ID

6211

Beschrijving

CALGB: 49907 ON-STUDY FORM Comparison of Combination Chemotherapy Regimens in Treating Older Women Who Have Undergone Surgery for Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A50D7D2E-A557-3317-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A50D7D2E-A557-3317-E034-080020C9C0E0

Trefwoorden

Versies (1)
  1. 18-12-14 18-12-14 - Martin Dugas
Geüploaded op

18 december 2014

DOI

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Creative Commons BY-NC 3.0 Legacy
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ON-STUDY FORM (CALGB 49907)

Engels

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1 Formulieren  
  1. StudyEvent: CALGB: 49907 ON-STUDY FORM
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Header
Beschrijving

Header

Alias
UMLS CUI-1
C1320722
CALGB Form
Beschrijving

CALGBForm

Datatype

text

CALGB Study No
Beschrijving

CALGBStudyNo

Datatype

text

CALGB Patient ID (Disease Description)
Beschrijving

CALGBPatientID

Datatype

text

Amended data?
Beschrijving

Amendeddata?

Datatype

text

Patient's Name
Beschrijving

Patient'sName

Datatype

text

Participating Group
Beschrijving

ParticipatingGroup

Datatype

text

Alias
NCI Thesaurus ObjectClass
C17005
UMLS 2011AA ObjectClass
C1257890
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Patient Hospital Number
Beschrijving

PatientHospitalNumber

Datatype

text

Participating Group Protocol No.
Beschrijving

ParticipatingGroupProtocolNo.

Datatype

text

Main Member Institution/Adjunct
Beschrijving

MainMemberInstitution/Adjunct

Datatype

text

Participating Group Patient No.
Beschrijving

ParticipatingGroupPatientNo.

Datatype

text

Surgical Procedures
Beschrijving

Surgical Procedures

First positive biopsy date (M)
Beschrijving

FirstPositiveBiopsyDate

Datatype

date

Most extensive primary surgery (mark one with an X)
Beschrijving

PrimarySurgeryType

Datatype

text

Date of most extensive primary surgery (if required, used date of last re-excision)
Beschrijving

PrimarySurgeryDate

Datatype

date

Sentinel node biopsy?
Beschrijving

Sentinelnodebiopsy?

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Sentinel node biopsy date (M)
Beschrijving

SentinelNodeBiopsyDate

Datatype

date

Sentinel node biopsy results (per protocol)
Beschrijving

SentinelNodeBiopsyResults

Datatype

text

Was axillary dissection performed?
Beschrijving

AxillaryDissectionInd

Datatype

text

Date of axillary dissection (M)
Beschrijving

AxillaryDissectionDate

Datatype

date

Total number of lymph nodes examined (if sentinel node biopsy and axillary node dissection were performed, enter the total number of nodes examined)
Beschrijving

Totalnumberoflymphnodesexamined

Datatype

double

Laboratory
Beschrijving

Laboratory

Granulocytes
Beschrijving

GRANULOCYTES

Datatype

text

Total bilirubin (mg/dl)
Beschrijving

Totalbilirubin

Datatype

double

Alias
NCI Thesaurus ValueDomain
C25209
UMLS 2011AA ValueDomain
C0242485
Creatinine (mg/dl)
Beschrijving

Lab,Renal,Creatinine

Datatype

double

Platelet count
Beschrijving

Plateletcount

Datatype

double

Bilirubin upper limit of institutional laboratory normal (mg/dl)
Beschrijving

Bilirubinupperlimitofinstitutionallaboratorynormal

Datatype

double

Alias
NCI Thesaurus ValueDomain
C25209
UMLS 2011AA ValueDomain
C0242485
Calculated creatinine clearance (mL/min)
Beschrijving

Calculatedcreatinineclearance

Datatype

double

% LVEF
Beschrijving

%LVEF

Datatype

text

% Lower limit of institutional normal LVEF
Beschrijving

%LowerlimitofinstitutionalnormalLVEF

Datatype

double

Pathology
Beschrijving

Pathology

Alias
UMLS CUI-1
C0030664
Tumor laterality (mark one with an X)
Beschrijving

PrimaryTumorLaterality

Datatype

text

Receptor status, ER (If measured in fmols/mg cytosol protein >=10 is positive. If other measures are used apply institutional standards; borderline results should be reported as positive)
Beschrijving

ERStatus

Datatype

text

Receptor status, PgR
Beschrijving

PgRStatus

Datatype

text

Pathologic primary tumor size (cm)
Beschrijving

PathologicPrimaryTumorSize

Datatype

double

Alias
NCI Thesaurus ValueDomain
C25209
UMLS 2011AA ValueDomain
C0242485
Histologic grade (combined histologic grade is used according to SRE/Elston classification)
Beschrijving

HistologicGrade

Datatype

text

Total number of positive lymph nodes (If sentinel node biopsy and axillary node dissection were performed, enter the sum of positive nodes)
Beschrijving

Totalnumberofpositivelymphnodes

Datatype

double

T (TNM classification)
Beschrijving

T(TNMclassification)

Datatype

double

N (TNM classification)
Beschrijving

N(TNMclassification)

Datatype

double

M (TNM classification) (Prior Systemic Therapy)
Beschrijving

M(TNMclassification)

Datatype

double

Prior breast cancer prevention therapy?
Beschrijving

Priorbreastcancerpreventiontherapy?

Datatype

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Yes, what type (prior breast cancer prevention therapy) (mark all that apply with an X)
Beschrijving

IfYes,whattype(priorbreastcancerpreventiontherapy)

Datatype

text

Other, specify (prior breast cancer therapy)
Beschrijving

Other,specify(priorbreastcancertherapy)

Datatype

text

Completed By (Print or Type Name)
Beschrijving

CompletedBy

Datatype

text

Date Completed
Beschrijving

DateCompleted

Datatype

date

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Similar models

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1 Formulieren
  1. StudyEvent: CALGB: 49907 ON-STUDY FORM
    1. Continue on next page
Name
Type
Description | Question | Decode (Coded Value)
Datatype
Alias
Item Group
Header
C1320722 (UMLS CUI-1)
CALGBForm
Item
CALGB Form
text
CALGBStudyNo
Item
CALGB Study No
text
CALGBPatientID
Item
CALGB Patient ID (Disease Description)
text
Item
Amended data?
text
CL.1
Code List
Amended data?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Patient'sName
Item
Patient's Name
text
ParticipatingGroup
Item
Participating Group
text
C17005 (NCI Thesaurus ObjectClass)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
PatientHospitalNumber
Item
Patient Hospital Number
text
ParticipatingGroupProtocolNo.
Item
Participating Group Protocol No.
text
MainMemberInstitution/Adjunct
Item
Main Member Institution/Adjunct
text
ParticipatingGroupPatientNo.
Item
Participating Group Patient No.
text
Item Group
Surgical Procedures
FirstPositiveBiopsyDate
Item
First positive biopsy date (M)
date
Item
Most extensive primary surgery (mark one with an X)
text
CL.2
Code List
Most extensive primary surgery (mark one with an X)
CL Item
Partial Mastectomy/lumpectomy/excisional Biopsy (Partial mastectomy/lumpectomy/excisional biopsy)
CL Item
Mastectomy, Nos (Mastectomy, NOS)
PrimarySurgeryDate
Item
Date of most extensive primary surgery (if required, used date of last re-excision)
date
Item
Sentinel node biopsy?
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.3
Code List
Sentinel node biopsy?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
SentinelNodeBiopsyDate
Item
Sentinel node biopsy date (M)
date
Item
Sentinel node biopsy results (per protocol)
text
CL.4
Code List
Sentinel node biopsy results (per protocol)
CL Item
Negative (Negative)
C25247 (NCI Thesaurus)
C0205160 (UMLS 2011AA)
CL Item
Positive (Positive)
C25246 (NCI Thesaurus)
C1446409 (UMLS 2011AA)
Item
Was axillary dissection performed?
text
CL.5
Code List
Was axillary dissection performed?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
AxillaryDissectionDate
Item
Date of axillary dissection (M)
date
Totalnumberoflymphnodesexamined
Item
Total number of lymph nodes examined (if sentinel node biopsy and axillary node dissection were performed, enter the total number of nodes examined)
double
Item Group
Laboratory
GRANULOCYTES
Item
Granulocytes
text
Totalbilirubin
Item
Total bilirubin (mg/dl)
double
C25209 (NCI Thesaurus ValueDomain)
C0242485 (UMLS 2011AA ValueDomain)
Lab,Renal,Creatinine
Item
Creatinine (mg/dl)
double
Plateletcount
Item
Platelet count
double
Bilirubinupperlimitofinstitutionallaboratorynormal
Item
Bilirubin upper limit of institutional laboratory normal (mg/dl)
double
C25209 (NCI Thesaurus ValueDomain)
C0242485 (UMLS 2011AA ValueDomain)
Calculatedcreatinineclearance
Item
Calculated creatinine clearance (mL/min)
double
%LVEF
Item
% LVEF
text
%LowerlimitofinstitutionalnormalLVEF
Item
% Lower limit of institutional normal LVEF
double
Item Group
Pathology
C0030664 (UMLS CUI-1)
Item
Tumor laterality (mark one with an X)
text
CL.6
Code List
Tumor laterality (mark one with an X)
CL Item
Left (Left)
C25229 (NCI Thesaurus)
C0205091 (UMLS 2011AA)
CL Item
Right (Right)
C25228 (NCI Thesaurus)
C0205090 (UMLS 2011AA)
CL Item
Bilateral (Bilateral)
Item
Receptor status, ER (If measured in fmols/mg cytosol protein >=10 is positive. If other measures are used apply institutional standards; borderline results should be reported as positive)
text
CL.7
Code List
Receptor status, ER (If measured in fmols/mg cytosol protein >=10 is positive. If other measures are used apply institutional standards; borderline results should be reported as positive)
CL Item
Negative (Negative)
C25247 (NCI Thesaurus)
C0205160 (UMLS 2011AA)
CL Item
Positive (Positive)
C25246 (NCI Thesaurus)
C1446409 (UMLS 2011AA)
Item
Receptor status, PgR
text
CL.8
Code List
Receptor status, PgR
CL Item
Negative (Negative)
C25247 (NCI Thesaurus)
C0205160 (UMLS 2011AA)
CL Item
Positive (Positive)
C25246 (NCI Thesaurus)
C1446409 (UMLS 2011AA)
PathologicPrimaryTumorSize
Item
Pathologic primary tumor size (cm)
double
C25209 (NCI Thesaurus ValueDomain)
C0242485 (UMLS 2011AA ValueDomain)
Item
Histologic grade (combined histologic grade is used according to SRE/Elston classification)
text
CL.9
Code List
Histologic grade (combined histologic grade is used according to SRE/Elston classification)
CL Item
Well Differentiated (Low)
C14171 (NCI Thesaurus)
C0205615 (UMLS 2011AA)
CL Item
Moderately Differentiated (Intermediate)
C14162 (NCI Thesaurus)
C0205616 (UMLS 2011AA)
CL Item
Poorly Differentiated (High)
C14167 (NCI Thesaurus)
C0205617 (UMLS 2011AA)
Totalnumberofpositivelymphnodes
Item
Total number of positive lymph nodes (If sentinel node biopsy and axillary node dissection were performed, enter the sum of positive nodes)
double
T(TNMclassification)
Item
T (TNM classification)
double
N(TNMclassification)
Item
N (TNM classification)
double
M(TNMclassification)
Item
M (TNM classification) (Prior Systemic Therapy)
double
Item
Prior breast cancer prevention therapy?
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.10
Code List
Prior breast cancer prevention therapy?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
If Yes, what type (prior breast cancer prevention therapy) (mark all that apply with an X)
text
CL.11
Code List
If Yes, what type (prior breast cancer prevention therapy) (mark all that apply with an X)
CL Item
Tamoxifen (Tamoxifen)
C855 (NCI Thesaurus)
C0039286 (UMLS 2011AA)
CL Item
Raloxifene (Raloxifene)
C1518 (NCI Thesaurus)
C0244404 (UMLS 2011AA)
CL Item
Other, Specify (Other, specify)
Other,specify(priorbreastcancertherapy)
Item
Other, specify (prior breast cancer therapy)
text
CompletedBy
Item
Completed By (Print or Type Name)
text
DateCompleted
Item
Date Completed
date
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