NTOG · Nordic Delphi draft · v0.3 · 1 August 2026

Lung Cancer Quality Indicators

Candidate measures for a shared Nordic dataset. Review the definitions, evidence, relationships and methods before Delphi selection.

10instrument measures
57candidate indicators
57relationships
17proposed core
75evidence records
Working instrument. Ten process measures form the first Delphi dataset. Full definitions and sources are in Evidence.
Scope. The accountable measures are processes. Outcomes, screening, nodules, pathology depth and research measures remain separate because they use different populations and data systems.

Core process indicatorsaccountable

Ten working process measures. Open a card for the full specification.

PurposeTimeliness of the diagnostic phase.
Level of measurementDiagnostic service / pathway
Inclusion criteriaAll referrals with radiological suspicion of lung cancer.
ExclusionsReferrals subsequently found non-oncological; patient declined work-up.
NumeratorPatients whose diagnostic confirmation is completed within the defined target
DenominatorPatients referred with radiological suspicion of lung cancer
StratificationReferral source; Final diagnosis (cancer / benign)
Data sourceRegistry pathway timestamps; where unavailable, structured MDT/pathway record.
Reporting intervalQuarterly
Direction of improvementShorter interval and higher within-target proportion are better.
Risk adjustmentReport unadjusted; interpret with case-mix.
Known limitationsReferral definitions differ between Nordic systems; report median AND proportion within target, not median alone.
Reporting formatReport as (i) median days referral→confirmation and (ii) % within target.
Data availability (Nordic, preliminary)
Data-availability dimensionFISEDKNOIS
Captured?
Nationally standardised?
Linkable?
Completeness known?
Available with acceptable delay?

Preliminary assessment for Delphi review — requires validation against each registry's current data dictionary; Iceland is shown as not yet assessed pending registry-lead validation; national and hospital-level data may differ, and some variables exist through linkage rather than in the lung-cancer registry.

Evidence basis
Proposed consensus questions
  • What target interval should define 'timely' diagnosis?
  • Which referral timestamp is the common start point across registries?
PurposeTimeliness and completeness of staging work-up.
Level of measurementDiagnostic service / pathway
Inclusion criteriaConfirmed lung cancer with intent to stage.
ExclusionsBest supportive care decided before staging; patient declined.
NumeratorPatients with a completed guideline-concordant staging package within target
DenominatorPatients with confirmed lung cancer proceeding to staging
StratificationClinical stage; Treatment intent (curative / non-curative)
Data sourceRegistry staging fields + imaging records; MDT record where absent.
Reporting intervalQuarterly
Direction of improvementHigher within-target completion is better.
Risk adjustmentNone; interpret by intent.
Known limitations'Completed staging' must be defined per clinical stage and intent (see C5).
Reporting formatMedian days and % completing staging within target.
Data availability (Nordic, preliminary)
Data-availability dimensionFISEDKNOIS
Captured?
Nationally standardised?
Linkable?
Completeness known?
Available with acceptable delay?

Preliminary assessment for Delphi review — requires validation against each registry's current data dictionary; Iceland is shown as not yet assessed pending registry-lead validation; national and hospital-level data may differ, and some variables exist through linkage rather than in the lung-cancer registry.

Evidence basis
Proposed consensus questions
  • Should the staging clock stop at last staging investigation or at MDT?
PurposeDiagnostic certainty where tissue diagnosis is clinically appropriate.
Level of measurementDiagnostic service
Inclusion criteriaPatients where tissue confirmation was clinically indicated.
ExclusionsFrailty or presumed stage I treated with SABR where confirmation not indicated; documented patient declination. A complementary indicator records documented reason for non-confirmation.
NumeratorCases with histological or cytological confirmation
DenominatorCases for whom tissue diagnosis was clinically indicated
StratificationClinical stage; Treatment intent
Data sourcePathology records linked to registry.
Reporting intervalAnnual
Direction of improvementHigher is better within the indicated population.
Risk adjustmentEligibility restriction (not risk adjustment) via 'when indicated'.
Known limitationsRequires explicit criteria for when confirmation is indicated; unconditioned rates penalise appropriate non-confirmation.
Reporting format% confirmed among indicated; plus % with documented reason when not confirmed.
Data availability (Nordic, preliminary)
Data-availability dimensionFISEDKNOIS
Captured?
Nationally standardised?
Linkable?
Completeness known?
Available with acceptable delay?

Preliminary assessment for Delphi review — requires validation against each registry's current data dictionary; Iceland is shown as not yet assessed pending registry-lead validation; national and hospital-level data may differ, and some variables exist through linkage rather than in the lung-cancer registry.

Evidence basis
Proposed consensus questions
  • What criteria define 'tissue diagnosis indicated'?
PurposeWhether acquired tissue supports both diagnosis and required predictive tests.
Level of measurementDiagnostic / pathology service
Inclusion criteriaAny diagnostic tissue/cytology procedure.
ExclusionsProcedures for non-oncological indication.
NumeratorCases with tissue sufficient for histology and the indicated predictive panel
DenominatorCases undergoing a diagnostic tissue procedure
StratificationProcedure type (bronchoscopy, EBUS, CT-guided, surgical); Histology
Data sourcePathology + procedure records.
Reporting intervalAnnual
Direction of improvementHigher sufficiency, lower repeat-biopsy rate are better.
Risk adjustmentReport by procedure type.
Known limitationsDistinguish failure points: material adequate vs test performed vs valid result.
Reporting format% adequate; companion metrics: repeat-biopsy rate, procedure complication rate, diagnostic yield by procedure.
Data availability (Nordic, preliminary)
Data-availability dimensionFISEDKNOIS
Captured?
Nationally standardised?
Linkable?
Completeness known?
Available with acceptable delay?

Preliminary assessment for Delphi review — requires validation against each registry's current data dictionary; Iceland is shown as not yet assessed pending registry-lead validation; national and hospital-level data may differ, and some variables exist through linkage rather than in the lung-cancer registry.

Evidence basis
Proposed consensus questions
  • Minimum tissue standard for the current predictive panel?
PurposeStaging appropriate to clinical stage and intended treatment.
Level of measurementDiagnostic service / MDT
Inclusion criteriaConfirmed lung cancer undergoing staging.
ExclusionsBest supportive care decided before staging.
NumeratorPatients receiving guideline-concordant anatomical, metabolic, brain and mediastinal staging for their clinical stage and intended treatment
DenominatorPatients with confirmed lung cancer staged
StratificationClinical stage; Treatment intent
Data sourceImaging + procedure records; MDT record.
Reporting intervalAnnual
Direction of improvementHigher concordance is better.
Risk adjustmentEligibility-conditioned.
Known limitationsConcordance is conditional — does NOT imply PET-CT plus EBUS/EUS for every radical candidate; brain imaging included where indicated.
Reporting format% concordant, by clinical stage and intent.
Data availability (Nordic, preliminary)
Data-availability dimensionFISEDKNOIS
Captured?
Nationally standardised?
Linkable?
Completeness known?
Available with acceptable delay?

Preliminary assessment for Delphi review — requires validation against each registry's current data dictionary; Iceland is shown as not yet assessed pending registry-lead validation; national and hospital-level data may differ, and some variables exist through linkage rather than in the lung-cancer registry.

Evidence basis
Proposed consensus questions
  • Adopt a shared Nordic staging-adequacy definition per stage/intent?
PurposePredictive testing completed in time to inform first treatment.
Level of measurementDiagnostic / molecular pathology / MDT
Inclusion criteriaPatients for whom predictive testing is guideline-indicated.
ExclusionsHistology/stage without predictive-testing indication in the applicable guideline version.
NumeratorEligible patients with guideline-concordant predictive biomarker results available before the treatment decision
DenominatorPatients eligible for predictive testing (by histology, stage, intent, year, national guideline)
StratificationHistology; Stage; Treatment intent; Guideline year
Data sourceMolecular pathology records linked to treatment decision date; MDT record.
Reporting intervalAnnual
Direction of improvementHigher and more timely availability is better.
Risk adjustmentVersioned eligibility.
Known limitationsDo NOT hard-code a fixed gene list; define a versioned minimum panel. Separate failure points: ordered / adequate tissue / valid result / available before decision.
Reporting format% with result available before decision; companion breakdown of the four failure points.
Data availability (Nordic, preliminary)
Data-availability dimensionFISEDKNOIS
Captured?
Nationally standardised?
Linkable?
Completeness known?
Available with acceptable delay?

Preliminary assessment for Delphi review — requires validation against each registry's current data dictionary; Iceland is shown as not yet assessed pending registry-lead validation; national and hospital-level data may differ, and some variables exist through linkage rather than in the lung-cancer registry.

Evidence basis
Proposed consensus questions
  • Governance for versioning the minimum panel as guidelines evolve?
PurposeMultidisciplinary decision-making with adequate information, not mere attendance.
Level of measurementMDT
Inclusion criteriaConfirmed lung cancer with a definitive treatment.
ExclusionsEmergency treatment precluding pre-treatment MDT (documented).
NumeratorPatients with a documented MDT treatment recommendation, with required diagnostic information available, before definitive treatment
DenominatorPatients with confirmed lung cancer proceeding to definitive treatment
StratificationStage; Treatment modality
Data sourceStructured MDT record.
Reporting intervalQuarterly
Direction of improvementHigher is better; attendance alone is insufficient.
Risk adjustmentNone.
Known limitationsA bare attendance rate can score 100% with poor preparation. Companion metrics: required information available at MDT; recommendation implemented or reason for deviation; time referral→MDT decision; re-discussion after material new information.
Reporting format% with documented recommendation and information complete; companion metrics as above.
Data availability (Nordic, preliminary)
Data-availability dimensionFISEDKNOIS
Captured?
Nationally standardised?
Linkable?
Completeness known?
Available with acceptable delay?

Preliminary assessment for Delphi review — requires validation against each registry's current data dictionary; Iceland is shown as not yet assessed pending registry-lead validation; national and hospital-level data may differ, and some variables exist through linkage rather than in the lung-cancer registry.

Evidence basis
Proposed consensus questions
  • Minimum information set required for a valid MDT decision?
PurposeEvery patient has a recorded decision and treatment intent.
Level of measurementMDT / treating service
Inclusion criteriaAll confirmed lung cancer.
ExclusionsNone (denominator deliberately includes untreated patients).
NumeratorPatients with a documented treatment recommendation and explicit treatment intent
DenominatorAll patients with confirmed lung cancer
StratificationStage; Intent (curative / non-curative / BSC)
Data sourceMDT / clinical record.
Reporting intervalAnnual
Direction of improvementHigher documentation completeness is better.
Risk adjustmentNone.
Known limitationsFoundational for interpreting C9–C10; includes untreated patients so under-treatment is visible.
Reporting format% with documented recommendation and intent.
Data availability (Nordic, preliminary)
Data-availability dimensionFISEDKNOIS
Captured?
Nationally standardised?
Linkable?
Completeness known?
Available with acceptable delay?

Preliminary assessment for Delphi review — requires validation against each registry's current data dictionary; Iceland is shown as not yet assessed pending registry-lead validation; national and hospital-level data may differ, and some variables exist through linkage rather than in the lung-cancer registry.

Evidence basis
Proposed consensus questions
  • Required fields for a complete decision record (TNM edition, stage, PS, intent)?
PurposeFirst treatment concordant with versioned guidelines, or deviation justified.
Level of measurementTreating service / MDT
Inclusion criteriaAll patients with a documented treatment decision.
ExclusionsInsufficient information is reported as its own class, not excluded.
NumeratorPatients whose treatment is classified concordant OR justified deviation
DenominatorAll patients with a documented treatment decision (including untreated)
StratificationStage; Intent; Modality
Data sourceTreatment records + versioned rule set + MDT documentation.
Reporting intervalAnnual
Direction of improvementHigher (concordant + justified) is better; unexplained deviation is the signal.
Risk adjustmentClassification rather than numeric adjustment.
Known limitationsRequires explicit versioned rules and capture of fitness, comorbidity, contraindications, preferences. Classify: concordant / justified deviation / unexplained deviation / insufficient information.
Reporting formatDistribution across the four classes.
Data availability (Nordic, preliminary)
Data-availability dimensionFISEDKNOIS
Captured?
Nationally standardised?
Linkable?
Completeness known?
Available with acceptable delay?

Preliminary assessment for Delphi review — requires validation against each registry's current data dictionary; Iceland is shown as not yet assessed pending registry-lead validation; national and hospital-level data may differ, and some variables exist through linkage rather than in the lung-cancer registry.

Evidence basis
Proposed consensus questions
  • Who maintains the versioned concordance rule set, and how often?
PurposeAccess to any guideline-concordant curative modality for eligible early/locally-advanced disease.
Level of measurementPathway / treating service
Inclusion criteriaStage I–III eligible for curative intent.
ExclusionsDocumented ineligibility (frailty, operability, competing mortality, patient preference).
NumeratorEligible stage I–III patients receiving guideline-concordant curative-intent treatment (surgery, SABR, chemoradiotherapy, or other curative approach)
DenominatorStage I–III patients eligible for curative-intent treatment
StratificationModality (surgery / SABR / CRT / other); Stage
Data sourceTreatment records; MDT eligibility documentation.
Reporting intervalAnnual
Direction of improvementHigher curative-intent receipt among eligible is better; modality mix reported separately.
Risk adjustmentEligibility-conditioned.
Known limitationsReplaces a bare resection rate — higher resection is NOT inherently better; report modalities separately, resection rate is a context indicator only.
Reporting format% receiving curative-intent among eligible; modality distribution alongside.
Data availability (Nordic, preliminary)
Data-availability dimensionFISEDKNOIS
Captured?
Nationally standardised?
Linkable?
Completeness known?
Available with acceptable delay?

Preliminary assessment for Delphi review — requires validation against each registry's current data dictionary; Iceland is shown as not yet assessed pending registry-lead validation; national and hospital-level data may differ, and some variables exist through linkage rather than in the lung-cancer registry.

Evidence basis
Proposed consensus questions
  • Shared Nordic definition of curative-intent eligibility?

Context indicatorsinterpret with case-mix

Reported alongside the core set for interpretation, not as direct service-comparison process measures.

X1
Stage distribution at diagnosis

Contextual outcome / system-level indicator. Affected by population risk, referral patterns, screening and case ascertainment; not a direct service-comparison process measure.

X2
Survival

Contextual outcome indicator. Report stage-specific; strongly case-mix dependent.

No established quality-indicator evidence identified; proposed for Delphi consensus.

X3
X4
Treatment modality distribution

Context indicator. Describes the balance of surgery / SABR / CRT / systemic therapy.

No established quality-indicator evidence identified; proposed for Delphi consensus.

Separate modules

Distinct populations, denominators or data systems. Developed as companion instruments, not folded into the core set.

Pulmonary nodule pathway

Different denominator population and data system (radiology follow-up infrastructure, nodule registry) from confirmed lung-cancer care. Kept as a separate module, not a core indicator.

  • Guideline-concordant nodule surveillance/work-up
  • Time to resolution of indeterminate nodule
  • Malignancy yield of the nodule pathway

Screening programme

Programme-level, not oncology-unit-level. Denominator ('eligible high-risk population') needs linked smoking and population data. Belongs in a screening module.

  • Eligible-population participation
  • Screen-detected stage distribution
  • Screening interval adherence
  • False-positive / downstream investigation rate

Pathology and molecular diagnostics

Procedure- and laboratory-level quality that underpins C4 and C6.

  • Tissue adequacy for predictive testing
  • Turnaround time to valid molecular result
  • Repeat-biopsy rate
  • Diagnostic yield by procedure

MDT quality

Depth of MDT functioning beyond the C7 decision indicator.

  • Information completeness at MDT
  • Recommendation implementation / documented deviation
  • Time referral→MDT decision
  • Re-discussion after material new information

Treatment and outcomes

Modality-specific treatment quality and outcomes.

  • 30/90-day treatment mortality
  • Curative-intent modality distribution
  • Guideline-concordant systemic therapy sequencing

No established quality-indicator evidence identified; proposed for Delphi consensus.

Data-availability assessment (preliminary)

Each core indicator carries a five-dimension availability grid per country (inside its card). Ratings are a preliminary reading of the registry literature and require validation against each registry's current data dictionary.

Yes Partial / uncertain No / not in lung-cancer registry Not yet assessed

Dimensions: captured · nationally standardised · linkable · completeness known · available with acceptable delay. Grounded in the Nordic registry comparison (Acta Oncologica 2023) and national registry descriptions. Finland's data sources include the population Cancer Registry together with regional and hospital systems and record linkage; this is specified per indicator rather than summarised as a single national status.

Draft. Definitions and Nordic data-availability ratings require registry-lead validation. This is a research and Delphi tool, not an endorsed clinical standard.

Evidence — 57 candidate indicators

Definitions, status and source for every candidate. Red rings mark the proposed 17-item core.

IDIndicatorPhase TypeStatusEvidence

Indicator relationships

Explore 57 documented links: prerequisites, shared measures, balancing pairs, overlaps and conflicts. Directed links are hypotheses, not proof of causation.

Methods & provenance

Scope. Two scoping-review streams are shown separately: the OpenAlex quality-indicator search and the PubMed scoping review documented in the NTOG Notion workspace. This is not a full PRISMA 2020 systematic review.

Study flow

Evidence-flow diagram for the OpenAlex and PubMed scoping reviews

632 unique records were screened: 604 from the OpenAlex scoping search and 28 from the PubMed scoping review after one duplicate. 75 were eligible—57 QI studies and 18 clinical-rationale studies. Ten PubMed records were excluded. The ten new indicators remain Delphi candidates.

Indicator balance (Donabedian)

Indicators by Donabedian category

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