ID

10594

Description

CALGB: 80101 ON-STUDY FORM NCT00052910 Chemotherapy and Radiation Therapy After Surgery in Treating Patients With Stomach or Esophageal Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9DA712C5-6067-535F-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9DA712C5-6067-535F-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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CALGB: 80101 ON-STUDY FORM NCT00052910

English

No Instruction available.

1 forms  
  1. StudyEvent: CALGB: 80101 ON-STUDY FORM
    1. No Instruction available.
CALGB clinical trial administrative data
Description

CALGB clinical trial administrative data

CALGB Form
Description

CALGBForm

Data type

text

CALGB Study No
Description

CALGBProtocolNumber

Data type

text

CALGB Patient ID
Description

CALGBPatientID

Data type

text

Amended data?
Description

AmendedDataInd

Data type

text

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Patient's Name
Description

PatientName,Last

Data type

text

Participating Group
Description

ParticipatingGroupCode

Data type

text

Patient Hospital Number
Description

PatientMedicalRecordNumber

Data type

text

Participating Group Protocol No.
Description

Particip.GroupProtocolNumber

Data type

float

Main Member Institution/Adjunct
Description

InstitutionName

Data type

text

Participating Group Patient No.
Description

PatientStudyID,ParticipatingGroup

Data type

text

Tumor Diagnosis
Description

Tumor Diagnosis

History of primary cancer other than gastric?
Description

PriorCancerInd

Data type

text

Yes, specify type of cancer
Description

PriorCancerType

Data type

text

Year of diagnosis
Description

PriorCancerDiagnosisDate

Data type

date

Caloric intake >/= 1500 Kcal/day
Description

Caloricintake>/=1500Kcal/day

Data type

boolean

Lab Data At Protocol Entry
Description

Lab Data At Protocol Entry

ANC (x10 3)
Description

Lab,Hematology,NeutrophilCount

Data type

float

Platelets (x10 3)
Description

Lab,Hematology,Platelets

Data type

float

Serum Creatinine (mg/dl)
Description

Lab,Renal,Creatinine

Data type

float

SGOT (U/ml)
Description

Lab,Hepatic,SGOT

Data type

float

Bilirubin (mg/dl)
Description

Lab,Hepatic,Bilirubin

Data type

float

Patient examined by RT oncologist?
Description

PatientexaminedbyRToncologist?

Data type

text

Bilateral renal function as determined by scan?
Description

Bilateralrenalfunctionasdeterminedbyscan?

Data type

text

Prior systemic chemotherapy?
Description

PriorChemotherapyInd

Data type

text

Prior immunotherapy?
Description

PriorImmunotherapyInd

Data type

text

Prior radiotherapy?
Description

PriorRTInd

Data type

text

Gastric Resection Data
Description

Gastric Resection Data

Date of gastric resection
Description

GastricResectionDate

Data type

text

Site of gastric primary
Description

PrimarySite

Data type

text

Name of institution where resection was done
Description

InstitutionName,Resection

Data type

text

Medicare ID number of institution
Description

ProfessionalOrganizationMedicareIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus Property-2
C16665
UMLS 2011AA Property-2
C0018717
NCI Thesaurus ObjectClass
C19711
UMLS 2011AA ObjectClass
C1522486
Histology & Staging Data
Description

Histology & Staging Data

Differentiation
Description

HistologicGrade

Data type

text

AJCC/UICC TNM Staging: T
Description

TStage,Clinical

Data type

text

AJCC/UICC TNM Staging: N
Description

NStage,Clinical

Data type

text

AJCC/UICC TNM Staging: M
Description

MStage,Clinical

Data type

text

If patient has T2N0M0, does tumor extend beyond muscularis propria?
Description

IfpatienthasT2N0M0,doestumorextendbeyondmuscularispropria?

Data type

boolean

Completed by
Description

PersonCompletingForm,FirstName

Data type

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Date completed
Description

FormCompletionDate,Original

Data type

date

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Similar models

No Instruction available.

1 forms
  1. StudyEvent: CALGB: 80101 ON-STUDY FORM
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
CALGB clinical trial administrative data
CALGBForm
Item
CALGB Form
text
CALGBProtocolNumber
Item
CALGB Study No
text
CALGBPatientID
Item
CALGB Patient ID
text
Item
Amended data?
text
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
CL.1
Code List
Amended data?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
PatientName,Last
Item
Patient's Name
text
ParticipatingGroupCode
Item
Participating Group
text
PatientMedicalRecordNumber
Item
Patient Hospital Number
text
Particip.GroupProtocolNumber
Item
Participating Group Protocol No.
float
InstitutionName
Item
Main Member Institution/Adjunct
text
PatientStudyID,ParticipatingGroup
Item
Participating Group Patient No.
text
Item Group
Tumor Diagnosis
Item
History of primary cancer other than gastric?
text
CL.2
Code List
History of primary cancer other than gastric?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes, specify type of cancer (Yes, specify type of cancer)
PriorCancerType
Item
Yes, specify type of cancer
text
PriorCancerDiagnosisDate
Item
Year of diagnosis
date
Caloricintake>/=1500Kcal/day
Item
Caloric intake >/= 1500 Kcal/day
boolean
Item Group
Lab Data At Protocol Entry
Lab,Hematology,NeutrophilCount
Item
ANC (x10 3)
float
Lab,Hematology,Platelets
Item
Platelets (x10 3)
float
Lab,Renal,Creatinine
Item
Serum Creatinine (mg/dl)
float
Lab,Hepatic,SGOT
Item
SGOT (U/ml)
float
Lab,Hepatic,Bilirubin
Item
Bilirubin (mg/dl)
float
PatientexaminedbyRToncologist?
Item
Patient examined by RT oncologist?
text
Bilateralrenalfunctionasdeterminedbyscan?
Item
Bilateral renal function as determined by scan?
text
PriorChemotherapyInd
Item
Prior systemic chemotherapy?
text
PriorImmunotherapyInd
Item
Prior immunotherapy?
text
PriorRTInd
Item
Prior radiotherapy?
text
Item Group
Gastric Resection Data
GastricResectionDate
Item
Date of gastric resection
text
Item
Site of gastric primary
text
CL.4
Code List
Site of gastric primary
CL Item
GE junction (GE junction)
CL Item
Cardia (Cardia)
C0007144 (NCI Metathesaurus)
CL Item
Fundus (Fundus)
C13378 (NCI Thesaurus)
C0740422 (UMLS 2011AA)
CL Item
Antrum (Antrum)
CL Item
Pylorus (Pylorus)
CL Item
Stomach, Not Otherwise Specified (Stomach, NOS)
InstitutionName,Resection
Item
Name of institution where resection was done
text
ProfessionalOrganizationMedicareIdentifierNumber
Item
Medicare ID number of institution
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C16665 (NCI Thesaurus Property-2)
C0018717 (UMLS 2011AA Property-2)
C19711 (NCI Thesaurus ObjectClass)
C1522486 (UMLS 2011AA ObjectClass)
Item Group
Histology & Staging Data
Item
Differentiation
text
CL.5
Code List
Differentiation
CL Item
Tumor Is Well Differentiated According To Who Grading System (Well differentiated (grade I))
CL Item
Moderately well differentiated (grade II) (Moderately well differentiated (grade II))
CL Item
Tumor Is Poorly Differentiated According To Who Grading System (Poorly differentiated (grade III))
CL Item
Tumor Is Undifferentiated According To Who Grading System (Undifferentiated (grade IV))
TStage,Clinical
Item
AJCC/UICC TNM Staging: T
text
NStage,Clinical
Item
AJCC/UICC TNM Staging: N
text
MStage,Clinical
Item
AJCC/UICC TNM Staging: M
text
IfpatienthasT2N0M0,doestumorextendbeyondmuscularispropria?
Item
If patient has T2N0M0, does tumor extend beyond muscularis propria?
boolean
PersonCompletingForm,FirstName
Item
Completed by
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
FormCompletionDate,Original
Item
Date completed
date
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