Gynaecological cancer (clinical) NBPDS

Identifying and definitional attributes
Metadata item type:	Data Set Specification
METEOR identifier:	599620
Registration status:	Health, Standard 14/05/2015
DSS type:	Data Set Specification (DSS)
Scope:	The purpose of the Gynaecological cancer (clinical) National best practice data set (NBPDS) is to define data standards for the national collection of gynaecological cancer data so that data collected is consistent and reliable. The data set is not mandated for collection but is recommended as best practice if gynaecological cancer data is to be collected. It enables individual treatment centres or health service areas to develop collection methods and policies appropriate for their service. The Gynaecological cancer (clinical) NBPDS is used in conjunction with the Cancer (clinical) NBPDS (CCNBPDS). The data elements with obligations described as mandatory or conditional for collection are recommended as best practice, while the data items described as optional are for collection at the discretion of the treating centre and may be contingent, for example, on the availability of resources. The scope for the Gynaecological cancer (clinical) NBPDS is to collect comprehensive data encompassing the time a person is first referred for the investigation of symptoms and for the entire duration of their illness so that treatment and outcomes are captured. The definitions used in this data set are designed to capture the provision of cancer care on a day-to-day level. They relate to the realities of cancer care and the need to optimise care by correctly diagnosing, evaluating and managing patients with gynaecological cancer. The data elements specified provide a framework for: providing a systematic foundation and promoting the delivery of evidence-based care to patients with gynaecological cancer informing treatment guidelines and professional education informing quality assurance guiding resource planning and the evaluation of cancer control activities Many of the data elements in this data set may also be used in the collection of data for other types of cancer. This data set is primarily directed at the clinical and clinical epidemiological use of cancer data. Treatment centres such as hospitals, radiotherapy centres and cancer specialist practices are the settings in which implementation of the Gynaecological cancer (clinical) NBPDS should be considered. The data set can also be used by a wider range of health and health-related establishments that create, use or maintain records on health-care clients.

Source and reference attributes

Submitting organisation:

Cancer Australia

Relational attributes

Related metadata references:

Metadata items in this Data Set Specification

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Seq No.	Metadata item	Obligation	Max occurs
1	Person with cancer—cytopathology result, code N	Mandatory	29
2	Person with cancer—lymphovascular invasion indicator, yes/no code N	Mandatory	1
3	Person with cancer—location of lymphovascular invasion of cervix, code N *Conditional obligation:* This data element is only to be recorded for patients with cervical cancer, as indicated by Person with cancer—primary site of cancer, topography code (ICD-O-3) ANN.N, and when Person with cancer—lymphovascular invasion indicator, yes/no code N indicates the presence of lymphovascular invasion.	Conditional	5
4	Person with cancer—location of lymphovascular invasion of corpus uteri, code N *Conditional obligation:* This data element is only to be recorded for patients with endometrial cancer, as indicated by Person with cancer—primary site of cancer, topography code (ICD-O-3) ANN.N, and when Person with cancer—lymphovascular invasion indicator, yes/no code N indicates the presence of lymphovascular invasion.	Conditional	5
5	Person with cancer—extent of primary cancer, cervical cancer staging (FIGO) code N[N] *Conditional obligation:* This data element is only to be recorded for patients with cervical cancer, as indicated by Person with cancer—primary site of cancer, topography code (ICD-O-3) ANN.N.	Conditional	1
6	Person with cancer—extent of primary cancer, endometrial cancer staging (FIGO) code N[N] *Conditional obligation:* This data element is only to be recorded for patients with endometrial cancer, as indicated by Person with cancer—primary site of cancer, topography code (ICD-O-3) ANN.N.	Conditional	1
7	Person with cancer—extent of primary cancer, ovarian cancer staging (FIGO) code N[N] *Conditional obligation:* This data element is only to be recorded for patients with ovarian cancer, as indicated by Person with cancer—primary site of cancer, topography code (ICD-O-3) ANN.N.	Conditional	1
8	Person with cancer—distant metastatic cancer indicator, yes/no/not stated/inadequately described code N	Mandatory	1
9	Person with cancer—distant metastatic site(s) at diagnosis, code N[N] *Conditional obligation:* This data element is to be completed if Person with cancer—distant metastatic cancer indicator, yes/no/not stated/inadequately described code N indicates the presence of metastatic cancer.	Conditional	20
10	Person with cancer—depth of myometrial invasion, total millimetres N[N] *Conditional obligation:* This data element is only to be recorded for patients with endometrial cancer, as indicated by Person with cancer—primary site of cancer, topography code (ICD-O-3) ANN.N.	Conditional	1
11	Person with cancer—myometrial thickness, total millimetres N[N] *Conditional obligation:* This data element is only to be recorded for patients with endometrial cancer, as indicated by Person with cancer—primary site of cancer, topography code (ICD-O-3) ANN.N.	Conditional	1
12	Person with cancer—depth of cervical cancer invasion, total millimetres N[N] *Conditional obligation:* This data element is only to be recorded for patients with cervical cancer, as indicated by Person with cancer—primary site of cancer, topography code (ICD-O-3) ANN.N.	Conditional	1
13	Person with cancer—tumour outside primary site indicator, yes/no/not stated/inadequately described code N	Mandatory	1
14	Person with cancer—tumour size outside primary site, code N	Mandatory	1
15	Person with cancer—multiple primary tumours indicator, yes/no code N	Mandatory	1
16	Person with cancer—multiple primary tumours descriptor, code N *Conditional obligation:* This data element is to be recorded if Person with cancer—multiple primary tumours indicator, yes/no code N indicates the presence of multiple primary tumours.	Conditional	1
17	Person—tissue sample collected indicator, yes/no code N	Mandatory	30
18	Organisation—organisation name, text X[X(199)] *Conditional obligation:* This data element is to be recorded when the data element Person—tissue sample collected indicator, yes/no code N indicates that a tissue sample has been collected. *DSS specific information:* Use this data element to record the name of the laboratory or biobank in which a tissue sample is stored. Collect this data element in conjunction with Person—tissue sample collected indicator, yes/no code N.	Conditional	10
19	Medical specialist—surgical specialty, initial gynaecological surgical speciality code N[N] *Conditional obligation:* This data element is only to be recorded for patients who have undergone surgery relating to their initial course of treatment for gynaecological cancer.	Conditional	10
20	Cancer treatment—post-initial surgery residual tumour size category, code N *Conditional obligation:* This data element is to be recorded then the data element Cancer treatment—residual (R) tumour indicator, yes/no code N indicates the presence of residual tumour after surgery.	Conditional	20
21	Cancer treatment—residual (R) tumour indicator, yes/no code N *Conditional obligation:* This data element is to be recorded for patients with ovarian cancer and stage IV endometrial cancer when surgical treatment for gynaecological cancer has been completed.	Conditional	1
22	Cancer treatment—primary surgical treatment complication indicator, yes/no/unknown code N	Mandatory	1
23	Cancer treatment—treatment complication type, cancer-related primary surgery complication type code N[N] *Conditional obligation:* This data element is to be recorded when Cancer treatment—primary surgical treatment complication indicator, yes/no/unknown code N indicates the presence of a treatment complication.	Conditional	10
24	Cancer treatment—gynaecological cancer post-radiotherapy complication indicator, yes/no/unknown code N *Conditional obligation:* This data element should be recorded in relation to the primary course of treatment for gynaecological cancer. *DSS specific information:* This relates to the primary course of treatment for gynaecological cancer.	Conditional	1
25	Cancer treatment—treatment complication type, gynaecological cancer-related radiotherapy code N *Conditional obligation:* This data element should be recorded when Cancer treatment—gynaecological cancer post-radiotherapy complication indicator, yes/no/unknown code N indicates the presence of a radiotherapy related treatment complication.	Conditional	10
26	Cancer treatment—treatment complication type, text X[X(149)] *Conditional obligation:* This data element is to be recorded when either Cancer treatment—treatment complication type, gynaecological cancer-related radiotherapy code N or Cancer treatment—treatment complication type, cancer-related primary surgery complication type code N[N] indicates an 'Other' type of treatment complication.	Conditional	10
27	Cancer treatment—systemic therapy treatment modification indicator, yes/no/unknown code N *Conditional obligation:* This data element is to be recorded for patients who have undergone systemic therapy as part of their cancer treatment. This includes chemotherapy, hormone therapy and immunotherapy.	Conditional	1
28	Cancer treatment—treatment modification type for cancer-related systemic therapy, code N[N] *Conditional obligation:* This data element is to be recorded when Cancer treatment—systemic therapy treatment modification indicator, yes/no/unknown code N indicates a modification to planned systemic therapy treatment.	Conditional	10
29	Cancer treatment—treatment plan modification, text X[X(149)] *Conditional obligation:* This data element is to be recorded when Cancer treatment—treatment modification type for cancer-related systemic therapy, code N[N] indicates an 'Other' type of treatment modification.	Conditional	10
30	Cancer treatment—primary course of chemotherapy delay indicator, yes/no/unknown code N *Conditional obligation:* This data element is to be recorded for patients who have undergone chemotherapy as part of their cancer treatment.	Conditional	5
31	Cancer treatment—primary course of chemotherapy delay reason, code N *Conditional obligation:* This data element is to be recorded when Cancer treatment—chemotherapy delay indicator, yes/no/unknown code N indicates a delay in planned chemotherapy treatment.	Conditional	10
32	Cancer treatment—cancer treatment type, code N[N] *Conditional obligation:* This data element is to be recorded for a patient having a first recurrence of cancer. All treatments administered to the patient during the first recurrence of cancer should be recorded. *DSS specific information:* This data element is to be recorded separately for the primary course of treatment and treatment for the first recurrence of cancer. All treatments administered to the patient as part of the primary course of treatment for the first recurrence of cancer should be recorded.	Conditional	5
33	Cancer treatment—other cancer treatment, text X[X(149)] *Conditional obligation:* This data element is to be recorded for a patient having treatment that cannot be defined as surgery, radiotherapy or systemic therapy according to the definitions of those data items in this data set. *DSS specific information:* This data element is to be used to describe treatment, other than surgery, radiotherapy or systemic therapy, used to treat a first recurrence of gynaecological cancer.	Conditional	10
34	Cancer treatment—outcome of treatment, code N.N *Conditional obligation:* This data element is conditional on a patient completing treatment for their first recurrence of cancer. *DSS specific information:* This data element is to be recorded for patients who have completed their primary course of treatment or treatment for the first recurrence of cancer. For patients who have completed treatment for their first recurrence of cancer this should be recorded multiple times, once in relation to their primary course of treatment and once in relation to treatment for the first recurrence of cancer.	Conditional	5

Gynaecological cancer (clinical) NBPDS

Identifying and definitional attributes

Source and reference attributes

Relational attributes

Metadata items in this Data Set Specification

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