Protocol - Cancer Treatments
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.
Specific Instructions:
Complete the entire protocol only if the respondent answers "Yes" to question 1.
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®
Protocol Name from Source:
Availability:
Personnel and Training Required
None
Equipment Needs
None
Requirements
Requirement Category | Required |
---|---|
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.
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
Standard | Name | ID | Source |
---|---|---|---|
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 |
Human Phenotype Ontology | Neoplasm | HP:0002664 | HPO |
Derived Variables
None
Process and Review
Not applicable.
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 VariablesVariable Name | Variable ID | Variable Description | dbGaP Mapping | |
---|---|---|---|---|
PX071101_Cancer_Chemotherapy | ||||
PX071101020501 | Did you receive Chemotherapy for this Cancer? | N/A | ||
PX071101_Cancer_Chemotherapy2 | ||||
PX071101030501 | Did you receive Chemotherapy for this Cancer? | N/A | ||
PX071101_Cancer_Chemotherapy_Completed_Date | ||||
PX071101020503 | Date Chemo completed? | N/A | ||
PX071101_Cancer_Chemotherapy_Drug_Name | ||||
PX071101020502 | Type of Chemo? | N/A | ||
PX071101_Cancer_Chemotherapy_Drug_Name2 | ||||
PX071101030502 | Type of Chemo? | N/A | ||
PX071101_Cancer_Chemotherapy_Hospital | ||||
PX071101020504 | Treatment Hospital? | N/A | ||
PX071101_Cancer_Chemotherapy_Hospital2 | ||||
PX071101030504 | Treatment Hospital? | N/A | ||
PX071101_Cancer_Chemotherapy_Started_Date2 | ||||
PX071101030503 | Date Chemo started? | N/A | ||
PX071101_Cancer_Diagnosis_Age | ||||
PX071101020300 | Age of Diagnosis? | Variable Mapping | ||
PX071101_Cancer_Diagnosis_Age2 | ||||
PX071101030300 | Age of Diagnosis? | Variable Mapping | ||
PX071101_Cancer_Diagnosis_Date | ||||
PX071101020200 | Date of Diagnosis? | Variable Mapping | ||
PX071101_Cancer_Diagnosis_Date2 | ||||
PX071101030200 | Date of Diagnosis? | Variable Mapping | ||
PX071101_Cancer_Hormonal_Therapy | ||||
PX071101020701 | Did you receive Hormonal Therapy for this Cancer? | N/A | ||
PX071101_Cancer_Hormonal_Therapy2 | ||||
PX071101030701 | Did you receive Hormonal Therapy for this Cancer? | N/A | ||
PX071101_Cancer_Hormonal_Therapy_Drug_Name | ||||
PX071101020702 | Name of Hormone Therapy? | N/A | ||
PX071101_Cancer_Hormonal_Therapy_Drug_Name2 | ||||
PX071101030702 | Name of Hormone Therapy? | N/A | ||
PX071101_Cancer_Hormonal_Therapy_Hospital | ||||
PX071101020704 | Treatment Hospital? | N/A | ||
PX071101_Cancer_Hormonal_Therapy_Hospital2 | ||||
PX071101030704 | Treatment Hospital? | N/A | ||
PX071101_Cancer_Hormonal_Therapy_Started_Date | ||||
PX071101020703 | Date Hormonal Therapy started? | N/A | ||
PX071101_Cancer_Hormonal_Therapy_Started_Date2 | ||||
PX071101030703 | Date Hormonal Therapy started? | N/A | ||
PX071101_Cancer_Laterality | ||||
PX071101020100 | Laterality? | N/A | ||
PX071101_Cancer_Laterality2 | ||||
PX071101030100 | Laterality? | Variable Mapping | ||
PX071101_Cancer_Other_Therapy | ||||
PX071101020801 | Did you receive any other type(s) of therapy? | N/A | ||
PX071101_Cancer_Other_Therapy2 | ||||
PX071101030801 | Did you receive any other type(s) of therapy? | N/A | ||
PX071101_Cancer_Other_Therapy_Hospital | ||||
PX071101020804 | Treatment Hospital? | N/A | ||
PX071101_Cancer_Other_Therapy_Hospital2 | ||||
PX071101030804 | Treatment Hospital? | N/A | ||
PX071101_Cancer_Other_Therapy_Name | ||||
PX071101020802 | Name of Other Therapy? | N/A | ||
PX071101_Cancer_Other_Therapy_Name2 | ||||
PX071101030802 | Name of Other Therapy? | N/A | ||
PX071101_Cancer_Other_Therapy_Started_Date | ||||
PX071101020803 | Date Other Therapy started? | N/A | ||
PX071101_Cancer_Other_Therapy_Started_Date2 | ||||
PX071101030803 | Date Other Therapy started? | N/A | ||
PX071101_Cancer_Radiation | ||||
PX071101020601 | Did you receive Radiation for this Cancer? | N/A | ||
PX071101_Cancer_Radiation2 | ||||
PX071101030601 | Did you receive Radiation for this Cancer? | N/A | ||
PX071101_Cancer_Radiation_Completed_Date | ||||
PX071101020602 | Date Radiation completed? | N/A | ||
PX071101_Cancer_Radiation_Hospital | ||||
PX071101020603 | Treatment Hospital | N/A | ||
PX071101_Cancer_Radiation_Hospital2 | ||||
PX071101030603 | Treatment Hospital | N/A | ||
PX071101_Cancer_Radiation_Started_Date2 | ||||
PX071101030602 | Date Radiation started? | N/A | ||
PX071101_Cancer_Recurrence | ||||
PX071101020901 | Have you had a Recurrence with this Cancer? | N/A | ||
PX071101_Cancer_Recurrence2 | ||||
PX071101030901 | Have you had a Recurrence with this Cancer? | N/A | ||
PX071101_Cancer_Recurrence_Date | ||||
PX071101020902 | Date of Recurrence? | N/A | ||
PX071101_Cancer_Recurrence_Date2 | ||||
PX071101030902 | Date of Recurrence? | N/A | ||
PX071101_Cancer_Recurrence_Hospital | ||||
PX071101020904 | Treatment Hospital? | N/A | ||
PX071101_Cancer_Recurrence_Hospital2 | ||||
PX071101030904 | Treatment Hospital? | N/A | ||
PX071101_Cancer_Recurrence_Site | ||||
PX071101020903 | Where did this cancer recur? (ex. lung, more | N/A | ||
PX071101_Cancer_Recurrence_Site2 | ||||
PX071101030903 | Where did this cancer recur? (ex. lung, more | N/A | ||
PX071101_Cancer_Site | ||||
PX071101020000 | Cancer Site/Type? | N/A | ||
PX071101_Cancer_Site2 | ||||
PX071101030000 | Cancer Site/Type? | N/A | ||
PX071101_Cancer_Surgery | ||||
PX071101020401 | Did you have Surgery for this Cancer? | N/A | ||
PX071101_Cancer_Surgery2 | ||||
PX071101030401 | Did you have Surgery for this Cancer? | N/A | ||
PX071101_Cancer_Surgery_Date | ||||
PX071101020403 | Surgery Date? | N/A | ||
PX071101_Cancer_Surgery_Date2 | ||||
PX071101030403 | Surgery Date? | N/A | ||
PX071101_Cancer_Surgery_Hospital | ||||
PX071101020404 | Treatment Hospital? | N/A | ||
PX071101_Cancer_Surgery_Hospital2 | ||||
PX071101030404 | Treatment Hospital? | N/A | ||
PX071101_Cancer_Surgery_Name | ||||
PX071101020402 | Name of Procedure? | N/A | ||
PX071101_Cancer_Surgery_Name2 | ||||
PX071101030402 | Name of Procedure? | N/A | ||
PX071101_Had_Cancer | ||||
PX071101010000 | Have you ever had cancer? | N/A |
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)