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pdfPost-PET Suspected Cancer Form
National Oncologic PET Registry
Facility ID #:
Registry Case Number: ______
Patient Name: ______________________
Your patient had a PET scan on: mm/dd/yyyy.
You previously indicated that the PET scan was done for assessing whether a suspicious lesion is
cancer.
•
•
After reviewing the PET report, please complete the following questions and return the form to the PET Facility.
This form must be entered into the database within 30 days of the PET scan.
1. Has a tissue biopsy been performed of a suspicious site?
Yes
No
2. Did the PET scan enable you to avoid any tests or procedures?
Yes
No
3. In light of the PET findings, which of the following management strategies are you now planning or have
you already undertaken? (you must check only one)
Observation (with close follow-up)
Additional Imaging (CT, MRI) or other non-invasive diagnostic tests
Tissue Biopsy (surgical, percutaneous, or endoscopic).
Note: If concurrent biopsy and total surgical resection are planned, then mark “surgical”
treatment listed below.
Treatment (if treatment is selected, then also complete the following)
Treatment Goal: (check one) Curative
Type(s): (all that apply)
Surgical
Palliative
Chemotherapy (including biologic modifiers)
Radiation Other
Supportive care
Yes No Will treatment be directly provided by you? (check one)
4. I have read the Referring Physician Information Statement and:
I Do give my consent for the inclusion of data collected for this patient in NOPR research.
I DO NOT give my consent for the inclusion of data collected for this patient in NOPR research.
5. Name of person who completed the paper form:
First Name: ________________ Last Name: ____________________ Date:
Version: 02/01/07
Post-PET Unknown Primary Tumor/Paraneoplastic Syndrome Form
National Oncologic PET Registry
Facility ID #:
Registry Case Number: ______
Patient Name: ______________________
Your patient had a PET scan on: mm/dd/yyyy.
You previously indicated that the PET scan was done for assessing a metastatic cancer of
unknown primary origin/a suspected paraneoplastic syndrome. (auto fill reason from Pre-PET Form)
After reviewing the PET report, please complete the following questions and return the form to the PET Facility.
This form must be entered into the database within 30 days of the PET scan.
•
•
1. Was a suspected primary cancer site identified?
2. Was a tissue biopsy or surgical excision performed of a suspected primary?
3. Did the PET scan enable you to avoid any tests or procedures?
Yes
No
Yes
No
Yes
No
4. In light of the PET findings, which of the following management strategies are you now planning or have
you already undertaken? (you must check only one)
Observation (with close follow-up)
Additional Imaging (CT, MRI) or other non-invasive diagnostic tests
Tissue Biopsy (surgical, percutaneous, or endoscopic).
Note: If concurrent biopsy and total surgical resection are planned, then mark “surgical” treatment
listed below.
Treatment (if treatment is selected, then also complete the following)
Treatment Goal: (check one)
Type(s): (all that apply)
Curative
Palliative
Surgical
Chemotherapy (including biologic modifiers)
Radiation
Other
Supportive care
Yes No Will treatment be directly provided by you? (check one)
5. I have read the Referring Physician Information Statement and:
I Do give my consent for the inclusion of data collected for this patient in NOPR research.
I DO NOT give my consent for the inclusion of data collected for this patient in NOPR research.
6.
Name of person who completed the paper form:
First Name: ________________ Last Name: ____________________ Date:
Version: 02/01/07
Post-PET Initial Staging Form
National Oncologic PET Registry
Facility ID #:
Registry Case Number: ______
Patient Name: ______________________
Your patient had a PET scan on: mm/dd/yyyy.
The PET scan was done for initial staging of (cancer type) (auto fill cancer type from Pre-PET Form).
•
•
After reviewing the PET report, please complete the following questions and return the form to the PET Facility.
This form must be entered into the database within 30 days of the PET scan.
1. Compared to your Pre-PET assessment, your impression of the extent of the patient’s cancer is? (check one)
More extensive
No change
Less extensive
2. Did the PET scan, show evidence of cancer activity that was not previously documented?
Yes No
a.
If yes, is some type of tissue biopsy planned of the area?
Yes No
3. Are any more tests or imaging or biopsies planned before starting treatment? Yes No
4. Did the PET scan enable you to avoid any tests or procedures?
Yes No
5. Your Post-PET working clinical summary staging is? (you must check only one)
No evidence of disease / In remission
Localized only
Regional by direct extension or lymph node involvement or both
Metastatic (distant) with a single suspected site
Metastatic (distant) with multiple suspected sites
Unknown or uncertain
6. In light of the PET findings, which of the following management strategies are you now planning or have
you already undertaken? (you must choose only one)
Observation (with close follow-up)
Additional Imaging (CT, MRI) or other non-invasive diagnostic tests
Tissue Biopsy (surgical, percutaneous, or endoscopic).
Note: If concurrent biopsy and total surgical resection are planned, then mark “surgical”
treatment listed below.
Treatment (if treatment is selected, then also complete the following)
Treatment Goal: (check one) Curative
Type(s): (all that apply)
Yes No
Palliative
Surgical
Chemotherapy (including biologic modifiers)
Radiation Other
Supportive care
Will treatment be directly provided by you? (check one)
7. I have read the Referring Physician Information Statement and:
I Do give my consent for the inclusion of data collected for this patient in NOPR research.
I DO NOT give my consent for the inclusion of data collected for this patient in NOPR research.
8. Name of person who completed the paper form:
First Name: _______________ Last Name: _______________________ Date:
Version: 02/01/07
Post-PET Restaging Cancer Form
National Oncologic PET Registry
Facility ID #:
Registry Case Number: ______
Patient Name: ______________________
Your patient had a PET scan on: mm/dd/yyyy.
The PET scan was done for restaging of (cancer type). (auto fill cancer type from Pre-PET Form).
•
•
After reviewing the PET report, please complete the following questions and return the form to the PET Facility.
This form must be entered into the database within 30 days of the PET scan.
1. Compared to your Pre-PET assessment, your impression of the overall extent of disease is? (choose one)
More extensive
No change
Less extensive
2. Did the PET scan show evidence of cancer activity that was not previously documented?
Yes No
a. If yes, is some type of tissue biopsy planned of the area?
Yes No
3. Your Post-PET working clinical staging is: (select only one)
No evidence of disease / In remission
Low probability of local recurrence (including regional lymph nodes) or metastases
Local recurrence (including regional lymph nodes)
Metastatic disease with single site
Metastatic disease with multiple sites
4. Did the PET scan enable you to avoid more tests or procedures?
Yes No
5. In light of the PET findings, which of the following management strategies are you now planning or have
you already undertaken? (you must check only one)
Observation (with close follow-up)
Additional Imaging (CT, MRI) or other non-invasive diagnostic tests
Tissue Biopsy (surgical, percutaneous, or endoscopic).
Note: If concurrent biopsy and total surgical resection are planned, then mark “surgical” treatment
listed below.
Treatment (if treatment is selected, then also complete the following)
Treatment Goal: (check one) Curative Palliative
Type(s): (all that apply)
Surgical
Chemotherapy (including biologic modifiers)
Radiation Other
Supportive care
Yes No
Will treatment be directly provided by you? (check one)
6. I have read the Referring Physician Information Statement and:
I Do give my consent for the inclusion of data collected for this patient in NOPR research.
I DO NOT give my consent for the inclusion of data collected for this patient in NOPR research.
7. Name of person who completed the paper form:
First Name: _______________ Last Name: _______________________ Date:
Version: 02/01/07
Post-PET Suspected Cancer Recurrence Form
National Oncologic PET Registry
Facility ID #:
Registry Case Number: ______
Patient Name: ______________________
Your patient had a PET scan on: mm/dd/yyyy.
The PET scan was done for a suspected recurrence of (cancer type). (auto fill cancer type from PrePET Form).
•
•
After reviewing the PET report, please complete the following questions and return the form to the PET Facility.
This form must be entered into the database within 30 days of the PET scan.
1. Compared to your Pre-PET assessment, your impression of the overall extent of disease is: (choose one)
More extensive
No change
Less extensive
2. Did the PET scan show evidence of cancer activity that was not previously documented?
Yes No
If yes, is some type of tissue biopsy planned of the area?
Yes No
3. Your Post-PET working clinical summary staging is: (select only one)
No evidence of disease / In remission
Low probability of local recurrence (including regional lymph nodes) or metastases
Local recurrence (including regional lymph nodes)
Metastatic disease with single site
Metastatic disease with multiple sites
4. Did the PET scan enable you to avoid more tests or procedures?
Yes No
5. In light of the PET findings, which of the following management strategies are you now planning or have
you already undertaken? (you must check only one)
Observation (with close follow-up)
Additional Imaging (CT, MRI) or other non-invasive diagnostic tests
Tissue Biopsy (surgical, percutaneous, or endoscopic).
Note: If concurrent biopsy and total surgical resection are planned, then mark “surgical”
treatment listed below.
Treatment (if treatment is selected, then also complete the following)
Treatment Goal: (check one)
Curative Palliative
Type(s): (all that apply)
Surgical Chemotherapy (including biologic modifiers)
Radiation Other
Supportive care
Yes No
Will treatment be directly provided by you? (check one)
6. I have read the Referring Physician Information Statement and:
I Do give my consent for the inclusion of data collected for this patient in NOPR research.
I DO NOT give my consent for the inclusion of data collected for this patient in NOPR research.
7. Name of person who completed the paper form:
First Name: _______________ Last Name: _______________________ Date:
Version: 02/01/07
Post-PET Treatment Monitoring Form
National Oncologic PET Registry
Facility ID #:
Registry Case Number: ______
Patient Name: ______________________
Your patient had a PET scan on: mm/dd/yyyy.
The PET scan was done for treatment response monitoring of (cancer type) to
chemo/radiation/or other therapy (auto fill from Pre-PET data form the cancer type and treatment type).
•
•
After reviewing the PET report, please complete the following questions and return the form to the PET Facility.
This form must be entered into the database within 30 days of the PET scan.
1. In light of the PET findings, which of the following management strategies are you now planning or have
you already undertaken? (you must check only one)
Observation (with close follow-up)
Additional Imaging (CT, MRI) or other non-invasive diagnostic tests
Tissue Biopsy (surgical, percutaneous, or endoscopic).
Note: If concurrent biopsy and total surgical resection are planned, then mark “surgical” treatment
listed below.
Treatment (if treatment is selected, then also complete the following)
Treatment Goal: (check one) Curative
Type(s): (all that apply)
Yes No
Palliative
Surgical Chemotherapy (including biologic modifiers)
Radiation Other
Supportive care
Will treatment be directly provided by you? (check one)
2. If treatment was selected above, please indicate if and how you will modify your therapeutic plan in light of
the PET findings. (you must check only one)
Adjust the dose or duration of therapy
Switch to another therapy
No change in therapy
Not applicable – “Treatment” was not selected in question #1 above
3. If PET were not available, would you have done some type of alternative assessment at this time?
Yes
No
4. Did the PET scan enable you to avoid more tests or procedures?
Yes No
5. In light of the PET results, how has the prognosis for your patient changed? (check one)
No change
Worse
Better
6. I have read the Referring Physician Information Statement and:
I Do give my consent for the inclusion of data collected for this patient in NOPR research.
I DO NOT give my consent for the inclusion of data collected for this patient in NOPR research.
7. Name of person who completed the paper form:
First Name: _______________ Last Name: _______________________ Date:
Version: 02/01/07
| File Type | application/pdf |
| File Title | Microsoft Word - nopr_postpet_forms.doc |
| Author | Sharon |
| File Modified | 2007-01-31 |
| File Created | 2007-01-31 |