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Protocol - Cancer Treatments

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Protocol Name from Source:

The Expert Review Panel has not reviewed this measure yet.

Availability:

Publicly available

Description:

These questions start by asking if the respondent has had cancer. For respondents who have had cancer, detailed follow-up questions ask about the type of cancer treatment, including surgery, chemotherapy, radiation, and hormone therapy.

Protocol:

1. Have you ever had cancer?

[ ] Yes

[ ] No

If so, please complete the following chart:

** Please include any diagnosis of Breast DCIS here, and specify Breast Cancer or DCIS.

Cancer Site/Type:

Example: Breast Cancer

Your Cancer:

Laterality (Left/Right/Not Applicable)

Left

Date of Diagnosis

12/2000

Age of Diagnosis

47

Did you have Surgery for this Cancer?

[X] Yes [_] No [_] Not Sure

[_] Yes [_] No [_] Not Sure

If yes: Name of Procedure

Radical mastectomy (left)

Surgery Date

1/5/2001

Treatment Hospital

Jefferson, Philadelphia, PA

Did you receive Chemotherapy for this Cancer?

[X] Yes [_] No [_] Not Sure

[_] Yes [_] No [_] Not Sure

If yes: Type of Chemo*

(Please choose from chemo drug list below)

Adriamycin® & Cytoxan®

Date Chemo completed

2/2001

Treatment Hospital

Jefferson, Philadelphia, PA

Did you receive Radiation for this Cancer?

[X] Yes [_] No [_] Not Sure

[_] Yes [_] No [_] Not Sure

Date Radiation completed

3/2001

Treatment Hospital

HUP

Did you receive Hormonal Therapy for this Cancer?

[X] Yes [_] No [_] Not Sure

[_] Yes [_] No [_] Not Sure

If yes: Name of Hormone Therapy

(ex. Tamoxifen, Aromasin®, Femara®)

Tamoxifen

Treatment Hospital

HUP

Date Hormonal Therapy started

4/2001

Did you receive any other type(s) of therapy?

[_] Yes [X] No [_] Not Sure

[_] Yes [_] No [_] Not Sure

If yes: Please specify.

Date Other Therapy started

Treatment Hospital

 

Have you had a Recurrence with this Cancer?

[X] Yes [_] No [_] Not Sure

[_] Yes [_] No [_] Not Sure

If yes: Date of Recurrence?

9/2002

Where did this cancer recur?

(ex. lung, breast, liver)

Lung

Treatment Hospital

HUP

If you have been diagnosed with more than one cancer, please complete the following chart:

Cancer Site/Type:

Example: Second Cancer:

Breast Cancer

Your Second Cancer:

Laterality (Left/Right/Not Applicable)

Right

Date of Diagnosis

5/2003

Age of Diagnosis

50

Did you have Surgery for this Cancer?

[X] Yes [_] No [_] Not Sure

[_] Yes [_] No [_] Not Sure

If yes: Name of Procedure

Radical mastectomy (right)

Surgery Date

6/1/2003

Treatment Hospital

Jefferson, Philadelphia, PA

Did you receive Chemotherapy for this Cancer?

[X] Yes [_] No [_] Not Sure

[_] Yes [_] No [_] Not Sure

If yes: Type of Chemo*

(Please choose from list below)

Adriamycin® & Cytoxan®

Date Chemo started

7/2003

Treatment Hospital

Jefferson, Philadelphia, PA

Did you receive Radiation for this Cancer?

[_] Yes [X] No [_] Not Sure

[_] Yes [_] No [_] Not Sure

Date Radiation started

 

Treatment Hospital

Did you receive Hormonal Therapy for this Cancer?

[X] Yes [_] No [_] Not Sure

[_] Yes [_] No [_] Not Sure

If yes: Name of Hormone Therapy

(ex. Tamoxifen, Aromasin®, Femara®)

Tamoxifen

Treatment Hospital

HUP

Date Hormonal Therapy started

8/2003

Did you receive any other type(s) of therapy?

[_] Yes [X] No [_] Not Sure

[_] Yes [_] No [_] Not Sure

If yes: Please specify.

Date Other Therapy started

Treatment Hospital

Have you had a Recurrence with this Cancer?

[X] Yes [_] No [_] Not Sure

[_] Yes [_] No [_] Not Sure

If yes: Date of Recurrence?

10/2004

Where did this cancer recur?

(ex. lung, breast, liver)

Chest Wall

Treatment Hospital

HUP

*Chemo Drug List Examples

Adriamycin®
Paclitaxel Taxotere®
Cytoxan®
Xeloda®
Other

Leucovorin®
Fluorouracil®
Methotrexate Taxol®
Herceptin®
Avastin®


Adriamycin is ® a registered trademark, Pharmacia Inc.
Cytoxan® and Taxol® are registered trademarks, Bristol-Myers Squibb Company.
Aromasin® is a registered trademark, Pfizer, Inc.
Femara® is a registered trademark, Novartis Pharmaceuticals Corporation.
Taxotere® is a registered trademark, Sanofi-Aventis U.S. LLC.
Xeloda® is a registered trademark, Roche Pharmaceuticals.
Leucovorin® is a registered trademark, Mayne Pharma (USA) Inc.
Fluorouracil® is a registered trademark, Gensia Sicor Pharmaceuticals, Inc.
Herceptin® and Avastin® are registered trademarks, Genentech, Inc.

Personnel and Training Required

None

Equipment Needs

None

Requirements

Requirement CategoryRequired
Average time of greater than 15 minutes in an unaffected individualNo
Major equipmentNo
Specialized requirements for biospecimen collectionNo
Specialized trainingNo

Mode of Administration

Self-administered

Life Stage:

Adult

Specific Instructions:

Complete the entire protocol only if the respondent answers "Yes" to question 1.

Research Domain Information

Release Date:

December 30, 2009

Definition

A measure to assess history of cancer treatments

Purpose

The purpose of this measure is to assess if a respondent has had cancer and the type(s) of treatment received.

Selection Rationale

This protocol was selected because it provides the respondent with a form to self-report on the cancer sites and the details of the types of treatment received.

Language

English

Standards

StandardNameIDSource
Common Data Elements (CDE)Person Cancer Treatment History Text2960986CDE Browser
Logical Observation Identifiers Names and Codes (LOINC)Cancer treatment proto62610-1LOINC

Process and Review

The Expert Review Panel has not reviewed this measure yet.

Source

University of Pennsylvania, Abramson Cancer Center, Cancer Risk Evaluation Program, Health History Questionnaire 9/2006, questions from pages 2&ndash3.

General References

None

Protocol ID:

71101

Variables:

Export Variables
Variable NameVariable IDVariable DescriptionVersiondbGaP Mapping
PX071101_Had_CancerPX071101010000Have you ever had cancer?4N/A
PX071101_Cancer_SitePX071101020000Cancer Site/Type?4N/A
PX071101_Cancer_LateralityPX071101020100Laterality?4N/A
PX071101_Cancer_Diagnosis_DatePX071101020200Date of Diagnosis?4N/A
PX071101_Cancer_Diagnosis_AgePX071101020300Age of Diagnosis?4N/A
PX071101_Cancer_SurgeryPX071101020401Did you have Surgery for this Cancer?4N/A
PX071101_Cancer_Surgery_NamePX071101020402Name of Procedure?4N/A
PX071101_Cancer_Surgery_DatePX071101020403Surgery Date?4N/A
PX071101_Cancer_Surgery_HospitalPX071101020404Treatment Hospital?4N/A
PX071101_Cancer_ChemotherapyPX071101020501Did you receive Chemotherapy for this Cancer?4N/A
PX071101_Cancer_Chemotherapy_Drug_NamePX071101020502Type of Chemo?4N/A
PX071101_Cancer_Chemotherapy_Completed_DatePX071101020503Date Chemo completed?4N/A
PX071101_Cancer_Chemotherapy_HospitalPX071101020504Treatment Hospital?4N/A
PX071101_Cancer_RadiationPX071101020601Did you receive Radiation for this Cancer?4N/A
PX071101_Cancer_Radiation_Completed_DatePX071101020602Date Radiation completed?4N/A
PX071101_Cancer_Radiation_HospitalPX071101020603Treatment Hospital4N/A
PX071101_Cancer_Hormonal_TherapyPX071101020701Did you receive Hormonal Therapy for this Cancer?4N/A
PX071101_Cancer_Hormonal_Therapy_Drug_NamePX071101020702Name of Hormone Therapy?4N/A
PX071101_Cancer_Hormonal_Therapy_Started_DatePX071101020703Date Hormonal Therapy started?4N/A
PX071101_Cancer_Hormonal_Therapy_HospitalPX071101020704Treatment Hospital?4N/A
PX071101_Cancer_Other_TherapyPX071101020801Did you receive any other type(s) of therapy?4N/A
PX071101_Cancer_Other_Therapy_NamePX071101020802Name of Other Therapy?4N/A
PX071101_Cancer_Other_Therapy_Started_DatePX071101020803Date Other Therapy started?4N/A
PX071101_Cancer_Other_Therapy_HospitalPX071101020804Treatment Hospital?4N/A
PX071101_Cancer_RecurrencePX071101020901Have you had a Recurrence with this Cancer?4N/A
PX071101_Cancer_Recurrence_DatePX071101020902Date of Recurrence?4N/A
PX071101_Cancer_Recurrence_SitePX071101020903Where did this cancer recur? (ex. lung, breast, liver)4N/A
PX071101_Cancer_Recurrence_HospitalPX071101020904Treatment Hospital?4N/A
PX071101_Cancer_Site2PX071101030000Cancer Site/Type?4N/A
PX071101_Cancer_Laterality2PX071101030100Laterality?4N/A
PX071101_Cancer_Diagnosis_Date2PX071101030200Date of Diagnosis?4N/A
PX071101_Cancer_Diagnosis_Age2PX071101030300Age of Diagnosis?4N/A
PX071101_Cancer_Surgery2PX071101030401Did you have Surgery for this Cancer?4N/A
PX071101_Cancer_Surgery_Name2PX071101030402Name of Procedure?4N/A
PX071101_Cancer_Surgery_Date2PX071101030403Surgery Date?4N/A
PX071101_Cancer_Surgery_Hospital2PX071101030404Treatment Hospital?4N/A
PX071101_Cancer_Chemotherapy2PX071101030501Did you receive Chemotherapy for this Cancer?4N/A
PX071101_Cancer_Chemotherapy_Drug_Name2PX071101030502Type of Chemo?4N/A
PX071101_Cancer_Chemotherapy_Started_Date2PX071101030503Date Chemo started?4N/A
PX071101_Cancer_Chemotherapy_Hospital2PX071101030504Treatment Hospital?4N/A
PX071101_Cancer_Radiation2PX071101030601Did you receive Radiation for this Cancer?4N/A
PX071101_Cancer_Radiation_Started_Date2PX071101030602Date Radiation started?4N/A
PX071101_Cancer_Radiation_Hospital2PX071101030603Treatment Hospital4N/A
PX071101_Cancer_Hormonal_Therapy2PX071101030701Did you receive Hormonal Therapy for this Cancer?4N/A
PX071101_Cancer_Hormonal_Therapy_Drug_Name2PX071101030702Name of Hormone Therapy?4N/A
PX071101_Cancer_Hormonal_Therapy_Started_Date2PX071101030703Date Hormonal Therapy started?4N/A
PX071101_Cancer_Hormonal_Therapy_Hospital2PX071101030704Treatment Hospital?4N/A
PX071101_Cancer_Other_Therapy2PX071101030801Did you receive any other type(s) of therapy?4N/A
PX071101_Cancer_Other_Therapy_Name2PX071101030802Name of Other Therapy?4N/A
PX071101_Cancer_Other_Therapy_Started_Date2PX071101030803Date Other Therapy started?4N/A
PX071101_Cancer_Other_Therapy_Hospital2PX071101030804Treatment Hospital?4N/A
PX071101_Cancer_Recurrence2PX071101030901Have you had a Recurrence with this Cancer?4N/A
PX071101_Cancer_Recurrence_Date2PX071101030902Date of Recurrence?4N/A
PX071101_Cancer_Recurrence_Site2PX071101030903Where did this cancer recur? (ex. lung, breast, liver)4N/A
PX071101_Cancer_Recurrence_Hospital2PX071101030904Treatment Hospital?4N/A