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Ovarian Cancer Registry
,WIRB® Protocol #20131983
The Department of Obstetrics and Gynecology at Inova Fairfax Hospital and the Gynecologic Cancer Center of Excellence (GYN-COE)
CONSENT FORM VERSION DATE:
G. Larry Maxwell, MD, Chair, Department of OB/GYN, Inova Fairfax Hospital, Falls Church, VA 22042, 703-776-6040;
Co-Director GYN-COE, 3289 Woodburn Rd, Suites 370, 375 and 390, Annandale, VA 22003
Website: https://www.endgyncancer.com Email: OCR@endgyncancer.com
Phone: (703) 785-3250
Fax: (703) 940-1390
This is a web-based Registry focused on Ovarian Cancer. The Registry is a clinical study that will recruit women with a history of ovarian, peritoneal, or tubal cancer to join and contribute data to support research. Participation in the Registry is completely voluntary and will not influence your medical care. You will be free to decide what you want to contribute to the Registry for research, and you will be able to change any of your decisions regarding research or withdraw from the Registry at any time.
Because this is a clinical study, each woman who joins the Registry will need to complete an online consent process. This can be done by reading or listening to an audio clip for this consent document, viewing a consent video, and electronically signing this consent. Because this is a web-based Registry, all of these steps are performed online. Select the Schedule an Appointment link to talk with a Registry Technician if you have questions about the Registry. Thank you for taking the time to learn about the Ovarian Cancer Registry. Let us know if you are interested in joining the circle to break the cycle. Working together we hope to pay it forward and put an end to GYN cancer.
This Registry is being established to support high quality research and make rapid advances that benefit women who develop ovarian, peritoneal or tubal cancer. Women with a history of ovarian, peritoneal or tubal cancer are eligible to join the Registry and contribute data to support research. Research performed using data from patients with the disease or condition of interest are the most likely to yield clinically meaningful results. We anticipate that up to 20,000 women will enroll in this Registry.
At present, these cancers are typically diagnosed at an advanced stage and often have a high disease burden. Data from women with invasive ovarian, peritoneal or tubal cancer are critically needed to support research studies with the following ultimate goals:
As data are used to support research, results will be published and used to support additional research studies. As knowledge and advances in science, medicine and technology continue to evolve, the Registry will be able to continue to make advances that benefit patients and society.
You are being asked to join the Registry if you have a history of invasive ovarian, peritoneal or tubal cancer, are at least 18 years old, and are able to make your own decisions.
You are not likely to directly benefit from contributing data to support research. We hope this study will benefit women in the future.
If you consent to being a part of the Ovarian Cancer Registry, you will become a Member of the Registry, create an account, and be given opportunities to contribute data and medical reports about you and your cancer to support research. You decide what you do and do not want to contribute for research and whether you want to be contacted about other research opportunities you qualify for. These other studies are optional and voluntary and may include special Registry sub-studies or independent companion research studies.
Registration Includes the Following Activities:
Participation in the Registry includes the following Activities:
If you choose to complete the consent process and become a Member of the Registry, you may complete any of the following forms to support the Registry and advance ovarian cancer research.
The main risk of contributing data to the Registry is the loss of privacy and confidentiality. The Registry utilizes all available steps and procedures to safeguard your privacy and confidentiality. While we believe that the risk to you is very low, we cannot tell you that there aren’t any risks. The Registry protects your privacy and confidentiality by limiting the amount of personal information that we request from you to your name, email, date of birth, phone number, city, state, zip code, country and dates such as dates of diagnosis, cancer surgeries and cancer evaluations. We do not ask you for your social security number or any account numbers.
Your personal information will be used to operate the Registry and will never be given to Researchers. Researchers will only be given access to coded de-identified data from the Registry.
To further advance ovarian cancer research, the Registry will partner with approved investigators on special Registry sub-studies and/or independent companion research projects. Members of the Registry who satisfy the eligibility criteria for these optional studies may be recruited to participate. If you are contacted about one of these special optional research studies and wish to learn more, you will be instructed to view promotion materials including brochures, webpages and/or videos about the research project. You will be required to complete a separate informed consent process should you wish to participate in any of these optional research studies. Your decision to participate in any optional research projects will not affect your care in any way and will not impact your participation in the Registry.
There is a potential cost to you in contributing data to the Registry for research. This is only a potential cost because some hospitals and doctors charge a fee to get copies of medical reports, you can either pay the fee or request that Registry attempt to secure funding to pay the fee. You will not be sent compensation directly to pay any fees associated with obtaining copies of medical reports and/or records. Please send an email with the amount of the fee, and to whom the fee needs to be paid to OCR@endgyncancer.com.
You will not be compensated for your participation in the study. Research done with your data may help to develop new products, tests and therapies in the future that could be patented and licensed. There are no plans to provide you or your family with any direct financial compensation or other benefits.
This is not a treatment study. If you are seeking treatment for your cancer, please contact your doctor to obtain a referral to a qualified health care professional to get treatment. Your alternative is to not take part in the research.
The Registry uses a secure website and online forms to collect information about you and your cancer to operate the Registry and for research. Some of the forms will collect personal identifiers that are necessary to operate the Registry, but these identifiers will never be shared with any Investigators doing research. The data that will be used for research will be stored in a secure coded electronic research record. If you choose to submit any medical reports, they can be securely emailed to the Registry at OCR@endgyncancer.com or via a secure encrypted eFax account at (703) 940-1390. Trained Registry staff assigned by the Principal Investigator will be responsible for the following:
Portions of your data may be viewed by or given to the U.S. Food and Drug Administration (FDA), Department of Health and Human Services (DHHS) agencies, the Western Institutional Review Board® (WIRB®) or other Institutional Review Boards, Inova Health System, Gynecologic Cancer Center of Excellence, the Henry M. Jackson Foundation for the Advancement of Military Medicine, the Uniformed Services University, Spark Media, Dataprise, and other Sponsors. Total confidentiality cannot be guaranteed because of the potential need to give information to these parties, but procedures and safeguards are in place to make this risk as small as possible. Individuals who work for these organizations are all required to keep patient data private and confidential, and to only use the data ethically for approved reasons.
Information about the Registry and results from research conducted using data from the Registry will be presented at meetings and in publications. Your protected health information will not be given to researchers and will not be included in any presentations or publications
You will be able to participate in the Ovarian Cancer Registry indefinitely, or as long as funding is available to continue to operate the Registry. You can change your mind about the use of your data or decided to stop being part of the Registry at any time by completing the online Change Your Consent Form and/or the Registry Withdrawal Form on the website.
This study is being funded by the Department of Obstetrics and Gynecology at Inova Fairfax Hospital, the Inova Research Foundation, and the Gynecologic Cancer Center of Excellence (GYN-COE).
You can use the online appointment scheduler on the website to schedule an appointment to talk to someone about the Registry and get answers to your
questions, concerns, or complaints about the research, or if you feel you have experienced a research-related harm. If you have questions about your rights as a research subject or if you have questions, concerns or complaints about this study, or if you want to talk to someone not on the research team about the research, you may contact the
Western Institutional Review Board® (WIRB®) at 1019 39th Avenue SE Suite 120, Puyallup, Washington 98374-2115, by calling 1-800-562-4789 or 360‑252‑2500,
or by sending an email to Help@wirb.com. WIRB is an organization of people who independently review research.
If you are interested in becoming a Member of the Ovarian Cancer Registry, please answer the two questions below and then click the following link to complete the consent process. You will be asked to electronically sign and date this consent after the attest statement, and then to create a Member account to login to the internal website for Members of the Registry.
Thank you for taking time to read this consent and to learn about the Ovarian Cancer Registry.
By providing your name, today’s date and your electronic signature you attest (confirm) that (1) you understand that participation in the Registry is voluntary and will not change your medical care, (2) you are free to decide what you contribute to the Registry for research, and (3) you can withdraw from the Registry at any time.
Although having an email is not required, if you wish to obtain one, please click here to make a Gmail account.