ID

6920

Description

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

Link

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

Keywords

Versions (2)
  1. 9/19/12 9/19/12 -
  2. 1/8/15 1/8/15 - Martin Dugas
Uploaded on

January 8, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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On-Study - Metastatic Bladder/Urothelial Cancer - On-Study Form - 2019330v2.31

English

No Instruction available.

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

Crf Header

Coordinating Group Protocol Number
Description

CoordinatingGroupProtocolNumber

Data type

text

Coordinating Group Code
Description

CoordinatingGroupCode

Data type

text

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

Protocol Title

Data type

text

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

PatientStudyID,CoordinatingGroup

Data type

text

Patient Study ID, Participating Group
Description

PatientStudyID,ParticipatingGroup

Data type

text

Participating Group Code
Description

ParticipatingGroupCode

Data type

text

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

InstitutionName

Data type

text

Affiliate Name
Description

AffiliateName

Data type

text

Patient Name, Last
Description

PatientName,Last

Data type

text

Patient Name, First
Description

PatientName,First

Data type

text

Patient Name, Middle
Description

PatientName,Middle

Data type

text

Bladder/urothelial: Form Administration
Description

Bladder/urothelial: Form Administration

Person Completing Form, Last Name
Description

PersonCompletingForm,LastName

Data type

text

Person Completing Form, First Name
Description

PersonCompletingForm,FirstName

Data type

text

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

AmendedDataInd

Data type

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
Description

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

Prior Muscle Invasive Disease Ind
Description

PriorMuscleInvasiveDiseaseInd

Data type

text

Bladder Tumor Location
Description

BladderTumorLocation

Data type

text

Initial Diagnosis Date, Pathologic
Description

InitialDiagnosisDate,Pathologic

Data type

date

Initial Diagnosis Date, Locally Advanced
Description

InitialDiagnosisDate,LocallyAdvanced

Data type

date

Initial Diagnosis Date, Metastatic
Description

InitialDiagnosisDate,Metastatic

Data type

date

Bladder/urothelial: Site(s) Of Disease
Description

Bladder/urothelial: Site(s) Of Disease

Progression Site, Adjacent Structures
Description

ProgressionSite,AdjacentStructures

Data type

text

Progression Site, Local-Regional Nodes
Description

ProgressionSite,Local-RegionalNodes

Data type

text

Progression Site, Other
Description

ProgressionSite,Other

Data type

text

Progression Site, Other
Description

ProgressionSite,Other

Data type

text

Metastatic Site
Description

MetastaticSite

Data type

text

Metastatic Site, Other
Description

MetastaticSite,Other

Data type

text

Metastatic Site, Other
Description

MetastaticSite,Other

Data type

text

Lymph Nodes, Distant Location
Description

LymphNodes,DistantLocation

Data type

text

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

Bladder/urothelial: Prior Treatment Affecting The Bladder/urothelium

Prior Intravesical Therapy Ind
Description

PriorIntravesicalTherapyInd

Data type

text

Prior Immunotherapy Type
Description

PriorImmunotherapyType

Data type

text

Prior Immunotherapy Count
Description

PriorImmunotherapyCount

Data type

float

Prior Immunotherapy Other Agent
Description

PriorImmunotherapyOtherAgent

Data type

text

Prior Intravesical Chemotherapy Type
Description

PriorIntravesicalChemotherapyType

Data type

text

Prior Intravesical Chemotherapy Count
Description

PriorIntravesicalChemotherapyCount

Data type

float

Prior Intravesical Chemotherapy Other Agent
Description

PriorIntravesicalChemotherapyOtherAgent

Data type

text

Prior Chemotherapy Ind
Description

PriorChemotherapyInd

Data type

text

Prior Neoadjuvant Chemotherapy Ind
Description

PriorNeoadjuvantChemotherapyInd

Data type

text

Prior Neoadjuvant Chemotherapy Type
Description

PriorNeoadjuvantChemotherapyType

Data type

text

Prior Neoadjuvant Chemotherapy Count
Description

PriorNeoadjuvantChemotherapyCount

Data type

float

Prior Neoadjuvant Chemotherapy Other Type
Description

PriorNeoadjuvantChemotherapyOtherType

Data type

text

Prior Adjuvant Chemotherapy Ind
Description

PriorAdjuvantChemotherapyInd

Data type

text

Prior Adjuvant Chemotherapy Type
Description

PriorAdjuvantChemotherapyType

Data type

text

Prior Adjuvant Chemotherapy Count
Description

PriorAdjuvantChemotherapyCount

Data type

float

Prior Adjuvant Chemotherapy Other Agent
Description

PriorAdjuvantChemotherapyOtherAgent

Data type

text

Prior Chemotherapy Ind, Metastatic
Description

PriorChemotherapyInd,Metastatic

Data type

text

Prior Metastatic Chemotherapy Type
Description

PriorMetastaticChemotherapyType

Data type

text

Prior Metastatic Chemotherapy Count
Description

PriorMetastaticChemotherapyCount

Data type

float

Prior Metastatic Chemotherapy Other Agent
Description

PriorMetastaticChemotherapyOtherAgent

Data type

text

Prior Pelvic RT Ind
Description

PriorPelvicRTInd

Data type

text

Prior Surgery Ind
Description

PriorSurgeryInd

Data type

text

Prior Surgery Type
Description

PriorSurgeryType

Data type

text

Prior Surgery, TURBT Count
Description

PriorSurgery,TURBTCount

Data type

float

Prior Surgery, Other Type
Description

PriorSurgery,OtherType

Data type

text

Prior Other Therapy Ind
Description

PriorOtherTherapyInd

Data type

text

Prior Other Therapy Name
Description

PriorOtherTherapyName

Data type

text

Allows Documentation Of Any Additional Cooments
Description

Allows Documentation Of Any Additional Cooments

Comments
Description

Comments

Data type

text

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1 forms
  1. StudyEvent: Metastatic Bladder/Urothelial Cancer - On-Study Form
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
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
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