ID

2792

Description

S0205 Advanced GI Carcinoma Prestudy Form S0205 Gemcitabine With or Without Cetuximab as First-Line Therapy in Treating Patients With Locally Advanced Unresectable or Metastatic Adenocarcinoma of the Pancreas Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A11A5640-9768-6C93-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A11A5640-9768-6C93-E034-080020C9C0E0

Keywords

Versions (2)
  1. 9/19/12 9/19/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
Uploaded on

September 19, 2012

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Pancreatic Cancer NCT00075686 Pre-Study - S0205 Advanced GI Carcinoma Prestudy Form - 2035482v3.0

English

Instructions: All dates are MONTH, DAY, YEAR. Explain any blank fields or blank dates in the Comments section. Place an X in appropriate boxes. Circle AMENDED items in red.

1 forms  
Unnamed1
Description

Unnamed1

SWOG Patient ID
Description

SWOGPatientID

Data type

text

SWOG Study No.
Description

SWOGStudyNo.

Data type

text

Registration Step
Description

RegistrationStep

Data type

text

Patient Initials (L, F M)
Description

PatientInitialsName

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25536
UMLS 2011AA Property
C1555582
Institution
Description

InstitutionName

Data type

text

Affiliate
Description

AffiliateName

Data type

text

Physician
Description

RegisteredInvestigator

Data type

text

Description Of Disease
Description

Description Of Disease

Date of initial diagnosis of pancreatic cancer
Description

InitialDiagnosisDate

Data type

date

Stage of disease at initial diagnosis
Description

StageGrouping

Data type

text

Current Disease Status
Description

Diseasestatus

Data type

text

Alias
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Metathesaurus Property
C0449438
Height (cm)
Description

PatientHeight

Data type

double

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25347
UMLS 2011AA Property
C0489786
Performance Status
Description

PerformanceStatus

Data type

text

Current Disease Sites (select all that apply)
Description

DiseaseInvolvementSite

Data type

text

Other, specify
Description

DiseaseInvolvementSite,Other

Data type

text

Prior Treatment Related To This Cancer
Description

Prior Treatment Related To This Cancer

Prior Systemic Therapy
Description

PriorChemotherapyInd

Data type

text

Prior Radiation Therapy
Description

PriorRTInd

Data type

text

Prior Surgery
Description

PriorSurgeryInd

Data type

text

Prior Immunotherapy
Description

PriorImmunotherapyInd

Data type

text

Comments
Description

Comments

Comments
Description

Comments

Data type

text

Ccrr Module For S0205 Advanced Gi Carcinoma Prestudy Form
Description

Ccrr Module For S0205 Advanced Gi Carcinoma Prestudy Form

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Similar models

Instructions: All dates are MONTH, DAY, YEAR. Explain any blank fields or blank dates in the Comments section. Place an X in appropriate boxes. Circle AMENDED items in red.

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Unnamed1
SWOGPatientID
Item
SWOG Patient ID
text
SWOGStudyNo.
Item
SWOG Study No.
text
RegistrationStep
Item
Registration Step
text
PatientInitialsName
Item
Patient Initials (L, F M)
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25536 (NCI Thesaurus Property)
C1555582 (UMLS 2011AA Property)
InstitutionName
Item
Institution
text
AffiliateName
Item
Affiliate
text
RegisteredInvestigator
Item
Physician
text
Item Group
Description Of Disease
InitialDiagnosisDate
Item
Date of initial diagnosis of pancreatic cancer
date
Item
Stage of disease at initial diagnosis
text
CL.1
Code List
Stage of disease at initial diagnosis
CL Item
The Cancer Is No Bigger Than 2 Centimeters (about 1 Inch) And Has Not Spread Outside The Breast. (I)
CL Item
Iia (II)
CL Item
Defined By Either Of The Following: The Cancer Is Smaller Than 5 Centimeters And Has Spread To The Lymh Nodes Under The Arm, Which Have Grown Into Each Other Or Into Other Structures And Are Attached To Them. The Cancer Is Bigger Than 5 Cm And Has Spre* (III)
CL Item
The Cancer Has Spread To Other Organs Of The Body, Most Often The Bones, Lungs, Liver, Or Brain. Or, Tumor Has Spread Locally To The Skin And Lymph Nodes Inside The Neck, Near The Collarbone. (IVA)
CL Item
IVB (IVB)
CL Item
Iib (IIB)
CL Item
Defined By Either Of The Following.: The Cancer Has Spread To Tissues Near The Breast (skin, Chest Wall, Including The Ribs And The Muscles In The Chest). The Cancer Has Spread To Lymph Nodes Inside The Chest Wall Along The Breast Bone. (IIIB)
Item
Current Disease Status
text
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C0449438 (NCI Metathesaurus Property)
CL.2
Code List
Current Disease Status
CL Item
Locally Advanced Unresectable (Locally advanced unresectable)
CL Item
Metastatic (Metastatic)
C14174 (NCI Thesaurus)
C0036525 (UMLS 2011AA)
PatientHeight
Item
Height (cm)
double
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25347 (NCI Thesaurus Property)
C0489786 (UMLS 2011AA Property)
PerformanceStatus
Item
Performance Status
text
Item
Current Disease Sites (select all that apply)
text
CL.3
Code List
Current Disease Sites (select all that apply)
CL Item
Primary Site/Direct Extension (Primary Site/Direct Extension)
CL Item
Regional Lymph Nodes (Regional Nodes)
CL Item
Distant Lymph Nodes (Distant Nodes)
CL Item
Lung (Lung/Pleura)
C12468 (NCI Thesaurus)
C0024109 (UMLS 2011AA)
CL Item
Liver (Liver)
C12392 (NCI Thesaurus)
C0023884 (UMLS 2011AA)
CL Item
Bone (Bone)
C12366 (NCI Thesaurus)
C0262950 (UMLS 2011AA)
CL Item
Other abdominal (Other abdominal)
CL Item
Other, Specify (Other, specify)
DiseaseInvolvementSite,Other
Item
Other, specify
text
Item Group
Prior Treatment Related To This Cancer
Item
Prior Systemic Therapy
text
CL.4
Code List
Prior Systemic Therapy
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
CL.5
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)
Item
Prior Surgery
text
CL.6
Code List
Prior Surgery
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Prior Immunotherapy
text
CL.7
Code List
Prior Immunotherapy
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item Group
Comments
Comments
Item
Comments
text
Item Group
Ccrr Module For S0205 Advanced Gi Carcinoma Prestudy Form
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