ID

6174

Description

NSABP Protocol B-40 - Treatment Form for Hormonal Therapy A Randomized Phase III Trial of Neoadjuvant Therapy in Patients With Palpable and Operable Breast Cancer Evaluating the Effect on Pathologic Complete Response (pCR) of Adding Capecitabine or Gemcitabine to Docetaxel When Administered Before AC With or Without Bevacizumab and Correlative Science Studies Attempting to Identify Predictors of High Likelihood for pCR With Each of the Regimens Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=1B7E215E-B69B-0BD3-E044-0003BA3F9857

Lien

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=1B7E215E-B69B-0BD3-E044-0003BA3F9857

Mots-clés

Versions (1)
  1. 15/12/2014 15/12/2014 - Martin Dugas
Téléchargé le

15 décembre 2014

DOI

Pour une demande vous connecter.

Licence

Creative Commons BY-NC 3.0 Legacy
Modèle Commentaires :

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Breast Cancer NCT00408408 Treatment - NSABP Protocol B-40 - Treatment Form for Hormonal Therapy - 2511670v1.0

Anglais

This paper worksheet may be completed to faciliate the entry of the information in NSABP Coordinator Online. Partially completed forms may be saved in Coordinator Online. DO NOT SUBMIT THIS WORKSHEET VIA FAX OR MAIL.

1 Formulaires  
General information
Description

General information

Alias
UMLS CUI-1
C1508263
Patient Initials (Last First Middle)
Description

Patient Initials (Last First Middle)

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25191
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
UMLS CUI-1
C2986440
NSABP Patient ID
Description

Patient National Surgical Adjuvant Breast Project Identifier Number

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25364
NCI Thesaurus Property
C15818
UMLS CUI-1
C1549740
Institution/Affiliate
Description

CombinedInstitutionName

Type de données

text

Person Completing Form, Last Name
Description

Person Completing Form, Last Name

Type de données

text

Alias
UMLS CUI-1
C1550483
UMLS CUI-2
C1301584
Person Completing Form, First Name
Description

Person Completing Form, First Name

Type de données

text

Alias
UMLS CUI-1
C1550483
UMLS CUI-2
C1443235
Person Completing Form, Phone
Description

Person Completing Form, Phone

Type de données

text

Alias
UMLS CUI-1
C1550483
UMLS CUI-2
C0039457
Are data amended
Description

Are data amended

Type de données

boolean

Alias
UMLS CUI-1
C0680532
Date form completed
Description

Date form completed

Type de données

date

Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ObjectClass
C40988
NCI Thesaurus Property
C25250
NCI Thesaurus ValueDomain
C25367
UMLS CUI-1
C1115437
Reason form completed
Description

Reason hormone therapy form completed

Type de données

integer

Alias
NCI Thesaurus ValueDomain
C25638
NCI Thesaurus ObjectClass
C19464
NCI Thesaurus Property
C25250
NCI Thesaurus ObjectClass
C15445
Hormone therapy
Description

Hormone therapy

Alias
UMLS CUI-1
C0279025
Agent Name
Description

Agent Name (Tamoxifen, Aromatase Inhibitor, Other specify)

Type de données

integer

Alias
NCI Thesaurus Property
C25364
NCI Thesaurus ObjectClass
C1708
NCI Thesaurus ValueDomain
C1708
NCI Thesaurus ValueDomain
C42614
UMLS CUI-1
C1254351
Other hormone therapy, specify
Description

Other hormone therapy

Type de données

text

Alias
NCI Thesaurus ValueDomain
C25685
NCI Thesaurus ObjectClass
C15445
NCI Thesaurus ObjectClass
C1708
NCI Thesaurus Property
C25382
Was agent administered
Description

Was agent administered

Type de données

boolean

Alias
NCI Thesaurus ValueDomain
C38147
NCI Thesaurus ObjectClass
C1708
NCI Thesaurus Property
C25382
UMLS CUI-1
C1254351
UMLS CUI-2
C1521801
Agent Start Date
Description

Agent Start Date

Type de données

date

Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ValueDomain
C25431
NCI Thesaurus ObjectClass
C1708
NCI Thesaurus Property
C25275
UMLS CUI-1
C0451613
Agent End Date (Leave date boxes blank if agent will continue beyond 5 years.)
Description

Agent End Date (Leave date boxes blank if agent will continue beyond 5 years.)

Type de données

date

Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ObjectClass
C1708
NCI Thesaurus Property
C25275
UMLS CUI-1
C0850893
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Similar models

This paper worksheet may be completed to faciliate the entry of the information in NSABP Coordinator Online. Partially completed forms may be saved in Coordinator Online. DO NOT SUBMIT THIS WORKSHEET VIA FAX OR MAIL.

1 Formulaires
Name
Type
Description | Question | Decode (Coded Value)
Type de données
Alias
Item Group
General information
C1508263 (UMLS CUI-1)
Patient Initials
Item
Patient Initials (Last First Middle)
text
C25191 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
C2986440 (UMLS CUI-1)
Patient ID NSABP
Item
NSABP Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
C15818 (NCI Thesaurus Property)
C1549740 (UMLS CUI-1)
CombinedInstitutionName
Item
Institution/Affiliate
text
Person Completing Form Last Name
Item
Person Completing Form, Last Name
text
C1550483 (UMLS CUI-1)
C1301584 (UMLS CUI-2)
Person Completing Form First Name
Item
Person Completing Form, First Name
text
C1550483 (UMLS CUI-1)
C1443235 (UMLS CUI-2)
Person Completing Form Phone
Item
Person Completing Form, Phone
text
C1550483 (UMLS CUI-1)
C0039457 (UMLS CUI-2)
Amended data
Item
Are data amended
boolean
C0680532 (UMLS CUI-1)
Date form completed
Item
Date form completed
date
C25164 (NCI Thesaurus ValueDomain)
C40988 (NCI Thesaurus ObjectClass)
C25250 (NCI Thesaurus Property)
C25367 (NCI Thesaurus ValueDomain)
C1115437 (UMLS CUI-1)
Item
Reason form completed
integer
C25638 (NCI Thesaurus ValueDomain)
C19464 (NCI Thesaurus ObjectClass)
C25250 (NCI Thesaurus Property)
C15445 (NCI Thesaurus ObjectClass)
CL.2
Code List
Reason form completed
CL Item
Patient Will Not Begin Hormonal Therapy (1)
CL Item
Patient Received Less Than 5 Years Of Hormonal Therapy, And Hormonal Treatment Has Ended (2)
CL Item
Patient Received 5 Years Of Hormonal Therapy, And Hormonal Treatment Has Ended (3)
CL Item
Patient Received 5 Years Of Hormonal Therapy, And Hormonal Treatment Will Continue (4)
Item Group
Hormone therapy
C0279025 (UMLS CUI-1)
Item
Agent Name
integer
C25364 (NCI Thesaurus Property)
C1708 (NCI Thesaurus ObjectClass)
C1708 (NCI Thesaurus ValueDomain)
C42614 (NCI Thesaurus ValueDomain)
C1254351 (UMLS CUI-1)
Agent
Code List
Agent Name
CL Item
Tamoxifen (1)
CL Item
Aromatase Inhibitor (2)
CL Item
Other (specify) (3)
Other hormone therapy
Item
Other hormone therapy, specify
text
C25685 (NCI Thesaurus ValueDomain)
C15445 (NCI Thesaurus ObjectClass)
C1708 (NCI Thesaurus ObjectClass)
C25382 (NCI Thesaurus Property)
Agent administered
Item
Was agent administered
boolean
C38147 (NCI Thesaurus ValueDomain)
C1708 (NCI Thesaurus ObjectClass)
C25382 (NCI Thesaurus Property)
C1254351 (UMLS CUI-1)
C1521801 (UMLS CUI-2)
Agent Start Date
Item
Agent Start Date
date
C25164 (NCI Thesaurus ValueDomain)
C25431 (NCI Thesaurus ValueDomain)
C1708 (NCI Thesaurus ObjectClass)
C25275 (NCI Thesaurus Property)
C0451613 (UMLS CUI-1)
Agent End Date
Item
Agent End Date (Leave date boxes blank if agent will continue beyond 5 years.)
date
C25164 (NCI Thesaurus ValueDomain)
C1708 (NCI Thesaurus ObjectClass)
C25275 (NCI Thesaurus Property)
C0850893 (UMLS CUI-1)
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