ID

2921

Beskrivning

Primary Endometrial Cancer - On-Study Form Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=16D70DED-556D-4F42-E044-0003BA3F9857

Länk

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=16D70DED-556D-4F42-E044-0003BA3F9857

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19 september 2012

DOI

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Creative Commons BY-NC 3.0 Legacy

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On-Study - Primary Endometrial Cancer - On-Study Form - 2019340v3.0

model
Detaljer

(Information contained in this section is optional and may be included at the discretion of the group; for example: preprinted labels or electronically populated fields may be used)

1 Formulär

StudyEvent: Primary Endometrial Cancer - On-Study Form
1. (Information contained in this section is optional and may be included at the discretion of the group; for example: preprinted labels or electronically populated fields may be used)

Name

Typ

Description | Question | Decode (Coded Value)

Datatyp

Alias

CRF Header

Item Group

Crf Header

ProtocolCoordinatingIdentifierNumber

Item

Coordinating Group Protocol No.

text

C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C25462 (NCI Thesaurus Property)
C0700114 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)

CoordinatingGroupIdentifierCode

Item

Coordinating Group Code

text

C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
C17005 (NCI Thesaurus ObjectClass)
C1257890 (UMLS 2011AA ObjectClass)
C25462 (NCI Thesaurus ObjectClass)
C0700114 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)

ProtocolTitleName

Item

Protocol Title

text

C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C42774 (NCI Thesaurus Property)
C1705823 (UMLS 2011AA Property)

PatientCoordinatingIdentifierNumber

Item

Patient Study ID

text

C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25462 (NCI Thesaurus Property)
C0700114 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)

CombinedInstitutionName

Item

Institution/Affiliate

text

C25454 (NCI Thesaurus ObjectClass)
C0205195 (UMLS 2011AA ObjectClass)
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ValueDomain)
C0018704 (UMLS 2011AA ValueDomain)

PatientParticipatingIdentifierNumber

Item

Other Patient ID

text

C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25608 (NCI Thesaurus Property)
C0679823 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)

ParticipatingGroupIdentifierCode

Item

Participating Group Code

text

C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
C25608 (NCI Thesaurus ObjectClass)
C0679823 (UMLS 2011AA ObjectClass)
C17005 (NCI Thesaurus ObjectClass)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)

PatientName

Item

Patient Name (initials acceptable)

text

C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)

Endometrial: Form Administration

Item Group

Sarcoma: Follow-up Reporting Period

ResponsiblePersonName

Item

Person Completing Form

text

C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25657 (NCI Thesaurus ObjectClass)
C1273518 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)

DataAmendedInd-3

Item

Are data amended (If amended, please circle the changed data in red when using paper form)

text

C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)

CL.1

Code List

Are data amended (If amended, please circle the changed data in red when using paper form)

CL Item

Yes (yes)

C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)

CL Item

No (no)

C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)

Endometrial: Disease Description

Item Group

Endometrial: Disease Description

PrimaryTumorDiagnosisDate

Item

Date of Definitive Histologic Diagnosis of Primary Tumor

date

C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C25251 (NCI Thesaurus ObjectClass)
C0205225 (UMLS 2011AA ObjectClass)
C15220 (NCI Thesaurus Property)
C0011900 (UMLS 2011AA Property)

GynecologicTumorGroupingStage

Item

Stage (at Diagnosis FIGO)

text

C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C28016 (NCI Thesaurus ObjectClass)
C0205480 (UMLS 2011AA ObjectClass)
C16899 (NCI Thesaurus ValueDomain)
C1300072 (UMLS 2011AA ValueDomain)
C25523 (NCI Thesaurus Property)
C1522242 (UMLS 2011AA Property)

CL.2

Code List

Stage (at Diagnosis FIGO)

CL Item

Refer To Figo Staging For Specific Gynecologic Cancer (IA)

CL Item

Refer To Figo Staging For Specific Gynecologic Cancer (IB)

CL Item

Refer To Figo Staging For Specific Gynecologic Cancer (IC)

CL Item

Refer To Figo Staging For Specific Gynecologic Cancer (IIA)

CL Item

Refer To Figo Staging For Specific Gynecologic Cancer (IIB)

CL Item

Refer To Figo Staging For Specific Gynecologic Cancer (IIIA)

CL Item

Refer To Figo Staging For Specific Gynecologic Cancer (IIIB)

CL Item

Refer To Figo Staging For Specific Gynecologic Cancer (IIIC)

CL Item

Refer To Figo Staging For Specific Gynecologic Cancer (IVA)

CL Item

Refer To Figo Staging For Specific Gynecologic Cancer (IVB)

GynecologicTumorHistologicGrade

Item

Histologic Grade (check highest grade)

text

C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C28016 (NCI Thesaurus ObjectClass)
C0205480 (UMLS 2011AA ObjectClass)
C25526 (NCI Thesaurus Property)
C0205462 (UMLS 2011AA Property)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
C25526 (NCI Thesaurus ValueDomain)
C0205462 (UMLS 2011AA ValueDomain)
C18000 (NCI Thesaurus ValueDomain)
C0919553 (UMLS 2011AA ValueDomain)

CL.3

Code List

Histologic Grade (check highest grade)

CL Item

Grade 1-well Differentiated (1)

CL Item

Grade 2-moderately Differentiated (2)

CL Item

Grade 3-poorly Differentiated (3)

GynecologicTumorHistologicCategory

Item

Histologic Type (check all that apply)

text

C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C28016 (NCI Thesaurus ObjectClass)
C0205480 (UMLS 2011AA ObjectClass)
C25526 (NCI Thesaurus Property)
C0205462 (UMLS 2011AA Property)
C25161 (NCI Thesaurus Property)
C0008902 (UMLS 2011AA Property)
C25372 (NCI Thesaurus ValueDomain)
C0683312 (UMLS 2011AA ValueDomain)
C25526 (NCI Thesaurus ValueDomain)
C0205462 (UMLS 2011AA ValueDomain)

CL.4

Code List

Histologic Type (check all that apply)

CL Item

Adenocarcinoma With Squamous Differentiation (Adenocarcinoma with Squamous Differentiation)

CL Item

Clear Cell Carcinoma (Clear cell carcinoma)

CL Item

Mixed Epithelial Carcinoma, Specify Components (Mixed epithelial carcinoma)

CL Item

Adenosquamous (Adenosquamous carcinoma)

CL Item

Serous Adenocarcinoma (Serous adenocarcinoma)

C40101 (NCI Thesaurus)
C0206701 (UMLS 2011AA)

CL Item

Adenocarcinoma, Unspecified (Adenocarcinoma, unspecified)

CL Item

Endometrioid Adenocarcinoma (Endometrioid adenocarcinoma)

C3769 (NCI Thesaurus)
C0206687 (UMLS 2011AA)

CL Item

Other, Specify (Other specify)

TumorHistologicCategorySpecify

Item

Other specify

text

C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C25526 (NCI Thesaurus Property)
C0205462 (UMLS 2011AA Property)
C25161 (NCI Thesaurus Property)
C0008902 (UMLS 2011AA Property)

DiseaseInvolvementSite

Item

Site of Involvement (s for Advanced Disease Studies)

text

C13717 (NCI Thesaurus ValueDomain)
C1515974 (UMLS 2011AA ValueDomain)
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C25548 (NCI Thesaurus Property)
C1314939 (UMLS 2011AA Property)

CL.5

Code List

Site of Involvement (s for Advanced Disease Studies)

CL Item

Bladder (Bladder)

C12414 (NCI Thesaurus)
C0005682 (UMLS 2011AA)

CL Item

Bone (Bone)

C12366 (NCI Thesaurus)
C0262950 (UMLS 2011AA)

CL Item

Colon (Colon)

C12382 (NCI Thesaurus)
C0009368 (UMLS 2011AA)

CL Item

Liver (Liver)

C12392 (NCI Thesaurus)
C0023884 (UMLS 2011AA)

CL Item

Lung (Lung)

C12468 (NCI Thesaurus)
C0024109 (UMLS 2011AA)

CL Item

Pelvic (other Than Above) (Pelvic (other than above))

CL Item

Abdomen (other Than Above) (Abdomen (other than above))

CL Item

Other Specify (Other)

DiseaseInvolvedSiteSpecify

Item

Other specify

text

C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C25547 (NCI Thesaurus Property)
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)

GynecologicLymphNodeAnatomicSite

Item

Lymph Node Type (Lymph Node Involvement Indicate the most sensitive method of evaluation with a positive finding)

text

C12745 (NCI Thesaurus ObjectClass)
C0024204 (UMLS 2011AA ObjectClass)
C28016 (NCI Thesaurus ObjectClass)
C0205480 (UMLS 2011AA ObjectClass)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C25421 (NCI Thesaurus Property)
C0002808 (UMLS 2011AA Property)
C13717 (NCI Thesaurus ValueDomain)
C1515974 (UMLS 2011AA ValueDomain)

CL.6

Code List

Lymph Node Type (Lymph Node Involvement Indicate the most sensitive method of evaluation with a positive finding)

CL Item

Para-aortic (para-aortic)

CL Item

Pelvic (pelvic)

C25399 (NCI Thesaurus)
C0030797 (UMLS 2011AA)

CL Item

Other Specify (other)

LymphNodeAnatomicSiteSpecify

Item

Other specify

text

C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C12745 (NCI Thesaurus ObjectClass)
C0024204 (UMLS 2011AA ObjectClass)
C25421 (NCI Thesaurus Property)
C0002808 (UMLS 2011AA Property)

LymphNodeInvolvementType

Item

Lymph Node Involvement

text

C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C12745 (NCI Thesaurus ObjectClass)
C0024204 (UMLS 2011AA ObjectClass)
C25547 (NCI Thesaurus Property)

CL.7

Code List

Lymph Node Involvement

CL Item

Not Evaluated (not evaluated)

CL Item

Positive (positive)

C25246 (NCI Thesaurus)
C1446409 (UMLS 2011AA)

CL Item

Negative (negative)

C25247 (NCI Thesaurus)
C0205160 (UMLS 2011AA)

CL Item

Equivocal (equivocal)

C86071 (NCI Thesaurus)
C0332241 (UMLS 2011AA)

CL Item

Unknown (unknown)

C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)

AssessmentMethodType

Item

Method of Evaluation

text

C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C20989 (NCI Thesaurus ObjectClass)
C0031809 (UMLS 2011AA ObjectClass)
C16847 (NCI Thesaurus Property)
C0449851 (UMLS 2011AA Property)

CL.8

Code List

Method of Evaluation

CL Item

Not Applicable (Not applicable)

C48660 (NCI Thesaurus)
C1272460 (UMLS 2011AA)

CL Item

Ct Scan (CT scan)

CL Item

Mri (MRI (NMR))

CL Item

Pathologic (Pathologic)

C25610 (NCI Thesaurus)
C1521733 (UMLS 2011AA)

CL Item

Physical Exam (Physical exam)

CL Item

Ultrasound (Ultrasound)

C64384 (NCI Thesaurus)
C1456803 (UMLS 2011AA)

CL Item

Other, Specify (Other, specify)

AssessmentMethodSpecify

Item

Other Specify

text

C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C20989 (NCI Thesaurus ObjectClass)
C0031809 (UMLS 2011AA ObjectClass)
C16847 (NCI Thesaurus Property)
C0449851 (UMLS 2011AA Property)

ENDOMETRIAL: DISEASE TREATMENT AND STATUS AT ENTRY

Item Group

Endometrial: Disease Treatment And Status At Entry

PrimarySurgeryType

Item

Primary Surgery Type

text

CL.9

Code List

Primary Surgery Type

CL Item

Omentectal Biopsy (Omentectal biopsy)

CL Item

Peritoneal Sampling (Peritoneal sampling)

CL Item

Bilateral Salpingo-oophorectomy (bilateral salpingo-oophorectomy)

CL Item

Cervical Conization (cervical conization)

CL Item

Omentectomy (omentectomy)

C0198614 (NCI Metathesaurus)

CL Item

Other, Specify (other, specify)

CL Item

Unilateral Salpingo-oophorectomy (unilateral salpingo-oophorectomy)

C28012 (NCI Thesaurus)
C0205092 (UMLS 2011AA)
C15323 (NCI Thesaurus)
C0036132 (UMLS 2011AA)

CL Item

Partial Hysterectomy (partial hysterectomy)

C40961 (NCI Thesaurus)
C1270947 (UMLS 2011AA)

CL Item

Pelvic Lymphadenectomy (pelvic lymphadenectomy)

CL Item

Pelvic Node Sampling/dissection (pelvic node sampling/dissection)

CL Item

Radical Hysterectomy (radical hysterectomy)

CL Item

Radical Trachelectomy (radical trachelectomy)

CL Item

Total Hysterectomy (total hysterectomy)

C15701 (NCI Thesaurus)
C0677962 (UMLS 2011AA)

CL Item

Para-aortic Node Sampling/dissection (para-aortic node sampling/dissection)

PrimarySurgeryOtherType

Item

Primary Surgery Other Type

text

PrimarySurgeryDate

Item

Primary Surgery Date

date

MyometrialInvasionDepth

Item

Myometrial Invasion Depth

text

CL.10

Code List

Myometrial Invasion Depth

CL Item

<50% Thickness (<50% thickness)

CL Item

None (None)

C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)

CL Item

> Or = 50% Thickness (> or = 50% thickness)

VascularLymphaticInvasionInd

Item

Vascular Lymphatic Invasion Ind

text

CL.11

Code List

Vascular Lymphatic Invasion Ind

CL Item

No (No)

C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)

CL Item

Unknown (unknown)

C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)

CL Item

Yes (Yes)

C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)

ResidualDisease

Item

Residual Disease

double

C25209 (NCI Thesaurus ValueDomain)
C0242485 (UMLS 2011AA ValueDomain)

Comments

Item Group

Allows Documentation Of Any Additional Cooments

Comments

Item

Comments

text

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On-Study - Primary Endometrial Cancer - On-Study Form - 2019340v3.0

(Information contained in this section is optional and may be included at the discretion of the group; for example: preprinted labels or electronically populated fields may be used)

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