Reporting Data Item

Business Justification

Definition

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

Permissible Values

3. KEY INVESTIGATIONS

3.0

ENCDv4.5b (3.3)

Cancer Imaging modality

To estimate the level of accuracy of the diagnosis and staging when accounting for casemix and outcome analysis. Required for the use of the Multi Disciplinary Meeting (MDM) module.

The types of investigations performed to diagnose and stage the patient.

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

3.1

ENCDv4.5b (3.2)

Date of investigation

Required for audit of the National Cancer Standards, and the use of the Multi Disciplinary Meeting (MDM) module.

The date the investigation was performed.

3.2

WBCCA

Cancer sampling modality – breast

To estimate the level of accuracy of the diagnosis and staging when accounting for casemix and outcome analysis. Required for submission to the Welsh Breast Cancer Clinical Audit.

The types of (breast sampling) investigations performed to diagnose and stage the patient.

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

•    Clinical fine needle aspiration

•    Guided fine needle aspiration

•    Clinical core biopsy

•    Guided core biopsy

•    Smear (nipple discharge cytology)

•    Punch biopsy

3.3

WBCCA

Cancer sampling modality – axilla

To estimate the level of accuracy of the diagnosis and staging when accounting for casemix and outcome analysis. Required for submission to the Welsh Breast Cancer Clinical Audit.

The types of (axilla sampling) investigations performed to diagnose and stage the patient.

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

•    Clinical fine needle aspiration

•    Guided fine needle aspiration

•    Clinical core biopsy

•    Guided core biopsy

3.4

WBCCA

Breast investigated

To enable analysis on pre-operative diagnosis results and outcomes. Required for submission to the Welsh Breast Cancer Clinical Audit.

On which breast each test below took place.

•    Left

•    Right

3.5

WBCCA

Mammogram findings

To enable analysis on pre-operative diagnosis. Required for submission to the Welsh Breast Cancer Clinical Audit.

Mammogram findings.

Breast Imaging Reporting and Database System Classification

Normal (R1)

Benign (R2)

Probably benign (R3)

Probably malignant (R4)

Malignant (R5)

3.6

WBCCA

Ultrasound findings

To enable analysis on pre-operative diagnosis results and outcomes. Required for submission to the Welsh Breast Cancer Clinical Audit.

Ultrasound findings.

Breast Imaging Reporting and Database System Classification

Normal (U1)

Benign (U2)

Probably benign (U3)

Probably malignant (U4)

Malignant (U5)

3.7

WBCCA

Clinical fine needle aspiration findings

To enable analysis on pre-operative diagnosis results and outcomes. Required for submission to the Welsh Breast Cancer Clinical Audit.

Clinical fine needle aspiration findings.

Breast Imaging Reporting and Database System Classification

Inadequate/Not useful (C1)

Normal/Benign (C2)

Probably benign (C3)

Probably malignant (C4)

Malignant (C5)

3.8

WBCCA

Guided fine needle aspiration findings

To enable analysis on pre-operative diagnosis results and outcomes. Required for submission to the Welsh Breast Cancer Clinical Audit.

Guided fine needle aspiration findings.

Breast Imaging Reporting and Database System Classification

•    Inadequate/Not useful (C1)

•    Normal/Benign (C2)

•    Probably benign (C3)

•    Probably malignant (C4)

•    Malignant (C5)

3.9

WBCCA

Clinical core biopsy findings

To enable analysis on pre-operative diagnosis results and outcomes. Required for submission to the Welsh Breast Cancer Clinical Audit.

Clinical core biopsy findings.

Breast Imaging Reporting and Database System Classification

•    Unsatisfactory / Normal tissue only (B1)

•    Benign (B2)

•    Benign but of uncertain malignant potential (B3)

•    Suspicious of malignancy (B4)

•    Malignant (B5)

3.10

WBCCA

Guided core biopsy findings

To enable analysis on pre-operative diagnosis results and outcomes. Required for submission to the Welsh Breast Cancer Clinical Audit.

Guided core biopsy findings.

Breast Imaging Reporting and Database System Classification

•    Unsatisfactory / Normal tissue only (B1)

•    Benign (B2)

•    Benign but of uncertain malignant potential (B3)

•    Suspicious of malignancy (B4)

•    Malignant (B5)

3.11

WBCCA

Smear (nipple discharge cytology) findings

To enable analysis on pre-operative diagnosis results and outcomes. Required for submission to the Welsh Breast Cancer Clinical Audit.

Nipple discharge smear, cytological findings.

Breast Imaging Reporting and Database System Classification

•    Inadequate/Not useful (C1)

•    Normal/Benign (C2)

•    Probably benign (C3)

•    Probably malignant (C4)

•    Malignant (C5)

3.12

WBCCA

Other procedure findings

To enable analysis on pre-operative diagnosis results and outcomes. Required for submission to the Welsh Breast Cancer Clinical Audit.

Other procedure findings.

Breast Imaging Reporting and Database System Classification

•    Inadequate/Not useful (C1)

•    Normal/Benign (C2)

•    Probably benign (C3)

•    Probably malignant (C4)

•    Malignant (C5)