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10552

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NCT00023829 FF Radiation Therapy Oncology Group Phase III Randomized Study of Adjuvant Therapy for High Risk pT3NO Prostate Cancer Long Term Follow-up Form Adjuvant Radiation Therapy Plus Hormone Therapy Compared With Radiation Therapy Alone in Treating Patients With Stage II or Stage III Prostate Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A56DBAD2-8C43-0FEF-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A56DBAD2-8C43-0FEF-E034-080020C9C0E0

Stichworte

  1. 19.09.12 19.09.12 -
  2. 28.05.15 28.05.15 -
  3. 03.06.15 03.06.15 -
Hochgeladen am

3. Juni 2015

DOI

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    NCT00023829 FF Radiation Therapy Oncology Group Phase III Randomized Study of Adjuvant Therapy for High Risk pT3NO Prostate Cancer Long Term Follow-up Form

    Instructions: Submit this form at the appropriate followup interval. Use -1 for unknown or not applicable unless otherwise specified in codetable. All dates to be reported mm-dd-yyyy unless otherwise indicated. This form may be used after 5 years provided none of the following events have occurred since the last submitted report: change in disease status; new or continuing toxicity; new therapy for cancer, the patient expired. If any of these events have occurred, submit the standard F1 form.

    RTOG clinical trial administrative data
    Beschreibung

    RTOG clinical trial administrative data

    RTOG Study
    Beschreibung

    RTOGStudy

    Datentyp

    text

    Case #
    Beschreibung

    Case#

    Datentyp

    text

    Institution
    Beschreibung

    Institution

    Datentyp

    text

    Institution No.
    Beschreibung

    InstitutionNo.

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337 (undefined)
    UMLS 2011AA ValueDomain
    C0237753 (Numbers)
    SNOMED
    260299005
    LOINC
    LP6841-3
    Patient Name, Last
    Beschreibung

    PatientName,Last

    Datentyp

    text

    Patient Name, First (1)
    Beschreibung

    PatientName,First

    Datentyp

    text

    Amended Data
    Beschreibung

    AmendedData

    Datentyp

    text

    Medical history
    Beschreibung

    Medical history

    PATIENT'S VITAL STATUS (2)
    Beschreibung

    Patient'sVitalStatus

    Datentyp

    text

    DATE OF LAST CONTACT OR DEATH (3)
    Beschreibung

    DeathDate/LastContactDate

    Datentyp

    date

    CAUSE OF DEATH (IF DEAD)
    Beschreibung

    Causeofdeath

    Datentyp

    text

    Due to other cause, specify (cause of death) (4)
    Beschreibung

    PrimaryCauseDeathOtherReasonSpecify

    Datentyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    UMLS 2011AA ObjectClass
    C0030705 (Patients)
    SNOMED
    116154003
    NCI Thesaurus ObjectClass-2
    C25251 (undefined)
    UMLS 2011AA ObjectClass-2
    C0205225 (Primary)
    SNOMED
    63161005
    LOINC
    LA21208-6
    NCI Metathesaurus ObjectClass
    C0007465 (Cause of Death)
    SNOMED
    16100001
    LOINC
    LA10595-9
    NCI Thesaurus Property
    C17649 (undefined)
    UMLS 2011AA Property
    C0205394 (Other)
    SNOMED
    74964007
    LOINC
    LP21049-9
    NCI Thesaurus Property-2
    C25365 (undefined)
    UMLS 2011AA Property-2
    C0678257 (Description)
    LOINC
    LP6800-9
    NCI Thesaurus ValueDomain
    C25685 (undefined)
    UMLS 2011AA ValueDomain
    C1521902 (To specify)
    HAS THE PATIENT HAD A DOCUMENTED CLINICAL ASSESSMENT FOR PROSTATE CANCER SINCE SUBMISSION OF THE PREVIOUS FOLLOWUP FORM?
    Beschreibung

    HASTHEPATIENTHADADOCUMENTEDCLINICALASSESSMENTFORPROSTATECANCERSINCESUBMISSIONOFTHEPREVIOUSFOLLOWUPFORM?

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704 (undefined)
    UMLS 2011AA ValueDomain
    C1527021 (Text)
    LOINC
    LP6885-0
    NCI Thesaurus ValueDomain-2
    C25180 (undefined)
    UMLS 2011AA ValueDomain-2
    C1522602 (Indicator)
    DATE OF LAST CLINICAL ASSESSMENT (5 PROSTATE: PSA MEASUREMENTS)
    Beschreibung

    CancerFollow-upStatusDate

    Datentyp

    date

    Alias
    NCI Thesaurus ObjectClass
    C2991 (undefined)
    UMLS 2011AA ObjectClass
    C0012634 (Disease)
    SNOMED
    64572001
    LOINC
    LP21006-9
    NCI Thesaurus Property
    C25365 (undefined)
    UMLS 2011AA Property
    C0678257 (Description)
    LOINC
    LP6800-9
    Follow-up PSA Value(s)
    Beschreibung

    Follow-upPSAValue(s)

    Datentyp

    text

    Date of PSA Assessment(s) (6)
    Beschreibung

    DateofPSAAssessment(s)

    Datentyp

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164 (undefined)
    UMLS 2011AA ValueDomain
    C0011008 (Date in time)
    SNOMED
    410671006
    HAS CLINICAL DISEASE STATUS local, regional, distant CHANGED SINCE THE LAST REPORT? (7 HAS A NEW PRIMARY CANCER OR MDS MYELODYSPLASTIC SYNDROME BEEN DIAGNOSED THAT HAS NOT BEEN PREVIOUSLY REPORTED?)
    Beschreibung

    HASCLINICALDISEASESTATUSlocal,regional,distantCHANGEDSINCETHELASTREPORT?

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C38148 (undefined)
    UMLS 2011AA ValueDomain
    C1512699 (Yes, No, or Unknown Response)
    New Primary Site
    Beschreibung

    NewCancerDiagnosisAnatomicSite

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C13717 (undefined)
    UMLS 2011AA ValueDomain
    C1515974 (Anatomic Site)
    NCI Thesaurus ObjectClass
    C25586 (undefined)
    UMLS 2011AA ObjectClass
    C0205314 (New)
    SNOMED
    7147002
    LOINC
    LA9039-4
    NCI Thesaurus ObjectClass-2
    C9305 (undefined)
    UMLS 2011AA ObjectClass-2
    C0006826 (Malignant Neoplasms)
    SNOMED
    363346000
    LOINC
    LP100805-3
    NCI Thesaurus Property
    C15220 (undefined)
    UMLS 2011AA Property
    C0011900 (Diagnosis)
    SNOMED
    439401001
    LOINC
    LP30831-9
    New Primary Cancer Date (Specify in comments new primary site)
    Beschreibung

    NewPrimaryCancerDate

    Datentyp

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164 (undefined)
    UMLS 2011AA ValueDomain
    C0011008 (Date in time)
    SNOMED
    410671006
    RENAL/GENITOURINARY TOXICITY ADVERSE EVENT REPORTS (AER) (Use CTC 2.0 to code severity)
    Beschreibung

    RENAL/GENITOURINARYTOXICITYADVERSEEVENTREPORTS(AER)

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704 (undefined)
    UMLS 2011AA ValueDomain
    C1527021 (Text)
    LOINC
    LP6885-0
    NCI Thesaurus ValueDomain-2
    C25180 (undefined)
    UMLS 2011AA ValueDomain-2
    C1522602 (Indicator)
    URINARY INCONTINENCE, Severity Grade (0-3)
    Beschreibung

    URINARYINCONTINENCE,SeverityGrade

    Datentyp

    text

    URINARY INCONTINENCE, Attribution (see table below)
    Beschreibung

    URINARYINCONTINENCE,Attribution

    Datentyp

    text

    Specify if other cause (urinary incontinence, attribution)
    Beschreibung

    Specifyifothercause(urinaryincontinence,attribution)

    Datentyp

    text

    URINARY INCONTINENCE, AER Begin Date
    Beschreibung

    URINARYINCONTINENCE,AERBeginDate

    Datentyp

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164 (undefined)
    UMLS 2011AA ValueDomain
    C0011008 (Date in time)
    SNOMED
    410671006
    URINARY FREQUENCY/URGENCY, Severity Grade (0-3)
    Beschreibung

    URINARYFREQUENCY/URGENCY,SeverityGrade

    Datentyp

    text

    URINARY FREQUENCY/URGENCY, Attribution (see table below)
    Beschreibung

    URINARYFREQUENCY/URGENCY,Attribution

    Datentyp

    text

    Specify if other cause (urinary frequency/urgency, attribution)
    Beschreibung

    Specifyifothercause(urinaryfrequency/urgency,attribution)

    Datentyp

    text

    URINARY FREQUENCY/URGENCY, AER Begin Date
    Beschreibung

    URINARYFREQUENCY/URGENCY,AERBeginDate

    Datentyp

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164 (undefined)
    UMLS 2011AA ValueDomain
    C0011008 (Date in time)
    SNOMED
    410671006
    ERECTILE IMPOTENCE, Severity Grade (0-3)
    Beschreibung

    ERECTILEIMPOTENCE,SeverityGrade

    Datentyp

    text

    ERECTILE IMPOTENCE, Attribution (see table below)
    Beschreibung

    ERECTILEIMPOTENCE,Attribution

    Datentyp

    text

    Specify if other cause (erectile impotence, attribution)
    Beschreibung

    Specifyifothercause(erectileimpotence,attribution)

    Datentyp

    text

    ERECTILE IMPOTENCE, AER Begin Date (9)
    Beschreibung

    ERECTILEIMPOTENCE,AERBeginDate

    Datentyp

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164 (undefined)
    UMLS 2011AA ValueDomain
    C0011008 (Date in time)
    SNOMED
    410671006
    NEW OR CONTINUING TOXICITY (>= Severity Grade 3) SINCE THE LAST REPORT? (10)
    Beschreibung

    NEWORCONTINUINGTOXICITY(>=SeverityGrade3)SINCETHELASTREPORT?

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704 (undefined)
    UMLS 2011AA ValueDomain
    C1527021 (Text)
    LOINC
    LP6885-0
    NCI Thesaurus ValueDomain-2
    C25180 (undefined)
    UMLS 2011AA ValueDomain-2
    C1522602 (Indicator)
    DID THE PATIENT RECEIVE ANY NON-PROTOCOL PROSTATE CANCER THERAPY SINCE THE LAST FOLLOW-UP?
    Beschreibung

    DIDTHEPATIENTRECEIVEANYNON-PROTOCOLPROSTATECANCERTHERAPYSINCETHELASTFOLLOW-UP?

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704 (undefined)
    UMLS 2011AA ValueDomain
    C1527021 (Text)
    LOINC
    LP6885-0
    NCI Thesaurus ValueDomain-2
    C25180 (undefined)
    UMLS 2011AA ValueDomain-2
    C1522602 (Indicator)
    COMMENTS
    Beschreibung

    Comments

    Datentyp

    text

    SIGNATURE
    Beschreibung

    Signature

    Datentyp

    text

    DATE
    Beschreibung

    Date

    Datentyp

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164 (undefined)
    UMLS 2011AA ValueDomain
    C0011008 (Date in time)
    SNOMED
    410671006
    Ccrr Module For Ff Radiation Therapy Oncology Group Phase Iii Randomized Study Of Adjuvant Therapy For High Risk Pt3no Prostate Cancer Long Term Follow-up Form
    Beschreibung

    Ccrr Module For Ff Radiation Therapy Oncology Group Phase Iii Randomized Study Of Adjuvant Therapy For High Risk Pt3no Prostate Cancer Long Term Follow-up Form

    Ähnliche Modelle

    Instructions: Submit this form at the appropriate followup interval. Use -1 for unknown or not applicable unless otherwise specified in codetable. All dates to be reported mm-dd-yyyy unless otherwise indicated. This form may be used after 5 years provided none of the following events have occurred since the last submitted report: change in disease status; new or continuing toxicity; new therapy for cancer, the patient expired. If any of these events have occurred, submit the standard F1 form.

    Name
    Typ
    Description | Question | Decode (Coded Value)
    Datentyp
    Alias
    Item Group
    RTOG clinical trial administrative data
    RTOGStudy
    Item
    RTOG Study
    text
    Case#
    Item
    Case #
    text
    Institution
    Item
    Institution
    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 (1)
    text
    AmendedData
    Item
    Amended Data
    text
    Item Group
    Medical history
    Item
    PATIENT'S VITAL STATUS (2)
    text
    Code List
    PATIENT'S VITAL STATUS (2)
    CL Item
    Alive (Alive)
    CL Item
    Dead (Dead)
    CL Item
    Unknown or not applicable (Unknown or not applicable)
    DeathDate/LastContactDate
    Item
    DATE OF LAST CONTACT OR DEATH (3)
    date
    Item
    CAUSE OF DEATH (IF DEAD)
    text
    Code List
    CAUSE OF DEATH (IF DEAD)
    CL Item
    Due To This Disease (Due to this disease)
    CL Item
    Due To Protocol Treatment (Due to protocol treatment)
    CL Item
    Due to other cause, specify (Due to other cause, specify)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    PrimaryCauseDeathOtherReasonSpecify
    Item
    Due to other cause, specify (cause of death) (4)
    text
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25251 (NCI Thesaurus ObjectClass-2)
    C0205225 (UMLS 2011AA ObjectClass-2)
    C0007465 (NCI Metathesaurus ObjectClass)
    C17649 (NCI Thesaurus Property)
    C0205394 (UMLS 2011AA Property)
    C25365 (NCI Thesaurus Property-2)
    C0678257 (UMLS 2011AA Property-2)
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    Item
    HAS THE PATIENT HAD A DOCUMENTED CLINICAL ASSESSMENT FOR PROSTATE CANCER SINCE SUBMISSION OF THE PREVIOUS FOLLOWUP FORM?
    text
    C25704 (NCI Thesaurus ValueDomain)
    C1527021 (UMLS 2011AA ValueDomain)
    C25180 (NCI Thesaurus ValueDomain-2)
    C1522602 (UMLS 2011AA ValueDomain-2)
    Code List
    HAS THE PATIENT HAD A DOCUMENTED CLINICAL ASSESSMENT FOR PROSTATE CANCER SINCE SUBMISSION OF THE PREVIOUS FOLLOWUP FORM?
    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)
    CancerFollow-upStatusDate
    Item
    DATE OF LAST CLINICAL ASSESSMENT (5 PROSTATE: PSA MEASUREMENTS)
    date
    C2991 (NCI Thesaurus ObjectClass)
    C0012634 (UMLS 2011AA ObjectClass)
    C25365 (NCI Thesaurus Property)
    C0678257 (UMLS 2011AA Property)
    Follow-upPSAValue(s)
    Item
    Follow-up PSA Value(s)
    text
    DateofPSAAssessment(s)
    Item
    Date of PSA Assessment(s) (6)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    Item
    HAS CLINICAL DISEASE STATUS local, regional, distant CHANGED SINCE THE LAST REPORT? (7 HAS A NEW PRIMARY CANCER OR MDS MYELODYSPLASTIC SYNDROME BEEN DIAGNOSED THAT HAS NOT BEEN PREVIOUSLY REPORTED?)
    text
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    Code List
    HAS CLINICAL DISEASE STATUS local, regional, distant CHANGED SINCE THE LAST REPORT? (7 HAS A NEW PRIMARY CANCER OR MDS MYELODYSPLASTIC SYNDROME BEEN DIAGNOSED THAT HAS NOT BEEN PREVIOUSLY REPORTED?)
    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
    New Primary Site
    text
    C13717 (NCI Thesaurus ValueDomain)
    C1515974 (UMLS 2011AA ValueDomain)
    C25586 (NCI Thesaurus ObjectClass)
    C0205314 (UMLS 2011AA ObjectClass)
    C9305 (NCI Thesaurus ObjectClass-2)
    C0006826 (UMLS 2011AA ObjectClass-2)
    C15220 (NCI Thesaurus Property)
    C0011900 (UMLS 2011AA Property)
    Code List
    New Primary Site
    CL Item
    None (None)
    C41132 (NCI Thesaurus)
    C0549184 (UMLS 2011AA)
    CL Item
    Aml/mds (AML/MDS)
    C9441 (NCI Thesaurus)
    CL Item
    Bcc (BCC)
    CL Item
    Bladder (Bladder)
    C12414 (NCI Thesaurus)
    C0005682 (UMLS 2011AA)
    CL Item
    Brain (Brain)
    C12439 (NCI Thesaurus)
    C0006104 (UMLS 2011AA)
    CL Item
    Colorectal (Colorectal)
    C13363 (NCI Thesaurus)
    C0555952 (UMLS 2011AA)
    CL Item
    Esophageal (Esophageal)
    C37950 (NCI Thesaurus)
    C1522619 (UMLS 2011AA)
    CL Item
    Gastric (Gastric)
    C13307 (NCI Thesaurus)
    C1704242 (UMLS 2011AA)
    CL Item
    Liver (Liver)
    C12392 (NCI Thesaurus)
    C0023884 (UMLS 2011AA)
    CL Item
    Lung (Lung)
    C12468 (NCI Thesaurus)
    C0024109 (UMLS 2011AA)
    CL Item
    Melanoma (Melanoma)
    C3224 (NCI Thesaurus)
    C0025202 (UMLS 2011AA)
    CL Item
    Nhl (NHL)
    CL Item
    Pancreatic (Pancreatic)
    C25726 (NCI Thesaurus)
    C0030274 (UMLS 2011AA)
    CL Item
    Renal (Renal)
    C25225 (NCI Thesaurus)
    C0022646 (UMLS 2011AA)
    CL Item
    Squamous-skin (Squamous-Skin)
    CL Item
    Other Hematologic, Specify (Other Hematologic, specify)
    CL Item
    Other Solid, Specify (Other solid, specify)
    CL Item
    Unknown Primary (Unknown primary)
    NewPrimaryCancerDate
    Item
    New Primary Cancer Date (Specify in comments new primary site)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    Item
    RENAL/GENITOURINARY TOXICITY ADVERSE EVENT REPORTS (AER) (Use CTC 2.0 to code severity)
    text
    C25704 (NCI Thesaurus ValueDomain)
    C1527021 (UMLS 2011AA ValueDomain)
    C25180 (NCI Thesaurus ValueDomain-2)
    C1522602 (UMLS 2011AA ValueDomain-2)
    Code List
    RENAL/GENITOURINARY TOXICITY ADVERSE EVENT REPORTS (AER) (Use CTC 2.0 to code severity)
    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
    URINARY INCONTINENCE, Severity Grade (0-3)
    text
    Code List
    URINARY INCONTINENCE, Severity Grade (0-3)
    CL Item
    0 (0)
    C0919414 (NCI Metathesaurus)
    CL Item
    1 (1)
    CL Item
    2 (2)
    C66833 (NCI Thesaurus)
    C0205448 (UMLS 2011AA)
    CL Item
    3 (3)
    Item
    URINARY INCONTINENCE, Attribution (see table below)
    text
    Code List
    URINARY INCONTINENCE, Attribution (see table below)
    CL Item
    Radiotherapy only (Radiotherapy only)
    CL Item
    Combined modality (Hormone, RT) (Combined modality (Hormone, RT))
    CL Item
    Tumor and Rx (Tumor and Rx)
    CL Item
    Hormones (Hormones)
    CL Item
    Other cause, specify (Other cause, specify)
    CL Item
    Unknown (Unknown)
    Specifyifothercause(urinaryincontinence,attribution)
    Item
    Specify if other cause (urinary incontinence, attribution)
    text
    URINARYINCONTINENCE,AERBeginDate
    Item
    URINARY INCONTINENCE, AER Begin Date
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    Item
    URINARY FREQUENCY/URGENCY, Severity Grade (0-3)
    text
    Code List
    URINARY FREQUENCY/URGENCY, Severity Grade (0-3)
    CL Item
    0 (0)
    C0919414 (NCI Metathesaurus)
    CL Item
    1 (1)
    CL Item
    2 (2)
    C66833 (NCI Thesaurus)
    C0205448 (UMLS 2011AA)
    CL Item
    3 (3)
    Item
    URINARY FREQUENCY/URGENCY, Attribution (see table below)
    text
    Code List
    URINARY FREQUENCY/URGENCY, Attribution (see table below)
    CL Item
    Radiotherapy only (Radiotherapy only)
    CL Item
    Combined modality (Hormone, RT) (Combined modality (Hormone, RT))
    CL Item
    Tumor and Rx (Tumor and Rx)
    CL Item
    Hormones (Hormones)
    CL Item
    Other cause, specify (Other cause, specify)
    CL Item
    Unknown (Unknown)
    Specifyifothercause(urinaryfrequency/urgency,attribution)
    Item
    Specify if other cause (urinary frequency/urgency, attribution)
    text
    URINARYFREQUENCY/URGENCY,AERBeginDate
    Item
    URINARY FREQUENCY/URGENCY, AER Begin Date
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    Item
    ERECTILE IMPOTENCE, Severity Grade (0-3)
    text
    Code List
    ERECTILE IMPOTENCE, Severity Grade (0-3)
    CL Item
    0 (0)
    C0919414 (NCI Metathesaurus)
    CL Item
    1 (1)
    CL Item
    2 (2)
    C66833 (NCI Thesaurus)
    C0205448 (UMLS 2011AA)
    CL Item
    3 (3)
    Item
    ERECTILE IMPOTENCE, Attribution (see table below)
    text
    Code List
    ERECTILE IMPOTENCE, Attribution (see table below)
    CL Item
    Radiotherapy only (Radiotherapy only)
    CL Item
    Combined modality (Hormone, RT) (Combined modality (Hormone, RT))
    CL Item
    Tumor and Rx (Tumor and Rx)
    CL Item
    Hormones (Hormones)
    CL Item
    Other cause, specify (Other cause, specify)
    CL Item
    Unknown (Unknown)
    Specifyifothercause(erectileimpotence,attribution)
    Item
    Specify if other cause (erectile impotence, attribution)
    text
    ERECTILEIMPOTENCE,AERBeginDate
    Item
    ERECTILE IMPOTENCE, AER Begin Date (9)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    Item
    NEW OR CONTINUING TOXICITY (>= Severity Grade 3) SINCE THE LAST REPORT? (10)
    text
    C25704 (NCI Thesaurus ValueDomain)
    C1527021 (UMLS 2011AA ValueDomain)
    C25180 (NCI Thesaurus ValueDomain-2)
    C1522602 (UMLS 2011AA ValueDomain-2)
    Code List
    NEW OR CONTINUING TOXICITY (>= Severity Grade 3) SINCE THE LAST REPORT? (10)
    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
    DID THE PATIENT RECEIVE ANY NON-PROTOCOL PROSTATE CANCER THERAPY SINCE THE LAST FOLLOW-UP?
    text
    C25704 (NCI Thesaurus ValueDomain)
    C1527021 (UMLS 2011AA ValueDomain)
    C25180 (NCI Thesaurus ValueDomain-2)
    C1522602 (UMLS 2011AA ValueDomain-2)
    Code List
    DID THE PATIENT RECEIVE ANY NON-PROTOCOL PROSTATE CANCER THERAPY SINCE THE LAST FOLLOW-UP?
    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)
    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 Ff Radiation Therapy Oncology Group Phase Iii Randomized Study Of Adjuvant Therapy For High Risk Pt3no Prostate Cancer Long Term Follow-up Form

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