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7405

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Southwest Oncology Group S0819 Lung Carcinoma First Site(s) Of Progression Or Relapse Form Carboplatin and Paclitaxel With or Without Bevacizumab and/or Cetuximab in Treating Patients With Stage IV or Recurrent Non-Small Cell Lung Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=684FE956-5A8B-A7DA-E040-BB89AD432A2B

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=684FE956-5A8B-A7DA-E040-BB89AD432A2B

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Versions (2)
  1. 9/19/12 9/19/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
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January 9, 2015

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    Lung Cancer NCT00946712 On-Study - Southwest Oncology Group S0819 Lung Carcinoma First Site(s) Of Progression Or Relapse Form - 2863883v1.0

    English

    Instructions: All dates are MONTH, DAY, YEAR. Place an X in appropriate boxes. Circle AMENDED items in red

    1 forms  
    1. StudyEvent: Southwest Oncology Group S0819 Lung Carcinoma First Site(s) Of Progression Or Relapse Form
      1. Instructions: All dates are MONTH, DAY, YEAR. Place an X in appropriate boxes. Circle AMENDED items in red
    Header
    Description

    Header

    SWOG Patient ID
    Description

    Trial subject ID SWOG

    Data type

    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.
    Description

    Protocol ID SWOG

    Data type

    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
    Description

    Registration Number

    Data type

    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)
    Description

    Patient Initials

    Data type

    text

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

    Institution Name

    Data type

    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
    Description

    Investigator Name

    Data type

    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
    Description

    Participating Group

    Data type

    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.
    Description

    Study Number Participating Group

    Data type

    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
    Description

    Trial subject ID Participating Group

    Data type

    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
    Vital Status
    Description

    Vital Status

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

    Date last contact

    Data type

    date

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS CUI-1
    C0805839
    NCI Thesaurus Property
    C25461
    NCI Thesaurus Property-2
    C25551
    NCI Thesaurus ValueDomain
    C25164
    NCI Thesaurus ValueDomain-2
    C25367
    Vital Status
    Description

    Patient Status

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C16960
    UMLS CUI-1
    C3846084
    NCI Thesaurus ValueDomain
    C18003
    NCI Thesaurus ValueDomain-2
    C25688
    NCI Thesaurus Property
    C25717
    Progression Or Relapse
    Description

    Progression Or Relapse

    Date of Relapse or Progression (MM DD YYYY)
    Description

    DiseaseRecurrentDiseaseCancerProgressionDiagnosisDate

    Data type

    date

    Alias
    NCI Thesaurus ObjectClass
    C2991
    UMLS 2011AA ObjectClass
    C0012634
    NCI Thesaurus Property
    C38155
    UMLS 2011AA Property
    C0277556
    NCI Thesaurus Property-2
    C15220
    UMLS 2011AA Property-2
    C0011900
    NCI Thesaurus Property-3
    C19987
    UMLS 2011AA Property-3
    C0242656
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    Sites of Progression (or Relapse at the time progression/relapse was detected select all that apply)
    Description

    Progression Site

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C13717
    UMLS CUI-1
    C0242656
    NCI Thesaurus Property
    C25341
    UMLS CUI-2
    C1515974
    NCI Thesaurus ObjectClass
    C25331
    Other specify (site)
    Description

    FirstProgressionLocal-RegionalSiteSpecify

    Data type

    text

    Alias
    NCI Thesaurus ObjectClass
    C25331
    NCI Thesaurus ObjectClass-2
    C25509
    UMLS 2011AA ObjectClass
    C1279901
    NCI Thesaurus Property
    C25341
    UMLS 2011AA Property
    C0450429
    NCI Thesaurus Property-2
    C25388
    UMLS 2011AA Property-2
    C1947913
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    Progression/Relapse site within previous RT field (For Regional Progression or Relapse select one)
    Description

    RadiationFieldCancerProgressionIndicator

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    NCI Thesaurus ObjectClass
    C54648
    UMLS 2011AA ObjectClass
    C1882536
    NCI Thesaurus Property
    C19987
    UMLS 2011AA Property
    C0242656
    Progression/Relapse site within previous RT field (For Regional Progression or Relapse select one)
    Description

    RadiationFieldCancerProgressionIndicator

    Data type

    text

    Alias
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    NCI Thesaurus ObjectClass
    C54648
    UMLS 2011AA ObjectClass
    C1882536
    NCI Thesaurus Property
    C19987
    UMLS 2011AA Property
    C0242656
    Comments
    Description

    Comments

    Comments
    Description

    Research Comments

    Data type

    text

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

    Instructions: All dates are MONTH, DAY, YEAR. Place an X in appropriate boxes. Circle AMENDED items in red

    1 forms
    1. StudyEvent: Southwest Oncology Group S0819 Lung Carcinoma First Site(s) Of Progression Or Relapse Form
      1. Instructions: All dates are MONTH, DAY, YEAR. Place an X in appropriate boxes. Circle AMENDED items in red
    Name
    Type
    Description | Question | Decode (Coded Value)
    Data type
    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
    Vital Status
    Date last contact
    Item
    Date of Last Contact or Death (MM DD YYYY)
    date
    C16960 (NCI Thesaurus ObjectClass)
    C0805839 (UMLS CUI-1)
    C25461 (NCI Thesaurus Property)
    C25551 (NCI Thesaurus Property-2)
    C25164 (NCI Thesaurus ValueDomain)
    C25367 (NCI Thesaurus ValueDomain-2)
    Item
    Vital Status
    text
    C16960 (NCI Thesaurus ObjectClass)
    C3846084 (UMLS CUI-1)
    C18003 (NCI Thesaurus ValueDomain)
    C25688 (NCI Thesaurus ValueDomain-2)
    C25717 (NCI Thesaurus Property)
    CL.1
    Code List
    Vital Status
    CL Item
    Alive (Alive)
    CL Item
    Dead (Dead)
    Item Group
    Progression Or Relapse
    DiseaseRecurrentDiseaseCancerProgressionDiagnosisDate
    Item
    Date of Relapse or Progression (MM DD YYYY)
    date
    C2991 (NCI Thesaurus ObjectClass)
    C0012634 (UMLS 2011AA ObjectClass)
    C38155 (NCI Thesaurus Property)
    C0277556 (UMLS 2011AA Property)
    C15220 (NCI Thesaurus Property-2)
    C0011900 (UMLS 2011AA Property-2)
    C19987 (NCI Thesaurus Property-3)
    C0242656 (UMLS 2011AA Property-3)
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    Item
    Sites of Progression (or Relapse at the time progression/relapse was detected select all that apply)
    text
    C13717 (NCI Thesaurus ValueDomain)
    C0242656 (UMLS CUI-1)
    C25341 (NCI Thesaurus Property)
    C1515974 (UMLS CUI-2)
    C25331 (NCI Thesaurus ObjectClass)
    CL.2
    Code List
    Sites of Progression (or Relapse at the time progression/relapse was detected select all that apply)
    CL Item
    Lung Parenchyma Adjacent To Primary Tumor (Lung parenchyma adjacent to primary tumor)
    CL Item
    Bronchial Stump (Bronchial stump)
    CL Item
    Ipsilateral Hilar Mediastinum (nodal) (Ipsilateral hilar mediastinum (nodal))
    CL Item
    Contralateral Hilar Mediastinum (nodal) (Contralateral hilar mediastinum (nodal))
    CL Item
    Ipsilateral Pleural Effusion (Ipsilateral pleural effusion)
    CL Item
    Contralateral Pleural Effusion (Contralateral pleural effusion)
    CL Item
    Ipsilateral Supraclavicular Nodes (Ipsilateral supraclavicular nodes)
    CL Item
    Contralateral Supraclavicular Nodes (Contralateral supraclavicular nodes)
    CL Item
    Separate Lobe Of The Ipsilateral Lung (Separate lobe of the ipsilateral lung)
    CL Item
    Contralateral Lung (Opposite lung)
    CL Item
    Pericardial Effusion (Pericardial effusion)
    C3319 (NCI Thesaurus)
    C0031039 (UMLS 2011AA)
    CL Item
    Brain (Brain)
    C12439 (NCI Thesaurus)
    C0006104 (UMLS 2011AA)
    CL Item
    Leptomeninges (Leptomeninges)
    C32979 (NCI Thesaurus)
    C0228126 (UMLS 2011AA)
    CL Item
    Liver (Liver)
    C12392 (NCI Thesaurus)
    C0023884 (UMLS 2011AA)
    CL Item
    Bone (Bone)
    C12366 (NCI Thesaurus)
    C0262950 (UMLS 2011AA)
    CL Item
    Adrenal Gland (Adrenal glands)
    C12666 (NCI Thesaurus)
    C0001625 (UMLS 2011AA)
    CL Item
    Kidney (Kidney)
    C12415 (NCI Thesaurus)
    C0022646 (UMLS 2011AA)
    CL Item
    Subcutaneous/skin (Subcutaneous/Skin)
    CL Item
    Other (Other)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    C17649 (NCI Thesaurus-3)
    C0205394 (UMLS 2011AA-4)
    FirstProgressionLocal-RegionalSiteSpecify
    Item
    Other specify (site)
    text
    C25331 (NCI Thesaurus ObjectClass)
    C25509 (NCI Thesaurus ObjectClass-2)
    C1279901 (UMLS 2011AA ObjectClass)
    C25341 (NCI Thesaurus Property)
    C0450429 (UMLS 2011AA Property)
    C25388 (NCI Thesaurus Property-2)
    C1947913 (UMLS 2011AA Property-2)
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    Item
    Progression/Relapse site within previous RT field (For Regional Progression or Relapse select one)
    text
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    C54648 (NCI Thesaurus ObjectClass)
    C1882536 (UMLS 2011AA ObjectClass)
    C19987 (NCI Thesaurus Property)
    C0242656 (UMLS 2011AA Property)
    CL.4
    Code List
    Progression/Relapse site within previous RT field (For Regional Progression or Relapse select one)
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Not Applicable (Not Applicable)
    C48660 (NCI Thesaurus)
    C1272460 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    Item
    Progression/Relapse site within previous RT field (For Regional Progression or Relapse select one)
    text
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    C54648 (NCI Thesaurus ObjectClass)
    C1882536 (UMLS 2011AA ObjectClass)
    C19987 (NCI Thesaurus Property)
    C0242656 (UMLS 2011AA Property)
    CL.4
    Code List
    Progression/Relapse site within previous RT field (For Regional Progression or Relapse select one)
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Not Applicable (Not Applicable)
    C48660 (NCI Thesaurus)
    C1272460 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    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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