ID

1062

Description

CALGB: 40601 POST-NEOADJUVANT CHEMOTHERAPY SURGICAL EVALUATION FORM Paclitaxel and Trastuzumab With or Without Lapatinib in Treating Patients With Stage II or Stage III Breast Cancer That Can Be Removed by Surgery Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=3A7CAEA0-52A1-0226-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=3A7CAEA0-52A1-0226-E044-0003BA3F9857

Keywords

Versions (3)
  1. 8/26/12 8/26/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
  3. 6/18/15 6/18/15 -
Uploaded on

August 26, 2012

DOI

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Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00770809 Follow-Up - CALGB: 40601 POST-NEOADJUVANT CHEMOTHERAPY SURGICAL EVALUATION FORM - 2683039v1.0

English

INSTRUCTIONS: Complete all information on this form. Submit within one week of registration along with the On-Study Form.

1 forms  
Unnamed1
Description

Unnamed1

CALGB Form
Description

CALGBFormIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C19464
UMLS 2011AA ObjectClass
C0376315
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ObjectClass
C25442
UMLS 2011AA ObjectClass
C1516238
CALGB Study No
Description

ProtocolCALGBIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus Property
C25442
UMLS 2011AA Property
C1516238
CALGB Patient ID
Description

PatientCALGBIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus Property
C25442
UMLS 2011AA Property
C1516238
Date of evaluation
Description

AssessmentPerformedDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C25367
NCI Thesaurus ValueDomain
C25367
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
Amended Data
Description

DataAmendedInd-3

Data type

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Unnamed2
Description

Unnamed2

Patient Initials (Last, First Middle)
Description

PatientInitialsName

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25536
UMLS 2011AA Property
C1555582
Patient Hospital No.
Description

PatientMedicalRecordNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25261
UMLS 2011AA Property
C0205476
NCI Thesaurus Property
C25198
UMLS 2011AA Property
C0034869
Institution/Affiliate
Description

CombinedInstitutionName

Data type

text

Alias
NCI Thesaurus ObjectClass
C25454
UMLS 2011AA ObjectClass
C0205195
NCI Thesaurus ObjectClass
C21541
UMLS 2011AA ObjectClass
C0018704
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ValueDomain
C21541
UMLS 2011AA ValueDomain
C0018704
Participating Group
Description

ParticipatingGroupName

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C25608
UMLS 2011AA ObjectClass
C0679823
NCI Thesaurus ObjectClass
C17005
UMLS 2011AA ObjectClass
C1257890
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Participating Group Study No.
Description

ProtocolParticipatingIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C25608
UMLS 2011AA Property
C0679823
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Participating Group Patient ID
Description

PatientParticipatingIdentifierNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25608
UMLS 2011AA Property
C0679823
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Breast Conserving Therapy
Description

Breast Conserving Therapy

Was the patient (after receiving neoadjuvant chemotherapy) a candidate for breast conserving treatment
Description

BreastConservationTreatmentPostNeoadjuvantTherapyQualificationInd-2

Data type

text

Alias
NCI Thesaurus ObjectClass
C15280
UMLS 2011AA ObjectClass
C0917927
NCI Thesaurus Property
C38008
UMLS 2011AA Property
C0687676
NCI Thesaurus Property
C15665
UMLS 2011AA Property
C0600558
NCI Thesaurus Property
C43608
UMLS 2011AA Property
C1709790
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Reason not a candidate (If no,)
Description

BreastConservationTreatmentPostNeoadjuvantTherapyNotQualificationReason

Data type

text

Alias
NCI Thesaurus ObjectClass
C15280
UMLS 2011AA ObjectClass
C0917927
NCI Thesaurus Property
C25594
UMLS 2011AA Property
C1518422
NCI Thesaurus Property
C38008
UMLS 2011AA Property
C0687676
NCI Thesaurus Property
C15665
UMLS 2011AA Property
C0600558
NCI Thesaurus Property
C43608
UMLS 2011AA Property
C1709790
NCI Thesaurus ValueDomain
C25638
UMLS 2011AA ValueDomain
C0392360
Other, specify
Description

BreastConservationTreatmentPostNeoadjuvantTherapyNotQualificationSpecify

Data type

text

Alias
NCI Thesaurus ObjectClass
C15280
UMLS 2011AA ObjectClass
C0917927
NCI Thesaurus Property
C25594
UMLS 2011AA Property
C1518422
NCI Thesaurus Property
C38008
UMLS 2011AA Property
C0687676
NCI Thesaurus Property
C15665
UMLS 2011AA Property
C0600558
NCI Thesaurus Property
C43608
UMLS 2011AA Property
C1709790
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Absolute contraindication to radiation therapy
Description

BreastConservationTreatmentRadiationTherapyMedicalContraindicationReason

Data type

text

Alias
NCI Thesaurus ValueDomain
C25638
UMLS 2011AA ValueDomain
C0392360
NCI Thesaurus ObjectClass
C15313
UMLS 2011AA ObjectClass
C1522449
NCI Thesaurus ObjectClass
C15280
UMLS 2011AA ObjectClass
C0917927
NCI Thesaurus Property
C50646
UMLS 2011AA Property
C1301624
Connective tissue disorder, specify
Description

BreastConservationTreatmentRadiationTherapyConnectiveTissueDisorderMedicalContraindicationSpecify

Data type

text

Alias
NCI Thesaurus ObjectClass
C15313
UMLS 2011AA ObjectClass
C1522449
NCI Thesaurus ObjectClass
C15280
UMLS 2011AA ObjectClass
C0917927
NCI Thesaurus Property
C26729
UMLS 2011AA Property
C0009782
NCI Thesaurus Property
C50646
UMLS 2011AA Property
C1301624
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Was breast conserving treatment attempted?
Description

BreastConservationTreatmentPostNeoadjuvantTherapyAttemptInd-2

Data type

text

Alias
NCI Thesaurus ObjectClass
C15280
UMLS 2011AA ObjectClass
C0917927
NCI Thesaurus Property
C38008
UMLS 2011AA Property
C0687676
NCI Thesaurus Property
C15665
UMLS 2011AA Property
C0600558
NCI Thesaurus Property
C39769
UMLS 2011AA Property
C1516084
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Reason not attempted?
Description

BreastConservationTreatmentPostNeoadjuvantTherapyNotAttemptReason

Data type

text

Alias
NCI Thesaurus ObjectClass
C15280
UMLS 2011AA ObjectClass
C0917927
NCI Thesaurus Property
C38008
UMLS 2011AA Property
C0687676
NCI Thesaurus Property
C15665
UMLS 2011AA Property
C0600558
NCI Thesaurus Property
C39769
UMLS 2011AA Property
C1516084
NCI Metathesaurus Property
CL052458
NCI Thesaurus ValueDomain
C25638
UMLS 2011AA ValueDomain
C0392360
Other, specify
Description

BreastConservationTreatmentPostNeoadjuvantTherapyNotAttemptSpecify

Data type

text

Alias
NCI Thesaurus ObjectClass
C15280
UMLS 2011AA ObjectClass
C0917927
NCI Thesaurus Property
C38008
UMLS 2011AA Property
C0687676
NCI Thesaurus Property
C15665
UMLS 2011AA Property
C0600558
NCI Thesaurus Property
C39769
UMLS 2011AA Property
C1516084
NCI Metathesaurus Property
CL052458
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Patient choice
Description

BreastConservationTreatmentPostNeoadjuvantTherapyRefuse

Data type

text

Alias
NCI Thesaurus ObjectClass
C15280
UMLS 2011AA ObjectClass
C0917927
NCI Thesaurus Property
C49161
UMLS 2011AA Property
C1705116
NCI Thesaurus Property
C38008
UMLS 2011AA Property
C0687676
NCI Thesaurus Property
C15665
UMLS 2011AA Property
C0600558
NCI Thesaurus ValueDomain
C25638
UMLS 2011AA ValueDomain
C0392360
Was BCT successful?
Description

BreastConservationTreatmentPostNeoadjuvantTherapySuccessPerformedInd-2

Data type

text

Alias
NCI Thesaurus ObjectClass
C15280
UMLS 2011AA ObjectClass
C0917927
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
NCI Thesaurus Property
C38008
UMLS 2011AA Property
C0687676
NCI Thesaurus Property
C15665
UMLS 2011AA Property
C0600558
NCI Thesaurus Property
C25362
UMLS 2011AA Property
C0597535
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Reason BCT unsuccessful?
Description

BreastConservationTreatmentPostNeoadjuvantTherapyFailedPerformedReason

Data type

text

Alias
NCI Thesaurus ObjectClass
C15280
UMLS 2011AA ObjectClass
C0917927
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
NCI Thesaurus Property
C38008
UMLS 2011AA Property
C0687676
NCI Thesaurus Property
C15665
UMLS 2011AA Property
C0600558
NCI Thesaurus Property
C44281
UMLS 2011AA Property
C0231175
NCI Thesaurus ValueDomain
C25638
UMLS 2011AA ValueDomain
C0392360
Other, specify
Description

BreastConservationTreatmentPostNeoadjuvantTherapyFailedPerformedSpecify

Data type

text

Alias
NCI Thesaurus ObjectClass
C15280
UMLS 2011AA ObjectClass
C0917927
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
NCI Thesaurus Property
C38008
UMLS 2011AA Property
C0687676
NCI Thesaurus Property
C15665
UMLS 2011AA Property
C0600558
NCI Thesaurus Property
C44281
UMLS 2011AA Property
C0231175
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Axillary Node
Description

Axillary Node

Was the patient's post-neoadjuvent chemotherapy treatment axillary nodal status evaluated?
Description

AxillaryLymphNodePostNeoadjuvantTherapyEvaluationInd-2

Data type

text

Alias
NCI Thesaurus ObjectClass
C12904
UMLS 2011AA ObjectClass
C0729594
NCI Thesaurus Property
C25214
UMLS 2011AA Property
C0220825
NCI Thesaurus Property
C38008
UMLS 2011AA Property
C0687676
NCI Thesaurus Property
C15665
UMLS 2011AA Property
C0600558
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Method of Evaluation
Description

AssessmentMethodType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C20989
UMLS 2011AA ObjectClass
C0031809
NCI Thesaurus Property
C16847
UMLS 2011AA Property
C0449851
Other Specify
Description

AssessmentMethodSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C20989
UMLS 2011AA ObjectClass
C0031809
NCI Thesaurus Property
C16847
UMLS 2011AA Property
C0449851
Results
Description

AxillaryLymphNodePostNeoadjuvantTherapyEvaluationResult

Data type

text

Alias
NCI Thesaurus ObjectClass
C12904
UMLS 2011AA ObjectClass
C0729594
NCI Thesaurus Property
C25214
UMLS 2011AA Property
C0220825
NCI Thesaurus Property
C38008
UMLS 2011AA Property
C0687676
NCI Thesaurus Property
C15665
UMLS 2011AA Property
C0600558
NCI Thesaurus ValueDomain
C20200
UMLS 2011AA ValueDomain
C1274040
Date of Evaluation
Description

LesionAssessmentDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C3824
UMLS 2011AA ObjectClass
C0221198
NCI Thesaurus Property
C20989
UMLS 2011AA Property
C0031809
NCI Thesaurus ValueDomain
C25367
Was blue dye used
Description

SentinelLymphNodeBiopsyBlueDyeUseInd-2

Data type

text

Alias
NCI Thesaurus ObjectClass
C15667
UMLS 2011AA ObjectClass
C0796693
NCI Thesaurus Property
C461
UMLS 2011AA Property
C0013343
NCI Thesaurus Property
C25340
UMLS 2011AA Property
C0457083
NCI Thesaurus Property
C48333
UMLS 2011AA Property
C1260957
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Was technetium used
Description

SentinelLymphNodeBiopsyTechnetium99mDextranUseInd-2

Data type

text

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus ObjectClass
C15667
UMLS 2011AA ObjectClass
C0796693
NCI Thesaurus Property
C25340
UMLS 2011AA Property
C0457083
NCI Thesaurus Property
C1243
UMLS 2011AA Property
C0076028
Required Laboratory Values
Description

Required Laboratory Values

Comments
Description

ResearchCommentsText

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
UMLS 2011AA Property
C0282411
Footer Module
Description

Footer Module

Completed by (Last name, First name)
Description

ResponsiblePersonName

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C25657
UMLS 2011AA ObjectClass
C1273518
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Date Form Completed (MM DD YYYY)
Description

FormCompleteDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C40988
UMLS 2011AA ObjectClass
C1516308
NCI Thesaurus Property
C25250
UMLS 2011AA Property
C0205197
NCI Thesaurus ValueDomain
C25367
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Similar models

INSTRUCTIONS: Complete all information on this form. Submit within one week of registration along with the On-Study Form.

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Unnamed1
CALGBFormIdentifierNumber
Item
CALGB Form
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C19464 (NCI Thesaurus ObjectClass)
C0376315 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25442 (NCI Thesaurus ObjectClass)
C1516238 (UMLS 2011AA ObjectClass)
ProtocolCALGBIdentifierNumber
Item
CALGB Study No
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25442 (NCI Thesaurus Property)
C1516238 (UMLS 2011AA Property)
PatientCALGBIdentifierNumber
Item
CALGB Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25442 (NCI Thesaurus Property)
C1516238 (UMLS 2011AA Property)
AssessmentPerformedDate
Item
Date of evaluation
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus ObjectClass)
C25367 (NCI Thesaurus ValueDomain)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
Item
Amended Data
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
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)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item Group
Unnamed2
PatientInitialsName
Item
Patient Initials (Last, First Middle)
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25536 (NCI Thesaurus Property)
C1555582 (UMLS 2011AA Property)
PatientMedicalRecordNumber
Item
Patient Hospital No.
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25261 (NCI Thesaurus Property)
C0205476 (UMLS 2011AA Property)
C25198 (NCI Thesaurus Property)
C0034869 (UMLS 2011AA Property)
CombinedInstitutionName
Item
Institution/Affiliate
text
C25454 (NCI Thesaurus ObjectClass)
C0205195 (UMLS 2011AA ObjectClass)
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ValueDomain)
C0018704 (UMLS 2011AA ValueDomain)
ParticipatingGroupName
Item
Participating Group
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25608 (NCI Thesaurus ObjectClass)
C0679823 (UMLS 2011AA ObjectClass)
C17005 (NCI Thesaurus ObjectClass)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
ProtocolParticipatingIdentifierNumber
Item
Participating Group Study No.
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C25608 (NCI Thesaurus Property)
C0679823 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
PatientParticipatingIdentifierNumber
Item
Participating Group Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25608 (NCI Thesaurus Property)
C0679823 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
Item Group
Breast Conserving Therapy
Item
Was the patient (after receiving neoadjuvant chemotherapy) a candidate for breast conserving treatment
text
C15280 (NCI Thesaurus ObjectClass)
C0917927 (UMLS 2011AA ObjectClass)
C38008 (NCI Thesaurus Property)
C0687676 (UMLS 2011AA Property)
C15665 (NCI Thesaurus Property)
C0600558 (UMLS 2011AA Property)
C43608 (NCI Thesaurus Property)
C1709790 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
CL.2
Code List
Was the patient (after receiving neoadjuvant chemotherapy) a candidate for breast conserving treatment
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Reason not a candidate (If no,)
text
C15280 (NCI Thesaurus ObjectClass)
C0917927 (UMLS 2011AA ObjectClass)
C25594 (NCI Thesaurus Property)
C1518422 (UMLS 2011AA Property)
C38008 (NCI Thesaurus Property)
C0687676 (UMLS 2011AA Property)
C15665 (NCI Thesaurus Property)
C0600558 (UMLS 2011AA Property)
C43608 (NCI Thesaurus Property)
C1709790 (UMLS 2011AA Property)
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
CL.3
Code List
Reason not a candidate (If no,)
CL Item
Absolute Contraindication To Radiation Therapy (Absolute contraindication to radiation therapy)
CL Item
Diffuse Suspicious Microcalcifications (Diffuse suspicious microcalcifications)
CL Item
Multicentric Breast Cancer (Multicentric breast cancer)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
Probable Poor Cosmetic Outcome (Probable poor cosmetic outcome)
CL Item
Breast Cancer Pt4 Tnm Finding (T4)
C48985 (NCI Thesaurus)
C1707033 (UMLS 2011AA)
CL Item
Tumor Is Too Large In Relation To Native Breast Size (Tumor is too large in relation to native breast size)
BreastConservationTreatmentPostNeoadjuvantTherapyNotQualificationSpecify
Item
Other, specify
text
C15280 (NCI Thesaurus ObjectClass)
C0917927 (UMLS 2011AA ObjectClass)
C25594 (NCI Thesaurus Property)
C1518422 (UMLS 2011AA Property)
C38008 (NCI Thesaurus Property)
C0687676 (UMLS 2011AA Property)
C15665 (NCI Thesaurus Property)
C0600558 (UMLS 2011AA Property)
C43608 (NCI Thesaurus Property)
C1709790 (UMLS 2011AA Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
Item
Absolute contraindication to radiation therapy
text
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
C15313 (NCI Thesaurus ObjectClass)
C1522449 (UMLS 2011AA ObjectClass)
C15280 (NCI Thesaurus ObjectClass)
C0917927 (UMLS 2011AA ObjectClass)
C50646 (NCI Thesaurus Property)
C1301624 (UMLS 2011AA Property)
CL.4
Code List
Absolute contraindication to radiation therapy
CL Item
Connective Tissue Disorder (Connective Tissue Disorder)
C26729 (NCI Thesaurus)
C0009782 (UMLS 2011AA)
CL Item
Patient Access To Prescribed Radiation Therapy (Patient access to prescribed radiation therapy)
CL Item
Patient Compliance With Prescribed Radiation Therapy (Patient compliance with prescribed radiation therapy)
CL Item
Prior Radiation Therapy (Prior radiation therapy)
C15477 (NCI Thesaurus)
C0279134 (UMLS 2011AA)
BreastConservationTreatmentRadiationTherapyConnectiveTissueDisorderMedicalContraindicationSpecify
Item
Connective tissue disorder, specify
text
C15313 (NCI Thesaurus ObjectClass)
C1522449 (UMLS 2011AA ObjectClass)
C15280 (NCI Thesaurus ObjectClass)
C0917927 (UMLS 2011AA ObjectClass)
C26729 (NCI Thesaurus Property)
C0009782 (UMLS 2011AA Property)
C50646 (NCI Thesaurus Property)
C1301624 (UMLS 2011AA Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
Item
Was breast conserving treatment attempted?
text
C15280 (NCI Thesaurus ObjectClass)
C0917927 (UMLS 2011AA ObjectClass)
C38008 (NCI Thesaurus Property)
C0687676 (UMLS 2011AA Property)
C15665 (NCI Thesaurus Property)
C0600558 (UMLS 2011AA Property)
C39769 (NCI Thesaurus Property)
C1516084 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
CL.5
Code List
Was breast conserving treatment attempted?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Reason not attempted?
text
C15280 (NCI Thesaurus ObjectClass)
C0917927 (UMLS 2011AA ObjectClass)
C38008 (NCI Thesaurus Property)
C0687676 (UMLS 2011AA Property)
C15665 (NCI Thesaurus Property)
C0600558 (UMLS 2011AA Property)
C39769 (NCI Thesaurus Property)
C1516084 (UMLS 2011AA Property)
CL052458 (NCI Metathesaurus Property)
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
CL.6
Code List
Reason not attempted?
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
Patient Choice (Patient choice)
BreastConservationTreatmentPostNeoadjuvantTherapyNotAttemptSpecify
Item
Other, specify
text
C15280 (NCI Thesaurus ObjectClass)
C0917927 (UMLS 2011AA ObjectClass)
C38008 (NCI Thesaurus Property)
C0687676 (UMLS 2011AA Property)
C15665 (NCI Thesaurus Property)
C0600558 (UMLS 2011AA Property)
C39769 (NCI Thesaurus Property)
C1516084 (UMLS 2011AA Property)
CL052458 (NCI Metathesaurus Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
Item
Patient choice
text
C15280 (NCI Thesaurus ObjectClass)
C0917927 (UMLS 2011AA ObjectClass)
C49161 (NCI Thesaurus Property)
C1705116 (UMLS 2011AA Property)
C38008 (NCI Thesaurus Property)
C0687676 (UMLS 2011AA Property)
C15665 (NCI Thesaurus Property)
C0600558 (UMLS 2011AA Property)
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
CL.7
Code List
Patient choice
CL Item
Avoid Possible Radiation Therapy (Avoid possible radiation therapy)
CL Item
Avoid Possible Return Trip To The Operating Room (Avoid possible return trip to the operating room)
Item
Was BCT successful?
text
C15280 (NCI Thesaurus ObjectClass)
C0917927 (UMLS 2011AA ObjectClass)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C38008 (NCI Thesaurus Property)
C0687676 (UMLS 2011AA Property)
C15665 (NCI Thesaurus Property)
C0600558 (UMLS 2011AA Property)
C25362 (NCI Thesaurus Property)
C0597535 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
CL.8
Code List
Was BCT successful?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Reason BCT unsuccessful?
text
C15280 (NCI Thesaurus ObjectClass)
C0917927 (UMLS 2011AA ObjectClass)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C38008 (NCI Thesaurus Property)
C0687676 (UMLS 2011AA Property)
C15665 (NCI Thesaurus Property)
C0600558 (UMLS 2011AA Property)
C44281 (NCI Thesaurus Property)
C0231175 (UMLS 2011AA Property)
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
CL.9
Code List
Reason BCT unsuccessful?
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
Positive Surgical Margin (Positive Margins)
C48620 (NCI Thesaurus)
C1709603 (UMLS 2011AA)
BreastConservationTreatmentPostNeoadjuvantTherapyFailedPerformedSpecify
Item
Other, specify
text
C15280 (NCI Thesaurus ObjectClass)
C0917927 (UMLS 2011AA ObjectClass)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C38008 (NCI Thesaurus Property)
C0687676 (UMLS 2011AA Property)
C15665 (NCI Thesaurus Property)
C0600558 (UMLS 2011AA Property)
C44281 (NCI Thesaurus Property)
C0231175 (UMLS 2011AA Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
Item Group
Axillary Node
Item
Was the patient's post-neoadjuvent chemotherapy treatment axillary nodal status evaluated?
text
C12904 (NCI Thesaurus ObjectClass)
C0729594 (UMLS 2011AA ObjectClass)
C25214 (NCI Thesaurus Property)
C0220825 (UMLS 2011AA Property)
C38008 (NCI Thesaurus Property)
C0687676 (UMLS 2011AA Property)
C15665 (NCI Thesaurus Property)
C0600558 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
CL.10
Code List
Was the patient's post-neoadjuvent chemotherapy treatment axillary nodal status evaluated?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Method of Evaluation
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C20989 (NCI Thesaurus ObjectClass)
C0031809 (UMLS 2011AA ObjectClass)
C16847 (NCI Thesaurus Property)
C0449851 (UMLS 2011AA Property)
CL.11
Code List
Method of Evaluation
CL Item
Clinical Examination (pe) (Clinical examination)
CL Item
Fine Needle Aspiration Biopsy (Fine needle aspiration biopsy)
CL Item
Mri Scan (MRI scan)
CL Item
Pet Scan (PET scan)
CL Item
Sentinel Node Biopsy (Sentinel node biopsy)
CL Item
Ultrasound (Ultrasound)
C64384 (NCI Thesaurus)
C1456803 (UMLS 2011AA)
CL Item
Axillary Dissection (Axillary dissection)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
AssessmentMethodSpecify
Item
Other Specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C20989 (NCI Thesaurus ObjectClass)
C0031809 (UMLS 2011AA ObjectClass)
C16847 (NCI Thesaurus Property)
C0449851 (UMLS 2011AA Property)
Item
Results
text
C12904 (NCI Thesaurus ObjectClass)
C0729594 (UMLS 2011AA ObjectClass)
C25214 (NCI Thesaurus Property)
C0220825 (UMLS 2011AA Property)
C38008 (NCI Thesaurus Property)
C0687676 (UMLS 2011AA Property)
C15665 (NCI Thesaurus Property)
C0600558 (UMLS 2011AA Property)
C20200 (NCI Thesaurus ValueDomain)
C1274040 (UMLS 2011AA ValueDomain)
CL.12
Code List
Results
CL Item
Equivocal (Equivocal)
C86071 (NCI Thesaurus)
C0332241 (UMLS 2011AA)
CL Item
Not Applicable (N/A)
C48660 (NCI Thesaurus)
C1272460 (UMLS 2011AA)
CL Item
Negative (Negative)
C25247 (NCI Thesaurus)
C0205160 (UMLS 2011AA)
CL Item
Positive (Positive)
C25246 (NCI Thesaurus)
C1446409 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
LesionAssessmentDate
Item
Date of Evaluation
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C3824 (NCI Thesaurus ObjectClass)
C0221198 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C25367 (NCI Thesaurus ValueDomain)
Item
Was blue dye used
text
C15667 (NCI Thesaurus ObjectClass)
C0796693 (UMLS 2011AA ObjectClass)
C461 (NCI Thesaurus Property)
C0013343 (UMLS 2011AA Property)
C25340 (NCI Thesaurus Property)
C0457083 (UMLS 2011AA Property)
C48333 (NCI Thesaurus Property)
C1260957 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
CL.13
Code List
Was blue dye used
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Was technetium used
text
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C15667 (NCI Thesaurus ObjectClass)
C0796693 (UMLS 2011AA ObjectClass)
C25340 (NCI Thesaurus Property)
C0457083 (UMLS 2011AA Property)
C1243 (NCI Thesaurus Property)
C0076028 (UMLS 2011AA Property)
CL.14
Code List
Was technetium used
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item Group
Required Laboratory Values
ResearchCommentsText
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
C0282411 (UMLS 2011AA Property)
Item Group
Footer Module
ResponsiblePersonName
Item
Completed by (Last name, First name)
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25657 (NCI Thesaurus ObjectClass)
C1273518 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
FormCompleteDate
Item
Date Form Completed (MM DD YYYY)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C40988 (NCI Thesaurus ObjectClass)
C1516308 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C25367 (NCI Thesaurus ValueDomain)
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