DOC

Demographics

By Dolores Reed,2014-06-26 19:58
8 views 0
Demographics ...

    LUCADA PATIENT DATA FORM

Demographics

    NHS Number Organisation Code Forenames Surname Sex Date of Birth Postcode

Referral Information

    ? Following an emergency admission ? Following a domiciliary visit

    ? Referral from consultant other than in A&E ? Referral from GP Source of ? Following A&E attendance ? General Dental Practitioner referral ? Community Dental Service ? Other source of referral

    ? Not known

    Date of decision to refer (2-week patients only)

    Lung cancer specialist referral date (non-2-week patients)

    Date first seen

    Place first seen

Investigations

    Had a CT scan? ? No ? Yes........Date: Had a PET scan? ? No ? Yes........Date: Had a bronchoscopy? ? No ? Yes........Date: Had a CT-guided biopsy? ? No ? Yes........Date: Had other diagnostic biopsy? ? No ? Yes........Date:

Diagnosis

     Date of diagnosis

     Place of diagnosis

     Pre-treatment histology

    ? Bronchus or lung, unspecified ? Malignant neoplasm of bronchus or lung

    ? Main bronchus, Carina, Hilus of lung ? Upper lobe, bronchus or lung (incl. pancoast)

    ? Middle lobe/lingular, bronchus or lung ? Lower lobe, bronchus or lung Primary ? Trachea ? Overlapping lesion of bronchus and lung site ? Mediastinum, part unspecified ? Pleura diagnosis ? Malignant neoplasm of heart, ? Overlapping lesion of heart, mediastinum and

    mediastinum and pleura pleura

    ? Mesothelioma ? Mesothelioma of pleura

    ? Left ? Midline ? Right Laterality ? Bilateral ? Unknown ? Not applicable

    ? Death certificate ? Clinical

    ? Clinical investigation ? Specific tumour markers Basis of diagnosis ? Cytology ? Histology of a metastasis

    ? Histology of a primary tumour ? Unknown

Staging

    Staging procedure performed?

    Mediastinoscopy/Mediastinotomy

    FNA staging procedure performed?

    Other staging procedure performed?

    Unknown staging procedure performed?

    Pre-treatment Stage T N M NSCLC Stage Will be calculated based on TNM above SCLC Stage ? Limited ? Extensive ? Unknown

    Page 1 of 4

    LUCADA PATIENT DATA FORM

Care Plan/MDT

    Discussed at MDT? ? Yes…….Date: ? No ? Unknown

    ? Curative ? Palliative Treatment intent ? Palliative (supportive care only) ? Unknown

    ? No specific anti-cancer treatment

    Treatment modalities ? Single modality ? Multiple modality ? Unknown

    ? Surgery ? Radiotherapy

    ? Chemotherapy ? Brachytherapy

    ? Palliative care ? Active monitoring

    ? Sequential chemotherapy and radiotherapy Suggested plan ? Concurrent chemotherapy and radiotherapy

    ? Induction chemo to downstage before surgery

    ? Neo-adjuvant chemotherapy and surgery

    ? Surgery followed by chemotherapy

Co-Morbidities

    Was there any reason why the ? Died ? COPD ? Refused patient did not receive the first ? Co-morbidity precluding treatment choice of treatment?

    ? Dementia/Cerebrovascular ? Cardiovascular disease

    disease Co-morbidities ? Renal failure ? Other malignancy

    ? Severe weight loss ? Other FEV1 Absolute

    FEV1 percentage

    Performance Status ? 0 ? 1 ? 2 ? 3 ? 4 ? Not recorded

Treatment - Surgery

    Hospital code

    Date of decision to operate

    Date of surgery

    ? Wedge resection of lesion of lung ? Multiple wedges resected

    ? Segmental resection ? Sleeve resection

    ? Lung resection with resection of chest wall (not identifying which

    lobe resection) Main surgical ? Carinal resection procedure ? Lobectomy ? Pneumonectomy

    ? Open operation on lung (open and close) ? Bilobectomy

    ? Other open operation on lung ? Extrapleural pneumonectomy

    ? Debulking pleurectomy ? Pleurodesis

    ? Presence of Completeness ? No residual ? Microscopic ? Macroscopic residual tumour tumour residual tumour residual tumour of resection cannot be assessed

    Surgical histology

    Date of surgical histology

    Pathological stage pT pN pM Pathological NSCLC Stage

    Pathological SCLC Stage

    Page 2 of 4

    LUCADA PATIENT DATA FORM

Treatment - Chemotherapy

    Hospital code

    Date of decision to treat

    Date of start of treatment

    ? Chemotherapy alone

    ? Neo-adjuvant chemotherapy before surgery Chemotherapy intent

     ? Part of a chemotherapy / radiotherapy treatment plan

     ? Adjuvant chemotherapy post surgery

    ? Induction chemotherapy to down stage before surgery

Treatment - Radiotherapy

    Hospital code

    Date of decision to treat

    Date of start of treatment

    ? Trachea ? Lung

    ? Mediastinum ? Skin Radiotherapy site ? Chest wall ? Bone

    ? Mesothelioma drain site ? Other Region of Body

    ? Brain

    ? Curative (radical) radiotherapy

    ? Curative (CHART / CHARTWEL) Radiotherapy intent ? Part of a chemotherapy / radiotherapy treatment plan

    ? Adjuvent following surgical treatment

    ? Palliative Radiotherapy

Treatment - Brachytherapy

    Hospital code

    Date of decision to treat

    Date of start of treatment

Treatment Palliative Care

    Hospital code

    Date of decision to treat

    Date of start of treatment

    Palliative Care Provider Type ? Hospital ? Community

    ? Hospice ? Nursing Home Palliative Care Community Provider ? Home care ? Other

    ? Unknown Palliative Care Intervention Given ? No ? Yes........Date:

Treatment Active Monitoring

    Hospital code

    Date of decision to treat

    Page 3 of 4

    LUCADA PATIENT DATA FORM

Outcomes

    ? Patient eligible, consented to and entered trial Trial status ? Patient not entered into clinical trial

    ? Clinical trial status unknown

    Date of death

    Was death treatment-related? ? Yes ? No ? Unknown

    ? Surgery ? Chemotherapy Morbidity type ? Radiotherapy ? Combination Was PCI given ? Yes ? No ? Unknown Was the original plan carried out? ? Yes ? No ? Unknown

    ? Cancer progressed through treatment such that a

    new treatment plan required

    ? Patient choice Reason for failure of original plan ? Patient died

    ? Treatment toxicity

    ? Disease progression

Lung Cancer Nurse Specialist

    Was patient assessed by LCNS? ? Yes ? No ? Unknown Date of first assessment by LCNS

    ? In clinic ? Home visit

    ? Ward Visit ? Telephone How was patient first assessed by LCNS? ? Other ? Unknown

    ? Not recorded

    ? Before diagnosis ? After diagnosis At what stage was the patient assessed ? Before and after diagnosis ? At diagnosis only by LCNS? ? Unknown ? Not recorded Was LCNS present when patient received ? Yes ? No ? Unknown their diagnosis?

Notes

    Page 4 of 4

Report this document

For any questions or suggestions please email
cust-service@docsford.com