ID

6907

Beschrijving

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

Trefwoorden

Versies (2)
  1. 19-09-12 19-09-12 -
  2. 08-01-15 08-01-15 - Martin Dugas
Geüploaded op

8 januari 2015

DOI

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Licentie

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

Engels

No Instruction available.

1 Formulieren  
  1. StudyEvent: Upper Gastrointestinal Cancers - Treatment Summary Form
    1. No Instruction available.
Crf Header
Beschrijving

Crf Header

Coordinating Group Protocol Number
Beschrijving

CoordinatingGroupProtocolNumber

Datatype

text

Coordinating Group Code
Beschrijving

CoordinatingGroupCode

Datatype

text

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

Protocol Title

Datatype

text

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

PatientStudyID,CoordinatingGroup

Datatype

text

Patient Study ID, Participating Group
Beschrijving

PatientStudyID,ParticipatingGroup

Datatype

text

Participating Group Code
Beschrijving

ParticipatingGroupCode

Datatype

text

Institution Name
Beschrijving

InstitutionName

Datatype

text

Affiliate Name
Beschrijving

AffiliateName

Datatype

text

Patient Name, Last
Beschrijving

PatientName,Last

Datatype

text

Patient Name, First
Beschrijving

PatientName,First

Datatype

text

Patient Name, Middle
Beschrijving

PatientName,Middle

Datatype

text

Gi: Treatment Plan
Beschrijving

Gi: Treatment Plan

Treatment Begin Date
Beschrijving

TreatmentBeginDate

Datatype

date

Treatment End Date
Beschrijving

TreatmentEndDate

Datatype

date

Off Treatment Reason
Beschrijving

OffTreatmentReason

Datatype

text

Off Treatment Reason, Other
Beschrijving

OffTreatmentReason,Other

Datatype

text

Gi: Treatment Summary - Surgery
Beschrijving

Gi: Treatment Summary - Surgery

Protocol Treatment, Surgery Ind
Beschrijving

ProtocolTreatment,SurgeryInd

Datatype

text

Protocol Surgery Date
Beschrijving

ProtocolSurgeryDate

Datatype

date

Protocol Surgery Type
Beschrijving

ProtocolSurgeryType

Datatype

text

Surgical Treatment Completed
Beschrijving

SurgicalTreatmentCompleted

Datatype

text

Surgical Treatment Modification Reason
Beschrijving

SurgicalTreatmentModificationReason

Datatype

text

Gi: Treatment Summary - Radiation Therapy
Beschrijving

Gi: Treatment Summary - Radiation Therapy

Protocol Treatment, RT Ind
Beschrijving

ProtocolTreatment,RTInd

Datatype

text

RT Begin Date
Beschrijving

RTBeginDate

Datatype

date

RT End Date
Beschrijving

RTEndDate

Datatype

date

RT Type
Beschrijving

RTType

Datatype

text

RT Type, Other
Beschrijving

RTType,Other

Datatype

text

RT Site
Beschrijving

RTSite

Datatype

text

RT Interruptions Ind
Beschrijving

RTInterruptionsInd

Datatype

text

RT Interruptions Reason
Beschrijving

RTInterruptionsReason

Datatype

text

Gi: Treatment Summary - Systemic Therapy
Beschrijving

Gi: Treatment Summary - Systemic Therapy

Protocol Treatment, Systemic Therapy Ind
Beschrijving

ProtocolTreatment,SystemicTherapyInd

Datatype

text

First Treatment Start Date
Beschrijving

FirstTreatmentStartDate

Datatype

date

Last Treatment Date
Beschrijving

LastTreatmentDate

Datatype

date

Systemic Therapy Type
Beschrijving

SystemicTherapyType

Datatype

text

Systemic Therapy Type, Other
Beschrijving

SystemicTherapyType,Other

Datatype

text

Agent Name
Beschrijving

AgentName

Datatype

text

Dose Modification (Change)
Beschrijving

DoseModification(Change)

Datatype

text

Therapy Modification Name
Beschrijving

TherapyModificationName

Datatype

text

Therapy Modification Reason
Beschrijving

TherapyModificationReason

Datatype

text

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Similar models

No Instruction available.

1 Formulieren
  1. StudyEvent: Upper Gastrointestinal Cancers - Treatment Summary Form
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Datatype
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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