ID

1201

Descripción

GOG Recurrent Gynecologic Cancer - On Study Form Comparison of Four Combination Chemotherapy Regimens Using Cisplatin in Treating Patients With Stage IVB, Recurrent, or Persistent Cancer of the Cervix Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=ABA39B7C-C8BC-2446-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=ABA39B7C-C8BC-2446-E034-0003BA12F5E7

Palabras clave

Versiones (2)
  1. 27/8/12 27/8/12 -
  2. 24/6/17 24/6/17 - Martin Dugas
Subido en

27 de agosto de 2012

DOI

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Licencia

Creative Commons BY-NC 3.0
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Cervical Cancer NCT00064077 On-Study - GOG Recurrent Gynecologic Cancer - On Study Form - 2058732v3.0

Inglés

FORM OS-R

1 formularios  
  1. StudyEvent: GOG Recurrent Gynecologic Cancer - On Study Form
    1. FORM OS-R
Header Module
Descripción

Header Module

Date form originally completed (m d y)
Descripción

FormCompletionDate,Original

Tipo de datos

date

Date form amended (m d y)
Descripción

FormCompletionDate,Amended

Tipo de datos

date

Person amending form, last name
Descripción

ResponsiblePersonReportingChangeLastName

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Patient Name, Last
Descripción

PatientName,Last

Tipo de datos

text

Patient Name, First
Descripción

PatientName,First

Tipo de datos

text

Patient Study ID
Descripción

PatientStudyID

Tipo de datos

text

Person Completing Form, Last Name
Descripción

PersonCompletingForm,LastName

Tipo de datos

text

Disease Description - Prior History
Descripción

Disease Description - Prior History

Date of definitive histologic diagnosis of primary tumor (m d y Note: Word ?tumor? obstructed by graphic)
Descripción

PrimaryTumorDiagnosisDate

Tipo de datos

date

Alias
NCI Thesaurus ObjectClass
C3262
UMLS 2011AA ObjectClass
C0027651
NCI Thesaurus Property
C15220
UMLS 2011AA Property
C0011900
Stage (at diagnosis FIGO)
Descripción

StageGrouping

Tipo de datos

text

Primary surgery date (m d y)
Descripción

PrimarySurgeryDate

Tipo de datos

date

Primary surgery type (check all that apply)
Descripción

PrimarySurgeryType

Tipo de datos

text

Other (Primary Surgery Type), specify
Descripción

PrimarySurgeryOtherType

Tipo de datos

text

Disease Description - Current History
Descripción

Disease Description - Current History

Current status of disease
Descripción

DiseaseStatus

Tipo de datos

text

Date of first recurrence or progression (m d y)
Descripción

ProgressionDate,First

Tipo de datos

date

What was the method used to determine progression? (recurrence or check all that apply)
Descripción

ProgressionAssessmentMethod

Tipo de datos

text

Site(s) of disease (at study entry check all that apply)
Descripción

DiseaseSite

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C3262
UMLS 2011AA ObjectClass
C0027651
NCI Thesaurus Property
C25341
UMLS 2011AA Property
C0450429
NCI Thesaurus ObjectClass
C12971
UMLS 2011AA ObjectClass
C0006141
Other (Sites of Disease), specify
Descripción

DiseaseSite,Other

Tipo de datos

text

Prior Treatment For Gynecologic Cancer
Descripción

Prior Treatment For Gynecologic Cancer

Prior systemic chemotherapy?
Descripción

PriorChemotherapyInd

Tipo de datos

text

Date prior chemotherapy started (m d y)
Descripción

PriorChemotherapyBeginDate

Tipo de datos

date

Date prior chemotherapy ended
Descripción

PriorChemotherapyEndDate

Tipo de datos

date

Chemotherapy regimen
Descripción

PriorChemotherapyRegimen

Tipo de datos

text

Second line, specify agent(s)
Descripción

PriorChemotherapyRegimen,Agent

Tipo de datos

text

Second line, specify agent(s)
Descripción

PriorChemotherapyRegimen,Agent

Tipo de datos

text

Other, specify agent(s)
Descripción

PriorChemotherapyRegimen,OtherAgent

Tipo de datos

text

No. of courses
Descripción

PriorChemotherapyCount

Tipo de datos

double

Prior hormonal therapy?
Descripción

PriorHormonalTherapyInd

Tipo de datos

text

Yes (Prior Hormonal), specify
Descripción

PriorHormonalTherapyType

Tipo de datos

text

Non-protocol biologic response modifier?
Descripción

Non-ProtocolBRMInd

Tipo de datos

text

Yes, (Non-protocol BRM) specify
Descripción

Non-ProtocolTherapyType

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C25590
UMLS 2011AA ObjectClass
C1518384
NCI Thesaurus ObjectClass
C2167
UMLS 2011AA ObjectClass
C1443775
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Prior radiation therapy?
Descripción

PriorRTInd

Tipo de datos

text

Yes, (Prior RT) specify
Descripción

Non-ProtocolRTType

Tipo de datos

text

Is the site of recurrence within the field previously treated by radiation therapy?
Descripción

RTRecurrenceSiteInd

Tipo de datos

text

Comments
Descripción

Comments

COMMENTS
Descripción

Comments

Tipo de datos

text

Footer Module
Descripción

Footer Module

Participating Group Code
Descripción

ParticipatingGroupCode

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
Participating Group Protocol Number
Descripción

ParticipatingGroupProtocolNumber

Tipo de datos

double

Participating Patient Study ID
Descripción

PatientParticipatingIdentifierNumber

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25608
UMLS 2011AA Property
C0679823
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Ccrr Module For Gog Recurrent Gynecologic Cancer - On Study Form
Descripción

Ccrr Module For Gog Recurrent Gynecologic Cancer - On Study Form

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Similar models

FORM OS-R

1 formularios
  1. StudyEvent: GOG Recurrent Gynecologic Cancer - On Study Form
    1. FORM OS-R
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Item Group
Header Module
FormCompletionDate,Original
Item
Date form originally completed (m d y)
date
FormCompletionDate,Amended
Item
Date form amended (m d y)
date
ResponsiblePersonReportingChangeLastName
Item
Person amending form, last name
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
PatientName,Last
Item
Patient Name, Last
text
PatientName,First
Item
Patient Name, First
text
PatientStudyID
Item
Patient Study ID
text
PersonCompletingForm,LastName
Item
Person Completing Form, Last Name
text
Item Group
Disease Description - Prior History
PrimaryTumorDiagnosisDate
Item
Date of definitive histologic diagnosis of primary tumor (m d y Note: Word ?tumor? obstructed by graphic)
date
C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C15220 (NCI Thesaurus Property)
C0011900 (UMLS 2011AA Property)
Item
Stage (at diagnosis FIGO)
text
CL.1
Code List
Stage (at diagnosis FIGO)
CL Item
Refer To Figo Staging For Specific Gynecologic Cancer (I)
CL Item
Refer To Figo Staging For Specific Gynecologic Cancer (II)
CL Item
Refer To Figo Staging For Specific Gynecologic Cancer (III)
CL Item
Refer To Figo Staging For Specific Gynecologic Cancer (IV)
PrimarySurgeryDate
Item
Primary surgery date (m d y)
date
Item
Primary surgery type (check all that apply)
text
CL.2
Code List
Primary surgery type (check all that apply)
CL Item
Partial Hysterectomy (Partial hysterectomy)
C40961 (NCI Thesaurus)
C1270947 (UMLS 2011AA)
CL Item
Radical Hysterectomy (Radical hysterectomy)
CL Item
Total Hysterectomy (Total hysterectomy)
C15701 (NCI Thesaurus)
C0677962 (UMLS 2011AA)
CL Item
Radical Trachelectomy (Radical Trachelectomy)
CL Item
Bilateral Salpingo-oophorectomy (Bilateral Salpingo-Oophorectomy)
CL Item
Unilateral Salpingo-oophorectomy (Unilateral Salpingo-Oophorectomy)
C28012 (NCI Thesaurus)
C0205092 (UMLS 2011AA)
C15323 (NCI Thesaurus)
C0036132 (UMLS 2011AA)
CL Item
Omentectomy (Omenectomy)
C0198614 (NCI Metathesaurus)
CL Item
Cervical Conization (Cervical conization)
CL Item
Para-aortic Node Sampling/dissection (Para-aortic node sampling/dissection)
CL Item
Pelvic Node Sampling/dissection (Pelvic node sampling/dissection)
CL Item
Other, Specify (Other, specify)
PrimarySurgeryOtherType
Item
Other (Primary Surgery Type), specify
text
Item Group
Disease Description - Current History
Item
Current status of disease
text
CL.3
Code List
Current status of disease
CL Item
Primary Gyn Disease Continues To Be Present Following Initial Treatment (Persistent)
CL Item
Recurrence Of Same Gyn Disease Previously Treated Successfully (Recurrence)
CL Item
Progression Of Gyn Disease Per Recist Criteria (Progression)
CL Item
Primary Tumor (Primary (advanced stage))
ProgressionDate,First
Item
Date of first recurrence or progression (m d y)
date
Item
What was the method used to determine progression? (recurrence or check all that apply)
text
CL.4
Code List
What was the method used to determine progression? (recurrence or check all that apply)
CL Item
Histology (Histologic)
C16681 (NCI Thesaurus)
C0019638 (UMLS 2011AA)
CL Item
Radiographic (Radiographic)
CL Item
Clinical Examination (Clinical)
Item
Site(s) of disease (at study entry check all that apply)
text
C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C12971 (NCI Thesaurus ObjectClass)
C0006141 (UMLS 2011AA ObjectClass)
CL.5
Code List
Site(s) of disease (at study entry check all that apply)
CL Item
Ascites (Ascites)
C2885 (NCI Thesaurus)
C0003962 (UMLS 2011AA)
CL Item
Bladder (Bladder)
C12414 (NCI Thesaurus)
C0005682 (UMLS 2011AA)
CL Item
Bone (Bone)
C12366 (NCI Thesaurus)
C0262950 (UMLS 2011AA)
CL Item
Cervix (Cervix)
C12311 (NCI Thesaurus)
C0007874 (UMLS 2011AA)
CL Item
Colon (Colon)
C12382 (NCI Thesaurus)
C0009368 (UMLS 2011AA)
CL Item
Cns/brain (CNS/Brain)
CL Item
Endometrium (Endometrium)
C12313 (NCI Thesaurus)
C0014180 (UMLS 2011AA)
CL Item
Liver (Liver)
C12392 (NCI Thesaurus)
C0023884 (UMLS 2011AA)
CL Item
Lung (Lung)
C12468 (NCI Thesaurus)
C0024109 (UMLS 2011AA)
CL Item
Lymph Nodes, Specify (Lymph nodes)
CL Item
Ovary (Ovary)
C12404 (NCI Thesaurus)
C0029939 (UMLS 2011AA)
CL Item
Parametrial Involvement (Parametrial involvement)
CL Item
Peritoneum (Peritoneum)
C12770 (NCI Thesaurus)
C0031153 (UMLS 2011AA)
CL Item
Pleura (Pleura)
C12469 (NCI Thesaurus)
C0032225 (UMLS 2011AA)
CL Item
Pleural Effusion (Pleural effusion)
C3331 (NCI Thesaurus)
C0021071 (UMLS 2011AA)
CL Item
Skin (Skin)
C12470 (NCI Thesaurus)
C1123023 (UMLS 2011AA)
CL Item
Uterus (Uterus)
C12405 (NCI Thesaurus)
C0042149 (UMLS 2011AA)
CL Item
Other, Specify (Other, specify)
DiseaseSite,Other
Item
Other (Sites of Disease), specify
text
Item Group
Prior Treatment For Gynecologic Cancer
Item
Prior systemic chemotherapy?
text
CL.6
Code List
Prior systemic chemotherapy?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
PriorChemotherapyBeginDate
Item
Date prior chemotherapy started (m d y)
date
PriorChemotherapyEndDate
Item
Date prior chemotherapy ended
date
Item
Chemotherapy regimen
text
CL.7
Code List
Chemotherapy regimen
CL Item
First Line Agent (First line, specify agent(s))
CL Item
Second Line Agent (Second line, specify agent(s))
CL Item
Other, Specify (Other, specify agent(s))
PriorChemotherapyRegimen,Agent
Item
Second line, specify agent(s)
text
PriorChemotherapyRegimen,Agent
Item
Second line, specify agent(s)
text
PriorChemotherapyRegimen,OtherAgent
Item
Other, specify agent(s)
text
PriorChemotherapyCount
Item
No. of courses
double
Item
Prior hormonal therapy?
text
CL.8
Code List
Prior hormonal therapy?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes, specify)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
PriorHormonalTherapyType
Item
Yes (Prior Hormonal), specify
text
Item
Non-protocol biologic response modifier?
text
CL.9
Code List
Non-protocol biologic response modifier?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes, specify)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Non-ProtocolTherapyType
Item
Yes, (Non-protocol BRM) specify
text
C25590 (NCI Thesaurus ObjectClass)
C1518384 (UMLS 2011AA ObjectClass)
C2167 (NCI Thesaurus ObjectClass)
C1443775 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
Item
Prior radiation therapy?
text
CL.10
Code List
Prior radiation therapy?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes, specify)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Non-ProtocolRTType
Item
Yes, (Prior RT) specify
text
Item
Is the site of recurrence within the field previously treated by radiation therapy?
text
CL.11
Code List
Is the site of recurrence within the field previously treated by radiation therapy?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item Group
Comments
Comments
Item
COMMENTS
text
Item Group
Footer Module
ParticipatingGroupCode
Item
Participating Group Code
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
ParticipatingGroupProtocolNumber
Item
Participating Group Protocol Number
double
PatientParticipatingIdentifierNumber
Item
Participating Patient Study ID
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25608 (NCI Thesaurus Property)
C0679823 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
Item Group
Ccrr Module For Gog Recurrent Gynecologic Cancer - On Study Form
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