ID
6666
Description
Tamoxifen/Exemestane Form (Form 24-TE) Brain Function in Premenopausal Women Receiving Tamoxifen With or Without Ovarian Function Suppression for Early-Stage Breast Cancer on Clinical Trial IBCSG-2402 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B70B84C2-ED22-2268-E034-0003BA12F5E7
Link
Keywords
Versions (2)
- 8/26/12 8/26/12 -
- 1/8/15 1/8/15 - Martin Dugas
Uploaded on
January 8, 2015
DOI
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License
Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00659373 Treatment - Tamoxifen/Exemestane Form (Form 24-TE) - 2080772v3.0
TAMOXIFEN/EXEMESTANE FORM (Form 24-TE) Instructions: This form is to be completed and submitted for all patients at each follow-up period (every 3 months in Year 1, and every 6 months in Years 2-6) until the completion of Tamoxifen/Exemestane. Report Tamoxifen/Exemestane given as treatment for recurrence/second primary on the Follow-Up Form (24-E). If patient is receiving another aromatase inhibitor,report on the Concomitant Medications Form (24-CCM). Mark your selection with an ?X? in the appropriate box(es). Use minus one (-1) to indicate that an answer is unknown, unobtainable, or not done.
Description
Tamoxifen
Description
DidpatientreceiveTamoxifenduringthisfollow-upperiod?
Data type
text
Description
Yes,tookTamoxifenbutrandomizedtoExemestane,checkreason(selectone)
Data type
text
Description
Other,specify(tookTamoxifenbutrandomizedtoExemestane)
Data type
text
Description
ComplianceCode
Data type
text
Description
Other,specify(compliancecode)
Data type
text
Description
Reasonnottakencode
Data type
text
Description
Adverseevent,specify
Data type
text
Description
Adverseevent,specify
Data type
text
Description
Adverseevent,specify
Data type
text
Description
Other,specify(reasonnottaken)
Data type
text
Description
Ifnon-protocoldosewasusedduringthisfollow-upperiod,whatdosagewasgiven?
Data type
text
Description
TreatmentFirstDoseBeginDate
Data type
date
Description
Enddateofnon-protocoldose
Data type
text
Description
Reasonnon-protocoldoseused
Data type
text
Description
Adverseevent,specify(reasonnon-protocoldoseused)
Data type
text
Description
Medicaldecision,specify(reasonnon-protocoldoseused)
Data type
text
Description
Other,specify(reasonnon-protocoldoseused)
Data type
text
Description
DateInterruptionStarted
Data type
text
Description
DateDrugResumed
Data type
text
Description
ReasonforInterruptionCode
Data type
text
Description
Other,specify(reasonforinterruption)
Data type
text
Description
IfpatientpermanentlydiscontinuedTamoxifenduringthisfollow-upperiodgivedateoflastdose.
Data type
text
Description
IfTamoxifenstoppedearlyorneverstarted,reason
Data type
text
Description
Medicaldecision,specify
Data type
text
Description
Other,specify
Data type
text
Description
IfTamoxifenwillstartlater,reason
Data type
text
Description
Adverseevent,specify(ifTamoxifenwillstartlater,reason)
Data type
text
Description
Medicaldecision,specify(ifTamoxifenwillstartlater,reason)
Data type
text
Description
Other,specify(ifTamoxifenwillstartlater,reason)
Data type
text
Description
Exemestane
Description
DidpatientreceiveExemestaneduringthisfollow-upperiod?
Data type
text
Description
Yes,tookExemestanebutrandomizedtoTamoxifen,checkreason
Data type
text
Description
Other,sourceofsurvivalinformation
Data type
text
Description
Dose
Data type
float
Alias
- NCI Thesaurus ObjectClass
- C15313
- UMLS 2011AA ObjectClass
- C1522449
- NCI Thesaurus Property
- C25256
- UMLS 2011AA Property
- C1265611
Description
ComplianceCode
Data type
text
Description
Numberoftabletsdispensed
Data type
text
Description
Other,specify(compliancecode)
Data type
text
Description
BatchNumber
Data type
text
Description
Reasonnottakencode
Data type
text
Description
PillsReceivedDate
Data type
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
- NCI Thesaurus Property
- C25639
- UMLS 2011AA Property
- C1514756
- NCI Thesaurus ObjectClass
- C25394
- UMLS 2011AA ObjectClass
- C0994475
Description
Adverseevent,specify
Data type
text
Description
Adverseevent,specify
Data type
text
Description
Adverseevent,specify
Data type
text
Description
Tabletsdispensedby(initials)
Data type
text
Description
Other,specify(reasonnottaken)
Data type
text
Description
Numberoftabletsreturned
Data type
text
Description
Ifnon-protocoldosewasusedduringthisfollow-upperiod,whatdosagewasgiven?
Data type
text
Description
PillsRemainingDate
Data type
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
- NCI Thesaurus ObjectClass
- C25394
- UMLS 2011AA ObjectClass
- C0994475
- NCI Thesaurus Property
- C25649
- UMLS 2011AA Property
- C1527428
Description
Enddateofnon-protocoldose
Data type
text
Description
Reasonnon-protocoldoseused
Data type
text
Description
Adverseevent,specify(reasonnon-protocoldoseused)
Data type
text
Description
Medicaldecision,specify(reasonnon-protocoldoseused)
Data type
text
Description
Other,specify(reasonnon-protocoldoseused)
Data type
text
Description
DateInterruptionStarted
Data type
text
Description
Treatment Start Date
Data type
date
Alias
- NCI Thesaurus ObjectClass
- C15368
- NCI Thesaurus Property
- C25509
- UMLS CUI-1
- C3173309
- NCI Thesaurus Property-2
- C25256
- NCI Thesaurus ValueDomain
- C25164
- NCI Thesaurus ValueDomain-2
- C25431
Description
DateDrugResumed
Data type
text
Description
ReasonforInterruptionCode
Data type
text
Description
Other,specify(reasonforinterruption)
Data type
text
Description
Medicaldecision,specify
Data type
text
Description
Other,specify
Data type
text
Description
IfpatientpermanentlydiscontinuedExemestaneduringthisfollow-upperiodgivedateoflastdose.
Data type
text
Description
IfExemestanestoppedearlyorneverstarted,reason
Data type
text
Description
IfExemestanewillstartlater,reason
Data type
text
Description
Adverseevent,specify(ifExemestanewillstartlater,reason)
Data type
text
Description
Medicaldecision,specify(ifExemestanewillstartlater,reason)
Data type
text
Description
Other,specify(ifExemestanewillstartlater,reason)
Data type
text
Description
Investigator Signature
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25704
- UMLS CUI-1
- C2346576
- NCI Thesaurus Property
- C25678
- NCI Thesaurus ObjectClass
- C17089
Description
Investigator Signature Date
Data type
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS CUI-1
- C2346576
- NCI Thesaurus Property
- C25678
- UMLS CUI-2
- C0011008
- NCI Thesaurus ValueDomain-2
- C25367
- NCI Thesaurus ObjectClass
- C17089
Similar models
TAMOXIFEN/EXEMESTANE FORM (Form 24-TE) Instructions: This form is to be completed and submitted for all patients at each follow-up period (every 3 months in Year 1, and every 6 months in Years 2-6) until the completion of Tamoxifen/Exemestane. Report Tamoxifen/Exemestane given as treatment for recurrence/second primary on the Follow-Up Form (24-E). If patient is receiving another aromatase inhibitor,report on the Concomitant Medications Form (24-CCM). Mark your selection with an ?X? in the appropriate box(es). Use minus one (-1) to indicate that an answer is unknown, unobtainable, or not done.
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
C0421451 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25367 (NCI Thesaurus ValueDomain-2)
C25155 (NCI Thesaurus Property)
C0805701 (UMLS 2011AA ValueDomain)
C25616 (NCI Thesaurus Property)
C2361257 (UMLS CUI-1)
C25651 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25431 (NCI Thesaurus ValueDomain-2)
C2361259 (UMLS CUI-1)
C25616 (NCI Thesaurus Property)
C15368 (NCI Thesaurus ObjectClass)
C25651 (NCI Thesaurus Property-2)
C0030705 (UMLS 2011AA ObjectClass)
C855 (NCI Thesaurus Property)
C0039286 (UMLS 2011AA Property)
C1097 (NCI Thesaurus Property-2)
C0060116 (UMLS 2011AA Property-2)
C15368 (NCI Thesaurus Property-3)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C0030705 (UMLS 2011AA ObjectClass)
C855 (NCI Thesaurus Property)
C0039286 (UMLS 2011AA Property)
C1097 (NCI Thesaurus Property-2)
C0060116 (UMLS 2011AA Property-2)
C15368 (NCI Thesaurus Property-3)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C0877248 (UMLS 2011AA)
C0034897 (UMLS 2011AA)
C1522449 (UMLS 2011AA ObjectClass)
C25256 (NCI Thesaurus Property)
C1265611 (UMLS 2011AA Property)
C0011008 (UMLS 2011AA ValueDomain)
C25639 (NCI Thesaurus Property)
C1514756 (UMLS 2011AA Property)
C25394 (NCI Thesaurus ObjectClass)
C0994475 (UMLS 2011AA ObjectClass)
C0011008 (UMLS 2011AA ValueDomain)
C25394 (NCI Thesaurus ObjectClass)
C0994475 (UMLS 2011AA ObjectClass)
C25649 (NCI Thesaurus Property)
C1527428 (UMLS 2011AA Property)
C0877248 (UMLS 2011AA)
C25509 (NCI Thesaurus Property)
C3173309 (UMLS CUI-1)
C25256 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25431 (NCI Thesaurus ValueDomain-2)
C0034897 (UMLS 2011AA)
C2346576 (UMLS CUI-1)
C25678 (NCI Thesaurus Property)
C17089 (NCI Thesaurus ObjectClass)
C2346576 (UMLS CUI-1)
C25678 (NCI Thesaurus Property)
C0011008 (UMLS CUI-2)
C25367 (NCI Thesaurus ValueDomain-2)
C17089 (NCI Thesaurus ObjectClass)