Form 2 Abstraction

OMB #: 0925-xxxx

Expiry Date: xx/xx/20xx

Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-xxxx). Do not return the completed form to this address.

Attachment 7: Patient Abstraction Form

Central and Eastern European Kidney Cancer Survival Study

Hospital Name___________________________________ Date:____________________________________

Patient Name: ______________________________ Birthdate:________________________________

Study ID Number:___________________________

Last Control Date: ___/___/_____ Physician’s Name:__________________________

Reason for visit:__________________________________________________________________________________

Follow-up Exams Performed-Excluding First Diagnosis of Kidney Cancer

Test Type Date Not Done Normal Abnormal Comments_________________________

Physical __/__/___ □ □ □ _____________________

Blood Tests __/__/___ □ □ □ _____________________

Sonogram __/__/___ □ □ □ _____________________

CT/MNR __/__/___ □ □ □ _____________________

Chest RX __/__/___ □ □ □ _____________________

Bone Scan __/__/___ □ □ □ _____________________

Other __/__/___ □ □ □ _____________________

Blood pressure at Dx________________________ Blood pressure at follow-up ___________________________________

Hypertensive at Dx Y / N Hypertensive at follow-up Y / N

Weight at Dx_______________________________Weight at follow-up ___________________________________

Smoking at Follow-up________________________________________________

Evidence of recurrence observed Y/N:______

If yes, please answer following questions

If no, please skip to conclusion and answer #1-stable

Cancer Treatments –Excluding First Diagnosis of Kidney Cancer 1=yes, 2=no

Y/N Date Characteristics-Comments___________________________

Surgery/Biopsy □ __/__/____ ___________________________________

Radiotherapy □ __/__/____ ___________________________________

Chemotherapy □ __/__/____ ___________________________________

Other □ __/__/____ ___________________________________

Tumor Information if Evidence of Recurrence or Progression Observed

Number of Tumors:__________________

Tumor Size:_________________________

Histologic Cell Type:

1 □ Clear Cell 6 □ Papillary Type II 11 □ Non RCC

2 □ Clear Cell w papillary features 7 □ Papillary non-Type I 12 □ Collecting Duct

3 □ Clear Cell with sarcomatoid 8 □ Chromophobe 13 □ TCC

4□ Sarcomatoid 9 □ Oncocytoma 14 □ HLRCC

5 □ Papillary Type I 10 □ Unclassified 15 □ Other___________________________

Stage

1 □ T0 2 □ T1 3 □ T2 4 □ T3 5 □ T4 6 □ TX

Regional Lymphnodes

1 □ N0 2 □ N1 3 □ N2 4 □ N3

Distant Metastases

1 □ M0 2 □ M1 3 □ M2

Fuhman Nuclear Grade

1 □ I 2 □ II 3 □ III 4 □ IV 5 □ NA

Tumor Grade

1 □ Well differentiated

2 □ Moderately differentiated

3 □ Poorly differentiated

4 □ Undifferentiated

5 □ Grade not determined

Conclusion

1 □ Patient is alive and stable, no evidence of recurrence or progression,

date last seen_________________________________

2 □ Patient is alive, evidence of recurrence or progression primary disease

3 □ Patient is deceased: Date of death:_________________________

Cause :1 □ Primary kidney cancer 2 □ Other Cause_________________________ 3 □ Unknown

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