ID

10559

Descripción

Radiation Therapy Oncology Group Follow-up Form Phase III Lung Prophylactic Cranial RT 10363 Radiation Therapy in Preventing CNS Metastases in Patients With Non-Small Cell Lung Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9EC372A6-6F06-05D5-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9EC372A6-6F06-05D5-E034-080020C9C0E0

Palabras clave

Versiones (5)
  1. 19/9/12 19/9/12 -
  2. 28/5/15 28/5/15 -
  3. 3/6/15 3/6/15 -
  4. 3/6/15 3/6/15 -
  5. 20/9/21 20/9/21 -
Subido en

3 de junio de 2015

DOI

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Licencia

Creative Commons BY-NC 3.0 Legacy
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Radiation Therapy Oncology Group Follow-up Form Phase III Lung Prophylactic Cranial RT 10363

Inglés

No Instruction available.

1 formularios  
  1. StudyEvent: Radiation Therapy Oncology Group Follow-up Form Phase III Lung Prophylactic Cranial RT
    1. No Instruction available.
Header Module
Descripción

Header Module

Case #
Descripción

Case#

Tipo de datos

text

Institution
Descripción

InstitutionName

Tipo de datos

text

Institution #
Descripción

NCIInstitutionNumber

Tipo de datos

text

Patient Name
Descripción

PatientName

Tipo de datos

text

Patient ID #
Descripción

PatientID#

Tipo de datos

text

Patient medical history
Descripción

Patient medical history

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

AmendedDataInd

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
DATE OF LAST CLINICAL ASSESSMENT
Descripción

CancerFollow-upStatusDate

Tipo de datos

date

Alias
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
PATIENT'S VITAL STATUS
Descripción

Patient'sVitalStatus

Tipo de datos

text

LAST CONTACT DATE / DEATH DATE
Descripción

DeathDate/LastContactDate

Tipo de datos

date

CAUSE OF DEATH
Descripción

DeathReason

Tipo de datos

text

Cause of death, other specify
Descripción

DeathReason,Specify

Tipo de datos

text

PERFORMANCE STATUS (ZUBROD)
Descripción

PerformanceStatus

Tipo de datos

text

HAS THE PATIENT DEVELOPED A FIRST PROGRESSION NOT PREVIOUSLY REPORTED? (Complete Q6 A and B)
Descripción

ProgressionInd

Tipo de datos

boolean

Sites of progression, lung
Descripción

Sitesofprogression,lung

Tipo de datos

text

Sites of progression, Lymph nodes (distant)
Descripción

Sitesofprogression,Lymphnodes(distant)

Tipo de datos

text

Sites of progression, pleural
Descripción

Sitesofprogression,pleural

Tipo de datos

text

Sites of progression, adrenals
Descripción

Sitesofprogression,adrenals

Tipo de datos

text

Sites of progression, liver
Descripción

Sitesofprogression,liver

Tipo de datos

text

Sites of progression, bone
Descripción

Sitesofprogression,bone

Tipo de datos

text

Sites of progression, CNS (Brain)
Descripción

Sitesofprogression,CNS(Brain)

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus Property
C25331
NCI Thesaurus ObjectClass
C12438
UMLS 2011AA ObjectClass
C0927232
CNS (Brain) Date
Descripción

ProgressionDate

Tipo de datos

date

Sites of progression, Other Specify
Descripción

Sitesofprogression,OtherSpecify

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ValueDomain-2
C17649
UMLS 2011AA ValueDomain-2
C0205394
Site of progression, other specify
Descripción

ProgressionSite,Other

Tipo de datos

text

PROGRESSION ASSESSMENT
Descripción

ProgressionAssessmentMethod

Tipo de datos

float

HAS A NEW PRIMARY OR MDS BEEN DIAGNOSED THAT HAS NOT BEEN PREVIOUSLY REPORTED?
Descripción

NewPrimaryCancerInd

Tipo de datos

text

NEW PRIMARY SITE
Descripción

NewPrimarySite

Tipo de datos

text

NEW PRIMARY HISTOLOGIC TYPE
Descripción

NewPrimary,HistologicType

Tipo de datos

text

DATE OF DIAGNOSIS
Descripción

NewPrimaryCancerDate

Tipo de datos

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
IS THE PATIENT RECEIVING ANY NON-PROTOCOL CANCER THERAPY NOT PREVIOUSLY REPORTED?
Descripción

Non-ProtocolTherapyInd

Tipo de datos

text

Non-Protocol RT
Descripción

Non-ProtocolRTInd

Tipo de datos

text

Date of first non-protocol therapy
Descripción

Non-ProtocolTherapyDate,First

Tipo de datos

date

Non-Protocol Surgery
Descripción

Non-protocolSurgeryPerformedInd-3

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
NCI Thesaurus ObjectClass
C15329
UMLS 2011AA ObjectClass
C0543467
NCI Thesaurus ObjectClass-2
C25590
UMLS 2011AA ObjectClass-2
C1518384
Non-Protocol Chemotherapy
Descripción

Non-ProtocolChemotherapyInd

Tipo de datos

text

Other Non-Protocol therapy
Descripción

OtherNon-ProtocolTherapyInd

Tipo de datos

text

Specify other
Descripción

OtherNon-ProtocolTherapyName

Tipo de datos

text

ANY CONTINUING OR NEW TREATMENT TOXICITIES RELATED TO PCI ONLY?
Descripción

ANYCONTINUINGORNEWTREATMENTTOXICITIESRELATEDTOPCIONLY?

Tipo de datos

text

LATE TREATMENT TOXICITY (occurred >90 days from start of XRT)
Descripción

LATETREATMENTTOXICITY

Tipo de datos

text

SEVERITY GRADE
Descripción

CTCAdverseEventGrade

Tipo de datos

text

TOXICITY
Descripción

Toxicity

Tipo de datos

text

#2 Toxicity Other, specify
Descripción

CTCAdverseEventTerm,Other

Tipo de datos

text

DATE OF 1ST OCCURRENCE OF GRADE=>3
Descripción

DATEOF1STOCCURRENCEOFGRADE=>3

Tipo de datos

date

Comments
Descripción

Comments

Signature of Person Completing This Form
Descripción

SignatureofPersonCompletingThisForm

Tipo de datos

text

Date
Descripción

FormCompletionDate,Original

Tipo de datos

date

Comments
Descripción

Comments

Tipo de datos

text

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Similar models

No Instruction available.

1 formularios
  1. StudyEvent: Radiation Therapy Oncology Group Follow-up Form Phase III Lung Prophylactic Cranial RT
    1. No Instruction available.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Item Group
Header Module
Case#
Item
Case #
text
InstitutionName
Item
Institution
text
NCIInstitutionNumber
Item
Institution #
text
PatientName
Item
Patient Name
text
PatientID#
Item
Patient ID #
text
Item Group
Patient medical history
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)
CancerFollow-upStatusDate
Item
DATE OF LAST CLINICAL ASSESSMENT
date
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
Item
PATIENT'S VITAL STATUS
text
CL.1
Code List
PATIENT'S VITAL STATUS
CL Item
Alive (Alive)
CL Item
Dead (Dead)
CL Item
Lost (Lost)
CL Item
Unknown (Unknown)
DeathDate/LastContactDate
Item
LAST CONTACT DATE / DEATH DATE
date
Item
CAUSE OF DEATH
text
CL.2
Code List
CAUSE OF DEATH
CL Item
Related to or probably related to the cancer under study (Related to or probably related to the cancer under study)
CL Item
(whether local, regional, or distant) ((whether local, regional, or distant))
CL Item
Related to or probably related to a second primary tumor (Related to or probably related to a second primary tumor)
CL Item
Related to or probably related to complications of protocol treatment (Related to or probably related to complications of protocol treatment)
CL Item
(explain in COMMENTS, requires a grade 5 toxicity code) ((explain in COMMENTS, requires a grade 5 toxicity code))
CL Item
Related to or probably related to complications of other treatment (Related to or probably related to complications of other treatment)
CL Item
Other cause, specify (Other cause, specify)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
DeathReason,Specify
Item
Cause of death, other specify
text
PerformanceStatus
Item
PERFORMANCE STATUS (ZUBROD)
text
ProgressionInd
Item
HAS THE PATIENT DEVELOPED A FIRST PROGRESSION NOT PREVIOUSLY REPORTED? (Complete Q6 A and B)
boolean
Item
Sites of progression, lung
text
CL.4
Code List
Sites of progression, lung
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown/not Evaluated (Unknown/not evaluated)
Item
Sites of progression, Lymph nodes (distant)
text
CL.5
Code List
Sites of progression, Lymph nodes (distant)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown/not Evaluated (Unknown/not evaluated)
Item
Sites of progression, pleural
text
CL.6
Code List
Sites of progression, pleural
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown/not Evaluated (Unknown/not evaluated)
Item
Sites of progression, adrenals
text
CL.7
Code List
Sites of progression, adrenals
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown/not Evaluated (Unknown/not evaluated)
Item
Sites of progression, liver
text
CL.8
Code List
Sites of progression, liver
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown/not Evaluated (Unknown/not evaluated)
Item
Sites of progression, bone
text
CL.9
Code List
Sites of progression, bone
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown/not Evaluated (Unknown/not evaluated)
Item
Sites of progression, CNS (Brain)
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25331 (NCI Thesaurus Property)
C12438 (NCI Thesaurus ObjectClass)
C0927232 (UMLS 2011AA ObjectClass)
CL.10
Code List
Sites of progression, CNS (Brain)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown/not Evaluated (Unknown/not evaluated)
ProgressionDate
Item
CNS (Brain) Date
date
Item
Sites of progression, Other Specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C17649 (NCI Thesaurus ValueDomain-2)
C0205394 (UMLS 2011AA ValueDomain-2)
CL.11
Code List
Sites of progression, Other Specify
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
Unknown/not Evaluated (Unknown/not evaluated)
ProgressionSite,Other
Item
Site of progression, other specify
text
ProgressionAssessmentMethod
Item
PROGRESSION ASSESSMENT
float
Item
HAS A NEW PRIMARY OR MDS BEEN DIAGNOSED THAT HAS NOT BEEN PREVIOUSLY REPORTED?
text
CL.13
Code List
HAS A NEW PRIMARY OR MDS 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)
NewPrimarySite
Item
NEW PRIMARY SITE
text
NewPrimary,HistologicType
Item
NEW PRIMARY HISTOLOGIC TYPE
text
NewPrimaryCancerDate
Item
DATE OF DIAGNOSIS
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Item
IS THE PATIENT RECEIVING ANY NON-PROTOCOL CANCER THERAPY NOT PREVIOUSLY REPORTED?
text
CL.14
Code List
IS THE PATIENT RECEIVING ANY NON-PROTOCOL CANCER THERAPY NOT 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
Non-Protocol RT
text
CL.15
Code List
Non-Protocol RT
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)
Non-ProtocolTherapyDate,First
Item
Date of first non-protocol therapy
date
Item
Non-Protocol Surgery
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C15329 (NCI Thesaurus ObjectClass)
C0543467 (UMLS 2011AA ObjectClass)
C25590 (NCI Thesaurus ObjectClass-2)
C1518384 (UMLS 2011AA ObjectClass-2)
CL.16
Code List
Non-Protocol Surgery
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
Non-Protocol Chemotherapy
text
CL.17
Code List
Non-Protocol Chemotherapy
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
Other Non-Protocol therapy
text
CL.18
Code List
Other Non-Protocol therapy
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)
OtherNon-ProtocolTherapyName
Item
Specify other
text
Item
ANY CONTINUING OR NEW TREATMENT TOXICITIES RELATED TO PCI ONLY?
text
CL.19
Code List
ANY CONTINUING OR NEW TREATMENT TOXICITIES RELATED TO PCI ONLY?
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)
LATETREATMENTTOXICITY
Item
LATE TREATMENT TOXICITY (occurred >90 days from start of XRT)
text
CTCAdverseEventGrade
Item
SEVERITY GRADE
text
Item
TOXICITY
text
CL.20
Code List
TOXICITY
CL Item
Brain (Brain)
CL Item
Skin (within the irradiated field) (Skin (within the irradiated field))
CL Item
Eye (Eye)
CL Item
Subcutaneous tissue (Subcutaneous tissue)
CL Item
#1 Toxicity Other, specify (#1 Toxicity Other, specify)
CL Item
#2 Toxicity Other, specify (#2 Toxicity Other, specify)
CTCAdverseEventTerm,Other
Item
#2 Toxicity Other, specify
text
DATEOF1STOCCURRENCEOFGRADE=>3
Item
DATE OF 1ST OCCURRENCE OF GRADE=>3
date
Item Group
Comments
SignatureofPersonCompletingThisForm
Item
Signature of Person Completing This Form
text
FormCompletionDate,Original
Item
Date
date
Comments
Item
Comments
text
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