ID

6490

Description

NSABP PROTOCOL B-36 Treatment Form for Adriamycin, Cyclophosphamide (AC) Comparison of Two Combination Chemotherapy Regimens in Treating Women With Breast Cancer NCT00087178 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=C87B5EFD-2DE6-59DF-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=C87B5EFD-2DE6-59DF-E034-0003BA12F5E7

Keywords

Versions (2)
  1. 8/26/12 8/26/12 -
  2. 1/5/15 1/5/15 - Martin Dugas
Uploaded on

January 5, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Treatment Form Breast Cancer Adriamycin, Cyclophosphamide (NCT00087178)

English

No Instruction available.

1 forms  
  1. StudyEvent: NSABP PROTOCOL B-36 Treatment Form for Adriamycin, Cyclophosphamide (AC)
    1. No Instruction available.
Header Section
Description

Header Section

Alias
UMLS CUI-1
C1320722
Patient Initials (Last, First Middle)
Description

Patient Initials

Data type

text

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

Patient ID NSABP

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
UMLS CUI-2
C1513905
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C15818
Institution Name
Description

Institution Name

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C1301943
NCI Thesaurus ObjectClass
C21541
NCI Thesaurus ValueDomain-2
C21541
NCI Thesaurus Property
C25364
Affiliate Name
Description

Affiliate Name

Data type

text

Alias
NCI Thesaurus ObjectClass
C21541
UMLS CUI-1
C1510825
NCI Thesaurus ObjectClass-2
C25413
NCI Thesaurus Property
C25364
NCI Thesaurus ValueDomain
C25191
NCI Thesaurus ValueDomain-2
C21541
Person Completing Form (Last Name)
Description

Person Completing Form Last Name

Data type

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS CUI-1
C1550483
NCI Thesaurus ObjectClass-2
C25657
UMLS CUI-2
C1301584
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C25551
NCI Thesaurus ValueDomain
C25191
Person Completing Form (First Name)
Description

Person Completing Form First Name

Data type

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS CUI-1
C1550483
NCI Thesaurus ObjectClass-2
C25657
UMLS CUI-2
C1443235
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C25509
NCI Thesaurus ValueDomain
C25191
Person Completing Form (Phone)
Description

Person Completing Form Phone

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C1550483
NCI Thesaurus ObjectClass
C25190
UMLS CUI-2
C1515258
NCI Thesaurus ObjectClass-2
C25657
NCI Thesaurus Property
C25395
Are data amended?
Description

Data amended

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS CUI-1
C0680532
NCI Thesaurus ObjectClass
C25474
NCI Thesaurus Property
C25416
Comments
Description

Research Comments

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS CUI-1
C0947611
NCI Thesaurus ObjectClass
C15319
NCI Thesaurus Property
C25393
Summary Of Adriamycin, Cyclophosphamide
Description

Summary Of Adriamycin, Cyclophosphamide

Treatment Begin Date
Description

Treatment Begin Date

Data type

date

Alias
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus Property
C25431
NCI Thesaurus Property-2
C25275
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ValueDomain-2
C25431
UMLS CUI-1
C3173309
Treatment End Date
Description

Treatment End Date

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus Property
C25275
UMLS CUI-1
C1531784
Cycle #
Description

CurrentTherapyCourseNumber

Data type

integer

Alias
NCI Thesaurus ValueDomain
C25337
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus Property
C25379
UMLS CUI-1
C2045829
Date Administered
Description

Concomitant Medication Start Date

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ValueDomain-2
C25431
NCI Thesaurus ObjectClass
C1708
NCI Thesaurus Property
C25275
UMLS CUI-1
C2826734
Agent name
Description

Agent

Data type

text

Alias
NCI Thesaurus Property
C25364
NCI Thesaurus ObjectClass
C1708
NCI Thesaurus ValueDomain
C1708
NCI Thesaurus ValueDomain-2
C42614
UMLS CUI-1
C1521826
Protocol Dose
Description

Dose

Data type

float

Measurement units
  • mg/m^2
Alias
NCI Thesaurus ObjectClass
C15313
NCI Thesaurus Property
C25256
UMLS CUI-1
C0178602
mg/m^2
Was this cycle delayed for toxicity?
Description

Chemotherapy delayed

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38148
NCI Thesaurus Property
C25477
NCI Thesaurus Property-2
C25472
NCI Thesaurus ObjectClass
C15368
UMLS CUI-1
C1299577
Was growth factor support employed?
Description

Growth factor administered

Data type

boolean

Alias
NCI Thesaurus ValueDomain
C38148
NCI Thesaurus ObjectClass
C20424
NCI Thesaurus Property
C25382
UMLS CUI-1
C0018284
UMLS CUI-2
C1521801
Reason Treatment Ended
Description

Select the reason that best explains why AC has ended, or why the patient did not begin AC.

Data type

integer

Alias
NCI Thesaurus ObjectClass
C25601
NCI Thesaurus Property
C25365
UMLS CUI-1
C1518544
UMLS CUI-2
C0566251
Other (specify)
Description

Off Treatment Reason, specify

Data type

text

Alias
UMLS CUI-1
C1518544
UMLS CUI-2
C0566251
UMLS CUI-3
C1521902
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Similar models

No Instruction available.

1 forms
  1. StudyEvent: NSABP PROTOCOL B-36 Treatment Form for Adriamycin, Cyclophosphamide (AC)
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header Section
C1320722 (UMLS CUI-1)
Patient Initials
Item
Patient Initials (Last, First Middle)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Patient ID NSABP
Item
NSABP Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1513905 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C15818 (NCI Thesaurus Property-2)
Institution Name
Item
Institution Name
text
C25191 (NCI Thesaurus ValueDomain)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass)
C21541 (NCI Thesaurus ValueDomain-2)
C25364 (NCI Thesaurus Property)
Affiliate Name
Item
Affiliate Name
text
C21541 (NCI Thesaurus ObjectClass)
C1510825 (UMLS CUI-1)
C25413 (NCI Thesaurus ObjectClass-2)
C25364 (NCI Thesaurus Property)
C25191 (NCI Thesaurus ValueDomain)
C21541 (NCI Thesaurus ValueDomain-2)
Person Completing Form Last Name
Item
Person Completing Form (Last Name)
text
C25190 (NCI Thesaurus ObjectClass)
C1550483 (UMLS CUI-1)
C25657 (NCI Thesaurus ObjectClass-2)
C1301584 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25551 (NCI Thesaurus Property-2)
C25191 (NCI Thesaurus ValueDomain)
Person Completing Form First Name
Item
Person Completing Form (First Name)
text
C25190 (NCI Thesaurus ObjectClass)
C1550483 (UMLS CUI-1)
C25657 (NCI Thesaurus ObjectClass-2)
C1443235 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25509 (NCI Thesaurus Property-2)
C25191 (NCI Thesaurus ValueDomain)
Person Completing Form Phone
Item
Person Completing Form (Phone)
text
C25337 (NCI Thesaurus ValueDomain)
C1550483 (UMLS CUI-1)
C25190 (NCI Thesaurus ObjectClass)
C1515258 (UMLS CUI-2)
C25657 (NCI Thesaurus ObjectClass-2)
C25395 (NCI Thesaurus Property)
Data amended
Item
Are data amended?
boolean
C38148 (NCI Thesaurus ValueDomain)
C0680532 (UMLS CUI-1)
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)
Research Comments
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C0947611 (UMLS CUI-1)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)
Item Group
Summary Of Adriamycin, Cyclophosphamide
Treatment Begin Date
Item
Treatment Begin Date
date
C15368 (NCI Thesaurus ObjectClass)
C25431 (NCI Thesaurus Property)
C25275 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25431 (NCI Thesaurus ValueDomain-2)
C3173309 (UMLS CUI-1)
Treatment End Date
Item
Treatment End Date
date
C25164 (NCI Thesaurus ValueDomain)
C15368 (NCI Thesaurus ObjectClass)
C25275 (NCI Thesaurus Property)
C1531784 (UMLS CUI-1)
Item
Cycle #
integer
C25337 (NCI Thesaurus ValueDomain)
C15368 (NCI Thesaurus ObjectClass)
C25379 (NCI Thesaurus Property)
C2045829 (UMLS CUI-1)
CL.2
Code List
Cycle #
CL Item
1 (1)
CL Item
2 (2)
CL Item
3 (3)
CL Item
4 (4)
Concomitant Medication Start Date
Item
Date Administered
date
C25164 (NCI Thesaurus ValueDomain)
C25431 (NCI Thesaurus ValueDomain-2)
C1708 (NCI Thesaurus ObjectClass)
C25275 (NCI Thesaurus Property)
C2826734 (UMLS CUI-1)
Item
Agent name
text
C25364 (NCI Thesaurus Property)
C1708 (NCI Thesaurus ObjectClass)
C1708 (NCI Thesaurus ValueDomain)
C42614 (NCI Thesaurus ValueDomain-2)
C1521826 (UMLS CUI-1)
CL.3
Code List
Agent name
CL Item
ADRIA (ADRIA)
CL Item
CYCLO (CYCLO)
Dose
Item
Protocol Dose
float
C15313 (NCI Thesaurus ObjectClass)
C25256 (NCI Thesaurus Property)
C0178602 (UMLS CUI-1)
Chemotherapy delayed
Item
Was this cycle delayed for toxicity?
boolean
C38148 (NCI Thesaurus ValueDomain)
C25477 (NCI Thesaurus Property)
C25472 (NCI Thesaurus Property-2)
C15368 (NCI Thesaurus ObjectClass)
C1299577 (UMLS CUI-1)
Growth factor administered
Item
Was growth factor support employed?
boolean
C38148 (NCI Thesaurus ValueDomain)
C20424 (NCI Thesaurus ObjectClass)
C25382 (NCI Thesaurus Property)
C0018284 (UMLS CUI-1)
C1521801 (UMLS CUI-2)
Item
Reason Treatment Ended
integer
C25601 (NCI Thesaurus ObjectClass)
C25365 (NCI Thesaurus Property)
C1518544 (UMLS CUI-1)
C0566251 (UMLS CUI-2)
CL.6
Code List
Reason Treatment Ended
CL Item
Treatment Completed Per Protocol Criteria (1)
CL Item
Adverse Event/side Effects/complications (2)
CL Item
Patient Off-treatment For Other Complicating Disease (3)
CL Item
Patient Withdrawal Or Refusal After Beginning Protocol Therapy (4)
CL Item
Disease Progression, Relapse During Active Treatment (5)
CL Item
Death On Study (6)
CL Item
Alternative Therapy (7)
CL Item
Other (8)
CL Item
Patient Withdrawal Or Refusal Before Beginning Protocol Therapy (9)
Off Treatment Reason, specify
Item
Other (specify)
text
C1518544 (UMLS CUI-1)
C0566251 (UMLS CUI-2)
C1521902 (UMLS CUI-3)
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