2 MISC Survey

OMB No. 0925-0046-12
Expiry Date: 2/28/2013

PerioperativeBCAN
1.
Public reporting burden for this collection of information is estimated to average 10 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 208927974, ATTN: PRA (0925-0046). Do not return the completed form to this address.

1. Where does the majority of your clinical practice occur?
j
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n

Non-Academic Setting

j
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n

Academic Setting

2. What is your professional degree?
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MD

j
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n

Nurse practitioner or RN

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n

Physician Assistant

Other (please specify)

3. What proportion of your practice is dedicated to the management of genitourinary
cancers?
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n

<10% of all referrals

j
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n

10% to 25% of all referrals

j
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n

25% to 50% of all referrals

j
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n

>50% of all referrals

2. Bladder Cancer Referral Information

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PerioperativeBCAN
4. How many patients with muscle invasive bladder were referred to your practice in
2010?
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n

0

j
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n

1-5

j
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n

6-12

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n

12 - 20

j
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n

>20

Other (please specify)

5. Of all patients referred to your practice with muscle invasive bladder cancer, what do
you estimate to be the relative contribution of each listed medical subspecialty as the
source of referral? Please make the sum total 100%.
Urologist
Radiation Oncologist
Family Physician or
Internist
Other Medical Oncologist
Other

6. Of all patients referred to your practice with muscle invasive bladder cancer for
consideration of neoadjuvant or adjuvant chemotherapy, what do you estimate to be the
relative contribution of each listed age group? Please make the sum total 100%.
<50 Years
50-64 Years
65- 84 Years
>85 Years

3. Perioperative Chemotherapy- General Staging/ Goals of Care
7. Do you offer neoadjuvant chemotherapy?
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n

Yes, to everyone who is eligible

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n

Sometimes, to high risk patients

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No

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PerioperativeBCAN
8. Do you offer neoadjuvant chemotherapy to patients with upper tract (renal pelvis or
ureter) urothelial cancer?
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n

Yes, to everyone who is eligible

j
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n

Sometimes, to high risk patients

j
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n

No

9. Do you offer adjuvant chemotherapy?
j
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n

Yes, to everyone who is eligible

j
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n

Sometimes, to high risk patients

j
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n

No

10. Do you offer adjuvant chemotherapy to patients with upper tract (renal pelvis or
ureter) urothelial cancer?
j
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n

Yes, to everyone who is eligible

j
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n

Sometimes, to high risk patients

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n

No

11. Of all of the patients you offer peri-operative chemotherapy to, what do you estimate
to be the relative contribution of each category? Please make the sum total 100%.
Neoadjuvant
Adjuvant
If you do not offer neoadjuvant therapy, please return the survey at this point. If you do, please continue to the next section focused on
neoadjuvant chemotherapy

4. Neoadjuvant Chemotherapy- Patient Characteristics

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PerioperativeBCAN
12. Of all patients with bladder cancer referred for consideration of neoadjuvant
chemotherapy, what do you estimate to be the relative contribution of each listed T stage of bladder cancer? Please make the sum total 100%.
T2: Invades muscle
T3: Invasion of perivesical
tissue
T4a: Invasion of adjacent
organ- prostate, uterus.
T4b: Invasion
pelvic/abdominal wall
T(any)N(any):Lymph node
involvement
T(any)M1: Metastatic
disease

5. Neoadjuvant Chemotherapy- Staging
13. Which of the following staging modalities do you require in order to make a decision
regarding neoadjuvant chemotherapy.
Check all that apply.
c
d
e
f
g

CT Chest

c
d
e
f
g

CT Abdomen & Pelvis

c
d
e
f
g

Bone Scan

c
d
e
f
g

CXR

c
d
e
f
g

US Abdomen & Pelvis

c
d
e
f
g

MRI Abdomen & Pelvis

c
d
e
f
g

Urine Cytology

c
d
e
f
g

PET scan

Other (please specify)

6.
At what functional status, stage, age and renal function would you not recommend neoadjuvant chemotherapy?
Please feel free to also include written comments.

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PerioperativeBCAN
14. At what functional status level would you NOT recommend neoadjuvant
chemotherapy.
j
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n

Functional Status is NOT a factor

j
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n

ECOG 1 or greater

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n

ECOG 2 or greater

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n

ECOG 3 or greater

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ECOG 4

Other (please specify)

15. At what T stage would you NOT recommend neoadjuvent chemotherapy? Check
ALL that apply.
c
d
e
f
g

T Stage is NOT a factor

c
d
e
f
g

T2: without lymphovascular invasion

c
d
e
f
g

T2: with lymphovascular invasion

c
d
e
f
g

T3: invasion of perivesical tissue

c
d
e
f
g

T4a: invasion of adjacent organs prostate, uterus, vagina

c
d
e
f
g

T4b: invasion of pelvic/abdominal wall

Other (please specify)

16. At what nodal status would you NOT recommend neoadjuvant chemotherapy, if
any?
c
d
e
f
g

Nodal Status is NOT a factor

c
d
e
f
g

N1: One positive LN <2cm in diameter

c
d
e
f
g

N2: One positive LN 2-5cm in diameter, or multiple positive LN

c
d
e
f
g

N3: One or more positive LN >5cm in diameter

Other (please specify)

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PerioperativeBCAN
17. At what age would you NOT recommend neoadjuvant chemotherapy?
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Age is NOT a factor

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n

> 65 yrs old

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n

> 70 years old

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n

> 75 years old

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n

> 80 years old

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n

> 85 years old

Other (please specify)

18. At what GFR value would you NOT recommend neoadjuvant chemotherapy?
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n

Renal function is NOT a factor

j
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n

<60 ml/min

j
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n

<50 ml/min

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n

<40 ml/min

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<30 ml/min

Other (please specify)

7. Neoadjuvant Chemotherapy- Regimen
19. If you use any of the following neoadjuvant chemotherapy regimens,please specify
the number of cycles used. Indicate all that apply.
Number of Cycles

6

Gemcitabine/ Cisplatin
Day 1, 8 of 21 day cycle

6

Gemcitabine/ Cisplatin
Day 1, 8, 15 of 28 day
cycle
Gemcitabine/ Carboplatin

6

Gemcitabine single agent

6

MVAC Schedule

6

High Dose MVAC

6

Other (please specify)

5
6

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PerioperativeBCAN
20. Please specify dosages for the corresponding neoadjuvant chemotherapy regimens
you use in your practice. Indicate all that apply.
Cisplatin

Gemcitabine

Carboplatin

Methotrexate

Vinblastine

doxorubicin

Paclitaxel

6

6

6

6

6

6

6

6

6

6

6

6

6

6

6

6

6

6

6

6

6

6

6

6

6

6

6

6

6

6

6

6

6

6

6

MVAC

6

6

6

6

6

6

6

HD MVAC

6

6

6

6

6

6

6

Cisplatin
and
Gemcitabine
Carboplatin
and
Gemcitabine
Cisplatin,
Gemcitabine
and
Paclitaxel
Carboplatin,
Gemcitabine
and
Paclitaxel
Single agent
Gemcitabine

Other (please specify)

5

6

21. What adjustments would you make if the patient had renal insufficiency? (Check all
that apply)
c
d
e
f
g

Renal function is NOT a factor

c
d
e
f
g

Split the dose of cisplatin (35mg/m2 d1 and d8)

c
d
e
f
g

Substitute cisplatin with carboplatin

c
d
e
f
g

Proceed directly to cystectomy without neoadjuvant chemotherapy

Other (please specify)

8. Neoadjuvant Chemotherapy- Staging and Follow-up

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PerioperativeBCAN
22. At what point during the neoadjuvant regimen do you restage patients?
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After 50% of cycles

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n

After completion of regimen

Other (please specify)

23. Which of the following staging modalities do you offer a patient undergoing
neoadjuvant chemotherapy, in order to assess response to treatment? Check all that
apply.
c
d
e
f
g

CT Chest

c
d
e
f
g

CT Abdomen & Pelvis

c
d
e
f
g

Bone Scan

c
d
e
f
g

Cystoscopy

c
d
e
f
g

CXR

c
d
e
f
g

US Abdomen & Pelvis

c
d
e
f
g

MRI Abdomen & Pelvis

c
d
e
f
g

CT/ MRI Head

c
d
e
f
g

Urine Cytology

c
d
e
f
g

PET scan

c
d
e
f
g

none

Other (please specify)

24. In your practice, what do you estimate to be the average time frame between the final
dose of neoadjuvant chemotherapy and cystectomy?
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2 weeks

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n

4 weeks

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n

6 weeks

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n

8 weeks

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> 8 weeks

Other (please specify)

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PerioperativeBCAN
9. Post Cystectomy Treatment
25. How do you manage patients that have pathologic residual disease (>pT2 or positive
LN) after neoadjuvant chemotherapy?
c
d
e
f
g

Observation until relapse

c
d
e
f
g

Adjuvant chemotherapy with a cisplatin-based combination

c
d
e
f
g

Adjuvant chemotherapy with a non-cisplatin-based combination

Other (please specify)

26. How often during the first year after neoadjuvant chemotherapy and cystectomy do
you use the following modalities? Check all that apply.
How often?
CT Chest, Abdomen &
Pelvis

6

CT Abdomen & Pelvis

6

Bone Scan

6

US Abdomen & Pelvis

6

MRI Abdomen & Pelvis

6

CXR

6

Urine Cytology

6

PET or PET/CT scan

6

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