Info
Dialog
Download

Rating Ratings

Description:

Radiation Therapy Oncology Group Follow-up Form Phase III Recurrent Head and Neck Study Combination Chemotherapy With or Without Radiation Therapy in Treating Patients With Recurrent Head and Neck Cancer That Cannot Be Removed By Surgery Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=EC4F6FCB-F88D-02BE-E034-0003BA3F9857

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=EC4F6FCB-F88D-02BE-E034-0003BA3F9857

Keywords:

Head and Neck Neoplasms

Clinical Trial

Baseline

Versions (4)

9/19/12 9/19/12 -
1/9/15 1/9/15 - Martin Dugas
8/4/15 8/4/15 - Martin Dugas
9/20/21 9/20/21 -

Uploaded on:

September 20, 2021

DOI:

To request one please log in.

License :

Creative Commons BY-NC 3.0 Legacy

Model comments :

You can comment on the data model here. Via the speech bubbles at the itemgroups and items you can add comments to those specificially.

Back to model comments

Itemgroup comments for :

Item comments for :

In order to download data models you must be logged in. Please log in or register for free.

Initial Evaluation recurrent Head and Neck Cancer RTOG NCT00113399

English 1

English

Details

No Instruction available.

1 forms

StudyEvent: Radiation Therapy Oncology Group Follow-up Form Phase III Recurrent Head and Neck Study Initial Evaluation Form
1. No Instruction available.

Header

RTOG Study

Case #

Institution Name

Institution No.

Participant's Initials

Participant's ID No.

Amended data

Yes

Age

years

PERFORMANCE STATUS (ZUBROD)

Completely Disabled (Completely disabled)

Ambulatory And Capable Of All Selfcare But Unable To Carry Out Any Work Activities (Ambulatory and capable of all selfcare but unable to carry out any work activities)

Capable Of Limited Selfcare, Confined To Bed Or Chair More Than 50% Of Waking Hours (Capable of limited selfcare, confined to bed or chair more than 50% of waking hours)

Fully Active, Able To Carry On All Pre-disease Performance Without Restriction (Fully active, able to carry on all pre-disease performance without restriction)

Restricted In Physically Strenuous Activity But Ambulatory (Restricted in physically strenuous activity but ambulatory)

ANC

1000/ul

Peripheral Platelet Count

1000/uL

Hemoglobin

g/dL

Bilirubin

mg/dL

Bilirubin ULN

mg/dL

AST (SGOT)

U/L

AST (SGOT) ULN

U/L

ALT (SGPT)

U/L

ALT (SGPT) ULN

U/L

Alkaline Phosphatase

U/L

Alkaline Phosphatase ULN

U/L

Creatinine Clearance

mL/min

Calcium

mmol/l

CORRECTED SERUM CALCIUM (mg/dl)

mg/dL

CT OR MRI OF TUMOR SITE

Not Done (Not done)

Normal (Normal)

Abnormal (Abnormal)

CHEST CT

Not Done (Not done)

Normal (Normal)

Abnormal (Abnormal)

ABDOMINAL CT

Not Done (Not done)

Normal (Normal)

Abnormal (Abnormal)

BIOPSY OF TUMOR OR NEEDLE ASPIRATE/BIOPSY OF METASTATIC LYMPH NODE

Not Done (Not done)

Normal (Normal)

Abnormal (Abnormal)

PHYSICAL ASSESSMENT OF CAROTID

Yes

DOPPLER ULTRASOUND

Yes

CT OR MR ANGIOGRAM

Yes

CIRCUMFERENTIAL TUMOR INVOLVEMENT OF CAROTID SHEATH

Yes

WAS CAROTID ARTERY STENT PLACED?

Yes

IV ANTIBIOTICS AT TIME OF REGISTRATION

Yes

HOSPITALIZED FOR COPD OR OTHER RESPIRATORY ILLNESS IN LAST 6 MONTHS

Yes

PREEXISTING GRADE > 2 PERIPHERAL SENSORY NEUROPATHY

Yes

SYMPTOMATIC OR UNCONTROLLED CARDIAC DISEASE

Yes

NEW YORK HEART ASSOCIATION CLASSIFICATION (If yes,)

No Symptoms With Ordinary Physical Activity (I)

Symptoms With Ordinary Physical Activity; Slight Limitation Of Activity (II)

Symptoms With Less Than Ordinary Physical Activity; Marked Limitation Of Activity (III)

Symptoms With Any Physical Activity Or Even At Rest (IV)

PRIOR SURGERY (FOR HEAD AND NECK CANCER)

Yes

PRIOR SURGERY DATE (MOST RECENT)

PRIOR CHEMOTHERAPY (FOR OTHER REASONS)

PRIOR CHEMOTHERAPY END DATE

PRIOR DOSE TO THE RECURRENT / NEW PRIMARY SITE

PRIOR DOSE TO THE SPINAL CORD

PRIOR RADIATION THERAPY END DATE

TYPE OF PATIENT DISEASE (CURRENT PRESENTATION)

Locally Recurrent (Locally recurrent)

Regionally Recurrent (Regionally recurrent)

Locally And Regionally Recurrent (Locally and regionally recurrent)

New Primary (New primary)

T STAGE (of new primary only)

T0, According To Ajcc Criteria (T0)

T1, According To Ajcc Criteria (T1)

T2, According To Ajcc Criteria (T2)

T3, According To Ajcc Criteria (T3)

3 more items in the detailed view.

N STAGE (of new primary only)

N0, According To Ajcc Guidelines (N0)

N1, According To Ajcc Criteria (N1)

N2a, According To Ajcc Guidelines (N2a)

N2b, According To Ajcc Guidelines (N2b)

3 more items in the detailed view.

PRIMARY SITE (CURRENT PRESENTATION)

Oral Cavity Nos (ORAL CAVITY, NOS)

Oral Tongue (Oral tongue)

Floor Of Mouth (Floor of mouth)

Buccal Mucosa (Buccal mucosa)

29 more items in the detailed view.

OTHER, SPECIFY

HISTOLOGIC DIAGNOSIS (CURRENT PRESENTATION)

Squamous Cell Carcinoma, Including Variants (Squamous cell carcinoma, including variants)

Other (Other)

HOW MANY RECURRENCES / NEW PRIMARIES HAS THE PATIENT HAD SINCE TREATMENT OF THE ORIGINAL HEAD AND NECK CANCER?

DATE OF FIRST RECURRENCE (OR NEW PRIMARY)

LARGEST MEASURABLE LESION

DISTANT METASTASES PRESENT?

Yes

DOES THE PATIENT HAVE A HISTORY OF PRIOR CANCER OTHER THAN THE UPPER AERO-DIGESTIVE TRACT?

No (No)

Yes (Yes)

Unknown (UNKNOWN)

SITE OF PRIOR CANCER

PRIOR CANCER DATE ERADICATED

WEIGHT LOSS IN PREVIOUS SIX MONTHS

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

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

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

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

Unknown (Unknown)

DOES THE PATIENT HAVE A PAST HISTORY OF SWALLOWING PROBLEMS?

No (No)

Yes (Yes)

Unknown (UNKNOWN)

HOW LONG WERE SWALLOWING PROBLEMS APPARENT? (If yes,)

Less Than 1 Month (Less than 1 month)

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

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

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

3 more items in the detailed view.

DOES THE PATIENT CURRENTLY HAVE SWALLOWING PROBLEMS?

No (No)

Yes (Yes)

Unknown (Unknown)

HOW LONG HAVE SWALLOWING PROBLEMS BEEN PRESENT? (If yes,)

Less Than 1 Month (Less than 1 month)

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

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

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

3 more items in the detailed view.

DOES THE PATIENT HAVE A PAST HISTORY OF TUBE FEEDINGS?

No (No)

Yes (Yes)

Unknown (Unknown)

HOW LONG WERE TUBE FEEDINGS GIVEN? (If yes,)

Less Than 1 Month (Less than 1 month)

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

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

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

3 more items in the detailed view.

DOES THE PATIENT CURRENTLY REQUIRE TUBE FEEDING?

No (No)

Yes (Yes)

Unknown (Unknown)

IS PATIENT DEPENDENT ON TUBE FEEDING FOR >50% OF NUTRITIONAL SUPPORT? (If yes,)

No (No)

Yes (Yes)

Unknown (Unknown)

Comments

COMMENTS

Person completing form

Form completion date, original

Back to the top of the page

Similar models

Show recommended models

Description:

Link:

Keywords:

Versions (4)

Uploaded on:

DOI:

License :

Model comments :

Itemgroup comments for :

Item comments for :

Initial Evaluation recurrent Head and Neck Cancer RTOG NCT00113399

No Instruction available.

Similar models

Contact

Help