ID

11339

Description

NCT00408408 NSABP Protocol B-40 - WORKSHEET FOR REPORTING BREAST RECONSTRUCTION INFORMATION A Randomized Phase III Trial of Neoadjuvant Therapy in Patients With Palpable and Operable Breast Cancer Evaluating the Effect on Pathologic Complete Response (pCR) of Adding Capecitabine or Gemcitabine to Docetaxel When Administered Before AC With or Without Bevacizumab and Correlative Science Studies Attempting to Identify Predictors of High Likelihood for pCR With Each of the Regimens Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=7D9B7B8C-E72A-A457-E040-BB89AD4372F6

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=7D9B7B8C-E72A-A457-E040-BB89AD4372F6

Keywords

Versions (3)
  1. 8/26/12 8/26/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
  3. 7/3/15 7/3/15 -
Uploaded on

July 3, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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NCT00408408 NSABP Protocol B-40 - WORKSHEET FOR REPORTING BREAST RECONSTRUCTION INFORMATION

English

(Submit for patients who reported a mastectomy on the Surgery/Pathology Report Form.) This paper worksheet may be completed to facilitate the entry of the information in NSABP Coordinator Online. Partially completed online forms may be saved in Coordinator Online. DO NOT SUBMIT THIS WORKSHEET VIA FAX OR MAIL. If the Surgery/Pathology Report Form indicates that a lumpectomy was performed, BR data submission will not be expected.

1 forms  
Header
Description

Header

Patient Initials (Last First Middle)
Description

Patient Initials

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
NSABP Patient ID
Description

Patient ID NSABP

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
UMLS CUI-2
C1513905
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C15818
BREAST RECONSTRUCTION INFORMATION
Description

BREAST RECONSTRUCTION INFORMATION

Time Interval for this Assessment
Description

PhysicalExaminationIntervalType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C20989
UMLS 2011AA ObjectClass
C0031809
NCI Thesaurus Property
C25543
UMLS 2011AA Property
C1272706
Did the patient receive breast reconstruction
Description

SurgicalProcedureBreastReconstructionPerformedInd-2

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
NCI Thesaurus ObjectClass
C15329
UMLS 2011AA ObjectClass
C0543467
NCI Thesaurus Property-2
C15354
UMLS 2011AA Property-2
C0085076
Type of breast reconstruction (If yes, mark all that apply)
Description

SurgicalProcedureBreastReconstructionPerformedType

Data type

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
NCI Thesaurus ObjectClass
C15329
UMLS 2011AA ObjectClass
C0543467
NCI Thesaurus Property-2
C15354
UMLS 2011AA Property-2
C0085076
Other, specify
Description

SurgicalProcedureBreastReconstructionPerformedSpecify

Data type

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
NCI Thesaurus ObjectClass
C15329
UMLS 2011AA ObjectClass
C0543467
NCI Thesaurus Property-2
C15354
UMLS 2011AA Property-2
C0085076
Footer
Description

Footer

Comments
Description

Research Comments

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS CUI-1
C0947611
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
Person Completing Form
Description

Person Completing Form

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C1550483
NCI Thesaurus ObjectClass
C25657
NCI Thesaurus Property
C25364
Date Form Completed
Description

Date Form Completed

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS CUI-1
C1115437
NCI Thesaurus ObjectClass
C40988
NCI Thesaurus Property
C25250
NCI Thesaurus ValueDomain-2
C25367
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Similar models

(Submit for patients who reported a mastectomy on the Surgery/Pathology Report Form.) This paper worksheet may be completed to facilitate the entry of the information in NSABP Coordinator Online. Partially completed online forms may be saved in Coordinator Online. DO NOT SUBMIT THIS WORKSHEET VIA FAX OR MAIL. If the Surgery/Pathology Report Form indicates that a lumpectomy was performed, BR data submission will not be expected.

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header
Patient Initials
Item
Patient Initials (Last First Middle)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Patient ID NSABP
Item
NSABP Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1513905 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C15818 (NCI Thesaurus Property-2)
Item Group
BREAST RECONSTRUCTION INFORMATION
Item
Time Interval for this Assessment
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C20989 (NCI Thesaurus ObjectClass)
C0031809 (UMLS 2011AA ObjectClass)
C25543 (NCI Thesaurus Property)
C1272706 (UMLS 2011AA Property)
CL.1
Code List
Time Interval for this Assessment
CL Item
Date Of Surgery To 3-5 Weeks Following Surgery (Date of surgery to 3-5 weeks following surgery)
CL Item
Day After Previous Time Interval To 9 Months Following Study Entry (Day after previous time interval to 9 months following study entry)
CL Item
Day After Previous Time Interval To 12 Months Following Study Entry (Day after previous time interval to 12 months following study entry)
CL Item
Day After Previous Time Interval To 24 Months Following Study Entry (Day after previous time interval to 24 months following study entry)
SurgicalProcedureBreastReconstructionPerformedInd-2
Item
Did the patient receive breast reconstruction
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C15329 (NCI Thesaurus ObjectClass)
C0543467 (UMLS 2011AA ObjectClass)
C15354 (NCI Thesaurus Property-2)
C0085076 (UMLS 2011AA Property-2)
Item
Type of breast reconstruction (If yes, mark all that apply)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C15329 (NCI Thesaurus ObjectClass)
C0543467 (UMLS 2011AA ObjectClass)
C15354 (NCI Thesaurus Property-2)
C0085076 (UMLS 2011AA Property-2)
CL.3
Code List
Type of breast reconstruction (If yes, mark all that apply)
CL Item
Breast Implant (Breast Implant)
C28335 (NCI Thesaurus)
C0179412 (UMLS 2011AA)
CL Item
Breast Tissue Expander (Tissue Expanders)
C85840 (NCI Thesaurus)
C0588162 (UMLS 2011AA)
CL Item
Rotated Flap (Rotated flap)
CL Item
Free Flap (Free Flap)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
SurgicalProcedureBreastReconstructionPerformedSpecify
Item
Other, specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C15329 (NCI Thesaurus ObjectClass)
C0543467 (UMLS 2011AA ObjectClass)
C15354 (NCI Thesaurus Property-2)
C0085076 (UMLS 2011AA Property-2)
Item Group
Footer
Research Comments
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C0947611 (UMLS CUI-1)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
Person Completing Form
Item
Person Completing Form
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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