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6937

Beschreibung

NCI Cooperative Group Follow-Up 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=A9C23658-5AE0-303F-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A9C23658-5AE0-303F-E034-0003BA12F5E7

Stichworte

Versionen (2)
  1. 26.08.12 26.08.12 -
  2. 08.01.15 08.01.15 - Martin Dugas
Hochgeladen am

8. Januar 2015

DOI

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Creative Commons BY-NC 3.0 Legacy
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    Bladder Cancer NCT00014534 Follow-Up - NCI Cooperative Group Follow-Up Form (CALGB-90104) - 2056490v3.0

    Englisch

    No Instruction available.

    1 Formulare  
    1. StudyEvent: NCI Cooperative Group Follow-Up Form (CALGB-90104)
      1. No Instruction available.
    Mskcc 00-138; Calgb-90104; Ecog
    Beschreibung

    Mskcc 00-138; Calgb-90104; Ecog

    Coordinating Group Protocol Number
    Beschreibung

    CoordinatingGroupProtocolNumber

    Datentyp

    text

    Coordinating Group Code
    Beschreibung

    CoordinatingGroupCode

    Datentyp

    text

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

    Protocol Title

    Datentyp

    text

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

    PatientStudyID,CoordinatingGroup

    Datentyp

    text

    Patient Study ID, Participating Group
    Beschreibung

    PatientStudyID,ParticipatingGroup

    Datentyp

    text

    Participating Group Code
    Beschreibung

    ParticipatingGroupCode

    Datentyp

    text

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

    InstitutionName

    Datentyp

    text

    Affiliate
    Beschreibung

    AffiliateName

    Datentyp

    text

    Patient Last Name (initials acceptable)
    Beschreibung

    PatientName,Last

    Datentyp

    text

    Patient First Name (initials acceptable)
    Beschreibung

    PatientName,First

    Datentyp

    text

    Patient Middle Name (initials acceptable)
    Beschreibung

    PatientName,Middle

    Datentyp

    text

    Form Administration
    Beschreibung

    Form Administration

    Person Completing Form, Last Name
    Beschreibung

    PersonCompletingForm,LastName

    Datentyp

    text

    Person Completing Form, First Name
    Beschreibung

    PersonCompletingForm,FirstName

    Datentyp

    text

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

    AmendedDataInd

    Datentyp

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C25474
    UMLS 2011AA ObjectClass
    C1511726
    NCI Thesaurus Property
    C25416
    UMLS 2011AA Property
    C1691222
    Vital Status
    Beschreibung

    Vital Status

    Patient's Vital Status
    Beschreibung

    Patient'sVitalStatus

    Datentyp

    text

    Primary Cause of Death (check one)
    Beschreibung

    DeathReason

    Datentyp

    text

    Describe cause of death
    Beschreibung

    DeathReason,Specify

    Datentyp

    text

    Date of Last Contact or Death (MM DD YYYY)
    Beschreibung

    DeathDate/LastContactDate

    Datentyp

    date

    Disease Follow-up Status
    Beschreibung

    Disease Follow-up Status

    Has the patient had a documented clinical assessment for this cancer?
    Beschreibung

    CancerFollow-upStatusInd

    Datentyp

    boolean

    Date of Last Clinical Assessment (MM DD YYYY)
    Beschreibung

    CancerFollow-upStatusDate

    Datentyp

    date

    Alias
    NCI Thesaurus ObjectClass
    C2991
    UMLS 2011AA ObjectClass
    C0012634
    NCI Thesaurus Property
    C25365
    UMLS 2011AA Property
    C0678257
    Chest X-ray Assessment Date
    Beschreibung

    ChestX-RayAssessmentDate

    Datentyp

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    Abdominal/Pelvic CT Assessment Date
    Beschreibung

    Abdominal/PelvicCTAssessmentDate

    Datentyp

    text

    Notice Of Progression
    Beschreibung

    Notice Of Progression

    Has the patient been diagnosed with a local recurrence that has not been previously reported?
    Beschreibung

    ProgressionInd,LocalAdvanced

    Datentyp

    boolean

    Date of First Local Progression (MM DD YYYY)
    Beschreibung

    ProgressionDate,FirstLocal

    Datentyp

    date

    Site(s) of First Local Progression (mark all that apply)
    Beschreibung

    ProgressionSite,FirstLocal

    Datentyp

    text

    Other, specify
    Beschreibung

    ProgressionSite,FirstLocal,Other

    Datentyp

    text

    Has the patient been diagnosed with a local-regional lymph node recurrence?
    Beschreibung

    ProgressionInd,LocalNodes

    Datentyp

    boolean

    Date of First Local-Regional Lymph Node Progression (MM DD YYYY)
    Beschreibung

    ProgressionDate,FirstLocalNode

    Datentyp

    date

    Site(s) of First Local-Regional Lymph Node Progression (mark all that apply)
    Beschreibung

    ProgressionSite,FirstLocalNode

    Datentyp

    text

    Has the patient been diagnosed with a distant metastatic progression that has not been previously reported?
    Beschreibung

    ProgressionInd,DistantMetastatic

    Datentyp

    boolean

    Date of First Distant Progression (MM DD YYYY)
    Beschreibung

    ProgressionDate,FirstDistant

    Datentyp

    date

    Site(s) of First Distant Progression (mark all that apply)
    Beschreibung

    ProgressionSite,FirstDistant

    Datentyp

    text

    Distant nodes, specify
    Beschreibung

    LymphNodes,DistantLocation

    Datentyp

    text

    Other, specify
    Beschreibung

    Other,specify

    Datentyp

    text

    Other, specify
    Beschreibung

    Other,specify

    Datentyp

    text

    Notice Of New Primary
    Beschreibung

    Notice Of New Primary

    Has a new primary cancer or myelodysplastic syndrome (MDS) been diagnosed that has not been previously reported?
    Beschreibung

    NewPrimaryCancerInd

    Datentyp

    boolean

    Date of Diagnosis (MM DD YYYY)
    Beschreibung

    NewPrimaryCancerDate

    Datentyp

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    Site(s) of New Primary (If new primary site is AML/MDS, please submit NCI AML/MDS form.)
    Beschreibung

    NewPrimarySite

    Datentyp

    text

    Notice Of Long Term Toxicity
    Beschreibung

    Notice Of Long Term Toxicity

    Has the patient experienced any severe (Grade >=3), long term toxicity that has not been previously reported?
    Beschreibung

    LateAdverseEventInd

    Datentyp

    text

    Late Adverse Event Term
    Beschreibung

    LateAdverseEventTerm

    Datentyp

    text

    Late Adverse Event Grade
    Beschreibung

    LateAdverseEventGrade

    Datentyp

    text

    Date of Onset of Long-Term Toxicity
    Beschreibung

    LateAdverseEventOnsetDate

    Datentyp

    date

    Comments
    Beschreibung

    Comments

    Comments
    Beschreibung

    Comments

    Datentyp

    text

    Ccrr Module For Nci Cooperative Group Follow-up Form (calgb-90104)
    Beschreibung

    Ccrr Module For Nci Cooperative Group Follow-up Form (calgb-90104)

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    No Instruction available.

    1 Formulare
    1. StudyEvent: NCI Cooperative Group Follow-Up Form (CALGB-90104)
      1. No Instruction available.
    Name
    Typ
    Description | Question | Decode (Coded Value)
    Datentyp
    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
    Vital Status
    Item
    Patient's Vital Status
    text
    CL.2
    Code List
    Patient's Vital Status
    CL Item
    Alive (Alive-NED)
    CL Item
    Alive (Alive with Disease)
    CL Item
    Dead (Dead)
    Item
    Primary Cause of Death (check one)
    text
    CL.3
    Code List
    Primary Cause of Death (check one)
    CL Item
    Due To This Disease (Due to this disease)
    CL Item
    Due To Protocol Treatment (Due to protocol treatment)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    CL Item
    Due to other cause (Due to other cause)
    DeathReason,Specify
    Item
    Describe cause of death
    text
    DeathDate/LastContactDate
    Item
    Date of Last Contact or Death (MM DD YYYY)
    date
    Item Group
    Disease Follow-up Status
    CancerFollow-upStatusInd
    Item
    Has the patient had a documented clinical assessment for this cancer?
    boolean
    CancerFollow-upStatusDate
    Item
    Date of Last Clinical Assessment (MM DD YYYY)
    date
    C2991 (NCI Thesaurus ObjectClass)
    C0012634 (UMLS 2011AA ObjectClass)
    C25365 (NCI Thesaurus Property)
    C0678257 (UMLS 2011AA Property)
    ChestX-RayAssessmentDate
    Item
    Chest X-ray Assessment Date
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    Abdominal/PelvicCTAssessmentDate
    Item
    Abdominal/Pelvic CT Assessment Date
    text
    Item Group
    Notice Of Progression
    ProgressionInd,LocalAdvanced
    Item
    Has the patient been diagnosed with a local recurrence that has not been previously reported?
    boolean
    ProgressionDate,FirstLocal
    Item
    Date of First Local Progression (MM DD YYYY)
    date
    Item
    Site(s) of First Local Progression (mark all that apply)
    text
    CL.6
    Code List
    Site(s) of First Local Progression (mark all that apply)
    CL Item
    abdominal wall (abdominal wall)
    CL Item
    prostate (prostate)
    CL Item
    urethra (urethra)
    CL Item
    pelvic wall (pelvic wall)
    CL Item
    skin (skin)
    CL Item
    Uterus (uterus)
    CL Item
    Peritoneum (peritoneum)
    CL Item
    vagina (vagina)
    CL Item
    Other, Specify (other, specify)
    ProgressionSite,FirstLocal,Other
    Item
    Other, specify
    text
    ProgressionInd,LocalNodes
    Item
    Has the patient been diagnosed with a local-regional lymph node recurrence?
    boolean
    ProgressionDate,FirstLocalNode
    Item
    Date of First Local-Regional Lymph Node Progression (MM DD YYYY)
    date
    Item
    Site(s) of First Local-Regional Lymph Node Progression (mark all that apply)
    text
    CL.8
    Code List
    Site(s) of First Local-Regional Lymph Node Progression (mark all that apply)
    CL Item
    Disease Is Present In The Internal Iliac Lymph Nodes (internal iliac)
    CL Item
    Disease Is Present In The External Iliac Lymph Nodes (external iliac)
    CL Item
    Disease Is Present In The Common Iliac Lymph Nodes (common iliac)
    CL Item
    Disease Is Present In The Hypogastric Lymph Nodes (hypogastric)
    CL Item
    Disease Is Present In The Para-aortic Lymph Nodes (para-aortic)
    CL Item
    Disease Is Present In Another Local-regional Lymph Nodes, Specify (other, specify)
    ProgressionInd,DistantMetastatic
    Item
    Has the patient been diagnosed with a distant metastatic progression that has not been previously reported?
    boolean
    ProgressionDate,FirstDistant
    Item
    Date of First Distant Progression (MM DD YYYY)
    date
    Item
    Site(s) of First Distant Progression (mark all that apply)
    text
    CL.10
    Code List
    Site(s) of First Distant Progression (mark all that apply)
    CL Item
    Bone (bone)
    C12366 (NCI Thesaurus)
    C0262950 (UMLS 2011AA)
    CL Item
    Liver (liver)
    C12392 (NCI Thesaurus)
    C0023884 (UMLS 2011AA)
    CL Item
    Lung (lung)
    C12468 (NCI Thesaurus)
    C0024109 (UMLS 2011AA)
    CL Item
    Peritoneum (peritoneum)
    CL Item
    Pleura (pleura)
    CL Item
    Skin (skin)
    C12470 (NCI Thesaurus)
    C1123023 (UMLS 2011AA)
    CL Item
    Central Nervous System (central nervous system/brain)
    CL Item
    Lymph Nodes (distant) (distant nodes, specify)
    CL Item
    other, specify (other, specify)
    LymphNodes,DistantLocation
    Item
    Distant nodes, specify
    text
    Other,specify
    Item
    Other, specify
    text
    Other,specify
    Item
    Other, specify
    text
    Item Group
    Notice Of New Primary
    NewPrimaryCancerInd
    Item
    Has a new primary cancer or myelodysplastic syndrome (MDS) been diagnosed that has not been previously reported?
    boolean
    NewPrimaryCancerDate
    Item
    Date of Diagnosis (MM DD YYYY)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    NewPrimarySite
    Item
    Site(s) of New Primary (If new primary site is AML/MDS, please submit NCI AML/MDS form.)
    text
    Item Group
    Notice Of Long Term Toxicity
    Item
    Has the patient experienced any severe (Grade >=3), long term toxicity that has not been previously reported?
    text
    CL.12
    Code List
    Has the patient experienced any severe (Grade >=3), long term toxicity that has not been previously reported?
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Unknown (Unknown)
    C17998 (NCI Thesaurus)
    C0439673 (UMLS 2011AA)
    LateAdverseEventTerm
    Item
    Late Adverse Event Term
    text
    LateAdverseEventGrade
    Item
    Late Adverse Event Grade
    text
    LateAdverseEventOnsetDate
    Item
    Date of Onset of Long-Term Toxicity
    date
    Item Group
    Comments
    Comments
    Item
    Comments
    text
    Item Group
    Ccrr Module For Nci Cooperative Group Follow-up Form (calgb-90104)
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