ID

2941

Beschrijving

Second Primary Form A Phase III, Randomized Study of Gemcitabine (Fixed-Dose Rate Infusion) and Oxaliplatin (NSC 266046) Versus Gemcitabine (Fixed-Dose Rate Infusion) Versus Gemcitabine (30-Minute Infusion) in Pancreatic Carcinoma Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A65D7C21-CE65-42A1-E034-0003BA0B1A09

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A65D7C21-CE65-42A1-E034-0003BA0B1A09

Trefwoorden

Versies (3)
  1. 19-09-12 19-09-12 -
  2. 01-06-15 01-06-15 -
  3. 03-06-15 03-06-15 -
Geüploaded op

19 september 2012

DOI

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Licentie

Creative Commons BY-NC 3.0 Legacy
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Pancreatic Cancer NCT00058149 Follow-Up - Second Primary Form - 2048713v3.0

Engels

No Instruction available.

1 Formulieren  
  1. StudyEvent: Second Primary Form
    1. No Instruction available.
Unnamed1
Beschrijving

Unnamed1

Registration Step
Beschrijving

RegistrationStep

Datatype

text

Patient?s Name
Beschrijving

Patient'sName

Datatype

text

ECOG Protocol No. (If patient has been on other therapeutic ECOG protocols, please list protocols and patient ID numbers.)
Beschrijving

ECOGProtocolNo.

Datatype

text

ECOG Protocol No. (If patient has been on other therapeutic ECOG protocols, please list protocols and patient ID numbers.)
Beschrijving

ECOGProtocolNo.

Datatype

text

ECOG Patient ID (If patient has been on other therapeutic ECOG protocols, please list protocols and patient ID numbers.)
Beschrijving

ECOGPatientID

Datatype

text

ECOG Patient ID (If patient has been on other therapeutic ECOG protocols, please list protocols and patient ID numbers.)
Beschrijving

ECOGPatientID

Datatype

text

Participating Group Protocol No.
Beschrijving

ParticipatingGroupProtocolNo.

Datatype

text

Participating Group Patient ID
Beschrijving

ParticipatingGroupPatientID

Datatype

text

Institution/Affiliate
Beschrijving

MainMemberInstitution/Affiliate

Datatype

text

Unnamed2
Beschrijving

Unnamed2

Are data amended? (If yes, please circle amended items in red)
Beschrijving

AmendedDataInd

Datatype

text

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Unnamed3
Beschrijving

Unnamed3

Date of Diagnosis of Second Primary Cancer
Beschrijving

DateofDiagnosisofSecondPrimaryCancer

Datatype

text

Site of Second Primary Cancer:
Beschrijving

SecondPrimaryMalignantNeoplasmAnatomicSiteText

Datatype

text

Alias
NCI Thesaurus ObjectClass
C25251
UMLS 2011AA ObjectClass
C0205225
NCI Thesaurus ObjectClass
C9305
UMLS 2011AA ObjectClass
C0006826
NCI Thesaurus ObjectClass
C25666
UMLS 2011AA ObjectClass
C0205436
NCI Thesaurus Property
C25341
UMLS 2011AA Property
C0450429
NCI Thesaurus Property
C25421
UMLS 2011AA Property
C0002808
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
Include information on histologic subtype(s). Please attach copies of any corroborating pathology reports.
Beschrijving

Includeinformationonhistologicsubtype(s).

Datatype

text

ECOG Protocol No. (If patient has been on other therapeutic ECOG protocols, please list protocols and patient ID numbers.)
Beschrijving

ECOGProtocolNo.

Datatype

text

ECOG Patient ID (If patient has been on other therapeutic ECOG protocols, please list protocols and patient ID numbers.)
Beschrijving

ECOGPatientID

Datatype

text

Briefly describe cancer therapy the patient has received prior to the diagnosis of the second primary and other than that given on ECOG protocols:
Beschrijving

BrieflydescribecancertherapythepatienthasreceivedpriortothediagnosisofthesecondprimaryandotherthanthatgivenonECOGprotocols

Datatype

text

Briefly describe treatment planned or given for the diagnosis of this second primary:
Beschrijving

Brieflydescribetreatmentplannedorgivenforthediagnosisofthissecondprimary:

Datatype

text

Unnamed4
Beschrijving

Unnamed4

Comments
Beschrijving

Comments

Datatype

text

Investigator Signature
Beschrijving

InvestigatorSignature

Datatype

text

Alias
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
NCI Thesaurus ObjectClass
C17089
UMLS 2011AA ObjectClass
C0035173
Date
Beschrijving

InvestigatorSignatureDate

Datatype

date

Ccrr Module For Second Primary Form
Beschrijving

Ccrr Module For Second Primary Form

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Similar models

No Instruction available.

1 Formulieren
  1. StudyEvent: Second Primary Form
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
Unnamed1
RegistrationStep
Item
Registration Step
text
Patient'sName
Item
Patient?s Name
text
ECOGProtocolNo.
Item
ECOG Protocol No. (If patient has been on other therapeutic ECOG protocols, please list protocols and patient ID numbers.)
text
ECOGProtocolNo.
Item
ECOG Protocol No. (If patient has been on other therapeutic ECOG protocols, please list protocols and patient ID numbers.)
text
ECOGPatientID
Item
ECOG Patient ID (If patient has been on other therapeutic ECOG protocols, please list protocols and patient ID numbers.)
text
ECOGPatientID
Item
ECOG Patient ID (If patient has been on other therapeutic ECOG protocols, please list protocols and patient ID numbers.)
text
ParticipatingGroupProtocolNo.
Item
Participating Group Protocol No.
text
ParticipatingGroupPatientID
Item
Participating Group Patient ID
text
MainMemberInstitution/Affiliate
Item
Institution/Affiliate
text
Item Group
Unnamed2
Item
Are data amended? (If yes, please circle amended items in red)
text
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
CL.1
Code List
Are data amended? (If yes, please circle amended items in red)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item Group
Unnamed3
DateofDiagnosisofSecondPrimaryCancer
Item
Date of Diagnosis of Second Primary Cancer
text
SecondPrimaryMalignantNeoplasmAnatomicSiteText
Item
Site of Second Primary Cancer:
text
C25251 (NCI Thesaurus ObjectClass)
C0205225 (UMLS 2011AA ObjectClass)
C9305 (NCI Thesaurus ObjectClass)
C0006826 (UMLS 2011AA ObjectClass)
C25666 (NCI Thesaurus ObjectClass)
C0205436 (UMLS 2011AA ObjectClass)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C25421 (NCI Thesaurus Property)
C0002808 (UMLS 2011AA Property)
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
Includeinformationonhistologicsubtype(s).
Item
Include information on histologic subtype(s). Please attach copies of any corroborating pathology reports.
text
ECOGProtocolNo.
Item
ECOG Protocol No. (If patient has been on other therapeutic ECOG protocols, please list protocols and patient ID numbers.)
text
ECOGPatientID
Item
ECOG Patient ID (If patient has been on other therapeutic ECOG protocols, please list protocols and patient ID numbers.)
text
BrieflydescribecancertherapythepatienthasreceivedpriortothediagnosisofthesecondprimaryandotherthanthatgivenonECOGprotocols
Item
Briefly describe cancer therapy the patient has received prior to the diagnosis of the second primary and other than that given on ECOG protocols:
text
Brieflydescribetreatmentplannedorgivenforthediagnosisofthissecondprimary:
Item
Briefly describe treatment planned or given for the diagnosis of this second primary:
text
Item Group
Unnamed4
Comments
Item
Comments
text
InvestigatorSignature
Item
Investigator Signature
text
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
InvestigatorSignatureDate
Item
Date
date
Item Group
Ccrr Module For Second Primary Form
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