ID

6866

Description

Superficial Bladder Cancer - Follow-Up Form Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=99CD59C5-A95F-3FA4-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=99CD59C5-A95F-3FA4-E034-080020C9C0E0

Keywords

Versions (2)
  1. 9/19/12 9/19/12 -
  2. 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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Follow-Up - Superficial Bladder Cancer - Follow-Up Form - 2019332v2.31

English

No Instruction available.

1 forms  
  1. StudyEvent: Superficial Bladder Cancer - Follow-Up Form
    1. No Instruction available.
Crf Header
Description

Crf Header

Coordinating Group Protocol Number
Description

CoordinatingGroupProtocolNumber

Data type

text

Coordinating Group Code
Description

CoordinatingGroupCode

Data type

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
Protocol Title
Description

Protocol Title

Data type

text

Alias
NCI Thesaurus ObjectClass
C25320
UMLS CUI-1
C2986303
NCI Thesaurus Property
C42774
Patient Study ID, Coordinating Group
Description

PatientStudyID,CoordinatingGroup

Data type

text

Patient Study ID, Participating Group
Description

PatientStudyID,ParticipatingGroup

Data type

text

Participating Group Code
Description

ParticipatingGroupCode

Data type

text

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
Institution Name
Description

InstitutionName

Data type

text

Affiliate Name
Description

AffiliateName

Data type

text

Patient Name, Last
Description

PatientName,Last

Data type

text

Patient Name, First
Description

PatientName,First

Data type

text

Patient Name, Middle
Description

PatientName,Middle

Data type

text

Bladder: Form Administration
Description

Bladder: Form Administration

Person Completing Form, Last Name
Description

PersonCompletingForm,LastName

Data type

text

Person Completing Form, First Name
Description

PersonCompletingForm,FirstName

Data type

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Amended Data Ind
Description

AmendedDataInd

Data type

text

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Bladder: Vital Status
Description

Bladder: Vital Status

Patient's Vital Status
Description

Patient'sVitalStatus

Data type

text

Death Reason
Description

DeathReason

Data type

text

Death Reason, Specify
Description

DeathReason,Specify

Data type

text

Death Date/Last Contact Date
Description

DeathDate/LastContactDate

Data type

date

Bladder: Disease Follow-up Status
Description

Bladder: Disease Follow-up Status

Cancer Follow-up Status Ind
Description

CancerFollow-upStatusInd

Data type

text

Cancer Follow-up Status Date
Description

CancerFollow-upStatusDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Bladder: Superficial Disease Follow-up Assessment
Description

Bladder: Superficial Disease Follow-up Assessment

Cytology Date
Description

CytologyDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C16491
UMLS 2011AA ObjectClass
C0010819
NCI Thesaurus Property
C25294
UMLS 2011AA Property
C0022885
Cytology Result
Description

CytologyResult

Data type

text

Alias
NCI Thesaurus ObjectClass
C16491
UMLS 2011AA ObjectClass
C0010819
NCI Thesaurus Property
C20200
UMLS 2011AA Property
C1274040
Cytology Result, Other
Description

CytologyResult,Other

Data type

text

Cystoscopy Date
Description

CystoscopyDate

Data type

date

Cystoscopy, Lesions Identified Ind
Description

Cystoscopy,LesionsIdentifiedInd

Data type

text

Cystoscopy, Papillary Tumors Present Ind
Description

Cystoscopy,PapillaryTumorsPresentInd

Data type

text

T Stage, Papillary Tumor
Description

TStage,PapillaryTumor

Data type

text

Histologic Grade
Description

HistologicGrade

Data type

text

Alias
NCI Thesaurus ValueDomain
C25526
UMLS 2011AA ValueDomain
C0205462
NCI Thesaurus ValueDomain-2
C18000
UMLS 2011AA ValueDomain-2
C0919553
CIS Ind
Description

CISInd

Data type

text

Progression, Superficial Bladder, Treatment Applied
Description

Progression,SuperficialBladder,TreatmentApplied

Data type

text

Progression, Superficial Bladder, Other Surgery
Description

Progression,SuperficialBladder,OtherSurgery

Data type

text

Progression, Superficial Bladder, Other Treatment
Description

Progression,SuperficialBladder,OtherTreatment

Data type

text

Bladder: Notice Of Progression
Description

Bladder: Notice Of Progression

Progression Ind, Superficial Bladder
Description

ProgressionInd,SuperficialBladder

Data type

text

Progression Date, First Local
Description

ProgressionDate,FirstLocal

Data type

date

Progression Site, First Local
Description

ProgressionSite,FirstLocal

Data type

text

Progression Site, First Local, Other
Description

ProgressionSite,FirstLocal,Other

Data type

text

Progression, T Category Increase
Description

Progression,TCategoryIncrease

Data type

text

Progression Ind, Distant Metastatic
Description

ProgressionInd,DistantMetastatic

Data type

text

Progression Date, First Distant
Description

ProgressionDate,FirstDistant

Data type

date

Progression Site, First Distant
Description

ProgressionSite,FirstDistant

Data type

text

Lymph Nodes, Distant Location
Description

LymphNodes,DistantLocation

Data type

text

Progression Site, Other
Description

ProgressionSite,Other

Data type

text

Bladder: Notice Of New Primary
Description

Bladder: Notice Of New Primary

New Primary Cancer Ind
Description

NewPrimaryCancerInd

Data type

text

New Primary Cancer Date
Description

NewPrimaryCancerDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
New Primary Site
Description

NewPrimarySite

Data type

text

Bladder: Long-term Toxicity
Description

Bladder: Long-term Toxicity

Late Adverse Event Ind
Description

LateAdverseEventInd

Data type

text

Late Adverse Event Term
Description

LateAdverseEventTerm

Data type

text

Late Adverse Event Grade
Description

LateAdverseEventGrade

Data type

text

Late Adverse Event Onset Date
Description

LateAdverseEventOnsetDate

Data type

date

Allows Documentation Of Any Additional Cooments
Description

Allows Documentation Of Any Additional Cooments

Comments
Description

Comments

Data type

text

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1 forms
  1. StudyEvent: Superficial Bladder Cancer - Follow-Up Form
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Crf Header
CoordinatingGroupProtocolNumber
Item
Coordinating Group Protocol Number
text
CoordinatingGroupCode
Item
Coordinating Group Code
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
Protocol Title
Item
Protocol Title
text
C25320 (NCI Thesaurus ObjectClass)
C2986303 (UMLS CUI-1)
C42774 (NCI Thesaurus Property)
PatientStudyID,CoordinatingGroup
Item
Patient Study ID, Coordinating Group
text
PatientStudyID,ParticipatingGroup
Item
Patient Study ID, Participating Group
text
ParticipatingGroupCode
Item
Participating Group Code
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
InstitutionName
Item
Institution Name
text
AffiliateName
Item
Affiliate Name
text
PatientName,Last
Item
Patient Name, Last
text
PatientName,First
Item
Patient Name, First
text
PatientName,Middle
Item
Patient Name, Middle
text
Item Group
Bladder: Form Administration
PersonCompletingForm,LastName
Item
Person Completing Form, Last Name
text
PersonCompletingForm,FirstName
Item
Person Completing Form, First Name
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
Item
Amended Data Ind
text
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
CL.1
Code List
Amended Data Ind
CL Item
Yes (YES)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (UNKNOWN)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
No (NO)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Item Group
Bladder: Vital Status
Item
Patient's Vital Status
text
CL.2
Code List
Patient's Vital Status
CL Item
Dead (Dead)
CL Item
Alive (Alive)
Item
Death Reason
text
CL.3
Code List
Death Reason
CL Item
Due To Other Cause (Due to other cause)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
Due To This Disease (Due to this disease)
CL Item
Due To Protocol Treatment (Due to protocol treatment)
DeathReason,Specify
Item
Death Reason, Specify
text
DeathDate/LastContactDate
Item
Death Date/Last Contact Date
date
Item Group
Bladder: Disease Follow-up Status
Item
Cancer Follow-up Status Ind
text
CL.4
Code List
Cancer Follow-up Status Ind
CL Item
Yes (YES)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (UNKNOWN)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
No (NO)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CancerFollow-upStatusDate
Item
Cancer Follow-up Status Date
date
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
Item Group
Bladder: Superficial Disease Follow-up Assessment
CytologyDate
Item
Cytology Date
date
C16491 (NCI Thesaurus ObjectClass)
C0010819 (UMLS 2011AA ObjectClass)
C25294 (NCI Thesaurus Property)
C0022885 (UMLS 2011AA Property)
Item
Cytology Result
text
C16491 (NCI Thesaurus ObjectClass)
C0010819 (UMLS 2011AA ObjectClass)
C20200 (NCI Thesaurus Property)
C1274040 (UMLS 2011AA Property)
CL.5
Code List
Cytology Result
CL Item
Inflammatory Changes With Or Without Dyscariosis (Inflammatory changes with or without dyscariosis)
CL Item
Moderate Dysplasia Or Papillary Clusters (suspect) (Moderate dysplasia or papillary clusters (suspect))
CL Item
Negative (Negative)
C25247 (NCI Thesaurus)
C0205160 (UMLS 2011AA)
CL Item
Normal Tissue (Normal exfoliated cells)
C33177 (NCI Thesaurus)
CL Item
Severe Dysplasia (Severe dysplasia)
C8364 (NCI Thesaurus)
C0334048 (UMLS 2011AA)
CL Item
Numerous Atypical And Malignant Cells (Numerous atypical and malignant cells)
CL Item
Other (Other, specify)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
Positive (Positive)
C25246 (NCI Thesaurus)
C1446409 (UMLS 2011AA)
CL Item
Not Done (Not done)
CL281691 (NCI Metathesaurus)
CytologyResult,Other
Item
Cytology Result, Other
text
CystoscopyDate
Item
Cystoscopy Date
date
Item
Cystoscopy, Lesions Identified Ind
text
CL.6
Code List
Cystoscopy, Lesions Identified Ind
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Cystoscopy, Papillary Tumors Present Ind
text
CL.7
Code List
Cystoscopy, Papillary Tumors Present Ind
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
T Stage, Papillary Tumor
text
CL.8
Code List
T Stage, Papillary Tumor
CL Item
Tx (Tx)
CL Item
Ta (Ta)
CL Item
T0 (T0)
CL Item
T1 (T1)
C1179687 (NCI Metathesaurus)
CL Item
T2 (T2)
CL Item
T3 (T3)
CL Item
T4 (T4)
Item
Histologic Grade
text
C25526 (NCI Thesaurus ValueDomain)
C0205462 (UMLS 2011AA ValueDomain)
C18000 (NCI Thesaurus ValueDomain-2)
C0919553 (UMLS 2011AA ValueDomain-2)
CL.9
Code List
Histologic Grade
CL Item
Tumor Grade Cannot Be Assessed (grade cannot be assessed (GX))
CL Item
Well Differentiated (well differentiated (G1))
C14171 (NCI Thesaurus)
C0205615 (UMLS 2011AA)
CL Item
Poorly Differentiated (poorly differentiated (G3))
C14167 (NCI Thesaurus)
C0205617 (UMLS 2011AA)
CL Item
Moderately Differentiated (moderately differentiated (G2))
C14162 (NCI Thesaurus)
C0205616 (UMLS 2011AA)
Item
CIS Ind
text
CL.10
Code List
CIS Ind
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Progression, Superficial Bladder, Treatment Applied
text
CL.11
Code List
Progression, Superficial Bladder, Treatment Applied
CL Item
Intravesical Chemotherapy Was Used To Treat Superficial Bladder Cancer Prior To Progression Or Diagnosis Of More Advanced Disease (intravesical chemotherapy)
CL Item
Intravesical Immunotherapy Was Used To Treat Superficial Bladder Cancer Prior To Progression Or Diagnosis Of More Advanced Disease (intravesical immunotherapy)
CL Item
Other Surgery Was Used To Treat Superficial Bladder Cancer Prior To Progression Or Diagnosis Of More Advanced Disease (surgery-other, specify)
CL Item
Another Treatment Was Used To Treat Superficial Bladder Cancer Prior To Progression Or Diagnosis Of More Advanced Disease (other, specify)
CL Item
Cystectomy Was Used To Treat Superficial Bladder Cancer Prior To Progression Or Diagnosis Of More Advanced Disease (surgery-cystectomy)
CL Item
No Treatment Was Given Prior To Progression Or Diagnosis Of More Advanced Disease (none)
Progression,SuperficialBladder,OtherSurgery
Item
Progression, Superficial Bladder, Other Surgery
text
Progression,SuperficialBladder,OtherTreatment
Item
Progression, Superficial Bladder, Other Treatment
text
Item Group
Bladder: Notice Of Progression
Item
Progression Ind, Superficial Bladder
text
CL.12
Code List
Progression Ind, Superficial Bladder
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
ProgressionDate,FirstLocal
Item
Progression Date, First Local
date
Item
Progression Site, First Local
text
CL.13
Code List
Progression Site, First Local
CL Item
Local Progression To The Abdominal Wall (abdominal wall)
CL Item
Progression To Another Site, Specify Site (other, specify)
CL Item
Local Progression To The Pelvic Wall (pelvic wall)
CL Item
Local Spread To Peritoneal Tissue (peritoneum)
CL Item
Local Spread To The Vagina (vagina)
CL Item
Spread Of Cancer To Skin Or Subcutaneous Tissue Near To The Bladder (skin)
CL Item
Local Spread To The Ureter (ureter)
CL Item
Local Spread To The Urethra (urethra)
CL Item
Local Spread To The Uterus (uterus)
CL Item
Local Spread To The Prostate (prostate)
ProgressionSite,FirstLocal,Other
Item
Progression Site, First Local, Other
text
Item
Progression, T Category Increase
text
CL.14
Code List
Progression, T Category Increase
CL Item
T Stage Of Tumor Cannot Be Assessed (Tx)
CL Item
T2 (T2)
CL Item
T3 (T3)
CL Item
T4 (T4)
Item
Progression Ind, Distant Metastatic
text
CL.15
Code List
Progression Ind, Distant Metastatic
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Unknown (unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
ProgressionDate,FirstDistant
Item
Progression Date, First Distant
date
Item
Progression Site, First Distant
text
CL.16
Code List
Progression Site, First Distant
CL Item
Bone (bone)
C12366 (NCI Thesaurus)
C0262950 (UMLS 2011AA)
CL Item
Central Nervous System Or Brain (central nervous system/brain)
CL Item
Distant Lymph Nodes (distant nodes)
CL Item
Liver (liver)
C12392 (NCI Thesaurus)
C0023884 (UMLS 2011AA)
CL Item
Skin (skin)
C12470 (NCI Thesaurus)
C1123023 (UMLS 2011AA)
CL Item
Other, Specify (other)
CL Item
Peritoneum (peritoneum)
C12770 (NCI Thesaurus)
C0031153 (UMLS 2011AA)
CL Item
Pleura (pleura)
C12469 (NCI Thesaurus)
C0032225 (UMLS 2011AA)
CL Item
Lung (lung)
C12468 (NCI Thesaurus)
C0024109 (UMLS 2011AA)
LymphNodes,DistantLocation
Item
Lymph Nodes, Distant Location
text
ProgressionSite,Other
Item
Progression Site, Other
text
Item Group
Bladder: Notice Of New Primary
Item
New Primary Cancer Ind
text
CL.17
Code List
New Primary Cancer Ind
CL Item
Yes (YES)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (UNKNOWN)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
No (NO)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
NewPrimaryCancerDate
Item
New Primary Cancer Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
NewPrimarySite
Item
New Primary Site
text
Item Group
Bladder: Long-term Toxicity
Item
Late Adverse Event Ind
text
CL.18
Code List
Late Adverse Event Ind
CL Item
Yes (YES)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (UNKNOWN)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CL Item
No (NO)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Item
Late Adverse Event Term
text
CL.19
Code List
Late Adverse Event Term
CL Item
Use Rtog/eortc Grading System (see Ctc Version 2.0. Http://ctep.info.nih.gov/ctc3/ctc.htm). (Use RTOG/EORTC grading system (See CTC version 2.0. http://ctep.info.nih.gov/CTC3/ctc.htm).)
LateAdverseEventGrade
Item
Late Adverse Event Grade
text
LateAdverseEventOnsetDate
Item
Late Adverse Event Onset Date
date
Item Group
Allows Documentation Of Any Additional Cooments
Comments
Item
Comments
text
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