ID
6666
Beschreibung
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
Stichworte
Versionen (2)
- 26.08.12 26.08.12 -
- 08.01.15 08.01.15 - Martin Dugas
Hochgeladen am
8. Januar 2015
DOI
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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.
Beschreibung
Tamoxifen
Beschreibung
DidpatientreceiveTamoxifenduringthisfollow-upperiod?
Datentyp
text
Beschreibung
Yes,tookTamoxifenbutrandomizedtoExemestane,checkreason(selectone)
Datentyp
text
Beschreibung
Other,specify(tookTamoxifenbutrandomizedtoExemestane)
Datentyp
text
Beschreibung
ComplianceCode
Datentyp
text
Beschreibung
Other,specify(compliancecode)
Datentyp
text
Beschreibung
Reasonnottakencode
Datentyp
text
Beschreibung
Adverseevent,specify
Datentyp
text
Beschreibung
Adverseevent,specify
Datentyp
text
Beschreibung
Adverseevent,specify
Datentyp
text
Beschreibung
Other,specify(reasonnottaken)
Datentyp
text
Beschreibung
Ifnon-protocoldosewasusedduringthisfollow-upperiod,whatdosagewasgiven?
Datentyp
text
Beschreibung
TreatmentFirstDoseBeginDate
Datentyp
date
Beschreibung
Enddateofnon-protocoldose
Datentyp
text
Beschreibung
Reasonnon-protocoldoseused
Datentyp
text
Beschreibung
Adverseevent,specify(reasonnon-protocoldoseused)
Datentyp
text
Beschreibung
Medicaldecision,specify(reasonnon-protocoldoseused)
Datentyp
text
Beschreibung
Other,specify(reasonnon-protocoldoseused)
Datentyp
text
Beschreibung
DateInterruptionStarted
Datentyp
text
Beschreibung
DateDrugResumed
Datentyp
text
Beschreibung
ReasonforInterruptionCode
Datentyp
text
Beschreibung
Other,specify(reasonforinterruption)
Datentyp
text
Beschreibung
IfpatientpermanentlydiscontinuedTamoxifenduringthisfollow-upperiodgivedateoflastdose.
Datentyp
text
Beschreibung
IfTamoxifenstoppedearlyorneverstarted,reason
Datentyp
text
Beschreibung
Medicaldecision,specify
Datentyp
text
Beschreibung
Other,specify
Datentyp
text
Beschreibung
IfTamoxifenwillstartlater,reason
Datentyp
text
Beschreibung
Adverseevent,specify(ifTamoxifenwillstartlater,reason)
Datentyp
text
Beschreibung
Medicaldecision,specify(ifTamoxifenwillstartlater,reason)
Datentyp
text
Beschreibung
Other,specify(ifTamoxifenwillstartlater,reason)
Datentyp
text
Beschreibung
Exemestane
Beschreibung
DidpatientreceiveExemestaneduringthisfollow-upperiod?
Datentyp
text
Beschreibung
Yes,tookExemestanebutrandomizedtoTamoxifen,checkreason
Datentyp
text
Beschreibung
Other,sourceofsurvivalinformation
Datentyp
text
Beschreibung
Dose
Datentyp
float
Alias
- NCI Thesaurus ObjectClass
- C15313
- UMLS 2011AA ObjectClass
- C1522449
- NCI Thesaurus Property
- C25256
- UMLS 2011AA Property
- C1265611
Beschreibung
ComplianceCode
Datentyp
text
Beschreibung
Numberoftabletsdispensed
Datentyp
text
Beschreibung
Other,specify(compliancecode)
Datentyp
text
Beschreibung
BatchNumber
Datentyp
text
Beschreibung
Reasonnottakencode
Datentyp
text
Beschreibung
PillsReceivedDate
Datentyp
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
Beschreibung
Adverseevent,specify
Datentyp
text
Beschreibung
Adverseevent,specify
Datentyp
text
Beschreibung
Adverseevent,specify
Datentyp
text
Beschreibung
Tabletsdispensedby(initials)
Datentyp
text
Beschreibung
Other,specify(reasonnottaken)
Datentyp
text
Beschreibung
Numberoftabletsreturned
Datentyp
text
Beschreibung
Ifnon-protocoldosewasusedduringthisfollow-upperiod,whatdosagewasgiven?
Datentyp
text
Beschreibung
PillsRemainingDate
Datentyp
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
Beschreibung
Enddateofnon-protocoldose
Datentyp
text
Beschreibung
Reasonnon-protocoldoseused
Datentyp
text
Beschreibung
Adverseevent,specify(reasonnon-protocoldoseused)
Datentyp
text
Beschreibung
Medicaldecision,specify(reasonnon-protocoldoseused)
Datentyp
text
Beschreibung
Other,specify(reasonnon-protocoldoseused)
Datentyp
text
Beschreibung
DateInterruptionStarted
Datentyp
text
Beschreibung
Treatment Start Date
Datentyp
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
Beschreibung
DateDrugResumed
Datentyp
text
Beschreibung
ReasonforInterruptionCode
Datentyp
text
Beschreibung
Other,specify(reasonforinterruption)
Datentyp
text
Beschreibung
Medicaldecision,specify
Datentyp
text
Beschreibung
Other,specify
Datentyp
text
Beschreibung
IfpatientpermanentlydiscontinuedExemestaneduringthisfollow-upperiodgivedateoflastdose.
Datentyp
text
Beschreibung
IfExemestanestoppedearlyorneverstarted,reason
Datentyp
text
Beschreibung
IfExemestanewillstartlater,reason
Datentyp
text
Beschreibung
Adverseevent,specify(ifExemestanewillstartlater,reason)
Datentyp
text
Beschreibung
Medicaldecision,specify(ifExemestanewillstartlater,reason)
Datentyp
text
Beschreibung
Other,specify(ifExemestanewillstartlater,reason)
Datentyp
text
Beschreibung
Investigator Signature
Datentyp
text
Alias
- NCI Thesaurus ValueDomain
- C25704
- UMLS CUI-1
- C2346576
- NCI Thesaurus Property
- C25678
- NCI Thesaurus ObjectClass
- C17089
Beschreibung
Investigator Signature Date
Datentyp
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
Ähnliche Modelle
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)