ID

1614

Beschreibung

CALGB: 80101 ON-STUDY FORM Chemotherapy and Radiation Therapy After Surgery in Treating Patients With Stomach or Esophageal Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9DA712C5-6067-535F-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9DA712C5-6067-535F-E034-080020C9C0E0

Stichworte

Versionen (3)
  1. 19.09.12 19.09.12 -
  2. 28.05.15 28.05.15 -
  3. 03.06.15 03.06.15 -
Hochgeladen am

19. September 2012

DOI

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Lizenz

Creative Commons BY-NC 3.0 Legacy
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Esophageal Cancer NCT00052910 On-Study - CALGB: 80101 ON-STUDY FORM - 2030014v3.0

Englisch

No Instruction available.

1 Formulare  
  1. StudyEvent: CALGB: 80101 ON-STUDY FORM
    1. No Instruction available.
Unnamed1
Beschreibung

Unnamed1

CALGB Form
Beschreibung

CALGBForm

Datentyp

text

CALGB Study No
Beschreibung

CALGBProtocolNumber

Datentyp

text

CALGB Patient ID
Beschreibung

CALGBPatientID

Datentyp

text

Amended data?
Beschreibung

AmendedDataInd

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Unnamed2
Beschreibung

Unnamed2

Patient's Name
Beschreibung

PatientName,Last

Datentyp

text

Participating Group
Beschreibung

ParticipatingGroupCode

Datentyp

text

Patient Hospital Number
Beschreibung

PatientMedicalRecordNumber

Datentyp

text

Participating Group Protocol No.
Beschreibung

Particip.GroupProtocolNumber

Datentyp

double

Main Member Institution/Adjunct
Beschreibung

InstitutionName

Datentyp

text

Participating Group Patient No.
Beschreibung

PatientStudyID,ParticipatingGroup

Datentyp

text

Unnamed3
Beschreibung

Unnamed3

History of primary cancer other than gastric?
Beschreibung

PriorCancerInd

Datentyp

text

Yes, specify type of cancer
Beschreibung

PriorCancerType

Datentyp

text

Year of diagnosis
Beschreibung

PriorCancerDiagnosisDate

Datentyp

date

Caloric intake >/= 1500 Kcal/day
Beschreibung

Caloricintake>/=1500Kcal/day

Datentyp

text

Lab Data At Protocol Entry
Beschreibung

Lab Data At Protocol Entry

ANC (x10 3)
Beschreibung

Lab,Hematology,NeutrophilCount

Datentyp

double

Platelets (x10 3)
Beschreibung

Lab,Hematology,Platelets

Datentyp

double

Serum Creatinine (mg/dl)
Beschreibung

Lab,Renal,Creatinine

Datentyp

double

SGOT (U/ml)
Beschreibung

Lab,Hepatic,SGOT

Datentyp

double

Bilirubin (mg/dl)
Beschreibung

Lab,Hepatic,Bilirubin

Datentyp

double

Patient examined by RT oncologist?
Beschreibung

PatientexaminedbyRToncologist?

Datentyp

text

Bilateral renal function as determined by scan?
Beschreibung

Bilateralrenalfunctionasdeterminedbyscan?

Datentyp

text

Prior systemic chemotherapy?
Beschreibung

PriorChemotherapyInd

Datentyp

text

Prior immunotherapy?
Beschreibung

PriorImmunotherapyInd

Datentyp

text

Prior radiotherapy?
Beschreibung

PriorRTInd

Datentyp

text

Gastric Resection Data
Beschreibung

Gastric Resection Data

Date of gastric resection
Beschreibung

GastricResectionDate

Datentyp

text

Site of gastric primary
Beschreibung

PrimarySite

Datentyp

text

Name of institution where resection was done
Beschreibung

InstitutionName,Resection

Datentyp

text

Medicare ID number of institution
Beschreibung

ProfessionalOrganizationMedicareIdentifierNumber

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus Property
C16665
UMLS 2011AA Property
C0018717
NCI Thesaurus ObjectClass
C19711
UMLS 2011AA ObjectClass
C1522486
Histology & Staging Data
Beschreibung

Histology & Staging Data

Differentiation
Beschreibung

HistologicGrade

Datentyp

text

AJCC/UICC TNM Staging: T
Beschreibung

TStage,Clinical

Datentyp

text

AJCC/UICC TNM Staging: N
Beschreibung

NStage,Clinical

Datentyp

text

AJCC/UICC TNM Staging: M
Beschreibung

MStage,Clinical

Datentyp

text

If patient has T2N0M0, does tumor extend beyond muscularis propria?
Beschreibung

IfpatienthasT2N0M0,doestumorextendbeyondmuscularispropria?

Datentyp

text

Completed by
Beschreibung

PersonCompletingForm,FirstName

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Date completed
Beschreibung

FormCompletionDate,Original

Datentyp

date

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Ähnliche Modelle

No Instruction available.

1 Formulare
  1. StudyEvent: CALGB: 80101 ON-STUDY FORM
    1. No Instruction available.
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Unnamed1
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)
Item Group
Unnamed2
PatientName,Last
Item
Patient's Name
text
ParticipatingGroupCode
Item
Participating Group
text
PatientMedicalRecordNumber
Item
Patient Hospital Number
text
Particip.GroupProtocolNumber
Item
Participating Group Protocol No.
double
InstitutionName
Item
Main Member Institution/Adjunct
text
PatientStudyID,ParticipatingGroup
Item
Participating Group Patient No.
text
Item Group
Unnamed3
Item
History of primary cancer other than gastric?
text
CL.2
Code List
History of primary cancer other than gastric?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes, specify type of cancer (Yes, specify type of cancer)
PriorCancerType
Item
Yes, specify type of cancer
text
PriorCancerDiagnosisDate
Item
Year of diagnosis
date
Item
Caloric intake >/= 1500 Kcal/day
text
CL.3
Code List
Caloric intake >/= 1500 Kcal/day
CL Item
No (No)
CL Item
Yes (Yes)
Item Group
Lab Data At Protocol Entry
Lab,Hematology,NeutrophilCount
Item
ANC (x10 3)
double
Lab,Hematology,Platelets
Item
Platelets (x10 3)
double
Lab,Renal,Creatinine
Item
Serum Creatinine (mg/dl)
double
Lab,Hepatic,SGOT
Item
SGOT (U/ml)
double
Lab,Hepatic,Bilirubin
Item
Bilirubin (mg/dl)
double
PatientexaminedbyRToncologist?
Item
Patient examined by RT oncologist?
text
Bilateralrenalfunctionasdeterminedbyscan?
Item
Bilateral renal function as determined by scan?
text
PriorChemotherapyInd
Item
Prior systemic chemotherapy?
text
PriorImmunotherapyInd
Item
Prior immunotherapy?
text
PriorRTInd
Item
Prior radiotherapy?
text
Item Group
Gastric Resection Data
GastricResectionDate
Item
Date of gastric resection
text
Item
Site of gastric primary
text
CL.4
Code List
Site of gastric primary
CL Item
GE junction (GE junction)
CL Item
Cardia (Cardia)
C0007144 (NCI Metathesaurus)
CL Item
Fundus (Fundus)
C13378 (NCI Thesaurus)
C0740422 (UMLS 2011AA)
CL Item
Antrum (Antrum)
CL Item
Pylorus (Pylorus)
CL Item
Stomach, Not Otherwise Specified (Stomach, NOS)
InstitutionName,Resection
Item
Name of institution where resection was done
text
ProfessionalOrganizationMedicareIdentifierNumber
Item
Medicare ID number of institution
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C16665 (NCI Thesaurus Property)
C0018717 (UMLS 2011AA Property)
C19711 (NCI Thesaurus ObjectClass)
C1522486 (UMLS 2011AA ObjectClass)
Item Group
Histology & Staging Data
Item
Differentiation
text
CL.5
Code List
Differentiation
CL Item
Tumor Is Well Differentiated According To Who Grading System (Well differentiated (grade I))
CL Item
Moderately well differentiated (grade II) (Moderately well differentiated (grade II))
CL Item
Tumor Is Poorly Differentiated According To Who Grading System (Poorly differentiated (grade III))
CL Item
Tumor Is Undifferentiated According To Who Grading System (Undifferentiated (grade IV))
TStage,Clinical
Item
AJCC/UICC TNM Staging: T
text
NStage,Clinical
Item
AJCC/UICC TNM Staging: N
text
MStage,Clinical
Item
AJCC/UICC TNM Staging: M
text
Item
If patient has T2N0M0, does tumor extend beyond muscularis propria?
text
CL.6
Code List
If patient has T2N0M0, does tumor extend beyond muscularis propria?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
PersonCompletingForm,FirstName
Item
Completed by
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
FormCompletionDate,Original
Item
Date completed
date
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