ID

43093

Description

Palliative Treatment for Head and Neck Cancer - On-Study Form Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=20B9E4F5-9DD3-2343-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=20B9E4F5-9DD3-2343-E044-0003BA3F9857

Keywords

Head and Neck Neoplasms

Clinical Trial

Palliative Care

On-Study Form

Uploaded on

September 20, 2021

DOI

To request one please log in.

License

Creative Commons BY-NC 3.0 Legacy

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On-Study - Palliative Treatment for Head and Neck Cancer - On-Study Form - 2267713v3.0

model
Details

[Note: This form is for trials enrolling patients with persistent, recurrent, or metastatic disease.]

1 forms

StudyEvent: Palliative Treatment for Head and Neck Cancer - On-Study Form
1. [Note: This form is for trials enrolling patients with persistent, recurrent, or metastatic disease.]

Name

Type

Description | Question | Decode (Coded Value)

Data type

Alias

CRF Header

Item Group

Crf Header

Protocol ID Coordinating Group

Item

Coordinating Group Protocol No.

text

C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1711341 (UMLS CUI-2)
C25462 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)

Coordinating Group Code

Item

Coordinating Group Code

text

C25162 (NCI Thesaurus ValueDomain)
C1711341 (UMLS CUI-1)
C17005 (NCI Thesaurus ObjectClass)
C0805701 (UMLS CUI-2)
C25462 (NCI Thesaurus ObjectClass-2)
C25364 (NCI Thesaurus Property)

Protocol Title

Item

Protocol Title

text

C25191 (NCI Thesaurus ValueDomain)
C2986303 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C42774 (NCI Thesaurus Property)

Patient Study ID

Item

Patient Study ID

text

C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25462 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)

Institution Name

Item

Institution/Affiliate

text

C25454 (NCI Thesaurus ObjectClass)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass-2)
C25364 (NCI Thesaurus Property)
C25191 (NCI Thesaurus ValueDomain)
C21541 (NCI Thesaurus ValueDomain-2)

Trial subject ID Participating Group

Item

Other Patient ID

text

C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C2347449 (UMLS CUI-2)
C25608 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)

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-2)
C1257890 (UMLS 2011AA ObjectClass-2)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)

Patient Initials

Item

Patient Initials

text

C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)

Head & Neck: Form Administration

Item Group

Head & Neck: Form Administration

Person Completing Form

Item

Person Completing Form

text

C25191 (NCI Thesaurus ValueDomain)
C1550483 (UMLS CUI-1)
C25657 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)

Data amended

Item

Are data amended? (If data are amended, please circle in red when using paper form)

boolean

C38148 (NCI Thesaurus ValueDomain)
C0680532 (UMLS CUI-1)
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)

Head & Neck: Patient Assessment

Item Group

Head & Neck: Patient Assessment

ECOG Performance Status

Item

Performance Status (check one)

text

C25664 (NCI Thesaurus ValueDomain)
C1520224 (UMLS CUI-1)
C25367 (NCI Thesaurus Property)
C25491 (NCI Thesaurus ValueDomain-2)
C20641 (NCI Thesaurus ObjectClass)

CL.2

Code List

Performance Status (check one)

CL Item

Fully Active, Able To Carry On All Pre-disease Performance Without Restriction. (0)

CL Item

Restricted In Physically Strenuous Activity But Ambulatory And Able To Carry Out Work Of A Light Or Sedentary Nature, E.g., Light Housework, Office Work. (1)

CL Item

Ambulatory And Capable Of All Selfcare But Unable To Carry Out Any Work Activities. Up And About More Than 50% Of Waking Hours. (2)

CL Item

Capable Of Only Limited Selfcare, Confined To Bed Or Chair More Than 50% Of Waking Hours. (3)

CL Item

Completely Disabled. Cannot Carry On Any Selfcare. Totally Confined To Bed Or Chair. (4)

Head & Neck: Disease Description - Initial Diagnosis of Disease

Item Group

Head & Neck: Disease Description - Initial Diagnosis Of Disease

CancerInitialDiagnosisDate

Item

Date of Initial Pathologic Diagnosis

date

C9305 (NCI Thesaurus ObjectClass)
C0006826 (UMLS 2011AA ObjectClass)
C25509 (NCI Thesaurus Property)
C1279901 (UMLS 2011AA Property)
C15220 (NCI Thesaurus Property-2)
C0011900 (UMLS 2011AA Property-2)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)

HeadandNeckTumorPrimaryLocation

Item

Primary Site

text

C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C12418 (NCI Thesaurus ObjectClass-2)
C0460004 (UMLS 2011AA ObjectClass-2)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C25251 (NCI Thesaurus Property-2)
C0205225 (UMLS 2011AA Property-2)
C13717 (NCI Thesaurus ValueDomain)
C1515974 (UMLS 2011AA ValueDomain)

CL.13

Code List

Primary Site

CL Item

Lip And Oral Cavity (Lip and oral cavity)

CL Item

Oral Cavity Nos (Oral cavity NOS)

CL Item

Oral Tongue (Oral Tongue)

CL Item

Floor Of Mouth (Floor of mouth)

C0026638 (NCI Metathesaurus)

CL Item

Buccal Mucosa (Buccal mucosa)

C12505 (NCI Thesaurus)
C1578559 (UMLS 2011AA)

CL Item

Lower Gingiva (Lower gingiva)

CL Item

Upper Gingiva (Upper gingiva)

CL Item

Retromolar Trigone (Retromolar trigone)

CL Item

Hard Palate (Hard palate)

C12230 (NCI Thesaurus)
C0226901 (UMLS 2011AA)

CL Item

Nasopharynx Nos (Nasopharynx NOS)

CL Item

Posterior Superior Wall (Posterior superior wall)

CL Item

Lateral Wall (Lateral wall)

CL Item

Oropharynx Nos (Oropharynx NOS)

CL Item

Supraglottic Larynx (Supraglottic larynx)

CL Item

Faucial Arch (Faucial arch)

CL Item

Tonsillar Fossa Tonsil (Tonsillar fossa, tonsil)

CL Item

Base Of Tongue (Base of tongue)

C0226958 (NCI Metathesaurus)

CL Item

Posterior Pharyngeal Wall (Posterior pharyngeal wall)

CL Item

Soft Palate (Soft palate)

C12231 (NCI Thesaurus)
C0030219 (UMLS 2011AA)

CL Item

Hypopharynx Nos (Hypopharynx NOS)

CL Item

Pyriform Fossa (Pyriform fossa)

CL Item

Postcricoid Area (Postcricoid area)

CL Item

Posterior Wall (Posterior wall)

CL Item

Salivary Glands Nos (Salivary glands NOS)

CL Item

Parotid (Parotid)

CL Item

Submandibular (Submandibular)

CL Item

Sublingual (Sublingual)

C89785 (NCI Thesaurus)

CL Item

Minor Salivary Glands (Minor salivary glands)

CL Item

Larynx Nos (Larynx NOS)

CL Item

Glottic Larynx (Glottic larynx)

CL Item

Subglottic Larynx (Subglottic larynx)

CL Item

Paranasal Sinuses Nos (Paranasal sinuses NOS)

CL Item

Antrum (Antrum)

CL Item

Ethmoid (Ethmoid)

CL Item

Sphenoid (Sphenoid)

CL Item

Frontal (Frontal)

CL Item

Nose Nos (Nose NOS)

CL Item

Nasal Cavity (Nasal cavity)

C12424 (NCI Thesaurus)
C0027423 (UMLS 2011AA)

CL Item

Unknown (Unknown)

C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)

CL Item

Other (Other)

C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)

Primary Disease Site

Item

Other specify

text

C25685 (NCI Thesaurus ValueDomain)
C0449695 (UMLS CUI-1)
C25341 (NCI Thesaurus Property)
C25251 (NCI Thesaurus ObjectClass)
C2991 (NCI Thesaurus ObjectClass-2)

HeadandNeckTumorHistologicCategory

Item

Histologic Type

text

C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C12418 (NCI Thesaurus ObjectClass-2)
C0460004 (UMLS 2011AA ObjectClass-2)
C25526 (NCI Thesaurus Property)
C0205462 (UMLS 2011AA Property)
C25161 (NCI Thesaurus Property-2)
C0008902 (UMLS 2011AA Property-2)
C25372 (NCI Thesaurus ValueDomain)
C0683312 (UMLS 2011AA ValueDomain)
C25526 (NCI Thesaurus ValueDomain-2)
C0205462 (UMLS 2011AA ValueDomain-2)

CL.14

Code List

Histologic Type

CL Item

Carcinoma In Situ (specify Histologic Type) (Carcinoma in situ)

CL Item

Squamous Cell Carcinoma Keratinizing (Squamous cell carcinoma, keratinizing)

CL Item

Squamous Cell Carcinoma Non-keratinizing (Squamous cell carcinoma, non-keratinizing)

CL Item

Verrucous Squamous Cell Carcinoma (Verrucous squamous cell carcinoma)

CL Item

Adenoid Squamous Cell Carcinoma (Adenoid squamous cell carcinoma)

CL Item

Basaloid Squamous Cell Carcinoma (Basaloid squamous cell carcinoma)

CL Item

Adenosquamous Carcinoma (Adenosquamous carcinoma)

C3727 (NCI Thesaurus)
C0206623 (UMLS 2011AA)

CL Item

Adenocarcinoma (Adenocarcinoma)

C2852 (NCI Thesaurus)
C0001418 (UMLS 2011AA)

CL Item

Spindle Cell Carcinoma (Spindle cell carcinoma)

CL Item

Acinic Cell Carcinoma (Acinic cell carcinoma)

CL Item

Mucoepidermoid Carcinoma (Mucoepidermoid carcinoma)

C3772 (NCI Thesaurus)
C0206694 (UMLS 2011AA)

CL Item

Adenoid Cystic Carcinoma (Adenoid cystic carcinoma)

C2970 (NCI Thesaurus)
C0010606 (UMLS 2011AA)

CL Item

Carcinoma In Pleomorphic Adenoma (Carcinoma in pleomorphic adenoma)

CL Item

Epithelial-myoepithelial Carcinoma (Epithelial-myoepithelial carcinoma)

C4199 (NCI Thesaurus)
C0334392 (UMLS 2011AA)

CL Item

Clear Cell Carcinoma (Clear cell carcinoma)

CL Item

Giant Cell Carcinoma (Giant cell carcinoma)

C3779 (NCI Thesaurus)
C0206703 (UMLS 2011AA)

CL Item

Small Cell Carcinoma (Small cell carcinoma)

C3915 (NCI Thesaurus)
C0262584 (UMLS 2011AA)

CL Item

Salivary Duct Carcinoma (Salivary duct carcinoma)

C5904 (NCI Thesaurus)
C1301194 (UMLS 2011AA)

CL Item

Carcinoid Tumor (Carcinoid tumor)

C2915 (NCI Thesaurus)
C0007095 (UMLS 2011AA)

CL Item

Atypical Carcinoid Tumor (Atypical carcinoid tumor)

CL017927 (NCI Metathesaurus)

CL Item

Lymphoepithelial Carcinoma (Lymphoepithelial carcinoma)

CL Item

Undifferentiated Carcinoma (Undifferentiated carcinoma)

C3692 (NCI Thesaurus)
C0205698 (UMLS 2011AA)

CL Item

Unknown (Unknown)

C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)

CL Item

Other (Other)

C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)

Histologic Type, other

Item

Other specify

text

C25685 (NCI Thesaurus ValueDomain)
C1299220 (UMLS CUI-1)
C3262 (NCI Thesaurus ObjectClass)
C25526 (NCI Thesaurus Property)
C25161 (NCI Thesaurus Property-2)

HeadandNeckTumorClinicalTStage

Item

Clinical T Stage (Clinical Impression of Tumor at Current Presentation use the version of the AJCC staging system specified in the protocol)

text

C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C12418 (NCI Thesaurus ObjectClass-2)
C0460004 (UMLS 2011AA ObjectClass-2)
C25398 (NCI Thesaurus Property)
C0205210 (UMLS 2011AA Property)
C25728 (NCI Thesaurus Property-2)
C0475455 (UMLS 2011AA Property-2)
C16899 (NCI Thesaurus ValueDomain)
C1300072 (UMLS 2011AA ValueDomain)

CL.16

Code List

Clinical T Stage (Clinical Impression of Tumor at Current Presentation use the version of the AJCC staging system specified in the protocol)

CL Item

T0, According To Ajcc Criteria (T0)

CL Item

Tis, According To Ajcc Criteria (Tis)

CL Item

T1, According To Ajcc Criteria (T1)

CL Item

T2, According To Ajcc Criteria (T2)

CL Item

T3, According To Ajcc Criteria (T3)

CL Item

T4a, According To Ajcc Guidelines (T4a)

CL Item

T4b, According To Ajcc Guidelines (T4b)

CL Item

Tx, According To Ajcc Criteria (TX)

HeadandNeckTumorClinicalNStage

Item

Clinical N Stage (overall)

text

C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C12418 (NCI Thesaurus ObjectClass-2)
C0460004 (UMLS 2011AA ObjectClass-2)
C25398 (NCI Thesaurus Property)
C0205210 (UMLS 2011AA Property)
C25580 (NCI Thesaurus Property-2)
C0456532 (UMLS 2011AA Property-2)
C16899 (NCI Thesaurus ValueDomain)
C1300072 (UMLS 2011AA ValueDomain)

CL.17

Code List

Clinical N Stage (overall)

CL Item

N0, According To Ajcc Guidelines (N0)

CL Item

N1, According To Ajcc Criteria (N1)

CL Item

N2, According To Ajcc Criteria (N2)

CL Item

N2a, According To Ajcc Guidelines (N2a)

CL Item

N2b, According To Ajcc Guidelines (N2b)

CL Item

N2c, According To Ajcc Guidelines (N2c)

CL Item

N3, According To Ajcc Guidelines (N3)

HeadandNeckTumorRightNStage

Item

Clinical N Stage, Right Side

text

C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C12418 (NCI Thesaurus ObjectClass-2)
C0460004 (UMLS 2011AA ObjectClass-2)
C25228 (NCI Thesaurus Property)
C0205090 (UMLS 2011AA Property)
C25580 (NCI Thesaurus Property-2)
C0456532 (UMLS 2011AA Property-2)
C16899 (NCI Thesaurus ValueDomain)
C1300072 (UMLS 2011AA ValueDomain)

CL.18

Code List

Clinical N Stage, Right Side

CL Item

N0, According To Ajcc Guidelines (N0)

CL Item

N1, According To Ajcc Criteria (N1)

CL Item

N2, According To Ajcc Criteria (N2)

CL Item

N2a, According To Ajcc Guidelines (N2a)

CL Item

N2b, According To Ajcc Guidelines (N2b)

CL Item

N2c, According To Ajcc Guidelines (N2c)

CL Item

N3, According To Ajcc Guidelines (N3)

HeadandNeckTumorLeftNStage

Item

Clinical N Stage, Left Side

text

C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C12418 (NCI Thesaurus ObjectClass-2)
C0460004 (UMLS 2011AA ObjectClass-2)
C25229 (NCI Thesaurus Property)
C0205091 (UMLS 2011AA Property)
C25580 (NCI Thesaurus Property-2)
C0456532 (UMLS 2011AA Property-2)
C16899 (NCI Thesaurus ValueDomain)
C1300072 (UMLS 2011AA ValueDomain)

CL.19

Code List

Clinical N Stage, Left Side

CL Item

N0, According To Ajcc Guidelines (N0)

CL Item

N1, According To Ajcc Criteria (N1)

CL Item

N2, According To Ajcc Criteria (N2)

CL Item

N2a, According To Ajcc Guidelines (N2a)

CL Item

N2b, According To Ajcc Guidelines (N2b)

CL Item

N2c, According To Ajcc Guidelines (N2c)

CL Item

N3, According To Ajcc Guidelines (N3)

HeadandNeckTumorClinicalMStage

Item

Clinical M Stage

text

C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C12418 (NCI Thesaurus ObjectClass-2)
C0460004 (UMLS 2011AA ObjectClass-2)
C25398 (NCI Thesaurus Property)
C0205210 (UMLS 2011AA Property)
C25727 (NCI Thesaurus Property-2)
C0456533 (UMLS 2011AA Property-2)
C16899 (NCI Thesaurus ValueDomain)
C1300072 (UMLS 2011AA ValueDomain)

CL.20

Code List

Clinical M Stage

CL Item

M0, According To Ajcc Guidelines (M0)

CL Item

M1, According To Ajcc Staging Definitions (M1)

CL Item

Mx, According To Ajcc Guidelines (MX)

Head & Neck: Disease Description - Current Diagnosis

Item Group

Head & Neck: Disease Description - Current Diagnosis

DiseaseRegistrationType

Item

Type of Patient Disease

text

C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25646 (NCI Thesaurus Property)
C1514821 (UMLS 2011AA Property)
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)

CL.10

Code List

Type of Patient Disease

CL Item

Persistent (Persistent)

CL Item

Recurrent (Recurrent)

C14173 (NCI Thesaurus)
C2945760 (UMLS 2011AA)

CL Item

Metastatic (Metastatic)

C14174 (NCI Thesaurus)
C0036525 (UMLS 2011AA)

HeadandNeckTumorSecondOccurrenceInd-2

Item

Is this a second primary in the upper aero-digestive tract

boolean

C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C12418 (NCI Thesaurus ObjectClass-2)
C0460004 (UMLS 2011AA ObjectClass-2)
C25666 (NCI Thesaurus Property)
C0205436 (UMLS 2011AA Property)
C25275 (NCI Thesaurus Property-2)
C2745955 (UMLS 2011AA Property-2)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)

HeadandNeckTumorPrimaryLocation

Item

Primary Site

text

CL.13

Code List

Primary Site

CL Item

Lip And Oral Cavity (Lip and oral cavity)

CL Item

Oral Cavity Nos (Oral cavity NOS)

CL Item

Oral Tongue (Oral Tongue)

CL Item

Floor Of Mouth (Floor of mouth)

C0026638 (NCI Metathesaurus)

CL Item

Buccal Mucosa (Buccal mucosa)

C12505 (NCI Thesaurus)
C1578559 (UMLS 2011AA)

CL Item

Lower Gingiva (Lower gingiva)

CL Item

Upper Gingiva (Upper gingiva)

CL Item

Retromolar Trigone (Retromolar trigone)

CL Item

Hard Palate (Hard palate)

C12230 (NCI Thesaurus)
C0226901 (UMLS 2011AA)

CL Item

Nasopharynx Nos (Nasopharynx NOS)

CL Item

Posterior Superior Wall (Posterior superior wall)

CL Item

Lateral Wall (Lateral wall)

CL Item

Oropharynx Nos (Oropharynx NOS)

CL Item

Supraglottic Larynx (Supraglottic larynx)

CL Item

Faucial Arch (Faucial arch)

CL Item

Tonsillar Fossa Tonsil (Tonsillar fossa, tonsil)

CL Item

Base Of Tongue (Base of tongue)

C0226958 (NCI Metathesaurus)

CL Item

Posterior Pharyngeal Wall (Posterior pharyngeal wall)

CL Item

Soft Palate (Soft palate)

C12231 (NCI Thesaurus)
C0030219 (UMLS 2011AA)

CL Item

Hypopharynx Nos (Hypopharynx NOS)

CL Item

Pyriform Fossa (Pyriform fossa)

CL Item

Postcricoid Area (Postcricoid area)

CL Item

Posterior Wall (Posterior wall)

CL Item

Salivary Glands Nos (Salivary glands NOS)

CL Item

Parotid (Parotid)

CL Item

Submandibular (Submandibular)

CL Item

Sublingual (Sublingual)

C89785 (NCI Thesaurus)

CL Item

Minor Salivary Glands (Minor salivary glands)

CL Item

Larynx Nos (Larynx NOS)

CL Item

Glottic Larynx (Glottic larynx)

CL Item

Subglottic Larynx (Subglottic larynx)

CL Item

Paranasal Sinuses Nos (Paranasal sinuses NOS)

CL Item

Antrum (Antrum)

CL Item

Ethmoid (Ethmoid)

CL Item

Sphenoid (Sphenoid)

CL Item

Frontal (Frontal)

CL Item

Nose Nos (Nose NOS)

CL Item

Nasal Cavity (Nasal cavity)

C12424 (NCI Thesaurus)
C0027423 (UMLS 2011AA)

CL Item

Unknown (Unknown)

C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)

CL Item

Other (Other)

C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)

ReferringInstitutionName

Item

Name of Referring Institution (If yes, where initial tumor was treated)

text

C21541 (NCI Thesaurus ObjectClass)
C0018704 (UMLS 2011AA ObjectClass)
C25642 (NCI Thesaurus ObjectClass-2)
C0205543 (UMLS 2011AA ObjectClass-2)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C21541 (NCI Thesaurus ValueDomain-2)
C0018704 (UMLS 2011AA ValueDomain-2)

Primary Disease Site

Item

Other specify

text

C25685 (NCI Thesaurus ValueDomain)
C0449695 (UMLS CUI-1)
C25341 (NCI Thesaurus Property)
C25251 (NCI Thesaurus ObjectClass)
C2991 (NCI Thesaurus ObjectClass-2)

HeadandNeckTumorHistologicCategory

Item

Histologic Type

text

CL.14

Code List

Histologic Type

CL Item

Carcinoma In Situ (specify Histologic Type) (Carcinoma in situ)

CL Item

Squamous Cell Carcinoma Keratinizing (Squamous cell carcinoma, keratinizing)

CL Item

Squamous Cell Carcinoma Non-keratinizing (Squamous cell carcinoma, non-keratinizing)

CL Item

Verrucous Squamous Cell Carcinoma (Verrucous squamous cell carcinoma)

CL Item

Adenoid Squamous Cell Carcinoma (Adenoid squamous cell carcinoma)

CL Item

Basaloid Squamous Cell Carcinoma (Basaloid squamous cell carcinoma)

CL Item

Adenosquamous Carcinoma (Adenosquamous carcinoma)

C3727 (NCI Thesaurus)
C0206623 (UMLS 2011AA)

CL Item

Adenocarcinoma (Adenocarcinoma)

C2852 (NCI Thesaurus)
C0001418 (UMLS 2011AA)

CL Item

Spindle Cell Carcinoma (Spindle cell carcinoma)

CL Item

Acinic Cell Carcinoma (Acinic cell carcinoma)

CL Item

Mucoepidermoid Carcinoma (Mucoepidermoid carcinoma)

C3772 (NCI Thesaurus)
C0206694 (UMLS 2011AA)

CL Item

Adenoid Cystic Carcinoma (Adenoid cystic carcinoma)

C2970 (NCI Thesaurus)
C0010606 (UMLS 2011AA)

CL Item

Carcinoma In Pleomorphic Adenoma (Carcinoma in pleomorphic adenoma)

CL Item

Epithelial-myoepithelial Carcinoma (Epithelial-myoepithelial carcinoma)

C4199 (NCI Thesaurus)
C0334392 (UMLS 2011AA)

CL Item

Clear Cell Carcinoma (Clear cell carcinoma)

CL Item

Giant Cell Carcinoma (Giant cell carcinoma)

C3779 (NCI Thesaurus)
C0206703 (UMLS 2011AA)

CL Item

Small Cell Carcinoma (Small cell carcinoma)

C3915 (NCI Thesaurus)
C0262584 (UMLS 2011AA)

CL Item

Salivary Duct Carcinoma (Salivary duct carcinoma)

C5904 (NCI Thesaurus)
C1301194 (UMLS 2011AA)

CL Item

Carcinoid Tumor (Carcinoid tumor)

C2915 (NCI Thesaurus)
C0007095 (UMLS 2011AA)

CL Item

Atypical Carcinoid Tumor (Atypical carcinoid tumor)

CL017927 (NCI Metathesaurus)

CL Item

Lymphoepithelial Carcinoma (Lymphoepithelial carcinoma)

CL Item

Undifferentiated Carcinoma (Undifferentiated carcinoma)

C3692 (NCI Thesaurus)
C0205698 (UMLS 2011AA)

CL Item

Unknown (Unknown)

C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)

CL Item

Other (Other)

C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)

DiseaseRecurrenceMostRecentDate

Item

Date of Most Recent Recurrence (Current Diagnosis of Head and Neck Cancer - MM/DD/YYYY)

date

C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C3352 (NCI Thesaurus Property)
C0034897 (UMLS 2011AA Property)
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C25577 (NCI Thesaurus ValueDomain-2)
C1513491 (UMLS 2011AA ValueDomain-2)

Histologic Type, other

Item

Other specify

text

C25685 (NCI Thesaurus ValueDomain)
C1299220 (UMLS CUI-1)
C3262 (NCI Thesaurus ObjectClass)
C25526 (NCI Thesaurus Property)
C25161 (NCI Thesaurus Property-2)

MetastaticDiseaseInitialDiagnosisDate

Item

Date of Initial Diagnosis of Metastatic Disease (MM/DD/YYYY)

date

C14174 (NCI Thesaurus ObjectClass)
C0036525 (UMLS 2011AA ObjectClass)
C2991 (NCI Thesaurus ObjectClass-2)
C0012634 (UMLS 2011AA ObjectClass-2)
C25536 (NCI Thesaurus Property)
C1555582 (UMLS 2011AA Property)
C15220 (NCI Thesaurus Property-2)
C0011900 (UMLS 2011AA Property-2)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)

CurrentDiseasePathologicDiagnosisDate

Item

Date of Current Pathologic Diagnosis (MM/DD/YYYY)

date

C25471 (NCI Thesaurus ObjectClass)
C0521116 (UMLS 2011AA ObjectClass)
C2991 (NCI Thesaurus ObjectClass-2)
C0012634 (UMLS 2011AA ObjectClass-2)
C25610 (NCI Thesaurus Property)
C1521733 (UMLS 2011AA Property)
C15220 (NCI Thesaurus Property-2)
C0011900 (UMLS 2011AA Property-2)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)

HeadandNeckTumorClinicalTStage

Item

Clinical T Stage (Clinical Impression of Tumor at Current Presentation use the version of the AJCC staging system specified in the protocol)

text

CL.16

Code List

Clinical T Stage (Clinical Impression of Tumor at Current Presentation use the version of the AJCC staging system specified in the protocol)

CL Item

T0, According To Ajcc Criteria (T0)

CL Item

Tis, According To Ajcc Criteria (Tis)

CL Item

T1, According To Ajcc Criteria (T1)

CL Item

T2, According To Ajcc Criteria (T2)

CL Item

T3, According To Ajcc Criteria (T3)

CL Item

T4a, According To Ajcc Guidelines (T4a)

CL Item

T4b, According To Ajcc Guidelines (T4b)

CL Item

Tx, According To Ajcc Criteria (TX)

NeckDiseaseStatusType

Item

Disease Status (at Registration)

text

C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C13063 (NCI Thesaurus ObjectClass)
C0027530 (UMLS 2011AA ObjectClass)
C2991 (NCI Thesaurus ObjectClass-2)
C0012634 (UMLS 2011AA ObjectClass-2)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)

CL.12

Code List

Disease Status (at Registration)

CL Item

Initial Diagnosis - Local Only (Initial Diagnosis - local only)

CL Item

Initial Diagnosis - Distant Only (Initial Diagnosis - distant only)

CL Item

Initial Diagnosis - Distant And Metastatic (Initial Diagnosis - distant and metastatic)

CL Item

Eradicated But Recurred Locally (Eradicated, but recurred locally)

CL Item

Eradicated But Recurred Locally And Distantly (Eradicated, but recurred locally and distantly)

CL Item

Eradicated But Recurred Locally And Distantly (Eradicated, but recurred distantly)

CL Item

Residual Disease After Prior Therapy (Residual disease after prior therapy)

CL Item

Metastatic Only (Metastatic only)

CL Item

Untreated (Untreated)

CL Item

Unknown (Unknown)

C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)

HeadandNeckTumorClinicalNStage

Item

Clinical N Stage (overall)

text

C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C12418 (NCI Thesaurus ObjectClass-2)
C0460004 (UMLS 2011AA ObjectClass-2)
C25398 (NCI Thesaurus Property)
C0205210 (UMLS 2011AA Property)
C25580 (NCI Thesaurus Property-2)
C0456532 (UMLS 2011AA Property-2)
C16899 (NCI Thesaurus ValueDomain)
C1300072 (UMLS 2011AA ValueDomain)

CL.17

Code List

Clinical N Stage (overall)

CL Item

N0, According To Ajcc Guidelines (N0)

CL Item

N1, According To Ajcc Criteria (N1)

CL Item

N2, According To Ajcc Criteria (N2)

CL Item

N2a, According To Ajcc Guidelines (N2a)

CL Item

N2b, According To Ajcc Guidelines (N2b)

CL Item

N2c, According To Ajcc Guidelines (N2c)

CL Item

N3, According To Ajcc Guidelines (N3)

HeadandNeckTumorRightNStage

Item

Clinical N Stage, Right Side

text

CL.18

Code List

Clinical N Stage, Right Side

CL Item

N0, According To Ajcc Guidelines (N0)

CL Item

N1, According To Ajcc Criteria (N1)

CL Item

N2, According To Ajcc Criteria (N2)

CL Item

N2a, According To Ajcc Guidelines (N2a)

CL Item

N2b, According To Ajcc Guidelines (N2b)

CL Item

N2c, According To Ajcc Guidelines (N2c)

CL Item

N3, According To Ajcc Guidelines (N3)

HeadandNeckTumorLeftNStage

Item

Clinical N Stage, Left Side

text

CL.19

Code List

Clinical N Stage, Left Side

CL Item

N0, According To Ajcc Guidelines (N0)

CL Item

N1, According To Ajcc Criteria (N1)

CL Item

N2, According To Ajcc Criteria (N2)

CL Item

N2a, According To Ajcc Guidelines (N2a)

CL Item

N2b, According To Ajcc Guidelines (N2b)

CL Item

N2c, According To Ajcc Guidelines (N2c)

CL Item

N3, According To Ajcc Guidelines (N3)

HeadandNeckTumorClinicalMStage

Item

Clinical M Stage

text

C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C12418 (NCI Thesaurus ObjectClass-2)
C0460004 (UMLS 2011AA ObjectClass-2)
C25398 (NCI Thesaurus Property)
C0205210 (UMLS 2011AA Property)
C25727 (NCI Thesaurus Property-2)
C0456533 (UMLS 2011AA Property-2)
C16899 (NCI Thesaurus ValueDomain)
C1300072 (UMLS 2011AA ValueDomain)

CL.20

Code List

Clinical M Stage

CL Item

M0, According To Ajcc Guidelines (M0)

CL Item

M1, According To Ajcc Staging Definitions (M1)

CL Item

Mx, According To Ajcc Guidelines (MX)

ExtracapsularDiseasePresentInd-3

Item

Is extracapsular spread present

text

C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C25502 (NCI Thesaurus ObjectClass-2)
C1517049 (UMLS 2011AA ObjectClass-2)

CL.15

Code List

Is extracapsular spread present

CL Item

Yes (Yes)

C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)

CL Item

No (No)

C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)

CL Item

Unknown (unknown)

C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)

PrimaryTumorSiteInd-3

Item

Primary Site (Sites of Disease)

boolean

C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C25251 (NCI Thesaurus ObjectClass-2)
C0205225 (UMLS 2011AA ObjectClass-2)

RegionalLymphNodeInvolvedInd-3

Item

Regional Lymph Nodes

boolean

C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C12745 (NCI Thesaurus ObjectClass)
C0024204 (UMLS 2011AA ObjectClass)
C25643 (NCI Thesaurus ObjectClass-2)
C0205147 (UMLS 2011AA ObjectClass-2)
C25547 (NCI Thesaurus Property)

DistantLymphNodeInvolvedInd-3

Item

Distant Lymph Nodes

boolean

C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C12745 (NCI Thesaurus ObjectClass)
C0024204 (UMLS 2011AA ObjectClass)
C25321 (NCI Thesaurus ObjectClass-2)
C0443203 (UMLS 2011AA ObjectClass-2)
C25547 (NCI Thesaurus Property)

RegionalTissueRecurrentInvolvedInd-3

Item

Regional soft tissue recurrence

boolean

C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25643 (NCI Thesaurus ObjectClass)
C0205147 (UMLS 2011AA ObjectClass)
C25547 (NCI Thesaurus Property)
C14173 (NCI Thesaurus Property-2)
C2945760 (UMLS 2011AA Property)
C12801 (NCI Thesaurus ObjectClass-2)
C0040300 (UMLS 2011AA ObjectClass-2)

LungInvolvedInd-3

Item

Lung

boolean

C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C12468 (NCI Thesaurus ObjectClass)
C0024109 (UMLS 2011AA ObjectClass)
C25547 (NCI Thesaurus Property)

LiverInvolvedInd-3

Item

Liver

boolean

C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C12392 (NCI Thesaurus ObjectClass)
C0023884 (UMLS 2011AA ObjectClass)
C25547 (NCI Thesaurus Property)

BoneInvolvedInd-3

Item

Bone

boolean

C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C12366 (NCI Thesaurus ObjectClass)
C0262950 (UMLS 2011AA ObjectClass)
C25547 (NCI Thesaurus Property)

DistantTissueSubcutaneousInvolvedSkinInd-3

Item

Distant Skin/Subcutaneous Tissue

boolean

C25321 (NCI Thesaurus ObjectClass)
C0443203 (UMLS 2011AA ObjectClass)
C12801 (NCI Thesaurus ObjectClass-2)
C0040300 (UMLS 2011AA ObjectClass-2)
C25547 (NCI Thesaurus Property)
C13353 (NCI Thesaurus Property-2)
C0443315 (UMLS 2011AA Property)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C12470 (NCI Thesaurus ValueDomain-2)
C1123023 (UMLS 2011AA ValueDomain-2)

OtherSiteInvolvedInd-3

Item

Other

boolean

C17649 (NCI Thesaurus ObjectClass)
C0205394 (UMLS 2011AA ObjectClass)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25547 (NCI Thesaurus Property)
CL111053 (NCI Metathesaurus ObjectClass)

OtherDiseaseSiteName

Item

If sites other than specified, indicate name

text

C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C17649 (NCI Thesaurus ObjectClass)
C0205394 (UMLS 2011AA ObjectClass)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C2991 (NCI Thesaurus ObjectClass-2)
C0012634 (UMLS 2011AA ObjectClass-2)

Head & Neck: Prior Health History - Palliative

Item Group

Head & Neck: Prior Health History - Palliative

ChronicDiseasePresentInd-3

Item

Does the patient have a chronic disease

boolean

C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C14141 (NCI Thesaurus ObjectClass-2)
C0205191 (UMLS 2011AA ObjectClass-2)

ChronicDiseaseDiagnosisType

Item

Chronic Disease (If yes,)

text

C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C15220 (NCI Thesaurus Property)
C0011900 (UMLS 2011AA Property)
C14141 (NCI Thesaurus ObjectClass-2)
C0205191 (UMLS 2011AA ObjectClass-2)

CL.31

Code List

Chronic Disease (If yes,)

CL Item

Coronary Artery Disease (Coronary Artery disease)

CL Item

Diabetes (Diabetes)

CL Item

Gastrointestinal Disease (Gastrointestinal Disease)

CL Item

High Blood Pressure (High Blood Pressure)

CL Item

Neurologic Disease (Neurologic disease)

CL Item

Peripheral Vascular Disease (Peripheral Vascular disease)

CL Item

Respiratory Problems (Respiratory problems)

CL Item

Other, Specify (Other)

ChronicDiseaseDiagnosisSpecify

Item

Other specify

text

C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C14141 (NCI Thesaurus ObjectClass-2)
C0205191 (UMLS 2011AA ObjectClass-2)
C15220 (NCI Thesaurus Property)
C0011900 (UMLS 2011AA Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C17649 (NCI Thesaurus ValueDomain-2)
C0205394 (UMLS 2011AA ValueDomain-2)

PriorCancerNotHeadandNeckInd-3

Item

Does the patient have a history of prior cancer other than the upper aero-digestive tract

boolean

C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25594 (NCI Thesaurus Property)
C1518422 (UMLS 2011AA Property)
C12418 (NCI Thesaurus Property-2)
C0460004 (UMLS 2011AA Property-2)
C9305 (NCI Thesaurus ObjectClass)
C0006826 (UMLS 2011AA ObjectClass)
C25629 (NCI Thesaurus ObjectClass-2)
C0332152 (UMLS 2011AA ObjectClass-2)

PriorCancerDiagnosisSite

Item

Site of Prior Cancer

text

C13717 (NCI Thesaurus ValueDomain)
C1515974 (UMLS 2011AA ValueDomain)
C9305 (NCI Thesaurus ObjectClass)
C0006826 (UMLS 2011AA ObjectClass)
C25629 (NCI Thesaurus ObjectClass-2)
C0332152 (UMLS 2011AA ObjectClass-2)
C15220 (NCI Thesaurus Property)
C0011900 (UMLS 2011AA Property)

PriorCancerDiagnosisDate

Item

Prior Cancer Diagnosis Date (mm dd yyyy)

date

C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C9305 (NCI Thesaurus ObjectClass)
C0006826 (UMLS 2011AA ObjectClass)
C25629 (NCI Thesaurus ObjectClass-2)
C0332152 (UMLS 2011AA ObjectClass-2)
C15220 (NCI Thesaurus Property)
C0011900 (UMLS 2011AA Property)

Weight Loss past six months

Item

Weight loss in previous six months (check one)

text

C25664 (NCI Thesaurus ValueDomain)
C1262477 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C3828652 (UMLS CUI-2)
C3445 (NCI Thesaurus Property)
C25613 (NCI Thesaurus ValueDomain-2)

CL.33

Code List

Weight loss in previous six months (check one)

CL Item

<5% Of Body Weight (< 5% of body weight)

CL Item

5 To <10% Of Body Weight (5 to < 10% of body weight)

CL Item

10 To <20% Of Body Weight (10 to <20% of body weight)

CL Item

> Or = 20% Of Body Weight (> or = 20% of body weight)

SwallowingFunctionPriorDeficitInd-3

Item

Does the patient have a past history of swallowing problems

text

C25518 (NCI Thesaurus ObjectClass)
C0542341 (UMLS 2011AA ObjectClass)
C38028 (NCI Thesaurus ObjectClass-2)
C0011167 (UMLS 2011AA ObjectClass-2)
C25629 (NCI Thesaurus Property)
C0332152 (UMLS 2011AA Property)
C37940 (NCI Thesaurus Property-2)
C0011155 (UMLS 2011AA Property-2)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)

CL.34

Code List

Does the patient have a past history of swallowing problems

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)

SwallowingFunctionPriorDeficitDuration

Item

How long were swallowing problems apparent (If yes,)

text

C25518 (NCI Thesaurus ObjectClass)
C0542341 (UMLS 2011AA ObjectClass)
C38028 (NCI Thesaurus ObjectClass-2)
C0011167 (UMLS 2011AA ObjectClass-2)
C25629 (NCI Thesaurus Property)
C0332152 (UMLS 2011AA Property)
C37940 (NCI Thesaurus Property-2)
C0011155 (UMLS 2011AA Property-2)
C25330 (NCI Thesaurus ValueDomain)
C0449238 (UMLS 2011AA ValueDomain)

CL.35

Code List

How long were swallowing problems apparent (If yes,)

CL Item

Less Than 1 Month (Less than 1 month)

CL Item

1 To <7 Months (1 to <7 months)

CL Item

7 To <13 Months (7 to <13 months)

CL Item

13 To <19 Months (13 to <19 months)

CL Item

19 To <24 Months (19 to <24 months)

CL Item

2 Years Or Longer (2 years or longer)

CL Item

Unknown (Unknown)

C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)

SwallowingFunctionCurrentDeficitInd-3

Item

Does the patient currently have swallowing problems

text

C25518 (NCI Thesaurus ObjectClass)
C0542341 (UMLS 2011AA ObjectClass)
C38028 (NCI Thesaurus ObjectClass-2)
C0011167 (UMLS 2011AA ObjectClass-2)
C25471 (NCI Thesaurus Property)
C0521116 (UMLS 2011AA Property)
C37940 (NCI Thesaurus Property-2)
C0011155 (UMLS 2011AA Property-2)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)

CL.36

Code List

Does the patient currently have swallowing problems

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)

SwallowingFunctionCurrentDeficitDuration

Item

How long have swallowing problems been present (If yes,)

text

C25518 (NCI Thesaurus ObjectClass)
C0542341 (UMLS 2011AA ObjectClass)
C38028 (NCI Thesaurus ObjectClass-2)
C0011167 (UMLS 2011AA ObjectClass-2)
C25471 (NCI Thesaurus Property)
C0521116 (UMLS 2011AA Property)
C37940 (NCI Thesaurus Property-2)
C0011155 (UMLS 2011AA Property-2)
C25330 (NCI Thesaurus ValueDomain)
C0449238 (UMLS 2011AA ValueDomain)

CL.37

Code List

How long have swallowing problems been present (If yes,)

CL Item

Less Than 1 Month (Less than 1 month)

CL Item

1 To <7 Months (1 to <7 months)

CL Item

7 To <13 Months (7 to <13 months)

CL Item

13 To <19 Months (13 to <19 months)

CL Item

19 To <24 Months (19 to <24 months)

CL Item

2 Years Or Longer (2 years or longer)

CL Item

Unknown (Unknown)

C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)

GavagePriorAdministrationInd-3

Item

Does the patient have a past history of tube feedings

text

C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25629 (NCI Thesaurus Property)
C0332152 (UMLS 2011AA Property)
C73430 (NCI Thesaurus ObjectClass)
C0041281 (UMLS 2011AA ObjectClass)
C25409 (NCI Thesaurus Property-2)
C1533734 (UMLS 2011AA Property-2)

CL.38

Code List

Does the patient have a past history of tube feedings

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)

GavagePriorAdministrationDuration

Item

How long were tube feedings given (If yes,)

text

C25629 (NCI Thesaurus Property)
C0332152 (UMLS 2011AA Property)
C73430 (NCI Thesaurus ObjectClass)
C0041281 (UMLS 2011AA ObjectClass)
C25409 (NCI Thesaurus Property-2)
C1533734 (UMLS 2011AA Property-2)
C25330 (NCI Thesaurus ValueDomain)
C0449238 (UMLS 2011AA ValueDomain)

CL.39

Code List

How long were tube feedings given (If yes,)

CL Item

Less Than 1 Month (Less than 1 month)

CL Item

1 To <7 Months (1 to <7 months)

CL Item

7 To <13 Months (7 to <13 months)

CL Item

13 To <19 Months (13 to <19 months)

CL Item

19 To <24 Months (19 to <24 months)

CL Item

2 Years Or Longer (2 years or longer)

CL Item

Unknown (Unknown)

C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)

GavageCurrentAdministrationInd-3

Item

Does the patient currently require tube feeding

text

C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25471 (NCI Thesaurus Property)
C0521116 (UMLS 2011AA Property)
C73430 (NCI Thesaurus ObjectClass)
C0041281 (UMLS 2011AA ObjectClass)
C25409 (NCI Thesaurus Property-2)
C1533734 (UMLS 2011AA Property-2)

CL.40

Code List

Does the patient currently require tube feeding

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)

GavagePrimaryAdministrationInd-3

Item

Is patient dependent on tube feeding for >50% of nutritional support (If yes,)

text

C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25251 (NCI Thesaurus Property)
C0205225 (UMLS 2011AA Property)
C73430 (NCI Thesaurus ObjectClass)
C0041281 (UMLS 2011AA ObjectClass)
C25409 (NCI Thesaurus Property-2)
C1533734 (UMLS 2011AA Property-2)

CL.41

Code List

Is patient dependent on tube feeding for >50% of nutritional support (If yes,)

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)

DietPerformanceStatusAssessmentIntakeScale

Item

Normalcy of Diet Rating (Ask the patient what kinds of foods are difficult for him/her to eat. Begin at the low end of the scale. Move up the scale, giving examples of foods in each category and asking patient if s/he can eat those food items. The patient's score is the highest )

text

CL092952 (NCI Metathesaurus ObjectClass)
C15222 (NCI Thesaurus ObjectClass)
C0012155 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C25538 (NCI Thesaurus ValueDomain-2)
C1512806 (UMLS 2011AA ValueDomain-2)

CL.42

Code List

CL Item

100= Full Diet (no Restrictions) (100)

CL Item

90= Full Diet (liquid Assist) (90)

CL Item

80= All Meat (80)

CL Item

70= Raw Carrots, Celery (70)

CL Item

60= Dry Bread And Crackers (60)

CL Item

50= Soft, Chewable Foods (e.g., Macaroni, Canned/soft Fruits, Cooked Vegetables, Fish, Hamburger, Small Pieces Of Meat) (50)

CL Item

40= Soft Foods Requiring No Chewing (e.g., Mashed Potatoes, Apple Sauce, Pudding) (40)

CL Item

30= Pureed Foods (in Blender) (30)

CL Item

20= Warm Liquids (20)

CL Item

10= Cold Liquids (10)

CL Item

0= Non-oral Feeding (tube Fed) (0)

DietaryPerformanceStatusAssessmentLocationScale

Item

Public Eating Rating (Ask the patient where s/he eats, with whom s/he eats, and whether s/he alters his/her diet according to where s/he is eating. Choose the score that best fits the patient.)

text

CL092952 (NCI Metathesaurus ObjectClass)
C15222 (NCI Thesaurus ObjectClass)
C0012155 (UMLS 2011AA ObjectClass)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C25341 (NCI Thesaurus ValueDomain-2)
C0450429 (UMLS 2011AA ValueDomain-2)

CL.43

Code List

Public Eating Rating (Ask the patient where s/he eats, with whom s/he eats, and whether s/he alters his/her diet according to where s/he is eating. Choose the score that best fits the patient.)

CL Item

100= No Restriction Of Place, Food Or Companion (eats Out At Any Opportunity) (100)

CL Item

75= No Restriction Of Place, But Restricts Diet When In Public (eats Anywhere, But May Limit Intake To Less "messy" Foods, E.g., Liquids) (75)

CL Item

50= Eats Only In Presence Of Selected Persons In Selected Places (50)

CL Item

25= Eats Only At Home In Presence Of Selected Persons (25)

CL Item

0= Always Eats Alone (0)

SpeechPerformanceStatusAssessmentComprehensionScale

Item

Understandability of Speech Rating (Score based on the interviewer's ability to understand the patient during conversation. Choose the score that best fits the patient.)

text

C25664 (NCI Thesaurus ValueDomain)
C0349674 (UMLS 2011AA ValueDomain)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C38025 (NCI Thesaurus ObjectClass)
C0037817 (UMLS 2011AA ObjectClass)
CL092952 (NCI Metathesaurus ObjectClass)

CL.44

Code List

Understandability of Speech Rating (Score based on the interviewer's ability to understand the patient during conversation. Choose the score that best fits the patient.)

CL Item

100= Always Understandable (100)

CL Item

75= Understandable Most Of The Time; Occasional Repetition Necessary (75)

CL Item

50= Usually Understandable; Face-to-face Contact Necessary (50)

CL Item

25= Difficult To Understand (25)

CL Item

0= Never Understandable; May Use Written Communication (0)

Head & Neck: Prior Treatment - Systemic Therapy

Item Group

Head & Neck: Prior Treatement - Systemic Therapy

Prior systemic therapy

Item

Prior systemic therapy

boolean

C38147 (NCI Thesaurus ValueDomain)
C1515119 (UMLS CUI-1)
C15698 (NCI Thesaurus ObjectClass)
C0332152 (UMLS CUI-2)
C25629 (NCI Thesaurus ObjectClass-2)
C25382 (NCI Thesaurus Property)

PriorTreatmentRegimenName

Item

Prior Treatment Regimen Name (s Drug, Agent, Biologic)

text

C25629 (NCI Thesaurus ObjectClass)
C0332152 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus ObjectClass-2)
C15697 (NCI Thesaurus Property)
C0040808 (UMLS 2011AA Property)
C42614 (NCI Thesaurus ValueDomain)
C0027365 (UMLS 2011AA ValueDomain)

PriorTreatmentRegimenBeginDate

Item

Prior Treatment Regimen Start Date (mm dd yyyy)

date

C25629 (NCI Thesaurus ObjectClass)
C0332152 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus ObjectClass-2)
C15697 (NCI Thesaurus Property)
C0040808 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25431 (NCI Thesaurus ValueDomain-2)
C0439659 (UMLS 2011AA ValueDomain-2)

PriorTreatmentRegimenEndDate

Item

Prior Treatment Regimen End Date (mm dd yyyy)

date

C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25629 (NCI Thesaurus ObjectClass)
C0332152 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus ObjectClass-2)
C15697 (NCI Thesaurus Property)
C0040808 (UMLS 2011AA Property)

PriorTreatmentRegimenType

Item

Prior Treatment Regimen Type (* Prior Treatment Regimen Type:)

text

C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C25629 (NCI Thesaurus ObjectClass)
C0332152 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus ObjectClass-2)
C15697 (NCI Thesaurus Property)
C0040808 (UMLS 2011AA Property)

CL.46

Code List

Prior Treatment Regimen Type (* Prior Treatment Regimen Type:)

CL Item

Adjuvant (Adjuvant)

C25722 (NCI Thesaurus)
C1522673 (UMLS 2011AA)

CL Item

Induction (Induction)

CL042203 (NCI Metathesaurus)

CL Item

Concurrent With Rt (Concurrent with RT)

CL Item

Palliative Therapy (Palliative)

C15292 (NCI Thesaurus)
C0030231 (UMLS 2011AA)

CL Item

Other Specify (Other)

CL Item

Unknown (Unknown)

C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)

PriorTherapyCompleteRegimenInd-3

Item

Did patient complete prior therapy regimen

text

C25629 (NCI Thesaurus ObjectClass)
C0332152 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus ObjectClass-2)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C15697 (NCI Thesaurus Property-2)
C0040808 (UMLS 2011AA Property-2)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)

CL.51

Code List

Did patient complete prior therapy regimen

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)

PriorTherapyEndReason

Item

Reason for Ending Prior Therapy (If no,)

text

C25629 (NCI Thesaurus ObjectClass)
C0332152 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus ObjectClass-2)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
C25496 (NCI Thesaurus Property-2)
C2746065 (UMLS 2011AA Property-2)
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)

CL.52

Code List

Reason for Ending Prior Therapy (If no,)

CL Item

Adverse Event/toxicity (Adverse Event/Toxicity)

CL Item

Progressive Disease (Progressive Disease)

C35571 (NCI Thesaurus)
C1335499 (UMLS 2011AA)

CL Item

Unknown (Unknown)

C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)

CL Item

Other (Other)

C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)

PriorTherapyEndReasonSpecify

Item

Other specify

text

C25629 (NCI Thesaurus ObjectClass)
C0332152 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus ObjectClass-2)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
C25496 (NCI Thesaurus Property-2)
C2746065 (UMLS 2011AA Property-2)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)

Head & Neck: Prior Treatment - Radiation Therapy

Item Group

Head & Neck: Prior Treatment - Radiation Therapy

Prior Radiation Therapy

Item

Prior Radiation Therapy

boolean

C38148 (NCI Thesaurus ValueDomain)
C1522449 (UMLS CUI-1)
C15313 (NCI Thesaurus ObjectClass)
C0332152 (UMLS CUI-2)
C25629 (NCI Thesaurus ObjectClass-2)
C25382 (NCI Thesaurus Property)

PriorRTSite

Item

Prior RT Site

text

C13717 (NCI Thesaurus ValueDomain)
C1515974 (UMLS 2011AA ValueDomain)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C15313 (NCI Thesaurus ObjectClass)
C1522449 (UMLS 2011AA ObjectClass)
C25629 (NCI Thesaurus ObjectClass-2)
C0332152 (UMLS 2011AA ObjectClass-2)

PriorTreatmentRegimenBeginDate

Item

Prior Treatment Regimen Start Date (mm dd yyyy)

date

C25629 (NCI Thesaurus ObjectClass)
C0332152 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus ObjectClass-2)
C15697 (NCI Thesaurus Property)
C0040808 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25431 (NCI Thesaurus ValueDomain-2)
C0439659 (UMLS 2011AA ValueDomain-2)

PriorTreatmentRegimenEndDate

Item

Prior Treatment Regimen End Date (mm dd yyyy)

date

PriorRTModalityType

Item

Prior RT Modality (* Prior RT Modality:)

text

C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C15313 (NCI Thesaurus ObjectClass)
C1522449 (UMLS 2011AA ObjectClass)
C25629 (NCI Thesaurus ObjectClass-2)
C0332152 (UMLS 2011AA ObjectClass-2)
C41147 (NCI Thesaurus Property)
C0695347 (UMLS 2011AA Property)

CL.50

Code List

Prior RT Modality (* Prior RT Modality:)

CL Item

Brachytherapy (Brachytherapy)

CL054378 (NCI Metathesaurus)

CL Item

External Beam (External beam)

CL Item

Imrt (IMRT)

CL Item

Other (Other)

C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)

CL Item

Unknown (Unknown)

C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)

PriorTherapyCompleteRegimenInd-3

Item

Did patient complete prior therapy regimen

text

CL.51

Code List

Did patient complete prior therapy regimen

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)

PriorTherapyEndReason

Item

Reason for Ending Prior Therapy (If no,)

text

CL.52

Code List

Reason for Ending Prior Therapy (If no,)

CL Item

Adverse Event/toxicity (Adverse Event/Toxicity)

CL Item

Progressive Disease (Progressive Disease)

C35571 (NCI Thesaurus)
C1335499 (UMLS 2011AA)

CL Item

Unknown (Unknown)

C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)

CL Item

Other (Other)

C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)

PriorTherapyEndReasonSpecify

Item

Other specify

text

C25629 (NCI Thesaurus ObjectClass)
C0332152 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus ObjectClass-2)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
C25496 (NCI Thesaurus Property-2)
C2746065 (UMLS 2011AA Property-2)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)

Head & Neck: Prior Treatment - Surgery

Item Group

Head & Neck: Prior Treatment - Surgery

Prior Surgery

Item

Prior Surgery

boolean

C38148 (NCI Thesaurus ValueDomain)
C0744961 (UMLS CUI-1)
C38000 (NCI Thesaurus Property)
C15329 (NCI Thesaurus ObjectClass)
C25629 (NCI Thesaurus ObjectClass-2)

PriorSurgeryPerformedText

Item

Prior Surgery Type (If yes,)

text

C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C15329 (NCI Thesaurus ObjectClass)
C0543467 (UMLS 2011AA ObjectClass)
C25629 (NCI Thesaurus ObjectClass-2)
C0332152 (UMLS 2011AA ObjectClass-2)

PriorSurgeryDate

Item

Prior Surgery Date (mm dd yyyy)

date

C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C15329 (NCI Thesaurus ObjectClass)
C0543467 (UMLS 2011AA ObjectClass)
C25629 (NCI Thesaurus ObjectClass-2)
C0332152 (UMLS 2011AA ObjectClass-2)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)

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On-Study - Palliative Treatment for Head and Neck Cancer - On-Study Form - 2267713v3.0

[Note: This form is for trials enrolling patients with persistent, recurrent, or metastatic disease.]

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