AmendedDataInd
Item
If this is a revised or corrected form, indicate by checking box
text
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
RTOGStudy
Item
RTOG Study
text
InstitutionName
Item
Institution Name
text
NCIInstitutionNumber
Item
Institution No.
text
PatientName,First
Item
Patient's Name
text
PatientStudyID,RegisteringGroup
Item
Patient's I.D. No.
text
RTBeginDate
Item
RADIATION THERAPY START DATE (External Beam)
date
RTEndDate
Item
RADIATION THERAPY END DATE (External Beam)
date
RTTotalDose
Item
TOTAL DOSE (Gy)
float
Item
WERE THERE ANY UNSCHEDULED INTERRUPTIONS IN RADIATION THERAPY (External Beam)
text
Code List
WERE THERE ANY UNSCHEDULED INTERRUPTIONS IN RADIATION THERAPY (External Beam)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes, Due To Toxicity (Yes, due to toxicity)
CL Item
Yes, For Other Reasons, Specify (Yes, due to other reason)
RadiationTherapyUnscheduledInterruptionSpecify
Item
Specify RT interruption reason
text
C15313 (NCI Thesaurus ObjectClass)
C1522449 (UMLS 2011AA ObjectClass)
C25594 (NCI Thesaurus Property)
C1518422 (UMLS 2011AA Property)
C25211 (NCI Thesaurus Property-2)
C0086960 (UMLS 2011AA Property-2)
C25542 (NCI Thesaurus Property-3)
C1512900 (UMLS 2011AA Property-3)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
Item
REASON EXTERNAL RADIATION THERAPY TREATMENT ENDED
text
Code List
REASON EXTERNAL RADIATION THERAPY TREATMENT ENDED
CL Item
Treatment Completed Per Protocol Criteria (Treatment completed per protocol criteria)
CL Item
Disease Progression, Relapse During Active Treatment (Disease progression, relapse during active treatment)
CL Item
Toxicity/side Effects/complications (Toxicity/side effects/complications)
CL Item
Death On Study (Death on study)
CL Item
Patient Withdrawal Or Refusal After Beginning Protocol Therapy (Patient withdrawal or refusal after beginning protocol therapy)
CL Item
Patient Withdrawal Or Refusal Prior To Beginning Protocol Therapy (Patient withdrawal or refusal prior to beginning protocol therapy)
CL Item
Alternative Therapy (Alternative therapy, specify)
CL Item
Other (Other complicating disease, specify)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
Other, Specify (Other, specify)
Alternativetherapy,specify(reasonradiationtherapyended)
Item
Alternative therapy, specify
text
OffTreatmentReason,ComplicatingDisease
Item
Other complicating disease, specify
text
Other,specify
Item
Other, specify
text
Intensity-ModulatedRadiationTherapyAdministrationInd-3
Item
DID TREATMENT INCLUDE IMRT
boolean
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C16135 (NCI Thesaurus ObjectClass)
C1512814 (UMLS 2011AA ObjectClass)
C25409 (NCI Thesaurus Property)
C1533734 (UMLS 2011AA Property)
Item
IF BRACHYTHERAPY NOT UTILIZED, PROVIDE REASON
text
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
C25601 (NCI Thesaurus Property)
C1518544 (UMLS 2011AA Property)
C15195 (NCI Thesaurus ObjectClass)
C0006098 (UMLS 2011AA ObjectClass)
Code List
IF BRACHYTHERAPY NOT UTILIZED, PROVIDE REASON
CL Item
Na Dose Administered Within Protocol Specifications (NA Dose administered within protocol specifications)
CL Item
Not Technically Feasible (Not technically feasible)
CL Item
Patient Refused (Patient refused)
CL Item
Inadequate To Treat Extent Of Disease (Inadequate to treat extent of disease)
CL Item
Md Preference (MD preference)
CL Item
Progression Or Relapse (Progression or relapse)
CL Item
Toxicity Or Treatment Reaction (Toxicity or treatment reaction)
CL Item
Death (Death)
C28554 (NCI Thesaurus)
C0011065 (UMLS 2011AA)
CL Item
Alternative Rx Given, Specify Rx (Alternative Rx given, specify Rx)
CL Item
Other Reason, Specify (Other reason, specify)
specifyRx(alternativeRxgiven)
Item
specify Rx (alternative Rx given)
text
Other,specify(reasontreatmentended)
Item
Other reason, specify
text
Item
ISOTOPE TYPE
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL Item
Other, Specify (Other, specify)
DATEOFPRE-IMPLANTTRUSSTUDY
Item
DATE OF PRE-IMPLANT TRUS STUDY
text
DATEOFIMPLANT
Item
DATE OF IMPLANT
text
CTPostBrachytherapyDate
Item
DATE OF POST-IMPLANT CT (BASIC DOSIMETRY INFORMATION)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C17204 (NCI Thesaurus ObjectClass)
C0040405 (UMLS 2011AA ObjectClass)
C38008 (NCI Thesaurus Property)
C0687676 (UMLS 2011AA Property)
CL054378 (NCI Metathesaurus Property)
AVERAGEACTIVITYPERSEEDASMEASUREDBYINSTITUTION
Item
AVERAGE ACTIVITY PER SEED AS MEASURED BY INSTITUTION (Activity)
text
AssessmentDate
Item
Date
date
MIDPOINTAPPARENTACTIVITYSTATEDBYTHEVENDOR
Item
MIDPOINT APPARENT ACTIVITY STATED BY THE VENDOR (Activity)
text
NUMBEROFSEEDSUSED
Item
NUMBER OF SEEDS USED
text
NUMBEROFNEEDLESUSED
Item
NUMBER OF NEEDLES USED
text
Item
SEED LOSS (were seeds expelled within the 3 weeks of implant? If yes, report details in Comments section)
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25560 (NCI Thesaurus Property)
C0745777 (UMLS 2011AA Property)
C67446 (NCI Thesaurus Property-2)
C1882540 (UMLS 2011AA Property-2)
C15195 (NCI Thesaurus ObjectClass)
C0006098 (UMLS 2011AA ObjectClass)
Code List
SEED LOSS (were seeds expelled within the 3 weeks of implant? If yes, report details in Comments section)
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
WERE DOSE VOLUME HISTOGRAMS DONE
text
Code List
WERE DOSE VOLUME HISTOGRAMS DONE
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
WAS AN INDWELLING URINARY CATHETER INSERTED SINCE IMPLANT
text
C15329 (NCI Thesaurus ObjectClass)
C0543467 (UMLS 2011AA ObjectClass)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C38008 (NCI Thesaurus Property-2)
C0687676 (UMLS 2011AA Property-2)
C15195 (NCI Thesaurus Property-3)
C0006098 (UMLS 2011AA Property-3)
C17446 (NCI Thesaurus Property-4)
C0085590 (UMLS 2011AA Property-4)
C12417 (NCI Thesaurus Property-5)
C0041967 (UMLS 2011AA Property-5)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
Code List
WAS AN INDWELLING URINARY CATHETER INSERTED SINCE IMPLANT
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)
DATEINSERTED
Item
DATE INSERTED (Provide estimate if exact date unknown)
text
DATEREMOVED
Item
DATE REMOVED (Provide estimate if exact date unknown)
text
Comments
Item
COMMENTS
text
Signature
Item
Signature
text
FormCompletionDate,Original
Item
Date
date