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ID

10055

Description

NSABP PROTOCOL B-35 PATHOLOGIST'S REPORT FORM Anastrozole or Tamoxifen in Treating Postmenopausal Women With Ductal Carcinoma in Situ Who Are Undergoing Lumpectomy and Radiation Therapy NCT00053898 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A01C3BB9-FE93-4CD3-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A01C3BB9-FE93-4CD3-E034-080020C9C0E0

Keywords

Versions (2)
  1. 8/26/12 8/26/12 -
  2. 3/22/15 3/22/15 - Martin Dugas
Uploaded on

March 22, 2015

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Creative Commons BY-NC 3.0 Legacy
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    Breast cancer NCT00053898

    English

    Form PRF (04-30-2002) This form is to be completed by the pathologist and submitted to the NSABP Biostatistical Center within 3 months of randomization. Please mail Form PRF separately from the slides and blocks.

    1 forms  
    Header
    Description

    Header

    First Three Letters of Patient's Last Name
    Description

    FirstThreeLettersofPatient'sLastName

    Data type

    text

    Patient Study ID
    Description

    PatientStudyID

    Data type

    text

    Institution Name
    Description

    InstitutionName

    Data type

    text

    Affiliate Name
    Description

    AffiliateName

    Data type

    text

    Are data amended? (If Yes, circle the amended items in red.)
    Description

    AmendedDataInd

    Data type

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C25474
    UMLS 2011AA ObjectClass
    C1511726
    NCI Thesaurus Property
    C25416
    UMLS 2011AA Property
    C1691222
    Accession Number (enter all that apply 123)
    Description

    AccessionNumber

    Data type

    float

    Pathology report
    Description

    Pathology report

    Alias
    UMLS CUI-1
    C0807321
    Pathologic Primary Tumor Size (cm leave blank if not directly measurable)
    Description

    PathologicPrimaryTumorSize

    Data type

    float

    Measurement units
    • cm
    Alias
    NCI Thesaurus ValueDomain
    C25209
    UMLS CUI-1
    C0475440
    cm
    Is measurement gross or microscopic? (mark one)
    Description

    DuctalBreastCarcinomainSituMicroscopicGrossSizeDocumentedStatus

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C2924
    NCI Thesaurus Property
    C25252
    NCI Thesaurus Property-2
    C43566
    NCI Thesaurus Property-3
    C25681
    NCI Thesaurus Property-4
    C25356
    NCI Thesaurus ValueDomain
    C25688
    UMLS CUI-1
    C0205288
    UMLS CUI-2
    C0439806
    Estimated Size (cm best guess, if possible)
    Description

    EstimatedSize

    Data type

    text

    Number of slides with DCIS present
    Description

    NumberofslideswithDCISpresent

    Data type

    integer

    Total slides examined for DCIS
    Description

    TotalslidesexaminedforDCIS

    Data type

    integer

    Type DCIS (mark one)
    Description

    TypeDCIS

    Data type

    text

    Alias
    UMLS CUI-1
    C0007124
    UMLS CUI-2
    C0008902
    Growth Patterns (mark all that apply)
    Description

    Growth Patterns (mark all that apply)

    Data type

    text

    Alias
    UMLS CUI-1
    C0449574
    Other, specify
    Description

    HistologicType,OtherName

    Data type

    text

    Dominant Growth Pattern (mark only one)
    Description

    Dominant Growth Pattern (mark only one)

    Data type

    text

    Other, specify
    Description

    HistologicType,Dominant,Other

    Data type

    text

    Percent Central Necrosis (% estimated necrotic surface area of DCIS associated with any growth pattern)
    Description

    Percent Central Necrosis (% estimated necrotic surface area of DCIS associated with any growth pattern)

    Data type

    integer

    Measurement units
    • %
    Alias
    UMLS CUI-1
    C1265871
    %
    Nuclear Grade (by SBR criteria; mark highest grade)
    Description

    NuclearGrade

    Data type

    text

    Microcalcifications (mark one)
    Description

    Microcalcifications (mark one)

    Data type

    text

    Alias
    UMLS CUI-1
    C0520594
    Margins of DCIS Resection (after re-excision, if done mark one)
    Description

    DCIS,MarginResult

    Data type

    text

    Nearest Margin (mm if margins are negative)
    Description

    SurgicalMarginDistance

    Data type

    float

    Pathologist Completing Form (print name signature)
    Description

    PathologistCompletingForm

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    NCI Thesaurus Property
    C40988
    NCI Thesaurus Property-2
    C25250
    NCI Thesaurus ObjectClass
    C17723
    UMLS CUI-1
    C0334866
    Pathologist's Phone Number
    Description

    Pathologist's Phone Number

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    NCI Thesaurus ValueDomain-2
    C25395
    NCI Thesaurus ObjectClass
    C17723
    NCI Thesaurus Property
    C40978
    UMLS CUI-1
    C0334866
    UMLS CUI-2
    C1515258
    Date Form Completed
    Description

    FormCompletionDate,Original

    Data type

    date

    Back to the top of the page

    Similar models

    Form PRF (04-30-2002) This form is to be completed by the pathologist and submitted to the NSABP Biostatistical Center within 3 months of randomization. Please mail Form PRF separately from the slides and blocks.

    1 forms
    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    Header
    FirstThreeLettersofPatient'sLastName
    Item
    First Three Letters of Patient's Last Name
    text
    PatientStudyID
    Item
    Patient Study ID
    text
    InstitutionName
    Item
    Institution Name
    text
    AffiliateName
    Item
    Affiliate Name
    text
    AmendedDataInd
    Item
    Are data amended? (If Yes, circle the amended items in red.)
    boolean
    C25474 (NCI Thesaurus ObjectClass)
    C1511726 (UMLS 2011AA ObjectClass)
    C25416 (NCI Thesaurus Property)
    C1691222 (UMLS 2011AA Property)
    AccessionNumber
    Item
    Accession Number (enter all that apply 123)
    float
    Item Group
    Pathology report
    C0807321 (UMLS CUI-1)
    Tumor size
    Item
    Pathologic Primary Tumor Size (cm leave blank if not directly measurable)
    float
    C25209 (NCI Thesaurus ValueDomain)
    C0475440 (UMLS CUI-1)
    Item
    Is measurement gross or microscopic? (mark one)
    text
    C2924 (NCI Thesaurus ObjectClass)
    C25252 (NCI Thesaurus Property)
    C43566 (NCI Thesaurus Property-2)
    C25681 (NCI Thesaurus Property-3)
    C25356 (NCI Thesaurus Property-4)
    C25688 (NCI Thesaurus ValueDomain)
    C0205288 (UMLS CUI-1)
    C0439806 (UMLS CUI-2)
    CL.2
    Code List
    Is measurement gross or microscopic? (mark one)
    CL Item
    Gross (Gross)
    C0439806 (UMLS CUI-1)
    CL Item
    Microscopic (Microscopic)
    C25252 (NCI Thesaurus)
    C0205288 (UMLS CUI-1)
    CL Item
    Not Directly Measurable (Not directly measurable)
    C1518373 (UMLS CUI-1)
    EstimatedSize
    Item
    Estimated Size (cm best guess, if possible)
    text
    Number of slides with DCIS
    Item
    Number of slides with DCIS present
    integer
    Total slides examined for DCIS
    Item
    Total slides examined for DCIS
    integer
    Item
    Type DCIS (mark one)
    text
    C0007124 (UMLS CUI-1)
    C0008902 (UMLS CUI-2)
    CL.3
    Code List
    Type DCIS (mark one)
    CL Item
    Comedo (Comedo)
    C26453 (NCI Thesaurus)
    C0279559 (UMLS CUI-1)
    CL Item
    Non-comedo (Non-comedo)
    C1334250 (UMLS CUI-1)
    Item
    Growth Patterns (mark all that apply)
    text
    C0449574 (UMLS CUI-1)
    CL.4
    Code List
    Growth Patterns (mark all that apply)
    CL Item
    Solid (Solid)
    C0205208 (UMLS CUI-1)
    CL Item
    Cribriform (Cribriform)
    C1621425 (UMLS CUI-1)
    CL Item
    Micropapillary (Micropapillary)
    C1334756 (UMLS CUI-1)
    CL Item
    Papillary (Papillary)
    C0205312 (UMLS CUI-1)
    CL Item
    Other, specify (Other, specify)
    HistologicType,OtherName
    Item
    Other, specify
    text
    Item
    Dominant Growth Pattern (mark only one)
    text
    CL.4
    Code List
    Dominant Growth Pattern (mark only one)
    CL Item
    Solid (Solid)
    C0205208 (UMLS CUI-1)
    CL Item
    Cribriform (Cribriform)
    C1621425 (UMLS CUI-1)
    CL Item
    Micropapillary (Micropapillary)
    C1334756 (UMLS CUI-1)
    CL Item
    Papillary (Papillary)
    C0205312 (UMLS CUI-1)
    CL Item
    Other, specify (Other, specify)
    HistologicType,Dominant,Other
    Item
    Other, specify
    text
    Percent Central Necrosis
    Item
    Percent Central Necrosis (% estimated necrotic surface area of DCIS associated with any growth pattern)
    integer
    C1265871 (UMLS CUI-1)
    Item
    Nuclear Grade (by SBR criteria; mark highest grade)
    text
    CL.6
    Code List
    Nuclear Grade (by SBR criteria; mark highest grade)
    CL Item
    Grade 1 (Grade 1)
    CL Item
    Grade 2 (Grade 2)
    CL Item
    Grade 3 (Grade 3)
    Item
    Microcalcifications (mark one)
    text
    C0520594 (UMLS CUI-1)
    CL.7
    Code List
    Microcalcifications (mark one)
    CL Item
    Present, Involving Benign Ducts (Present, involving benign tissue elements)
    CL Item
    Present, Involving Dcis (Present, involving DCIS)
    CL Item
    Present, Involving Both Benign Ducts And Dcis (Present, involving both benign tissue elements and DCIS)
    CL Item
    None (None)
    C41132 (NCI Thesaurus)
    C0549184 (UMLS 2011AA)
    Item
    Margins of DCIS Resection (after re-excision, if done mark one)
    text
    CL.8
    Code List
    Margins of DCIS Resection (after re-excision, if done mark one)
    CL Item
    Positive (Positive)
    CL Item
    Indefinite (Indefinite)
    CL Item
    Negative (Negative)
    CL Item
    Unable to evaluate margins (Unable to evaluate margins)
    SurgicalMarginDistance
    Item
    Nearest Margin (mm if margins are negative)
    float
    Pathologist
    Item
    Pathologist Completing Form (print name signature)
    text
    C25191 (NCI Thesaurus ValueDomain)
    C40988 (NCI Thesaurus Property)
    C25250 (NCI Thesaurus Property-2)
    C17723 (NCI Thesaurus ObjectClass)
    C0334866 (UMLS CUI-1)
    Pathologist Telephone Number
    Item
    Pathologist's Phone Number
    text
    C25337 (NCI Thesaurus ValueDomain)
    C25395 (NCI Thesaurus ValueDomain-2)
    C17723 (NCI Thesaurus ObjectClass)
    C40978 (NCI Thesaurus Property)
    C0334866 (UMLS CUI-1)
    C1515258 (UMLS CUI-2)
    FormCompletionDate,Original
    Item
    Date Form Completed
    date
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