ID

2275

Descripción

FS Radiation Therapy Oncology Group Phase III Randomized Study of Intermediate Risk Prostate Cancer Initial Follow-up Form for Acute RT Interstitial Brachytherapy With or Without External-Beam Radiation Therapy in Treating Patients With Prostate Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AA892EFD-56AF-589E-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AA892EFD-56AF-589E-E034-0003BA12F5E7

Palabras clave

Versiones (2)
  1. 19/9/12 19/9/12 -
  2. 19/3/15 19/3/15 - Martin Dugas
Subido en

19 de septiembre de 2012

DOI

Para solicitar uno, por favor iniciar sesión.

Licencia

Creative Commons BY-NC 3.0 Legacy
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NCT00063882 Follow-Up - FS Radiation Therapy Oncology Group Phase III Randomized Study of Intermediate Risk Prostate Cancer Initial Follow-up Form for Acute RT - 2058144v3.0

Inglés

INSTRUCTIONS: Submit this form at the appropriate followup interval. Use -1 for unknown or not applicable unless otherwise specified in codetable. All dates to be reported mm-dd-yyyy unless otherwise indicated.

1 formularios  
  1. StudyEvent: FS Radiation Therapy Oncology Group Phase III Randomized Study of Intermediate Risk Prostate Cancer Initial Follow-up Form for Acute RT
    1. INSTRUCTIONS: Submit this form at the appropriate followup interval. Use -1 for unknown or not applicable unless otherwise specified in codetable. All dates to be reported mm-dd-yyyy unless otherwise indicated.
Unnamed1
Descripción

Unnamed1

AMENDED DATA
Descripción

AmendedDataInd

Tipo de datos

text

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

Unnamed2

RTOG Study
Descripción

RTOGStudy

Tipo de datos

text

Case #
Descripción

Case#

Tipo de datos

text

Institution Name
Descripción

InstitutionName

Tipo de datos

text

Institution No.
Descripción

NCIInstitutionNumber

Tipo de datos

text

Patient Name, Last
Descripción

PatientName,Last

Tipo de datos

text

Patient Name, First
Descripción

PatientName,First

Tipo de datos

text

Unnamed3
Descripción

Unnamed3

Unnamed4
Descripción

Unnamed4

PATIENT'S VITAL STATUS
Descripción

Patient'sVitalStatus

Tipo de datos

text

DATE OF LAST CONTACT OR DEATH
Descripción

DeathDate/LastContactDate

Tipo de datos

date

CAUSE OF DEATH
Descripción

DeathReason

Tipo de datos

text

Due to other cause, specify (cause of death)
Descripción

PrimaryCauseDeathOtherReasonSpecify

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass
C25251
UMLS 2011AA ObjectClass
C0205225
NCI Metathesaurus ObjectClass
C0007465
NCI Thesaurus Property
C17649
UMLS 2011AA Property
C0205394
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
HAS THE PATIENT HAD A DOCUMENTED CLINICAL ASSESSMENT FOR PROSTATE CANCER SINCE SUBMISSION OF THE PREVIOUS FOLLOWUP FORM?
Descripción

CancerFollow-upStatusInd

Tipo de datos

text

DATE OF LAST CLINICAL ASSESSMENT
Descripción

CancerFollow-upStatusDate

Tipo de datos

date

Alias
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
PERFORMANCE STATUS (ZUBROD)
Descripción

PerformanceStatus

Tipo de datos

text

Follow-up PSA Value(s)
Descripción

Follow-upPSAValue(s)

Tipo de datos

text

Date of PSA Assessment(s)
Descripción

AssessmentDate

Tipo de datos

date

HAS THE PATIENT HAD A PROSTATE BIOPSY SINCE SUBMISSION OF THE LAST FOLLOWUP FORM?
Descripción

HASTHEPATIENTHADAPROSTATEBIOPSYSINCESUBMISSIONOFTHELASTFOLLOWUPFORM?

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Biopsy Date
Descripción

BiopsyDate

Tipo de datos

date

HAS THE PATIENT DEVELOPED A FIRST PROGRESSION THAT HAS NOT BEEN PREVIOUSLY REPORTED?
Descripción

ProgressionInd

Tipo de datos

text

HAS THE PATIENT BEEN DIAGNOSED WITH BIOCHEMICAL RECURRENCE SINCE SUBMISSION OF LAST FOLLOW-UP FORM? (See Protocol Section 11)
Descripción

ProgressionInd,Biochemical

Tipo de datos

text

DATE OF FIRST BIOCHEMICAL PROGRESSION
Descripción

ProgressionDate,FirstBiochemical

Tipo de datos

date

PSA VALUE AT PROGRESSION
Descripción

ProgressionPSAValue

Tipo de datos

double

HAS THE PATIENT BEEN DIAGNOSED WITH FIRST LOCAL-REGIONAL RECURRENCE SINCE SUBMISSION OF LAST FOLLOW-UP FORM? (See Protocol Section 11)
Descripción

ProgressionInd,FirstLocal-Regional

Tipo de datos

text

Date of First Local-Regional Progression
Descripción

ProgressionDate,FirstLocal-Regional

Tipo de datos

date

Site(s) of Local/Regional Progression
Descripción

ProgressionSite(s),FirstLocal-Regional

Tipo de datos

text

HAS THE PATIENT BEEN DIAGNOSED WITH FIRST DISTANT RECURRENCE SINCE SUBMISSION OF THE LAST FOLLOW-UP FORM?
Descripción

ProgressionInd,FirstDistant

Tipo de datos

text

Date of First Distant Progression
Descripción

ProgressionDate,FirstDistant

Tipo de datos

date

Site(s) of First Distant Progression
Descripción

ProgressionSite,FirstDistant

Tipo de datos

text

WHAT WAS THE METHOD USED TO DETERMINE distant PROGRESSION
Descripción

AssessmentType

Tipo de datos

text

WHAT WAS THE METHOD USED TO DETERMINE distant PROGRESSION
Descripción

AssessmentType

Tipo de datos

text

Other, specify (method used to determine distant progression)
Descripción

AssessmentType,Specify

Tipo de datos

text

Other, specify (method used to determine distant progression)
Descripción

AssessmentType,Specify

Tipo de datos

text

Unnamed5
Descripción

Unnamed5

AMENDED DATA
Descripción

AmendedDataInd

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
DATE FROM (Q2)
Descripción

IntervalReportFromDate

Tipo de datos

date

Unnamed6
Descripción

Unnamed6

RTOG Study
Descripción

RTOGStudy

Tipo de datos

text

Case #
Descripción

Case#

Tipo de datos

text

Institution Name
Descripción

InstitutionName

Tipo de datos

text

Institution No.
Descripción

NCIInstitutionNumber

Tipo de datos

text

Patient Name, Last
Descripción

PatientName,Last

Tipo de datos

text

Patient Name, First
Descripción

PatientName,First

Tipo de datos

text

Unnamed7
Descripción

Unnamed7

DID THE PATIENT RECEIVE ANY NON-PROTOCOL PROSTATE CANCER THERAPY SINCE THE LAST FOLLOW-UP (If yes, enter therapy type and date for each therapy delivered during the follow-up period.)
Descripción

Non-ProtocolTherapyInd

Tipo de datos

text

Non-Protocol Therapy Type
Descripción

Non-ProtocolTherapyAdministeredType

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus ObjectClass
C25590
UMLS 2011AA ObjectClass
C1518384
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Radiation to other sites, specify (non-protocol therapy type)
Descripción

Radiationtoothersites,specify(non-protocoltherapytype)

Tipo de datos

text

Other, specify (non-protocol therapy type)
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
Surgical procedure related to previous RT, specify (non-protocol therapy type)
Descripción

SurgicalprocedurerelatedtopreviousRT,specify(non-protocoltherapytype)

Tipo de datos

text

Complementary Alternative Medicine, specify (non-protocol therapy type)
Descripción

ComplementaryAlternativeMedicine,specify(non-protocoltherapytype)

Tipo de datos

text

Date of first non-protocol therapy
Descripción

Non-ProtocolTherapyDate,First

Tipo de datos

date

Specify (non-protocol prostate cancer therapy) (HAS A NEW PRIMARY CANCER OR MDS MYELODYSPLASTIC SYNDROME BEEN DIAGNOSED THAT HAS NOT BEEN PREVIOUSLY REPORTED?)
Descripción

Specify(non-protocolprostatecancertherapy)

Tipo de datos

text

New Primary Site
Descripción

NewPrimarySite

Tipo de datos

text

New Primary Site
Descripción

NewPrimarySite

Tipo de datos

text

New Primary Cancer Date
Descripción

NewPrimaryCancerDate

Tipo de datos

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Specify (new primary site)
Descripción

Specify(newprimarysite)

Tipo de datos

text

Unnamed8
Descripción

Unnamed8

AMENDED DATA
Descripción

AmendedDataInd

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
DATE FROM (Q2)
Descripción

IntervalReportFromDate

Tipo de datos

date

Unnamed9
Descripción

Unnamed9

RTOG Study
Descripción

RTOGStudy

Tipo de datos

text

Case #
Descripción

Case#

Tipo de datos

text

Institution Name
Descripción

InstitutionName

Tipo de datos

text

Institution No.
Descripción

NCIInstitutionNumber

Tipo de datos

text

Patient Name, Last
Descripción

PatientName,Last

Tipo de datos

text

Patient Name, First
Descripción

PatientName,First

Tipo de datos

text

Unnamed10
Descripción

Unnamed10

NEW OR CONTINUING TOXICITY (>Severity Grade 3) SINCE THE LAST REPORT? (For severe toxicity grade > 3 observed during the report period, provide a date of onset, assign attribution, and describe toxicity and treatment given. Do not list a toxicity code more than once in the reporting section of this form. If toxicity cannot b)
Descripción

NEWORCONTINUINGTOXICITY(>SeverityGrade3)SINCETHELASTREPORT?

Tipo de datos

text

IMT CODE ADVERSE EVENT BASED ON CTEP TOXICITY TERM
Descripción

IMTCODEADVERSEEVENTBASEDONCTEPTOXICITYTERM

Tipo de datos

text

CTC ADVERSE EVENT TERM
Descripción

CTCAdverseEventTerm

Tipo de datos

text

COMMON TOXICITY GENERAL CATEGORY
Descripción

CTCAdverseEventCategory

Tipo de datos

text

CTC ADVERSE EVENT GRADE
Descripción

CTCAdverseEventGrade

Tipo de datos

text

CTC ADVERSE EVENT ONSET DATE (GRADE > OR = 3)
Descripción

CTCAdverseEventReportBeginDate

Tipo de datos

date

CTC ADVERSE EVENT ATTRIBUTION CODE
Descripción

CTCAdverseEventAttributionCode

Tipo de datos

text

Other cause, specify (CTC Adverse Event Attribution Code)
Descripción

CTCAdverseEventTerm,Other

Tipo de datos

text

SPECIFY
Descripción

Specify

Tipo de datos

text

COMMENTS
Descripción

Comments

Tipo de datos

text

SIGNATURE
Descripción

SignatureofPersonCompletingThisForm

Tipo de datos

text

DATE
Descripción

FormCompletionDate,Original

Tipo de datos

date

Ccrr Module For Fs Radiation Therapy Oncology Group Phase Iii Randomized Study Of Intermediate Risk Prostate Cancer Initial Follow-up Form For Acute Rt
Descripción

Ccrr Module For Fs Radiation Therapy Oncology Group Phase Iii Randomized Study Of Intermediate Risk Prostate Cancer Initial Follow-up Form For Acute Rt

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INSTRUCTIONS: Submit this form at the appropriate followup interval. Use -1 for unknown or not applicable unless otherwise specified in codetable. All dates to be reported mm-dd-yyyy unless otherwise indicated.

1 formularios
  1. StudyEvent: FS Radiation Therapy Oncology Group Phase III Randomized Study of Intermediate Risk Prostate Cancer Initial Follow-up Form for Acute RT
    1. INSTRUCTIONS: Submit this form at the appropriate followup interval. Use -1 for unknown or not applicable unless otherwise specified in codetable. All dates to be reported mm-dd-yyyy unless otherwise indicated.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Item Group
Unnamed1
AmendedDataInd
Item
AMENDED DATA
text
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
Item Group
Unnamed2
RTOGStudy
Item
RTOG Study
text
Case#
Item
Case #
text
InstitutionName
Item
Institution Name
text
NCIInstitutionNumber
Item
Institution No.
text
PatientName,Last
Item
Patient Name, Last
text
PatientName,First
Item
Patient Name, First
text
Item Group
Unnamed3
Item Group
Unnamed4
Item
PATIENT'S VITAL STATUS
text
CL.1
Code List
PATIENT'S VITAL STATUS
CL Item
Alive (Alive)
CL Item
Dead (Dead)
DeathDate/LastContactDate
Item
DATE OF LAST CONTACT OR DEATH
date
Item
CAUSE OF DEATH
text
CL.2
Code List
CAUSE OF DEATH
CL Item
N/A (N/A)
CL Item
Due To This Disease (Due to this disease)
CL Item
Due To Protocol Treatment (Due to protocol treatment)
CL Item
Due To Other Cause (Due to other cause, specify)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
PrimaryCauseDeathOtherReasonSpecify
Item
Due to other cause, specify (cause of death)
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25251 (NCI Thesaurus ObjectClass)
C0205225 (UMLS 2011AA ObjectClass)
C0007465 (NCI Metathesaurus ObjectClass)
C17649 (NCI Thesaurus Property)
C0205394 (UMLS 2011AA Property)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
Item
HAS THE PATIENT HAD A DOCUMENTED CLINICAL ASSESSMENT FOR PROSTATE CANCER SINCE SUBMISSION OF THE PREVIOUS FOLLOWUP FORM?
text
CL.3
Code List
HAS THE PATIENT HAD A DOCUMENTED CLINICAL ASSESSMENT FOR PROSTATE CANCER SINCE SUBMISSION OF THE PREVIOUS FOLLOWUP FORM?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CancerFollow-upStatusDate
Item
DATE OF LAST CLINICAL ASSESSMENT
date
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
PerformanceStatus
Item
PERFORMANCE STATUS (ZUBROD)
text
Follow-upPSAValue(s)
Item
Follow-up PSA Value(s)
text
AssessmentDate
Item
Date of PSA Assessment(s)
date
Item
HAS THE PATIENT HAD A PROSTATE BIOPSY SINCE SUBMISSION OF THE LAST FOLLOWUP FORM?
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.4
Code List
HAS THE PATIENT HAD A PROSTATE BIOPSY SINCE SUBMISSION OF THE LAST FOLLOWUP FORM?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
BiopsyDate
Item
Biopsy Date
date
Item
HAS THE PATIENT DEVELOPED A FIRST PROGRESSION THAT HAS NOT BEEN PREVIOUSLY REPORTED?
text
CL.5
Code List
HAS THE PATIENT DEVELOPED A FIRST PROGRESSION THAT HAS NOT BEEN PREVIOUSLY REPORTED?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
HAS THE PATIENT BEEN DIAGNOSED WITH BIOCHEMICAL RECURRENCE SINCE SUBMISSION OF LAST FOLLOW-UP FORM? (See Protocol Section 11)
text
CL.6
Code List
HAS THE PATIENT BEEN DIAGNOSED WITH BIOCHEMICAL RECURRENCE SINCE SUBMISSION OF LAST FOLLOW-UP FORM? (See Protocol Section 11)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
ProgressionDate,FirstBiochemical
Item
DATE OF FIRST BIOCHEMICAL PROGRESSION
date
ProgressionPSAValue
Item
PSA VALUE AT PROGRESSION
double
Item
HAS THE PATIENT BEEN DIAGNOSED WITH FIRST LOCAL-REGIONAL RECURRENCE SINCE SUBMISSION OF LAST FOLLOW-UP FORM? (See Protocol Section 11)
text
CL.7
Code List
HAS THE PATIENT BEEN DIAGNOSED WITH FIRST LOCAL-REGIONAL RECURRENCE SINCE SUBMISSION OF LAST FOLLOW-UP FORM? (See Protocol Section 11)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
ProgressionDate,FirstLocal-Regional
Item
Date of First Local-Regional Progression
date
ProgressionSite(s),FirstLocal-Regional
Item
Site(s) of Local/Regional Progression
text
Item
HAS THE PATIENT BEEN DIAGNOSED WITH FIRST DISTANT RECURRENCE SINCE SUBMISSION OF THE LAST FOLLOW-UP FORM?
text
CL.9
Code List
HAS THE PATIENT BEEN DIAGNOSED WITH FIRST DISTANT RECURRENCE SINCE SUBMISSION OF THE LAST FOLLOW-UP FORM?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
ProgressionDate,FirstDistant
Item
Date of First Distant Progression
date
ProgressionSite,FirstDistant
Item
Site(s) of First Distant Progression
text
Item
WHAT WAS THE METHOD USED TO DETERMINE distant PROGRESSION
text
CL.10
Code List
WHAT WAS THE METHOD USED TO DETERMINE distant PROGRESSION
CL Item
Clinical Examination (Physical exam)
CL Item
Pathologic (Pathologic)
CL Item
Radiographic (Radiographic)
CL Item
Nuclear scan (Nuclear scan)
CL Item
Other (Other, specify)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
Item
WHAT WAS THE METHOD USED TO DETERMINE distant PROGRESSION
text
CL.10
Code List
WHAT WAS THE METHOD USED TO DETERMINE distant PROGRESSION
CL Item
Clinical Examination (Physical exam)
CL Item
Pathologic (Pathologic)
CL Item
Radiographic (Radiographic)
CL Item
Nuclear scan (Nuclear scan)
CL Item
Other (Other, specify)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
AssessmentType,Specify
Item
Other, specify (method used to determine distant progression)
text
AssessmentType,Specify
Item
Other, specify (method used to determine distant progression)
text
Item Group
Unnamed5
AmendedDataInd
Item
AMENDED DATA
text
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
IntervalReportFromDate
Item
DATE FROM (Q2)
date
Item Group
Unnamed6
RTOGStudy
Item
RTOG Study
text
Case#
Item
Case #
text
InstitutionName
Item
Institution Name
text
NCIInstitutionNumber
Item
Institution No.
text
PatientName,Last
Item
Patient Name, Last
text
PatientName,First
Item
Patient Name, First
text
Item Group
Unnamed7
Item
DID THE PATIENT RECEIVE ANY NON-PROTOCOL PROSTATE CANCER THERAPY SINCE THE LAST FOLLOW-UP (If yes, enter therapy type and date for each therapy delivered during the follow-up period.)
text
CL.11
Code List
DID THE PATIENT RECEIVE ANY NON-PROTOCOL PROSTATE CANCER THERAPY SINCE THE LAST FOLLOW-UP (If yes, enter therapy type and date for each therapy delivered during the follow-up period.)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Non-Protocol Therapy Type
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C15368 (NCI Thesaurus ObjectClass)
C25590 (NCI Thesaurus ObjectClass)
C1518384 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
CL.12
Code List
Non-Protocol Therapy Type
CL Item
None (None)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
CL Item
Radiation To Pelvis (Radiation to pelvis)
CL Item
Radiation To Other Sites, Specify (Radiation to other sites, specify)
CL Item
Surgery (Surgery)
C17173 (NCI Thesaurus)
C0038894 (UMLS 2011AA)
CL Item
Chemotherapy (Chemotherapy)
C15632 (NCI Thesaurus)
C0392920 (UMLS 2011AA)
CL Item
Hormones (Hormones)
CL Item
Other Specify (Other, specify)
CL Item
Surgical Procedure Related To Previous Rt, Specify (Surgical procedure related to previous RT, specify)
CL Item
Complementary Alternative Medicine, Specify (Complementary Alternative Medicine, specify)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Radiationtoothersites,specify(non-protocoltherapytype)
Item
Radiation to other sites, specify (non-protocol therapy type)
text
Non-ProtocolTherapyType
Item
Other, specify (non-protocol therapy type)
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)
SurgicalprocedurerelatedtopreviousRT,specify(non-protocoltherapytype)
Item
Surgical procedure related to previous RT, specify (non-protocol therapy type)
text
ComplementaryAlternativeMedicine,specify(non-protocoltherapytype)
Item
Complementary Alternative Medicine, specify (non-protocol therapy type)
text
Non-ProtocolTherapyDate,First
Item
Date of first non-protocol therapy
date
Specify(non-protocolprostatecancertherapy)
Item
Specify (non-protocol prostate cancer therapy) (HAS A NEW PRIMARY CANCER OR MDS MYELODYSPLASTIC SYNDROME BEEN DIAGNOSED THAT HAS NOT BEEN PREVIOUSLY REPORTED?)
text
NewPrimarySite
Item
New Primary Site
text
NewPrimarySite
Item
New Primary Site
text
NewPrimaryCancerDate
Item
New Primary Cancer Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Specify(newprimarysite)
Item
Specify (new primary site)
text
Item Group
Unnamed8
AmendedDataInd
Item
AMENDED DATA
text
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
IntervalReportFromDate
Item
DATE FROM (Q2)
date
Item Group
Unnamed9
RTOGStudy
Item
RTOG Study
text
Case#
Item
Case #
text
InstitutionName
Item
Institution Name
text
NCIInstitutionNumber
Item
Institution No.
text
PatientName,Last
Item
Patient Name, Last
text
PatientName,First
Item
Patient Name, First
text
Item Group
Unnamed10
Item
NEW OR CONTINUING TOXICITY (>Severity Grade 3) SINCE THE LAST REPORT? (For severe toxicity grade > 3 observed during the report period, provide a date of onset, assign attribution, and describe toxicity and treatment given. Do not list a toxicity code more than once in the reporting section of this form. If toxicity cannot b)
text
CL.14
Code List
NEW OR CONTINUING TOXICITY (>Severity Grade 3) SINCE THE LAST REPORT? (For severe toxicity grade > 3 observed during the report period, provide a date of onset, assign attribution, and describe toxicity and treatment given. Do not list a toxicity code more than once in the reporting section of this form. If toxicity cannot b)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
IMTCODEADVERSEEVENTBASEDONCTEPTOXICITYTERM
Item
IMT CODE ADVERSE EVENT BASED ON CTEP TOXICITY TERM
text
CTCAdverseEventTerm
Item
CTC ADVERSE EVENT TERM
text
Item
COMMON TOXICITY GENERAL CATEGORY
text
CL.15
Code List
COMMON TOXICITY GENERAL CATEGORY
CL Item
Allergy/Immunology (Allergy/Immunology)
CL Item
Auditory/Hearing (Auditory/Hearing)
CL Item
Blood/Bone marrow (Blood/Bone marrow)
CL Item
Cardiovascular (Arrhythmia) (Cardiovascular (Arrhythmia))
CL Item
Cardiovascular (General) (Cardiovascular (General))
CL Item
Coagulation (Coagulation)
CL Item
Constitutional Symptoms (Constitutional Symptoms)
CL Item
Dermatology/Skin (Dermatology/Skin)
CL Item
Endocrine (Endocrine)
CL Item
Gastrointestinal (Gastrointestinal)
CL Item
Hemorrhage (Hemorrhage)
CL Item
Hepatic (Hepatic)
CL Item
Infection Febrile Neutropenia (Infection Febrile Neutropenia)
CL Item
Lymphatics (Lymphatics)
CL Item
Metabolic/Laboratory (Metabolic/Laboratory)
CL Item
Musculoskeletal (Musculoskeletal)
CL Item
Neurology (Neurology)
CL Item
Ocular/Visual (Ocular/Visual)
CL Item
Pain (Pain)
CL Item
Pulmonary (Pulmonary)
CL Item
Renal/Genitourinary (Renal/Genitourinary)
CL Item
Second Malignancy (Second Malignancy)
CL Item
Sexual/Reproductive Function (Sexual/Reproductive Function)
CL Item
Syndromes (Syndromes)
CTCAdverseEventGrade
Item
CTC ADVERSE EVENT GRADE
text
CTCAdverseEventReportBeginDate
Item
CTC ADVERSE EVENT ONSET DATE (GRADE > OR = 3)
date
Item
CTC ADVERSE EVENT ATTRIBUTION CODE
text
CL.16
Code List
CTC ADVERSE EVENT ATTRIBUTION CODE
CL Item
Radiotherapy only (Radiotherapy only)
CL Item
Chemotherapy only (Chemotherapy only)
CL Item
Combined modality (Combined modality)
CL Item
Tumor and Rx (Tumor and Rx)
CL Item
Hormones (Hormones)
CL Item
Other cause, specify (Other cause, specify)
CL Item
Unknown (Unknown)
CTCAdverseEventTerm,Other
Item
Other cause, specify (CTC Adverse Event Attribution Code)
text
Specify
Item
SPECIFY
text
Comments
Item
COMMENTS
text
SignatureofPersonCompletingThisForm
Item
SIGNATURE
text
FormCompletionDate,Original
Item
DATE
date
Item Group
Ccrr Module For Fs Radiation Therapy Oncology Group Phase Iii Randomized Study Of Intermediate Risk Prostate Cancer Initial Follow-up Form For Acute Rt
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