ID

2620

Description

I1 Radiation Therapy Oncology Group Phase III Randomized Study of Adjuvant Therapy for High Risk pT3NO Prostate Cancer Initial Evaluation Form Adjuvant Radiation Therapy Plus Hormone Therapy Compared With Radiation Therapy Alone in Treating Patients With Stage II or Stage III Prostate Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A4E26ACF-75E7-25EA-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A4E26ACF-75E7-25EA-E034-080020C9C0E0

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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NCT00023829 On-Study - I1 Radiation Therapy Oncology Group Phase III Randomized Study of Adjuvant Therapy for High Risk pT3NO Prostate Cancer Initial Evaluation Form - 2039983v3.0

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  
  1. StudyEvent: I1 Radiation Therapy Oncology Group Phase III Randomized Study of Adjuvant Therapy for High Risk pT3NO Prostate Cancer Initial Evaluation Form
    1. 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.
Unnamed1
Description

Unnamed1

AMENDED DATA
Description

AmendedData

Data type

text

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

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

Unnamed3
Description

Unnamed3

Unnamed4
Description

Unnamed4

PATIENT BIRTH DATE (2)
Description

PatientBirthDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25275
UMLS 2011AA Property
C2745955
PERFORMANCE STATUS (3)
Description

PERFORMANCESTATUS

Data type

text

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

HASPATIENTHADANOTHERMALIGNANCY

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
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 (5 HISTOPATHOLOGIC TYPE)
Description

FirstPositiveBiopsyDate

Data type

date

HISTOLOGIC TYPE
Description

HistologicType

Data type

text

Other, specify (histologic type) (B)
Description

Other,specify(histologictype)

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

POSITIVE SURGICAL MARGINS
Description

POSITIVESURGICALMARGINS

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
SEMINAL VESICLE INVASION (pathologic)
Description

SEMINALVESICLEINVASION

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
PRIOR RADIATION THERAPY
Description

PRIORRADIATIONTHERAPY

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Specify (prior radiation therapy) (8)
Description

Specify(priorradiationtherapy)

Data type

text

PRIOR CHEMOTHERAPY (for any reason)
Description

PRIORCHEMOTHERAPY

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Prior chemotherapy end date (9)
Description

PriorChemotherapyEndDate

Data type

date

PRIOR HORMONAL THERAPY (A)
Description

PRIORHORMONALTHERAPY

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
PRIOR HORMONAL THERAPY TYPE FINASTERIDE
Description

PRIORHORMONALTHERAPYTYPEFINASTERIDE

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
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 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

ORCHIECTOMY
Description

ORCHIECTOMY

Data type

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Orchiectomy date (E)
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 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 complementary alternative medicine therapy)
Description

Specify(priororcurrentcomplementaryalternativemedicinetherapy)

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

AmendedData

Data type

text

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

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

Unnamed7
Description

Unnamed7

ALKALINE PHOSPHATASE
Description

ALKALINEPHOSPHATASE

Data type

text

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
Description

TOTALBILIRUBIN

Data type

text

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
Baseline PSA Value
Description

BaselinePSAValue

Data type

text

TIME POINT (12 GU DYSFUNCTION AT STUDY ENTRY Use CTC 2.0 to code severity)
Description

TIMEPOINT

Data type

text

URINARY INCONTINENCE, Severity Grade (0-3)
Description

URINARYINCONTINENCE,SeverityGrade

Data type

text

URINARY INCONTINENCE, Attribution
Description

URINARYINCONTINENCE,Attribution

Data type

text

Other (attribution, urinary incontinence)
Description

Other(attribution,urinaryincontinence)

Data type

text

URINARY FREQUENCY/URGENCY, Severity Grade (0-3)
Description

URINARYFREQUENCY/URGENCY,SeverityGrade

Data type

text

URINARY FREQUENCY/URGENCY, Attribution
Description

URINARYFREQUENCY/URGENCY,Attribution

Data type

text

Other (attribution, urinary frequency/urgency)
Description

Other(attribution,urinaryfrequency/urgency)

Data type

text

ERECTILE IMPOTENCE, Severity Grade (0-3)
Description

ERECTILEIMPOTENCE,SeverityGrade

Data type

text

ERECTILE IMPOTENCE, Attribution
Description

ERECTILEIMPOTENCE,Attribution

Data type

text

Other (erectile impotence) (13)
Description

Other(erectileimpotence)

Data type

text

T STAGE, PATHOLOGIC (14A)
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

ROACH RISK CALCULATION (15)
Description

ROACHRISKCALCULATION

Data type

text

M STAGE, CLINICAL
Description

MStage,Clinical

Data type

text

COMMENTS
Description

Comments

Data type

text

Signature
Description

Signature

Data type

text

Date
Description

Date

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Ccrr Module For I1 Radiation Therapy Oncology Group Phase Iii Randomized Study Of Adjuvant Therapy For High Risk Pt3no Prostate Cancer Initial Evaluation Form
Description

Ccrr Module For I1 Radiation Therapy Oncology Group Phase Iii Randomized Study Of Adjuvant Therapy For High Risk Pt3no 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
  1. StudyEvent: I1 Radiation Therapy Oncology Group Phase III Randomized Study of Adjuvant Therapy for High Risk pT3NO Prostate Cancer Initial Evaluation Form
    1. 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.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Unnamed1
AmendedData
Item
AMENDED DATA
text
Item Group
Unnamed2
RTOGStudy
Item
RTOG Study
text
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
Item Group
Unnamed3
Item Group
Unnamed4
PatientBirthDate
Item
PATIENT BIRTH DATE (2)
date
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
Item
PERFORMANCE STATUS (3)
text
CL.1
Code List
PERFORMANCE STATUS (3)
CL Item
0 (0)
C0919414 (NCI Metathesaurus)
CL Item
1 (1)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
3 (3)
CL Item
4 (4)
CL Item
-1 (-1)
Item
HAS PATIENT HAD ANOTHER MALIGNANCY (other than study site)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.2
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 (5 HISTOPATHOLOGIC TYPE)
date
Item
HISTOLOGIC TYPE
text
CL.3
Code List
HISTOLOGIC TYPE
CL Item
Adenocarcinoma_2005009 (Adenocarcinoma)
CL Item
Other_specify_2005013 (Other, specify)
CL Item
Unknown or not applicable (Unknown or not applicable)
Other,specify(histologictype)
Item
Other, specify (histologic type) (B)
text
Item
GLEASON SCORE, PRIMARY PATTERN ([most frequently seen] 1-5, 9=unknown)
double
CL.4
Code List
GLEASON SCORE, PRIMARY PATTERN ([most frequently seen] 1-5, 9=unknown)
CL Item
1 (1)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
3 (3)
CL Item
4 (4)
CL Item
5 (5)
CL Item
Unknown (9)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
GLEASON SCORE, SECONDARY PATTERN ([second most frequently seen] 1-5, 9=unknown)
double
CL.5
Code List
GLEASON SCORE, SECONDARY PATTERN ([second most frequently seen] 1-5, 9=unknown)
CL Item
1 (1)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
3 (3)
CL Item
4 (4)
CL Item
5 (5)
CL Item
Unknown (9)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
GLEASON SCORE, WORST PATTERN ([worst pathological grade seen in any specimen] 1-5, 9=unknown)
double
CL.6
Code List
GLEASON SCORE, WORST PATTERN ([worst pathological grade seen in any specimen] 1-5, 9=unknown)
CL Item
1 (1)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
3 (3)
CL Item
4 (4)
CL Item
5 (5)
CL Item
Unknown (9)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
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.7
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
POSITIVE SURGICAL MARGINS
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.8
Code List
POSITIVE SURGICAL MARGINS
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
SEMINAL VESICLE INVASION (pathologic)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.9
Code List
SEMINAL VESICLE INVASION (pathologic)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
PRIOR RADIATION THERAPY
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.10
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)
Specify(priorradiationtherapy)
Item
Specify (prior radiation therapy) (8)
text
Item
PRIOR CHEMOTHERAPY (for any reason)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.11
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 (9)
date
Item
PRIOR HORMONAL THERAPY (A)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.12
Code List
PRIOR HORMONAL THERAPY (A)
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 FINASTERIDE
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.13
Code List
PRIOR HORMONAL THERAPY TYPE FINASTERIDE
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 TESTOSTERONE
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.14
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
PriorHormonalTherapyEndDate
Item
Prior hormonal therapy end date (C)
date
Item
PRIOR OTHER HORMONAL THERAPY
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.15
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
Item
ORCHIECTOMY
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.16
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 (E)
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 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)
Specify(priororcurrentcomplementaryalternativemedicinetherapy)
Item
Specify (prior or current complementary alternative medicine therapy)
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
AmendedData
Item
AMENDED DATA
text
Item Group
Unnamed6
RTOGStudy
Item
RTOG Study
text
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
Item Group
Unnamed7
Item
ALKALINE PHOSPHATASE
text
CL.18
Code List
ALKALINE PHOSPHATASE
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)
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)
Item
TOTAL BILIRUBIN
text
CL.21
Code List
TOTAL BILIRUBIN
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)
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)
BaselinePSAValue
Item
Baseline PSA Value
text
Item
TIME POINT (12 GU DYSFUNCTION AT STUDY ENTRY Use CTC 2.0 to code severity)
text
CL.22
Code List
TIME POINT (12 GU DYSFUNCTION AT STUDY ENTRY Use CTC 2.0 to code severity)
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
URINARY INCONTINENCE, Severity Grade (0-3)
text
CL.23
Code List
URINARY INCONTINENCE, Severity Grade (0-3)
CL Item
0 (0)
C0919414 (NCI Metathesaurus)
CL Item
1 (1)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
3 (3)
Item
URINARY INCONTINENCE, Attribution
text
CL.24
Code List
URINARY INCONTINENCE, Attribution
CL Item
Not Applicable (Not applicable)
C48660 (NCI Thesaurus)
C1272460 (UMLS 2011AA)
CL Item
Surgical (Surgical)
C25698 (NCI Thesaurus)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
Other(attribution,urinaryincontinence)
Item
Other (attribution, urinary incontinence)
text
Item
URINARY FREQUENCY/URGENCY, Severity Grade (0-3)
text
CL.25
Code List
URINARY FREQUENCY/URGENCY, Severity Grade (0-3)
CL Item
0 (0)
C0919414 (NCI Metathesaurus)
CL Item
1 (1)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
3 (3)
Item
URINARY FREQUENCY/URGENCY, Attribution
text
CL.26
Code List
URINARY FREQUENCY/URGENCY, Attribution
CL Item
Not Applicable (Not applicable)
C48660 (NCI Thesaurus)
C1272460 (UMLS 2011AA)
CL Item
Surgical (Surgical)
C25698 (NCI Thesaurus)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
Other(attribution,urinaryfrequency/urgency)
Item
Other (attribution, urinary frequency/urgency)
text
Item
ERECTILE IMPOTENCE, Severity Grade (0-3)
text
CL.27
Code List
ERECTILE IMPOTENCE, Severity Grade (0-3)
CL Item
0 (0)
C0919414 (NCI Metathesaurus)
CL Item
1 (1)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
3 (3)
Item
ERECTILE IMPOTENCE, Attribution
text
CL.28
Code List
ERECTILE IMPOTENCE, Attribution
CL Item
Not Applicable (Not applicable)
C48660 (NCI Thesaurus)
C1272460 (UMLS 2011AA)
CL Item
Surgical (Surgical)
C25698 (NCI Thesaurus)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
Other(erectileimpotence)
Item
Other (erectile impotence) (13)
text
Item
T STAGE, PATHOLOGIC (14A)
text
CL.29
Code List
T STAGE, PATHOLOGIC (14A)
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.30
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.31
Code List
N STAGE, CLINICAL (RADIOGRAPHIC)
CL Item
No Regional Lymph Node Metastasis (N0)
CL Item
Metastasis To Movable Ipsilateral Axillary Lymph Node(s) (N1)
CL Item
Regional Lymph Nodes Cannot Be Assessed (e.g., Previously Removed) (NX)
Item
ROACH RISK CALCULATION (15)
text
CL.32
Code List
ROACH RISK CALCULATION (15)
CL Item
<15% (<15%)
CL Item
>=15% (>=15%)
Item
M STAGE, CLINICAL
text
CL.33
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
Signature
Item
Signature
text
Date
Item
Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Item Group
Ccrr Module For I1 Radiation Therapy Oncology Group Phase Iii Randomized Study Of Adjuvant Therapy For High Risk Pt3no Prostate Cancer Initial Evaluation Form
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