ID

2601

Beschreibung

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

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=AA891CBF-EF6D-5893-E034-0003BA12F5E7

Stichworte

Versionen (2)
  1. 19.09.12 19.09.12 -
  2. 23.03.15 23.03.15 - Martin Dugas
Hochgeladen am

19. September 2012

DOI

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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

Englisch

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.

1 Formulare  
Unnamed1
Beschreibung

Unnamed1

Amended Data
Beschreibung

AmendedDataInd

Datentyp

text

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

Unnamed2

RTOG Study
Beschreibung

RTOGStudy

Datentyp

text

Case #
Beschreibung

Case#

Datentyp

text

Institution Name
Beschreibung

InstitutionName

Datentyp

text

Institution No.
Beschreibung

NCIInstitutionNumber

Datentyp

text

Patient Name, Last
Beschreibung

PatientName,Last

Datentyp

text

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)
Beschreibung

PatientName,First

Datentyp

text

Unnamed3
Beschreibung

Unnamed3

Unnamed4
Beschreibung

Unnamed4

PATIENT BIRTH DATE
Beschreibung

PatientBirthDate

Datentyp

date

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25275
UMLS 2011AA Property
C2745955
PERFORMANCE STATUS (ZUBROD)
Beschreibung

PerformanceStatus

Datentyp

text

HAS PATIENT HAD ANOTHER MALIGNANCY (other than study site)
Beschreibung

PriorCancerInd

Datentyp

text

Specify Site (malignancy other than study site)
Beschreibung

SpecifySite(malignancyotherthanstudysite)

Datentyp

text

DATE ERADICATED (mm/yyyy If not NED from second malignancy, leave date blank.)
Beschreibung

DATEERADICATED

Datentyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus Property
C20985
UMLS 2011AA Property
C0547070
DATE OF INITIAL DIAGNOSIS OF PRIMARY TUMOR (HISTOPATHOLOGIC TYPE)
Beschreibung

FirstPositiveBiopsyDate

Datentyp

date

HISTOLOGIC TYPE
Beschreibung

HistologicType

Datentyp

text

Other, specify (histologic type)
Beschreibung

HistologicType,OtherVariant

Datentyp

text

GLEASON SCORE, PRIMARY PATTERN ([most frequently seen] 1-5, 9=unknown)
Beschreibung

GleasonScore,PrimaryPattern

Datentyp

double

GLEASON SCORE, SECONDARY PATTERN ([second most frequently seen] 1-5, 9=unknown)
Beschreibung

GleasonScore,SecondaryPattern

Datentyp

double

GLEASON SCORE, WORST PATTERN ([worst pathological grade seen in any specimen] 1-5, 9=unknown)
Beschreibung

GleasonScore,WorstPattern

Datentyp

double

GLEASON SCORE, COMBINED ([sum of the primary and secondary, unless unknown] 99=Unknown)
Beschreibung

GleasonScore,Combined

Datentyp

double

Prostate: Prior Treatment
Beschreibung

Prostate: Prior Treatment

PRIOR PROSTATECTOMY
Beschreibung

PriorProstatectomyInd

Datentyp

text

Prior prostatectomy date
Beschreibung

PriorProstatectomyDate

Datentyp

date

PRIOR RADIATION THERAPY
Beschreibung

PriorRTInd

Datentyp

text

Specify (prior radiation therapy)
Beschreibung

RTOtherType

Datentyp

text

PRIOR CHEMOTHERAPY (for any reason)
Beschreibung

PriorChemotherapyInd

Datentyp

text

Prior chemotherapy end date
Beschreibung

PriorChemotherapyEndDate

Datentyp

date

Specify (prior chemotherapy)
Beschreibung

SystemicTherapyType,Other

Datentyp

text

PRIOR HORMONAL THERAPY
Beschreibung

PriorHormonalTherapyInd

Datentyp

text

PRIOR HORMONAL THERAPY TYPE
Beschreibung

PriorHormonalType

Datentyp

text

Prior hormonal therapy start date
Beschreibung

PriorHormonalTherapyBeginDate

Datentyp

date

Prior hormonal therapy end date (C)
Beschreibung

PriorHormonalTherapyEndDate

Datentyp

date

Specify (Prior Hormonal Therapy Type)
Beschreibung

Other,specify(priorhormonaltherapy)

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
ORCHIECTOMY
Beschreibung

ORCHIECTOMY

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Orchiectomy date
Beschreibung

OrchiectomyDate

Datentyp

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
PRIOR SURGERY (TURP)
Beschreibung

PriorSurgeryInd

Datentyp

text

Prior surgery (TURP) date
Beschreibung

PriorSurgeryDate

Datentyp

date

PRIOR OR CURRENT COMPLEMENTARY ALTERNATIVE MEDICINE (CAM) THERAPY
Beschreibung

PRIORORCURRENTCOMPLEMENTARYALTERNATIVEMEDICINE(CAM)THERAPY

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Specify (prior or current CAM)
Beschreibung

OtherTherapyName

Datentyp

text

Date prior or current CAM therapy started
Beschreibung

DatepriororcurrentCAMtherapystarted

Datentyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Prior CAM therapy end date (if continuing leave blank)
Beschreibung

PriorCAMtherapyenddate

Datentyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Unnamed5
Beschreibung

Unnamed5

Amended Data
Beschreibung

AmendedDataInd

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Unnamed6
Beschreibung

Unnamed6

RTOG Study
Beschreibung

RTOGStudy

Datentyp

text

Case #
Beschreibung

Case#

Datentyp

text

Institution Name
Beschreibung

InstitutionName

Datentyp

text

Institution No.
Beschreibung

NCIInstitutionNumber

Datentyp

text

Patient Name, Last
Beschreibung

PatientName,Last

Datentyp

text

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)
Beschreibung

PatientName,First

Datentyp

text

Unnamed7
Beschreibung

Unnamed7

PALPABLE TUMOR (at study entry)
Beschreibung

PALPABLETUMOR

Datentyp

text

LARGEST DIMENSION (cm)
Beschreibung

TumorSize,LargestDimension

Datentyp

double

PERPENDICULAR DIMENION (cm)
Beschreibung

TumorSize,SecondDimension

Datentyp

double

DIMENSIONS REPORTED ARE
Beschreibung

DIMENSIONSREPORTEDARE

Datentyp

text

TUMOR BEYOND CAPSULE AS DETERMINED BY CLINICAL EXAMINATION
Beschreibung

ExtracapsularExtensionInd

Datentyp

text

VOLUME OF GLAND BY TRUS (Grams)
Beschreibung

TumorSize,TotalVolume

Datentyp

double

VOLUME OF GLAND BY TRUS (Grams)
Beschreibung

TumorSize,TotalVolume

Datentyp

double

Baseline PSA Date
Beschreibung

BaselinePSADate

Datentyp

date

Bseline PSA Value
Beschreibung

BaselinePSAValue

Datentyp

double

TIME POINT
Beschreibung

TIMEPOINT

Datentyp

text

PRIOR HORMONAL THERAPY TYPE TESTOSTERONE
Beschreibung

PRIORHORMONALTHERAPYTYPETESTOSTERONE

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Prior hormonal therapy end date (C)
Beschreibung

PriorHormonalTherapyEndDate

Datentyp

date

PRIOR OTHER HORMONAL THERAPY
Beschreibung

PRIOROTHERHORMONALTHERAPY

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Specify (prior other hormonal therapy)
Beschreibung

Specify(priorotherhormonaltherapy)

Datentyp

text

Date prior other hormonal therapy started (D)
Beschreibung

PriorOtherHormonalTherapyBeginDate

Datentyp

date

Specify (prior or current complementary alternative medicine therapy)
Beschreibung

Specify(priororcurrentcomplementaryalternativemedicinetherapy)

Datentyp

text

PRIOR OR CURRENT COMPLEMENTARY ALTERNATIVE MEDICINE (CAM) THERAPY
Beschreibung

PRIORORCURRENTCOMPLEMENTARYALTERNATIVEMEDICINE(CAM)THERAPY

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Date prior or current CAM therapy started
Beschreibung

DatepriororcurrentCAMtherapystarted

Datentyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Prior CAM therapy end date (if continuing leave blank)
Beschreibung

PriorCAMtherapyenddate

Datentyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Unnamed5
Beschreibung

Unnamed5

AMENDED DATA
Beschreibung

AmendedData

Datentyp

text

Unnamed6
Beschreibung

Unnamed6

Case #
Beschreibung

Case#

Datentyp

text

Institution Name
Beschreibung

InstitutionName

Datentyp

text

Institution No.
Beschreibung

InstitutionNo.

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
Patient Name, Last
Beschreibung

PatientName,Last

Datentyp

text

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)
Beschreibung

PatientName,First

Datentyp

text

RTOG Study
Beschreibung

RTOGStudy

Datentyp

text

Unnamed7
Beschreibung

Unnamed7

Alk Phos Value
Beschreibung

AlkPhosValue

Datentyp

double

SPECIFY (unit of measure)
Beschreibung

SPECIFY(unitofmeasure)

Datentyp

text

Lab normal range (alkaline phosphatase) (B)
Beschreibung

Labnormalrange(alkalinephosphatase)

Datentyp

text

ALT (SGPT)
Beschreibung

ALT(SGPT)

Datentyp

text

ALT Value
Beschreibung

ALTValue

Datentyp

double

Lab normal range (ALT) (C)
Beschreibung

LaboratoryProcedureSerumGlutamicPyruvicTransaminaseResultNormalRangeText

Datentyp

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
Total Bilirubin Value
Beschreibung

TotalBilirubinValue

Datentyp

double

Alias
NCI Thesaurus ValueDomain
C25209
UMLS 2011AA ValueDomain
C0242485
Lab normal range (total bilirubin) (11 BASELINE PSA VALUE)
Beschreibung

Labnormalrange(totalbilirubin)

Datentyp

text

Baseline PSA Date
Beschreibung

BaselinePSADate

Datentyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
T STAGE, PATHOLOGIC
Beschreibung

TStage,Pathologic

Datentyp

text

N STAGE, PATHOLOGIC (SURGICAL)
Beschreibung

NStage,Pathologic

Datentyp

text

N STAGE, CLINICAL (RADIOGRAPHIC)
Beschreibung

NStage,Clinical

Datentyp

text

M STAGE, CLINICAL
Beschreibung

MStage,Clinical

Datentyp

text

COMMENTS
Beschreibung

Comments

Datentyp

text

Signature
Beschreibung

SignatureofPersonCompletingThisForm

Datentyp

text

Date
Beschreibung

FormCompletionDate,Original

Datentyp

date

ALKALINE PHOSPHATASE
Beschreibung

ALKALINEPHOSPHATASE

Datentyp

text

TOTAL BILIRUBIN
Beschreibung

TOTALBILIRUBIN

Datentyp

text

Baseline PSA Value
Beschreibung

BaselinePSAValue

Datentyp

text

TIME POINT
Beschreibung

TIMEPOINT

Datentyp

text

Ccrr Module For I1 Radiation Therapy Oncology Group Phase Iii Randomized Study Of Intermediate Risk Prostate Cancer Initial Evaluation Form
Beschreibung

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.

1 Formulare
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
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 (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 Group
Unnamed3
Item Group
Unnamed4
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
CL.1
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
CL.2
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 Group
Prostate: Prior Treatment
Item
PRIOR PROSTATECTOMY
text
CL.3
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
CL.4
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
CL.5
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
CL.6
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
CL.7
Code List
PRIOR HORMONAL THERAPY TYPE
CL Item
No (No)
CL Item
Yes (Yes)
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.8
Code List
ORCHIECTOMY
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
CL.9
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)
CL.17
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)
Item Group
Unnamed5
AmendedDataInd
Item
Amended Data
text
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
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 (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 Group
Unnamed7
Item
PALPABLE TUMOR (at study entry)
text
CL.11
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
CL.12
Code List
DIMENSIONS REPORTED ARE
CL Item
N/a (N/A)
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
CL.13
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
Item
TIME POINT
text
CL.14
Code List
TIME POINT
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)
CL.15
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)
CL.16
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)
CL.17
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)
Item Group
Unnamed5
AmendedData
Item
AMENDED DATA
text
Item Group
Unnamed6
Case#
Item
Case #
text
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
Item Group
Unnamed7
AlkPhosValue
Item
Alk Phos Value
double
Item
SPECIFY (unit of measure)
text
CL.19
Code List
SPECIFY (unit of measure)
CL Item
U/ml (u/ml)
CL Item
U/l (u/l)
Labnormalrange(alkalinephosphatase)
Item
Lab normal range (alkaline phosphatase) (B)
text
Item
ALT (SGPT)
text
CL.20
Code List
ALT (SGPT)
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
CL.23
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
CL.24
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
CL.25
Code List
N STAGE, CLINICAL (RADIOGRAPHIC)
CL Item
N0 (N0)
CL Item
N1 (N1)
CL Item
NX (NX)
Item
M STAGE, CLINICAL
text
CL.26
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
Bone(s) (M1b)
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
CL.18
Code List
ALKALINE PHOSPHATASE
CL Item
Not done (Not done)
CL Item
Normal (Normal)
CL Item
Abnormal, elevated (Abnormal, elevated)
CL Item
Abnormal, < normal (Abnormal, < normal)
Item
TOTAL BILIRUBIN
text
CL.21
Code List
TOTAL BILIRUBIN
CL Item
Not done (Not done)
CL Item
Normal (Normal)
CL Item
Abnormal, elevated (Abnormal, elevated)
CL Item
Abnormal, < normal (Abnormal, < normal)
BaselinePSAValue
Item
Baseline PSA Value
text
Item
TIME POINT
text
CL.22
Code List
TIME POINT
CL Item
Pre-surgery (Pre-surgery)
CL Item
Post-surgery (Post-surgery)
CL Item
Study entry (Study entry)
CL Item
Pre-hormone (Pre-hormone)
Item Group
Ccrr Module For I1 Radiation Therapy Oncology Group Phase Iii Randomized Study Of Intermediate Risk Prostate Cancer Initial Evaluation Form
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