ID

6907

Description

Upper Gastrointestinal Cancers - Treatment Summary Form Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=99CD59C5-A9B4-3FA4-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=99CD59C5-A9B4-3FA4-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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Treatment - Upper Gastrointestinal Cancers - Treatment Summary Form - 2020210v2.31

English

No Instruction available.

1 forms  
  1. StudyEvent: Upper Gastrointestinal Cancers - Treatment Summary 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

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

Gi: Treatment Plan
Description

Gi: Treatment Plan

Treatment Begin Date
Description

TreatmentBeginDate

Data type

date

Treatment End Date
Description

TreatmentEndDate

Data type

date

Off Treatment Reason
Description

OffTreatmentReason

Data type

text

Off Treatment Reason, Other
Description

OffTreatmentReason,Other

Data type

text

Gi: Treatment Summary - Surgery
Description

Gi: Treatment Summary - Surgery

Protocol Treatment, Surgery Ind
Description

ProtocolTreatment,SurgeryInd

Data type

text

Protocol Surgery Date
Description

ProtocolSurgeryDate

Data type

date

Protocol Surgery Type
Description

ProtocolSurgeryType

Data type

text

Surgical Treatment Completed
Description

SurgicalTreatmentCompleted

Data type

text

Surgical Treatment Modification Reason
Description

SurgicalTreatmentModificationReason

Data type

text

Gi: Treatment Summary - Radiation Therapy
Description

Gi: Treatment Summary - Radiation Therapy

Protocol Treatment, RT Ind
Description

ProtocolTreatment,RTInd

Data type

text

RT Begin Date
Description

RTBeginDate

Data type

date

RT End Date
Description

RTEndDate

Data type

date

RT Type
Description

RTType

Data type

text

RT Type, Other
Description

RTType,Other

Data type

text

RT Site
Description

RTSite

Data type

text

RT Interruptions Ind
Description

RTInterruptionsInd

Data type

text

RT Interruptions Reason
Description

RTInterruptionsReason

Data type

text

Gi: Treatment Summary - Systemic Therapy
Description

Gi: Treatment Summary - Systemic Therapy

Protocol Treatment, Systemic Therapy Ind
Description

ProtocolTreatment,SystemicTherapyInd

Data type

text

First Treatment Start Date
Description

FirstTreatmentStartDate

Data type

date

Last Treatment Date
Description

LastTreatmentDate

Data type

date

Systemic Therapy Type
Description

SystemicTherapyType

Data type

text

Systemic Therapy Type, Other
Description

SystemicTherapyType,Other

Data type

text

Agent Name
Description

AgentName

Data type

text

Dose Modification (Change)
Description

DoseModification(Change)

Data type

text

Therapy Modification Name
Description

TherapyModificationName

Data type

text

Therapy Modification Reason
Description

TherapyModificationReason

Data type

text

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1 forms
  1. StudyEvent: Upper Gastrointestinal Cancers - Treatment Summary 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
Item
Participating Group Code
text
CL.1
Code List
Participating Group Code
CL Item
Http://ctep.info.nih.gov. (http://ctep.info.nih.gov.)
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
Gi: Treatment Plan
TreatmentBeginDate
Item
Treatment Begin Date
date
TreatmentEndDate
Item
Treatment End Date
date
Item
Off Treatment Reason
text
CL.2
Code List
Off Treatment Reason
CL Item
Alternative Therapy (Alternative therapy)
CL Item
Death After Beginning Protocol Therapy (Death after beginning protocol therapy)
CL Item
Death On Study (Death on study)
CL Item
Death Prior To Beginning Protocol Therapy (Death prior to beginning protocol therapy)
CL Item
Disease Progression, Relapse During Active Treatment (Disease progression, relapse during active treatment)
CL Item
Treatment Completed Per Protocol Criteria (Treatment completed per protocol criteria)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
CL Item
Patient Off-treatment For Other Complicating Disease (Patient off-treatment for other complicating disease)
CL Item
Patient Withdrawal Or Refusal After Beginning Protocol Therapy (Patient withdrawal or refusal after beginning protocol therapy)
CL Item
Patient Withdrawal Or Refusal Prior To Beginning Protocol Therapy (Patient withdrawal or refusal prior to beginning protocol therapy)
CL Item
Toxicity/side Effects/complications (Toxicity/Side effects/Complications)
CL Item
Disease Progression, Relapse Prior To Beginning Protocol Therapy (Disease progression, relapse prior to beginning protocol therapy)
OffTreatmentReason,Other
Item
Off Treatment Reason, Other
text
Item Group
Gi: Treatment Summary - Surgery
Item
Protocol Treatment, Surgery Ind
text
CL.3
Code List
Protocol Treatment, Surgery Ind
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
ProtocolSurgeryDate
Item
Protocol Surgery Date
date
ProtocolSurgeryType
Item
Protocol Surgery Type
text
Item
Surgical Treatment Completed
text
CL.4
Code List
Surgical Treatment Completed
CL Item
Yes, Surgical Treatment Was Completed As Per Protocol (Yes)
CL Item
No, Surgical Treatment Was Not Done (specify) (no, surgical treatment was not done (specify))
CL Item
No, Surgical Treatment Was Modified From Protocol Specification (specify) (no, surgical treatment was modified from protocol specification (specify))
SurgicalTreatmentModificationReason
Item
Surgical Treatment Modification Reason
text
Item Group
Gi: Treatment Summary - Radiation Therapy
Item
Protocol Treatment, RT Ind
text
CL.5
Code List
Protocol Treatment, RT Ind
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
RTBeginDate
Item
RT Begin Date
date
RTEndDate
Item
RT End Date
date
Item
RT Type
text
CL.6
Code List
RT Type
CL Item
Adjuvant Radiation Therapy (Adjuvant RT)
CL Item
Brachytherapy (Brachytherapy)
CL054378 (NCI Metathesaurus)
CL Item
Palliative Radiation Therapy (Palliative RT)
CL Item
Neoadjuvant Radiation Therapy (Neoadjuvant RT)
CL Item
Other, Specify (Other, specify)
CL Item
External Beam Radiation (External beam radiation)
RTType,Other
Item
RT Type, Other
text
RTSite
Item
RT Site
text
Item
RT Interruptions Ind
text
CL.7
Code List
RT Interruptions Ind
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes, For Other Reasons, Specify (Yes, for other reasons, specify)
CL Item
Yes, Due To Toxicity (Yes, due to toxicity)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
RTInterruptionsReason
Item
RT Interruptions Reason
text
Item Group
Gi: Treatment Summary - Systemic Therapy
Item
Protocol Treatment, Systemic Therapy Ind
text
CL.8
Code List
Protocol Treatment, Systemic Therapy Ind
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
FirstTreatmentStartDate
Item
First Treatment Start Date
date
LastTreatmentDate
Item
Last Treatment Date
date
Item
Systemic Therapy Type
text
CL.9
Code List
Systemic Therapy Type
CL Item
Chemotherapy (Chemotherapy)
C15632 (NCI Thesaurus)
C0392920 (UMLS 2011AA)
CL Item
Other Specify (Other, specify)
CL Item
Immunotherapy (Immunotherapy)
C15262 (NCI Thesaurus)
C0021083 (UMLS 2011AA)
SystemicTherapyType,Other
Item
Systemic Therapy Type, Other
text
AgentName
Item
Agent Name
text
Item
Dose Modification (Change)
text
CL.10
Code List
Dose Modification (Change)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
(i.e., The Treatment Change Was Not Part Of Protocol Guidelines) (Yes, unplanned)
CL Item
(i.e., The Treatment Was Changed According To Protocol Guidelines) (Yes, planned)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
TherapyModificationName
Item
Therapy Modification Name
text
TherapyModificationReason
Item
Therapy Modification Reason
text
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