ID

6380

Descrição

NSABP PROTOCOL B-35 ON-STUDY FORM Anastrozole or Tamoxifen in Treating Postmenopausal Women With Ductal Carcinoma in Situ Who Are Undergoing Lumpectomy and Radiation Therapy Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A051F12F-A237-0456-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A051F12F-A237-0456-E034-080020C9C0E0

Palavras-chave

Versões (3)
  1. 18/12/2014 18/12/2014 - Martin Dugas
  2. 02/06/2015 02/06/2015 -
  3. 03/06/2015 03/06/2015 -
Transferido a

18 de dezembro de 2014

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Licença

Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00053898 On-Study - NSABP PROTOCOL B-35 ON-STUDY FORM - 2034013v3.0

Inglês

Form ON (04-30-2002) Submit within 30 days of registration. Attach All applicable Operative Reports and Pathology Reports.

1 Formulários  
Unnamed1
Descrição

Unnamed1

First Three Letters of Patient's Last Name
Descrição

FirstThreeLettersofPatient'sLastName

Tipo de dados

text

Patient Study ID
Descrição

PatientStudyID

Tipo de dados

text

Institution Name
Descrição

InstitutionName

Tipo de dados

text

Affiliate Name
Descrição

AffiliateName

Tipo de dados

text

Person Completing Form Last Name
Descrição

PersonCompletingForm,LastName

Tipo de dados

text

Person Completing Form First Name
Descrição

PersonCompletingForm,FirstName

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Person Completing Form Phone
Descrição

PersonCompletingForm,Phone

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
Are data amended? (If Yes, circle the amended items in red.)
Descrição

AmendedDataInd

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Unnamed2
Descrição

Unnamed2

Unnamed3
Descrição

Unnamed3

Fine Needle Aspiration Cytology (Circle Y or N for Yes, No)
Descrição

FineNeedleAspirationCytology

Tipo de dados

text

Core (or Tru Cut) Needle Biopsy (Circle Y or N for Yes, No)
Descrição

Core(orTruCut)NeedleBiopsy

Tipo de dados

text

Incisional Biopsy (Circle Y or N for Yes, No)
Descrição

IncisionalBiopsy

Tipo de dados

text

Excisional Biopsy or Lumpectomy (Circle Y or N for Yes, No)
Descrição

SurgicalProcedureLumpectomyExcisionalBiopsyPerformed

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C15329
UMLS 2011AA ObjectClass
C0543467
NCI Thesaurus Property
C15755
UMLS 2011AA Property
C0024885
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
NCI Thesaurus Property
C15385
UMLS 2011AA Property
C0184921
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Resection of Lumpectomy Margins (Circle Y or N for Yes, No)
Descrição

SurgicalProcedureLumpectomySurgicalMarginExcisionPerformedInd-2

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C15329
UMLS 2011AA ObjectClass
C0543467
NCI Thesaurus Property
C15755
UMLS 2011AA Property
C0024885
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
NCI Thesaurus Property
C15232
UMLS 2011AA Property
C0728940
NCI Thesaurus Property
C41227
UMLS 2011AA Property
C0229985
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Sentinel Node Biopsy (Circle Y or N for Yes, No)
Descrição

SentinelNodeBiopsyInd

Tipo de dados

text

Axillary Dissection (Circle Y or N for Yes, No)
Descrição

AxillaryDissectionInd

Tipo de dados

text

DATE OF PROCEDURE (Month, Day, Year)
Descrição

SurgicalProcedurePerformedDate

Tipo de dados

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
NCI Thesaurus ObjectClass
C15329
UMLS 2011AA ObjectClass
C0543467
ACCESSION NUMBER (Pathology Specimen Number)
Descrição

AccessionNumber

Tipo de dados

double

Unnamed4
Descrição

Unnamed4

Unnamed5
Descrição

Unnamed5

First Three Letters of Patient's Last Name
Descrição

FirstThreeLettersofPatient'sLastName

Tipo de dados

text

Patient Study ID
Descrição

PatientStudyID

Tipo de dados

text

Disease Description
Descrição

Disease Description

Tumor Laterality
Descrição

PrimaryTumorLaterality

Tipo de dados

text

Was the tumor or microcalcification evident on mammogram?
Descrição

Wasthetumorormicrocalcificationevidentonmammogram?

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Was the tumor evident by ultrasound?
Descrição

Wasthetumorevidentbyultrasound?

Tipo de dados

text

Was the tumor palpable?
Descrição

PalpableTumorPresentIndicator

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
NCI Thesaurus ObjectClass
C3262
UMLS 2011AA ObjectClass
C0027651
NCI Thesaurus Property
C25626
UMLS 2011AA Property
C0150312
NCI Thesaurus ObjectClass
C25606
UMLS 2011AA ObjectClass
C0522499
Were there any breast symptoms? (e.g., pain, nipple discharge or retraction, skin dimpling)
Descrição

Werethereanybreastsymptoms?

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Receptor Status (by Ihc)
Descrição

Receptor Status (by Ihc)

ER Status
Descrição

ERStatus

Tipo de dados

text

PgR
Descrição

PgRStatus

Tipo de dados

text

If unknown, please explain:
Descrição

Ifunknown,pleaseexplain:

Tipo de dados

text

Quality Of Life
Descrição

Quality Of Life

Did the patient complete the Quality of Life baseline form?
Descrição

DidthepatientcompletetheQualityofLifebaselineform?

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If the baseline QOL form was not completed, indicate the reason below. (Protocol Approved Reasons)
Descrição

BaselineQOLIncompleteFormReason

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass
C25213
UMLS 2011AA ObjectClass
C1442488
NCI Thesaurus Property
C19464
UMLS 2011AA Property
C0376315
NCI Thesaurus Property
C49160
UMLS 2011AA Property
C0205257
NCI Thesaurus ValueDomain
C25638
UMLS 2011AA ValueDomain
C0392360
Other Reason (if applicable)
Descrição

OtherReason(ifapplicable)

Tipo de dados

text

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Similar models

Form ON (04-30-2002) Submit within 30 days of registration. Attach All applicable Operative Reports and Pathology Reports.

1 Formulários
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
Alias
Item Group
Unnamed1
FirstThreeLettersofPatient'sLastName
Item
First Three Letters of Patient's Last Name
text
PatientStudyID
Item
Patient Study ID
text
InstitutionName
Item
Institution Name
text
AffiliateName
Item
Affiliate Name
text
PersonCompletingForm,LastName
Item
Person Completing Form Last Name
text
PersonCompletingForm,FirstName
Item
Person Completing Form First Name
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
PersonCompletingForm,Phone
Item
Person Completing Form Phone
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
Item
Are data amended? (If Yes, circle the amended items in red.)
text
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
CL.1
Code List
Are data amended? (If Yes, circle the amended items in red.)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Item Group
Unnamed2
Item Group
Unnamed3
Item
Fine Needle Aspiration Cytology (Circle Y or N for Yes, No)
text
CL.2
Code List
Fine Needle Aspiration Cytology (Circle Y or N for Yes, No)
CL Item
Y (Y)
CL Item
N (N)
C14562 (NCI Thesaurus)
Item
Core (or Tru Cut) Needle Biopsy (Circle Y or N for Yes, No)
text
CL.3
Code List
Core (or Tru Cut) Needle Biopsy (Circle Y or N for Yes, No)
CL Item
Y (Y)
CL Item
N (N)
C14562 (NCI Thesaurus)
Item
Incisional Biopsy (Circle Y or N for Yes, No)
text
CL.4
Code List
Incisional Biopsy (Circle Y or N for Yes, No)
CL Item
Y (Y)
CL Item
N (N)
C14562 (NCI Thesaurus)
Item
Excisional Biopsy or Lumpectomy (Circle Y or N for Yes, No)
text
C15329 (NCI Thesaurus ObjectClass)
C0543467 (UMLS 2011AA ObjectClass)
C15755 (NCI Thesaurus Property)
C0024885 (UMLS 2011AA Property)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C15385 (NCI Thesaurus Property)
C0184921 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
CL.5
Code List
Excisional Biopsy or Lumpectomy (Circle Y or N for Yes, No)
CL Item
Y (Y)
CL Item
N (N)
Item
Resection of Lumpectomy Margins (Circle Y or N for Yes, No)
text
C15329 (NCI Thesaurus ObjectClass)
C0543467 (UMLS 2011AA ObjectClass)
C15755 (NCI Thesaurus Property)
C0024885 (UMLS 2011AA Property)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C15232 (NCI Thesaurus Property)
C0728940 (UMLS 2011AA Property)
C41227 (NCI Thesaurus Property)
C0229985 (UMLS 2011AA Property)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
CL.6
Code List
Resection of Lumpectomy Margins (Circle Y or N for Yes, No)
CL Item
Y (Y)
CL Item
N (N)
Item
Sentinel Node Biopsy (Circle Y or N for Yes, No)
text
CL.7
Code List
Sentinel Node Biopsy (Circle Y or N for Yes, No)
CL Item
Yes (Y)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (N)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Item
Axillary Dissection (Circle Y or N for Yes, No)
text
CL.8
Code List
Axillary Dissection (Circle Y or N for Yes, No)
CL Item
Yes (Y)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (N)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
SurgicalProcedurePerformedDate
Item
DATE OF PROCEDURE (Month, Day, Year)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C15329 (NCI Thesaurus ObjectClass)
C0543467 (UMLS 2011AA ObjectClass)
AccessionNumber
Item
ACCESSION NUMBER (Pathology Specimen Number)
double
Item Group
Unnamed4
Item Group
Unnamed5
FirstThreeLettersofPatient'sLastName
Item
First Three Letters of Patient's Last Name
text
PatientStudyID
Item
Patient Study ID
text
Item Group
Disease Description
Item
Tumor Laterality
text
CL.9
Code List
Tumor Laterality
CL Item
Left Breast (Left Breast)
CL Item
Right Breast (Right Breast)
Item
Was the tumor or microcalcification evident on mammogram?
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.10
Code List
Was the tumor or microcalcification evident on mammogram?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Item
Was the tumor evident by ultrasound?
text
CL.11
Code List
Was the tumor evident by ultrasound?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Not Done (Not done)
CL281691 (NCI Metathesaurus)
Item
Was the tumor palpable?
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C25606 (NCI Thesaurus ObjectClass)
C0522499 (UMLS 2011AA ObjectClass)
CL.12
Code List
Was the tumor palpable?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Item
Were there any breast symptoms? (e.g., pain, nipple discharge or retraction, skin dimpling)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.13
Code List
Were there any breast symptoms? (e.g., pain, nipple discharge or retraction, skin dimpling)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Item Group
Receptor Status (by Ihc)
Item
ER Status
text
CL.14
Code List
ER Status
CL Item
Negative (Negative by IHC)
C25247 (NCI Thesaurus)
C0205160 (UMLS 2011AA)
CL Item
Positive (Positive by IHC)
C25246 (NCI Thesaurus)
C1446409 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
PgR
text
CL.15
Code List
PgR
CL Item
Negative (Negative by IHC)
C25247 (NCI Thesaurus)
C0205160 (UMLS 2011AA)
CL Item
Positive (Positive by IHC)
C25246 (NCI Thesaurus)
C1446409 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Ifunknown,pleaseexplain:
Item
If unknown, please explain:
text
Item Group
Quality Of Life
Item
Did the patient complete the Quality of Life baseline form?
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.16
Code List
Did the patient complete the Quality of Life baseline form?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Item
If the baseline QOL form was not completed, indicate the reason below. (Protocol Approved Reasons)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25213 (NCI Thesaurus ObjectClass)
C1442488 (UMLS 2011AA ObjectClass)
C19464 (NCI Thesaurus Property)
C0376315 (UMLS 2011AA Property)
C49160 (NCI Thesaurus Property)
C0205257 (UMLS 2011AA Property)
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
CL.17
Code List
If the baseline QOL form was not completed, indicate the reason below. (Protocol Approved Reasons)
CL Item
Patient Does Not Speak English, French, Or Spanish (Patient does not speak English, French, or Spanish)
CL Item
Patient Refused (Patient refused)
CL Item
Other Reason (Other reason)
OtherReason(ifapplicable)
Item
Other Reason (if applicable)
text
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