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Protocol - Cancer Treatments

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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.
Protocol Name from Source:

The Expert Review Panel has not reviewed this measure yet.

Availability:

Publicly available

Personnel and Training Required

None

Equipment Needs

None

Requirements
Requirement CategoryRequired
Major equipment No
Specialized training No
Specialized requirements for biospecimen collection No
Average time of greater than 15 minutes in an unaffected individual No
Mode of Administration

Self-administered questionnaire

Life Stage:

Adult

Participants:

Women, aged 18 years and above*

*While this protocol was used in a study of women, the Cancer Working Group deems it appropriate to use with adult males.

Specific Instructions:

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

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 Text 2960986 CDE Browser
Logical Observation Identifiers Names and Codes (LOINC) Cancer treatment proto 62610-1 LOINC
Derived Variables

None

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_Cancer_Chemotherapy PX071101020501 Did you receive Chemotherapy for this Cancer? 4 N/A
PX071101_Cancer_Chemotherapy2 PX071101030501 Did you receive Chemotherapy for this Cancer? 4 N/A
PX071101_Cancer_Chemotherapy_Completed_Date PX071101020503 Date Chemo completed? 4 N/A
PX071101_Cancer_Chemotherapy_Drug_Name PX071101020502 Type of Chemo? 4 N/A
PX071101_Cancer_Chemotherapy_Drug_Name2 PX071101030502 Type of Chemo? 4 N/A
PX071101_Cancer_Chemotherapy_Hospital PX071101020504 Treatment Hospital? 4 N/A
PX071101_Cancer_Chemotherapy_Hospital2 PX071101030504 Treatment Hospital? 4 N/A
PX071101_Cancer_Chemotherapy_Started_Date2 PX071101030503 Date Chemo started? 4 N/A
PX071101_Cancer_Diagnosis_Age PX071101020300 Age of Diagnosis? 4 Variable Mapping
PX071101_Cancer_Diagnosis_Age2 PX071101030300 Age of Diagnosis? 4 Variable Mapping
PX071101_Cancer_Diagnosis_Date PX071101020200 Date of Diagnosis? 4 Variable Mapping
PX071101_Cancer_Diagnosis_Date2 PX071101030200 Date of Diagnosis? 4 Variable Mapping
PX071101_Cancer_Hormonal_Therapy PX071101020701 Did you receive Hormonal Therapy for this Cancer? 4 N/A
PX071101_Cancer_Hormonal_Therapy2 PX071101030701 Did you receive Hormonal Therapy for this Cancer? 4 N/A
PX071101_Cancer_Hormonal_Therapy_Drug_Name PX071101020702 Name of Hormone Therapy? 4 N/A
PX071101_Cancer_Hormonal_Therapy_Drug_Name2 PX071101030702 Name of Hormone Therapy? 4 N/A
PX071101_Cancer_Hormonal_Therapy_Hospital PX071101020704 Treatment Hospital? 4 N/A
PX071101_Cancer_Hormonal_Therapy_Hospital2 PX071101030704 Treatment Hospital? 4 N/A
PX071101_Cancer_Hormonal_Therapy_Started_Date PX071101020703 Date Hormonal Therapy started? 4 N/A
PX071101_Cancer_Hormonal_Therapy_Started_Date2 PX071101030703 Date Hormonal Therapy started? 4 N/A
PX071101_Cancer_Laterality PX071101020100 Laterality? 4 N/A
PX071101_Cancer_Laterality2 PX071101030100 Laterality? 4 N/A
PX071101_Cancer_Other_Therapy PX071101020801 Did you receive any other type(s) of therapy? 4 N/A
PX071101_Cancer_Other_Therapy2 PX071101030801 Did you receive any other type(s) of therapy? 4 N/A
PX071101_Cancer_Other_Therapy_Hospital PX071101020804 Treatment Hospital? 4 N/A
PX071101_Cancer_Other_Therapy_Hospital2 PX071101030804 Treatment Hospital? 4 N/A
PX071101_Cancer_Other_Therapy_Name PX071101020802 Name of Other Therapy? 4 N/A
PX071101_Cancer_Other_Therapy_Name2 PX071101030802 Name of Other Therapy? 4 N/A
PX071101_Cancer_Other_Therapy_Started_Date PX071101020803 Date Other Therapy started? 4 N/A
PX071101_Cancer_Other_Therapy_Started_Date2 PX071101030803 Date Other Therapy started? 4 N/A
PX071101_Cancer_Radiation PX071101020601 Did you receive Radiation for this Cancer? 4 N/A
PX071101_Cancer_Radiation2 PX071101030601 Did you receive Radiation for this Cancer? 4 N/A
PX071101_Cancer_Radiation_Completed_Date PX071101020602 Date Radiation completed? 4 N/A
PX071101_Cancer_Radiation_Hospital PX071101020603 Treatment Hospital 4 N/A
PX071101_Cancer_Radiation_Hospital2 PX071101030603 Treatment Hospital 4 N/A
PX071101_Cancer_Radiation_Started_Date2 PX071101030602 Date Radiation started? 4 N/A
PX071101_Cancer_Recurrence PX071101020901 Have you had a Recurrence with this Cancer? 4 N/A
PX071101_Cancer_Recurrence2 PX071101030901 Have you had a Recurrence with this Cancer? 4 N/A
PX071101_Cancer_Recurrence_Date PX071101020902 Date of Recurrence? 4 N/A
PX071101_Cancer_Recurrence_Date2 PX071101030902 Date of Recurrence? 4 N/A
PX071101_Cancer_Recurrence_Hospital PX071101020904 Treatment Hospital? 4 N/A
PX071101_Cancer_Recurrence_Hospital2 PX071101030904 Treatment Hospital? 4 N/A
PX071101_Cancer_Recurrence_Site PX071101020903 Where did this cancer recur? (ex. lung, breast, liver) 4 N/A
PX071101_Cancer_Recurrence_Site2 PX071101030903 Where did this cancer recur? (ex. lung, breast, liver) 4 N/A
PX071101_Cancer_Site PX071101020000 Cancer Site/Type? 4 N/A
PX071101_Cancer_Site2 PX071101030000 Cancer Site/Type? 4 N/A
PX071101_Cancer_Surgery PX071101020401 Did you have Surgery for this Cancer? 4 N/A
PX071101_Cancer_Surgery2 PX071101030401 Did you have Surgery for this Cancer? 4 N/A
PX071101_Cancer_Surgery_Date PX071101020403 Surgery Date? 4 N/A
PX071101_Cancer_Surgery_Date2 PX071101030403 Surgery Date? 4 N/A
PX071101_Cancer_Surgery_Hospital PX071101020404 Treatment Hospital? 4 N/A
PX071101_Cancer_Surgery_Hospital2 PX071101030404 Treatment Hospital? 4 N/A
PX071101_Cancer_Surgery_Name PX071101020402 Name of Procedure? 4 N/A
PX071101_Cancer_Surgery_Name2 PX071101030402 Name of Procedure? 4 N/A
PX071101_Had_Cancer PX071101010000 Have you ever had cancer? 4 N/A
Research Domain Information
Measure Name:

Cancer Treatments

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.

Keywords

cancer, treatment, Chemotherapy, radiation, surgery, hormone therapy, chemo, Cancer Risk Evaluation Program (CREP)