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

NBOCAP

WBCA

Recorded height at  initial presentation

To enable calculation of body mass index for case-mix, also required for submission to the Welsh and National Bowel Cancer Clinical Audits.

This is the record of a person’s height in metres at their initial consultation for suspected cancer.

Metres

3.3

NBOCAP

WBCA

Recorded weight at initial presentation

To enable calculation of body mass index for case-mix, also required for submission to the Welsh and National Bowel Cancer Clinical Audits.

This is the record of the person’s weight in kilos at their initial consultation for suspected cancer.

Kilos

3.4

NBOCAP

WBCA

Patient procedure result – colonoscopy

National guidelines are that total colonoscopy should be carried out before surgery on all patients with bowel cancer. The guidelines have a qualifier of ‘before or within six months of surgery’ but best practice is colonoscopy before planning treatment. Required for submission to the Welsh and National Bowel Cancer Clinical Audits.

Records the result of a colonoscopy examination.

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.

•     Normal (no evidence of tumour / true negative / false negative)

•     Abnormal (tumour or polyp)

•     Incomplete (bowel not fully visualised)

3.5

NBOCAP

WBCA

Colonoscopy incomplete reason

Enables analysis of incomplete colonoscopies to be performed, also required for the submission to the Welsh and National Bowel Cancer Clinical Audits.

Records the reason why the colonoscopy could not be completed.

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.

•     Obstructing cancer

•     Poor bowel preparation

•     Patient intolerance

•     Technical reason

•     Other

3.6

NBOCAP

WBCA

Patient procedure result – CT (Computerised Tomography) scan liver

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

CT (Computerised Tomography) scan liver – only report liver metastases

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

3.7

NBOCAP

WBCA

Patient procedure result – CT (Computerised Tomography) scan lung

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

CT (Computerised Tomography) scan lung – only report lung metastases

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

3.8

NBOCAP

WBCA

Patient procedure result – first MRI (Magnetic Resonance Imaging) T (Tumour) stage

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

This item records the T (Tumour) stage of a rectal cancer as shown on a pelvic MRI (Magnetic Resonance Imaging) scan. It is only applicable for rectal cancer. Recto-sigmoid tumours are excluded.

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

3.9

NBOCAP

WBCA

Patient procedure result – first MRI (Magnetic Resonance Imaging) N (Nodal) stage

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

This item records the N (Nodal) stage of a rectal cancer as shown on a pelvic MRI (Magnetic Resonance Imaging) scan. It is only applicable for rectal cancer. Recto sigmoid tumours are excluded.

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

3.10

NBOCAP

WBCA

Patient procedure result – first MRI (Magnetic Resonance Imaging) scan margins threatened

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

Threatened margin refers to cancer (tumour or nodal deposits) breaching or within 1mm of the boundary of the mesorectal plane.

•     Yes

•     No

3.11

WBCA

Patient procedure result – endoanal ultrasound Sm (Submucosa) / T (Tumour) stage

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

This item records the Sm (Submucosa) / T (Tumour) stage of a rectal cancer as shown on an endoanal ultrasound. It is only applicable for rectal cancer; recto-sigmoid tumours are excluded.

Refer to JRSGC JCGC (Japanese Research Society for Gastric Cancer Japanese Classification of Gastric Cancer) and  the UICC (International Union Against Cancer) TNM (Tumour, Node and Metastasis) Classifications of Malignant Tumours

3.12

WBCA

Patient procedure result – endoanal ultrasound N (Nodal) stage

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

This item records the N (Nodal) stage of a rectal cancer as shown on an endoanal ultrasound. It is only applicable for rectal cancer; recto-sigmoid tumours are excluded.

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

3.13

NBOCAP

WBCA

Height of tumour above anal verge

To enable analysis of permanent stoma rates and abdominoperineal resections based on the reported height of tumour above the anal verge. Required for submission to the Welsh and National Bowel Cancer Clinical Audit.

The distance from the anal verge to the lower margin of the tumour, applicable to rectal cancer only

Centimetres