ID

10557

Descrizione

T1 Radiation Therapy Oncology Group Phase III Randomized Study of Intermediate Risk Prostate Cancer Radiotherapy Form NCT00063882 Interstitial Brachytherapy With or Without External-Beam Radiation Therapy in Treating Patients With Prostate Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AA89543F-5C0D-58C5-E034-0003BA12F5E7

collegamento

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AA89543F-5C0D-58C5-E034-0003BA12F5E7

Keywords

versioni (3)
  1. 19/09/12 19/09/12 -
  2. 28/05/15 28/05/15 -
  3. 03/06/15 03/06/15 -
Caricato su

3 giugno 2015

DOI

Per favore, per richiedere un accesso.

Licenza

Creative Commons BY-NC 3.0 Legacy
Commenti del modello :

Puoi commentare il modello dati qui. Tramite i fumetti nei gruppi di articoli e articoli è possibile aggiungere commenti a quelli in modo specifico.

Torna ai commenti del modello
Commenti del gruppo di articoli per :

Commenti dell'articolo per :

Per scaricare i modelli di dati devi essere registrato. Per favore accesso o registrati GRATIS.

T1 Radiation Therapy Oncology Group Phase III Randomized Study of Intermediate Risk Prostate Cancer Radiotherapy Form NCT00063882

Inglese

INSTRUCTIONS: Submit this form at the completion of protocol therapy. Use -1 for unknown or not applicable unless otherwise specified in the codetable. All dates to be reported mm-dd-yyyy unless otherwise indicated. A copy must be submitted to the RTOG

1 moduli  
Header Module
Descrizione

Header Module

If this is a revised or corrected form, indicate by checking box
Descrizione

AmendedDataInd

Tipo di dati

text

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
RTOG clinical trial administrative data
Descrizione

RTOG clinical trial administrative data

RTOG Study
Descrizione

RTOGStudy

Tipo di dati

text

Case #
Descrizione

Case#

Tipo di dati

text

Institution Name
Descrizione

InstitutionName

Tipo di dati

text

Institution No.
Descrizione

NCIInstitutionNumber

Tipo di dati

text

Patient's Name
Descrizione

PatientName,First

Tipo di dati

text

Patient's I.D. No.
Descrizione

PatientStudyID,RegisteringGroup

Tipo di dati

text

RADIOTHERAPY documentation
Descrizione

RADIOTHERAPY documentation

RADIATION THERAPY START DATE (External Beam)
Descrizione

RTBeginDate

Tipo di dati

date

RADIATION THERAPY END DATE (External Beam)
Descrizione

RTEndDate

Tipo di dati

date

TOTAL DOSE (Gy)
Descrizione

RTTotalDose

Tipo di dati

float

WERE THERE ANY UNSCHEDULED INTERRUPTIONS IN RADIATION THERAPY (External Beam)
Descrizione

RTInterruptionsInd

Tipo di dati

text

Specify RT interruption reason
Descrizione

RadiationTherapyUnscheduledInterruptionSpecify

Tipo di dati

text

Alias
NCI Thesaurus ObjectClass
C15313
UMLS 2011AA ObjectClass
C1522449
NCI Thesaurus Property
C25594
UMLS 2011AA Property
C1518422
NCI Thesaurus Property-2
C25211
UMLS 2011AA Property-2
C0086960
NCI Thesaurus Property-3
C25542
UMLS 2011AA Property-3
C1512900
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
REASON EXTERNAL RADIATION THERAPY TREATMENT ENDED
Descrizione

OffTreatmentReason

Tipo di dati

text

Alternative therapy, specify
Descrizione

Alternativetherapy,specify(reasonradiationtherapyended)

Tipo di dati

text

Other complicating disease, specify
Descrizione

OffTreatmentReason,ComplicatingDisease

Tipo di dati

text

Other, specify
Descrizione

Other,specify

Tipo di dati

text

DID TREATMENT INCLUDE IMRT
Descrizione

Intensity-ModulatedRadiationTherapyAdministrationInd-3

Tipo di dati

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C16135
UMLS 2011AA ObjectClass
C1512814
NCI Thesaurus Property
C25409
UMLS 2011AA Property
C1533734
IF BRACHYTHERAPY NOT UTILIZED, PROVIDE REASON
Descrizione

BrachytherapyOff-TreatmentReason

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25638
UMLS 2011AA ValueDomain
C0392360
NCI Thesaurus Property
C25601
UMLS 2011AA Property
C1518544
NCI Thesaurus ObjectClass
C15195
UMLS 2011AA ObjectClass
C0006098
specify Rx (alternative Rx given)
Descrizione

specifyRx(alternativeRxgiven)

Tipo di dati

text

Other reason, specify
Descrizione

Other,specify(reasontreatmentended)

Tipo di dati

text

ISOTOPE TYPE
Descrizione

ISOTOPETYPE

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
DATE OF PRE-IMPLANT TRUS STUDY
Descrizione

DATEOFPRE-IMPLANTTRUSSTUDY

Tipo di dati

text

DATE OF IMPLANT
Descrizione

DATEOFIMPLANT

Tipo di dati

text

DATE OF POST-IMPLANT CT (BASIC DOSIMETRY INFORMATION)
Descrizione

CTPostBrachytherapyDate

Tipo di dati

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C17204
UMLS 2011AA ObjectClass
C0040405
NCI Thesaurus Property
C38008
UMLS 2011AA Property
C0687676
NCI Metathesaurus Property
CL054378
AVERAGE ACTIVITY PER SEED AS MEASURED BY INSTITUTION (Activity)
Descrizione

AVERAGEACTIVITYPERSEEDASMEASUREDBYINSTITUTION

Tipo di dati

text

Date
Descrizione

AssessmentDate

Tipo di dati

date

MIDPOINT APPARENT ACTIVITY STATED BY THE VENDOR (Activity)
Descrizione

MIDPOINTAPPARENTACTIVITYSTATEDBYTHEVENDOR

Tipo di dati

text

NUMBER OF SEEDS USED
Descrizione

NUMBEROFSEEDSUSED

Tipo di dati

text

NUMBER OF NEEDLES USED
Descrizione

NUMBEROFNEEDLESUSED

Tipo di dati

text

SEED LOSS (were seeds expelled within the 3 weeks of implant? If yes, report details in Comments section)
Descrizione

BrachytherapyRadioactiveSeedImplantDosingUnitLostInd-3

Tipo di dati

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus Property
C25560
UMLS 2011AA Property
C0745777
NCI Thesaurus Property-2
C67446
UMLS 2011AA Property-2
C1882540
NCI Thesaurus ObjectClass
C15195
UMLS 2011AA ObjectClass
C0006098
WERE DOSE VOLUME HISTOGRAMS DONE
Descrizione

WEREDOSEVOLUMEHISTOGRAMSDONE

Tipo di dati

text

WAS AN INDWELLING URINARY CATHETER INSERTED SINCE IMPLANT
Descrizione

SurgicalProcedureCatheterUrethraPostBrachytherapyPerformedTherapyInd-3

Tipo di dati

text

Alias
NCI Thesaurus ObjectClass
C15329
UMLS 2011AA ObjectClass
C0543467
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
NCI Thesaurus Property-2
C38008
UMLS 2011AA Property-2
C0687676
NCI Thesaurus Property-3
C15195
UMLS 2011AA Property-3
C0006098
NCI Thesaurus Property-4
C17446
UMLS 2011AA Property-4
C0085590
NCI Thesaurus Property-5
C12417
UMLS 2011AA Property-5
C0041967
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
DATE INSERTED (Provide estimate if exact date unknown)
Descrizione

DATEINSERTED

Tipo di dati

text

DATE REMOVED (Provide estimate if exact date unknown)
Descrizione

DATEREMOVED

Tipo di dati

text

Footer module
Descrizione

Footer module

COMMENTS
Descrizione

Comments

Tipo di dati

text

Signature
Descrizione

Signature

Tipo di dati

text

Date
Descrizione

FormCompletionDate,Original

Tipo di dati

date

Ccrr Module For T1 Radiation Therapy Oncology Group Phase Iii Randomized Study Of Intermediate Risk Prostate Cancer Radiotherapy Form
Descrizione

Ccrr Module For T1 Radiation Therapy Oncology Group Phase Iii Randomized Study Of Intermediate Risk Prostate Cancer Radiotherapy Form

Ritorna all'inizio della pagina

Similar models

INSTRUCTIONS: Submit this form at the completion of protocol therapy. Use -1 for unknown or not applicable unless otherwise specified in the codetable. All dates to be reported mm-dd-yyyy unless otherwise indicated. A copy must be submitted to the RTOG

1 moduli
Name
genere
Description | Question | Decode (Coded Value)
Tipo di dati
Alias
Item Group
Header Module
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)
Item Group
RTOG clinical trial administrative data
RTOGStudy
Item
RTOG Study
text
Case#
Item
Case #
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
Item Group
RADIOTHERAPY documentation
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
CL.1
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
CL.2
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)
CL.4
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.5
Code List
ISOTOPE TYPE
CL Item
I-125 (I-125)
CL Item
Pd-103 (Pd-103)
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)
CL.6
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
CL.7
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)
CL.8
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
Item Group
Footer module
Comments
Item
COMMENTS
text
Signature
Item
Signature
text
FormCompletionDate,Original
Item
Date
date
Item Group
Ccrr Module For T1 Radiation Therapy Oncology Group Phase Iii Randomized Study Of Intermediate Risk Prostate Cancer Radiotherapy Form
Ritorna all'inizio della pagina 

Contatto

Si prega di utilizzare questo modulo per feedback, domande e suggerimenti per miglioramenti.

I campi contrassegnati da * sono obbligatori.

Aiuto

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial