ID

6866

Descrizione

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

collegamento

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

Keywords

versioni (2)
  1. 19/09/12 19/09/12 -
  2. 08/01/15 08/01/15 - Martin Dugas
Caricato su

8 gennaio 2015

DOI

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Licenza

Creative Commons BY-NC 3.0 Legacy
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Follow-Up - Superficial Bladder Cancer - Follow-Up Form - 2019332v2.31

Inglese

No Instruction available.

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

Crf Header

Coordinating Group Protocol Number
Descrizione

CoordinatingGroupProtocolNumber

Tipo di dati

text

Coordinating Group Code
Descrizione

CoordinatingGroupCode

Tipo di dati

text

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

Protocol Title

Tipo di dati

text

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

PatientStudyID,CoordinatingGroup

Tipo di dati

text

Patient Study ID, Participating Group
Descrizione

PatientStudyID,ParticipatingGroup

Tipo di dati

text

Participating Group Code
Descrizione

ParticipatingGroupCode

Tipo di dati

text

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

InstitutionName

Tipo di dati

text

Affiliate Name
Descrizione

AffiliateName

Tipo di dati

text

Patient Name, Last
Descrizione

PatientName,Last

Tipo di dati

text

Patient Name, First
Descrizione

PatientName,First

Tipo di dati

text

Patient Name, Middle
Descrizione

PatientName,Middle

Tipo di dati

text

Bladder: Form Administration
Descrizione

Bladder: Form Administration

Person Completing Form, Last Name
Descrizione

PersonCompletingForm,LastName

Tipo di dati

text

Person Completing Form, First Name
Descrizione

PersonCompletingForm,FirstName

Tipo di dati

text

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

AmendedDataInd

Tipo di dati

text

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

Bladder: Vital Status

Patient's Vital Status
Descrizione

Patient'sVitalStatus

Tipo di dati

text

Death Reason
Descrizione

DeathReason

Tipo di dati

text

Death Reason, Specify
Descrizione

DeathReason,Specify

Tipo di dati

text

Death Date/Last Contact Date
Descrizione

DeathDate/LastContactDate

Tipo di dati

date

Bladder: Disease Follow-up Status
Descrizione

Bladder: Disease Follow-up Status

Cancer Follow-up Status Ind
Descrizione

CancerFollow-upStatusInd

Tipo di dati

text

Cancer Follow-up Status Date
Descrizione

CancerFollow-upStatusDate

Tipo di dati

date

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

Bladder: Superficial Disease Follow-up Assessment

Cytology Date
Descrizione

CytologyDate

Tipo di dati

date

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

CytologyResult

Tipo di dati

text

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

CytologyResult,Other

Tipo di dati

text

Cystoscopy Date
Descrizione

CystoscopyDate

Tipo di dati

date

Cystoscopy, Lesions Identified Ind
Descrizione

Cystoscopy,LesionsIdentifiedInd

Tipo di dati

text

Cystoscopy, Papillary Tumors Present Ind
Descrizione

Cystoscopy,PapillaryTumorsPresentInd

Tipo di dati

text

T Stage, Papillary Tumor
Descrizione

TStage,PapillaryTumor

Tipo di dati

text

Histologic Grade
Descrizione

HistologicGrade

Tipo di dati

text

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

CISInd

Tipo di dati

text

Progression, Superficial Bladder, Treatment Applied
Descrizione

Progression,SuperficialBladder,TreatmentApplied

Tipo di dati

text

Progression, Superficial Bladder, Other Surgery
Descrizione

Progression,SuperficialBladder,OtherSurgery

Tipo di dati

text

Progression, Superficial Bladder, Other Treatment
Descrizione

Progression,SuperficialBladder,OtherTreatment

Tipo di dati

text

Bladder: Notice Of Progression
Descrizione

Bladder: Notice Of Progression

Progression Ind, Superficial Bladder
Descrizione

ProgressionInd,SuperficialBladder

Tipo di dati

text

Progression Date, First Local
Descrizione

ProgressionDate,FirstLocal

Tipo di dati

date

Progression Site, First Local
Descrizione

ProgressionSite,FirstLocal

Tipo di dati

text

Progression Site, First Local, Other
Descrizione

ProgressionSite,FirstLocal,Other

Tipo di dati

text

Progression, T Category Increase
Descrizione

Progression,TCategoryIncrease

Tipo di dati

text

Progression Ind, Distant Metastatic
Descrizione

ProgressionInd,DistantMetastatic

Tipo di dati

text

Progression Date, First Distant
Descrizione

ProgressionDate,FirstDistant

Tipo di dati

date

Progression Site, First Distant
Descrizione

ProgressionSite,FirstDistant

Tipo di dati

text

Lymph Nodes, Distant Location
Descrizione

LymphNodes,DistantLocation

Tipo di dati

text

Progression Site, Other
Descrizione

ProgressionSite,Other

Tipo di dati

text

Bladder: Notice Of New Primary
Descrizione

Bladder: Notice Of New Primary

New Primary Cancer Ind
Descrizione

NewPrimaryCancerInd

Tipo di dati

text

New Primary Cancer Date
Descrizione

NewPrimaryCancerDate

Tipo di dati

date

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

NewPrimarySite

Tipo di dati

text

Bladder: Long-term Toxicity
Descrizione

Bladder: Long-term Toxicity

Late Adverse Event Ind
Descrizione

LateAdverseEventInd

Tipo di dati

text

Late Adverse Event Term
Descrizione

LateAdverseEventTerm

Tipo di dati

text

Late Adverse Event Grade
Descrizione

LateAdverseEventGrade

Tipo di dati

text

Late Adverse Event Onset Date
Descrizione

LateAdverseEventOnsetDate

Tipo di dati

date

Allows Documentation Of Any Additional Cooments
Descrizione

Allows Documentation Of Any Additional Cooments

Comments
Descrizione

Comments

Tipo di dati

text

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1 moduli
  1. StudyEvent: Superficial Bladder Cancer - Follow-Up Form
    1. No Instruction available.
Name
genere
Description | Question | Decode (Coded Value)
Tipo di dati
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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