Title of measure: Functional Assessment of Cancer Therapy-Brain (FACT-Br)

Similar documents
MER Baseline Enrollment Questionnaire. To be completed by Participant at time of Enrollment

The Rehabilitation Institute Cancer Rehabilitation

The Rehabilitation Institute Cancer Rehabilitation

CHILDHOOD C 3 HANGE CARE TOOL: PROVIDER REPORT

Models and definitions of quality of life

This is a repository copy of Health-related quality of life after treatment for bladder cancer in England.

Psychometric validation of the functional assessment of cancer therapy brain (FACT-Br) for assessing quality of life in patients with brain metastases

Quality of Life in Epilepsy for Adolescents: QOLIE-AD-48 (Version 1)

keep track of other information like warning discuss with your doctor, and numbers of signs for relapse, things you want to

QUALITY OF LIFE IN CANCER CLINICAL TRIALS A Practical Guide For. Research Staff

Medicare Wellness Visit

Patient Follow-up Form - Version 1.1

These questions are about the physical problems which may have occurred as a result of your stroke. Quite a bit of strength

SUPPLEMENT MATERIALS. Appendix A: Cleveland Global Quality of Life (CGQL) [0 being the WORST and 10 being the BEST]

did you feel sad or depressed? did you feel sad or depressed for most of the day, nearly every day?

LEO (Lymphoma Epidemiology & Outcomes) Baseline Enrollment Questionnaire. To be completed by Participant at time of Enrollment

Exercise. Good Weight A PT E R. Staying Healthy

Tinnitus Functional Index (TFI)

D2 Building Relationships, Enhancing Quality of Life, and Empowering Cancer Patients with Self-Hypnosis Groups (Holly Forester-Miller, PhD)

Stroke Impact Scale VERSION 3.0

Optimal Health Questionnaire

suicide Part of the Plainer Language Series

The quality of life in adolescents with phenylketonuria

Session 6: Choosing and using HRQoL measures vs Multi-Attribute Utility Instruments QLU-C10D and EQ-5D as examples

Psychological Sleep Services Sleep Assessment

PERSONAL HISTORY QUESTIONNAIRE

Medical History. Instructions. My telephone number is: 1 Tools Medical History

BACKGROUND HISTORY QUESTIONNAIRE

Initial Patient Questionnaire

Understanding Alzheimer s Disease What you need to know

QUALITY OF LIFE IN EPILEPSY - QOLIE-31 (Version 1.0)

Sleep Health Center. You have been scheduled for an Insomnia Treatment Program consultation to further discuss your

Wellbeing Measurement Framework for Colleges

The Psychiatric Liaison Team for Older Adults

Fairly often During the last week, on average, how severe has been? Moderate 3

Medicare Annual Wellness Visit Patient History

MOTOR VEHICLE ACCIDENT PAIN CHART

Do not write below this line DSM IV Code: Primary Secondary. Clinical Information

EMOTIONAL SUPPORT ANIMAL (ESA) PSYCHOLOGICAL EVALUATION PART I: PERSONAL INFORMATION STREET ADDRESS CITY/STATE

INSOMNIA SEVERITY INDEX

WHAT YOU SHOULD KNOW ABOUT. Glioblastoma (GBM)

Here are a few ideas to help you cope and get through this learning period:

Brief Pain Inventory (Short Form)

Problem Summary. * 1. Name

Affective Control Scale

Quality of Life Instrument - Breast Cancer Patient Version

COURSE INTRODUCTION TOTAL HEALTH THE HEALTH TRIANGLE & THE WELLNESS CONTINUUM

Description and Psychometrics

SHARED EXPERIENCES. Suggestions for living well with Alzheimer s disease

To: Our Medicare Patients. Subject: Your Welcome to Medicare Exam

How Should I Communicate as a Caregiver?

movement is medicine The benefits of physical activity for mental and physical health Information leaflet

Which CCSF Health Education Program Is Right For You?

We all have our share of good days and bad. After all, life is filled with. many ups and downs. Some days may be so bad that we have trouble doing

HEALTH STATUS QUESTIONNAIRE 2.0

IMPORTANT THINGS TO KNOW WHEN YOU HAVE HEPATITIS C

Stay Married with the FIT Technique Go from Pissed off to Peaceful in Three Simple Steps!

Take control of your pain therapy. Getting started with Algovita SCS.

UNDERSTANDING THE RELATIONSHIP BETWEEN MENTAL HEALTH & MENTAL ILLNESS. Module Two: the Guide Resource Dr. Stan Kutcher & Ms. Yifeng Wei March 2015

Useful Self Assessment tools to help identify your needs and how you are feeling for patients and their family/caregivers

Managing Psychosocial and Family Distress after Cancer Treatment

Mental Health and Suicide Prevention: What Everyone Should Know

Please complete this form before your Doctor visit. We will review this together and make any changes needed.

Memory & Aging Clinic Questionnaire

EMOTIONAL SUPPORT ANIMAL (ESA) PSYCHOLOGICAL EVALUATION. Important Information

MEDICARE ANNUAL WELLNESS VISIT QUESTIONNAIRE

FACTSHEET F18 COPING WITH TIREDNESS

Impact of Cancer Scale Tool

Psychological wellbeing in heart failure

Peer Support / Social Activities Overview and Application Form

SAN DIEGO SEXUAL MEDICINE

Bringing It All Together Ways to Stay Motivated

LupusPRO (Lupus Patient Reported Outcome Tool) v1.7

PATIENT SURVEY FOR ADMINISTRATIVE USE ONLY. TO BE COMPLETED BY STUDY COORDINATOR.

A VIDEO SERIES. living WELL. with kidney failure LIVING WELL

CBT Intake Form. Patient Name: Preferred Name: Last. First. Best contact phone number: address: Address:

Buy full version here - for $7.00

Measuring Psychological Wealth: Your Well-Being Balance Sheet

Problem Situation Form for Parents

In order to receive the maximum benefit from your rehabilitation program, it is important to understand and comply with the following guidelines:

Patient Scheduled Letter Thunderbird Internal Medicine Sleep Center 5620 W. Thunderbird Rd., Suite C-1 Glendale, AZ (602)

National Institute on Drug Abuse (NIDA) What is Addiction?

POST CONCUSSION SYMPTOM SCALE

The emotional side of diabetes

Living Life with Persistent Pain. A guide to improving your quality of life, in spite of pain

ADULT HISTORY QUESTIONNAIRE

HEADACHE HISTORY. Indicate the area of your head where your headaches seem to be concentrated. Please check those that apply:

Understanding and Recognizing Childhood Depression

o never o 1 day per week or less o 2-3 days per week o 4-6 days per week o every day

The University of Iowa College of Nursing Alzheimer's Family Involvement in Care Study. Caregiver Stress Inventory (CSI) (4-9) (10-13)

PATIENT NAME: DATE OF DISCHARGE: DISCHARGE SURVEY

Unit One. A Healthy Foundation

SCL-90. Backaches 0 (T) In this case, the respondent experienced backaches a little bit (1). Please proceed with the questionnaire.

Abusing drugs can reduce the effectiveness of your treatment, prolong your illness and increase the risk of side effects.

Emotional Health and ADHD

Client s Name: Today s Date: Partner s Name (if being seen as a couple): Address, City, State, Zip: Home phone: Work phone: Cell phone:

Kaiser Permanente Colorado

Seek, Test, Treat and Retain for Vulnerable Populations: Data Harmonization Measure

Coping with Cancer. Patient Education Social Work and Care Coordination Cancer Programs. Feeling in Control

University of Oregon HEDCO Clinic Fluency Center. Diagnostic Intake Form for Adults Who Stutter

Transcription:

Title of measure: Functional Assessment of Cancer Therapy-Brain (FACT-Br) This summary was last revised 5 October 2010. Brief overview: The Functional Assessment of Cancer Therapy-Brain (FACT-Br) is a commonly used instrument measuring general quality of life (QOL) that reflects symptoms or problems associated with brain malignancies across 5 scales [1]. The measure yields information about total QOL, as well as information about the dimensions of physical well-being, social/family well-being, emotional well being, functional well-being, and diseasespecific concerns. The FACT-Br is written at the 4th grade reading level, and patients can filled out it in 5-10 minutes. The self-report of quality of life can be completed by the patient or with the assistance of the examiner and does not require pre-certification. Validated (Yes/No): Yes [2]. The Functional Assessment of Cancer Therapy (FACT) scale has been developed following principles of test construction and evaluation and, recently, has undergone through psychometric testing for validity and reliability [1, 2]. The FACT-G (General version) was developed to provide information about health status that is specific to cancer patients. FACT-BR (brain) was developed as a new combined brain subscale questionnaire and checked for validation and reliability by Weitzner and coworkers [2] in 1995. Psychometric properties and references: FACT-Br subscale, brain tumor specific version, is a 23-item questionnaire that can be completed in 5 to 10 minutes with little or no assistance in patients who are not neurologically incapacitated. This brain subscale is usually used along with the core (general) questionnaire [2] that includes 27 items. Patients rate all 5 items using a five-point Likert scale ranging from 0 "not " to 4 "very." Overall, higher ratings suggest higher QOL. Items are totaled to produce the following subscales, along with an overall QOL score: physical well-being (7 items); social/family well-being (7 items); emotional well-being (6 items); functional well-being (7 items); and concerns relevant to patients with brain tumors (23 items). Clinically significant changes: specifically available for FACT-Br. Website or how to register to use: Go to www.facit.org and click on Registration+Requests to use one or more of the FACT scales, which can be obtained by completing a User s Agreement and completing one Collaborator s Project Information Form per project. This information can be found under the User s Agreement link on the website. The permission information should be given to RTOG headquarters for each RTOG QOL study. List any fees for usage: Currently, there are no fees for use of any of the English versions of the FACT questionnaires.. Languages available: The FACT has been translated into many languages, and translations are accessible at the FACIT web site, http://www.facit.org/translation/licensure.aspx. Please check the website for the specific languages available for FACT-BR.

Instructions for CRAs and or credentialing for administration: There is no credentialing needed for administration. Each protocol has instructions for the Clinical Research Associates. As well, a variety of information to assist in the administration of the FACT questionnaires is available from the website (under the administration and scoring guidelines link). Quality assurance for administration (if needed): None. Scoring of instrument: The website has a repository of information that assists in the scoring of the FACT questionnaires and in the interpretation of the results. References: 1. Cella DF, Tulsky DS, Gray G, et al. The Functional Assessment of Cancer Therapy scale: development and validation of the general measure. J Clin Oncol 1993;11:570-579. 2. Weitzner MA, Meyers CA, Gelke CK, et al. 1995. The Functional Assessment of Cancer Therapy (FACT) scale: Development of a brain subscale and revalidation of the general version (FACT-G) in patients with primary brain tumors. Cancer 75(5):1151-1161.

FACT-BR (Version 4) Below is a list of statements that other people with your illness have said are important. By circling one (1) number per line, please indicate how true each statement has been for you PHYSICAL WELL-BEING a GP1 I have a lack of energy... 0 1 2 3 4 GP2 I have nausea... 0 1 2 3 4 GP3 Because of my physical condition, I have trouble meeting the needs of my family... 0 1 2 3 4 GP4 I have pain... 0 1 2 3 4 GP5 I am bothered by side effects of treatment... 0 1 2 3 4 GP6 I feel ill... 0 1 2 3 4 GP7 I am forced to spend time in bed... 0 1 2 3 4 SOCIAL/FAMILY WELL-BEING a GS1 I feel close to my friends... 0 1 2 3 4 GS2 I get emotional support from my family... 0 1 2 3 4 GS3 I get support from my friends... 0 1 2 3 4 GS4 My family has accepted my illness... 0 1 2 3 4 GS5 I am satisfied with family communication about my illness... 0 1 2 3 4 GS6 I feel close to my partner (or the person who is my main support)... 0 1 2 3 4 Q1 Regardless of your current level of sexual activity, please answer the following question. If you prefer not to answer it, please check this box and go to the next section. GS7 I am satisfied with my sex life... 0 1 2 3 4

By circling one (1) number per line, please indicate how true each statement has been for you EMOTIONAL WELL-BEING a GE1 I feel sad... 0 1 2 3 4 GE2 I am satisfied with how I am coping with my illness... 0 1 2 3 4 GE3 I am losing hope in the fight against my illness... 0 1 2 3 4 GE4 I feel nervous... 0 1 2 3 4 GE5 I worry about dying... 0 1 2 3 4 GE6 I worry that my condition will get worse... 0 1 2 3 4 FUNCTIONAL WELL-BEING a GF1 I am able to work (include work at home)... 0 1 2 3 4 GF2 My work (include work at home) is fulfilling... 0 1 2 3 4 GF3 I am able to enjoy life... 0 1 2 3 4 GF4 I have accepted my illness... 0 1 2 3 4 GF5 I am sleeping well... 0 1 2 3 4 GF6 I am enjoying the things I usually do for fun... 0 1 2 3 4 GF7 I am content with the quality of my life right now... 0 1 2 3 4

By circling one (1) number per line, please indicate how true each statement has been for you ADDITIONAL CONCERNS a Br1 I am able to concentrate... 0 1 2 3 4 Br2 I have had seizures (convulsions)... 0 1 2 3 4 Br3 I can remember new things... 0 1 2 3 4 Br4 I get frustrated that I cannot do things I used to... 0 1 2 3 4 Br5 I am afraid of having a seizure (convulsion)... 0 1 2 3 4 Br6 I have trouble with my eyesight... 0 1 2 3 4 Br7 I feel independent... 0 1 2 3 4 NTX 6 I have trouble hearing... 0 1 2 3 4 Br8 I am able to find the right word(s) to say what I mean... 0 1 2 3 4 Br9 I have difficulty expressing my thoughts... 0 1 2 3 4 Br10 I am bothered by the change in my personality... 0 1 2 3 4 Br11 I am able to make decisions and take responsibility... 0 1 2 3 4 Br12 I am bothered by the drop in my contribution to the family... 0 1 2 3 4 Br13 I am able to put my thoughts together... 0 1 2 3 4 Br14 I need help in caring for myself (bathing, dressing, eating, etc.)... 0 1 2 3 4 Br15 I am able to put my thoughts into action... 0 1 2 3 4 Br16 I am able to read like I used to... 0 1 2 3 4 Br17 I am able to write like I used to... 0 1 2 3 4 Br18 I am able to drive a vehicle (my car, truck, etc.)... 0 1 2 3 4 Br19 I have trouble feeling sensations in my arms, hands, or legs... 0 1 2 3 4 Br20 I have weakness in my arms or legs... 0 1 2 3 4 Br21 I have trouble with coordination... 0 1 2 3 4 An 10 I get headaches... 0 1 2 3 4