ID

6907

Descrizione

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

collegamento

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=99CD59C5-A9B4-3FA4-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

Per favore, per richiedere un accesso.

Licenza

Creative Commons BY-NC 3.0 Legacy
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Treatment - Upper Gastrointestinal Cancers - Treatment Summary Form - 2020210v2.31

Inglese

No Instruction available.

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

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

Gi: Treatment Plan
Descrizione

Gi: Treatment Plan

Treatment Begin Date
Descrizione

TreatmentBeginDate

Tipo di dati

date

Treatment End Date
Descrizione

TreatmentEndDate

Tipo di dati

date

Off Treatment Reason
Descrizione

OffTreatmentReason

Tipo di dati

text

Off Treatment Reason, Other
Descrizione

OffTreatmentReason,Other

Tipo di dati

text

Gi: Treatment Summary - Surgery
Descrizione

Gi: Treatment Summary - Surgery

Protocol Treatment, Surgery Ind
Descrizione

ProtocolTreatment,SurgeryInd

Tipo di dati

text

Protocol Surgery Date
Descrizione

ProtocolSurgeryDate

Tipo di dati

date

Protocol Surgery Type
Descrizione

ProtocolSurgeryType

Tipo di dati

text

Surgical Treatment Completed
Descrizione

SurgicalTreatmentCompleted

Tipo di dati

text

Surgical Treatment Modification Reason
Descrizione

SurgicalTreatmentModificationReason

Tipo di dati

text

Gi: Treatment Summary - Radiation Therapy
Descrizione

Gi: Treatment Summary - Radiation Therapy

Protocol Treatment, RT Ind
Descrizione

ProtocolTreatment,RTInd

Tipo di dati

text

RT Begin Date
Descrizione

RTBeginDate

Tipo di dati

date

RT End Date
Descrizione

RTEndDate

Tipo di dati

date

RT Type
Descrizione

RTType

Tipo di dati

text

RT Type, Other
Descrizione

RTType,Other

Tipo di dati

text

RT Site
Descrizione

RTSite

Tipo di dati

text

RT Interruptions Ind
Descrizione

RTInterruptionsInd

Tipo di dati

text

RT Interruptions Reason
Descrizione

RTInterruptionsReason

Tipo di dati

text

Gi: Treatment Summary - Systemic Therapy
Descrizione

Gi: Treatment Summary - Systemic Therapy

Protocol Treatment, Systemic Therapy Ind
Descrizione

ProtocolTreatment,SystemicTherapyInd

Tipo di dati

text

First Treatment Start Date
Descrizione

FirstTreatmentStartDate

Tipo di dati

date

Last Treatment Date
Descrizione

LastTreatmentDate

Tipo di dati

date

Systemic Therapy Type
Descrizione

SystemicTherapyType

Tipo di dati

text

Systemic Therapy Type, Other
Descrizione

SystemicTherapyType,Other

Tipo di dati

text

Agent Name
Descrizione

AgentName

Tipo di dati

text

Dose Modification (Change)
Descrizione

DoseModification(Change)

Tipo di dati

text

Therapy Modification Name
Descrizione

TherapyModificationName

Tipo di dati

text

Therapy Modification Reason
Descrizione

TherapyModificationReason

Tipo di dati

text

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Similar models

No Instruction available.

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