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

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

Keywords

Versions (2)
  1. 9/19/12 9/19/12 -
  2. 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

English

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 forms  
Unnamed1
Description

Unnamed1

Amended Data
Description

AmendedDataInd

Data type

text

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

Unnamed2

RTOG Study
Description

RTOGStudy

Data type

text

Case #
Description

Case#

Data type

text

Institution Name
Description

InstitutionName

Data type

text

Institution No.
Description

NCIInstitutionNumber

Data type

text

Patient Name, Last
Description

PatientName,Last

Data type

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)
Description

PatientName,First

Data type

text

Unnamed3
Description

Unnamed3

Unnamed4
Description

Unnamed4

PATIENT BIRTH DATE
Description

PatientBirthDate

Data type

date

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

PerformanceStatus

Data type

text

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

PriorCancerInd

Data type

text

Specify Site (malignancy other than study site)
Description

SpecifySite(malignancyotherthanstudysite)

Data type

text

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

DATEERADICATED

Data type

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)
Description

FirstPositiveBiopsyDate

Data type

date

HISTOLOGIC TYPE
Description

HistologicType

Data type

text

Other, specify (histologic type)
Description

HistologicType,OtherVariant

Data type

text

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

GleasonScore,PrimaryPattern

Data type

double

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

GleasonScore,SecondaryPattern

Data type

double

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

GleasonScore,WorstPattern

Data type

double

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

GleasonScore,Combined

Data type

double

Prostate: Prior Treatment
Description

Prostate: Prior Treatment

PRIOR PROSTATECTOMY
Description

PriorProstatectomyInd

Data type

text

Prior prostatectomy date
Description

PriorProstatectomyDate

Data type

date

PRIOR RADIATION THERAPY
Description

PriorRTInd

Data type

text

Specify (prior radiation therapy)
Description

RTOtherType

Data type

text

PRIOR CHEMOTHERAPY (for any reason)
Description

PriorChemotherapyInd

Data type

text

Prior chemotherapy end date
Description

PriorChemotherapyEndDate

Data type

date

Specify (prior chemotherapy)
Description

SystemicTherapyType,Other

Data type

text

PRIOR HORMONAL THERAPY
Description

PriorHormonalTherapyInd

Data type

text

PRIOR HORMONAL THERAPY TYPE
Description

PriorHormonalType

Data type

text

Prior hormonal therapy start date
Description

PriorHormonalTherapyBeginDate

Data type

date

Prior hormonal therapy end date (C)
Description

PriorHormonalTherapyEndDate

Data type

date

Specify (Prior Hormonal Therapy Type)
Description

Other,specify(priorhormonaltherapy)

Data type

text

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

ORCHIECTOMY

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Orchiectomy date
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
PRIOR SURGERY (TURP)
Description

PriorSurgeryInd

Data type

text

Prior surgery (TURP) date
Description

PriorSurgeryDate

Data type

date

PRIOR OR CURRENT COMPLEMENTARY ALTERNATIVE MEDICINE (CAM) THERAPY
Description

PRIORORCURRENTCOMPLEMENTARYALTERNATIVEMEDICINE(CAM)THERAPY

Data type

text

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

OtherTherapyName

Data type

text

Date prior or current CAM therapy started
Description

DatepriororcurrentCAMtherapystarted

Data type

date

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

PriorCAMtherapyenddate

Data type

date

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

Unnamed5

Amended Data
Description

AmendedDataInd

Data type

text

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

Unnamed6

RTOG Study
Description

RTOGStudy

Data type

text

Case #
Description

Case#

Data type

text

Institution Name
Description

InstitutionName

Data type

text

Institution No.
Description

NCIInstitutionNumber

Data type

text

Patient Name, Last
Description

PatientName,Last

Data type

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)
Description

PatientName,First

Data type

text

Unnamed7
Description

Unnamed7

PALPABLE TUMOR (at study entry)
Description

PALPABLETUMOR

Data type

text

LARGEST DIMENSION (cm)
Description

TumorSize,LargestDimension

Data type

double

PERPENDICULAR DIMENION (cm)
Description

TumorSize,SecondDimension

Data type

double

DIMENSIONS REPORTED ARE
Description

DIMENSIONSREPORTEDARE

Data type

text

TUMOR BEYOND CAPSULE AS DETERMINED BY CLINICAL EXAMINATION
Description

ExtracapsularExtensionInd

Data type

text

VOLUME OF GLAND BY TRUS (Grams)
Description

TumorSize,TotalVolume

Data type

double

VOLUME OF GLAND BY TRUS (Grams)
Description

TumorSize,TotalVolume

Data type

double

Baseline PSA Date
Description

BaselinePSADate

Data type

date

Bseline PSA Value
Description

BaselinePSAValue

Data type

double

TIME POINT
Description

TIMEPOINT

Data type

text

PRIOR HORMONAL THERAPY TYPE TESTOSTERONE
Description

PRIORHORMONALTHERAPYTYPETESTOSTERONE

Data type

text

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

PriorHormonalTherapyEndDate

Data type

date

PRIOR OTHER HORMONAL THERAPY
Description

PRIOROTHERHORMONALTHERAPY

Data type

text

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

Specify(priorotherhormonaltherapy)

Data type

text

Date prior other hormonal therapy started (D)
Description

PriorOtherHormonalTherapyBeginDate

Data type

date

Specify (prior or current complementary alternative medicine therapy)
Description

Specify(priororcurrentcomplementaryalternativemedicinetherapy)

Data type

text

PRIOR OR CURRENT COMPLEMENTARY ALTERNATIVE MEDICINE (CAM) THERAPY
Description

PRIORORCURRENTCOMPLEMENTARYALTERNATIVEMEDICINE(CAM)THERAPY

Data type

text

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

DatepriororcurrentCAMtherapystarted

Data type

date

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

PriorCAMtherapyenddate

Data type

date

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

Unnamed5

AMENDED DATA
Description

AmendedData

Data type

text

Unnamed6
Description

Unnamed6

Case #
Description

Case#

Data type

text

Institution Name
Description

InstitutionName

Data type

text

Institution No.
Description

InstitutionNo.

Data type

text

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

PatientName,Last

Data type

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)
Description

PatientName,First

Data type

text

RTOG Study
Description

RTOGStudy

Data type

text

Unnamed7
Description

Unnamed7

Alk Phos Value
Description

AlkPhosValue

Data type

double

SPECIFY (unit of measure)
Description

SPECIFY(unitofmeasure)

Data type

text

Lab normal range (alkaline phosphatase) (B)
Description

Labnormalrange(alkalinephosphatase)

Data type

text

ALT (SGPT)
Description

ALT(SGPT)

Data type

text

ALT Value
Description

ALTValue

Data type

double

Lab normal range (ALT) (C)
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
Total Bilirubin Value
Description

TotalBilirubinValue

Data type

double

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

Labnormalrange(totalbilirubin)

Data type

text

Baseline PSA Date
Description

BaselinePSADate

Data type

date

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

TStage,Pathologic

Data type

text

N STAGE, PATHOLOGIC (SURGICAL)
Description

NStage,Pathologic

Data type

text

N STAGE, CLINICAL (RADIOGRAPHIC)
Description

NStage,Clinical

Data type

text

M STAGE, CLINICAL
Description

MStage,Clinical

Data type

text

COMMENTS
Description

Comments

Data type

text

Signature
Description

SignatureofPersonCompletingThisForm

Data type

text

Date
Description

FormCompletionDate,Original

Data type

date

ALKALINE PHOSPHATASE
Description

ALKALINEPHOSPHATASE

Data type

text

TOTAL BILIRUBIN
Description

TOTALBILIRUBIN

Data type

text

Baseline PSA Value
Description

BaselinePSAValue

Data type

text

TIME POINT
Description

TIMEPOINT

Data type

text

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

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
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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