ID

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
Uploaded on

January 8, 2015

DOI

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License

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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