Patient Survival Time Estimation ( exclusively for advanced stages)

Form for Assessing the Survival Duration of a Patient with ADVANCED STAGE Cancer

THE INFORMATION TO BE COMPLETED MAY CONTAIN A HIGH DEGREE OF SUBJECTIVITY

IT WILL BE INTERPRETED BY ARTIFICIAL INTELLIGENCE ALGORITHMS ONLY IN CORRELATION WITH OTHER INVESTIGATIONS PERFORMED AND THE RESPONSE TO THERAPY

WARNING

THE PURPOSE OF COMPLETING THIS FORM IS A SENSITIVE SUBJECT THAT MAY RAISE ETHICAL ISSUES

THE RESULT OF THIS INTERPRETATION CAN PUT GREAT PSYCHOLOGICAL PRESSURE ON THE PATIENT AND THE FAMILY

IF YOU DECIDE TO COMPLETE IT, PLEASE DO NOT RUSH AND CAREFULLY ANALYZE EACH POINT. YOU CAN MAKE ADDITIONS TO EACH POINT IN THE FORM

List of Symptoms for Prognosis Evaluation in Cancer

1. Performance Status and General (Systemic) Symptoms
These reflect the impact of the disease on the entire body and are among the most important predictors of survival.

• Level of physical activity:
• Time spent in bed or in a chair in the last 24 hours (estimate in number of hours)………
• Mobility: whether the patient can walk alone, with support, or if they are bedridden (choose from the options if applicable)………………………………
• Ability to perform work or household activities (describe what type of activity they can perform)…………………………………………….
• Self-care ability and Degree of autonomy: the ability to move, to take care of oneself, the need for help with personal hygiene, dressing, or feeding (describe the option that best matches the patient's condition)…………………………………………………………………………………………..
• Fatigue (Asthenia):
• Energy level assessed on a scale (e.g., 0-10 where 0 means total exhaustion with the patient usually bedridden)………………….
• Nutritional status:
• Loss of appetite (Anorexia) and changes in food consumption: Assessed on a scale from "normal appetite" to "complete absence of appetite" and briefly describe if there are changes in eating habits………………………………………..
• Unintentional weight loss: Number of kilograms lost and the time period (e.g., number of kilograms in the last 3-6 months or another chosen interval) and assess if there is rapid weight loss (in short periods of time, if so, describe briefly)………………………………………..
• General state of well-being:
• The patient's subjective perception of their own health status, rated on a scale of 0-10………….
• Other general (constitutional) symptoms:
• Unexplained fever or persistent low-grade fever: description of the frequency, duration, and intensity of febrile episodes……………………………………………………………………………………..
• Night sweats: Presence and severity of intense sweats that may indicate a systemic response of the body to the disease or complications……………………………………………………………….

2. Pain
Pain is one of the most common and feared symptoms in cancer patients. Its detailed evaluation is crucial (describe for each point if it applies).

• Presence and Intensity: A numerical scale is used (0 = no pain, 10 = the worst imaginable pain)…………
• Location: Identification of painful areas………………………………………………………………………
• Character of the pain: Sharp, dull, burning, stabbing, etc…………………………………………………..
• Impact of the pain: How it affects sleep, activity, mood……………………………………………………
• Periodicity: (persistence or fluctuations in intensity)……………………………………………………….

3. Gastrointestinal Symptoms
(describe for each point if it applies)

• Abdominal pain: Location and intensity of the pain, useful for identifying local complications…………………………………………..
• Nausea: Frequency and intensity, association with meals or other specific conditions………………………………………….
• Vomiting: Frequency……………………………………………….
• Changes in bowel habits: Presence of diarrhea, constipation, or alternation between them………………………………………………..
• Constipation: Frequency of stools, difficulty in passing them…………………………………………..
• Diarrhea: Number and consistency of stools………………………………………………………………..
• Difficulty swallowing (Dysphagia): For liquids, for solids, or both……………………………………………
• Dry mouth (Xerostomia): Whether it is present or not……………..
• Digestive bleeding (hematemesis - vomiting red or dark blood with a "coffee ground" appearance, melena - blood loss through the anus that can range from bright red to black and foul-smelling like "tar")…………………………………………..
• Jaundice (yellowing of the skin and mucous membranes, especially the conjunctivae - the whites of the eyes)………………………………………………………………….
• Bloating and abdominal discomfort: Signs of possible intestinal complications or treatment effects.Specify if the bloating is generalized or localized and if it improves after passing gas through burping or anally. Specify if the patient feels pressure on internal organs or on the skin, which may be tense……………………………………………………..
• Oral feeding capacity: If the patient can swallow solid, semi-solid, or only liquid foods, and if swallowing is due to an obstruction with nasal regurgitation or is a consequence of pain on swallowing (the patient can theoretically swallow but avoids it due to pain)……………………………………………………………….

4. Respiratory Symptoms
(describe for each point if it applies)

• Shortness of breath (Dyspnea):
• Frequency and severity of breathing difficulties, and whether it occurs at rest or only on exertion…………………………………………………
• Rate the intensity of the shortness of breath (if any) on a scale of 0 to 10……………
• Assess if the shortness of breath improves when lying down or when sitting and leaning forward……………………………………………..
• If the shortness of breath improves when lying down, specify if it occurs when the patient is lying on the diseased or healthy side…………………………………………………………….
• Cough: Frequency of episodes, whether it is productive (with sputum or blood) or dry…………………………………………
• Hemoptysis (blood in sputum): whether it is a small amount appearing as streaks of blood or more abundant, and its color (bright red or darker), specify if clots are also present……………………………………
• Chest pain: location (back, front, side), in the (upper or lower) part, whether it is related to breathing, and if it improves when lying on the diseased or healthy side, or if the pain is permanent………………………………………

5. Cardiovascular and Circulatory Symptoms
(describe for each point if it applies)

• Palpitations: Sensation of a rapid or irregular heartbeat, its intensity, and frequency…………………………….
• Peripheral Edema: Presence of swelling, location (lower limbs: ankles, calves, thighs, or inguinal region; or upper limbs: hand, wrist joint, forearm, elbow, arm, or axillary area), and severity……………………………………….
• Chest Pain: specify if there is chest pain (at the sternum or in other regions) and its connection to certain medications, efforts (getting out of bed, eating, etc.), or to generalized pain if it is due to the cancer……………………………………………

6. Psycho-emotional and Cognitive Symptoms (describe for each point if it applies)
These reflect both the impact of the disease on the nervous system and the emotional burden of the diagnosis.

• Emotional state:
• Anxiety: Level of restlessness, worry, or tension - choose which option is closest to reality and quantify on a scale of 0 to 10…………….
• Depression: Presence of sadness, hopelessness, loss of interest in pleasant activities, mood changes, lack of interest in daily activities - choose which option is closest to reality and quantify on a scale of 0 to 10……………..
• Cognitive state: (describe for each point if it applies)
• Somnolence: Level of alertness (the patient is present and participates in conversation), tendency to doze off……………………………………………………………………………….
• Confusion or delirium: Disorientation in time and space, difficulty concentrating…………………………………………………………..
• Insomnia: Difficulties with initiating or maintaining sleep and whether they are related to a specific cause (pain, suffocation, nausea, etc.) or due to "dark" thoughts……………………………………………………………..
• Sleep disturbances: Insomnia or fragmented sleep, or frequent, prolonged, or unrefreshing awakenings……………………………………………………………..
• Social withdrawal: Reduced interest in daily activities and its effects on quality of life, social isolation - choose which option is closest to reality………………………………………………………………..
• Confusion or cognitive alterations: difficulty in understanding, in making decisions, disorientation in time and space - choose which option is closest to reality………………………………………………………………….
• Other Psychological Parameters
• Desire to continue treatments…………………..
• Neurological symptoms:
• Persistent headache: Frequency, intensity, and possible association with other neurological symptoms (numbness, tingling, motor deficit, paresis, paralysis)…………………………………………………..
• Visual or hearing disturbances……………………………………………………………..
• Dizziness and Vertigo: Variations in spatial perception and balance, frequency of episodes………………………………………………………………..
• Confusion (especially in recognizing family members), disorientation in time and/or space (the patient describes being elsewhere and does not recognize objects in the room)…………………………………………………..
• Seizures or Major Neurological Alterations: Onset of seizures, coordination disorders or abnormal perception, visual or auditory hallucinations……………………………………………………………………………
• Muscle weakness, paresis…describe ………………………………………………
• Gait or balance disorders……………………………………………………………………..
• Difficulty concentrating on simple tasks or in understanding dialogue……………………………………….
• Paresthesias: Sensations of numbness, tingling, or burning, which may indicate nerve involvement…………………………………………………………………………

7. Urinary Symptoms: (describe for each point if it applies)

• Hematuria (blood in urine) or abnormal appearance of urine (color, degree of turbidity (cloudy), abnormal smell)……………………………………………..
• Dysuria (difficulty urinating) or burning sensation during urination…………………………………………….
• Urinary incontinence - involuntary loss of urine; specify if the patient feels the urge to urinate but cannot control it, or if they do not feel the urge and lose urine involuntarily, and if these symptoms are associated with back pain in the lumbar region…………………………………………………………………………

8. Other Specific Symptoms (describe for each point if it applies)
These may appear depending on the location of the primary cancer or metastases.

• Edema: Swelling of the legs, hands (described earlier in the form), or other parts of the body………………………………………………..
• Bleeding: Any type of abnormal bleeding (vaginal, rectal, nasal, gingival, spontaneous bruises or from minor trauma)…………………………………………………………………………………….

9. Osteo-articular Symptoms: (describe for each point if it applies)

• Bone pain:
• Temporary: if it worsens with effort (getting out of bed, changing position in bed, walking, or pressing on the sensitive area)…………………………………………………………………….
• Persistent…………………………………………………………………………….
• Periodicity: (is it more intense at night at rest or during the day with movement)………………………………..
• Pathological fractures: if they have occurred recently or if there is a suspicion of their occurrence (sudden pain sometimes accompanied by a sound that may suggest a fracture, immediately followed by an inability to move the affected area)………………………………………………………………………………..

10. Cutaneous (Skin) Symptoms: (describe for each point if it applies)

• New skin lesions or changes in existing lesions or ulcers, wounds that do not heal………………………………………….
• Pruritus (itching): localized or generalized and describe if they are accompanied by other skin changes ……………………………………………………………………….
• Peripheral edema: swelling of the extremities where pressing for 7-10 seconds leaves a persistent pit (indentation)…………………………………………………………….
• Changes in the appearance of a region (swelling, nodules, redness, local heat, etc.)………………………………………………………………..
• Band-like skin rash accompanied by clear fluid-filled vesicles, preceded by severe pain in the respective area and accompanied by severe itching, and specify if it appeared after a treatment or not………………………………………………………………………………………..
• Pressure sores (bedsores) that have appeared as a result of prolonged bed immobilization and as a result of the body's weakening (the most common pressure sores appear in the lumbar and sacral regions, as well as on the back of the heels)……………………………………………………………………………………….

11. Other Relevant Signs and Symptoms: (describe for each point if it applies)

• Ascites (fluid in the abdomen associated with an increase in its volume and a sensation of pressure in the upper area, especially during meals); specify how much discomfort it causes the patient and estimate the volume (if the navel (belly button) is pushed outwards or the skin of the abdomen is tense and shiny)………………………………………………………………………………………………………
• Generalized edema (several combined regions: face, neck, upper or lower limbs, lower abdomen (inguinal area) or, in men, at the level of the testicles and scrotum)………………………………………………….
• Lymphadenopathy (enlarged lymph nodes) in the inguinal, axillary, lateral neck, or submandibular regions…………………………………………………………………………
• Signs of recurrent infection ;fever, chills…………………………………………………………
• Painful and red oral mucosa, ulcerations on the lips or corners of the mouth, canker sores or white lesions on the tongue, gums, or inside of the cheek; describe what you observe if present……………………………………………………
• Hematologic and Metabolic Symptoms
• Signs of anemia: Pallor, irregular heartbeat, or a feeling of extreme fatigue, which can be correlated with low hemoglobin levels……………………………………………………………………………
• Metabolic imbalances: Changes in energy metabolism and fluid-electrolyte balance, which can affect the patient's overall condition………………………………………………………………..

12. Endocrine and Metabolic Symptoms (describe for each point if it applies)

• Symptoms of Endocrine Dysfunction:
• Hot Flashes or Excessive Sweating: Common in certain types of cancer (e.g., breast cancer)…………………………………….
• Metabolic Changes: Sudden changes that can influence weight or energy…………………………………………………………………….

13…Side Effects of Treatment: (describe for each point if it applies)

• Chemotherapy-Induced Neuropathy: Numbness or abnormal sensations in the limbs (assess if the numbness is more intense in the hands and if it is associated with discomfort when touching cold objects (for example, taking a product out of the refrigerator))……………………………………………………………………………
• Digestive or Hematological Problems: occurring as a result of cancer treatment ………………………………………………………………………………

14. Nutritional and Hydration Status (describe for each point if it applies)

• Patient's current weight and height and weight before the onset of cancer (how much weight the patient has lost from their initial weight)………………………………………………………………….
• Level of food and fluid intake: includes the frequency and quantity of meals and fluids consumed (how many meals per day and the approximate amount of food compared to a person without cancer)……………………………………………………………………….

OTHER SUBJECTIVELY ASSESSED PARAMETERS (try to appreciate and describe in your own words what you think)

• Evolution of symptoms over time: Monitoring changes in intensity and frequency to assess the speed of disease progression and response to treatment. ……………………………………………………………………………………………….
• Response to treatment: Possible improvement or worsening of symptoms following therapeutic interventions, an important prognostic indicator…………………………………………………………………………………………………
• Correlation of Symptoms with Treatment: It is useful to mention whether the symptoms are attributed to the natural evolution of the disease or may be side effects of the oncological treatment……………………………………………………………………………………………

IF THERE ARE OTHER SYMPTOMS NOT INCLUDED IN THIS FORM, PLEASE NOTE THEM DOWN