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INSTRUCTIONS: Submit this form at the completion of protocol hormone therapy. Use -1 for unknown or not applicable unless otherwise specified in the code table. All dates to be reported mm-dd-yyyy unless otherwise indicated.

1 Formulär  
  1. StudyEvent: TF Radiation Therapy Oncology Group Phase III Randomized Study of Adjuvant Therapy for High Risk pT3NO Prostate Cancer Hormone Protocol Treatment Summary Form
    1. INSTRUCTIONS: Submit this form at the completion of protocol hormone therapy. Use -1 for unknown or not applicable unless otherwise specified in the code table. All dates to be reported mm-dd-yyyy unless otherwise indicated.
Unnamed1
Beskrivning

Unnamed1

RTOG Study
Beskrivning

RTOGStudy

Datatyp

text

Case #
Beskrivning

Case#

Datatyp

text

Institution Name
Beskrivning

InstitutionName

Datatyp

text

Institution No.
Beskrivning

InstitutionNo.

Datatyp

text

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

PatientName,Last

Datatyp

text

Patient Name, First
Beskrivning

PatientName,First

Datatyp

text

Unnamed2
Beskrivning

Unnamed2

Amended Data
Beskrivning

AmendedData

Datatyp

text

Unnamed3
Beskrivning

Unnamed3

Agent (AGENT NAME)
Beskrivning

Agent

Datatyp

text

(if other, specify) (agent)
Beskrivning

(ifother,specify)(agent)

Datatyp

text

Agent total cumulative dose
Beskrivning

AgentTotalCumulativeDose

Datatyp

double

First Date above agent protocol therapy was given
Beskrivning

FirstDateaboveagentprotocoltherapywasgiven

Datatyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Last Date above agent protocol therapy was given
Beskrivning

LastDateaboveagentprotocoltherapywasgiven

Datatyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Reason treatment ended (REASON TREATMENT ENDED)
Beskrivning

OffTreatmentReason

Datatyp

text

(specify) (reason treatment ended)
Beskrivning

(specify)(reasontreatmentended)

Datatyp

text

Comments
Beskrivning

Comments

Datatyp

text

Signature
Beskrivning

Signature

Datatyp

text

Date
Beskrivning

Date

Datatyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Ccrr Module For Tf Radiation Therapy Oncology Group Phase Iii Randomized Study Of Adjuvant Therapy For High Risk Pt3no Prostate Cancer Hormone Protocol Treatment Summary Form
Beskrivning

Ccrr Module For Tf Radiation Therapy Oncology Group Phase Iii Randomized Study Of Adjuvant Therapy For High Risk Pt3no Prostate Cancer Hormone Protocol Treatment Summary Form

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Similar models

INSTRUCTIONS: Submit this form at the completion of protocol hormone therapy. Use -1 for unknown or not applicable unless otherwise specified in the code table. All dates to be reported mm-dd-yyyy unless otherwise indicated.

1 Formulär
  1. StudyEvent: TF Radiation Therapy Oncology Group Phase III Randomized Study of Adjuvant Therapy for High Risk pT3NO Prostate Cancer Hormone Protocol Treatment Summary Form
    1. INSTRUCTIONS: Submit this form at the completion of protocol hormone therapy. Use -1 for unknown or not applicable unless otherwise specified in the code table. All dates to be reported mm-dd-yyyy unless otherwise indicated.
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Item Group
Unnamed1
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
text
Item Group
Unnamed2
AmendedData
Item
Amended Data
text
Item Group
Unnamed3
Item
Agent (AGENT NAME)
text
CL.1
Code List
Agent (AGENT NAME)
CL Item
Zoladex (Zoladex)
CL Item
Lupron (Lupron)
C0701459 (NCI Metathesaurus)
CL Item
Suprafact (Suprafact)
CL Item
Flutamide (Flutamide)
C509 (NCI Thesaurus)
C0016384 (UMLS 2011AA)
CL Item
Casodex (Casodex)
C0591237 (NCI Metathesaurus)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
Unknown Or Not Applicable (Unknown or not applicable)
(ifother,specify)(agent)
Item
(if other, specify) (agent)
text
AgentTotalCumulativeDose
Item
Agent total cumulative dose
double
FirstDateaboveagentprotocoltherapywasgiven
Item
First Date above agent protocol therapy was given
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
LastDateaboveagentprotocoltherapywasgiven
Item
Last Date above agent protocol therapy was given
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Item
Reason treatment ended (REASON TREATMENT ENDED)
text
CL.2
Code List
Reason treatment ended (REASON TREATMENT ENDED)
CL Item
Treatment Completed Per Protocol Criteria (Treatment completed per protocol criteria)
CL Item
Disease Progression, Relapse During Active Treatment (Disease progression, relapse during active treatment)
CL Item
Toxicity/side Effects/complications (Toxicity/side effects/complications)
CL Item
Death On Study (Death on study)
CL Item
Patient Withdrawal Or Refusal After Beginning Protocol Therapy (Patient withdrawal or refusal after beginning protocol therapy)
CL Item
Patient Withdrawal Or Refusal Prior To Beginning Protocol Therapy (Patient withdrawal or refusal prior to beginning protocol therapy)
CL Item
Alternative Therapy (Alternative therapy, specify below)
CL Item
Other complicating disease, specify below (Other complicating disease, specify below)
CL Item
Other, Specify (Other, specify below)
CL Item
Unknown or not applicable (Unknown or not applicable)
(specify)(reasontreatmentended)
Item
(specify) (reason treatment ended)
text
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 Tf Radiation Therapy Oncology Group Phase Iii Randomized Study Of Adjuvant Therapy For High Risk Pt3no Prostate Cancer Hormone Protocol Treatment Summary Form
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