Appendix 3: Proposed 30 Day Systemic Anti-Cancer Therapy (SACT) Mortality Proforma. Sections 1-5 to be completed by treating consultant Section 1. Patient & Disease Details Patient ID Oncology Consultant Form completed by Patient Initials Treating hospital/unit Date completed Age Known to palliative care (Delete 2 choices) Gender M/F Yes No Unknown (Delete 1) Primary Tumour Treatment Intent Co-morbidities (Delete 2 choices) ie lung (Delete 3 choices) YES NO Unknown Neo-adjuvant Histopathology List: Adjuvant ie adenocarcinoma Palliative-please state line at Death: ie TNM and stage Clinical patient? YES NO Curative (Delete 1) Section 2. Assessment of SACT Use Date of decision to Enter date/ not documented SACT Regimen i.e Gem/carbo DD/MM/YY /Not doc q3/52ly treat and Interval Cycle (inc. number Cycle X of Y Did death occur Please how many planned) YES NO within 30 days (Delete 1) days Regimen listed in the of final SACT YES NO site-specific algorithm cycle Written informed YES NO Grade of person Consultant patient consent Consent- consenting ST3+ obtained Good (Delete as required) (Review consent form Average Other- and documented Poor toxicities) (Delete as required) ECOG pre cycle 1 (at PS= x/Not doc ECOG at final PS= x/Not consent) cycle doc Last SACT cycle Consultant SACT Approved prescribed by whom? ST3+ prescription doctor (Delete 3 choices) Nurse signed by: Approved Other- (Delete as required) pharmacist Other Written protocol (Delete 1 choice) Was there an YES NO Yes No available for this appropriate Comment - regimen? response assessment to Was there a deviation (Delete 1 choice) Yes No SACT from protocol? Comment- documented (Delete 1) Was dose BSA/weight FBC Renal function Hepatic Cardiac appropriate for: accounting function function (state yes/no) for any dose reduction Please give detail if answer no above there any Grade Not applicable (1st cycle) In your opinion 3/4 toxicities prior to None documented was the final SACT cycle Yes - appropriate (Delete as required) dose administered i.e.
Appendix 3: Proposed 30 Day Systemic Anti-Cancer Therapy (SACT) Mortality Proforma. Sections 1-5 to be completed by treating consultant Section 1. Patient & Disease Details Patient ID Oncology Consultant Form completed by Patient Initials Treating hospital/unit Date completed Age Known to palliative care (Delete 2 choices) Gender M/F (Delete 1) Yes No Unknown Primary Tumour ie lung Histopathology ie adenocarcinoma at Death: ie TNM and stage Treatment Intent (Delete 3 choices) Neo-adjuvant Adjuvant Palliative-please state line Curative Co-morbidities (Delete 2 choices) YES NO Unknown List: Clinical patient? YES NO (Delete 1) Section 2. Assessment of SACT Use Date of decision to treat Enter date/ not documented DD/MM/YY /Not doc SACT Regimen and Interval i.e Gem/carbo q3/52ly Cycle (inc. number planned) Regimen listed in the site-specific algorithm Cycle X of Y YES NO (Delete 1) Did death occur within 30 days of final SACT cycle Please how many days YES NO Written informed patient consent obtained (Review consent form and documented toxicities) (Delete as required) YES NO Consent- Good Average Poor Grade of person consenting (Delete as required) Consultant ST3+ Other- ECOG pre cycle 1 (at consent) PS= x/Not doc ECOG at final cycle PS= x/Not doc Last SACT cycle prescribed by whom? (Delete 3 choices) Consultant ST3+ Nurse Other- SACT prescription signed by: (Delete as required) Approved doctor Approved pharmacist Other Written protocol available for this regimen? (Delete 1 choice) Yes No Was there an appropriate response assessment to SACT documented (Delete 1) YES NO Comment - Was there a deviation from protocol? (Delete 1 choice) Yes No Comment- Was dose appropriate for: (state yes/no) BSA/weight accounting for any dose reduction FBC Renal function Hepatic function Cardiac function Please give detail if answer no above there any Grade 3/4 toxicities prior to final SACT cycle (Delete as required) Not applicable (1st cycle) None documented Yes - In your opinion was the appropriate dose administered i.e.
ncb-30-day-sact-mm-052016.docx