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ID

10839

Descrição

CALGB: 80405 ON-STUDY FORM NCT00265850 Cetuximab and/or Bevacizumab Combined With Combination Chemotherapy in Treating Patients With Metastatic Colorectal Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=F39D0458-B14A-5DB0-E034-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=F39D0458-B14A-5DB0-E034-0003BA3F9857

Palavras-chave

  1. 27/08/2012 27/08/2012 -
  2. 09/01/2015 09/01/2015 - Martin Dugas
  3. 09/06/2015 09/06/2015 -
Transferido a

9 de junho de 2015

DOI

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Licença

Creative Commons BY-NC 3.0 Legacy

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    CALGB: 80405 ON-STUDY FORM NCT00265850

    INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted.

    Header
    Descrição

    Header

    CALGB Form
    Descrição

    Form ID CALGB

    Tipo de dados

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C3262252
    NCI Thesaurus ObjectClass
    C19464
    UMLS CUI-2
    C1516238
    NCI Thesaurus Property
    C25364
    NCI Thesaurus ObjectClass-2
    C25442
    CALGB Study No
    Descrição

    Protocol ID CALGB

    Tipo de dados

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C3274381
    NCI Thesaurus ObjectClass
    C25320
    UMLS CUI-2
    C1516238
    NCI Thesaurus Property
    C25364
    NCI Thesaurus Property-2
    C25442
    CALGB Patient ID
    Descrição

    Trial subject ID CALGB

    Tipo de dados

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C2348585
    NCI Thesaurus ObjectClass
    C16960
    UMLS CUI-2
    C1516238
    NCI Thesaurus Property
    C25364
    NCI Thesaurus Property-2
    C25442
    Start date of first treatment
    Descrição

    FirstProtocolTreatmentBeginDate

    Tipo de dados

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C25320
    UMLS 2011AA ObjectClass
    C1507394
    NCI Thesaurus Property
    C15368
    NCI Thesaurus ValueDomain-2
    C25431
    UMLS 2011AA ValueDomain-2
    C0439659
    NCI Thesaurus ObjectClass-2
    C25509
    UMLS 2011AA ObjectClass-2
    C1279901
    Are data amended
    Descrição

    Data amended

    Tipo de dados

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38148
    UMLS CUI-1
    C0680532
    NCI Thesaurus ObjectClass
    C25474
    NCI Thesaurus Property
    C25416
    Patient demographics
    Descrição

    Patient demographics

    Patient Initials
    Descrição

    Patient Initials

    Tipo de dados

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C2986440
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25536
    Patient Hospital No
    Descrição

    Patient Hospital No

    Tipo de dados

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C0421459
    NCI Thesaurus Property
    C16960
    NCI Thesaurus Property-2
    C25364
    NCI Thesaurus ObjectClass
    C16696
    Institution/Affiliate
    Descrição

    Institution Name

    Tipo de dados

    text

    Alias
    NCI Thesaurus ObjectClass
    C25454
    UMLS CUI-1
    C1301943
    NCI Thesaurus ObjectClass-2
    C21541
    NCI Thesaurus Property
    C25364
    NCI Thesaurus ValueDomain
    C25191
    NCI Thesaurus ValueDomain-2
    C21541
    Participating Group
    Descrição

    Participating Group

    Tipo de dados

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C2347449
    NCI Thesaurus ObjectClass
    C25608
    NCI Thesaurus ObjectClass-2
    C17005
    NCI Thesaurus Property
    C25364
    Participating Group Study No.
    Descrição

    Study Number Participating Group

    Tipo de dados

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C3274381
    NCI Thesaurus ObjectClass
    C25320
    UMLS CUI-2
    C2347449
    NCI Thesaurus Property
    C25608
    NCI Thesaurus Property-2
    C25364
    Participating Group Patient ID
    Descrição

    Trial subject ID Participating Group

    Tipo de dados

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C2348585
    NCI Thesaurus ObjectClass
    C16960
    UMLS CUI-2
    C2347449
    NCI Thesaurus Property
    C25608
    NCI Thesaurus Property-2
    C25364
    Patient Description
    Descrição

    Patient Description

    Date of original diagnosis of colorectal cancer (MM DD YYYY)
    Descrição

    ColorectalCancerOriginalDiagnosisDate

    Tipo de dados

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus Property
    C25604
    UMLS 2011AA Property
    C0205313
    NCI Thesaurus Property-2
    C15220
    UMLS 2011AA Property-2
    C0011900
    NCI Metathesaurus ObjectClass
    C0009402
    MedDRA Code (disease)
    Descrição

    MedDRACode

    Tipo de dados

    float

    Alias
    NCI Thesaurus ValueDomain
    C25162
    UMLS 2011AA ValueDomain
    C0805701
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Metathesaurus ObjectClass
    CL104089
    Has the patient had any prior cancer diagnosed? (other than colorectal?)
    Descrição

    PriorCancerDiagnosisInd-3

    Tipo de dados

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38148
    UMLS 2011AA ValueDomain
    C1512699
    NCI Thesaurus ObjectClass
    C9305
    UMLS 2011AA ObjectClass
    C0006826
    NCI Thesaurus ObjectClass-2
    C25629
    UMLS 2011AA ObjectClass-2
    C0332152
    NCI Thesaurus Property
    C15220
    UMLS 2011AA Property
    C0011900
    Type of Prior Cancer (If Yes,)
    Descrição

    PriorCancerTypeText

    Tipo de dados

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS 2011AA ValueDomain
    C1527021
    NCI Thesaurus ObjectClass
    C9305
    UMLS 2011AA ObjectClass
    C0006826
    NCI Thesaurus ObjectClass-2
    C25629
    UMLS 2011AA ObjectClass-2
    C0332152
    NCI Thesaurus Property
    C25365
    UMLS 2011AA Property
    C0678257
    Prior Cancer Diagnosis Date (year YYYY)
    Descrição

    PriorCancerDiagnosisDate

    Tipo de dados

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C9305
    UMLS 2011AA ObjectClass
    C0006826
    NCI Thesaurus ObjectClass-2
    C25629
    UMLS 2011AA ObjectClass-2
    C0332152
    NCI Thesaurus Property
    C15220
    UMLS 2011AA Property
    C0011900
    SWOG Patient ID (from SWOG SpecTrak System)
    Descrição

    Trial subject ID SWOG

    Tipo de dados

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C2348585
    NCI Thesaurus ObjectClass
    C16960
    UMLS CUI-2
    C1519429
    NCI Thesaurus Property
    C25364
    NCI Thesaurus Property-2
    C25699
    Lab Data At Protocol Entry
    Descrição

    Lab Data At Protocol Entry

    Peripheral WBC Count
    Descrição

    Leukocytes (WBC)

    Tipo de dados

    float

    Unidades de medida
    • 1000/uL
    Alias
    NCI Thesaurus ObjectClass
    C25294
    UMLS CUI-1
    C0023508
    NCI Thesaurus Property
    C12529
    NCI Thesaurus Property-2
    C20200
    NCI Thesaurus ValueDomain
    C25712
    NCI Thesaurus ValueDomain-2
    C38024
    1000/uL
    Absolute neutrophil count
    Descrição

    Neutrophil count

    Tipo de dados

    float

    Alias
    NCI Thesaurus ObjectClass
    C25294
    UMLS CUI-1
    C0200633
    NCI Thesaurus Property
    C12533
    NCI Thesaurus Property-2
    C20200
    NCI Thesaurus ValueDomain
    C25304
    NCI Thesaurus ValueDomain-2
    C25712
    Peripheral Neutrophils (%)
    Descrição

    Neutrophil percentage

    Tipo de dados

    float

    Unidades de medida
    • %
    Alias
    NCI Thesaurus ObjectClass
    C25294
    UMLS CUI-1
    C1171400
    NCI Thesaurus Property
    C12533
    NCI Thesaurus Property-2
    C20200
    NCI Thesaurus ValueDomain
    C25613
    NCI Thesaurus ValueDomain-2
    C25712
    %
    Hemoglobin
    Descrição

    LaboratoryProcedureHemoglobinResultSpecifiedValue

    Tipo de dados

    float

    Unidades de medida
    • g/dL
    Alias
    NCI Thesaurus Property
    C16676
    UMLS 2011AA Property
    C0019046
    NCI Thesaurus Property-2
    C20200
    UMLS 2011AA Property-2
    C1274040
    NCI Thesaurus ObjectClass
    C25294
    UMLS 2011AA ObjectClass
    C0022885
    NCI Thesaurus ValueDomain
    C25712
    UMLS 2011AA ValueDomain
    C1522609
    g/dL
    Peripheral platelet count
    Descrição

    Platelets

    Tipo de dados

    float

    Unidades de medida
    • 1000/uL
    Alias
    NCI Thesaurus Property
    C20200
    UMLS CUI-1
    C0005821
    NCI Thesaurus Property-2
    C12520
    NCI Thesaurus ObjectClass
    C25294
    NCI Thesaurus ValueDomain
    C25712
    1000/uL
    Bilirubin
    Descrição

    HepaticBilirubinLabValue

    Tipo de dados

    float

    Unidades de medida
    • mg/dL
    Alias
    NCI Thesaurus Property
    C20200
    UMLS 2011AA Property
    C1274040
    NCI Thesaurus Property-2
    C305
    UMLS 2011AA Property-2
    C0005437
    NCI Thesaurus ObjectClass
    C25294
    UMLS 2011AA ObjectClass
    C0022885
    NCI Thesaurus ValueDomain
    C25712
    UMLS 2011AA ValueDomain
    C1522609
    mg/dL
    Magnesium
    Descrição

    LaboratoryProcedureMagnesiumResultSpecifiedValue

    Tipo de dados

    float

    Unidades de medida
    • mmol/L
    Alias
    NCI Thesaurus ObjectClass
    C25294
    UMLS 2011AA ObjectClass
    C0022885
    NCI Thesaurus Property
    C20200
    UMLS 2011AA Property
    C1274040
    NCI Thesaurus Property-2
    C29239
    UMLS 2011AA Property-2
    C0024467
    NCI Thesaurus ValueDomain
    C25712
    UMLS 2011AA ValueDomain
    C1522609
    NCI Thesaurus ValueDomain-2
    C38024
    UMLS 2011AA ValueDomain-2
    C0205369
    mmol/L
    SGOT
    Descrição

    HepaticSGOT(AST)LabUnspecifiedValue

    Tipo de dados

    float

    Alias
    NCI Thesaurus ObjectClass
    C13308
    UMLS 2011AA ObjectClass
    C0205054
    NCI Thesaurus Property
    C25202
    UMLS 2011AA Property
    C0242192
    NCI Thesaurus Property-2
    C37984
    UMLS 2011AA Property-2
    C0022877
    NCI Thesaurus ValueDomain
    C38046
    UMLS 2011AA ValueDomain
    C0205370
    NCI Thesaurus ValueDomain-2
    C25712
    UMLS 2011AA ValueDomain-2
    C1522609
    SGOT (AST) ULN
    Descrição

    LaboratoryProcedureSerumGlutamicOxaloaceticTransferaseResultUnspecifiedUpperLimitofNormalValue

    Tipo de dados

    float

    Alias
    NCI Thesaurus ObjectClass
    C25294
    UMLS 2011AA ObjectClass
    C0022885
    NCI Thesaurus Property
    C25202
    UMLS 2011AA Property
    C0242192
    NCI Thesaurus Property-2
    C20200
    UMLS 2011AA Property-2
    C1274040
    NCI Thesaurus ValueDomain
    C25712
    UMLS 2011AA ValueDomain
    C1522609
    NCI Thesaurus ValueDomain-2
    C25706
    UMLS 2011AA ValueDomain-2
    C1519815
    Creatinine
    Descrição

    RenalCreatinineLabSpecifiedValue

    Tipo de dados

    float

    Unidades de medida
    • mg/dL
    Alias
    NCI Thesaurus ObjectClass
    C25225
    UMLS 2011AA ObjectClass
    C0022646
    NCI Thesaurus Property
    C399
    UMLS 2011AA Property
    C0010294
    NCI Thesaurus Property-2
    C25294
    UMLS 2011AA Property-2
    C0022885
    NCI Thesaurus ValueDomain
    C25712
    UMLS 2011AA ValueDomain
    C1522609
    mg/dL
    Creatinine ULN
    Descrição

    Creatinine, serum ULN

    Tipo de dados

    float

    Alias
    NCI Thesaurus ObjectClass
    C25294
    UMLS CUI-1
    C0201976
    NCI Thesaurus Property
    C20200
    UMLS CUI-2
    C1519815
    NCI Thesaurus Property-2
    C399
    NCI Thesaurus ValueDomain
    C25712
    NCI Thesaurus ValueDomain-2
    C25706
    Albumin
    Descrição

    Albumin

    Tipo de dados

    float

    Alias
    NCI Thesaurus Property
    C20200
    UMLS CUI-1
    C0201838
    NCI Thesaurus Property-2
    C214
    NCI Thesaurus ObjectClass
    C25294
    NCI Thesaurus ValueDomain
    C25712
    Lactate Dehydrogenase (LDH)
    Descrição

    LDH

    Tipo de dados

    float

    Unidades de medida
    • U/L
    Alias
    NCI Thesaurus Property
    C20200
    UMLS CUI-1
    C0202113
    NCI Thesaurus ObjectClass
    C25294
    NCI Thesaurus ValueDomain
    C25712
    NCI Thesaurus Property-2
    C25184
    U/L
    Urinalysis result (Mark one with an X)
    Descrição

    UrinalysisProteinLevelAmount

    Tipo de dados

    text

    Alias
    NCI Thesaurus ObjectClass
    C17241
    UMLS 2011AA ObjectClass
    C0042014
    NCI Thesaurus Property
    C17021
    UMLS 2011AA Property
    C0033684
    NCI Thesaurus ValueDomain
    C25417
    NCI Thesaurus Property-2
    C25554
    UMLS 2011AA Property-2
    C0441889
    Protein from 24 hour urine collection (for patients who have > 2+ proteinuria)
    Descrição

    UrinaryProteinCollectionValue

    Tipo de dados

    float

    Unidades de medida
    • g/24 hours
    Alias
    NCI Thesaurus Property
    C25453
    UMLS 2011AA Property
    C1516698
    NCI Thesaurus ValueDomain
    C25712
    UMLS 2011AA ValueDomain
    C1522609
    NCI Thesaurus ObjectClass
    C17021
    UMLS 2011AA ObjectClass
    C0033684
    g/24 hours
    Disease description (Mark one with an X)
    Descrição

    ColorectalCancerDescriptionDiseaseType

    Tipo de dados

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Metathesaurus ObjectClass
    C0009402
    NCI Thesaurus Property
    C25365
    UMLS 2011AA Property
    C0678257
    NCI Metathesaurus Property
    C0012634
    Currently involved sites of disease (Mark all that apply with an X.)
    Descrição

    ColorectalCancerInvolvedDiseaseSite

    Tipo de dados

    text

    Alias
    NCI Thesaurus ValueDomain
    C13717
    UMLS 2011AA ValueDomain
    C1515974
    NCI Thesaurus Property
    C25547
    NCI Metathesaurus ObjectClass
    C0009402
    NCI Metathesaurus Property
    C0012634
    Intent of treatment (Mark one with an X.)
    Descrição

    ColorectalCancerIntentTreatmentType

    Tipo de dados

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus Property
    C15368
    NCI Metathesaurus ObjectClass
    C0009402
    NCI Thesaurus Property-2
    C25725
    UMLS 2011AA Property
    C1283828
    For Patients Who Consented To The Correlative Sciences Companion Study
    Descrição

    For Patients Who Consented To The Correlative Sciences Companion Study

    Specimen collected time (Serum)
    Descrição

    BloodSpecimenCollectionTime

    Tipo de dados

    time

    Alias
    NCI Thesaurus ObjectClass
    C12434
    UMLS 2011AA ObjectClass
    C0229664
    NCI Thesaurus ValueDomain
    C25207
    UMLS 2011AA ValueDomain
    C0040223
    NCI Thesaurus ObjectClass-2
    C19157
    UMLS 2011AA ObjectClass-2
    C0370003
    NCI Thesaurus Property
    C25452
    Number of hours between last meal and blood collection
    Descrição

    CollectionBloodHourFastingSpecify

    Tipo de dados

    text

    Alias
    NCI Thesaurus ObjectClass
    C12434
    UMLS 2011AA ObjectClass
    C0229664
    NCI Thesaurus ObjectClass-2
    C25453
    UMLS 2011AA ObjectClass-2
    C1516698
    NCI Thesaurus Property
    C25529
    UMLS 2011AA Property
    C0439227
    NCI Metathesaurus Property
    C0015663
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    Prior Therapy Data
    Descrição

    Prior Therapy Data

    Date of last surgical resection for colorectal cancer (If applicable, submit operative and pathology reports.)
    Descrição

    SurgicalProcedureColorectalCarcinomaPerformedMostRecentDate

    Tipo de dados

    date

    Alias
    NCI Thesaurus ObjectClass
    C15329
    UMLS 2011AA ObjectClass
    C0543467
    NCI Thesaurus Property
    C38000
    UMLS 2011AA Property
    C0884358
    NCI Thesaurus Property-2
    C2955
    UMLS 2011AA Property-2
    C0009402
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ValueDomain-2
    C25577
    UMLS 2011AA ValueDomain-2
    C1513491
    Prior Systemic Chemotherapy
    Descrição

    PriorChemotherapyAdministeredInd-3

    Tipo de dados

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38148
    UMLS 2011AA ValueDomain
    C1512699
    NCI Thesaurus ObjectClass
    C15632
    UMLS 2011AA ObjectClass
    C0392920
    NCI Thesaurus ObjectClass-2
    C25629
    UMLS 2011AA ObjectClass-2
    C0332152
    NCI Thesaurus Property
    C25382
    UMLS 2011AA Property
    C1521801
    specify agents (If Yes, Mark one with an X.)
    Descrição

    PriorAgentColorectalCancerTherapyType

    Tipo de dados

    text

    Alias
    NCI Thesaurus ObjectClass
    C25629
    UMLS 2011AA ObjectClass
    C0332152
    NCI Thesaurus ObjectClass-2
    C1708
    UMLS 2011AA ObjectClass-2
    C0450442
    NCI Thesaurus Property
    C15368
    NCI Metathesaurus Property
    C0009402
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    Other, specify
    Descrição

    PriorAgentColorectalCancerTherapySpecify

    Tipo de dados

    text

    Alias
    NCI Thesaurus ObjectClass
    C25629
    UMLS 2011AA ObjectClass
    C0332152
    NCI Thesaurus ObjectClass-2
    C1708
    UMLS 2011AA ObjectClass-2
    C0450442
    NCI Thesaurus Property
    C15368
    NCI Metathesaurus Property
    C0009402
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    Prior Chemotherapy Begin Date
    Descrição

    PriorChemotherapyAdministeredBeginDate

    Tipo de dados

    date

    Alias
    NCI Thesaurus ObjectClass
    C15632
    UMLS 2011AA ObjectClass
    C0392920
    NCI Thesaurus ObjectClass-2
    C25629
    UMLS 2011AA ObjectClass-2
    C0332152
    NCI Thesaurus Property
    C25382
    UMLS 2011AA Property
    C1521801
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ValueDomain-2
    C25431
    UMLS 2011AA ValueDomain-2
    C0439659
    Prior Chemotherapy End Date
    Descrição

    PriorChemotherapyAdministeredEndDate

    Tipo de dados

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C15632
    UMLS 2011AA ObjectClass
    C0392920
    NCI Thesaurus ObjectClass-2
    C25629
    UMLS 2011AA ObjectClass-2
    C0332152
    NCI Thesaurus Property
    C25382
    UMLS 2011AA Property
    C1521801
    Prior chemotherapy for advanced or metastatic colorectal cancer
    Descrição

    PatientChemotherapyMetastasisColorectalCarcinomaPersonalMedicalHistoryInd-2

    Tipo de dados

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C15632
    UMLS 2011AA Property
    C0392920
    NCI Thesaurus Property-2
    C19151
    UMLS 2011AA Property-2
    C0027627
    NCI Thesaurus Property-3
    C2955
    UMLS 2011AA Property-3
    C0009402
    NCI Thesaurus Property-4
    C18772
    UMLS 2011AA Property-4
    C0262926
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Prior radiation therapy (with or without radiosensitizing chemotherapy)
    Descrição

    Prior Radiation Therapy

    Tipo de dados

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38148
    UMLS CUI-1
    C1522449
    NCI Thesaurus ObjectClass
    C15313
    UMLS CUI-2
    C0332152
    NCI Thesaurus ObjectClass-2
    C25629
    NCI Thesaurus Property
    C25382
    RT begin date
    Descrição

    Radiation Therapy Start Date

    Tipo de dados

    date

    Alias
    NCI Thesaurus ObjectClass
    C15313
    UMLS CUI-1
    C1522449
    NCI Thesaurus Property
    C25431
    UMLS CUI-2
    C0808070
    NCI Thesaurus Property-2
    C25275
    NCI Thesaurus ValueDomain
    C25164
    NCI Thesaurus ValueDomain-2
    C25367
    RT End Date
    Descrição

    Radiation Therapy End Date

    Tipo de dados

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS CUI-1
    C1522449
    NCI Thesaurus ObjectClass
    C15313
    UMLS CUI-2
    C0806020
    NCI Thesaurus Property
    C25275
    NCI Thesaurus Property-2
    C25496
    Patient receiving full-dose anticoagulants
    Descrição

    FullDoseAnticoagulantAgentCurrentUseInd-2

    Tipo de dados

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C25488
    UMLS 2011AA ObjectClass
    C0178602
    NCI Thesaurus ObjectClass-2
    C263
    UMLS 2011AA ObjectClass-2
    C0003280
    NCI Thesaurus ObjectClass-3
    C25517
    UMLS 2011AA ObjectClass-3
    C0443225
    NCI Thesaurus Property
    C25471
    UMLS 2011AA Property
    C0521116
    NCI Thesaurus Property-2
    C25340
    UMLS 2011AA Property-2
    C0457083
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    is the patient receiving a stable dose of warfarin and has an in-range INR or receiving a stable dose of heparin (If yes,)
    Descrição

    PatientWarfarinTreatmentInd-2

    Tipo de dados

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C15368
    NCI Metathesaurus Property
    C0043031
    Arterial thrombotic event risk factors (Mark all that apply with an X.)
    Descrição

    ArterialThrombosisRiskFactorType

    Tipo de dados

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Metathesaurus ObjectClass
    C0221464
    NCI Metathesaurus ObjectClass-2
    C0040053
    NCI Thesaurus Property
    C17103
    UMLS 2011AA Property
    C0035648
    Prior ATE code
    Descrição

    ArterialThrombosisPriorEventType

    Tipo de dados

    text

    Alias
    NCI Thesaurus ObjectClass
    C26891
    UMLS 2011AA ObjectClass
    C0040053
    NCI Metathesaurus ObjectClass
    C0221464
    NCI Thesaurus Property
    C25499
    UMLS 2011AA Property
    C0441471
    NCI Thesaurus Property-2
    C25629
    UMLS 2011AA Property-2
    C0332152
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    Other, specify
    Descrição

    ArterialThrombosisPriorEventSpecify

    Tipo de dados

    text

    Alias
    NCI Thesaurus ObjectClass
    C26891
    UMLS 2011AA ObjectClass
    C0040053
    NCI Metathesaurus ObjectClass
    C0221464
    NCI Thesaurus Property
    C25499
    UMLS 2011AA Property
    C0441471
    NCI Thesaurus Property-2
    C25629
    UMLS 2011AA Property-2
    C0332152
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    Prior ATE onset date (of most recent events)
    Descrição

    PriorArterialThrombosisEventDate

    Tipo de dados

    date

    Alias
    NCI Thesaurus ObjectClass
    C25629
    UMLS 2011AA ObjectClass
    C0332152
    NCI Metathesaurus ObjectClass
    C0221464
    NCI Metathesaurus ObjectClass-2
    C0040053
    NCI Thesaurus Property
    C25499
    UMLS 2011AA Property
    C0441471
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    Does patient have history of significant bleeding episodes
    Descrição

    PatientHistoryHemorrhageEventInd-2

    Tipo de dados

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25499
    UMLS 2011AA Property
    C0441471
    NCI Thesaurus Property-2
    C26791
    UMLS 2011AA Property-2
    C0019080
    NCI Metathesaurus Property
    C1321503
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Specify type
    Descrição

    PatientHistoryHemorrhageEventText

    Tipo de dados

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25499
    UMLS 2011AA Property
    C0441471
    NCI Thesaurus Property-2
    C26791
    UMLS 2011AA Property-2
    C0019080
    NCI Metathesaurus Property
    C1321503
    NCI Thesaurus ValueDomain
    C25704
    UMLS 2011AA ValueDomain
    C1527021
    Date (MM DD YYYY)
    Descrição

    PatientHistoryHemorrhageEventDate

    Tipo de dados

    date

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25499
    UMLS 2011AA Property
    C0441471
    NCI Thesaurus Property-2
    C26791
    UMLS 2011AA Property-2
    C0019080
    NCI Metathesaurus Property
    C1321503
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    Does patient have history of GI perforation
    Descrição

    PatientHistoryGIPerforationInd-2

    Tipo de dados

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C25190
    UMLS 2011AA ObjectClass
    C0027361
    NCI Thesaurus Property
    C34082
    UMLS 2011AA Property
    C0017189
    NCI Thesaurus Property-2
    C18772
    UMLS 2011AA Property-2
    C0262926
    NCI Thesaurus Property-3
    C4080
    UMLS 2011AA Property-3
    C0549099
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Specify date of onset (MM DD YYYY)
    Descrição

    PersonGastrointestinalTractPerforationPersonalMedicalHistoryDate

    Tipo de dados

    date

    Alias
    NCI Thesaurus ObjectClass
    C25190
    UMLS 2011AA ObjectClass
    C0027361
    NCI Thesaurus Property
    C34082
    UMLS 2011AA Property
    C0017189
    NCI Thesaurus Property-2
    C18772
    UMLS 2011AA Property-2
    C0262926
    NCI Thesaurus Property-3
    C4080
    UMLS 2011AA Property-3
    C0549099
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    Completed by
    Descrição

    Person Completing Form

    Tipo de dados

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C1550483
    NCI Thesaurus ObjectClass
    C25657
    NCI Thesaurus Property
    C25364
    Date Form Originally Completed (MM DD YYYY)
    Descrição

    Form Completion Date

    Tipo de dados

    date

    Alias
    NCI Thesaurus ObjectClass
    C19464
    UMLS CUI-1
    C1549507
    NCI Thesaurus Property
    C25250
    NCI Thesaurus Property-2
    C25604
    NCI Thesaurus ValueDomain
    C25164
    NCI Thesaurus ValueDomain-2
    C25367

    Similar models

    INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted.

    Name
    Tipo
    Description | Question | Decode (Coded Value)
    Tipo de dados
    Alias
    Item Group
    Header
    Form ID CALGB
    Item
    CALGB Form
    text
    C25337 (NCI Thesaurus ValueDomain)
    C3262252 (UMLS CUI-1)
    C19464 (NCI Thesaurus ObjectClass)
    C1516238 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    C25442 (NCI Thesaurus ObjectClass-2)
    Protocol ID CALGB
    Item
    CALGB Study No
    text
    C25337 (NCI Thesaurus ValueDomain)
    C3274381 (UMLS CUI-1)
    C25320 (NCI Thesaurus ObjectClass)
    C1516238 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    C25442 (NCI Thesaurus Property-2)
    Trial subject ID CALGB
    Item
    CALGB Patient ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C2348585 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C1516238 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    C25442 (NCI Thesaurus Property-2)
    FirstProtocolTreatmentBeginDate
    Item
    Start date of first treatment
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25320 (NCI Thesaurus ObjectClass)
    C1507394 (UMLS 2011AA ObjectClass)
    C15368 (NCI Thesaurus Property)
    C25431 (NCI Thesaurus ValueDomain-2)
    C0439659 (UMLS 2011AA ValueDomain-2)
    C25509 (NCI Thesaurus ObjectClass-2)
    C1279901 (UMLS 2011AA ObjectClass-2)
    Data amended
    Item
    Are data amended
    boolean
    C38148 (NCI Thesaurus ValueDomain)
    C0680532 (UMLS CUI-1)
    C25474 (NCI Thesaurus ObjectClass)
    C25416 (NCI Thesaurus Property)
    Item Group
    Patient demographics
    Patient Initials
    Item
    Patient Initials
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2986440 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25536 (NCI Thesaurus Property)
    Patient Hospital No
    Item
    Patient Hospital No
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0421459 (UMLS CUI-1)
    C16960 (NCI Thesaurus Property)
    C25364 (NCI Thesaurus Property-2)
    C16696 (NCI Thesaurus ObjectClass)
    Institution Name
    Item
    Institution/Affiliate
    text
    C25454 (NCI Thesaurus ObjectClass)
    C1301943 (UMLS CUI-1)
    C21541 (NCI Thesaurus ObjectClass-2)
    C25364 (NCI Thesaurus Property)
    C25191 (NCI Thesaurus ValueDomain)
    C21541 (NCI Thesaurus ValueDomain-2)
    Participating Group
    Item
    Participating Group
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2347449 (UMLS CUI-1)
    C25608 (NCI Thesaurus ObjectClass)
    C17005 (NCI Thesaurus ObjectClass-2)
    C25364 (NCI Thesaurus Property)
    Study Number Participating Group
    Item
    Participating Group Study No.
    text
    C25337 (NCI Thesaurus ValueDomain)
    C3274381 (UMLS CUI-1)
    C25320 (NCI Thesaurus ObjectClass)
    C2347449 (UMLS CUI-2)
    C25608 (NCI Thesaurus Property)
    C25364 (NCI Thesaurus Property-2)
    Trial subject ID Participating Group
    Item
    Participating Group Patient ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C2348585 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C2347449 (UMLS CUI-2)
    C25608 (NCI Thesaurus Property)
    C25364 (NCI Thesaurus Property-2)
    Item Group
    Patient Description
    ColorectalCancerOriginalDiagnosisDate
    Item
    Date of original diagnosis of colorectal cancer (MM DD YYYY)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25604 (NCI Thesaurus Property)
    C0205313 (UMLS 2011AA Property)
    C15220 (NCI Thesaurus Property-2)
    C0011900 (UMLS 2011AA Property-2)
    C0009402 (NCI Metathesaurus ObjectClass)
    MedDRACode
    Item
    MedDRA Code (disease)
    float
    C25162 (NCI Thesaurus ValueDomain)
    C0805701 (UMLS 2011AA ValueDomain)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    CL104089 (NCI Metathesaurus ObjectClass)
    PriorCancerDiagnosisInd-3
    Item
    Has the patient had any prior cancer diagnosed? (other than colorectal?)
    boolean
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    C9305 (NCI Thesaurus ObjectClass)
    C0006826 (UMLS 2011AA ObjectClass)
    C25629 (NCI Thesaurus ObjectClass-2)
    C0332152 (UMLS 2011AA ObjectClass-2)
    C15220 (NCI Thesaurus Property)
    C0011900 (UMLS 2011AA Property)
    PriorCancerTypeText
    Item
    Type of Prior Cancer (If Yes,)
    text
    C25704 (NCI Thesaurus ValueDomain)
    C1527021 (UMLS 2011AA ValueDomain)
    C9305 (NCI Thesaurus ObjectClass)
    C0006826 (UMLS 2011AA ObjectClass)
    C25629 (NCI Thesaurus ObjectClass-2)
    C0332152 (UMLS 2011AA ObjectClass-2)
    C25365 (NCI Thesaurus Property)
    C0678257 (UMLS 2011AA Property)
    PriorCancerDiagnosisDate
    Item
    Prior Cancer Diagnosis Date (year YYYY)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C9305 (NCI Thesaurus ObjectClass)
    C0006826 (UMLS 2011AA ObjectClass)
    C25629 (NCI Thesaurus ObjectClass-2)
    C0332152 (UMLS 2011AA ObjectClass-2)
    C15220 (NCI Thesaurus Property)
    C0011900 (UMLS 2011AA Property)
    Trial subject ID SWOG
    Item
    SWOG Patient ID (from SWOG SpecTrak System)
    text
    C25337 (NCI Thesaurus ValueDomain)
    C2348585 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C1519429 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    C25699 (NCI Thesaurus Property-2)
    Item Group
    Lab Data At Protocol Entry
    Leukocytes (WBC)
    Item
    Peripheral WBC Count
    float
    C25294 (NCI Thesaurus ObjectClass)
    C0023508 (UMLS CUI-1)
    C12529 (NCI Thesaurus Property)
    C20200 (NCI Thesaurus Property-2)
    C25712 (NCI Thesaurus ValueDomain)
    C38024 (NCI Thesaurus ValueDomain-2)
    Neutrophil count
    Item
    Absolute neutrophil count
    float
    C25294 (NCI Thesaurus ObjectClass)
    C0200633 (UMLS CUI-1)
    C12533 (NCI Thesaurus Property)
    C20200 (NCI Thesaurus Property-2)
    C25304 (NCI Thesaurus ValueDomain)
    C25712 (NCI Thesaurus ValueDomain-2)
    Neutrophil percentage
    Item
    Peripheral Neutrophils (%)
    float
    C25294 (NCI Thesaurus ObjectClass)
    C1171400 (UMLS CUI-1)
    C12533 (NCI Thesaurus Property)
    C20200 (NCI Thesaurus Property-2)
    C25613 (NCI Thesaurus ValueDomain)
    C25712 (NCI Thesaurus ValueDomain-2)
    LaboratoryProcedureHemoglobinResultSpecifiedValue
    Item
    Hemoglobin
    float
    C16676 (NCI Thesaurus Property)
    C0019046 (UMLS 2011AA Property)
    C20200 (NCI Thesaurus Property-2)
    C1274040 (UMLS 2011AA Property-2)
    C25294 (NCI Thesaurus ObjectClass)
    C0022885 (UMLS 2011AA ObjectClass)
    C25712 (NCI Thesaurus ValueDomain)
    C1522609 (UMLS 2011AA ValueDomain)
    Platelets
    Item
    Peripheral platelet count
    float
    C20200 (NCI Thesaurus Property)
    C0005821 (UMLS CUI-1)
    C12520 (NCI Thesaurus Property-2)
    C25294 (NCI Thesaurus ObjectClass)
    C25712 (NCI Thesaurus ValueDomain)
    HepaticBilirubinLabValue
    Item
    Bilirubin
    float
    C20200 (NCI Thesaurus Property)
    C1274040 (UMLS 2011AA Property)
    C305 (NCI Thesaurus Property-2)
    C0005437 (UMLS 2011AA Property-2)
    C25294 (NCI Thesaurus ObjectClass)
    C0022885 (UMLS 2011AA ObjectClass)
    C25712 (NCI Thesaurus ValueDomain)
    C1522609 (UMLS 2011AA ValueDomain)
    LaboratoryProcedureMagnesiumResultSpecifiedValue
    Item
    Magnesium
    float
    C25294 (NCI Thesaurus ObjectClass)
    C0022885 (UMLS 2011AA ObjectClass)
    C20200 (NCI Thesaurus Property)
    C1274040 (UMLS 2011AA Property)
    C29239 (NCI Thesaurus Property-2)
    C0024467 (UMLS 2011AA Property-2)
    C25712 (NCI Thesaurus ValueDomain)
    C1522609 (UMLS 2011AA ValueDomain)
    C38024 (NCI Thesaurus ValueDomain-2)
    C0205369 (UMLS 2011AA ValueDomain-2)
    HepaticSGOT(AST)LabUnspecifiedValue
    Item
    SGOT
    float
    C13308 (NCI Thesaurus ObjectClass)
    C0205054 (UMLS 2011AA ObjectClass)
    C25202 (NCI Thesaurus Property)
    C0242192 (UMLS 2011AA Property)
    C37984 (NCI Thesaurus Property-2)
    C0022877 (UMLS 2011AA Property-2)
    C38046 (NCI Thesaurus ValueDomain)
    C0205370 (UMLS 2011AA ValueDomain)
    C25712 (NCI Thesaurus ValueDomain-2)
    C1522609 (UMLS 2011AA ValueDomain-2)
    LaboratoryProcedureSerumGlutamicOxaloaceticTransferaseResultUnspecifiedUpperLimitofNormalValue
    Item
    SGOT (AST) ULN
    float
    C25294 (NCI Thesaurus ObjectClass)
    C0022885 (UMLS 2011AA ObjectClass)
    C25202 (NCI Thesaurus Property)
    C0242192 (UMLS 2011AA Property)
    C20200 (NCI Thesaurus Property-2)
    C1274040 (UMLS 2011AA Property-2)
    C25712 (NCI Thesaurus ValueDomain)
    C1522609 (UMLS 2011AA ValueDomain)
    C25706 (NCI Thesaurus ValueDomain-2)
    C1519815 (UMLS 2011AA ValueDomain-2)
    RenalCreatinineLabSpecifiedValue
    Item
    Creatinine
    float
    C25225 (NCI Thesaurus ObjectClass)
    C0022646 (UMLS 2011AA ObjectClass)
    C399 (NCI Thesaurus Property)
    C0010294 (UMLS 2011AA Property)
    C25294 (NCI Thesaurus Property-2)
    C0022885 (UMLS 2011AA Property-2)
    C25712 (NCI Thesaurus ValueDomain)
    C1522609 (UMLS 2011AA ValueDomain)
    Creatinine, serum ULN
    Item
    Creatinine ULN
    float
    C25294 (NCI Thesaurus ObjectClass)
    C0201976 (UMLS CUI-1)
    C20200 (NCI Thesaurus Property)
    C1519815 (UMLS CUI-2)
    C399 (NCI Thesaurus Property-2)
    C25712 (NCI Thesaurus ValueDomain)
    C25706 (NCI Thesaurus ValueDomain-2)
    Albumin
    Item
    Albumin
    float
    C20200 (NCI Thesaurus Property)
    C0201838 (UMLS CUI-1)
    C214 (NCI Thesaurus Property-2)
    C25294 (NCI Thesaurus ObjectClass)
    C25712 (NCI Thesaurus ValueDomain)
    LDH
    Item
    Lactate Dehydrogenase (LDH)
    float
    C20200 (NCI Thesaurus Property)
    C0202113 (UMLS CUI-1)
    C25294 (NCI Thesaurus ObjectClass)
    C25712 (NCI Thesaurus ValueDomain)
    C25184 (NCI Thesaurus Property-2)
    Item
    Urinalysis result (Mark one with an X)
    text
    C17241 (NCI Thesaurus ObjectClass)
    C0042014 (UMLS 2011AA ObjectClass)
    C17021 (NCI Thesaurus Property)
    C0033684 (UMLS 2011AA Property)
    C25417 (NCI Thesaurus ValueDomain)
    C25554 (NCI Thesaurus Property-2)
    C0441889 (UMLS 2011AA Property-2)
    Code List
    Urinalysis result (Mark one with an X)
    CL Item
    0 (0)
    C0919414 (NCI Metathesaurus)
    CL Item
    1+ (1+)
    CL Item
    2+ (2+)
    CL Item
    3+ (3+)
    CL Item
    4+ (4+)
    UrinaryProteinCollectionValue
    Item
    Protein from 24 hour urine collection (for patients who have > 2+ proteinuria)
    float
    C25453 (NCI Thesaurus Property)
    C1516698 (UMLS 2011AA Property)
    C25712 (NCI Thesaurus ValueDomain)
    C1522609 (UMLS 2011AA ValueDomain)
    C17021 (NCI Thesaurus ObjectClass)
    C0033684 (UMLS 2011AA ObjectClass)
    Item
    Disease description (Mark one with an X)
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C0009402 (NCI Metathesaurus ObjectClass)
    C25365 (NCI Thesaurus Property)
    C0678257 (UMLS 2011AA Property)
    C0012634 (NCI Metathesaurus Property)
    Code List
    Disease description (Mark one with an X)
    CL Item
    Locally Advanced (Locally advanced)
    CL Item
    Metastatic (Metastatic)
    C14174 (NCI Thesaurus)
    C0036525 (UMLS 2011AA)
    Item
    Currently involved sites of disease (Mark all that apply with an X.)
    text
    C13717 (NCI Thesaurus ValueDomain)
    C1515974 (UMLS 2011AA ValueDomain)
    C25547 (NCI Thesaurus Property)
    C0009402 (NCI Metathesaurus ObjectClass)
    C0012634 (NCI Metathesaurus Property)
    Code List
    Currently involved sites of disease (Mark all that apply with an X.)
    CL Item
    Primary Site Or Tumor Bed (Primary site or tumor bed)
    CL Item
    Liver (Liver)
    C12392 (NCI Thesaurus)
    C0023884 (UMLS 2011AA)
    CL Item
    Other (Other)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    CL Item
    Bone (Bone)
    C12366 (NCI Thesaurus)
    C0262950 (UMLS 2011AA)
    CL Item
    Cns/brain (CNS/Brain)
    CL Item
    Intra-abdominal (Intra-abdominal)
    CL Item
    Lung (Lung)
    C12468 (NCI Thesaurus)
    C0024109 (UMLS 2011AA)
    Item
    Intent of treatment (Mark one with an X.)
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C15368 (NCI Thesaurus Property)
    C0009402 (NCI Metathesaurus ObjectClass)
    C25725 (NCI Thesaurus Property-2)
    C1283828 (UMLS 2011AA Property)
    Code List
    Intent of treatment (Mark one with an X.)
    CL Item
    Palliative (Palliative)
    CL Item
    Neoadjuvant Chemotherapy With The Potential For Resection Of All Sites Of Metastatic Disease (Neoadjuvant chemotherapy with the potential for resection of all sites of metastatic disease)
    Item Group
    For Patients Who Consented To The Correlative Sciences Companion Study
    BloodSpecimenCollectionTime
    Item
    Specimen collected time (Serum)
    time
    C12434 (NCI Thesaurus ObjectClass)
    C0229664 (UMLS 2011AA ObjectClass)
    C25207 (NCI Thesaurus ValueDomain)
    C0040223 (UMLS 2011AA ValueDomain)
    C19157 (NCI Thesaurus ObjectClass-2)
    C0370003 (UMLS 2011AA ObjectClass-2)
    C25452 (NCI Thesaurus Property)
    CollectionBloodHourFastingSpecify
    Item
    Number of hours between last meal and blood collection
    text
    C12434 (NCI Thesaurus ObjectClass)
    C0229664 (UMLS 2011AA ObjectClass)
    C25453 (NCI Thesaurus ObjectClass-2)
    C1516698 (UMLS 2011AA ObjectClass-2)
    C25529 (NCI Thesaurus Property)
    C0439227 (UMLS 2011AA Property)
    C0015663 (NCI Metathesaurus Property)
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    Item Group
    Prior Therapy Data
    SurgicalProcedureColorectalCarcinomaPerformedMostRecentDate
    Item
    Date of last surgical resection for colorectal cancer (If applicable, submit operative and pathology reports.)
    date
    C15329 (NCI Thesaurus ObjectClass)
    C0543467 (UMLS 2011AA ObjectClass)
    C38000 (NCI Thesaurus Property)
    C0884358 (UMLS 2011AA Property)
    C2955 (NCI Thesaurus Property-2)
    C0009402 (UMLS 2011AA Property-2)
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25577 (NCI Thesaurus ValueDomain-2)
    C1513491 (UMLS 2011AA ValueDomain-2)
    PriorChemotherapyAdministeredInd-3
    Item
    Prior Systemic Chemotherapy
    boolean
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    C15632 (NCI Thesaurus ObjectClass)
    C0392920 (UMLS 2011AA ObjectClass)
    C25629 (NCI Thesaurus ObjectClass-2)
    C0332152 (UMLS 2011AA ObjectClass-2)
    C25382 (NCI Thesaurus Property)
    C1521801 (UMLS 2011AA Property)
    Item
    specify agents (If Yes, Mark one with an X.)
    text
    C25629 (NCI Thesaurus ObjectClass)
    C0332152 (UMLS 2011AA ObjectClass)
    C1708 (NCI Thesaurus ObjectClass-2)
    C0450442 (UMLS 2011AA ObjectClass-2)
    C15368 (NCI Thesaurus Property)
    C0009402 (NCI Metathesaurus Property)
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    Code List
    specify agents (If Yes, Mark one with an X.)
    CL Item
    5fu Based Therapy (5FU based therapy)
    CL Item
    Irinotecan (Irinotecan)
    CL Item
    Oxaliplatin (Oxaliplatin)
    C1181 (NCI Thesaurus)
    C0069717 (UMLS 2011AA)
    CL Item
    Cetuximab (Cetuximab)
    C1723 (NCI Thesaurus)
    C0879636 (UMLS 2011AA)
    CL Item
    Bevacizumab (Bevacizumab)
    C2039 (NCI Thesaurus)
    C0796392 (UMLS 2011AA)
    CL Item
    Other (Other)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    PriorAgentColorectalCancerTherapySpecify
    Item
    Other, specify
    text
    C25629 (NCI Thesaurus ObjectClass)
    C0332152 (UMLS 2011AA ObjectClass)
    C1708 (NCI Thesaurus ObjectClass-2)
    C0450442 (UMLS 2011AA ObjectClass-2)
    C15368 (NCI Thesaurus Property)
    C0009402 (NCI Metathesaurus Property)
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    PriorChemotherapyAdministeredBeginDate
    Item
    Prior Chemotherapy Begin Date
    date
    C15632 (NCI Thesaurus ObjectClass)
    C0392920 (UMLS 2011AA ObjectClass)
    C25629 (NCI Thesaurus ObjectClass-2)
    C0332152 (UMLS 2011AA ObjectClass-2)
    C25382 (NCI Thesaurus Property)
    C1521801 (UMLS 2011AA Property)
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25431 (NCI Thesaurus ValueDomain-2)
    C0439659 (UMLS 2011AA ValueDomain-2)
    PriorChemotherapyAdministeredEndDate
    Item
    Prior Chemotherapy End Date
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C15632 (NCI Thesaurus ObjectClass)
    C0392920 (UMLS 2011AA ObjectClass)
    C25629 (NCI Thesaurus ObjectClass-2)
    C0332152 (UMLS 2011AA ObjectClass-2)
    C25382 (NCI Thesaurus Property)
    C1521801 (UMLS 2011AA Property)
    PatientChemotherapyMetastasisColorectalCarcinomaPersonalMedicalHistoryInd-2
    Item
    Prior chemotherapy for advanced or metastatic colorectal cancer
    boolean
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C15632 (NCI Thesaurus Property)
    C0392920 (UMLS 2011AA Property)
    C19151 (NCI Thesaurus Property-2)
    C0027627 (UMLS 2011AA Property-2)
    C2955 (NCI Thesaurus Property-3)
    C0009402 (UMLS 2011AA Property-3)
    C18772 (NCI Thesaurus Property-4)
    C0262926 (UMLS 2011AA Property-4)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    Prior Radiation Therapy
    Item
    Prior radiation therapy (with or without radiosensitizing chemotherapy)
    boolean
    C38148 (NCI Thesaurus ValueDomain)
    C1522449 (UMLS CUI-1)
    C15313 (NCI Thesaurus ObjectClass)
    C0332152 (UMLS CUI-2)
    C25629 (NCI Thesaurus ObjectClass-2)
    C25382 (NCI Thesaurus Property)
    Radiation Therapy Start Date
    Item
    RT begin date
    date
    C15313 (NCI Thesaurus ObjectClass)
    C1522449 (UMLS CUI-1)
    C25431 (NCI Thesaurus Property)
    C0808070 (UMLS CUI-2)
    C25275 (NCI Thesaurus Property-2)
    C25164 (NCI Thesaurus ValueDomain)
    C25367 (NCI Thesaurus ValueDomain-2)
    Radiation Therapy End Date
    Item
    RT End Date
    date
    C25164 (NCI Thesaurus ValueDomain)
    C1522449 (UMLS CUI-1)
    C15313 (NCI Thesaurus ObjectClass)
    C0806020 (UMLS CUI-2)
    C25275 (NCI Thesaurus Property)
    C25496 (NCI Thesaurus Property-2)
    FullDoseAnticoagulantAgentCurrentUseInd-2
    Item
    Patient receiving full-dose anticoagulants
    boolean
    C25488 (NCI Thesaurus ObjectClass)
    C0178602 (UMLS 2011AA ObjectClass)
    C263 (NCI Thesaurus ObjectClass-2)
    C0003280 (UMLS 2011AA ObjectClass-2)
    C25517 (NCI Thesaurus ObjectClass-3)
    C0443225 (UMLS 2011AA ObjectClass-3)
    C25471 (NCI Thesaurus Property)
    C0521116 (UMLS 2011AA Property)
    C25340 (NCI Thesaurus Property-2)
    C0457083 (UMLS 2011AA Property-2)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    PatientWarfarinTreatmentInd-2
    Item
    is the patient receiving a stable dose of warfarin and has an in-range INR or receiving a stable dose of heparin (If yes,)
    boolean
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C15368 (NCI Thesaurus Property)
    C0043031 (NCI Metathesaurus Property)
    Item
    Arterial thrombotic event risk factors (Mark all that apply with an X.)
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C0221464 (NCI Metathesaurus ObjectClass)
    C0040053 (NCI Metathesaurus ObjectClass-2)
    C17103 (NCI Thesaurus Property)
    C0035648 (UMLS 2011AA Property)
    Code List
    Arterial thrombotic event risk factors (Mark all that apply with an X.)
    CL Item
    Prior Arterial Thrombotic Event (Prior arterial thrombotic event)
    CL Item
    Prior Coronary Artery Disease (Prior coronary artery disease)
    CL Item
    History Of Hypertension (History of hypertension)
    CL Item
    History Of Smoking (History of smoking)
    CL Item
    History Of Hyperlipidemia (History of hyperlipidemia)
    CL Item
    Diabetes (Diabetes)
    CL Item
    Peripheral Vascular Disease (Peripheral vascular disease)
    CL Item
    No Risk Factors (No risk factors)
    Item
    Prior ATE code
    text
    C26891 (NCI Thesaurus ObjectClass)
    C0040053 (UMLS 2011AA ObjectClass)
    C0221464 (NCI Metathesaurus ObjectClass)
    C25499 (NCI Thesaurus Property)
    C0441471 (UMLS 2011AA Property)
    C25629 (NCI Thesaurus Property-2)
    C0332152 (UMLS 2011AA Property-2)
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    Code List
    Prior ATE code
    CL Item
    Cardiac Stenting/angioplasty (Cardiac stenting/angioplasty)
    CL Item
    Cva (CVA)
    CL Item
    Mi (MI)
    CL Item
    Other (Other)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    CL Item
    Tia (TIA)
    CL Item
    Unstable Angina (Unstable angina)
    C66911 (NCI Thesaurus)
    C0002965 (UMLS 2011AA)
    ArterialThrombosisPriorEventSpecify
    Item
    Other, specify
    text
    C26891 (NCI Thesaurus ObjectClass)
    C0040053 (UMLS 2011AA ObjectClass)
    C0221464 (NCI Metathesaurus ObjectClass)
    C25499 (NCI Thesaurus Property)
    C0441471 (UMLS 2011AA Property)
    C25629 (NCI Thesaurus Property-2)
    C0332152 (UMLS 2011AA Property-2)
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    PriorArterialThrombosisEventDate
    Item
    Prior ATE onset date (of most recent events)
    date
    C25629 (NCI Thesaurus ObjectClass)
    C0332152 (UMLS 2011AA ObjectClass)
    C0221464 (NCI Metathesaurus ObjectClass)
    C0040053 (NCI Metathesaurus ObjectClass-2)
    C25499 (NCI Thesaurus Property)
    C0441471 (UMLS 2011AA Property)
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    PatientHistoryHemorrhageEventInd-2
    Item
    Does patient have history of significant bleeding episodes
    boolean
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25499 (NCI Thesaurus Property)
    C0441471 (UMLS 2011AA Property)
    C26791 (NCI Thesaurus Property-2)
    C0019080 (UMLS 2011AA Property-2)
    C1321503 (NCI Metathesaurus Property)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    PatientHistoryHemorrhageEventText
    Item
    Specify type
    text
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25499 (NCI Thesaurus Property)
    C0441471 (UMLS 2011AA Property)
    C26791 (NCI Thesaurus Property-2)
    C0019080 (UMLS 2011AA Property-2)
    C1321503 (NCI Metathesaurus Property)
    C25704 (NCI Thesaurus ValueDomain)
    C1527021 (UMLS 2011AA ValueDomain)
    PatientHistoryHemorrhageEventDate
    Item
    Date (MM DD YYYY)
    date
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25499 (NCI Thesaurus Property)
    C0441471 (UMLS 2011AA Property)
    C26791 (NCI Thesaurus Property-2)
    C0019080 (UMLS 2011AA Property-2)
    C1321503 (NCI Metathesaurus Property)
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    PatientHistoryGIPerforationInd-2
    Item
    Does patient have history of GI perforation
    boolean
    C25190 (NCI Thesaurus ObjectClass)
    C0027361 (UMLS 2011AA ObjectClass)
    C34082 (NCI Thesaurus Property)
    C0017189 (UMLS 2011AA Property)
    C18772 (NCI Thesaurus Property-2)
    C0262926 (UMLS 2011AA Property-2)
    C4080 (NCI Thesaurus Property-3)
    C0549099 (UMLS 2011AA Property-3)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    PersonGastrointestinalTractPerforationPersonalMedicalHistoryDate
    Item
    Specify date of onset (MM DD YYYY)
    date
    C25190 (NCI Thesaurus ObjectClass)
    C0027361 (UMLS 2011AA ObjectClass)
    C34082 (NCI Thesaurus Property)
    C0017189 (UMLS 2011AA Property)
    C18772 (NCI Thesaurus Property-2)
    C0262926 (UMLS 2011AA Property-2)
    C4080 (NCI Thesaurus Property-3)
    C0549099 (UMLS 2011AA Property-3)
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    Person Completing Form
    Item
    Completed by
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1550483 (UMLS CUI-1)
    C25657 (NCI Thesaurus ObjectClass)
    C25364 (NCI Thesaurus Property)
    Form Completion Date
    Item
    Date Form Originally Completed (MM DD YYYY)
    date
    C19464 (NCI Thesaurus ObjectClass)
    C1549507 (UMLS CUI-1)
    C25250 (NCI Thesaurus Property)
    C25604 (NCI Thesaurus Property-2)
    C25164 (NCI Thesaurus ValueDomain)
    C25367 (NCI Thesaurus ValueDomain-2)

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