ID

6920

Beskrivning

Metastatic Bladder/Urothelial Cancer - On-Study Form Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=99CD59C5-A95B-3FA4-E034-080020C9C0E0

Länk

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=99CD59C5-A95B-3FA4-E034-080020C9C0E0

Nyckelord

Versioner (2)
  1. 2012-09-19 2012-09-19 -
  2. 2015-01-08 2015-01-08 - Martin Dugas
Uppladdad den

8 januari 2015

DOI

För en begäran logga in.

Licens

Creative Commons BY-NC 3.0 Legacy
Modellkommentarer :

Här kan du kommentera modellen. Med hjälp av pratbubblor i Item-grupperna och Item kan du lägga in specifika kommentarer.

Tillbaka till modellkommentarer
Itemgroup-kommentar för :

Item-kommentar för :

Du måste vara inloggad för att kunna ladda ner formulär. Var vänlig logga in eller registrera dig utan kostnad.

On-Study - Metastatic Bladder/Urothelial Cancer - On-Study Form - 2019330v2.31

Engelsk

No Instruction available.

1 Formulär  
  1. StudyEvent: Metastatic Bladder/Urothelial Cancer - On-Study Form
    1. No Instruction available.
Crf Header
Beskrivning

Crf Header

Coordinating Group Protocol Number
Beskrivning

CoordinatingGroupProtocolNumber

Datatyp

text

Coordinating Group Code
Beskrivning

CoordinatingGroupCode

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
Protocol Title
Beskrivning

Protocol Title

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C25320
UMLS CUI-1
C2986303
NCI Thesaurus Property
C42774
Patient Study ID, Coordinating Group
Beskrivning

PatientStudyID,CoordinatingGroup

Datatyp

text

Patient Study ID, Participating Group
Beskrivning

PatientStudyID,ParticipatingGroup

Datatyp

text

Participating Group Code
Beskrivning

ParticipatingGroupCode

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
Institution Name
Beskrivning

InstitutionName

Datatyp

text

Affiliate Name
Beskrivning

AffiliateName

Datatyp

text

Patient Name, Last
Beskrivning

PatientName,Last

Datatyp

text

Patient Name, First
Beskrivning

PatientName,First

Datatyp

text

Patient Name, Middle
Beskrivning

PatientName,Middle

Datatyp

text

Bladder/urothelial: Form Administration
Beskrivning

Bladder/urothelial: Form Administration

Person Completing Form, Last Name
Beskrivning

PersonCompletingForm,LastName

Datatyp

text

Person Completing Form, First Name
Beskrivning

PersonCompletingForm,FirstName

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Amended Data Ind
Beskrivning

AmendedDataInd

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Bladder/urothelial: Disease Description For Metastatic Bladder/urothelial Cancer
Beskrivning

Bladder/urothelial: Disease Description For Metastatic Bladder/urothelial Cancer

Prior Muscle Invasive Disease Ind
Beskrivning

PriorMuscleInvasiveDiseaseInd

Datatyp

text

Bladder Tumor Location
Beskrivning

BladderTumorLocation

Datatyp

text

Initial Diagnosis Date, Pathologic
Beskrivning

InitialDiagnosisDate,Pathologic

Datatyp

date

Initial Diagnosis Date, Locally Advanced
Beskrivning

InitialDiagnosisDate,LocallyAdvanced

Datatyp

date

Initial Diagnosis Date, Metastatic
Beskrivning

InitialDiagnosisDate,Metastatic

Datatyp

date

Bladder/urothelial: Site(s) Of Disease
Beskrivning

Bladder/urothelial: Site(s) Of Disease

Progression Site, Adjacent Structures
Beskrivning

ProgressionSite,AdjacentStructures

Datatyp

text

Progression Site, Local-Regional Nodes
Beskrivning

ProgressionSite,Local-RegionalNodes

Datatyp

text

Progression Site, Other
Beskrivning

ProgressionSite,Other

Datatyp

text

Progression Site, Other
Beskrivning

ProgressionSite,Other

Datatyp

text

Metastatic Site
Beskrivning

MetastaticSite

Datatyp

text

Metastatic Site, Other
Beskrivning

MetastaticSite,Other

Datatyp

text

Metastatic Site, Other
Beskrivning

MetastaticSite,Other

Datatyp

text

Lymph Nodes, Distant Location
Beskrivning

LymphNodes,DistantLocation

Datatyp

text

Bladder/urothelial: Prior Treatment Affecting The Bladder/urothelium
Beskrivning

Bladder/urothelial: Prior Treatment Affecting The Bladder/urothelium

Prior Intravesical Therapy Ind
Beskrivning

PriorIntravesicalTherapyInd

Datatyp

text

Prior Immunotherapy Type
Beskrivning

PriorImmunotherapyType

Datatyp

text

Prior Immunotherapy Count
Beskrivning

PriorImmunotherapyCount

Datatyp

float

Prior Immunotherapy Other Agent
Beskrivning

PriorImmunotherapyOtherAgent

Datatyp

text

Prior Intravesical Chemotherapy Type
Beskrivning

PriorIntravesicalChemotherapyType

Datatyp

text

Prior Intravesical Chemotherapy Count
Beskrivning

PriorIntravesicalChemotherapyCount

Datatyp

float

Prior Intravesical Chemotherapy Other Agent
Beskrivning

PriorIntravesicalChemotherapyOtherAgent

Datatyp

text

Prior Chemotherapy Ind
Beskrivning

PriorChemotherapyInd

Datatyp

text

Prior Neoadjuvant Chemotherapy Ind
Beskrivning

PriorNeoadjuvantChemotherapyInd

Datatyp

text

Prior Neoadjuvant Chemotherapy Type
Beskrivning

PriorNeoadjuvantChemotherapyType

Datatyp

text

Prior Neoadjuvant Chemotherapy Count
Beskrivning

PriorNeoadjuvantChemotherapyCount

Datatyp

float

Prior Neoadjuvant Chemotherapy Other Type
Beskrivning

PriorNeoadjuvantChemotherapyOtherType

Datatyp

text

Prior Adjuvant Chemotherapy Ind
Beskrivning

PriorAdjuvantChemotherapyInd

Datatyp

text

Prior Adjuvant Chemotherapy Type
Beskrivning

PriorAdjuvantChemotherapyType

Datatyp

text

Prior Adjuvant Chemotherapy Count
Beskrivning

PriorAdjuvantChemotherapyCount

Datatyp

float

Prior Adjuvant Chemotherapy Other Agent
Beskrivning

PriorAdjuvantChemotherapyOtherAgent

Datatyp

text

Prior Chemotherapy Ind, Metastatic
Beskrivning

PriorChemotherapyInd,Metastatic

Datatyp

text

Prior Metastatic Chemotherapy Type
Beskrivning

PriorMetastaticChemotherapyType

Datatyp

text

Prior Metastatic Chemotherapy Count
Beskrivning

PriorMetastaticChemotherapyCount

Datatyp

float

Prior Metastatic Chemotherapy Other Agent
Beskrivning

PriorMetastaticChemotherapyOtherAgent

Datatyp

text

Prior Pelvic RT Ind
Beskrivning

PriorPelvicRTInd

Datatyp

text

Prior Surgery Ind
Beskrivning

PriorSurgeryInd

Datatyp

text

Prior Surgery Type
Beskrivning

PriorSurgeryType

Datatyp

text

Prior Surgery, TURBT Count
Beskrivning

PriorSurgery,TURBTCount

Datatyp

float

Prior Surgery, Other Type
Beskrivning

PriorSurgery,OtherType

Datatyp

text

Prior Other Therapy Ind
Beskrivning

PriorOtherTherapyInd

Datatyp

text

Prior Other Therapy Name
Beskrivning

PriorOtherTherapyName

Datatyp

text

Allows Documentation Of Any Additional Cooments
Beskrivning

Allows Documentation Of Any Additional Cooments

Comments
Beskrivning

Comments

Datatyp

text

Tillbaka till toppen

Similar models

No Instruction available.

1 Formulär
  1. StudyEvent: Metastatic Bladder/Urothelial Cancer - On-Study Form
    1. No Instruction available.
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Item Group
Crf Header
CoordinatingGroupProtocolNumber
Item
Coordinating Group Protocol Number
text
CoordinatingGroupCode
Item
Coordinating Group Code
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
Protocol Title
Item
Protocol Title
text
C25320 (NCI Thesaurus ObjectClass)
C2986303 (UMLS CUI-1)
C42774 (NCI Thesaurus Property)
PatientStudyID,CoordinatingGroup
Item
Patient Study ID, Coordinating Group
text
PatientStudyID,ParticipatingGroup
Item
Patient Study ID, Participating Group
text
ParticipatingGroupCode
Item
Participating Group Code
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
InstitutionName
Item
Institution Name
text
AffiliateName
Item
Affiliate Name
text
PatientName,Last
Item
Patient Name, Last
text
PatientName,First
Item
Patient Name, First
text
PatientName,Middle
Item
Patient Name, Middle
text
Item Group
Bladder/urothelial: Form Administration
PersonCompletingForm,LastName
Item
Person Completing Form, Last Name
text
PersonCompletingForm,FirstName
Item
Person Completing Form, First Name
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
Item
Amended Data Ind
text
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
CL.1
Code List
Amended Data Ind
CL Item
Yes (YES)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (UNKNOWN)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
No (NO)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Item Group
Bladder/urothelial: Disease Description For Metastatic Bladder/urothelial Cancer
Item
Prior Muscle Invasive Disease Ind
text
CL.2
Code List
Prior Muscle Invasive Disease Ind
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Bladder Tumor Location
text
CL.3
Code List
Bladder Tumor Location
CL Item
The Location Of The Bladder Tumor Is In The Bladder (bladder)
CL Item
The Location Of The Bladder Tumor Is In The Prostate (prostate)
CL Item
The Location Of The Bladder Tumor Is In The Urethra (urethra)
CL Item
The Location Of The Bladder Tumor Is In The Ureter (ureter)
CL Item
The Location Of The Bladder Tumor Is In The Renal Pelvis (renal pelvis)
InitialDiagnosisDate,Pathologic
Item
Initial Diagnosis Date, Pathologic
date
InitialDiagnosisDate,LocallyAdvanced
Item
Initial Diagnosis Date, Locally Advanced
date
InitialDiagnosisDate,Metastatic
Item
Initial Diagnosis Date, Metastatic
date
Item Group
Bladder/urothelial: Site(s) Of Disease
Item
Progression Site, Adjacent Structures
text
CL.4
Code List
Progression Site, Adjacent Structures
CL Item
Primary Cancer Has Spread Adjacently Into The Abdominal Wall (abdominal wall)
CL Item
Primary Cancer Has Not Spread To Any Adjacent Structures (none)
CL Item
Primary Cancer Has Spread Adjacently Into Other Structures, Specify (other, specify)
CL Item
Primary Cancer Has Spread Adjacently Into The Pelvic Wall (pelvic wall)
CL Item
Primary Cancer Has Spread Into The Vagina (vagina)
CL Item
Primary Cancer Has Spread Into The Prostate (prostate)
CL Item
Primary Cancer Has Spread Into The Skin Or Subcutaneous Tissue Near To The Bladder (skin)
CL Item
Primary Cancer Has Spread Into The Urethra (urethra)
CL Item
Primary Cancer Has Spread Into The Uterus (uterus)
CL Item
Primary Cancer Has Spread Adjacently Into Peritoneal Tissue (peritoneum)
Item
Progression Site, Local-Regional Nodes
text
CL.5
Code List
Progression Site, Local-Regional Nodes
CL Item
Primary Cancer Has Spread To The Common Iliac Lymph Nodes (common iliac)
CL Item
Primary Cancer Has Spread To The External Iliac Lymph Nodes (external iliac)
CL Item
Primary Cancer Has Spread To The Hypogastric Lymph Nodes (hypogastric)
CL Item
Primary Cancer Has Spread To The Para-aortic Lymph Nodes (para-aortic)
CL Item
Primary Cancer Has Not Spread To Any Local-regional Lymph Nodes (none)
CL Item
Primary Cancer Has Spread To Other Local-regional Lymph Nodes, Specify (other, specify)
CL Item
Primary Cancer Has Spread To The Internal Iliac Lymph Nodes (internal iliac)
ProgressionSite,Other
Item
Progression Site, Other
text
ProgressionSite,Other
Item
Progression Site, Other
text
Item
Metastatic Site
text
CL.6
Code List
Metastatic Site
CL Item
Bone (Bone)
C12366 (NCI Thesaurus)
C0262950 (UMLS 2011AA)
CL Item
Bone Marrow (Bone marrow)
C12431 (NCI Thesaurus)
C0005953 (UMLS 2011AA)
CL Item
Brain (Brain)
CL Item
Distant Nodes (Distant nodes)
CL Item
Distant Skin/subcutaneous Tissue (Distant skin/subcutaneous tissue)
CL Item
First Other, Specify (First Other, specify)
CL Item
Second Other, Specify (Second Other, specify)
CL Item
Liver (Liver)
C12392 (NCI Thesaurus)
C0023884 (UMLS 2011AA)
CL Item
Lung (Lung)
C12468 (NCI Thesaurus)
C0024109 (UMLS 2011AA)
CL Item
Opposite Breast (Opposite breast)
CL Item
Other Cns (Other CNS)
CL Item
Pleura (Pleura)
CL Item
Ipsilateral Supraclavicular Nodes (Ipsilateral supraclavicular nodes)
MetastaticSite,Other
Item
Metastatic Site, Other
text
MetastaticSite,Other
Item
Metastatic Site, Other
text
LymphNodes,DistantLocation
Item
Lymph Nodes, Distant Location
text
Item Group
Bladder/urothelial: Prior Treatment Affecting The Bladder/urothelium
Item
Prior Intravesical Therapy Ind
text
CL.7
Code List
Prior Intravesical Therapy Ind
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Prior Immunotherapy Type
text
CL.8
Code List
Prior Immunotherapy Type
CL Item
Interferon (Interferon)
C20493 (NCI Thesaurus)
C0733470 (UMLS 2011AA)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
Bcg (BCG)
C1328 (NCI Thesaurus)
PriorImmunotherapyCount
Item
Prior Immunotherapy Count
float
PriorImmunotherapyOtherAgent
Item
Prior Immunotherapy Other Agent
text
Item
Prior Intravesical Chemotherapy Type
text
CL.9
Code List
Prior Intravesical Chemotherapy Type
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
Thiotepa (Thiotepa)
C875 (NCI Thesaurus)
C0039871 (UMLS 2011AA)
CL Item
Mmc (MMC)
PriorIntravesicalChemotherapyCount
Item
Prior Intravesical Chemotherapy Count
float
PriorIntravesicalChemotherapyOtherAgent
Item
Prior Intravesical Chemotherapy Other Agent
text
Item
Prior Chemotherapy Ind
text
CL.10
Code List
Prior Chemotherapy Ind
CL Item
Yes (YES)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (UNKNOWN)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
No (NO)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Item
Prior Neoadjuvant Chemotherapy Ind
text
CL.11
Code List
Prior Neoadjuvant Chemotherapy Ind
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Prior Neoadjuvant Chemotherapy Type
text
CL.12
Code List
Prior Neoadjuvant Chemotherapy Type
CL Item
Carboplatin/paclitaxel (Carboplatin/Paclitaxel)
C10662 (NCI Thesaurus)
C0281297 (UMLS 2011AA)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
Cisplatin/gemcitabine (Cisplatin/Gemcitabine)
C11117 (NCI Thesaurus)
C0338265 (UMLS 2011AA)
CL Item
M-vac (M-VAC)
PriorNeoadjuvantChemotherapyCount
Item
Prior Neoadjuvant Chemotherapy Count
float
PriorNeoadjuvantChemotherapyOtherType
Item
Prior Neoadjuvant Chemotherapy Other Type
text
Item
Prior Adjuvant Chemotherapy Ind
text
CL.13
Code List
Prior Adjuvant Chemotherapy Ind
CL Item
Yes (YES)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (UNKNOWN)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
No (NO)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Item
Prior Adjuvant Chemotherapy Type
text
CL.14
Code List
Prior Adjuvant Chemotherapy Type
CL Item
Carboplatin/paclitaxel (Carboplatin/Paclitaxel)
C10662 (NCI Thesaurus)
C0281297 (UMLS 2011AA)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
Cisplatin/gemcitabine (Cisplatin/Gemcitabine)
C11117 (NCI Thesaurus)
C0338265 (UMLS 2011AA)
CL Item
M-vac (M-VAC)
PriorAdjuvantChemotherapyCount
Item
Prior Adjuvant Chemotherapy Count
float
PriorAdjuvantChemotherapyOtherAgent
Item
Prior Adjuvant Chemotherapy Other Agent
text
Item
Prior Chemotherapy Ind, Metastatic
text
CL.15
Code List
Prior Chemotherapy Ind, Metastatic
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Prior Metastatic Chemotherapy Type
text
CL.16
Code List
Prior Metastatic Chemotherapy Type
CL Item
Carboplatin/paclitaxel (Carboplatin/Paclitaxel)
C10662 (NCI Thesaurus)
C0281297 (UMLS 2011AA)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
Cisplatin/gemcitabine (Cisplatin/Gemcitabine)
C11117 (NCI Thesaurus)
C0338265 (UMLS 2011AA)
CL Item
M-vac (M-VAC)
PriorMetastaticChemotherapyCount
Item
Prior Metastatic Chemotherapy Count
float
PriorMetastaticChemotherapyOtherAgent
Item
Prior Metastatic Chemotherapy Other Agent
text
Item
Prior Pelvic RT Ind
text
CL.17
Code List
Prior Pelvic RT Ind
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Prior Surgery Ind
text
CL.18
Code List
Prior Surgery Ind
CL Item
Yes (YES)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (UNKNOWN)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
No (NO)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Item
Prior Surgery Type
text
CL.19
Code List
Prior Surgery Type
CL Item
Patient Previosly Had A Turbt (TURBT)
CL Item
Patient Previosly Had A Radical Cystectomy (radical cystectomy)
CL Item
Patient Previosly Had A Partial Cystectomy (partial cystectomy)
CL Item
Patient Previously Had Other Surgery, Specify (other, specify)
PriorSurgery,TURBTCount
Item
Prior Surgery, TURBT Count
float
PriorSurgery,OtherType
Item
Prior Surgery, Other Type
text
Item
Prior Other Therapy Ind
text
CL.20
Code List
Prior Other Therapy Ind
CL Item
Yes (YES)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (UNKNOWN)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
No (NO)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
PriorOtherTherapyName
Item
Prior Other Therapy Name
text
Item Group
Allows Documentation Of Any Additional Cooments
Comments
Item
Comments
text
Tillbaka till toppen 

Kontakt

Använd detta formulär för feedback, frågor och förslag på förbättringar.

Fält markerade med * är obligatoriska.

Hjälp

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial