ID

23023

Beschrijving

IBCSG Long Term Follow-Up Medication Form (18-LTF-M) Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=889C3F60-2C7B-8540-E040-BB89AD4303DD

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=889C3F60-2C7B-8540-E040-BB89AD4303DD

Trefwoorden

Versies (2)
  1. 26-08-12 26-08-12 -
  2. 20-06-17 20-06-17 - Martin Dugas
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20 juni 2017

DOI

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Creative Commons BY-NC 3.0
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IBCSG Long Term Follow-Up Medication Form (18-LTF-M)

Engels

Instructions: This form is to be completed if the patient received bone active medication, non-steroidal, anti-inflammatory drug or extended adjuvant therapy during this follow-up period. Use minus one (-1) to indicate that an answer is unknown, unobtainable or not done

1 Formulieren  
Header Module
Beschrijving

Header Module

Alias
UMLS CUI-1
C1320722
Visit number
Beschrijving

Hospital Admission Ordinal Number

Datatype

integer

Alias
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus ObjectClass
C16696
NCI Thesaurus Property
C25385
UMLS CUI [1]
C1549755
IBCSG Patient ID
Beschrijving

International Breast Cancer Study Group Identifier Number

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C25530
UMLS CUI [1,1]
C4037772
UMLS CUI [1,2]
C1512890
IBCSG Study No.
Beschrijving

Protocol International Breast Cancer Study Group Identifier Number

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus ObjectClass
C25320
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C25530
UMLS CUI [1,1]
C1507394
UMLS CUI [1,2]
C1512890
Randomization No.
Beschrijving

RandomizationNumber

Datatype

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ValueDomain
C25364
UMLS 2011AA ValueDomain
C0600091
NCI Thesaurus Property
C25196
UMLS 2011AA Property
C0034656
Institution Code Number
Beschrijving

Institution Identifier Number

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus ObjectClass
C21541
NCI Thesaurus Property
C25364
UMLS CUI [1,1]
C1301943
UMLS CUI [1,2]
C0805701
Institution Name
Beschrijving

InstitutionName

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C21541
UMLS 2011AA ObjectClass
C0018704
NCI Thesaurus ValueDomain-2
C21541
UMLS 2011AA ValueDomain-2
C0018704
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Long Term Follow-up Medication
Beschrijving

Long Term Follow-up Medication

Alias
UMLS CUI-1
C1517942
UMLS CUI-2
C0013227
Did the patient receive bone active medication other than calcium or vitamin D during this follow-up period (e.g., bisphosphonates)
Beschrijving

Medication Osteoporosis Administered Indicator

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25180
NCI Thesaurus Property
C3298
NCI Thesaurus ObjectClass
C459
NCI Thesaurus Property-2
C25382
UMLS CUI [1,1]
C0029456
UMLS CUI [1,2]
C0013227
If yes or continuing
Beschrijving

Medication Osteoporosis

Datatype

integer

Alias
NCI Thesaurus ValueDomain
C25284
NCI Thesaurus Property
C3298
NCI Thesaurus ObjectClass
C459
NCI Thesaurus Property-2
C25382
UMLS CUI [1,1]
C0029456
UMLS CUI [1,2]
C0013227
Specify
Beschrijving

Medication Osteoporosis, specify

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25685
NCI Thesaurus Property
C3298
NCI Thesaurus ObjectClass
C459
NCI Thesaurus Property-2
C25382
UMLS CUI [1,1]
C0029456
UMLS CUI [1,2]
C0013227
Did the patient receive glucocorticosteroids during this follow-up period
Beschrijving

Concomitant Medication Corticosteroids

Datatype

text

Alias
NCI Thesaurus ObjectClass
C459
NCI Thesaurus ObjectClass-2
C25730
NCI Thesaurus Property
C2322
NCI Thesaurus Property-2
C25382
NCI Thesaurus ValueDomain
C25180
UMLS CUI [1,1]
C0001617
UMLS CUI [1,2]
C0013227
Specify (If yes or continuing, medication)
Beschrijving

Concomitant Medication OtherCorticosteroid

Datatype

text

Alias
NCI Thesaurus ObjectClass
C459
NCI Thesaurus ObjectClass-2
C25730
NCI Thesaurus Property
C17649
NCI Thesaurus Property-2
C2322
NCI Thesaurus Property-3
C25382
NCI Thesaurus ValueDomain
C25685
UMLS CUI [1]
C0013227C0001617
Did the patient receive continuous, non-steroidal, anti-inflammatory drug during this follow-up period (e.g., COX-2 inhibitors, aspirin, Ibuprofen)
Beschrijving

Nonsteroidal Antiinflammatory Drug Regular Use

Datatype

text

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C18772
NCI Thesaurus Property-2
C257
NCI Thesaurus Property-3
C25340
NCI Thesaurus Property-4
C25647
NCI Thesaurus ValueDomain
C25180
UMLS CUI [1,1]
C0003211
UMLS CUI [1,2]
C0205272
Specify (If yes or continuing, medication)
Beschrijving

Nonsteroidal Antiinflammatory Drug Medication

Datatype

text

Alias
NCI Thesaurus ObjectClass
C459
NCI Thesaurus ObjectClass-2
C257
NCI Thesaurus Property
C25616
NCI Thesaurus Property-2
C25651
NCI Thesaurus ValueDomain
C25685
UMLS CUI [1,1]
C0013227
UMLS CUI [1,2]
C0003211
Did patient receive extended adjuvant endocrine therapy for primary breast cancer during this follow-up period (If treatment was given for breast cancer recurrence, do not record)
Beschrijving

Adjuvant Hormonal Therapy

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25180
NCI Thesaurus ObjectClass
C15445
NCI Thesaurus ObjectClass-2
C2140
NCI Thesaurus Property
C25382
UMLS CUI [1]
C2367461
Begin date (If yes or continuing day month year)
Beschrijving

Adjuvant Hormone Therapy Begin Date

Datatype

date

Alias
NCI Thesaurus ObjectClass
C15445
NCI Thesaurus ObjectClass-2
C2140
NCI Thesaurus Property
C25431
NCI Thesaurus Property-2
C25275
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ValueDomain-2
C25431
UMLS CUI [1,1]
C2367461
UMLS CUI [1,2]
C0808070
End date (day month year)
Beschrijving

Adjuvant Hormone Therapy End Date

Datatype

date

Alias
NCI Thesaurus ObjectClass
C15445
NCI Thesaurus ObjectClass-2
C2140
NCI Thesaurus Property
C25275
NCI Thesaurus Property-2
C25496
NCI Thesaurus ValueDomain
C25164
UMLS CUI [1,1]
C2367461
UMLS CUI [1,2]
C0806020
Adjuvant Hormonal Therapy Administered Type (Extended)
Beschrijving

Adjuvant Hormonal Therapy Type

Datatype

integer

Alias
NCI Thesaurus ValueDomain
C25284
NCI Thesaurus ObjectClass
C15445
NCI Thesaurus ObjectClass-2
C2140
NCI Thesaurus Property
C25382
UMLS CUI [1]
C2367461
Other, specify
Beschrijving

New Adjuvant Hormone Therapy, specify

Datatype

text

Alias
NCI Thesaurus ObjectClass
C25586
NCI Thesaurus ObjectClass-2
C15445
NCI Thesaurus ObjectClass-3
C2140
NCI Thesaurus Property
C25382
NCI Thesaurus ValueDomain
C25685
UMLS CUI [1]
C2367461
Reason Stopped (If extended treatment stopped, what was the reason)
Beschrijving

Prior Treatment Discontinued Reason

Datatype

integer

Alias
NCI Thesaurus ValueDomain
C25638
NCI Thesaurus ObjectClass
C25629
NCI Thesaurus ObjectClass-2
C15368
NCI Thesaurus Property
C25484
UMLS CUI [1,1]
C4288399
UMLS CUI [1,2]
C0566251
Other specify
Beschrijving

Off-treatment Reason

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25685
NCI Thesaurus ObjectClass
C25601
NCI Thesaurus Property
C25365
UMLS CUI [1,1]
C1518544
UMLS CUI [1,2]
C0566251
Footer Module
Beschrijving

Footer Module

Alias
UMLS CUI-1
C2825232
Investigator/Designee Signature
Beschrijving

Investigator Signature

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25704
NCI Thesaurus Property
C25678
NCI Thesaurus ObjectClass
C17089
NCI Thesaurus Property-2
C25479
UMLS CUI [1]
C2346576
Signature date
Beschrijving

Investigator Signature Date

Datatype

date

Maateenheden
  • day month year
Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus Property
C25678
NCI Thesaurus ValueDomain-2
C25367
NCI Thesaurus ObjectClass
C17089
UMLS CUI [1,1]
C2346576
UMLS CUI [1,2]
C0011008
day month year
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Similar models

Instructions: This form is to be completed if the patient received bone active medication, non-steroidal, anti-inflammatory drug or extended adjuvant therapy during this follow-up period. Use minus one (-1) to indicate that an answer is unknown, unobtainable or not done

1 Formulieren
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
Header Module
C1320722 (UMLS CUI-1)
Hospital Admission Ordinal Number
Item
Visit number
integer
C25337 (NCI Thesaurus ValueDomain)
C16696 (NCI Thesaurus ObjectClass)
C25385 (NCI Thesaurus Property)
C1549755 (UMLS CUI [1])
International Breast Cancer Study Group Identifier Number
Item
IBCSG Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
C25530 (NCI Thesaurus Property-2)
C4037772 (UMLS CUI [1,1])
C1512890 (UMLS CUI [1,2])
Protocol International Breast Cancer Study Group Identifier Number
Item
IBCSG Study No.
text
C25337 (NCI Thesaurus ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
C25530 (NCI Thesaurus Property-2)
C1507394 (UMLS CUI [1,1])
C1512890 (UMLS CUI [1,2])
RandomizationNumber
Item
Randomization No.
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus ValueDomain)
C0600091 (UMLS 2011AA ValueDomain)
C25196 (NCI Thesaurus Property)
C0034656 (UMLS 2011AA Property)
Institution Identifier Number
Item
Institution Code Number
text
C25337 (NCI Thesaurus ValueDomain)
C21541 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
C1301943 (UMLS CUI [1,1])
C0805701 (UMLS CUI [1,2])
InstitutionName
Item
Institution Name
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C21541 (NCI Thesaurus ValueDomain-2)
C0018704 (UMLS 2011AA ValueDomain-2)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
Item Group
Long Term Follow-up Medication
C1517942 (UMLS CUI-1)
C0013227 (UMLS CUI-2)
Item
Did the patient receive bone active medication other than calcium or vitamin D during this follow-up period (e.g., bisphosphonates)
text
C25180 (NCI Thesaurus ValueDomain)
C3298 (NCI Thesaurus Property)
C459 (NCI Thesaurus ObjectClass)
C25382 (NCI Thesaurus Property-2)
C0029456 (UMLS CUI [1,1])
C0013227 (UMLS CUI [1,2])
CL.1
Code List
Did the patient receive bone active medication other than calcium or vitamin D during this follow-up period (e.g., bisphosphonates)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS CUI-1)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS CUI-1)
CL Item
Continuing (Continuing)
C1553904 (UMLS CUI-1)
Item
If yes or continuing
integer
C25284 (NCI Thesaurus ValueDomain)
C3298 (NCI Thesaurus Property)
C459 (NCI Thesaurus ObjectClass)
C25382 (NCI Thesaurus Property-2)
C0029456 (UMLS CUI [1,1])
C0013227 (UMLS CUI [1,2])
CL.2
Code List
If yes or continuing
CL Item
Biphosphonate Therapy (1)
C0012544 (UMLS CUI-1)
CL Item
Other (2)
C0205394 (UMLS CUI-1)
Medication Osteoporosis, specify
Item
Specify
text
C25685 (NCI Thesaurus ValueDomain)
C3298 (NCI Thesaurus Property)
C459 (NCI Thesaurus ObjectClass)
C25382 (NCI Thesaurus Property-2)
C0029456 (UMLS CUI [1,1])
C0013227 (UMLS CUI [1,2])
Item
Did the patient receive glucocorticosteroids during this follow-up period
text
C459 (NCI Thesaurus ObjectClass)
C25730 (NCI Thesaurus ObjectClass-2)
C2322 (NCI Thesaurus Property)
C25382 (NCI Thesaurus Property-2)
C25180 (NCI Thesaurus ValueDomain)
C0001617 (UMLS CUI [1,1])
C0013227 (UMLS CUI [1,2])
CL.3
Code List
Did the patient receive glucocorticosteroids during this follow-up period
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS CUI-1)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS CUI-1)
CL Item
Continuing (Continuing)
C1553904 (UMLS CUI-1)
Concomitant Medication OtherCorticosteroid
Item
Specify (If yes or continuing, medication)
text
C459 (NCI Thesaurus ObjectClass)
C25730 (NCI Thesaurus ObjectClass-2)
C17649 (NCI Thesaurus Property)
C2322 (NCI Thesaurus Property-2)
C25382 (NCI Thesaurus Property-3)
C25685 (NCI Thesaurus ValueDomain)
C0013227C0001617 (UMLS CUI [1])
Item
Did the patient receive continuous, non-steroidal, anti-inflammatory drug during this follow-up period (e.g., COX-2 inhibitors, aspirin, Ibuprofen)
text
C16960 (NCI Thesaurus ObjectClass)
C18772 (NCI Thesaurus Property)
C257 (NCI Thesaurus Property-2)
C25340 (NCI Thesaurus Property-3)
C25647 (NCI Thesaurus Property-4)
C25180 (NCI Thesaurus ValueDomain)
C0003211 (UMLS CUI [1,1])
C0205272 (UMLS CUI [1,2])
CL.4
Code List
Did the patient receive continuous, non-steroidal, anti-inflammatory drug during this follow-up period (e.g., COX-2 inhibitors, aspirin, Ibuprofen)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS CUI-1)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS CUI-1)
CL Item
Continuing (Continuing)
C1553904 (UMLS CUI-1)
Nonsteroidal Antiinflammatory Drug Medication
Item
Specify (If yes or continuing, medication)
text
C459 (NCI Thesaurus ObjectClass)
C257 (NCI Thesaurus ObjectClass-2)
C25616 (NCI Thesaurus Property)
C25651 (NCI Thesaurus Property-2)
C25685 (NCI Thesaurus ValueDomain)
C0013227 (UMLS CUI [1,1])
C0003211 (UMLS CUI [1,2])
Item
Did patient receive extended adjuvant endocrine therapy for primary breast cancer during this follow-up period (If treatment was given for breast cancer recurrence, do not record)
text
C25180 (NCI Thesaurus ValueDomain)
C15445 (NCI Thesaurus ObjectClass)
C2140 (NCI Thesaurus ObjectClass-2)
C25382 (NCI Thesaurus Property)
C2367461 (UMLS CUI [1])
CL.5
Code List
Did patient receive extended adjuvant endocrine therapy for primary breast cancer during this follow-up period (If treatment was given for breast cancer recurrence, do not record)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS CUI-1)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS CUI-1)
CL Item
Continuing (Continuing)
C1553904 (UMLS CUI-1)
Adjuvant Hormone Therapy Begin Date
Item
Begin date (If yes or continuing day month year)
date
C15445 (NCI Thesaurus ObjectClass)
C2140 (NCI Thesaurus ObjectClass-2)
C25431 (NCI Thesaurus Property)
C25275 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25431 (NCI Thesaurus ValueDomain-2)
C2367461 (UMLS CUI [1,1])
C0808070 (UMLS CUI [1,2])
Adjuvant Hormone Therapy End Date
Item
End date (day month year)
date
C15445 (NCI Thesaurus ObjectClass)
C2140 (NCI Thesaurus ObjectClass-2)
C25275 (NCI Thesaurus Property)
C25496 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C2367461 (UMLS CUI [1,1])
C0806020 (UMLS CUI [1,2])
Item
Adjuvant Hormonal Therapy Administered Type (Extended)
integer
C25284 (NCI Thesaurus ValueDomain)
C15445 (NCI Thesaurus ObjectClass)
C2140 (NCI Thesaurus ObjectClass-2)
C25382 (NCI Thesaurus Property)
C2367461 (UMLS CUI [1])
CL.6
Code List
Adjuvant Hormonal Therapy Administered Type (Extended)
CL Item
Letrozole (1)
C0246421 (UMLS CUI-1)
CL Item
Tamoxifen (2)
C0039286 (UMLS CUI-1)
CL Item
Anastrozole (3)
C0290883 (UMLS CUI-1)
CL Item
Exemestane (4)
C0851344 (UMLS CUI-1)
CL Item
Other (5)
C0205394 (UMLS CUI-1)
New Adjuvant Hormone Therapy, specify
Item
Other, specify
text
C25586 (NCI Thesaurus ObjectClass)
C15445 (NCI Thesaurus ObjectClass-2)
C2140 (NCI Thesaurus ObjectClass-3)
C25382 (NCI Thesaurus Property)
C25685 (NCI Thesaurus ValueDomain)
C2367461 (UMLS CUI [1])
Item
Reason Stopped (If extended treatment stopped, what was the reason)
integer
C25638 (NCI Thesaurus ValueDomain)
C25629 (NCI Thesaurus ObjectClass)
C15368 (NCI Thesaurus ObjectClass-2)
C25484 (NCI Thesaurus Property)
C4288399 (UMLS CUI [1,1])
C0566251 (UMLS CUI [1,2])
CL.7
Code List
Reason Stopped (If extended treatment stopped, what was the reason)
CL Item
Completed Treatment (1)
C0580352 (UMLS CUI-1)
CL Item
Physician Decision (2)
C1709536 (UMLS CUI-1)
CL Item
Adverse Event (3)
C0877248 (UMLS CUI-1)
CL Item
Disease progression or second malignancy (4)
C0242656 (UMLS CUI-1)
C0085183 (UMLS CUI-3)
CL Item
Other (5)
C0205394 (UMLS CUI-1)
Off-treatment Reason
Item
Other specify
text
C25685 (NCI Thesaurus ValueDomain)
C25601 (NCI Thesaurus ObjectClass)
C25365 (NCI Thesaurus Property)
C1518544 (UMLS CUI [1,1])
C0566251 (UMLS CUI [1,2])
Item Group
Footer Module
C2825232 (UMLS CUI-1)
Investigator Signature
Item
Investigator/Designee Signature
text
C25704 (NCI Thesaurus ValueDomain)
C25678 (NCI Thesaurus Property)
C17089 (NCI Thesaurus ObjectClass)
C25479 (NCI Thesaurus Property-2)
C2346576 (UMLS CUI [1])
Investigator Signature Date
Item
Signature date
date
C25164 (NCI Thesaurus ValueDomain)
C25678 (NCI Thesaurus Property)
C25367 (NCI Thesaurus ValueDomain-2)
C17089 (NCI Thesaurus ObjectClass)
C2346576 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
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