Att 2Aii_Head&Neck Survey Sent Advance

SURVEY ON MULTIDISCIPLINARY TREATMENT PLANNING FOR HEAD

Thank you for participating in the Multidisciplinary Treatment Planning Survey for the NCI Community Cancer Centers Program (NCCCP). This 
survey is being conducted by the National Cancer Institute (NCI) to understand how NCCCP sites conduct multidisciplinary treatment planning, a 
feature of multidisciplinary care, and to gain insight into the variety of ways it is structured and implemented for different types of cancers. 
This survey is designed to solicit information about the multidisciplinary treatment planning services being planned for head and neck cancer 
patients at your facility. This cancer was chosen because your facility has reported multidisciplinary care experience in this area. This survey is 
intended to obtain information at the organizational level and not at the physician or specialty level.  
As the Principal Investigator, we ask that you work with the Quality of Care Lead at your facility. They have been identified as the most appropriate 
respondent to complete this survey. We encourage them to consult with other colleagues at your Cancer Center to accurately respond to these 
questions. There are no right or wrong answers. Your responses will help expand existing knowledge of multidisciplinary treatment planning for 
cancer and inform future research in cancer care delivery.  

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SURVEY ON MULTIDISCIPLINARY TREATMENT PLANNING FOR HEAD
Burden Statement and Consent Page

Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching exis

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

currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions 
Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892­7974, ATTN: PRA (0925­XXXX). Do not return the completed form to this address.  

Your participation in this study is voluntary. You can decide not to be in the study, and that will not affect your status in the NCCCP. You will not 
receive an incentive to participate in this study.  
Other 
Your privacy is very important to us. Your name and facility will not be linked to your answers & will not show up on any reports about this study. 
Instead, a code number will be assigned to your survey. Your responses will be kept secure to the extent provided by law and will only be accessible 
to the study team. All responses will be reported in aggregate.  
Although your participation in this research may not benefit you personally, it will help us understand how NCCCP sites conduct multidiscplinary 
treatment planning.  
There are no risks to individuals or organizations participating in this survey.  
If you have questions about this study or to opt out, please contact Lead Investigator, Dr. Irene Prabhu Das at 240­276­6799 or 
Some 
[email protected]. If you have any questions about your rights as a participant in this study or any concerns or complaints, please contact 
the National Cancer Institute's OMB Project Clearance Liaison at 301­480­0541 or [email protected].  
I have read and understand the above information. By clicking the "Next" button below, I consent to participate voluntarily in this survey.  

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SURVEY ON MULTIDISCIPLINARY TREATMENT PLANNING FOR HEAD
Survey Instructions

Please review ALL the instructions before beginning the survey. 
For purposes of this survey, multidisciplinary treatment planning is commonly understood as a coordinated approach that brings together multiple 
cancer specialists as well as other clinicians and professionals to plan the appropriate treatment and other integral services for a cancer patient 
once a confirmed diagnosis is made (e.g., through surgery or biopsy). Therefore, multidisciplinary treatment planning occurs before initiating the 
required complex, multi­modality therapies.  
• It is important that you consult with colleagues at your Cancer Center if you are unable to answer questions that may be administrative in nature 
and/or may not apply to your specialty. You may choose to print and share the survey to obtain the responses to some or all of the questions. Once 
you obtain the responses you need, you can then complete the survey online. No written surveys will be accepted.  
• If your facility has a formal written policy, standard operating procedures, or a performance evaluation tool for multidisciplinary care (other than 
the NCCCP MDC Assessment Tool), please obtain access to them in advance to help complete the survey.  
• We encourage you to answer all of the questions so that we can best understand multidisciplinary treatment planning at your facility and 
adequately represent it in the survey results.  
• Your responses will be kept secure to the extent provided by law. Final results will not identify your facility site. Only aggregate results of this 
survey will be used. Neither you nor your facility will be linked to the final results.  
• The survey should take no more than one hour to complete. This includes time to consult with your colleagues and team to respond to the survey 
questions. Your responses will be saved as you complete the survey. You do not have to complete the survey in one sitting. However, please save 
this web link used to access the survey, as you will need to click on the link again to access the survey if you chose to complete it at another time.  

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SURVEY ON MULTIDISCIPLINARY TREATMENT PLANNING FOR HEAD
A. OVERVIEW OF MULTIDISCIPLINARY TREATMENT PLANNING FOR CANCER
CARE
For the following questions, please think about typical head and neck cancer cases at your Cancer Center. 
For purposes of this survey, multidisciplinary treatment planning is defined as a coordinated approach that brings together multiple cancer 
specialists as well as other clinicians and professionals to plan the appropriate treatment and other integral services for a cancer patient once a 
confirmed diagnosis is made (e.g., through surgery or biopsy). Therefore, multidisciplinary treatment planning occurs before initiating the required 
complex, multi­modality therapies.  

1. Please choose the statement that best describes how the treatment planning approach
for head and neck cancer patients at your facility compares with the survey’s definition of
multidisciplinary treatment planning.
j The survey definition of multidisciplinary treatment planning exactly describes the treatment planning approach for head and neck 
k
l
m
n
cancer patients at my facility. 

j The survey definition of multidisciplinary treatment planning describes some but not all aspects of the treatment planning approach for 
k
l
m
n
head and neck cancer patients at my facility. 

j The survey definition of multidisciplinary treatment planning does not at all describe the treatment planning approach for head and neck 
k
l
m
n
cancer patients at my facility. 

j Other (please specify)
k
l
m
n

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6  

2. What is the multidisciplinary treatment planning approach for head and neck cancer
patients called at your facility?
j Multidisciplinary Conference
k
l
m
n
j Multidisciplinary Clinic
k
l
m
n
Other 

j Multidisciplinary Team
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l
m
n
j Tumor Board
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l
m
n

j Tumor Conference
k
l
m
n

j Cancer Conference
k
l
m
n

j Other (please specify)
k
l
m
n

Sometimes 

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SURVEY ON MULTIDISCIPLINARY TREATMENT PLANNING FOR HEAD
3. Once a patient is definitively diagnosed with head and neck cancer, would you describe
the multidisciplinary treatment planning as prospective?

j Yes
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m
n
j No
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n

j A mixture of prospective and retrospective
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l
m
n
j Other (please specify)
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l
m
n

4. How frequently does your facility hold multidisciplinary treatment planning meetings for
head and neck cancer cases, either in­person or virtually?
j Four times per month/Weekly
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l
m
n
j Three times per month
k
l
m
n

j Two times per month/Bi­weekly
k
l
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n
j Once a month
k
l
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n
j As needed
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l
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n

j Other (please specify)
k
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m
n

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SURVEY ON MULTIDISCIPLINARY TREATMENT PLANNING FOR HEAD
A. OVERVIEW OF MULTIDISCIPLINARY TREATMENT PLANNING FOR CANCER
CARE

5. Are head and neck cancer patients typically invited to attend treatment planning
meetings with the multidisciplinary cancer care team?

j Yes
k
l
m
n
j No
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n

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SURVEY ON MULTIDISCIPLINARY TREATMENT PLANNING FOR HEAD
A. OVERVIEW OF MULTIDISCIPLINARY TREATMENT PLANNING FOR CANCER
CARE

6. Why are patients not invited? (CHECK ALL THAT APPLY)
c Medical providers would not be able to speak as freely in the presence of the patient.
d
e
f
g
c Our facility lacks the infrastructure to accommodate patient attendance.
d
e
f
g
c It is an inefficient use of time to include the patient.
d
e
f
g

c There are concerns about legal liability/accountability for decisions regarding a patient’s treatment.
d
e
f
g
c The discussion may be too overwhelming or confusing for the patient.
d
e
f
g

c Medical providers aren’t able to bill for time spent with patients in these discussions.
d
e
f
g

c There are concerns that inviting patients may compromise the privacy of their health information.
d
e
f
g
c Other (please specify)
d
e
f
g

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SURVEY ON MULTIDISCIPLINARY TREATMENT PLANNING FOR HEAD
A. OVERVIEW OF MULTIDISCIPLINARY TREATMENT PLANNING FOR CANCER
CARE

7. Which best describes the physicians that participate in multidisciplinary treatment
planning discussions about head and neck cancer patients at your facility?
j They are all private practice physicians.
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l
m
n

j They are mostly private practice physicians.
k
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m
n
Other 

j They are an even mix of private practice physicians and physicians employed by this facility.
k
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n
j They are mostly physicians employed by this facility.
k
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m
n
j They are all physicians employed by this facility.
k
l
m
n
j Other (please specify)
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l
m
n

8. Does your Cancer Center have a formal written policy or standard operating procedures
for providing multidisciplinary treatment planning?

j Yes
k
l
m
n
Decisions 

j No
k
l
m
n

j Under development
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m
n

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SURVEY ON MULTIDISCIPLINARY TREATMENT PLANNING FOR HEAD
A. OVERVIEW OF MULTIDISCIPLINARY TREATMENT PLANNING FOR CANCER
CARE
9. Would your facility be willing to share a copy of your Cancer Center's policy or standard
operating procedures?
j Yes (The researchers will contact you)
k
l
m
n
j No
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n

j I don't know
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SURVEY ON MULTIDISCIPLINARY TREATMENT PLANNING FOR HEAD
B. INITIAL CASE PRESENTATION

This section asks questions about multidisciplinary treatment planning meetings and initial case presentations for head and neck cancer patients 
at your Cancer Center.  

10. Are multidisciplinary treatment planning meetings for head and neck cancer cases held
on a set schedule or only as needed?
j Set schedule
k
l
m
n
j As needed
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m
n
j Both
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n
Other 

11. Is there a formally designated person(s) or position(s) that coordinates
multidisciplinary treatment planning meetings for head and neck cancer?

j Yes
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n
j No
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SURVEY ON MULTIDISCIPLINARY TREATMENT PLANNING FOR HEAD

12. Who is responsible for coordinating multidisciplinary treatment planning meetings?
(CHECK ALL THAT APPLY)
c Nurse
d
e
f
g

c Patient/Nurse Navigator
d
e
f
g
c Tumor/Cancer Registrar
d
e
f
g

c Tumor Conference Administrative Coordinator
d
e
f
g
c Clerical Staff
d
e
f
g

c Clinic Nursing Staff
d
e
f
g
c Physician
d
e
f
g

c Nurse Practitioner/Physician Assistant
d
e
f
g
c Other (please specify)
d
e
f
g
Other 

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SURVEY ON MULTIDISCIPLINARY TREATMENT PLANNING FOR HEAD
B. INITIAL CASE PRESENTATION

13. Is there a dedicated space for multidisciplinary treatment planning meetings for head
and neck cancer cases?

j Yes
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l
m
n
j No
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n

14. How frequently are the case materials or information provided to members of the
multidisciplinary treatment planning team before the meeting?
j All of the time
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m
n
Other 

j Most of the time
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m
n

j Some of the time
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n
j Rarely
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n

j None of the time
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n

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SURVEY ON MULTIDISCIPLINARY TREATMENT PLANNING FOR HEAD
B. INITIAL CASE PRESENTATION

15. How many team members receive the materials or information prior to the meeting?
j Everyone on the team
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n
j Most of the team
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j Some of the team
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SURVEY ON MULTIDISCIPLINARY TREATMENT PLANNING FOR HEAD
Other 

B. INITIAL CASE PRESENTATION

16. Once patients have a confirmed head and neck cancer diagnosis, who decides if the
case needs to be presented? (CHECK ALL THAT APPLY)
c Medical Oncologist
d
e
f
g

c Surgical Oncologist
d
e
f
g

c Radiation Oncologist
d
e
f
g
c General Surgeon
d
e
f
g

c Site­Specific Cancer Specialist
d
e
f
g
Some 
c Pathologist
d
e
f
g

c Nurse Practitioner/Physician Assistant
d
e
f
g
c Patient/Nurse Navigator
d
e
f
g

c No one person or role decides, any team member can request a case to be presented
d
e
f
g
c Other (please specify)
d
e
f
g

17. When is the initial case presentation for confirmed cancer cases typically held?
j After definitive cancer diagnosis and before multi­modality therapy is initiated
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m
n
j Sometime after multi­modality therapy is initiated
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n
j A mixture of both
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n

j Some other time (please specify)
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n

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18. Does your facility have guidelines indicating when the initial case presentation should
be scheduled once cancer is diagnosed?

j Yes
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l
m
n
j No
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n

j Under development
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SURVEY ON MULTIDISCIPLINARY TREATMENT PLANNING FOR HEAD
B. INITIAL CASE PRESENTATION

Some 

19. Would your facility be willing to share a copy of your initial case presentation
guidelines?
j Yes (The researchers will contact you)
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l
m
n
j No
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n

j Don't know
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SURVEY ON MULTIDISCIPLINARY TREATMENT PLANNING FOR HEAD
B. INITIAL CASE PRESENTATION

20. Which care providers are expected to attend the initial case presentation of head and
neck cancer cases? (CHECK ALL THAT APPLY)
c Medical Oncologist
d
e
f
g

c Surgical Oncologist
d
e
f
g

c Radiation Oncologist
d
e
f
g

c Site­Specific Cancer Specialist
d
e
f
g
c Primary Care Physician
d
e
f
g

c Surgeon (General and Specialty)
d
e
f
g

Other 

c Pathologist
d
e
f
g
c Radiologist
d
e
f
g

c Palliative Care Specialist
d
e
f
g
c Clinic Nurse
d
e
f
g

c Clinical Trials Nurse/Research Nurse/Clinical Research Associate
d
e
f
g
c Nurse Practitioner/Physician Assistant
d
e
f
g
c Social Workers
d
e
f
g
c Psychologist
d
e
f
g

c Patient/Nurse Navigator
d
e
f
g
c Genetic Counselor
d
e
f
g

c Tumor/Cancer Registrar
d
e
f
g
c Primary Care Physician
d
e
f
g
c Clergy
d
e
f
g

c Dietitian
d
e
f
g

Someone 

c Speech, Occupational, or Physical Therapist
d
e
f
g

c Other Provider (please specify)
d
e
f
g

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SURVEY ON MULTIDISCIPLINARY TREATMENT PLANNING FOR HEAD
21. Are initial case presentations for head and neck cancer held even when some of the
expected care providers are not able to participate?

j Yes
k
l
m
n
j No
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n

j Sometimes (please indicate what this depends on)
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n

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SURVEY ON MULTIDISCIPLINARY TREATMENT PLANNING FOR HEAD
B. INITIAL CASE PRESENTATION

22. How frequently does the primary care physician attend initial case presentations for
head and neck cancer patients?
j Never
k
l
m
n
Other 

j Rarely
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n

j Sometimes
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n
j Often
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n

j Always
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n

23. When care providers convene for the initial case presentation for head and neck
cancer patients, how do they usually attend?
j All in person
k
l
m
n

j All teleconference/Conference Call
k
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m
n

j All virtual (Computer­based i.e. video­conference, Telemedicine, etc.)
k
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m
n
j A mix of in­person and teleconferencing
k
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n
j A mix of in­person and virtual
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n

j A mix of in­person, teleconferencing, and virtual
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n

Other 

24. How often is attendance taken at initial case presentations?
j Never
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n

j Rarely
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n

j Sometimes
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j Often
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j Always
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SURVEY ON MULTIDISCIPLINARY TREATMENT PLANNING FOR HEAD

B. INITIAL CASE PRESENTATION

25. What case materials or information are available at initial case presentations? (CHECK
ALL THAT APPLY)
c PET/CT and other radiology films and reports
d
e
f
g
c Clinician dictations or notes
d
e
f
g
c Out­patient records
d
e
f
g
Other 

c Diagnostic test results
d
e
f
g

c Pathology results/slides
d
e
f
g

c History and physical (most recent or comprehensive)
d
e
f
g
c Family history
d
e
f
g

c Genetic testing results
d
e
f
g

c List of physicians involved
d
e
f
g

c Guidelines (e.g., NCCN, NQF, ASCO)
d
e
f
g
c Adjuvant! Online assessment tool
d
e
f
g
c Open clinical trials
d
e
f
g
c Consults
d
e
f
g

c Other (please specify)
d
e
f
g

26. After the multidisciplinary treatment planning options for head and neck cancer cases
have been discussed, how are treatment decisions/recommendations ultimately made?
j By consensus among team members.
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n
j By a vote by the team members.
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n

j By one person on the team (i.e. treating physician, medical oncologist, etc.)
k
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n
j In consultation with the patient and/or family
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n

j Decisions are made in some other way (please specify)
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SURVEY ON MULTIDISCIPLINARY TREATMENT PLANNING FOR HEAD
C. CLINICAL TRIALS

The next few questions are about how determination of clinical trials eligibility fits into multidisciplinary treatment planning for head and neck
cancer patients at your Cancer Center.  

27. How often is screening for clinical trial eligibility done prior to the initial case
presentation for head and neck cancer patients?
j Never
k
l
m
n

j Rarely
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m
n

Other 

j Sometimes
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m
n

j Often
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n

j Always
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n

28. When are clinical trial options for head and neck cancer patients typically discussed
among the multidisciplinary treatment planning team?
j Prior to the initial case presentation
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n

j At the time of the initial case presentation
k
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n
j Prior to initiation of first line treatment
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n

j After proceeding with standard therapy
k
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m
n
j Other (please specify)
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m
n

29. How does the multidisciplinary team for head and neck cancer typically assess patient
eligibility for clinical trials? (Who is involved, what information is presented, tools used,
and any addition information regarding the process)
Other 

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SURVEY ON MULTIDISCIPLINARY TREATMENT PLANNING FOR HEAD
D. PATIENTS & MULTIDISCIPLINARY TREATMENT PLANNING

These next questions are about patient involvement in multidisciplinary treatment planning. Please continue to think about typical head and neck
cancer cases that require multi­modality therapies once a definitive cancer diagnosis has been made.  

30. Prior to the initial case presentation, how often does your facility provide head and
Other 
neck
cancer patients with information about multidisciplinary treatment planning?
j Never
k
l
m
n

j Rarely
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n

j Sometimes
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n
j Often
k
l
m
n

j Always
k
l
m
n
Other 

j Other (please specify)
k
l
m
n

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SURVEY ON MULTIDISCIPLINARY TREATMENT PLANNING FOR HEAD
D. PATIENTS & MULTIDISCIPLINARY TREATMENT PLANNING

31. How are head and neck cancer patients informed about the multidisciplinary treatment
planning? (CHECK ALL THAT APPLY)
c We provide written communication to the patient summarizing the approach.
d
e
f
g
c Interpreter services are provided as needed to explain the approach.
d
e
f
g
c A dedicated nurse/patient navigator discusses with patient.
d
e
f
g
c The attending physician discusses with patient.
d
e
f
g
c Other (please specify)
d
e
f
g

Other 

32. Who usually invites head and neck cancer patients to attend the initial case
presentation? (CHECK ALL THAT APPLY)
c Not Applicable, patients are not invited to attend
d
e
f
g
c Nurse
d
e
f
g

c Patient/Nurse Navigator
d
e
f
g

Other 

c Clerical Staff
d
e
f
g

c Social Worker
d
e
f
g
c Physician
d
e
f
g

c Nurse Practitioner/Physician Assistant
d
e
f
g
c Other (please specify)
d
e
f
g

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SURVEY ON MULTIDISCIPLINARY TREATMENT PLANNING FOR HEAD
D. PATIENTS & MULTIDISCIPLINARY TREATMENT PLANNING

33. When are head and neck cancer patients invited to attend? (CHECK ALL THAT APPLY)
c At the initial consult appointment
d
e
f
g

Other 

c After the initial consult by phone
d
e
f
g

c After the initial consult at a subsequent appointment
d
e
f
g
c Some other time (please describe)
d
e
f
g

5
6  

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SURVEY ON MULTIDISCIPLINARY TREATMENT PLANNING FOR HEAD
D. PATIENTS & MULTIDISCIPLINARY TREATMENT PLANNING

34. How often do head and neck cancer patients attend the initial case presentation?
j Never
k
l
m
n

j Rarely
k
l
m
n

j Sometimes
k
l
m
n
j Often
k
l
m
n

j Always
k
l
m
n

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SURVEY ON MULTIDISCIPLINARY TREATMENT PLANNING FOR HEAD
D.Other 
PATIENTS & MULTIDISCIPLINARY TREATMENT PLANNING

35. For those head and neck cancer patients who are invited but do not attend, what are
some of the reasons? (CHECK ALL THAT APPLY)
c The patient is not feeling well enough.
d
e
f
g

c The patient feels overwhelmed with diagnosis/medical system.
d
e
f
g

c The patient is concerned about hearing things that will upset them.
d
e
f
g

c The patient feels the medical team is responsible for making treatment decisions.
d
e
f
g
c The time/location of the meeting is inconvenient for the patient.
d
e
f
g
c Some other reason (please specify)
d
e
f
g

5
6  

Other 

36. Are head and neck cancer patients welcomed to invite their family members to attend
the initial case presentation?

j Yes
k
l
m
n
j No
k
l
m
n

37. What information about the initial case presentation is shared with head and neck
cancer patients who do not attend the presentation? (CHECK ALL THAT APPLY)
c Meeting date and time
d
e
f
g
c List of attendees
d
e
f
g
c Treatment plan
d
e
f
g

c Summary (verbal or written) of the meeting
d
e
f
g

c Recommendations from the treatment planning meeting
d
e
f
g
c No information is shared
d
e
f
g
c Other (please specify)
d
e
f
g

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SURVEY ON MULTIDISCIPLINARY TREATMENT PLANNING FOR HEAD
D. PATIENTS & MULTIDISCIPLINARY TREATMENT PLANNING

For these next two questions, please think about all head and neck cancer patients, whether or not they attended the initial case presentation. 

38. Who follows up with head and neck cancer patients after the initial case presentation?
(CHECK ALL THAT APPLY)
c Nurse
d
e
f
g

c Patient/Nurse Navigator
d
e
f
g
c Clerical Staff
d
e
f
g

c Social Worker
d
e
f
g
c Physician
d
e
f
g

c Nurse Practitioner/Physician Assistant
d
e
f
g
c No one follows up
d
e
f
g

c Someone else (please specify)
d
e
f
g

39. How does follow­up typically occur? (e.g. in writing, by telephone, in­person
discussion, patient portal, etc.) Please describe.
5
6  

Other 

40. How soon after the initial case presentation for head and neck cancer patients does
the follow­up typically occur?
j The same day
k
l
m
n
j 1 day after
k
l
m
n

j 2­3 days after
k
l
m
n
j 4­7 days after
k
l
m
n

j 8­14 days after
k
l
m
n

j 15 days or more
k
l
m
n

j No follow­up occurs
k
l
m
n

j Other (please specify)
k
l
m
n
Other 

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SURVEY ON MULTIDISCIPLINARY TREATMENT PLANNING FOR HEAD
E. POST­MEETING FOLLOW­UP

This section asks about multidisciplinary treatment planning after the initial case presentation. Please continue to think about typical head and
neck cancer cases that require multi­modality therapies once a definitive cancer diagnosis has been made.  

41. After the initial case presentation, does the multidisciplinary team for head and neck
cancer patients meet to modify the current treatment plan?
j Never
k
l
m
n

j Rarely
k
l
m
n

j Sometimes
k
l
m
n
j Often
k
l
m
n

j Always
k
l
m
n

j Other (please specify)
k
l
m
n

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SURVEY ON MULTIDISCIPLINARY TREATMENT PLANNING FOR HEAD
E. POST­MEETING FOLLOW­UP

42. What are the reasons for reconvening to modify the current treatment plan? (CHECK
Other 
ALL THAT APPLY)

c Disease has progressed
d
e
f
g

c Patient is unable to tolerate/maintain current treatment plan
d
e
f
g
c Second primary is diagnosed
d
e
f
g

c Patient has a co­morbid condition
d
e
f
g

c Need to assess clinical trial options
d
e
f
g

c Pathology and imaging are discordant
d
e
f
g

c Case demonstrates more advanced disease than originally anticipated
d
e
f
g
c Other (please specify)
d
e
f
g

43. Do additional specialists, who were not part of the initial case presentations, ever
participate in subsequent meetings about head and neck cancer cases?

j Yes
k
l
m
n
j No
k
l
m
n

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SURVEY ON MULTIDISCIPLINARY TREATMENT PLANNING FOR HEAD
E. POST­MEETING FOLLOW­UP

44. Which specialists or other professionals, who were not part of the initial case
presentation, have participated in subsequent meetings about head and neck cancer
cases? (CHECK ALL THAT APPLY)
c Site­Specific Cancer Specialist
d
e
f
g
c Primary Care Physician
d
e
f
g

c General Surgeon or Surgical Specialist
d
e
f
g
c Pathologist
d
e
f
g

c Palliative Care Specialist
d
e
f
g
c Clinic Nurse
d
e
f
g

c Clinical Trials Nurse/Research Nurse/Clinical Research Associate
d
e
f
g
c Nurse Practitioner/Physician Assistant
d
e
f
g
c Social Worker/ Psychologist
d
e
f
g
c Patient/Nurse Navigator
d
e
f
g
c Genetics Counselor
d
e
f
g
c Clergy
d
e
f
g

c Dietitian
d
e
f
g

c Speech, Occupational, or Physical Therapist
d
e
f
g
c Pain Management Specialist
d
e
f
g
c Dentist/Oral Surgeon
d
e
f
g
c OBGYN
d
e
f
g

c Other (please specify)
d
e
f
g
Other 

For the following questions, please think about your entire multidisciplinary care process for head and neck cancer cases not just the 
multidisciplinary treatment planning meeting. 

45. A treatment plan is a comprehensive, formal plan prospectively outlining anticipated
treatment approaches. Is a written treatment plan typically developed for individual head
and neck cancer patients?

j Yes
k
l
m
n
Other 

j No
k
l
m
n

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SURVEY ON MULTIDISCIPLINARY TREATMENT PLANNING FOR HEAD
E. POST­MEETING FOLLOW­UP

46. Do head and neck cancer patients typically receive a copy of the written treatment
plan?

j Yes
k
l
m
n
j No
k
l
m
n
Other 

j Other (please specify)
k
l
m
n

47. Is a copy of the written treatment plan typically included in the patient’s medical
record?

j Yes
k
l
m
n
j No
k
l
m
n

j Other (please specify)
k
l
m
n

48. Do primary care physicians typically receive a copy of the treatment plan?

j Yes
k
l
m
n
j No
k
l
m
n

j Other (please specify)
k
l
m
n

49. A treatment summary is a document that retrospectively summarizes treatments the
patient has received. Is a treatment summary typically developed for individual head and
neck cancer patients?

j Yes
k
l
m
n
j No
k
l
m
n

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SURVEY ON MULTIDISCIPLINARY TREATMENT PLANNING FOR HEAD
E. POST­MEETING FOLLOW­UP

50. Do head and neck cancer patients typically receive a copy of the treatment summary?

j Yes
k
l
m
n
j No
k
l
m
n

j Other (please specify)
k
l
m
n

51. Do primary care physicians typically receive a copy of the treatment summary?

j Yes
k
l
m
n
j No
k
l
m
n

j Other (please specify)
k
l
m
n

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SURVEY ON MULTIDISCIPLINARY TREATMENT PLANNING FOR HEAD
F. MULTIDISCIPLINARY TREATMENT PLANNING INFRASTRUCTURE

These next questions are about the infrastructure and billing associated with multidisciplinary treatment planning for head and neck cancer cases. 

52. What type of medical records system is used to support the provision of
multidisciplinary treatment planning for head and neck cancer patients?
j Paper chart
k
l
m
n

j Electronic Medical Record (EMR)
k
l
m
n
j Mixture of paper and EMR
k
l
m
n
j Other (please specify)
k
l
m
n

53. From which departments can results/reports be accessed in preparation for the
multidisciplinary treatment planning meetings about head and neck cancer cases?
(CHECK ALL THAT APPLY)
c Laboratory
d
e
f
g
c Radiology
d
e
f
g

c Radiation Oncology
d
e
f
g
c Pharmacy
d
e
f
g

c Medical Oncology
d
e
f
g
c Nuclear Medicine
d
e
f
g
c Surgery
d
e
f
g

c Pathology
d
e
f
g
c Nursing
d
e
f
g

c Clerical Staff
d
e
f
g

c Other (i.e. other hospital departments and/or private practice physician records). Please specify.
d
e
f
g

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SURVEY ON MULTIDISCIPLINARY TREATMENT PLANNING FOR HEAD
F. MULTIDISCIPLINARY TREATMENT PLANNING INFRASTRUCTURE

54. An “integrated” medical records system is one in which patient data within the hospital
can be linked or shared with a physician or practice/clinic at another location that sees the
same patient. In your opinion, how integrated is the medical records system that supports
multidisciplinary treatment planning for head and neck cancer cases at your facility?
j Not at all integrated
k
l
m
n

j Somewhat integrated
k
l
m
n
j Fully integrated
k
l
m
n

j Other (please specify)
k
l
m
n

55. At this facility, are private practice physicians monetarily compensated for their time in
multidisciplinary treatment planning meetings for head and neck cancer cases?

j Yes
k
l
m
n
j No
k
l
m
n

j Don't know
k
l
m
n

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SURVEY ON MULTIDISCIPLINARY TREATMENT PLANNING FOR HEAD
F. MULTIDISCIPLINARY TREATMENT PLANNING INFRASTRUCTURE

56. How are private practice physicians monetarily compensated for attending the
multidisciplinary treatment planning meetings for head and neck cancer? (e.g.
consultation charge through patient's insurance, fee negotiated with hospital, etc.) Please
describe.
5
6  

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SURVEY ON MULTIDISCIPLINARY TREATMENT PLANNING FOR HEAD
F. MULTIDISCIPLINARY TREATMENT PLANNING INFRASTRUCTURE

57. Are non­financial incentives provided to private practice physicians in exchange for
provision of multidisciplinary treatment planning for head and neck cancer?

j Yes
k
l
m
n
j No
k
l
m
n

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SURVEY ON MULTIDISCIPLINARY TREATMENT PLANNING FOR HEAD

F. MULTIDISCIPLINARY TREATMENT PLANNING INFRASTRUCTURE
58. What are the non­financial incentives? (CHECK ALL THAT APPLY)
c Hospital privileges
d
e
f
g

c Research staff support
d
e
f
g

c Support with credentialing
d
e
f
g

c Continuing Medical Education credits or units
d
e
f
g
c Conference registration and/or travel fees
d
e
f
g

c Marketing and promotion of multidisciplinary care provision
d
e
f
g
c Cancer Center membership
d
e
f
g
c Meals provided
d
e
f
g

c Other (please specify)
d
e
f
g

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SURVEY ON MULTIDISCIPLINARY TREATMENT PLANNING FOR HEAD
G. ASSESSMENT OF MULTIDISCIPLINARY TREATMENT PLANNING

These next few questions are about the evaluation of multidisciplinary treatment planning at this facility. 

59. Does your Cancer Center evaluate the performance of multidisciplinary treatment
planning for head and neck cancer? (Please exclude the use of the MDC Assessment
tool.)

j Yes
k
l
m
n
j No
k
l
m
n

j Other (please specify)
k
l
m
n

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SURVEY ON MULTIDISCIPLINARY TREATMENT PLANNING FOR HEAD
G. ASSESSMENT OF MULTIDISCIPLINARY TREATMENT PLANNING

60. What dimensions are used to evaluate the performance of multidisciplinary treatment
planning for head and neck cancer? (CHECK ALL THAT APPLY)
c Frequency of meetings
d
e
f
g

c Timeliness to treatment
d
e
f
g

c Use of clinical and pathological staging variables to confirm staging
d
e
f
g

c Use of a physician “agreement of participation” to determine membership
d
e
f
g
c Use of clinical guidelines to develop treatment plan
d
e
f
g

c Minimum percent of patient participation in clinical trials
d
e
f
g
c Screening for clinical trial eligibility
d
e
f
g

c Clinical trials offered to eligible patients
d
e
f
g

c Clinical trial enrollment of eligible patients
d
e
f
g

c Patient satisfaction with the recommended treatment plan
d
e
f
g
c Do not evaluate
d
e
f
g

c Other (please specify)
d
e
f
g

5
6  

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SURVEY ON MULTIDISCIPLINARY TREATMENT PLANNING FOR HEAD
G. ASSESSMENT OF MULTIDISCIPLINARY TREATMENT PLANNING

61. Would your facility be willing to share a copy of your evaluation documents (excluding
the MDC Assessment tool)?
j Yes (A researcher will contact you)
k
l
m
n
j No
k
l
m
n

j Don't know
k
l
m
n

62. How does the Cancer Center utilize the MDC Assessment tool?
5
6  

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SURVEY ON MULTIDISCIPLINARY TREATMENT PLANNING FOR HEAD
H. ADDITIONAL THOUGHTS ABOUT MULTIDISCIPLINARY TREATMENT
PLANNING

63. Is there anything else about multidisciplinary treatment planning that you would like to
share?
5
6  

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SURVEY ON MULTIDISCIPLINARY TREATMENT PLANNING FOR HEAD
I. CLOSING QUESTIONS

64. Please indicate which of these reflects your experience in responding to the survey
questions:
j I answered the questions on my own without consulting anyone.
k
l
m
n

j I consulted with the other colleagues in the Cancer Center before I responded to the questions.
k
l
m
n
j I requested someone else to answer the questions.
k
l
m
n

j I worked with another person to complete the survey together.
k
l
m
n

65. What is your specialty?
j Medical Oncologist
k
l
m
n

j Surgical Oncologist
k
l
m
n

j Radiation Oncologist
k
l
m
n
j Surgeon
k
l
m
n

j Pathologist
k
l
m
n
j Radiologist
k
l
m
n

j Registered Nurse
k
l
m
n

j Other Cancer Specialist or Medical Specialty (please specify)
k
l
m
n

66. Are you employed by your Cancer Center or in private practice?
j Cancer Center only
k
l
m
n

j Private practice only
k
l
m
n
j Both
k
l
m
n

j Other (please specify)
k
l
m
n

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SURVEY ON MULTIDISCIPLINARY TREATMENT PLANNING FOR HEAD
67. Please indicate your cancer center's CoC accreditation cancer program category.
j Academic Comprehensive Cancer Program
k
l
m
n
j Community Cancer Program
k
l
m
n

j Comprehensive Cancer Program
k
l
m
n

j Integrated Network Cancer Program
k
l
m
n
j Other (please specify)
k
l
m
n

68. What is your cancer center's annual case volume for the most recent year?

69. Please identify the total number of licensed beds in the hospital affiliated with the
NCCCP site.

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SURVEY ON MULTIDISCIPLINARY TREATMENT PLANNING FOR HEAD

THANK YOU FOR TAKING THE TIME TO COMPLETE THIS SURVEY.  

Your responses will be very helpful in understanding multidisciplinary care within the NCCCP. 

Please review or double check your responses prior to clicking the "Done" button. Once you click "Done" you will not be able to log back into the 
survey. 

Please click "Done" when you are ready to submit your answers. 

Page 43