Survivorship Questionnaire for Clinicians

Medical Providers of Pediatric, Adolescent, Young Adult, and Adult

The Survivorship Working Group of the Georgia Comprehensive Cancer Control Program (GC3) would appreciate your input regarding your availability to provide medical follow-up for cancer survivors. We define this group as individuals of any age diagnosed with cancer between ages of birth and 17 (pediatric and adolescent); 18-39 (young adult); and 40 and over (adult) who have completed treatment without evidence of relapse or recurrence at the time of the survey. Those who have had recurrent disease or subsequent cancers in the past may be included if they are not receiving therapy and are tumor-free.
The questionnaire will be used to expand care for cancer survivors and identify resources needed by providers who treat them. We understand that venues for long-term follow-up vary by specialty and locale. Our goal is to maximize appropriate, culturally sensitive follow-up of survivors as close to home as possible. Support of providers is equally important as the number and complexity of survivors grows.
Thank you very much for taking the time to make a difference in the lives of cancer survivors in GA. We will contact you if you indicate your willingness to work with the Survivorship Working Group after all results are tabulated.

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* 1. What is your specialty?

General Internal Medicine

Family Medicine

General Pediatrics

Medical Oncology

Pediatric Oncology

Other (please specify)

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* 2. Do you currently see cancer survivors in your practice?

Yes

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* 3. How many survivors do you see each year? Please select all that apply.

0-10

11-20

21-30

31-40

41-50

more than 50

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* 4. What diagnoses do you see? (Malignancies diagnosed in survivors at age 18 and older) Please select all that apply.

Breast

Colon/GI

Lung

Genitourinary except prostate

Prostate

Ovarian

Testicular

Brain tumor

Primary head and neck

Thyroid

Leukemia

Non-Hodgkin lymphoma

Hodgkin lymphoma

Other (please specify)

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* 5. What diagnoses do you see? (Malignancies diagnosed in survivors aged birth to 17 years)

Leukemia

Non-Hodgkin lymphoma

Hodgkin lymphoma

Brain tumor

Neuroblastoma

Wilms and other urinary tract cancers

Ovarian germ cell

Testicular

Thyroid

Retinoblastoma

Rhabdomyosarcoma

Non-rhabdomyosarcoma soft tissue sarcomas

Other (please specify)

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* 6. How often do you see survivors? Please select all that apply.

New patient

Annually in follow up

If more than annually:

every 3 months

every 6 months

As needed between annual visits

Only as needed after the initial visit

Other (please specify)

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* 7. What are the ages at diagnosis of the survivors you see each year? Please select all that apply.

0-10 years

11-20 years

21-30 years

31-39 years

40-49 years

50-59 years

60-69 years

70 years and older

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* 8. What Guidelines, if any, do you use? Please select all that apply.

Children’s Oncology Group Survivorship Guidelines

National Comprehensive Cancer Network Survivorship Guidelines

American Society of Clinical Oncology Survivorship Guidelines

National Standards for Cancer Survivorship Care

None

Other (please specify)

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* 9. What additional resources, if any, do you offer cancer survivors?

Social Service

Psychology

Diet, nutrition, and wellness counseling

Genetic counseling

Legal and financial counseling

Clinical trial patient education

Survivorship care plan

Workplace accommodations

Housing stability

Transportation

Cognitive assessment

Edema therapy

Rehabilitation (speech, occupational, and/or physical therapy; audiology)

Medical subspecialty referrals

Onco-fertility referrals

Other (please specify)

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* 10. What reasons, if any, do you not see cancer survivors? Please select all that apply.

None referred

Uncertain expectations

Not enough time

Not interested

Lack of knowledge about treating survivors

Would like more information about seeing cancer survivors

N/A

Other (please specify)

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* 11. Tell us about additional challenges you encounter with seeing cancer survivors. Please select all that apply.

Limited staffing

Inadequate funding

Financial constraints

Billing/coding

Organizational/systems constraints

Other (please specify)

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* 12. Tell us about any survivorship activities or support programs you have in place for survivors

Assessment of quality of life and survivorship care

Assessment of practical, psychosocial, or physical effects of cancer

Assessment of lifestyle and wellness behaviors

Training of other survivorship providers

Other (please specify)

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* 13. What do you think could be done to address challenges in seeing cancer survivors?

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* 14. Select if you are willing to be contacted regarding future training or educational opportunities related to cancer survivorship:

Yes

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* 15. Please provide the best way to contact you:

Phone

Fax

Mail

Survivorship Questionnaire for Clinicians

Medical Providers of Pediatric, Adolescent, Young Adult, and Adult

Question Title

* 1. What is your specialty?

Question Title

* 2. Do you currently see cancer survivors in your practice?

Question Title

* 3. How many survivors do you see each year? Please select all that apply.

Question Title

* 4. What diagnoses do you see? (Malignancies diagnosed in survivors at age 18 and older) Please select all that apply.

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* 5. What diagnoses do you see? (Malignancies diagnosed in survivors aged birth to 17 years)

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* 6. How often do you see survivors? Please select all that apply.

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* 7. What are the ages at diagnosis of the survivors you see each year? Please select all that apply.

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* 8. What Guidelines, if any, do you use? Please select all that apply.

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* 9. What additional resources, if any, do you offer cancer survivors?

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* 10. What reasons, if any, do you not see cancer survivors? Please select all that apply.

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* 11. Tell us about additional challenges you encounter with seeing cancer survivors. Please select all that apply.

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* 12. Tell us about any survivorship activities or support programs you have in place for survivors

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* 13. What do you think could be done to address challenges in seeing cancer survivors?

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* 14. Select if you are willing to be contacted regarding future training or educational opportunities related to cancer survivorship:

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* 15. Please provide the best way to contact you:

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* 16. Please share the name(s) and contact information of others in your practice who may be interested in follow up: