NKCA SotN 2024 Methodological Supplement
Source: data.gov.uk (2024-09-19)

National Kidney Cancer Audit State of the Nation Report 2024. The National Kidney Cancer Audit (NKCA) aims to evaluate the patterns of care and outcomes for people with kidney cancer in England and Wales, using routinely collected data and to support services to improve their care quality.

This State of the Nation report aims to help NHS organisations to benchmark their kidney cancer care against measurable standards, to identify unwarranted variation in measures of processes and outcomes, and to describe national levels and patterns of these measures in England and Wales.

The performance indicators include people diagnosed with kidney cancer between January 2017 to December 2021 in England using the National Cancer Registration Dataset (NCRD), and January 2022 to December 2022 in Wales. It reports on eight performance indicators for England and four for Wales outlined in the NKCA Quality Improvement Plan 2024. The report also describes the national picture and variation between NHS trusts in England/Health Boards in Wales. 

For the national picture sections, we use the most recently available data in England from the Rapid Cancer Registration Dataset (RCRD) reporting on people diagnosed between 1st January 2019 and 30th September 2023, and in Wales between 1st January 2022 and 31st December 2022.

National Kidney Cancer Audit
State of the Nation Report 2024
Methodological Supplement

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NKCA State of the Nation Report 2024 - Methodological Supplement

Contents
Abbreviations ........................................................................................................ 3
Introduction .......................................................................................................... 3
Overview of audit design ......................................................................................... 4
Inclusion / exclusion criteria ................................................................................. 4
Indicator definitions ............................................................................................ 4
Outlier process ................................................................................................... 5
Sources of data ...................................................................................................... 5
English datasets .................................................................................................. 5
Welsh datasets ................................................................................................... 6
Data definitions ..................................................................................................... 7
Coding of key data items ...................................................................................... 7
Completeness of key data items ............................................................................... 9
Patient characteristics / important clinical variables .................................................. 10
Indicator definitions ............................................................................................. 13
PI1: Percentage of people with kidney cancer with the data completeness measure
recorded for MDT meeting ................................................................................. 13
PI2: Percentage of people with kidney cancer who are consented for a clinical trial .... 14
PI3: Percentage of people with a small renal mass (≤4cm) who have a biopsy ............ 15
PI4: Percentage of people with a T3+ and/or 10cm+ and/or N1 and M0 renal cell
carcinoma (RCC) who have a radical nephrectomy within 31 days of decision to treat . 16
PI5: Percentage of people with T1b-3NxM0 RCC (T2-3NxM0 RCC for Wales) who have
surgery............................................................................................................ 17
PI6: Percentage of people with T1aN0M0 RCC who undergo nephron sparing treatment
...................................................................................................................... 18
PI7: Percentage of people presenting with M1 RCC who have initial SACT within 12
months of diagnosis .......................................................................................... 19
PI8: Percentage of people with kidney cancer who die within 30 days of starting SACT
treatment ........................................................................................................ 20
Statistical analysis ................................................................................................ 20
NHS organisations ............................................................................................. 20
Risk adjustment of indicators ............................................................................. 21
References .......................................................................................................... 22

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Abbreviations
Acronym
Description
CaNISC
Cancer Information System for Wales
CCI
Charlson Comorbidity Index
COSD
Cancer Outcomes and Services Dataset
ECOG
Eastern Cooperative Oncology Group
HES APC
Hospital Episode Statistics Admitted Patient
Care
ICD-10
International classification of diseases and
related health problems,10th
revision
IMD
Index of Multiple Deprivation
LSOA
Lower Super Output Areas
MDT
Multidisciplinary Team
NCDR
National Cancer Data Repository
NCRD
National Cancer Registration Dataset
NDRS
National Disease Registration Service
NKCA
National Kidney Cancer Audit
NSS
Nephron sparing surgery
ONS
Office for National Statistics
PEDW
Patient Episode Database for Wales
PI
Performance indicator
PS
Performance status
RCC
Renal cell carcinoma
RCRD
Rapid cancer registry data
RCS
Royal College of Surgeons of England
RN
Radical nephrectomy
RTDS
Radiotherapy dataset
SACT
Systemic anti-cancer dataset
WCN
Wales Cancer Network

Introduction
The purpose of this document is to share the methodology of the NKCA State of the Nation
(SotN) report 2024.

In this report, we make use of the ‘gold-standard’ National Cancer Registration Dataset
(NCRD) and the Rapid Cancer Registration Dataset (RCRD) for England as well as the NKCA
dataset from Wales (described below) to describe process and outcome measures from
selected aspects of the care pathway for people with kidney cancer.

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Overview of audit design
Inclusion / exclusion criteria
Patients are eligible for inclusion in the prospective audit if they have newly diagnosed
kidney cancer using the ICD10 diagnostic code of “C64” (malignant neoplasm of kidney,
except renal pelvis).

A patient is included in the prospective audit in England if they have a record of newly
diagnosed kidney cancer in the National Cancer Registration Dataset (or Rapid Cancer
Registration Dataset). A patient is included in the prospective audit in Wales if a completed
NKCA record was submitted and the Wales Cancer Network (WCN) can assign that record to
a diagnosing Health Board.

Inclusion criteria:
• Tumour group listed as “Kidney” and site ICD-10 code listed as “C64”

Exclusion criteria:
• Younger than 18 years old when diagnosed
• Diagnosed via death certificate only
• Date of diagnosis is the same as Office of National Statistics (ONS) date of death
• Diagnosed and treated outside of an NHS organisation in England or Wales
• Provider (e.g. Trust or Health Board) of diagnosis is not provided

Multiple kidney cancer tumours
Where someone had more than one kidney cancer tumour record, only one tumour record
was analysed. This record was prioritised by:
1) Tumour with earliest diagnosis date was analysed
a. Note: Tumours with earlier diagnosis date were prioritised to avoid picking up
any recurrences
2) (If tumours had the same diagnosis date) Tumour with complete TNM was analysed
3) (If tumours had same diagnosis date and all had TNM complete/incomplete) The
tumour with the most advanced stage based on TNM was analysed

Indicator definitions
Table 1. Cancer registration dataset and time period that define the population for each performance
indicator
Performance indicators
England
Wales
PI1: Percentage of people with kidney cancer with the data
completeness measure recorded for MDT meeting
National Cancer
Registration Dataset
(NCRD)

People with kidney
cancer diagnosed
between
01/xx-xxxx-xxxx
Cancer Network
Information
System Cymru
(CaNISC)

People with kidney
cancer diagnosed
between
01/xx-xxxx-xxxx
PI2: Percentage of people with kidney cancer who are
consented for a clinical trial (England only) *
PI3: Percentage of people with a small renal mass (≤4cm)
who have a biopsy (England only) *
PI4: Percentage of people with a T3+ and/or 10cm+ and/or
N1 and M0 renal cell carcinoma (RCC) who have a radical

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Performance indicators
England
Wales
nephrectomy within 31 days of decision to treat (England
only) *
PI5: Percentage of people with T1b-3NxM0 RCC (T2-3NxM0
RCC for Wales) who have surgery
PI6: Percentage of people with T1aN0M0 RCC who undergo
nephron sparing treatment
PI7: Percentage of people presenting with M1 RCC who have
initial SACT within 12 months of diagnosis
NCRD
People with kidney
cancer diagnosed
between
01/xx-xxxx-xxxx
PI8: Percentage of people with kidney cancer who die within
30 days of starting SACT treatment
*Measured in England only due to the availability of relevant data for Wales. MDT: Multi-disciplinary team; SACT: systemic
anti-cancer therapy.

More detail on how the indicators were calculated can be found in the indicator definitions
section below.

Outlier process
Further information about the outlier process can be found in the FAQs for NATCAN (point
17).

Sources of data
English datasets

In England, the National Kidney Cancer Audit (NKCA) works with the National Disease
Registration Service (NDRS), NHS England, as a data collection partner. NDRS collects patient-
level data from all NHS acute providers using a range of national data-feeds. This includes
the Cancer Outcomes and Services Dataset (COSD), which specifies the data items that need
to be submitted. Data are submitted to the National Cancer Data Repository (NCDR) on a
monthly basis via MDT (Multidisciplinary Team) electronic data collection systems. Clinical
sign-off of data submitted to NDRS is not mandated in England. For this State of the Nation
report NCRAS provided data from the ‘gold-standard’ National Cancer Registration Dataset
(NCRD) and the Rapid Cancer Registration Dataset (RCRD).

National Cancer Registration Dataset (NCRD) and Rapid Cancer Registration Dataset
(RCRD)

This year, we choose to use the NCRD to report on our performance indicators and use the
RCRD for the national picture sections of the report. The NCRD undergoes more processing
to improve its data completeness compared to the RCRD and also contains a broader range
of variables. On the other hand, the RCRD has the advantage that it is available to us much
more quickly after a patient is diagnosed so we can conduct more timely analyses. The

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National Prostate Cancer Audit (NPCA) has found that RCRD captures approximately 90% of
prostate cancer diagnoses that are seen in the NCRD dataset, with consistent completeness
of data collection across trusts.

Completeness of Cancer Registrations

As with cancer registries in other countries, cancer registrations in England can take up to 5
years after the end of a given calendar year to reach 100% completeness and stability. NDRS
uses an active system of gathering information on cancer diagnoses from multiple sources
across the patient pathway. Completeness varies by tumour type because different patient
pathways provide different opportunities for data flows into NDRS. The ‘Gold standard’
cancer registration dataset (NCRD) that is used in cancer statistics bulletins and available for
analysis outside of NDRS contains over 98% of all the people that will eventually be found by
the registration process, and the completeness for a calendar year of data increases over
time. More information about the cancer registration process can be found here.

In future years the NKCA will work to align the reporting periods in England and Wales, and
to provide more timely reporting. In England this will require the use of Rapid Cancer
Registration Data (RCRD) as well as ‘gold standard’ National Cancer Registration Data
(NCRD)1, and development work is needed to ensure the RCRD is of sufficient data quality.

Welsh datasets

The NKCA’s data collection partner in Wales is the Wales Cancer Network (WCN), Public
Health Wales. The NKCA dataset is captured through a national system, Cancer Information
System Cymru (CaNISC), after identification by hospital cancer services and uploaded via
electronic MDT data collection systems. Prior to submission of NKCA data to the WCN, each
patient record is validated (frequently by an MDT coordinator) and signed off by a
designated clinician. Patient records are signed off when all key data items have been
completed. For this annual report, WCN have provided, as usual, Cancer Network
Information System Cymru (CaNISC), Patient Episode Database for Wales (PEDW) and Office
for National Statistics (ONS) data in Wales.

We urge centres to work with their data collection leads to ensure kidney cancer data is
collected as completely as possible as the audit is only as accurate as the data we receive.

This report presents results from the prospective audit for men diagnosed with, or treated
for, kidney cancer between January 2019 and September 2023 in England and between
January 2022 and December 2022 in Wales. For England, diagnoses were linked to data from
Hospital Episode Statistics (HES), the Radiotherapy Dataset (RTDS) and the Systemic Anti-
Cancer Therapy dataset (SACT). For Wales, data are captured through Cancer Network

1 The audits in NATCAN do not ‘collect’ clinical data. The cancer audits utilise the nationally mandated flows of data from hospitals
to the National Disease Registration Service (NDRS) in NHSE and the Wales Cancer Network in Public Health Wales, thereby
minimising the burden of data collection on provider teams. Further information about the timeliness of National Cancer
Registration Dataset (NCRD) can be found on the NATCAN website https://www.natcan.org.uk/resources/timeliness-of-the-
national-cancer-registration-dataset-ncrd/

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Information System Cymru (CaNISC) and linked to additional data items from the Patient
Episode Database for Wales (PEDW), Office for National Statistics (ONS) and CaNISC.

Data definitions
Coding of key data items

Table 2. Data sources and identification methods for different kidney cancer procedure types
Procedure
Data Source
Identification Method
Biopsy
England: HES APC
Wales: CaNISC,
PEDW
Table C4. Renal Biopsy OPCS-4 codes
Surgery
England: HES APC
Wales: CaNISC,
PEDW
Table C1. Radical nephrectomy OPCS-4 codes, Table
C2. Nephron sparing surgery OPCS-4 codes
Ablation
England: HES APC
Wales: PEDW
Identified by all the codes in Table C3. Ablation OPCS-
4 codes
SACT

England: SACT
For patients without a record of another type of
cancer, all records in SACT were counted. For patients
with a record of another type of cancer, only records
in SACT where the primary diagnosis was C64 were
counted
England: HES APC
Wales: PEDW
SACT was identified by all the codes in Table C6.
Systemic therapy OPCS-4 codes and Table C7.
Systemic therapy ICD-10 codes as long as they were
accompanied by C64 in diag1 or a metastasis code in
diag1 (C77/C78/C79) with C64 in diag2

Lists of surgical codes used

Table C1. Radical nephrectomy OPCS-4 codes
OPCS-4
Description
M02.1
Nephrectomy and excision of perirenal tissue
M02.5
Nephrectomy NEC
M02.8
Other specified total excision of kidney
M02.9
Unspecified total excision of kidney

Table C2. Nephron sparing surgery OPCS-4 codes
OPCS-4
Description
M03.8
Other specified partial excision of kidney
M03.9
Unspecified partial excision of kidney
M04.2
Open excision of lesion of kidney NEC

Table C3. Ablation OPCS-4 codes

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OPCS-4
Description
M10.4
Endoscopic cryoablation of lesion of kidney
M13.7
Percutaneous radio frequency ablation of lesion of kidney
Y11.2
Cryotherapy to organ NOC
Y13.7
Microwave destruction of lesion of organ NOC

Table C4. Renal biopsy OPCS-4 code
OPCS-4
Description
M13.1
Percutaneous needle biopsy of lesion of kidney

Table C5. Surgery approach OPCS-4 codes – secondary codes
OPCS-4
Description
Laparoscopic
Y75.1
Approach Abdominal Cavity Laparoscopically Assisted
Y75.2
Approach Abdominal Cavity Laparoscopic NEC
Y75.4
Approach Abdominal Cavity Hand Assisted Minimal Access
Robotic
Y75.3
Approach Abdominal Cavity Robotic Assisted Minimal Access &
Approach Abdominal Cavity Robotic Minimal Access
* Surgeries which were not accompanied by a code which suggested that they had a laparoscopic or robotic approach
(Table C5) were assumed to be open procedures.

Lists of systemic therapy codes used

Table C6. Systemic therapy OPCS-4 codes
OPCS-4
Description
X29.2
Continuous intravenous infusion of therapeutic substance NEC
X35.2
Intravenous chemotherapy
X37.3
Intramuscular chemotherapy
X38.4
Subcutaneous chemotherapy
X39.1
Oral administration of therapeutic substance
X70.1
Procurement of drugs for chemotherapy for neoplasm for regimens in Band 1
X70.2
Procurement of drugs for chemotherapy for neoplasm for regimens in Band 2
X70.3
Procurement of drugs for chemotherapy for neoplasm for regimens in Band 3
X70.4
Procurement of drugs for chemotherapy for neoplasm for regimens in Band 4
X70.5
Procurement of drugs for chemotherapy for neoplasm for regimens in Band 5
X70.8
Other specified procurement of drugs for chemotherapy for neoplasm in Bands
1-5
X70.9
Unspecified procurement of drugs for chemotherapy for neoplasm in Bands 1-5
X71.1
Procurement of drugs for chemotherapy for neoplasm for regimens in Band 6
X71.2
Procurement of drugs for chemotherapy for neoplasm for regimens in Band 7
X71.3
Procurement of drugs for chemotherapy for neoplasm for regimens in Band 8
X71.4
Procurement of drugs for chemotherapy for neoplasm for regimens in Band 9
X71.5
Procurement of drugs for chemotherapy for neoplasm for regimens in Band 10

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X71.8
Other specified procurement of drugs for chemotherapy for neoplasm in Bands
6-10
X71.9
Unspecified procurement of drugs for chemotherapy for neoplasm in Bands 6-
10
X72.1
Delivery of complex chemotherapy for neoplasm including prolonged infusional
treatment
at first attendance
X72.2
Delivery of complex parenteral chemotherapy for neoplasm at first attendance
X72.3
Delivery of simple parenteral chemotherapy for neoplasm at first attendance
X72.4
Delivery of subsequent element of cycle of chemotherapy for neoplasm
X72.8
Other specified delivery of chemotherapy for neoplasm
X72.9
Unspecified delivery of chemotherapy for neoplasm
X73.1
Delivery of exclusively oral chemotherapy for neoplasm
X73.8
Other specified delivery of oral chemotherapy for neoplasm
X73.9
Unspecified delivery of oral chemotherapy for neoplasm
X74.8
Other specified other chemotherapy drugs
X74.9
Unspecified other chemotherapy drugs

Table C7. Systemic therapy ICD-10 codes
ICD-10
Description
Z08.2
Follow-up examination after chemotherapy for malignant neoplasm
Z29.2
Other prophylactic chemotherapy
Z51.1
Chemotherapy session for neoplasm
Z51.2
Other chemotherapy
Z54.2
Convalescence following chemotherapy

Completeness of key data items
The completeness of five key data items (performance status, T, N, M stage and ethnicity) in
England and Wales is reported below.

Table 3. Data completeness for selected data items for people newly diagnosed with kidney cancer in
England between 1st January 2019 and 31st December 2021 and in Wales between 1st January 2022
and 31st December 2022.
Data variable
England
Wales
N
% complete
N
% complete
Time period
covered
1 Jan 2019 – 31 Dec 2021
1 Jan 2022 – 31 Dec 2022
No. of people
with a new
diagnosis of
kidney cancer
28,229
[NCRD]

490
[CaNISC]

Performance
status
11,217
[NCRD]
40%
344
[CaNISC]
70%
T stage
22,360
79%
364
74%

10
[NCRD]
[CaNISC]
N stage
20,214
[NCRD]
72%
330
[CaNISC]
67%
M stage
21,614
[NCRD]
77%
314
[CaNISC]
64%
Ethnicity
26,650
[NCRD]
94%
285
[PEDW]
58%

Patient characteristics / important clinical variables

Comorbidity status

The NKCA team used the Royal College of Surgeons of England (RCS) modified Charlson
Comorbidity Index (CCI) to measure the comorbidity burden of patients (see Armitage et al.1
for details).

The CCI is a commonly used scoring system for medical comorbidities. It consists of a
grouped score that is calculated based on the absence (0) or presence (≥1) of the pre-
specified medical conditions listed in Table 4. The CCI was calculated using information on
secondary diagnoses (ICD-10 codes) in the hospital admission data (HES/PEDW) recorded
within the 12-month period prior to a patient’s diagnosis. The CCI score was used to perform
risk-adjustment for certain performance indicators. Indicators for which risk adjustment was
performed are outlined in Table 6.

Table 4. Pre-specified conditions included in the assignment of Charlson Comorbidity Index
score
Medical condition
ICD-10 diagnostic code(s)
AIDS/HIV infection
B20; B21; B22; B23; B24
Cerebrovascular disease
G45; G46; I6
Chronic pulmonary disease
Chronic: I26; I27; J40; J41; J42; J43; J44; J45;
J47; J60; J61;
J62; J63; J64; J65; J66; J67; J684; J701; J703
Acute: J46**
Congestive cardiac failure
I11; I13; I42; I43; I50; I255; I517
Dementia
A810; F00; F01; F02; F03; F051; G30; G31
Diabetes mellitus
E10; E11; E12; E13; E14
Hemiplegia or paraplegia
G114; G81; G82; G83
Liver disease
B18; I85; I864; I982; K70; K71; K721; K729;
K76; R162;
Z944
Metastatic solid tumour
C77; C78; C79
Myocardial infarction (MI)
Acute MI: I21**; I22**; I23**
History of MI: I252
Peripheral vascular disease
I70; I71; I72; I73; I770; I771; K551; K558;
K559; R02; Z958;

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Z959
Renal disease (RD)
Chronic: I12; I13; N01; N03; N05; N07; N08;
N18; N25; Z49;
Z940; Z992
Acute: N171**; N172**; N19**
Rheumatological disease
M05; M06; M09; M120; M315; M32; M33;
M34; M35; M36
** Code associated with an acute episode, only counted in admissions prior to the index admission.

Deprivation / socioeconomic status

In England and Wales, small regional areas are assigned a measure of social deprivation,
called the Index of Multiple Deprivation (IMD). The Index is constructed from various
individual deprivation scales and a score is derived for each area (Lower Super Output Areas
[LSOA]), which contain approximately 1500 people) in England and Wales. Separate IMD
scores are derived from England and Wales. In the analyses, patients were categorised into
one of five socioeconomic groups (1=least deprived; 5=most deprived) based on the IMD
score of the area in which they lived. The five categories were based on the quintiles of the
ranked IMD scores.

Performance status

Performance status is used by clinicians to classify a patient’s functional impairment. It is
used to group patients when comparing treatment effectiveness and assessing prognosis to
help remove differences in patient case-mix. This is important for the audit because the
distribution of patient performance status can vary between organisations, and case mix
adjustment is required for some indicators. Details of the indicators for which case mix
adjustment was performed can be found in Table 6.

Various scoring systems exist for evaluating performance status. The World Health
Organisation classification is collected by the cancer registration services. Table 5 outlines
the World Health Organisation classification. Clinicians use standard criteria to assign
patient’s a performance status score, and each category describes the extent to which a
person can perform activities of daily living.

Table 5. Performance status classification, as defined by the World Health Organisation classification
Grade
Description
0
Able to carry out all normal activity without restriction
1
Restricted in strenuous activity but ambulatory and able to carry out light
work
2
Ambulatory and capable of all self-care but unable to carry out any work
activities; up and about more than 50% of waking hours
3
Symptomatic and in a chair or in bed for greater than 50% of the day but
not bedridden
4
Completely disabled; cannot carry out any self-care; totally confined to
bed or chair

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TNM/staging

The anatomical extent of a cancer. This indicates whether a cancer is only present in the
kidney/primary site (localised disease) or whether it has spread to other areas of the body
(metastatic spread). It is usually denoted by the TNM staging process where “T” represents
the local stage, “N” the presence of lymph node involvement and “M” represents the
presence of metastatic disease.

T1 is divided into T1a and T1b depending on how big the cancer is:
• T1a means the cancer measures 4cm or less
• T1b means the cancer measures between 4cm and 7cm
T2 is divided into T2a and T2b depending on size:
• T2a means the cancer measures between 7cm and 10cm
• T2b means the cancer measures more than 10cm but completely inside the kidney
T3 is divided into T3a, T3b and T3c depending on whether the cancer has grown into
surrounding tissues or main blood vessels:
• T3a means the cancer has grown into the nearby tissues or the renal vein
• T3b means the cancer has grown into the vena cava, but hasn't spread above the
diaphragm (sheet of muscle that separates chest and abdominal cavity, which helps
us breathe)
• T3c means the cancer has grown into the vena cava and spread above the
diaphragm. Or has grown into the wall of the vena cava
T4 means the cancer has spread beyond the layer of tissue around the kidney (fascia). It
might have spread into the adrenal gland above the kidney
N0 means that the nearby lymph nodes do not contain cancer cells
N1 means there are cancer cells in lymph nodes near the kidney
M0 means the cancer has not spread to other parts of the body
M1 means the cancer has spread to other parts of the body such as the lungs

For Wales, any TNM stages recorded as X e.g. MX were regarded as M stage was not known.

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Indicator definitions
PI1: Percentage of people with kidney cancer with the data completeness
measure recorded for MDT meeting

Indicator
Percentage of people with kidney cancer
with the data completeness measure
recorded for MDT meeting
Notes
Denominator
Number of people with a new diagnosis of
kidney cancer

Numerator
Number of people with kidney cancer with
MDT meeting recorded

Exclusions
None

Country
England and Wales
England: MDT meeting was
classified as recorded if date
of first MDT meeting was
recorded
Wales: MDT meeting was
classified as recorded if it was
recorded that treatment plan
was discussed by the MDT
Time Periods
England: People with kidney cancer
diagnosed between Jan 2019 – Dec 2021
Wales: People with kidney cancer
diagnosed between Jan 2022 – Dec 2022

Reporting level
England: Presented at the level of
diagnosing Trust
Wales: Presented at the level of
diagnosing Health Board

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PI2: Percentage of people with kidney cancer who are consented for a clinical
trial

Indicator
Percentage of people with kidney cancer
who are consented for a clinical trial
Notes
Denominator
Number of people with a new diagnosis of
kidney cancer and whether they
participated in a clinical trial recorded

Numerator
Number of people with kidney cancer who
are consented for a clinical trial

Exclusions
People who didn’t have whether they
participated in a clinical trial recorded

Country
England only
Wales was excluded as there
was no equivalent data item
about whether a person was
consented to a clinical trial
Time Periods
People with kidney cancer diagnosed
between Jan 2019 – Jan 2021

Reporting level
Presented at the level of the diagnosing
Trust

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PI3: Percentage of people with a small renal mass (≤4cm) who have a biopsy

Indicator
Percentage of people with a small renal
mass (≤4cm) who have a biopsy
Notes
Denominator
Number of people who have ≤4cm or
T1aN0M0 renal mass

Numerator
Number of people who have ≤4cm or
T1aN0M0 renal mass who have a biopsy

Exclusions
People with N1 RCC, people with M1
RCC, people with tumour size > 4cm,
people with ≥ T1b RCC
We included people with T1a
RCC who were missing N and/or
M stage as it is our clinical
assumption that these patients
are N0 and M0
Country
England only
Wales was excluded from this
indicator as only 5% of the T1
RCC was differentiated into T1a
or T1b and there was no
tumour/lesion size available in
the Welsh data
Time periods
People with kidney cancer diagnosed
between Jan 2019 – Dec 2021

Reporting level
Presented at the level of diagnosing Trust
Codes used
Table C4. Renal Biopsy OPCS-4 codes

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PI4: Percentage of people with a T3+ and/or 10cm+ and/or N1 and M0 renal
cell carcinoma (RCC) who have a radical nephrectomy within 31 days of
decision to treat

Indicator
Percentage of people with a T3+
and/or 10cm+ and/or N1 and M0
renal cell carcinoma (RCC) who have
a radical nephrectomy within 31
days of decision to treat
Notes
Denominator
Number of people with T3+ and/or
10cm+ and/or N1 and/or stage 3
renal cell carcinoma (RCC) who have
a radical nephrectomy

Numerator
Number of people with T3+ and/or
10cm+ and/or N1 and/or stage 3
who have a radical nephrectomy
within 31 days of decision to treat
For England, we are unable to use
diagnosis date, as for most patients it
is the same as the surgery date.
Instead, we used Cancer Waiting
Time ‘treatment period start’ date
which represents the decision to
treat date
Exclusions
People with M1 RCC, people with
stage 1 RCC, people whose surgery is
earlier or on the same date as
decision to treat date
(treatment_period_start), people
missing a decision to treat date
(treat_period_start)
We decided to include those missing
M stage as it is a fair clinical
assumption that if they are receiving
surgery they are M0

Country
England only
Wales was excluded due to lack of
appropriate decision to treat date
Time periods
People with kidney cancer diagnosed
between Jan 2019 – Dec 2021

Reporting
level
England: Presented at the level of
diagnosing Trust

Codes used
Table C1. Radical nephrectomy
OPCS-4 codes
Table C2. Nephron sparing surgery
OPCS-4 codes

Clinical
definition
T3+ and/or 10cm+ and/or N1 and
M0 RCC: Tumour extends into major
veins or perinephric tissues or
invades beyond Gerota fascia and/or
tumour more than 10cm in size
and/or metastasis in regional lymph
node(s) with no distant metastasis

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PI5: Percentage of people with T1b-3NxM0 RCC (T2-3NxM0 RCC for Wales) who
have surgery

Indicator
Percentage of people with T1b-3NxM0
RCC (T2-3NxM0 RCC for Wales) who
have surgery
Notes
Denominator
Number of people with T1b-3NxM0 or
stage 2 or 3 RCC or tumour size > 4 cm
T1b-3 includes: T1b, T2, T2a, T2b,
T3, T3a, T3b, T3c
Nx includes: N0, N1, N missing

Numerator
Number of people with T1b-3NxM0 or
stage 2 or 3 RCC or tumour size > 4 cm
who undergo surgery between 31 days
prior to diagnosis and 365 days
following diagnosis

Exclusions
Both: People with M1 RCC, people with
missing M stage, people with stage 4
disease, people with T4 RCC
England only: People with T1a RCC,
people with tumour size ≤ 4cm
Wales only: People with T1 RCC, people
with stage 1 RCC
This excludes stage 1 patients who
have a tumour size of equal to or
less than 4 cm
Country
England and Wales
We used T2-3NxM0 RCC for Wales
(same as England except excluding
T1b and tumour size > 4 cm as
both unavailable)
Time periods
England: People diagnosed with kidney
cancer between Jan 2019 – Dec 2021
Wales: People diagnosed with kidney
cancer between Jan – Dec 2022

Reporting level
England: Presented at the level of
diagnosing Trust
Wales: Presented at the level of
diagnosing Health Board

Codes used
Table C1. Radical nephrectomy OPCS-4
codes
Table C2. Nephron sparing surgery
OPCS-4 codes

Clinical
definition
T1b-3NxM0 RCC: Tumour is more than
4cm in size or tumour extends into
major veins or perinephric tissues with
no distant metastasis
T2-3NxM0 RCC: Tumour is more than
7cm in size or tumour extends into
major veins or perinephric tissues with
no distant metastasis

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PI6: Percentage of people with T1aN0M0 RCC who undergo nephron sparing
treatment

Indicator
Percentage of people with T1aN0M0
RCC who undergo nephron sparing
treatment
Notes
Denominator
Number of people with T1aN0M0 RCC
or tumour size ≤ 4cm who undergo
surgery (RN or NSS) or ablation
between 31 days prior and 365 days
following diagnosis

Numerator
Number of people with T1aN0M0 RCC
or tumour size ≤ 4cm who undergo
nephron sparing treatment (NSS or
ablation) between 31 days prior and
365 days following diagnosis

Exclusions
People with M1 RCC, people with N1
RCC, people with tumour size > 4cm,
people with ≥ T1b RCC
We included people with missing
N status and/or M status as N1
and M1 will be rare in people with
T1a RCC
Country
England only
Wales was excluded from this
indicator as only 5% of the T1 RCC
was differentiated into T1a or T1b
and there was no tumour/lesion
size available in the Welsh data
Time periods
People with kidney cancer diagnosed
between Jan 2019 – Dec 2021

Reporting level
Presented at the level of diagnosing
Trust

Codes used
Table C1. Radical nephrectomy OPCS-4
codes
Table C2. Nephron sparing surgery
OPCS-4 codes
Table C3. Ablation OPCS-4 codes

Clinical
definition
T1aN0M0 RCC: Tumour is less than or
equal to 4cm in size with no regional
lymph node metastasis and no distant
metastasis

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PI7: Percentage of people presenting with M1 RCC who have initial SACT within
12 months of diagnosis

Indicator
Percentage of people presenting
with M1 RCC who have initial SACT
within 12 months of diagnosis
Notes
Denominator
Number of people presenting with
metastatic RCC

Numerator
Number of people presenting with
metastatic RCC who have initial SACT
within 12 months of diagnosis

Exclusions
People with M0 RCC, people whose
M status is missing

Country
England and Wales

Time Periods
England: People with kidney cancer
diagnosed between Jan 2017 – Dec
2021
Wales: People with kidney cancer
diagnosed between Jan – Dec 2022

Reporting level
England: Presented at the level of
diagnosing Trust
Wales: Presented at the level of
diagnosing Health Board

Codes used
Table C6. Systemic therapy OPCS-4
codes
Table C7. Systemic therapy ICD-10
codes

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PI8: Percentage of people with kidney cancer who die within 30 days of starting
SACT treatment

Indicator
Percentage of people with kidney
cancer who die within 30 days of
starting SACT treatment
Notes
Denominator
Number of people diagnosed with
metastatic RCC who underwent SACT
treatment

Numerator
Number of people diagnosed with
metastatic RCC who die within 30
days of starting SACT treatment

Exclusions
People with M0 RCC
We included people with missing M
stage as our clinical assumption is that
they are M1 if they received SACT in
this time period
Country
England and Wales

Time Periods
England: People with kidney cancer
diagnosed between Jan 2017 – Dec
2021
Wales: People with kidney cancer
diagnosed between Jan – Dec 2022

Reporting
level
England: Presented at the level of
treating Trust
Wales: Presented at the level of
diagnosing Health Board
For Wales, we were unable to identify
treating Health Board for the patients
with SACT only recorded in CaNISC so
results were reported at the level of
diagnosing Health Board instead.
Codes used
Table C6. Systemic therapy OPCS-4
codes
Table C7. Systemic therapy ICD-10
codes

Statistical analysis
All statistical analyses were performed using Stata version 17.0.

Variation between providers
To more appropriately assess variation between English providers for the performance
indicators, we excluded Trusts within less than 10 patients in the denominator.

NHS organisations
In this report (except for the results of PI8: Percentage of people with kidney cancer who die
within 30 days of starting SACT treatment), English patients were allocated to NHS

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organisations based on the “Trust of diagnosis” recorded within the dataset. Welsh patients
were allocated to NHS organisations based on the “Health Board of diagnosis” recorded
within the dataset.

Risk adjustment of indicators
The provider level results for some indicators were risk adjusted. Please see below which
indicator’s provider-level results were risk adjusted and which data items were involved in
the risk adjustment. Multivariable logistic regression was carried out to produce the risk
adjusted results.

Table 6. Risk adjustment strategy for performance indicators
Indicator
Risk Adjusted
Notes
PI1: Percentage of people
with kidney cancer with
MDT meeting recorded
No

PI2: Percentage of people
with kidney cancer who are
consented for a clinical trial
(England only)
No

PI3: Percentage of people
with a small renal mass
(<4cm) who have a biopsy
(England only)
No

PI4: Percentage of people
with a T3+ and/or 10cm+
and/or N1 renal cell
carcinoma (RCC) who have
a radical nephrectomy
within 31 days of diagnosis
(England only)
Yes: age, gender,
ethnicity, co-morbidity
and deprivation
Risk adjusting this indicator as
patient characteristics may
impact the time to treatment

PI5: Percentage of people
with T1b-3NxM0 RCC (T2-
3NxM0 RCC for Wales) who
have surgery
Yes: age, gender,
ethnicity, co-morbidity
and deprivation
Risk adjusting this indicator as
patient characteristics may
impact treatment decisions

PI6: Percentage of people
with T1aN0M0 RCC** who
undergo nephron sparing
treatment
Yes: age, gender,
ethnicity, co-morbidity
and deprivation.
Risk adjusting this indicator as
patient characteristics may
impact treatment decisions

PI7: Percentage of people
presenting with M1 RCC
who have initial SACT
within 12 months of
diagnosis
Yes: age, gender,
ethnicity, co-morbidity
and deprivation
Risk adjusting this indicator as
patient characteristics may
impact treatment decisions

PI8: Percentage of people
with kidney cancer who die
Yes: age, gender,
ethnicity, co-morbidity
and deprivation
Risk adjusting this indicator as
patient characteristics may
impact treatment decisions

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within 30 days of starting
SACT treatment

Please see below the format and categories of the risk adjustment variables.

Table 7. Format of risk adjustment variables
Risk
Adjustment
Variable
Format
Age
Categorical – 6 categories: <45, 45-54, 55-64, 65-74, 75-84, >85

Gender
Categorical – 3 categories: male, female, missing
Ethnicity
Categorical – 6 categories: White, Mixed, Asian/Asian British,
Black/Black British, Other, missing
Deprivation
Categorical – 6 categories: 1- least deprived, 2, 3, 4, 5 – most
deprived, missing
Co-morbidity
Categorical – 3 categories: 0, 1, ≥2 co-morbidities

References

1. Armitage, J. N., van der Meulen, J. H. & Royal College of Surgeons Comorbidity
Consensus Group. Identifying co-morbidity in surgical patients using
administrative data with the Royal College of Surgeons Charlson Score. Br J Surg 97,
772–81 (2010).