Description:

E2108 FACT-B + Local Symptoms-9 Early Surgery or Standard Palliative Therapy in Treating Patients With Stage IV Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=8E06DE1E-7AF1-0A7A-E040-BB89AD43472D

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=8E06DE1E-7AF1-0A7A-E040-BB89AD43472D

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Versions (2) ▾
  1. 8/27/12
  2. 1/9/15
Uploaded on:

January 9, 2015

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License:
Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT01242800 Quality of Life - E2108 FACT-B + Local Symptoms-9 - 3129088v1.0

INSTITUTION INSTRUCTIONS: Have the patient complete this form (in blue or black ink) at the intervals required per protocol and submit original to the ECOG Coordinating Center. Keep a copy for your files

Header
On Treatment
Reporting Period (Choose one)
Header
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
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
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
Additional Concerns
I have been short of breath (B2)
I am self-concious about the way I dress (B3)
One or both of my arms are swollen and tender (B4)
I feel sexually attractive (B5)
I am bothered by my hair loss (B6)
I worry that other members of my family might someday get the same illness I have (B7)
I worry about the effects of stress on my illness (B8)
I am bothered by a change in weight (B9)
I am able to feel like a woman
I have certain areas of my body where I experience significant pain
I worry about the effects of stress on my illness
I have pain or discomfort in my breast and/or chest wall
The pain or discomfort in my breast and/or chest wall has limited my ability to work (including work at home)
The lumps or open sores in my breast and/or chest wall have limited my ability to work (including work at home)
The lumps or open sores in my breast and/or chest wall have limited my social activities
On which side was your breast cancer
Movement of my arm on this side is painful
I have a poor range of arm movements on this side
My arm on this side feels numb
I have stiffness of my arm on this side

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