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7309

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S1007 Chemotherapy Form (S1007CHEMO) Tamoxifen Citrate, Letrozole, Anastrozole, or Exemestane With or Without Chemotherapy in Treating Patients With Invasive RxPONDER Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=90C9DFFB-23F1-84DB-E040-BB89AD437DC2

Länk

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=90C9DFFB-23F1-84DB-E040-BB89AD437DC2

Nyckelord

  1. 2012-08-26 2012-08-26 -
  2. 2015-01-09 2015-01-09 - Martin Dugas
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9 januari 2015

DOI

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Creative Commons BY-NC 3.0 Legacy

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    Breast Cancer NCT01272037 Treatment - S1007 Chemotherapy Form (S1007CHEMO) - 3139708v1.0

    Instructions: Submit this form at the completion of chemotherapy. All dates are MONTH, DAY, YEAR. Explain any blank fields or blank dates in the Comments section. Place an X in appropriate boxes. Circle AMENDED items in red and write AMENDED across top of form

    Header
    Beskrivning

    Header

    SWOG Patient ID
    Beskrivning

    Trial subject ID SWOG

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C2348585
    NCI Thesaurus ObjectClass
    C16960
    UMLS CUI-2
    C1519429
    NCI Thesaurus Property
    C25364
    NCI Thesaurus Property-2
    C25699
    SWOG Study No.
    Beskrivning

    Protocol ID SWOG

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C3274381
    NCI Thesaurus ObjectClass
    C25320
    UMLS CUI-2
    C1519429
    NCI Thesaurus Property
    C25364
    NCI Thesaurus Property-2
    C25699
    Registration Step
    Beskrivning

    Registration Number

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C1514821
    NCI Thesaurus ObjectClass
    C25646
    UMLS CUI-2
    C0237753
    NCI Thesaurus Property
    C16154
    NCI Thesaurus ValueDomain-2
    C16154
    Patient Initials (L, F M)
    Beskrivning

    Patient Initials

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C2986440
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25536
    Institution/Affiliate
    Beskrivning

    Institution Name

    Datatyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C25454
    UMLS CUI-1
    C1301943
    NCI Thesaurus ObjectClass-2
    C21541
    NCI Thesaurus Property
    C25364
    NCI Thesaurus ValueDomain
    C25191
    NCI Thesaurus ValueDomain-2
    C21541
    Physician
    Beskrivning

    Investigator Name

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C2826892
    NCI Thesaurus Property
    C25364
    NCI Thesaurus ObjectClass
    C17089
    NCI Thesaurus ObjectClass-2
    C25644
    Participating Group Name
    Beskrivning

    Participating Group

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C2347449
    NCI Thesaurus ObjectClass
    C25608
    NCI Thesaurus ObjectClass-2
    C17005
    NCI Thesaurus Property
    C25364
    Participating Group Study No.
    Beskrivning

    Study Number Participating Group

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C3274381
    NCI Thesaurus ObjectClass
    C25320
    UMLS CUI-2
    C2347449
    NCI Thesaurus Property
    C25608
    NCI Thesaurus Property-2
    C25364
    Participating Group Patient ID
    Beskrivning

    Trial subject ID Participating Group

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C2348585
    NCI Thesaurus ObjectClass
    C16960
    UMLS CUI-2
    C2347449
    NCI Thesaurus Property
    C25608
    NCI Thesaurus Property-2
    C25364
    Unnamed2
    Beskrivning

    Unnamed2

    Chemotherapy Regimen (select one; if drugs were substituted or omitted during treatment because of toxicity, indicate the initial planned regimen)
    Beskrivning

    ChemotherapyRegimenType

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus ObjectClass
    C15632
    UMLS 2011AA ObjectClass
    C0392920
    NCI Thesaurus Property
    C15697
    UMLS 2011AA Property
    C0040808
    specify study number and treatment arm (other regimen given as part of a CTSU adjuvant therapy protocol)
    Beskrivning

    AdjuvantChemotherapyRegimenSpecify

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    NCI Thesaurus ObjectClass
    C15632
    UMLS 2011AA ObjectClass
    C0392920
    NCI Thesaurus ObjectClass-2
    C2140
    UMLS 2011AA ObjectClass-2
    C0001552
    NCI Thesaurus Property
    C15697
    UMLS 2011AA Property
    C0040808
    specify drugs and schedule (other chemotherapy regimen)
    Beskrivning

    ChemotherapyRegimenSpecify

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    NCI Thesaurus ObjectClass
    C15632
    UMLS 2011AA ObjectClass
    C0392920
    NCI Thesaurus Property
    C15697
    UMLS 2011AA Property
    C0040808
    Date Chemotherapy Began (date 1st cycle given MM DD YYYY)
    Beskrivning

    Chemotherapy Start Date

    Datatyp

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS CUI-1
    C1302181
    NCI Thesaurus ObjectClass
    C15632
    UMLS CUI-2
    C3173309
    NCI Thesaurus ValueDomain-2
    C25431
    NCI Thesaurus Property
    C25382
    Date Chemotherapy Ended (date last cycle given MM DD YYYY)
    Beskrivning

    ChemotherapyAdministeredEndDate

    Datatyp

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ObjectClass
    C15632
    UMLS 2011AA ObjectClass
    C0392920
    NCI Thesaurus Property
    C25382
    UMLS 2011AA Property
    C1521801
    Total number of chemotherapy cycles completed
    Beskrivning

    ChemotherapyTotalCycleCompleteCount

    Datatyp

    float

    Alias
    NCI Thesaurus ObjectClass
    C15632
    UMLS 2011AA ObjectClass
    C0392920
    NCI Thesaurus Property
    C25250
    UMLS 2011AA Property
    C0205197
    NCI Thesaurus Property-2
    C25304
    UMLS 2011AA Property-2
    C0439810
    NCI Thesaurus Property-3
    C25472
    UMLS 2011AA Property-3
    C1511572
    NCI Thesaurus ValueDomain
    C25463
    UMLS 2011AA ValueDomain
    C0750480
    Was chemotherapy ever delayed or reduced because of toxicity
    Beskrivning

    TreatmentInterruptionInd-2

    Datatyp

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus ObjectClass
    C15368
    NCI Thesaurus Property
    C25542
    UMLS 2011AA Property
    C1512900
    Comments
    Beskrivning

    Comments

    Comments
    Beskrivning

    Research Comments

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS CUI-1
    C0947611
    NCI Thesaurus ObjectClass
    C15319
    NCI Thesaurus Property
    C25393

    Similar models

    Instructions: Submit this form at the completion of chemotherapy. All dates are MONTH, DAY, YEAR. Explain any blank fields or blank dates in the Comments section. Place an X in appropriate boxes. Circle AMENDED items in red and write AMENDED across top of form

    Name
    Typ
    Description | Question | Decode (Coded Value)
    Datatyp
    Alias
    Item Group
    Header
    Trial subject ID SWOG
    Item
    SWOG Patient ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C2348585 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C1519429 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    C25699 (NCI Thesaurus Property-2)
    Protocol ID SWOG
    Item
    SWOG Study No.
    text
    C25337 (NCI Thesaurus ValueDomain)
    C3274381 (UMLS CUI-1)
    C25320 (NCI Thesaurus ObjectClass)
    C1519429 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    C25699 (NCI Thesaurus Property-2)
    Registration Number
    Item
    Registration Step
    text
    C25337 (NCI Thesaurus ValueDomain)
    C1514821 (UMLS CUI-1)
    C25646 (NCI Thesaurus ObjectClass)
    C0237753 (UMLS CUI-2)
    C16154 (NCI Thesaurus Property)
    C16154 (NCI Thesaurus ValueDomain-2)
    Patient Initials
    Item
    Patient Initials (L, F M)
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2986440 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25536 (NCI Thesaurus Property)
    Institution Name
    Item
    Institution/Affiliate
    text
    C25454 (NCI Thesaurus ObjectClass)
    C1301943 (UMLS CUI-1)
    C21541 (NCI Thesaurus ObjectClass-2)
    C25364 (NCI Thesaurus Property)
    C25191 (NCI Thesaurus ValueDomain)
    C21541 (NCI Thesaurus ValueDomain-2)
    Investigator Name
    Item
    Physician
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2826892 (UMLS CUI-1)
    C25364 (NCI Thesaurus Property)
    C17089 (NCI Thesaurus ObjectClass)
    C25644 (NCI Thesaurus ObjectClass-2)
    Participating Group
    Item
    Participating Group Name
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2347449 (UMLS CUI-1)
    C25608 (NCI Thesaurus ObjectClass)
    C17005 (NCI Thesaurus ObjectClass-2)
    C25364 (NCI Thesaurus Property)
    Study Number Participating Group
    Item
    Participating Group Study No.
    text
    C25337 (NCI Thesaurus ValueDomain)
    C3274381 (UMLS CUI-1)
    C25320 (NCI Thesaurus ObjectClass)
    C2347449 (UMLS CUI-2)
    C25608 (NCI Thesaurus Property)
    C25364 (NCI Thesaurus Property-2)
    Trial subject ID Participating Group
    Item
    Participating Group Patient ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C2348585 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C2347449 (UMLS CUI-2)
    C25608 (NCI Thesaurus Property)
    C25364 (NCI Thesaurus Property-2)
    Item Group
    Unnamed2
    Item
    Chemotherapy Regimen (select one; if drugs were substituted or omitted during treatment because of toxicity, indicate the initial planned regimen)
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C15632 (NCI Thesaurus ObjectClass)
    C0392920 (UMLS 2011AA ObjectClass)
    C15697 (NCI Thesaurus Property)
    C0040808 (UMLS 2011AA Property)
    Code List
    Chemotherapy Regimen (select one; if drugs were substituted or omitted during treatment because of toxicity, indicate the initial planned regimen)
    CL Item
    Docetaxel And Cyclophosphamide (Docetaxel and cyclophosphamide)
    CL Item
    5-fu, Doxorubicin (or Epirubicin), And Cyclophosphamide (5-FU, doxorubicin (or epirubicin), and cyclophosphamide)
    CL Item
    Doxorubicin (or Epirubicin) And Cyclophosphamide (ac/ec) Followed By Paclitaxel (Doxorubicin (or epirubicin) and cyclophosphamide (AC/EC) followed by paclitaxel)
    CL Item
    Doxorubicin (or Epirubicin) And Cyclophosphamide (ac/ec) Followed By Weekly Paclitaxel X 12 (Doxorubicin (or epirubicin) and cyclophosphamide (AC/EC) followed by weekly paclitaxel x 12)
    CL Item
    5-fu, Doxorubicin (or Epirubicin) And Cyclophosphamide Followed By Docetaxel (q 3 Weeks, 4 Cycles Each) (5-FU, doxorubicin (or epirubicin) and cyclophosphamide followed by docetaxel (q 3 weeks, 4 cycles each))
    CL Item
    5-fu, Doxorubicin (or Epirubicin) And Cyclophosphamide Followed By Docetaxel (3 Cycles Each) (5-FU, doxorubicin (or epirubicin) and cyclophosphamide followed by docetaxel (3 cycles each))
    CL Item
    Dose Dense Doxorubicin And Cyclophosphamide Followed By Dose Dense Paclitaxel (q 2 Weeks, 4 Cycles Each) (Dose dense doxorubicin and cyclophosphamide followed by dose dense paclitaxel (q 2 weeks, 4 cycles each))
    CL Item
    Docetaxel, Doxorubicin, And Cyclophosphamide (6 Cycles) (Docetaxel, doxorubicin, and cyclophosphamide (6 cycles))
    CL Item
    5-fu, Doxorubicin (or Epirubicin) And Cyclophosphamide (fac) Followed By Weekly Paclitaxel X 12 (5-FU, doxorubicin (or epirubicin) and cyclophosphamide (FAC) followed by weekly paclitaxel x 12)
    CL Item
    Weekly Paclitaxel X 12 Followed By 5-fu, Doxorubicin (or Epirubicin) And Cyclophosphamide (fac) (Weekly paclitaxel x 12 followed by 5-FU, doxorubicin (or epirubicin) and cyclophosphamide (FAC))
    CL Item
    Other Regimen Given As Part Of A Ctsu Adjuvant Therapy Protocol (other regimen given as part of a CTSU adjuvant therapy protocol)
    CL Item
    Other Chemotherapy Regimen (Other chemotherapy regimen)
    AdjuvantChemotherapyRegimenSpecify
    Item
    specify study number and treatment arm (other regimen given as part of a CTSU adjuvant therapy protocol)
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C15632 (NCI Thesaurus ObjectClass)
    C0392920 (UMLS 2011AA ObjectClass)
    C2140 (NCI Thesaurus ObjectClass-2)
    C0001552 (UMLS 2011AA ObjectClass-2)
    C15697 (NCI Thesaurus Property)
    C0040808 (UMLS 2011AA Property)
    ChemotherapyRegimenSpecify
    Item
    specify drugs and schedule (other chemotherapy regimen)
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C15632 (NCI Thesaurus ObjectClass)
    C0392920 (UMLS 2011AA ObjectClass)
    C15697 (NCI Thesaurus Property)
    C0040808 (UMLS 2011AA Property)
    Chemotherapy Start Date
    Item
    Date Chemotherapy Began (date 1st cycle given MM DD YYYY)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C1302181 (UMLS CUI-1)
    C15632 (NCI Thesaurus ObjectClass)
    C3173309 (UMLS CUI-2)
    C25431 (NCI Thesaurus ValueDomain-2)
    C25382 (NCI Thesaurus Property)
    ChemotherapyAdministeredEndDate
    Item
    Date Chemotherapy Ended (date last cycle given MM DD YYYY)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C15632 (NCI Thesaurus ObjectClass)
    C0392920 (UMLS 2011AA ObjectClass)
    C25382 (NCI Thesaurus Property)
    C1521801 (UMLS 2011AA Property)
    ChemotherapyTotalCycleCompleteCount
    Item
    Total number of chemotherapy cycles completed
    float
    C15632 (NCI Thesaurus ObjectClass)
    C0392920 (UMLS 2011AA ObjectClass)
    C25250 (NCI Thesaurus Property)
    C0205197 (UMLS 2011AA Property)
    C25304 (NCI Thesaurus Property-2)
    C0439810 (UMLS 2011AA Property-2)
    C25472 (NCI Thesaurus Property-3)
    C1511572 (UMLS 2011AA Property-3)
    C25463 (NCI Thesaurus ValueDomain)
    C0750480 (UMLS 2011AA ValueDomain)
    TreatmentInterruptionInd-2
    Item
    Was chemotherapy ever delayed or reduced because of toxicity
    boolean
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C15368 (NCI Thesaurus ObjectClass)
    C25542 (NCI Thesaurus Property)
    C1512900 (UMLS 2011AA Property)
    Item Group
    Comments
    Research Comments
    Item
    Comments
    text
    C25704 (NCI Thesaurus ValueDomain)
    C0947611 (UMLS CUI-1)
    C15319 (NCI Thesaurus ObjectClass)
    C25393 (NCI Thesaurus Property)

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