Reporting Data Item

Definition

Format

Code List
(Code)

Code List (Text)

Status

NHS Wales DD

COSD

Identification Of Patient
Demographics

NHS Number

NHS Wales Data Dictionary

NHS Wales Data Dictionary

N/A

N/A

M

NHS Number

NHS Number

NHS Number Status Indicator

NHS Wales Data Dictionary

Code List

NHS Wales Data Dictionary

NHS Wales Data Dictionary

M

NHS Number Status Indicator

NHS Number Status Indicator Code

Unique Pathway Identifier

An identifier which together with the organisation code uniquely identifies a patient pathway

an24

N/A

N/A

M

N/A

N/A

Birth Date

NHS Wales Data Dictionary

ccyymmdd

N/A

N/A

M

Birth Date

Person Birth Date

Sex (At Birth)

NHS Wales Data Dictionary

Code List

F

Female

M

Sex

N/A

N

N - Non-Binary

M

Male

Z

Not disclosed or unknown, e.g. for unborn baby

Gender Identity

NHS Wales Data Dictionary

Code List

F

Female

M

Gender

Person Stated Gender Code

M

Male

N

Non-Binary

Z

Not disclosed or unknown, e.g. for unborn baby

Person Sexual Orientation Code (At Diagnosis)

Persons sexual orientation as self declared at the time of the patients diagnosis. 

Code List

1

Heterosexual or Straight

R

N/A

Person Sexual Orientation Code (At Diagnosis)

2

Gay or Lesbian

3

Bisexual

4

Other sexual orientation not listed

U

Person asked and does not know or is not sure

Z

Not Stated (person asked but declined to provide a response)

9

Not Known (Not Recorded)

General Medical Practitioner Code (GP Code)

NHS Wales Data Dictionary

NHS Wales Data Dictionary

N/A

N/A

R

GP Code

General Medical Practitioner (Specified) 

General Medical Practice Code (GP Practice Code)

NHS Wales Data Dictionary

NHS Wales Data Dictionary

N/A

N/A

R

Organisation Code - GP Practice Code

General Medical Practice Code (Patient Registration)

Ethnic Group/Category

NHS Wales Data Dictionary

Code List

NHS Wales Data Dictionary

99

NHS Wales Data Dictionary


Unknown

R

Ethnic Group

Ethnic Category

Case Record Number (Local Patient Identifier)

NHS Wales Data Dictionary

NHS Wales Data Dictionary

N/A

N/A

M

Local Patient Identifier

Local Patient Identifier

Patient Name - Family Name (Surname)

The patients surname used to describe family, clan or marital association

an35

N/A

N/A

R

N/A

Person Family Name 

Patient Name - Person Given Name (Forename)

The persons forename(s) or given name(s)

an35

N/A

N/A

R

N/A

Person Given Name 

Person Family Name (At Birth)

The patients surname at birth

an35

N/A

N/A

R

N/A

Person Family Name (At Birth)

Patient Address (At Diagnosis)

NHS Wales Data Dictionary

At admission, attendance or diagnosis

NHS Wales Data Dictionary

N/A

N/A

R

Patient's Usual Address

Patient Usual Address (At Diagnosis) 

Patient Postcode (At Diagnosis)

NHS Wales Data Dictionary

At admission, attendance or diagnosis

NHS Wales Data Dictionary

N/A

N/A

R

Postcode of Usual Address

Postcode Of Usual Address (At Diagnosis) 

Referral Details (This Section Includes Details From Referral Up To First Appointment (For The Primary Diagnosis) And Is Therefore To Be Recorded Once For Each New Primary Cancer Diagnosis.

Source Of Cancer Referral

This is a classification used to identify the source of referral of each episode or referral

Code List

Initiated by the Consultant or Independent Nurse responsible for the Out-Patient Episode

R

N/A

Source Of Referral For Out-Patients

01

Following an emergency admission

02

Following a Domiciliary visit

10

Following an Accident And Emergency Attendance (including Minor Injuries Units and Walk In Centres)

11

Other  - initiated by the Consultant responsible for the Consultant out patient episode

Not initiated by the Consultant or Independent Nurse responsible for the  Out-Patient Episode 

03

Referral from a General Medical Practitioner

04

Referral from A&E Department (including minor injuries units and walk in centres)

05

Referral from a Consultant or Independent Nurse, other than in an A&E department

06

Self-referral

07

Referral from Prosthetist

08

Other sources of referral

12

Referral from a General Practitioner with a Special Interest (GPwSI) or dentist with a Special Interest (DwSI)

13

Referral from a Specialist Nurse (Secondary Care)

14

Referral from an Allied Health Professional (AHP)

15

Referral from Optometrist

16

Referral from an Orthoptist

17

Referral from a National Screening Programme

171

Breast Test Wales - screening referral

172

Bowel Screening Wales - screening referral

173

Cervical Screening Wales - screening referral

174

Other Screening Service (not Breast, Bowel or Cervical)

92

General Dental Practitioner

93

Community Dental Service

97

Other - not initiated by the Consultant responsible for the Consultant Out Patient Episode

Date Of Cancer Referral

The date on which the decsion was made to refer a patient with suspected cancer.   This should be the first point of referral from one of the following:
(a) the date on the letter or proforma from the referring clinician or GP.    This definition will need to be reviewed in line with SCP definitions
(b) the date of admission to hospital in the case of patients admitted as an emergency
(c) the date of the first OPA appt, if the referral was a self-referral
(d) the date on the recall letter for patients recalled following a routine screening appt

ccyymmdd

N/A

N/A

M

N/A

N/A

Date Of Receipt Of Cancer Referral

The date that the referral request is received by the provider.   (Applies to all referral routes, not just from primary care)
(a) Date when letter/fax/electronic form is received.  In the case of a written referral, this should be the date on which the letter/fax arrived in the hospital.  The most likely source of this data will be a date stamp of teh receiving department on the referral letter
(b) Date of verbal request
(c) Date of admission to hospital in the case of patients admitted as an emergency
(d) The date of the first out patient appointment, if the referral was a self referral 

ccyymmdd

N/A

N/A

M

N/A

N/A

Cancer Waiting Times Eligibility Identifier (Presentation Of Disease At Referral)

To note Cancer Waiting Times (CWT) eligibility and a trigger of new presenation of disease.

Boolean

N/A

N/A

M

N/A

N/A

Pathway Start Date (Point Of Suspicion Of Cancer)

The date when a clinician suspects that patient may have cancer - this is for all routes of referral other than via the GP USC route
See Definitions document for pathway start date defnitions http://www.walescanet.wales.nhs.uk/scp-key-documents  
(Point of Suspicion Document)

ccyymmdd

N/A

N/A

M

N/A

N/A

Organisation Code (Referred To) (Code Of Provider)

NHS Wales Data Dictionary

NHS Wales Data Dictionary

N/A

N/A

M

Organisation Code - LHB/Trust Code

Organisation Identifier (Code Of Provider)

Organisation Site Code (Referred To) (Code Of Provider)

NHS Wales Data Dictionary

NHS Wales Data Dictionary

N/A

N/A

M

Organisation Code - LHB/Trust Site Code

N/A

Date First Seen

The date that the patient is first seen in the Health Board that receives the first referral.   It is the date first seen in secondary care for this diagnosis.

ccyymmdd

N/A

N/A

R

N/A

Date First Seen

Professional Registration Issuer Code - Consultant (First Seen)

A code which identifies the professional registration body

Code List

02

General Dental Council

M

N/A

Professional Registration Issuer Code - Consultant (First Seen)

03

General Medical Council

04

General Optical Council

08

Health and Care Professions Council

09

Nursing and Midwifery Council

Professional Registration Entry Identifier - Consultant (First Seen)

NHS Wales Data Dictionary

The consultant or health care professional who first sees the patient following the initial referral which leads to the cancer diagnosis

NHS Wales Data Dictionary

N/A

N/A

M

Consultant Code

Professional Registration Entry Identifier - Consultant (First Seen)

Organisation Site Identifier (Provider First Seen)

NHS Wales Data Dictionary

The organisation site where there was the first contact with the patient (first seen)

NHS Wales Data Dictionary

N/A

N/A

R

Organisation Code - LHB/Trust Site Code

Organisation Site Identifier (Provider First Seen)

Date First Seen (Cancer Specialist)

This is the date that the patient is first seen by the appropriate specialist for cancer care within the care spell/episode.  This is the person who are most able to progress the diagnosis of the primary tumour.  If patients first appointment is with the appropriate cancer specialist this will be the same as the date first seen

ccyymmdd

N/A

N/A

R

N/A

Date First Seen (Cancer Specialist)

Organisation Site Identifier (Provider First Cancer Specialist)

NHS Wales Data Dictionary

The organisation site where the patient is first seen by an appropriate cancer specialist on the date first seen (cancer specialist).   If the patient's first appointment is with the appropriate cancer specialist this will be the same as the provider first seen

NHS Wales Data Dictionary

N/A

N/A

R

Organisation Code - LHB/Trust Site Code

Organisation Site Identifier (Provider First Cancer Specialist)

Consultant Code (Cancer Specialist)

NHS Wales Data Dictionary

The consultant who is most able to progress the diagnosis of the primary tumour - this is the code of the consultant who is responsible for the appointment recorded under the date first seen (cancer specialist).   If the patient's first appointment is with the approriate cancer specialist this will be the same as the consultant first seen

NHS Wales Data Dictionary

N/A

N/A

R

Consultant Code

N/A

Cancer Referral Patient Status (Primary)

The status of referral requests for patients referred with a suspected cancer, or referred with breast symptoms with cancer not orignally suspected.  To be used for all patients regardless of referral route.

Code List

14

Suspected primary cancer

R

N/A

N/A

09

Under investigation following symptomatic referral, cancer not suspected (breast referrals only)

03

No new cancer diagnosis identified by the Healthcare Provider

31

Diagnosis of new cancer confirmed 

Cancer Symptoms First Noted Date

Record the time when the symptoms were first noted related to this diagnosis as agreed between the consultant and the patient.  This will normally be recorded by the consultant first seeing the patient in secondary care.   Depending on length of time this should normally include at least the month and year.  The day should also be included if known.   If symptoms have been present for a long time then it may only be possible to record the year. 

ccyymmdd

N/A

N/A

R for CTYA

O for other sites

N/A

Cancer Symptoms First Noted Date

Key Imaging Investigations (Multiple Occurrences Per Tumour)

Organisation Site Identifier Of Imaging

NHS Wales Data Dictionary

The organisation site at which the imaging took place

NHS Wales Data Dictionary

N/A

N/A

M

Organisation Code - LHB/Trust Site Code

Organisation Site Identifier (Of Imaging)

Date Of Imaging (Procedure Date)

NHS Wales Data Dictionary

The date the imaging was performed

ccyymmdd

N/A

N/A

M

Procedure Date

Procedure Date (Cancer Imaging)

Date Imaging Reported

The date the imaging was reported

ccyymmdd

N/A

N/A

R

N/A

N/A

Imaging Outcome

Record the outcome for the imaging event as agreed with the radiologist or clinical team

Code List

01

Abnormal – used when patient does not have normal imaging and the radiologist deems there to be a finding or mass correlating with a disease process which could be benign or malignant disease

R

N/A

Imaging Outcome

02

Normal – used when imaging investigation looks completely normal in the radiologists opinion

03

Benign – used when patients imaging has shown an abnormality or mass on imaging and in the radiologists opinion this looks benign given the features on the image. 

04

Non-diagnostic – when the image taken  and when to the radiologist it is unclear and therefore they cannot make a diagnosis

05

Inadequate – when the image is difficult to interpret and needs to be repeated, this could be down to system or human reason

09

Not Known

Image Code (NICIP)

This is the National Interim Clinical Imaging Procedure Code Set is used to identify both the test modality and body site of test

an6

N/A

N/A

M

N/A

Image Code (NICIP)

Image Code (NICIP) Description

Description associated with Image Code (NICIP)

an100

N/A

N/A

D

N/A

N/A

Imaging Code (SNOMED)

Imaging code is the SNOMED concept ID which is used to identify both the test modality and body site of the test Required if NICIP not available

min n6 max n18

N/A

N/A

R

N/A

Image Code (NICIP)

Image Code (SNOMED) Description

Description associated with Image Code (SNOMED)

an100

N/A

N/A

D

N/A

N/A

Cancer Imaging Modality

The type of imaging procedure used during an Imaging or Radiodiagnostic event for a cancer care spell.

Only completed if NICIP/SNOMED is not available

Code List

C01X

Standard Radiography

R

N/A

Cancer Imaging Modality

C01M

Mammogram

C02X

CT Scan

C02C

Virtual colonoscopy

C03X

MRI Scan

C04F

FDG PET Scan

C04O

Other PET Scan

C05X

Ultrasound Scan

C06X

Nuclear Medicine imaging

C08A

Angiography

C08B

Barium

C08U

Urography (IV and retrograde)

C09X

Intervention radiography

CXXX

Other

Imaging Anatomical Site

A classification of the part of the body that is the subject of an Imaging or Radiodiagnostic Event - coded. (The coding frame used is the OPCS-4 'Z' coding  plus two additional local codes for whole body and multiple sites)

Only completed if NICIP/SNOMED code is not available - this data item is required to be completed when imaging modality data item is completed

Code List

Z921

Head NEC

R

N/A

Imaging Anatomical Site

Z923

Neck NEC

Z924

Chest NEC

Z925

Back NEC

Z926

Abdomen NEC

Z927

Trunk NEC

Z899

Arm NEC

Z909

Leg NEC

Z019

Brain NEC

Z069

Spine NEC

Z301

Liver NEC

CZ001

Whole body

CZ002

Multiple sites

Z929

Other

Anatomical Side

Side of the body that is the subject of an Imaging or Radiodiagnostic Event

Only completed if NICIP/SNOMED code is not available - this data item is required to be completed with imaging modality and anatomical site

Code List

L

Left

R

N/A

Anatomical Side (Imaging)

R

Right

M

Midline

B

Bilateral

8

Not applicable

9

Not Known

Imaging Text Report

This is the full text provided in the imaging report.  This is also required by cancer registries to derive final stage and diagnosis date for cancer registration
When either one of the mandatory data items are completed for imaging either NICIP code, SNOMED code or Imaging Modality this data item is required

an270000

N/A

N/A

R

N/A

Imaging Report Text

Lesion Size (Radiological)

The size in millimetres of the maximum diameter of the primary lesion, largest if more than one

n3.n2

N/A

N/A

R

N/A

Lesion Size (Radiological)

Diagnostic Procedures
(Multiple Occurrences Per Tumour)

Organisation Site Identifier (Diagnostic Procedure)

NHS Wales Data Dictionary

The Organisation site where the diagnostic procedure took place

NHS Wales Data Dictionary

N/A

N/A

M

Organisation Code - LHB/Trust Site Code

Organisation Site Identifier (Diagnostic Procedure)

Diagnostic Procedure Date

This is the date the diagnostic procedure was carried out

ccyymmdd

N/A

N/A

M

N/A

Diagnostic Procedure Date

Diagnostic Procedure (OPCS)

Record the diagnostic  procedure(s) carried out using OPCS.
This may be recorded in addition or instead of SNOMED Diagnostic Procedure

an4

N/A

N/A

M

N/A

Diagnostic Procedure (OPCS)

Diagnostic Procedure (OPCS) Description

Description associated with Diagnostic Procedure (OPCS)

an100

N/A

N/A

D

N/A

N/A

Diagnostic Procedure (SNOMED)

Record the diagnostic procedure(s) carried out using SNOMED.  
This may be recorded in addition or instead of OPCS Diagnostic Procedure

min n6 max n18

N/A

N/A

M

N/A

Diagnostic Procedure (SNOMED CT)

Diagnostic Procedure (SNOMED) Description

Description associated with Diagnostic Procedure (SNOMED)

an100

N/A

N/A

D

N/A

N/A

Sentinel Node Biopsy Outcome (Diagnostic Procedure)

Record the outcome of the Sentinel Node Biopsy

Code List

P

Malignant

R

N/A

Sentinel Node Biopsy Outcome

N

No Malignancy

Core Diagnosis
(One Occurrence Per Primary Cancer Pathway)

Organisation Site Identifier (Of Diagnosis)

NHS Wales Data Dictionary

The organisation site where the patient diagnosis took place

NHS Wales Data Dictionary

N/A

N/A

R

Organisation Code - LHB/Trust Site Code

Organisation Site Identifier (Of Diagnosis)

Primary Cancer Site Code (ICD)

NHS Wales Data Dictionary

The site of the primary cancer for which the patient is receiving care.

NHS Wales Data Dictionary

N/A

N/A

M

Primary ICD Diagnostic Code

Primary Cancer Site Code (ICD)

Primary Cancer Site (ICD) Description

Description associated with Primary Cancer Site (ICD) Description

an100

N/A

N/A

D

Primary ICD Diagnostic Code

N/A

Primary Cancer Site Code (SNOMED)

The site of the primary cancer for which the patient is receiving care.

min n6 max n18

N/A

N/A

M

N/A

N/A

Primary Cancer Site (SNOMED) Description

Description associated with Primary Cancer Site (SNOMED) Description

an100

N/A

N/A

D

N/A

N/A

Tumour Laterality

Identifies the side of the body for a tumour relating to paired organs within a patient.   This refers to the side of the body on which the cancer originates.   

For the central nervous system, the definition of bilateral is 'evidence that the tumour is crossing the midline'. 

Code List

L

Left

M

N/A

Tumour Laterality

R

Right

M

Midline

B

Bilateral

8

Not Applicable

9

Not Known

Date Of Primary Diagnosis - Clinically Agreed

Record the date when the primary cancer was confirmed. 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’.

ccyymmdd

N/A

N/A

M

N/A

Date Of Primary Diagnosis - Clinically Agreed

Basis Of Diagnosis

 This is the method used to confirm the cancer. 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.

Code List

Non-microscopic

R

N/A

Basis Of Diagnosis (Cancer)

0

Death Certificate: The only information available is from a death certificate

1

Clinical: Diagnosis made before death but without the benefit of any of the following (2-7)

2

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 metastasis: 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

9

Unknown: No information on how the diagnosis has been made (e.g. PAS or HISS record only)

Morphology (Pre Treatment) (ICD10 V4)

Cell type of malignant disease determined before the start of treatment (ICD10 V4)

min an4 max an6

N/A

N/A

O

N/A

N/A

Morphology (Pre Treatment) (SNOMED)

Cell type of malignant disease determined before the start of treatment (SNOMED)

min n6 max n18

N/A

N/A

M

N/A

N/A

Morphology Description (Pre Treatment) (SNOMED)

Morphology (Pre Treatment) (SNOMED) Description

an100

N/A

N/A

D

N/A

N/A

Morphology (SNOMED) Diagnosis

This is the patients diagnosis using the SNOMED code for the cell type of the malignant disease recorded as part of a cancer spell/episode. 

min n6 max n18

N/A

N/A

M

N/A

Morphology (SNOMED) Diagnosis

Morphology Description (SNOMED) Diagnosis

Morphology (SNOMED) Diagnosis Description

an100

N/A

N/A

D

N/A

N/A

SNOMED Version (Diagnosis)

The version of SNOMED used to encode morphology (SNOMED) pathology and topography (SNOMED) pathology

Code List

01

SNOMED II

M

N/A

SNOMED Version (Diagnosis)

02

SNOMED 3

03

SNOMED 3.5

04

SNOMED RT

05

SNOMED CT

99

Not Known

Grade Of Differentiation (At Diagnosis)

The Grade of differentiation at diagnosis is the definitive grade of the tumour at the time of the patients diagnosis.  
Note: Required for all urological cancers except Prostate and Testis cancer. Data item not applicable to CNS, Sarcoma or Haematological tumour sites

Code List

GX

Grade of differentiation is not appropriate or cannot be assessed

R

N/A

Grade Of Differentiation (At Diagnosis)

G1

Well differentiated

G2

Moderately differentiated

G3

Poorly differentiated

G4

Undifferentiated / anaplastic

G9

Not Applicable

Performance Status (At Diagnosis)

A World Health Organisation/ECOG classification indicating a person's status relating to activity / disability.

Code List

0

Able to carry out all normal activity without restriction

R

N/A

Performance Status (Adult)

1

Restricted in physically strenuous activity, but able ambulatory and able to carry out light work

2

Ambulatory and capable of all self-care but unable to carry out any work activities; up and about more than 50% of waking hours

3

Symptomatic and in a chair or in bed for greater than 50% of the day but not bedridden

4

Completely disabled; cannot carry out any self-care; totally confirned to bed or chair

9

Not recorded

Diagnosis Code (SNOMED)

Diagnosis code (SNOMED) which is used to identify the clinical diagnosis given to the patient

min n6 max n18

N/A

N/A

R

N/A

Diagnosis Code (SNOMED CT)

Diagnosis Description (SNOMED)

Description associated with Diagnosis Code (SNOMED)

an100

N/A

N/A

D

N/A

N/A

Metastatic Site (At Diagnosis)

The site of the metastatic disease, if any, at diagnosis.  More than one site can be recorded

Code List

02

Brain

M

N/A

Metastatic Site

03

Liver

04

Lung

07

Unknown metastatic site

08

Skin

09

Distant lymph nodes

10

Bone (excluding Bone Marrow)

11

Bone Marrow

12

Regional Lymph Nodes

97

Not Applicable

98

Other Metastatic Site

Diagnosis - Additional Data Items - Child Group Of Core Diagnosis – May Be Up To One Occurrence Per Tumour

Primary Diagnosis Subsidiary Comment

Additional comments on diagnosis where coding is difficult or imprecise.  (Examples of this would be:  "papillary glioneuronal tumour" or "angiocentric glioma" to specify recently described diagnoses which do not have ICD10 or ICD-O-3 coding.  anaplastic ependymoma or ependymoblastoma to distinguish between these two diagnoses which may have different treatment decisions or outcomes but which cannot be distinguished in ICD10 or ICD-O-3 coding.)

an50

N/A

N/A

R

N/A

Primary Diagnosis Subsidiary Comment

Secondary Diagnosis (ICD)

Types (ICD10 codes) of other significant conditions (e.g. Down Syndrome, NF1, Fanconi anaemia) which may predispose to cancer or influence treatment. Possible multiple entries

min an4 max an6

N/A

N/A

R

N/A

Secondary Diagnosis (ICD)

Secondary Diagnosis (ICD) Description

Description associated with Secondary Diagnosis (ICD)

an100

N/A

N/A

D

N/A

N/A

Secondary Diagnosis (SNOMED)

Types (SNOMED codes) of other significant conditions (e.g. Down Syndrome, NF1, Fanconi anaemia) which may predispose to cancer or influence treatment. Possible multiple entries

min n6 max n18

N/A

N/A

R

N/A

N/A

Secondary Diagnosis (SNOMED) Description

Description associated with Secondary Diagnosis (SNOMED)

an100

N/A

N/A

D

N/A

N/A

Other Significant Diagnosis Subsidiary Comment (Secondary Diagnosis Comment)

Additional comments on other significant conditions where coding is difficult or imprecise.  (For example "NF1" or "NF2" to distinguish between these two distinct conditions which may have different treatment decisions or outcomes but cannot be coded separately.)

an50

N/A

N/A

R

N/A

Other Significant Diagnosis Subsidiary Comment

Familial Cancer Syndrome

Indicate whether there is a possible or confirmed familial cancer syndrome

Code List

Y

Yes

R

N/A

Familial Cancer Syndrome

N

No

P

Possible

9

Not Known

Familial Cancer Syndrome Subsidiary Comment

Where Familial Cancer Syndrome is Yes or Possible this field can be used to provide further details. For example, 'Li-Fraumeni', 'Rhabdoid tumour predisposition syndrome' or 'Biallelic PMS2 mutation' to identify distinct syndromes which may have different treatment decisions or outcomes but cannot be coded separately.

an50

N/A

N/A

R

N/A

Familial Cancer Syndrome Subsidiary Comment

Banked Tissue - Core Diagnosis
(One Occurrence Per Tumour)

Banked Tissue Status (At Diagnosis)

Indicates whether any tissue was banked at diagnosis

Code List

1

Patient approached, consented

R

N/A

Banked Tissue At Diagnosis

2

Patient approached, but declined

3

Patient not approached

9

Not Known (Not Recorded)

Type Of Tissue Banked At Diagnosis

Type of Tissue Banked (At Diagnosis)

Code List

1

Tumour

R

N/A

Type Of Tissue Banked At Diagnosis

2

Blood

3

CSF

4

Bone Marrow

5

Urine

6

Other

Other - Type Of Tissue Banked (At Diagnosis)

If Other is chosen in type of tissue banked, specify the other type

an50

N/A

N/A

R

N/A

N/A

Person Observations - Core  (Multiple Occurrences Can Be Recorded)

Person Height (Metres)

Height of the patient in Metres

n1.n2

N/A

N/A

R

N/A

Person Observation Height In Metres

Person Weight (Kgs)

Weight of the patient in kgs

n3.n3

N/A

N/A

R

N/A

Person Observation (Weight)

Body Mass Index (BMI)

Estimate of a patient's BMI - autocalculated if height and weight provided - at diagnosis

n2.n1

N/A

N/A

D

N/A

Body Mass Index

Date Observation Measured

Date the patient's observation weight or height was measured. Must be completed if Person Height (Metres) or Person Weight (Kgs) recorded

ccyymmdd

N/A

N/A

R

N/A

Date Observation Measured

Clinical Nurse Specialist & Risk Factor Assessment - Core (One Occurrence Of This Group Per Tumour)

Clinical Nurse Specialist Indication Code

Record if and when the patient saw an appropriate site specific clinical nurse specialist

Code List

Y1

Yes - CNS present when patient given diagnosis

R

N/A

Clinical Nurse Specialist Indication Code

Y3

Yes - CNS not present when patient given diagnosis but saw the patient during same consultant clinic session

Y4

Yes - CNS not present during consultant clinic session when patient given diagnosis but saw patient at another time

Y5

Yes - CNS not present when patient given diagnosis but the patient was seen by a trained member of the CNS team

Y6

Yes - CNS not present when patient given diagnosis but the patient was seen by a trained member of the MDT

NI

No - Patient not seen at all by CNS but CNS informed of diagnosis

NN

No - Patient not seen at all by CNS and CNS not informed of diagnosis

99

Not known/Not recorded

Date Clinical Nurse Specialist Seen

Date of contact with the cancer specialist nurse

ccyymmdd

N/A

N/A

R

N/A

N/A

Tobacco Smoking Status

Specify the current tobacco smoking status of the patient.

Code List

1

Current smoker

R

N/A

Tobacco Smoking Status

2

Ex smoker

4

Never smoked

9

Unknown

Tobacco Smoking Cessation

Was treatment for tobacco addiction/cessation given to the patient

Code List

1

Patient treated

R

N/A

Tobacco Smoking Cessation

2

Patient not treated

3

Patient offered treatment but declined

8

Not applicable (Not current tobacco user)

9

Not Known (Not recorded)

History Of Alcohol (Current)

Specify the current history of alcohol consumption for the patient (≤3 months) from date of diagnosis.
These are based on the UK Chief Medical Officer Alcohol Guideline Review (Jan 2016)

Code List

1

Heavy (>14 Units per week)

R

N/A

History Of Alcohol (Current)

2

Light   (≤14 Units per week)

3

None in this period

Z

Not Stated (PERSON asked but declined to provide a response) 

9

Not Known (Not recorded)

History Of Alcohol (Past)

Specify the past history of alcohol consumption for the patient (>3 months) from date of diagnosis.
These are based on the UK Chief Medical Officer Alcohol Guideline Review (Jan 2016)

Code List

1

Heavy (>14 Units per week)

R

N/A

History Of Alcohol (Past)

2

Light   (≤14 Units per week)

3

None ever

Z

Not Stated (PERSON asked but declined to provide a response) 

9

Not Known (Not recorded)

Diabetes Mellitus Indicator

Does the patient have a diagnosis of diabetes?

Code List

Y

Yes

R

N/A

Diabetes Mellitus Indicator

N

No

9

Not Known

Diabetes Mellitus Type

If Diabetes Mellitus Indicator = Y, specify the type of diabetes the patient has

Code List

1

Type 1

R

N/A

N/A

2

Type 2

9

Not Known

Menopausal Status

Record the menopausal status (at the point of diagnosis) of female patients only

Code List

1

Premenopausal

R

N/A

Menopausal Status

2

Perimenopausal

3

Postmenopausal

8

Not Applicable

9

Not Known

Physical Activity (Current)

Specify the current physical activity level

Code List

1

Achieves guidance level of physical activity

R

N/A

Physical Activity (Current)

2

Does not achieve guidance level of physical activity

Z

Not Stated (Person asked but declined to provide a response)

9

Not Known (Not recorded)

Holistic Needs Assessment
(Multiples Can Be Added Throughout Pathway)

Holistic Needs Assessment Status

An indication of whether a patient has been offered a HNA for completion
Picklist item 05 - 'Offered but patient is unable to complete' could relate to patients who have cognitive difficulties, picklist item 04 - 'Not Offered' covers patients who would not normally be expected to undergo HNA due to being on a clinical pathway that deliberately does not include it (eg, some skin cancer patients or because the patient has been referred on to another provider who will offer the HNA)

Code List

01

Offered and Undecided

R

N/A

Assessment Offered

02

Offered and Declined

03

Offered and Accepted

04

Not Offered

05

Offered but patient unable to complete (eg, due to cognitive difficulties)

Holistic Needs Assessment Completed Date

The date a Holistic Needs Assessment is completed.
Every HNA should be recorded but only HNAs carried out in Secondary care setting

ccyymmdd

N/A

N/A

R

N/A

Assessment Completed Date

Holistic Needs Assessment Point Of Pathway

The point of the pathway where a Holistic Needs Assessment is completed.

Code List

91

Point of Suspicion 

R

N/A

Assessment Point Of Pathway

01

Initial cancer diagnosis

02

Start of treatment

03

During treatment

04

End of treatment

05

Diagnosis of recurrence

06

Transition to palliative care

07

Prehabilitation 

97

Other

Staff Role Carrying Out The Holistic Needs Assessment

Record the role of the individual carrying out the Holistic Needs Assessment (secondary care only). The staff role is needed in order to support workforce planning of who and how HNA activities are being carried out. HNAs are carried out by any health or social care professional and also by support workers/care navigators, volunteers or by the person themselves from home. Also note that Cancer Information & Support Co-ordinators are roles specifically to Wales and often each Health Board has one of these Co-ordinators who assist in the completion of HNAs therefore this role has been added to picklist item 04.  

Code List

01

Cancer Nurse Specialist

R

N/A

Staff Role Carrying Out The Assessment

02

Other Nurse

03

Allied Health Professional

04

Support worker/Care Navigator/Cancer Information & Support Co-ordinator

05

Psychologist or other mental health professional

06

Consultant/Medical Team

08

Other

09

Not Known

Holistic Needs Assessment Care Plan (This Is Called PCSP In England) (Multiples Can Be Added Throughout Pathway)

Care Planning Offered

An indication of whether a patient has been offered a Holistic Needs Assessment (HNA) Care Plan

Code List

01

Offered and Undecided

R

N/A

Care Planning Offered

02

Offered and Declined

03

Offered and Accepted

04

Not Offered

05

Offered but patient unable to complete

06

Not required (no concerns from HNA)

Care Planning Completed Date

The date Holistic Needs Assessment (HNA) Care Planning is completed

ccyymmdd

N/A

N/A

R

N/A

Care Planning Completed Date

Point Of Pathway

The point of the pathway where Holistic Needs Assessment (HNA) Care Planning is completed

Code List

91

Point of Suspicion

R

N/A

Point Of Pathway

01

Initial cancer diagnosis

02

Start of treatment

03

During treatment

04

End of treatment

05

Diagnosis of recurrence

06

Transition to palliative care

07

Prehabilitation 

97

Other

Staff Role Carrying Out The Planning

Record the role of the individual carrying out the Holistic Needs Assessment (HNA) Care Plan (secondary care only)

Code List

01

Cancer Nurse Specialist

R

N/A

Staff Role Carrying Out The Planning

02

Other Nurse

03

Allied Health Professional

04

Support worker/Care Navigator/Cancer Information & Support Co-ordinator

05

Psychologist or other mental health professional

06

Consultant/Medical Team

08

Other

09

Not Known

Keyworker
(Multiples Can Be Added Throughout Pathway)

Keyworker Allocated

Has a keyworker been allocated to the patient

Code List

Y

Yes

R

N/A

N/A

N

No

Date Keyworker Allocated

Date when Key worker was allocated

ccyymmdd

R

N/A

N/A

Keyworker Allocation Point In Pathway

The point in the patient pathway when a keyworker was allocated

Code List

91

Point of Suspicion

R

N/A

N/A

01

Initial cancer diagnosis

02

Start of treatment

03

During treatment

04

End of treatment

05

Diagnosis of recurrence

06

Transition to palliative care

07

Prehabilitation 

98

Other

Rehabilitation (Multiples Can Be Added Through Pathway)

Rehabilitation Status

An indication of whether a patient has been offered a referral to the rehabilitation services

Code List

01

Offered and Accepted - Referral made

R

N/A

N/A

02

Offered and Declined - No referral made

03

Not Required

04

Rehab service unavailable for this cancer/tumour site

Rehabilitation Referral Date

The date of referral to the rehabilitation service

ccyymmdd

N/A

N/A

R

N/A

N/A

Rehabilitation - Point In Pathway

The point in the patient pathway when rehabilitation services was allocated

Code List

91

Point of Suspicion

R

N/A

N/A

01

Initial cancer diagnosis

02

Start of treatment

03

During treatment

04

End of treatment

05

Diagnosis of recurrence

06

Transition to palliative care

07

Prehabilitation 

08

Late onset - consequence of cancer

98

Other

Rehabilitation Intent

Specify the intention for the cancer rehabilitation referral

Code List

01

Preventative Rehabilitaton/Prehabilitation

R

N/A

N/A

02

Restorative Rehabilitation

03

No Intervention Required

04

Supportive Rehabilitation

05

Palliative Rehabilitation

06

Comfort Measures Only

98

Other

MDT
(Multiples Occurrences Required Per Tumour)

MDT Meeting Discussion Indicator

Record if the patient was not discussed within an MDT meeting

Code List

4

Not discussed at all

M

N/A

Multidisciplinary Team Meeting Discussion

9

Not Known

MDT Meeting Discussion Type

Record if the patient was discussed with a Multidisciplinary team meeting (MDT)

Code List

1

Discussed within a Health Board MDT

M

N/A

Multidisciplinary Team Meeting Discussion Type

2

Patient on predefined Standard of Care reviewed outside the MDT

3

Discussed at MDT in another Health Board

MDT Meeting Date

Record the date of each Multidisciplinary Team meeting where the patient was discussed. (This will include but will not be limited to the date when a treatment planning decision was made which is covered specifically under MDT date discussed treatment plan (COSD data label MDT Discussion Date (Cancer)).   If a patient is on a Predefined Standard of Care reviewed outside MDT, use the date of discussion where this was minuted

ccyymmdd

N/A

N/A

M

N/A

Multidisciplinary Team Meeting Date

Organisation Site Identifier MDT Meeting

NHS Wales Data Dictionary

The Organisation Site where the Multidisciplinary Team Meeting took place. 
Note: For joint MDT meetings a new MDT section must be recorded for each meeting

NHS Wales Data Dictionary

N/A

N/A

M

Organisation Code - LHB/Trust Site Code

Organisation Site Identifier Of Multidisciplinary Team Meeting

MDT Meeting Identifier (MDT Meeting Type)

Record the relevant meeting identifier

All MDTs in Wales have been allocated one of the codes listed

Code List

0100

Breast

M

N/A

Multidisciplinary Team Meeting Type

0101

Breast MDT

0200

Brain/Central Nervous System

0201

Brain Central Nervous System (CNS)/Neuroscience  MDT

0202

Rehabilitation and Non-Surgical (Network) MDT

0203

Pituitary MDT

0204

Skull base MDT

0205

Spinal cord MDT

0206

Low grade glioma MDT

0207

Metastasis to brain MDT

0208

Stereotactic Radiosurgery (SRS) MDT

0209

Genetic subtypes MDT

0300

Colorectal

0301

Colorectal MDT

0302

Anal MDT

0400

Childhood and TYA

0401

Paediatric Combined Diagnostic and Treatment MDT

0402

Paediatric Haematology only MDT

0403

Paediatric non-CNS solid tumours only MDT

0404

Paediatric CNS malignancy only MDT

0405

Paediatric Late Effects MDT

0406

Paediatric (POSCU) MDT

0407

Teenage and Young Adult MDT

0408

Teenage and Young Adult Late Effects MDT

0500

Gynaecology

0501

Gynaecology local MDT

0502

Gynaecology Specialist MDT

0600

Haematology

0601

Haematology MDT

0602

Lymphoma MDT

0603

Plasma Cell MDT

0604

Myeloid  MDT

0605

Bone marrow transplant MDT

0700

Head and Neck (including Thyroid)

0701

Upper Aerodigestive Tract (UAT) only MDT

0702

Upper Aerodigestive Tract (UAT) and Thyroid MDT

0703

Thyroid Only MDT

0800

Lung

0801

Lung MDT

0802

Mesothelioma Specialist MDT

0900

Sarcoma

0901

Bone and Soft tissue MDT

0902

Bone MDT

0903

Soft tissue MDT

1000

Skin

1001

Skin Local MDT

1002

Skin Specialist MDT

1003

Melanoma MDT

1004

Supra T-Cell Lymphoma MDT

1100

Upper GI

1101

Upper GI Local MDT

1102

Oesophago-Gastric Specialist MDT

1103

Hepatobiliary and Pancreatic (HPB)  Specialist MDT

1104

Pancreatic/Biliary (PB) Specialist MDT

1105

Hepatic Specialist MDT

1200

Urology

1201

Urology Local MDT

1202

Urology Specialist MDT

1203

Testicular Supranetwork  MDT

1204

Penile Supranetwork MDT

1300

Other

1301

CUP MDT

1302

Neuroendocrine MDT

1303

Palliative Care MDT

1304

Enhanced Supportive Care MDT

MDT Meeting Type Comment

To provide additional information on the MDT Meeting type, if not covered in the list provided (see MDT Meeting Identifier (MDT Meeting Type)).

AN60

N/A

N/A

O

N/A

Multidisciplinary Meeting Type Comment

Cancer Care Plan
(One Care Plan Per Tumour)

MDT Discussion Date

The date on which the patient's cancer care plan was discussed at a MDT meeting and the treatment planning decision was made

ccyymmdd

N/A

N/A

R

N/A

Multidisciplinary Team Discussion Date (Cancer) 

Professional Registration Issuer Code - Consultant (MDT Lead)

A code which identifies the professional registration body

Code List

02

General Dental Council

M

N/A

Professional Registration Issuer Code - Consultant (Multidisciplinary Team Lead)

03

General Medical Council

04

General Optical Council

08

Health and Care Professions Council

09

Nursing and Midwifery Council

Professional Registration Entry Identifier - Consultant (MDT Lead)

NHS Wales Data Dictionary

The registration identifier allocated by an Organisation for the Consultant or health care professional who is the multidisciplinary team (MDT) lead responsible for the management and decisions made at the MDT

NHS Wales Data Dictionary

N/A

N/A

M

Consultant Code

Professional Registration Entry Identifier - Consultant (Multidisciplinary Team Lead)

Cancer Plan Intent

This is required to be recorded when the care plan is agreed - for Haematology it is understood that for the majority of cases this data item would be Z - Non Curative

Code List

C

Curative

R

N/A

Cancer Care Plan Intent

Z

Non Curative

X

No Active Treatment 

9

Not known

Planned Cancer Treatment Type

This is the clinically proposed treatment, usually agreed at the MDT meeting and may not be the same as the treatment which is subsequently agreed with the patient.  
More than one planned treatment type may be recorded and these may either be alternative or sequential treatments.  This should only be recorded when the first treatment planning decision is made.

Code List

01

Surgery

R

N/A

Planned Cancer Treatment Type

02

Teletherapy 

03

Chemotherapy

04

Hormone Therapy

05

Specialist palliative care

06

Brachytherapy

07

Biological Therapy

10

Other Active Treatment

11

No active treatment

12

Bisphosphonates 

13

Anti Cancer Drug - Other

14

Radiotherapy - Other

99

Not known

Reason For No Specific Anti Cancer Treatment

The reason why the patient did not receive any specific anti-cancer treatment. 
The permissible value 'Unfit: poor performance status' is dependent up on the output value for the 'Final pre treatment performance status agreed by the MDT'

Code List

01

Patient declined treatment

R

N/A

No Cancer Treatment Reason

02

Unfit: poor performance status

03

Unfit: significant co-morbidity

04

Unfit: Advanced stage cancer

05

Unknown primary site

06

Died before treatment

07

No anti-cancer treatment available

08

Other

10

Watchful waiting

99

Not known

Adult Comorbidity Evaluation (Ace 27) Score

The overall comorbidity score is defined according to the highest ranked single ailment, except in the case where two or more Grade 2 ailments occur in different organ systems.  In this situation the overall comorbidity score should be designated Grade 3.    
The nature of any relevant co-morbidity, to be recorded at the MDT prior to the beginning of treatment
(N/A for skin diagnoses)

Code List

0

None

O

N/A

Adult Comorbidity Evaluation - 27 Score

1

Mild

2

Moderate

3

Severe

9

Not Known

Molecular & Biomarkers - Germline Testing For Cancer Predisposition
(Multiple Occurrences Can Be Added)

Germline Genetic Testing Offered (Offer Status)

An indication of whether a patient has been offered a germline genetic test

Code List

01

Offered and Undecided

R

N/A

Germline Genetic Testing Offered

02

Offered and Declined

03

Offered and Accepted

04

Not Offered

Type Of Germline Genetic Test Offered

Record the germline/genetic test offered to the patient.  More than one can be selected

Code List

01

Hereditary Breast and Ovarian Cancer (BRCA1/BRCA2/NGS Panel)

R

N/A

Germline Genetic Test Offered

02

Lynch Syndrome/HNPCC (MLH1/MSH2/MSH6/PMS2/EPCAM/NGS Panel)

03

Myeoid Neoplasms (CEBPA/DDX41/RUNX1/ANKRD26/ETV6/GATA2)

97

Other

Other Type Of Germline Genetic Test Offered

Record if 97 Other is selected for above data item.  Specify the Gene or Syndrome that was offered

an30

R

N/A

Other Germline Genetic Test Offered

Germline Analysis Offered Date

Record the date on which the germline genetic test was offered

ccyymmdd

R

N/A

Germline Analysis Offered Date

Organistation Identifier Of Reporting Regional Genetics Laboratory

NHS Wales Data Dictionary

The organisation where the reporting lab is based

NHS Wales Data Dictionary

N/A

N/A

R

Organisation Code - LHB/Trust Code

Organistation Identifier Of Reporting Regional Genetics Laboratory

Referral To Clinical Geneticist Offered

Indicate whether the patient has been offered a referral to a Regional Clinical Genetics Service

Code List

01

Offered and Undecided

R

N/A

Referral To Clinical Geneticist Offered

02

Offered and Declined

03

Offered and Accepted

04

Not Offered

Molecular & Biomarkers - Somatic Testing For Targeted Therapy And Personalised Medicine
(Multiple Occurences Can Be Added)

Gene Or Stratification Biomarker Type Analysed

Record the specific Gene or Stratification Biomarker analysed for the patient, regardless of test outcome.  

More than one of these can be selected

Code List

01

ALK Fusions

R

N/A

Gene Or Stratification Biomarker Analysed

02

BRC-ABL Fusion

03

BRAF Mutation

04

BRCA1 Mutation

05

BRCA2 Mutation

06

EGFR Mutation

07

ERBB2 (HER2/neu) Amplification/Overexpression

08

JAK2

09

KIT (CD117) Mutation

10

KRAS Mutation

11

Microsatellite Instability (MSI)/Mismatch Repair Analysis

12

NGS Panel (specify in Other below)

13

NRAS Mutation

14

Oncotype DX Gene Expression Test

15

PDGFRA Mutation

16

PIK3CA Mutation

17

RET Fusions

18

ROS Fusions

19

PD-L1

97

Other

Other Gene Or Stratification Biomarker Analysed

Record if 97 Other, or 12 NGS Panel is selected for above data item.  Specify the Gene or Stratification that was analysed

an30

N/A

N/A

R

N/A

Other Gene Or Stratification Biomarker Analysed

Date Gene Or Stratification Biomarker Reported

Record the date the Gene or Stratification Biomarker was reported

ccyymmdd

N/A

N/A

M

N/A

Date Gene Or Stratification Biomarker Reported

Organistation Identifier Of Reporting Laboratory

NHS Wales Data Dictionary

The organisation where the reporting lab is based

NHS Wales Data Dictionary

N/A

N/A

M

Organisation Code - LHB/Trust Code

Organistation Identifier Of Reporting Laboratory

Clinical Trials
(Multiple Occurrences Can Be Added)

Patient Trial Status

Code List

01

Patient approached, consented to and entered clinical trial

R

N/A

Patient Trial Status (Cancer) 

02

Patient approached, but declined clinical trial

03

Patient approached and consented, but failed screening

09

Not Known (Not Recorded)

99

No Trial available

Clinical Trial Decision Date

This is a mandatory date for 01 & 02 above only and links each Clinical Trial (if more than one entered).  If there are more than one entered on the same day, record the first Clinical Trial only

ccyymmdd

N/A

N/A

R

N/A

Clinical Trial Decision Date (Patient)

Date Clinical Trial Started

This will allow multiple trials to be recorded if applicable.  Each trial has to be part of the primary diagnosis treatment pathway.

ccyymmdd

N/A

n/A

R

N/A

Date Clinical Trial Started

Cancer Clinical Trial Treatment Type

Where a trial covers more than one type of treatment, eg chemotherapy compared with radiotherapy, then the option for "combined treatment" should be selected.  Where the trial covers a treatment type not specified eg, biological therapies 'Other' should be selected from the list.

Code List

01

Surgery

R

N/A

Cancer Clinical Trial Treatment Type

02

Chemotherapy

03

Hormone therapy

04

Immunotherapy

05

Radiotherapy

06

Combination treatment

07

Observational study

08

Biological therapy (Welsh specific)

09

Cellular therapy (Welsh specific)

98

Other

Study Identification Number

Record Clinical Trial Study Identification Number

an11

N/A

N/A

R

N/A

N/A

IRAS Number

Record Integrated Research Application System (IRAS) Number

an6

N/A

N/A

R

N/A

N/A

Clinical Trial Name/Acronym

Record the Clinical Trial Name or Acronym given

an30

N/A

N/A

R

N/A

N/A

Staging
This Data Should Be Recorded At The Time That The First Cancer Care Plan Is Agreed

T Stage (Final Pre Treatment)

A code which classifies the size and extent of the primary tumour before treatment.

The T (tumour) part of the TNM (Tumour, Nodes, 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 discoved only at autopsy, or via a death certificate, then no pre-treatment TNM stage will be recorded.

an15

N/A

N/A

R

N/A

T Category (Final Pretreatment)

N Stage (Final Pre Treatment)

A code which classifies the absence or presence and extent of regional lymph node metastases before treatment      

The N (tumour) part of the TNM (Tumour, Nodes, 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 discoved only at autopsy, or via a death certificate, then no pre-treatment TNM stage will be recorded.

an15

N/A

N/A

R

N/A

N Category (Final Pretreatment)

M Stage (Final Pre Treatment)

A code which classifies the absence or presence of distant metastases pre-treatment    

The M (tumour) part of the TNM (Tumour, Nodes, 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 discoved only at autopsy, or via a death certificate, then no pre-treatment TNM stage will be recorded.

an15

N/A

N/A

R

N/A

M Category (Final Pretreatment)

TNM Stage Grouping (Final Pre Treatment)

To record the overall clinical TNM Stage grouping of the tumour, derived from each T, N, M component prior to treatment.    This classification is based on all the evidence available to the clinician with responsibility  for assessing the patient and for the patients treatment plan.   The overall pre-treatment TNM stage grouping indicates the tumour stage at the time the treatment plan was devised

an15

N/A

N/A

R

N/A

TNM Stage Grouping (Final Pretreatment)

Stage Date (Final Pre Treatment Stage)

The date of the TNM Staging & Stage Grouping (final pre treatment)

ccyymmdd

N/A

N/A

R

N/A

Stage Date (Final Pre Treatment Stage)

Organisation Site Identifier
(Reported Pre Treatment TNM Stage)

NHS Wales Data Dictionary

The Organisation Site where the diagnosing MDT agreed the final pre treatment TNM stage

NHS Wales Data Dictionary

N/A

N/A

R

Organisation Code - LHB/Trust Site Code

Organisation Site Identifier (Reported Pretreatment TNM Stage)

T Stage (Integrated Stage)

A code which classifies the size and extent of the primary tumour after treatment and/or after all available evidence has been collected
 

an15

N/A

N/A

R

N/A

T Category (Integrated Stage)

N Stage (Integrated Stage)

A code which classifies the absence or presence and extent of regional lymph node metastases after treatment and/or after all available evidence has been collected

an15

N/A

N/A

R

N/A

N Category (Integrated Stage)

M Stage (Integrated Stage)

A code which classifies the absence or presence of distant metastases after treatment and/or after all available evidence has been collected

 

an15

N/A

N/A

R

N/A

M Category (Integrated Stage)

TNM Stage Grouping (Integrated Stage)

To record the overall TNM stage grouping for the tumour derived from each T, N, and M component after treatment.  

The overall integrated TNM stage grouping indicates the tumour stage after treatment and/or after all available evidence has been collected

This classification is based on all the evidence available to the clinician with responsibility for assessing the patient. It will be determined on the basis of all the clinical, imaging and pathological data available following the first surgical procedure ie, this is the integration of the pathological staging with the clinical staging. 

an15

N/A

N/A

R

N/A

TNM Stage Grouping (Integrated)

Stage Date (Integrated Stage)

The date of the TNM Staging & Stage Grouping (Integrated)

ccyymmdd

N/A

N/A

R

N/A

Stage Date (Integrated Stage)

Organisation Site Identifier (Integrated Stage)

NHS Wales Data Dictionary

The Organisation Site where the treating MDT post surgery (where surgery was the first treatment) agreed the Integrated TNM stage

NHS Wales Data Dictionary

N/A

N/A

R

Organisation Code - LHB/Trust Site Code

Organisation Site Identifier (Reported Integrated TNM Stage)

TNM Coding Edition

The TNM coding edition used

Code List

1

UICC (Union for International Cancer Control)

M

N/A

TNM Coding Edition

2

AJCC (American Joint Committee on Cancer)

3

ENETS (European Neuroendocrine Tumour Society)

TNM Version Number

The AJCC, UICC or ENETS version number used for Tumour, Node and Metastasis (TNM) Staging for cancer diagnosis

an2

N/A

N/A

M

N/A

TNM Version Number (Staging)

Site Specific Staging
(These Fields Are Only Required Where There Is A Site Specific Stage Recorded For A Patient And Will Not Be Applicable To Every Cancer - These Data Items Must Be Linked With The Site Specific Stage Fields Within The Separate Site Specific Datasets)

Organisation Site Identifier (Site Specific Stage)

NHS Wales Data Dictionary

The Organisation Site which carried out the site specific stage

NHS Wales Data Dictionary

N/A

N/A

M

Organisation Code - LHB/Trust Site Code

Organisation Site Identifier (Site Specific Stage)

Stage Date (Site Specific Stage)

The date of the sample/MDT which provided a positive stage outcome

ccyymmdd

N/A

N/A

M

N/A

Stage Date (Site Specific Stage)

Treatments - New Section - Core Treatment Summary - To Record Cancer Treatment Details
(Multiple Occurrences Of This Group Can Be Added)

Cancer Treatment Event Type

The treatment event reached during a cancer patient pathway

Code List

01

First Definitive Treatment for a New Primary Cancer

R

N/A

N/A

02

Second or subsequent treatment for a New Primary Cancer

03

Treatment for a local recurrence of a Primary Cancer

04

Treatment for a regional recurrence of cancer

05

Treatment for a distant recurrence of cancer (metastatic disease)

06

Treatment for multiple recurrence of cancer (local and/or regional and/or distant)

07

First Treatment for Metastatic disease following an Unknown Primary Cancer

08

Second or subsequent treatment for Metastatic disease following an Unknown Primary Cancer

09

Treatment for relapse of primary cancer (second or subsequent)

10

Treatment for progression of primary cancer (second or subsequent)

11

Treatment for transformation of primary cancer type (second or subsequent)

Adjunctive Therapy

Adjunctive therapy is therapy given in addition to the main therapy to maximise its effectiveness.   

This field allows for the accurate recording of these to determine if adjunctive therapy was adjuvant (after the main therapy) or Neo-adjuvant (before the main therapy) or not applicable

Code List

1

Adjuvant

R

N/A

Adjunctive Therapy

2

Neo-adjuvant

3

Not Applicable (Primary Treatment)

9

Not Known

Cancer Treatment Intent

The original intention of the cancer treatment intent being provided  

SACT and RTDS should use these fields   

* Disease modification is Drug specific  
** Diagnostic and Staging are Surgery specific

Code List

01

Curative

R

N/A

Cancer Treatment Intent

02

Palliative

03

Disease Modification *

04

Diagnostic **

05

Staging **

06

Uncertain of Treatment Intent

09

Not Known

98

Other

Treatment Start Date (Cancer)

This is the start date of the first, second or subsequent cancer treatment given to a patient who is receiving care for a cancer condition

ccyymmdd

N/A

N/A

M

N/A

Treatment Start Date (Cancer)

Cancer Treatment Modality

The type of treatment or care which was delivered in a Cancer Treatment Period

Code List

01

Surgery

M

N/A

Cancer Treatment Modality (Registration)

02

Anti-Cancer Drug Regimen (Cytotoxic Chemotherapy)

03

Anti-Cancer Drug Regimen (Hormone Therapy)

04

Chemoradiotherapy

05

Teletherapy (Beam Radiation excluding Proton therapy)

06

Brachytherapy

07

Specialist Palliative Care

08

Active Monitoring (excluding Non Specialist palliative care)

09

Non Specialist Palliative Care (excluding Active monitoring)

10

Radiofrequency Ablation (RFA)

11

High Intensity Focused Ultrasound (HIFU)

12

Cryotherapy

13

Proton Therapy

14

Anti-Cancer Drug Regimen (Other)

15

Anti-Cancer Drug Regimen (Immunotherapy)

16

Light Therapy (including Photodynamic Therapy and Psoralen and Ultraviolet A Therapy (PUVA Therapy)

17

Hyperbaric Oxygen Therapy

19

Radioisotope Therapy (including Radioiodine)

20

Laser Treatment (including Argon Beam Therapy)

21

Biological Therapies (excluding Immunotherapy)

22

Radiosurgery

97

Other Treatment (not listed)

98

All Treatment Declined

Organisation Site Identifier (Of Provider Cancer Treatment Start Date)

NHS Wales Data Dictionary

The Organisation Site where the treatment start date for cancer is recorded

NHS Wales Data Dictionary

N/A

N/A

M

Organisation Code - LHB/Trust Site Code

Organisation Site Identifier (Of Provider Cancer Treatment Start Date)

Professional Registration Issuer Code - Consultant (Treatment)

A code which identifies the professional registration body

Code List

02

General Dental Council

M

N/A

Professional Registration Issuer Code - Consultant (Treatment)

03

General Medical Council

04

General Optical Council

08

Health and Care Professions Council

09

Nursing and Midwifery Council

Professional Registration Entry Identifier - Consultant (Treatment)

NHS Wales Data Dictionary

The consultant or health care professional responsible for the treatment of the patient

NHS Wales Data Dictionary

N/A

N/A

M

Consultant Code

Professional Registration Entry Identifier - Consultant (Treatment)

End Of Treatment Summary Date

The date of completion of End of Treatment Summary at the end of acute (secondary care) treatment/s which was sent to the patient and/or the GP (multiple repeating data item)

ccyymmdd

N/A

N/A

O

N/A

End Of Treatment Summary Date

Discharge Date

NHS Wales Data Dictionary

ccyymmdd

N/A

N/A

R

Discharge Date

Discharge Date (Hospital Provider Spell) 

Discharge Destination

NHS Wales Data Dictionary

NHS Wales Data Dictionary

NHS Wales Data Dictionary

NHS Wales Data Dictionary

R

Discharge Destination

Discharge Destination (Hospital Provider Spell) 

Treatment - Surgery
To Record The Surgery Details
(Multiple Occurrences Per Tumour)

Procedure Intent

The treatment intent of the procedure(s) being carried out

Code List

04

Diagnostic

M

N/A

N/A

05

Staging

01

Curative

02

Palliative

09

Not Known

Date Of Decision To Treat (Surgery)

The date of the decision to treat

ccyymmdd

N/A

N/A

R

N/A

N/A

Procedure Date

NHS Wales Data Dictionary

ccyymmdd

N/A

N/A

M

Procedure Date

Procedure Date

Surgical Admission Type

The type of surgical admission

Code List

1

Elective

R

N/A

Surgical Admission Type

2

Emergency

9

Not Known

Professional Registration Issuer Code - Consultant (Surgeon)

A code which identifies the professional registration body for the Consultant or Health Care Professional who is responsible for the treatment of the patient.   If he/she is part of a surgical team, add all consultant surgeons responsible for the procedure.

Data item can be added multiple times with below data item if multiple surgeons were responsible for procedure

Code List

02

General Dental Council

M

N/A

Professional Registration Issuer Code - Consultant (Surgeon)

03

General Medical Council

04

General Optical Council

08

Health and Care Professions Council

09

Nursing and Midwifery Council

Professional Registration Entry Identifier - Consultant (Surgeon)

NHS Wales Data Dictionary

The consultant surgeon responsible for the treatment of the patient.   If he/she is part of a surgical team, add all consultant surgeons responsible for the procedure

Data item can be added multiple times with below data item if multiple surgeons were responsible for procedure

NHS Wales Data Dictionary

N/A

N/A

M

Consultant Code

Professional Registration Entry Identifier - Consultant (Surgeon)

Organisation Site Code - Procedure

NHS Wales Data Dictionary

The Organisation Site where the procedure took place and patient was treated

NHS Wales Data Dictionary

N/A

N/A

M

Organisation Code - LHB/Trust Site Code

N/A

Primary Procedure (OPCS)

NHS Wales Data Dictionary

NHS Wales Data Dictionary

N/A

N/A

R

Primary OPCS Code

Primary Procedure (OPCS)

Primary Procedure (OPCS) Description

Description associated with Primary Procedure (OPCS)

an100

N/A

N/A

D

N/A

N/A

Primary Procedure (SNOMED)

The main procedure carried out using SNOMED.  This may be recorded in addition to Primary Procedure OPCS

min n6 max n18

N/A

N/A

R

N/A

Primary Procedure (SNOMED CT)

Primary Procedure (SNOMED) Description

Description associated with Primary Procedure (SNOMED)

an100

N/A

N/A

D

N/A

N/A

Procedure(s) (OPCS)

NHS Wales Data Dictionary

This is a procedure(s) other than the primary procedure (OPCS) carried out and recorded.

Multiple occurrences may occur as more than one procedure can be recorded)  

NHS Wales Data Dictionary

N/A

N/A

R

Secondary OPCS Code

Procedure (OPCS)

 Procedure(s) (OPCS) Description in name and definition

Description associated with Procedures (OPCS) Description

an100

N/A

N/A

D

N/A

N/A

Procedure(s) (SNOMED)

This is the procedure other than the primary procedure carried out and recorded.   This may occur more than once and recorded in addition to Procedure OPCS

min n6 max n18

N/A

N/A

R

N/A

Procedure (SNOMED CT)

Procedure(s) (SNOMED) Description

Description associated with Procedure(s) (SNOMED)

an100

N/A

N/A

D

N/A

N/A

Unplanned Return To Theatre Indicator

If it is a planned primary procedure, select N (as this is not an unplanned return to theatre)

If this is an unplanned return to theatre (within the same admission/discharge period) then create a completely  new surgery treatment record for this and then select Y

The admission and discharge dates for both however would be the same, the procedure date, OPCS procedure and possibly surgeon(s) may be different

Code List

Y

Yes

R

N/A

Unplanned Return To Theatre Indicator

N

No

9