Download Questionnaire: Treatment follow up - V3 27/01/12

Study Number:
Centre Code:
Date of Birth:
Day
Month
Initials:
Year
The IMPACT Study - Identification of Men with a genetic
predisposition to ProstAte Cancer: Targeted screening in men at
higher genetic risk and controls
TREATMENT FOLLOW-UP FORM
Thank you for collaborating in the IMPACT study. Your patient has been diagnosed
with prostate cancer and last year you sent information about the types of treatment
and investigations he has received. Please could you complete this short follow-up
form to update us about any new treatments or investigations he has received. All of
this information is strictly confidential and will only be used for the IMPACT study.
If you have any queries please contact:
Ms Elizabeth Bancroft
Research Nurse
Cancer Genetics Unit
Royal Marsden NHS trust Foundation
Downs Road, Sutton Surrey SM2 5PT UK
Tel: +44 (0)207 808 2136
Fax: +44 (0)208 770 1489
Email: [email protected]
Thank you for completing this questionnaire
Version 3 27.01.12 Treatment Follow up Questionnaire
1
Date of Completed Treatment Questionnaire (Data Centre to complete):
Day
Month
Year
-
1. Date of last visit:
Day
Month
Year
2. Please record all PSA values since last visit:
Date
PSA value
3.1 Since the last visit, has the patient had disease recurrence? (If NO, please go to 4.)
No
Yes
Biochemical Recurrence (PSA only)
Local recurrence
Lymphatic node relapse
Para aortic nodes
Pelvic nodes
Metastatic disease:
Other
Bone
Other
3.2. Has the patient received any treatment after the recurrence?
No
Yes
Radical Prostatectomy only
Radical Prostatectomy and adjuvant radiation therapy
Prostatectomy and radiotherapy and hormones
Radiotherapy alone
Radiotherapy and adjuvant androgen ablation
Brachytherapy
Cryoablation Therapy
High-Intensity Focused Ultrasonography (HIFU)
Hormonotherapy alone
Chemotherapy alone
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3.3 Hormone Treatment:
If since the last visit the patient has received HT, tick as appropriate:
LHRH alone
-
Start Date:
-
Duration (months)……………………………..
Response?:
Complete Response
Partial Response
Stabilization
Progression
Stabilization
Progression
Stabilization
Progression
Antiandrogens alone
Start Date
-
-
Duration (months)……………………………..
Response?:
Complete Response
Partial Response
LHRH+Antiandrogens
Start Date
-
-
Duration (months)……………………………..
Response?:
Complete Response
Partial Response
If since the last visit, the patient has received more than one line of HT, could you specify the
lines and reason for change it, please?
…………………………………………………………………………………….........................
...............................................................................................……………………………………
…………………………………………………………………………………………………….
3.4 Chemotherapy
If since the last visit, the patient has received chemotherapy, please complete the following
items:
1st line:
Start Date
-
-
End Date
-
-
Number of Cycles……
Drug 1………………………….….mg/m2
Drug 2……………………………..mg/m2
Drug 3……………………………..mg/m2
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Any grade 3 or 4 toxicity?
No
Yes, please specify…………………………….
Response:
Complete Response
Partial Response
Stabilization
Progression
Comments………………………….…………
2nd line:
Start Date
-
-
End Date
-
-
Number of Cycles……
Drug 1………………………….….mg/m2
Drug 2……………………………..mg/m2
Drug 3……………………………..mg/m2
Any grade 3 or 4 toxicity?
No
Yes, please specify…………………………….
Response:
Complete Response
Partial Response
Stabilization
Progression
Comments………………………….…………
3nd line:
Start Date
-
-
End Date
-
-
Number of Cycles……
Drug 1………………………….….mg/m2
Drug 2……………………………..mg/m2
Drug 3……………………………..mg/m2
Any grade 3 or 4 toxicity?
No
Yes, please specify…………………………….
Response:
Complete Response
Partial Response
Stabilization
Progression
Comments………………………….…………
Version 3 27.01.12 Treatment Follow up Questionnaire
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4.1. Please list of any of the following that have occurred in the last year:
Type of Imaging
CT Scan
Date of report
Result (please enclose copies of reports*)
1
2
MRI
1
2
Transrectal Ultrasound
(TRUS)
1
2
Bone Scan
1
2
IVP
1
(Intravenous Pyleogram)
2
Other
1
2
* Please remove any patient identifiers from imaging reports and replace with IMPACT study number.
4.2. If any of the pervious exams have been done for any other reason different from follow
up (i.e. pain, bleeding, etc…), please specify:
……………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………….
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………
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5. Please ask the patient to score the following urinary symptoms:
Over the past month,
how often have you…
Not at
all
Less than 1
time in 5
1. … had a sensation of
not emptying your
bladder completely
after you finished
urinating? ?
2. …had to urinate
again less than two
hours after you finished
urinating?
3. …stopped and
started again several
times while urinated?
4. …found it difficult to
postpone urination?
5. …had a weak urinary
stream?
6. …had to push or
strain to begin urination
0
7. Over the last month
how many times did
you typically get up to
urinate from the time
you went to bed at night
until you got up in the
morning?
About
half the
time
3
More than
half the
time
4
Almost
always
1
Less than
half the
time
2
0
1
2
3
4
5
0
1
2
3
4
5
0
1
2
3
4
5
0
1
2
3
4
5
0
1
2
3
4
5
None
Once
Twice
3 times
4 times
0
1
2
3
4
5 times
or more
5
Score
5
Total Score ________
0 – no symptoms
1-7 indicate mild symptoms of an enlarged prostate
8-19 indicates moderate symptoms of an enlarged prostate
20-35 indicates severe symptoms
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6. Please ask the patient to score the following questions about sexual function:
1. How do you rate your
confidence that you could get
and keep an erection?
2. When you had erections
with sexual stimulation, how
often were you erections hard
enough for penetration
(entering your partner)?
3. During sexual intercourse,
how often were you able to
maintain your erection after
you had penetrated (entered)
your partner
4. During sexual intercourse,
how difficult was it to
maintain your erection to
completion of intercourse?
5. When you attempted sexual
intercourse, how often was it
satisfactory for you?
No sexual
activity
Very
low
1
Almost
never or
never
0
No sexual
activity
1
Almost
never or
never
0
Did not
attempt
intercourse
0
No sexual
activity
1
Extreme
ly
difficult
1
Almost
never or
never
0
1
Low
2
A few times
(much less
than half the
time)
2
A few times
(much less
than half the
time)
2
Very
difficult
2
A few times
(much less
than half the
time)
2
Medium
High
3
4
Most times
(much more
than half the
time)
4
Most times
(much more
than half the
time)
4
Slightly
difficult
Very
high
5
Almost
always
or
always
5
Almost
always
or
always
5
Not
difficult
4
Most times
(much more
than half the
time)
4
5
Almost
always
or
always
5
Sometimes
(about
half the
time)
3
Sometimes
(about
half the
time)
3
Difficult
3
Sometimes
(about
half the
time)
3
SCORE
Total Score ________
(If the score is 21 or less the patient may be showing signs of erectile dysfunction)
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7. Please complete the below:
Assessment for Late Side-Effects after Radiotherapy (Score symptoms over the last 4 weeks)
Please circle appropriate response
URINARY SYMPTOMS (excluding urinary tract infections)
Average daytime frequency
1. >2 hourly
2. 2 hourly
3. 1-2 hourly (no treatment)
4. 1-2 hourly (simple out-patient
management)
5. <1 hourly
9. Unknown
Nocturia
1. 0-1 times
2. 2-3 times
3. 4-5 times
4. 6-8 times
5. >8 times
9. Unknown
Incontinence
1. None
2. Occasional incontinence
3. Frequent incontinence
requiring use of pads
4. Unknown
BOWEL SYMPTOMS
Frequency
1. 1-2 times
2. 3-4 times (no medical treatment)
3. 3-4 times (simple out-patient
management)
4. ≥ 5 times +/- treatment
9. Unknown
Rectal Bleeding
1. None
2. Occasional (no treatment)
3. Moderate (simple outpatient
management)
4. Severe (blood transfusion,
surgery)
9. Unknown
Erectile Potency
1. Normal Erection
2. Decreased
3. Absent
9. Unknown
RTOG Gradings for late side effects after radiotherapy (Score symptoms over the last 4 weeks)
Please Grade 0-5
Diarrhoea
______
Proctitis
______
Cystitis
______
Grading System
Grade 0 – no symptoms
Grade 1 – minor symptoms requiring no treatment
Grade 2 – symptoms responding to simple outpatient management,
lifestyle (performance status not affected)
Grade 3 – distressing symptoms altering patient’s lifestyle performance
status). Hospitalisation for diagnosis or minor surgical
intervention (such as urethral dilation) may be required
Grade 4 – major surgical intervention (such as laparotomy, colostomy,
cystectomy) or prolonged hospitalisation required
Grade 5 – fatal complications
Haematuria ______
Diarrhoea is defined as a clinical syndrome characterised by frequent loose bowel movements without associated
rectal irriation (tenesmus)
Proctitis is defined as a clinical syndrome characterised by rectal irritation or urgency (tenesmus), presence of musus
or blood in the stool and, in some patients, with frequent, sometimes looses, bowel movements.
Cystitis is difined as a syndrome characterised by irritative bladder symptoms such as frequency and dysuria.
Haematuria may or may not be part of the clinical picture of cystitis.
Please sign and below & enter the date of completion – thank you.
Signed …………………………………………………………….
Date
Day
Month
Year
Version 3 27.01.12 Treatment Follow up Questionnaire
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