ID

2601

Descrizione

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

collegamento

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

Keywords

versioni (2)
  1. 19/09/12 19/09/12 -
  2. 23/03/15 23/03/15 - Martin Dugas
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19 settembre 2012

DOI

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Licenza

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

Inglese

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 moduli  
Unnamed1
Descrizione

Unnamed1

Amended Data
Descrizione

AmendedDataInd

Tipo di dati

text

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

Unnamed2

RTOG Study
Descrizione

RTOGStudy

Tipo di dati

text

Case #
Descrizione

Case#

Tipo di dati

text

Institution Name
Descrizione

InstitutionName

Tipo di dati

text

Institution No.
Descrizione

NCIInstitutionNumber

Tipo di dati

text

Patient Name, Last
Descrizione

PatientName,Last

Tipo di dati

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)
Descrizione

PatientName,First

Tipo di dati

text

Unnamed3
Descrizione

Unnamed3

Unnamed4
Descrizione

Unnamed4

PATIENT BIRTH DATE
Descrizione

PatientBirthDate

Tipo di dati

date

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

PerformanceStatus

Tipo di dati

text

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

PriorCancerInd

Tipo di dati

text

Specify Site (malignancy other than study site)
Descrizione

SpecifySite(malignancyotherthanstudysite)

Tipo di dati

text

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

DATEERADICATED

Tipo di dati

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)
Descrizione

FirstPositiveBiopsyDate

Tipo di dati

date

HISTOLOGIC TYPE
Descrizione

HistologicType

Tipo di dati

text

Other, specify (histologic type)
Descrizione

HistologicType,OtherVariant

Tipo di dati

text

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

GleasonScore,PrimaryPattern

Tipo di dati

double

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

GleasonScore,SecondaryPattern

Tipo di dati

double

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

GleasonScore,WorstPattern

Tipo di dati

double

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

GleasonScore,Combined

Tipo di dati

double

Prostate: Prior Treatment
Descrizione

Prostate: Prior Treatment

PRIOR PROSTATECTOMY
Descrizione

PriorProstatectomyInd

Tipo di dati

text

Prior prostatectomy date
Descrizione

PriorProstatectomyDate

Tipo di dati

date

PRIOR RADIATION THERAPY
Descrizione

PriorRTInd

Tipo di dati

text

Specify (prior radiation therapy)
Descrizione

RTOtherType

Tipo di dati

text

PRIOR CHEMOTHERAPY (for any reason)
Descrizione

PriorChemotherapyInd

Tipo di dati

text

Prior chemotherapy end date
Descrizione

PriorChemotherapyEndDate

Tipo di dati

date

Specify (prior chemotherapy)
Descrizione

SystemicTherapyType,Other

Tipo di dati

text

PRIOR HORMONAL THERAPY
Descrizione

PriorHormonalTherapyInd

Tipo di dati

text

PRIOR HORMONAL THERAPY TYPE
Descrizione

PriorHormonalType

Tipo di dati

text

Prior hormonal therapy start date
Descrizione

PriorHormonalTherapyBeginDate

Tipo di dati

date

Prior hormonal therapy end date (C)
Descrizione

PriorHormonalTherapyEndDate

Tipo di dati

date

Specify (Prior Hormonal Therapy Type)
Descrizione

Other,specify(priorhormonaltherapy)

Tipo di dati

text

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

ORCHIECTOMY

Tipo di dati

text

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

OrchiectomyDate

Tipo di dati

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)
Descrizione

PriorSurgeryInd

Tipo di dati

text

Prior surgery (TURP) date
Descrizione

PriorSurgeryDate

Tipo di dati

date

PRIOR OR CURRENT COMPLEMENTARY ALTERNATIVE MEDICINE (CAM) THERAPY
Descrizione

PRIORORCURRENTCOMPLEMENTARYALTERNATIVEMEDICINE(CAM)THERAPY

Tipo di dati

text

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

OtherTherapyName

Tipo di dati

text

Date prior or current CAM therapy started
Descrizione

DatepriororcurrentCAMtherapystarted

Tipo di dati

date

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

PriorCAMtherapyenddate

Tipo di dati

date

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

Unnamed5

Amended Data
Descrizione

AmendedDataInd

Tipo di dati

text

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

Unnamed6

RTOG Study
Descrizione

RTOGStudy

Tipo di dati

text

Case #
Descrizione

Case#

Tipo di dati

text

Institution Name
Descrizione

InstitutionName

Tipo di dati

text

Institution No.
Descrizione

NCIInstitutionNumber

Tipo di dati

text

Patient Name, Last
Descrizione

PatientName,Last

Tipo di dati

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)
Descrizione

PatientName,First

Tipo di dati

text

Unnamed7
Descrizione

Unnamed7

PALPABLE TUMOR (at study entry)
Descrizione

PALPABLETUMOR

Tipo di dati

text

LARGEST DIMENSION (cm)
Descrizione

TumorSize,LargestDimension

Tipo di dati

double

PERPENDICULAR DIMENION (cm)
Descrizione

TumorSize,SecondDimension

Tipo di dati

double

DIMENSIONS REPORTED ARE
Descrizione

DIMENSIONSREPORTEDARE

Tipo di dati

text

TUMOR BEYOND CAPSULE AS DETERMINED BY CLINICAL EXAMINATION
Descrizione

ExtracapsularExtensionInd

Tipo di dati

text

VOLUME OF GLAND BY TRUS (Grams)
Descrizione

TumorSize,TotalVolume

Tipo di dati

double

VOLUME OF GLAND BY TRUS (Grams)
Descrizione

TumorSize,TotalVolume

Tipo di dati

double

Baseline PSA Date
Descrizione

BaselinePSADate

Tipo di dati

date

Bseline PSA Value
Descrizione

BaselinePSAValue

Tipo di dati

double

TIME POINT
Descrizione

TIMEPOINT

Tipo di dati

text

PRIOR HORMONAL THERAPY TYPE TESTOSTERONE
Descrizione

PRIORHORMONALTHERAPYTYPETESTOSTERONE

Tipo di dati

text

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

PriorHormonalTherapyEndDate

Tipo di dati

date

PRIOR OTHER HORMONAL THERAPY
Descrizione

PRIOROTHERHORMONALTHERAPY

Tipo di dati

text

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

Specify(priorotherhormonaltherapy)

Tipo di dati

text

Date prior other hormonal therapy started (D)
Descrizione

PriorOtherHormonalTherapyBeginDate

Tipo di dati

date

Specify (prior or current complementary alternative medicine therapy)
Descrizione

Specify(priororcurrentcomplementaryalternativemedicinetherapy)

Tipo di dati

text

PRIOR OR CURRENT COMPLEMENTARY ALTERNATIVE MEDICINE (CAM) THERAPY
Descrizione

PRIORORCURRENTCOMPLEMENTARYALTERNATIVEMEDICINE(CAM)THERAPY

Tipo di dati

text

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

DatepriororcurrentCAMtherapystarted

Tipo di dati

date

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

PriorCAMtherapyenddate

Tipo di dati

date

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

Unnamed5

AMENDED DATA
Descrizione

AmendedData

Tipo di dati

text

Unnamed6
Descrizione

Unnamed6

Case #
Descrizione

Case#

Tipo di dati

text

Institution Name
Descrizione

InstitutionName

Tipo di dati

text

Institution No.
Descrizione

InstitutionNo.

Tipo di dati

text

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

PatientName,Last

Tipo di dati

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)
Descrizione

PatientName,First

Tipo di dati

text

RTOG Study
Descrizione

RTOGStudy

Tipo di dati

text

Unnamed7
Descrizione

Unnamed7

Alk Phos Value
Descrizione

AlkPhosValue

Tipo di dati

double

SPECIFY (unit of measure)
Descrizione

SPECIFY(unitofmeasure)

Tipo di dati

text

Lab normal range (alkaline phosphatase) (B)
Descrizione

Labnormalrange(alkalinephosphatase)

Tipo di dati

text

ALT (SGPT)
Descrizione

ALT(SGPT)

Tipo di dati

text

ALT Value
Descrizione

ALTValue

Tipo di dati

double

Lab normal range (ALT) (C)
Descrizione

LaboratoryProcedureSerumGlutamicPyruvicTransaminaseResultNormalRangeText

Tipo di dati

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
Descrizione

TotalBilirubinValue

Tipo di dati

double

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

Labnormalrange(totalbilirubin)

Tipo di dati

text

Baseline PSA Date
Descrizione

BaselinePSADate

Tipo di dati

date

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

TStage,Pathologic

Tipo di dati

text

N STAGE, PATHOLOGIC (SURGICAL)
Descrizione

NStage,Pathologic

Tipo di dati

text

N STAGE, CLINICAL (RADIOGRAPHIC)
Descrizione

NStage,Clinical

Tipo di dati

text

M STAGE, CLINICAL
Descrizione

MStage,Clinical

Tipo di dati

text

COMMENTS
Descrizione

Comments

Tipo di dati

text

Signature
Descrizione

SignatureofPersonCompletingThisForm

Tipo di dati

text

Date
Descrizione

FormCompletionDate,Original

Tipo di dati

date

ALKALINE PHOSPHATASE
Descrizione

ALKALINEPHOSPHATASE

Tipo di dati

text

TOTAL BILIRUBIN
Descrizione

TOTALBILIRUBIN

Tipo di dati

text

Baseline PSA Value
Descrizione

BaselinePSAValue

Tipo di dati

text

TIME POINT
Descrizione

TIMEPOINT

Tipo di dati

text

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

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

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Similar models

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 moduli
Name
genere
Description | Question | Decode (Coded Value)
Tipo di dati
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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