ID
1012
Descripción
E5103 Epirubicin Supplemental Form 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=9531CDB7-EDAC-013E-E040-BB89AD437CC8
Link
Palabras clave
Versiones (3)
- 26/8/12 26/8/12 -
- 8/1/15 8/1/15 - Martin Dugas
- 8/6/15 8/6/15 -
Subido en
26 de agosto de 2012
DOI
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Licencia
Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00433511 Treatment - E5103 Epirubicin Supplemental Form - 3159174v1.0
INSTRUCTIONS: Complete and submit this form at the end of each cycle of Step 1 during the Doxorubicin shortage IF Doxorubicin was not administered due to drug shortage. On the E5103 Treatment Form - Step 1, for Doxorubicin, be sure to record ¿0.0mg¿ for Agent Total Dose, "02=dose held" for Dose Modification and ¿06=alternative therapy for other reason" for Dose Modification Reason
- StudyEvent: E5103 Epirubicin Supplemental Form
Descripción
Unnamed2
Descripción
PatientInitialsName
Tipo de datos
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
Descripción
ProtocolECOGIdentifierNumber
Tipo de datos
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
Descripción
PatientECOGIdentifierNumber
Tipo de datos
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
Descripción
ProtocolParticipatingIdentifierNumber
Tipo de datos
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
Descripción
CombinedInstitutionName
Tipo de datos
text
Alias
- NCI Thesaurus ObjectClass
- C25454
- UMLS 2011AA ObjectClass
- C0205195
- NCI Thesaurus ObjectClass
- C21541
- UMLS 2011AA ObjectClass
- C0018704
- NCI Thesaurus Property
- C25364
- UMLS 2011AA Property
- C0600091
- NCI Thesaurus ValueDomain
- C25191
- UMLS 2011AA ValueDomain
- C1547383
- NCI Thesaurus ValueDomain
- C21541
- UMLS 2011AA ValueDomain
- C0018704
Descripción
PatientParticipatingIdentifierNumber
Tipo de datos
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
Descripción
Unnamed3
Descripción
DataAmendedText
Tipo de datos
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
Descripción
DataAmendedDate
Tipo de datos
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
Descripción
Unnamed4
Descripción
TreatmentEvaluationPeriodType
Tipo de datos
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
Descripción
Unnamed 4
Descripción
AgentCourseTotalDose
Tipo de datos
double
Alias
- NCI Thesaurus ValueDomain
- C25304
- UMLS 2011AA ValueDomain
- C0439810
- NCI Thesaurus Property
- C25379
- UMLS 2011AA Property
- C0750729
- NCI Thesaurus ValueDomain
- C25488
- UMLS 2011AA ValueDomain
- C0178602
- NCI Thesaurus ObjectClass
- C1708
- UMLS 2011AA ObjectClass
- C0450442
Descripción
DoseModificationStatus
Tipo de datos
text
Alias
- NCI Thesaurus ObjectClass
- C25488
- UMLS 2011AA ObjectClass
- C0178602
- NCI Thesaurus ValueDomain
- C25688
- UMLS 2011AA ValueDomain
- C0449438
- NCI Thesaurus Property
- C25572
Descripción
DoseModificationReason
Tipo de datos
text
Alias
- NCI Thesaurus ValueDomain
- C25638
- UMLS 2011AA ValueDomain
- C0392360
- NCI Thesaurus ObjectClass
- C25488
- UMLS 2011AA ObjectClass
- C0178602
- NCI Thesaurus Property
- C25572
Descripción
DoseModificationReasonSpecify
Tipo de datos
text
Alias
- NCI Thesaurus ValueDomain
- C25685
- UMLS 2011AA ValueDomain
- C1521902
- NCI Thesaurus ObjectClass
- C25488
- UMLS 2011AA ObjectClass
- C0178602
- NCI Thesaurus Property
- C25572
Descripción
Comments
Descripción
InvestigatorSignatureText
Tipo de datos
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
Descripción
InvestigatorSignatureDate
Tipo de datos
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
Similar models
INSTRUCTIONS: Complete and submit this form at the end of each cycle of Step 1 during the Doxorubicin shortage IF Doxorubicin was not administered due to drug shortage. On the E5103 Treatment Form - Step 1, for Doxorubicin, be sure to record ¿0.0mg¿ for Agent Total Dose, "02=dose held" for Dose Modification and ¿06=alternative therapy for other reason" for Dose Modification Reason
- StudyEvent: E5103 Epirubicin Supplemental Form
C0237753 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25491 (NCI Thesaurus Property)
C1512162 (UMLS 2011AA Property)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25491 (NCI Thesaurus Property)
C1512162 (UMLS 2011AA Property)
C1547383 (UMLS 2011AA ValueDomain)
C19464 (NCI Thesaurus Property)
C0376315 (UMLS 2011AA Property)
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25452 (NCI Thesaurus ObjectClass)
C0237753 (UMLS 2011AA ValueDomain)
C25646 (NCI Thesaurus ObjectClass)
C1514821 (UMLS 2011AA ObjectClass)
C16154 (NCI Thesaurus Property)
C1704379 (UMLS 2011AA Property)
C16154 (NCI Thesaurus ValueDomain)
C1704379 (UMLS 2011AA ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25536 (NCI Thesaurus Property)
C1555582 (UMLS 2011AA Property)
C0237753 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25491 (NCI Thesaurus Property)
C1512162 (UMLS 2011AA Property)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25491 (NCI Thesaurus Property)
C1512162 (UMLS 2011AA Property)
C0237753 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C25608 (NCI Thesaurus Property)
C0679823 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C0205195 (UMLS 2011AA ObjectClass)
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ValueDomain)
C0018704 (UMLS 2011AA ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25608 (NCI Thesaurus Property)
C0679823 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C1527021 (UMLS 2011AA ValueDomain)
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
C0011008 (UMLS 2011AA ValueDomain)
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
C25367 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25214 (NCI Thesaurus Property)
C0220825 (UMLS 2011AA Property)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C15368 (NCI Thesaurus ObjectClass)
C0439810 (UMLS 2011AA ValueDomain)
C25379 (NCI Thesaurus Property)
C0750729 (UMLS 2011AA Property)
C25488 (NCI Thesaurus ValueDomain)
C0178602 (UMLS 2011AA ValueDomain)
C1708 (NCI Thesaurus ObjectClass)
C0450442 (UMLS 2011AA ObjectClass)
C0178602 (UMLS 2011AA ObjectClass)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
C25572 (NCI Thesaurus Property)
C1707814 (UMLS 2011AA)
C49505 (NCI Thesaurus)
C1707814 (UMLS 2011AA)
C0392360 (UMLS 2011AA ValueDomain)
C25488 (NCI Thesaurus ObjectClass)
C0178602 (UMLS 2011AA ObjectClass)
C25572 (NCI Thesaurus Property)
C0877248 (UMLS 2011AA)
C0205394 (UMLS 2011AA)
C1521902 (UMLS 2011AA ValueDomain)
C25488 (NCI Thesaurus ObjectClass)
C0178602 (UMLS 2011AA ObjectClass)
C25572 (NCI Thesaurus Property)
C1527021 (UMLS 2011AA ValueDomain)
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
C0011008 (UMLS 2011AA ValueDomain)
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C25367 (NCI Thesaurus ValueDomain)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)