscopic, thoracoscopic, open,
robotic or converted). Record the access used to perform the main procedure. Recording the
surgical access is standard clinical practice and should be obtained from the operational
notes.

Note:
i. The code Trans Anal (for TME excisions) is not present in Core but has been added here as a site-specific requirement. Whilst the Core data item has additional codes, only the adjacent codes are applicable to the Colorectal site-specific standard.
ii. Code 5 is applicable to rectal tumours only

Code List

1

Open operation

 R

Surgical Access Type (CR6310)

3

Laparoscopic/Thoracoscopic with unplanned conversion to open surgery

4

Laparoscopic/Thoracoscopic completed

5

Trans Anal (For TME excisions)

Z

Not applicable

Stoma

Specify the type of stoma created

Code List

1

Ileostomy temporary

R

N/A

2

Ileostomy permanent

3

Colostomy temporary

4

Colostomy permanent

Surgical Complications

Any complications relevant to the surgical treatments that the patient has received (during primary treatment period)

(Multiples can be chosen)

Code List

1

Leak

R

N/A

2

Abscess

3

Bleed

4

Obstruction

5

Stoma malfunction

6

Readmission (within 14 days of surgical procedure)

7

Other

Surgical Complications - 'Other'

If Other is recorded for data item Surgical Complications, please specify the surgical complications relevant to the surgical treatments that the patient has received
(during primary treatment period)

max an100

N/A

N/A

R

N/A

Cancer Treatment Curability

The Surgeons opinion of the completeness of the excision based on clinical findings at the time of the operation which should not be revised in the light of subsequent histopathology reporting. 

Curative means no local tumour was visibly present after the surgical procedure.  
Palliative means that visible tumour was left behind after the surgical resection

Code List

1

Curative

R

N/A

2

Palliative

3

Uncertain

Immediate Post Operative Care

To determine immediate post operative care requirements for the patient

Code List

1

Standard Ward Care

R

N/A

2

High Care Area

3

Level 2 HDU care

4

Level 3 ICU care

Colorectal - Pathology. To carry details of pathology for colorectal cancer (May be up to one occurrence of this group per pathology report)

Local Invasion Polypoid Tumours (Haggitt level)

The level of invasion into the stalk of the polyp
For pT1 or ypT1 stage only

Code List

1

Haggitt Level 1 - carcinoma invading through muscularis mucosa into submucosa but limited to the head of the polyp

R

N/A

2

Haggitt Level 2 - Carcinoma invading the level of the neck of the adenoma

3

Haggitt Level 3 - Carcinoma invading any part of the stalk

4

Haggitt Level 4 - Carcinoma invading into the submucosa of the bowel wall below the stalk of the polyp but above the muscularis propria

8

Haggitt Level - Not applicable/Not assessable

Local Invasion Sessile Tumours (Kikuchi level)

The level of sub mucosal infiltration of the pathological T1 tumour

Note: For pT1 or ypT1 Stage only

Code List

1

Kikuchi Level Sm1 - Invasion of the superficial one-third of the submucosa

R

N/A

2

Kikuchi Level Sm2 - Invasion of the middle one-third of the submucosa

3

Kikuchi Level Sm3 - Invasion of the deep one-third of the submucosa

8

Kikuchi Level - Not applicable/Not assessable

Status of Circumferential Excision Margin

Record if the edge of the tumour is 1 mm or less from the circumferential resection margin (ie, 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

Code List

0

Margin Not Involved

R

Status of Circumferential Excision Margin (pCO5300)

1

Margin Involved

9

Not Known

Distance to Circumferential Margin

Record the distance from the outer margin of the tumour to the closest non peritonealised circumferential resection margin in mm.

Note: For rectal cancer only

max n2.max n2

N/A

N/A

R

Distance to Circumferential Margin (pCO5210)

Plane of Surgical Excision

This is the quality of the surgical excision as seen by the pathologist.  This grades the resection on its worst plane.

Note: For rectal cancer only

Code List

1

Mesorectal fascia plane

R

Plane of Surgical Excision (pCO5260)

2

Intramesorectal plane

3

Muscularis propria plane

Response to Pre-Operative Therapy

If preoperative therapy was given what was the response.

Note: A four tier system, similar to that described by Ryan et al. (Pathological response following long-course neoadjuvant chemoradiotherapy for locally advanced rectal cancer)

Code List

08

No viable cancer cells (TRS 0)

R

Response to Pre-Operative Therapy (pCO5290)

09

Single cells or rare small groups of cancer cells (TRS 1)

10

Residual cancer with evident tumour regression (TRS 2)

11

No evident tumour regression (TRS 3)

97

Not Applicable

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

Code List

0

Margins not involved

R

Positive Proximal or Distal Resection Margin (pCO5190)

1

Margin involved

8

Not submitted by pathologist

9

Not Known

Distance from Dentate Line

Record the distance of the tumour from the dentate line in mm measured on the gross specimen

Note: For abdominoperineal excision specimens only.

mm (max n3.max n2)

N/A

N/A

R

Distance from Dentate Line (pCO5270)

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

mm

(max n3.max n2)

N/A

N/A

R

Distance Beyond Muscularis Propria (pCO5280)

Tumour Regression Grade

Record the tumour regression grade.
This is applicable to Rectal cancers only treated with pre-operative Radiotherapy

Note: For rectal cancer only

Code List

1

Grade 1 - Complete regression, no viable tumour cells, fibrosis extending through bowel wall

R

N/A

2

Grade 2 - Isolated single cell or small clusters of tumour cells scattered through fibrosis

3

Grade 3 - Fibrosis predominates, outgrowing residual tumour

4

Grade 4 - Residual tumour outgrows fibrosis

5

Grade 5 - Extensive residual tumour without fibrosis

Grade of Differentiation (Pathological) *

Grade of Differentiation (Pathological) is the definitive grade of the tumour based on the evidence from a pathological examination

Note: The Core data item has additional codes, however only the adjacent codes are applicable to the Colorectal site-specific standard

Code List

G1

Well differentiated

R

Grade of Differentiation (Pathological) (pCR0860)

G3

Poorly differentiated

Colorectal - Treatment. To carry details of certain treatments for colorectal cancer (May be up to one occurrence of this group per treatments given)

Biological/Immunological Treatment Given

Record the specific Biological/Immunological treatment given

Code List

1

Cetuximab

R

N/A

2

Bevacizumab

3

Pantimumab

7

Other

Other Biological/Immunological Treatment given

If Other is recorded for data item Biological/Immunological Treatment Given, please specify the biological/immunological treatment given

max an50

N/A

N/A

R

N/A

Biomarkers (One occurrence of this group per Core)

Dihydropyrimidine Dehydrogenase (DPD) Performed

Record if DPD test was performed

Code List

Y

Yes

R

N/A

N

No

Dihydropyrimidine Dehydrogenase (DPD) Status

To record the DPD Status for the patient, if performed
 

Code List

1

DPYP variant homozygous

R

N/A

2

DPYP variant heterozygous

3

No variant detected

9

Not known

Vascular Endothelial Growth Factor (VEGF) Status

Select the recorded outcome for the VEGF Mutational status.  

Code List

07

Wild Type

 R

N/A

08

Sensitising/activating mutation(s) only

09

Resistance mutation - with or without other mutation

98

Not Applicable (Not Assessed)

99

Not Known (Failed Analysis)

KRAS Status

Select the recorded outcome for the KRAS Mutational status.  

Code List

07

Wild Type

 R

N/A

08

Sensitising/activating mutation(s) only

09

Resistance mutation - with or without other mutation

98

Not Applicable (Not Assessed)

99

Not Known (Failed Analysis)

NRAS Status

Select the recorded outcome for the NRAS Mutational status.  

Code List

07

Wild Type

 R

N/A

08

Sensitising/activating mutation(s) only

09

Resistance mutation - with or without other mutation

98

Not Applicable (Not Assessed)

99

Not Known (Failed Analysis)

BRAF Status

Select the recorded outcome for the BRAF Mutational status.  

Code List

07

Wild Type

 R

N/A

08

Sensitising/activating mutation(s) only

09

Resistance mutation - with or without other mutation

98

Not Applicable (Not Assessed)

99

Not Known (Failed Analysis)