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6935

Description

NCI Cooperative Group On-Study Form (CALGB-90104) Combination Chemotherapy in Treating Patients With Bladder Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A9C0279B-A154-2673-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A9C0279B-A154-2673-E034-0003BA12F5E7

Keywords

Versions (2)
  1. 8/26/12 8/26/12 -
  2. 1/8/15 1/8/15 - Martin Dugas
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January 8, 2015

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Creative Commons BY-NC 3.0 Legacy
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    Bladder Cancer NCT00014534 On-Study - NCI Cooperative Group On-Study Form (CALGB-90104) - 2056020v3.0

    English

    No Instruction available.

    1 forms  
    1. StudyEvent: NCI Cooperative Group On-Study Form (CALGB-90104)
      1. No Instruction available.
    Mskcc 00-138; Calgb-90104; Ecog
    Description

    Mskcc 00-138; Calgb-90104; Ecog

    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

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

    InstitutionName

    Data type

    text

    Affiliate
    Description

    AffiliateName

    Data type

    text

    Patient Last Name (initials acceptable)
    Description

    PatientName,Last

    Data type

    text

    Patient First Name (initials acceptable)
    Description

    PatientName,First

    Data type

    text

    Patient Middle Name (initials acceptable)
    Description

    PatientName,Middle

    Data type

    text

    Form Administration
    Description

    Form Administration

    Person Completing Form, Last Name
    Description

    PersonCompletingForm,LastName

    Data type

    text

    Person Completing Form, First Name
    Description

    PersonCompletingForm,FirstName

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C25190
    UMLS 2011AA ObjectClass
    C0027361
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    Are data amended?
    Description

    AmendedDataInd

    Data type

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C25474
    UMLS 2011AA ObjectClass
    C1511726
    NCI Thesaurus Property
    C25416
    UMLS 2011AA Property
    C1691222
    Disease Description For Muscle Invasive Bladder Cancer
    Description

    Disease Description For Muscle Invasive Bladder Cancer

    Date of Initial Symptom
    Description

    SymptomaticDeteriorationDate

    Data type

    date

    Has the patient had a prior history of superficial disease?
    Description

    PriorSuperficialDiseaseInd

    Data type

    boolean

    No. of Prior Occurrences of Papillary
    Description

    PriorPapillaryOccurrences

    Data type

    float

    NO. of Prior Occurrences of CIS
    Description

    PriorCISOccurrences

    Data type

    float

    Date of Initial Pathologic Diagnosis
    Description

    InitialDiagnosisDate

    Data type

    date

    Date of Initial Pathologic Diagnosis
    Description

    InitialDiagnosisDate

    Data type

    date

    Date of Initial Diagnosis of Metastatic Disease
    Description

    InitialDiagnosisDate,Metastatic

    Data type

    date

    Date of Current Pathologic Diagnosis
    Description

    PathologicDiagnosisDate

    Data type

    date

    Date of Most Recent Prior Recurrence
    Description

    PriorRecentRecurrenceDate

    Data type

    date

    Alias
    NCI Thesaurus ObjectClass
    C2991
    UMLS 2011AA ObjectClass
    C0012634
    NCI Thesaurus Property
    C25279
    UMLS 2011AA Property
    C0332162
    Histologic Type (mark all that apply)
    Description

    HistologicType

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25372
    UMLS 2011AA ValueDomain
    C0683312
    NCI Thesaurus ValueDomain-2
    C25526
    UMLS 2011AA ValueDomain-2
    C0205462
    Other, specify
    Description

    HistologicType,OtherName

    Data type

    text

    Histologic Grade (check the highest grade)
    Description

    HistologicGrade

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25526
    UMLS 2011AA ValueDomain
    C0205462
    NCI Thesaurus ValueDomain-2
    C18000
    UMLS 2011AA ValueDomain-2
    C0919553
    Pathologic T Stage (Indicate highest stage at the current presentation of disease)
    Description

    TStage,Pathologic

    Data type

    text

    Pathologic N Stage (Distant Metastasis)
    Description

    NStage,Pathologic

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C16899
    UMLS 2011AA ValueDomain
    C1300072
    Pathologic M Stage
    Description

    MStage,Pathologic

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C16899
    UMLS 2011AA ValueDomain
    C1300072
    Lymph Node Type
    Description

    LymphNodesType

    Data type

    text

    Other, specify
    Description

    LymphNodeType,Other

    Data type

    text

    Lymph Node Involvement
    Description

    LymphNodeInvolvement

    Data type

    text

    No. of Lymph Nodes Examined
    Description

    LymphNode(s)ExaminedNumber

    Data type

    float

    Alias
    NCI Thesaurus Property
    C25500
    UMLS 2011AA Property
    C0332128
    NCI Thesaurus ObjectClass
    C12745
    UMLS 2011AA ObjectClass
    C0024204
    No. of Positive Lymph Nodes
    Description

    LymphNode(s)PositiveNumber

    Data type

    float

    Alias
    NCI Thesaurus Property
    C25246
    UMLS 2011AA Property
    C1446409
    NCI Thesaurus ObjectClass
    C12745
    UMLS 2011AA ObjectClass
    C0024204
    Is the tumor(s) at the surgical margin?
    Description

    TumorMarginInd

    Data type

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C3262
    UMLS 2011AA ObjectClass
    C0027651
    NCI Thesaurus Property
    C25563
    UMLS 2011AA Property
    C0205284
    Muscle Invasive Bladder Disease: Prior Treatment Affecting The Bladder
    Description

    Muscle Invasive Bladder Disease: Prior Treatment Affecting The Bladder

    Prior Intravesical Therapy (Note: If no, skip to Prior Surgery below)
    Description

    PriorIntravesicalTherapyInd

    Data type

    boolean

    Type of Prior Immunotherapy
    Description

    PriorImmunotherapyType

    Data type

    text

    No. of Courses
    Description

    PriorImmunotherapyCount

    Data type

    float

    Specify agent
    Description

    PriorImmunotherapyOtherAgent

    Data type

    text

    Agent Start Date
    Description

    AgentBeginDate

    Data type

    date

    Agent End Date
    Description

    AgentEndDate

    Data type

    date

    Type of Prior Chemotherapy
    Description

    PriorIntravesicalChemotherapyType

    Data type

    text

    No. of Courses
    Description

    PriorChemotherapyCount

    Data type

    float

    Specify agent
    Description

    PriorIntravesicalChemotherapyOtherAgent

    Data type

    text

    Prior Surgery (for urothelial disease)
    Description

    PriorSurgeryInd

    Data type

    boolean

    Prior Surgery Type
    Description

    PriorSurgeryType

    Data type

    text

    Other, specify
    Description

    PriorSurgeryType,Other

    Data type

    text

    TURBT, Number
    Description

    PriorSurgery,TURBTCount

    Data type

    float

    Any Other Prior Therapy
    Description

    PriorOtherTherapyInd

    Data type

    boolean

    Name of other Prior Therapies
    Description

    PriorOtherTherapyName

    Data type

    text

    Comments
    Description

    Comments

    Comments
    Description

    Comments

    Data type

    text

    Ccrr Module For Nci Cooperative Group On-study Form (calgb-90104)
    Description

    Ccrr Module For Nci Cooperative Group On-study Form (calgb-90104)

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    Similar models

    No Instruction available.

    1 forms
    1. StudyEvent: NCI Cooperative Group On-Study Form (CALGB-90104)
      1. No Instruction available.
    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    Alias
    Item Group
    Mskcc 00-138; Calgb-90104; Ecog
    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
    text
    PatientName,Last
    Item
    Patient Last Name (initials acceptable)
    text
    PatientName,First
    Item
    Patient First Name (initials acceptable)
    text
    PatientName,Middle
    Item
    Patient Middle Name (initials acceptable)
    text
    Item Group
    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)
    AmendedDataInd
    Item
    Are data amended?
    boolean
    C25474 (NCI Thesaurus ObjectClass)
    C1511726 (UMLS 2011AA ObjectClass)
    C25416 (NCI Thesaurus Property)
    C1691222 (UMLS 2011AA Property)
    Item Group
    Disease Description For Muscle Invasive Bladder Cancer
    SymptomaticDeteriorationDate
    Item
    Date of Initial Symptom
    date
    PriorSuperficialDiseaseInd
    Item
    Has the patient had a prior history of superficial disease?
    boolean
    PriorPapillaryOccurrences
    Item
    No. of Prior Occurrences of Papillary
    float
    PriorCISOccurrences
    Item
    NO. of Prior Occurrences of CIS
    float
    InitialDiagnosisDate
    Item
    Date of Initial Pathologic Diagnosis
    date
    InitialDiagnosisDate
    Item
    Date of Initial Pathologic Diagnosis
    date
    InitialDiagnosisDate,Metastatic
    Item
    Date of Initial Diagnosis of Metastatic Disease
    date
    PathologicDiagnosisDate
    Item
    Date of Current Pathologic Diagnosis
    date
    PriorRecentRecurrenceDate
    Item
    Date of Most Recent Prior Recurrence
    date
    C2991 (NCI Thesaurus ObjectClass)
    C0012634 (UMLS 2011AA ObjectClass)
    C25279 (NCI Thesaurus Property)
    C0332162 (UMLS 2011AA Property)
    Item
    Histologic Type (mark all that apply)
    text
    C25372 (NCI Thesaurus ValueDomain)
    C0683312 (UMLS 2011AA ValueDomain)
    C25526 (NCI Thesaurus ValueDomain-2)
    C0205462 (UMLS 2011AA ValueDomain-2)
    CL.3
    Code List
    Histologic Type (mark all that apply)
    CL Item
    Transitional Cell Carcinoma (Transitional cell carcinoma)
    C2930 (NCI Thesaurus)
    C0007138 (UMLS 2011AA)
    CL Item
    Other Specify (Other, specify)
    HistologicType,OtherName
    Item
    Other, specify
    text
    Item
    Histologic Grade (check the highest grade)
    text
    C25526 (NCI Thesaurus ValueDomain)
    C0205462 (UMLS 2011AA ValueDomain)
    C18000 (NCI Thesaurus ValueDomain-2)
    C0919553 (UMLS 2011AA ValueDomain-2)
    CL.4
    Code List
    Histologic Grade (check the highest grade)
    CL Item
    Well Differentiated (Well differentiated (G1))
    C14171 (NCI Thesaurus)
    C0205615 (UMLS 2011AA)
    CL Item
    Moderately Differentiated (Moderately differentiated (G2))
    C14162 (NCI Thesaurus)
    C0205616 (UMLS 2011AA)
    CL Item
    Poorly Differentiated (Poorly differentiated (G3))
    C14167 (NCI Thesaurus)
    C0205617 (UMLS 2011AA)
    CL Item
    Tumor Grade Cannot Be Assessed (Grade cannot be assessed (GX))
    Item
    Pathologic T Stage (Indicate highest stage at the current presentation of disease)
    text
    CL.5
    Code List
    Pathologic T Stage (Indicate highest stage at the current presentation of disease)
    CL Item
    No Evidence Of Primary Tumor (T0)
    CL Item
    Tumor Invades Subepithelial Connective Tissue (T1)
    CL Item
    Tumor Invades Superficial Muscles (inner Half) (T2a)
    CL Item
    Tumor Invades Deep Muscles (outer Half) (T2b)
    CL Item
    Tumor Invades Perivesical Tissue Microscopically (T3a)
    CL Item
    Tumor Invades Perivesical Tissue Macroscopically (extravesical Mass) (T3b)
    CL Item
    Inflammatory Carcinoma (T4)
    C0334385 (NCI Metathesaurus)
    Item
    Pathologic N Stage (Distant Metastasis)
    text
    C16899 (NCI Thesaurus ValueDomain)
    C1300072 (UMLS 2011AA ValueDomain)
    CL.6
    Code List
    Pathologic N Stage (Distant Metastasis)
    CL Item
    No Regional Lymph Node Metastasis (N0)
    CL Item
    Metastasis In A Single Lymph Node, 2 Cm Or Less In Greatest Dimension (N1)
    CL Item
    Metastasis In A Single Lymph Node, More Than 2 Cm But Not More Than 5 Cm In Greatest Dimension; Or Multiple Lymph Nodes, None More Than 5 Cm In Greatest Dimension (N2)
    CL Item
    Metastasis In A Lymph Node More Than 5 Cm In Greatest Dimension (N3)
    CL Item
    Regional Lymph Nodes Cannot Be Assessed (Nx)
    Item
    Pathologic M Stage
    text
    C16899 (NCI Thesaurus ValueDomain)
    C1300072 (UMLS 2011AA ValueDomain)
    CL.7
    Code List
    Pathologic M Stage
    CL Item
    M0, According To Ajcc Staging Definitions (M0)
    CL Item
    M1, According To Ajcc Staging Definitions (M1)
    CL Item
    Mx (Mx)
    Item
    Lymph Node Type
    text
    CL.8
    Code List
    Lymph Node Type
    CL Item
    Internal Iliac (Internal Iliac)
    CL Item
    External Iliac (External Iliac)
    CL Item
    Common Iliac (Common Iliac)
    CL Item
    Hypogastric (Hypogastric)
    CL Item
    Para-aortic (Para-aortic)
    CL Item
    Other, Specify (Other, specify)
    LymphNodeType,Other
    Item
    Other, specify
    text
    Item
    Lymph Node Involvement
    text
    CL.9
    Code List
    Lymph Node Involvement
    CL Item
    Not Evaluated (not evaluated)
    CL Item
    Positive (positive)
    CL Item
    Negative (negative)
    CL Item
    Equivocal (equivocal)
    CL Item
    Unknown (unknown)
    LymphNode(s)ExaminedNumber
    Item
    No. of Lymph Nodes Examined
    float
    C25500 (NCI Thesaurus Property)
    C0332128 (UMLS 2011AA Property)
    C12745 (NCI Thesaurus ObjectClass)
    C0024204 (UMLS 2011AA ObjectClass)
    LymphNode(s)PositiveNumber
    Item
    No. of Positive Lymph Nodes
    float
    C25246 (NCI Thesaurus Property)
    C1446409 (UMLS 2011AA Property)
    C12745 (NCI Thesaurus ObjectClass)
    C0024204 (UMLS 2011AA ObjectClass)
    TumorMarginInd
    Item
    Is the tumor(s) at the surgical margin?
    boolean
    C3262 (NCI Thesaurus ObjectClass)
    C0027651 (UMLS 2011AA ObjectClass)
    C25563 (NCI Thesaurus Property)
    C0205284 (UMLS 2011AA Property)
    Item Group
    Muscle Invasive Bladder Disease: Prior Treatment Affecting The Bladder
    PriorIntravesicalTherapyInd
    Item
    Prior Intravesical Therapy (Note: If no, skip to Prior Surgery below)
    boolean
    Item
    Type of Prior Immunotherapy
    text
    CL.12
    Code List
    Type of Prior Immunotherapy
    CL Item
    Bcg (BCG)
    C1328 (NCI Thesaurus)
    CL Item
    Interferon (Interferon)
    C20493 (NCI Thesaurus)
    C0733470 (UMLS 2011AA)
    CL Item
    Other (Other)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    PriorImmunotherapyCount
    Item
    No. of Courses
    float
    PriorImmunotherapyOtherAgent
    Item
    Specify agent
    text
    AgentBeginDate
    Item
    Agent Start Date
    date
    AgentEndDate
    Item
    Agent End Date
    date
    Item
    Type of Prior Chemotherapy
    text
    CL.13
    Code List
    Type of Prior Chemotherapy
    CL Item
    Mmc (MMC)
    CL Item
    Thiotepa (Thiotepa)
    C875 (NCI Thesaurus)
    C0039871 (UMLS 2011AA)
    CL Item
    Other (Other)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    PriorChemotherapyCount
    Item
    No. of Courses
    float
    PriorIntravesicalChemotherapyOtherAgent
    Item
    Specify agent
    text
    PriorSurgeryInd
    Item
    Prior Surgery (for urothelial disease)
    boolean
    Item
    Prior Surgery Type
    text
    CL.15
    Code List
    Prior Surgery Type
    CL Item
    Patient Previosly Had A Partial Cystectomy (Partial cystectomy)
    CL Item
    Patient Previosly Had A Radical Cystectomy (radical cystectomy)
    CL Item
    Patient Previosly Had A Turbt (TURBT)
    CL Item
    Patient Previously Had Other Surgery, Specify (Other, specify)
    PriorSurgeryType,Other
    Item
    Other, specify
    text
    PriorSurgery,TURBTCount
    Item
    TURBT, Number
    float
    PriorOtherTherapyInd
    Item
    Any Other Prior Therapy
    boolean
    PriorOtherTherapyName
    Item
    Name of other Prior Therapies
    text
    Item Group
    Comments
    Comments
    Item
    Comments
    text
    Item Group
    Ccrr Module For Nci Cooperative Group On-study Form (calgb-90104)
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