ID
1065
Beschrijving
Tamoxifen/Exemestane Form (Form 24-TE) Brain Function in Premenopausal Women Receiving Tamoxifen With or Without Ovarian Function Suppression for Early-Stage Breast Cancer on Clinical Trial IBCSG-2402 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B70B84C2-ED22-2268-E034-0003BA12F5E7
Link
Trefwoorden
Versies (2)
- 26-08-12 26-08-12 -
- 08-01-15 08-01-15 - Martin Dugas
Geüploaded op
26 augustus 2012
DOI
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Licentie
Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00659373 Treatment - Tamoxifen/Exemestane Form (Form 24-TE) - 2080772v3.0
TAMOXIFEN/EXEMESTANE FORM (Form 24-TE) Instructions: This form is to be completed and submitted for all patients at each follow-up period (every 3 months in Year 1, and every 6 months in Years 2-6) until the completion of Tamoxifen/Exemestane. Report Tamoxifen/Exemestane given as treatment for recurrence/second primary on the Follow-Up Form (24-E). If patient is receiving another aromatase inhibitor,report on the Concomitant Medications Form (24-CCM). Mark your selection with an ?X? in the appropriate box(es). Use minus one (-1) to indicate that an answer is unknown, unobtainable, or not done.
Beschrijving
Tamoxifen
Beschrijving
DidpatientreceiveTamoxifenduringthisfollow-upperiod?
Datatype
text
Beschrijving
Yes,tookTamoxifenbutrandomizedtoExemestane,checkreason(selectone)
Datatype
text
Beschrijving
Other,specify(tookTamoxifenbutrandomizedtoExemestane)
Datatype
text
Beschrijving
ComplianceCode
Datatype
text
Beschrijving
Other,specify(compliancecode)
Datatype
text
Beschrijving
Reasonnottakencode
Datatype
text
Beschrijving
Adverseevent,specify
Datatype
text
Beschrijving
Adverseevent,specify
Datatype
text
Beschrijving
Adverseevent,specify
Datatype
text
Beschrijving
Other,specify(reasonnottaken)
Datatype
text
Beschrijving
Ifnon-protocoldosewasusedduringthisfollow-upperiod,whatdosagewasgiven?
Datatype
text
Beschrijving
TreatmentFirstDoseBeginDate
Datatype
date
Beschrijving
Enddateofnon-protocoldose
Datatype
text
Beschrijving
Reasonnon-protocoldoseused
Datatype
text
Beschrijving
Adverseevent,specify(reasonnon-protocoldoseused)
Datatype
text
Beschrijving
Medicaldecision,specify(reasonnon-protocoldoseused)
Datatype
text
Beschrijving
Other,specify(reasonnon-protocoldoseused)
Datatype
text
Beschrijving
DateInterruptionStarted
Datatype
text
Beschrijving
DateDrugResumed
Datatype
text
Beschrijving
ReasonforInterruptionCode
Datatype
text
Beschrijving
Other,specify(reasonforinterruption)
Datatype
text
Beschrijving
IfpatientpermanentlydiscontinuedTamoxifenduringthisfollow-upperiodgivedateoflastdose.
Datatype
text
Beschrijving
IfTamoxifenstoppedearlyorneverstarted,reason
Datatype
text
Beschrijving
Medicaldecision,specify
Datatype
text
Beschrijving
Other,specify
Datatype
text
Beschrijving
IfTamoxifenwillstartlater,reason
Datatype
text
Beschrijving
Adverseevent,specify(ifTamoxifenwillstartlater,reason)
Datatype
text
Beschrijving
Medicaldecision,specify(ifTamoxifenwillstartlater,reason)
Datatype
text
Beschrijving
Other,specify(ifTamoxifenwillstartlater,reason)
Datatype
text
Beschrijving
Exemestane
Beschrijving
DidpatientreceiveExemestaneduringthisfollow-upperiod?
Datatype
text
Beschrijving
Yes,tookExemestanebutrandomizedtoTamoxifen,checkreason
Datatype
text
Beschrijving
Other,sourceofsurvivalinformation
Datatype
text
Beschrijving
Dose
Datatype
double
Alias
- NCI Thesaurus ObjectClass
- C15313
- UMLS 2011AA ObjectClass
- C1522449
- NCI Thesaurus Property
- C25256
- UMLS 2011AA Property
- C1265611
Beschrijving
ComplianceCode
Datatype
text
Beschrijving
Numberoftabletsdispensed
Datatype
text
Beschrijving
Other,specify(compliancecode)
Datatype
text
Beschrijving
BatchNumber
Datatype
text
Beschrijving
Reasonnottakencode
Datatype
text
Beschrijving
PillsReceivedDate
Datatype
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
- NCI Thesaurus Property
- C25639
- UMLS 2011AA Property
- C1514756
- NCI Thesaurus ObjectClass
- C25394
- UMLS 2011AA ObjectClass
- C0994475
Beschrijving
Adverseevent,specify
Datatype
text
Beschrijving
Adverseevent,specify
Datatype
text
Beschrijving
Adverseevent,specify
Datatype
text
Beschrijving
Tabletsdispensedby(initials)
Datatype
text
Beschrijving
Other,specify(reasonnottaken)
Datatype
text
Beschrijving
Numberoftabletsreturned
Datatype
text
Beschrijving
Ifnon-protocoldosewasusedduringthisfollow-upperiod,whatdosagewasgiven?
Datatype
text
Beschrijving
PillsRemainingDate
Datatype
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
- NCI Thesaurus ObjectClass
- C25394
- UMLS 2011AA ObjectClass
- C0994475
- NCI Thesaurus Property
- C25649
- UMLS 2011AA Property
- C1527428
Beschrijving
Enddateofnon-protocoldose
Datatype
text
Beschrijving
Reasonnon-protocoldoseused
Datatype
text
Beschrijving
Adverseevent,specify(reasonnon-protocoldoseused)
Datatype
text
Beschrijving
Medicaldecision,specify(reasonnon-protocoldoseused)
Datatype
text
Beschrijving
Other,specify(reasonnon-protocoldoseused)
Datatype
text
Beschrijving
DateInterruptionStarted
Datatype
text
Beschrijving
TreatmentFirstDoseBeginDate
Datatype
date
Alias
- NCI Thesaurus ObjectClass
- C15368
- NCI Thesaurus Property
- C25509
- UMLS 2011AA Property
- C1279901
- NCI Thesaurus Property
- C25256
- UMLS 2011AA Property
- C1265611
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
- NCI Thesaurus ValueDomain
- C25431
- UMLS 2011AA ValueDomain
- C0439659
Beschrijving
DateDrugResumed
Datatype
text
Beschrijving
ReasonforInterruptionCode
Datatype
text
Beschrijving
Other,specify(reasonforinterruption)
Datatype
text
Beschrijving
Medicaldecision,specify
Datatype
text
Beschrijving
Other,specify
Datatype
text
Beschrijving
IfpatientpermanentlydiscontinuedExemestaneduringthisfollow-upperiodgivedateoflastdose.
Datatype
text
Beschrijving
IfExemestanestoppedearlyorneverstarted,reason
Datatype
text
Beschrijving
IfExemestanewillstartlater,reason
Datatype
text
Beschrijving
Adverseevent,specify(ifExemestanewillstartlater,reason)
Datatype
text
Beschrijving
Medicaldecision,specify(ifExemestanewillstartlater,reason)
Datatype
text
Beschrijving
Other,specify(ifExemestanewillstartlater,reason)
Datatype
text
Beschrijving
InvestigatorSignatureText
Datatype
text
Alias
- NCI Thesaurus ValueDomain
- C25704
- UMLS 2011AA ValueDomain
- C1527021
- NCI Thesaurus Property
- C25678
- UMLS 2011AA Property
- C1519316
- NCI Thesaurus ObjectClass
- C17089
- UMLS 2011AA ObjectClass
- C0035173
Beschrijving
InvestigatorSignatureDate
Datatype
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
- NCI Thesaurus Property
- C25678
- UMLS 2011AA Property
- C1519316
- NCI Thesaurus ValueDomain
- C25367
- NCI Thesaurus ObjectClass
- C17089
- UMLS 2011AA ObjectClass
- C0035173
Similar models
TAMOXIFEN/EXEMESTANE FORM (Form 24-TE) Instructions: This form is to be completed and submitted for all patients at each follow-up period (every 3 months in Year 1, and every 6 months in Years 2-6) until the completion of Tamoxifen/Exemestane. Report Tamoxifen/Exemestane given as treatment for recurrence/second primary on the Follow-Up Form (24-E). If patient is receiving another aromatase inhibitor,report on the Concomitant Medications Form (24-CCM). Mark your selection with an ?X? in the appropriate box(es). Use minus one (-1) to indicate that an answer is unknown, unobtainable, or not done.
C1547383 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25536 (NCI Thesaurus Property)
C1555582 (UMLS 2011AA Property)
C0011008 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus ValueDomain)
C25155 (NCI Thesaurus Property)
C0005615 (UMLS 2011AA Property)
C0805701 (UMLS 2011AA ValueDomain)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C25651 (NCI Thesaurus Property)
C0700287 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25431 (NCI Thesaurus ValueDomain)
C0439659 (UMLS 2011AA ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C15368 (NCI Thesaurus ObjectClass)
C25651 (NCI Thesaurus Property)
C0700287 (UMLS 2011AA Property)
C0030705 (UMLS 2011AA ObjectClass)
C855 (NCI Thesaurus Property)
C0039286 (UMLS 2011AA Property)
C1097 (NCI Thesaurus Property)
C0060116 (UMLS 2011AA Property)
C15368 (NCI Thesaurus Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C0030705 (UMLS 2011AA ObjectClass)
C855 (NCI Thesaurus Property)
C0039286 (UMLS 2011AA Property)
C1097 (NCI Thesaurus Property)
C0060116 (UMLS 2011AA Property)
C15368 (NCI Thesaurus Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C0877248 (UMLS 2011AA)
C0034897 (UMLS 2011AA)
C1522449 (UMLS 2011AA ObjectClass)
C25256 (NCI Thesaurus Property)
C1265611 (UMLS 2011AA Property)
C0011008 (UMLS 2011AA ValueDomain)
C25639 (NCI Thesaurus Property)
C1514756 (UMLS 2011AA Property)
C25394 (NCI Thesaurus ObjectClass)
C0994475 (UMLS 2011AA ObjectClass)
C0011008 (UMLS 2011AA ValueDomain)
C25394 (NCI Thesaurus ObjectClass)
C0994475 (UMLS 2011AA ObjectClass)
C25649 (NCI Thesaurus Property)
C1527428 (UMLS 2011AA Property)
C0877248 (UMLS 2011AA)
C25509 (NCI Thesaurus Property)
C1279901 (UMLS 2011AA Property)
C25256 (NCI Thesaurus Property)
C1265611 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25431 (NCI Thesaurus ValueDomain)
C0439659 (UMLS 2011AA ValueDomain)
C0034897 (UMLS 2011AA)
C1527021 (UMLS 2011AA ValueDomain)
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
C0011008 (UMLS 2011AA ValueDomain)
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C25367 (NCI Thesaurus ValueDomain)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)