ID

1614

Beskrivning

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

Länk

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

Nyckelord

Versioner (3)
  1. 2012-09-19 2012-09-19 -
  2. 2015-05-28 2015-05-28 -
  3. 2015-06-03 2015-06-03 -
Uppladdad den

19 september 2012

DOI

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Licens

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

Engelsk

No Instruction available.

1 Formulär  
  1. StudyEvent: CALGB: 80101 ON-STUDY FORM
    1. No Instruction available.
Unnamed1
Beskrivning

Unnamed1

CALGB Form
Beskrivning

CALGBForm

Datatyp

text

CALGB Study No
Beskrivning

CALGBProtocolNumber

Datatyp

text

CALGB Patient ID
Beskrivning

CALGBPatientID

Datatyp

text

Amended data?
Beskrivning

AmendedDataInd

Datatyp

text

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

Unnamed2

Patient's Name
Beskrivning

PatientName,Last

Datatyp

text

Participating Group
Beskrivning

ParticipatingGroupCode

Datatyp

text

Patient Hospital Number
Beskrivning

PatientMedicalRecordNumber

Datatyp

text

Participating Group Protocol No.
Beskrivning

Particip.GroupProtocolNumber

Datatyp

double

Main Member Institution/Adjunct
Beskrivning

InstitutionName

Datatyp

text

Participating Group Patient No.
Beskrivning

PatientStudyID,ParticipatingGroup

Datatyp

text

Unnamed3
Beskrivning

Unnamed3

History of primary cancer other than gastric?
Beskrivning

PriorCancerInd

Datatyp

text

Yes, specify type of cancer
Beskrivning

PriorCancerType

Datatyp

text

Year of diagnosis
Beskrivning

PriorCancerDiagnosisDate

Datatyp

date

Caloric intake >/= 1500 Kcal/day
Beskrivning

Caloricintake>/=1500Kcal/day

Datatyp

text

Lab Data At Protocol Entry
Beskrivning

Lab Data At Protocol Entry

ANC (x10 3)
Beskrivning

Lab,Hematology,NeutrophilCount

Datatyp

double

Platelets (x10 3)
Beskrivning

Lab,Hematology,Platelets

Datatyp

double

Serum Creatinine (mg/dl)
Beskrivning

Lab,Renal,Creatinine

Datatyp

double

SGOT (U/ml)
Beskrivning

Lab,Hepatic,SGOT

Datatyp

double

Bilirubin (mg/dl)
Beskrivning

Lab,Hepatic,Bilirubin

Datatyp

double

Patient examined by RT oncologist?
Beskrivning

PatientexaminedbyRToncologist?

Datatyp

text

Bilateral renal function as determined by scan?
Beskrivning

Bilateralrenalfunctionasdeterminedbyscan?

Datatyp

text

Prior systemic chemotherapy?
Beskrivning

PriorChemotherapyInd

Datatyp

text

Prior immunotherapy?
Beskrivning

PriorImmunotherapyInd

Datatyp

text

Prior radiotherapy?
Beskrivning

PriorRTInd

Datatyp

text

Gastric Resection Data
Beskrivning

Gastric Resection Data

Date of gastric resection
Beskrivning

GastricResectionDate

Datatyp

text

Site of gastric primary
Beskrivning

PrimarySite

Datatyp

text

Name of institution where resection was done
Beskrivning

InstitutionName,Resection

Datatyp

text

Medicare ID number of institution
Beskrivning

ProfessionalOrganizationMedicareIdentifierNumber

Datatyp

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
Beskrivning

Histology & Staging Data

Differentiation
Beskrivning

HistologicGrade

Datatyp

text

AJCC/UICC TNM Staging: T
Beskrivning

TStage,Clinical

Datatyp

text

AJCC/UICC TNM Staging: N
Beskrivning

NStage,Clinical

Datatyp

text

AJCC/UICC TNM Staging: M
Beskrivning

MStage,Clinical

Datatyp

text

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

IfpatienthasT2N0M0,doestumorextendbeyondmuscularispropria?

Datatyp

text

Completed by
Beskrivning

PersonCompletingForm,FirstName

Datatyp

text

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

FormCompletionDate,Original

Datatyp

date

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Similar models

No Instruction available.

1 Formulär
  1. StudyEvent: CALGB: 80101 ON-STUDY FORM
    1. No Instruction available.
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
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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