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ID

44596

Descrizione

Southwest Oncology Group Registration Form (S0226) S0226 Anastrozole With or Without Fulvestrant as First-Line Therapy in Postmenopausal Women With Metastatic Breast Cancer NCT00075764 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=C3225DE6-8BA0-26CF-E034-0003BA12F5E7

collegamento

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=C3225DE6-8BA0-26CF-E034-0003BA12F5E7

Keywords

versioni (3)
  1. 26/08/12 26/08/12 -
  2. 24/04/15 24/04/15 - Martin Dugas
  3. 27/09/21 27/09/21 -
Caricato su

27 settembre 2021

DOI

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Licenza

Creative Commons BY-NC 3.0 Legacy
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    Breast Cancer Registration SWOG S0226 NCT00075764

    Inglese

    No Instruction available.

    1 moduli  
    1. StudyEvent: Southwest Oncology Group Registration Form (S0226)
      1. No Instruction available.
    Header
    Descrizione

    Header

    Alias
    UMLS CUI-1
    C1320722
    SWOG Study No.
    Descrizione

    SWOGStudyNo.

    Tipo di dati

    text

    Registration Step
    Descrizione

    RegistrationStep

    Tipo di dati

    text

    Assigned Treatment Arm
    Descrizione

    AssignedTreatmentArm

    Tipo di dati

    text

    Activation Date
    Descrizione

    ActivationDate

    Tipo di dati

    text

    Last Amended Date
    Descrizione

    LastAmendedDate

    Tipo di dati

    text

    Patient's Name
    Descrizione

    Patient'sName

    Tipo di dati

    text

    SWOG Patient ID
    Descrizione

    SWOGPatientID

    Tipo di dati

    text

    Other Group Patient Number
    Descrizione

    OtherGroupPatientNumber

    Tipo di dati

    text

    Participating Group Protocol Number
    Descrizione

    ParticipatingGroupProtocolNumber

    Tipo di dati

    text

    Caller's SWOG Roster ID
    Descrizione

    Caller'sSWOGRosterID

    Tipo di dati

    text

    IRB Approval Date
    Descrizione

    IRBApprovalDate

    Tipo di dati

    text

    SWOG Investigator Number
    Descrizione

    SWOGInvestigatorNumber

    Tipo di dati

    text

    Other Group Investigator Number (OR)
    Descrizione

    OtherGroupInvestigatorIdentifierNumber

    Tipo di dati

    text

    Alias
    NCI Thesaurus ObjectClass
    C17649
    UMLS 2011AA ObjectClass
    C0205394
    NCI Thesaurus ObjectClass-2
    C25936
    UMLS 2011AA ObjectClass-2
    C0035173
    NCI Thesaurus ObjectClass-3
    C43359
    UMLS 2011AA ObjectClass-3
    C0441833
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    Other Group Investigator Name
    Descrizione

    OtherGroupInvestigatorIdentifierName

    Tipo di dati

    text

    Alias
    NCI Thesaurus ObjectClass
    C17649
    UMLS 2011AA ObjectClass
    C0205394
    NCI Thesaurus ObjectClass-2
    C25936
    UMLS 2011AA ObjectClass-2
    C0035173
    NCI Thesaurus ObjectClass-3
    C43359
    UMLS 2011AA ObjectClass-3
    C0441833
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    Other Group Institution Number
    Descrizione

    OtherGroupTreatingInstitutionIdentifierNumber

    Tipo di dati

    text

    Alias
    NCI Thesaurus ObjectClass
    C17649
    UMLS 2011AA ObjectClass
    C0205394
    NCI Thesaurus ObjectClass-2
    C25705
    UMLS 2011AA ObjectClass-2
    C1522326
    NCI Thesaurus ObjectClass-3
    C41206
    UMLS 2011AA ObjectClass-3
    C1272753
    NCI Thesaurus ObjectClass-4
    C43359
    UMLS 2011AA ObjectClass-4
    C0441833
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    Other Group Institution Name
    Descrizione

    OtherGroupTreatingInstitutionIdentifierName

    Tipo di dati

    text

    Alias
    NCI Thesaurus ObjectClass
    C17649
    UMLS 2011AA ObjectClass
    C0205394
    NCI Thesaurus ObjectClass-2
    C25705
    UMLS 2011AA ObjectClass-2
    C1522326
    NCI Thesaurus ObjectClass-3
    C41206
    UMLS 2011AA ObjectClass-3
    C1272753
    NCI Thesaurus ObjectClass-4
    C43359
    UMLS 2011AA ObjectClass-4
    C0441833
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    NCI Thesaurus ValueDomain-2
    C21541
    UMLS 2011AA ValueDomain-2
    C0018704
    SWOG Treating Institution Number
    Descrizione

    SWOGTreatingInstitutionNumber

    Tipo di dati

    text

    Date HIPAA Authorization signed
    Descrizione

    DateHIPAAAuthorizationsigned

    Tipo di dati

    text

    Method of Payment
    Descrizione

    MethodofPayment

    Tipo di dati

    text

    Patient Social Security Number
    Descrizione

    PatientSocialSecurityNumber

    Tipo di dati

    text

    Patient's ZIP Code
    Descrizione

    Patient'sZIPCode

    Tipo di dati

    text

    Country of Residence
    Descrizione

    CountryofResidence

    Tipo di dati

    text

    Social Insurance Number
    Descrizione

    SocialInsuranceNumber

    Tipo di dati

    text

    Postal Code
    Descrizione

    PostalCode

    Tipo di dati

    text

    Patient data
    Descrizione

    Patient data

    Alias
    UMLS CUI-1
    C2707520
    Patient's Date of Birth
    Descrizione

    Patient'sDateofBirth

    Tipo di dati

    date

    Alias
    UMLS CUI-1
    C0421451
    Projected Start Date of Treatment
    Descrizione

    ProjectedStartDateofTreatment

    Tipo di dati

    date

    Alias
    UMLS CUI-1
    C3173309
    Patient Gender
    Descrizione

    Patient Gender

    Tipo di dati

    text

    Alias
    UMLS CUI-1
    C0079399
    Patient's Ethnicity
    Descrizione

    Patient's Ethnicity

    Tipo di dati

    text

    Alias
    UMLS CUI-1
    C0015031
    Patient's Race
    Descrizione

    Patient's Race

    Tipo di dati

    text

    Alias
    UMLS CUI-1
    C0034510
    Prior adjuvant tamoxifen therapy
    Descrizione

    Prior adjuvant tamoxifen therapy

    Tipo di dati

    boolean

    Consent
    Descrizione

    Consent

    Alias
    UMLS CUI-1
    C1511481
    Date Informed Consent Signed
    Descrizione

    DateInformedConsentSigned

    Tipo di dati

    date

    Alias
    UMLS CUI-1
    C2985782
    My tissue may be kept for use in research to learn about, prevent, treat, or cure cancer.
    Descrizione

    Mytissuemaybekeptforuseinresearchtolearnabout,prevent,treat,orcurecancer.

    Tipo di dati

    boolean

    Alias
    UMLS CUI-1
    C0040300
    UMLS CUI-2
    C1516225
    My tissue may be kept for research about other health problems
    Descrizione

    Mytissuemaybekeptforresearchaboutotherhealthproblems

    Tipo di dati

    boolean

    Alias
    UMLS CUI-1
    C0040300
    UMLS CUI-2
    C0035168
    Someone from Southwest Oncology Group may contact me in the future to ask me to take part in more research
    Descrizione

    SomeonefromSouthwestOncologyGroupmaycontactmeinthefuturetoaskmetotakepartinmoreresearch

    Tipo di dati

    boolean

    Alias
    UMLS CUI-1
    C0521104
    UMLS CUI-2
    C2051501
    I agree to allow my study doctor, or someone approved by my study doctor, to contact me regard future research involving my participation in this study
    Descrizione

    SouthwestOncologyGroupPatientResearchConsentInd-2

    Tipo di dati

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus ObjectClass-2
    C25699
    NCI Thesaurus Property
    C15319
    NCI Thesaurus Property-2
    C25460
    NCI Thesaurus ValueDomain
    C38147
    UMLS CUI-1
    C0030705
    UMLS CUI-2
    C1519429
    UMLS CUI-3
    C1511481
    UMLS CUI-4
    C1512698
    I agree to submit blood samples for the purpose of determining how my body metabolizes the drugs, fulvestrant and anastrozole
    Descrizione

    PatientBloodSpecimenAgentMetabolismConsentInd-2

    Tipo di dati

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C12434
    NCI Thesaurus Property-2
    C1708
    NCI Thesaurus Property-3
    C19157
    NCI Thesaurus Property-4
    C25460
    NCI Thesaurus Property-5
    C21198
    NCI Thesaurus ValueDomain
    C38147
    UMLS CUI-1
    C0521104
    UMLS CUI-2
    C0178913
    UMLS CUI-3
    C0935916
    I agree to submit blood samples for the analysis of human epidermal growth factor receptor 2 (HER-2) protein to see if high levels will predict if I am less likely to respond to hormone therapy
    Descrizione

    PatientBloodSpecimenEpidermalGrowthFactorReceptorConsentInd-2

    Tipo di dati

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C12434
    NCI Thesaurus Property-2
    C19157
    NCI Thesaurus Property-3
    C25460
    NCI Thesaurus Property-4
    C17068
    NCI Thesaurus ValueDomain
    C38147
    UMLS CUI-1
    C0521104
    UMLS CUI-2
    C0178913
    UMLS CUI-3
    C0034802
    I agree to submit a blood specimen for genetic expression studies to study what role the protocol treatment is having on my disease
    Descrizione

    PatientBloodSpecimenGeneExpressionConsentInd-2

    Tipo di dati

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C12434
    NCI Thesaurus Property-2
    C19157
    NCI Thesaurus Property-3
    C25460
    NCI Thesaurus Property-4
    C16608
    NCI Thesaurus ValueDomain
    C38147
    UMLS CUI-1
    C0521104
    UMLS CUI-2
    C0178913
    UMLS CUI-3
    C0017262
    I agree to submit a tissue specimen for the analysis of estrogen receptor (ER) and human epidermal growth factor receptor 2 (HER-2) to see if certain levels will predict if I am likely to respond to hormone therapy
    Descrizione

    PatientTissueSpecimenEpidermalGrowthFactorReceptorEstrogenReceptorConsentInd-2

    Tipo di dati

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C12801
    NCI Thesaurus Property-2
    C19157
    NCI Thesaurus Property-3
    C17069
    NCI Thesaurus Property-4
    C25460
    NCI Thesaurus Property-5
    C17068
    NCI Thesaurus ValueDomain
    C38147
    UMLS CUI-1
    C1511481
    UMLS CUI-2
    C1292533
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    Similar models

    No Instruction available.

    1 moduli
    1. StudyEvent: Southwest Oncology Group Registration Form (S0226)
      1. No Instruction available.
    Name
    genere
    Description | Question | Decode (Coded Value)
    Tipo di dati
    Alias
    Item Group
    Header
    C1320722 (UMLS CUI-1)
    SWOGStudyNo.
    Item
    SWOG Study No.
    text
    RegistrationStep
    Item
    Registration Step
    text
    AssignedTreatmentArm
    Item
    Assigned Treatment Arm
    text
    ActivationDate
    Item
    Activation Date
    text
    LastAmendedDate
    Item
    Last Amended Date
    text
    Patient'sName
    Item
    Patient's Name
    text
    SWOGPatientID
    Item
    SWOG Patient ID
    text
    OtherGroupPatientNumber
    Item
    Other Group Patient Number
    text
    ParticipatingGroupProtocolNumber
    Item
    Participating Group Protocol Number
    text
    Caller'sSWOGRosterID
    Item
    Caller's SWOG Roster ID
    text
    IRBApprovalDate
    Item
    IRB Approval Date
    text
    SWOGInvestigatorNumber
    Item
    SWOG Investigator Number
    text
    OtherGroupInvestigatorIdentifierNumber
    Item
    Other Group Investigator Number (OR)
    text
    C17649 (NCI Thesaurus ObjectClass)
    C0205394 (UMLS 2011AA ObjectClass)
    C25936 (NCI Thesaurus ObjectClass-2)
    C0035173 (UMLS 2011AA ObjectClass-2)
    C43359 (NCI Thesaurus ObjectClass-3)
    C0441833 (UMLS 2011AA ObjectClass-3)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    OtherGroupInvestigatorIdentifierName
    Item
    Other Group Investigator Name
    text
    C17649 (NCI Thesaurus ObjectClass)
    C0205394 (UMLS 2011AA ObjectClass)
    C25936 (NCI Thesaurus ObjectClass-2)
    C0035173 (UMLS 2011AA ObjectClass-2)
    C43359 (NCI Thesaurus ObjectClass-3)
    C0441833 (UMLS 2011AA ObjectClass-3)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    OtherGroupTreatingInstitutionIdentifierNumber
    Item
    Other Group Institution Number
    text
    C17649 (NCI Thesaurus ObjectClass)
    C0205394 (UMLS 2011AA ObjectClass)
    C25705 (NCI Thesaurus ObjectClass-2)
    C1522326 (UMLS 2011AA ObjectClass-2)
    C41206 (NCI Thesaurus ObjectClass-3)
    C1272753 (UMLS 2011AA ObjectClass-3)
    C43359 (NCI Thesaurus ObjectClass-4)
    C0441833 (UMLS 2011AA ObjectClass-4)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    OtherGroupTreatingInstitutionIdentifierName
    Item
    Other Group Institution Name
    text
    C17649 (NCI Thesaurus ObjectClass)
    C0205394 (UMLS 2011AA ObjectClass)
    C25705 (NCI Thesaurus ObjectClass-2)
    C1522326 (UMLS 2011AA ObjectClass-2)
    C41206 (NCI Thesaurus ObjectClass-3)
    C1272753 (UMLS 2011AA ObjectClass-3)
    C43359 (NCI Thesaurus ObjectClass-4)
    C0441833 (UMLS 2011AA ObjectClass-4)
    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)
    SWOGTreatingInstitutionNumber
    Item
    SWOG Treating Institution Number
    text
    DateHIPAAAuthorizationsigned
    Item
    Date HIPAA Authorization signed
    text
    Item
    Method of Payment
    text
    CL.10
    Code List
    Method of Payment
    CL Item
    Private (Private)
    CL Item
    Medicare (Medicare)
    CL Item
    Medicare and Private (Medicare and Private)
    CL Item
    Medicaid (Medicaid)
    CL Item
    Medicaid and Medicare (Medicaid and Medicare)
    CL Item
    No insurance (self-pay) (No insurance (self-pay))
    CL Item
    No insurance (no means) (No insurance (no means))
    CL Item
    Other, specify at registration (Other, specify at registration)
    CL Item
    unknown (unknown)
    CL Item
    Veterans Admin (Veterans Admin)
    CL Item
    Military (Military)
    PatientSocialSecurityNumber
    Item
    Patient Social Security Number
    text
    Patient'sZIPCode
    Item
    Patient's ZIP Code
    text
    CountryofResidence
    Item
    Country of Residence
    text
    SocialInsuranceNumber
    Item
    Social Insurance Number
    text
    PostalCode
    Item
    Postal Code
    text
    Item Group
    Patient data
    C2707520 (UMLS CUI-1)
    Birth date
    Item
    Patient's Date of Birth
    date
    C0421451 (UMLS CUI-1)
    Treatment start date
    Item
    Projected Start Date of Treatment
    date
    C3173309 (UMLS CUI-1)
    Item
    Patient Gender
    text
    C0079399 (UMLS CUI-1)
    CL.9
    Code List
    Patient Gender
    CL Item
    Female (Female)
    C0086287 (UMLS CUI-1)
    CL Item
    Male (Male)
    C0086582 (UMLS CUI-1)
    Item
    Patient's Ethnicity
    text
    C0015031 (UMLS CUI-1)
    CL.11
    Code List
    Patient's Ethnicity
    CL Item
    Unknown (Unknown)
    CL Item
    No (not Spanish) (No (not Spanish))
    CL Item
    Yes, Mexican (Yes, Mexican)
    CL Item
    Yes, Puerto Rican (Yes, Puerto Rican)
    CL Item
    Yes, Cuban (Yes, Cuban)
    CL Item
    Yes, Central American (Yes, Central American)
    CL Item
    Yes, South American (Yes, South American)
    CL Item
    Yes, Other (Yes, Other)
    CL Item
    Yes, NOS (Yes, NOS)
    Item
    Patient's Race
    text
    C0034510 (UMLS CUI-1)
    CL.12
    Code List
    Patient's Race
    CL Item
    White or Caucasian (White or Caucasian)
    CL Item
    Black or African American (Black or African American)
    CL Item
    Native Hawaiian or Other Pacific Islander (Native Hawaiian or Other Pacific Islander)
    CL Item
    Asian (Asian)
    CL Item
    American Indian or Alaska Native (American Indian or Alaska Native)
    Prior adjuvant tamoxifen therapy
    Item
    Prior adjuvant tamoxifen therapy
    boolean
    Item Group
    Consent
    C1511481 (UMLS CUI-1)
    Informed consent date
    Item
    Date Informed Consent Signed
    date
    C2985782 (UMLS CUI-1)
    Tissue for cancer research
    Item
    My tissue may be kept for use in research to learn about, prevent, treat, or cure cancer.
    boolean
    C0040300 (UMLS CUI-1)
    C1516225 (UMLS CUI-2)
    Tissue for research
    Item
    My tissue may be kept for research about other health problems
    boolean
    C0040300 (UMLS CUI-1)
    C0035168 (UMLS CUI-2)
    Permission for further contact
    Item
    Someone from Southwest Oncology Group may contact me in the future to ask me to take part in more research
    boolean
    C0521104 (UMLS CUI-1)
    C2051501 (UMLS CUI-2)
    Permission for further contact regarding research
    Item
    I agree to allow my study doctor, or someone approved by my study doctor, to contact me regard future research involving my participation in this study
    boolean
    C16960 (NCI Thesaurus ObjectClass)
    C25699 (NCI Thesaurus ObjectClass-2)
    C15319 (NCI Thesaurus Property)
    C25460 (NCI Thesaurus Property-2)
    C38147 (NCI Thesaurus ValueDomain)
    C0030705 (UMLS CUI-1)
    C1519429 (UMLS CUI-2)
    C1511481 (UMLS CUI-3)
    C1512698 (UMLS CUI-4)
    Permission for blood sample fulvestrant
    Item
    I agree to submit blood samples for the purpose of determining how my body metabolizes the drugs, fulvestrant and anastrozole
    boolean
    C16960 (NCI Thesaurus ObjectClass)
    C12434 (NCI Thesaurus Property)
    C1708 (NCI Thesaurus Property-2)
    C19157 (NCI Thesaurus Property-3)
    C25460 (NCI Thesaurus Property-4)
    C21198 (NCI Thesaurus Property-5)
    C38147 (NCI Thesaurus ValueDomain)
    C0521104 (UMLS CUI-1)
    C0178913 (UMLS CUI-2)
    C0935916 (UMLS CUI-3)
    Permission blood sample HER-2
    Item
    I agree to submit blood samples for the analysis of human epidermal growth factor receptor 2 (HER-2) protein to see if high levels will predict if I am less likely to respond to hormone therapy
    boolean
    C16960 (NCI Thesaurus ObjectClass)
    C12434 (NCI Thesaurus Property)
    C19157 (NCI Thesaurus Property-2)
    C25460 (NCI Thesaurus Property-3)
    C17068 (NCI Thesaurus Property-4)
    C38147 (NCI Thesaurus ValueDomain)
    C0521104 (UMLS CUI-1)
    C0178913 (UMLS CUI-2)
    C0034802 (UMLS CUI-3)
    Permission blood sample gene expression
    Item
    I agree to submit a blood specimen for genetic expression studies to study what role the protocol treatment is having on my disease
    boolean
    C16960 (NCI Thesaurus ObjectClass)
    C12434 (NCI Thesaurus Property)
    C19157 (NCI Thesaurus Property-2)
    C25460 (NCI Thesaurus Property-3)
    C16608 (NCI Thesaurus Property-4)
    C38147 (NCI Thesaurus ValueDomain)
    C0521104 (UMLS CUI-1)
    C0178913 (UMLS CUI-2)
    C0017262 (UMLS CUI-3)
    consent tissue specimen
    Item
    I agree to submit a tissue specimen for the analysis of estrogen receptor (ER) and human epidermal growth factor receptor 2 (HER-2) to see if certain levels will predict if I am likely to respond to hormone therapy
    boolean
    C16960 (NCI Thesaurus ObjectClass)
    C12801 (NCI Thesaurus Property)
    C19157 (NCI Thesaurus Property-2)
    C17069 (NCI Thesaurus Property-3)
    C25460 (NCI Thesaurus Property-4)
    C17068 (NCI Thesaurus Property-5)
    C38147 (NCI Thesaurus ValueDomain)
    C1511481 (UMLS CUI-1)
    C1292533 (UMLS CUI-2)
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