COSD & Source of Referral

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1 COSD & Source of Referral A Brief guide October 2014 Michael Sharpe Data Improvement Manager National Cancer Registration Service

2 What is COSD? Cancer and Outcomes Services Dataset Clinical dataset for all newly diagnosed cancers (and recurrences) Covers more cancers then CWT! Live from January 2013 Has both Core and Site Specific items Shares a lot of items with CWT and national audits User guide available at NCIN.org.uk 2 Overview

3 What are the key items of a diagnosis? ICD10 C codes for invasive tumours, D codes for non-invasive. Bladder tumours, skin cancers, and breast cancers have lots of In-situ (ptis) and pta cases. Any of these should be recorded with a D code, not a C! Date of Diagnosis Should be the date the cancer diagnosis was clinically confirmed. I.E., the date the first cancer-positive pathology was reported, or the date of the MDT. 3 Items Overview for diagnosis

4 4 Items Overview for diagnosis What are the key items of a diagnosis? Snomed/ICD-0-3 The Morphology of the cancer, or cell type. Examples are: Grade Code Meaning M8070/3 Squamous Cell Carcinoma M8140/3 Adenocarcinoma The grade of the tumour is the difference between the normal cells and the cancer cells. Grade Description 1 Well differentiated 2 Moderately differentiated 3 Poorly differentiated 4 Undifferentiated/Anaplastic

5 Staging: The Basics What is stage? Stage is an assessment of how far a tumour has spread. The TNM System The most widely used system for grading stage is the TNM system: Other Systems FIGO Stage (Gynaecology) Dukes Stage (Colorectal) T(n) N(n) Tumour Nodes An assessment of the size of a tumour and how far it has grown through local tissue Typically graded 0 4, for example T1 An assessment of spread to local and regional lymph nodes Typically graded 0 3, for example N2 Ann Arbor (Lymphoma -Haem) AJCC (Skin mm s) RAI stage (CLL - Haem) M(n) Metastasis An assessment of distant (metastatic) spread of the disease Typically graded 0 or 1, for example M0 Binet stage (CLL - Haem) 5 Staging ISS Stage (Myeloma - Haem)

6 Staging: The Basics A Sample Pathway for a Colorectal Patient 1 TNM Final Pre-Treatment Stage 2 TNM Integrated Stage T2 N0 M0 Diagnostic Treatment Outpatient Referral from GP Suspicion of Cancer Diagnostics Ordered CT Staging T1 N0 M0 MRI Staging T2 N0 M0 Clinical examination T2 Nx Mx Pre-Treatment MDT Discussion TNM Final Pre-Treatment Stage Determined Treatment Plan Decided

7 Staging: The Basics A Sample Pathway for a Colorectal Patient 1 TNM Final Pre-Treatment Stage 2 T2 N0 M0 TNM Integrated Stage T2 N0 M0 Diagnostic Treatment Surgery Resection Diagnostics Ordered CT Staging T1 N0 M0 MRI Staging T2 N0 M0 Biopsy Staging T2 Nx Mx Pre-Treatment MDT Discussion TNM Final Pre-Treatment Stage Determined Treatment Plan Decided Histopathology Report T2 N0 Mx Liver Staging Tx Nx M0 Post-Treatment MDT Discussion TNM Integrated Stage Determined

8 Staging: Stage grouping What is stage grouping? Once the values for the T, N and M have been determined they are combined, and an overall stage is assigned. The TNM can be categorized into an overall stage grouping between 1 to 4, which is often referral as roman numeral staging I, II, III, and IV. This stage grouping describes the progression of the cancer. Stage 0 Carcinoma in situ Early form Stage I Localized Stage II Localized / Early locally advanced Stage III Late locally advanced Stage IV Very Extensive /Metastasized Example of stage grouping for a a primary breast tumor Tumour is less than 2 cm across No lymph node involvement Has not spread to distant parts of the body T1 N0 M0 Stage I Localized 8 Staging

9 The Use of Mx (and Nx) Change in the use of Mx if used, no longer counts as full stage COSD User Guide states (v2.1, pg 20): TNM editions prior to TNM7 included the category MX to identify when distant metastases could not be assessed. TNM7 removed this category, because the overuse of the MX category meant that a large proportion of tumours was not staged (a TNM group stage cannot be applied if MX is used). According to the rules of TNM7, M0 should be used if there is no positive evidence of distant metastases. 9 Staging Overview

10 Staging Completeness from September London Cancer % Target Barking, Havering and Redbridge Homerton University Barnet and Chase Farm RNOH Royal Free Barts Health Princess Alexandra UCLH North Middlesex Whittington Great Ormond Street 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 10 Progress in Staging Full Stage

11 Staging Completeness from September London Cancer % Target Royal Free Homerton University Barking, Havering and Redbridge RNOH Barts Health North Middlesex Barnet and Chase Farm Whittington Princess Alexandra UCLH Great Ormond Street 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 11 Progress in Staging Full Stage

12 Staging Completeness 2013 London Cancer by Tumour Site Lung Colorectal Soft Tissue Head and Neck Breast Melanoma Urology Upper GI Non-melanoma Skin Haem Gynae Endocrine (inc. thyroid) HPB Other Cardiothoracic 70% Target 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 12 Progress in Staging Full Stage

13 Head and Neck Colorectal Other Cardiothoracic Staging Completeness 2014 London Cancer by Tumour Site Lung Breast Soft Tissue Melanoma Gynae Endocrine (inc. thyroid) Urology Upper GI Non-melanoma Skin Haem HPB 70% Target 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 13 Progress in Staging Full Stage

14 Staging Completeness for all sites 2013 (Jan Dec), By Region 100% 90% 80% 70% 60% 50% 40% 30% % 10% % Kent London Cancer London Cancer Alliance Surrey, West sussex & Hampshire Sussex 14 Progress in Staging Full Stage

15 Staging Completeness for All Sites 2014 (Jan-Aug), By Region 100% 90% 80% 70% 60% 50% 40% 30% 20% % % Kent London Cancer London Cancer Alliance Surrey, West sussex & Hampshire Sussex 15 Progress in Staging Full Stage

16 Other Key Indicators Overview, Basis of Diagnosis Three more Key Indicators identified nationally for focus: Basis of Diagnosis WHO Performance Status CNS Indicator Basis of Diagnosis is the most authoritive means we have to say a patient has cancer, not the first. 16 Other Key indicators

17 Other Key Indicators 2 CNS Indicator Code Y1 Y2 NI NN Meaning Nurse was present when the patient was given diagnosis Nurse was not present when diagnosis was given, but has seen patient Nurse has no seen patient, but is aware of them Nurse has not seen patient and is not aware of them Joint Clinics (in which the patient sees the Nurse just after seeing a clinician) count as Y2. 17 Other Key indicators

18 Other Key Indicators 3 Performance Status For COSD, Performance Status is performance status at the time the treatment plan is made. Be careful, as Oncologists like to take the performance status on an ongoing basis through a patients care. Make sure you only capture the performance status at the time the treatment plan is made. 18 Other Key indicators

19 Source of Referral for Outpatients Source of Referral for Outpatients is an item used in both CWT and COSD Applies to the first provider to see the patient as an outpatient If you are receiving the referral from another Trust, you should use their Source of Referral Nationally, multiple codes can apply Locally, a flow chart has been developed to give a consistent approach across Trusts. Check with your manager as to whether they want you to use this! 19 Source of Referral

20 20 Source of Referral Source of Referral

21 Data Flows to NCRS Understanding Data Flows

22 NHS Acute Trust Regional Office Trust Data Streams to Regional Office Radiotherapy COSD / MDT Pathology PAS Radiology Audit CWT Chemo 22 Where does the data go?

23 NHS Acute Trust Regional Office Radiotherapy COSD Data The primary area of focus for most improvement work during and before COSD / MDT Pathology PAS Radiology Encore Audit CWT Chemo 23 Source of Referral

24 NHS Acute Trust Regional Office PAS, Pathology & Radiology Radiotherapy COSD / MDT Pathology PAS Radiology Encore Audit CWT Chemo 24 Source of Referral

25 NHS Acute Trust Regional Office Radiotherapy NatCat Radiotherapy Reviewing a new project aiming for direct data feeds from Radiotherapy to NCRS. COSD / MDT Pathology PAS Radiology Encore Audit CWT Chemo 25 Source of Referral

26 NHS Acute Trust Regional Office NatCat Audit and CWT Radiotherapy COSD / MDT Pathology PAS Radiology Encore Audit CWT Open Exeter Chemo 26 Source of Referral

27 NHS Acute Trust Regional Office NatCat Chemotherapy Radiotherapy COSD / MDT Pathology PAS Radiology Encore Audit CWT Open Exeter Chemo Oxford 27 Source of Referral

28 NHS Acute Trust Regional Office NatCat Death Certificates Radiotherapy COSD / MDT Pathology Death Cert ONS PAS Radiology Encore Audit CWT Open Exeter Chemo Oxford 28 Source of Referral

29 What is the data used for? Service Profiles Trust level profiles, containing detailed treatment information Complete National Picture Tells us what s happening country wide examples of good and bad practice National Analysis COSD has already enabled us to do analysis never before possible Better information for the Teams supplying the information Level 3 reports are now live. Level 4 reports are coming shortly these will be clinical profiles, intended to be available on a rolling basis. 29 What Overview do we do with the data?

30 Online Training Where can I get further training? Understanding Cancer at The Document Library on the Portal Sign up today! Your local management and clinical team Your local Data Improvement Manager 30 Further Overview Training

31 Thank you for your contributions so far Contact details: Michael Sharpe Data Improvement Manager, NCRS