ICHOM Patient Centered Outcomes Measure Set for Breast Cancer
1.0.0 - trial-use

ICHOM Patient Centered Outcomes Measure Set for Breast Cancer, published by HL7 International - Clinical Interoperability Council Group. This is not an authorized publication; it is the continuous build for version 1.0.0). This version is based on the current content of https://github.com/HL7/fhir-ichom-breast-cancer-ig/ and changes regularly. See the Directory of published versions

## Questionnaire: PatientReportedFollowUp (Experimental)

Official URL: http://hl7.org/fhir/uv/ichom-breast-cancer/Questionnaire/PatientReportedFollowUp | Version: 1.0.0
Standards status: Informative | Computable Name: PatientReportedFollowUp

Patient-reported response at every 6 months for first 2 years post-treatment, after 2 years tracked annually for up to 10 years

Structure

LinkId | Text | Cardinality | Type | Description & Constraints
--- | --- | --- | --- | ---
PatientReportedFollowUp | Patient-reported response at every 6 months for first 2 years post-treatment, after 2 years tracked annually for up to 10 years |  | Questionnaire | http://hl7.org/fhir/uv/ichom-breast-cancer/Questionnaire/PatientReportedFollowUp#1.0.0
General-Information-Clinical | General information | 1..1 | group |
NA-Clinical | What is the patient's medical record number? | 1..1 | string |
LastName-Clinical | What is the patient's last name? | 1..1 | string |
Degree-of-Health-EORTC-QLQ | Degree of Health - EORTC-QLQ | 0..1 | group |
EORTCQLQ-Question01-05 | We are interested in some things about you and your health. Please answer all of the questions yourself by selecting the answer that best applies to you. There are no 'right' or 'wrong' answers. The information that you provide will remain strictly confidential. | 0..1 | group |
EORTCQLQC30_Q01 | Do you have any trouble doing strenuous activities, like carrying a heavy shopping bag or a suitcase? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q02 | Do you have any trouble taking a long walk? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q03 | Do you have any trouble taking a short walk outside of the house? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q04 | Do you need to stay in bed or a chair during the day? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q05 | Do you need help with eating, dressing, washing yourself or using the toilet? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQ-Question06-28 | During the past week: | 0..1 | group |
EORTCQLQC30_Q06 | Were you limited in doing either your work or other daily activities? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q07 | Were you limited in pursuing your hobbies or other leisure time activities? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q08 | Were you short of breath? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q09 | Have you had pain? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q10 | Did you need to rest? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q11 | Have you had trouble sleeping? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q12 | Have you felt weak? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q13 | Have you lacked appetite? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q14 | Have you felt nauseated? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q15 | Have you vomited? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q16 | Have you been constipated? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q17 | Have you had diarrhea? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q18 | Were you tired? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q19 | Did pain interfere with your daily activities? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q20 | Have you had difficulty in concentrating on things, like reading a newspaper or watching television? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q21 | Did you feel tense? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q22 | Did you worry? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q23 | Did you feel irritable? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q24 | Did you feel depressed? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q25 | Have you had difficulty remembering things? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q26 | Has your physical condition or medical treatment interfered with your family life? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q27 | Has your physical condition or medical treatment interfered with your social activities? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQC30_Q28 | Has your physical condition or medical treatment caused you financial difficulties? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQ-Question29-30 | For the following questions please select the number between 1 and 7 that best applies to you, with 1 = Very poor and 7 = Excellent. | 0..1 | group |
EORTCQLQC30_Q29 | How would you rate your overall health during the past week? | 1..1 | choice | Options: 7 options
EORTCQLQC30_Q30 | How would you rate your overall quality of life during the past week? | 1..1 | choice | Options: 7 options
EORTCQLQ-Question31-43 | Patients sometimes report that they have the following symptoms or problems. Please indicate the extent to which you have experienced these symptoms or problems during the past week. Please answer by selecting the answer that best applies to you. During the past week: | 0..1 | group |
EORTCQLQBR45_Q31 | Have you had dry mouth? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q32 | Have food and drink tasted different than usual? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q33 | Have your eyes been painful, irritated or watery? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q34 | Have you lost any hair? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q35 | Have you been upset by the loss of your hair? | 0..1 | choice | Enable When: EORTCQLQBR45_Q34 != Not at all (Agreement response CodeSystem#no) Value Set: Agreement response ValueSet
EORTCQLQBR45_Q36 | Have you felt ill or unwell? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q37 | Have you had hot flushes? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q38 | Have you had headaches? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q39 | Have you felt physically less attractive as a result of your disease or treatment? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q40 | Have you felt less feminine as a result of your disease or treatment? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q41 | Have you had problems looking at yourself naked? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q42 | Have you been dissatisfied with your body? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q43 | Have you worried about your health in the future? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQ-Question44-46 | During the past four weeks: | 0..1 | group |
EORTCQLQBR45_Q44 | Have you been sexually active? (with or without intercourse) | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q45 | To what extent were you sexually active? (with or without intercourse) | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q46 | Has sex been enjoyable for you? | 0..1 | choice | Enable When: EORTCQLQBR45_Q45 != Not at all (Agreement response CodeSystem#no) Value Set: Agreement response ValueSet
EORTCQLQ-Question47-69 | During the past week: | 0..1 | group |
EORTCQLQBR45_Q48 | Have you had a swollen arm or hand? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q49 | Have you had problems raising your arm or moving it sideways? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q50 | Have you had any pain in the area of your affected breast? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q51 | Has the area of your affected breast been swollen? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q52 | Has the area of your affected breast been oversensitive? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q53 | Have you had skin problems on or in the area of your affected breast (e.g., itchy, dry, flaky)? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q54 | Have you sweated excessively? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q55 | Have you had mood swings? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q56 | Have you been dizzy? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q57 | Have you had soreness in your mouth? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q58 | Have you had any reddening in your mouth? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q59 | Have you had pain in your hands or feet? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q60 | Have you had any redenning on your hands or feet? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q61 | Have you had tingling in your fingers or toes? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q62 | Have you had numbness in your fingers or toes? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q63 | Have you had problems with your joints? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q64 | Have you had stiffness in your joints? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q65 | Have you had pain in your joints? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q66 | Have you had aches or pains in your bones? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q67 | Have you had aches or pains in your muscles? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q68 | Have you gained weight? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q69 | Has weight gain been a problem for you? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQ-Question70-71 | During the past four weeks: | 0..1 | group |
EORTCQLQBR45_Q70 | Have you had a dry vagina? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q71 | Have you had discomfort in your vagina? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQ-Question72-73 | Please answer the following two questions only if you have been sexually active: | 0..1 | group |
EORTCQLQBR45_Q72 | Have you had pain in your vagina during sexual activity? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q73 | Have you experienced a dry vagina during sexual activity? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQ-Question74-75 | During the past week: | 0..1 | group |
EORTCQLQBR45_Q74 | Have you been satisfied with the cosmetic result of the surgery? | 1..1 | choice | Value Set: Agreement response ValueSet
EORTCQLQBR45_Q75 | Have you been satisfied with the appearance of the skin of your affected breast (thoracic area)? | 1..1 | choice | Value Set: Agreement response ValueSet
Degree-of-Health-BreastQ | Degree of Health BreastQ | 0..1 | group |
BreastQ_Surgery | Which type of surgery did you receive? | 1..1 | choice | Value Set: Types of breast surgery ValueSet
MastectomyFollowUp | With your breast area in mind, in the past 2 weeks, how satisfied or dissatisfied have you been with: | 0..1 | group | Enable When: BreastQ_Surgery = Mastectomy without immediate reconstruction (Breast surgery types CodeSystem#mastectomy-without-immediate-reconstruction)
BREASTQMASTP_Q01 | How you look in the mirror clothed? | 0..1 | choice | Enable When: BreastQ_Surgery = Mastectomy without immediate reconstruction (Breast surgery types CodeSystem#mastectomy-without-immediate-reconstruction) Value Set: Satisfaction response ValueSet
BREASTQMASTP_Q02 | How comfortably your bras fit? | 0..1 | choice | Enable When: BreastQ_Surgery = Mastectomy without immediate reconstruction (Breast surgery types CodeSystem#mastectomy-without-immediate-reconstruction) Value Set: Satisfaction response ValueSet
BREASTQMASTP_Q03 | Being able to wear clothing that is more fitted? | 0..1 | choice | Enable When: BreastQ_Surgery = Mastectomy without immediate reconstruction (Breast surgery types CodeSystem#mastectomy-without-immediate-reconstruction) Value Set: Satisfaction response ValueSet
BREASTQMASTP_Q04 | How you look in the mirror unclothed? | 0..1 | choice | Enable When: BreastQ_Surgery = Mastectomy without immediate reconstruction (Breast surgery types CodeSystem#mastectomy-without-immediate-reconstruction) Value Set: Satisfaction response ValueSet
BreastConservingTherapyFollowUp | The following questions are about your breasts and your breast cancer treatment (by treatment, we mean lumpectomy with or without radiation). If you have had a lumpectomy and radiation of both breasts, answer these questions thinking of the breast you are least satisfied with. With your breasts in mind, in the past week, how satisfied or dissatisfied have you been with: | 0..1 | group | Enable When: BreastQ_Surgery = Breast conserving surgery (BCS) (Breast surgery types CodeSystem#bcs) BreastQ_Surgery = BCS with mammoplasty (Breast surgery types CodeSystem#bcs-with-mammoplasty)
BREASTQBCTP_Q01 | How you look in the mirror clothed? | 0..1 | choice | Enable When: BreastQ_Surgery = Breast conserving surgery (BCS) (Breast surgery types CodeSystem#bcs) BreastQ_Surgery = BCS with mammoplasty (Breast surgery types CodeSystem#bcs-with-mammoplasty) Value Set: Satisfaction response ValueSet
BREASTQBCTP_Q02 | The shape of your lumpectomy breast when you are wearing a bra? | 0..1 | choice | Enable When: BreastQ_Surgery = Breast conserving surgery (BCS) (Breast surgery types CodeSystem#bcs) BreastQ_Surgery = BCS with mammoplasty (Breast surgery types CodeSystem#bcs-with-mammoplasty) Value Set: Satisfaction response ValueSet
BREASTQBCTP_Q03 | How normal you feel in your clothes? | 0..1 | choice | Enable When: BreastQ_Surgery = Breast conserving surgery (BCS) (Breast surgery types CodeSystem#bcs) BreastQ_Surgery = BCS with mammoplasty (Breast surgery types CodeSystem#bcs-with-mammoplasty) Value Set: Satisfaction response ValueSet
BREASTQBCTP_Q04 | Being able to wear clothing that is more fitted? | 0..1 | choice | Enable When: BreastQ_Surgery = Breast conserving surgery (BCS) (Breast surgery types CodeSystem#bcs) BreastQ_Surgery = BCS with mammoplasty (Breast surgery types CodeSystem#bcs-with-mammoplasty) Value Set: Satisfaction response ValueSet
BREASTQBCTP_Q05 | How your lumpectomy breast sits/hangs? | 0..1 | choice | Enable When: BreastQ_Surgery = Breast conserving surgery (BCS) (Breast surgery types CodeSystem#bcs) BreastQ_Surgery = BCS with mammoplasty (Breast surgery types CodeSystem#bcs-with-mammoplasty) Value Set: Satisfaction response ValueSet
BREASTQBCTP_Q06 | How smoothly shaped your lumpectomy breast looks? | 0..1 | choice | Enable When: BreastQ_Surgery = Breast conserving surgery (BCS) (Breast surgery types CodeSystem#bcs) BreastQ_Surgery = BCS with mammoplasty (Breast surgery types CodeSystem#bcs-with-mammoplasty) Value Set: Satisfaction response ValueSet
BREASTQBCTP_Q07 | The contour (outline) of your lumpectomy breast? | 0..1 | choice | Enable When: BreastQ_Surgery = Breast conserving surgery (BCS) (Breast surgery types CodeSystem#bcs) BreastQ_Surgery = BCS with mammoplasty (Breast surgery types CodeSystem#bcs-with-mammoplasty) Value Set: Satisfaction response ValueSet
BREASTQBCTP_Q08 | How equal in size your breasts are to each other? | 0..1 | choice | Enable When: BreastQ_Surgery = Breast conserving surgery (BCS) (Breast surgery types CodeSystem#bcs) BreastQ_Surgery = BCS with mammoplasty (Breast surgery types CodeSystem#bcs-with-mammoplasty) Value Set: Satisfaction response ValueSet
BREASTQBCTP_Q09 | How normal your lumpectomy breast looks? | 0..1 | choice | Enable When: BreastQ_Surgery = Breast conserving surgery (BCS) (Breast surgery types CodeSystem#bcs) BreastQ_Surgery = BCS with mammoplasty (Breast surgery types CodeSystem#bcs-with-mammoplasty) Value Set: Satisfaction response ValueSet
BREASTQBCTP_Q10 | How much your breast look the same? | 0..1 | choice | Enable When: BreastQ_Surgery = Breast conserving surgery (BCS) (Breast surgery types CodeSystem#bcs) BreastQ_Surgery = BCS with mammoplasty (Breast surgery types CodeSystem#bcs-with-mammoplasty) Value Set: Satisfaction response ValueSet
BREASTQBCTP_Q11 | How you look in the mirror unclothed? | 0..1 | choice | Enable When: BreastQ_Surgery = Breast conserving surgery (BCS) (Breast surgery types CodeSystem#bcs) BreastQ_Surgery = BCS with mammoplasty (Breast surgery types CodeSystem#bcs-with-mammoplasty) Value Set: Satisfaction response ValueSet
ReconstructionFollowUp | If you have had a mastectomy and reconstruction of both breasts, answer these questions thinking of the breast you are least satisfied with. With your breasts in mind ,in the past week, how satisfied or dissatisfied have you been with: | 0..1 | group | Enable When: BreastQ_Surgery = Mastectomy with immediate reconstruction (Breast surgery types CodeSystem#mastectomy-with-immediate-reconstruction)
BREASTQRECP_Q01 | How you look in the mirror clothed? | 0..1 | choice | Enable When: BreastQ_Surgery = Mastectomy with immediate reconstruction (Breast surgery types CodeSystem#mastectomy-with-immediate-reconstruction) Value Set: Satisfaction response ValueSet
BREASTQRECP_Q02 | The shape of your reconstructed breast(s) when you are wearing a bra? | 0..1 | choice | Enable When: BreastQ_Surgery = Mastectomy with immediate reconstruction (Breast surgery types CodeSystem#mastectomy-with-immediate-reconstruction) Value Set: Satisfaction response ValueSet
BREASTQRECP_Q03 | How normal you feel in your clothes? | 0..1 | choice | Enable When: BreastQ_Surgery = Mastectomy with immediate reconstruction (Breast surgery types CodeSystem#mastectomy-with-immediate-reconstruction) Value Set: Satisfaction response ValueSet
BREASTQRECP_Q04 | The size of your reconstructed breast(s)? | 0..1 | choice | Enable When: BreastQ_Surgery = Mastectomy with immediate reconstruction (Breast surgery types CodeSystem#mastectomy-with-immediate-reconstruction) Value Set: Satisfaction response ValueSet
BREASTQRECP_Q05 | Being able to wear clothing that is more fitted? | 0..1 | choice | Enable When: BreastQ_Surgery = Mastectomy with immediate reconstruction (Breast surgery types CodeSystem#mastectomy-with-immediate-reconstruction) Value Set: Satisfaction response ValueSet
BREASTQRECP_Q06 | How your breasts are lined up in relation to each other? | 0..1 | choice | Enable When: BreastQ_Surgery = Mastectomy with immediate reconstruction (Breast surgery types CodeSystem#mastectomy-with-immediate-reconstruction) Value Set: Satisfaction response ValueSet
BREASTQRECP_Q07 | How comfortably your bras fit? | 0..1 | choice | Enable When: BreastQ_Surgery = Mastectomy with immediate reconstruction (Breast surgery types CodeSystem#mastectomy-with-immediate-reconstruction) Value Set: Satisfaction response ValueSet
BREASTQRECP_Q08 | The softness of your reconstructed breast(s)? | 0..1 | choice | Enable When: BreastQ_Surgery = Mastectomy with immediate reconstruction (Breast surgery types CodeSystem#mastectomy-with-immediate-reconstruction) Value Set: Satisfaction response ValueSet
BREASTQRECP_Q09 | How equal in size your breasts are to each other? | 0..1 | choice | Enable When: BreastQ_Surgery = Mastectomy with immediate reconstruction (Breast surgery types CodeSystem#mastectomy-with-immediate-reconstruction) Value Set: Satisfaction response ValueSet
BREASTQRECP_Q10 | How natural your reconstructed breast(s) looks? | 0..1 | choice | Enable When: BreastQ_Surgery = Mastectomy with immediate reconstruction (Breast surgery types CodeSystem#mastectomy-with-immediate-reconstruction) Value Set: Satisfaction response ValueSet
BREASTQRECP_Q11 | How naturally your reconstructed breast(s) sits/hangs? | 0..1 | choice | Enable When: BreastQ_Surgery = Mastectomy with immediate reconstruction (Breast surgery types CodeSystem#mastectomy-with-immediate-reconstruction) Value Set: Satisfaction response ValueSet
BREASTQRECP_Q12 | How your reconstructed breast(s) feel to touch? | 0..1 | choice | Enable When: BreastQ_Surgery = Mastectomy with immediate reconstruction (Breast surgery types CodeSystem#mastectomy-with-immediate-reconstruction) Value Set: Satisfaction response ValueSet
BREASTQRECP_Q13 | How much your reconstructed breast(s) feels like a natural part of your body? | 0..1 | choice | Enable When: BreastQ_Surgery = Mastectomy with immediate reconstruction (Breast surgery types CodeSystem#mastectomy-with-immediate-reconstruction) Value Set: Satisfaction response ValueSet
BREASTQRECP_Q14 | How closely matched (similar) your breasts are to each other? | 0..1 | choice | Enable When: BreastQ_Surgery = Mastectomy with immediate reconstruction (Breast surgery types CodeSystem#mastectomy-with-immediate-reconstruction) Value Set: Satisfaction response ValueSet
BREASTQRECP_Q15 | How your reconstructed breast(s) look now compared to before you had any breast surgery? | 0..1 | choice | Enable When: BreastQ_Surgery = Mastectomy with immediate reconstruction (Breast surgery types CodeSystem#mastectomy-with-immediate-reconstruction) Value Set: Satisfaction response ValueSet
BREASTQRECP_Q16 | How you look in the mirror unclothed? | 0..1 | choice | Enable When: BreastQ_Surgery = Mastectomy with immediate reconstruction (Breast surgery types CodeSystem#mastectomy-with-immediate-reconstruction) Value Set: Satisfaction response ValueSet
Documentation for this format

Option Sets

Answer options for EORTCQLQC30_Q29

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Answer options for EORTCQLQC30_Q30

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