ID

3007

Description

RTOG-0924 T1: Treatment Form Androgen-Deprivation Therapy and Radiation Therapy in Treating Patients With Prostate Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9D869ED1-F383-8812-E040-BB89AD432EA8

Lien

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9D869ED1-F383-8812-E040-BB89AD432EA8

Mots-clés

  1. 19/09/2012 19/09/2012 -
  2. 09/01/2015 09/01/2015 - Martin Dugas
Téléchargé le

19 septembre 2012

DOI

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Licence

Creative Commons BY-NC 3.0 Legacy

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Prostate Cancer NCT01368588 Treatment - RTOG-0924 T1: Treatment Form - 3196837v1.0

Instructions: Form is submitted upon completion or termination of RT for all patients assigned RT. Dates are mmdd-yyyy unless specified otherwise. If assigned radiation and none given, complete Q#7, sign date and submit form.

Unnamed Module 1
Description

Unnamed Module 1

RTOG Study No.
Description

ProtocolRTOGIdentifierNumber

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus Property
C19778
UMLS 2011AA Property
C1514695
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Case #
Description

RadiationTherapyOncologyGroupPatientCaseIdentifierNumber

Type de données

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ObjectClass
C19778
UMLS 2011AA ObjectClass
C1514695
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus Property
C49152
UMLS 2011AA Property
C1706256
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
Institution Name
Description

InstitutionName

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus ObjectClass
C21541
UMLS 2011AA ObjectClass
C0018704
NCI Thesaurus ValueDomain
C21541
UMLS 2011AA ValueDomain
C0018704
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Institution No.
Description

InstitutionIdentifierNumber

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C21541
UMLS 2011AA ObjectClass
C0018704
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Patient Initials
Description

PatientInitialsName

Type de données

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
RTOG Patient ID
Description

PatientRadiationTherapyOncologyGroupIdentifierNumber

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C19778
UMLS 2011AA Property
C1514695
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Amended data
Description

DataAmendedInd-3

Type de données

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Module 1
Description

Module 1

Radiation Therapy Start Date
Description

RTBeginDate

Type de données

date

Alias
NCI Thesaurus ObjectClass
C15313
UMLS 2011AA ObjectClass
C1522449
NCI Thesaurus Property
C25431
UMLS 2011AA Property
C0439659
NCI Thesaurus Property
C25275
UMLS 2011AA Property
C2745955
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ValueDomain
C25367
Radiation Therapy End Date
Description

RTEndDate

Type de données

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C15313
UMLS 2011AA ObjectClass
C1522449
NCI Thesaurus Property
C25275
UMLS 2011AA Property
C2745955
NCI Thesaurus Property
C25496
UMLS 2011AA Property
C2746065
Total elapsed days (INCLUDING BOTH EXTERNAL RADIATION THERAPY AND BRACHYTHERAPY)
Description

RadiationTherapyTotalDayCount

Type de données

double

Alias
NCI Thesaurus ObjectClass
C15313
UMLS 2011AA ObjectClass
C1522449
NCI Thesaurus Property
C25304
UMLS 2011AA Property
C0439810
NCI Thesaurus Property
C25301
UMLS 2011AA Property
C0439228
NCI Thesaurus ValueDomain
C25301
UMLS 2011AA ValueDomain
C0439228
NCI Thesaurus ValueDomain
C25463
UMLS 2011AA ValueDomain
C0750480
RT Total Fraction Count
Description

RadiationTherapyTotalFractionsCount

Type de données

double

Alias
NCI Thesaurus Property
C25304
UMLS 2011AA Property
C0439810
NCI Thesaurus ObjectClass
C15313
UMLS 2011AA ObjectClass
C1522449
NCI Thesaurus ValueDomain
C25463
UMLS 2011AA ValueDomain
C0750480
NCI Thesaurus Property
C25514
UMLS 2011AA Property
C1264633
RT Total Dose (TO PTV)
Description

RTAdministeredTotalDose

Type de données

double

Alias
NCI Thesaurus ValueDomain
C25304
UMLS 2011AA ValueDomain
C0439810
NCI Thesaurus ObjectClass
C15313
UMLS 2011AA ObjectClass
C1522449
NCI Thesaurus ValueDomain
C25488
UMLS 2011AA ValueDomain
C0178602
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Were there any unscheduled interruptions in radiation therapy? (EXCLUDING HOLIDAYS)
Description

RTInterruptionInd

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
NCI Thesaurus ObjectClass
C15313
UMLS 2011AA ObjectClass
C1522449
NCI Thesaurus Property
C25542
UMLS 2011AA Property
C1512900
Specify RT interruption reason
Description

RadiationTherapyUnscheduledInterruptionSpecify

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C15313
UMLS 2011AA ObjectClass
C1522449
NCI Thesaurus Property
C25594
UMLS 2011AA Property
C1518422
NCI Thesaurus Property
C25211
UMLS 2011AA Property
C0086960
NCI Thesaurus Property
C25542
UMLS 2011AA Property
C1512900
Reason Treatment Ended
Description

Off-treatmentReason

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25638
UMLS 2011AA ValueDomain
C0392360
NCI Thesaurus ObjectClass
C25601
UMLS 2011AA ObjectClass
C1518544
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Alternative Therapy, specify
Description

Off-treatmentAlternativeReasonSpecify

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C25601
UMLS 2011AA ObjectClass
C1518544
NCI Thesaurus Property
C25415
UMLS 2011AA Property
C1523987
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Other specify
Description

Off-treatmentReasonSpecify

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C25601
UMLS 2011AA ObjectClass
C1518544
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Type of Radiation Therapy Administered
Description

RTAdministeredType

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C15313
UMLS 2011AA ObjectClass
C1522449
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
What method of daily prostate localization was used
Description

DailyLocalizationProstateMethodType

Type de données

text

Alias
NCI Thesaurus ObjectClass
C12410
UMLS 2011AA ObjectClass
C0033572
NCI Metathesaurus ObjectClass
CL052062
NCI Thesaurus ObjectClass
C28264
UMLS 2011AA ObjectClass
C0475264
NCI Thesaurus Property
C16847
UMLS 2011AA Property
C0449851
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Other, specify
Description

DailyLocalizationProstateMethodSpecify

Type de données

text

Alias
NCI Thesaurus ObjectClass
C12410
UMLS 2011AA ObjectClass
C0033572
NCI Metathesaurus ObjectClass
CL052062
NCI Thesaurus ObjectClass
C28264
UMLS 2011AA ObjectClass
C0475264
NCI Thesaurus Property
C16847
UMLS 2011AA Property
C0449851
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
Brachytherapy
Description

Brachytherapy

IF BRACHYTHERAPY NOT UTILIZED, PROVIDE REASON
Description

BrachytherapyOff-TreatmentReason

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25638
UMLS 2011AA ValueDomain
C0392360
NCI Thesaurus Property
C25601
UMLS 2011AA Property
C1518544
NCI Thesaurus ObjectClass
C15195
UMLS 2011AA ObjectClass
C0006098
Specify therapy
Description

AlternativeTherapyAdministeredSpecify

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus ObjectClass
C25415
UMLS 2011AA ObjectClass
C1523987
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Other reason, specify
Description

BrachytherapyOffTreatmentReasonSpecify

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus Property
C25601
UMLS 2011AA Property
C1518544
NCI Thesaurus ObjectClass
C15195
UMLS 2011AA ObjectClass
C0006098
Low-dose Radiation
Description

Low-dose Radiation

Date of implant
Description

BrachytherapyImplantDate

Type de données

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C15195
UMLS 2011AA ObjectClass
C0006098
NCI Thesaurus Property
C17948
UMLS 2011AA Property
C0013183
Date of post-implant CT
Description

CTPostBrachytherapyDate

Type de données

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C17204
UMLS 2011AA ObjectClass
C0040405
NCI Thesaurus Property
C38008
UMLS 2011AA Property
C0687676
NCI Metathesaurus Property
CL054378
Seed loss (were seeds expelled within the 3 weeks of implant? If yes, report details in Comment section.)
Description

BrachytherapyRadioactiveSeedImplantDosingUnitLostInd-3

Type de données

text

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus Property
C25560
UMLS 2011AA Property
C0745777
NCI Thesaurus Property
C67446
UMLS 2011AA Property
C1882540
NCI Thesaurus ObjectClass
C15195
UMLS 2011AA ObjectClass
C0006098
Was an indwelling urinary catheter inserted since implant
Description

SurgicalProcedureCatheterUrethraPostBrachytherapyPerformedTherapyInd-3

Type de données

text

Alias
NCI Thesaurus ObjectClass
C15329
UMLS 2011AA ObjectClass
C0543467
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
NCI Thesaurus Property
C38008
UMLS 2011AA Property
C0687676
NCI Thesaurus Property
C15195
UMLS 2011AA Property
C0006098
NCI Thesaurus Property
C17446
UMLS 2011AA Property
C0085590
NCI Thesaurus Property
C12417
UMLS 2011AA Property
C0041967
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
Date inserted (Provide estimate if exact date unknown)
Description

SurgicalProcedureCatheterUrethraPostBrachytherapyPerformedDate

Type de données

date

Alias
NCI Thesaurus ObjectClass
C15329
UMLS 2011AA ObjectClass
C0543467
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
NCI Thesaurus Property
C38008
UMLS 2011AA Property
C0687676
NCI Thesaurus Property
C15195
UMLS 2011AA Property
C0006098
NCI Thesaurus Property
C17446
UMLS 2011AA Property
C0085590
NCI Thesaurus Property
C12417
UMLS 2011AA Property
C0041967
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Date removed (Provide estimate if exact date unknown)
Description

SurgicalProcedureCatheterUrethraPostBrachytherapyRemovePerformedDate

Type de données

date

Alias
NCI Thesaurus ObjectClass
C15329
UMLS 2011AA ObjectClass
C0543467
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
NCI Thesaurus Property
C38008
UMLS 2011AA Property
C0687676
NCI Thesaurus Property
C15195
UMLS 2011AA Property
C0006098
NCI Thesaurus Property
C17446
UMLS 2011AA Property
C0085590
NCI Thesaurus Property
C64914
UMLS 2011AA Property
C1883720
NCI Thesaurus Property
C12417
UMLS 2011AA Property
C0041967
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
High-dose Radiation
Description

High-dose Radiation

Date of implant fraction #1
Description

BrachytherapyFirstFractionationImplantationDate

Type de données

date

Alias
NCI Thesaurus ObjectClass
C15195
UMLS 2011AA ObjectClass
C0006098
NCI Thesaurus Property
C25509
UMLS 2011AA Property
C1279901
NCI Thesaurus Property
C15654
UMLS 2011AA Property
C0016640
NCI Thesaurus Property
C51982
UMLS 2011AA Property
C0021107
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Time of implant fraction #1
Description

BrachytherapyFirstFractionationImplantationTime

Type de données

time

Alias
NCI Thesaurus ObjectClass
C15195
UMLS 2011AA ObjectClass
C0006098
NCI Thesaurus Property
C25509
UMLS 2011AA Property
C1279901
NCI Thesaurus Property
C15654
UMLS 2011AA Property
C0016640
NCI Thesaurus Property
C51982
UMLS 2011AA Property
C0021107
NCI Thesaurus ValueDomain
C25207
UMLS 2011AA ValueDomain
C0040223
Date of implant fraction #2
Description

BrachytherapySecondFractionationImplantationDate

Type de données

date

Alias
NCI Thesaurus ObjectClass
C15195
UMLS 2011AA ObjectClass
C0006098
NCI Thesaurus Property
C25666
UMLS 2011AA Property
C0205436
NCI Thesaurus Property
C15654
UMLS 2011AA Property
C0016640
NCI Thesaurus Property
C51982
UMLS 2011AA Property
C0021107
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Total elapsed days (INCLUDING BOTH EXTERNAL RADIATION THERAPY AND BRACHYTHERAPY)
Description

RadiationTherapyTotalDayCount

Type de données

double

Alias
NCI Thesaurus ObjectClass
C15313
UMLS 2011AA ObjectClass
C1522449
NCI Thesaurus Property
C25304
UMLS 2011AA Property
C0439810
NCI Thesaurus Property
C25301
UMLS 2011AA Property
C0439228
NCI Thesaurus ValueDomain
C25301
UMLS 2011AA ValueDomain
C0439228
NCI Thesaurus ValueDomain
C25463
UMLS 2011AA ValueDomain
C0750480
Time of implant fraction #2
Description

BrachytherapySecondFractionationImplantationTime

Type de données

time

Alias
NCI Thesaurus ObjectClass
C15195
UMLS 2011AA ObjectClass
C0006098
NCI Thesaurus Property
C25666
UMLS 2011AA Property
C0205436
NCI Thesaurus Property
C15654
UMLS 2011AA Property
C0016640
NCI Thesaurus Property
C51982
UMLS 2011AA Property
C0021107
NCI Thesaurus ValueDomain
C25207
UMLS 2011AA ValueDomain
C0040223
Number of implant catheters used
Description

BrachytherapyCatheterImplantationUseCount

Type de données

double

Alias
NCI Thesaurus ObjectClass
C15195
UMLS 2011AA ObjectClass
C0006098
NCI Thesaurus Property
C17446
UMLS 2011AA Property
C0085590
NCI Thesaurus Property
C25340
UMLS 2011AA Property
C0457083
NCI Thesaurus Property
C51982
UMLS 2011AA Property
C0021107
NCI Thesaurus ValueDomain
C25463
UMLS 2011AA ValueDomain
C0750480
Footer
Description

Footer

Comments
Description

ResearchCommentsText

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
UMLS 2011AA Property
C0282411
Signature of Person Completing This Form
Description

ResponsiblePersonSignatureText

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus ObjectClass
C25657
UMLS 2011AA ObjectClass
C1273518
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
Date Form Originally Completed
Description

FormOriginalCompleteDate

Type de données

date

Alias
NCI Thesaurus ObjectClass
C19464
UMLS 2011AA ObjectClass
C0376315
NCI Thesaurus Property
C25250
UMLS 2011AA Property
C0205197
NCI Thesaurus Property
C25604
UMLS 2011AA Property
C0205313
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ValueDomain
C25367

Similar models

Instructions: Form is submitted upon completion or termination of RT for all patients assigned RT. Dates are mmdd-yyyy unless specified otherwise. If assigned radiation and none given, complete Q#7, sign date and submit form.

Name
Type
Description | Question | Decode (Coded Value)
Type de données
Alias
Item Group
Unnamed Module 1
ProtocolRTOGIdentifierNumber
Item
RTOG Study No.
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C19778 (NCI Thesaurus Property)
C1514695 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
RadiationTherapyOncologyGroupPatientCaseIdentifierNumber
Item
Case #
text
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C19778 (NCI Thesaurus ObjectClass)
C1514695 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C49152 (NCI Thesaurus Property)
C1706256 (UMLS 2011AA Property)
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
InstitutionName
Item
Institution Name
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C21541 (NCI Thesaurus ValueDomain)
C0018704 (UMLS 2011AA ValueDomain)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
InstitutionIdentifierNumber
Item
Institution No.
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
PatientInitialsName
Item
Patient Initials
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)
PatientRadiationTherapyOncologyGroupIdentifierNumber
Item
RTOG Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C19778 (NCI Thesaurus Property)
C1514695 (UMLS 2011AA Property)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
Item
Amended data
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)
Code List
Amended data
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item Group
Module 1
RTBeginDate
Item
Radiation Therapy Start Date
date
C15313 (NCI Thesaurus ObjectClass)
C1522449 (UMLS 2011AA ObjectClass)
C25431 (NCI Thesaurus Property)
C0439659 (UMLS 2011AA Property)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus ValueDomain)
RTEndDate
Item
Radiation Therapy End Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C15313 (NCI Thesaurus ObjectClass)
C1522449 (UMLS 2011AA ObjectClass)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
C25496 (NCI Thesaurus Property)
C2746065 (UMLS 2011AA Property)
RadiationTherapyTotalDayCount
Item
Total elapsed days (INCLUDING BOTH EXTERNAL RADIATION THERAPY AND BRACHYTHERAPY)
double
C15313 (NCI Thesaurus ObjectClass)
C1522449 (UMLS 2011AA ObjectClass)
C25304 (NCI Thesaurus Property)
C0439810 (UMLS 2011AA Property)
C25301 (NCI Thesaurus Property)
C0439228 (UMLS 2011AA Property)
C25301 (NCI Thesaurus ValueDomain)
C0439228 (UMLS 2011AA ValueDomain)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
RadiationTherapyTotalFractionsCount
Item
RT Total Fraction Count
double
C25304 (NCI Thesaurus Property)
C0439810 (UMLS 2011AA Property)
C15313 (NCI Thesaurus ObjectClass)
C1522449 (UMLS 2011AA ObjectClass)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
C25514 (NCI Thesaurus Property)
C1264633 (UMLS 2011AA Property)
RTAdministeredTotalDose
Item
RT Total Dose (TO PTV)
double
C25304 (NCI Thesaurus ValueDomain)
C0439810 (UMLS 2011AA ValueDomain)
C15313 (NCI Thesaurus ObjectClass)
C1522449 (UMLS 2011AA ObjectClass)
C25488 (NCI Thesaurus ValueDomain)
C0178602 (UMLS 2011AA ValueDomain)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
Item
Were there any unscheduled interruptions in radiation therapy? (EXCLUDING HOLIDAYS)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C15313 (NCI Thesaurus ObjectClass)
C1522449 (UMLS 2011AA ObjectClass)
C25542 (NCI Thesaurus Property)
C1512900 (UMLS 2011AA Property)
Code List
Were there any unscheduled interruptions in radiation therapy? (EXCLUDING HOLIDAYS)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes, Due To Toxicity (Yes, due to toxicity)
CL Item
Yes, Due To Other Reason (Yes, due to other reason)
RadiationTherapyUnscheduledInterruptionSpecify
Item
Specify RT interruption reason
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C15313 (NCI Thesaurus ObjectClass)
C1522449 (UMLS 2011AA ObjectClass)
C25594 (NCI Thesaurus Property)
C1518422 (UMLS 2011AA Property)
C25211 (NCI Thesaurus Property)
C0086960 (UMLS 2011AA Property)
C25542 (NCI Thesaurus Property)
C1512900 (UMLS 2011AA Property)
Item
Reason Treatment Ended
text
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
C25601 (NCI Thesaurus ObjectClass)
C1518544 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
Code List
Reason Treatment Ended
CL Item
Treatment Completed Per Protocol Criteria (Treatment completed per protocol criteria)
CL Item
Disease Progression, Relapse During Active Treatment (Disease progression, relapse during active treatment)
CL Item
Adverse Event/side Effects/complications (Adverse Event/Side Effects/Complications)
CL Item
Death On Study (Death on study)
CL Item
Patient Withdrawal Or Refusal After Beginning Protocol Therapy (Patient withdrawal/refusal after beginning protocol therapy)
CL Item
Patient Withdrawal Or Refusal Before Beginning Protocol Therapy (Patient withdrawal/refusal prior to beginning protocol therapy)
CL Item
Alternative Therapy (Alternative therapy)
CL Item
Patient Off-treatment For Other Complicating Disease (Patient off-treatment for other complicating disease)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
Off-treatmentAlternativeReasonSpecify
Item
Alternative Therapy, specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C25601 (NCI Thesaurus ObjectClass)
C1518544 (UMLS 2011AA ObjectClass)
C25415 (NCI Thesaurus Property)
C1523987 (UMLS 2011AA Property)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
Off-treatmentReasonSpecify
Item
Other specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C25601 (NCI Thesaurus ObjectClass)
C1518544 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
Item
Type of Radiation Therapy Administered
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C15313 (NCI Thesaurus ObjectClass)
C1522449 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
Code List
Type of Radiation Therapy Administered
CL Item
3d Conformal + Imrt Boost (3D Conformal + IMRT Boost)
CL Item
Imrt (IMRT)
CL Item
Low-dose Treatment Brachytherapy 3-dimensional Conformal Radiation Therapy (3DCRT + Brachytherapy LDR)
C16035 (NCI Thesaurus)
C0600521 (UMLS 2011AA)
C15195 (NCI Thesaurus)
C0006098 (UMLS 2011AA)
C49341 (NCI Thesaurus)
C1708745 (UMLS 2011AA)
CL Item
Low-dose Treatment Brachytherapy Imrt (IMRT + Brachytherapy LDR)
C15195 (NCI Thesaurus)
C0006098 (UMLS 2011AA)
C16135 (NCI Thesaurus)
C1512814 (UMLS 2011AA)
C49341 (NCI Thesaurus)
C1708745 (UMLS 2011AA)
CL Item
High-dose Rate Brachytherapy 3-dimensional Conformal Radiation Therapy (3DCRT + Brachytherapy HDR)
C16035 (NCI Thesaurus)
C0600521 (UMLS 2011AA)
C15651 (NCI Thesaurus)
C0454270 (UMLS 2011AA)
CL Item
High-dose Rate Brachytherapy Imrt (IMRT + Brachytherapy HDR)
C16135 (NCI Thesaurus)
C1512814 (UMLS 2011AA)
C15651 (NCI Thesaurus)
C0454270 (UMLS 2011AA)
Item
What method of daily prostate localization was used
text
C12410 (NCI Thesaurus ObjectClass)
C0033572 (UMLS 2011AA ObjectClass)
CL052062 (NCI Metathesaurus ObjectClass)
C28264 (NCI Thesaurus ObjectClass)
C0475264 (UMLS 2011AA ObjectClass)
C16847 (NCI Thesaurus Property)
C0449851 (UMLS 2011AA Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
Code List
What method of daily prostate localization was used
CL Item
Cbct (CBCT)
CL Item
Helical Ct (Helical CT)
CL Item
Ct On Rails (CT on Rails)
CL Item
Portal Image/epid (Portal Image/EPID)
CL Item
Ultra Sound (Ultra sound)
CL Item
Optical Tracking (Optical Tracking)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
No Daily Localization Used (No Daily Localization Used)
DailyLocalizationProstateMethodSpecify
Item
Other, specify
text
C12410 (NCI Thesaurus ObjectClass)
C0033572 (UMLS 2011AA ObjectClass)
CL052062 (NCI Metathesaurus ObjectClass)
C28264 (NCI Thesaurus ObjectClass)
C0475264 (UMLS 2011AA ObjectClass)
C16847 (NCI Thesaurus Property)
C0449851 (UMLS 2011AA Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
Item Group
Brachytherapy
Item
IF BRACHYTHERAPY NOT UTILIZED, PROVIDE REASON
text
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
C25601 (NCI Thesaurus Property)
C1518544 (UMLS 2011AA Property)
C15195 (NCI Thesaurus ObjectClass)
C0006098 (UMLS 2011AA ObjectClass)
Code List
IF BRACHYTHERAPY NOT UTILIZED, PROVIDE REASON
CL Item
Na Dose Administered Within Protocol Specifications (NA Dose administered within protocol specifications)
CL Item
Not Technically Feasible (Not technically feasible)
CL Item
Patient Refused (Patient refused)
CL Item
Inadequate To Treat Extent Of Disease (Inadequate to treat extent of disease)
CL Item
Md Preference (MD preference)
CL Item
Progression Or Relapse (Progression or relapse)
CL Item
Toxicity Or Treatment Reaction (Toxicity or treatment reaction)
CL Item
Death (Death)
C28554 (NCI Thesaurus)
C0011065 (UMLS 2011AA)
CL Item
Alternative Therapy Given (Alternative therapy given)
CL Item
Other Reason, Specify (Other reason, specify)
AlternativeTherapyAdministeredSpecify
Item
Specify therapy
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C15368 (NCI Thesaurus ObjectClass)
C25415 (NCI Thesaurus ObjectClass)
C1523987 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
BrachytherapyOffTreatmentReasonSpecify
Item
Other reason, specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C25601 (NCI Thesaurus Property)
C1518544 (UMLS 2011AA Property)
C15195 (NCI Thesaurus ObjectClass)
C0006098 (UMLS 2011AA ObjectClass)
Item Group
Low-dose Radiation
BrachytherapyImplantDate
Item
Date of implant
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C15195 (NCI Thesaurus ObjectClass)
C0006098 (UMLS 2011AA ObjectClass)
C17948 (NCI Thesaurus Property)
C0013183 (UMLS 2011AA Property)
CTPostBrachytherapyDate
Item
Date of post-implant CT
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C17204 (NCI Thesaurus ObjectClass)
C0040405 (UMLS 2011AA ObjectClass)
C38008 (NCI Thesaurus Property)
C0687676 (UMLS 2011AA Property)
CL054378 (NCI Metathesaurus Property)
Item
Seed loss (were seeds expelled within the 3 weeks of implant? If yes, report details in Comment section.)
text
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25560 (NCI Thesaurus Property)
C0745777 (UMLS 2011AA Property)
C67446 (NCI Thesaurus Property)
C1882540 (UMLS 2011AA Property)
C15195 (NCI Thesaurus ObjectClass)
C0006098 (UMLS 2011AA ObjectClass)
Code List
Seed loss (were seeds expelled within the 3 weeks of implant? If yes, report details in Comment section.)
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
Was an indwelling urinary catheter inserted since implant
text
C15329 (NCI Thesaurus ObjectClass)
C0543467 (UMLS 2011AA ObjectClass)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C38008 (NCI Thesaurus Property)
C0687676 (UMLS 2011AA Property)
C15195 (NCI Thesaurus Property)
C0006098 (UMLS 2011AA Property)
C17446 (NCI Thesaurus Property)
C0085590 (UMLS 2011AA Property)
C12417 (NCI Thesaurus Property)
C0041967 (UMLS 2011AA Property)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
Code List
Was an indwelling urinary catheter inserted since implant
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)
SurgicalProcedureCatheterUrethraPostBrachytherapyPerformedDate
Item
Date inserted (Provide estimate if exact date unknown)
date
C15329 (NCI Thesaurus ObjectClass)
C0543467 (UMLS 2011AA ObjectClass)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C38008 (NCI Thesaurus Property)
C0687676 (UMLS 2011AA Property)
C15195 (NCI Thesaurus Property)
C0006098 (UMLS 2011AA Property)
C17446 (NCI Thesaurus Property)
C0085590 (UMLS 2011AA Property)
C12417 (NCI Thesaurus Property)
C0041967 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
SurgicalProcedureCatheterUrethraPostBrachytherapyRemovePerformedDate
Item
Date removed (Provide estimate if exact date unknown)
date
C15329 (NCI Thesaurus ObjectClass)
C0543467 (UMLS 2011AA ObjectClass)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C38008 (NCI Thesaurus Property)
C0687676 (UMLS 2011AA Property)
C15195 (NCI Thesaurus Property)
C0006098 (UMLS 2011AA Property)
C17446 (NCI Thesaurus Property)
C0085590 (UMLS 2011AA Property)
C64914 (NCI Thesaurus Property)
C1883720 (UMLS 2011AA Property)
C12417 (NCI Thesaurus Property)
C0041967 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Item Group
High-dose Radiation
BrachytherapyFirstFractionationImplantationDate
Item
Date of implant fraction #1
date
C15195 (NCI Thesaurus ObjectClass)
C0006098 (UMLS 2011AA ObjectClass)
C25509 (NCI Thesaurus Property)
C1279901 (UMLS 2011AA Property)
C15654 (NCI Thesaurus Property)
C0016640 (UMLS 2011AA Property)
C51982 (NCI Thesaurus Property)
C0021107 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
BrachytherapyFirstFractionationImplantationTime
Item
Time of implant fraction #1
time
C15195 (NCI Thesaurus ObjectClass)
C0006098 (UMLS 2011AA ObjectClass)
C25509 (NCI Thesaurus Property)
C1279901 (UMLS 2011AA Property)
C15654 (NCI Thesaurus Property)
C0016640 (UMLS 2011AA Property)
C51982 (NCI Thesaurus Property)
C0021107 (UMLS 2011AA Property)
C25207 (NCI Thesaurus ValueDomain)
C0040223 (UMLS 2011AA ValueDomain)
BrachytherapySecondFractionationImplantationDate
Item
Date of implant fraction #2
date
C15195 (NCI Thesaurus ObjectClass)
C0006098 (UMLS 2011AA ObjectClass)
C25666 (NCI Thesaurus Property)
C0205436 (UMLS 2011AA Property)
C15654 (NCI Thesaurus Property)
C0016640 (UMLS 2011AA Property)
C51982 (NCI Thesaurus Property)
C0021107 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
RadiationTherapyTotalDayCount
Item
Total elapsed days (INCLUDING BOTH EXTERNAL RADIATION THERAPY AND BRACHYTHERAPY)
double
C15313 (NCI Thesaurus ObjectClass)
C1522449 (UMLS 2011AA ObjectClass)
C25304 (NCI Thesaurus Property)
C0439810 (UMLS 2011AA Property)
C25301 (NCI Thesaurus Property)
C0439228 (UMLS 2011AA Property)
C25301 (NCI Thesaurus ValueDomain)
C0439228 (UMLS 2011AA ValueDomain)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
BrachytherapySecondFractionationImplantationTime
Item
Time of implant fraction #2
time
C15195 (NCI Thesaurus ObjectClass)
C0006098 (UMLS 2011AA ObjectClass)
C25666 (NCI Thesaurus Property)
C0205436 (UMLS 2011AA Property)
C15654 (NCI Thesaurus Property)
C0016640 (UMLS 2011AA Property)
C51982 (NCI Thesaurus Property)
C0021107 (UMLS 2011AA Property)
C25207 (NCI Thesaurus ValueDomain)
C0040223 (UMLS 2011AA ValueDomain)
BrachytherapyCatheterImplantationUseCount
Item
Number of implant catheters used
double
C15195 (NCI Thesaurus ObjectClass)
C0006098 (UMLS 2011AA ObjectClass)
C17446 (NCI Thesaurus Property)
C0085590 (UMLS 2011AA Property)
C25340 (NCI Thesaurus Property)
C0457083 (UMLS 2011AA Property)
C51982 (NCI Thesaurus Property)
C0021107 (UMLS 2011AA Property)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
Item Group
Footer
ResearchCommentsText
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
C0282411 (UMLS 2011AA Property)
ResponsiblePersonSignatureText
Item
Signature of Person Completing This Form
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25657 (NCI Thesaurus ObjectClass)
C1273518 (UMLS 2011AA ObjectClass)
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
FormOriginalCompleteDate
Item
Date Form Originally Completed
date
C19464 (NCI Thesaurus ObjectClass)
C0376315 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C25604 (NCI Thesaurus Property)
C0205313 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus ValueDomain)

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