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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 Referred to 1st Specialist:
Date Seen by 1st Specialist:
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
Recommended Discussion:
Please Select
1. Stage II-III NSCLC
2. Stage I-III SCLC
3. Thymoma
4. Patients requiring MDT input for diagnosis
5. Patients requiring MDT input for treatment
6. Patients requiring MDT input for complex post-treatment issues
7. Oligometastatic lung cancer
Consider Discussion:
Please Select
1. Review of all surgical pathology
2. Mesothelioma
3. Carcinoid tumours
4. Lung oligometastases
5. Stage I NSCLC in patients unfit for surgery (refer to RO)
Documentation Only:
Please Select
1. Stage IV NSCLC treated according to guidelines
2. Stage IV SCLC treated according to guidelines
3. Stage I NSCLC in patients fit for surgery (refer to surgeon)
4. No active treatment due to poor ECOG
5. No active treatment due to comorbidities
6. No active treatment due to patient preference
PATIENT PRESENTING SYMPTOMS
Weight loss in last 6 months:
Greater or equal to 10%
Less than 10%
None
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
Tobacco Consumption:
No (Never)
Yes (Current or Ex-smoker)
Pack years smoked:
Alcoholism:
Yes
No
Diabetes Mellitus:
Yes
No
Renal Insufficiency:
Yes
No
Respiratory Comorbidity:
Yes
No
Cardiovascular Comorbidity:
Yes
No
Prior Cancer type:
Please Select
None
Breast
Colorectal
Gynae
Head & Neck
Lung
Multiple
Prostate
Upper GI
Other (Specify)
Other (Specify):
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 (Specify):
Reason for no pathology:
Please Select
1. Non-diagnostic
2. Contraindicated
3. Patient refusal
Overall stage:
Please Select
0 – TisN0M0
IA1 – T1mi-T1aN0M0
IA2 – T1bN0M0
IA3 – T1cN0M0
IB – T2aN0M0
IIA – T2bN0M0
IIB – T1a-T2bN1M0 or T3N0M0
IIIA – T1a-T2bN2M0 or T3-4N1M0 or T4N0M0
IIIB – T1a-T2bN3M0 or T3-4N2M0
IIIC – T3-4N3M0
IVA – Any T Any N M1a-1b
IVB – Any T Any N M1c
V - Recurrent
Other Pathology:
Multiple Primary Lung Cancers:
Yes
No
No. of primaries:
Stage IV NSCLC No. of mets
Please Select
1
2
3
4
5
CLINICAL STAGE
T:
Please Select
0 No evidence of primary tumour
1A (<=1cm)
1B (>1cm <=2cm)
1C (>2cm <=3cm)
1Mi (Minimally invasive adenocarcinoma)
2A (>3cm <=4cm)
2B (>4cm <=5cm)
3 (>5cm <=7cm OR invades pleura/cw OR separate nodule(s) in same lobe)
4 (>7cm OR invades mediastinum structures OR nodules(s) in ipsilateral lobe)
Is Carcinoma in situ
X Unknown
N:
Please Select
0 - No nodes involved
1 - Mets in ipsilateral peribrochial & hilar nodes, intrapulmonary nodes
2 - Mets in ipsilateral mediastinal &/or subcarinal lymph node/s
3 - Mets in contralateral nodes or SC lymph nodes
x - Regional lymph nodes cannot be assessed
M:
Please Select
0 - No distant metastasis
1A - Tumour nodule/s in contralateral; pleural/pericardial effuse
1B - Single extrathoracic met in single organ OR distant node
1C - Multiple extrathoracic metastases
PET STAGE
T:
Please Select
0 No evidence of primary tumour
1A (<=1cm)
1B (>1cm <=2cm)
1C (>2cm <=3cm)
1Mi (Minimally invasive adenocarcinoma)
2A (>3cm <=4cm)
2B (>4cm <=5cm)
3 (>5cm <=7cm OR invades pleura/cw OR separate nodule(s) in same lobe)
4 (>7cm OR invades mediastinum structures OR nodules(s) in ipsilateral lobe)
Is Carcinoma in situ
X Unknown
N:
Please Select
0 - No nodes involved
1 - Mets in ipsilateral peribrochial & hilar nodes, intrapulmonary nodes
2 - Mets in ipsilateral mediastinal &/or subcarinal lymph node/s
3 - Mets in contralateral nodes or SC lymph nodes
x - Regional lymph nodes cannot be assessed
M:
Please Select
0 - No distant metastasis
1A - Tumour nodule/s in contralateral; pleural/pericardial effuse
1B - Single extrathoracic met in single organ OR distant node
1C - Multiple extrathoracic metastases
PATHOLOGICAL STAGE
T:
Please Select
0 No evidence of primary tumour
1A (<=1cm)
1B (>1cm <=2cm)
1C (>2cm <=3cm)
1Mi (Minimally invasive adenocarcinoma)
2A (>3cm <=4cm)
2B (>4cm <=5cm)
3 (>5cm <=7cm OR invades pleura/cw OR separate nodule(s) in same lobe)
4 (>7cm OR invades mediastinum structures OR nodules(s) in ipsilateral lobe)
Is Carcinoma in situ
X Unknown
N:
Please Select
0 - No nodes involved
1 - Mets in ipsilateral peribrochial & hilar nodes, intrapulmonary nodes
2 - Mets in ipsilateral mediastinal &/or subcarinal lymph node/s
3 - Mets in contralateral nodes or SC lymph nodes
x - Regional lymph nodes cannot be assessed
M:
Please Select
0 - No distant metastasis
1A - Tumour nodule/s in contralateral; pleural/pericardial effuse
1B - Single extrathoracic met in single organ OR distant node
1C - Multiple extrathoracic metastases
PFT (% Predicted)
FEV1 (% predicted):
FVC (% predicted):
DLCO (% predicted):
PREVIOUS TREATMENTS FOR LUNG CANCER - CURRENT OR RECURRENT
Previous Intent:
Yes
No
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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