ID
6666
Beskrivning
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
Länk
Nyckelord
Versioner (2)
- 2012-08-26 2012-08-26 -
- 2015-01-08 2015-01-08 - Martin Dugas
Uppladdad den
8 januari 2015
DOI
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Licens
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.
Beskrivning
Tamoxifen
Beskrivning
DidpatientreceiveTamoxifenduringthisfollow-upperiod?
Datatyp
text
Beskrivning
Yes,tookTamoxifenbutrandomizedtoExemestane,checkreason(selectone)
Datatyp
text
Beskrivning
Other,specify(tookTamoxifenbutrandomizedtoExemestane)
Datatyp
text
Beskrivning
ComplianceCode
Datatyp
text
Beskrivning
Other,specify(compliancecode)
Datatyp
text
Beskrivning
Reasonnottakencode
Datatyp
text
Beskrivning
Adverseevent,specify
Datatyp
text
Beskrivning
Adverseevent,specify
Datatyp
text
Beskrivning
Adverseevent,specify
Datatyp
text
Beskrivning
Other,specify(reasonnottaken)
Datatyp
text
Beskrivning
Ifnon-protocoldosewasusedduringthisfollow-upperiod,whatdosagewasgiven?
Datatyp
text
Beskrivning
TreatmentFirstDoseBeginDate
Datatyp
date
Beskrivning
Enddateofnon-protocoldose
Datatyp
text
Beskrivning
Reasonnon-protocoldoseused
Datatyp
text
Beskrivning
Adverseevent,specify(reasonnon-protocoldoseused)
Datatyp
text
Beskrivning
Medicaldecision,specify(reasonnon-protocoldoseused)
Datatyp
text
Beskrivning
Other,specify(reasonnon-protocoldoseused)
Datatyp
text
Beskrivning
DateInterruptionStarted
Datatyp
text
Beskrivning
DateDrugResumed
Datatyp
text
Beskrivning
ReasonforInterruptionCode
Datatyp
text
Beskrivning
Other,specify(reasonforinterruption)
Datatyp
text
Beskrivning
IfpatientpermanentlydiscontinuedTamoxifenduringthisfollow-upperiodgivedateoflastdose.
Datatyp
text
Beskrivning
IfTamoxifenstoppedearlyorneverstarted,reason
Datatyp
text
Beskrivning
Medicaldecision,specify
Datatyp
text
Beskrivning
Other,specify
Datatyp
text
Beskrivning
IfTamoxifenwillstartlater,reason
Datatyp
text
Beskrivning
Adverseevent,specify(ifTamoxifenwillstartlater,reason)
Datatyp
text
Beskrivning
Medicaldecision,specify(ifTamoxifenwillstartlater,reason)
Datatyp
text
Beskrivning
Other,specify(ifTamoxifenwillstartlater,reason)
Datatyp
text
Beskrivning
Exemestane
Beskrivning
DidpatientreceiveExemestaneduringthisfollow-upperiod?
Datatyp
text
Beskrivning
Yes,tookExemestanebutrandomizedtoTamoxifen,checkreason
Datatyp
text
Beskrivning
Other,sourceofsurvivalinformation
Datatyp
text
Beskrivning
Dose
Datatyp
float
Alias
- NCI Thesaurus ObjectClass
- C15313
- UMLS 2011AA ObjectClass
- C1522449
- NCI Thesaurus Property
- C25256
- UMLS 2011AA Property
- C1265611
Beskrivning
ComplianceCode
Datatyp
text
Beskrivning
Numberoftabletsdispensed
Datatyp
text
Beskrivning
Other,specify(compliancecode)
Datatyp
text
Beskrivning
BatchNumber
Datatyp
text
Beskrivning
Reasonnottakencode
Datatyp
text
Beskrivning
PillsReceivedDate
Datatyp
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
Beskrivning
Adverseevent,specify
Datatyp
text
Beskrivning
Adverseevent,specify
Datatyp
text
Beskrivning
Adverseevent,specify
Datatyp
text
Beskrivning
Tabletsdispensedby(initials)
Datatyp
text
Beskrivning
Other,specify(reasonnottaken)
Datatyp
text
Beskrivning
Numberoftabletsreturned
Datatyp
text
Beskrivning
Ifnon-protocoldosewasusedduringthisfollow-upperiod,whatdosagewasgiven?
Datatyp
text
Beskrivning
PillsRemainingDate
Datatyp
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
Beskrivning
Enddateofnon-protocoldose
Datatyp
text
Beskrivning
Reasonnon-protocoldoseused
Datatyp
text
Beskrivning
Adverseevent,specify(reasonnon-protocoldoseused)
Datatyp
text
Beskrivning
Medicaldecision,specify(reasonnon-protocoldoseused)
Datatyp
text
Beskrivning
Other,specify(reasonnon-protocoldoseused)
Datatyp
text
Beskrivning
DateInterruptionStarted
Datatyp
text
Beskrivning
Treatment Start Date
Datatyp
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
Beskrivning
DateDrugResumed
Datatyp
text
Beskrivning
ReasonforInterruptionCode
Datatyp
text
Beskrivning
Other,specify(reasonforinterruption)
Datatyp
text
Beskrivning
Medicaldecision,specify
Datatyp
text
Beskrivning
Other,specify
Datatyp
text
Beskrivning
IfpatientpermanentlydiscontinuedExemestaneduringthisfollow-upperiodgivedateoflastdose.
Datatyp
text
Beskrivning
IfExemestanestoppedearlyorneverstarted,reason
Datatyp
text
Beskrivning
IfExemestanewillstartlater,reason
Datatyp
text
Beskrivning
Adverseevent,specify(ifExemestanewillstartlater,reason)
Datatyp
text
Beskrivning
Medicaldecision,specify(ifExemestanewillstartlater,reason)
Datatyp
text
Beskrivning
Other,specify(ifExemestanewillstartlater,reason)
Datatyp
text
Beskrivning
Investigator Signature
Datatyp
text
Alias
- NCI Thesaurus ValueDomain
- C25704
- UMLS CUI-1
- C2346576
- NCI Thesaurus Property
- C25678
- NCI Thesaurus ObjectClass
- C17089
Beskrivning
Investigator Signature Date
Datatyp
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)