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11561

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NCT01349322 RTOG-1005 QP: Radiation Therapy Oncology Group Phase III Whole Breast Irradiation for Early Stage Breast Cancer Patient Cosmesis Evaluation Form Higher-Dose Radiation Therapy or Standard Radiation Therapy in Treating Patients With Early-Stage Breast Cancer That Was Removed by Surgery Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9D7B30AD-FF6E-0FB3-E040-BB89AD435271

Länk

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9D7B30AD-FF6E-0FB3-E040-BB89AD435271

Nyckelord

  1. 2012-09-19 2012-09-19 -
  2. 2015-01-09 2015-01-09 - Martin Dugas
  3. 2015-01-09 2015-01-09 - Martin Dugas
  4. 2015-07-08 2015-07-08 -
Uppladdad den

8 juli 2015

DOI

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Creative Commons BY-NC 3.0 Legacy

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    NCT01349322 RTOG-1005 QP: Radiation Therapy Oncology Group Phase III Whole Breast Irradiation for Early Stage Breast Cancer Patient Cosmesis Evaluation Form

    This form is completed by the investigator (rater) and submitted at each time point specified by the protocol, whether or not any of the patient assessment items (Q's 6,7,8) are answered

    1. StudyEvent: RTOG-1005 QP: Radiation Therapy Oncology Group Phase III Whole Breast Irradiation for Early Stage Breast Cancer Patient Cosmesis Evaluation Form
      1. This form is completed by the investigator (rater) and submitted at each time point specified by the protocol, whether or not any of the patient assessment items (Q's 6,7,8) are answered
    RTOG clinical trial administrative data
    Beskrivning

    RTOG clinical trial administrative data

    RTOG Study No.
    Beskrivning

    Protocol ID RTOG

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C3274381
    NCI Thesaurus ObjectClass
    C25320
    UMLS CUI-2
    C1514695
    NCI Thesaurus Property
    C19778
    NCI Thesaurus Property-2
    C25364
    Case #
    Beskrivning

    RadiationTherapyOncologyGroupPatientCaseIdentifierNumber

    Datatyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus ObjectClass-2
    C19778
    UMLS 2011AA ObjectClass-2
    C1514695
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus Property-2
    C49152
    UMLS 2011AA Property-2
    C1706256
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    Institution Name
    Beskrivning

    Institution Name

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C1301943
    NCI Thesaurus ObjectClass
    C21541
    NCI Thesaurus ValueDomain-2
    C21541
    NCI Thesaurus Property
    C25364
    Institution No.
    Beskrivning

    Institution Number

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C1301943
    NCI Thesaurus ObjectClass
    C21541
    UMLS CUI-2
    C0805701
    NCI Thesaurus Property
    C25364
    Patient Initials
    Beskrivning

    Patient Initials

    Datatyp

    text

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

    Trial subject ID RTOG

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C2348585
    NCI Thesaurus ObjectClass
    C16960
    UMLS CUI-2
    C1514695
    NCI Thesaurus Property
    C19778
    NCI Thesaurus Property-2
    C25364
    Are data amended
    Beskrivning

    Data amended

    Datatyp

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38148
    UMLS CUI-1
    C0680532
    NCI Thesaurus ObjectClass
    C25474
    NCI Thesaurus Property
    C25416
    Time point
    Beskrivning

    AssessmentPeriodType

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus ObjectClass
    C20989
    UMLS 2011AA ObjectClass
    C0031809
    NCI Thesaurus Property
    C25616
    UMLS 2011AA Property
    C1948053
    Treatment Start Date
    Beskrivning

    Treatment Begin Date

    Datatyp

    date

    Alias
    NCI Thesaurus ObjectClass
    C15368
    NCI Thesaurus Property
    C25431
    UMLS CUI-1
    C3173309
    NCI Thesaurus Property-2
    C25275
    NCI Thesaurus ValueDomain
    C25164
    NCI Thesaurus ValueDomain-2
    C25431
    Evaluation performed by
    Beskrivning

    PersonEvaluationSocialRoleType

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus ObjectClass
    C25190
    UMLS 2011AA ObjectClass
    C0027361
    NCI Thesaurus Property
    C25214
    UMLS 2011AA Property
    C0220825
    NCI Thesaurus Property-2
    C25199
    UMLS 2011AA Property-2
    C0035820
    Date Questionnaire Completed (MM DD YYYY)
    Beskrivning

    QualityofLifeCompleteAssessmentDate

    Datatyp

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C17047
    UMLS 2011AA ObjectClass
    C0518214
    NCI Thesaurus Property
    C25250
    UMLS 2011AA Property
    C0205197
    NCI Thesaurus Property-2
    C25367
    Reason Questionnaire was not Completed
    Beskrivning

    Incomplete documentation, reason

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25638
    UMLS CUI-1
    C1548386
    NCI Thesaurus ObjectClass
    C16960
    UMLS CUI-2
    C0566251
    NCI Metathesaurus Property
    C0034394
    Patient refused for other reason, specify
    Beskrivning

    PatientRefuseIncompleteQuestionnaireSpecify

    Datatyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Metathesaurus Property
    C0034394
    NCI Thesaurus Property
    C49160
    UMLS 2011AA Property
    C0205257
    NCI Thesaurus Property-2
    C49161
    UMLS 2011AA Property-2
    C1705116
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    Other reason, specify
    Beskrivning

    PatientIncompleteQuestionnaireOtherSpecify

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    NCI Thesaurus ValueDomain-2
    C17649
    UMLS 2011AA ValueDomain-2
    C0205394
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Metathesaurus Property
    C0034394
    Breast Reconstruction Assessment
    Beskrivning

    Breast Reconstruction Assessment

    Please assess breast cosmesis at this time
    Beskrivning

    BreastReconstructionAssessmentSatus

    Datatyp

    text

    Alias
    NCI Thesaurus Property
    C25367
    NCI Thesaurus ObjectClass
    C12971
    UMLS 2011AA ObjectClass
    C0006141
    NCI Thesaurus ValueDomain
    C25688
    UMLS 2011AA ValueDomain
    C0449438
    NCI Thesaurus ObjectClass-2
    C25351
    UMLS 2011AA ObjectClass-2
    C0524865
    Skin telangiectasia
    Beskrivning

    BreastReconstructionTelangiectasiaAssessmentIndicator

    Datatyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C12971
    UMLS 2011AA ObjectClass
    C0006141
    NCI Thesaurus ObjectClass-2
    C25351
    UMLS 2011AA ObjectClass-2
    C0524865
    NCI Thesaurus Property
    C25367
    NCI Thesaurus Property-2
    C28194
    UMLS 2011AA Property
    C0039446
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    Skin atrophy
    Beskrivning

    BreastReconstructionAtrophyAssessmentIndicator

    Datatyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C12971
    UMLS 2011AA ObjectClass
    C0006141
    NCI Thesaurus ObjectClass-2
    C25351
    UMLS 2011AA ObjectClass-2
    C0524865
    NCI Thesaurus Property
    C25367
    NCI Thesaurus Property-2
    C79748
    UMLS 2011AA Property
    C0333641
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    Scarring
    Beskrivning

    BreastReconstructionScarAssessmentIndicator

    Datatyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C12971
    UMLS 2011AA ObjectClass
    C0006141
    NCI Thesaurus ObjectClass-2
    C25351
    UMLS 2011AA ObjectClass-2
    C0524865
    NCI Thesaurus Property
    C25367
    NCI Thesaurus Property-2
    C34483
    UMLS 2011AA Property
    C2004491
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    Pigment change
    Beskrivning

    BreastReconstructionPigmentAssessmentIndicator

    Datatyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C12971
    UMLS 2011AA ObjectClass
    C0006141
    NCI Thesaurus ObjectClass-2
    C25351
    UMLS 2011AA ObjectClass-2
    C0524865
    NCI Thesaurus Property
    C25367
    NCI Thesaurus Property-2
    C747
    UMLS 2011AA Property
    C0031916
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    Erythema
    Beskrivning

    BreastReconstructionErythemaAssessmentIndicator

    Datatyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C12971
    UMLS 2011AA ObjectClass
    C0006141
    NCI Thesaurus ObjectClass-2
    C25351
    UMLS 2011AA ObjectClass-2
    C0524865
    NCI Thesaurus Property
    C25367
    NCI Thesaurus Property-2
    C26901
    UMLS 2011AA Property
    C0041834
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    Fat necrosis
    Beskrivning

    BreastReconstructionFatNecrosisAssessmentIndicator

    Datatyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C12971
    UMLS 2011AA ObjectClass
    C0006141
    NCI Thesaurus ObjectClass-2
    C25351
    UMLS 2011AA ObjectClass-2
    C0524865
    NCI Thesaurus Property
    C25367
    NCI Thesaurus Property-2
    C26772
    UMLS 2011AA Property
    C0015668
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    Fibrosis
    Beskrivning

    BreastReconstructionFibrosisAssessmentIndicator

    Datatyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C12971
    UMLS 2011AA ObjectClass
    C0006141
    NCI Thesaurus ObjectClass-2
    C25351
    UMLS 2011AA ObjectClass-2
    C0524865
    NCI Thesaurus Property
    C25367
    NCI Thesaurus Property-2
    C3044
    UMLS 2011AA Property
    C0016059
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    Retraction or contour defect
    Beskrivning

    BreastReconstructionDefectAssessmentIndicator

    Datatyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C12971
    UMLS 2011AA ObjectClass
    C0006141
    NCI Thesaurus ObjectClass-2
    C25351
    UMLS 2011AA ObjectClass-2
    C0524865
    NCI Thesaurus Property
    C25367
    NCI Thesaurus Property-2
    C43429
    UMLS 2011AA Property
    C1457869
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    Volume loss
    Beskrivning

    BreastReconstructionLossAssessmentIndicator

    Datatyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C12971
    UMLS 2011AA ObjectClass
    C0006141
    NCI Thesaurus ObjectClass-2
    C25351
    UMLS 2011AA ObjectClass-2
    C0524865
    NCI Thesaurus Property
    C25367
    NCI Thesaurus Property-2
    C25559
    UMLS 2011AA Property
    C1517945
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    Other significant treatment effect
    Beskrivning

    BreastReconstructionOtherAssessmentIndicator

    Datatyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C12971
    UMLS 2011AA ObjectClass
    C0006141
    NCI Thesaurus ObjectClass-2
    C25351
    UMLS 2011AA ObjectClass-2
    C0524865
    NCI Thesaurus Property
    C17649
    UMLS 2011AA Property
    C0205394
    NCI Thesaurus Property-2
    C25367
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    Specify
    Beskrivning

    BreastReconstructionOtherAssessmentSpecify

    Datatyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C12971
    UMLS 2011AA ObjectClass
    C0006141
    NCI Thesaurus ObjectClass-2
    C25351
    UMLS 2011AA ObjectClass-2
    C0524865
    NCI Thesaurus Property
    C17649
    UMLS 2011AA Property
    C0205394
    NCI Thesaurus Property-2
    C25367
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    Footer Module
    Beskrivning

    Footer Module

    Comments
    Beskrivning

    Research Comments

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS CUI-1
    C0947611
    NCI Thesaurus ObjectClass
    C15319
    NCI Thesaurus Property
    C25393
    Signature
    Beskrivning

    Responsible Person Signature

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS CUI-1
    C1550483
    NCI Thesaurus ObjectClass
    C25190
    NCI Thesaurus ObjectClass-2
    C25657
    NCI Thesaurus Property
    C25678
    Date
    Beskrivning

    ResponsiblePersonSignatureDate

    Datatyp

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C25190
    UMLS 2011AA ObjectClass
    C0027361
    NCI Thesaurus ObjectClass-2
    C25657
    UMLS 2011AA ObjectClass-2
    C1273518
    NCI Thesaurus Property
    C25678
    UMLS 2011AA Property
    C1519316
    Date Form Completed
    Beskrivning

    Date Form Completed

    Datatyp

    date

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

    Similar models

    This form is completed by the investigator (rater) and submitted at each time point specified by the protocol, whether or not any of the patient assessment items (Q's 6,7,8) are answered

    1. StudyEvent: RTOG-1005 QP: Radiation Therapy Oncology Group Phase III Whole Breast Irradiation for Early Stage Breast Cancer Patient Cosmesis Evaluation Form
      1. This form is completed by the investigator (rater) and submitted at each time point specified by the protocol, whether or not any of the patient assessment items (Q's 6,7,8) are answered
    Name
    Typ
    Description | Question | Decode (Coded Value)
    Datatyp
    Alias
    Item Group
    RTOG clinical trial administrative data
    Protocol ID RTOG
    Item
    RTOG Study No.
    text
    C25337 (NCI Thesaurus ValueDomain)
    C3274381 (UMLS CUI-1)
    C25320 (NCI Thesaurus ObjectClass)
    C1514695 (UMLS CUI-2)
    C19778 (NCI Thesaurus Property)
    C25364 (NCI Thesaurus Property-2)
    RadiationTherapyOncologyGroupPatientCaseIdentifierNumber
    Item
    Case #
    text
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C19778 (NCI Thesaurus ObjectClass-2)
    C1514695 (UMLS 2011AA ObjectClass-2)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C49152 (NCI Thesaurus Property-2)
    C1706256 (UMLS 2011AA Property-2)
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    Institution Name
    Item
    Institution Name
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1301943 (UMLS CUI-1)
    C21541 (NCI Thesaurus ObjectClass)
    C21541 (NCI Thesaurus ValueDomain-2)
    C25364 (NCI Thesaurus Property)
    Institution Number
    Item
    Institution No.
    text
    C25337 (NCI Thesaurus ValueDomain)
    C1301943 (UMLS CUI-1)
    C21541 (NCI Thesaurus ObjectClass)
    C0805701 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    Patient Initials
    Item
    Patient Initials
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2986440 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25536 (NCI Thesaurus Property)
    Trial subject ID RTOG
    Item
    RTOG Patient ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C2348585 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C1514695 (UMLS CUI-2)
    C19778 (NCI Thesaurus Property)
    C25364 (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
    Time point
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C20989 (NCI Thesaurus ObjectClass)
    C0031809 (UMLS 2011AA ObjectClass)
    C25616 (NCI Thesaurus Property)
    C1948053 (UMLS 2011AA Property)
    Code List
    Time point
    CL Item
    Pretreatment (Pretreatment)
    CL Item
    1 Year Post Rt Completion (1 year post RT Completion)
    CL Item
    3 Years Post Rt Completion (3 years post RT Completion)
    Treatment Begin Date
    Item
    Treatment Start Date
    date
    C15368 (NCI Thesaurus ObjectClass)
    C25431 (NCI Thesaurus Property)
    C3173309 (UMLS CUI-1)
    C25275 (NCI Thesaurus Property-2)
    C25164 (NCI Thesaurus ValueDomain)
    C25431 (NCI Thesaurus ValueDomain-2)
    Item
    Evaluation performed by
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C25190 (NCI Thesaurus ObjectClass)
    C0027361 (UMLS 2011AA ObjectClass)
    C25214 (NCI Thesaurus Property)
    C0220825 (UMLS 2011AA Property)
    C25199 (NCI Thesaurus Property-2)
    C0035820 (UMLS 2011AA Property-2)
    Code List
    Evaluation performed by
    CL Item
    Surgeon (Surgeon)
    C18071 (NCI Thesaurus)
    C0582175 (UMLS 2011AA)
    CL Item
    Radiation Oncologist (Radiation Oncologist)
    C17833 (NCI Thesaurus)
    C1514693 (UMLS 2011AA)
    QualityofLifeCompleteAssessmentDate
    Item
    Date Questionnaire Completed (MM DD YYYY)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C17047 (NCI Thesaurus ObjectClass)
    C0518214 (UMLS 2011AA ObjectClass)
    C25250 (NCI Thesaurus Property)
    C0205197 (UMLS 2011AA Property)
    C25367 (NCI Thesaurus Property-2)
    Item
    Reason Questionnaire was not Completed
    text
    C25638 (NCI Thesaurus ValueDomain)
    C1548386 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C0566251 (UMLS CUI-2)
    C0034394 (NCI Metathesaurus Property)
    Code List
    Reason Questionnaire was not Completed
    CL Item
    Not Applicable, Questionnaire Was Completed (Not applicable, questionnaire was completed)
    CL Item
    Patient Refused Due To Illness (Patient refused due to illness)
    CL Item
    Patient Refused For Other Reason (Patient refused for other reason)
    CL Item
    Patient Unable To Be Contacted (Patient unable to be contacted)
    CL Item
    Institution Error (Institutional error)
    CL Item
    Patient Withdrew Consent Prior/after (Patient withdrew consent prior/after)
    CL Item
    Other Reason (Other reason)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    PatientRefuseIncompleteQuestionnaireSpecify
    Item
    Patient refused for other reason, specify
    text
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C0034394 (NCI Metathesaurus Property)
    C49160 (NCI Thesaurus Property)
    C0205257 (UMLS 2011AA Property)
    C49161 (NCI Thesaurus Property-2)
    C1705116 (UMLS 2011AA Property-2)
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    PatientIncompleteQuestionnaireOtherSpecify
    Item
    Other reason, specify
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C17649 (NCI Thesaurus ValueDomain-2)
    C0205394 (UMLS 2011AA ValueDomain-2)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C0034394 (NCI Metathesaurus Property)
    Item Group
    Breast Reconstruction Assessment
    Item
    Please assess breast cosmesis at this time
    text
    C25367 (NCI Thesaurus Property)
    C12971 (NCI Thesaurus ObjectClass)
    C0006141 (UMLS 2011AA ObjectClass)
    C25688 (NCI Thesaurus ValueDomain)
    C0449438 (UMLS 2011AA ValueDomain)
    C25351 (NCI Thesaurus ObjectClass-2)
    C0524865 (UMLS 2011AA ObjectClass-2)
    Code List
    Please assess breast cosmesis at this time
    CL Item
    Excellent (Excellent)
    CL Item
    Good (Good)
    CL Item
    Fair (Fair)
    CL Item
    Poor (Poor)
    Item
    Skin telangiectasia
    text
    C12971 (NCI Thesaurus ObjectClass)
    C0006141 (UMLS 2011AA ObjectClass)
    C25351 (NCI Thesaurus ObjectClass-2)
    C0524865 (UMLS 2011AA ObjectClass-2)
    C25367 (NCI Thesaurus Property)
    C28194 (NCI Thesaurus Property-2)
    C0039446 (UMLS 2011AA Property)
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    Code List
    Skin telangiectasia
    CL Item
    None (None)
    CL Item
    Yes, Present But Does Not Affect Cosmesis (Yes, present but does not affect cosmesis)
    CL Item
    Yes, Present And Affects Cosmesis (Yes, present and affects cosmesis)
    Item
    Skin atrophy
    text
    C12971 (NCI Thesaurus ObjectClass)
    C0006141 (UMLS 2011AA ObjectClass)
    C25351 (NCI Thesaurus ObjectClass-2)
    C0524865 (UMLS 2011AA ObjectClass-2)
    C25367 (NCI Thesaurus Property)
    C79748 (NCI Thesaurus Property-2)
    C0333641 (UMLS 2011AA Property)
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    Code List
    Skin atrophy
    CL Item
    None (None)
    CL Item
    Yes, Present But Does Not Affect Cosmesis (Yes, present but does not affect cosmesis)
    CL Item
    Yes, Present And Affects Cosmesis (Yes, present and affects cosmesis)
    Item
    Scarring
    text
    C12971 (NCI Thesaurus ObjectClass)
    C0006141 (UMLS 2011AA ObjectClass)
    C25351 (NCI Thesaurus ObjectClass-2)
    C0524865 (UMLS 2011AA ObjectClass-2)
    C25367 (NCI Thesaurus Property)
    C34483 (NCI Thesaurus Property-2)
    C2004491 (UMLS 2011AA Property)
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    Code List
    Scarring
    CL Item
    None (None)
    CL Item
    Yes, Present But Does Not Affect Cosmesis (Yes, present but does not affect cosmesis)
    CL Item
    Yes, Present And Affects Cosmesis (Yes, present and affects cosmesis)
    Item
    Pigment change
    text
    C12971 (NCI Thesaurus ObjectClass)
    C0006141 (UMLS 2011AA ObjectClass)
    C25351 (NCI Thesaurus ObjectClass-2)
    C0524865 (UMLS 2011AA ObjectClass-2)
    C25367 (NCI Thesaurus Property)
    C747 (NCI Thesaurus Property-2)
    C0031916 (UMLS 2011AA Property)
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    Code List
    Pigment change
    CL Item
    None (None)
    CL Item
    Yes, Present But Does Not Affect Cosmesis (Yes, present but does not affect cosmesis)
    CL Item
    Yes, Present And Affects Cosmesis (Yes, present and affects cosmesis)
    Item
    Erythema
    text
    C12971 (NCI Thesaurus ObjectClass)
    C0006141 (UMLS 2011AA ObjectClass)
    C25351 (NCI Thesaurus ObjectClass-2)
    C0524865 (UMLS 2011AA ObjectClass-2)
    C25367 (NCI Thesaurus Property)
    C26901 (NCI Thesaurus Property-2)
    C0041834 (UMLS 2011AA Property)
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    Code List
    Erythema
    CL Item
    None (None)
    CL Item
    Yes, Present But Does Not Affect Cosmesis (Yes, present but does not affect cosmesis)
    CL Item
    Yes, Present And Affects Cosmesis (Yes, present and affects cosmesis)
    Item
    Fat necrosis
    text
    C12971 (NCI Thesaurus ObjectClass)
    C0006141 (UMLS 2011AA ObjectClass)
    C25351 (NCI Thesaurus ObjectClass-2)
    C0524865 (UMLS 2011AA ObjectClass-2)
    C25367 (NCI Thesaurus Property)
    C26772 (NCI Thesaurus Property-2)
    C0015668 (UMLS 2011AA Property)
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    Code List
    Fat necrosis
    CL Item
    None (None)
    CL Item
    Yes, Present But Does Not Affect Cosmesis (Yes, present but does not affect cosmesis)
    CL Item
    Yes, Present And Affects Cosmesis (Yes, present and affects cosmesis)
    Item
    Fibrosis
    text
    C12971 (NCI Thesaurus ObjectClass)
    C0006141 (UMLS 2011AA ObjectClass)
    C25351 (NCI Thesaurus ObjectClass-2)
    C0524865 (UMLS 2011AA ObjectClass-2)
    C25367 (NCI Thesaurus Property)
    C3044 (NCI Thesaurus Property-2)
    C0016059 (UMLS 2011AA Property)
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    Code List
    Fibrosis
    CL Item
    None (None)
    CL Item
    Yes, Present But Does Not Affect Cosmesis (Yes, present but does not affect cosmesis)
    CL Item
    Yes, Present And Affects Cosmesis (Yes, present and affects cosmesis)
    Item
    Retraction or contour defect
    text
    C12971 (NCI Thesaurus ObjectClass)
    C0006141 (UMLS 2011AA ObjectClass)
    C25351 (NCI Thesaurus ObjectClass-2)
    C0524865 (UMLS 2011AA ObjectClass-2)
    C25367 (NCI Thesaurus Property)
    C43429 (NCI Thesaurus Property-2)
    C1457869 (UMLS 2011AA Property)
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    Code List
    Retraction or contour defect
    CL Item
    None (None)
    CL Item
    Yes, Present But Does Not Affect Cosmesis (Yes, present but does not affect cosmesis)
    CL Item
    Yes, Present And Affects Cosmesis (Yes, present and affects cosmesis)
    Item
    Volume loss
    text
    C12971 (NCI Thesaurus ObjectClass)
    C0006141 (UMLS 2011AA ObjectClass)
    C25351 (NCI Thesaurus ObjectClass-2)
    C0524865 (UMLS 2011AA ObjectClass-2)
    C25367 (NCI Thesaurus Property)
    C25559 (NCI Thesaurus Property-2)
    C1517945 (UMLS 2011AA Property)
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    Code List
    Volume loss
    CL Item
    None (None)
    CL Item
    Yes, Present But Does Not Affect Cosmesis (Yes, present but does not affect cosmesis)
    CL Item
    Yes, Present And Affects Cosmesis (Yes, present and affects cosmesis)
    Item
    Other significant treatment effect
    text
    C12971 (NCI Thesaurus ObjectClass)
    C0006141 (UMLS 2011AA ObjectClass)
    C25351 (NCI Thesaurus ObjectClass-2)
    C0524865 (UMLS 2011AA ObjectClass-2)
    C17649 (NCI Thesaurus Property)
    C0205394 (UMLS 2011AA Property)
    C25367 (NCI Thesaurus Property-2)
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    Code List
    Other significant treatment effect
    CL Item
    None (None)
    CL Item
    Yes, Present But Does Not Affect Cosmesis (Yes, present but does not affect cosmesis)
    CL Item
    Yes, Present And Affects Cosmesis (Yes, present and affects cosmesis)
    BreastReconstructionOtherAssessmentSpecify
    Item
    Specify
    text
    C12971 (NCI Thesaurus ObjectClass)
    C0006141 (UMLS 2011AA ObjectClass)
    C25351 (NCI Thesaurus ObjectClass-2)
    C0524865 (UMLS 2011AA ObjectClass-2)
    C17649 (NCI Thesaurus Property)
    C0205394 (UMLS 2011AA Property)
    C25367 (NCI Thesaurus Property-2)
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    Item Group
    Footer Module
    Research Comments
    Item
    Comments
    text
    C25704 (NCI Thesaurus ValueDomain)
    C0947611 (UMLS CUI-1)
    C15319 (NCI Thesaurus ObjectClass)
    C25393 (NCI Thesaurus Property)
    Responsible Person Signature
    Item
    Signature
    text
    C25704 (NCI Thesaurus ValueDomain)
    C1550483 (UMLS CUI-1)
    C25190 (NCI Thesaurus ObjectClass)
    C25657 (NCI Thesaurus ObjectClass-2)
    C25678 (NCI Thesaurus Property)
    ResponsiblePersonSignatureDate
    Item
    Date
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25190 (NCI Thesaurus ObjectClass)
    C0027361 (UMLS 2011AA ObjectClass)
    C25657 (NCI Thesaurus ObjectClass-2)
    C1273518 (UMLS 2011AA ObjectClass-2)
    C25678 (NCI Thesaurus Property)
    C1519316 (UMLS 2011AA 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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