The IMPACT Study - Identification of Men with a Genetic Predisposition to Prostate Cancer

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:

Thank you for completing this questionnaire

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.)

Yes Biochemical Recurrence (PSA only)

Local recurrence

Lymphatic node relapse Para aortic nodes

Pelvic nodes

Other

Metastatic disease: Bone

Other

3.2. Has the patient received any treatmentafter 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

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

Antiandrogens alone

Start Date - -

Duration (months)……………………………..

Response?:

Complete Response Partial Response Stabilization Progression

LHRH+Antiandrogens

Start Date - -

Duration (months)……………………………..

Response?:

Complete Response Partial Response Stabilization Progression

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

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………………………….…………

4.1. Please list of any of the following that have occurred in the last year:

Type of Imaging / Date of report / Result (please enclose copies of reports*)
CT Scan / 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:

……………………………………………………………………………………………………………………….

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

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 / Less than half the time / About half the time / More than half the time / Almost always / Score
1. … had a sensation of not emptying your bladder completely after you finished urinating? ? / 0 / 1 / 2 / 3 / 4 / 5
2. …had to urinate again less than two hours after you finished urinating? / 0 / 1 / 2 / 3 / 4 / 5
3. …stopped and started again several times while urinated? / 0 / 1 / 2 / 3 / 4 / 5
4. …found it difficult to postpone urination? / 0 / 1 / 2 / 3 / 4 / 5
5. …had a weak urinary stream? / 0 / 1 / 2 / 3 / 4 / 5
6. …had to push or strain to begin urination / 0 / 1 / 2 / 3 / 4 / 5
None / Once / Twice / 3 times / 4 times / 5 times or more
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? / 0 / 1 / 2 / 3 / 4 / 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

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? / Very low
1 / Low
2 / Medium
3 / High
4 / Very high
5
2. When you had erections with sexual stimulation, how often were you erections hard enough for penetration (entering your partner)? / No sexual activity
0 / Almost never or never
1 / A few times (much less than half the time)
2 / Sometimes (about half the time)
3 / Most times (much more than half the time)
4 / Almost always or always
5
3. During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner / No sexual activity
0 / Almost never or never
1 / A few times (much less than half the time)
2 / Sometimes (about half the time)
3 / Most times (much more than half the time)
4 / Almost always or always
5
4. During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse? / Did not attempt intercourse
0 / Extremely difficult
1 / Very difficult
2 / Difficult
3 / Slightly difficult
4 / Not difficult
5
5. When you attempted sexual intercourse, how often was it satisfactory for you? / No sexual activity
0 / Almost never or never
1 / A few times (much less than half the time)
2 / Sometimes (about half the time)
3 / Most times (much more than half the time)
4 / Almost always or always
5
SCORE

Total Score ______

(If the score is 21 or less the patient may be showing signs of erectile dysfunction)

7. Please complete the below:

Please sign and below & enter the date of completion – thank you.

Signed…………………………………………………………….

Date - -

Day Month Year

Version 327.01.12 Treatment Follow up Questionnaire