Probe: Could you tell me about when?
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1 PERIODIC ASSESSMENT OF TREATMENT AND VITAL/DISEASE STATUS Periodic Assessment of Cancer Treatment and Disease Status (To be administered to patient at 3 months and reviewed at 6, 9 and 12 months) Instructions: After the first time this form is administered, only need to update any fields as indicated by respondent. 1. Did you meet with a surgeon to discuss possible surgery for your probable or proven lung cancer? a. When did you first meet with the surgeon? MM/DD/YY Probe: Could you tell me about when? b. What kind of a surgeon did you meet with? (check one) General surgeon Cardiothoracic (heart or lung) surgeon c. What was the surgeon s name? d. In what city or town did you see the surgeon? e. Did you have surgery for your probable or proven lung cancer? 1. Were you offered surgery? a. Did your surgeon tell you that surgery was NOT a good option for you? Did they tell you why surgery was not a good option for you? reason? a. Did you decide against having surgery? (Reason did not undergo surgery: ) (Reason decided against surgery ) 1. When did you have surgery for your lung cancer? MM/DD/YY
2 Probe: Could you tell me about when? 2. What was the name of the surgeon who did your lung surgery? 3. In what city or town was the surgery done? 2. Did you meet with a radiation oncologist (or radiation doctor ) to discuss treatment for your probable or proven lung cancer? a. When did you first meet with the radiation oncologist? MM/DD/YY Probe: Could you tell me about when? b. What was the radiation oncologist s name? c. In what city or town did you see the radiation oncologist? d. Did you receive stereotactic body radiation therapy (SBRT) or other radiation therapy for your lung cancer? 1. Were you offered stereotactic body radiation therapy (SBRT)? a. Did your radiation oncologist tell you that stereotactic body radiation therapy (SBRT) was NOT a good option for you? Did they tell you why stereotactic body radiation therapy (SBRT) was not a good option for you? a. Did you decide against having stereotactic body radiation therapy (SBRT) (Reason not received: ) (Reason: ) 2. Were you offered other radiation therapy? a. Did your radiation oncologist tell you that other radiation therapy was NOT a good option for you?
3 Did they tell you why other radiation therapy was not a good option for you? a. Did you decide against having other radiation therapy? (Reason not received: ) (Reason: ) (check one) Stereotactic body radiation therapy (SBRT) (but you did not undergo surgical resection) Other radiation therapy (but you did not undergo surgical resection) Radiation before surgical resection Radiation after surgical resection Radiation before and after surgical resection 3. Did you meet with a medical oncologist (or chemotherapy doctor ) to discuss treatment for your probable or proven lung cancer? a. When did you first meet with the medical oncologist? MM/DD/YY Probe: Could you tell me about when? b. What was the medical oncologist s name? c. In what city or town did you see the medical oncologist? d. Did you receive chemotherapy for your lung cancer? 1. Were you offered chemotherapy? a. Did your medical oncologist tell you that chemotherapy was NOT a good option for you? Did they tell you why chemotherapy was not a good option for you? a. Did you decide against having chemotherapy? (Reason not received: )
4 (check one) Instead of surgery Before surgery After surgery Before and after surgery (Reason: ) 4. Do you currently have one or more doctors who are primarily following you for your probable or proven lung cancer? a. What kind of doctor are they? (Complete all that apply) Primary care doctor? Pulmonologist (or lung doctor)? General surgeon? Cardiothoracic (heart and lung) surgeon? Medical Oncologist? _
5 Radiation Oncologist? _ b. In what city or town did you see the doctor? 5. As far as you know, are you free of lung cancer at this time? a. Do you currently have lung cancer in (check one or more) Your lungs? The lymph nodes in your chest? Other parts of your body? Notes:
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