ID

6935

Descrição

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

Palavras-chave

  1. 26/08/2012 26/08/2012 -
  2. 08/01/2015 08/01/2015 - Martin Dugas
Transferido a

8 de janeiro de 2015

DOI

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Licença

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

No Instruction available.

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

Mskcc 00-138; Calgb-90104; Ecog

Coordinating Group Protocol Number
Descrição

CoordinatingGroupProtocolNumber

Tipo de dados

text

Coordinating Group Code
Descrição

CoordinatingGroupCode

Tipo de dados

text

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

Protocol Title

Tipo de dados

text

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

PatientStudyID,CoordinatingGroup

Tipo de dados

text

Patient Study ID, Participating Group
Descrição

PatientStudyID,ParticipatingGroup

Tipo de dados

text

Participating Group Code
Descrição

ParticipatingGroupCode

Tipo de dados

text

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

InstitutionName

Tipo de dados

text

Affiliate
Descrição

AffiliateName

Tipo de dados

text

Patient Last Name (initials acceptable)
Descrição

PatientName,Last

Tipo de dados

text

Patient First Name (initials acceptable)
Descrição

PatientName,First

Tipo de dados

text

Patient Middle Name (initials acceptable)
Descrição

PatientName,Middle

Tipo de dados

text

Form Administration
Descrição

Form Administration

Person Completing Form, Last Name
Descrição

PersonCompletingForm,LastName

Tipo de dados

text

Person Completing Form, First Name
Descrição

PersonCompletingForm,FirstName

Tipo de dados

text

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

AmendedDataInd

Tipo de dados

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
Descrição

Disease Description For Muscle Invasive Bladder Cancer

Date of Initial Symptom
Descrição

SymptomaticDeteriorationDate

Tipo de dados

date

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

PriorSuperficialDiseaseInd

Tipo de dados

boolean

No. of Prior Occurrences of Papillary
Descrição

PriorPapillaryOccurrences

Tipo de dados

float

NO. of Prior Occurrences of CIS
Descrição

PriorCISOccurrences

Tipo de dados

float

Date of Initial Pathologic Diagnosis
Descrição

InitialDiagnosisDate

Tipo de dados

date

Date of Initial Pathologic Diagnosis
Descrição

InitialDiagnosisDate

Tipo de dados

date

Date of Initial Diagnosis of Metastatic Disease
Descrição

InitialDiagnosisDate,Metastatic

Tipo de dados

date

Date of Current Pathologic Diagnosis
Descrição

PathologicDiagnosisDate

Tipo de dados

date

Date of Most Recent Prior Recurrence
Descrição

PriorRecentRecurrenceDate

Tipo de dados

date

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

HistologicType

Tipo de dados

text

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

HistologicType,OtherName

Tipo de dados

text

Histologic Grade (check the highest grade)
Descrição

HistologicGrade

Tipo de dados

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)
Descrição

TStage,Pathologic

Tipo de dados

text

Pathologic N Stage (Distant Metastasis)
Descrição

NStage,Pathologic

Tipo de dados

text

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

MStage,Pathologic

Tipo de dados

text

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

LymphNodesType

Tipo de dados

text

Other, specify
Descrição

LymphNodeType,Other

Tipo de dados

text

Lymph Node Involvement
Descrição

LymphNodeInvolvement

Tipo de dados

text

No. of Lymph Nodes Examined
Descrição

LymphNode(s)ExaminedNumber

Tipo de dados

float

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

LymphNode(s)PositiveNumber

Tipo de dados

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?
Descrição

TumorMarginInd

Tipo de dados

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
Descrição

Muscle Invasive Bladder Disease: Prior Treatment Affecting The Bladder

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

PriorIntravesicalTherapyInd

Tipo de dados

boolean

Type of Prior Immunotherapy
Descrição

PriorImmunotherapyType

Tipo de dados

text

No. of Courses
Descrição

PriorImmunotherapyCount

Tipo de dados

float

Specify agent
Descrição

PriorImmunotherapyOtherAgent

Tipo de dados

text

Agent Start Date
Descrição

AgentBeginDate

Tipo de dados

date

Agent End Date
Descrição

AgentEndDate

Tipo de dados

date

Type of Prior Chemotherapy
Descrição

PriorIntravesicalChemotherapyType

Tipo de dados

text

No. of Courses
Descrição

PriorChemotherapyCount

Tipo de dados

float

Specify agent
Descrição

PriorIntravesicalChemotherapyOtherAgent

Tipo de dados

text

Prior Surgery (for urothelial disease)
Descrição

PriorSurgeryInd

Tipo de dados

boolean

Prior Surgery Type
Descrição

PriorSurgeryType

Tipo de dados

text

Other, specify
Descrição

PriorSurgeryType,Other

Tipo de dados

text

TURBT, Number
Descrição

PriorSurgery,TURBTCount

Tipo de dados

float

Any Other Prior Therapy
Descrição

PriorOtherTherapyInd

Tipo de dados

boolean

Name of other Prior Therapies
Descrição

PriorOtherTherapyName

Tipo de dados

text

Comments
Descrição

Comments

Comments
Descrição

Comments

Tipo de dados

text

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

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

Similar models

No Instruction available.

  1. StudyEvent: NCI Cooperative Group On-Study Form (CALGB-90104)
    1. No Instruction available.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
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)
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)
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
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)
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)
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
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
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
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
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
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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