ID

11689

Descripción

CALGB: 49808 ON-STUDY FORM Combination Chemotherapy, Surgery, and Radiation Therapy With or Without Dexrazoxane and Trastuzumab in Treating Women With Stage III or Stage IV Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9E35395C-88BE-227A-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9E35395C-88BE-227A-E034-080020C9C0E0

Palabras clave

Versiones (3)
  1. 28/7/15 28/7/15 - Julian Varghese
  2. 28/7/15 28/7/15 - Julian Varghese
  3. 28/7/15 28/7/15 - Julian Varghese
Subido en

28 de julio de 2015

DOI

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Licencia

Creative Commons BY-NC 3.0 Legacy
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CALGB: 49808 ON-STUDY FORM

Inglés

No Instruction available.

1 formularios  
  1. StudyEvent: CALGB: 49808 ON-STUDY FORM
    1. No Instruction available.
Administrative Data
Descripción

Administrative Data

CALGB Form
Descripción

CALGBForm

Tipo de datos

text

CALGB Study No
Descripción

CALGBProtocolNumber

Tipo de datos

text

CALGB Patient ID
Descripción

CALGBPatientID

Tipo de datos

text

Amended data?
Descripción

AmendedDataInd

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Patient's Name
Descripción

Patient'sName

Tipo de datos

text

Participating Group
Descripción

ParticipatingGroup

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C17005
UMLS 2011AA ObjectClass
C1257890
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Patient Hospital Number
Descripción

PatientHospitalNumber

Tipo de datos

text

Participating Group Protocol No.
Descripción

ParticipatingGroupProtocolNo.

Tipo de datos

text

Main Member Institution/Adjunct
Descripción

MainMemberInstitution/Adjunct

Tipo de datos

text

Participating Group Patient No.
Descripción

ParticipatingGroupPatientNo.

Tipo de datos

text

Menopausal Status
Descripción

Menopausal Status

Menopausal Status (mark one with an X)
Descripción

MenopausalStatus

Tipo de datos

text

Disease Description
Descripción

Disease Description

Tumor Laterality (mark one with an X)
Descripción

TumorLaterality

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C3262
UMLS 2011AA ObjectClass
C0027651
NCI Thesaurus Property
C25185
UMLS 2011AA Property
C0332304
Receptor Status, ER
Descripción

ERStatus

Tipo de datos

text

Receptor Status, PgR
Descripción

PgRStatus

Tipo de datos

text

Histologic Grade
Descripción

HistologicGrade

Tipo de datos

text

Histologic Subtype (mark one with an X)
Descripción

HistologicSubtype

Tipo de datos

text

Histologic Subtype Other, specify
Descripción

HistologicSubtypeOther,specify

Tipo de datos

text

Type of Primary Biopsy
Descripción

TypeofPrimaryBiopsy

Tipo de datos

text

HER-2 neu Status (mark one with an X)
Descripción

HER-2neuStatus

Tipo de datos

text

Assuming a good or exceptional response to neoadjuvant treatment, will the patient likely be a candidate for breast-conserving surgery?
Descripción

Assumingagoodorexceptionalresponsetoneoadjuvanttreatment,willthepatientlikelybeacandidateforbreast-conservingsurgery?

Tipo de datos

boolean

If not, principle reason (mark one with an X)
Descripción

Ifnot,principlereason

Tipo de datos

text

If not, principle reason, Other, specify
Descripción

Ifnot,principlereason,Other,specify

Tipo de datos

text

Disease Assessment
Descripción

Disease Assessment

Disease Assessment
Descripción

DiseaseAssessment

Tipo de datos

text

Primary Tumor Size (cm)
Descripción

PrimaryTumorSize

Tipo de datos

float

Disease Stage
Descripción

DiseaseStage

Tipo de datos

text

If the patient was diagnosed with a T4 tumor for physican's final staging above, indicate the type of tumor (mark one with an X)
Descripción

IfthepatientwasdiagnosedwithaT4tumorforphysican'sfinalstagingabove,indicatethetypeoftumor

Tipo de datos

text

Comments
Descripción

Comments

Comments
Descripción

Comments

Tipo de datos

text

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Similar models

No Instruction available.

1 formularios
  1. StudyEvent: CALGB: 49808 ON-STUDY FORM
    1. No Instruction available.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Item Group
Administrative Data
CALGBForm
Item
CALGB Form
text
CALGBProtocolNumber
Item
CALGB Study No
text
CALGBPatientID
Item
CALGB Patient ID
text
Item
Amended data?
text
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
CL.1
Code List
Amended data?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Patient'sName
Item
Patient's Name
text
ParticipatingGroup
Item
Participating Group
text
C17005 (NCI Thesaurus ObjectClass)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
PatientHospitalNumber
Item
Patient Hospital Number
text
ParticipatingGroupProtocolNo.
Item
Participating Group Protocol No.
text
MainMemberInstitution/Adjunct
Item
Main Member Institution/Adjunct
text
ParticipatingGroupPatientNo.
Item
Participating Group Patient No.
text
Item Group
Menopausal Status
Item
Menopausal Status (mark one with an X)
text
CL.2
Code List
Menopausal Status (mark one with an X)
CL Item
Pre (Pre)
CL Item
Post (Post)
CL Item
Above categories not applicable AND Age= <50 (Above categories not applicable AND Age= <50)
CL Item
Above categories not applicable AND Age=>50 (Above categories not applicable AND Age=>50)
Item Group
Disease Description
Item
Tumor Laterality (mark one with an X)
text
C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C25185 (NCI Thesaurus Property)
C0332304 (UMLS 2011AA Property)
CL.3
Code List
Tumor Laterality (mark one with an X)
CL Item
Left (Left)
C25229 (NCI Thesaurus)
C0205091 (UMLS 2011AA)
CL Item
Right (Right)
C25228 (NCI Thesaurus)
C0205090 (UMLS 2011AA)
CL Item
Bilateral (Bilateral)
C13332 (NCI Thesaurus)
C0238767 (UMLS 2011AA)
Item
Receptor Status, ER
text
CL.4
Code List
Receptor Status, ER
CL Item
Negative (Negative)
C25247 (NCI Thesaurus)
C0205160 (UMLS 2011AA)
CL Item
Positive (Positive)
C25246 (NCI Thesaurus)
C1446409 (UMLS 2011AA)
Item
Receptor Status, PgR
text
CL.5
Code List
Receptor Status, PgR
CL Item
Negative (Negative)
C25247 (NCI Thesaurus)
C0205160 (UMLS 2011AA)
CL Item
Positive (Positive)
C25246 (NCI Thesaurus)
C1446409 (UMLS 2011AA)
Item
Histologic Grade
text
CL.6
Code List
Histologic Grade
CL Item
Low (Low)
CL Item
Intermediate (Intermediate)
CL Item
High (High)
Item
Histologic Subtype (mark one with an X)
text
CL.7
Code List
Histologic Subtype (mark one with an X)
CL Item
Ductal (Ductal)
CL Item
Lobular (Lobular)
CL Item
Mixed Ductal and Lobular (Mixed Ductal and Lobular)
CL Item
Other, specify (Other, specify)
HistologicSubtypeOther,specify
Item
Histologic Subtype Other, specify
text
Item
Type of Primary Biopsy
text
CL.8
Code List
Type of Primary Biopsy
CL Item
Core Needle Biopsy (Core needle biopsy)
CL Item
Incisional Biopsy (Incisional biopsy)
C15386 (NCI Thesaurus)
C0184922 (UMLS 2011AA)
Item
HER-2 neu Status (mark one with an X)
text
CL.9
Code List
HER-2 neu Status (mark one with an X)
CL Item
Dako Herceptest 3+ (Dako Herceptest 3+)
CL Item
Dako Herceptest <3+/fish+ (Dako Herceptest <3+/FISH+)
CL Item
Fish+ (ihc Not Done) (FISH+ (IHC not done))
CL Item
Ihc (non-dako Herceptest) Strong Positive (IHC (non-Dako Herceptest) strong positive)
Assumingagoodorexceptionalresponsetoneoadjuvanttreatment,willthepatientlikelybeacandidateforbreast-conservingsurgery?
Item
Assuming a good or exceptional response to neoadjuvant treatment, will the patient likely be a candidate for breast-conserving surgery?
boolean
Item
If not, principle reason (mark one with an X)
text
CL.11
Code List
If not, principle reason (mark one with an X)
CL Item
Multicentric Disease (Multicentric Disease)
CL Item
Institutional Norm (Institutional norm)
CL Item
Inflammatory Disease (Inflammatory Disease)
CL Item
Specific Anatomy Of Primary (Specific anatomy of primary)
CL Item
Diffuse Microcalcifications (Diffuse Microcalcifications)
CL Item
Patient Choice/family History (Patient choice/Family History)
CL Item
Other, Specify: (Other, specify)
Ifnot,principlereason,Other,specify
Item
If not, principle reason, Other, specify
text
Item Group
Disease Assessment
Item
Disease Assessment
text
CL.12
Code List
Disease Assessment
CL Item
Physical Exam (Physical Exam)
CL Item
Mammogram (Mammogram)
C20178 (NCI Thesaurus)
C0024671 (UMLS 2011AA)
CL Item
Ultrasound (Ultrasound)
C64384 (NCI Thesaurus)
C1456803 (UMLS 2011AA)
CL Item
Physician's Final Staging (Physician's Final Staging)
PrimaryTumorSize
Item
Primary Tumor Size (cm)
float
Item
Disease Stage
text
CL.13
Code List
Disease Stage
CL Item
T (T)
CL Item
N (N)
C14562 (NCI Thesaurus)
CL Item
M (M)
Item
If the patient was diagnosed with a T4 tumor for physican's final staging above, indicate the type of tumor (mark one with an X)
text
CL.14
Code List
If the patient was diagnosed with a T4 tumor for physican's final staging above, indicate the type of tumor (mark one with an X)
CL Item
Skin Only (Skin only)
CL Item
Chest Wall Only (Chest wall only)
CL Item
Skin And Chest Wall (Skin and chest wall)
CL Item
Inflammatory (Inflammatory)
C25535 (NCI Thesaurus)
C0333348 (UMLS 2011AA)
CL Item
Not Applicable (Not applicable)
C48660 (NCI Thesaurus)
C1272460 (UMLS 2011AA)
Item Group
Comments
Comments
Item
Comments
text
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