ID

43139

Beschrijving

FORM 9 - RECURRENCE AND CONTRALATERAL BREAST CANCER REPORT Quality Of Life Companion Study For JMA27 (NCIC-MA.27): A Randomized Phase III Trial Of Exemestane Versus Anastrozole With Or Without Celecoxib In Postmenopausal Women With Receptor Positive Primary Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=ABE31B86-C179-5457-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=ABE31B86-C179-5457-E034-0003BA12F5E7

Trefwoorden

Versies (3)
  1. 26-08-12 26-08-12 -
  2. 09-01-15 09-01-15 - Martin Dugas
  3. 20-09-21 20-09-21 -
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20 september 2021

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Breast Cancer NCT00090974 Follow-Up - FORM 9 - RECURRENCE AND CONTRALATERAL BREAST CANCER REPORT - 2058833v3.0

Engels

Submit within 6 weeks of the date of diagnosis.

1 Formulieren  
  1. StudyEvent: FORM 9 - RECURRENCE AND CONTRALATERAL BREAST CANCER REPORT
    1. Submit within 6 weeks of the date of diagnosis.
Patient Information
Beschrijving

Patient Information

Patient Study ID, Coordinating Group
Beschrijving

PatientStudyID,CoordinatingGroup

Datatype

text

Patient Initials (first - middle - last)
Beschrijving

Patient Initials

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Patient Medical Record Number
Beschrijving

PatientMedicalRecordNumber

Datatype

text

Investigator Name
Beschrijving

InvestigatorName

Datatype

text

Institution Name
Beschrijving

InstitutionName

Datatype

text

Registered Investigator (NCI Investigator #)
Beschrijving

RegisteredInvestigator

Datatype

text

Disease Status
Beschrijving

Disease Status

Has the patient been diagnosed with first local-regional recurrence?
Beschrijving

ProgressionInd,FirstLocal-Regional

Datatype

boolean

Date of First Local-Regional Progression (yyyy mmm dd)
Beschrijving

ProgressionDate,FirstLocal-Regional

Datatype

date

Has the patient been diagnosed with first distant recurrence/progression?
Beschrijving

ProgressionInd,FirstDistant

Datatype

boolean

Date of First Distant Progression (yyyy mmm dd)
Beschrijving

ProgressionDate,FirstDistant

Datatype

date

Has the patient been diagnosed with contralateral breast cancer? (since submission of the last follow-up form)
Beschrijving

Hasthepatientbeendiagnosedwithcontralateralbreastcancer?

Datatype

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
Date of Diagnosis of Contralateral Breast Cancer (yyyy mmm dd)
Beschrijving

ContralateralBreastCancerDiagnosisDate

Datatype

date

Alias
NCI Thesaurus ObjectClass
C12971
UMLS 2011AA ObjectClass
C0006141
NCI Thesaurus ObjectClass-2
C9305
UMLS 2011AA ObjectClass-2
C0006826
NCI Thesaurus ObjectClass-3
C25307
UMLS 2011AA ObjectClass-3
C0441988
NCI Thesaurus Property
C15220
UMLS 2011AA Property
C0011900
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Supporting Documentation
Beschrijving

Supporting Documentation

Comments
Beschrijving

Comments

COMMENTS
Beschrijving

Comments

Datatype

text

Investigator Signature
Beschrijving

Investigator Signature

Investigator Signature
Beschrijving

InvestigatorSignature

Datatype

text

Alias
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
NCI Thesaurus ObjectClass
C17089
UMLS 2011AA ObjectClass
C0035173
Person Completing Form, Last Name
Beschrijving

PersonCompletingForm,LastName

Datatype

text

Person Completing Form, First Name
Beschrijving

PersonCompletingForm,FirstName

Datatype

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Form Completion Date, Original (yyyy mmm dd)
Beschrijving

FormCompletionDate,Original

Datatype

date

Header
Beschrijving

Header

Patient Study ID, Coordinating Group
Beschrijving

PatientStudyID,CoordinatingGroup

Datatype

text

Patient Initials (first - middle - last)
Beschrijving

Patient Initials

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Recurrence Table
Beschrijving

Recurrence Table

Site(s) Local-Regional, Ipsilateral Breast (Check)
Beschrijving

Local-RegionalBreastIpsilateralProgressionInd-3

Datatype

boolean

Alias
NCI Thesaurus ObjectClass
C12971
UMLS 2011AA ObjectClass
C0006141
NCI Thesaurus ObjectClass-2
C25388
UMLS 2011AA ObjectClass-2
C1947913
NCI Thesaurus Property
C25331
NCI Thesaurus Property-2
C25308
UMLS 2011AA Property
C0441989
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
Definite Date (yyyy-mmm-dd)
Beschrijving

PriorRecentRecurrenceDate

Datatype

date

Alias
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Thesaurus Property
C25279
UMLS 2011AA Property
C0332162
Site(s) Local-Regional, Chest Wall (Check)
Beschrijving

Local-RegionalBreastChestWallProgressionInd-3

Datatype

boolean

Alias
NCI Thesaurus ObjectClass
C12971
UMLS 2011AA ObjectClass
C0006141
NCI Thesaurus ObjectClass-2
C25388
UMLS 2011AA ObjectClass-2
C1947913
NCI Thesaurus Property
C25331
NCI Metathesaurus Property
CL035093
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus ValueDomain-2
C25755
UMLS 2011AA ValueDomain-2
C0871261
Site(s) Local-Regional, Regional Nodes/axilla (Check)
Beschrijving

Site(s)Local-Regional,RegionalNodes/axilla,IND

Datatype

boolean

Site(s) Distant, Lung (Check)
Beschrijving

Sitesofprogression,lung

Datatype

boolean

Site(s) Distant, Liver (Check)
Beschrijving

Sitesofprogression,liver

Datatype

boolean

Site(s) Distant, Bone (Check)
Beschrijving

Sitesofprogression,bone

Datatype

boolean

Site(s) Distant, Central Nervous System (Check)
Beschrijving

Sitesofprogression,CNS(Brain)

Datatype

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
NCI Thesaurus Property
C25331
NCI Thesaurus ObjectClass
C12438
UMLS 2011AA ObjectClass
C3714787
Site(s) Distant, Bone Marrow (Check)
Beschrijving

Site(s)Distant,BoneMarrow

Datatype

boolean

Site(s) Distant, Ascites (Check)
Beschrijving

Site(s)Distant,Ascites

Datatype

boolean

Site(s) Distant, Pleural Effusion (Check)
Beschrijving

Site(s)Distant,PleuralEffusion

Datatype

boolean

Site(s) Distant, First Other, Specify (Check)
Beschrijving

Site(s)Distant,FirstOther,Specify

Datatype

boolean

Site(s) Distant, Second Other, Specify (Check)
Beschrijving

Site(s)Distant,SecondOther,Specify

Datatype

boolean

Alias
NCI Thesaurus Property
C25341
UMLS 2011AA Property
C0450429
NCI Thesaurus ObjectClass
C25331
NCI Thesaurus Property-2
C25321
UMLS 2011AA Property-2
C0443203
NCI Thesaurus ObjectClass-2
C25666
UMLS 2011AA ObjectClass
C0205436
Site(s) Distant, Second Other, Specify
Beschrijving

ProgressionSite,Other

Datatype

text

Site(s) Distant, Second Other, Specify
Beschrijving

ProgressionSite,Other

Datatype

text

Suspected Date (yyyy-mmm-dd)
Beschrijving

ProgressionSuspectedBeginDate

Datatype

date

Suspected Date (yyyy-mmm-dd)
Beschrijving

ProgressionSuspectedBeginDate

Datatype

date

Suspected Date (yyyy-mmm-dd)
Beschrijving

ProgressionSuspectedBeginDate

Datatype

date

Suspected Date (yyyy-mmm-dd)
Beschrijving

ProgressionSuspectedBeginDate

Datatype

date

Suspected Date (yyyy-mmm-dd)
Beschrijving

ProgressionSuspectedBeginDate

Datatype

date

Suspected Date (yyyy-mmm-dd)
Beschrijving

ProgressionSuspectedBeginDate

Datatype

date

Suspected Date (yyyy-mmm-dd)
Beschrijving

ProgressionSuspectedBeginDate

Datatype

date

Suspected Date (yyyy-mmm-dd)
Beschrijving

ProgressionSuspectedBeginDate

Datatype

date

Suspected Date (yyyy-mmm-dd)
Beschrijving

ProgressionSuspectedBeginDate

Datatype

date

Suspected Date (yyyy-mmm-dd)
Beschrijving

ProgressionSuspectedBeginDate

Datatype

date

Suspected Date (yyyy-mmm-dd)
Beschrijving

ProgressionSuspectedBeginDate

Datatype

date

Suspected Date (yyyy-mmm-dd)
Beschrijving

ProgressionSuspectedBeginDate

Datatype

date

Definite Date (yyyy-mmm-dd)
Beschrijving

RecurrenceDate

Datatype

date

Definite Date (yyyy-mmm-dd)
Beschrijving

RecurrenceDate

Datatype

date

Definite Date (yyyy-mmm-dd)
Beschrijving

RecurrenceDate

Datatype

date

Definite Date (yyyy-mmm-dd)
Beschrijving

RecurrenceDate

Datatype

date

Definite Date (yyyy-mmm-dd)
Beschrijving

RecurrenceDate

Datatype

date

Definite Date (yyyy-mmm-dd)
Beschrijving

RecurrenceDate

Datatype

date

Definite Date (yyyy-mmm-dd)
Beschrijving

RecurrenceDate

Datatype

date

Definite Date (yyyy-mmm-dd)
Beschrijving

RecurrenceDate

Datatype

date

Definite Date (yyyy-mmm-dd)
Beschrijving

RecurrenceDate

Datatype

date

Definite Date (yyyy-mmm-dd)
Beschrijving

RecurrenceDate

Datatype

date

Definite Date (yyyy-mmm-dd)
Beschrijving

RecurrenceDate

Datatype

date

Ccrr Module For Form 9 - Recurrence And Contralateral Breast Cancer Report
Beschrijving

Ccrr Module For Form 9 - Recurrence And Contralateral Breast Cancer Report

Terug naar het begin van de pagina

Similar models

Submit within 6 weeks of the date of diagnosis.

1 Formulieren
  1. StudyEvent: FORM 9 - RECURRENCE AND CONTRALATERAL BREAST CANCER REPORT
    1. Submit within 6 weeks of the date of diagnosis.
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
Patient Information
PatientStudyID,CoordinatingGroup
Item
Patient Study ID, Coordinating Group
text
Patient Initials
Item
Patient Initials (first - middle - last)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
PatientMedicalRecordNumber
Item
Patient Medical Record Number
text
InvestigatorName
Item
Investigator Name
text
InstitutionName
Item
Institution Name
text
RegisteredInvestigator
Item
Registered Investigator (NCI Investigator #)
text
Item Group
Disease Status
ProgressionInd,FirstLocal-Regional
Item
Has the patient been diagnosed with first local-regional recurrence?
boolean
ProgressionDate,FirstLocal-Regional
Item
Date of First Local-Regional Progression (yyyy mmm dd)
date
ProgressionInd,FirstDistant
Item
Has the patient been diagnosed with first distant recurrence/progression?
boolean
ProgressionDate,FirstDistant
Item
Date of First Distant Progression (yyyy mmm dd)
date
Hasthepatientbeendiagnosedwithcontralateralbreastcancer?
Item
Has the patient been diagnosed with contralateral breast cancer? (since submission of the last follow-up form)
boolean
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
ContralateralBreastCancerDiagnosisDate
Item
Date of Diagnosis of Contralateral Breast Cancer (yyyy mmm dd)
date
C12971 (NCI Thesaurus ObjectClass)
C0006141 (UMLS 2011AA ObjectClass)
C9305 (NCI Thesaurus ObjectClass-2)
C0006826 (UMLS 2011AA ObjectClass-2)
C25307 (NCI Thesaurus ObjectClass-3)
C0441988 (UMLS 2011AA ObjectClass-3)
C15220 (NCI Thesaurus Property)
C0011900 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Item Group
Supporting Documentation
Item Group
Comments
Comments
Item
COMMENTS
text
Item Group
Investigator Signature
InvestigatorSignature
Item
Investigator Signature
text
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
PersonCompletingForm,LastName
Item
Person Completing Form, Last Name
text
PersonCompletingForm,FirstName
Item
Person Completing Form, First Name
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
FormCompletionDate,Original
Item
Form Completion Date, Original (yyyy mmm dd)
date
Item Group
Header
PatientStudyID,CoordinatingGroup
Item
Patient Study ID, Coordinating Group
text
Patient Initials
Item
Patient Initials (first - middle - last)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Item Group
Recurrence Table
Local-RegionalBreastIpsilateralProgressionInd-3
Item
Site(s) Local-Regional, Ipsilateral Breast (Check)
boolean
C12971 (NCI Thesaurus ObjectClass)
C0006141 (UMLS 2011AA ObjectClass)
C25388 (NCI Thesaurus ObjectClass-2)
C1947913 (UMLS 2011AA ObjectClass-2)
C25331 (NCI Thesaurus Property)
C25308 (NCI Thesaurus Property-2)
C0441989 (UMLS 2011AA Property)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
PriorRecentRecurrenceDate
Item
Definite Date (yyyy-mmm-dd)
date
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C25279 (NCI Thesaurus Property)
C0332162 (UMLS 2011AA Property)
Local-RegionalBreastChestWallProgressionInd-3
Item
Site(s) Local-Regional, Chest Wall (Check)
boolean
C12971 (NCI Thesaurus ObjectClass)
C0006141 (UMLS 2011AA ObjectClass)
C25388 (NCI Thesaurus ObjectClass-2)
C1947913 (UMLS 2011AA ObjectClass-2)
C25331 (NCI Thesaurus Property)
CL035093 (NCI Metathesaurus Property)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25755 (NCI Thesaurus ValueDomain-2)
C0871261 (UMLS 2011AA ValueDomain-2)
Site(s)Local-Regional,RegionalNodes/axilla,IND
Item
Site(s) Local-Regional, Regional Nodes/axilla (Check)
boolean
Sitesofprogression,lung
Item
Site(s) Distant, Lung (Check)
boolean
Sitesofprogression,liver
Item
Site(s) Distant, Liver (Check)
boolean
Sitesofprogression,bone
Item
Site(s) Distant, Bone (Check)
boolean
Sitesofprogression,CNS(Brain)
Item
Site(s) Distant, Central Nervous System (Check)
boolean
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C25331 (NCI Thesaurus Property)
C12438 (NCI Thesaurus ObjectClass)
C3714787 (UMLS 2011AA ObjectClass)
Site(s)Distant,BoneMarrow
Item
Site(s) Distant, Bone Marrow (Check)
boolean
Site(s)Distant,Ascites
Item
Site(s) Distant, Ascites (Check)
boolean
Site(s)Distant,PleuralEffusion
Item
Site(s) Distant, Pleural Effusion (Check)
boolean
Site(s)Distant,FirstOther,Specify
Item
Site(s) Distant, First Other, Specify (Check)
boolean
Site(s)Distant,SecondOther,Specify
Item
Site(s) Distant, Second Other, Specify (Check)
boolean
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C25331 (NCI Thesaurus ObjectClass)
C25321 (NCI Thesaurus Property-2)
C0443203 (UMLS 2011AA Property-2)
C25666 (NCI Thesaurus ObjectClass-2)
C0205436 (UMLS 2011AA ObjectClass)
ProgressionSite,Other
Item
Site(s) Distant, Second Other, Specify
text
ProgressionSite,Other
Item
Site(s) Distant, Second Other, Specify
text
ProgressionSuspectedBeginDate
Item
Suspected Date (yyyy-mmm-dd)
date
ProgressionSuspectedBeginDate
Item
Suspected Date (yyyy-mmm-dd)
date
ProgressionSuspectedBeginDate
Item
Suspected Date (yyyy-mmm-dd)
date
ProgressionSuspectedBeginDate
Item
Suspected Date (yyyy-mmm-dd)
date
ProgressionSuspectedBeginDate
Item
Suspected Date (yyyy-mmm-dd)
date
ProgressionSuspectedBeginDate
Item
Suspected Date (yyyy-mmm-dd)
date
ProgressionSuspectedBeginDate
Item
Suspected Date (yyyy-mmm-dd)
date
ProgressionSuspectedBeginDate
Item
Suspected Date (yyyy-mmm-dd)
date
ProgressionSuspectedBeginDate
Item
Suspected Date (yyyy-mmm-dd)
date
ProgressionSuspectedBeginDate
Item
Suspected Date (yyyy-mmm-dd)
date
ProgressionSuspectedBeginDate
Item
Suspected Date (yyyy-mmm-dd)
date
ProgressionSuspectedBeginDate
Item
Suspected Date (yyyy-mmm-dd)
date
RecurrenceDate
Item
Definite Date (yyyy-mmm-dd)
date
RecurrenceDate
Item
Definite Date (yyyy-mmm-dd)
date
RecurrenceDate
Item
Definite Date (yyyy-mmm-dd)
date
RecurrenceDate
Item
Definite Date (yyyy-mmm-dd)
date
RecurrenceDate
Item
Definite Date (yyyy-mmm-dd)
date
RecurrenceDate
Item
Definite Date (yyyy-mmm-dd)
date
RecurrenceDate
Item
Definite Date (yyyy-mmm-dd)
date
RecurrenceDate
Item
Definite Date (yyyy-mmm-dd)
date
RecurrenceDate
Item
Definite Date (yyyy-mmm-dd)
date
RecurrenceDate
Item
Definite Date (yyyy-mmm-dd)
date
RecurrenceDate
Item
Definite Date (yyyy-mmm-dd)
date
Item Group
Ccrr Module For Form 9 - Recurrence And Contralateral Breast Cancer Report
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