ID

2620

Beschrijving

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

Trefwoorden

Versies (2)
  1. 19-09-12 19-09-12 -
  2. 23-03-15 23-03-15 - Martin Dugas
Geüploaded op

19 september 2012

DOI

Voor een aanvraag inloggen.

Licentie

Creative Commons BY-NC 3.0 Legacy
Model Commentaren :

Hier kunt u commentaar leveren op het model. U kunt de tekstballonnen bij de itemgroepen en items gebruiken om er specifiek commentaar op te geven.

Terug naar het model Commentaren
Itemgroep Commentaren voor :

Item Commentaren voor :

U moet ingelogd zijn om formulieren te downloaden. AUB inloggen of schrijf u gratis in.

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

Engels

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 Formulieren  
  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
Beschrijving

Unnamed1

AMENDED DATA
Beschrijving

AmendedData

Datatype

text

Unnamed2
Beschrijving

Unnamed2

RTOG Study
Beschrijving

RTOGStudy

Datatype

text

Case #
Beschrijving

Case#

Datatype

text

Institution Name
Beschrijving

InstitutionName

Datatype

text

Institution No.
Beschrijving

InstitutionNo.

Datatype

text

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

PatientName,Last

Datatype

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)
Beschrijving

PatientName,First

Datatype

text

Unnamed3
Beschrijving

Unnamed3

Unnamed4
Beschrijving

Unnamed4

PATIENT BIRTH DATE (2)
Beschrijving

PatientBirthDate

Datatype

date

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

PERFORMANCESTATUS

Datatype

text

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

HASPATIENTHADANOTHERMALIGNANCY

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Specify Site (malignancy other than study site)
Beschrijving

SpecifySite(malignancyotherthanstudysite)

Datatype

text

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

DATEERADICATED

Datatype

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)
Beschrijving

FirstPositiveBiopsyDate

Datatype

date

HISTOLOGIC TYPE
Beschrijving

HistologicType

Datatype

text

Other, specify (histologic type) (B)
Beschrijving

Other,specify(histologictype)

Datatype

text

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

GleasonScore,PrimaryPattern

Datatype

double

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

GleasonScore,SecondaryPattern

Datatype

double

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

GleasonScore,WorstPattern

Datatype

double

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

GleasonScore,Combined

Datatype

double

Prostate: Prior Treatment
Beschrijving

Prostate: Prior Treatment

PRIOR PROSTATECTOMY
Beschrijving

PriorProstatectomyInd

Datatype

text

Prior prostatectomy date
Beschrijving

PriorProstatectomyDate

Datatype

date

POSITIVE SURGICAL MARGINS
Beschrijving

POSITIVESURGICALMARGINS

Datatype

text

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

SEMINALVESICLEINVASION

Datatype

text

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

PRIORRADIATIONTHERAPY

Datatype

text

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

Specify(priorradiationtherapy)

Datatype

text

PRIOR CHEMOTHERAPY (for any reason)
Beschrijving

PRIORCHEMOTHERAPY

Datatype

text

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

PriorChemotherapyEndDate

Datatype

date

PRIOR HORMONAL THERAPY (A)
Beschrijving

PRIORHORMONALTHERAPY

Datatype

text

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

PRIORHORMONALTHERAPYTYPEFINASTERIDE

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
PRIOR HORMONAL THERAPY TYPE TESTOSTERONE
Beschrijving

PRIORHORMONALTHERAPYTYPETESTOSTERONE

Datatype

text

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

PriorHormonalTherapyEndDate

Datatype

date

Prior hormonal therapy end date (C)
Beschrijving

PriorHormonalTherapyEndDate

Datatype

date

PRIOR OTHER HORMONAL THERAPY
Beschrijving

PRIOROTHERHORMONALTHERAPY

Datatype

text

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

Specify(priorotherhormonaltherapy)

Datatype

text

Date prior other hormonal therapy started (D)
Beschrijving

PriorOtherHormonalTherapyBeginDate

Datatype

date

ORCHIECTOMY
Beschrijving

ORCHIECTOMY

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Orchiectomy date (E)
Beschrijving

OrchiectomyDate

Datatype

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
Beschrijving

PRIORORCURRENTCOMPLEMENTARYALTERNATIVEMEDICINE(CAM)THERAPY

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Specify (prior or current complementary alternative medicine therapy)
Beschrijving

Specify(priororcurrentcomplementaryalternativemedicinetherapy)

Datatype

text

Date prior or current CAM therapy started
Beschrijving

DatepriororcurrentCAMtherapystarted

Datatype

date

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

PriorCAMtherapyenddate

Datatype

date

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

Unnamed5

AMENDED DATA
Beschrijving

AmendedData

Datatype

text

Unnamed6
Beschrijving

Unnamed6

RTOG Study
Beschrijving

RTOGStudy

Datatype

text

Case #
Beschrijving

Case#

Datatype

text

Institution Name
Beschrijving

InstitutionName

Datatype

text

Institution No.
Beschrijving

InstitutionNo.

Datatype

text

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

PatientName,Last

Datatype

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)
Beschrijving

PatientName,First

Datatype

text

Unnamed7
Beschrijving

Unnamed7

ALKALINE PHOSPHATASE
Beschrijving

ALKALINEPHOSPHATASE

Datatype

text

Alk Phos Value
Beschrijving

AlkPhosValue

Datatype

double

SPECIFY (unit of measure)
Beschrijving

SPECIFY(unitofmeasure)

Datatype

text

Lab normal range (alkaline phosphatase) (B)
Beschrijving

Labnormalrange(alkalinephosphatase)

Datatype

text

ALT (SGPT)
Beschrijving

ALT(SGPT)

Datatype

text

ALT Value
Beschrijving

ALTValue

Datatype

double

Lab normal range (ALT) (C)
Beschrijving

LaboratoryProcedureSerumGlutamicPyruvicTransaminaseResultNormalRangeText

Datatype

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
Beschrijving

TOTALBILIRUBIN

Datatype

text

Total Bilirubin Value
Beschrijving

TotalBilirubinValue

Datatype

double

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

Labnormalrange(totalbilirubin)

Datatype

text

Baseline PSA Date
Beschrijving

BaselinePSADate

Datatype

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Baseline PSA Value
Beschrijving

BaselinePSAValue

Datatype

text

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

TIMEPOINT

Datatype

text

URINARY INCONTINENCE, Severity Grade (0-3)
Beschrijving

URINARYINCONTINENCE,SeverityGrade

Datatype

text

URINARY INCONTINENCE, Attribution
Beschrijving

URINARYINCONTINENCE,Attribution

Datatype

text

Other (attribution, urinary incontinence)
Beschrijving

Other(attribution,urinaryincontinence)

Datatype

text

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

URINARYFREQUENCY/URGENCY,SeverityGrade

Datatype

text

URINARY FREQUENCY/URGENCY, Attribution
Beschrijving

URINARYFREQUENCY/URGENCY,Attribution

Datatype

text

Other (attribution, urinary frequency/urgency)
Beschrijving

Other(attribution,urinaryfrequency/urgency)

Datatype

text

ERECTILE IMPOTENCE, Severity Grade (0-3)
Beschrijving

ERECTILEIMPOTENCE,SeverityGrade

Datatype

text

ERECTILE IMPOTENCE, Attribution
Beschrijving

ERECTILEIMPOTENCE,Attribution

Datatype

text

Other (erectile impotence) (13)
Beschrijving

Other(erectileimpotence)

Datatype

text

T STAGE, PATHOLOGIC (14A)
Beschrijving

TStage,Pathologic

Datatype

text

N STAGE, PATHOLOGIC (SURGICAL)
Beschrijving

NStage,Pathologic

Datatype

text

N STAGE, CLINICAL (RADIOGRAPHIC)
Beschrijving

NStage,Clinical

Datatype

text

ROACH RISK CALCULATION (15)
Beschrijving

ROACHRISKCALCULATION

Datatype

text

M STAGE, CLINICAL
Beschrijving

MStage,Clinical

Datatype

text

COMMENTS
Beschrijving

Comments

Datatype

text

Signature
Beschrijving

Signature

Datatype

text

Date
Beschrijving

Date

Datatype

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
Beschrijving

Ccrr Module For I1 Radiation Therapy Oncology Group Phase Iii Randomized Study Of Adjuvant Therapy For High Risk Pt3no Prostate Cancer Initial Evaluation Form

Terug naar het begin van de pagina

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 Formulieren
  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)
Datatype
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
Terug naar het begin van de pagina 

Contact

Gebruik dit formulier voor feedback, vragen en verbeteringsvoorstellen.

Velden gemarkeerd met een * zijn verplicht.

Help

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial