Description:

RTOG-0436: Radiation Therapy Oncology Group Phase III Esophagus FACT-E (Version 4) Paclitaxel, Cisplatin, and Radiation Therapy With or Without Cetuximab in Treating Patients With Locally Advanced Esophageal Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=2CAEEF21-9D12-21F1-E044-0003BA3F9857

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=2CAEEF21-9D12-21F1-E044-0003BA3F9857

Versions (3) ▾
  1. 9/19/12
  2. 1/9/15
  3. 1/9/15
Uploaded on:

September 19, 2012

DOI:
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License:
Creative Commons BY-NC 3.0 Legacy
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Esophageal Cancer NCT00655876 Quality of Life - RTOG-0436: Radiation Therapy Oncology Group Phase III Esophagus FACT-E (Version 4) - 2617850v1.0

No Instruction available.

  1. StudyEvent: RTOG-0436: Radiation Therapy Oncology Group Phase III Esophagus FACT-E (Version 4)
    1. No Instruction available.
Unnamed1
Amended Data
Unnamed 1
Time point of this assessment
Was patient questionnaire completed
Reason Questionnaire was not Completed
Specify method of completion
Did the patient require any assistance in completing the questionnaire?
Specify the person who assisted the patient
Extent of assistance given
Physical Well-being
I have a lack of energy
I have nausea
Because of my physical condition, I have trouble meeting the needs of my family
I have pain
I am bothered by side effects of treatment
I feel ill
I am forced to spend time in bed
Social/family Well-being
I feel close to my friends
I get emotional support from my family
I get support from my friends
My family has accepted my illness
I am satisfied with family communication about my illness
I feel close to my partner (or the person who is my main support)
I am satisfied with my sex life
Emotional Well-being
I feel sad
I am satisfied with how I am coping with my illness
I am losing hope in the fight against my illness
I feel nervous
I worry about dying
I worry that my condition will get worse
Functional Well-being
I am able to work (include work at home)
My work is fulfilling (include work at home)
I am able to enjoy life
I have accepted my illness
I am sleeping well
I am enjoying the things I usually do for fun
I am content with the quality of my life right now
Additional Concerns
I am able to eat the foods that I like
My mouth is dry
I have trouble breathing
My voice has its usual quality and strength
I am able to eat as much food as I want
I am unhappy with how my face and neck look
I can swallow naturally and easily
I smoke cigarettes or other tobacco products
I drink alcohol (e.g. beer, wine, etc.)
I am able to communicate with others
I can eat solid foods
I have pain in my mouth, throat or neck