Progress Notes Details in Cancer Treatment
The patient's progress notes contain detailed information about cancer treatment response assessment, including imaging findings, disease progression indicators, and patient-reported outcomes that guide clinical decision-making.
Imaging Assessment Documentation
- Progress notes document changes in tumor measurements using RECIST 1.1 criteria, with special attention to lesions ≥1.0 cm in longest dimension for visceral disease and ≥1.5 cm in short axis for nodal disease 1
- Notes include waterfall plots to visually represent changes in tumor size over time, with complete elimination of disease at any site recorded separately 1
- Lymph node assessments are documented separately for pelvic (regional) nodes versus extrapelvic (distant/metastatic) nodes 1
Disease Progression Documentation
- Progress notes record the date of disease progression, defined as the date of the scan that first documents new lesions 1
- For bone lesions, the "2+2 rule" is applied - at least two new lesions on first post-treatment scan, with at least two additional lesions on the next scan to confirm progression 1
- Notes specifically mention that changes in intensity of uptake alone do not constitute progression or regression 1
- Documentation includes the proportion of patients who have not progressed at fixed time intervals (6 and 12 months) 1
Treatment Response Assessment
- Progress notes contain documentation of treatment efficacy using standardized criteria, with response defined as improved or stable (no new lesions) or worse (new lesions) 1
- For patients treated beyond initial progression, notes record whether subsequent scans confirmed true progression or pseudo-progression 1
- Documentation includes the median duration patients were treated beyond initial progression before treatment was discontinued 1
- Notes record any new toxicities that arose or existing toxicities that worsened while patients were treated beyond initial progression 1
Patient-Reported Outcomes
- Progress notes include patient-reported outcomes (PROs) that capture symptoms, treatment side effects, and quality of life measures 1
- Documentation shows whether patients experienced clinically meaningful pain at baseline (e.g., ≥4 on a 10-point pain intensity scale) and response to treatment (e.g., 30% relative or 2-point absolute improvement) 1
- Notes record serial assessments of global changes in health-related quality of life, urinary or bowel compromise, pain management, and additional anticancer therapy 1
- Documentation includes whether PRO alerts triggered unscheduled visits or interventions for symptom management 1
Follow-up Planning
- Progress notes document the follow-up schedule, typically including interim history and physical examinations every 3-6 months for 1-2 years, then every 6-12 months until year 3, then annually 1
- Notes include laboratory studies ordered, such as CBC, platelets, ESR (if elevated at time of initial diagnosis), and chemistry profiles 1
- Documentation shows whether imaging studies were ordered, such as CT scans at 6,12, and 24 months following completion of therapy 1
- For patients who completed treatment, notes indicate whether PET/CT was ordered only if the last PET was Deauville 4-5, to confirm complete response 1
Toxicity Management
- Progress notes document immune-related adverse events with their onset, duration, and management strategies 1
- Notes specify whether toxicities required corticosteroids or other immunosuppressive agents such as mycophenolate mofetil and tumor necrosis factor-alpha antagonists 1
- Documentation includes whether toxicities led to treatment modifications, delays, or discontinuations 1
- For patients receiving maintenance therapy, notes record whether treatment was continued until disease progression or unacceptable toxicity 1