ID

2930

Beschrijving

ELIGIBILITY CHECK 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=A570754B-7D62-2952-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A570754B-7D62-2952-E034-080020C9C0E0

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Versies (2)
  1. 19-09-12 19-09-12 -
  2. 23-03-15 23-03-15 - Martin Dugas
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19 september 2012

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Prostate Cancer NCT00023829 Eligibility - ELIGIBILITY CHECK - 2038574v3.0

Engels

(6/10/02)

1 Formulieren  
  1. StudyEvent: ELIGIBILITY CHECK
    1. (6/10/02)
Unnamed1
Beschrijving

Unnamed1

RTOG Institution #
Beschrijving

RTOGInstitution#

Datatype

text

RTOG Case # (17.)
Beschrijving

RTOGCase#

Datatype

text

Unnamed2
Beschrijving

Unnamed2

Does the patient have pathological stage T2-3N0M0 prostate cancer? (2. If the patient is T2)
Beschrijving

DoesthepatienthavepathologicalstageT2-3N0M0prostatecancer?

Datatype

text

does the patient have Gleason score >= 7, pre-op PSA > 10, and positive surgical margins? (3. If the patient is T3)
Beschrijving

doesthepatienthaveGleasonscore>=7,pre-opPSA>10,andpositivesurgicalmargins?

Datatype

text

is the Gleason score >= 7? (If yes)
Beschrijving

IstheGleasonscore>=7?

Datatype

text

does patient have ONE or more of the following: a) Pre-op PSA > 10? b) Positive surgical margins? c) Seminal vesicle invasion? (If no)
Beschrijving

doespatienthaveONEormoreofthefollowing:a)Pre-opPSA>10?b)Positivesurgicalmargins?c)Seminalvesicleinvasion?

Datatype

text

does patient have TWO or more of the following: a) Pre-op PSA > 10? b) Positive surgical margins? c) Seminal vesicle invasion? (4.)
Beschrijving

doespatienthaveTWOormoreofthefollowing:a)Pre-opPSA>10?b)Positivesurgicalmargins?c)Seminalvesicleinvasion?

Datatype

text

Was the pre-op PS 40.0? (5.)
Beschrijving

Wasthepre-opPS40.0?

Datatype

text

Is post-op PSA <= 0.2? (6.)
Beschrijving

Ispost-opPSA<=0.2?

Datatype

text

Is Zubrod status 0-1? (7.)
Beschrijving

IsZubrodstatus0-1?

Datatype

text

Are lymph nodes negative by lymph node sampling or lymph node dissection? (8.)
Beschrijving

Arelymphnodesnegativebylymphnodesamplingorlymphnodedissection?

Datatype

text

What is the WBC? (x 1000)
Beschrijving

WhatistheWBC?

Datatype

text

What is the platelet count? (x 1000)
Beschrijving

Whatistheplateletcount?

Datatype

text

What is the hgb? (>= 11.4)
Beschrijving

Whatisthehgb?

Datatype

text

What is creatinine? ( 2.5)
Beschrijving

Whatiscreatinine?

Datatype

text

What is ALT? (within 3 x normal)
Beschrijving

WhatisALT?

Datatype

text

Will treatment begin within 6 weeks of randomization? (14.)
Beschrijving

Willtreatmentbeginwithin6weeksofrandomization?

Datatype

text

If patient was receiving finasteride, has it been administered 60 days prior to this randomization? (15.)
Beschrijving

Ifpatientwasreceivingfinasteride,hasitbeenadministered60dayspriortothisrandomization?

Datatype

text

If patient was receiving testosterone, has it been administered 90 days prior to this randomization? (16.)
Beschrijving

Ifpatientwasreceivingtestosterone,hasitbeenadministered90dayspriortothisrandomization?

Datatype

text

Has any prior pharmacologic androgen ablation for prostate cancer been initiated greater than 10 months before randomization? (17.)
Beschrijving

Hasanypriorpharmacologicandrogenablationforprostatecancerbeeninitiatedgreaterthan10monthsbeforerandomization?

Datatype

text

Any prior pelvic radiation therapy or orchiectomy? (18.)
Beschrijving

Anypriorpelvicradiationtherapyororchiectomy?

Datatype

text

Any previous chemotherapy within the last 5 years?
Beschrijving

Anypreviouschemotherapywithinthelast5years?

Datatype

text

Unnamed3
Beschrijving

Unnamed3

RTOG Institution #
Beschrijving

RTOGInstitution#

Datatype

text

RTOG Case # (17.)
Beschrijving

RTOGCase#

Datatype

text

Unnamed4
Beschrijving

Unnamed4

Have all mandatory lab studies been done? (20.)
Beschrijving

Haveallmandatorylabstudiesbeendone?

Datatype

text

Any prior or concurrent malignancy other than non-melanoma skin cancer? (If yes)
Beschrijving

Anypriororconcurrentmalignancyotherthannon-melanomaskincancer?

Datatype

text

disease free for 5 years? (1.)
Beschrijving

diseasefreefor5years?

Datatype

text

Unnamed5
Beschrijving

Unnamed5

Name of institutional person registering this case? (2.)
Beschrijving

Nameofinstitutionalpersonregisteringthiscase?

Datatype

text

Has the Eligibility Checklist (above) been completed? (3.)
Beschrijving

HastheEligibilityChecklist(above)beencompleted?

Datatype

text

Is the patient eligible for this study? (4.)
Beschrijving

Isthepatienteligibleforthisstudy?

Datatype

text

Date the study-specific Consent Form was signed? (must be prior to study entry)
Beschrijving

Datethestudy-specificConsentFormwassigned?

Datatype

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Patient's Name (6.)
Beschrijving

Patient'sName

Datatype

text

Verifying Physician (7.)
Beschrijving

VerifyingPhysician

Datatype

text

Patient's ID Number (8.)
Beschrijving

Patient'sIDNumber

Datatype

text

Date of Birth (9.)
Beschrijving

DateofBirth

Datatype

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Race (10.)
Beschrijving

Race

Datatype

text

Social Security Number (11.)
Beschrijving

SocialSecurityNumber

Datatype

text

Patient's Country of Residence (12.)
Beschrijving

Patient'sCountryofResidence

Datatype

text

Zip Code (13.)
Beschrijving

ZipCode

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
Patient's Insurance Status (14.)
Beschrijving

Patient'sInsuranceStatus

Datatype

text

Will any component of the patient's care be given at a military or VA facility? (15.)
Beschrijving

Willanycomponentofthepatient'scarebegivenatamilitaryorVAfacility?

Datatype

text

Does the patient have seminal vesicle invasion? (16.)
Beschrijving

Doesthepatienthaveseminalvesicleinvasion?

Datatype

text

Specify pre-operative PSA
Beschrijving

Specifypre-operativePSA

Datatype

text

Unnamed6
Beschrijving

Unnamed6

RTOG Institution #
Beschrijving

RTOGInstitution#

Datatype

text

RTOG Case # (17.)
Beschrijving

RTOGCase#

Datatype

text

Unnamed7
Beschrijving

Unnamed7

Specify Gleason score (18.)
Beschrijving

SpecifyGleasonscore

Datatype

double

Are there positive surgical (inked) margins? (19.)
Beschrijving

Aretherepositivesurgical(inked)margins?

Datatype

text

Did patient receive neoadjuvant hormonal therapy? (20.)
Beschrijving

Didpatientreceiveneoadjuvanthormonaltherapy?

Datatype

text

Is the patient going to receive IMRT? (20.)
Beschrijving

IsthepatientgoingtoreceiveIMRT?

Datatype

text

Treatment Start Date (21.)
Beschrijving

TreatmentStartDate

Datatype

date

Treatment Assignment
Beschrijving

TreatmentAssignment

Datatype

text

Completed by
Beschrijving

CompletedBy

Datatype

text

Date
Beschrijving

Date

Datatype

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Ccrr Module For Eligibility Check
Beschrijving

Ccrr Module For Eligibility Check

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Similar models

(6/10/02)

1 Formulieren
  1. StudyEvent: ELIGIBILITY CHECK
    1. (6/10/02)
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
Unnamed1
RTOGInstitution#
Item
RTOG Institution #
text
RTOGCase#
Item
RTOG Case # (17.)
text
Item Group
Unnamed2
Item
Does the patient have pathological stage T2-3N0M0 prostate cancer? (2. If the patient is T2)
text
CL.1
Code List
Does the patient have pathological stage T2-3N0M0 prostate cancer? (2. If the patient is T2)
CL Item
Yes (Y)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
does the patient have Gleason score >= 7, pre-op PSA > 10, and positive surgical margins? (3. If the patient is T3)
text
CL.2
Code List
does the patient have Gleason score >= 7, pre-op PSA > 10, and positive surgical margins? (3. If the patient is T3)
CL Item
Yes (Y)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
is the Gleason score >= 7? (If yes)
text
CL.3
Code List
is the Gleason score >= 7? (If yes)
CL Item
Yes (Y)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (N)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Item
does patient have ONE or more of the following: a) Pre-op PSA > 10? b) Positive surgical margins? c) Seminal vesicle invasion? (If no)
text
CL.4
Code List
does patient have ONE or more of the following: a) Pre-op PSA > 10? b) Positive surgical margins? c) Seminal vesicle invasion? (If no)
CL Item
Yes (Y)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Not Applicable (NA)
C48660 (NCI Thesaurus)
C1272460 (UMLS 2011AA)
Item
does patient have TWO or more of the following: a) Pre-op PSA > 10? b) Positive surgical margins? c) Seminal vesicle invasion? (4.)
text
CL.5
Code List
does patient have TWO or more of the following: a) Pre-op PSA > 10? b) Positive surgical margins? c) Seminal vesicle invasion? (4.)
CL Item
Yes (Y)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Not Applicable (NA)
C48660 (NCI Thesaurus)
C1272460 (UMLS 2011AA)
Item
Was the pre-op PS 40.0? (5.)
text
CL.6
Code List
Was the pre-op PS 40.0? (5.)
CL Item
Yes (Y)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Is post-op PSA <= 0.2? (6.)
text
CL.7
Code List
Is post-op PSA <= 0.2? (6.)
CL Item
Yes (Y)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Is Zubrod status 0-1? (7.)
text
CL.8
Code List
Is Zubrod status 0-1? (7.)
CL Item
Yes (Y)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Are lymph nodes negative by lymph node sampling or lymph node dissection? (8.)
text
CL.9
Code List
Are lymph nodes negative by lymph node sampling or lymph node dissection? (8.)
CL Item
Yes (Y)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (N)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
WhatistheWBC?
Item
What is the WBC? (x 1000)
text
Whatistheplateletcount?
Item
What is the platelet count? (x 1000)
text
Whatisthehgb?
Item
What is the hgb? (>= 11.4)
text
Whatiscreatinine?
Item
What is creatinine? ( 2.5)
text
WhatisALT?
Item
What is ALT? (within 3 x normal)
text
Item
Will treatment begin within 6 weeks of randomization? (14.)
text
CL.10
Code List
Will treatment begin within 6 weeks of randomization? (14.)
CL Item
Yes (Y)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
If patient was receiving finasteride, has it been administered 60 days prior to this randomization? (15.)
text
CL.11
Code List
If patient was receiving finasteride, has it been administered 60 days prior to this randomization? (15.)
CL Item
Yes (Y)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
If patient was receiving testosterone, has it been administered 90 days prior to this randomization? (16.)
text
CL.12
Code List
If patient was receiving testosterone, has it been administered 90 days prior to this randomization? (16.)
CL Item
Yes (Y)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Has any prior pharmacologic androgen ablation for prostate cancer been initiated greater than 10 months before randomization? (17.)
text
CL.13
Code List
Has any prior pharmacologic androgen ablation for prostate cancer been initiated greater than 10 months before randomization? (17.)
CL Item
No (N)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Item
Any prior pelvic radiation therapy or orchiectomy? (18.)
text
CL.14
Code List
Any prior pelvic radiation therapy or orchiectomy? (18.)
CL Item
No (N)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Item
Any previous chemotherapy within the last 5 years?
text
CL.15
Code List
Any previous chemotherapy within the last 5 years?
CL Item
No (N)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Item Group
Unnamed3
RTOGInstitution#
Item
RTOG Institution #
text
RTOGCase#
Item
RTOG Case # (17.)
text
Item Group
Unnamed4
Item
Have all mandatory lab studies been done? (20.)
text
CL.16
Code List
Have all mandatory lab studies been done? (20.)
CL Item
Yes (Y)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Any prior or concurrent malignancy other than non-melanoma skin cancer? (If yes)
text
CL.17
Code List
Any prior or concurrent malignancy other than non-melanoma skin cancer? (If yes)
CL Item
Yes (Y)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (N)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Item
disease free for 5 years? (1.)
text
CL.18
Code List
disease free for 5 years? (1.)
CL Item
Yes (Y)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item Group
Unnamed5
Nameofinstitutionalpersonregisteringthiscase?
Item
Name of institutional person registering this case? (2.)
text
Item
Has the Eligibility Checklist (above) been completed? (3.)
text
CL.19
Code List
Has the Eligibility Checklist (above) been completed? (3.)
CL Item
Yes (Y)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Is the patient eligible for this study? (4.)
text
CL.20
Code List
Is the patient eligible for this study? (4.)
CL Item
Yes (Y)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Datethestudy-specificConsentFormwassigned?
Item
Date the study-specific Consent Form was signed? (must be prior to study entry)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Patient'sName
Item
Patient's Name (6.)
text
VerifyingPhysician
Item
Verifying Physician (7.)
text
Patient'sIDNumber
Item
Patient's ID Number (8.)
text
DateofBirth
Item
Date of Birth (9.)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Race
Item
Race (10.)
text
SocialSecurityNumber
Item
Social Security Number (11.)
text
Patient'sCountryofResidence
Item
Patient's Country of Residence (12.)
text
ZipCode
Item
Zip Code (13.)
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
Patient'sInsuranceStatus
Item
Patient's Insurance Status (14.)
text
Willanycomponentofthepatient'scarebegivenatamilitaryorVAfacility?
Item
Will any component of the patient's care be given at a military or VA facility? (15.)
text
Item
Does the patient have seminal vesicle invasion? (16.)
text
CL.21
Code List
Does the patient have seminal vesicle invasion? (16.)
CL Item
Yes (Y)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (N)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Item
Specify pre-operative PSA
text
CL.22
Code List
Specify pre-operative PSA
CL Item
< =10 (< =10)
CL Item
> 10 (> 10)
Item Group
Unnamed6
RTOGInstitution#
Item
RTOG Institution #
text
RTOGCase#
Item
RTOG Case # (17.)
text
Item Group
Unnamed7
Item
Specify Gleason score (18.)
double
CL.23
Code List
Specify Gleason score (18.)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
3 (3)
CL Item
4 (4)
CL Item
5 (5)
CL Item
6 (6)
CL Item
7 (7)
CL Item
8 (8)
CL Item
9 (9)
CL Item
10 (10)
Item
Are there positive surgical (inked) margins? (19.)
text
CL.24
Code List
Are there positive surgical (inked) margins? (19.)
CL Item
Yes (Y)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (N)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Item
Did patient receive neoadjuvant hormonal therapy? (20.)
text
CL.25
Code List
Did patient receive neoadjuvant hormonal therapy? (20.)
CL Item
Yes (Y)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (N)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Item
Is the patient going to receive IMRT? (20.)
text
CL.26
Code List
Is the patient going to receive IMRT? (20.)
CL Item
Yes (Y)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (N)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
TreatmentStartDate
Item
Treatment Start Date (21.)
date
TreatmentAssignment
Item
Treatment Assignment
text
CompletedBy
Item
Completed by
text
Date
Item
Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Item Group
Ccrr Module For Eligibility Check
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