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43141

Description

Southwest Oncology Group S0931 Recurrence Assessment Form (Form #46940) Everolimus in Treating Patients With Kidney Cancer Who Have Undergone Surgery Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=7E26385C-8CD8-C34F-E040-BB89AD434A8D

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=7E26385C-8CD8-C34F-E040-BB89AD434A8D

Keywords

Versions (3)
  1. 9/19/12 9/19/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
  3. 9/20/21 9/20/21 -
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September 20, 2021

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Creative Commons BY-NC 3.0 Legacy
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    Kidney Cancer NCT01120249 Response - Southwest Oncology Group S0931 Recurrence Assessment Form (Form #46940) - 2998562v1.0

    English

    Instructions: Please submit at protocol specified intervals and at time of recurrence. All dates are MONTH, DAY, YEAR. Place an X in appropriate boxes. Circle AMENDED items in red and write AMENDED across the top of the form

    1 forms  
    Header
    Description

    Header

    SWOG Patient ID
    Description

    Trial subject ID SWOG

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C2348585
    NCI Thesaurus ObjectClass
    C16960
    UMLS CUI-2
    C1519429
    NCI Thesaurus Property
    C25364
    NCI Thesaurus Property-2
    C25699
    SWOG Study No.
    Description

    Protocol ID SWOG

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C3274381
    NCI Thesaurus ObjectClass
    C25320
    UMLS CUI-2
    C1519429
    NCI Thesaurus Property
    C25364
    NCI Thesaurus Property-2
    C25699
    Registration Step
    Description

    Registration Number

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C1514821
    NCI Thesaurus ObjectClass
    C25646
    UMLS CUI-2
    C0237753
    NCI Thesaurus Property
    C16154
    NCI Thesaurus ValueDomain-2
    C16154
    Patient Initials (L, F M)
    Description

    Patient Initials

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C2986440
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25536
    Date of Evaluation (MM DD YYYY)
    Description

    LesionAssessmentDate

    Data type

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C3824
    UMLS 2011AA ObjectClass
    C0221198
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    NCI Thesaurus ValueDomain-2
    C25367
    Institution/Affiliate
    Description

    Institution Name

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C25454
    UMLS CUI-1
    C1301943
    NCI Thesaurus ObjectClass-2
    C21541
    NCI Thesaurus Property
    C25364
    NCI Thesaurus ValueDomain
    C25191
    NCI Thesaurus ValueDomain-2
    C21541
    Physician
    Description

    Investigator Name

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C2826892
    NCI Thesaurus Property
    C25364
    NCI Thesaurus ObjectClass
    C17089
    NCI Thesaurus ObjectClass-2
    C25644
    Participating Group Name
    Description

    Participating Group

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C2347449
    NCI Thesaurus ObjectClass
    C25608
    NCI Thesaurus ObjectClass-2
    C17005
    NCI Thesaurus Property
    C25364
    Participating Study No.
    Description

    Study Number Participating Group

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C3274381
    NCI Thesaurus ObjectClass
    C25320
    UMLS CUI-2
    C2347449
    NCI Thesaurus Property
    C25608
    NCI Thesaurus Property-2
    C25364
    Participating Patient ID
    Description

    Trial subject ID Participating Group

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C2348585
    NCI Thesaurus ObjectClass
    C16960
    UMLS CUI-2
    C2347449
    NCI Thesaurus Property
    C25608
    NCI Thesaurus Property-2
    C25364
    Clinical Assessment
    Description

    Clinical Assessment

    Has the patient had a documented clinical assessment for this cancer? (during this report period)
    Description

    Documented clinical assessment for this cancer

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38148
    UMLS CUI-1
    C1522577
    NCI Thesaurus Property
    C16033
    UMLS CUI-2
    C0006826
    NCI Thesaurus ObjectClass
    C9305
    NCI Thesaurus Property-2
    C25365
    Date of Last Clinical Assessment (If yes MM DD YYYY)
    Description

    Follow-Up Date

    Data type

    date

    Alias
    NCI Thesaurus ObjectClass
    C9305
    UMLS CUI-1
    C3694716
    NCI Thesaurus Property
    C16033
    NCI Thesaurus Property-2
    C25365
    NCI Thesaurus ValueDomain
    C25164
    NCI Thesaurus ValueDomain-2
    C25367
    Symptomatic Deterioration
    Description

    ResponseSymptomaticDeteriorationInd-3

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38148
    UMLS 2011AA ValueDomain
    C1512699
    NCI Thesaurus ObjectClass
    C25755
    UMLS 2011AA ObjectClass
    C0871261
    NCI Thesaurus Property
    C25269
    UMLS 2011AA Property
    C0231220
    NCI Thesaurus Property-2
    C25751
    UMLS 2011AA Property-2
    C0868945
    Notice Of Recurrence
    Description

    Notice Of Recurrence

    Has the patient been diagnosed with recurrence of disease (during this report period Second primary is not a basis for recurrence. See section 10.1 for acceptable criteria for recurrence)
    Description

    RecurrentDiseaseFirstDiagnosisInd-3

    Data type

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38148
    UMLS 2011AA ValueDomain
    C1512699
    NCI Thesaurus ObjectClass
    C38155
    UMLS 2011AA ObjectClass
    C0277556
    NCI Thesaurus Property
    C25509
    UMLS 2011AA Property
    C1279901
    NCI Thesaurus Property-2
    C15220
    UMLS 2011AA Property-2
    C0011900
    Date of First Recurrence (If yes)
    Description

    RecurrentDiseaseFirstDiagnosisDate

    Data type

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C38155
    UMLS 2011AA ObjectClass
    C0277556
    NCI Thesaurus Property
    C25509
    UMLS 2011AA Property
    C1279901
    NCI Thesaurus Property-2
    C15220
    UMLS 2011AA Property-2
    C0011900
    How was recurrence discovered (If yes - select one)
    Description

    RecurrenceIdentifiedType

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus ObjectClass
    C3352
    UMLS 2011AA ObjectClass
    C0034897
    NCI Thesaurus Property
    C25737
    UMLS 2011AA Property
    C0205396
    Other, specify
    Description

    RecurrenceIdentifiedSpecify

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    NCI Thesaurus ObjectClass
    C3352
    UMLS 2011AA ObjectClass
    C0034897
    NCI Thesaurus Property
    C25737
    UMLS 2011AA Property
    C0205396
    Site of recurrence (If yes - select all that apply)
    Description

    RenalCellCarcinomaRecurrentDiseaseSite

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C13717
    UMLS 2011AA ValueDomain
    C1515974
    NCI Thesaurus Property
    C38155
    UMLS 2011AA Property
    C0277556
    NCI Thesaurus ObjectClass
    C9385
    UMLS 2011AA ObjectClass
    C0007134
    Explain why (Unknown)
    Description

    RenalCellCarcinomaRecurrentDiseaseSpecify

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    NCI Thesaurus Property
    C38155
    UMLS 2011AA Property
    C0277556
    NCI Thesaurus ObjectClass
    C9385
    UMLS 2011AA ObjectClass
    C0007134
    Was biopsy performed
    Description

    BiopsyPerformedInd-3

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C38148
    UMLS 2011AA ValueDomain
    C1512699
    NCI Thesaurus ObjectClass
    C15189
    UMLS 2011AA ObjectClass
    C0005558
    NCI Thesaurus Property
    C38000
    UMLS 2011AA Property
    C0884358
    Date of Biopsy (If yes)
    Description

    Biopsy Date

    Data type

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS CUI-1
    C0005558
    NCI Thesaurus ValueDomain-2
    C25367
    NCI Thesaurus ObjectClass
    C15189
    UMLS CUI-2
    C0011008
    NCI Thesaurus Property
    C25275
    Biopsy Result (If yes)
    Description

    BiopsyResultType

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus ObjectClass
    C15189
    UMLS 2011AA ObjectClass
    C0005558
    NCI Thesaurus Property
    C20200
    UMLS 2011AA Property
    C1274040
    Other, specify
    Description

    BiopsyResultSpecify

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    NCI Thesaurus ObjectClass
    C15189
    UMLS 2011AA ObjectClass
    C0005558
    NCI Thesaurus Property
    C20200
    UMLS 2011AA Property
    C1274040
    Comments
    Description

    Comments

    Comments
    Description

    Research Comments

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS CUI-1
    C0947611
    NCI Thesaurus ObjectClass
    C15319
    NCI Thesaurus Property
    C25393
    Back to the top of the page

    Similar models

    Instructions: Please submit at protocol specified intervals and at time of recurrence. All dates are MONTH, DAY, YEAR. Place an X in appropriate boxes. Circle AMENDED items in red and write AMENDED across the top of the form

    1 forms
    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    Header
    Trial subject ID SWOG
    Item
    SWOG Patient ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C2348585 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C1519429 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    C25699 (NCI Thesaurus Property-2)
    Protocol ID SWOG
    Item
    SWOG Study No.
    text
    C25337 (NCI Thesaurus ValueDomain)
    C3274381 (UMLS CUI-1)
    C25320 (NCI Thesaurus ObjectClass)
    C1519429 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    C25699 (NCI Thesaurus Property-2)
    Registration Number
    Item
    Registration Step
    text
    C25337 (NCI Thesaurus ValueDomain)
    C1514821 (UMLS CUI-1)
    C25646 (NCI Thesaurus ObjectClass)
    C0237753 (UMLS CUI-2)
    C16154 (NCI Thesaurus Property)
    C16154 (NCI Thesaurus ValueDomain-2)
    Patient Initials
    Item
    Patient Initials (L, F M)
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2986440 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25536 (NCI Thesaurus Property)
    LesionAssessmentDate
    Item
    Date of Evaluation (MM DD YYYY)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C3824 (NCI Thesaurus ObjectClass)
    C0221198 (UMLS 2011AA ObjectClass)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    C25367 (NCI Thesaurus ValueDomain-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)
    Investigator Name
    Item
    Physician
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2826892 (UMLS CUI-1)
    C25364 (NCI Thesaurus Property)
    C17089 (NCI Thesaurus ObjectClass)
    C25644 (NCI Thesaurus ObjectClass-2)
    Participating Group
    Item
    Participating Group Name
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2347449 (UMLS CUI-1)
    C25608 (NCI Thesaurus ObjectClass)
    C17005 (NCI Thesaurus ObjectClass-2)
    C25364 (NCI Thesaurus Property)
    Study Number Participating Group
    Item
    Participating Study No.
    text
    C25337 (NCI Thesaurus ValueDomain)
    C3274381 (UMLS CUI-1)
    C25320 (NCI Thesaurus ObjectClass)
    C2347449 (UMLS CUI-2)
    C25608 (NCI Thesaurus Property)
    C25364 (NCI Thesaurus Property-2)
    Trial subject ID Participating Group
    Item
    Participating 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)
    Item Group
    Clinical Assessment
    Documented clinical assessment for this cancer
    Item
    Has the patient had a documented clinical assessment for this cancer? (during this report period)
    boolean
    C38148 (NCI Thesaurus ValueDomain)
    C1522577 (UMLS CUI-1)
    C16033 (NCI Thesaurus Property)
    C0006826 (UMLS CUI-2)
    C9305 (NCI Thesaurus ObjectClass)
    C25365 (NCI Thesaurus Property-2)
    Follow-Up Date
    Item
    Date of Last Clinical Assessment (If yes MM DD YYYY)
    date
    C9305 (NCI Thesaurus ObjectClass)
    C3694716 (UMLS CUI-1)
    C16033 (NCI Thesaurus Property)
    C25365 (NCI Thesaurus Property-2)
    C25164 (NCI Thesaurus ValueDomain)
    C25367 (NCI Thesaurus ValueDomain-2)
    ResponseSymptomaticDeteriorationInd-3
    Item
    Symptomatic Deterioration
    boolean
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    C25755 (NCI Thesaurus ObjectClass)
    C0871261 (UMLS 2011AA ObjectClass)
    C25269 (NCI Thesaurus Property)
    C0231220 (UMLS 2011AA Property)
    C25751 (NCI Thesaurus Property-2)
    C0868945 (UMLS 2011AA Property-2)
    Item Group
    Notice Of Recurrence
    RecurrentDiseaseFirstDiagnosisInd-3
    Item
    Has the patient been diagnosed with recurrence of disease (during this report period Second primary is not a basis for recurrence. See section 10.1 for acceptable criteria for recurrence)
    boolean
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    C38155 (NCI Thesaurus ObjectClass)
    C0277556 (UMLS 2011AA ObjectClass)
    C25509 (NCI Thesaurus Property)
    C1279901 (UMLS 2011AA Property)
    C15220 (NCI Thesaurus Property-2)
    C0011900 (UMLS 2011AA Property-2)
    RecurrentDiseaseFirstDiagnosisDate
    Item
    Date of First Recurrence (If yes)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C38155 (NCI Thesaurus ObjectClass)
    C0277556 (UMLS 2011AA ObjectClass)
    C25509 (NCI Thesaurus Property)
    C1279901 (UMLS 2011AA Property)
    C15220 (NCI Thesaurus Property-2)
    C0011900 (UMLS 2011AA Property-2)
    Item
    How was recurrence discovered (If yes - select one)
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C3352 (NCI Thesaurus ObjectClass)
    C0034897 (UMLS 2011AA ObjectClass)
    C25737 (NCI Thesaurus Property)
    C0205396 (UMLS 2011AA Property)
    CL.4
    Code List
    How was recurrence discovered (If yes - select one)
    CL Item
    Routine Radiologic Evaluation (Routine radiologic evaluation)
    CL Item
    Development Of Symptoms (Development of symptoms)
    CL Item
    Clinical Evaluation (Clinical evaluation)
    CL Item
    Other (Other)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    RecurrenceIdentifiedSpecify
    Item
    Other, specify
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C3352 (NCI Thesaurus ObjectClass)
    C0034897 (UMLS 2011AA ObjectClass)
    C25737 (NCI Thesaurus Property)
    C0205396 (UMLS 2011AA Property)
    Item
    Site of recurrence (If yes - select all that apply)
    text
    C13717 (NCI Thesaurus ValueDomain)
    C1515974 (UMLS 2011AA ValueDomain)
    C38155 (NCI Thesaurus Property)
    C0277556 (UMLS 2011AA Property)
    C9385 (NCI Thesaurus ObjectClass)
    C0007134 (UMLS 2011AA ObjectClass)
    CL.5
    Code List
    Site of recurrence (If yes - select all that apply)
    CL Item
    Central Nervous System (Central nervous system)
    C12438 (NCI Thesaurus)
    C3714787 (UMLS 2011AA)
    CL Item
    Liver (Liver)
    C12392 (NCI Thesaurus)
    C0023884 (UMLS 2011AA)
    CL Item
    Lung (Lung)
    C12468 (NCI Thesaurus)
    C0024109 (UMLS 2011AA)
    CL Item
    Recurrent Disease Lymph Node (Lymph node recurrence)
    C12745 (NCI Thesaurus)
    C0024204 (UMLS 2011AA)
    C38155 (NCI Thesaurus-3)
    C0277556 (UMLS 2011AA-4)
    CL Item
    Other (Other)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    CL Item
    Other Organs (Other organs)
    CL Item
    Renal Bed (Renal bed)
    CL Item
    Skeletal (Skeletal)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    RenalCellCarcinomaRecurrentDiseaseSpecify
    Item
    Explain why (Unknown)
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C38155 (NCI Thesaurus Property)
    C0277556 (UMLS 2011AA Property)
    C9385 (NCI Thesaurus ObjectClass)
    C0007134 (UMLS 2011AA ObjectClass)
    Item
    Was biopsy performed
    text
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    C15189 (NCI Thesaurus ObjectClass)
    C0005558 (UMLS 2011AA ObjectClass)
    C38000 (NCI Thesaurus Property)
    C0884358 (UMLS 2011AA Property)
    CL.6
    Code List
    Was biopsy performed
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    Biopsy Date
    Item
    Date of Biopsy (If yes)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0005558 (UMLS CUI-1)
    C25367 (NCI Thesaurus ValueDomain-2)
    C15189 (NCI Thesaurus ObjectClass)
    C0011008 (UMLS CUI-2)
    C25275 (NCI Thesaurus Property)
    Item
    Biopsy Result (If yes)
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C15189 (NCI Thesaurus ObjectClass)
    C0005558 (UMLS 2011AA ObjectClass)
    C20200 (NCI Thesaurus Property)
    C1274040 (UMLS 2011AA Property)
    CL.7
    Code List
    Biopsy Result (If yes)
    CL Item
    Benign (Benign)
    C14172 (NCI Thesaurus)
    C0205183 (UMLS 2011AA)
    CL Item
    Malignant (Malignant)
    C14143 (NCI Thesaurus)
    C0205282 (UMLS 2011AA)
    CL Item
    Atypical/indeterminate (Atypical/indeterminate)
    CL Item
    Other (Other)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    BiopsyResultSpecify
    Item
    Other, specify
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C15189 (NCI Thesaurus ObjectClass)
    C0005558 (UMLS 2011AA ObjectClass)
    C20200 (NCI Thesaurus Property)
    C1274040 (UMLS 2011AA Property)
    Item Group
    Comments
    Research Comments
    Item
    Comments
    text
    C25704 (NCI Thesaurus ValueDomain)
    C0947611 (UMLS CUI-1)
    C15319 (NCI Thesaurus ObjectClass)
    C25393 (NCI Thesaurus Property)
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