ID

23027

Beschreibung

IBCSG Long Term Follow-Up Recurrence Form (18-LTF-RC) Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=889C7665-5F9A-48C7-E040-BB89AD436937

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=889C7665-5F9A-48C7-E040-BB89AD436937

Stichworte

Versionen (2)
  1. 26.08.12 26.08.12 -
  2. 20.06.17 20.06.17 - Martin Dugas
Hochgeladen am

20. Juni 2017

DOI

Für eine Beantragung loggen Sie sich ein.

Lizenz

Creative Commons BY-NC 3.0
Modell Kommentare :

Hier können Sie das Modell kommentieren. Über die Sprechblasen an den Itemgruppen und Items können Sie diese spezifisch kommentieren.

Zurück zu Modell Kommentaren
Itemgroup Kommentare für :

Item Kommentare für :

Um Formulare herunterzuladen müssen Sie angemeldet sein. Bitte loggen Sie sich ein oder registrieren Sie sich kostenlos.

IBCSG Long Term Follow-Up Recurrence Form (18-LTF-RC)

Englisch

Complete this form for patients with a proven recurrence. Use minus one (-1) to indicate that an answer is unknown unobtainable or not done

1 Formulare  
Header Module
Beschreibung

Header Module

Alias
UMLS CUI-1
C1320722
Visit number
Beschreibung

Hospital Admission Ordinal Number

Datentyp

integer

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

International Breast Cancer Study Group Identifier Number

Datentyp

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.
Beschreibung

Protocol International Breast Cancer Study Group Identifier Number

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus ObjectClass
C25320
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C25530
UMLS CUI [1,1]
C3274381
UMLS CUI [1,2]
C1512890
Randomization No.
Beschreibung

Randomization Number

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus ValueDomain
C25364
NCI Thesaurus Property
C25196
UMLS CUI [1]
C2986235
Institution Code Number
Beschreibung

Institution Identifier Number

Datentyp

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
Beschreibung

Institution Name

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25191
NCI Thesaurus ObjectClass
C21541
NCI Thesaurus ValueDomain-2
C21541
NCI Thesaurus Property
C25364
UMLS CUI [1]
C1301943
Proven Recurrence/Metastasis Or Contralateral Invasive Breast Cancer
Beschreibung

Proven Recurrence/Metastasis Or Contralateral Invasive Breast Cancer

Alias
UMLS CUI-1
C0679254
Site (Sites of Recurrence Local Regional Distant)
Beschreibung

Breast Cancer Recurrence Site

Datentyp

integer

Alias
NCI Thesaurus ValueDomain
C13717
NCI Thesaurus Property
C38155
NCI Thesaurus ObjectClass
C4872
UMLS CUI [1,1]
C4055130
UMLS CUI [1,2]
C0678222
Specify (If yes, submit page 2 of this form and specify recurrence site)
Beschreibung

Breast Carcinoma Recurrent Disease

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25685
NCI Thesaurus Property
C38155
NCI Thesaurus ObjectClass
C4872
UMLS CUI [1]
C0278493
Date of diagnosis of recurrent/metastatic disease (day month year)
Beschreibung

Recurrence date

Datentyp

date

Alias
NCI Thesaurus ObjectClass
C14174
NCI Thesaurus ObjectClass-2
C14173
NCI Thesaurus ObjectClass-3
C2991
NCI Thesaurus Property
C25536
NCI Thesaurus Property-2
C15220
NCI Thesaurus ValueDomain
C25164
UMLS CUI [1]
C0807712
Hormone Receptor Analysis
Beschreibung

Hormone Receptor Analysis

Alias
UMLS CUI-1
C0523374
Was Hormone Receptor Analysis performed (on a recurrence reported during this follow-up period)
Beschreibung

Estrogen Receptor Progesterone Receptor Analysis

Datentyp

boolean

Alias
NCI Thesaurus ObjectClass
C25391
NCI Thesaurus ObjectClass-2
C17069
NCI Thesaurus ObjectClass-3
C17075
NCI Thesaurus Property
C38000
NCI Thesaurus ValueDomain
C38147
UMLS CUI [1]
C0523374
Specify (If yes, submit page 2 of this form and specify recurrence site)
Beschreibung

Breast Carcinoma Recurrent Disease

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25685
NCI Thesaurus Property
C38155
NCI Thesaurus ObjectClass
C4872
UMLS CUI [1]
C0278493
Date Specimen collected
Beschreibung

Specimen Collected Date

Datentyp

date

Maßeinheiten
  • day month year
Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ObjectClass
C19157
NCI Thesaurus Property
C25452
NCI Thesaurus Property-2
C25275
UMLS CUI [1]
C1317250
day month year
ER % Positive (Results of immunohistochemistry IHC: Percent of positive cells use 0-100)
Beschreibung

Estrogen Receptor Positive

Datentyp

float

Maßeinheiten
  • %
Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI [1,1]
C0279754
%
PR % Positive (Results of immunohistochemistry IHC: Percent of positive cells use 0-100)
Beschreibung

Progesterone Receptor Positive

Datentyp

float

Maßeinheiten
  • %
Alias
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus ObjectClass
C17075
NCI Thesaurus Property
C25554
UMLS CUI [1]
C0279759
%
ER Status (select one)
Beschreibung

Estrogen Receptor Status

Datentyp

integer

Alias
NCI Thesaurus ValueDomain
C3262
NCI Thesaurus ObjectClass
C17069
NCI Thesaurus ValueDomain-2
C25688
NCI Thesaurus Property
C25554
UMLS CUI [1]
C1516974
PgR Status (select one)
Beschreibung

Progesterone Receptor Status

Datentyp

integer

Alias
NCI Thesaurus ValueDomain
C25284
NCI Thesaurus ObjectClass
C17075
NCI Metathesaurus Property
C0678257
UMLS CUI [1]
C1514471
Footer Module
Beschreibung

Footer Module

Alias
UMLS CUI-1
C2825232
Investigator/Designee Signature
Beschreibung

Investigator Signature

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25704
NCI Thesaurus Property
C25678
NCI Thesaurus ObjectClass
C17089
NCI Thesaurus Property-2
C25479
UMLS CUI [1]
C2346576
Investigator Signature Date
Beschreibung

Investigator Signature Date

Datentyp

date

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
Zum Seitenanfang zurückkehren

Ähnliche Modelle

Complete this form for patients with a proven recurrence. Use minus one (-1) to indicate that an answer is unknown unobtainable or not done

1 Formulare
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
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)
C3274381 (UMLS CUI [1,1])
C1512890 (UMLS CUI [1,2])
Randomization Number
Item
Randomization No.
text
C16960 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus ValueDomain)
C25196 (NCI Thesaurus Property)
C2986235 (UMLS CUI [1])
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])
Institution Name
Item
Institution Name
text
C25191 (NCI Thesaurus ValueDomain)
C21541 (NCI Thesaurus ObjectClass)
C21541 (NCI Thesaurus ValueDomain-2)
C25364 (NCI Thesaurus Property)
C1301943 (UMLS CUI [1])
Item Group
Proven Recurrence/Metastasis Or Contralateral Invasive Breast Cancer
C0679254 (UMLS CUI-1)
Item
Site (Sites of Recurrence Local Regional Distant)
integer
C13717 (NCI Thesaurus ValueDomain)
C38155 (NCI Thesaurus Property)
C4872 (NCI Thesaurus ObjectClass)
C4055130 (UMLS CUI [1,1])
C0678222 (UMLS CUI [1,2])
CL.1
Code List
Site (Sites of Recurrence Local Regional Distant)
CL Item
Chest Wall (1)
C0205076 (UMLS CUI-1)
CL Item
Scar (2)
C0241158 (UMLS CUI-1)
CL Item
Breast Tissue (3)
C1521747 (UMLS CUI-1)
CL Item
Breast Scar / Skin (4)
C4029865 (UMLS CUI-1)
CL Item
Chest Wall / Outside Breast (5)
C0205157 (UMLS CUI-1)
C0006141 (UMLS CUI-2)
CL Item
Ipsi Axillary Nodes (6)
C0729594 (UMLS CUI-1)
C0441989 (UMLS CUI-2)
CL Item
Ipsi Axilla (7)
C0004454 (UMLS CUI-1)
C0441989 (UMLS CUI-2)
CL Item
Ipsi Internal Mammary Nodes (8)
C0542554 (UMLS CUI-1)
C0441989 (UMLS CUI-2)
CL Item
Ipsi Infraclavicular Nodes (9)
C0229743 (UMLS CUI-1)
C0441989 (UMLS CUI-2)
CL Item
Ipsi Supraclavicular Nodes (10)
C0229730 (UMLS CUI-1)
C0441989 (UMLS CUI-2)
CL Item
Specify Site (11)
C0449695 (UMLS CUI-1)
Breast Carcinoma Recurrent Disease
Item
Specify (If yes, submit page 2 of this form and specify recurrence site)
text
C25685 (NCI Thesaurus ValueDomain)
C38155 (NCI Thesaurus Property)
C4872 (NCI Thesaurus ObjectClass)
C0278493 (UMLS CUI [1])
Recurrence date
Item
Date of diagnosis of recurrent/metastatic disease (day month year)
date
C14174 (NCI Thesaurus ObjectClass)
C14173 (NCI Thesaurus ObjectClass-2)
C2991 (NCI Thesaurus ObjectClass-3)
C25536 (NCI Thesaurus Property)
C15220 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C0807712 (UMLS CUI [1])
Item Group
Hormone Receptor Analysis
C0523374 (UMLS CUI-1)
Estrogen Receptor Progesterone Receptor Analysis
Item
Was Hormone Receptor Analysis performed (on a recurrence reported during this follow-up period)
boolean
C25391 (NCI Thesaurus ObjectClass)
C17069 (NCI Thesaurus ObjectClass-2)
C17075 (NCI Thesaurus ObjectClass-3)
C38000 (NCI Thesaurus Property)
C38147 (NCI Thesaurus ValueDomain)
C0523374 (UMLS CUI [1])
Breast Carcinoma Recurrent Disease
Item
Specify (If yes, submit page 2 of this form and specify recurrence site)
text
C25685 (NCI Thesaurus ValueDomain)
C38155 (NCI Thesaurus Property)
C4872 (NCI Thesaurus ObjectClass)
C0278493 (UMLS CUI [1])
Specimen Collected Date
Item
Date Specimen collected
date
C25164 (NCI Thesaurus ValueDomain)
C19157 (NCI Thesaurus ObjectClass)
C25452 (NCI Thesaurus Property)
C25275 (NCI Thesaurus Property-2)
C1317250 (UMLS CUI [1])
Estrogen Receptor Positive
Item
ER % Positive (Results of immunohistochemistry IHC: Percent of positive cells use 0-100)
float
C25337 (NCI Thesaurus ValueDomain)
C0279754 (UMLS CUI [1,1])
Progesterone Receptor Positive
Item
PR % Positive (Results of immunohistochemistry IHC: Percent of positive cells use 0-100)
float
C25337 (NCI Thesaurus ValueDomain)
C17075 (NCI Thesaurus ObjectClass)
C25554 (NCI Thesaurus Property)
C0279759 (UMLS CUI [1])
Item
ER Status (select one)
integer
C3262 (NCI Thesaurus ValueDomain)
C17069 (NCI Thesaurus ObjectClass)
C25688 (NCI Thesaurus ValueDomain-2)
C25554 (NCI Thesaurus Property)
C1516974 (UMLS CUI [1])
CL.3
Code List
ER Status (select one)
CL Item
Negative (1)
C0205160 (UMLS CUI-1)
CL Item
Positive (2)
C1446409 (UMLS CUI-1)
CL Item
Unknown (3)
C0439673 (UMLS CUI-1)
Item
PgR Status (select one)
integer
C25284 (NCI Thesaurus ValueDomain)
C17075 (NCI Thesaurus ObjectClass)
C0678257 (NCI Metathesaurus Property)
C1514471 (UMLS CUI [1])
CL.4
Code List
PgR Status (select one)
CL Item
Negative (1)
C0205160 (UMLS CUI-1)
CL Item
Positive (2)
C1446409 (UMLS CUI-1)
CL Item
Unknown (3)
C0439673 (UMLS CUI-1)
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
Investigator 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])
Zum Seitenanfang zurückkehren 

Kontakt

Benutzen Sie dieses Formular für Rückmeldungen, Fragen und Verbesserungsvorschläge.

Mit * gekennzeichnete Felder sind notwendig.

Hilfe

Benötigen Sie Hilfe bei der Suche? Um mehr Details zu erfahren und die Suche effektiver nutzen zu können schauen Sie sich doch das entsprechende Video auf unserer Tutorial Seite an.

Zum Video