ID

10568

Description

Radiation Therapy Oncology Group On Study Form Phase III Lung - Prophylactic Cranial RT NCT00048997 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=9EC372A6-724E-05D5-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9EC372A6-724E-05D5-E034-080020C9C0E0

Keywords

Versions (3)
  1. 9/19/12 9/19/12 -
  2. 5/28/15 5/28/15 -
  3. 6/3/15 6/3/15 -
Uploaded on

June 3, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Radiation Therapy Oncology Group On Study Form Phase III Lung - Prophylactic Cranial RT NCT00048997

English

No Instruction available.

1 forms  
  1. StudyEvent: Radiation Therapy Oncology Group On Study Form Phase III Lung - Prophylactic Cranial RT
    1. No Instruction available.
Header Module
Description

Header Module

Case #
Description

Case#

Data type

text

Institution
Description

InstitutionName

Data type

text

Institution #
Description

NCIInstitutionNumber

Data type

text

Patient Name
Description

PatientName

Data type

text

Patient ID #
Description

PatientID#

Data type

text

Patient Characteristics
Description

Patient Characteristics

PATIENT'S DATE OF BIRTH
Description

PatientBirthDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25275
UMLS 2011AA Property
C2745955
PERFORMANCE STATUS (ZUBROD)
Description

PerformanceStatus

Data type

text

PRIOR TREATMENT TYPE (Administered for current lung cancer)
Description

PriorTreatmentType

Data type

text

PRIOR CHEMOTHERAPY
Description

PriorChemotherapyInd

Data type

text

Agent Name
Description

AgentName

Data type

text

Total Agent Cumulative dose
Description

AgentTotalCumulativeDose

Data type

float

Agent End dose
Description

AgentMostRecentDose

Data type

float

PRIOR RADIATION
Description

PriorRTInd

Data type

text

Prior RT End Date
Description

PriorRTEndDate

Data type

date

PRIOR SURGERY
Description

PriorSurgeryInd

Data type

text

MOST EXTENSIVE SURGERY
Description

PrimarySurgeryType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Most Extensive Surgery Other, Specify
Description

PrimarySurgery,OtherType

Data type

text

Date of most extensive surgery
Description

PrimarySurgeryDate

Data type

date

DATE OF INITIAL DIAGNOSIS OF PRIMARY TUMOR
Description

FirstPositiveBiopsyDate

Data type

date

HISTOLOGIC TYPE
Description

HistologicType

Data type

text

Histologic Type Other, specify
Description

HistologicType,OtherName

Data type

text

STAGE GROUPING (Prior to planned definitive therapy)
Description

StageGrouping

Data type

text

OVERALL TUMOR RESPONSE (Primary tumor, after all planned treatment)
Description

OverallTumorResponse

Data type

text

Response Duration begin date
Description

ResponseDurationBeginDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C25755
UMLS 2011AA ObjectClass
C0871261
NCI Thesaurus Property
C25275
UMLS 2011AA Property
C2745955
HAS THE PATIENT DEVELOPED A FIRST PROGRESSION NOT PREVIOUSLY REPORTED? (DISTANT)
Description

ProgressionInd

Data type

boolean

PROGRESSION ASSESSMENT
Description

ProgressionAssessmentMethod

Data type

float

Sites of progression, lung
Description

Sitesofprogression,lung

Data type

text

Sites of progression, Lymph nodes (distant)
Description

Sitesofprogression,Lymphnodes(distant)

Data type

text

Sites of progression, pleural
Description

Sitesofprogression,pleural

Data type

text

Sites of progression, adrenals
Description

Sitesofprogression,adrenals

Data type

text

Sites of progression, liver
Description

Sitesofprogression,liver

Data type

text

Sites of progression, bone
Description

Sitesofprogression,bone

Data type

text

Sites of progression, Other Specify
Description

Sitesofprogression,OtherSpecify

Data type

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
Description

ProgressionSite,Other

Data type

text

Comments
Description

Comments

Comments
Description

Comments

Data type

text

Signature of Person Completing This Form
Description

SignatureofPersonCompletingThisForm

Data type

text

Date
Description

FormCompletionDate,Original

Data type

date

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Similar models

No Instruction available.

1 forms
  1. StudyEvent: Radiation Therapy Oncology Group On Study Form Phase III Lung - Prophylactic Cranial RT
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
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 Characteristics
PatientBirthDate
Item
PATIENT'S DATE OF BIRTH
date
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
PerformanceStatus
Item
PERFORMANCE STATUS (ZUBROD)
text
Item
PRIOR TREATMENT TYPE (Administered for current lung cancer)
text
CL.2
Code List
PRIOR TREATMENT TYPE (Administered for current lung cancer)
CL Item
No (No)
CL Item
Yes (Yes)
CL Item
Unknown (Unknown)
Item
PRIOR CHEMOTHERAPY
text
CL.3
Code List
PRIOR 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)
AgentName
Item
Agent Name
text
AgentTotalCumulativeDose
Item
Total Agent Cumulative dose
float
AgentMostRecentDose
Item
Agent End dose
float
Item
PRIOR RADIATION
text
CL.4
Code List
PRIOR RADIATION
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)
PriorRTEndDate
Item
Prior RT End Date
date
Item
PRIOR SURGERY
text
CL.5
Code List
PRIOR 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
MOST EXTENSIVE SURGERY
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.6
Code List
MOST EXTENSIVE SURGERY
CL Item
Exploratory Thoractomy (Exploratory Thoractomy)
CL Item
Lobectomy (Lobectomy)
C15272 (NCI Thesaurus)
C0023928 (UMLS 2011AA)
CL Item
Bilobectomy (Bilobectomy)
CL Item
Sleeve Resection (Sleeve Resection)
CL Item
Pneumonectomy (Pneumonectomy)
C15305 (NCI Thesaurus)
C0032284 (UMLS 2011AA)
CL Item
Other, specify (Other, specify)
PrimarySurgery,OtherType
Item
Most Extensive Surgery Other, Specify
text
PrimarySurgeryDate
Item
Date of most extensive surgery
date
FirstPositiveBiopsyDate
Item
DATE OF INITIAL DIAGNOSIS OF PRIMARY TUMOR
date
Item
HISTOLOGIC TYPE
text
CL.7
Code List
HISTOLOGIC TYPE
CL Item
Squamous Cell Carcinoma (Squamous cell carcinoma)
C2929 (NCI Thesaurus)
C0007137 (UMLS 2011AA)
CL Item
Adenocarcinoma (Adenocarcinoma)
C2852 (NCI Thesaurus)
C0001418 (UMLS 2011AA)
CL Item
Large cell (Large cell)
CL Item
Combined squamous & adenocarcinoma (Combined squamous & adenocarcinoma)
CL Item
Non-lobar and non-diffuse bronchoalveolar carcinoma (Non-lobar and non-diffuse bronchoalveolar carcinoma)
CL Item
Non-small Cell Carcinoma, NOS (Non-small Cell Carcinoma, NOS)
CL Item
Small cell/oat cell (Small cell/oat cell)
CL Item
Other, Specify (Other, specify)
HistologicType,OtherName
Item
Histologic Type Other, specify
text
Item
STAGE GROUPING (Prior to planned definitive therapy)
text
CL.8
Code List
STAGE GROUPING (Prior to planned definitive therapy)
CL Item
I (I)
CL Item
II (II)
CL Item
IIIa (IIIa)
CL Item
IIIb (IIIb)
CL Item
IV (IV)
Item
OVERALL TUMOR RESPONSE (Primary tumor, after all planned treatment)
text
CL.9
Code List
OVERALL TUMOR RESPONSE (Primary tumor, after all planned treatment)
CL Item
Complete response (Complete response)
CL Item
Partial Response (Partial Response)
C18212 (NCI Thesaurus)
CL Item
Less than Partial Response (Less than Partial Response)
CL Item
Stable (Stable)
CL Item
Progression (Progression)
CL Item
Not assessed (Not assessed)
CL Item
Other (Other)
ResponseDurationBeginDate
Item
Response Duration begin date
date
C25755 (NCI Thesaurus ObjectClass)
C0871261 (UMLS 2011AA ObjectClass)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
ProgressionInd
Item
HAS THE PATIENT DEVELOPED A FIRST PROGRESSION NOT PREVIOUSLY REPORTED? (DISTANT)
boolean
ProgressionAssessmentMethod
Item
PROGRESSION ASSESSMENT
float
Item
Sites of progression, lung
text
CL.15
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.16
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.17
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.18
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.19
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.20
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, Other Specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C17649 (NCI Thesaurus ValueDomain-2)
C0205394 (UMLS 2011AA ValueDomain-2)
CL.21
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
Item Group
Comments
Comments
Item
Comments
text
SignatureofPersonCompletingThisForm
Item
Signature of Person Completing This Form
text
FormCompletionDate,Original
Item
Date
date
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