ID

6490

Beschrijving

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

Trefwoorden

Versies (2)
  1. 26-08-12 26-08-12 -
  2. 05-01-15 05-01-15 - Martin Dugas
Geüploaded op

5 januari 2015

DOI

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Licentie

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

Engels

No Instruction available.

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

Header Section

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

Patient Initials

Datatype

text

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

Patient ID NSABP

Datatype

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
Beschrijving

Institution Name

Datatype

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
Beschrijving

Affiliate Name

Datatype

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)
Beschrijving

Person Completing Form Last Name

Datatype

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)
Beschrijving

Person Completing Form First Name

Datatype

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)
Beschrijving

Person Completing Form Phone

Datatype

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?
Beschrijving

Data amended

Datatype

boolean

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

Research Comments

Datatype

text

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

Summary Of Adriamycin, Cyclophosphamide

Treatment Begin Date
Beschrijving

Treatment Begin Date

Datatype

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
Beschrijving

Treatment End Date

Datatype

date

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

CurrentTherapyCourseNumber

Datatype

integer

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

Concomitant Medication Start Date

Datatype

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
Beschrijving

Agent

Datatype

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
Beschrijving

Dose

Datatype

float

Maateenheden
  • 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?
Beschrijving

Chemotherapy delayed

Datatype

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?
Beschrijving

Growth factor administered

Datatype

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
Beschrijving

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

Datatype

integer

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

Off Treatment Reason, specify

Datatype

text

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

No Instruction available.

1 Formulieren
  1. StudyEvent: NSABP PROTOCOL B-36 Treatment Form for Adriamycin, Cyclophosphamide (AC)
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Datatype
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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