ID

6516

Beskrivning

CALGB: 90401 TREATMENT FORM Docetaxel and Prednisone With or Without Bevacizumab in Treating Patients With Prostate Cancer That Did Not Respond to Hormone Therapy NCT00110214 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=EF49A3AB-7EC3-51E0-E034-0003BA3F9857

Länk

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=EF49A3AB-7EC3-51E0-E034-0003BA3F9857

Nyckelord

Treatment Form

C61

2012-09-19 2012-09-19 -
2015-01-08 2015-01-08 - Martin Dugas
2015-01-09 2015-01-09 - Martin Dugas

Uppladdad den

8 januari 2015

DOI

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Licens

Creative Commons BY-NC 3.0 Legacy

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TREATMENT FORM Prostate Cancer (NCT00110214)

model
Detaljer

INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink

1 Formulär

StudyEvent: CALGB: 90401 TREATMENT FORM
1. INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink

Name

Typ

Description | Question | Decode (Coded Value)

Datatyp

Alias

Header

Item Group

Header

Form ID CALGB

Item

CALGB Form

text

C25337 (NCI Thesaurus ValueDomain)
C3262252 (UMLS CUI-1)
C19464 (NCI Thesaurus ObjectClass)
C1516238 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25442 (NCI Thesaurus ObjectClass-2)

Protocol ID CALGB

Item

CALGB Study No.

text

C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C1516238 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25442 (NCI Thesaurus Property-2)

Trial subject ID CALGB

Item

CALGB Patient ID

text

C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1516238 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25442 (NCI Thesaurus Property-2)

Patient Initials

Item

Patient Initials

text

C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)

Medical Record Number

Item

Patient Hospital No.

text

C25337 (NCI Thesaurus ValueDomain)
C1301894 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25261 (NCI Thesaurus Property)
C25198 (NCI Thesaurus Property-2)

Institution Name

Item

Institution/Affiliate

text

C25454 (NCI Thesaurus ObjectClass)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass-2)
C25364 (NCI Thesaurus Property)
C25191 (NCI Thesaurus ValueDomain)
C21541 (NCI Thesaurus ValueDomain-2)

Participating Group

Item

Participating Group

text

C25191 (NCI Thesaurus ValueDomain)
C2347449 (UMLS CUI-1)
C25608 (NCI Thesaurus ObjectClass)
C17005 (NCI Thesaurus ObjectClass-2)
C25364 (NCI Thesaurus Property)

Study Number Participating Group

Item

Participating Group Study No.

text

C25337 (NCI Thesaurus ValueDomain)
C3274381 (UMLS CUI-1)
C25320 (NCI Thesaurus ObjectClass)
C2347449 (UMLS CUI-2)
C25608 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)

Trial subject ID Participating Group

Item

Participating Group Patient ID

text

C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C2347449 (UMLS CUI-2)
C25608 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)

Data amended

Item

Are data amended

boolean

C38148 (NCI Thesaurus ValueDomain)
C0680532 (UMLS CUI-1)
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)

PatientWithdrawnConsentClinicalInd-2

Item

Patient has withdrawn consent for clinical follow-up.

boolean

C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25460 (NCI Thesaurus Property)
C1511481 (UMLS 2011AA Property)
C38061 (NCI Thesaurus Property-2)
C2349954 (UMLS 2011AA Property-2)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C25398 (NCI Thesaurus ValueDomain-2)
C0205210 (UMLS 2011AA ValueDomain-2)

PatientWithdrawnConsentSurvivalInd-2

Item

Patient has withdrawn consent for survival follow-up.

boolean

C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25460 (NCI Thesaurus Property)
C1511481 (UMLS 2011AA Property)
C38061 (NCI Thesaurus Property-2)
C2349954 (UMLS 2011AA Property-2)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C17177 (NCI Thesaurus ValueDomain-2)
C0038952 (UMLS 2011AA ValueDomain-2)

PatientWithdrawConsentDate

Item

Withdrawn consent date

date

C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25460 (NCI Thesaurus Property)
C1511481 (UMLS 2011AA Property)
C38061 (NCI Thesaurus Property-2)
C2349954 (UMLS 2011AA Property-2)

Person Completing Form

Item

Completed by

text

C25191 (NCI Thesaurus ValueDomain)
C1550483 (UMLS CUI-1)
C25657 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)

Date Form Completed

Item

Date form completed

date

C25164 (NCI Thesaurus ValueDomain)
C1115437 (UMLS CUI-1)
C40988 (NCI Thesaurus ObjectClass)
C25250 (NCI Thesaurus Property)
C25367 (NCI Thesaurus ValueDomain-2)

Clinical Data

Item Group

Clinical Data

C1516606 (UMLS CUI-1)

Cycle Number Chemotherapeutics

Item

Currrent cycle number

text

C25337 (NCI Thesaurus ValueDomain)
C2045829 (UMLS CUI-1)
C25471 (NCI Thesaurus Property)
C15368 (NCI Thesaurus ObjectClass)
C25379 (NCI Thesaurus Property-2)

Chemotherapy Cycle Start Date

Item

Cycle start date

date

C25164 (NCI Thesaurus ValueDomain)
C1302181 (UMLS CUI-1)
C15368 (NCI Thesaurus ObjectClass)
C25431 (NCI Thesaurus ValueDomain-2)
C3173309 (UMLS CUI-2)
C25379 (NCI Thesaurus Property)

Chemotherapy Cycle End Date

Item

Cycle end date

date

C25164 (NCI Thesaurus ValueDomain)
C1302181 (UMLS CUI-1)
C15368 (NCI Thesaurus ObjectClass)
C25379 (NCI Thesaurus Property)
C0806020 (UMLS CUI-2)

Patient Height

Item

Height

float

C25209 (NCI Thesaurus ValueDomain)
C0489786 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25347 (NCI Thesaurus Property)

Patient Weight

Item

Weight

float

C25209 (NCI Thesaurus ValueDomain)
C0005910 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25208 (NCI Thesaurus Property)

Body Surface Area

Item

BSA

float

C25209 (NCI Thesaurus ValueDomain)
C0005902 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25157 (NCI Thesaurus Property)

Agent

Item

Agent name

text

C25364 (NCI Thesaurus Property)
C1521826 (UMLS CUI-1)
C1708 (NCI Thesaurus ObjectClass)
C1708 (NCI Thesaurus ValueDomain)
C42614 (NCI Thesaurus ValueDomain-2)

AgentAdministeredDose

Item

Dose

float

C25488 (NCI Thesaurus ValueDomain)
C0178602 (UMLS 2011AA ValueDomain)
C1708 (NCI Thesaurus ObjectClass)
C0450442 (UMLS 2011AA ObjectClass)
C1708 (NCI Thesaurus ValueDomain-2)
C0450442 (UMLS 2011AA ValueDomain-2)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)

AgentAdministeredDayDuration

Item

No. of days administered

float

C25301 (NCI Thesaurus ValueDomain)
C0439228 (UMLS 2011AA ValueDomain)
C1708 (NCI Thesaurus ObjectClass)
C0450442 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C25330 (NCI Thesaurus ValueDomain-2)
C0449238 (UMLS 2011AA ValueDomain-2)

AgentPlaceboAdministeredInd-2

Item

Administered?

boolean

C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C753 (NCI Thesaurus Property)
C0032042 (UMLS 2011AA Property)
C1708 (NCI Thesaurus ObjectClass)
C0450442 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property-2)
C1521801 (UMLS 2011AA Property-2)

Dose Modification Status

Item

Dose modification (^1)

text

C25488 (NCI Thesaurus ObjectClass)
C1707811 (UMLS CUI-1)
C25688 (NCI Thesaurus ValueDomain)
C25572 (NCI Thesaurus Property)

CL.3

Code List

Dose modification (^1)

CL Item

No Dose Modification (No dose modification)

CL Item

Dose Held (Dose held)

CL Item

Dose Delayed (Dose delayed)

CL Item

Dose Reduced (Dose reduced)

C49505 (NCI Thesaurus)
C1707814 (UMLS 2011AA)
C49505 (NCI Thesaurus-3)
C1707814 (UMLS 2011AA-4)

CL Item

Dose Delayed And Reduced (Dose delayed and reduced)

CL Item

Drug Discontinued (Drug discontinued)

Dose Modification Reason

Item

Dose modification reason (^2)

text

C25638 (NCI Thesaurus ValueDomain)
C1707811 (UMLS CUI-1)
C25488 (NCI Thesaurus ObjectClass)
C0392360 (UMLS CUI-2)
C25572 (NCI Thesaurus Property)

CL.4

Code List

Dose modification reason (^2)

CL Item

Hypersensitivity (Hypersensitivity)

C3114 (NCI Thesaurus)
C0020517 (UMLS 2011AA)

CL Item

Patient Refusal/noncompliance (Patient refusal/noncompliance)

CL Item

Scheduling (Scheduling)

CL Item

Dosing Error (Dosing error)

CL Item

Change In Bsa (Change in BSA)

CL Item

Hematologic Toxicity (Hematologic toxicity)

CL Item

Hepatic Dysfunction (Hepatic dysfunction)

CL Item

Pns Toxicity (PNS toxicity)

CL Item

Cns Toxicity (CNS toxicity)

CL Item

Gi Toxicity (GI toxicity)

CL Item

Cardiotoxicity (Cardiotoxicity)

C27994 (NCI Thesaurus)
C0876994 (UMLS 2011AA)

CL Item

Pulmonary Toxicity (Pulmonary toxicity)

CL Item

Renal Toxicity (Renal toxicity)

CL Item

Infection/fever (Infection/fever)

CL Item

Other (Other)

C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)

Dose Modification Reason, other

Item

If dose modification = 99, specify

text

C25685 (NCI Thesaurus ValueDomain)
C1707811 (UMLS CUI-1)
C25488 (NCI Thesaurus ObjectClass)
C3840932 (UMLS CUI-2)
C25572 (NCI Thesaurus Property)

ConcomitantMedicationReceivedType

Item

Concomitant medications received this cycle (Mark all that apply with an X.)

text

C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C459 (NCI Thesaurus ObjectClass)
C0013227 (UMLS 2011AA ObjectClass)
C25639 (NCI Thesaurus Property)
C1514756 (UMLS 2011AA Property)
C25730 (NCI Thesaurus ObjectClass-2)
C0521115 (UMLS 2011AA ObjectClass-2)

CL.5

Code List

Concomitant medications received this cycle (Mark all that apply with an X.)

CL Item

Growth Factor (Growth factor)

C20424 (NCI Thesaurus)
C0018284 (UMLS 2011AA)

CL Item

Anti-platelet Agents (Anti-platelet agents)

CL Item

Aspirin (Aspirin)

CL Item

Anti-coagulant Agents (Anti-coagulant agents)

CL Item

Lipid-lowering Drugs (Lipid-lowering drugs)

GrowthFactorAgentCurrentReportPeriodAdministeredType

Item

Growth factor (Use per NCCN / ASCO guidelines described in 90401 memorandum dated 8/15/07. Mark all that apply with an X.)

text

C20424 (NCI Thesaurus ObjectClass)
C0018284 (UMLS 2011AA ObjectClass)
C1708 (NCI Thesaurus ObjectClass-2)
C0450442 (UMLS 2011AA ObjectClass-2)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C25471 (NCI Thesaurus Property-2)
C0521116 (UMLS 2011AA Property-2)
C25375 (NCI Thesaurus Property-3)
C0684224 (UMLS 2011AA Property-3)
C25382 (NCI Thesaurus Property-4)
C1521801 (UMLS 2011AA Property-4)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)

CL.6

Code List

Growth factor (Use per NCCN / ASCO guidelines described in 90401 memorandum dated 8/15/07. Mark all that apply with an X.)

CL Item

Epoetin Alfa (Epoetin)

C2695 (NCI Thesaurus)
C0357126 (UMLS 2011AA)

CL Item

Granulocyte-macrophage Colony-stimulating Factor (G-CSF)

CL Item

Oprelvekin (Neumega)

C1303 (NCI Thesaurus)
C0537668 (UMLS 2011AA)

CL Item

Other (Other)

C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)

GrowthFactorAgentCurrentReportPeriodAdministeredSpecify

Item

Other, specify

text

C20424 (NCI Thesaurus ObjectClass)
C0018284 (UMLS 2011AA ObjectClass)
C1708 (NCI Thesaurus ObjectClass-2)
C0450442 (UMLS 2011AA ObjectClass-2)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C25471 (NCI Thesaurus Property-2)
C0521116 (UMLS 2011AA Property-2)
C25375 (NCI Thesaurus Property-3)
C0684224 (UMLS 2011AA Property-3)
C25382 (NCI Thesaurus Property-4)
C1521801 (UMLS 2011AA Property-4)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)

AcetylsalicylicAcidAdministeredDailyAmount

Item

Aspirin (Mark one with an X.)

text

C25473 (NCI Thesaurus ValueDomain)
C0332173 (UMLS 2011AA ValueDomain)
C287 (NCI Thesaurus ObjectClass)
C0004057 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C25417 (NCI Thesaurus ValueDomain-2)

CL.7

Code List

Aspirin (Mark one with an X.)

CL Item

81 Mg/daily (81 mg/daily)

CL Item

325 Mg/daily (325 mg/daily)

ReducedPlateletAgentAdministeredCode

Item

Agent code (*)

text

C25640 (NCI Thesaurus ObjectClass)
C0392756 (UMLS 2011AA ObjectClass)
C1708 (NCI Thesaurus ObjectClass-2)
C0450442 (UMLS 2011AA ObjectClass-2)
C12520 (NCI Thesaurus ObjectClass-3)
C0005821 (UMLS 2011AA ObjectClass-3)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)

CL.8

Code List

Agent code (*)

CL Item

Clopidogrel (clopidogrel)

CL Item

Ticlopidine (ticlopidine)

CL Item

Dipyridamole (dipyridamole)

C445 (NCI Thesaurus)
C0012582 (UMLS 2011AA)

CL Item

Other (Other)

C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)

ReducedPlateletAgentSpecify

Item

Other, specify generic name

text

C25640 (NCI Thesaurus ObjectClass)
C0392756 (UMLS 2011AA ObjectClass)
C1708 (NCI Thesaurus ObjectClass-2)
C0450442 (UMLS 2011AA ObjectClass-2)
C12520 (NCI Thesaurus ObjectClass-3)
C0005821 (UMLS 2011AA ObjectClass-3)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)

DailyDoseAdministeredCount

Item

Frequency (no. of daily doses)

float

C25473 (NCI Thesaurus ObjectClass)
C0332173 (UMLS 2011AA ObjectClass)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
C25488 (NCI Thesaurus ObjectClass-2)
C0178602 (UMLS 2011AA ObjectClass-2)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)

Concomitant Medication Start Date

Item

Agent start date

date

C25164 (NCI Thesaurus ValueDomain)
C2826734 (UMLS CUI-1)
C25431 (NCI Thesaurus ValueDomain-2)
C1708 (NCI Thesaurus ObjectClass)
C25275 (NCI Thesaurus Property)

Concomitant Medication End Date

Item

Agent end date

date

C25164 (NCI Thesaurus ValueDomain)
C2826744 (UMLS CUI-1)
C1708 (NCI Thesaurus ObjectClass)
C25275 (NCI Thesaurus Property)

AnticoagulantAgentAdministeredName

Item

Agent code (**)

text

C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C263 (NCI Thesaurus ObjectClass)
C0003280 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)

CL.9

Code List

Agent code (**)

CL Item

Low Molecular Weight Heparin (Low molecular weight heparin)

CL Item

Warfarin (Warfarin)

CL Item

Other (Other)

C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)

AnticoagulantAgentAdministeredSpecify

Item

Other, specify generic name

text

C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C263 (NCI Thesaurus ObjectClass)
C0003280 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)

ReducedLipidAgentAdministeredCode

Item

Agent code (***)

text

C25640 (NCI Thesaurus ObjectClass)
C0392756 (UMLS 2011AA ObjectClass)
C1708 (NCI Thesaurus ObjectClass-2)
C0450442 (UMLS 2011AA ObjectClass-2)
C616 (NCI Thesaurus ObjectClass-3)
C0023779 (UMLS 2011AA ObjectClass-3)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C0027365 (NCI Metathesaurus ValueDomain)

CL.10

Code List

Agent code (***)

CL Item

Atorvastatin (atorvastatin)

C28837 (NCI Thesaurus)
C0082029 (UMLS 2011AA)

CL Item

Fluvastatin (fluvastatin)

CL Item

Lovastatin (lovastatin)

C620 (NCI Thesaurus)
C0024027 (UMLS 2011AA)

CL Item

Pravastatin (pravastatin)

CL Item

Rosuvastatin (rosuvastatin)

CL Item

Simvastatin (simvastatin)

CL Item

Fenofibrate (fenofibrate)

C29047 (NCI Thesaurus)
C0033228 (UMLS 2011AA)

CL Item

Gemfibrozil (gemfibrozil)

C29071 (NCI Thesaurus)
C0017245 (UMLS 2011AA)

CL Item

Cholestyramine (cholestyramine)

C28929 (NCI Thesaurus)
C0008402 (UMLS 2011AA)

CL Item

Other (Other)

C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)

ReducedLipidAgentSpecify

Item

Other, specify generic name

text

Drug treatment discontinued during chemotherapy cycle

Item

Was treatment permanently discontinued during this cycle (bevacizumab/placebo)

boolean

C15368 (NCI Thesaurus ObjectClass)
C25471 (NCI Thesaurus Property)
C0558681 (UMLS CUI-1)
C25472 (NCI Thesaurus Property-2)
C0347984 (UMLS CUI-2)
C25484 (NCI Thesaurus Property-3)
C1302181 (UMLS CUI-3)
C38147 (NCI Thesaurus ValueDomain)

Off Treatment Reason

Item

Reason treatment ended (*)

text

C25638 (NCI Thesaurus ValueDomain)
C1518544 (UMLS CUI-1)
C25601 (NCI Thesaurus ObjectClass)
C0566251 (UMLS CUI-2)
C25365 (NCI Thesaurus Property)

CL.14

Code List

Reason treatment ended (*)

CL Item

Treatment Completed Per Protocol Criteria (Treatment completed per protocol criteria)

CL Item

Disease Progression, Relapse During Active Treatment (Disease progression, relapse during active treatment)

CL Item

Adverse Event/side Effects/complications (Adverse event/side effects/complications)

CL Item

Death On Study (Death on study)

CL Item

Patient Withdrawal Or Refusal (Patient withdrawal or refusal prior to beginning protocol therapy)

CL Item

Patient Withdrawal Or Refusal After Beginning Protocol Therapy (Patient withdrawal/refusal after beginning protocol therapy)

CL Item

Alternative Therapy (Alternative therapy)

CL Item

Patient Off-treatment For Other Complicating Disease (Patient off-treatment for other complicating disease)

CL Item

Other (Other)

C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)

Off-TreatmentOtherReasonSpecify

Item

If Other reason, specify:

text

C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C17649 (NCI Thesaurus Property)
C0205394 (UMLS 2011AA Property)
C25601 (NCI Thesaurus ObjectClass)
C1518544 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property-2)
C0678257 (UMLS 2011AA Property-2)

ChemotherapyTotalCycleCompleteCount

Item

Total number of cycles completed (bevacizumab/placebo)

float

C15632 (NCI Thesaurus ObjectClass)
C0392920 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C25304 (NCI Thesaurus Property-2)
C0439810 (UMLS 2011AA Property-2)
C25472 (NCI Thesaurus Property-3)
C1511572 (UMLS 2011AA Property-3)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)

LastDoseDate

Item

last dose date (bevacizumab/placebo)

date

C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25488 (NCI Thesaurus ObjectClass)
C0178602 (UMLS 2011AA ObjectClass)
C25551 (NCI Thesaurus ObjectClass-2)
C1517741 (UMLS 2011AA ObjectClass-2)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)

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TREATMENT FORM Prostate Cancer (NCT00110214)

INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink

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