ID

1201

Beschrijving

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

Trefwoorden

Versies (2)
  1. 27-08-12 27-08-12 -
  2. 24-06-17 24-06-17 - Martin Dugas
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27 augustus 2012

DOI

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

Engels

FORM OS-R

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

Header Module

Date form originally completed (m d y)
Beschrijving

FormCompletionDate,Original

Datatype

date

Date form amended (m d y)
Beschrijving

FormCompletionDate,Amended

Datatype

date

Person amending form, last name
Beschrijving

ResponsiblePersonReportingChangeLastName

Datatype

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
Beschrijving

PatientName,Last

Datatype

text

Patient Name, First
Beschrijving

PatientName,First

Datatype

text

Patient Study ID
Beschrijving

PatientStudyID

Datatype

text

Person Completing Form, Last Name
Beschrijving

PersonCompletingForm,LastName

Datatype

text

Disease Description - Prior History
Beschrijving

Disease Description - Prior History

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

PrimaryTumorDiagnosisDate

Datatype

date

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

StageGrouping

Datatype

text

Primary surgery date (m d y)
Beschrijving

PrimarySurgeryDate

Datatype

date

Primary surgery type (check all that apply)
Beschrijving

PrimarySurgeryType

Datatype

text

Other (Primary Surgery Type), specify
Beschrijving

PrimarySurgeryOtherType

Datatype

text

Disease Description - Current History
Beschrijving

Disease Description - Current History

Current status of disease
Beschrijving

DiseaseStatus

Datatype

text

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

ProgressionDate,First

Datatype

date

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

ProgressionAssessmentMethod

Datatype

text

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

DiseaseSite

Datatype

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
Beschrijving

DiseaseSite,Other

Datatype

text

Prior Treatment For Gynecologic Cancer
Beschrijving

Prior Treatment For Gynecologic Cancer

Prior systemic chemotherapy?
Beschrijving

PriorChemotherapyInd

Datatype

text

Date prior chemotherapy started (m d y)
Beschrijving

PriorChemotherapyBeginDate

Datatype

date

Date prior chemotherapy ended
Beschrijving

PriorChemotherapyEndDate

Datatype

date

Chemotherapy regimen
Beschrijving

PriorChemotherapyRegimen

Datatype

text

Second line, specify agent(s)
Beschrijving

PriorChemotherapyRegimen,Agent

Datatype

text

Second line, specify agent(s)
Beschrijving

PriorChemotherapyRegimen,Agent

Datatype

text

Other, specify agent(s)
Beschrijving

PriorChemotherapyRegimen,OtherAgent

Datatype

text

No. of courses
Beschrijving

PriorChemotherapyCount

Datatype

double

Prior hormonal therapy?
Beschrijving

PriorHormonalTherapyInd

Datatype

text

Yes (Prior Hormonal), specify
Beschrijving

PriorHormonalTherapyType

Datatype

text

Non-protocol biologic response modifier?
Beschrijving

Non-ProtocolBRMInd

Datatype

text

Yes, (Non-protocol BRM) specify
Beschrijving

Non-ProtocolTherapyType

Datatype

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?
Beschrijving

PriorRTInd

Datatype

text

Yes, (Prior RT) specify
Beschrijving

Non-ProtocolRTType

Datatype

text

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

RTRecurrenceSiteInd

Datatype

text

Comments
Beschrijving

Comments

COMMENTS
Beschrijving

Comments

Datatype

text

Footer Module
Beschrijving

Footer Module

Participating Group Code
Beschrijving

ParticipatingGroupCode

Datatype

text

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

ParticipatingGroupProtocolNumber

Datatype

double

Participating Patient Study ID
Beschrijving

PatientParticipatingIdentifierNumber

Datatype

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
Beschrijving

Ccrr Module For Gog Recurrent Gynecologic Cancer - On Study Form

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Similar models

FORM OS-R

1 Formulieren
  1. StudyEvent: GOG Recurrent Gynecologic Cancer - On Study Form
    1. FORM OS-R
Name
Type
Description | Question | Decode (Coded Value)
Datatype
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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