Head and Neck Cancer - ISD Scotland...TNM Tumour Classification (Final) {Head and Neck Cancer} - Oral Cavity amend T3 'Tumour more than 4cm in greatest dimension or more than 10mm

Data Definitions for the National Minimum Core Dataset for Head and Neck Cancer. Developed by ISD Scotland, 2014

Head and Neck Cancer

Data Definitions for the National Minimum Core Dataset to Support the Introduction of Head and Neck Cancer Quality Performance Indicators

Definitions developed by ISD Scotland in Collaboration with the Head and Neck Quality Performance Indicator Development Group

Version 3.4: July 2019

To be used in conjunction with:

1. Head and Neck Cancer Quality Performance Indicators 2. Head and Neck QPI Dataset Validations (latest published version) 3. Head and Neck Measurability of QPI (latest published version)


DOCUMENT CONTROL SHEET Key Information

Title Head and Neck Cancer – Data Definitions for Minimum Core Dataset for Quality Performance Indicators (QPIs)

Date Published/Issued July 2019

Date Effective From 1St

April 2018 (TNM8 changes from April 2019)

Version/Issue Number V3.4

Document Type Guidance

Document Status Final

Standard Audience NHS staff involved in implementing and recording Head and Neck Cancer Quality Performance Indicators

Cross References

Head and Neck Cancer Quality Performance Indicators Head and Neck Cancer Measurability of Quality Performance Indicators

Author Information Services Division of NHS National Services Scotland

Version Date Summary of Changes Name Changes Marked

V1.1 July 2014 Changes to be applied for patients diagnosed from 1

st April 2014

Brian Murray,

Charlotte Anthony

ISD

See page xiii

V1.2 September 2014

Amend Definitive Operative Procedure Jane Garrett

ISD

See page xii

V1.3 October 2014

Change in version number due to validation changes

Jane Garrett

ISD

See page xii

V1.4 November 2014

Changes agreed outwith review to support data collection

Jane Garrett

ISD

See page xi

V2.0 April 2015 Changes agreed at 9 month review. Changes to be applied for patients diagnosed from 1

st April 2015

Charlotte Anthony

ISD

See page ix

V2.1 June 2015 Changes made out-with review Charlotte Anthony

ISD

See page viii

V2.2 August 2015

Changes made outwith review Charlotte Anthony

ISD

See page viii

V2.3 November 2015


ISD

See page vii

V2.4 March 2016 Amendments following Baseline Review Charlotte Anthony

ISD

See page vii


V2.5 June 2016 Changes made outwith review Karen Heatlie

ISD

See page vii

V2.6 February 2017


ISD

See page vii

V2.7 July 2017 Changes made outwith review Charlotte Anthony

ISD

See page vii

V3.0 August 2018

Changes agreed at Formal Review Jane Garrett

ISD

See page iv

V3.1 November 2018

Changes agreed outwith review to support data collection

Jane Garrett

ISD

See page v

V3.2 March 2019 TNM 8 updates

Jane Garrett

ISD

See page iv

V3.3 April 2019 Changes made outwith review Jane Garrett

ISD

See page iii

V3.4 July 2019 Changes made outwith review Jane Garrett

ISD

See page iii


CONTENTS PREFACE ............................................................................................................................................. i NOTES FOR IMPLEMENTATION OF CHANGES ............................................................................. ii CONVENTIONS .................................................................................................................................. ii REVISIONS TO DATASET .................................................................................................................iii CRITERIA FOR INCLUSION OF PATIENTS IN AUDIT ................................................................... xiii DATABASE SPECIFICATION ...........................................................................................................xiv

Section 1: Demographic Items ........................................................................................... 1 Person Family Name (at Diagnosis) .................................................................................................... 2 Person Given Name ............................................................................................................................ 3 Patient Postcode (at Disgnosis) .......................................................................................................... 4 Date of Birth ......................................................................................................................................... 5 Person Sex at Birth .............................................................................................................................. 6 CHI Number ......................................................................................................................................... 7

Section 2: Pre-treatment Imaging & Staging Investigations ............................................ 8 Location of Diagnosis {Cancer} ........................................................................................................... 9 Date of Diagnosis {Cancer} ............................................................................................................... 10 Site of Origin of Primary Tumour {Cancer} ........................................................................................ 11 Date of Histological/Cytological Diagnosis {Cancer} ......................................................................... 14 Imaging Completed ........................................................................................................................... 15 Date of Imaging Completed ............................................................................................................... 16 Date Imaging Reported ..................................................................................................................... 17 Date Discussed by Care Team (MDT) .............................................................................................. 18 Smoking ............................................................................................................................................. 19 Smoking Cessation ............................................................................................................................ 20 Date Offered Referral for Smoking Cessation ................................................................................... 21 Oral Assessment Required................................................................................................................ 22 Date of Oral Assessment ................................................................................................................... 23 Nutritional Screening ......................................................................................................................... 24 Date of Nutritional Screening............................................................................................................. 25 Specialist Speech and Language Therapist Access ......................................................................... 26 Date of Specialist Speech and Language Therapist Access ............................................................ 27 TNM Tumour Classification (Final) {Head and Neck Cancer} ........................................................... 28 TNM Nodal Classification (Final) {Head and Neck Cancer} .............................................................. 32 TNM Metastases Classification (Final) {Head and Neck Cancer} ..................................................... 36 WHO/ ECOG Performance Status .................................................................................................... 38 Type of First Cancer Treatment ........................................................................................................ 39 Date of First Cancer Treatment ......................................................................................................... 40 Date of Definitive Treatment {Head and Neck Cancer} ..................................................................... 41

Section 3: Surgery ............................................................................................................ 42 Location Code {Cancer Surgery} ....................................................................................................... 43 Consultant in Charge of Surgery ....................................................................................................... 44 Date of Definitive Surgery.................................................................................................................. 45 Intent of Definitive Surgery ................................................................................................................ 46 Definitive Operative Procedure 1-9 {Head and Neck Cancer} .......................................................... 47

Section 4: Pathological Details ........................................................................................ 52 Morphology of Tumour ...................................................................................................................... 53 HPV Status of Tumour ....................................................................................................................... 55 P16 Status of Tumour ........................................................................................................................ 56 Surgical Margins ................................................................................................................................ 57 Extracapsular Spread ........................................................................................................................ 58

Section 5: Oncology ........................................................................................................ 59 Location Code 1-2 {Oncology Treatment} ......................................................................................... 60 Date Treatment Started (Radiotherapy) {Head and Neck Cancer} (1-2) .......................................... 61 Date Treatment Completed (Radiotherapy) {Head and Neck Cancer} (1-2) .................................... 62 Radiotherapy Course Type {Head and Neck Cancer} (1-2) .............................................................. 63 Intensity-Modulated Radiation Therapy (IMRT) ................................................................................ 64 Date Treatment Started Systemic Anti-Cancer Therapy (SACT) {Cancer} 1-2 ................................ 65 Date Treatment Completed Systemic Anti-Cancer Therapy (SACT) {Cancer} 1-2 ........................... 66


Type of Systemic Anti-Cancer Therapy (SACT) 1-2 {Head and Neck Cancer} ................................ 67 Section 6: Clinical Trial Entry ........................................................................................... 68

Patient Entered into Clinical Trial {Cancer} ....................................................................................... 69 Section 7: Death Details ................................................................................................... 70

Date of Death .................................................................................................................................... 71


i

PREFACE Following the publication of Better Cancer Care: An Action Plan in October 2008, the Scottish Government established the Scottish Cancer Taskforce to oversee its implementation. The NHS Scotland Healthcare Quality Strategy in 2010 expands on this by articulating quality ambitions. A quality measurement framework has been developed setting out measures and targets which will be used to monitor, challenge, manage and report progress. Part of this strategy is the development of quality performance indicators (QPIs) to drive quality improvement in cancer care throughout NHS Scotland. As high quality data are required to enable comparisons over time and between regions, it is important that national data definitions are used to facilitate consistent data collection. National data definitions already in use have been used as much as possible to allow electronic data capture, thereby minimising duplication of data collection. Where national data definitions do not already exist, definitions used in other systems have been incorporated. To ensure that findings are comparable across Scotland, the national dataset and data definitions in conjunction with the final quality performance indicators were agreed through public engagement and are now ready for implementation for patients diagnosed from 1st April 2014.


ii

NOTES FOR IMPLEMENTATION OF CHANGES The following changes should be implemented for all patients who are diagnosed with Head and Neck cancer on or after 1st April 2015, who are eligible for inclusion in the Head and Neck cancer audit. Changes to definitions fall into the following categories:

to address problems with ongoing audit and standardise data definitions, where feasible, between different cancer sites

to address problems with existing definitions

to allow Quality Performance Indicators to be measured and reported against

If you have difficulties in using individual definitions within this document please contact General Enquiries on the Collection of the Minimum Core Data Set If you have any comments on the attached data definitions ISD would welcome your feedback. Please contact:

[email protected]

CONVENTIONS The layout for each item is standard as shown below where it is applicable: Common Name(s): Main Source of Data Item Standard: Definition: Field Name: Field Type: Field Length: Notes for Users: Codes and Values: Related Data Item(s): In addition the following two conventions have been used in the document:

{curly brackets} - definition relates to one specific named data set

'described elsewhere' - indicates there is a definition for the named item within this document

mailto:[email protected]


iii

REVISIONS TO DATASET The following changes have been made to facilitate the recording of data. Change made out with review (July 2019) TNM Tumour Classification (Final) {Head and Neck Cancer} - Oral Cavity amend T3 'Tumour more than 4cm in greatest dimension or more than 10mm depth of invasion' to T3 'Tumour more than 2 cm but not more than 4 cm in greater dimension and depth of invasion more than 10 mm or tumur more than 4 cm in greatest dimension and not more than 10 mm depth of invasion'. amend T4a ' Tumour invades through the cortical bone of the mandible or maxillary sinus, or invades the skin of the face' to T4a 'Tumour more than 4 cm in greatest dimension and more than 10 mm depth of invasion or tumour invades through the cortical bone of the mandible or maxilla or involves the maxillary sinus, or invades the skin of the face' Pharynx - Hypopharynx amend T3 ' oesophgus' to 'oesophageal mucosa' TNM Nodal Classification (Final) {Head and Neck Cancer} - Pharynx - Nasopharynx amend N2 -node(s)' to 'nodes' Change made out with review (April 2019) Date of Diagnosis {Cancer} - Notes for Users amend ‘09/09/0909’ to ‘09/09/1900’ Date of Histological/Cytological Diagnosis - Notes for Users amend ‘09/09/0909’ to ‘09/09/1900’; amend ‘10/10/1010’ to ‘10/10/1900’ Date of Imaging Completed - Notes for Users amend ‘09/09/0909’ to ‘09/09/1900’; amend ‘10/10/1010’ to ‘10/10/1900’ Date Imaging Reported - Notes for Users amend ‘09’09’0909’ to ‘09/09/1900’; amend ‘10/10/1010’ to ‘10/10/1900’ Date discussed by Care Team - Notes for Users amend ‘09/09/0909’ to ‘09/09/1900’; amend ‘10/10/1010’ to ‘10/10/1900’ Smoking Cessation - Codes and Values table delete code 95 Patient declined Date Offered Referral for Smoking Cessation - Notes for Users amend ‘09/09/0909’ to ‘09/09/1900’; amend ‘10/10/1010’ to ‘10/10/1900’ Date of Oral Assessment - Notes for Users amend ‘09/09/0909’ to ‘09/09/1900’; amend ‘10/10/1010’ to ‘10/10/1900’ Date of Nutritional Screening - Notes for Users amend ‘09/09/0909’ to ‘09/09/1900’; amend ‘10/10/1010’ to ‘10/10/1900’ Date of Specialist Speech and Language Therapist Access - Notes for Users amend ‘09/09/0909’ to ‘09/09/1900’; amend ‘10/10/1010’ to ‘10/10/1900’ Date of First Cancer Treatment - Notes for Users amend ‘09/09/0909’ to ‘09/09/1900’; amend ‘10/10/1010’ to ‘10/10/1900’


iv

Date of Definitive Treatment {Head and Neck} - Notes for Users amend ‘09/09/0909’ to ‘09/09/1900’; amend ‘10/10/1010’ to ‘10/10/1900’ Date of Definitive Surgery - Notes for Users amend ‘09/09/0909’ to ‘09/09/1900’; amend ‘10/10/1010’ to ‘10/10/1900’ Date Treatment Started (Radiotherapy) {Head and Neck} (1-2) - Notes for Users amend ‘09/09/0909’ to ‘09/09/1900’; amend ‘10/10/1010’ to ‘10/10/1900’ Date Treatment Completed (Radiotherapy) {Head and Neck} (1-2) - Notes for Users amend ‘09/09/0909’ to ‘09/09/1900’; amend ‘10/10/1010’ to ‘10/10/1900’ Date Treatment Started Systemic Anti-Cancer Therapy (SACT) {Cancer} 1-2 - Notes for Users amend ‘09/09/0909’ to ‘09/09/1900’; amend ‘10/10/1010’ to ‘10/10/1900 Date Treatment Completed Systemic Anti-Cancer Therapy (SACT) {Cancer} 1-2 - Notes for Users amend ‘09/09/0909’ to ‘09/09/1900’; amend ‘10/10/1010’ to ‘10/10/1900 Date of Death - Notes for Users amend ‘09/09/0909’ to ‘09/09/1900’; amend ‘10/10/1010’ to ‘10/10/1900 TNM 8 changes (March 2019) Dataset TNM Tumour Classification (Final) {Head and Neck Cancer} - Main Source of Data Item Standard, Definition amend ‘Seventh Edition, 2009’ to ‘Eighth Edition, 2017’; Codes and Values table Oral Cavity value updated for T1, T2, T3, T4a, add footnote; Pharynx –Oropharynx value updated for T1, T2, T3, T4a and T4b add code and value for T4, add footnote; Pharynx – Hypopharynx value updated for T1, T2, T3 and T4a, add footnote; Pharynx – Nasopharynx value updated for T1, T2, T3, and T4; Larynx – Supraglottis value updated for T1, T2, T3, T4a and T4b; Larynx – Glottis value updated for T1, T2, T3, T4a and T4b, add code T1a, T1b; Larynx – Subglottis value updated for T1, T2, T3, T4a and T4b; Nasal Cavity and Paranasal Sinuses - Maxillary Sinus value updated T1, T2, T3, T4a and T4b; Nasal Cavity and Paranasal Sinuses – Nasal Cavity and Ethmoid Sinus value updated for T1, T2 and T3; Salivary Glands value updated for T1, T2, T3, T4a and T4b, add footnote; Bone value updated for T1 and T2 TNM Nodal Classification (Final) {Head and Neck Cancer} - Main Source of Data Item Standard, Definition amend ‘Seventh Edition, 2009’ to ‘Eighth Edition, 2017’; Codes and Values table Oral Cavity value updated for N1, N2a, N2b, N2c, add N3a, N3b, remove N3, add footnote; Pharynx – Oropharynx and Hypopharynx amend title to ‘Pharynx – Oropharynx p16-Negative and Hypopharynx’, value updated for N1, N2a, N2b, N2c, add N3a, N3b, remove N3, add footnote; add new table Pharynx – Oropharynx p16-Positive Clinical, add footnote; Pharynx – Nasopharynx value updated for N1, N2, N3, remove N3a, N3b; Larynx value updated for N1, N2a, N2b, N2c, add N3a, N3b, remove N3, add footnote; Nasal Cavity and Paranasal Sinuses value updated for N1, N2a, N2b, N2c, add N3a, N3b, remove N3, add footnote; Salivary Glands value updated for N1, N2a, N2b, N2c, add N3a, N3b, remove N3, add footnote TNM Metastases Classification (Final) {Head and Neck Cancer} - Main Source of Data Item Standard, Definition amend ‘Seventh Edition, 2009’ to ‘Eighth Edition, 2017’; Codes and Values table Oral Cavity, Pharynx – Oropharynx and Hypopharynx, Pharynx – Nasopharynx, Larynx, Nasal Cavity and Paranasal Sinuses, Salivary Glands remove MX Regional metastasis cannot be assessed


v

Change made out with review (November 2018) Database Specification Date of Oral Assessment (Pre-treatment) - Title remove ‘pre-treatment’ Dataset Date Imaging Complete - Notes for Users add ‘If the patient has more than one CT and/or MRI scan the date of the final procedure for staging and assessment’ should be recorded.’ Oral Assessment Required - Notes for Users add ‘This refers to the consideration of whether oral assessment is required before the patient receives surgery, radiotherapy and / or chemotherapy’; Definition, Notes for Users, explanatory notes remove ‘pre-treatment’ Date of Oral Assessment (Pre-treatment) - Title, definition remove ‘pre-treatment’ Changes following Formal Review August 2018 Database Specification: Imaging Completed – Title remove ‘(Pre treatment)’ Date Imaging Completed – Title remove ‘Pre treatment’; Date Imaging Reported – Add New Data Item Field Name: CTREPORTDATE; Field Type: Date (DD/MM/CCYY), Field Length: 10 Date Referral for Smoking Cessation – Title amend to Date Offered Referral for Smoking Cessation Oral Assessment Required Field – add new Data Item name: ORALREG; Field Type: Integer, Field Length: 2 Dataset Person Family Name (at Diagnosis) – link updated Person Given Name – link updated Patient Postcode at Diagnosis {Cancer} – link updated

Date of Birth – link updated

Imaging Completed – Title, Related Data Items remove ‘(Pre treatment)’; Notes for Users amend ‘prior to treatment’ to ‘for staging and assessment’ Date Imaging Completed - Title, Notes for Users, Related Data Items remove ‘Pre treatment’; Date Imaging Reported – add new data item Smoking – Related Data Item amend ‘Date referred for Smoking Cessation’ to ‘Date Offered Referral for Smoking Cessation’


vi

Smoking Cessation – Definition amend ‘is referred for, before first treatment’ to ‘has been offered referral to’ Date Referral for Smoking Cessation – Title amend to Date Offered Referral for Smoking Cessation; Definition amend ‘referred, before first treatment’ to ‘offered referral’; Notes for Users updated see dataset for details Oral Assessment Required – add new data item Nutritional Screening – Definition amend ‘prior to first treatment’ to ‘as part of initial assessment’; Notes for Users remove ‘prior to first treatment’ Date of Nutritional Screening - Definition amend ‘prior to first treatment’ to ‘as part of initial assessment’; Notes for Users add ‘as part of their initial assessment’, ‘normally’, ‘If the MUST assessment date is not available in clinical documentation and recorded at MDT, then the MDT date should be used’ Specialist Speech and Language Therapist Access – Definition amend ‘before treatment’ to ‘as part of initial assessment’; Notes for Users remove ‘All head and neck cancer patients should have a pre-treatment assessment of speech and swallowing.’ Date of Specialist Speech and language Therapist Access - Definition amend ‘before treatment’ to ‘as part of initial assessment’; Notes for Users remove ‘All head and neck cancer patients should have a pre-treatment assessment of speech and swallowing.’ Add ‘This is the date the patient was seen by a Specialist Speech and Language Therapist (SLT) as part of initial assessment, which should normally be before they receive treatment.’ WHO/ ECOG Performance Status – Notes for Users add ‘QPI 10’ Date of First Cancer Treatment – Notes for Users add ‘Where this has subsequently been confirmed at MDT, the date of MDT should be recorded’ Date of Definitive Treatment {Head and Neck Cancer} - Notes for Users add ‘Where this has subsequently been confirmed at MDT, the date of MDT should be recorded’ Date of Definitive Surgery – Notes for Users add ‘QPI 7’ Intent of Definitive Surgery - Notes for Users add ‘QPI 7’ Definitive Operative Procedure 1-9 {Head and Neck Cancer} – Codes and Values table Add D01.1 Pinnectomy - Total excision, D01.2 Pinnectomy – Partial excision, V12.5 O33.1 Lateral Skull Base Resection , S17.1 Y61.5 Reconstruction with Myocutaneous Rectus Abdominis Free Flap, B08.1 Thyroidectomy, total, B08.2 Thyroidectomy, subtotal, B08.3 Hemithyroidectomy, E35.2 Endoscopic resection of lesion of larynx, Y08.4 – Laser destruction of lesion of organ noc, F28.2 – Destruction of lesion of palate, F38.3 – Destruction of lesion of floor of mouth, F38.4 – Destruction of lesion of mouth, nec, V06.1 – Medial Maxillectomy, E14.2 – Intranasal Ethmoidectomy, E14.3 – External Ethmoidectomy, F 10.1 – Full dental clearance (includes dental clearance nec), F10.9 – Dental extraction unspecified (includes extraction of single tooth). Morphology of Tumour - Notes for Users add ‘QPI(s) 8, 10 and for’ Extracapsular Spread – Main Source of Data Item Standard amend ‘(2nd edition) June 2005’ to ‘(November 2013); Definition amend ‘The presence of tumour in soft tissue outside the capsule of an involved node.’ To ‘Evidence of spread of tumour through the full thickness


vii

of the lymph node capsule’ Notes for Users add ‘If the neck dissection is negative with no evidence of involved nodes, code as 96 (Not applicable).’ Date Treatment Started (Radiotherapy) {Head and Neck Cancer} (1-2) – Notes for Users add ‘Required for QPI 7’ Change made outwith review (July 2017) Date of Imaging Completed (Pre-treatment) – Amended definition from ‘This denotes the date the CT and/or MRI of the primary site, lymph node draining and chest were completed. for staging and assessment.’ to ‘This denotes the date the CT or MRI of the primary site and draining lymph nodes and CT chest were completed for staging and assessment.’ Definitive Operative Procedure 1-9 {Head and Neck Cancer} (OPCODE1-9) – Codes and Values table the following OPCS4 codes have added; Y66.8 – Other specified harvest of bone, S18.1 – Distant fasciocutaneous subcutaneous pedicle flap to head or neck, T91.1 - Biopsy of sentinel lymph node NEC, V07.1 - Extensive Excision of bone of face Z94.2 Right side operation, Z94.3 Left side operation Morphology of Tumour – Codes and Values table add 9081/3 Teratocarcinoma mixed embryonal carcinoma and teratoma Changes made outwith review (February 2017) Definitive Operative Procedure (OPCODE 1-9) – Codes and Values table add Y76.6 - Endonasal endoscopic approach to other body cavity (excludes Functional endoscopic nasal surgery and under Salivary Gland – D10.4 Simple mastoidectomy (includes Mastoidectomy NEC) Morphology of Tumour – Codes and Values table add code 9522/3 - olfactory (nasal cavity) neuroblastoma Changes made outwith review (June 2016) Criteria for Inclusion of Patients in Audit - Add ‘Patients with Neuroendocrine tumours’ Morphology of Tumour – Codes and Values table remove the code 8041/3 Small cell carcinoma, NOS from the data item

Revisions following Baseline Review (November 2015) Dataset Date of Oral Assessment (Pre-operative) – Title changed to Date of Oral Assessment (Pre-treatment) Intent of Definitive Surgery – Notes for Users add ‘Required for QPI(s)’ inserted 2, 3; Codes and Values table added ‘03 – Diagnostic Excision Biopsy Only’ Surgical Margins – Notes for Users changed code R0 to 01; Codes and Values table removed all explanatory notes and changed codes R0 to 01, R1 to 02, R2 to 03


viii

Database Specification Date of Oral Assessment (Pre-operative) – Title changed to Date of Oral Assessment (Pre-treatment) Definitive Operative Procedure – Codes and Values table add code E35.3 Endoscopic Destruction of Lesion of Larynx

Revision to Dataset outwith Review (August 2015)

Morphology of Tumour – Codes and Values table add ‘8032/3 Spindle Cell Carcinoma’ and ‘8720/3 Malignant Melanoma, NOS’

Revisions to Dataset outwith 9 month review (June 2015)

Location of Diagnosis – Codes and Values table removed X1010 Not applicable

HPV Status of Tumour – Notes for Users and explanatory notes added ‘A patient with oropharynx cancer with no HPV/P16 tested should be recorded as not recorded. Codes and Values table added 01 Positive, 02 Negative, 03 Not Accessible where there is insufficient tissue to perform HPV/P16 testing, 96 Not Applicable Site not an Oropharynx, 99 Not Recorded.

P16 Status of Tumour - Notes for Users ass ‘A patient with oropharynx cancer with no HPV/P16 tested should be recorded as not recorded’. Codes and Values tables added 01 Positive, 02 Negative, 03 Not Accessible.

HPV Status of Tumour - moved from Pre-treatment Imaging and Staging Investigations to Pathological Details P16 Status of Tumour – Moved from Pre-treatment Imaging and Staging Investigations to Pathological Details TNM Tumour Classification (Final) {Head and Neck Cancer} - Notes for users add “The original clinical/radiological staging would have precedence in patients who have neo-adjuvant therapy.” TNM Nodal Classification (Final) {Head and Neck Cancer} – Notes for Users add “The original clinical/radiological staging would have precedence in patients who have neo-adjuvant therapy.” TNM Metastatis Classification (Final) {Head and Neck Cancer} – Notes for Users add ‘The original clinical/radiological staging would have precedence in patients who have neo-adjuvant therapy.’

Date of Definitive Surgery – Notes for Users removed required for QPI 3 and 12 Intent of Definitive Surgery and removed required for QPI 3 and changed 12 to 11

Definitive Operative Procedure 1-9 {Head and Neck Cancer} - Removed required for QPI 10. Codes and Values table add B01.2 Trans-sphenoidal hypophysectomy, Y59.6 Lower leg flap of skin and fascia, S18.3 Distant fasciocutaneous flap to head or neck, Y24.1 Microvascular reconstruction of organ, S60.8 Other operations on skin - other specified, Y59.8 Harvest of flap of skin and fascia - other specified.


ix

Date Treatment Started (Radiotherapy) {Head and Neck Cancer} (1-2) - Notes for Users removed required for QPI(s) 3, 10, 11

Date Treatment Complete (Radiotherapy) {Head and Neck Cancer} (1-2) – Notes for Users amended 12 to 11

Radiotherapy Course Type – Notes for Users removed required for QPI 12 amended explanatory notes in code 06 – Chemoradiotherapy – from Radical radiotherapy given in combination with chemotherapy, either concurrent or sequentially’ to ‘Radical radiotherapy given in combination with concurrent chemotherapy’.

Date Treatment Started Systemic Anti-Cancer therapy (SACT) {Cancer} 1-2 – Notes for Users amended from 11 to 12

Type of Systemic Anti-Cancer Therapy – Notes for Users removed QPI 12, amended explanatory notes in code 05 – Chemoradiotherapy – removed ‘Can be sequential or concurrent’ added ‘Radical radiotherapy given in combination with concurrent chemotherapy’ Morphology of Tumour – Codes and Values table add ‘8502/3 Mammary analogue secretory carcinoma’

Date of Death – Notes for Users removed QPI 3 & 12 and keep QPI 11.

Revisions to Dataset following 9 Month Review (March 2015)

Person Given Name – Title updated to PATSFNAME to reflect validations

Person Sex at Birth – Codes and Values table added ‘0’ to codes

Location of Diagnosis {Cancer} – Notes for Users removed ‘provisionally’ from last paragraph and added the following text “and would retain responsibility for collection of the patient record.”

Date of Diagnosis {Cancer} – Notes for Users removed ‘confirms’ and added the following text in the first paragraph “gives a provisional diagnosis of head and neck cancer, whether by cytology, histology or other methods and is subsequently confirmed. Added In circumstances where there is no cytological or histological diagnosis the date of clinical decision of cancer diagnosis should be recorded.”

Site of Origin of Primary Tumour {Cancer} – Field length changed from 9 to 7, Codes and Values table code C32.3A(2) changed to C32.3A2 TNM Tumour Classification (Clinical) {Head and Neck Cancer} –Title changed from (Clinical) to (Final). Definition removed ‘as determined by pre-treatment investigations (not pathological)’; removed ‘Clinical TNM is derived from all the clinical, radiological and biochemical results prior to treatment. The TNM system is base on the assessment of three components (T tumour, N node and M metastases) and the addition of numbers after the letter components to indicate the extent of the malignant disease. Notes for Users add This is a pre/non-operative classification as defined by the Multidisciplinary Team Meeting (MDT) based on best knowledge. This may be at any MDT meeting up until first treatment.’


x

Added “Final TNM staging is a clinical/radiological/pathological classification of the size and extent of the patient’s cancer. This represents the poorest (most advanced) stage of disease evident, as agreed by the MDT and informed by all available clinical, radiological and histopathological information. For patients undergoing surgery, the final TNM stage can be recorded from that agreed at the post-operative surgical MDT” TNM Nodal Classification (Clinical {Head and Neck Cancer} – Title changed from (Clinical) to (Final); Definition removed ‘as determined by pre-treatment investigations (not pathological)’; removed ‘Clinical TNM is derived from all the clinical, radiological and biochemical results prior to treatment. The TNM system is base on the assessment of three components (T tumour, N node and M metastases) and the addition of numbers after the letter components to indicate the extent of the malignant disease. This is a pre/non-operative classification as defined by the Multidisciplinary Team Meeting (MDT) based on best knowledge. This may be at any MDT meeting up until first treatment.’ Added “Final TNM staging is a clinical/radiological/pathological classification of the size and extent of the patient’s cancer. This represents the poorest (most advanced) stage of disease evident, as agreed by the MDT and informed by all available clinical, radiological and histopathological information. For patients undergoing surgery, the final TNM stage can be recorded from that agreed at the post-operative surgical MDT” TNM Metastases Classification (Clinical) {Head and Neck Cancer} – Title changed from (Clinical) to (Final); Definition remove ‘as determined by pre-treatment investigations (not pathological)’; removed ‘Clinical TNM is derived from all the clinical, radiological and biochemical results prior to treatment. The TNM system is base on the assessment of three components (T tumour, N node and M metastases) and the addition of numbers after the letter components to indicate the extent of the malignant disease. This is a pre/non-operative classification as defined by the Multidisciplinary Team Meeting (MDT) based on best knowledge. This may be at any MDT meeting up until first treatment.’ Added “Final TNM staging is a clinical/radiological/pathological classification of the size and extent of the patient’s cancer. This represents the poorest (most advanced) stage of disease evident, as agreed by the MDT and informed by all available clinical, radiological and histopathological information. For patients undergoing surgery, the final TNM stage can be recorded from that agreed at the post-operative surgical MDT”. Codes and values table for Pharynx – Nasopharynx added code MX Regional metastasis cannot be assessed, M0 No distant metastasis, M1 Distant metastasis, 96 Not applicable, 99 Not recorded] Type of First Cancer Treatment – Notes for Users added “but if MDT states that the tonsillectomy is the definitive treatment record type of first cancer treatment as surgery.” Date of First Cancer Treatment – Notes for Users added “Tonsillectomy is for diagnostic purposes only and should not be recorded as first treatment, but if MDT states that the tonsillectomy is the definitive treatment record as Date of First Cancer Treatment.” Date of Definitive Treatment {Head and Neck Cancer} – Notes for Users added “If MDT states that a tonsillectomy is the definitive treatment this is the date that should be recorded” Intent of Surgery – Title changed to “Intent of Definitive Surgery” Definitive Operative Procedure 1-9 {Head and Neck Cancer} – Codes and Values table added F38.8 Extirpation of lesion of other part of mouth – other specified, F10.4 Extraction of multiple teeth NEC, S21.3 Hair bearing flap of skin to nasolabial area, D02.1 Excision of lesion of external ear, E36.9 Diagnostic endoscopic examination of larynx, unspecified. E02.8 Plastic operations on nose - Other specified, E49.1 Diagnostic fibreoptic endoscopic examination of lower respiratory tract and biopsy of lesion of lower respiratory tract F23.8 Extirpation of lesion of tongue, F26.8 Other operations on tongue - Other specified


xi

T85.9 Blocked dissection of lymph nodes – unspecified, V19.8 Other operations on mandible - Other specified, Z94.1 Bilateral, Z94.4 Unilateral Morphology of Tumour – Codes and Values table added 8746/3 - Mucosal lentiginous melanoma Intensity-Modulated Radiation Therapy (IMRT) – Notes for Users added “this includes VMAT (eg. Rapid ARC)” Type of Systemic Anti-Cancer Therapy (SACT) 1-2 {Head and Neck Cancer} – Codes and Values table add code 08 – Chemotherapy HPV Status of Tumour – add new Data Item P16 Status of Tumour – add New Data Item Database Specification Site of Origin of Primary Tumour {Cancer} - Field Size changed from 9 to 7 HPV Status of Tumour – add New data Item Field Name: HPVSTATUS, Field Type: Integer, Field Length: 2. P16 Status of Tumour data – add new Data Item Field Name: P16STATUS, Field Type: Integer, Field Length: 2. TNM Tumour Classification (Clinical) {Head and Neck Cancer} - Title changed to TNM Tumour Classification (Final) {Head and Neck Cancer}; Field Name changed from CT to cT TNM Nodal Classification (Clinical) {Head and Neck Cancer} - Title changed to TNM Nodal Classification (Final) {Head and Neck Cancer}; Field Name changed from CN to cN TNM Metastases Classification (Clinical) {Head and Neck Cancer} - Title changed to TNM Metastases Classification (Final) {Head and Neck Cancer}; Field Name changed from CM to cM Intent of Surgery - Title changed to Intent of Definitive Surgery Definitive Operative Procedure 1-9 {Head and Neck Cancer} - Field Type changed from Integer to Characters

Revisions to Dataset outwith review (November 2014)

Definitive Operative Procedure 1-9 {Head and Neck Cancer} – Codes and Values table add S17.3 - Distant Myocultaneous to Head or Neck NEC and S36.1 Full Thickness Autograph to Head or Neck

Morphology of Tumour - Codes and Values table add 9290/3 Ameloblastic odontosarcoma (Ameloblastic fibrodentinosarcoma, Ameloblastic fibro-odontosarcoma), 9310/3 Ameloblastoma, malignant (Adamantinoma, malignant), 9330/3 Ameloblastic fibrosarcoma (Ameloblastic sarcoma, Odontogenic fibrosarcoma), 9342/3 Odonteogenic carcinosarcoma. Change in version number due to validation changes


xii

Revisions to Dataset outwith review (September 2014)

Dataset

Definitive Operative Procedure 1-9 {Head and Neck Cancer) – Field name added OPCODE6-OPCODE9, Amendment to Notes for Users, Codes and Values table Diagnostic Procedure codes deleted. Amendment of codes for Creation of pharyngostome from code E28.1 to E23.8 Y16.1; Reconstruction mouth- with primary closure code will change from code F39.1 to F39.8 and Laser excision lesion hypopharynx and Laser excision oropharynx are combined with code E24.2 Y08.2

Database Specification

Definitive Operative Procedure 1-9 {Head and Neck Cancer) - Field names added OPCODE6-OPCODE9

Revisions to Dataset outwith review (July 2014)

Site of Origin of Primary Tumour (SITE) – Notes for Users added to indicate which ICD-10 subcategories do not map to a specific TNM stage. Enhancement to code descriptions and addition of Bone tables to TNM Tumour (cT), Nodal (cN) and Metastases (cM) Classifications (Clinical), Date of Definitive Treatment {Head and Neck Cancer} – add new Data Item Database Specification Date of Definitive Treatment {Head and Neck Cancer} – add new Data Item Field Name: DEFTREATDATE, Field Type: Date, Field Length: 10.


xiii

CRITERIA FOR INCLUSION OF PATIENTS IN AUDIT To facilitate national comparisons the same patients must be audited throughout Scotland. The following eligibility criteria have been documented for this purpose. Include:

All patients with a confirmed new primary invasive cancer of the head and neck (ICD-10 C00.3, C00.4, C00.5, C01-C13, C14.0, C14.8, C30-C32, or C76) and (C41.0 or C41.1 where morphology of tumour is 9270/3)

All patients who have had a previous primary malignancy of any site or a concurrent primary malignancy of another site

A separate record should be entered for each tumour of distinct origin. However, if there are multiple tumours within the head and neck, which have the same histology, record this as one tumour.

Exclude:

Patients where the origin of the primary is uncertain

Patients with tumour type sarcoma, lymphoma, melanoma (except mucosal), skin (including pinna)

Patients with neuroendocrine tumours

Patients with recurrent disease (as opposed to a new primary)

Patients with metastases in the head and neck originating from another primary site

Patients with carcinoma in situ, non-invasive tumours, or dysplasia

Patients, at date of diagnosis, under 16 years of age i.e. up to 15 years 364 days

Patients where the only record of their cancer is from a death certificate (DCO)

Patients with normal residence outwith Scotland

Patients whose definitive cancer treatment was privately funded or undertaken outwith NHS Scotland.

NB:

Only treatments as part of the initial treatment plan should be recorded.

Patients treated within 6 months of a patient initially refusing further investigation or whose initial treatment is ‘Watch and Wait’ can also be recorded.


xiv

DOWNLOAD FORMAT

To assist with downloading data to ISD for the National Quality Assurance Programme and other agreed activities, all sites should be able export data according to the following specification.

DATABASE SPECIFICATION

Data Item Field Name Field Type Size Page

Section 1: Demographic Items 1

Person Family Name (at Diagnosis) PATSNAME Characters 35 2 Person Given Name PATSFNAME Characters 35 3 Patient Postcode (at Diagnosis) PATPCODE Characters 8 4

Date of Birth DOB Date (DD/MM/CCYY)

10 5

Person Sex at Birth SEX Integer 2 6 CHI Number CHINUM Characters 10 7 Section 2: Pre-treatment Imaging & Staging Investigations

8

Location of Diagnosis {Cancer} HOSP Characters 5 9

Date of Diagnosis {Cancer) DIAGDATE Date (DD/MM/CCYY)

10 10

Site of Origin of Primary Tumour {Cancer}

SITE Characters 7 11

Date of Histological/Cytological Diagnosis {Cancer}

HDIAG Date (DD/MM/CCYY)

10 14

Imaging Completed CTINVEST Integer 2 15

Date of Imaging Completed CTDATE Date (DD/MM/CCYY)

10 16

Date Imaging Reported CTREPORTDATE Date (DD/MM/CCYY)

10 17

Date Discussed by Care Team (MDT) MDTDATE Date (DD/MM/CCYY)

10 18

Smoking SMOKE Integer 2 19 Smoking Cessation SMOKCESS Integer 2 20 Date Offered Referral for Smoking Cessation

SMOKCENDATE Date (DD/MM/CCYY)

10 21

Oral Assessment Required ORALREQ Integer 2 22

Date of Oral Assessment DENSCREEN Date (DD/MM/CCYY)

10 23

Nutritional Screening NUTSCREEN Integer 2 24

Date of Nutritional Screening NUTSCREENDATE Date (DD/MM/CCYY)

10 25

Specialist Speech and Language Therapist Access

SLTASSESS Integer 2 26

Date of Specialist Speech and Language Therapist Access

SLTDATE Date (DD/MM/CCYY)

10 27

TNM Tumour Classification (Final) {Head and Neck Cancer}

cT Characters 3 28

TNM Nodal Classification (Final) {Head and Neck Cancer}

cN Characters 3 32

TNM Metastases Classification (Final) {Head and Neck Cancer}

cM Characters 2 36

WHO/ECOG Performance Status PSTATUS Integer 1 38


xv

Type of First Cancer Treatment FIRSTTREATTYPE Integer 2 39

Date of First Cancer Treatment FIRSTTREATDATE Date (DD/MM/CCYY)

10 40

Date of Definitive Treatment {Head and Neck Cancer}

DEFTREATDATE Date (DD/MM/CCYY)

10 40

Section 3: Surgery 42

Location Code {Cancer Surgery} HOSPSURG Characters 5 43 Consultant in charge of Surgery SURGCON Characters 20 44

Date of Definitive Surgery SURGDATE Date (DD/MM/CCYY)

10 45

Intent of Definitive Surgery OPINTENT Characters 2 46 Definitive Operative Procedure 1-9 {Head and Neck Cancer}

OPCODE1 Characters

10 47

Definitive Operative Procedure 1-9 {Head and Neck Cancer}

OPCODE2 Characters

10 47


OPCODE3 Characters

10 47


OPCODE4 Characters

10 47


OPCODE5 Characters

10 47


OPCODE6 Characters

10 47


OPCODE7 Characters

10 47


OPCODE8 Characters

10 47


OPCODE9 Characters

10 47

Section 4: Pathological Details 52

Morphology of Tumour MORPHOL Characters 6 53

HPV Status of Tumour HPVSTATUS Integer 2 55 P16 Status of Tumour P16STATUS Integer 2 56 Surgical Margins SURGMARG Characters 4 57 Extracapsular Spread EXCAPSPREAD Integer 2 58 Section 5: Oncology 59

Location Code 1-2 {Oncology Treatment} HOSPNONSURG1 Characters 5 60 Location Code 1-2 {Oncology Treatment} HOSPNONSURG2 Characters 5 60 Date Treatment Started (Radiotherapy) {Head and Neck Cancer} (1-2)

RSTARTDATE1 Date (DD/MM/CCYY)

10 61

Date Treatment Started (Radiotherapy) {Head and Neck Cancer} (1-2)

RSTARTDATE2 Date (DD/MM/CCYY)

10 61

Date Treatment Completed (Radiotherapy) {Head and Neck Cancer} (1-2)

RCOMPDATE1 Date (DD/MM/CCYY)

10 62

Date Treatment Completed (Radiotherapy) {Head and Neck Cancer} (1-2)

RCOMPDATE2 Date (DD/MM/CCYY)

10 62

Radiotherapy Course Type {Head and Neck Cancer} (1-2)

RCOURSETYPE1 Integer 2 63

Radiotherapy Course Type {Head and Neck Cancer} (1-2)

RCOURSETYPE2 Integer 2 63

Intensity-Modulated Radiation Therapy IMRT Integer 2 64


xvi

(IMRT) Date Treatment Started Systemic Anti-Cancer Therapy (SACT) {Cancer} 1-2

CHEMDATE1 Date (DD/MM/CCYY)

10 65

Date Treatment Started Systemic Anti-Cancer Therapy (SACT) {Cancer} 1-2

CHEMDATE2 Date (DD/MM/CCYY)

10 65

Date Treatment Completed Systemic Anti-Cancer Therapy (SACT) {Cancer} 1-2

CHEMENDATE1 Date (DD/MM/CCYY)

10 66

Date Treatment Completed Systemic Anti-Cancer Therapy (SACT) {Cancer} 1-2

CHEMENDATE2 Date (DD/MM/CCYY)

10 66

Type of Systemic Anti-Cancer Therapy (SACT) 1-2 {Head and Neck Cancer}

CHEMTYPE1 Integer 2 67

Type of Systemic Anti-Cancer Therapy (SACT) 1-2 {Head and Neck Cancer}

CHEMTYPE2 Integer 2 67

Section 6: Clinical Trial Entry 68 Patient Entered into Clinical Trial {Cancer}

TRIAL Integer 2 69

Section 7: Death Details 70

Date of Death DOD Date (DD/MM/CCYY)

10 71


1

Section 1: Demographic Items


2

Person Family Name (at Diagnosis) Common Name(s): Surname, Family name Main Source of Data Item Standard: Government Data Standards Catalogue

Definition: That part of a person's name which is used to describe family, clan, tribal group,

or marital association at the time of diagnosis. Field Name: PATSNAME Field Type: Characters Field Length: 35

Notes for Users: Main Source of Standard: Government Data Standards Catalogue The surname of a person represents that part of the name of a person indicating the family group of which the person is part. It should be noted that in Western culture this is normally the latter part of the name of a person. However, this is not necessarily true of all cultures. This will, of course, give rise to some problems in the representation of the name. This is resolved by including the data item Name Element Position in the structured name indicating the order of the name elements. From SMR Definitions and Codes

http://webarchive.nationalarchives.gov.uk/20120404204735/http:/umbr4.cabinetoffice.gov.uk/govtalk/schemasstandards/e-gif/datastandards/person_information/person_name/person_family_name.aspx


3

Person Given Name

Common Name(s): Forename, Given Name, Personal Name Main Source of Data Item Standard: Government Data Standards Catalogue Definition: The forename or given name of a person.

Field Name: PATSFNAME Field Type: Characters Field Length: 35 Notes for Users: Main Source of Standard: Government Data Standards Catalogue The first forename of a person represents that part of the name of a person which after the surname is the principal identifier of a person. Where the person's preferred forename is not the first forename, the related data item 'Preferred Forename' should be used to indicate this.

http://webarchive.nationalarchives.gov.uk/20120404204736/http:/umbr4.cabinetoffice.gov.uk/govtalk/schemasstandards/e-gif/datastandards/person_information/person_name/person_given_name.aspx


4

Patient Postcode (at Disgnosis) Main Source of Data Item Standard: Government Data Standards Catalogue Definition: Postcode of patient's usual place of residence on the date of diagnosis Field Name: PATPCODE Field Type: Characters Field Length: Maximum 8

Notes for Users: Postcode is included in BS7666 Address (GDSC) but there is also a separate Post Code standard which will be populated from BS7666 Address Post Code. This item can be derived from the date of diagnosis and patient address at that time Related Data Item(s): Date of Diagnosis {Cancer}

http://webarchive.nationalarchives.gov.uk/20120404201641/http:/umbr4.cabinetoffice.gov.uk/govtalk/schemasstandards/e-gif/datastandards/address/postcode.aspx


5

Date of Birth Main source of Data Item Standard: Government Data Standards Catalogue Definition: The date on which a person was born or is officially deemed to have been born, as recorded on the Birth Certificate. Field Name: DOB Field Type: Date (DD/MM/CCYY) Field Length: 10 Notes for Users: If the patient's date of birth is recorded differently on different occasions, the most frequently used or latest date should be recorded. The patient's full date of birth inclusive of the century should be recorded. The format should be DD/MM/CCYY e.g. 01/02/2011. Related Data Item(s): CHI Number

http://webarchive.nationalarchives.gov.uk/20120404201701/http:/umbr4.cabinetoffice.gov.uk/govtalk/schemasstandards/e-gif/datastandards/person_information/person_birth_date.aspx


6

Person Sex at Birth Common Name(s): Sex at Birth Main Source of Data Item Standard of Standard: Derived from the nearest equivalent Government Data Standards Catalogue standard ‘Person Gender at Registration’ Definition: This is a factual statement, as far as is known, about the phenotypic (biological) sex of the person at birth Field Name: SEX Field Type: Integer Field Length: 2 Notes for Users: A person’s sex has clinical implications, both in terms of the individual’s health and the health care provided to them. In the majority of cases, the phenotypic (biological) sex and genotypic sex are the same and the phenotypic sex is usually easily determined. In a small number of cases, accurate determination of genotype may be required Codes and Values: Code Value Explanatory Notes

01 Male

02 Female

09 Not specified/Indeterminate Where it has not been possible to determine if the person is male or female at birth, e.g. intersex / hermaphrodite.

99 Not recorded

Related Data Item(s): CHI Number


7

CHI Number Main Source of Data Item Standard of Standard: Scottish Executive Health Department. Definition: The Community Health Index (CHI) is a population register, which is used in Scotland for health care purposes. The CHI number uniquely identifies a person on the index. Field Name: CHINUM Field Type: Characters Field Length: 10 Notes for Users: The Community Health Index (CHI) is a computer based population index whose main function at present is to support primary care services. CHI contains details of all Scottish residents registered with a General Practitioner and was originally envisaged and implemented as a population-based index to help assess the success of immunisation and screening programmes. It is therefore closely integrated with systems for child health, cervical cytology and breast screening call and recall…It is intended that this number, the Scottish equivalent of the new NHS number in England and Wales, should become the Unique Patient Identifier throughout the NHS in Scotland. From Designed to Care - Scottish Office The CHI number is a unique numeric identifier, allocated to each patient on first registration with the system. The CHI number is a 10-character code consisting of the 6-digit date of birth (DDMMYY), two digits, a 9th digit which is always even for females and odd for males and an arithmetical check digit. (ISD, Information Services, NHS National Services Scotland) The CHI number should always be used to identify a patient. However, Health record identifiers, such as hospital numbers in Patient Administration Systems (PAS), may be used locally, in conjunction with the CHI number or in the absence of the CHI number, to track patients and their records.

Although there may be no number when a patient presents for treatment, there must be an allocation at some point in the episode of care as CHI is mandatory on all clinical communications. Non-Scottish patients and other temporary residents can have a CHI number allocated if required but it is envisaged that future development may allow the identifying number used in other UK countries to be used in Scotland. Related Data Item(s): Date of Birth Person Sex at Birth


8

Section 2: Pre-treatment Imaging & Staging Investigations


9

Location of Diagnosis {Cancer} Main Source of Data Item Standard: The National Audit Cancer Datasets developed by the regional Cancer Networks supported by Information Services. Definition: The patient's hospital of investigation in which the diagnosis of cancer was first made. Field Name: HOSP Field Type: Characters Field Length: 5 Notes for Users: Required for analysis purposes and clarifying responsibility for data collection. Details of location codes for hospitals can be found in the "Definitions and Codes for the NHS in Scotland" manual produced by ISD Scotland. Location codes for hospitals are five character codes maintained by ISD Scotland and the General Register Office (Scotland). The first character denotes the health board, the next three are assigned and the fifth denotes the type of location (H=hospital) e.g. A111H=Crosshouse Hospital G107H=Glasgow Royal Infirmary X9999=Not recorded If a patient was diagnosed at one hospital but transferred to another for confirmation of the diagnosis only e.g. biopsy, then returns to the original hospital, the first hospital should be recorded as the Location of diagnosis and would retain responsibility for collection of the patient record Related Data Items: Date of Diagnosis {Cancer}


10

Date of Diagnosis {Cancer} Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services. Definition: The date on which the cancer was first diagnosed whether by histology, cytology, immunology, cytogenetics or clinical (including radiological) methods. Field Name: DIAGDATE Field Type: Date (DD/MM/CCYY) Field length: 10 Notes for Users: Required for national survival analysis and national comparative analysis. Required for QPI(s) 1–11. The date recorded is the date of the first investigative procedure that gives a provisional diagnosis of head and neck cancer, whether by cytology, histology or other methods and is subsequently confirmed. In circumstances where there is no cytological or histological diagnosis the date of clinical decision of cancer diagnosis should be recorded. If the exact date is not documented, record as 09/09/1900. The date recorded is the date the procedure was performed, not the date the report was issued. Related Data Items: Location of Diagnosis {Cancer} Date of Histological/Cytological Diagnosis {Cancer}


11

Site of Origin of Primary Tumour {Cancer} Main Source of Data Item Standard: The World Health Organisation (WHO) and the Cancer Registration New Data definitions for Socrates (August 1999 Version 8.0).

Definition: The anatomical site of origin of the primary tumour according to the International Classification of Diseases (ICD-10). Field Name: SITE Field Type: Characters ICD-10 Field length: 7 Notes for Users: Required for QPI(s): 1-11 For ICD-10, tumours should be assigned to the subcategory that includes the point of origin of the tumour. A tumour that overlaps the boundaries of two or more subcategories and whose point of origin cannot be determined should be classified as subcategory ‘8’. It should be noted that this subcategory should only be used where it is impossible to identify the specific site of origin of the tumour. ICD-10 codes with subcategory ‘9’ (unspecified) should be avoided whenever possible as many codes listed ending with ‘9’ will not map to a specific TNM stage. There are also some other ICD-10 codes listed which do not map to a specific TNM stage. All ICD-10 codes which do not map to a specific TNM stage have their values listed with an * below. If in doubt clarify the ICD-10 subcategory code with the relevant clinician. If C41 is recorded then Morphology of Tumour should be recorded as M9270/3. Codes and Values: ICD-10 Code

Value

Oral Cavity

C00.3 Lip, inner aspect, mucosa of upper

C00.4 Lip, inner aspect, mucosa of lower

C00.5 Lip, inner aspect, unspecified

C02.0 Tongue, dorsal surface, anterior 2/3

C02.1 Tongue, lateral border, tip of tongue

C02.2 Tongue, ventral, inferior surface

C02.3 Anterior parts of tongue, part unspecified

C02.8 Overlapping lesion of tongue

C02.9 Tongue, unspecified

C03.0 Upper gum (including alveolar ridge and gingival)

C03.1 Lower gum (including alveolar ridge and gingival)

C03.9 Gum, unspecified

C04.0 Anterior floor of mouth

C04.1 Lateral floor of mouth

C04.8 Overlapping lesion of floor of mouth

C04.9 Floor of mouth, unspecified

C05.0 Hard palate

C05.8 Overlapping lesion of palate

C05.9 Palate, unspecified

C06.0 Cheek mucosa

C06.1 Mouth, vestibule (buccal sulcus and labial)


12

C06.2 Retromolar trigone

C06.8 Overlapping lesion of other and unspecified parts of mouth

C06.9 Mouth, unspecified

Salivary Glands

C07.X Parotid gland

C08.0 Submandibular gland

C08.1 Sublingual gland

C08.8 Overlapping lesion of major salivary glands

C08.9 Major salivary glands, unspecified

Oropharynx

C01.X Base of tongue

C02.4 Lingual tonsil

C05.1 Soft palate

C05.2 Uvula

C09.0 Tonsillar fossa

C09.1 1C

Tonsillar pillar (anterior) (posterior)

C09.8 Overlapping lesion of tonsil

C09.9 Tonsil, unspecified (faucial, palatine)

C10.0 Vallecula

C10.1 Anterior surface of epiglottis

C10.2 Lateral wall of oropharynx

C10.3 Posterior wall of oropharynx

C10.4 Branchial cleft*

C10.8 Overlapping lesion of oropharynx*

C10.9 Oropharynx, unspecified*

Nasopharynx

C11.0 Superior wall of nasopsharynx (roof)

C11.1 Posterior wall of nasopsharynx (adenoid, pharyngeal tonsil) C11.2 Lateral wall of nasopsharynx (fossa of rosenmuller, opening of auditory tube, pharyngeal recess)

C11.3 Anterior wall of nasopharynx (floor, nasopharyngeal surface of soft palate, posterior margin of choana – septum)

C11.8 Overlapping lesion of nasopharynx

C11.9 Nasopharynx, unspecified

Hypopharynx

C12.X Pyriform sinus

C13.0 Postcricoid region

C13.1 Ayrepiglottic fold, hypopharyngeal aspect

C13.2 Posterior wall of hypopharynx

C13.8 Overlapping lesion of hypopharynx

C13.9 Hypopharynx, unspecified; Hypopharyngeal wall NOS; Laryngopharynx

Other and ill-defined sites in lip, oral cavity and pharynx

C14.0 Pharynx unspecified*

C14.8 Overlapping lesion of lip, oral cavity and pharynx*

Nasal cavity and middle ear

C30.0 Nasal cavity; Cartilage; concha; internal; septum; vestibule

C30.1 Middle ear; Eustachian tube; inner ear; mastoid air cells*


13

Accessory sinuses C31.0 Maxillary sinus

C31.1 Ethmoidal sinus

C31.2 Frontal sinus*

C31.3 Sphenoidal sinus*

C31.8 Overlapping lesion of accessory sinuses*

C31.9 Accessory sinus, unspecified*

Larynx

C32.0 Glottis; intrinsic larynx;

C32.0A True vocal cords

C32.0B Anterior commissure

C32.0C Posterior commissure

C32.1 Supraglottis; extrinsic larynx; posterior (laryngeal) surface of epiglottis; ventricular bands

C32.1A Suprahyoid epiglottis; (tip, laryngeal surface)

C32.1B Aryepiglottic fold laryngeal aspect

C32.1D Infrahyoid epiglottis

C32.1E False vocal cords

C32.2 Subglottis

C32.3 Laryngeal cartilage*

C32.3A Arytenoid cartilage*

C32.3A2 Laryngeal cartilage, Arytenoid cartilage*

C32.3B Cricoid cartilage*

C32.3C Thyroid cartilage*

C32.8 Overlapping lesion of larynx*

C32.9 Larynx, unspecified*

Bones

C41.0 Maxilla

C41.1 Mandible

Ill-defined sites

C76.0 Ill-defined site, head face and neck; cheek NOS; nose NOS*

C99.X Not recorded*

Related Data Items:


14

Date of Histological/Cytological Diagnosis {Cancer} Main Source of Data Item Standard: The National Audit Cancer Datasets developed by the regional Cancer Networks supported by Information Services. Definition: The date on which the head and neck cancer was first diagnosed whether by histology or cytology. Field Name: HDIAG Format: Date (DD/MM/CCYY) Field length: 10 Notes for Users: Required for QPI: 1 There may be more than one biopsy/histology report. If there is a discrepancy between reports of cytology and histology, the histology report should be recorded as the definitive report if prior to treatment. If no cytological or histological diagnosis was made, record as 10/10/1900 (Not applicable) If the exact date is not documented, record as 09/09/1900 (Not recorded). The date recorded is the date the procedure was performed, not the date the report was issued. Related Data Items: Date of Diagnosis {Cancer}


15

Imaging Completed Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by the Information Services. Definition: A record to show that patients with head and neck cancer have complete computed tomography (CT) and/or Magnetic resonance imaging (MRI) of the primary site and draining lymph nodes with CT of the chest. Field Name: CTINVEST Field Type: Integer Field Length: 2 Notes for Users: Required for QPI: 2. A CT and/or MRI of the primary site, draining lymph node and a CT of the chest should be carried out for staging and assessment. The primary site, draining lymph node and chest may be assessed separately however, if all three are assessed then select ‘01’. Codes and Values: Code Value Explanatory Notes

01 Yes Primary site, draining lymph nodes and chest assessed

02 No Primary site, draining lymph nodes and chest assessed not assessed

95 Patient declined investigations

96 Not applicable

99 Not recorded

Related Data Item(s): Date of Imaging Completed


16

Date of Imaging Completed Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services. Definition: This denotes the date the CT or MRI of the primary site and draining lymph nodes and CT chest were completed for staging and assessment. Field Name: CTDATE Field Type: Date (DD/MM/CCYY). Field Length: 10 Notes for Users: Required for QPI: 2. A CT and/or MRI scan should be completed and reported by the multi-disciplinary team (MDT) for patients with head and neck cancer who are being considered for treatment with curative intent. If the patient has more than one CT and/or MRI scan the date of the final procedure for staging and assessment’ should be recorded.. If the exact date of the CT/MRI Scan is not documented, record as 09/09/1900. If CT/MRI scan was not performed, e.g. patient refused record as 10/10/1900 (not applicable). Related Data Item(s): Imaging Completed


17

Date Imaging Reported Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services. Definition: This denotes the date the CT or MRI for staging and assessment is reported. Field Name: CTREPORTDATE Field Type: Date (DD/MM/CCYY). Field Length: 10 Notes for Users: Required for QPI: 2. If more than one CT and/or MRI scan is undertaken the date of the report of the final procedure should be recorded to align with date of investigation. If the exact date of the CT/MRI scan report is not documented record as 09/09/1900 (Not Recorded). If CT/MRI scan was not performed, record as 10/10/1900 (Not applicable). Related Data Item(s): Imaging Completed Date of Imaging Completed


18

Date Discussed by Care Team (MDT) Common name: Date discussed by multidisciplinary team (MDT) {Cancer} Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services. Definition: This denotes the date the care team meeting was held to discuss the management of the patient's care. Field Name: MDTDATE Field Type: Date (DD/MM/CCYY) Field Length: 10 Notes for Users: Required for QPI: 3 A cancer multidisciplinary care team may include surgeons, oncologists, radiologists, pathologists, nurses, speech language therapists, physiotherapists and others relevant to the treatment of a specific cancer. The team meets on a regular basis to discuss optimal patient management. Documentation of the discussion should be included in the case-note or other formal documentation. The first MDT meeting date will be recorded. If the patient has not been discussed by the MDT record as 10/10/1900 (Not applicable). If the date of the MDT meeting is unknown record as 09/09/1900 (Not recorded)

Related data Item(s):


19

Smoking Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services. Definition: This denotes if the patient is an active smoker at the time of referral (GP or other) for head and neck cancer. Field Name: SMOKE Field Type: Integer Field Length: 2 Notes for Users: Required for QPI: 4 A smoker is a person who is actively smoking at the time of referral to the head and neck services leading to a diagnosis of head and neck cancer. Codes and Values: Code Value

01 Yes

02 No

99 Not recorded

Related data Item(s): Smoking Cessation Date Offered Referral for Smoking Cessation


20

Smoking Cessation Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services. Definition: This denotes whether the patient has been offered referral to smoking cessation. Field Name: SMOKCESS Field Type: Integer Field Length: 2 Notes for Users: Required for QPI: 4 Codes and Values: Code Value Explanatory Notes

01 Yes

02 No

96 Not applicable E.g. patient is a non smoker or died before being referred.

99 Not recorded



21

Date Offered Referral for Smoking Cessation Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services. Definition: This denotes the date the patient is offered referral for smoking cessation. Field Name: SMOKCENDATE Field Type: Date (DD/MM/CCYY) Field Length: 10 Notes for Users: Required for QPI: 4 This is the date the patient is first offered referral for smoking cessation, which should normally be before they receive their first treatment. Where referral to smoking is discussed at the clinic visit, the date of the clinic visit should be documented. If the exact date is not documented, record as 09/09/1900. If the patient was not offered referral smoking cessation, e.g. where not applicable, record as 10/10/1900 (not applicable). Related data Item(s): Smoking Smoking Cessation


22

Oral Assessment Required Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services. Definition: This denotes whether the patient requires oral assessment as agreed by Restorative Dentistry and the MDT. Field Name: ORALREQ Field Type: Integer Field Length: 2 Notes for Users: Required for QPI: 5 This refers to the consideration of whether oral assessment is required before the patient receives surgery, radiotherapy and / or chemotherapy’ If the patient does not require oral assessment and this has been agreed by Restorative Dentistry and the MDT, record as 02 (No). If the outcomes of discussion between Restorative Dentistry and the MDT have not been documented, record as 99 (Not recorded). If the decision for oral assessment has not been agreed by both Restorative Dentistry and the MDT, record as 96 (Not applicable). Codes and Values: Code Value Explanatory Notes

01 Yes Agreed by Restorative Dentistry and MDT that the patient does require assessment.

02 No Agreed by Restorative Dentistry and MDT that the patient does not require assessment.

96 Not applicable Decision not been agreed by Restorative Dentistry and MDT

99 Not recorded Unknown


23

Date of Oral Assessment Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services. Definition: This denotes the date when the patient has had dental assessment. Field Name: DENSCREEN Field Type: Date (DD/MM/CCYY) Field Length: 10 Notes for Users: Required for QPI: 5 Within the care spell this is the date of the first oral assessment by a dentist, which contributes to the preparation for treatment. Record the date of the patient’s first assessment after referral and not the assessment that led to referral. If the exact date of the oral assessment is not documented, record as 09/09/1900. If oral screening was not performed, e.g. patient refused, record as 10/10/1900 (not applicable). Related data Item(s):


24

Nutritional Screening Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services. Definition: This denotes whether the patient underwent nutritional screening as part of initial assessment. Field Name: NUTSCREEN Field Type: Integer Field Length: 2 Notes for Users: Required for QPI: 6 Patients must receive nutritional screening with the validated Malnutrition Universal Screening Tool (MUST). Code Value Explanatory Notes

01 Yes

02 No

95 Patient declined

96 Not applicable E.g. patient died before being screened.

99 Not recorded

Related data Item(s): Date of Nutritional Screening


25

Date of Nutritional Screening Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services. Definition: This denotes the date the patient underwent nutritional screening as part of initial assessment. Field Name: NUTSCREENDATE Field Type: Date (DD/MM/CCYY) Field Length: 10 Notes for Users: Required for QPI: 6 This is the date the patient underwent nutritional screening as part of their initial assessment, which should normally be before they receive their first treatment. If the MUST assessment date is not available in clinical documentation and recorded at MDT, then the MDT date should be used. If the exact date of the screening is not documented, record as 09/09/1900. If the patient did not receive nutritional screening, e.g. patient declined or where not applicable, record as 10/10/1900 (not applicable). Related data Item(s):


26

Specialist Speech and Language Therapist Access Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services. Definition: This denotes whether the patient was seen by a Specialist Speech and Language Therapist (SLT) to assess and treat voice, speech and swallowing as part of initial assessment. Field Name: SLTASSESS Field Type: Integer Field Length: 2 Notes for Users: Required for QPI: 7 Codes and Values: Code Value Explanatory Notes

01 Yes

02 No

95 Patient declined

96 Not applicable E.g. patient died before being assessed.

99 Not recorded

Related data Item(s): Date of Specialist Speech and Language Therapist Access


27

Date of Specialist Speech and Language Therapist Access Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services. Definition: This denotes the date when the patient was seen by a Specialist Speech and Language Therapist (SLT) to assess and treat voice, speech and swallowing as part of initial assessment. Field Name: SLTDATE Field Type: Date (DD/MM/CCYY) Field Length: 10 Notes for Users: Required for QPI: 7 This is the date the patient was seen by a Specialist Speech and Language Therapist (SLT) as part of initial assessment, which should normally be before they receive treatment. If the exact date of the SLT assessment is not documented, record as 09/09/1900. If SLT assessment was not performed, e.g. patient refused, record as 10/10/1900 (not applicable). Related data Item(s): Specialist Speech and Language Therapist Access


28

TNM Tumour Classification (Final) {Head and Neck Cancer} Common name: Clinical TNM Tumour Classification (Head and Neck Cancer) Main Source of Data Item Standard: TNM Classification (TNM Classification of Malignant Tumours, Eighth Edition, UICC, 2017). Definition: The size and extent of the tumour, coded according to the official TNM Classification (TNM Classification of Malignant Tumours, Eighth Edition, 2017). Field Name: cT Field Type: Characters Field length: 3 Notes for Users: Required for QPI(S): 5, 9 Final TNM staging is a clinical/radiological/pathological classification of the size and extent of the patient’s cancer. This represents the poorest (most advanced) stage of disease evident, as agreed by the MDT and informed by all available clinical, radiological and histopathological information. The original clinical/radiological staging would have precedence in patients who have neo-adjuvant therapy. For patients undergoing surgery, the final TNM stage can be recorded from that agreed at the post-operative surgical MDT. Codes and Values: Oral Cavity Code Value

TX Primary tumour cannot be assessed

T1 Tumour 2cm or less in greatest dimension and 5mm or less depth of invasion*

T2 Tumour 2cm or less in greatest dimension and more than 5mm but no more than 10mm depth of invasion or Tumour more than 2cm but not more than 4cm in greatest dimension and depth of invasion no more than 10mm

T3 Tumour more than 2 cm but not more than 4 cm in greater dimension and depth of invasion more than 10 mm or tumour more than 4 cm in greatest dimension and not more than 10 mm depth of invasion

T4a Tumour more than 4 cm in greatest dimension and more than 10 mm depth of invasion or tumour invades through the cortical bone of the mandible or maxilla or involves the maxillary sinus, or invades the skin of the face

T4b Tumour invades masticator space, pterygoid plates, or skull base, or encases internal carotid artery

96 T Classification Not applicable

99 T Classification Not recorded/Not known

*Superficial erosion alone of bone/tooth socket by gingival primary is not sufficient to classify a tumour as T4a

Pharynx -Oropharynx Code Value


T1 Tumour 2cm or less in greatest dimension

T2 Tumour more than 2cm but not more than 4cm in greatest dimension

T3 Tumour more than 4cm in greatest dimension or extension to lingual surface of epiglottis.

T4 (p16-Positive) Tumour invades any of the following: larynx*, deep/extrinsic muscle of tongue (genioglossus, hyoglossus, palatoglossus, and styloglossus), medial pterygoid, hard palate, mandible*, lateral pterygoid muscle, pterygoid plates, lateral nasopharynx, skull base; or encases carotid artery


29

T4a (p16-Negative) Tumour invades any of the following: larynx*, deep/extrinsic muscle of tongue (genioglossus, hyglossus, palatoglossus, and styloglossus), medial pterygoid, hard palate, or mandible.

T4b (p16-Negative) Tumour invades any of the following: lateral pterygoid muscle, pterygoid plates, lateral nasopharynx, skull base; or encases carotid artery



*Mucosal extension to lingual surface of epiglottis from primary tumours of the base of the tongue and

vallecula does not constitute invasion of the larynx. Pharynx - Hypopharynx Code Value


T1 Tumour limited to one subsite of hypopharynx and/or 2cm or less in greatest dimension

T2 Tumour invades more than one subsite of hypopharynx or an adjacent site, or measures more than 2cm but not more than 4cm in greatest dimension, without fixation of hemilarynx

T3 Tumour more than 4cm in greatest dimension or with fixation of hemilarynx or extension to oesophageal mucosa

T4a Tumour invades any of the following: thyroid/cricoid cartilage, hyoid bone, thyroid gland, oesophagus, central compartment soft tissue*

T4b Tumour invades prevertebral fascia, encases carotid artery, or invades mediastinal structures



*Central compartment soft tissue includes prelaryngeal strap muscles and subcutaneous fat

Pharynx - Nasopharynx Code Value


T1 Tumour confined to nasopharynx, or extends to oropharynx and/or nasal cavity without parapharyngeal involvement

T2 Tumour with extension to parapharyngeal space and/or infiltration of the medial pterygoid, lateral pterygoid, and/or prevertebral muscles

T3 Tumour invades bony structures of skull base cervical vertebra, pterygoid structures, and/or paranasal sinuses

T4 Tumour with intracranial extension and/or involvement of cranial nerves, hypopharynx, orbit, parotid gland and/or infiltration beyond the lateral surface of the lateral pterygoid muscle.



Larynx - Supraglottis Code Value


T1 Tumour limited to one subsite of supraglottis with normal vocal cord mobility

T2 Tumour invades mucosa of more than one adjacent subsite of supraglottis or glottis or region outside the supraglottis (e.g. mucosa of base of tongue, vallecula, medial wall of piriform sinus) without fixation of the larynx

T3 Tumour limited to larynx with vocal cord fixation and/or invades any of the following: postcricoid area, pre-epiglottic space, paraglottic space, and/or inner cortex of thyroid cartilage

T4a Tumour invades through the thyroid cartilage, and/or invades tissues beyond the larynx, e.g., trachea, soft tissues of neck including deep/extrinsic muscle of tongue (genioglossus, hyoglossus, palatoglossus, and styloglossus), strap muscles, thyroid, or oesophagus

T4b Tumour invades prevertebral space, encases carotid artery, or mediastinal structures




30

Larynx - Glottis Code Value


T1 Tumour limited to vocal cord(s) (may involve anterior or posterior commissure) with normal mobility:

T1a Tumour limited to one vocal cord

T1b Tumour involves both vocal cords

T2 Tumour extends to supraglottis and/or subglottis and/or with impaired vocal cord mobility

T3 Tumour limited to larynx with vocal cord fixation and/or invades paraglottic space, and/or inner cortex of the thyroid cartilage

T4a Tumour invades through the outer cortex of the thyroid cartilage, and/or invades tissues beyond the larynx, e.g. trachea, soft tissues of neck including deep/extrinsic muscle of tongue (genioglossus, hyoglossus, palatoglossus, and styloglossus), strap muscles, thyroid, oesophagus




Larynx - Subglottis Code Value


T1 Tumour limited to subglottis

T2 Tumour extends to vocal cord(s) with normal or impaired mobility

T3 Tumour limited to larynx with vocal cord fixation

T4a Tumour invades cricoid or thyroid cartilage and/or invades tissues beyond the larynx, e.g. trachea, soft tissues of neck, including deep/extrinsic muscle of tongue (genioglossus, hyoglossus, palatoglossus, and styloglossus),strap muscles, thyroid, oesophagus




Nasal Cavity and Paranasal Sinuses - Maxillary Sinus

Code Value


T1 Tumour limited to the mucosa with no erosion or destruction of bone

T2 Tumour causing bone erosion or destruction, including extension into the hard palate and/or middle nasal meatus, except extension to posterior wall of maxillary sinus and pterygoid plates.

T3 Tumour invades any of the following: bone of posterior wall of maxillary sinus, subcutaneous tissues, floor of medial wall of orbit, pterygoid fossa,or ethmoid sinuses

T4a Tumour invades any of the following: anterior orbital contents, skin of cheek, pterygoid plates, infratemporal fossa, cribriform plate, sphenoid or frontal sinuses

T4b Tumour invades any of the following: orbital apex, dura, brain, middle cranial fossa, cranial nerves other than maxillary division of trigeminal nerve (V2), nasopharynx, or clivas




31

Nasal Cavity and Paranasal Sinuses – Nasal Cavity and Ethmoid Sinus Code Value


T1 Tumour restricted to one subsite of nasal cavity or ethmoid sinus, with or without bony invasion

T2 Tumour involves two subsites in a single site or extends to involve an adjacent site within the nasoethmoidal complex, with or without bony invasion

T3 Tumour extends to invade the medial wall or floor of the orbit, maxillary sinus, palate, or cribriform plate

T4a Tumour invades any of the following: anterior orbital contents, skin of nose or cheek, minimal extension to anterior cranial fossa, pterygoid plates, sphenoid or frontal sinuses

T4b Tumour invades any of the following; orbital apex, dura, brain, middle cranial fossa, cranial nerves other than V2, nasopharynx, or clivas



Salivary Glands Code Value


T1 Tumour 2cm or less in greatest dimension without extraparenchymal extension*

T2 Tumour more than 2cm but not more than 4cm in greatest dimension without extraparenchymal extension*

T3 Tumour more than 4cm and/or tumour with extraparenchymal extension*

T4a Tumour invades skin, mandiable, ear canal, and/or facial nerve

T4b Tumour invades base of skull, and/or pterygoid plates, and/or encases carotid artery



*Extraparenchymal extension is clinical or macroscopic evidence of invasion of soft tissues or nerve,

except those listed under T4a and T4b. Microscopic evidence alone does not constitute extraparenchymal extension for classification purposes. Bone Code Value Explanatory Notes


T1 Tumour 8cm or less in greatest dimension

T2 Tumour more than 8cm in greatest dimension

T3 Discontinuous tumours in the primary bone site



Related data items: TNM Metastases Classification (Final) {Head and Neck Cancer}


32

TNM Nodal Classification (Final) {Head and Neck Cancer}

Common name: Clinical TNM Nodal Classification (Head and Neck Cancer). Main Source of Data Item Standard: TNM Classification (TNM Classification of Malignant Tumours, Eighth Edition, UICC, 2017). Definition: The extent of regional lymph node metastases as according to the official TNM Classification (TNM Classification of Malignant Tumours, Eighth Edition, 2017). Field Name: cN Field Type: Characters Field length: 3 Notes for Users: Required for QPI(s): 5, 9 Final TNM staging is a clinical/radiological/pathological classification of the size and extent of the patient’s cancer. This represents the poorest (most advanced) stage of disease evident, as agreed by the MDT and informed by all available clinical, radiological and histopathological information. For patients undergoing surgery, the final TNM stage can be recorded from that agreed at the post-operative surgical MDT. The original clinical/radiological staging would have precedence in patients who have neo-adjuvant therapy. If stage is not documented in case notes/clinical systems, do not deduce from other information and record as ‘not recorded’. Codes and Values:

Oral Cavity

Code Value

NX Regional lymph nodes cannot be assessed

N0 No regional lymph node metastasis

N1 Metastasis in single ipsilateral lymph node, 3cm or less in greatest dimension without extranodal extension N2a Metastasis in single ipsilateral lymph node, more than 3cm but not more than 6cm in greatest dimension without extranodal extension

N2b Metastasis in multiple ipsilateral lymph nodes, none more than 6cm in greatest dimension, without extranodal extension. N2c Metastasis in bilateral or contralateral lymph nodes, none more than 6cm in greatest dimension, without extranodal extension

N3a Metastasis in a lymph node more than 6cm in greatest dimension without extranodal extension N3b Metastasis in a single or multiple lymph nodes with clinical extranodal extension*

96 Not applicable

99 Not recorded

*The presence of skin involvement or soft tissue invasion with deep fixation/tethering to underlying muscle or adjacent structures or clinical signs of nerve involvement is classified as clinical extranodal extension. Midline nodes are considered ipsilateral nodes.


33

Pharynx – Oropharynx p16-Negative and Hypopharynx

Code Value



N1 Metastasis in single ipsilateral lymph node, 3cm or less in greatest dimension without extranodal extension N2a Metastasis in single ipsilateral lymph node more than 3cm but not more than 6cm in greatest dimension without extranodal extension

N2b Metastasis in multiple ipsilateral lymph nodes, none more than 6cm in greatest dimension, without extranodal extension. N2c Metastasis in bilateral or contralateral lymph nodes, none more than 6cm in greatest dimension, without extranodal extension.

N3a Metastasis in a lymph node more than 6cm in greatest dimension without extranodal extension.

N3b Metastasis in a single or multiple lymph nodes with clinical extranodal extension*

96 Not applicable

99 Not recorded

*The presence of skin involvement or soft tissue invasion with deep fixation/tethering to underlying

muscle or adjacent structures or clinical signs of nerve involvement is classified as clinical extranodal

extension.

Midline nodes are considered ipsilateral nodes.

Pharynx – Oropharynx p16-Positive Clinical

Code Value



N1 Unilateral metastasis, in lymph node(s), all 6cm or less in greatest dimension

N2 Contralateral or bilateral metastasis in lymph node(s), all 6cm or less in greatest dimension

N3 Metastasis in lymph node(s) greater than 6cm in dimension. 96 Not applicable

99 Not recorded

Note Midline nodes are considered ipsilateral nodes

Pharynx - Nasopharynx

Code Value



N1 Unilateral metastasis, in cervical lymph node(s), and/or unilateral or bilateral metastasis in retropharyngeal lymph nodes, 6cm or less in greatest dimension, above the caudal border of cricoid cartilage

N2 Bilateral metastasis in cervical lymph nodes, 6cm or less in greatest dimension, above the caudal border of cricoid cartilage

N3 Metastasis in cervical lymph node(s) greater than 6cm in dimension and/or extension below the caudal border of cricoid cartilage

96 Not applicable

99 Not recorded

Note Midline nodes are considered ipsilateral nodes


34

Larynx

Code Value



N1 Metastasis in single ipsilateral lymph node, 3cm or less in greatest dimension without extranodal extension

N2a Metastasis in single ipsilateral lymph node, more than 3cm but not more that 6cm in greatest dimension without extranodal extension

N2b Metastasis in multiple ipsilateral lymph nodes, none more than 6cm in greatest dimension, without extranodal extension

N2c Metastasis in bilateral or contralateral lymph nodes, none more than 6cm in greatest dimension, without extranodal extension

N3a Metastasis in a lymph node more than 6cm in greatest dimension without extranodal extension


96 Not applicable

99 Not recorded

* The presence of skin involvement or soft tissue invasion with deep fixation/tethering to underlying muscle or adjacent structures or clinical signs of nerve involvement is classified as clinical extra nodal extension. Midline nodes are considered ipsilateral nodes

Nasal Cavity and Paranasal Sinuses

Code Value



N1 Metastasis in single ipsilateral lymph node, 3cm or less in greatest dimension without extranodal extension

N2a Metastasis in single ipsilateral lymph node, more than 3cm but not more than 6cm in greatest dimension without extranodal extension


N2c Metastasis in bilateral or contralateral lymph nodes, none more than 6cm in greatest dimension, without extrandal extension



96 Not applicable

99 Not recorded

* The presence of skin involvement or soft tissue invasion with deep fixation/tethering to underlying muscle or adjacent structures or clinical signs of nerve involvement is classified as clinical extra nodal extension. Midline nodes are considered ipsilateral nodes


35

Salivary Glands

Code Value



N1 Metastasis in a single ipsilateral lymph node, 3cm or less in greatest dimension without extranodal extension

N2a Metastasis in single ipsilateral lymph node, more than 3cm but not more than 6cm in greatest dimension without extranodal extension


N2c Metastasis in bilateral or contralateral lymph nodes, none more than 6cm in greatest dimension, without extranodal extension


M3b Metastasis in a single or multiple lymph nodes with clinical extranodal extension*

96 Not applicable

99 Not recorded

* The presence of skin involvement or soft tissue invasion with deep fixation/tethering to underlying

muscle or adjacent structures or clinical signs of nerve involvement is classified as clinical extra nodal extension. Midline nodes are considered ipsilateral nodes

Bone

Code Value Explanatory Notes



N1 Regional lymph node metastasis

96 Not applicable

99 Not recorded

Related Data items: TNM Tumour Classification (Final) {Head and Neck Cancer} TNM Metastases Classification (Final) {Head and Neck Cancer}


36

TNM Metastases Classification (Final) {Head and Neck Cancer} Common name: Clinical TNM Metastases Classification (Head and Neck Cancer). Main Source of Data Item Standard: TNM Classification (TNM Classification of Malignant Tumours, Eighth Edition, UICC, 2017). Definition: The extent of metastatic spread of the tumour as agreed at the multidisciplinary according to the official TNM Classification (TNM Classification of Malignant Tumours, Eighth Edition, 2017). Field Name: cM Field Type: Characters Field length: 2 Notes for Users: Required for QPI(s): Required for national survival analysis and national comparative analysis. Final TNM staging is a clinical/radiological/pathological classification of the size and extent of the patient’s cancer. This represents the poorest (most advanced) stage of disease evident, as agreed by the MDT and informed by all available clinical, radiological and histopathological information. The original clinical/radiological staging would have precedence in patients who have neo-adjuvant therapy. Codes and Values: Oral Cavity


M0 No distant metastasis

M1 Distant metastasis

96 Not applicable

99 Not recorded

Pharynx – Oropharynx and Hypopharynx




96 Not applicable

99 Not recorded

Pharynx – Nasopharynx




96 Not applicable

99 Not recorded


37

Larynx




96 Not applicable

99 Not recorded

Nasal Cavity and Paranasal Sinuses




96 Not applicable

99 Not recorded

Salivary Glands




96 Not applicable

99 Not recorded

Bone



M1a Distant metastasis – Lung

M1b Distant metastasis – Other distant sites

96 Not applicable

99 Not recorded

Related data items: TNM tumour Classification (Final) {Head and Neck Cancer}


38

WHO/ ECOG Performance Status

Main Source of Data Item Standard: WHO (World Health Organisation) and ECOG (Eastern Cooperative Oncology Group) Definition: An overall assessment of the functional/physical performance of the patient. Field Name: PSTATUS Field Type: Integer Field length: 1 Notes for Users: Required for QPI: 10 and for survival analysis The WHO/ECOG performance status is a grade on a five point scale (range 0 to 4) at the time of investigation in which '0' denotes normal activity and '4' a patient who is 100% bedridden. If it is not documented do not deduce from other information and record as 'Not recorded'. This item may occur more than once throughout a patient’s record. This field relates to pre-treatment performance status i.e. at the time of the MDT closest to actual treatment. If the performance status falls between two scores, record the higher value i.e. the worst performance status. Codes and values: Code Value

0 Fully active, able to carry on all pre-disease performance without restriction

1 Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g. light housework, office work

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

3 Capable of only limited self care, confined to bed or chair more than 50% of waking hours

4 Completely disabled, cannot carry on any self care, totally confined to bed or chair

9 Not recorded

Related Data Items:


39

Type of First Cancer Treatment Common name: Mode of first treatment

Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services. Definition: This denotes the first specific treatment modality administered to a patient.

Field Name: FIRSTTREATTYPE Field Type: Integer Field length: 2 Notes for Users: Required for national survival analysis and national comparative analysis. For any particular modality it is the first treatment and not specifically the definitive treatment i.e. this does not include purely diagnostic biopsies such as incisional biopsies, needle biopsies or core biopsies. Record patients as having ‘supportive care only’ if a decision was taken not to give the patient any active treatment as part of their primary therapy. No active treatment includes watchful waiting and supportive care but not palliative chemotherapy and/or radiotherapy. Dilatation without other treatment is not considered as active treatment. Steroids etc should not be recorded as first treatment if more substantive treatment such as radiotherapy, chemotherapy or surgery is given. If no further treatment is given, then record as supportive care. Tonsillectomy is for diagnostic purposes only and should not be recorded as first treatment, but if MDT states that the tonsillectomy is the definitive treatment record type of first cancer treatment as surgery. Codes and Values:

Code Description Explanatory notes

01 Surgery

02 Radiotherapy

03 Chemotherapy

05 Endoscopic

07 Supportive care No active treatment

11 Other therapy

12 Watchful waiting No active treatment

13 Biological therapy Excludes biological therapy as part of combined treatment

15 Chemoradiotherapy Includes biological therapy as part of combined treatment

94 Patient died before treatment

95 Patient refused all therapies

99 Not recorded

Related Data Item(s): Date of First Cancer Treatment


40

Date of First Cancer Treatment Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services. Definition: This denotes the date the type of first cancer treatment was given to the patient. Field Name: FIRSTTREATDATE Field Type: Date (DD/MM/CCYY) Field Length: 10

Notes for Users: Required for QPI(s): 1, 2, 3, 4, 5, 6, 7

This field should be recorded for all patients including those with supportive care only (‘No active treatment’) (see below). If type of first cancer treatment is ‘supportive care only’, the date recorded should be the first date the decision was taken not to give the patient treatment as part of their primary therapy. Where this has subsequently been confirmed at MDT, the date of MDT should be recorded. The aim of this date is to distinguish between patients who have initially had no treatment but receive some therapy when symptoms develop. Tonsillectomy is for diagnostic purposes only and should not be recorded as first treatment, but if MDT states that the tonsillectomy is the definitive treatment record as Date of First Cancer Treatment. The date recorded should be that of the first type of cancer treatment. If the exact date is not documented, record as 09/09/1900 (Not recorded). If the patient died before treatment or the patient refused treatment, record as 10/10/1900 (Not applicable). Related Data Item(s): Type of First Cancer Treatment


41

Date of Definitive Treatment {Head and Neck Cancer} Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services. Definition: This denotes the date definitive cancer treatment was given to the patient. Field Name: DEFTREATDATE Field Type: Date (DD/MM/CCYY) Field Length: 10

Notes for Users: Required for QPI: 3

For patients with head and neck cancer definitive treatment will be either:

Surgery;

Radiotherapy; or

Systemic Anti Cancer Therapy. It is the date of this treatment that should be recorded. If a patient receives more than one of the treatments listed it is the first which should be recorded. If an operation to relieve symptoms and a further operation which aims to remove the tumour is performed the second operation is the one that should be coded in this field. If MDT states that a tonsillectomy is the definitive treatment this is the date that should be recorded. For patients undergoing no active treatment (e.g. supportive care only) the date recorded should be the first date the decision was taken not to give the patient treatment as part of their primary therapy. Where this has subsequently been confirmed at MDT, the date of MDT should be recorded. This will therefore be the same date as the First Treatment Date for these patients. If the exact date is not documented, record as 09/09/1900 (Not recorded). If the patient died before treatment or the patient refused treatment, record as 10/10/1900 (Not applicable). Related Data Item(s):


42

Section 3: Surgery


43

Location Code {Cancer Surgery} Common Name(s): Location, Location of Contact. Main Source of Data Item Standard: NHS National Reference Files, http://www.natref.scot.nhs.uk/. Definition: This is the reference number of any building or set of buildings where events pertinent to NHS Scotland take place. Locations include hospitals, health centres, GP surgeries, clinics, NHS board offices, nursing homes, schools and patient/client’s home. Field Name: HOSPSURG Field Type: Characters Field Length: 5 Notes for Users: Required for QPI(s): Local and survival analysis This is the hospital of first definitive surgery which removes the primary tumour. This may be a planned excision even if close margins are found and further surgery is required. On occasion, this result will be achieved by excision biopsy. This should be included as site of first definitive surgery. Each location has a location code, which is maintained jointly by ISD and General Register Office (Scotland).http://www.show.scot.nhs.uk/smrfiles/information.html – datafiles. Location must be viewed as an address and not a code. If any new locations arise where NHS healthcare is delivered/administered, please ensure that the Reference Files Team at ISD is informed using form LOC-NEW (which can be downloaded from the website below) so that a new code may be issued as appropriate. http://www.show.scot.nhs.uk/smrfiles Information about location should be electronically stored, managed and transferred using the relevant location code. IT systems should allow the recording and display of locations on the user interface as the relevant location name and associated address, etc. If the location code is not documented, record as X9999. If surgery has not been performed or the patient has refused surgery, record as inapplicable, X1010. Examples of codes are given below:

Code Institution A111H CROSSHOUSE HOSPITAL

C418H ROYAL ALEXANDRA HOSPITAL

F704H VICTORIA HOSPITAL, KIRKCALDY

G107H GLASGOW ROYAL INFIRMARY

G405H SOUTHERN GENERAL HOSPITAL, GLASGOW

Related Data Item(s):

http://www.natref.scot.nhs.uk/

http://www.show.scot.nhs.uk/smrfiles


44

Consultant in Charge of Surgery Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services. Definition: This is the name of the consultant who is in charge of the final definitive (or only) surgery. Field Name: SURGCON Field Type: Characters Field Length: 20 Notes for Users: Required for survival analysis and comparative analysis The surname and forename of the consultant should be recorded to distinguish between consultants with common surnames. NB: on the database, the consultant’s name will be stored as a GMC number If the clinician’s name is not recorded code as 9999. If no surgery was performed record as inapplicable (1010). If the patient is managed by a team rather than with a consultant in overall charge, record as inapplicable, 1010. If the patient is managed by a locum, record only that the clinician is a locum consultant, LOCUM. Related Data Item(s):


45

Date of Definitive Surgery Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services. Definition: This is date the main (definitive) or only operation performed for treatment of head and neck cancer. Field Name: SURGDATE Field Type: Date (DD/MM/CCYY). Field Length: 10 Notes for Users: Required for QPI(s): 7, 10, 11 This is the date of tumour resection and not the date of any diagnostic surgical procedures. If the exact date of surgery is not known, record as 09/09/1900 (Not recorded). If no surgery was performed, record as 10/10/1900 (Not applicable). All treatments given as part of the initial treatment plan. Related Data Items:


46

Intent of Definitive Surgery Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services. Definition: Final assessment of intent of surgery as defined by the Multidisciplinary Team (MDT).

Field Name: OPINTENT Field Type: Integer Field length: 2 Notes for Users: Required for QPI(s): 2, 3, 7, 8, 11 This information should be recorded at MDT, clinical letter or within electronic prescribing systems, this should not be deduced. Record the intent established pre-operatively. Codes and Values:

Code Value Explanatory Note

01 Curative

02 Palliative

03 Diagnostic Excision Biopsy Only

95 Patient refused

96 Not applicable

99 Not recorded



47

Definitive Operative Procedure 1-9 {Head and Neck Cancer} Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services Definition: This denotes the surgical procedure performed for treatment of cancer. This also includes nodal and reconstructive surgery performed on the patient for treatment of cancer. Field Name: OPCODE1 OPCODE2 OPCODE3 OPCODE4 OPCODE5

OPCODE6 OPCODE7 OPCODE8 OPCODE9 Field Type: Characters Field Length: 10 Notes for Users: Required for QPI: 8 If an operation to relieve symptoms and a further operation which aims to remove the tumour is performed the second operation is the one that should be coded in this field. If any operation is not listed then please contact ISD Scotland as described elsewhere so that standard codes can be allocated throughout Scotland. Operation is coded to the 4-digit code according to the Fourth Revision of the OPCS Classification of Surgical Operations (OPCS4). Centres using READ codes may continue provided the codes can be mapped to OPCS. It should be noted that it may be necessary to record up to nine codes in order to fully specify the operation. Also, more than one procedure can be recorded when carried out at the same definitive operation theatre visit. Please note that only surgery occurring within six months of diagnosis should be included in the analysis against the relevant QPI. If the patient refused treatment code as ‘95’ or did not undergo surgery for other reasons code as Not Applicable ‘96’. Coding instructions and a full list of codes are included in the OPCS4 manual. Codes and Values: Description 1 OPCS 2 OPCS 3 OPCS 4 OPCS 5 OPCS

LARYNX

Microlaryngoscopy – laser removal lesion E34.1

Microlaryngoscopy – cold removal lesion E34.2

Vertical hemi-laryngectomy E29.3

Supraglottic laryngectomy E29.2

Total laryngectomy E29.1

Partial laryngectomy NEC E29.4


48

Laryngectomy nec E29.6

Laryngofissure E30.1

Excision of lesion of larynx using lateral pharyngotomy as approach E30.2

Laryngofissure and chordectomy E29.5

Endoscopic Destruction of Lesion of Larynx E35.3

Endoscopic partial laryngectomy E35.6

Excision of lesion of trachea NEC E39.1

Tracheo-oesophageal puncture E41.4

Tracheostomy, permanent E42.1

Tracheostomy, temporary E42.3

Revision tracheal stoma E42.4

Open destruction of lesion of trachea E43.1

PHARYNX

Cricopharyngeal myotomy E28.1

Pharyngotomy (open excision lesion pha) E23.1

Pharyngectomy,partial E19.2

Laryngo-pharyngectomy - Primary closure E19.1 E29.1 E21.4

Laryngo-pharyngectomy - free jejunum E19.1 E29.1 G03.2

Laryngo-pharyngectomy - pect major E19.1 E29.1 E21.4 S17.1 Y61.2

Total L-p oesophagectomy + pullup E19.1 E29.1 G02.1

Total oesophagectomy and anastomosis of pharynx to stomach G02.1

Creation of pharyngostome E23.8 Y16.1

NECK DISSECTIONS (USING WATKINSON OPCS CODE EXTENSIONS) NECK DISSECTION T85.1

RADICAL

Neck dissection modified T85.1A

Modified Type I accessory preserved T85.1Ai

Modified Type II accessory +IJV kept T85.1Aii

Modified Type III sternomastoid,IJV + accessory kept

T85.1Aiii

SELECTIVE NECK DISSECTION (SND) T85.1B

SND Level 1 (suprahyoid) T85.1Bi

SND Level 1-3 (supra omohyoid) T85.1Bii

SND Level 1-4 (anterolateral) T85.1Biii

SND Level 2-4 (lateral) T85.1Biv

SND Level 5 (posterior) T85.1Bv

SND Level 2-5 (posterolateral) T85.1Bvi

SND Level 6 (central compartment) T85.1Bvii

SND Level 7 (superior mediastinum) T85.1Bviii

Excision or biopsy of cervical lymph node T87.2

LIP, ORAL CAVITY


49

Floor of mouth excision F38.1

Buccal mucosa excision F38.2

Extirpation of lesion of other part of mouth – other specified F38.8

Excision lesion of tongue F23.1

Reconstruction mouth – with flap F39.1

With primary closure F39.8

With buccal flap F39.2 S28.8

With pect major F39.2 S17.1 Y61.2

With radial forearm F39.2 S20.8 Y59.2

Reconstruction mouth with SSG F39.2 S35.3

Reconstruction mouth with primary closure F39.8

Excision of lesion of gingiva F20.2

Partial excision of lip/shave/vermillion adv F01.1

Wedge resection of lip F01.8

Excision of lesion of lip F02.1

Reconstruction lip with skin flap (ABBE ) F04.2 S24.8

Excision of lesion of palate F28.1

Bilateral dissection tonsillectomy F34.1

Bilateral guillotine tonsillectomy F34.2

Bilateral laser tonsillectomy F34.3

Bilateral excision of tonsil NEC F34.4

Tonsillectomy - unilateral F34.9

Excision lesion jaw NEC V14.4

Extraction of multiple teeth NEC F10.4

ORAL AND MANDIBULAR PROCEDURE

Mandibulotomy/split/division of jaw V16.8

Marginal mandibulectomy V14.3

Mandibulectomy, extensive V14.2

Hemimandibulectomy V14.1

Partial glossectomy F22.2

Total glossectomy F22.1

Pectoralis major-skin and muscle S17.1 Y61.2

: Muscle S17.1 Y63.8

Latissimus dorsi - skin and muscle S17.1 Y61.3

: Muscle S17.1 Y63.1

Distant Myocultaneous S17.3

Radial forearm fasciocutaneous S20.8 Y59.2

Reconstruction mandible

With rib V19.1 Y66.2

With radius V19.1 Y66.4 Y59.2

With fibula V19.1 Y66.6 Y59.8

With iliac crest V19.1 Y66.3 Y59.8

PALATE

Palatectomy, partial, uvulectomy F32.4

Palatectomy, total F32.8 Y05.1

Repair palate using palatal flap F30.1

Repair of palate using skin flap F30.2

Repair of palate using tongue flap F30.3

Repair of palate using mucosal flap F30.5

Repair of palate using skin graft F30.4

SALIVARY GLAND

Sublingual gland excision F44.5


50

Submandibular gland excision F44.4

Parotidectomy,superficial F44.2

Parotidectomy, total F44.1

Parotidectomy NEC F44.3

Excision of lesion of parotid gland F45.1

Excision of lesion of submadibular gland F45.2

Excision of lesion of sublingual gland F45.3

Excision of lesion of salivary gland NEC F45.4

Trans-sphenoidal hypophysectomy B01.2

Simple mastoidectomy (includes Mastoidectomy NEC)

D10.4

MAXILLA, NOSE & CRANIOFACIAL ETC

Maxillectomy, partial V07.2

Maxillectomy, total V06.8

Orbital exenteration C01.1

Craniofacial resection of ethmoids E14.8 Y46.2

Excision of lesion of septum of nose E03.2

Septectomy E03.7

Excision of lesion of turbinate of nose NEC E04.3

Rhinectomy, partial E01.8

Rhinectomy, total E01.1

Rhinotomy, lateral E17.4

Nasopharynx excision E24.1

Endonasal endoscopic approach to other body cavity (excludes Functional endoscopic nasal surgery (Y76.2) Y76.6

Other operations on Nose – Other Specified E10.8

GENERAL

Repair of cranial nerve

: Repair of facial nerve A30.4

: Repair of accessory nerve A30.8

: Repair of hypoglossal nerve A30.8

Radial forearm fasciocutaneous S20.8 Y59.2

Full thickness autograft of skin to head or neck S36.1

Lower leg flap of skin and fascia Y59.6

Extensive Excision of bone of face V07.1

Distant fasciocutaneous subcutaneous pedicle flap to head or neck S18.1

OTHER PROCEDURES

Photodynamic therapy to oral cavity Use destructive lesion F42.8 Y13.8

Photodynamic therapy to pharynx/larynx

- Use pharynx destruction E24.8 Y13.8

- Use larynx destruction E35.8 Y13.8

Laser excision lesion hypopharynx/ oropharynx E24.2 Y08.2

Laser excision lesion nasopharynx E24.1 Y08.2

Hair bearing flap of skin to nasolabial area S21.3


51

Excision of lesion of external ear D02.1

Diagnostic endoscopic examination of larynx, unspecified. E36.9

Plastic operations on nose - Other specified E02.8

Diagnostic fibreoptic endoscopic examination of lower respiratory tract and biopsy of lesion of lower respiratory tract E49.1

Extirpation of lesion of tongue F23.8

Other operations on tongue - Other specified F26.8

Blocked dissection of lymph nodes - unspecified T85.9

Other operations on mandible - Other specified V19.8

Distant fasciocutaneous flap to head or neck S18.3

Microvascular reconstruction of organ Y24.1

Other operations on skin - other specified S60.8

Harvest of flap of skin and fascia - other specified. Y59.8

Biopsy of sentinel lymph node NEC T91.1

Other specified harvest of bone. Y66.8

Pinnectomy - Total excision D01.1

Pinnectomy – Partial excision D01.2

Lateral Skull Base Resection V12.5 O33.1

Reconstruction with Myocutaneous Rectus Abdominis Free Flap S17.1 Y61.5

Thyroidectomy, total B08.1

Thyroidectomy, subtotal B08.2

Hemithyroidectomy, B08.3

Endoscopic resection of lesion of larynx E35.2

Laser destruction of lesion of organ noc Y08.4

Destruction of lesion of palate F28.2

Destruction of lesion of floor of mouth F38.3

Destruction of lesion of mouth, nec F38.4

Medial Maxillectomy V06.1

Intranasal Ethmoidectomy E14.2

External Ethmoidectomy E14.3

Full dental clearance (includes dental clearance nec) F10.1

Dental extraction unspecified (includes extraction of single tooth). F10.9

Bilateral Z94.1

Unilateral Z94.4

Right side operation Z94.2

Left side operation Z94.3

Related Data Item(s): Date of Definitive Surgery Intent of Definitive Surgery


52

Section 4: Pathological Details


53

Morphology of Tumour Main Source of Data Item Standard: This is the morphology of the tumour according to the International Classification of Diseases for Oncology (ICD-O(3)). Definition: This is the morphology of the tumour according to the International Classification of Diseases for Oncology (ICD-O(3)). Field Name: MORPHOL Field Type: Characters Field Length: 6 Notes for Users: Required for QPI(s): 8, 10 and for national survival analysis and national comparative analysis. The morphology terms have five-digit code numbers which run from 8000/0 to 9989/1; the first four digits indicate the specific histological terms and the fifth digit, after the slash, is a behaviour code. If material supplied cannot be assessed code to ‘Not assessable’ (1111/1). If not recorded, record as 9999/9 (Not recorded). If the pathology report is negative code to 8888/8. If no invasive diagnostic procedures were undertaken record as ‘Not applicable’ (1010/0). Codes and Values: Code Description

8000/3 Neoplasm Malignant; Tumour, malignant NOS; Malignancy; Cancer; Unclassified tumour, malignant; Blastoma NOS

8001/3 Tumour cells, malignant

8010/3 Carcinoma

8012/3 Large cell undifferentiated carcinoma

8020/3 Carcinoma, undifferentiated, NOS

8032/3 Spindle Cell Carcinoma

8051/3 Verrucous carcinoma NOS, Verrucous squamous cell carcinoma

8052/3 Papillary squamous cell carcinoma

8070/3 Squamous cell carcinoma, NOS

8071/3 Squamous cell carcinoma keratinizing NOS, squamous cell carcinoma, large cell keratinizing

8072/3 Squamous cell carcinoma, large cell nonkeratinizing

8073/3 Squamous cell carcinoma, small cell nonkeratinizing

8074/3 Squamous cell carcinoma, spindle cell

8075/3 Adenoid squamous cell carcinoma; Pseudoglandular squamous cell carcinoma

8082/3 Lymphoepithelial carcinoma

8083/3 Basaloid squamous carcincoma

8120/3 Transitional cell carcinoma

8140/3 Adenocarcinoma, NOS

8147/3 Basal cell adenocarcinoma

8200/3 Adenoid cystic carcincoma

8260/3 Papillary adenocarcinoma NOS

8290/3 Oncocytic carcinoma

8310/3 Clear cell carcinoma

8410/3 Sebaceous adenocarcinoma; sebaceous carcinoma

8430/3 Mucoepidermoid carcincoma


54

8480/3 Mucinous adenocarcinoma

8500/3 Salivary duct carcinoma

8502/3 Mammary analogue secretory carcinoma

8525/3 Polymorphous low-grade adenocarcinoma

8550/3 Acinic cell carcinoma

8560/3 Adenosquamous carcinoma

8562/3 Epithelial-myoepithelial carcinoma

8720/3 Malignant Melanoma, NOS

8746/3 Mucosal lentiginous melanoma

8940/3 Salivary gland type mixed tumour, malignant

8941/3 Carcinoma in pleomorphic adenoma

8980/3 Carcinosarcoma

8982/3 Myoepithelial carcinoma

9081/3 Teratocarcinoma mixed embryonal carcinoma and teratoma

9270/3 Odontogenic tumour malignant, odontogenic carcinoma, primary intraosseous carcinoma, ameloblastic carcinoma

9290/3 Ameloblastic odontosarcoma (Ameloblastic fibrodentinosarcoma, Ameloblastic fibro-odontosarcoma)

9310/3 Ameloblastoma, malignant (Adamantinoma, malignant)

9330/3 Ameloblastic fibrosarcoma (Ameloblastic sarcoma, Odontogenic fibrosarcoma)

9342/3 Odonteogenic carcinosarcoma

9522/3 olfactory (nasal cavity) neuroblastoma

1111/1 Not assessable

8888/8 Negative Pathology

9999/9 Not recorded

1010/0 Not applicable



55

HPV Status of Tumour Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services Definition: This denotes the HPV status of the tumour. Field Name: HPVSTATUS Field Type: Integer Field Length: 2 Notes for Users: HPV testing in oropharyngeal cancer patients has become an important prognostic factor in the management and treatment of patients. The Scottish HPV Reference Laboratory performs molecular HPV typing of all oropharyngeal squamous carcinomas diagnosed in Scotland prospectively. A patient with oropharynx cancer with no HPV tested should be recorded as not recorded. Codes & Values


01 Positive

02 Negative

03 Not Accessible where there is insufficient tissue to perform HPV testing

96 Not Applicable Site not an Oropharynx

99 Not Recorded



56

P16 Status of Tumour Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services Definition: This denotes the P16 status of the tumour. Field Name: P16STATUS Field Type: Integer Field Length: 2 Notes for Users: P16 protein expression is increasingly being used as a surrogate marker for oncogenic human papillomavirus (HPV) infection in head and neck squamous cell carcinomas. A patient with oropharynx cancer with no P16 tested should be recorded as not recorded Codes & Values


01 Positive

02 Negative

03 Not Accessible where there is insufficient tissue to perform P16 testing

96 Not Applicable Site not an Oropharynx

99 Not Recorded



57

Surgical Margins Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services. Definition: Surgical margin in a pathology report defines the visible margin or free edge of "normal" tissue. Field Name: SURGMARG Field Type: Characters Field Length: 4 Notes for Users: Required for QPI(s): 8, 10 This will be confirmed by microscopic examination and the result can be found on the pathology report relating to the specimen from the final definitive (or only) surgery performed to head and neck as described elsewhere.

Where there is no residual disease after neo-adjuvant chemotherapy or radiotherapy, record as ‘8888’ ‘Not Assessable’. This is the final excision margin. If no distance is given or if a second procedure is carried out to achieve clear margins record as code 01 if no residual disease. Sometimes a measurement will be given which can be added to original margin of clearance but often it is only stated as “clear” in which case it should be recorded as Code 01. If the patient is not treated by surgery, code as 96 (Not applicable). Codes and Values: Code Value Explanatory Notes

01 Clear by >5mm

02 1-5mm

03 <1mm

8888 Not assessable

96 Not applicable

99 Not recorded



58

Extracapsular Spread Main Source of Data Item Standard: The Royal College of Pathologists, Datasets for Histopathology reports on head and neck carcinomas and salivary neoplasm’s (November 2013) Definition: Evidence of spread of tumour through the full thickness of the lymph node capsule. Field Name: EXCAPSPREAD Field Type: Integer Field Length: 2 Notes for Users: Required for QPI: 10 This is only applicable to patients who have had their nodes examined during surgery. If the patient is not treated by surgery or nodes were not examined, code as 96 (Not applicable). If the neck dissection is negative with no evidence of involved nodes, code as 96 (Not applicable). Codes and Values:


01 Yes Include histological evidence that is uncertain

02 No

96 Not Applicable E.g. Patient did not have surgery, no node removed

99 Not recorded

Related Data Items:


59

Section 5: Oncology


60

Location Code 1-2 {Oncology Treatment} Common Name(s): Location Main Source of Data Item Standard: Derived from SMR data standards. Definition: This is the reference number of any building or set of buildings where events pertinent to NHS Scotland take place. Locations include hospitals, health centres, GP surgeries, clinics, NHS board offices, nursing homes, schools and patient/client’s home. Field Name: HOSPNONSURG1 HOSPNONSURG2 Field Type: Characters Field Length: 5 Notes for Users: Required for local/national analysis The hospital in which the patient received the majority of SACT Treatment should be recorded in HOSPNONSURG1. The hospital in which the patient received the majority of Radiotherapy Treatment should be recorded in HOSPNONSURG2. Location codes for hospitals are five character codes maintained by ISD and the General Register Office (Scotland). http://www.natref.scot.nhs.uk/ Location must be viewed as an address and not a code. If any new locations arise where NHS healthcare is delivered/administered, please ensure that the Reference Files Team at ISD is informed using form LOC-NEW (which can be downloaded from the website below) so that a new code may be issued as appropriate. http://www.isdscotland.org/Products-and-Services/Data-Definitions-and-References/National-Reference-Files/ The first character denotes the health board, the next three are assigned and the fifth denotes the type of location (H=hospital) e.g. A111H=Crosshouse Hospital G107H=Glasgow Royal Infirmary Information about location should be electronically stored, managed and transferred using the relevant location code. IT systems should allow the recording and display of locations on the user interface as the relevant location name and associated address, etc. If the location code is not documented, record as X9999. Related Data Items:

http://www.natref.scot.nhs.uk/





61

Date Treatment Started (Radiotherapy) {Head and Neck Cancer} (1-2) Main Source of Data Item Standard: The National Audit Cancer Datasets developed by the regional Cancer Networks supported by Information Services. Definition: The date cancer treatment course commenced. Field Name: RSTARTDATE1 RSTARTDATE2 Field Type: Date (DD/MM/CCYY) Field length: 10 Notes for Users: Required for QPI: 7 This is the first fraction of a course of radiotherapy. Up to two courses may be recorded

For the purposes of national audit, only radiotherapy given as part of the primary treatment plan should be recorded. Palliative radiotherapy to other (metastatic) sites is only recorded if part of the initial treatment plan. If the date radiotherapy started is unknown, record as 09/09/1900 (Not recorded). If radiotherapy has not been given or the patient has refused radiotherapy, record as 10/10/1900 (not applicable). Related Data Items: Date Treatment Completed (Radiotherapy) {Head and Neck Cancer} (1-2) Radiotherapy Course Type {Head and Neck Cancer} (1-2)


62

Date Treatment Completed (Radiotherapy) {Head and Neck Cancer} (1-2) Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services Definition: The date cancer treatment course ended. Field Name: RCOMPDATE1 RCOMPDATE2 Field Type: Date (DD/MM/CCYY) Field Length: 10 Notes for Users: Required for QPI: 11 This is the last fraction of a course of radiotherapy. It should be noted this can be the same day as the day the therapy started. If the date treatment completed is unknown, record as 09/09/1900 (Not recorded). If treatment has not been given, record as 10/10/1900 (not applicable). Related Data Item(s): Date Treatment Started (Radiotherapy) {Head and Neck Cancer} (1-2) Radiotherapy Course Type {Head and Neck Cancer} (1-2)


63

Radiotherapy Course Type {Head and Neck Cancer} (1-2) Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services. Definition: The type of course of external beam radiotherapy administered for the treatment of the cancer. Field Name: RCOURSETYPE1 RCOURSETYPE2 Field Type: Integer Field length: 2 Notes for Users: Required for QPI(s): 7, 9, 10, 11 Combined treatments may be administered concurrently/synchronously e.g. chemotherapy and radiotherapy, intra-operative radiotherapy. For patients undergoing chemoradiotherapy the radiotherapy element should be recorded as code ‘06’ and recorded also in ‘Type of SACT’ under code ‘05’. All treatments given as part of the initial treatment plan

Codes and Values: Code Value Explanatory Notes

01 Adjuvant It is given after potentially curative surgery

02 Radical It is primary treatment and is given with curative intent

03 Palliative The aim is solely to relieve symptoms

04 Neo-adjuvant It is given before potentially curative surgery

06 Chemoradiotherapy

Radical radiotherapy given in combination with concurrent chemotherapy. Chemotherapy element of this combined treatment should be recorded separately in field Type of Systemic Anti-Cancer Therapy (SACT) 1-2 {Head and Neck Cancer}.

94 Patient died before radiotherapy treatment

95 Patient refused radiotherapy treatment

96 Not applicable e.g. no radiotherapy given.

99 Not recorded

Related Data Items: Date Treatment Started (Radiotherapy) {Head and Neck Cancer} (1-2) Date Treatment Completed (Radiotherapy) {Head and Neck Cancer} (1-2)


64

Intensity-Modulated Radiation Therapy (IMRT) Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services. Definition: This denotes whether the radiotherapy given was Intensity-Modulated Radiation Therapy (IMRT). Field Name: IMRT Field Type: Integer Field length: 2 Notes for Users: Required for QPI: 9 All treatments given as part of the initial treatment plan Intensity modulated radiotherapy (IMRT) is one type of conformal radiotherapy, this includes VMAT (e.g. Rapid ARC). Like conformal radiotherapy, IMRT shapes the radiation beams to closely fit the area where the cancer is. But it also changes the radiotherapy dose depending on the shape of the tumour. This means that the central part of the cancer receives the highest dose of radiotherapy and a surrounding area of tissue gets lower doses.

Codes and Values: Code Value Explanatory Notes

01 Yes IMRT given

02 No No IMRT given

96 Not applicable e.g. no radiotherapy given.

99 Not recorded

Related Data Items: Date Treatment Started (Radiotherapy) {Head and Neck Cancer} (1-2) Date Treatment Completed (Radiotherapy) {Head and Neck Cancer} (1-2) Radiotherapy Course Type {Head and Neck Cancer} (1-2)


65

Date Treatment Started Systemic Anti-Cancer Therapy (SACT) {Cancer} 1-2 Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services. Definition: The date systemic anti-cancer therapy course commenced. Field Name: CHEMDATE1 CHEMDATE2 Field Type: Date (DD/MM/CCYY) Field length: 10 Notes for Users: Required for QPI(s): This is the first dose of the first cycle of a course of systemic anti-cancer therapy. If the date SACT started is unknown, record as 09/09/1900 (Not recorded). If SACT has not been given or the patient has refused SACT, record as 10/10/1900 (not applicable). Related data items: Date Treatment Completed Systemic Anti-Cancer Therapy (SACT) {Cancer} 1-2 Type of Systemic Anti-Cancer Therapy (SACT) 1-2 {Head and Neck Cancer}


66

Date Treatment Completed Systemic Anti-Cancer Therapy (SACT) {Cancer} 1-2 Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services.

Definition: The date systemic anti-cancer therapy course ended. Field Name: CHEMENDATE1 CHEMENDATE2 Field Type: Date (DD/MM/CCYY) Field length: 10 Notes for Users: Required for QPI: 11 This is the first day of the last cycle of a course of chemotherapy. It should be noted this can be the same day as the day the therapy started. If the date treatment started is unknown, record as 09/09/1900 (Not recorded). If SACT has not been given or the patient has refused SACT, record as 10/10/1900 (Not applicable). Related data items: Date Treatment Started Systemic Anti-Cancer Therapy (SACT) {Cancer} 1-2 Type of Systemic Anti-Cancer Therapy (SACT) 1-2 {Head and Neck Cancer}


67

Type of Systemic Anti-Cancer Therapy (SACT) 1-2 {Head and Neck Cancer} Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services. Definition: The type of course of cytotoxic or biological drugs administered for the treatment of the cancer. Cytotoxic drugs are drugs which destroy cells. Field Name: CHEMTYPE1 CHEMTYPE2 Field Type: Integer Field Length: 2 Notes for Users: Required for QPI(s): 10, 11 Patients may have ongoing systemic therapy both before and after surgery. These patients should be recorded under neo-adjuvant Type. Some patients may have separate completion chemotherapy post-operatively. This may be recorded as two courses neo-adjuvant and adjuvant. Systemic therapy must be treatment received for initial management and not treatment for recurrence or relapse. For patients undergoing chemoradiotherapy the chemotherapy element should be recorded as code ‘05’ and recorded also in ‘Radiotherapy Course Type’ under code ‘06’. Codes and Values:

Value Explanatory Notes

01 Neoadjuvant Therapy given prior to radiotherapy or first definitive surgery to reduce tumour size

02 Adjuvant Chemotherapy given after surgery within 3 months of surgery

04 Palliative Systemic therapy given for symptom control without curative intent e.g. for patients with metastatic disease at time of diagnosis

05 Chemoradiotherapy Radical radiotherapy given in combination with concurrent chemotherapy Radiotherapy element of this combined treatment should be recorded separately in field ‘Radiotherapy Course Type’

08 Chemotherapy

07 Biological Therapy

94 Patient died before SACT treatment i.e. Patient who died before receiving planned SACT treatment

95 Patient refused SACT treatment

96 Not applicable e.g. Systemic therapy not given

99 Not recorded

Related Data Items: Date Treatment Started Systemic Anti-Cancer Therapy (SACT) {Cancer} 1-2 Date Treatment Completed Systemic Anti-Cancer Therapy (SACT) {Cancer} 1-2


68

Section 6: Clinical Trial Entry


69

Patient Entered into Clinical Trial {Cancer} Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services. Definition: An indication of whether or not the patient received treatment within the context of a clinical trial. Field Name: TRIAL Field Type: Integer Field Length: 2 Notes for Users: Required for generic QPIs. This relates only to participation in clinical trials which may be national or international multi-centred trials. The majority of non-commercial multi-centred trials available in Scotland are National Cancer Research Network (NCRN) badged or equivalent. Some academic and university units may have ongoing local trials which should not be included here. These can be recorded on local trials databases. Codes and Values:

Code Value

01 Yes

02 No

99 Not recorded

Related Data Items:


70

Section 7: Death Details


71

Date of Death Main Source of Data Item Standard: The National Cancer Audit Datasets developed by the regional Cancer Networks supported by Information Services. Definition: This is the certified date of death as recorded by the General Register Office (Scotland) (GRO(S)). Field Name: DOD Field Type: Date (DD/MM/CCYY). Field Length: 10 Notes for Users: Required for QPI: 11 If the exact date is not documented, record as 09/09/1900 (Not recorded). If the patient is alive use the code 10/10/1900 (Not applicable). Related Data Items:

Documents

Head and Neck Cancer - ISD Scotland...TNM Tumour Classification (Final) {Head and Neck Cancer} - Oral Cavity amend T3 'Tumour more than 4cm in greatest dimension or more than 10mm