State of the Nation Report 2025
Source: data.gov.uk (2025-09-24)

National Non-Hodgkin Lymphoma Audit State of the Nation Report 2025. The National NNHLA Audit (NNHLA) determines whether the care received by people diagnosed with non-Hodgkin lymphoma in England and Wales is consistent with current recommended practice and provides information to support healthcare providers, commissioners and regulators in helping improve care. The NNHLA reports a set of process and outcome measures that cover important aspects of the care pathway for people diagnosed with non-Hodgkin lymphoma.

This second State of the Nation report provides an overview of the pattern of care and outcomes for people diagnosed with non-Hodgkin lymphoma between 1 January 2022 and 31 December 2022 in England, and 1 January 2023 and 31 to December 2023 in Wales. This includes 8 out of the 11 performance indicators for England, and 4 out of the 11 performance indicators for Wales. This year, the report includes a new contextualising measure on the proportion of people diagnosed with NHL presenting as an emergency prior to diagnosis (reported for England only). The performance indicators are outlined in the NNHLA Quality Improvement Plan 2024. The number of performance indicators reported will increase in future years, depending on the completeness and quality of the data available to the NNHLA, and methodological development work being carried out.

Findings in the report lead to five recommendations highlighting where improvements in care are needed. These recommendations are aligned to the quality improvement goals of the NNHLA.

A Data Dashboard provides results for individual organisations enabling regional and national comparisons to support local quality improvement, in addition to an Action Plan Template to support MDT discussions.

The audit uses information that is routinely collected by the NHS. For people diagnosed and treated in England, the data are collated, maintained and quality assured by NHS England’s National Disease Registration Service (NDRS). For people in Wales, data are provided by Wales Cancer Network (WCN), using the Cancer Network Information System Cymru (Canisc) electronic patient record system. A Methodology Supplement provides information on the data used in this report and the NNHLA performance indicators.

To further support quality improvement activities, NNHLA publishes quarterly reports of data quality metrics, as well as a subset of performance indicators. These quarterly reports will be further developed in the next 12 months. The NNHLA web pages also provide access to other sources of information about non-Hodgkin lymphoma.

Copyright © 2025 Healthcare Quality Improvement Partnership (HQIP)
1
National Non-Hodgkin Lymphoma Audit 
State of the Nation Report 2025
An audit of care received by people diagnosed with non-Hodgkin lymphoma between 1 January 
2022 and 31 December 2022 in England and 1 January 2023 and 31 December 2023 in Wales.
Version 2 - September 2025

Copyright © 2025 Healthcare Quality Improvement Partnership (HQIP)
Citation for this document: 
National Non-Hodgkin Lymphoma Audit 
(NNHLA) State of the Nation Report 2025. 
London: 
National Cancer Audit Collaborating Centre, 
Royal College of Surgeons of England, 2025. 
Version 2 September 2025
This version of the report includes the 
correction of a small number of hyperlink 
errors.
This document was prepared by members of the NNHLA project team
David Cutter, Co-Clinical Lead/Consultant Oncologist
Cathy Burton, Co-Clinical Lead/Consultant Haematologist
Kate Walker, Senior Methodologist/Professor of Medical Statistics
Lu Han, Methodologist
Ruhi Kanani, Clinical Fellow
Ella Barber, Data Scientist
Vikki Hart, Senior Project Manager
Faine Chan, Project Coordinator
With review and input from:
NNHLA Clinical Reference Group
NATCAN Executive Team
The Royal College of Surgeons of England (RCS) is an independent professional body committed 
to enabling surgeons to achieve and maintain the highest standards of surgical practice and 
patient care. As part of this it supports audit and the evaluation of clinical effectiveness for surgery. 
Registered Charity no: 212808.
The National Cancer Audit Collaborating Centre (NATCAN) is commissioned by the Healthcare 
Quality Improvement Partnership (HQIP) and funded by NHS England and Welsh Government as part 
of the National Clinical Audit and Patient Outcomes Programme (NCAPOP). NATCAN delivers national 
audits in bowel, breast (primary and metastatic), kidney, lung, non-Hodgkin lymphoma, oesophago-
gastric, ovarian, pancreatic and prostate cancers.
The British Society for Haematology (BSH) is the professional body for haematologists. It is one of 
the key partners of the Audit. Registered Charity no: 1005735
The Royal College of Radiologists is the professional body for clinical radiologists and clinical 
oncologists. It is one of the key partners of the Audit. Registered Charity no: 211540
This work uses data that has been provided by patients and collected by the NHS as part of their care 
and support. For patients diagnosed in England, the data is collated, maintained and quality assured 
by the National Disease Registration Service (NDRS), which is part of NHS England. Access to the 
data was facilitated by the NHS England Data Access Request Service.
NHS Wales is implementing a new cancer informatics system. As a result, the quality and 
completeness of data from Wales is likely to have been impacted due to implementation of this new 
system across multiple NHS organisations (Health Boards), which has resulted in data being supplied 
by both old and new systems. Additionally, and reflecting the uncertainty of data quality, the data 
submitted to the audit may not have undergone routine clinical validation prior to submission to the 
Wales Cancer Network (WCN), Public Health Wales.
© 2025 Healthcare Quality Improvement Partnership (HQIP)
Copyright All rights reserved. No part of this publication may be reproduced in any form (including photocopying or storing it in any medium by electronic means and whether or not 
transiently or incidentally to some other use of this publication) without the written permission of the copyright owner. Applications for the copyright owner’s written permission to 
reproduce any part of this publication should be addressed to the publisher.

Copyright © 2025 Healthcare Quality Improvement Partnership (HQIP)
Contents
1.	
Introduction	
1
­2.	
Infographic	
4
3.	
Recommendations	
5
4.	
Results for England and Wales	
8
4.1	
Data Completeness 	
8
4.2	
Characteristics of people diagnosed with non-Hodgkin lymphoma (NHL)	
8
4.3	
Diagnosis and Staging	
9
4.4	
Diagnosis to Treatment Pathway	
11
4.5	
Treatment	
13
4.6	
Outcomes 	
17
5.	
Commentary	
19

Copyright © 2025 Healthcare Quality Improvement Partnership (HQIP)
1
1.	 Introduction
The National Non-Hodgkin Lymphoma Audit 
(NNHLA) is one of ten national cancer audits 
within the National Cancer Audit Collaborating 
Centre (NATCAN), which is commissioned by 
the Healthcare Quality Improvement Partnership 
(HQIP) on behalf of NHS England and the Welsh 
Government. The aim of NATCAN is to provide 
regular information on patterns and variation in 
delivery of cancer care from diagnosis to treatment, 
using this information to improve access to treatment 
and facilitate quality improvement initiatives, 
with a view to optimising outcomes nationally.
The National Non-Hodgkin Lymphoma Audit 
(NNHLA) evaluates patterns of care and outcomes 
for people diagnosed with non-Hodgkin lymphoma 
(NHL) in England and Wales in line with its Quality 
Improvement Plan. This sets out the scope, 
care pathway, 5 quality improvement goals 
and 11 performance indicators that are utilised 
to measure progress against these goals.
The NNHLA assesses current clinical practice 
against standards set out in national guidelines. It 
also reports on performance indicators that have 
been drawn from extensive reviews of existing 
literature and of UK-specific guidelines relevant 
to NHL; produced by National Institute for Health 
and Care Excellence (NICE), NHS England, 
as well as the British Society of Haematology 
(BSH). The work of the audit also aligns itself 
with the UK Blood Cancer Action Plan which was 
published in September 2024, which sets out 
17 recommendations on workforce, diagnosis, 
access to care, clinical trials, access to treatments 
and data to improve survival from blood cancer, 
including non-Hodgkin lymphoma, in the UK.
This year’s report includes people diagnosed 
with NHL from 1 January 2022 to 31 December 
2022 in England, and 1 January 2023 to 31 
December 2023 in Wales. It reports on 8 out of 
the 11 performance indicators for England, and 
5 out of the 11 performance indicators for Wales 
outlined in the NNHLA Quality Improvement Plan 
(see Table 1). The report provides results on a 
new accompanying contextualising measure 
regarding emergency presentations for those 
diagnosed with NHL in England from January 2021 
to December 2022. Although the data presented 
in this report relates to treatment up to the end 
of 2022 in England and 2023 in Wales, it is being 
published in September 2025 to allow sufficient 
follow-up time for the full care pathway to be 
captured, including definitive treatment and short-
term outcomes. This is particularly important in 
NHL, where treatment pathways can span many 
months, and sufficient time is needed to ensure 
that key quality indicators, such as completion of 
multi-modality treatment and survival outcomes, 
are accurately recorded and reported (Timeliness 
of the National Cancer Registration Dataset 
(NCRD) - National Cancer Audit Collaborating 
Centre). To further support quality improvement 
activities, NNHLA also publishes quarterly reports 
of a subset of performance indicators (England 
only), which use more timely Rapid Cancer 
Registration Data (lag of approximately 6 months 
from diagnosis to reporting of data), available here.
The Audit derives its indicators using information 
that is routinely collected by the NHS as part of the 
care and support given to people diagnosed with 
non-Hodgkin lymphoma, rather than data collected 
specifically for the Audit1. For people diagnosed or 
treated in England, the data are collated, maintained 
and quality assured by NHS England’s National 
Disease Registration Service (NDRS). For people 
diagnosed or treated in Wales, data are provided by 
Wales Cancer Network (WCN)2, using the Cancer 
Network Information System Cymru (CaNISC) or 
Ca ncer Dataset Form (CDF). For full details of the 
data and methods used within this report, please 
see the NNHLA Methodology Supplement.
This report describes the national picture and 
variation between NHS trusts in England/hospitals 
in Wales. As this is the second State of the Nation 
report published for the Audit, we are now able to 
draw on data from previous years. Accordingly, 
the report will present trends over time for the 
performance indicators (Longitudinal Analysis), 
using data from England (2020, 2021 and 2022) 
and Wales (2022 and 2023). When interpreting 
the trends, it is important to acknowledge that 
the data for England begins in 2020, a period that 
may be considered atypical due to the impact of 
the COVID-19 pandemic on healthcare delivery, 
resource allocation and clinical practice.
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 NHS England and the Wales Cancer Network in Public Health Wales, thereby minimising the burden of data collection on provider teams.
2	
NHS Wales is part way through a cancer informatics implementation programme which is designed to improve the data capture and reporting capabilities of NHS Wales. 
This ongoing implementation is impacting the data quality within NHS Wales in the short term with multiple systems being used and different implementation dates 
across cancer sites and organisations resulting in a complex data landscape. NHS Wales has committed to continue to submit audit data annually until data submissions 
are sourced exclusively from the new cancer informatics solution. This will be from 2026 onwards that NHS Wales will be able to supply quarterly data using this new 
integrated, and more accessible digital platform.

Copyright © 2025 Healthcare Quality Improvement Partnership (HQIP)
2
Further development work and/or additional data 
is required to report on all 11 indicators for both 
nations, and in future years the NNHLA will work 
to align the reporting periods for both England and 
Wales, as well as providing more timely reporting.
The findings of this report have guided the 
development of 5 recommendations aimed at 
improving the quality of care for people with NHL 
(see Recommendations). These are directed at 
Cancer Alliances, Integrated Care Boards and 
NHS trusts/health boards, highlighting priorities 
for enhancing data quality, the treatment pathway, 
and patient outcomes—specifically, where 
current practice does not meet established, 
clinically relevant targets. These are important to 
address as they can be associated with poorer 
patient outcomes and increased variability in 
care delivery. By targeting these indicators, the 
recommendations focus on opportunities where 
improvement is most likely to enhance clinical 
outcomes, promote consistency across services, 
and reduce unwarranted variation in care.
An outlier process has also been carried out 
regarding survival outcomes. This process involves 
identification of providers whose performance, 
in terms of patient survival, deviates significantly 
from the national or expected range. This includes 
both positive and negative outliers based on 
analysis accounting for different case-mix and 
confounding factors. Identifying these outliers 
allows for further local investigation into potential 
drivers of variation, such as differences in clinical 
practice, resource availability or data quality. This 
supports targeted improvement efforts where 
outcomes are poorer than expected and shared 
learning of best practice where outcomes are better.
The NNHLA also continues to provide quarterly 
reports to NHS trusts in England. These are 
presented in the form of interactive data dashboards 
that are publicly available. These dashboards 
provide provider-level data quality and performance 
indicator reports for England every 3 months. 
They provide data so that NHS organisations can 
review their data quality and delivery of care in 
relation to other NHS trusts, Cancer Alliances and 
the national average. The aim of the dashboards 
is to help support NHS trusts track their progress 
and performance in line with local quality 
improvement initiatives. They will also be used to 
provide the basis for national quality improvement 
initiatives designed and launched by the Audit. 
Additional materials that accompany 
this report include:
•	 A methodology supplement with details about the 
Audit’s data sources and methods
•	 An online glossary that explains technical terms 
used in this report
•	 Information about the outlier process
•	 Resources to support local monitoring of practice 
and quality improvement, such as provider-level 
results on the Data Dashboard and downloadable 
reports and a local action plan template. 
•	 A summary of this report for people living with 
NHL and for the public is available on the Audit’s 
website.

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Table 1.* Performance indicators (PIs) and accompanying contextual measure included in this report.
Performance Indicators and contextualising measure (in order of appearance 
in report)
England^
Wales#
New Contextualising measure1:
Proportion of people diagnosed with NHL presenting as an emergency prior to 
diagnosis.
Yes 
(1/1/2021-31/12/2022)
No. In development.
1. Proportion of people diagnosed with NHL discussed at a multi-disciplinary team 
(MDT) meeting within 4 weeks of diagnosis.
Yes 
(1/1/2022-31/12/2022)
No. Data not available 
for Wales.
2. Proportion of people diagnosed with NHL seen by a clinical nurse specialist 
(CNS).
Yes 
(1/1/2022-31/12/2022)
Yes 
(1/1/2023-31/12/2023)
4. Proportion of people with high-grade lymphoma (Burkitt Lymphoma (BL), 
Diffuse Large B-Cell Lymphoma (DLBCL) or high-grade T-cell) receiving systemic 
anti-cancer therapy (SACT), who start SACT within 62 days of referral.
Yes 
(1/1/2022-31/12/2022)
Yes 
(1/1/2023-31/12/2023)
5. First-line systemic anti-cancer therapy (SACT) regimens received by people 
with high-grade lymphoma (BL, DLBCL or high-grade T-cell).
Yes 
(1/1/2021-31/12/2022)
No. In development. 
7. Proportion of people with high-grade lymphoma (BL, DLBCL or high-grade 
T-cell) who start radiotherapy within 8 weeks of end of first-line systemic anti-
cancer therapy (SACT).
Yes 
(1/1/2022-31/12/2022)
No. Regimen-level 
SACT data not 
provided
8. Proportion of people with NHL receiving radiotherapy, reported by subtype.
Yes 
(1/1/2022-31/12/2022)
Yes 
(1/1/2023-31/12/2023)
9. Proportion of people diagnosed with NHL who are recorded as having received 
an episode of care that was delivered as part of a clinical trial, reported by sub-
type.
Yes 
(1/1/2021-31/12/2022)
No. Data not available 
for Wales
11. Overall 2-year survival of people with high-grade lymphoma (BL, DLBCL, 
mantle cell or high-grade T-cell).
Yes. 1 and 2-year 
survival reported by 
sub-type nationally
Yes. 1-year survival 
reported by sub-type 
nationally
Further Development work needed
3. Proportion of people diagnosed with BL or DLBCL undergoing treatment who 
have MYC testing.
No. In development.
No. In development.
6. Proportion of people diagnosed with NHL with severe acute toxicity after SACT, 
reported by sub-type.
No. In development.
No. In development.
10. Time to treatment for relapse of follicular lymphoma, other B-cell lymphomas 
(incl. chronic lymphocytic leukaemia (CLL), marginal zone lymphoma) and T-cell 
lymphomas which are not high-grade.
No. In development.
No. In development.
1: A contextual measure is defined within a specific clinical setting or population; in this case, it refers to emergency presentations occurring prior to a non-Hodgkin lymphoma 
(NHL) diagnosis.
* See methodology supplement for the exact definitions of each performance indicator
^ England data: National Cancer Registration Dataset (NCRD)
# Welsh data: Cancer Network Information System Cymru (CaNISC)

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Timing of Radiotherapy delivery
Percentage of people diagnosed with high-grade 
lymphoma,who received radiotherapy within 8 weeks 
of end of first line SACT.
England 2022
Age 
Sex
Ethnicity
Deprivation 
Performance 
status
Staging 
(Ann Arbor)
Staging 
(Binet) 
Clinical 
Nurse 
Specialist 
(CNS)
Multi-
Disciplinary 
Team meeting 
(MDT)
Wales 2023
100%
89%
42%
82%
79%
68%
8%
82%
Clinical Nurse Specialist 
(CNS) seen, where recorded
England 2022 83%
Wales 2023 96%
Systemic Anti-Cancer Therapy (SACT)
Percentage of people diagnosed with high grade lymphoma, 
who receive SACT within 62 days of referral
Mean age at 
diagnosis for both 
England & Wales 
End date for 1st line chemotherapy was not provided for Wales so this indicator could not be measured.
MDT discussion within 4 weeks 
of diagnosis, where recorded
England 2022 - 60.0%, (high-
grade 65%, low-grade 54%)
No data on MDT discussion was provided 
for Wales
Grade of lymphoma
England 2022
high-grade 50 %, 
low-grade 49%, not 
classified 0.8%
Wales 2023 
high-grade 50%, 
low-grade 45%, not 
classified 5% 
Overall
One-year survival outcomes
81%
England 2022
83%
Wales 2023
75%
Wales 2023
high-grade 
91%
England 2022
94%
Wales 2023
low-grade 
71%
England 2022
Emergency presentation
England 2022 - 28%
England 2022
Trial Participation
Percentage of people with NHL who are recorded as 
having received an episode of care that was delivered 
as part of a clinical trial in England 2022*
* Note 47% data missing. No data on trial participation for Wales was available
Two-year survival outcomes*
74%
England 2022
63%
England 2022
85%
England 2022
Overall
low-grade
high-grade 
Development work underway for Welsh data. 
Not available for Wales due to insufficient follow up period
England 2022
Wales 2023
Summary of results for people diagnosed with Non-Hodgkin Lymphoma 
(NHL) in England (2022) and Wales (2023).
Data completeness
Diagnosis and staging 
Treatment
Survival
No data 
on MDT 
discussion was 
provided for 
Wales
69
years
100%
100%
87%
100%
100%
50%
63%
29%
40% 
72%
Diagnoses per year
England
15,433 diagnosed in 2022
Wales
729 diagnosed in 2023
55%
33%
2%
48%
40% data completeness for England 2022
­2.	 Infographic

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5
3.	 Recommendations
Recommendations developed in collaboration with NNHLA Clinical Reference Group and based on key findings in this report.
Recommendation
Audience
Audit Findings
Quality 
Improvement Goal
National Guidance/Standards/Resources
Clinical Recommendations
1.	 Reduce the current rate of emergency 
presentations of NHL by reviewing 
diagnostic pathways into and within 
secondary care to improve timely 
investigation, and examine variation 
in rates of emergency presentation by 
geographies and population groups to 
identify potential causes of this.
England: NHS 
England, Primary 
Care, Cancer 
Alliances working 
with NHS trusts
Wales:
Primary care, 
health boards
Proportion of people with NHL presenting with 
a new diagnosis of NHL via the emergency 
department or presenting to the emergency 
department within 28 days prior to diagnosis: 
England 2022: Mean: 28.4% (Range*: 0.0-75.0%)
Median (IQR**): 27.5% (22.7-33.0%)
Goal #1: Improving 
timely diagnosis 
and treatment.
NHS Cancer Programme: Faster Diagnosis 
Framework 2022 
UK Blood Cancer Action Plan 2024
NICE guidance, "Haematological cancers: 
improving outcomes" (NG47) 2016
Cancer Genomic Improvement Programme 2023
Kane E, Howell D, Smith A, Crouch S, Burton C, 
Roman E, Patmore R. Emergency admission and 
survival from aggressive non-Hodgkin lymphoma: 
a report from the UK's population-based 
haematological malignancy research network. 
European journal of cancer. 2017 
Smith MJ, Fernandez MA, Belot A, Quartagno M, 
Bonaventure A, Majano SB, Rachet B, Njagi EN. 
Investigating the inequalities in route to diagnosis 
amongst patients with diffuse large B-cell or 
follicular lymphoma in England. British journal of 
cancer. 2021
Howell D, Hart R, Smith A, Macleod U, Patmore R, 
Roman E. ‘Unpacking’pathways to lymphoma and 
myeloma diagnosis: Do experiences align with the 
Model of Pathways to Treatment? Findings from 
a UK qualitative study with patients and relatives. 
BMJ open. 2020
2.	 Local review at NHS trust/health board 
level is needed to identify diagnostic and 
treatment pathway delays and reduce 
inter-provider variation in people with 
high-grade NHL starting SACT within 
62 days of referral. This may include 
examination of delays along the pathway,  
chemotherapy unit capacity and staffing, 
and mode of delivery of SACT, in order to 
understand system-level delays.
England: Cancer 
Alliances working 
with NHS trusts
Wales: health 
boards
Proportion of people with high grade NHL 
commencing 1st line SACT within 62 days of 
referral. 
England 2022: 55.0% (Range* 0-100.0%); 
Median (IQR)**: 54.0% (45.0-64.0%) 
Wales 2023***: 48.2% (Range* 8.0-91.0%) 
Median (IQR)**: 43.0% (35.0-56.0%)
Note: results for this performance indicator 
have worsened compared to 2020 and 2021 in 
England.
Goal #1: Improving 
timely diagnosis 
and treatment.
NHS England (2023) Changes to cancer waiting 
times standards from 1 Oct 2023

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6
Recommendation
Audience
Audit Findings
Quality 
Improvement Goal
National Guidance/Standards/Resources
3.	 Identify patient and hospital factors 
contributing to delays in starting 
radiotherapy after last administered dose 
of SACT and explore strategies to reduce 
inter-provider variation across NHS trusts 
and health boards. 
This may include ensuring specialist 
representation at MDT meetings, in 
line with the national requirement for 
individual scheduled treatment planning 
MDT meetings to be quorate on 95% or 
more occasions, earlier identification of 
appropriate candidates for radiotherapy 
through an MDT setting with mandated 
clinical oncology attendance and 
earlier referral and review by clinical 
oncology teams to discuss radiotherapy 
suitability prior to completion of systemic 
treatment. It may also include review of 
radiotherapy unit capacity and staffing.
England: Cancer 
Alliances working 
with NHS trusts
Wales: health 
boards
Proportion of people with NHL receiving 
radiotherapy within 8 weeks of last administered 
dose of SACT:
England 2022: 32.5% (Range*: 0.0-100.0%)
Median (IQR**): 28.6% (11.1-50.0%)
Wales 2023: Not available
Note: results for this performance indicator 
have worsened compared to 2020 and 2021 in 
England.
Goal #1: Improving 
timely diagnosis 
and treatment.
No national guidance set. Recommendation agreed 
by the NNHLA Clinical Reference Group
NHS England (2020) Multi-disciplinary team 
streamlining guidance
4.	 Identify reasons why individuals with 
non-Hodgkin lymphoma are not enrolled 
in clinical trials to ensure equitable 
access to research opportunities, 
while also strengthening clinical 
record-keeping practices to support 
identification and reduction of 
participation disparities.
England: Cancer 
Alliances working 
with NHS trusts
Wales: health 
boards
Proportion of people diagnosed with NHL who 
are recorded as having received an episode of 
care that was delivered as part of a clinical trial. 
England 2022: 2.0% (Range**** 0-14.55%)
Median (IQR**): 0.0% (0.0-0.0%)
Wales: Not available
Goal #1: Improving 
timely diagnosis 
and treatment.
No national guidance set.
Recommendation agreed by the NNHLA Clinical 
Reference Group

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7
Recommendation
Audience
Audit Findings
Quality 
Improvement Goal
National Guidance/Standards/Resources
Data Quality Recommendation
5.	 Ensure there is a designated coordinator 
or clinician to improve the completeness 
and quality of data items recorded in the 
national cancer datasets at each NHS 
trust/health board (with particular focus 
on staging in England and Wales and 
treatment delivery in Wales). 
This will allow better risk adjustment of 
outcome variables including survival 
outcomes for people with non-Hodgkin 
lymphoma and effectively inform outlier 
identification. 
The launch of the Audit’s national quality 
improvement initiative in October 2025 
will further support this effort. NHS 
trusts/health boards are encouraged to 
participate in the initiative to enhance 
data quality.
England: Integrated 
Care Boards (ICBs) 
working with NHS 
trusts
Wales: health 
boards
Completeness for staging as follows:
(Binet – chronic lymphocytic leukaemia CLL, Ann 
Arbor – All other NHL)
England 2022: 63.0% (Ann Arbor), 29.1% (Binet)
Wales 2023:
67.5% (Ann Arbor), 7.8% (Binet)
N/A
NHS organisations have an obligation to submit 
accurate and timely data to the English National 
Disease Registration Service (NDRS) and Wales 
Cancer Network (WCN). The Cancer Outcome and 
Services Data set (COSD) has been the national 
standard for reporting cancer in the NHS in England 
since January 2013. Feedback reports for the data 
submitted are available through CancerStats2. 
COSD is the main source for the rapid cancer 
registration dataset and improved completeness 
of this dataset is required to ensure quarterly 
reporting. The Welsh Health Circular (NHS Wales) 
mandates high quality data submissions for the 
national cancer audits.
* Range - across all NHS trusts in England and health boards in Wales
** IQR – interquartile range 
*** Results updated using  the Patient Episode Database for Wales (PEDW)
**** Range - across all Cancer Alliances in England

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8
4.	 Results for England and Wales
4.1	 Data Completeness 
Key Message: NHS trusts and multi-disciplinary 
teams should ensure key data items are submitted 
to cancer registries for all people diagnosed 
with NHL. Particular attention should be given 
to documentation of staging, MDT records and 
CNS involvement in both England and Wales.
It is important to note that data was provided and is 
presented for different calendar years for England 
(2022) compared to Wales (2023).
Descriptive Data
Reporting completeness of key data items is 
vital and important to ensure fair comparisons 
between NHS trusts/hospitals and when drawing 
conclusions regarding the process indicators 
about healthcare delivery and outcomes (see 
Supplementary Results, Table 1 and Table 2).
In England, data completeness of age, sex and 
deprivation (index of multiple deprivation (IMD) 
quintiles) was excellent (100%) (Supplementary 
Table 1). In Wales, data completeness of age was 
also 100%. However, levels of data completeness 
were lower for sex (89.0%) and deprivation 
(82.2%). Completeness of data for ethnicity was 
86.8% in England (2022) and 42.2% in Wales 
(2023). Completeness of data for performance 
status was also poor; with 50.2% and 78.5% 
completeness in England (2022) and Wales 
(2023) respectively. Completeness of Charlson 
Comorbidity Index was also low due to incomplete 
linkage to Hospital Episode Statistics (HES) data 
in England and Patient Episode Data for Wales; 
68.0% in England 2022, and 61.6% in Wales 2023.
There was excellent data completeness for grade 
of NHL in both England and Wales (see Table 2). 
In England (2022), Ann Arbor staging was 
documented for 63.0% of people; Binet staging, 
pertaining only to people diagnosed with CLL, was 
recorded for only 29.1% of cases. Staging data in 
Wales in 2023 was more complete for Ann Arbor 
staging (67.5%), but less complete for Binet 
staging (7.8%) (see Table 2). There was poor 
overall completeness of data for prognostic 
indices; data completeness for both IPI 
(International Prog nostic Index for DLBCL) and the 
Follicular Lymphoma International Prognostic Index 
2 (FLIPI2)) was 9.7% and 8.6% respectively for 
England. No data on prognostic indices was 
available for Wales (see Table 2). Overall, 
compared to results presented in last year’s State 
of the Nation report, staging and prognostic 
indices completeness has worsened from 2020 to 
2022 in England and 2022 to 2023 in Wales.
A request for access to data regarding FLIPI1 has 
been made to NDRS, with aims to include this in future 
iterations of the State of the Nation reports and the 
quarterly report dashboards. Completeness of data 
for prognostic indices should remain a priority for 
providers, as it will help clinicians and the Audit team 
to clarify if appropriate care is being delivered and 
help more accurately prognosticate outcomes for 
those with NHL.
Record-keeping for MDT discussions within 4 
weeks of diagnosis was recorded as 72% in 2022 in 
England (stable compared to 2020-2021), however 
it is unclear whether this is due to poor record-
keeping or no discussion in an MDT. No data on MDT 
discussion was provided for Wales. The proportion of 
people diagnosed with NHL, seen by a clinical nurse 
specialist was recorded in 40% of cases in England 
in 2022, and in 82% of cases in Wales in 2023. This 
marks an improvement in data completeness in both 
England and Wales compared to last year’s report.
With regards to treatment delivery, no data was 
available on regimen-level SACT and limited data was 
available on radiotherapy delivery for Wales. No data 
on trial participation was available for Wales.
4.2	 Characteristics of people diagnosed 
with non-Hodgkin lymphoma (NHL)
‘Gold standard’ Cancer Registration data (England) 
identified 15,433 people diagnosed with NHL in 
2022, across 135 English NHS trusts. CaNISC 
data identified 729 people diagnosed with NHL 
in Wales in 2023 across 17 Welsh hospitals.
In both England and Wales, there was a similar mean 
age of 69 years at diagnosis, with a diagnosis most 
likely to be made between the ages of 70 and 79. A 
higher number of male individuals were diagnosed 
with NHL (53.3-57.5%). The majority were of White 
British ethnicity (91.2-98.1%), although more than half 
of data for ethnicity was not recorded for the Wales 
cohort. A higher proportion of people diagnosed with 
NHL lived in the least deprived quintiles in England 
and Wales. Most people included in the Audit with 
a recorded performance status, were performance 
status 0-1 (82.9% people in England (2022), 75.5% 
in Wales (2023)). More than 75% of people with NHL 
who had a Charlson comorbidity index available 
(through linkage to HES or PEDW data) had zero or 
one comorbidities in England and Wales. However, 
drawing any conclusions is difficult as 30-40% of data 
was missing for this data item (Supplementary Table 
1).
Overall, the patient characteristics for England 
in 2022 and Wales 2023 have not changed 
compared to last year’s State of the Nation report 
2024 (England 2020-2021 and Wales 2022).

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9
Table 2. Characteristics of the NHL cancer diagnoses in England in 2022 and Wales 2023.
England 2022
Wales 2023
n
%
n
%
Total
15,433
100
729
100
Ann Arbor staging
Total
11,792
100
575
100
1
1,192
16.1
56
14.4
2
845
11.4
57
14.7
3
1,457
19.6
92
23.7
4
3,934
53.0
183
47.2
Missing (% of total)
4,364 (37.0)
187 (32.5)
Binet staging (CLL)1
Total
3,641
100
154
100
A
844
79.8
9
75.0
B
146
13.8
<5 *
*
C
68
6.4
*
*
Missing (% of total)
2,583 (70.9)
142 (92.2)
NHL grade
High
7,710
50.0
366
50.2
Low
7,608
49.3
327
44.9
Not classified
115
0.8
36
4.9
NHL sub-type
Mature B-cell neoplasms
Burkitt lymphoma
114
0.7
<5 *
*
Chronic lymphocytic leukaemia
3,641
23.6
154
21.1
Follicular lymphoma
2,345
15.2
115
15.8
Large B-cell lymphomas
4,125
26.7
215
29.5
Mantle cell lymphoma
578
3.8
35
4.8
Marginal zone lymphoma
1,270
8.2
30-40 *
*
NHL, NOS2
1,262
8.2
50
6.9
Mature T- and NK-cell neoplasms 
Peripheral T-cell lymphomas
585
3.8
27
3.7
Cutaneous T-cell lymphomas
340
2.2
10
1.4
Other
1,173
7.6
88
12.1
IPI3 for DLBCL4
Total DLBCL
3,945
100
-
-
Recorded
384
9.7
-
-
Missing 
3,561
90.3
-
-
FLIPI25 for FL6
Total FL
2,345
100
-
-
Recorded
202
8.6
-
-
Missing
2,143
91.4
-
-
Note: Sum of percentages may not equal 100% due to rounding 
CLL1: Chronic lymphocytic leukaemia; NOS2: Not otherwise specified; IPI3: International Prognostic Indices; DLBCL4: Diffuse Large B-Cell Lymphoma; FLIPI25: Follicular Lymphoma 
International Prognostic Indices 2; FL6: Follicular Lymphoma 
*Exact numbers and percentages suppressed to protect patient confidentiality
4.3	 Diagnosis and Staging
Key Message: Improved staging should be 
prioritised as complete staging data will allow risk-
adjusted comparisons between groups of people 
diagnosed with NHL and NHS trusts/ MDTs.
There is highly complete recording of sub-type 
based on diagnostic and morphology coding (see 
Methodology Supplement). 15,433 people were 
diagnosed with NHL in England in 2022, and 729 
people were diagnosed in Wales in 2023. This 
marks an increase of 8-10% of people diagnosed 
with NHL annually in England (from 2020-2022) 
and Wales (2022 to 2023). Supplementary Table 
1 and Table 2 summarise the characteristics of 
people with NHL and their cancers separately for 
England and Wales in 2022 and 2023 respectively.

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10
Table 3. Proportion of individuals newly diagnosed with NHL who present as emergency presentations in England
Denominator
England 2021***
England 2022
Route of 
admission
Number
Total
 (%)
Variation by trusts*
Number
Total
(%)
Variation by trusts*
Emergency
4,606
15,208
30.3
Range: 0-90%
Median (IQR**): 30 
(24.5-34.5%)
4,388
15,433
28.4
Range: 0-75%
Median (IQR): 27.5 
(22.7-33.0%)
Non-Emergency
10,374
15,208
68.2
Range: 10-100%
Median (IQR): 68.4 
(63.9-73.5%)
10,688
15,433
69.3
Range: 25-100%
Median (IQR): 70.1 
(65.0-74.4%)
Missing
228
15,208
1.5
Range: 0.0-13.2% 
Median (IQR): 0.9 
(0.0-2.3%)
357
15,433
2.3
Range: 0.0-21.9%
Median (IQR): 1.4 
(0.0-2.9%)
* Variation between trusts in England. 
** Interquartile range (IQR).
*** Data were impacted by the COVID19 pandemic and so will be atypical to some degree during 2020-21.
The three most common sub-types were large 
B-cell lymphoma (LBCL), chronic lymphocytic 
leukaemia (CLL) and follicular lymphoma (Table 
2). The incidence of low-grade and high-
grade disease was similar across England and 
Wales (Table 2). People included in the Audit 
presented at a late stage of diagnosis, with 53.0% 
and 47.2% presenting with stage 4 disease in 
England 2022 and Wales 2023 respectively.
With CLL, the pattern suggested that people 
in all cohorts were more likely to present at 
an earlier stage, although clear conclusions 
can’t be drawn due to the large volume of 
missing data (around 70-90%) (Table 2).
Contextualising measure: Proportion of 
people diagnosed with NHL presenting 
as an emergency prior to diagnosis.
Key Message: NHS trusts and health boards 
should prioritise review of primary and 
secondary care referral pathways to reduce 
the rate of emergency presentations for those 
newly diagnosed with NHL in England.
Table 3 demonstrates the proportion of those 
diagnosed with NHL in England who present as 
an emergency presentation via the emergency 
department, or who present to the emergency 
department within 28 days of initial diagnosis. 
This has been collated using a combination of 
datasets including Hospital Episode Statistics 
(HES), Rapid Cancer Registration Dataset and 
the Cancer Registration Gold Dataset.
More than a quarter of people newly diagnosed 
with NHL present in the emergency setting in 
England in 2022, with little variation between 
trusts. Supplementary Tables 2–6 show that a 
greater proportion of these individuals are from 
minority ethnic backgrounds, and aged over 80 
years. As expected with the more aggressive 
trajectory of disease, a higher proportion of these 
presentations are seen in the high-grade sub-
types, particularly Burkitt lymphoma, Large B-cell 
lymphoma and Peripheral T-cell lymphoma.
Trends over time: A similar incidence of 
emergency presentations was observed in 
the 2021 England data, indicating this remains 
an ongoing issue and may partly account 
for the higher proportion of individuals with 
NHL presenting at a late stage (Table 3).

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11
4.4	 Diagnosis to Treatment Pathway
PI1: Proportion of people diagnosed with 
NHL discussed at a multi-disciplinary 
meeting within 4 weeks of diagnosis.
Data completeness for MDT discussion of 
people diagnosed in England in 2022 was 72%. 
Where data were recorded, 60% of all cases 
were discussed in an MDT within 4 weeks of 
diagnosis. People with high-grade lymphoma 
were more likely to be discussed within this time 
period, Overall, there is large variation in practice 
regarding timing of MDT discussions between 
trusts/hospitals (Table 4). No data was available 
for this performance indicator for Wales.
However, further analysis demonstrated that over 
80% of all cases were discussed within 8 weeks 
of diagnosis, with almost 90% of high-grade cases 
discussed within this time (Supplementary Table 7).
Trends over time: When comparing the data for 
England 2022 to data collected in England 2020-
2021, there has been a decline in the proportion 
of individuals with NHL being discussed in an 
MDT within 4 weeks of diagnosis. This may 
reflect pressures on resources and a reduction in 
service capacity in the post COVID-19 period.
Key Message: NHS trusts in England must 
ensure that MDTs conduct timely discussions for 
every newly diagnosed patient, with particular 
urgency for those with high-grade NHL. Protocols 
should be in place to ensure timely discussion, 
with the appropriate clinical information 
available, and identify responsible personnel 
to coordinate and oversee documentation in 
the MDTs. There should be regular audits to 
monitor compliance and drive improvement.
PI 2: Proportion of people diagnosed with NHL 
seen by a clinical nurse specialist (CNS).
Key Message: Ongoing improvement is needed at 
NHS trust level regarding record of, and involvement 
of CNS teams in England to ensure people with NHL 
receive the appropriate support during treatment.
Where CNS information was recorded, over 
95% of people with NHL were seen by a CNS in 
Wales, whereas only 83% were seen by a CNS in 
England (Table 5). CNS contact was higher in the 
high-grade cases for both England and Wales, 
with some variation seen between NHS trusts/
health boards. Given that there was 40% data 
completeness for this item in England and 82% 
data completeness in Wales, it is difficult to draw 
definitive conclusions about support provided 
by CNSs to people diagnosed with NHL.
Trends over time: The overall proportion of 
people with NHL in England and Wales who 
had contact with their CNS has remained stable 
since last year’s State of the Nation report.
Table 4. Proportion* of people with NHL discussed in an MDT1 within 4 weeks of diagnosis*****
Denominator
England 
2020
Variation 
2020**
England 
2021 
Variation 
2021**
England 
2022
Variation 
2022**
All NHL
69.0%
Range: 0-100%
Median (IQR***): 
70% (57-76%)
63.5%
Range: 0-100%
Median (IQR): 65% 
(51-72%)
60.0%
Range: 0-100%
Median (IQR): 60% 
(50-70%)
High-grade 
lymphoma
74.5%
Range: 0-100%
Median (IQR): 74% 
(64-83%)
68.6%
Range: 0-100%
Median (IQR): 70% 
(58-79%)
65.2%
Range: 0-100%
Median (IQR): 65% 
(50-77%)
Low-grade 
lymphoma
61.8%
Range: 0-100%
Median (IQR): 63% 
(47-71%)
57.3%
Range: 0-100%
Median (IQR): 57% 
(47-69%)
53.9%
Range: 0-100%
Median (IQR): 53% 
(43-64%)
* Percentage where information available (72% data completeness for England 2022)
** Variation between trusts in England. 
*** Interquartile range (IQR).
**** Data were impacted by the COVID-19 pandemic and so will be atypical to some degree during 2020-21.
MDT1: Multi-disciplinary team 

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12
Table 5. Percentage* of people diagnosed with NHL seen by CNS1 in England (2020-2022) and Wales (2022-2023)****
Denominator
England 
2020
Variation 
2020**
England 
2021 
England 
2022
Variation 
2022**
Wales 
2022
Variation** 
2022
Wales 
2023
Variation 
2023**
All NHL
81.5%
Range: 
0-100% 
Median 
(IQR***): 
92% (78-
100%)
82.2%
83.0%
Range: 
0-100% 
Median 
(IQR): 93% 
(77-100%)
96.0%
Range: 60-
100% 
Median 
(IQR***): 
99% (86-
100%)
96.0%
Range: 
0-100% 
Median 
(IQR): 95% 
(89-100%)
High-grade 
lymphoma
85.8%
Range: 
0-100% 
Median 
(IQR): 96% 
(82-100%)
86.6%
86.4%
Range: 
0-100% 
Median 
(IQR): 96% 
(82-100%)
98.2%
Range: 82-
100% 
Median 
(IQR): 100% 
(100-100%)
96.8%
Range: 
0-100% 
Median 
(IQR): 100% 
(92-100%)
Low-grade 
lymphoma
76.0%
Range: 
0-100% 
Median 
(IQR): 92% 
(68-100%)
77.2%
79.4%
Range: 
7-100% 
Median 
(IQR): 93% 
(71-100%)
93.9%
Range: 33-
100% 
Median 
(IQR): 100% 
(78-100%)
95.0%
Range: 
0-100% 
Median 
(IQR): 50% 
(3-97%)
* Percentage where information available (40% data completeness for England 2022)
** Variation between NHS trusts in England/hospitals in Wales
*** Interquartile range (IQR).
**** Data were impacted by the COVID-19 pandemic and so will be atypical to some degree during 2020-21.
CNS1: Clinical Nurse Specialist
PI4: Proportion of people with high-grade lymphoma 
(Burkitt lymphoma (BL), DLBCL (Diffuse Large 
B-Cell Lymphoma) or high-grade T-cell) receiving 
SACT, who start SACT within 62 days of referral.
Key Message: 55% of people with high-grade 
NHL in England receiving SACT (2022) and 48% 
of people with high-grade NHL in Wales receiving 
SACT (2023), start SACT within 62 days of 
referral.
Around half of people with high-grade NHL 
in England receiving SACT do not start first-
line SACT within the target of 62 days across 
both Engalnd and Wales (Table 6). There is 
noticeable variation across hospitals and NHS 
trusts, indicating possible challenges in the 
referral process, access to specialist services, 
and resource distribution that warrant further 
investigation and improvement locally.
Trends over time: In England (2020-2022) 
and Wales (2022-2023) there is a reduction in 
people with NHL starting SACT within 62 days of 
referral, highlighting the need for health boards 
(Wales) and Cancer Alliances (working closely 
with NHS trusts in England) to improve the 
treatment pathway and consequent outcomes 
for those with NHL, in keeping with the cancer 
waiting times target set out by NHS England.
Table 6. Proportion of people with high-grade lymphoma and receive SACT, who start SACT within 62 days of referral in England 
2020-2022**** and Wales 2022-2023.
Denominator
England 
2020
Variation 
2020*
England 
2021 
Variation 
2021*
England 
2022
Variation 
2022**
Wales 
2022
Variation 
2022*
Wales 
2023
Variation 
2023**
High-grade 
lymphoma
66.1%
Range: 
0-100% 
Median 
(IQR***: 
65%
(54-76%)
62.0%
Range: 
0-100% 
Median 
(IQR): 
63%
(53-71%)
55.0%
Range: 
0-100% 
Median 
(IQR):  
54% 
(45-64%)
51.2%
Range: 
0-100% 
Median 
(IQR***): 
50%
(26-67%)
48.2%
Range: 
8-91% 
Median 
(IQR): 
43%
(36-56%)
* Variation between NHS trusts in England. 
** Variation between hospitals in Wales. Results updated using Wales Admitted Patient Care Dataset (APC).
*** Interquartile range (IQR).
**** Data were impacted by the COVID-19 pandemic and so will be atypical to some degree during 2020-21.

Copyright © 2025 Healthcare Quality Improvement Partnership (HQIP)
13
4.5	 Treatment
PI5: First-line SACT treatment regimens 
received by people with high-grade lymphoma 
(BL, DLBCL or high-grade T-cell).
Table 7. Proportions of people diagnosed with high-grade subtypes of NHL receiving acceptable first-line treatment SACT 
regimens for England 2021-2022.**
NHL High-grade subtype
Cohort *
Acceptable1 (%)
Variation **
DLBCL, NOS ***
England 2021
98.0%
Range: 83.3-100% Median (IQR): 100% (97.3-100%)
England 2022
98.1%
Range: 50-100% Median (IQR): 100% (100-100%)
Burkitt lymphoma
England 2021
96.4%
Range: 0-100% Median (IQR): 100% (100-100%)
England 2022
90.9%
Range: 0-100% Median (IQR): 100% (100-100%)
Peripheral T-cell lymphoma, NOS
England 2021
95.9%
Range: 0-100% Median (IQR): 100% (100-100%)
England 2022
98.1%
Range: 66.7-100% Median (IQR): 100% (100-100%)
Cutaneous T-cell lymphoma
England 2021
Too low to report
England 2022
Too low to report
* Data were impacted by the COVID-19 pandemic and so will be atypical to some degree during 2020-21. 
** Variation between NHS trusts in England.
 *** NOS: Not otherwise specified.
1 Acceptable regimen were defined as recommended first-line regime as per NICE guidelines or an appropriate adjustment such as anthracycline replacement (see Methodology 
Supplement for more details).
Separate analysis of SACT regimens using the 
SACT dataset were used for DLBCL Not Otherwise 
Specified (NOS), Burkitt Lymphoma, Peripheral 
T-cell lymphoma (NOS) and Cutaneous T-cell cases 
for England (Table 7) to establish the proportion of 
people with each sub-type receiving an acceptable 
first-line regimens. “Acceptable” regimens were 
defined as recommended first-line regimens as per 
NICE guidelines or an appropriate adjustment such 
as anthracycline replacement (see Methodology 
Supplement for more details). Suboptimal regimes 
were defined as not meeting criteria as acceptable 
regimens; they may be clinically appropriate for 
the individual but deemed to be less effective than 
the “acceptable” regimens. Excluded regimens 
were regimens in the dataset that were incorrectly 
coded or not used in the first-line setting.
All people with DLBCL (NOS) cases who started 
SACT within 3 months of diagnosis were included 
with around 6,000 cases noted between 2021 
and 2022 in England. In 2021 and 2022, 54 and 
58 variations in the recorded first-line regimens 
were noted respectively, with around 98% of 
people with valid first-line SACT records (after 
exclusions) receiving regimens considered  
acceptable first-line regimens for this subtype.
All people with Burkitt lymphoma who started 
SACT within 3 months of diagnosis were 
included with around 200 cases noted between 
2021 and 2022 in England. In 2021 and 2022, 
17 and 20 variations in first-line regimens 
were noted respectively, with around 94% of 
people with valid first-line SACT records (after 
exclusions) receiving regimens considered 
acceptable first-line regimens for this subtype. 
All people with Peripheral T-cell lymphoma 
(NOS) who started SACT within 3 months of 
diagnosis were included with around 200 cases 
noted between 2021 and 2022 in England. In 
2021 and 2022, 17 and 19 variations in first-
line regimens were noted, with around 97% of 
people with valid first-line SACT records (after 
exclusions) receiving regimens considered 
acceptable first-line regimens for this subtype. 
An analysis of regimes was carried out for 
Cutaneous T-cell lymphoma cases during 
the same time period but due to the small 
numbers recorded, further details on this have 
therefore not been included in this report. 
Key Message: Over 90% of high-grade 
lymphoma cases are receiving an acceptable 
first-line SACT treatment regimen, or appropriate 
alternative in England (2021-2022).

Copyright © 2025 Healthcare Quality Improvement Partnership (HQIP)
14
Further analysis of optimal, adjusted and suboptimal 
treatment regimens by patient characteristics 
is presented in the Supplementary Tables 8-12. 
Due to low overall numbers, meaningful trends 
can only be observed within the DLBCL (NOS) 
cohort. In this group, increasing age and poorer 
performance status were associated with a higher 
likelihood of receiving adjusted or suboptimal 
regimens; likely reflecting clinical decisions 
to avoid more intensive first-line therapies in 
more frail patients. However, this pattern did 
not hold for patients with performance status 
4, who may have presented with aggressive 
disease and required immediate administration 
of optimal therapy without adjustment.
The wide variation in regimens delivered 
across subtypes highlights the need for more 
consistent treatment guidelines to reduce 
variability in care. Reassuringly, over 90% of 
patients were still considered to have received 
an acceptable first-line regimen. Improved 
data completeness on performance status and 
comorbidities would support further analysis to 
better understand the rationale for adjusted or 
suboptimal treatments in different NHL subtypes.
PI 7: Proportion of people with high-grade lymphoma 
(BL, DLBCL or high-grade T-cell) who start 
radiotherapy within 8 weeks of end of first-line SACT.
Key Message: Less than 40% of people with 
high-grade lymphoma due to receive radiotherapy 
start their radiotherapy within 8 weeks of the 
end of first-line SACT, with wide variation 
between trusts. This demonstrates a worsening 
delay in radiotherapy delivery compared to 
last year’s State of the Nation report.
Table 8. Proportion of people with high-grade NHL who receive first-line SACT (and are due to receive radiotherapy) who then 
receive radiotherapy within 8 weeks of last administered dose of SACT in England (2022).
Denominator
England 2021 **
England 2022
Percentage (%) 
Variation 2021 *
Percentage (%)
Variation 2022 *
People with high-grade lymphoma 
who started SACT within 6 months of 
diagnosis and received radiotherapy 
within 6 months of last dose of SACT 
36.0%
Range: 0-100%
Median (IQR):31.0 
(0.0-50.0%)
32.5%
Range: 0-100%
Median (IQR): 28.6 
(11.1-50.0%)
* Variation between trusts in England 
** Data were impacted by the COVID-19 pandemic and so will be atypical to some degree during 2020-21.
For this report, no data was provided on SACT 
regimens in Wales, so it was not possible to 
report radiotherapy delivery following SACT. 
In England, the results have been recalculated 
for 2021 with an adjustment to the denominator 
(see Methodology Supplement); this has 
been applied to results for England 2022. The 
denominator was all those who started SACT 
within 6 months of diagnosis, who then went 
on to receive radiotherapy within 6 months of 
last administered dose of SACT (Table 8). 
Around a third of people in this Audit in England 
commenced radiotherapy within 8 weeks of 
completing first-line SACT, with wide variation 
between NHS trusts/hospitals. This increased 
to around 50% by 12 weeks (Supplementary 
Table 13). Radiotherapy delivery within 8 weeks 
is considered optimal, with delivery within 12 
weeks regarded as an acceptable timeframe. 
There is considerable variation across NHS trusts, 
warranting further investigation to understand 
the underlying causes and to determine whether 
any geographic patterns are present.
Trends over time: Comparison between 
results for England 2022 and England 2021 
demonstrate a reduction in timely delivery of 
radiotherapy after first-line SACT, which warrants 
review by NHS trusts of their assessment 
and referral pathway for radiotherapy.

Copyright © 2025 Healthcare Quality Improvement Partnership (HQIP)
15
PI 8: Proportion of people with NHL receiving 
radiotherapy, reported by subtype.
Key Message: Further analysis of variation 
in care across NHS hospitals is required 
to understand the use and delivery of 
radiotherapy for varying sub-types.
The most common sub-types receiving radiotherapy 
were large B-cell lymphoma, follicular lymphoma, 
marginal zone lymphoma and cutaneous T-cell 
lymphoma in England, with a similar pattern seen 
in Wales (Table 9). There were consistent rates in 
radiotherapy delivery by sub-type within 1 year 
and 2 years of diagnosis in England. Due to current 
difficulties in radiotherapy capture with existing 
databases in Wales, only limited conclusions can 
be drawn from the current data provided for Wales; 
this may explain lower proportions of radiotherapy 
delivery in Wales compared to England. Further 
analysis on indications for radiotherapy delivery 
and future analyses exploring variations in 
radiotherapy delivery at an NHS trust and hospital 
level, as well as the structure of radiotherapy 
referral pathways/tertiary referral centres services, 
will increase our understanding of differences 
in care delivery across England and Wales.
Trends over time: There has been no significant 
change in radiotherapy delivery over time by sub-
type (England 2020-2022 and Wales 2022-2023) 
(Supplementary Table 14).
Table 9. Proportion of people with NHL who received radiotherapy by sub-type within 1 year and 2 years of diagnosis for England 
(2022) and with 1 year of diagnosis for Wales (2023).
Denominator
England 2022
Wales 2023
NHL sub-type
1 year (%)
Variation 2022 *
2 years 
(% ) **
Variation 2022 *
1 year (%)
Variation 2023 ***
ALL
11.9
Range: 0-100%
Median (IQR): 10.9% 
(8.1-14.4%)
13.2
Range: 0-100%
Median (IQR): 12.2 
(9.1-15.5%)
8.8
Range: 0-25%
Median (IQR): 9% 
(6-9%)
Burkitt lymphoma
9.6
Range: 0-100%
Median (IQR): 0% 
(0-0%)
9.6
Range: 0-100%
Median (IQR): 0% 
(0-0%)
0.0
Range: 0-0%
Median (IQR): 0% 
(0-0%)
Chronic 
lymphocytic 
leukaemia
0.4
Range: 0-5.9%
Median (IQR): 0% 
(0-0%)
0.5
Range: 0-6.2%
Median (IQR): 0% 
(0-0%)
0.0
Range: 0-0%
Median (IQR): 0% 
(0-0%)
Follicular 
lymphoma
17.3
Range: 0-100%
Median (IQR): 16.2% 
(9.1-22.7%)
19.3
Range: 0-100%
Median (IQR): 17.4% 
(10.0-26.7%)
17.4
Range: 0-50%
Median (IQR): 18% 
(11-25%)
Large B-cell 
lymphoma
21.0
Range: 0-100%
Median (IQR): 20.1% 
(14.1-28.2%)
22.8
Range: 0-100%
Median (IQR): 22.2% 
(14.8-30.0%)
9.8
Range: 0-33%
Median (IQR): 10% 
(0-17%)
Mantle cell 
lymphoma
4.3
Range: 0-100%
Median (IQR): 0% 
(0-0%)
5.9
Range: 0-100%
Median (IQR): 0% 
(0-8.2%)
11.4
Range: 0-100%
Median (IQR): 0% 
(0-17%)
Marginal zone 
lymphoma
19.2
Range: 0-100%
Median (IQR): 14.3% 
(0.0-26.4%)
21.0
Range: 0-100%
Median (IQR): 16% 
(0.0-29.5%)
18.8
Range: 0-50%
Median (IQR): 0% 
(0-33%)
NHL, Not 
otherwise 
specified
8.1
Range: 0-100%
Median (IQR): 0% 
(0.0-13.4%)
8.6
Range: 0-100%
Median (IQR): 0% 
(0.0-16.7%)
12.0
Range: 0-33%
Median (IQR): 0% 
(0-13%)
Peripheral T-cell 
lymphoma
9.4
Range: 0-100%
Median (IQR): 0% 
(0-12.5%)
11.3
Range: 0-100%
Median (IQR): 0% 
(0.0-15.4%)
7.4
Range: 0-100%
Median (IQR): 0%
(0-0%)
Cutaneous T-cell 
lymphoma
20.6
Range: 0-100%
Median (IQR): 0% 
(0.0-33.3%)
23.8
Range: 0-100%
Median (IQR): 0% 
(0.0-38.4%)
20.0
Range: 0-100%
Median (IQR): 0% 
(0-100%)
Other
3.8
Range: 0-100%
Median (IQR): 0% 
(0-0.8%)
4.5
Range: 0-100%
Median (IQR): 0% 
(0.0-6.8%)
3.4
Range: 0-12%
Median (IQR): 0% 
(0-0%)
* Variation between NHS trusts in England 
** RTDS data complete to July 2024; 2-year follow-up may be incomplete for 2022 diagnoses.
*** Variation between hospitals in Wales

Copyright © 2025 Healthcare Quality Improvement Partnership (HQIP)
16
PI 9: Proportion of people diagnosed with 
NHL who were recorded as having received 
an episode of care that was delivered as part 
of a clinical trial, reported by sub-type.
Table 10. Proportion of people diagnosed with NHL who were recorded as having received an episode of care that was delivered 
as part of a clinical trial, reported by sub-type in England 2021 and 2022.**
NHL sub-type
England 2021
(%)
Variation in England 2021*
England 2022
(%)
Variation in England 2022*
All NHL
1.6
Range:0.26 – 3.85%
Median (IQR): 1.43 
(0.64 – 2.34) %
2.0
Range: 0.00 – 6.81%
Median (IQR): 1.86 
(0.99 – 2.46) %
High-grade lymphoma
1.9
Range: 0.00 – 4.93%
Median (IQR): 1.56 
(0.70 – 2.29) %
3.0
Range: 0.00 – 9.77%
Median (IQR): 2.21 
(1.22 – 4.25) %
Low-grade lymphoma
1.3
Range: 0.00 – 4.42%
Median (IQR): 0.88 
(0.00 – 2.22) %
0.9
Range: 0.00 – 4.35%
Median (IQR): 0.67 
(0.00 – 1.21) %
Burkitt lymphoma
0.0
0.0
Chronic lymphocytic leukaemia
0.5
0.4
Cutaneous T-cell lymphoma
1.2
0.0
Follicular lymphoma
2.8
1.9
Large B-cell lymphoma
1.9
3.7
Mantle cell lymphoma
3.7
2.2
Marginal zone lymphoma
0.0
0.3
NHL, Not otherwise specified
1.0
0.3
Other
2.6
2.0
Peripheral T-cell lymphoma
2.1
2.3
* Variation between Cancer Alliances in England
** Data were impacted by the COVID-19 pandemic and so will be atypical to some degree during 2020-21.
Ranges and further variation data are not provided for subtypes of non-Hodgkin lymphoma (NHL) due to small sample sizes
Two per cent of all NHL individuals had a record 
of having received an episode of care that was 
delivered as part of a clinical trial in England 2022; 
this is slightly higher in high-grade cases (3%) 
compared to low-grade cases (0.9%) (Table 10). 
No data on trial participation was available for 
Wales. Record-keeping for trial participation also 
needs to be improved, with data completeness 
approximately 47%, varying between 21.1-71.1% 
when reviewed by sub-type. LBCL was the most 
common sub-type among those who had a record 
of trial participation (England 2022), while the lowest 
recorded rates were observed in cases of Burkitt 
lymphoma and Cutaneous T-cell lymphoma.
Although this performance indicator is reported at 
the Cancer Alliance level due to the small number 
of trial participants, the overall consistency in 
low rates suggests that limited record of trial 
participation is a widespread issue across England.
Trends over time: Overall proportion of people 
with NHL with recorded clinical trial participation 
increased from 1.6% to 2.0% from 2021 to 2022 
in England. This trend may reflect the reduction 
in research resources during the COVID-19 
pandemic, with the increase observed in 2022 
potentially attributable to the resumption of 
research trials in the post-pandemic period.
Key Message: 2.0% all individuals diagnosed with 
NHL in England in 2022 were recorded as having 
received an episode of care that was delivered 
as part of a clinical trial, reported by sub-type.

Copyright © 2025 Healthcare Quality Improvement Partnership (HQIP)
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4.6	 Outcomes 
PI 11: Overall 2-year survival of people with high-
grade lymphoma (BL, DLBCL, mantle cell or high-
grade T-cell).
Key Message: Overall 1-year survival for all NHL 
cases was approximately 80% in England and 
Wales; around 70% for high-grade cases and 90% 
for low-grade cases.  
Overall 2-year survival was around 70% for all 
NHL cases in England; reducing to around 60% for 
high-grade cases and around 84% for low-grade 
cases in England.
Due to the follow-up period required for reporting of 
overall survival, 1-year survival has been provided 
for cases in England in 2020, 2021 and 2022 as 
well as Wales in 2022 and 2023. 2-year survival is 
therefore only available for NHL cases in England in 
2020 and 2021. Survival data for this year’s report 
has also undergone risk adjustment for a number of 
patient and tumour characteristics including age, sex, 
sub-type, staging (Ann Arbor and Binet separately), 
performance status, Charlson comorbidity index, 
diagnosis route and diagnosis year. 
Overall, 1-year survival for all NHL cases was 
slightly higher in Wales compared to England. A 
similar pattern was noted for high-grade cases, 
however, 95% confidence intervals suggest no 
significant difference across years or country 
(Table 11 and 12). 2-year survival was noted to 
be slightly higher in 2021 in England for high-
grade cases NHL, compared to 2020 (Table 12).
Table 11. Overall 1-year survival for all NHL cases in England 2020-2022 and Wales 2022-2023. **
Denominator
England
2020
Variation 
2020 ***
England
2021 
Variation
2021 ***
England
2022
Variation
2022 ***
Wales
2022
Variation
2022 ****
Wales
2023
Variation
2023 ****
All NHL
78.9%
95% 
CI*: 78.2-
80.0%
80.5%
95% 
CI: 79.8-
81.1%
80.8%
95% 
CI: 80.2-
81.4%
82.7%
95%
CI*: 79.5-
85.6%
83.1%
95% 
CI: 80.2-
85.8% 
High-grade 
lymphoma
69.0%
95% 
CI: 67.9-
70.0%
71.2%
95% 
CI: 70.2-
72.2%
71.0%
95% 
CI: 70.0-
72.1%
72.3%
95% 
CI: 66.9-
77.2%
74.9%
95% 
CI: 70.1-
79.2%
Low-grade 
lymphoma
90.2%
95% 
CI: 89.5-
90.9%
90.8%
95% 
CI: 90.1-
91.4%
91.0%
95% 
CI: 90.3-
91.6%
92.7%
95% 
CI: 89.2-
95.3%
93.6%
95% 
CI: 90.4-
96.0%
* confidence interval (CI)
** Data were impacted by the COVID-19 pandemic and so will be atypical to some degree during 2020-21.
*** Variation between NHS trusts in England
**** Variation between hospitals in Wales
Table 12. Overall 2-year survival for all NHL cases in England 2020-2021.**
Denominator
England 2020
Variation 2020 ***
England 2021 
Variation 2021 ***
All NHL
71.7%
95% CI *: 71.0-72.5%
73.6%
95% CI: 72.9-74.3%
High-grade lymphoma
60.8%
95% CI: 59.6-61.9% 
63.2%
95% CI: 62.1-64.3%
Low-grade lymphoma
84.1%
95% CI: 83.2-85.0%
84.8%
95% CI: 84.0-85.6%
* confidence interval (CI)
 ** Data were impacted by the COVID-19 pandemic and so will be atypical to some degree during 2020-21.
*** Variation between NHS trusts in England

Copyright © 2025 Healthcare Quality Improvement Partnership (HQIP)
18
Outlier Analysis:
As part of this year’s report, an outlier analysis has 
been carried out for 1-year survival in both England 
and Wales and 2-year survival in England (Funnel 
plots 1 and 2). The funnel plots demonstrate that 
there is 1 NHS trust in England considered more 
than 3 standard deviations from the national average 
in a positive direction. There are no negatively 
alarm-level outlying NHS trusts noted for 1-year 
or 2-year survival. There are some trusts in funnel 
plots 1 and 2 that are considered more than 2 
standard deviations from the national average 
in a negative direction. This will be monitored 
and in line with our outlier policy, if these trusts 
remain within this range for two consecutive 
years, will be considered an alarm. As this is the 
first year of reporting, trusts will be monitored 
for a further year before any action is taken. The 
funnel plots demonstrate variation between NHS 
trusts/hospitals in both England and Wales.
Funnel Plot 1. 1-year survival for all people diagnosed with 
NHL in England* (2021-2022) and Wales (2022-2023).
40
50
60
70
80
90
100
Adjusted one-year survival (all patients)
0
50 100 150 200 250 300 350 400 450 500 550 600 650 700 750
Number of Patients (England 2021-22; Wales 2022-23)
Trust in England
Trust in Wales
99.8% limits
95% limits
National average (England and Wales)
* Data were impacted by the COVID-19 pandemic and so will be atypical to some 
degree during 2020-21.
Funnel Plot 2. 2-year survival for all people diagnosed with 
NHL in England* (2021-2022).
30
40
50
60
70
80
90
100
Adjusted two-year survival (all patients)
0
50
100 150 200 250 300 350 400 450 500 550 600 650
Number of Patients (England 2020-21)
Trust in England
99.8% limits
95% limits
National average (England)
* Data were impacted by the COVID-19 pandemic and so will be atypical to some 
degree during 2020-21.

Copyright © 2025 Healthcare Quality Improvement Partnership (HQIP)
19
This is the second State of the Nation report 
produced by the National Non-Hodgkin Lymphoma 
Audit (NNHLA), providing a comprehensive 
overview of the patterns of care for individuals 
diagnosed with non-Hodgkin lymphoma in 
England and Wales during 2022 and 2023 
respectively. The report not only presents the 
most recent data but also offers a commentary 
on trends observed since the publication of 
the inaugural State of the Nation report (2024). 
A longitudinal analysis for all performance 
indicators (PIs) is included in Supplementary 
documents, and detailed results by individual 
NHS trust are also provided on our webpages.
Data Considerations:
•	 Direct comparisons between England and Wales 
remain challenging due to differences in data 
collection periods, especially in the context of the 
post-COVID-19 pandemic recovery period. These 
differences may partly explain poorer outcomes in 
England for some performance indicators.
•	 Data quality remains a critical concern. This has 
implications for identifying outliers, adjusting 
survival estimates and analysing variations in 
treatment. A forthcoming quality improvement (QI) 
initiative launched by the NNHLA will aim to help 
address these challenges in more depth.
•	 While improvements of the IT infrastructure in 
Wales are underway, current limitations have 
affected the completeness of performance 
indicator reporting for Welsh providers.
Process and Outcome Observations:
A decline in several key performance indicators 
over recent years across England and Wales, 
highlights the urgent need for targeted quality 
improvement at a local level. Of particular 
concern is the variation in 1-year and 2-year 
survival outcomes between providers—which 
reflects inequity in care and requires immediate 
attention, also highlighted in our outlier process.
Poor performance against the 62-day target for 
initiating SACT is a major contributor to these 
outcomes, particularly for patients with high-grade 
disease. 
5.	 Commentary
Timely MDT discussions and timely use of 
consolidation radiotherapy are also important 
components of the care pathway. Addressing 
these areas alongside treatment initiation may 
contribute to improved outcomes. An action plan 
template for NHS trusts/health boards will be made 
available on our website to support this work.
The incidence of emergency presentations 
remains significant from the data collected. There 
are multi-factorial reasons which will be further 
interrogated during the course of the Audit further 
highlighting the importance of earlier diagnosis 
and streamlined pathway coordination. 
Next Steps:
The development and dissemination of interactive 
quarterly data dashboards will provide more timely 
insights, with data available with a six-month lag 
to each NHS trust. This will enable NHS trusts to 
monitor their performance relative to other NHS 
trusts and their Cancer Alliance, assess changes 
over time, and track improvements in response 
to local quality improvement (QI) initiatives.
The NNHLA will launch an upcoming National QI 
initiative in October 2025, with the focus on 
improving data quality across NHS trusts/health 
boards and Cancer Alliances, in England and 
Wales. This will be done in collaboration with the 
NDRS data liaison teams and aligns with our first 
quality improvement goal of improving timely 
diagnosis and treatment. While improvements in 
data quality have historically been observed in 
more established audits over time, our aim is to 
accelerate this process through direct engagement 
with individual NHS trusts and the provision of 
supportive materials. Enhancing data quality is 
essential for drawing more definitive conclusions, 
gaining deeper insights into the underlying factors 
influencing process outcomes, and improving the 
accuracy of survival analyses and outlier 
reporting. This will not only provide a more 
accurate and nuanced representation of current 
non-Hodgkin lymphoma care across England and 
Wales but also support NHS trusts in 
understanding their own delivery of care and 
identifying opportunities for improvement.