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Lung MDT Assessment Form
(Information with red asterisk (
*
) must be supplied)
Surname:
*
First Name:
*
MRN:
Date of Birth:
*
Age:
PRESENTING CLINICIAN
Clinician Name:
*
Presentation Date:
*
Date GP referred to 1
st
Specialist:
*
Date Seen by 1
st
Specialist:
*
*
Or date of decision to act if long standing patient
MDT Location:
1. Liv/Mac
2. Bankstown
REVIEW AT MEETING
Pathology:
REF #:
Comments:
PET:
REF #:
Comments:
Radiology:
REF #:
Comments:
External:
Provider & REF #:
Comments:
* Triage Category - Choose ONE option only
For Discussion:
Please Select
1. Consideration for multimodality treatment
2. Consideration for curative treatment without pathological diagnosis
3. Review of all post-operative pathology
4. Suspected or confirmed thymoma
5. Local recurrence, oligorecurrence, oligoprogressive or oligometastatic NSCLC being considered for local therapy
6. Other
Other:
*
For Documentation:
Please Select
1. Pathologically confirmed Stage I NSCLC fit for surgery
2. Pathologically confirmed Stage I NSCLC not fit for surgery but fit for RT
3. Stage IV NSCLC / SCLC treated according to guidelines
4. Not fit for any treatment due to poor performance status, frailty, comorbidities
5. Patient preference not to pursue diagnosis +/- treatment
PATIENT PRESENTATION
ECOG:
*
0
1
2
3
4
Clinical Frailty Scale:
Please Select
1 - Very fit - robust, active, energetic, well motivated and fit, these people commonly exercise regularly and are in the most fit group for their age
2 - Well - without active disease, but less fit than people in category 1
3 - Well, with treated comorbid disease - disease symptoms are well controlled compared with those in category 4
4 - Apparently vulnerable - although not frankly dependant, these people commonly complain of being 'slowed up' or have disease symptoms
5 - Mildly frail - with limited dependence on others for instrumental activities of daily living
6 - Moderately frail - help is needed with both instrumental and non-instrumental activities of daily living
7 - Severely frail - completely dependant on others for the activities of daily living, or terminally ill
8 - Severely frail and approaching end of life - completely dependant and may not recover from minor illness
9 - Terminally ill - life expectancy <6 months but not otherwise living with servere frailty
Weight loss in last 6 months:
Greater or equal to 10%
Less than 10%
None
Mode of Presentation:
*
Please Select
1 - Screen detected cancer
2 - Incidental cancer detected on imaging
3 - Symptomatic presentation
4 - Other/NA - not lung cancer
COMORBIDITIES
COPD:
Yes
No
Interstitial lung disease:
Yes
No
Cardiovascular disease:
Yes
No
Cerebrovascular disease:
Yes
No
Renal impairment:
Yes
No
Hepatic impairment:
Yes
No
Autoimmune disease:
Yes
No
Dementia/cognitive impairment:
Yes
No
Psychosocial issues:
Yes
No
SMOKING STATUS
Tobacco consumption:
*
Please Select
0 - Never
1 - Previous
2 - Current
Pack Years:
Vape use:
Please Select
0 - Never
1 - Previous
2 - Current
Shisha use:
Please Select
0 - Never
1 - Previous
2 - Current
Marijuana use:
Please Select
0 - Never
1 - Previous
2 - Current
PATHOLOGY AND STAGING
Pathology:
*
Please Select
1. Small Cell Lung Carcinoma
2. Squamous Cell Carcinoma
3. Adenocarcinoma
4. Large Cell Carcinoma
5. Mesothelioma
6. Thymoma
7. Carcinoid
8. Non-small cell lung cancer NOS
9. Other type (Specify)
Other Pathology (Specify):
*
Reason for no pathology:
Please Select
1. Non-diagnostic
2. Contraindicated
3. Patient refusal
4. Other (Specify)
Other (Specify):
Overall stage:
*
Please Select
0 - TisN0M0
IA1 - T1mi-T1aN0M0
IA2 - T1bN0M0
IA3 - T1cN0M0
IB - T2aN0M0
IIA - T1N1M0 or T2bN0M0
IIB - T1N2aM0 or T2N1M0 or T3N0M0
IIIA - T1N2bM0 or T2N2aM0 or T3N1-N2aM0 or T4N0-N1M0
IIIB - T1N3M0 or T2N2b-N3M0 or T3N2bM0 or T4N2a-N2bM0
IIC - T3-T4N3M0
IVA - Any T Any N M1a-M1b
IVB - Any T Any N M1c
Unknown - Unknown
V - Recurrent
Multiple Primary Lung Cancers:
Yes
No
No. of primaries:
Stage IV NSCLC No. of mets
Please Select
1
2
3
4
5
STAGE
T:
Please Select
0 No evidence of primary tumour
1a (≤1 cm)
1b (>1 to ≤ 2 cm)
1c (>2 to ≤ 3 cm)
2a (>3 to ≤ 4 cm or invades visceral pleura, main bronchus or atelectasis)
2b (>4 to ≤ 5 cm)
3 (>5 to ≤7 cm or invasion of parietal pleura, chest wall, pericardium or separate nodules same lobe)
4 (>7 cm or mediastinal invasion or separate nodules different ipsilateral lung)
X Unknown
N:
Please Select
0 - No regional lymph node metastases
1 - metastasis in ipsilateral intrapulmonary/peribronchial/hilar lymph node(s), including nodal involvement by direct extension
2a - metastasis to single ipsilateral mediastinal or subcarinal lymph node station
2b - metastasis to multiple ipsilateral mediastinal and/or subcarinal lymph node stations
3 - metastasis in contralateral hilar/mediastinal/scalene/supraclavicular lymph node (s)
X - Regional lymph nodes cannot be assessed
M:
Please Select
0 - No distant Metastasis
1a - Contralateral tumour nodules or malignant pleural/pericardial effusion
1b - Single extrathoracic metastasis
1c1 - Multiple metastases in 1 organ system
1c2 - Multiple metastases in >1 organ systems
PFT (% Predicted)
FEV1 (% predicted):
FVC (% predicted):
DLCO (% predicted):
PREVIOUS TREATMENTS FOR LUNG CANCER - CURRENT OR RECURRENT
Previous Intent:
Curative
Palliative
Previous Lung Surgery:
Yes
No
Previous Radiotherapy:
Please Select
No
Curative
Palliative
Post-operative
Pre-operative
Prophylactic Cranial Irradiation
Previous Systemic Therapy:
Please Select
No
Concurrent
Palliative
Adjuvant
Neo-Adjuvant
No Active Treatment:
Please Select
N/A
Patient decision
Palliative & asymptomatic
Poor ECOG
Comorbidity
Other (Specify)
Other (Specify):
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