ID

43139

Beskrivning

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

Länk

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

Nyckelord

Versioner (3)
  1. 2012-08-26 2012-08-26 -
  2. 2015-01-09 2015-01-09 - Martin Dugas
  3. 2021-09-20 2021-09-20 -
Uppladdad den

20 september 2021

DOI

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Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00090974 Follow-Up - FORM 9 - RECURRENCE AND CONTRALATERAL BREAST CANCER REPORT - 2058833v3.0

Engelsk

Submit within 6 weeks of the date of diagnosis.

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

Patient Information

Patient Study ID, Coordinating Group
Beskrivning

PatientStudyID,CoordinatingGroup

Datatyp

text

Patient Initials (first - middle - last)
Beskrivning

Patient Initials

Datatyp

text

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

PatientMedicalRecordNumber

Datatyp

text

Investigator Name
Beskrivning

InvestigatorName

Datatyp

text

Institution Name
Beskrivning

InstitutionName

Datatyp

text

Registered Investigator (NCI Investigator #)
Beskrivning

RegisteredInvestigator

Datatyp

text

Disease Status
Beskrivning

Disease Status

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

ProgressionInd,FirstLocal-Regional

Datatyp

boolean

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

ProgressionDate,FirstLocal-Regional

Datatyp

date

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

ProgressionInd,FirstDistant

Datatyp

boolean

Date of First Distant Progression (yyyy mmm dd)
Beskrivning

ProgressionDate,FirstDistant

Datatyp

date

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

Hasthepatientbeendiagnosedwithcontralateralbreastcancer?

Datatyp

boolean

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

ContralateralBreastCancerDiagnosisDate

Datatyp

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
Beskrivning

Supporting Documentation

Comments
Beskrivning

Comments

COMMENTS
Beskrivning

Comments

Datatyp

text

Investigator Signature
Beskrivning

Investigator Signature

Investigator Signature
Beskrivning

InvestigatorSignature

Datatyp

text

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

PersonCompletingForm,LastName

Datatyp

text

Person Completing Form, First Name
Beskrivning

PersonCompletingForm,FirstName

Datatyp

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)
Beskrivning

FormCompletionDate,Original

Datatyp

date

Header
Beskrivning

Header

Patient Study ID, Coordinating Group
Beskrivning

PatientStudyID,CoordinatingGroup

Datatyp

text

Patient Initials (first - middle - last)
Beskrivning

Patient Initials

Datatyp

text

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

Recurrence Table

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

Local-RegionalBreastIpsilateralProgressionInd-3

Datatyp

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)
Beskrivning

PriorRecentRecurrenceDate

Datatyp

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)
Beskrivning

Local-RegionalBreastChestWallProgressionInd-3

Datatyp

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)
Beskrivning

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

Datatyp

boolean

Site(s) Distant, Lung (Check)
Beskrivning

Sitesofprogression,lung

Datatyp

boolean

Site(s) Distant, Liver (Check)
Beskrivning

Sitesofprogression,liver

Datatyp

boolean

Site(s) Distant, Bone (Check)
Beskrivning

Sitesofprogression,bone

Datatyp

boolean

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

Sitesofprogression,CNS(Brain)

Datatyp

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)
Beskrivning

Site(s)Distant,BoneMarrow

Datatyp

boolean

Site(s) Distant, Ascites (Check)
Beskrivning

Site(s)Distant,Ascites

Datatyp

boolean

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

Site(s)Distant,PleuralEffusion

Datatyp

boolean

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

Site(s)Distant,FirstOther,Specify

Datatyp

boolean

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

Site(s)Distant,SecondOther,Specify

Datatyp

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
Beskrivning

ProgressionSite,Other

Datatyp

text

Site(s) Distant, Second Other, Specify
Beskrivning

ProgressionSite,Other

Datatyp

text

Suspected Date (yyyy-mmm-dd)
Beskrivning

ProgressionSuspectedBeginDate

Datatyp

date

Suspected Date (yyyy-mmm-dd)
Beskrivning

ProgressionSuspectedBeginDate

Datatyp

date

Suspected Date (yyyy-mmm-dd)
Beskrivning

ProgressionSuspectedBeginDate

Datatyp

date

Suspected Date (yyyy-mmm-dd)
Beskrivning

ProgressionSuspectedBeginDate

Datatyp

date

Suspected Date (yyyy-mmm-dd)
Beskrivning

ProgressionSuspectedBeginDate

Datatyp

date

Suspected Date (yyyy-mmm-dd)
Beskrivning

ProgressionSuspectedBeginDate

Datatyp

date

Suspected Date (yyyy-mmm-dd)
Beskrivning

ProgressionSuspectedBeginDate

Datatyp

date

Suspected Date (yyyy-mmm-dd)
Beskrivning

ProgressionSuspectedBeginDate

Datatyp

date

Suspected Date (yyyy-mmm-dd)
Beskrivning

ProgressionSuspectedBeginDate

Datatyp

date

Suspected Date (yyyy-mmm-dd)
Beskrivning

ProgressionSuspectedBeginDate

Datatyp

date

Suspected Date (yyyy-mmm-dd)
Beskrivning

ProgressionSuspectedBeginDate

Datatyp

date

Suspected Date (yyyy-mmm-dd)
Beskrivning

ProgressionSuspectedBeginDate

Datatyp

date

Definite Date (yyyy-mmm-dd)
Beskrivning

RecurrenceDate

Datatyp

date

Definite Date (yyyy-mmm-dd)
Beskrivning

RecurrenceDate

Datatyp

date

Definite Date (yyyy-mmm-dd)
Beskrivning

RecurrenceDate

Datatyp

date

Definite Date (yyyy-mmm-dd)
Beskrivning

RecurrenceDate

Datatyp

date

Definite Date (yyyy-mmm-dd)
Beskrivning

RecurrenceDate

Datatyp

date

Definite Date (yyyy-mmm-dd)
Beskrivning

RecurrenceDate

Datatyp

date

Definite Date (yyyy-mmm-dd)
Beskrivning

RecurrenceDate

Datatyp

date

Definite Date (yyyy-mmm-dd)
Beskrivning

RecurrenceDate

Datatyp

date

Definite Date (yyyy-mmm-dd)
Beskrivning

RecurrenceDate

Datatyp

date

Definite Date (yyyy-mmm-dd)
Beskrivning

RecurrenceDate

Datatyp

date

Definite Date (yyyy-mmm-dd)
Beskrivning

RecurrenceDate

Datatyp

date

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

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

Tillbaka till toppen

Similar models

Submit within 6 weeks of the date of diagnosis.

1 Formulär
  1. StudyEvent: FORM 9 - RECURRENCE AND CONTRALATERAL BREAST CANCER REPORT
    1. Submit within 6 weeks of the date of diagnosis.
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
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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