English

INSTRUCTIONS: Submit this form at the completion of protocol hormone therapy. Use -1 for unknown or not applicable unless otherwise specified in the code table. All dates to be reported mm-dd-yyyy unless otherwise indicated.

1 forms  
  1. StudyEvent: TF Radiation Therapy Oncology Group Phase III Randomized Study of Adjuvant Therapy for High Risk pT3NO Prostate Cancer Hormone Protocol Treatment Summary Form
    1. INSTRUCTIONS: Submit this form at the completion of protocol hormone therapy. Use -1 for unknown or not applicable unless otherwise specified in the code table. All dates to be reported mm-dd-yyyy unless otherwise indicated.
RTOG clinical trial administrative data
Description

RTOG clinical trial administrative data

RTOG Study
Description

RTOGStudy

Data type

text

Case #
Description

Case#

Data type

text

Institution Name
Description

InstitutionName

Data type

text

Institution No.
Description

InstitutionNo.

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
Patient Name, Last
Description

PatientName,Last

Data type

text

Patient Name, First
Description

PatientName,First

Data type

text

Amended Data
Description

AmendedData

Data type

text

Chemotherapy status
Description

Chemotherapy status

Agent (AGENT NAME)
Description

Agent

Data type

text

(if other, specify) (agent)
Description

(ifother,specify)(agent)

Data type

text

Agent total cumulative dose
Description

AgentTotalCumulativeDose

Data type

float

First Date above agent protocol therapy was given
Description

FirstDateaboveagentprotocoltherapywasgiven

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Last Date above agent protocol therapy was given
Description

LastDateaboveagentprotocoltherapywasgiven

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Reason treatment ended (REASON TREATMENT ENDED)
Description

OffTreatmentReason

Data type

text

(specify) (reason treatment ended)
Description

(specify)(reasontreatmentended)

Data type

text

Comment
Description

Comment

Comments
Description

Comments

Data type

text

Signature
Description

Signature

Data type

text

Date
Description

Date

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Ccrr Module For Tf Radiation Therapy Oncology Group Phase Iii Randomized Study Of Adjuvant Therapy For High Risk Pt3no Prostate Cancer Hormone Protocol Treatment Summary Form
Description

Ccrr Module For Tf Radiation Therapy Oncology Group Phase Iii Randomized Study Of Adjuvant Therapy For High Risk Pt3no Prostate Cancer Hormone Protocol Treatment Summary Form

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Similar models

INSTRUCTIONS: Submit this form at the completion of protocol hormone therapy. Use -1 for unknown or not applicable unless otherwise specified in the code table. All dates to be reported mm-dd-yyyy unless otherwise indicated.

1 forms
  1. StudyEvent: TF Radiation Therapy Oncology Group Phase III Randomized Study of Adjuvant Therapy for High Risk pT3NO Prostate Cancer Hormone Protocol Treatment Summary Form
    1. INSTRUCTIONS: Submit this form at the completion of protocol hormone therapy. Use -1 for unknown or not applicable unless otherwise specified in the code table. All dates to be reported mm-dd-yyyy unless otherwise indicated.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
RTOG clinical trial administrative data
RTOGStudy
Item
RTOG Study
text
Case#
Item
Case #
text
InstitutionName
Item
Institution Name
text
InstitutionNo.
Item
Institution No.
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
PatientName,Last
Item
Patient Name, Last
text
PatientName,First
Item
Patient Name, First
text
AmendedData
Item
Amended Data
text
Item Group
Chemotherapy status
Item
Agent (AGENT NAME)
text
CL.1
Code List
Agent (AGENT NAME)
CL Item
Zoladex (Zoladex)
CL Item
Lupron (Lupron)
C0701459 (NCI Metathesaurus)
CL Item
Suprafact (Suprafact)
CL Item
Flutamide (Flutamide)
C509 (NCI Thesaurus)
C0016384 (UMLS 2011AA)
CL Item
Casodex (Casodex)
C0591237 (NCI Metathesaurus)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
Unknown Or Not Applicable (Unknown or not applicable)
(ifother,specify)(agent)
Item
(if other, specify) (agent)
text
AgentTotalCumulativeDose
Item
Agent total cumulative dose
float
FirstDateaboveagentprotocoltherapywasgiven
Item
First Date above agent protocol therapy was given
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
LastDateaboveagentprotocoltherapywasgiven
Item
Last Date above agent protocol therapy was given
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Item
Reason treatment ended (REASON TREATMENT ENDED)
text
CL.2
Code List
Reason treatment ended (REASON 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 below)
CL Item
Other complicating disease, specify below (Other complicating disease, specify below)
CL Item
Other, Specify (Other, specify below)
CL Item
Unknown or not applicable (Unknown or not applicable)
(specify)(reasontreatmentended)
Item
(specify) (reason treatment ended)
text
Item Group
Comment
Comments
Item
Comments
text
Signature
Item
Signature
text
Date
Item
Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Item Group
Ccrr Module For Tf Radiation Therapy Oncology Group Phase Iii Randomized Study Of Adjuvant Therapy For High Risk Pt3no Prostate Cancer Hormone Protocol Treatment Summary Form
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