NSABP Protocol C-09: Quality of Life Form Oxaliplatin and Capecitabine With or Without an Hepatic Arterial Infusion With Floxuridine in Treating Patients Who Are Undergoing Surgery and/or Ablation for Liver Metastases Due to Colorectal Cancer NCT00268463 Source Form: NCI FormBuilder:

  1. 8/27/12 8/27/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
  3. 3/21/15 3/21/15 - Martin Dugas
  4. 4/10/21 4/10/21 - Ahmed Rafee, MD
  5. 9/20/21 9/20/21 -
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September 20, 2021

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Creative Commons BY 4.0
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Colorectal cancer metastases (NCT00268463)

All patients in C-09 should complete this questionnaire at: (1) baseline (after consent and prior to randomization) and (2) 4-6 weeks after surgery

Are data amended (check box if yes, and circle amended items)
This form is being filled out
Time Point
Does the patient have a hepatic pump
indicate location of hepatic pump
Treatment satisfaction
Receiving treatment is convenient for me
I am satisfied with my current treatment
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 have swelling or cramps in my stomach area
I am losing weight
I have control of my bowels
I can digest my food well
I have diarrhea
I have a good appetite
I like the appearance of my body
Do you have an ostomy appliance
I am embarrassed by my ostomy appliance
Caring for my ostomy appliance is difficult
I have numbness or tingling in my hands
I have numbness or tingling in my feet
I feel discomfort in my hands
I feel discomfort in my feet
I have joint pain or muscle cramps
I feel weak all over
I have trouble hearing
I get a ringing or buzzing in my ears
I have trouble buttoning buttons
I have trouble feeling the shape of small objects when they are in my hand
I have trouble walking
I have pain in my hands or feet when I am exposed to cold temperatures
I have difficulty breathing when I am exposed to cold temperatures
Abdominal pain or cramping
Gas pain
Mouth sores
Skin problems (including rash, dry skin, itching, irritation or redness)
Skin redness or peeling on hands and feet
Hair loss
Pain at intravenous site
Eye problems
Other problems (Specify below)
How self conscious have you felt about your body and your appearance
How satisfied have you been with the way your chemotherapy is being delivered
How much have you feared that your pump will be dislodged
How much discomfort or pain has your pump caused you
How much have you protected your body where the pump is located
Did you feel full of life
Did you have a lot of energy
Did you feel worn out
Did you feel tired
Your ability to do vigorous activities
The position you like to sleep in
Your ability to eat a full meal
Your ability to lift things
Hugging family or friends
Bending over or twisting
Your ability to travel
The type of clothing you wear
Your comfort in sexual activities

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