ID
2601
Description
I1 Radiation Therapy Oncology Group Phase III Randomized Study of Intermediate Risk Prostate Cancer Initial Evaluation Form 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=AA891CBF-EF6D-5893-E034-0003BA12F5E7
Link
Keywords
Versions (2)
- 9/19/12 9/19/12 -
- 3/23/15 3/23/15 - Martin Dugas
Uploaded on
September 19, 2012
DOI
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License
Creative Commons BY-NC 3.0 Legacy
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NCT00063882 On-Study - I1 Radiation Therapy Oncology Group Phase III Randomized Study of Intermediate Risk Prostate Cancer Initial Evaluation Form - 2057879v3.0
INSTRUCTIONS: Submit this form at patient's entry on study. Use -1 for unknown or not applicable unless otherwise specified in the codetable. All dates to be reported mm-dd-yyyy unless otherwise indicated.
- StudyEvent: I1 Radiation Therapy Oncology Group Phase III Randomized Study of Intermediate Risk Prostate Cancer Initial Evaluation Form
Description
Unnamed2
Description
RTOGStudy
Data type
text
Description
Case#
Data type
text
Description
InstitutionName
Data type
text
Description
NCIInstitutionNumber
Data type
text
Description
PatientName,Last
Data type
text
Description
PatientName,First
Data type
text
Description
Unnamed3
Description
Unnamed4
Description
PatientBirthDate
Data type
date
Alias
- NCI Thesaurus ObjectClass
- C16960
- UMLS 2011AA ObjectClass
- C0030705
- NCI Thesaurus Property
- C25275
- UMLS 2011AA Property
- C2745955
Description
PerformanceStatus
Data type
text
Description
PriorCancerInd
Data type
text
Description
SpecifySite(malignancyotherthanstudysite)
Data type
text
Description
DATEERADICATED
Data type
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
- NCI Thesaurus Property
- C20985
- UMLS 2011AA Property
- C0547070
Description
FirstPositiveBiopsyDate
Data type
date
Description
HistologicType
Data type
text
Description
HistologicType,OtherVariant
Data type
text
Description
GleasonScore,PrimaryPattern
Data type
double
Description
GleasonScore,SecondaryPattern
Data type
double
Description
GleasonScore,WorstPattern
Data type
double
Description
GleasonScore,Combined
Data type
double
Description
Prostate: Prior Treatment
Description
PriorProstatectomyInd
Data type
text
Description
PriorProstatectomyDate
Data type
date
Description
PriorRTInd
Data type
text
Description
RTOtherType
Data type
text
Description
PriorChemotherapyInd
Data type
text
Description
PriorChemotherapyEndDate
Data type
date
Description
SystemicTherapyType,Other
Data type
text
Description
PriorHormonalTherapyInd
Data type
text
Description
PriorHormonalType
Data type
text
Description
PriorHormonalTherapyBeginDate
Data type
date
Description
PriorHormonalTherapyEndDate
Data type
date
Description
Other,specify(priorhormonaltherapy)
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
ORCHIECTOMY
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
OrchiectomyDate
Data type
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
- NCI Thesaurus ObjectClass
- C15288
- UMLS 2011AA ObjectClass
- C0007347
- NCI Thesaurus Property
- C25275
- UMLS 2011AA Property
- C2745955
Description
PriorSurgeryInd
Data type
text
Description
PriorSurgeryDate
Data type
date
Description
PRIORORCURRENTCOMPLEMENTARYALTERNATIVEMEDICINE(CAM)THERAPY
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
OtherTherapyName
Data type
text
Description
DatepriororcurrentCAMtherapystarted
Data type
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
Description
PriorCAMtherapyenddate
Data type
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
Description
Unnamed5
Description
Unnamed6
Description
RTOGStudy
Data type
text
Description
Case#
Data type
text
Description
InstitutionName
Data type
text
Description
NCIInstitutionNumber
Data type
text
Description
PatientName,Last
Data type
text
Description
PatientName,First
Data type
text
Description
Unnamed7
Description
PALPABLETUMOR
Data type
text
Description
TumorSize,LargestDimension
Data type
double
Description
TumorSize,SecondDimension
Data type
double
Description
DIMENSIONSREPORTEDARE
Data type
text
Description
ExtracapsularExtensionInd
Data type
text
Description
TumorSize,TotalVolume
Data type
double
Description
TumorSize,TotalVolume
Data type
double
Description
BaselinePSADate
Data type
date
Description
BaselinePSAValue
Data type
double
Description
TIMEPOINT
Data type
text
Description
PRIORHORMONALTHERAPYTYPETESTOSTERONE
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
PriorHormonalTherapyEndDate
Data type
date
Description
PRIOROTHERHORMONALTHERAPY
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
Specify(priorotherhormonaltherapy)
Data type
text
Description
PriorOtherHormonalTherapyBeginDate
Data type
date
Description
Specify(priororcurrentcomplementaryalternativemedicinetherapy)
Data type
text
Description
PRIORORCURRENTCOMPLEMENTARYALTERNATIVEMEDICINE(CAM)THERAPY
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
DatepriororcurrentCAMtherapystarted
Data type
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
Description
PriorCAMtherapyenddate
Data type
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
Description
Unnamed5
Description
Unnamed6
Description
Case#
Data type
text
Description
InstitutionName
Data type
text
Description
InstitutionNo.
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25337
- UMLS 2011AA ValueDomain
- C0237753
Description
PatientName,Last
Data type
text
Description
PatientName,First
Data type
text
Description
RTOGStudy
Data type
text
Description
Unnamed7
Description
AlkPhosValue
Data type
double
Description
SPECIFY(unitofmeasure)
Data type
text
Description
Labnormalrange(alkalinephosphatase)
Data type
text
Description
ALT(SGPT)
Data type
text
Description
ALTValue
Data type
double
Description
LaboratoryProcedureSerumGlutamicPyruvicTransaminaseResultNormalRangeText
Data type
text
Alias
- NCI Thesaurus ObjectClass
- C25294
- UMLS 2011AA ObjectClass
- C0022885
- NCI Thesaurus Property
- C20200
- UMLS 2011AA Property
- C1274040
- NCI Thesaurus Property
- C25293
- UMLS 2011AA Property
- C0376147
- NCI Thesaurus ValueDomain
- C25704
- UMLS 2011AA ValueDomain
- C1527021
- NCI Thesaurus ValueDomain
- C14165
- UMLS 2011AA ValueDomain
- C0205307
- NCI Thesaurus ValueDomain
- C38013
- UMLS 2011AA ValueDomain
- C1514721
Description
TotalBilirubinValue
Data type
double
Alias
- NCI Thesaurus ValueDomain
- C25209
- UMLS 2011AA ValueDomain
- C0242485
Description
Labnormalrange(totalbilirubin)
Data type
text
Description
BaselinePSADate
Data type
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
Description
TStage,Pathologic
Data type
text
Description
NStage,Pathologic
Data type
text
Description
NStage,Clinical
Data type
text
Description
MStage,Clinical
Data type
text
Description
Comments
Data type
text
Description
SignatureofPersonCompletingThisForm
Data type
text
Description
FormCompletionDate,Original
Data type
date
Description
ALKALINEPHOSPHATASE
Data type
text
Description
TOTALBILIRUBIN
Data type
text
Description
BaselinePSAValue
Data type
text
Description
TIMEPOINT
Data type
text
Description
Ccrr Module For I1 Radiation Therapy Oncology Group Phase Iii Randomized Study Of Intermediate Risk Prostate Cancer Initial Evaluation Form
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INSTRUCTIONS: Submit this form at patient's entry on study. Use -1 for unknown or not applicable unless otherwise specified in the codetable. All dates to be reported mm-dd-yyyy unless otherwise indicated.
- StudyEvent: I1 Radiation Therapy Oncology Group Phase III Randomized Study of Intermediate Risk Prostate Cancer Initial Evaluation Form
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
C0030705 (UMLS 2011AA ObjectClass)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C0011008 (UMLS 2011AA ValueDomain)
C20985 (NCI Thesaurus Property)
C0547070 (UMLS 2011AA Property)
C0205394 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C1522602 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C0011008 (UMLS 2011AA ValueDomain)
C15288 (NCI Thesaurus ObjectClass)
C0007347 (UMLS 2011AA ObjectClass)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C1522602 (UMLS 2011AA ValueDomain)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C0011008 (UMLS 2011AA ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
C1298908 (UMLS 2011AA)
C0439673 (UMLS 2011AA)
C0439673 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C0439673 (UMLS 2011AA)
C1522602 (UMLS 2011AA ValueDomain)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C1522602 (UMLS 2011AA ValueDomain)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C1522602 (UMLS 2011AA ValueDomain)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C0011008 (UMLS 2011AA ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C0205307 (UMLS 2011AA)
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)
C0242485 (UMLS 2011AA ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C1269798 (UMLS 2011AA)