ID

2944

Beskrivning

On-Study Form Gemcitabine With or Without Radiation Therapy in Treating Patients With Pancreatic Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A670D091-E97C-4BF1-E034-0003BA0B1A09

Länk

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A670D091-E97C-4BF1-E034-0003BA0B1A09

Nyckelord

Versioner (4)
  1. 2012-09-19 2012-09-19 -
  2. 2015-06-01 2015-06-01 -
  3. 2015-06-03 2015-06-03 -
  4. 2021-09-20 2021-09-20 -
Uppladdad den

19 september 2012

DOI

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Licens

Creative Commons BY-NC 3.0 Legacy
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Pancreatic Cancer NCT00057876 On-Study - On-Study Form - 2049990v3.0

Engelsk

No Instruction available.

1 Formulär  
  1. StudyEvent: On-Study Form
    1. No Instruction available.
Unnamed1
Beskrivning

Unnamed1

Registration Step
Beskrivning

RegistrationStep

Datatyp

text

Patient?s Name
Beskrivning

Patient'sName

Datatyp

text

ECOG Protocol No.
Beskrivning

ECOGProtocolNo.

Datatyp

text

ECOG Protocol No.
Beskrivning

ECOGProtocolNo.

Datatyp

text

ECOG Patient ID
Beskrivning

ECOGPatientID

Datatyp

text

ECOG Patient ID
Beskrivning

ECOGPatientID

Datatyp

text

Participating Group Protocol No.
Beskrivning

ParticipatingGroupProtocolNo.

Datatyp

text

Participating Group Patient ID
Beskrivning

ParticipatingGroupPatientID

Datatyp

text

Institution/Affiliate
Beskrivning

MainMemberInstitution/Affiliate

Datatyp

text

Unnamed2
Beskrivning

Unnamed2

Are data amended?
Beskrivning

AmendedDataInd

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Performance status
Beskrivning

PerformanceStatus

Datatyp

text

Weight loss in previous 6 months (choose one)
Beskrivning

WeightLossPriorSixMonths

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C3445
UMLS 2011AA Property
C0043096
Anatomic Description Of Disease
Beskrivning

Anatomic Description Of Disease

Date of initial diagnosis of primary tumor (first positive biopsy date)
Beskrivning

FirstPositiveBiopsyDate

Datatyp

date

Primary site (choose one)
Beskrivning

PrimarySite

Datatyp

text

Other specify (primary site)
Beskrivning

PrimarySite,Other

Datatyp

text

Histologic Type (choose one)
Beskrivning

HistologicType

Datatyp

text

Other, specify (histologic type)
Beskrivning

HistologicType,OtherName

Datatyp

text

Histologic grade (choose one)
Beskrivning

HistologicGrade

Datatyp

text

Staging
Beskrivning

Staging

Clinical T Stage
Beskrivning

TStage,Clinical

Datatyp

text

Clinical N Stage
Beskrivning

NStage,Clinical

Datatyp

text

Clinical M Stage
Beskrivning

MStage,Clinical

Datatyp

text

Site(s) Of Involvement
Beskrivning

Site(s) Of Involvement

Primary tumor/Pancreas
Beskrivning

Primarytumor/Pancreas

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Regional lymph nodes
Beskrivning

RegionalLymphNode(s)Ind

Datatyp

text

Distant lymph nodes
Beskrivning

DistantLymphNode(s)Ind

Datatyp

text

Adjacent viscera/vessels
Beskrivning

Adjacentviscera/vessels

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Liver
Beskrivning

LiverSiteInd

Datatyp

text

Peritoneum
Beskrivning

PeritoneumInd

Datatyp

text

Lung
Beskrivning

LungSiteInd

Datatyp

text

Bone
Beskrivning

BoneSiteInd

Datatyp

text

Other
Beskrivning

OtherSiteInd

Datatyp

text

Specify other disease involvement
Beskrivning

OtherSiteName

Datatyp

text

Comments
Beskrivning

Comments

Datatyp

text

Investigator Signature
Beskrivning

InvestigatorSignature

Datatyp

text

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

InvestigatorSignatureDate

Datatyp

date

Ccrr Module For On-study Form
Beskrivning

Ccrr Module For On-study Form

Other, specify
Beskrivning

DiseaseInvolvementSite,Other

Datatyp

text

Tillbaka till toppen

Similar models

No Instruction available.

1 Formulär
  1. StudyEvent: On-Study Form
    1. No Instruction available.
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Item Group
Unnamed1
RegistrationStep
Item
Registration Step
text
Patient'sName
Item
Patient?s Name
text
ECOGProtocolNo.
Item
ECOG Protocol No.
text
ECOGProtocolNo.
Item
ECOG Protocol No.
text
ECOGPatientID
Item
ECOG Patient ID
text
ECOGPatientID
Item
ECOG Patient ID
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?
text
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
CL.1
Code List
Are data amended?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Performance status
text
CL.2
Code List
Performance status
CL Item
0 (Fully active, able to carry on all pre-disease performance without restriction (Karnofsky 90-100))
C0919414 (NCI Metathesaurus)
CL Item
1 (Restricted in physically strenuous activity but ambulatory (K 70-80))
CL Item
2 (Ambulatory and capable of all selfcare but unable to carry out any work activities (K 50-60))
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
3 (Capable of only limited selfcare, confined to bed or chair more than 50% of waking hours (K 30-40))
CL Item
4 (completely disabled (K 10-20))
Item
Weight loss in previous 6 months (choose one)
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C3445 (NCI Thesaurus Property)
C0043096 (UMLS 2011AA Property)
CL.3
Code List
Weight loss in previous 6 months (choose one)
CL Item
<5% Of Body Weight (less than 5% of body weight)
CL Item
5 To <10% Of Body Weight (5 - <10% of body weight)
CL Item
10 To <20% Of Body Weight (10 - <20% of body weight)
CL Item
> Or = 20% Of Body Weight (greater than or equal to 20% of body weight)
Item Group
Anatomic Description Of Disease
FirstPositiveBiopsyDate
Item
Date of initial diagnosis of primary tumor (first positive biopsy date)
date
Item
Primary site (choose one)
text
CL.4
Code List
Primary site (choose one)
CL Item
Head Of Pancreas (Head of pancreas)
C0227579 (NCI Metathesaurus)
CL Item
Body Of Pancreas (Body of pancreas)
C0227582 (NCI Metathesaurus)
CL Item
Tail Of Pancreas (Tail of pancreas)
C0227590 (NCI Metathesaurus)
CL Item
Uncinate Process (Uncinate process)
CL Item
Diffuse (Diffuse)
C14175 (NCI Thesaurus)
C0205219 (UMLS 2011AA)
CL Item
Pancreas, Not Otherwise Specified (Pancreas, NOS)
CL Item
Other, Specify (Other, specify)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
PrimarySite,Other
Item
Other specify (primary site)
text
Item
Histologic Type (choose one)
text
CL.5
Code List
Histologic Type (choose one)
CL Item
Ductal Adenocarcinoma (Ductal adenocarcinoma)
CL Item
Adenosquamous Carcinoma (Adenosquamous carcinoma)
C3727 (NCI Thesaurus)
C0206623 (UMLS 2011AA)
CL Item
Mucinous Adenocarcinoma (Mucinous adenocarcinoma)
C26712 (NCI Thesaurus)
C0007130 (UMLS 2011AA)
CL Item
Mucinous Noncystic Carcinoma (Mucinous noncystic carcinoma)
CL Item
Neuroendocrine Carcinoma (Neuroendocrine carcinoma)
C3773 (NCI Thesaurus)
C0206695 (UMLS 2011AA)
CL Item
Acinar Cell Carcinoma (Acinar cell carcinoma)
C3768 (NCI Thesaurus)
C0206685 (UMLS 2011AA)
CL Item
Mixed-type (ductal-endocrine Or Acinar-endocrine) (Mixed type (ductal-endocrine or acinar-endocrine)
CL Item
Signet Ring Cell Carcinoma (Signet ring cell carcinoma)
C3774 (NCI Thesaurus)
C0206696 (UMLS 2011AA)
CL Item
Small Cell Carcinoma (Small cell carcinoma)
C3915 (NCI Thesaurus)
C0262584 (UMLS 2011AA)
CL Item
Undifferentiated (anaplastic) Carcinoma (Undifferentiated (anaplastic) carcinoma)
CL Item
Other, Specify (Other, specify)
HistologicType,OtherName
Item
Other, specify (histologic type)
text
Item
Histologic grade (choose one)
text
CL.6
Code List
Histologic grade (choose one)
CL Item
Tumor Is Well Differentiated According To Who Grading System (Well differentiated)
CL Item
Tumor Is Moderately Differentiated According To Who Grading System (Moderately differentiated)
CL Item
Tumor Is Poorly Differentiated According To Who Grading System (Poorly differentiated)
CL Item
Tumor Is Undifferentiated According To Who Grading System (Undifferentiated)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item Group
Staging
Item
Clinical T Stage
text
CL.7
Code List
Clinical T Stage
CL Item
T0, According To Ajcc Criteria (0)
CL Item
T1, According To Ajcc Criteria (1)
CL Item
T2, According To Ajcc Criteria (2)
CL Item
T3, According To Ajcc Criteria (3)
CL Item
T4, According To Ajcc Criteria (4)
CL Item
Tx, According To Ajcc Criteria (X)
Item
Clinical N Stage
text
CL.8
Code List
Clinical N Stage
CL Item
No Lymph Node Involvement According To Ajcc Guidelines (0)
CL Item
N1, According To Ajcc Criteria (1)
CL Item
Lymph Node Involvement Cannot Be Assessed According To Ajcc Guidelines (use For Esophageal, Gastric, And Pancreatic) (X)
Item
Clinical M Stage
text
CL.9
Code List
Clinical M Stage
CL Item
No Distant Metastases According To Ajcc Guidelines (0)
CL Item
Distant Metastases Present According To Ajcc Guidelines (1)
CL Item
Distant Metastases Presence Or Absence Cannot Be Assessed According To Ajcc Guidelines (X)
Item Group
Site(s) Of Involvement
Item
Primary tumor/Pancreas
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.10
Code List
Primary tumor/Pancreas
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Regional lymph nodes
text
CL.11
Code List
Regional lymph nodes
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Distant lymph nodes
text
CL.12
Code List
Distant lymph nodes
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Adjacent viscera/vessels
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.13
Code List
Adjacent viscera/vessels
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Liver
text
CL.14
Code List
Liver
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Peritoneum
text
CL.15
Code List
Peritoneum
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Lung
text
CL.16
Code List
Lung
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Bone
text
CL.17
Code List
Bone
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Other
text
CL.18
Code List
Other
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
OtherSiteName
Item
Specify other disease involvement
text
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 On-study Form
DiseaseInvolvementSite,Other
Item
Other, specify
text
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