ID

10623

Description

CALGB: 49808 RADIOTHERAPY REPORT FORM NCT00016276 Combination Chemotherapy, Surgery, and Radiation Therapy With or Without Dexrazoxane and Trastuzumab in Treating Women With Stage III or Stage IV Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9E35395C-8724-227A-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9E35395C-8724-227A-E034-080020C9C0E0

Keywords

Versions (3)
  1. 8/26/12 8/26/12 -
  2. 5/22/15 5/22/15 -
  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: 49808 RADIOTHERAPY REPORT FORM NCT00016276

English

No Instruction available.

1 forms  
  1. StudyEvent: CALGB: 49808 RADIOTHERAPY REPORT 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

From
Description

From

Data type

text

To (Date of last contact or death)
Description

To

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 clinical trial data
Description

Patient clinical trial data

Patient's Name
Description

Patient'sName

Data type

text

Participating Group
Description

ParticipatingGroup

Data type

text

Alias
NCI Thesaurus ObjectClass
C17005
UMLS 2011AA ObjectClass
C1257890
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Patient Hospital Number
Description

PatientHospitalNumber

Data type

text

Participating Group Protocol No.
Description

ParticipatingGroupProtocolNo.

Data type

text

Main Member Institution/Adjunct
Description

MainMemberInstitution/Adjunct

Data type

text

Participating Group Patient No.
Description

ParticipatingGroupPatientNo.

Data type

text

Radiation Treatment
Description

Radiation Treatment

Has the patient received radiation therapy?
Description

Hasthepatientreceivedradiationtherapy?

Data type

text

If No, reason
Description

IfNo,reason

Data type

text

Date radiation therapy ended
Description

Dateradiationtherapyended

Data type

text

What was the total number of days the patient was treated with radiation?
Description

Whatwasthetotalnumberofdaysthepatientwastreatedwithradiation?

Data type

text

Was there a break in radiation treatment due to toxicity?
Description

Wasthereabreakinradiationtreatmentduetotoxicity?

Data type

text

If Yes, reason
Description

IfYes,reason

Data type

text

Date of last radiation therapy prior to break
Description

Dateoflastradiationtherapypriortobreak

Data type

text

Date of first radiation therapy after break
Description

Dateoffirstradiationtherapyafterbreak

Data type

text

Fields of radiation therapy (mark all that apply with an X)
Description

Fieldsofradiationtherapy

Data type

text

Fields of radiation therapy Other, specify
Description

FieldsofradiationtherapyOther,specify

Data type

text

Did patient begin taking tamoxifen during this reporting period?
Description

Didpatientbegintakingtamoxifenduringthisreportingperiod?

Data type

text

If Yes, date tamoxifen started
Description

IfYes,datetamoxifenstarted

Data type

text

Comments
Description

Comments

Comments
Description

Comments

Data type

text

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Similar models

No Instruction available.

1 forms
  1. StudyEvent: CALGB: 49808 RADIOTHERAPY REPORT 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
From
Item
From
text
To
Item
To (Date of last contact or death)
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)
Item Group
Patient clinical trial data
Patient'sName
Item
Patient's Name
text
ParticipatingGroup
Item
Participating Group
text
C17005 (NCI Thesaurus ObjectClass)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
PatientHospitalNumber
Item
Patient Hospital Number
text
ParticipatingGroupProtocolNo.
Item
Participating Group Protocol No.
text
MainMemberInstitution/Adjunct
Item
Main Member Institution/Adjunct
text
ParticipatingGroupPatientNo.
Item
Participating Group Patient No.
text
Item Group
Radiation Treatment
Item
Has the patient received radiation therapy?
text
CL.2
Code List
Has the patient received radiation therapy?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
IfNo,reason
Item
If No, reason
text
Dateradiationtherapyended
Item
Date radiation therapy ended
text
Whatwasthetotalnumberofdaysthepatientwastreatedwithradiation?
Item
What was the total number of days the patient was treated with radiation?
text
Item
Was there a break in radiation treatment due to toxicity?
text
CL.3
Code List
Was there a break in radiation treatment due to toxicity?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
IfYes,reason
Item
If Yes, reason
text
Dateoflastradiationtherapypriortobreak
Item
Date of last radiation therapy prior to break
text
Dateoffirstradiationtherapyafterbreak
Item
Date of first radiation therapy after break
text
Item
Fields of radiation therapy (mark all that apply with an X)
text
CL.4
Code List
Fields of radiation therapy (mark all that apply with an X)
CL Item
Ipsilateral Breast (Ipsilateral breast)
CL Item
Supraclavicular Field (Supraclavicular field)
CL Item
Axillary Fields (Axillary fields)
CL Item
Internal Mammary Fields (Internal mammary fields)
CL Item
Ipsilateral Chest Wall (Ipsilateral chest wall)
CL Item
Other, Specify: (Other, specify)
FieldsofradiationtherapyOther,specify
Item
Fields of radiation therapy Other, specify
text
Item
Did patient begin taking tamoxifen during this reporting period?
text
CL.5
Code List
Did patient begin taking tamoxifen during this reporting period?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
IfYes,datetamoxifenstarted
Item
If Yes, date tamoxifen started
text
Item Group
Comments
Comments
Item
Comments
text
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