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ID

688

Beschrijving

CALGB: 49808 RESPONSE/PROGRESSION FORM Combination Chemotherapy, Surgery, and Radiation Therapy With or Without Dexrazoxane and Trastuzumab in Treating Women With Stage III or Stage IV Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9E35395C-867B-227A-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9E35395C-867B-227A-E034-080020C9C0E0

Trefwoorden

Versies (3)
  1. 26-08-12 26-08-12 -
  2. 22-05-15 22-05-15 -
  3. 03-06-15 03-06-15 -
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26 augustus 2012

DOI

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Licentie

Creative Commons BY-NC 3.0 Legacy
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    Breast Cancer NCT00016276 Response - CALGB: 49808 RESPONSE/PROGRESSION FORM - 2032254v3.0

    Engels

    No Instruction available.

    1 Formulieren  
    1. StudyEvent: CALGB: 49808 RESPONSE/PROGRESSION FORM
      1. No Instruction available.
    Unnamed1
    Beschrijving

    Unnamed1

    CALGB Form
    Beschrijving

    CALGBForm

    Datatype

    text

    CALGB Study No
    Beschrijving

    CALGBProtocolNumber

    Datatype

    text

    CALGB Patient ID
    Beschrijving

    CALGBPatientID

    Datatype

    text

    From
    Beschrijving

    From

    Datatype

    text

    To (Date of last contact or death)
    Beschrijving

    To

    Datatype

    text

    Amended data?
    Beschrijving

    AmendedDataInd

    Datatype

    text

    Alias
    NCI Thesaurus ObjectClass
    C25474
    UMLS 2011AA ObjectClass
    C1511726
    NCI Thesaurus Property
    C25416
    UMLS 2011AA Property
    C1691222
    Unnamed2
    Beschrijving

    Unnamed2

    Patient's Name
    Beschrijving

    Patient'sName

    Datatype

    text

    Participating Group
    Beschrijving

    ParticipatingGroup

    Datatype

    text

    Alias
    NCI Thesaurus ObjectClass
    C17005
    UMLS 2011AA ObjectClass
    C1257890
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    Patient Hospital Number
    Beschrijving

    PatientHospitalNumber

    Datatype

    text

    Participating Group Protocol No.
    Beschrijving

    ParticipatingGroupProtocolNo.

    Datatype

    text

    Main Member Institution/Adjunct
    Beschrijving

    MainMemberInstitution/Adjunct

    Datatype

    text

    Participating Group Patient No.
    Beschrijving

    ParticipatingGroupPatientNo.

    Datatype

    text

    Response Assessment (clinical/radiographic)
    Beschrijving

    Response Assessment (clinical/radiographic)

    Has the patient achieved a response (not previously reported)?
    Beschrijving

    Hasthepatientachievedaresponse(notpreviouslyreported)?

    Datatype

    text

    Date overall partial response first documented
    Beschrijving

    Dateoverallpartialresponsefirstdocumented

    Datatype

    text

    Date overall complete response first documented
    Beschrijving

    Dateoverallcompleteresponsefirstdocumented

    Datatype

    text

    Has the patient been diagnosed with a new progression during this reporting period (not previously reported)?
    Beschrijving

    Hasthepatientbeendiagnosedwithanewprogressionduringthisreportingperiod(notpreviouslyreported)?

    Datatype

    text

    Date response/stable disease last documented (IF NO:)
    Beschrijving

    Dateresponse/stablediseaselastdocumented

    Datatype

    text

    Has the patient been diagnosed with a new local-regional recurrence since submission of the last follow-up form? (IF YES:)
    Beschrijving

    Hasthepatientbeendiagnosedwithanewlocal-regionalrecurrencesincesubmissionofthelastfollow-upform?

    Datatype

    text

    Date of new Local-Regional Recurrence
    Beschrijving

    DateofnewLocal-RegionalRecurrence

    Datatype

    text

    Site(s) of First Local-Regional Recurrence (mark all that apply with an X)
    Beschrijving

    Site(s)ofFirstLocal-RegionalRecurrence

    Datatype

    text

    How was this recurrence information obtained?
    Beschrijving

    Howwasthisrecurrenceinformationobtained?

    Datatype

    text

    Has the patient been diagnosed with a first distant progression since submission of the last follow-up form? (IF YES, continued)
    Beschrijving

    Hasthepatientbeendiagnosedwithafirstdistantprogressionsincesubmissionofthelastfollow-upform?

    Datatype

    text

    Date of First Distant Progression
    Beschrijving

    ProgressionDate,FirstDistant

    Datatype

    date

    Site(s) of First Distant Progression
    Beschrijving

    Site(s)ofFirstDistantProgression

    Datatype

    text

    How was this progression information obtained?
    Beschrijving

    Howwasthisprogressioninformationobtained?

    Datatype

    text

    Comments
    Beschrijving

    Comments

    Comments
    Beschrijving

    Comments

    Datatype

    text

    Terug naar het begin van de pagina

    Similar models

    No Instruction available.

    1 Formulieren
    1. StudyEvent: CALGB: 49808 RESPONSE/PROGRESSION FORM
      1. No Instruction available.
    Name
    Type
    Description | Question | Decode (Coded Value)
    Datatype
    Alias
    Item Group
    Unnamed1
    CALGBForm
    Item
    CALGB Form
    text
    CALGBProtocolNumber
    Item
    CALGB Study No
    text
    CALGBPatientID
    Item
    CALGB Patient ID
    text
    From
    Item
    From
    text
    To
    Item
    To (Date of last contact or death)
    text
    Item
    Amended data?
    text
    C25474 (NCI Thesaurus ObjectClass)
    C1511726 (UMLS 2011AA ObjectClass)
    C25416 (NCI Thesaurus Property)
    C1691222 (UMLS 2011AA Property)
    CL.1
    Code List
    Amended data?
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    Item Group
    Unnamed2
    Patient'sName
    Item
    Patient's Name
    text
    ParticipatingGroup
    Item
    Participating Group
    text
    C17005 (NCI Thesaurus ObjectClass)
    C1257890 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    PatientHospitalNumber
    Item
    Patient Hospital Number
    text
    ParticipatingGroupProtocolNo.
    Item
    Participating Group Protocol No.
    text
    MainMemberInstitution/Adjunct
    Item
    Main Member Institution/Adjunct
    text
    ParticipatingGroupPatientNo.
    Item
    Participating Group Patient No.
    text
    Item Group
    Response Assessment (clinical/radiographic)
    Item
    Has the patient achieved a response (not previously reported)?
    text
    CL.2
    Code List
    Has the patient achieved a response (not previously reported)?
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    Dateoverallpartialresponsefirstdocumented
    Item
    Date overall partial response first documented
    text
    Dateoverallcompleteresponsefirstdocumented
    Item
    Date overall complete response first documented
    text
    Item
    Has the patient been diagnosed with a new progression during this reporting period (not previously reported)?
    text
    CL.3
    Code List
    Has the patient been diagnosed with a new progression during this reporting period (not previously reported)?
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    Dateresponse/stablediseaselastdocumented
    Item
    Date response/stable disease last documented (IF NO:)
    text
    Item
    Has the patient been diagnosed with a new local-regional recurrence since submission of the last follow-up form? (IF YES:)
    text
    CL.4
    Code List
    Has the patient been diagnosed with a new local-regional recurrence since submission of the last follow-up form? (IF YES:)
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    DateofnewLocal-RegionalRecurrence
    Item
    Date of new Local-Regional Recurrence
    text
    Item
    Site(s) of First Local-Regional Recurrence (mark all that apply with an X)
    text
    CL.5
    Code List
    Site(s) of First Local-Regional Recurrence (mark all that apply with an X)
    CL Item
    Ipsilateral Breast (Ipsilateral breast)
    CL Item
    Chest Wall (Chest wall)
    CL035093 (NCI Metathesaurus)
    C62484 (NCI Thesaurus)
    C0205076 (UMLS 2011AA)
    CL Item
    Axillary Nodes (Axillary nodes)
    CL Item
    Internal Mammary (Internal mammary)
    CL Item
    Supraclavicular Nodes (Supraclavicular nodes)
    CL Item
    Axilla (Axilla)
    C12674 (NCI Thesaurus)
    C0004454 (UMLS 2011AA)
    CL Item
    Infraclavicular Nodes (Infraclavicular nodes)
    Item
    How was this recurrence information obtained?
    text
    CL.6
    Code List
    How was this recurrence information obtained?
    CL Item
    Documented Clinical Assessment (Documented clinical assessment)
    CL Item
    Patient Self Report Only (Patient self report only)
    Item
    Has the patient been diagnosed with a first distant progression since submission of the last follow-up form? (IF YES, continued)
    text
    CL.7
    Code List
    Has the patient been diagnosed with a first distant progression since submission of the last follow-up form? (IF YES, continued)
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    ProgressionDate,FirstDistant
    Item
    Date of First Distant Progression
    date
    Site(s)ofFirstDistantProgression
    Item
    Site(s) of First Distant Progression
    text
    Item
    How was this progression information obtained?
    text
    CL.8
    Code List
    How was this progression information obtained?
    CL Item
    Documented Clinical Assessment (Documented clinical assessment)
    CL Item
    Patient Self Report Only (Patient self report only)
    Item Group
    Comments
    Comments
    Item
    Comments
    text
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