Cancer Outcomes and Services Data Set - Pathology

PathologyFrom January 2016 Pathology Laboratories across England were mandated through DCB1521 17/2014, to collect and return structured pathology using the COSDS XML Schema.

Overview

Due to Covid-19, the implementation date of the Cancer Outcomes and Services Data Set (COSDS) version 9 was deferred until 1 July 2020.

Introduction

The Cancer Outcomes and Services Data Set is a compiled data set which provides the standard for secondary uses information required to support national cancer registration and associated analysis (at local, regional, national and international level), as well as other national cancer audit programmes.

The standard and XML Schema consists of:

a set of individual data items, with their definitions
the assemblage of data items into discrete data sets
the means of flowing the data items
compilation of the data items into a reconciled and verified data set.

Additionally, the output supports commissioning and service development through provision of relevant information on service delivery and outcomes.

All PATIENTS diagnosed with or receiving cancer treatment in or funded by the NHS in England are covered by the standard. This includes adult and paediatric cancer PATIENTS. The standard applies to all ORGANISATIONS providing Cancer Services within secondary care. It does not apply to general practice ORGANISATIONS.

The Cancer Outcomes and Services Data Set covers diseases as defined by the United Kingdom and Ireland Association of Cancer Registries (UKIACR) as described in the User Guide at Appendix A and B.

Unless otherwise specified, the term cancer is used throughout the standard and related documents to cover all conditions registerable by the United Kingdom and Ireland Association of Cancer Registries.

Submission Information

Providers of Cancer Services are required to provide a monthly return on all cancer PATIENTS using the Cancer Outcomes and Services Data Set.

The Cancer Outcomes and Services Data Set is submitted to the National Cancer Registration and Analysis Service (NCRAS) using the COSDS XML Schema.

While the core and cancer site specific data sets are shown as separate data sets within the NHS Data Model and Dictionary, the COSDS XML Schema integrates each core and cancer site specific set of data elements. Documentation provided on the Technology Reference Update Distribution (TRUD) page at: NHS Data Model and Dictionary XML Schemas gives full details of the specification.

For all diagnoses not covered by a cancer site specific data set, only the Core Data Set should be completed. A full list of diagnoses mapped to the appropriate data set is provided in the National Cancer Registration and Analysis Service User Guide.

Pathology

From January 2016 Pathology Laboratories across England were mandated through DCB1521 17/2014, to collect and return structured pathology using the COSDS XML Schema.

This replaced the current reporting to the National Cancer Registration and Analysis Service of electronic pathology reports which were then transcribed by the National Cancer Registration and Analysis Service into the Cancer Registration Reports. This also prevented Cancer Service teams, for example, Multidisciplinary Teams, Pathway Co-ordinators, duplicating the work, which had been happening as part of their data collection process.

From April 2020, the pathology data can only be collected and submitted using the separate Pathology Data Set and Pathology XML Schema. Pathology data items have been removed from the main Cancer Outcomes and Services Data Set.

This allows the Cancer Service teams to concentrate on collecting and reporting all the other clinical data required for the Cancer Outcomes and Services Data Set and the Pathologists to collect and report the pathology items. This will reduce the burden of data collection for the Cancer Service teams and allow for more accurate pathology reporting to be submitted to the National Cancer Registration and Analysis Service.

There will be no requirement for Pathology Laboratories to double report. Once their Laboratory Information Management Systems (LIMS) are updated to report in the COSDS XML Schema, all other pathology reporting can cease.

Further Guidance

Further guidance for submission of the Cancer Outcomes and Services Data Set is provided by the National Cancer Registration and Analysis Service at Cancer Outcomes and Services Dataset.

Mandation

The Mandation column indicates the recommendation for the inclusion of data.

M = Mandatory: this data element is mandatory and the technical process (e.g. submission of the data set, production of output etc) cannot be completed without this data element being present
R = Required: NHS business processes cannot be delivered without this data element
O = Optional: the inclusion of this data element is optional as required for local purposes.

XML Schema

For guidance on the XML Schema constraints, see the Cancer Outcomes and Services Data Set XML Schema Constraints.

For guidance on downloading the XML Schema, see XML Schema TRUD Download.

Specification


SUBMISSION HEADER To carry the submission header details.One occurrence of this group is required.
Mandation	Data Elements
M	COSDS SUBMISSION IDENTIFIER
M	ORGANISATION IDENTIFIER (CODE OF SUBMITTING ORGANISATION)
M	COSDS SUBMISSION RECORD COUNT
M	REPORTING PERIOD START DATE
M	REPORTING PERIOD END DATE
M	DATE AND TIME DATA SET CREATED


RECORD IDENTIFIER To carry the record identifier details.One occurrence of this group is required.
Mandation	Data Elements
M	COSDS UNIQUE IDENTIFIER


LINKAGE IDENTIFIER CHOICE - CORE - PATHOLOGY
Mandation	CHOICE 1 - NHS NUMBER To carry patient identity details for linkage.One occurrence of this group is required.
M	NHS NUMBER
Or
Mandation	CHOICE 2 - LOCAL PATIENT IDENTIFIER To carry patient identity details for linkage.One occurrence of this group is required.
M	LOCAL PATIENT IDENTIFIER (EXTENDED)


LINKAGE IDENTIFIER - CORE - PATHOLOGY To carry patient identity details for linkage.One occurrence of this group is required.
Mandation	Data Elements
M	NHS NUMBER STATUS INDICATOR CODE
M	PERSON BIRTH DATE
M	ORGANISATION IDENTIFIER (CODE OF PROVIDER)


DEMOGRAPHICS - CORE - PATHOLOGY To carry patient demographic details.One occurrence of this group is permitted.
Mandation	Data Elements
R	PERSON FAMILY NAME
R	PERSON GIVEN NAME
R	PATIENT USUAL ADDRESS (AT DIAGNOSIS) - ADDRESS STRUCTURED Or PATIENT USUAL ADDRESS (AT DIAGNOSIS) - ADDRESS UNSTRUCTURED
R	POSTCODE OF USUAL ADDRESS (AT DIAGNOSIS)
R	PERSON STATED GENDER CODE


PATHOLOGY DETAILS PART 1 - CORE - PATHOLOGY To carry pathology details.Multiple occurrences of this group are permitted.
Mandation	Data Elements
M	INVESTIGATION RESULT DATE
M	SERVICE REPORT IDENTIFIER
R	PATHOLOGY OBSERVATION REPORT IDENTIFIER
R	SERVICE REPORT STATUS
M	PROFESSIONAL REGISTRATION ISSUER CODE (PATHOLOGY TEST REQUESTED BY)
M	PROFESSIONAL REGISTRATION ENTRY IDENTIFIER (PATHOLOGY TEST REQUESTED BY)
R	ORGANISATION SITE IDENTIFIER (OF PATHOLOGY TEST REQUEST)
R	SAMPLE COLLECTION DATE
R	SAMPLE RECEIPT DATE
R	ORGANISATION IDENTIFIER (OF AUTHORISING PATHOLOGIST)
M	PROFESSIONAL REGISTRATION ISSUER CODE (PATHOLOGY REPORT AUTHORISED BY)
M	PROFESSIONAL REGISTRATION ENTRY IDENTIFIER (PATHOLOGY REPORT AUTHORISED BY)
R	CANCER SPECIMEN NATURE


TOPOGRAPHY/MORPHOLOGY - CORE - PATHOLOGY To carry Topography/Morphology SNOMED pathology details.One occurrence of this group is permitted.
Mandation	Data Elements
M	SNOMED VERSION (PATHOLOGY)


TOPOGRAPHY/MORPHOLOGY CHOICE - CORE - PATHOLOGY
Mandation	CHOICE 1 - TOPOGRAPHY SNOMED To carry pathology Topography SNOMED details.One occurrence of this group is required.
M	TOPOGRAPHY (SNOMED PATHOLOGY) Multiple occurrences of this item are permitted
Or
Mandation	CHOICE 2 - MORPHOLOGY SNOMED To carry pathology Morphology SNOMED details.One occurrence of this group is required.
M	MORPHOLOGY (SNOMED PATHOLOGY) Multiple occurrences of this item are permitted


PATHOLOGY DETAILS PART 2 CORE - PATHOLOGY To carry pathology details.Multiple occurrences of this group are permitted.
Mandation	Data Elements
R	DIAGNOSIS (ICD PATHOLOGICAL) Multiple occurrences of this item are permitted
R	TUMOUR LATERALITY (PATHOLOGICAL)
R	PATHOLOGY INVESTIGATION TYPE
R	PATHOLOGY REPORT TEXT
R	LESION SIZE (PATHOLOGICAL)
R	GRADE OF DIFFERENTIATION (PATHOLOGICAL)
R	CANCER VASCULAR OR LYMPHATIC INVASION
R	EXCISION MARGIN INDICATION CODE
R	SYNCHRONOUS TUMOUR INDICATOR
R	NUMBER OF NODES EXAMINED
R	NUMBER OF NODES POSITIVE
R	TNM CODING EDITION
R	TNM VERSION NUMBER (PATHOLOGICAL)
R	T CATEGORY (PATHOLOGICAL)
R	N CATEGORY (PATHOLOGICAL)
R	M CATEGORY (PATHOLOGICAL)
R	TNM STAGE GROUPING (PATHOLOGICAL)
R	NEOADJUVANT THERAPY INDICATOR
R	KI-67 STAINING PERFORMED INDICATION CODE
R	KI-67 PERCENTAGE RESULT
R	MLH1 IMMUNOHISTOCHEMISTRY NUCLEAR EXPRESSION INTACT INDICATION CODE
R	PMS2 IMMUNOHISTOCHEMISTRY NUCLEAR EXPRESSION INTACT INDICATION CODE
R	MSH2 IMMUNOHISTOCHEMISTRY NUCLEAR EXPRESSION INTACT INDICATION CODE
R	MSH6 IMMUNOHISTOCHEMISTRY NUCLEAR EXPRESSION INTACT INDICATION CODE
R	MICROSATELLITE INSTABILITY TESTING RESULT


BREAST - PATHOLOGY To carry pathology details for Breast cancer.One occurrence of this data group is permitted.
Mandation	Data Elements
R	MULTIFOCAL TUMOUR INDICATOR (BREAST)
R	DUCTAL CARCINOMA IN SITU GRADE
R	NON INVASIVE TUMOUR SIZE
R	WHOLE TUMOUR SIZE
R	METASTASIS EXTENT CODE
R	DISTANCE TO MARGIN
O	ALLRED SCORE (ESTROGEN RECEPTOR)
R	ESTROGEN RECEPTOR STATUS
O	ALLRED SCORE (PROGESTERONE RECEPTOR)
O	BREAST PROGESTERONE RECEPTOR STATUS
R	HUMAN EPIDERMAL GROWTH FACTOR RECEPTOR STATUS (BREAST)
R	HUMAN EPIDERMAL GROWTH FACTOR IN SITU HYBRIDISATION RECEPTOR STATUS (BREAST)
R	CYTOLOGY RESULT CODE (BREAST)
R	CYTOLOGY RESULT CODE (NODE)
R	NEEDLE CORE BIOPSY RESULT CODE (BREAST)
R	NEEDLE CORE BIOPSY RESULT CODE (AXILLARY LYMPH NODE)


CENTRAL NERVOUS SYSTEM (CNS) - PATHOLOGY To carry pathology details for Central Nervous System (CNS) cancer.One occurrence of this data group is permitted.
Mandation	Data Elements
R	MOLECULAR DIAGNOSTIC CODE Multiple occurrences of this item are permitted
R	HORMONE EXPRESSION TYPE Multiple occurrences of this item are permitted


COLORECTAL - PATHOLOGY To carry pathology details for Colorectal cancer.One occurrence of this data group is permitted.
Mandation	Data Elements
R	MARGIN INVOLVED INDICATION CODE (COLORECTAL PROXIMAL OR DISTAL RESECTION MARGIN)
R	DISTANCE TO CLOSEST NON PERITONEALISED RESECTION MARGIN
R	PLANE OF SURGICAL EXCISION INDICATOR
R	DISTANCE FROM DENTATE LINE
R	DISTANCE BEYOND MUSCULARIS PROPRIA
R	PREOPERATIVE THERAPY RESPONSE TYPE
R	MARGIN INVOLVED INDICATION CODE (CIRCUMFERENTIAL MARGIN)


CHILDREN, TEENAGERS AND YOUNG ADULTS (CTYA): RENAL PATHOLOGY (PAEDIATRIC KIDNEY) - PATHOLOGY To carry renal (paediatric kidney) pathology details for Children, Teenagers, and Young Adults (CTYA) cancer.One occurrence of this data group is permitted.
Mandation	Data Elements
R	TUMOUR RUPTURE INDICATOR (PATHOLOGICAL)
R	ANAPLASTIC NEPHROBLASTOMA TYPE
R	TUMOUR INVASION INDICATOR (PERIRENAL FAT)
R	TUMOUR INVASION INDICATOR (RENAL SINUS)
R	RENAL VEIN TUMOUR INDICATOR (PAEDIATRIC KIDNEY)
R	VIABLE TUMOUR EVIDENCE AT RESECTION MARGIN
R	INTERNATIONAL SOCIETY OF PAEDIATRIC ONCOLOGY TUMOUR LOCAL STAGE


GYNAECOLOGICAL - PATHOLOGY To carry pathology details for Gynaecological cancer.One occurrence of this data group is permitted.
Mandation	Data Elements
R	MICROSCOPIC INVOLVEMENT INDICATION CODE (FALLOPIAN TUBE)
R	MICROSCOPIC INVOLVEMENT INDICATION CODE (OVARIAN)
R	MICROSCOPIC INVOLVEMENT INDICATION CODE (UTERINE SEROSA)
R	OMENTUM INVOLVEMENT INDICATION CODE


GYNAECOLOGICAL: FALLOPIAN TUBE, OVARIAN EPITHELIAL AND PRIMARY PERITONEAL - PATHOLOGY To carry pathology details for Gynaecological cancer for Fallopian Tube, Ovarian Epithelial and Primary Peritoneal.One occurrence of this group is permitted.
Mandation	Data Elements
R	GYNAECOLOGICIAL CAPSULE STATUS
R	OVARY SURFACE INVOLVEMENT INDICATOR
R	PERITONEAL CYTOLOGY RESULT CODE
R	PERITONEAL INVOLVEMENT INDICATION CODE


GYNAECOLOGICAL: ENDOMETRIAL - PATHOLOGY To carry pathology details for Gynaecological cancer for Endometrial.One occurrence of this group is permitted.
Mandation	Data Elements
R	MICROSCOPIC INVOLVEMENT INDICATOR (CERVICAL STROMA)
R	MYOMETRIAL INVASION IDENTIFICATION CODE
R	MICROSCOPIC INVOLVEMENT INDICATOR (PARAMETRIUM)
R	PERITONEAL WASHINGS IDENTIFIED
R	PERITONEAL INVOLVEMENT INDICATOR (ENDOMETRIAL CANCER)
R	GYNAECOLOGICIAL CANCER SITE OF PERITONEAL INVOLVEMENT


GYNAECOLOGICAL: CERVICAL - PATHOLOGY To carry pathology details for Gynaecological cancer for Cervical.One occurrence of this group is permitted.
Mandation	Data Elements
R	CERVICAL GLANDULAR INTRAEPITHELIAL NEOPLASIA PRESENCE AND GRADE
R	CERVICAL INTRAEPITHELIAL NEOPLASIA PRESENCE AND GRADE
R	SMILE INDICATION CODE
R	RESECTION MARGIN INVOLVEMENT INDICATOR
R	PARACERVICAL OR PARAMETRIAL INVOLVEMENT INDICATOR
R	UNINVOLVED CERVICAL STROMA THICKNESS
R	MICROSCOPIC INVOLVEMENT INDICATOR (VAGINAL)
R	INVASIVE THICKNESS


GYNAECOLOGICAL: NODES - PATHOLOGY To carry pathology details for Gynaecological cancer for Nodes.One occurrence of this group is permitted.
Mandation	Data Elements
R	NUMBER OF NODES EXAMINED (PARA-AORTIC)
R	NUMBER OF NODES POSITIVE (PARA-AORTIC)
R	NUMBER OF NODES EXAMINED (PELVIC)
R	NUMBER OF NODES POSITIVE (PELVIC)
R	NUMBER OF NODES EXAMINED (INGUINO-FEMORAL)
R	NUMBER OF NODES POSITIVE (INGUINO-FEMORAL)
R	EXTRANODAL SPREAD INDICATOR


HEAD AND NECK: VARIOUS - PATHOLOGY To carry pathology details for various Head and Neck cancers.One occurrence of this group is permitted.
Mandation	Data Elements
R	MAXIMUM DEPTH OF INVASION
R	BONE INVASION INDICATION CODE
R	CARTILAGE INVASION INDICATION CODE
R	ANATOMICAL SIDE (NECK DISSECTION)


HEAD AND NECK: SALIVARY - PATHOLOGY To carry salivary pathology details for Head and Neck cancer.One occurrence of this group is permitted.
Mandation	Data Elements
M	MACROSCOPIC EXTRAGLANDULAR EXTENSION INDICATION CODE


HEAD AND NECK: GENERAL AND SALIVARY - PATHOLOGY To carry general and salivary pathology details for Head and Neck cancer.One occurrence of this group is permitted.
Mandation	Data Elements
R	ANATOMICAL SIDE (POSITIVE NODES)
R	LARGEST METASTASIS (LEFT NECK)
R	LARGEST METASTASIS (RIGHT NECK)
R	EXTRACAPSULAR SPREAD INDICATION CODE


HEAD AND NECK: HUMAN PAPILLOMAVIRUS (HPV) - PATHOLOGY To carry human papilloma virus pathology details for Head and Neck cancer.One occurrence of this group is permitted.
Mandation	Data Elements
R	P16 IMMUNOHISTOCHEMISTRY TEST RESULT
R	HUMAN PAPILLOMAVIRUS IN SITU HYBRIDISATION TEST RESULT


LUNG - PATHOLOGY To carry pathology details for Lung cancer.One occurrence of this data group is permitted.
Mandation	Data Elements
R	EXTENT OF ATELECTASIS
R	EXTENT OF PLEURAL INVASION
R	TUMOUR INVASION INDICATOR (PERICARDIUM)
R	TUMOUR INVASION INDICATOR (DIAPHRAGM)
R	TUMOUR INVASION INDICATOR (GREAT VESSELS)
R	TUMOUR INVASION INDICATOR (HEART)
R	MALIGNANT PLEURAL EFFUSION INDICATOR
R	TUMOUR INVASION INDICATOR (MEDIASTINUM)
R	SATELLITE TUMOUR NODULES LOCATION


SARCOMA: BONE AND SOFT TISSUE - PATHOLOGY To carry pathology details for Sarcoma for Bone and Soft Tissue.One occurrence of this data group is permitted.
Mandation	Data Elements
R	GENETIC CONFIRMATION INDICATOR


SARCOMA: BONE - PATHOLOGY To carry pathology details for Sarcoma for Bone.One occurrence of this group is permitted.
Mandation	Data Elements
R	SARCOMA TUMOUR BREACH IDENTIFIER
R	TUMOUR NECROSIS PERCENTAGE


SARCOMA: SOFT TISSUE - PATHOLOGY To carry pathology details for Sarcoma for Soft Tissue.One occurrence of this group is permitted.
Mandation	Data Elements
R	SARCOMA TUMOUR DEPTH
R	MITOTIC RATE (SARCOMA)


SKIN: BASAL CELL CARCINOMAS (BCC) - PATHOLOGY To carry pathology details for Basal Cell Carcinoma (BCC) for skin cancer.One occurrence of this group is required.
Mandation	Data Elements
R	SKIN CANCER LESION SPECIMEN IDENTIFIER
R	PERINEURAL INVASION INDICATOR (SKIN)
R	LESION DIAMETER GREATER THAN 20MM INDICATION CODE


SKIN: SQUAMOUS CELL CARCINOMA (SCC) - PATHOLOGY To carry pathology details for Squamous Cell Carcinoma (SCC) for skin cancer.One occurrence of this group is required.
Mandation	Data Elements
R	SKIN CANCER LESION SPECIMEN IDENTIFIER
R	PERINEURAL INVASION INDICATOR (SKIN)
R	LESION DIAMETER GREATER THAN 20MM INDICATION CODE
R	CLARKS LEVEL IV INDICATION CODE
R	LESION VERTICAL THICKNESS GREATER THAN 2MM INDICATION CODE


SKIN: MALIGNANT MELANOMA (MM) - PATHOLOGY To carry pathology details for Malignant Melanoma (MM) for skin cancer.One occurrence of this group is permitted.
Mandation	Data Elements
R	SKIN CANCER LESION SPECIMEN IDENTIFIER
R	SKIN ULCERATION INDICATION CODE
R	MITOTIC RATE (SKIN)
R	MICROSATELLITE OR IN-TRANSIT METASTASIS INDICATION CODE
R	TUMOUR REGRESSION INDICATION CODE (SKIN)
R	BRESLOW THICKNESS
R	TUMOUR INFILTRATING LYMPHOCYTE TYPE
R	NUMBER OF SENTINEL NODES SAMPLED
R	NUMBER OF SENTINEL NODES POSITIVE
R	NUMBER OF NODES SAMPLED (POST SENTINEL NODE COMPLETION LYMPHADENECTOMY)
R	NUMBER OF NODES POSITIVE (POST SENTINEL NODE COMPLETION LYMPHADENECTOMY)


UPPER GASTROINTESTINAL (GI): VARIOUS - PATHOLOGY To carry pathology details for various Upper Gastrointestinal (GI) cancers.One occurrence of this data group is permitted.
Mandation	Data Elements
R	NUMBER OF COLORECTAL METASTASES IN LIVER
R	MARGIN INVOLVED INDICATION CODE (PROXIMAL OR DISTAL RESECTION MARGIN)
R	MARGIN INVOLVED INDICATION CODE (CIRCUMFERENTIAL MARGIN)


UROLOGICAL: BLADDER - PATHOLOGY To carry pathology details for Urological cancer for the bladder.One occurrence of this group is permitted.
Mandation	Data Elements
R	DETRUSOR MUSCLE PRESENCE INDICATION CODE
R	TUMOUR GRADE (UROLOGY)


UROLOGICAL: KIDNEY - PATHOLOGY To carry pathology details for Urological cancer for the kidney.One occurrence of this group is permitted.
Mandation	Data Elements
R	TUMOUR NECROSIS INDICATION CODE
R	TUMOUR INVASION INDICATOR (PERINEPHRIC FAT)
R	TUMOUR INVASION INDICATION CODE (DIRECT ADRENAL)
R	RENAL VEIN TUMOUR THROMBUS INDICATION CODE (UROLOGICAL)
R	TUMOUR INVASION INDICATOR (GEROTAS FASCIA)


UROLOGICAL: PENIS - PATHOLOGY To carry pathology details for Urological cancer for the penis.One occurrence of this group is permitted.
Mandation	Data Elements
R	TUMOUR INVASION INDICATOR (CORPUS SPONGIOSUM)
R	TUMOUR INVASION INDICATOR (CORPUS CAVERNOSUM)
R	TUMOUR INVASION INDICATOR (URETHRA OR PROSTATE)


UROLOGICAL: PROSTATE - PATHOLOGY To carry pathology details for Urological cancer for prostate.One occurrence of this group is permitted.
Mandation	Data Elements
R	GLEASON GRADE (PRIMARY)
R	GLEASON GRADE (SECONDARY)
R	GLEASON GRADE (TERTIARY)
R	PERINEURAL INVASION INDICATOR (UROLOGICAL)
R	TURP TUMOUR PERCENTAGE


UROLOGICAL: TESTICULAR - PATHOLOGY To carry pathology details for Urological cancer for testicular.One occurrence of this group is permitted.
Mandation	Data Elements
M	TUMOUR INVASION INDICATOR (RETE TESTIS)

Also Known As

This data set is also known by these names:

Context	Alias
Also known as	Cancer Outcomes and Services Data Set: Pathology
Full name	Pathology Data Set
Short name	Pathology