Global Treatment Adherence Survey

Cancer Academy Global Treatment Adherence Survey

author: Darryl Mitteldorf, LCSW

Build notes. Use this survey for patients who can report on the past 30 days. Put all seven items on one page. Make every item required. This is a brief custom questionnaire. Use chart or appointment data when possible.

Field name	Type	Exact question text	Response setup
overall_follow_plan	Opinion Scale	In the past 30 days, how closely did you follow your cancer treatment plan?	0 to 10; left: Not at all; right: Completely
oral_missed	Multiple Choice	In the past 30 days, how often did you miss or skip a cancer medicine you were supposed to take at home? Do not count doses your cancer team told you to hold.	Never; 1 time; 2 to 3 times; 4 or more times; I did not take cancer medicine at home
injection_missed	Multiple Choice	In the past 30 days, did you miss or delay any planned cancer injection or shot visit, not counting changes planned by your cancer care team?	No; Yes, once; Yes, more than once; I did not receive injections or shots
radiation_missed	Multiple Choice	In the past 30 days, did you miss, delay, or stop any planned radiation treatment, not counting changes planned by your cancer care team?	No; Yes, one treatment; Yes, more than one treatment; Yes, I stopped before finishing; I did not receive radiation
infusion_missed	Multiple Choice	In the past 30 days, did you miss, delay, or stop any planned immunotherapy or IV infusion treatment, not counting changes planned by your cancer care team?	No; Yes, one treatment; Yes, more than one treatment; Yes, I stopped before finishing; I did not receive immunotherapy or IV treatment
main_reason	Multiple Choice	If you missed, delayed, or stopped any treatment, what was the main reason?	I did not miss or delay any treatment; Side effects or feeling sick; Forgot; Transportation; Cost or insurance; Scheduling problem; Work or family duties; Felt overwhelmed or upset; My cancer team told me to hold or delay treatment; Other
help_needed	Multiple Choice	Would you like help with anything that makes treatment harder to complete?	Yes; No

Optional hidden fields
respondent_id, source, visit_date, cancer_type

End screen text
Thank you. Your answers help us improve support for patients during treatment.

Scoring rule. Primary outcome is all-applicable-treatment adherence. A response is fully adherent when each applicable treatment item shows no missed, skipped, or delayed care. Secondary readouts are mean overall_follow_plan, percent requesting help, and main reasons for missed or delayed care. Review any row where the main reason says the cancer team told the patient to hold or delay treatment.