CALGBForm
Item
CALGB Form
text
CALGBStudyNo
Item
CALGB Study No
text
CALGBPatientID
Item
CALGB Patient ID
text
To
Item
To (date of last contact or death)
text
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Patient'sName
Item
Patient's Name
text
ParticipatingGroup
Item
Participating Group
text
C17005 (NCI Thesaurus ObjectClass)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
PatientHospitalNumber
Item
Patient Hospital Number
text
ParticipatingGroupProtocolNo.
Item
Participating Group Protocol No.
text
MainMemberInstitution/Adjunct
Item
Main Member Institution/Adjunct
text
ParticipatingGroupPatientNo.
Item
Participating Group Patient No.
text
Item
Patient's Vital Status (mark one with an X)
text
Code List
Patient's Vital Status (mark one with an X)
Item
Cause of death (if dead)
text
Code List
Cause of death (if dead)
CL Item
Due To This Disease (Due to this disease)
CL Item
Due To Protocol Treatment (Due to protocol treatment)
CL Item
Due To Other Cause (Due to other cause)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
DeathReason,Specify
Item
Describe cause of death (Disease Assessment)
text
Item
Has patient had a documented clinical assessment for this cancer since submission of the previous follow-up form?
text
Code List
Has patient had a documented clinical assessment for this cancer since submission of the previous follow-up form?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
How was this progression information obtained? (mark one with an X)
text
Code List
How was this progression information obtained? (mark one with an X)
CL Item
Documented clinical assessment (Documented clinical assessment)
CL Item
Patient Self Report Only (Patient self report only)
CancerFollow-upStatusDate
Item
Date of last clinical assessment (M)
date
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
Item
Has the patient been diagnosed with a first local-regional recurrence/progression since submission of the last follow-up form?
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Code List
Has the patient been diagnosed with a first local-regional recurrence/progression since submission of the last follow-up form?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
ProgressionDate,FirstLocal-Regional
Item
Date of first local-regional progression (M)
date
Item
Site(s) of first local-regional progression (mark all that apply with an X)
text
Code List
Site(s) of first local-regional progression (mark all that apply with an X)
CL Item
Ipsilateral breast (Ipsilateral breast)
CL Item
Axillary nodes (Axillary nodes)
CL Item
Supraclavicular nodes (Supraclavicular nodes)
CL Item
Infraclavicular nodes (Infraclavicular nodes)
CL Item
Chest wall (Chest wall)
CL Item
Internal mammary nodes (Internal mammary nodes)
Item
Has the patient been diagnosed with a first distant recurrence/progression since submission of the last follow-up form?
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Code List
Has the patient been diagnosed with a first distant recurrence/progression since submission of the last follow-up form?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
ProgressionDate,FirstDistant
Item
Date of first distant progression (M)
date
ProgressionSite,FirstDistant
Item
Site(s) of first distant progression
text
Item
How was this progression information obtained? (mark one with an X)
text
Code List
How was this progression information obtained? (mark one with an X)
CL Item
Documented clinical assessment (Documented clinical assessment)
CL Item
Patient Self Report Only (Patient self report only)
Item
Has a new primary cancer of myelodysplastic syndrome (MDS) been diagnosed that has not been previously reported?
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Code List
Has a new primary cancer of myelodysplastic syndrome (MDS) been diagnosed that has not been previously reported?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
NewPrimaryCancerDate
Item
Date of diagnosis (M)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
NewPrimarySite
Item
Site(s) of New Primary (If new primary site is AML/MDS, submit NCI AML/MDS form. All other new primaries must be reported using the MEDWATCH form C-804. Submit to CALGB Central Office)
text
Item
Current Menopausal Status (If premenopausal prior to chemotherapy mark one with an X)
text
Code List
Current Menopausal Status (If premenopausal prior to chemotherapy mark one with an X)
CL Item
Regular Menses Continue/resume (Regular menses continue/resume)
CL Item
Regular Menses Have Stopped (Regular menses have stopped)
Resumptiondate
Item
Resumption date
text
Cessationdate
Item
Cessation date (M)
text
Item
Has the patient experienced (prior to diagnosis of recurrence or second primary) any severe (Grade >= 3), long term treatment related toxicity that has not been previously reported? (Long-Term Cardiac Toxicity)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Code List
Has the patient experienced (prior to diagnosis of recurrence or second primary) any severe (Grade >= 3), long term treatment related toxicity that has not been previously reported? (Long-Term Cardiac Toxicity)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
IMTCode
Item
IMT Code
text
IMTCode
Item
IMT Code
text
CTCAdverseEventTerm
Item
CTC Adverse Event Term
text
CTCAdverseEventTerm
Item
CTC Adverse Event Term
text
Item
Grade (only 3, 4, 5)
double
Code List
Grade (only 3, 4, 5)
Item
Grade (only 3, 4, 5)
double
Code List
Grade (only 3, 4, 5)
DateofOnset
Item
Date of Onset (M)
text
DateofOnset
Item
Date of Onset (M)
text
Item
Did patient receive non-protocol cancer therapy prior to first recurrence and not previously reported? (mark all that apply with an X)
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Code List
Did patient receive non-protocol cancer therapy prior to first recurrence and not previously reported? (mark all that apply with an X)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Non-Protocol Therapy
text
Code List
Non-Protocol Therapy
CL Item
Non-protocol Chemotherapy, Specify (Non-protocol chemotherapy, specify)
CL Item
Non-protocol Hormonal Therapy, Specify (Non-protocol hormonal therapy, specify)
CL Item
Non-protocol Biologic Response Modifier Therapy, Specify (Non-protocol biologic response modifier therapy, specify)
CL Item
Non-protocol Radiation Therapy, Specify (Non-protocol radiation therapy, specify)
CL Item
Non-protocol High Dose Chemotherapy/autologous Cell Transplant (Non-protocol high dose chemotherapy/autologous cell transplant)
Non-ProtocolChemotherapyAdministeredSpecify
Item
Non-protocol chemotherapy, specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C15632 (NCI Thesaurus ObjectClass)
C0392920 (UMLS 2011AA ObjectClass)
C25590 (NCI Thesaurus ObjectClass)
C1518384 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
Non-ProtocolHormoneTherapyAdministeredSpecify
Item
Non-protocol hormonal therapy, specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C15445 (NCI Thesaurus ObjectClass)
C0279025 (UMLS 2011AA ObjectClass)
C25590 (NCI Thesaurus ObjectClass)
C1518384 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
Non-protocolbiologicresponsemodifiertherapy,specify
Item
Non-protocol biologic response modifier therapy, specify
text
Non-ProtocolRadiationTherapyAdministeredSpecify
Item
Non-protocol radiation therapy, specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C15313 (NCI Thesaurus ObjectClass)
C1522449 (UMLS 2011AA ObjectClass)
C25590 (NCI Thesaurus ObjectClass)
C1518384 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
Item
Did this patient receive any tamoxifen?
text
Code List
Did this patient receive any tamoxifen?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Is the patient still receiving tamoxifen?
text
Code List
Is the patient still receiving tamoxifen?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Datetamoxifenstarted
Item
Date tamoxifen started (if not previously reported)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
TamoxifenDiscontinuedDate
Item
If patient discontinued tamoxifen since last follow-up, give date (M)
date
Item
Did the patient receive any aromatase inhibitors?
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Code List
Did the patient receive any aromatase inhibitors?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Which aromatase inhibitor? (mark one with an X)
text
Code List
Which aromatase inhibitor? (mark one with an X)
CL Item
Anastrozole (Anastrozole)
C1607 (NCI Thesaurus)
C0290882 (UMLS 2011AA)
CL Item
Letrozole (Letrozole)
C1527 (NCI Thesaurus)
C0246421 (UMLS 2011AA)
CL Item
Other, Specify (Other, specify)
Other,specify(aromataseinhibitor)
Item
Other, specify (aromatase inhibitor)
text
Item
Is the patient still receiving aromatase inhibitor?
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Code List
Is the patient still receiving aromatase inhibitor?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Datearomataseinhibitorstarted
Item
Date aromatase inhibitor started (if not previously reported)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C15445 (NCI Thesaurus ObjectClass)
C0279025 (UMLS 2011AA ObjectClass)
C1740 (NCI Thesaurus ObjectClass)
C0593802 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
Ifpatientdiscontinuedaromataseinhibitorsincelastfollow-up,givedate
Item
If patient discontinued aromatase inhibitor since last follow-up, give date (M)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
CompletedBy
Item
Completed By (Print or Type Name)
text
DateCompleted
Item
Date Completed (M)
date