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ID

1017

Descrição

NSABP Protocol B-40 - WORKSHEET FOR REPORTING BREAST RECONSTRUCTION INFORMATION A Randomized Phase III Trial of Neoadjuvant Therapy in Patients With Palpable and Operable Breast Cancer Evaluating the Effect on Pathologic Complete Response (pCR) of Adding Capecitabine or Gemcitabine to Docetaxel When Administered Before AC With or Without Bevacizumab and Correlative Science Studies Attempting to Identify Predictors of High Likelihood for pCR With Each of the Regimens Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=7D9B7B8C-E72A-A457-E040-BB89AD4372F6

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=7D9B7B8C-E72A-A457-E040-BB89AD4372F6

Palavras-chave

Versões (3)
  1. 26/08/2012 26/08/2012 -
  2. 09/01/2015 09/01/2015 - Martin Dugas
  3. 03/07/2015 03/07/2015 -
Transferido a

26 de agosto de 2012

DOI

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Licença

Creative Commons BY-NC 3.0 Legacy
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    Breast Cancer NCT00408408 Treatment - NSABP Protocol B-40 - WORKSHEET FOR REPORTING BREAST RECONSTRUCTION INFORMATION - 2990080v1.0

    Inglês

    (Submit for patients who reported a mastectomy on the Surgery/Pathology Report Form.) This paper worksheet may be completed to facilitate the entry of the information in NSABP Coordinator Online. Partially completed online forms may be saved in Coordinator Online. DO NOT SUBMIT THIS WORKSHEET VIA FAX OR MAIL. If the Surgery/Pathology Report Form indicates that a lumpectomy was performed, BR data submission will not be expected.

    1 Formulários  
    Unnamed1
    Descrição

    Unnamed1

    Patient Initials (Last First Middle)
    Descrição

    PatientInitialsName

    Tipo de dados

    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
    NSABP Patient ID
    Descrição

    PatientNationalSurgicalAdjuvantBreastProjectIdentifierNumber

    Tipo de dados

    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
    C15818
    UMLS 2011AA Property
    C1513905
    Unnamed 2
    Descrição

    Unnamed 2

    Time Interval for this Assessment
    Descrição

    PhysicalExaminationIntervalType

    Tipo de dados

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus ObjectClass
    C20989
    UMLS 2011AA ObjectClass
    C0031809
    NCI Thesaurus Property
    C25543
    UMLS 2011AA Property
    C1272706
    Did the patient receive breast reconstruction
    Descrição

    SurgicalProcedureBreastReconstructionPerformedInd-2

    Tipo de dados

    text

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus Property
    C38000
    UMLS 2011AA Property
    C0884358
    NCI Thesaurus ObjectClass
    C15329
    UMLS 2011AA ObjectClass
    C0543467
    NCI Thesaurus Property
    C15354
    UMLS 2011AA Property
    C0085076
    Type of breast reconstruction (If yes, mark all that apply)
    Descrição

    SurgicalProcedureBreastReconstructionPerformedType

    Tipo de dados

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus Property
    C38000
    UMLS 2011AA Property
    C0884358
    NCI Thesaurus ObjectClass
    C15329
    UMLS 2011AA ObjectClass
    C0543467
    NCI Thesaurus Property
    C15354
    UMLS 2011AA Property
    C0085076
    Other, specify
    Descrição

    SurgicalProcedureBreastReconstructionPerformedSpecify

    Tipo de dados

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    NCI Thesaurus Property
    C38000
    UMLS 2011AA Property
    C0884358
    NCI Thesaurus ObjectClass
    C15329
    UMLS 2011AA ObjectClass
    C0543467
    NCI Thesaurus Property
    C15354
    UMLS 2011AA Property
    C0085076
    Footer
    Descrição

    Footer

    Comments
    Descrição

    ResearchCommentsText

    Tipo de dados

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS 2011AA ValueDomain
    C1527021
    NCI Thesaurus ObjectClass
    C15319
    NCI Thesaurus Property
    C25393
    UMLS 2011AA Property
    C0282411
    Person Completing Form
    Descrição

    ResponsiblePersonName

    Tipo de dados

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    NCI Thesaurus ObjectClass
    C25657
    UMLS 2011AA ObjectClass
    C1273518
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    Date Form Completed
    Descrição

    FormCompleteDate

    Tipo de dados

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C40988
    UMLS 2011AA ObjectClass
    C1516308
    NCI Thesaurus Property
    C25250
    UMLS 2011AA Property
    C0205197
    NCI Thesaurus ValueDomain
    C25367
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    Similar models

    (Submit for patients who reported a mastectomy on the Surgery/Pathology Report Form.) This paper worksheet may be completed to facilitate the entry of the information in NSABP Coordinator Online. Partially completed online forms may be saved in Coordinator Online. DO NOT SUBMIT THIS WORKSHEET VIA FAX OR MAIL. If the Surgery/Pathology Report Form indicates that a lumpectomy was performed, BR data submission will not be expected.

    1 Formulários
    Name
    Tipo
    Description | Question | Decode (Coded Value)
    Tipo de dados
    Alias
    Item Group
    Unnamed1
    PatientInitialsName
    Item
    Patient Initials (Last First Middle)
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25536 (NCI Thesaurus Property)
    C1555582 (UMLS 2011AA Property)
    PatientNationalSurgicalAdjuvantBreastProjectIdentifierNumber
    Item
    NSABP Patient ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C15818 (NCI Thesaurus Property)
    C1513905 (UMLS 2011AA Property)
    Item Group
    Unnamed 2
    Item
    Time Interval for this Assessment
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C20989 (NCI Thesaurus ObjectClass)
    C0031809 (UMLS 2011AA ObjectClass)
    C25543 (NCI Thesaurus Property)
    C1272706 (UMLS 2011AA Property)
    CL.1
    Code List
    Time Interval for this Assessment
    CL Item
    Date Of Surgery To 3-5 Weeks Following Surgery (Date of surgery to 3-5 weeks following surgery)
    CL Item
    Day After Previous Time Interval To 9 Months Following Study Entry (Day after previous time interval to 9 months following study entry)
    CL Item
    Day After Previous Time Interval To 12 Months Following Study Entry (Day after previous time interval to 12 months following study entry)
    CL Item
    Day After Previous Time Interval To 24 Months Following Study Entry (Day after previous time interval to 24 months following study entry)
    Item
    Did the patient receive breast reconstruction
    text
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C38000 (NCI Thesaurus Property)
    C0884358 (UMLS 2011AA Property)
    C15329 (NCI Thesaurus ObjectClass)
    C0543467 (UMLS 2011AA ObjectClass)
    C15354 (NCI Thesaurus Property)
    C0085076 (UMLS 2011AA Property)
    CL.2
    Code List
    Did the patient receive breast reconstruction
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    Item
    Type of breast reconstruction (If yes, mark all that apply)
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C38000 (NCI Thesaurus Property)
    C0884358 (UMLS 2011AA Property)
    C15329 (NCI Thesaurus ObjectClass)
    C0543467 (UMLS 2011AA ObjectClass)
    C15354 (NCI Thesaurus Property)
    C0085076 (UMLS 2011AA Property)
    CL.3
    Code List
    Type of breast reconstruction (If yes, mark all that apply)
    CL Item
    Breast Implant (Breast Implant)
    C28335 (NCI Thesaurus)
    C0179412 (UMLS 2011AA)
    CL Item
    Breast Tissue Expander (Tissue Expanders)
    C85840 (NCI Thesaurus)
    C0588162 (UMLS 2011AA)
    CL Item
    Rotated Flap (Rotated flap)
    CL Item
    Free Flap (Free Flap)
    CL Item
    Other (Other)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    SurgicalProcedureBreastReconstructionPerformedSpecify
    Item
    Other, specify
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C38000 (NCI Thesaurus Property)
    C0884358 (UMLS 2011AA Property)
    C15329 (NCI Thesaurus ObjectClass)
    C0543467 (UMLS 2011AA ObjectClass)
    C15354 (NCI Thesaurus Property)
    C0085076 (UMLS 2011AA Property)
    Item Group
    Footer
    ResearchCommentsText
    Item
    Comments
    text
    C25704 (NCI Thesaurus ValueDomain)
    C1527021 (UMLS 2011AA ValueDomain)
    C15319 (NCI Thesaurus ObjectClass)
    C25393 (NCI Thesaurus Property)
    C0282411 (UMLS 2011AA Property)
    ResponsiblePersonName
    Item
    Person Completing Form
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C25657 (NCI Thesaurus ObjectClass)
    C1273518 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    FormCompleteDate
    Item
    Date Form Completed
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C40988 (NCI Thesaurus ObjectClass)
    C1516308 (UMLS 2011AA ObjectClass)
    C25250 (NCI Thesaurus Property)
    C0205197 (UMLS 2011AA Property)
    C25367 (NCI Thesaurus ValueDomain)
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