ID
1003
Description
E5103 Treatment Form - Step 1 Doxorubicin, Cyclophosphamide, and Paclitaxel With or Without Bevacizumab in Treating Patients With Lymph Node-Positive or High-Risk, Lymph Node-Negative Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=22B13531-DF02-6120-E044-0003BA3F9857
Link
Keywords
Versions (3)
- 8/26/12 8/26/12 -
- 1/8/15 1/8/15 - Martin Dugas
- 6/3/15 6/3/15 -
Uploaded on
August 26, 2012
DOI
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License
Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00433511 Treatment - E5103 Treatment Form - Step 1 - 2544363v1.0
INSTRUCTIONS: Complete this form at the end of each cycle (1 cycle =3 weeks). Submit original to the ECOG Coordinating Center. Keep a copy for your files. Refer to forms packet for submission schedule
Description
Unnamed2
Description
PatientInitialsName
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25191
- UMLS 2011AA ValueDomain
- C1547383
- NCI Thesaurus ObjectClass
- C16960
- UMLS 2011AA ObjectClass
- C0030705
- NCI Thesaurus Property
- C25536
- UMLS 2011AA Property
- C1555582
Description
ProtocolECOGIdentifierNumber
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25337
- UMLS 2011AA ValueDomain
- C0237753
- NCI Thesaurus ObjectClass
- C25320
- UMLS 2011AA ObjectClass
- C1507394
- NCI Thesaurus Property
- C25364
- UMLS 2011AA Property
- C0600091
- NCI Thesaurus Property
- C25491
- UMLS 2011AA Property
- C1512162
Description
PatientECOGIdentifierNumber
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25337
- UMLS 2011AA ValueDomain
- C0237753
- NCI Thesaurus ObjectClass
- C16960
- UMLS 2011AA ObjectClass
- C0030705
- NCI Thesaurus Property
- C25364
- UMLS 2011AA Property
- C0600091
- NCI Thesaurus Property
- C25491
- UMLS 2011AA Property
- C1512162
Description
ProtocolParticipatingIdentifierNumber
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25337
- UMLS 2011AA ValueDomain
- C0237753
- NCI Thesaurus ObjectClass
- C25320
- UMLS 2011AA ObjectClass
- C1507394
- NCI Thesaurus Property
- C25608
- UMLS 2011AA Property
- C0679823
- NCI Thesaurus Property
- C25364
- UMLS 2011AA Property
- C0600091
Description
PatientParticipatingIdentifierNumber
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25337
- UMLS 2011AA ValueDomain
- C0237753
- NCI Thesaurus ObjectClass
- C16960
- UMLS 2011AA ObjectClass
- C0030705
- NCI Thesaurus Property
- C25608
- UMLS 2011AA Property
- C0679823
- NCI Thesaurus Property
- C25364
- UMLS 2011AA Property
- C0600091
Description
CombinedInstitutionName
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25191
- UMLS 2011AA ValueDomain
- C1547383
- NCI Thesaurus ObjectClass
- C25454
- UMLS 2011AA ObjectClass
- C0205195
- NCI Thesaurus ObjectClass
- C21541
- UMLS 2011AA ObjectClass
- C0018704
- NCI Thesaurus ValueDomain
- C21541
- UMLS 2011AA ValueDomain
- C0018704
- NCI Thesaurus Property
- C25364
- UMLS 2011AA Property
- C0600091
Description
Unnamed Module 4
Description
TreatmentEvaluationPeriodType
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25284
- UMLS 2011AA ValueDomain
- C0332307
- NCI Thesaurus Property
- C25214
- UMLS 2011AA Property
- C0220825
- NCI Thesaurus Property
- C25616
- UMLS 2011AA Property
- C1948053
- NCI Thesaurus ObjectClass
- C15368
Description
Unnamed3
Description
DataAmendedText
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25704
- UMLS 2011AA ValueDomain
- C1527021
- NCI Thesaurus ObjectClass
- C25474
- UMLS 2011AA ObjectClass
- C1511726
- NCI Thesaurus Property
- C25416
- UMLS 2011AA Property
- C1691222
Description
DataAmendedDate
Data type
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
- NCI Thesaurus ObjectClass
- C25474
- UMLS 2011AA ObjectClass
- C1511726
- NCI Thesaurus Property
- C25416
- UMLS 2011AA Property
- C1691222
- NCI Thesaurus ValueDomain
- C25367
Description
Therapy Administered
Description
TherapeuticProcedureRegimenType
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25284
- UMLS 2011AA ValueDomain
- C0332307
- NCI Thesaurus ObjectClass
- C49236
- UMLS 2011AA ObjectClass
- C0087111
- NCI Thesaurus Property
- C15697
- UMLS 2011AA Property
- C0040808
Description
TreatmentReportingPeriodBeginDate
Data type
date
Alias
- NCI Thesaurus ObjectClass
- C15368
- NCI Thesaurus Property
- C25616
- UMLS 2011AA Property
- C1948053
- NCI Thesaurus Property
- C25651
- UMLS 2011AA Property
- C0700287
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
- NCI Thesaurus ValueDomain
- C25431
- UMLS 2011AA ValueDomain
- C0439659
Description
TreatmentReportingPeriodEndDate
Data type
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
- NCI Thesaurus Property
- C25616
- UMLS 2011AA Property
- C1948053
- NCI Thesaurus ObjectClass
- C15368
- NCI Thesaurus Property
- C25651
- UMLS 2011AA Property
- C0700287
Description
PersonBodySurfaceAreaValue
Data type
double
Measurement units
- m2
Alias
- NCI Thesaurus ObjectClass
- C25190
- UMLS 2011AA ObjectClass
- C0027361
- NCI Thesaurus ValueDomain
- C25712
- UMLS 2011AA ValueDomain
- C1522609
- NCI Thesaurus Property
- C25157
- UMLS 2011AA Property
- C0005902
Description
PatientWeightMeasurement
Data type
double
Measurement units
- Kg
Alias
- NCI Thesaurus ValueDomain
- C25209
- UMLS 2011AA ValueDomain
- C0242485
- NCI Thesaurus ObjectClass
- C16960
- UMLS 2011AA ObjectClass
- C0030705
- NCI Thesaurus Property
- C25208
- UMLS 2011AA Property
- C0043100
Description
AgentName
Data type
text
Alias
- NCI Thesaurus Property
- C25364
- UMLS 2011AA Property
- C0600091
- NCI Thesaurus ObjectClass
- C1708
- UMLS 2011AA ObjectClass
- C0450442
- NCI Thesaurus ValueDomain
- C1708
- UMLS 2011AA ValueDomain
- C0450442
- NCI Thesaurus ValueDomain
- C42614
- UMLS 2011AA ValueDomain
- C0027365
Description
AgentFirstCourseTotalDose
Data type
double
Alias
- NCI Thesaurus ObjectClass
- C1708
- UMLS 2011AA ObjectClass
- C0450442
- NCI Thesaurus Property
- C25509
- UMLS 2011AA Property
- C1279901
- NCI Thesaurus Property
- C25379
- UMLS 2011AA Property
- C0750729
- NCI Thesaurus ValueDomain
- C25304
- UMLS 2011AA ValueDomain
- C0439810
- NCI Thesaurus ValueDomain
- C25488
- UMLS 2011AA ValueDomain
- C0178602
Description
DoseModificationStatus
Data type
text
Alias
- NCI Thesaurus ObjectClass
- C25488
- UMLS 2011AA ObjectClass
- C0178602
- NCI Thesaurus ValueDomain
- C25688
- UMLS 2011AA ValueDomain
- C0449438
- NCI Thesaurus Property
- C25572
Description
DoseModificationReason
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25638
- UMLS 2011AA ValueDomain
- C0392360
- NCI Thesaurus ObjectClass
- C25488
- UMLS 2011AA ObjectClass
- C0178602
- NCI Thesaurus Property
- C25572
Description
DoseModificationReasonSpecify
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25685
- UMLS 2011AA ValueDomain
- C1521902
- NCI Thesaurus ObjectClass
- C25488
- UMLS 2011AA ObjectClass
- C0178602
- NCI Thesaurus Property
- C25572
Description
DoseChemotherapyAdverseEventModificationType
Data type
text
Alias
- NCI Thesaurus ObjectClass
- C25488
- UMLS 2011AA ObjectClass
- C0178602
- NCI Thesaurus Property
- C15632
- UMLS 2011AA Property
- C0392920
- NCI Thesaurus Property
- C41331
- UMLS 2011AA Property
- C0877248
- NCI Thesaurus Property
- C25572
- NCI Thesaurus ValueDomain
- C25284
- UMLS 2011AA ValueDomain
- C0332307
Description
DoseBevacizumabAdverseEventModificationType
Data type
text
Alias
- NCI Thesaurus ObjectClass
- C25488
- UMLS 2011AA ObjectClass
- C0178602
- NCI Thesaurus Property
- C2039
- UMLS 2011AA Property
- C0796392
- NCI Thesaurus Property
- C41331
- UMLS 2011AA Property
- C0877248
- NCI Thesaurus Property
- C25572
- NCI Thesaurus ValueDomain
- C25284
- UMLS 2011AA ValueDomain
- C0332307
Description
DoseAdverseEventModificationSpecify
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25685
- UMLS 2011AA ValueDomain
- C1521902
- NCI Thesaurus Property
- C41331
- UMLS 2011AA Property
- C0877248
- NCI Thesaurus ObjectClass
- C25488
- UMLS 2011AA ObjectClass
- C0178602
- NCI Thesaurus Property
- C25572
Description
DoseAdverseEventModificationSpecify
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25685
- UMLS 2011AA ValueDomain
- C1521902
- NCI Thesaurus Property
- C41331
- UMLS 2011AA Property
- C0877248
- NCI Thesaurus ObjectClass
- C25488
- UMLS 2011AA ObjectClass
- C0178602
- NCI Thesaurus Property
- C25572
Description
Non-protocol Therapy
Description
Non-protocolCancerTreatmentConcurrentClinicalTrialProtocolTherapeuticProcedureAdministeredInd-3
Data type
text
Alias
- NCI Thesaurus ObjectClass
- C25590
- UMLS 2011AA ObjectClass
- C1518384
- NCI Thesaurus ObjectClass
- C16212
- UMLS 2011AA ObjectClass
- C0920425
- NCI Thesaurus Property
- C25320
- UMLS 2011AA Property
- C1507394
- NCI Thesaurus Property
- C49236
- UMLS 2011AA Property
- C0087111
- NCI Thesaurus Property
- C25456
- UMLS 2011AA Property
- C0205420
- NCI Thesaurus Property
- C25382
- UMLS 2011AA Property
- C1521801
- NCI Thesaurus ValueDomain
- C38148
- UMLS 2011AA ValueDomain
- C1512699
Description
Comments
Description
InvestigatorSignatureText
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25704
- UMLS 2011AA ValueDomain
- C1527021
- NCI Thesaurus Property
- C25678
- UMLS 2011AA Property
- C1519316
- NCI Thesaurus ObjectClass
- C17089
- UMLS 2011AA ObjectClass
- C0035173
Description
InvestigatorSignatureDate
Data type
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
- NCI Thesaurus Property
- C25678
- UMLS 2011AA Property
- C1519316
- NCI Thesaurus ValueDomain
- C25367
- NCI Thesaurus ObjectClass
- C17089
- UMLS 2011AA ObjectClass
- C0035173
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INSTRUCTIONS: Complete this form at the end of each cycle (1 cycle =3 weeks). Submit original to the ECOG Coordinating Center. Keep a copy for your files. Refer to forms packet for submission schedule
C0237753 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
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C0600091 (UMLS 2011AA Property)
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C25452 (NCI Thesaurus ObjectClass)
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C0220825 (UMLS 2011AA ObjectClass)
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C0700287 (UMLS 2011AA ObjectClass)
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C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
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C1507394 (UMLS 2011AA ObjectClass)
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C0600091 (UMLS 2011AA Property)
C1547383 (UMLS 2011AA ValueDomain)
C25454 (NCI Thesaurus ObjectClass)
C0205195 (UMLS 2011AA ObjectClass)
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C21541 (NCI Thesaurus ValueDomain)
C0018704 (UMLS 2011AA ValueDomain)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C0332307 (UMLS 2011AA ValueDomain)
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C1511726 (UMLS 2011AA ObjectClass)
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C15697 (NCI Thesaurus Property)
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C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C25651 (NCI Thesaurus Property)
C0700287 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25431 (NCI Thesaurus ValueDomain)
C0439659 (UMLS 2011AA ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C15368 (NCI Thesaurus ObjectClass)
C25651 (NCI Thesaurus Property)
C0700287 (UMLS 2011AA Property)
C0027361 (UMLS 2011AA ObjectClass)
C25712 (NCI Thesaurus ValueDomain)
C1522609 (UMLS 2011AA ValueDomain)
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C1707814 (UMLS 2011AA)
C0392360 (UMLS 2011AA ValueDomain)
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