PATIENT(Form1)PatientID:_____________________________________Methodofidentification__________________________Age:____________(years)Sex:M/F/UnknownBMI:_____________Weightloss≥10%:_____________Performancestatus: 0/1/2/3/4/UnknownASA: 1/2/3/4/5/UnknownSmoking:No,never/Stopped>6wks/Yes/UnknownDiabetes:No/Diet/Medication/Insulin/UnknownHIVtested: No/Yes,Negative/Yes,PositivePresentation:Symptomatic/Screening/Incidentally/UnknownDateoffirstconsult:____/____/____(DD/MM/YY)Whodidthepatientfirstconsult?_____________________________________________Distancefromhometohospital:_______________km

DISEASE&NEOADJUVANTTREATMENT(Form2)

Cancertype(circle): Breast/Gastric/ColorectalSTAGINGAllpatientsUltrasoundscan: 0/1/2/3/9CT: 0/1/2/3/9MRI: 0/1/2/3/9GastricorColorectalcanceronlyEndoscopy/colonoscopy: 0/1/2/3/9Endoscopy/colonoscopybiopsy: 0/1/2/3/9Endoscopic/transanalultrasound 0/1/2/3/9Staginglaparoscopy: 0/1/2/3/9BreastcanceronlyMammogram: 0/1/2/3/9Fineneedleaspiration: 0/1/2/3/9Corebiopsy: 0/1/2/3/9Openbiopsy: 0/1/2/3/9Receptorstatusonpre-opbiopsy:ER: 0/1/2/3/9PR: 0/1/2/3/9 HER2: 0/1/2/3/9 Ki-67: 0/1/2/3/9 AllpatientsClinicalTNM:T1/T2/T3/T4|N0/N1/N2/N3|M0/M1EssentialTNM(Gastric/Colon):M+/R+/A/LEssentialTNM(Breast): M+/R2/R1/A/L2/L1Neoadjuvanttherapy:_____________________________

GlobalSurg3:Qualityandoutcomesinglobalcancersurgery

ShortDataCollectionForm

globalsurg.org/gs3

PLEASECOMPLETETHISFORMWITHTHEDATADICTIONARYFORREFERENCE

OPERATION(Form3)Admissiondate:____/____/____(DD/MM/YY)____:____(24H)Knifetoskin:____/____/____(DD/MM/YY)____:____(24H)Urgency: Elective/EmergencyIntentofoperation: Palliative/CurativeChecklistused?:

No,notavailable/No,available/Yes/UnknownPrimaryoperation:_______________________________BreastcanceronlySentinellymphnodebiopsy:_______________________Axillarylymphnodedissection:_____________________Resectionmarginscheckedatsurgery:_______________Reconstruction:_________________________________GastricorColorectalcanceronlyOperativeapproach:_____________________________Site:__________________________________________Anastomosis:___________________________________Obstruction:____________Perforation:_____________GastriccanceronlyD2lymphadenectomy:____________________________ColorectalcanceronlyStomaformed:(ifyes,whattype)___________________

0.No,notavailableinthishospital1.No,notindicated2.No,indicatedandavailable,butpatientnotabletopay3.Yes9.Unknown

0.No,notavailableinthishospital1.No,butavailableinthishospital2.Yes,NEGATIVEresult3.Yes,POSTIIVEresult9.Unknown

Notetousers:Thisformispatient-identifiableinformationandshouldbekeptinasecurelocation,thendestroyedappropriatelyoncedatauploadedontoREDCap

PATHOLOGY(Form4)AllpatientsMostvalidbasisforcancerdiagnosis:_______________________________________________Histology:______________________________________Sizeofinvasivetumour:_________________________cmPathologicalTstage(pT):T1/T2/T3/T4(a/b/c/d)/TisLymphnodesPathologicalNstage(pN):N0/N1/N2NumberINVOLVEDinspecimen:____________________TOTALnumberinspecimen:_______________________Histologicalgrade: 1/2/3/4Lymphaticorvascularinvasion:No/Yes/UnknownGastricorColorectalcanceronlyResectionmargin: R0/R1/R2ColorectalcanceronlyPerineuralinvasion: No/Yes/UnknownCircumferentialresectionmargin:_______________mmBreastcanceronlyMargin:_______________________________________Receptorstatusonpathologicalspecimen:ER: 0/1/2/3/9PR: 0/1/2/3/9 Ki-67: 0/1/2/3/9BreastandgastriccanceronlyHER2: 0/1/2/3/9

OUTCOMES&ADJUVANTTREATMENT(Form5)

FOLLOW-UPLengthofstay:_________days(firstdayaftersurgery=1)30-dayfollow-upmethod:________________________30-daymortality: Alive/Died/UnknownDateofdeath:______/______/_______(DD/MM/YY)COMPLICATIONSMinorcomplication(CD1):No/Yes/UnknownMinorcomplication(CD2):No/Yes/UnknownReintervention(unplanned)(CD3):No/Yes(noGA)/Yes(GA)/UnknownCriticalcareadmission(unplanned)(CD4):No/Yes(singleorgan)/Yes(multiorgan)/UnknownHospitalre-admission(unplanned):No/Yes/UnknownSPECIFICCOMPLICATIONSSSI: 0/1/2/3/4/5/9Post-opbleed:

0/1/2/3/4/5/9BreastcanceronlyPost-opseroma:

0/1/2/3/4/5/9GastricorColorectalcanceronlyAnastomoticleak: 0/1/2/3/4/5/9Intra-abdominalabscess: 0/1/2/3/4/5/9

AllpatientsAdjuvanttreatmentplanned:______________________

NotesDonotuse“Unknown”,pleasefindout!MostvalidbasisofcancerdiagnosisClinicalonlyImagingExploratorysurgery/endoscopynohistologyTumourspecificmarkersCytologyHistologyofmetastasis/secondaryHistologyofprimary/biopsyEssentialTNMBreast Gastric/Colorectal

0.No,notavailableinthishospital1.No,butavailableinthishospital2.Yes,NEGATIVEresult3.Yes,POSTIIVEresult9.Unknown

0,No1,Yes,ClavienDindo12,Yes,ClavienDindo23,Yes,ClavienDindo34,Yes,ClavienDindo45,Yes,ClavienDindo59,Unknown

BMI:Weight(kg)/height2(metres)Underweight(BMI<18.5)Normalweight(BMI18.5to24.9)Overweight(BMI25to30)Obese(BMI>30)

Performancestatus0,Fullyactive1,Restrictedinstrenuousactivityonly2,Ambulatory&capableofallselfcare3,Capableofonlylimitedselfcare4,Completelydisabled9,Unknown

ASA1,normal/healthy2,mildsystemicdisease3,severesystemicdisease4,severesystemicdisease,constantthreattolife5,notexpectedtosurvivewithouttheoperation9,Unknown

Whodidpatientfirstconsult?Localclinic:familydoctorLocalclinic:nurseLocalclinic:specialistdoctorHospital:out-patientclinicHospital:in-patientOther/nonmedicalhealerUnknown

30-dayfollow-upmethodStillinpatientClinicreviewTelephonereviewCommunity/homereviewDischargedbefore30daysandnotcontactedagain

Notetousers:Thisformispatient-identifiableinformationandshouldbekeptinasecurelocation,thendestroyedappropriatelyoncedatauploadedontoREDCap