AmendedDataInd
Item
Amended Data
text
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
RTOGStudy
Item
RTOG Study
text
InstitutionName
Item
Institution Name
text
NCIInstitutionNumber
Item
Institution No.
text
PatientName,Last
Item
Patient Name, Last
text
PatientName,First
Item
Patient Name, First (10 Chemistry - labs at study entry-specify all values and normal lab ranges. See protocol for requirements 1 Not done; 2 Normal; 3 Abnormal, elevated, 4 Abnormal, < normal)
text
PatientBirthDate
Item
PATIENT BIRTH DATE
date
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
PerformanceStatus
Item
PERFORMANCE STATUS (ZUBROD)
text
Item
HAS PATIENT HAD ANOTHER MALIGNANCY (other than study site)
text
Code List
HAS PATIENT HAD ANOTHER MALIGNANCY (other than study site)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
SpecifySite(malignancyotherthanstudysite)
Item
Specify Site (malignancy other than study site)
text
DATEERADICATED
Item
DATE ERADICATED (mm/yyyy If not NED from second malignancy, leave date blank.)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C20985 (NCI Thesaurus Property)
C0547070 (UMLS 2011AA Property)
FirstPositiveBiopsyDate
Item
DATE OF INITIAL DIAGNOSIS OF PRIMARY TUMOR (HISTOPATHOLOGIC TYPE)
date
Item
HISTOLOGIC TYPE
text
Code List
HISTOLOGIC TYPE
CL Item
Adenocarcinoma (Adenocarcinoma)
CL Item
Other (Other, specify)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
HistologicType,OtherVariant
Item
Other, specify (histologic type)
text
GleasonScore,PrimaryPattern
Item
GLEASON SCORE, PRIMARY PATTERN ([most frequently seen] 1-5, 9=unknown)
double
GleasonScore,SecondaryPattern
Item
GLEASON SCORE, SECONDARY PATTERN ([second most frequently seen] 1-5, 9=unknown)
double
GleasonScore,WorstPattern
Item
GLEASON SCORE, WORST PATTERN ([worst pathological grade seen in any specimen] 1-5, 9=unknown)
double
GleasonScore,Combined
Item
GLEASON SCORE, COMBINED ([sum of the primary and secondary, unless unknown] 99=Unknown)
double
Item
PRIOR PROSTATECTOMY
text
Code List
PRIOR PROSTATECTOMY
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
PriorProstatectomyDate
Item
Prior prostatectomy date
date
Item
PRIOR RADIATION THERAPY
text
Code List
PRIOR RADIATION THERAPY
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
RTOtherType
Item
Specify (prior radiation therapy)
text
Item
PRIOR CHEMOTHERAPY (for any reason)
text
Code List
PRIOR CHEMOTHERAPY (for any reason)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
PriorChemotherapyEndDate
Item
Prior chemotherapy end date
date
SystemicTherapyType,Other
Item
Specify (prior chemotherapy)
text
Item
PRIOR HORMONAL THERAPY
text
Code List
PRIOR HORMONAL THERAPY
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
PRIOR HORMONAL THERAPY TYPE
text
Code List
PRIOR HORMONAL THERAPY TYPE
PriorHormonalTherapyBeginDate
Item
Prior hormonal therapy start date
date
PriorHormonalTherapyEndDate
Item
Prior hormonal therapy end date (C)
date
Other,specify(priorhormonaltherapy)
Item
Specify (Prior Hormonal Therapy Type)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
ORCHIECTOMY
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
OrchiectomyDate
Item
Orchiectomy date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C15288 (NCI Thesaurus ObjectClass)
C0007347 (UMLS 2011AA ObjectClass)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
Item
PRIOR SURGERY (TURP)
text
Code List
PRIOR SURGERY (TURP)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
PriorSurgeryDate
Item
Prior surgery (TURP) date
date
Item
PRIOR OR CURRENT COMPLEMENTARY ALTERNATIVE MEDICINE (CAM) THERAPY
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Code List
PRIOR OR CURRENT COMPLEMENTARY ALTERNATIVE MEDICINE (CAM) THERAPY
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
OtherTherapyName
Item
Specify (prior or current CAM)
text
DatepriororcurrentCAMtherapystarted
Item
Date prior or current CAM therapy started
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
PriorCAMtherapyenddate
Item
Prior CAM therapy end date (if continuing leave blank)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
AmendedDataInd
Item
Amended Data
text
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
RTOGStudy
Item
RTOG Study
text
InstitutionName
Item
Institution Name
text
NCIInstitutionNumber
Item
Institution No.
text
PatientName,Last
Item
Patient Name, Last
text
PatientName,First
Item
Patient Name, First (10 Chemistry - labs at study entry-specify all values and normal lab ranges. See protocol for requirements 1 Not done; 2 Normal; 3 Abnormal, elevated, 4 Abnormal, < normal)
text
Item
PALPABLE TUMOR (at study entry)
text
Code List
PALPABLE TUMOR (at study entry)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes, One Lobe (Yes, one lobe)
CL Item
Yes, Both Lobes (Yes, both lobes)
CL Item
Yes, Nos (Yes, NOS)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
TumorSize,LargestDimension
Item
LARGEST DIMENSION (cm)
double
TumorSize,SecondDimension
Item
PERPENDICULAR DIMENION (cm)
double
Item
DIMENSIONS REPORTED ARE
text
Code List
DIMENSIONS REPORTED ARE
CL Item
Tumor Dimensions (Tumor dimensions)
CL Item
Prostate Dimensions (Prostate dimensions)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
TUMOR BEYOND CAPSULE AS DETERMINED BY CLINICAL EXAMINATION
text
Code List
TUMOR BEYOND CAPSULE AS DETERMINED BY CLINICAL EXAMINATION
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)
TumorSize,TotalVolume
Item
VOLUME OF GLAND BY TRUS (Grams)
double
TumorSize,TotalVolume
Item
VOLUME OF GLAND BY TRUS (Grams)
double
BaselinePSADate
Item
Baseline PSA Date
date
BaselinePSAValue
Item
Bseline PSA Value
double
CL Item
Study Entry (Study entry)
CL Item
Pre-hormone (Pre-hormone)
CL Item
Diagnostic (Diagnostic)
Item
PRIOR HORMONAL THERAPY TYPE TESTOSTERONE
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Code List
PRIOR HORMONAL THERAPY TYPE TESTOSTERONE
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
PriorHormonalTherapyEndDate
Item
Prior hormonal therapy end date (C)
date
Item
PRIOR OTHER HORMONAL THERAPY
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Code List
PRIOR OTHER HORMONAL THERAPY
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Specify(priorotherhormonaltherapy)
Item
Specify (prior other hormonal therapy)
text
PriorOtherHormonalTherapyBeginDate
Item
Date prior other hormonal therapy started (D)
date
Specify(priororcurrentcomplementaryalternativemedicinetherapy)
Item
Specify (prior or current complementary alternative medicine therapy)
text
Item
PRIOR OR CURRENT COMPLEMENTARY ALTERNATIVE MEDICINE (CAM) THERAPY
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Code List
PRIOR OR CURRENT COMPLEMENTARY ALTERNATIVE MEDICINE (CAM) THERAPY
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
DatepriororcurrentCAMtherapystarted
Item
Date prior or current CAM therapy started
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
PriorCAMtherapyenddate
Item
Prior CAM therapy end date (if continuing leave blank)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
InstitutionName
Item
Institution Name
text
InstitutionNo.
Item
Institution No.
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
PatientName,Last
Item
Patient Name, Last
text
PatientName,First
Item
Patient Name, First (10 Chemistry - labs at study entry-specify all values and normal lab ranges. See protocol for requirements 1 Not done; 2 Normal; 3 Abnormal, elevated, 4 Abnormal, < normal)
text
RTOGStudy
Item
RTOG Study
text
AlkPhosValue
Item
Alk Phos Value
double
Item
SPECIFY (unit of measure)
text
Code List
SPECIFY (unit of measure)
Labnormalrange(alkalinephosphatase)
Item
Lab normal range (alkaline phosphatase) (B)
text
CL Item
Not Done (Not done)
CL281691 (NCI Metathesaurus)
CL Item
Normal (Normal)
C14165 (NCI Thesaurus)
C0205307 (UMLS 2011AA)
CL Item
Abnormal, Elevated (Abnormal, elevated)
CL Item
Abnormal, < Normal (Abnormal, < normal)
ALTValue
Item
ALT Value
double
LaboratoryProcedureSerumGlutamicPyruvicTransaminaseResultNormalRangeText
Item
Lab normal range (ALT) (C)
text
C25294 (NCI Thesaurus ObjectClass)
C0022885 (UMLS 2011AA ObjectClass)
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)
C25293 (NCI Thesaurus Property)
C0376147 (UMLS 2011AA Property)
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C14165 (NCI Thesaurus ValueDomain)
C0205307 (UMLS 2011AA ValueDomain)
C38013 (NCI Thesaurus ValueDomain)
C1514721 (UMLS 2011AA ValueDomain)
TotalBilirubinValue
Item
Total Bilirubin Value
double
C25209 (NCI Thesaurus ValueDomain)
C0242485 (UMLS 2011AA ValueDomain)
Labnormalrange(totalbilirubin)
Item
Lab normal range (total bilirubin) (11 BASELINE PSA VALUE)
text
BaselinePSADate
Item
Baseline PSA Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Item
T STAGE, PATHOLOGIC
text
Code List
T STAGE, PATHOLOGIC
CL Item
T1a, Clinically Inapparent Tumor Not Palpable Or Visible By Imaging (see Ajcc Definition) (T1a)
CL Item
T1b, Clinically Inapparent Tumor Not Palpable Or Visible By Imaging (see Ajcc Definition) (T1b)
CL Item
T1c, Clinically Inapparent Tumor Not Palpable Or Visible By Imaging (see Ajcc Definition) (T1c)
CL Item
T2, Tumor Confined Within The Prostate (see Ajcc Definition) (T2, NOS)
CL Item
T2a, Tumor Confined Within The Prostate (see Ajcc Definition) (T2a)
CL Item
T2b, Tumor Confined Within The Prostate (see Ajcc Definition) (T2b)
CL Item
T3, Tumor Extends Through The Prostatic Capsule (see Ajcc Definition) (T3, NOS)
CL Item
T3a, Tumor Extends Through The Prostatic Capsule (see Ajcc Definition) (T3a)
CL Item
T3b, Tumor Extends Through The Prostatic Capsule (see Ajcc Definition) (T3b)
CL Item
T4, Tumor Is Fixed Or Invades Adjacent Structures (see Ajcc Definition) (T4)
CL Item
Primary Tumor Cannot Be Assessed (TX)
Item
N STAGE, PATHOLOGIC (SURGICAL)
text
Code List
N STAGE, PATHOLOGIC (SURGICAL)
CL Item
No Regional Lymph Node Metastasis (N0)
CL Item
Metastatis In Regional Lymph Node Or Nodes (see Ajcc Definition) (N1)
CL Item
No node sampling (No node sampling)
Item
N STAGE, CLINICAL (RADIOGRAPHIC)
text
Code List
N STAGE, CLINICAL (RADIOGRAPHIC)
Item
M STAGE, CLINICAL
text
Code List
M STAGE, CLINICAL
CL Item
No Distant Metastasis (M0)
CL Item
Distant Metastasis (M1)
C18206 (NCI Thesaurus)
C1269798 (UMLS 2011AA)
CL Item
Nonregional Lymph Node(s) (M1a)
CL Item
Other Site(s) (M1c)
CL Item
Distant Metastsis Cannot Be Assessed (MX)
Comments
Item
COMMENTS
text
SignatureofPersonCompletingThisForm
Item
Signature
text
FormCompletionDate,Original
Item
Date
date
Item
ALKALINE PHOSPHATASE
text
Code List
ALKALINE PHOSPHATASE
CL Item
Not done (Not done)
CL Item
Abnormal, elevated (Abnormal, elevated)
CL Item
Abnormal, < normal (Abnormal, < normal)
Item
TOTAL BILIRUBIN
text
Code List
TOTAL BILIRUBIN
CL Item
Not done (Not done)
CL Item
Abnormal, elevated (Abnormal, elevated)
CL Item
Abnormal, < normal (Abnormal, < normal)
BaselinePSAValue
Item
Baseline PSA Value
text
CL Item
Pre-surgery (Pre-surgery)
CL Item
Post-surgery (Post-surgery)
CL Item
Study entry (Study entry)
CL Item
Pre-hormone (Pre-hormone)