CERVICAL CANCER OPERATIVE CARE and POSTOP COMPLICATIONS WITHIN 30 DAYS Data Collection Form January 12, 2015

CERVICAL CANCER OPERATIVE CARE AND POSTOP COMPLICATIONS WITHIN 30 DAYS Data Collection Form January 12, 2015

I. PATIENT DEMOGRAPHICS Medical Record Number Date of Birth Zip Code

 White/Caucasian  Asian  Native Hawaiian/Pacific Islander  Unknown Race (select all applicable)  African American  American Indian/Alaskan Native  Hispanic/Latino/Spanish  Chose Not to Disclose II. CERVICAL CANCER SCREENING Date of screening ______Is patient U.S. born:  Yes  No  Unknown

Has patient seen a healthcare provider in the past 5 years?  Yes  No Has patient ever had a pregnancy?  Yes  No How many pregnancies has the patient had altogether? (include all pregnancies including those ending Date of most recent pregnancy: ______in live birth, miscarriage, abortion, still birth, and ectopic pregnancies.) ______Did a pregnancy delay disease management?  Yes  No

Has patient had a Pap test in the past 5 years?  Yes  No (If yes, please complete table below for all Pap results in the past 5 years)

Date of Type of Lab Image- Performed by Satisfactory Endocervical/ Pap result Was patient Date of Was Treated for Date of Type of Performed by Pap Pap where based test result? TZ referred to colposcopy colposcopy an abnormal abnormal treatment run? evaluation? component colposcopy? satisfactory? PAP or PAP or (Name) present? cervical cervical received biopsy in the biopsy past 5 treatment years? Family Family practice practice Normal Primary care Primary care (NILM) LEEP STM/ Yes physician Yes physician ASC-US Yes Cold knife Glass slide No Gynecologist No Yes Yes No Gynecologist LSIL No cone ThinPrep Not Gyn/onc Not No Not reported Yes No Gyn/onc HSIL Not CO2 Laser SurePath indicated Advanced indicated Not indicated Advanced AGC indicated therapy __/___/___ MM/DD/YEAR Practice Clinician __/___/___ MM/DD/YEAR __/___/___ MM/DD/YEAR Practice AIS Cryo (APN,PA, NP) Clinician Other (specify) (APN,PA, NP) Other (specify) Family Family practice practice Normal Primary care Primary care (NILM) LEEP STM/ Yes physician Yes physician ASC-US Yes Cold knife Glass slide No Gynecologist No Yes Yes No Gynecologist LSIL No cone ThinPrep Not Gyn/onc Not No Not reported Yes No Gyn/onc HSIL Not CO2 Laser SurePath indicated Advanced indicated Not indicated Advanced

__/___/___ MM/DD/YEAR AGC indicated __/___/___ MM/DD/YEAR therapy Practice Clinician __/___/___ MM/DD/YEAR Practice AIS Cryo (APN,PA, NP) Clinician Other (specify) (APN,PA, NP) Other (specify) Family Family practice practice Normal Primary care Primary care (NILM) LEEP STM/ Yes physician Yes physician ASC-US Yes Cold knife Glass slide No Gynecologist No Yes Yes No Gynecologist LSIL No cone ThinPrep Not Gyn/onc Not No Not reported Yes No Gyn/onc HSIL Not CO2 Laser SurePath indicated Advanced indicated Not indicated Advanced AGC indicated therapy

__/___/___ MM/DD/YEAR  __/___/___ MM/DD/YEAR __/___/___ MM/DD/YEAR Practice Clinician Practice AIS Cryo (APN,PA, NP) Clinician Other (specify) (APN,PA, NP) Other (specify) Family Family practice practice Primary care Normal Primary care physician (NILM) LEEP STM/ Yes Yes physician Gynecologist ASC-US Yes Cold knife Glass slide No No Yes Yes No Gynecologist Gyn/onc LSIL No cone ThinPrep Not Not No Not reported Yes No Gyn/onc Advanced HSIL Not CO2 Laser SurePath indicated indicated Not indicated Advanced Practice Clinician AGC indicated therapy __/___/___ MM/DD/YEAR  __/___/___ MM/DD/YEAR __/___/___ MM/DD/YEAR Practice (APN,PA, NP) AIS Cryo Clinician Other (specify) (APN,PA, NP) Other (specify)

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Has patient had an HPV in the past 5 years?  Yes  No (If yes, please complete table below for all HPV results in the past 5 years)

Date of HPV Type of HPV Lab where HPV result HPV Results of Performed by Was patient Date of Was run? genotyping genotyping? referred to colposcopy colposcopy (Name) performed? colposcopy? satisfactory?  Qiagen  Family practice  Cervista  Primary care physician  Positive HR  Positive  Roche Cobas HPV 16  Gynecologist  Negative HR HPV 18  Negative Yes Yes No __/___/___ Aptima Gyn/onc __/___/___   No Not reported MM/DD/YEAR  Indeterminate HPV 45  Not Reported  MM/DD/YEAR Laboratory Advanced Practice  Not Reported  Not indicated Developed Test (LDT)  Clinician (APN,PA, NP)  Not Specified  Other (specify)______

 Qiagen  Family practice  Cervista  Primary care physician  Positive HR  Positive  Roche Cobas HPV 16  Gynecologist  Negative HR HPV 18  Negative Yes Yes No __/___/___ Aptima Gyn/onc __/___/___   No Not reported MM/DD/YEAR  Indeterminate HPV 45  Not Reported  MM/DD/YEAR Laboratory Advanced Practice  Not Reported  Not indicated Developed Test (LDT)  Clinician (APN,PA, NP)  Not Specified  Other (specify)______

Please complete table below for all results in the past 5 years

Has patient had a uterus biopsy performed?  Yes  No Has patient had an anus biopsy performed?  Yes  No Has patient had a vulva biopsy performed?  Yes  No Has patient had a vagina biopsy performed?  Yes  No Has patient had a cervical biopsy performed?  Yes  No Complete all applicable tables.

UTERUS

Date of uterus biopsy test Uterus biopsy test results Performed by

 Family practice  Normal  Primary care physician  AGUS ___/____/_____  Gynecologist MM/DD/YEAR  Hyperplasia without atypia Gyn/onc  Hyperplasia with atypia  Advanced Practice Clinician (APN,PA, NP)  Cancer   Other (specify)______ Family practice  Normal  Primary care physician  AGUS ___/____/_____  Gynecologist MM/DD/YEAR  Hyperplasia without atypia Gyn/onc  Hyperplasia with atypia  Advanced Practice Clinician (APN,PA, NP)  Cancer   Other (specify)______ Family practice  Normal  Primary care physician  AGUS ___/____/_____  Gynecologist MM/DD/YEAR  Hyperplasia without atypia Gyn/onc  Hyperplasia with atypia  Advanced Practice Clinician (APN,PA, NP)  Cancer   Other (specify)______ Family practice  Normal  Primary care physician  AGUS  Gynecologist ___/____/_____ MM/DD/YEAR  Hyperplasia without atypia  Gyn/onc  Hyperplasia with atypia  Advanced Practice Clinician (APN,PA, NP) Cancer   Other (specify)______

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ANUS Date of Anus biopsy test Anus biopsy test results Performed by

 Family practice  Normal  Primary care physician  Dysplasia – mild  Gynecologist ___/____/_____ MM/DD/YEAR  Dysplasia - moderate  Gyn/onc  Dysplasia - severe  Advanced Practice Clinician (APN,PA, NP) Cancer   Other (specify)______

VULVA Date of Vulva biopsy test Vulva biopsy test results Performed by

 Family practice  Normal  Primary care physician  VIN-1  Gynecologist ___/____/_____ MM/DD/YEAR  VIN-2  Gyn/onc  VIN-3  Advanced Practice Clinician (APN,PA, NP) Cancer   Other (specify)______

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VAGINA Date of Vagina biopsy test Vagina biopsy test results Performed by

 Family practice  Normal  Primary care physician  AGUS  Gynecologist ___/____/_____  VAIN-1 Gyn/onc MM/DD/YEAR  VAIN-2  Advanced Practice Clinician (APN,PA, NP)  VAIN-3   Cancer  Other (specify)______

CERVICAL Date of Cervical biopsy test Cervical biopsy test results Performed by

 Family practice  CIN-1  Primary care physician  CIN-2  Gynecologist ___/____/_____  CIN-3 Gyn/onc MM/DD/YEAR  CGIN/Atypical glandular cells  Advanced Practice Clinician (APN,PA, NP)  LSIL   HSIL  Other (specify)______ Family practice  CIN-1  Primary care physician  CIN-2  Gynecologist ___/____/_____  CIN-3 Gyn/onc MM/DD/YEAR  CGIN/Atypical glandular cells  Advanced Practice Clinician (APN,PA, NP)  LSIL   HSIL  Other (specify)______ Family practice  CIN-1  Primary care physician  CIN-2  Gynecologist ___/____/_____  CIN-3 Gyn/onc MM/DD/YEAR  CGIN/Atypical glandular cells  Advanced Practice Clinician (APN,PA, NP)  LSIL   HSIL  Other (specify)______ Family practice  CIN-1  Primary care physician  CIN-2  Gynecologist ___/____/_____  CIN-3 Gyn/onc MM/DD/YEAR  CGIN/Atypical glandular cells  Advanced Practice Clinician (APN,PA, NP)  LSIL   HSIL  Other (specify)______

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Has patient had a Endocervical Curettage (ECC) in the past 5 years?  Yes  No (If yes, please complete table below for all results in the past 5 years)

ENDOCERVICAL CURETTAGE (ECC) Date of Endocervical Curettage (ECC) test Endocervical Curettage (ECC) test results Performed by

 Family practice  Normal  Primary care physician  Inadequate  Gynecologist ___/____/_____ MM/DD/YEAR  AIS  Gyn/onc  CGIN/Atypical glandular cells  Advanced Practice Clinician (APN,PA, NP) Cancer   Other (specify)______

Has patient taken any immunosuppressant Yes medications within the past 5 years? No

Has patient taken any anti-retrovirals medications Yes within the past 5 years? No

 Abnormal bleeding  Bleeding after intercourse Has patient experienced symptoms of cervical disease Yes Discharge If yes to symptoms, please select all that apply.  within the past 5 years? No  Pain  Urinary symptoms)  Other (specify)______II. HOSPITALIZATION Hospital Admit Date Hospital Discharge Date

III. PREOPERATIVE RISK FACTORS Height (cm)/(in) Weight (kg)/(lb) Body Mass Index (Calculated field) ASA Class (time of surgery) 1 2 3 4

Diabetes:  Yes  No If Yes, Select Medication:  None  Insulin  Oral Hypoglycemic Current Smoker (within one year of surgery):  Yes  No Prior Abdominal Surgery:  Yes  No Year:______

History of Conditions/Previous Interventions (select all applicable): Cardiac Surgery (includes: stent, CABG, Valve, Pacemaker, Other Cardiac Surgery):  Yes  No Creatinine level >1.5:  Yes  No Steroid Use (Use of oral/parenteral steroids for >10 days in prior 30 days):  Yes  No Pulmonary:  Yes  No  COPD  Pulmonary HTN  Other Heme:  Yes  No  DVT/PE (within 90 days)  Transfusion  Other Neuro:  Yes  No  Stroke  Other Endocrine:  Yes  No  Thyroid Hyper  Thyroid Hypo  Afib/Arrhythmia  Angina (within 30 days)  CHF (within 30 days) Cardiac Conditions:  Yes  No  HTN  MI (within 6 months)  Other Presurgical Radiotherapy:  Yes  No

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Neoadjuvant Therapy:  Yes  No Neoadjuvant Therapy start date______

Which neoadjuvant chemotherapy drugs were used? ______

Neoadjuvant therapy cycles ______Did patient undergo surgery?:  Yes  No IV. HISTOLOGY

Squamous Cell  Adenocarcinoma Adenosquamos Glassy Cell Neuroendocrine Clear Cell: Other: Carcinoma      

Largest Primary Tumor Diameter (cm) Lymphovascular Space Invasion:  Yes  No  Unknown V. SURGICAL PATHOLOGY FIGO Stage:  IA  IA1  IA2  IB  IB1  IB2  IIA  IIA1  IIA2  IIB  IIIA  IIIB  IVA  IVB  Recurrent Number of Right Nodes Removed Number of Left Nodes Removed TOTALS (calculated field) Pelvic Lymphadenectomy:  Yes  No Number of Right Nodes Positive Number of Left Nodes Positive TOTALS (calculated field) If Yes, Provide Information

Paraaortic Lymphadenectomy: Total Number Removed Total Number Positive  Yes  No If Yes, Provide Information

H & E Positive:  Yes  No

Microstaged Positive:  Yes  No If SLN positive, was Ultra Staging Sentinel Lymph Node: Yes No   Positive:  Yes  No Performed?  Yes  No Isolated (ITC) Positive:  Yes  No If Yes, Provide Information: If Yes, Select: Micromets Positive:  Yes  No

Macromets Positive:  Yes  No

Was chemosensitivity assay ordered:  Yes  No

VI. SURGERY National Provider Identifier: Date of Surgery:

Surgeon Specialty:  Gynecologic Oncology  Obstetrics and Gynecology  General Surgery  Other

Surgical Approach:  Laparotomy  Conventional Laparoscopy  Robotic-assisted If Yes: Did patient convert to Laparotomy:  Yes  No  Large BMI  Extension Adhesion  Other______ Large Uterus  Anesthesia or Insufflation Related Problems  N/A  Spleen  Small Bowel Serosa/Mensentery  Diaphragm  Liver  Other Extent of Cancer: (if stage IV):  Below Pelvic Brim  Lung  Carcinomatosis (>50% of all peritoneal surfaces involved by tumor) Previous hysterectomy: If yes, date: ______(only year needed)  Yes  No  Hysterectomy Type I (extrafascial)  Hysterectomy Type II (modified radical)  Hysterectomy Type III (radical)

Exenteration (Total/Anterior/ Operation:  Cold Knife Cone/LEEP Other Posterior)  

 Radical Trachelectomy  Biopsy only Uterine weight (in grams): ______

If patient undergoes radical surgery, Select: Operative Note Completed/Present (within 48 hours of Operation)  Positive lymph nodes  Positive parametria  Positive vaginal margin  Yes  No Estimated Blood Loss (ml)

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OR Entry Time: ______(24 hr. clock)

Skin Incision Start Time: ______(24 hr. clock) Skin Incision Stop Time: ______(24 hr. clock) OR Exit Time: ______(24 hr. clock)

VII. POSTOPERATIVE COMPLICATIONS WITHIN 30 DAYS Patient Medical Record Number Date of Birth Zip Code

Date of Occurrence Postoperative Complication:  Yes  No Unplanned ICU transfer or admission:  Yes  No Grade 2 Complication:  Wound Infection  UTI  Pneumonia  Other Condition Requiring  Yes  No Requiring Antibiotics Antibiotics (select all applicable)  Blood Transfusion  Total Parenteral Nutrition  DVT  PE  Lymphatic Bowel Perforation Other  Wound Disruption  or Obstruction  Return to OR  Bleeding  Fistula Grade 3 Complication:  Abdominal Abscess  Cuff Dehiscence  Yes  No  PEG  Laparoscopy  Upper Endoscopy Endoscopic Procedures (select all applicable)  Colonoscopy  Other Interventional Radiology  Ureteral Stent Placement  Colonic Stent  Other:  Cardiac  CNS  Hematologic Organ Failure  GI/Hepatic  Renal  Respiratory Date of Death Grade 4 Complication: Postoperative Complication-Related Death:  Yes  No

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