ID

2243

Description

LUNG CARCINOMA RADIATION THERAPY FORM S0023: Combination Chemo Plus RT With or Without Gefitinib in Treating Patients With Unresectable Stage III NSCLC Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9E343E83-5FEB-119F-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9E343E83-5FEB-119F-E034-080020C9C0E0

Keywords

Versions (2)
  1. 9/19/12 9/19/12 -
  2. 5/8/15 5/8/15 - Martin Dugas
Uploaded on

September 19, 2012

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Lung Cancer NCT00020709 Registration - LUNG CARCINOMA RADIATION THERAPY FORM - 2031928v3.0

English

No Instruction available.

1 forms  
  1. StudyEvent: LUNG CARCINOMA RADIATION THERAPY FORM
    1. No Instruction available.
Unnamed1
Description

Unnamed1

SWOG Patient ID
Description

SWOGPatientID

Data type

text

SWOG Study No.
Description

SWOGStudyNo.

Data type

text

Registration Step
Description

RegistrationStep

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ValueDomain
C16154
UMLS 2011AA ValueDomain
C1704379
Patient Initials (L, F,M)
Description

PatientInitials

Data type

text

Social Security No.
Description

SocialSecurityNo.

Data type

text

Institution / Affiliate
Description

Institution/Affiliate

Data type

text

Physician
Description

Physician

Data type

text

Hosp. No.
Description

Hosp.No.

Data type

text

Group Name (Groups other than SWOG )
Description

GroupName

Data type

text

Study No. (Groups other than SWOG )
Description

StudyNo.

Data type

double

Pt. ID (Groups other than SWOG )
Description

Pt.ID

Data type

text

Treating Radiation Oncologist
Description

TreatingRadiationOncologist

Data type

text

RT Facility
Description

RTFacility

Data type

text

RT Facility Code
Description

RTFacilityCode

Data type

text

Unnamed2
Description

Unnamed2

Radiation Therapy Start Date
Description

RTBeginDate

Data type

date

RT End Date
Description

RTEndDate

Data type

date

Were there any unscheduled interruptions in radiation therapy?
Description

Werethereanyunscheduledinterruptionsinradiationtherapy?

Data type

text

If Yes, Specify RT Interruptions Reason
Description

IfYes,SpecifyRTInterruptionsReason

Data type

text

Treatment Information
Description

Treatment Information

Total Dose to Isocenter (cGy)
Description

TotalDosetoIsocenter

Data type

text

Total Fractions
Description

TotalFractions

Data type

text

Radiation Source
Description

RadiationSource

Data type

text

Other, specify
Description

CytogeneticAnalysis,OtherReason,NoSuccess

Data type

text

Fractions
Description

Fractions

Data type

text

Number of Days
Description

NumberofDays

Data type

text

Number of Days
Description

NumberofDays

Data type

text

Radiation Energy (MeV)
Description

RadiationEnergy

Data type

text

Maximum Dose to Critical Structures
Description

MaximumDosetoCriticalStructures

Data type

text

Spinal Cord
Description

SpinalCord

Data type

text

Heart
Description

Heart

Data type

text

Esophagus
Description

Esophagus

Data type

text

Other structures
Description

TumorExtension,OtherStructures

Data type

text

Specify
Description

Specify

Data type

text

Specify
Description

Specify

Data type

text

Specify
Description

Specify

Data type

text

Dose (cGy)
Description

RadiationTherapyDose

Data type

text

Alias
NCI Thesaurus ObjectClass
C15313
UMLS 2011AA ObjectClass
C1522449
NCI Thesaurus Property
C25256
UMLS 2011AA Property
C1265611
Dose (cGy)
Description

RadiationTherapyDose

Data type

text

Alias
NCI Thesaurus ObjectClass
C15313
UMLS 2011AA ObjectClass
C1522449
NCI Thesaurus Property
C25256
UMLS 2011AA Property
C1265611
%Of Total Lung Receiving>=2000 cGy
Description

%OfTotalLungReceiving>=2000cGy

Data type

text

%Of Right Lung Receiving>=2000 cGy
Description

%OfRightLungReceiving>=2000cGy

Data type

text

Primary Tumor location
Description

PrimaryTumorlocation

Data type

text

%Of Left Lung Receiving>=2000 cGy
Description

%OfLeftLungReceiving>=2000cGy

Data type

text

Unnamed4
Description

Unnamed4

Form completed by
Description

Formcompletedby

Data type

text

Facility
Description

Facility

Data type

text

Telephone Number
Description

TelephoneNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ValueDomain
C25395
UMLS 2011AA ValueDomain
C0039457
Date
Description

Date

Data type

text

Unnamed5
Description

Unnamed5

Radiation Oncologist's Signature
Description

RadiationOncologyPhysicianSignatureText

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
NCI Thesaurus ObjectClass
C25741
UMLS 2011AA ObjectClass
C0031831
NCI Thesaurus ObjectClass
C17833
UMLS 2011AA ObjectClass
C1514693
Notes
Description

Notes

Notes
Description

Notes

Data type

text

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No Instruction available.

1 forms
  1. StudyEvent: LUNG CARCINOMA RADIATION THERAPY FORM
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Unnamed1
SWOGPatientID
Item
SWOG Patient ID
text
SWOGStudyNo.
Item
SWOG Study No.
text
RegistrationStep
Item
Registration Step
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16154 (NCI Thesaurus ValueDomain)
C1704379 (UMLS 2011AA ValueDomain)
PatientInitials
Item
Patient Initials (L, F,M)
text
SocialSecurityNo.
Item
Social Security No.
text
Institution/Affiliate
Item
Institution / Affiliate
text
Physician
Item
Physician
text
Hosp.No.
Item
Hosp. No.
text
GroupName
Item
Group Name (Groups other than SWOG )
text
StudyNo.
Item
Study No. (Groups other than SWOG )
double
Pt.ID
Item
Pt. ID (Groups other than SWOG )
text
TreatingRadiationOncologist
Item
Treating Radiation Oncologist
text
RTFacility
Item
RT Facility
text
RTFacilityCode
Item
RT Facility Code
text
Item Group
Unnamed2
RTBeginDate
Item
Radiation Therapy Start Date
date
RTEndDate
Item
RT End Date
date
Item
Were there any unscheduled interruptions in radiation therapy?
text
CL.1
Code List
Were there any unscheduled interruptions in radiation therapy?
CL Item
Yes (Yes)
CL Item
No (No)
IfYes,SpecifyRTInterruptionsReason
Item
If Yes, Specify RT Interruptions Reason
text
Item Group
Treatment Information
TotalDosetoIsocenter
Item
Total Dose to Isocenter (cGy)
text
TotalFractions
Item
Total Fractions
text
Item
Radiation Source
text
CL.2
Code List
Radiation Source
CL Item
Co_60_2005542 (Co 60)
CL Item
Megavoltage_2005543 (Megavoltage)
CL Item
Electron_2005544 (Electron)
CL Item
Combination_2005545 (Combination)
CL Item
Other_specify_2005546 (Other, specify)
CytogeneticAnalysis,OtherReason,NoSuccess
Item
Other, specify
text
Fractions
Item
Fractions
text
NumberofDays
Item
Number of Days
text
NumberofDays
Item
Number of Days
text
Item
Radiation Energy (MeV)
text
CL.4
Code List
Radiation Energy (MeV)
CL Item
P98not_applicable2005561 (98=not applicable)
MaximumDosetoCriticalStructures
Item
Maximum Dose to Critical Structures
text
SpinalCord
Item
Spinal Cord
text
Heart
Item
Heart
text
Esophagus
Item
Esophagus
text
TumorExtension,OtherStructures
Item
Other structures
text
Specify
Item
Specify
text
Specify
Item
Specify
text
Specify
Item
Specify
text
RadiationTherapyDose
Item
Dose (cGy)
text
C15313 (NCI Thesaurus ObjectClass)
C1522449 (UMLS 2011AA ObjectClass)
C25256 (NCI Thesaurus Property)
C1265611 (UMLS 2011AA Property)
RadiationTherapyDose
Item
Dose (cGy)
text
C15313 (NCI Thesaurus ObjectClass)
C1522449 (UMLS 2011AA ObjectClass)
C25256 (NCI Thesaurus Property)
C1265611 (UMLS 2011AA Property)
%OfTotalLungReceiving>=2000cGy
Item
%Of Total Lung Receiving>=2000 cGy
text
%OfRightLungReceiving>=2000cGy
Item
%Of Right Lung Receiving>=2000 cGy
text
Item
Primary Tumor location
text
CL.5
Code List
Primary Tumor location
CL Item
Left_lung2005574 (Left lung)
CL Item
Right_lung2005575 (Right lung)
%OfLeftLungReceiving>=2000cGy
Item
%Of Left Lung Receiving>=2000 cGy
text
Item Group
Unnamed4
Formcompletedby
Item
Form completed by
text
Facility
Item
Facility
text
TelephoneNumber
Item
Telephone Number
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25395 (NCI Thesaurus ValueDomain)
C0039457 (UMLS 2011AA ValueDomain)
Date
Item
Date
text
Item Group
Unnamed5
RadiationOncologyPhysicianSignatureText
Item
Radiation Oncologist's Signature
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C25741 (NCI Thesaurus ObjectClass)
C0031831 (UMLS 2011AA ObjectClass)
C17833 (NCI Thesaurus ObjectClass)
C1514693 (UMLS 2011AA ObjectClass)
Item Group
Notes
Notes
Item
Notes
text
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