ID

11146

Descripción

CALGB: ADJUVANT RADIOTHERAPY REPORT FORM 2 NCT00041119 Four Versus Six Cycles of Cyclophosphamide/Doxorubicin or Paclitaxel in Adjuvant Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=E03851EE-EEDC-5498-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=E03851EE-EEDC-5498-E034-0003BA12F5E7

Palabras clave

  1. 26/8/12 26/8/12 -
  2. 9/1/15 9/1/15 - Martin Dugas
  3. 21/6/15 21/6/15 -
Subido en

21 de junio de 2015

DOI

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Licencia

Creative Commons BY-NC 3.0 Legacy

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    CALGB: ADJUVANT RADIOTHERAPY REPORT FORM 2 NCT00041119

    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
    Descripción

    Header

    CALGB Form
    Descripción

    CALGB Form

    Tipo de datos

    text

    Alias
    UMLS CUI-1
    C3262252 (Form version:Identifier:Point in time:Form:Nominal)
    LOINC
    68356-5
    UMLS CUI-2
    C1516238 (Cancer and Leukemia Group B)
    LOINC
    LA4261-9
    CALGB Study No
    Descripción

    Protocol ID CALGB

    Tipo de datos

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337 (undefined)
    UMLS CUI-1
    C3274381 (Clinical Trial Registry Identifier)
    NCI Thesaurus ObjectClass
    C25320 (undefined)
    UMLS CUI-2
    C1516238 (Cancer and Leukemia Group B)
    LOINC
    LA4261-9
    NCI Thesaurus Property
    C25364 (undefined)
    NCI Thesaurus Property-2
    C25442 (undefined)
    CALGB Patient ID
    Descripción

    Trial subject ID CALGB

    Tipo de datos

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337 (undefined)
    UMLS CUI-1
    C2348585 (Clinical Trial Subject Unique Identifier)
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    UMLS CUI-2
    C1516238 (Cancer and Leukemia Group B)
    LOINC
    LA4261-9
    NCI Thesaurus Property
    C25364 (undefined)
    NCI Thesaurus Property-2
    C25442 (undefined)
    Are data amended
    Descripción

    Data amended

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38148 (undefined)
    UMLS CUI-1
    C0680532 (Amendment)
    NCI Thesaurus ObjectClass
    C25474 (undefined)
    NCI Thesaurus Property
    C25416 (undefined)
    Patient demographics
    Descripción

    Patient demographics

    Patient Initials
    Descripción

    Patient Initials

    Tipo de datos

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191 (undefined)
    UMLS CUI-1
    C2986440 (Person Initials)
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    NCI Thesaurus Property
    C25536 (undefined)
    Participating Group
    Descripción

    Participating Group

    Tipo de datos

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191 (undefined)
    UMLS CUI-1
    C2347449 (Participating Clinical Study Organization)
    NCI Thesaurus ObjectClass
    C25608 (undefined)
    NCI Thesaurus ObjectClass-2
    C17005 (undefined)
    NCI Thesaurus Property
    C25364 (undefined)
    Patient Hospital No.
    Descripción

    Medical Record Number

    Tipo de datos

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337 (undefined)
    UMLS CUI-1
    C1301894 (Medical record number)
    SNOMED
    398225001
    LOINC
    MTHU047637
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    NCI Thesaurus Property
    C25261 (undefined)
    NCI Thesaurus Property-2
    C25198 (undefined)
    Participating Group Study No.
    Descripción

    Study Number Participating Group

    Tipo de datos

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337 (undefined)
    UMLS CUI-1
    C3274381 (Clinical Trial Registry Identifier)
    NCI Thesaurus ObjectClass
    C25320 (undefined)
    UMLS CUI-2
    C2347449 (Participating Clinical Study Organization)
    NCI Thesaurus Property
    C25608 (undefined)
    NCI Thesaurus Property-2
    C25364 (undefined)
    Institution/Affiliate
    Descripción

    Institution Name

    Tipo de datos

    text

    Alias
    NCI Thesaurus ObjectClass
    C25454 (undefined)
    UMLS CUI-1
    C1301943 (Institution name)
    SNOMED
    398321007
    NCI Thesaurus ObjectClass-2
    C21541 (undefined)
    NCI Thesaurus Property
    C25364 (undefined)
    NCI Thesaurus ValueDomain
    C25191 (undefined)
    NCI Thesaurus ValueDomain-2
    C21541 (undefined)
    Participating Group Patient ID
    Descripción

    Trial subject ID Participating Group

    Tipo de datos

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337 (undefined)
    UMLS CUI-1
    C2348585 (Clinical Trial Subject Unique Identifier)
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    UMLS CUI-2
    C2347449 (Participating Clinical Study Organization)
    NCI Thesaurus Property
    C25608 (undefined)
    NCI Thesaurus Property-2
    C25364 (undefined)
    Radiation Treatment
    Descripción

    Radiation Treatment

    Has the patient received adjuvant radiation therapy (prior to diagnosis of recurrence or second primary cancer)
    Descripción

    AdjuvantRadiationTherapyAdministeredInd-3

    Tipo de datos

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38148 (undefined)
    UMLS 2011AA ValueDomain
    C1512699 (Yes, No, or Unknown Response)
    NCI Thesaurus ObjectClass
    C15313 (undefined)
    UMLS 2011AA ObjectClass
    C1522449 (Therapeutic radiology procedure)
    SNOMED
    53438000
    LOINC
    LA4351-8
    NCI Thesaurus ObjectClass-2
    C2140 (undefined)
    UMLS 2011AA ObjectClass-2
    C0001552 (Pharmaceutical Adjuvants)
    NCI Thesaurus Property
    C25382 (undefined)
    UMLS 2011AA Property
    C1521801 (Having administered)
    Date adjuvant radiation therapy started
    Descripción

    AdjuvantRadiationTherapyBeginDate

    Tipo de datos

    date

    Alias
    NCI Thesaurus ObjectClass
    C15313 (undefined)
    UMLS 2011AA ObjectClass
    C1522449 (Therapeutic radiology procedure)
    SNOMED
    53438000
    LOINC
    LA4351-8
    NCI Thesaurus ObjectClass-2
    C2140 (undefined)
    UMLS 2011AA ObjectClass-2
    C0001552 (Pharmaceutical Adjuvants)
    NCI Thesaurus Property
    C25431 (undefined)
    UMLS 2011AA Property
    C0439659 (Beginning)
    SNOMED
    255395001
    LOINC
    LP21371-7
    NCI Thesaurus Property-2
    C25275 (undefined)
    UMLS 2011AA Property-2
    C2745955 (Occurrence)
    SNOMED
    246454002
    NCI Thesaurus ValueDomain
    C25164 (undefined)
    UMLS 2011AA ValueDomain
    C0011008 (Date in time)
    SNOMED
    410671006
    NCI Thesaurus ValueDomain-2
    C25431 (undefined)
    UMLS 2011AA ValueDomain-2
    C0439659 (Beginning)
    SNOMED
    255395001
    LOINC
    LP21371-7
    Date adjuvant radiation therapy ended
    Descripción

    AdjuvantRadiationTherapyEndDate

    Tipo de datos

    date

    Alias
    NCI Thesaurus ObjectClass
    C15313 (undefined)
    UMLS 2011AA ObjectClass
    C1522449 (Therapeutic radiology procedure)
    SNOMED
    53438000
    LOINC
    LA4351-8
    NCI Thesaurus ObjectClass-2
    C2140 (undefined)
    UMLS 2011AA ObjectClass-2
    C0001552 (Pharmaceutical Adjuvants)
    NCI Thesaurus Property
    C25275 (undefined)
    UMLS 2011AA Property
    C2745955 (Occurrence)
    SNOMED
    246454002
    NCI Thesaurus Property-2
    C25496 (undefined)
    UMLS 2011AA Property-2
    C2746065 (Stop (qualifier value))
    SNOMED
    422117008
    NCI Thesaurus ValueDomain
    C25164 (undefined)
    UMLS 2011AA ValueDomain
    C0011008 (Date in time)
    SNOMED
    410671006
    Nature of radiotherapy (mark one box with an X)
    Descripción

    RadiationTherapyPerformedType

    Tipo de datos

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284 (undefined)
    UMLS 2011AA ValueDomain
    C0332307 (Type - attribute)
    SNOMED
    261664005
    NCI Thesaurus ObjectClass
    C15313 (undefined)
    UMLS 2011AA ObjectClass
    C1522449 (Therapeutic radiology procedure)
    SNOMED
    53438000
    LOINC
    LA4351-8
    NCI Thesaurus Property
    C38000 (undefined)
    UMLS 2011AA Property
    C0884358 (Performed)
    SNOMED
    398166005
    LOINC
    LA19974-7
    Completed By (Last Name, First Name)
    Descripción

    Person Completing Form

    Tipo de datos

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191 (undefined)
    UMLS CUI-1
    C1550483 (data entry person)
    NCI Thesaurus ObjectClass
    C25657 (undefined)
    NCI Thesaurus Property
    C25364 (undefined)
    Date form completed
    Descripción

    Date Form Completed

    Tipo de datos

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164 (undefined)
    UMLS CUI-1
    C1115437 (Date form completed)
    LOINC
    MTHU014518
    NCI Thesaurus ObjectClass
    C40988 (undefined)
    NCI Thesaurus Property
    C25250 (undefined)
    NCI Thesaurus ValueDomain-2
    C25367 (undefined)

    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 datos
    Alias
    Item Group
    Header
    CALGB Form
    Item
    CALGB Form
    text
    C3262252 (UMLS CUI-1)
    C1516238 (UMLS CUI-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)
    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)
    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)
    Medical Record Number
    Item
    Patient Hospital No.
    text
    C25337 (NCI Thesaurus ValueDomain)
    C1301894 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25261 (NCI Thesaurus Property)
    C25198 (NCI Thesaurus Property-2)
    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)
    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)
    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
    Radiation Treatment
    AdjuvantRadiationTherapyAdministeredInd-3
    Item
    Has the patient received adjuvant radiation therapy (prior to diagnosis of recurrence or second primary cancer)
    boolean
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    C15313 (NCI Thesaurus ObjectClass)
    C1522449 (UMLS 2011AA ObjectClass)
    C2140 (NCI Thesaurus ObjectClass-2)
    C0001552 (UMLS 2011AA ObjectClass-2)
    C25382 (NCI Thesaurus Property)
    C1521801 (UMLS 2011AA Property)
    AdjuvantRadiationTherapyBeginDate
    Item
    Date adjuvant radiation therapy started
    date
    C15313 (NCI Thesaurus ObjectClass)
    C1522449 (UMLS 2011AA ObjectClass)
    C2140 (NCI Thesaurus ObjectClass-2)
    C0001552 (UMLS 2011AA ObjectClass-2)
    C25431 (NCI Thesaurus Property)
    C0439659 (UMLS 2011AA Property)
    C25275 (NCI Thesaurus Property-2)
    C2745955 (UMLS 2011AA Property-2)
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25431 (NCI Thesaurus ValueDomain-2)
    C0439659 (UMLS 2011AA ValueDomain-2)
    AdjuvantRadiationTherapyEndDate
    Item
    Date adjuvant radiation therapy ended
    date
    C15313 (NCI Thesaurus ObjectClass)
    C1522449 (UMLS 2011AA ObjectClass)
    C2140 (NCI Thesaurus ObjectClass-2)
    C0001552 (UMLS 2011AA ObjectClass-2)
    C25275 (NCI Thesaurus Property)
    C2745955 (UMLS 2011AA Property)
    C25496 (NCI Thesaurus Property-2)
    C2746065 (UMLS 2011AA Property-2)
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    Item
    Nature of radiotherapy (mark one box with an X)
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C15313 (NCI Thesaurus ObjectClass)
    C1522449 (UMLS 2011AA ObjectClass)
    C38000 (NCI Thesaurus Property)
    C0884358 (UMLS 2011AA Property)
    Code List
    Nature of radiotherapy (mark one box with an X)
    CL Item
    Whole Breast Radiation - External Beam - Following Breast Conserving Surgery (Whole breast radiation - external beam - following breast conserving surgery)
    CL Item
    Intra-operative Brachytherapy Following Breast Conserving Surgery (Intra-operative brachytherapy following breast conserving surgery)
    CL Item
    Partial Breast Radiation - External Beam - Following Breast Conserving Surgery (Partial breast radiation - external beam - following breast conserving surgery)
    CL Item
    Partial Breast Radiation - Brachytherapy - Following Breast Conserving Surgery (Partial breast radiation - brachytherapy - following breast conserving surgery)
    CL Item
    Chest Wall And/or Nodal Radiation After Mastectomy (Chest wall and/or nodal radiation after mastectomy)
    Person Completing Form
    Item
    Completed By (Last Name, First Name)
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1550483 (UMLS CUI-1)
    C25657 (NCI Thesaurus ObjectClass)
    C25364 (NCI Thesaurus Property)
    Date Form Completed
    Item
    Date form completed
    date
    C25164 (NCI Thesaurus ValueDomain)
    C1115437 (UMLS CUI-1)
    C40988 (NCI Thesaurus ObjectClass)
    C25250 (NCI Thesaurus Property)
    C25367 (NCI Thesaurus ValueDomain-2)

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