ID

8048

Descripción

USMCI 8214/Z6091: Systemic Therapy Form Standard Therapy With or Without Surgery and Mitomycin C in Treating Patients With Advanced Limited Peritoneal Dissemination of Colon Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=62075F41-0F8D-15EF-E040-BB89AD43299C

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=62075F41-0F8D-15EF-E040-BB89AD43299C

Palabras clave

Versiones (4)
  1. 27/8/12 27/8/12 -
  2. 12/12/14 12/12/14 - Martin Dugas
  3. 9/1/15 9/1/15 - Martin Dugas
  4. 9/1/15 9/1/15 - Martin Dugas
Subido en

9 de enero de 2015

DOI

Para solicitar uno, por favor iniciar sesión.

Licencia

Creative Commons BY-NC 3.0 Legacy
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Colorectal Cancer NCT01167725 Eligibility - USMCI 8214/Z6091: Systemic Therapy Form - 2831237v1.0

Inglés

No Instruction available.

1 formularios  
  1. StudyEvent: USMCI 8214/Z6091: Systemic Therapy Form
    1. No Instruction available.
Header Module
Descripción

Header Module

Visit
Descripción

American College of Surgeons Oncology Group Visit Period Type

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25284
NCI Thesaurus Property
C25616
NCI Thesaurus ObjectClass
C19712
NCI Thesaurus ObjectClass-2
C25716
UMLS CUI-1
C0332307
UMLS CUI-2
C1948053
UMLS CUI-3
C1515944
UMLS CUI-4
C0545082
Patient ID
Descripción

Patient Study ID

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25462
NCI Thesaurus Property-2
C25364
Institution No.
Descripción

Institution Number

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C1301943
NCI Thesaurus ObjectClass
C21541
UMLS CUI-2
C0805701
NCI Thesaurus Property
C25364
Institution Name
Descripción

Institution Name

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C1301943
NCI Thesaurus ObjectClass
C21541
NCI Thesaurus ValueDomain-2
C21541
NCI Thesaurus Property
C25364
Header Module
Descripción

Header Module

Current Cycle Number
Descripción

Cycle Number Chemotherapeutics

Tipo de datos

float

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2045829
NCI Thesaurus Property
C25471
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus Property-2
C25379
Cycle Start Date
Descripción

Chemotherapy Cycle Start Date

Tipo de datos

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS CUI-1
C1302181
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus ValueDomain-2
C25431
UMLS CUI-2
C3173309
NCI Thesaurus Property
C25379
Cycle end date
Descripción

Chemotherapy Cycle End Date

Tipo de datos

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS CUI-1
C1302181
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus Property
C25379
UMLS CUI-2
C0806020
Systemic therapy
Descripción

Systemic therapy

Alias
UMLS CUI-1
C1515119
Treating physician
Descripción

TreatingPhysicianName

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Thesaurus ObjectClass
C25741
UMLS 2011AA ObjectClass
C0031831
NCI Thesaurus ObjectClass-2
C25705
UMLS 2011AA ObjectClass-2
C1522326
Weight
Descripción

Patient Weight

Tipo de datos

float

Unidades de medida
  • Kg
Alias
NCI Thesaurus ValueDomain
C25209
UMLS CUI-1
C0005910
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25208
Kg
Performance Status (ECOG)
Descripción

ECOG Performance Status

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25664
UMLS CUI-1
C1520224
NCI Thesaurus Property
C25367
NCI Thesaurus ValueDomain-2
C25491
NCI Thesaurus ObjectClass
C20641
Was treatment given during this cycle
Descripción

CurrentTherapyCourseAdministeredInd-2

Tipo de datos

boolean

Alias
NCI Thesaurus ObjectClass
C25471
UMLS 2011AA ObjectClass
C0521116
NCI Thesaurus ObjectClass-2
C15368
NCI Thesaurus Property
C25379
UMLS 2011AA Property
C0750729
NCI Thesaurus Property-2
C25382
UMLS 2011AA Property-2
C1521801
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Was this cycle of treatment delayed
Descripción

Chemotherapy delayed

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS CUI-1
C1299577
NCI Thesaurus Property
C25477
NCI Thesaurus Property-2
C25472
NCI Thesaurus ObjectClass
C15368
Reason
Descripción

TreatmentCycleDelayReason

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus Property
C25477
NCI Thesaurus Property-2
C25472
UMLS 2011AA Property
C1511572
NCI Thesaurus ValueDomain
C25638
UMLS 2011AA ValueDomain
C0392360
NCI Thesaurus ValueDomain-2
C15368
NCI Thesaurus ValueDomain-3
C25476
UMLS 2011AA ValueDomain-2
C0205421
Specify
Descripción

TreatmentCycleDelayReasonText

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus Property
C25477
NCI Thesaurus Property-2
C25472
UMLS 2011AA Property
C1511572
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ValueDomain-2
C25638
UMLS 2011AA ValueDomain-2
C0392360
NCI Thesaurus ValueDomain-3
C25476
UMLS 2011AA ValueDomain-3
C0205421
Agent Name
Descripción

Agent

Tipo de datos

text

Alias
NCI Thesaurus Property
C25364
UMLS CUI-1
C1521826
NCI Thesaurus ObjectClass
C1708
NCI Thesaurus ValueDomain
C1708
NCI Thesaurus ValueDomain-2
C42614
Other, specify
Descripción

AgentAdministeredSpecify

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus ObjectClass
C1708
UMLS 2011AA ObjectClass
C0450442
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Was agent administered
Descripción

Agent administered during reporting period

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C38147
UMLS CUI-1
C0450442
NCI Thesaurus ObjectClass
C1708
UMLS CUI-2
C1521801
NCI Thesaurus Property
C25382
Treatment dose modified
Descripción

AgentDoseModifiedIndicator

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
NCI Thesaurus Property
C25446
UMLS 2011AA Property
C0392747
NCI Thesaurus ObjectClass
C1708
UMLS 2011AA ObjectClass
C0450442
Agent Total Dose
Descripción

AgentCourseTotalDose

Tipo de datos

float

Alias
NCI Thesaurus ValueDomain
C25304
NCI Thesaurus Property
C25379
NCI Thesaurus ValueDomain-2
C25488
NCI Thesaurus ObjectClass
C1708
UMLS CUI-1
C2986497
Did the patient receive cytokine support
Descripción

AgentCytokineAdministeredInd-3

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C38148
NCI Thesaurus Property
C20464
NCI Thesaurus ObjectClass
C1708
NCI Thesaurus Property-2
C25382
UMLS CUI-1
C0199974
Type
Descripción

AgentCytokineAdministeredType

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus Property
C20464
UMLS 2011AA Property
C0079189
NCI Thesaurus ObjectClass
C1708
UMLS 2011AA ObjectClass
C0450442
NCI Thesaurus Property-2
C25382
UMLS 2011AA Property-2
C1521801
Specify
Descripción

AgentCytokineAdministeredSpecify

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25685
UMLS 2011AA ValueDomain
C1521902
NCI Thesaurus Property
C20464
UMLS 2011AA Property
C0079189
NCI Thesaurus ObjectClass
C1708
UMLS 2011AA ObjectClass
C0450442
NCI Thesaurus Property-2
C25382
UMLS 2011AA Property-2
C1521801
Did the patient receive PRBC
Descripción

PackedRedBloodCellTransfusionReceivedInd-2

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C38147
NCI Thesaurus Property
C25639
NCI Thesaurus ObjectClass
C15409
UMLS CUI-1
C1512698
UMLS CUI-2
C1514756
UMLS CUI-3
C0199962
Did the patient receive platelet transfusion
Descripción

PlateletTransfusionAdministeredInd-2

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C38148
NCI Thesaurus ObjectClass
C15366
NCI Thesaurus Property
C25382
UMLS CUI-1
C1512699
UMLS CUI-2
C0086818
UMLS CUI-3
C1521801
Did the patient receive FFP transfusion
Descripción

FreshFrozenPlasmaTransfusionReceiveInd-2

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C38147
NCI Thesaurus Property
C25639
NCI Metathesaurus ObjectClass
C0016709
NCI Thesaurus ObjectClass
C15408
UMLS CUI-1
C1512698
UMLS CUI-2
C1514756
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Similar models

No Instruction available.

1 formularios
  1. StudyEvent: USMCI 8214/Z6091: Systemic Therapy Form
    1. No Instruction available.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Item Group
Header Module
Item
Visit
text
C25284 (NCI Thesaurus ValueDomain)
C25616 (NCI Thesaurus Property)
C19712 (NCI Thesaurus ObjectClass)
C25716 (NCI Thesaurus ObjectClass-2)
C0332307 (UMLS CUI-1)
C1948053 (UMLS CUI-2)
C1515944 (UMLS CUI-3)
C0545082 (UMLS CUI-4)
CL.1
Code List
Visit
CL Item
Systemic Therapy (Systemic Therapy)
Patient Study ID
Item
Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25462 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
Institution Number
Item
Institution No.
text
C25337 (NCI Thesaurus ValueDomain)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass)
C0805701 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
Institution Name
Item
Institution Name
text
C25191 (NCI Thesaurus ValueDomain)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass)
C21541 (NCI Thesaurus ValueDomain-2)
C25364 (NCI Thesaurus Property)
Item Group
Header Module
Cycle Number Chemotherapeutics
Item
Current Cycle Number
float
C25337 (NCI Thesaurus ValueDomain)
C2045829 (UMLS CUI-1)
C25471 (NCI Thesaurus Property)
C15368 (NCI Thesaurus ObjectClass)
C25379 (NCI Thesaurus Property-2)
Chemotherapy Cycle Start Date
Item
Cycle Start Date
date
C25164 (NCI Thesaurus ValueDomain)
C1302181 (UMLS CUI-1)
C15368 (NCI Thesaurus ObjectClass)
C25431 (NCI Thesaurus ValueDomain-2)
C3173309 (UMLS CUI-2)
C25379 (NCI Thesaurus Property)
Chemotherapy Cycle End Date
Item
Cycle end date
date
C25164 (NCI Thesaurus ValueDomain)
C1302181 (UMLS CUI-1)
C15368 (NCI Thesaurus ObjectClass)
C25379 (NCI Thesaurus Property)
C0806020 (UMLS CUI-2)
Item Group
Systemic therapy
C1515119 (UMLS CUI-1)
TreatingPhysicianName
Item
Treating physician
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C25741 (NCI Thesaurus ObjectClass)
C0031831 (UMLS 2011AA ObjectClass)
C25705 (NCI Thesaurus ObjectClass-2)
C1522326 (UMLS 2011AA ObjectClass-2)
Patient Weight
Item
Weight
float
C25209 (NCI Thesaurus ValueDomain)
C0005910 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25208 (NCI Thesaurus Property)
Item
Performance Status (ECOG)
text
C25664 (NCI Thesaurus ValueDomain)
C1520224 (UMLS CUI-1)
C25367 (NCI Thesaurus Property)
C25491 (NCI Thesaurus ValueDomain-2)
C20641 (NCI Thesaurus ObjectClass)
CL.2
Code List
Performance Status (ECOG)
CL Item
Fully Active, Able To Carry On All Pre-disease Performance Without Restriction. (0)
CL Item
Restricted In Physically Strenuous Activity But Ambulatory And Able To Carry Out Work Of A Light Or Sedentary Nature, E.g., Light Housework, Office Work. (1)
CL Item
Ambulatory And Capable Of All Selfcare But Unable To Carry Out Any Work Activities. Up And About More Than 50% Of Waking Hours. (2)
CL Item
Capable Of Only Limited Selfcare, Confined To Bed Or Chair More Than 50% Of Waking Hours. (3)
CL Item
Completely Disabled. Cannot Carry On Any Selfcare. Totally Confined To Bed Or Chair. (4)
CurrentTherapyCourseAdministeredInd-2
Item
Was treatment given during this cycle
boolean
C25471 (NCI Thesaurus ObjectClass)
C0521116 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus ObjectClass-2)
C25379 (NCI Thesaurus Property)
C0750729 (UMLS 2011AA Property)
C25382 (NCI Thesaurus Property-2)
C1521801 (UMLS 2011AA Property-2)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
Chemotherapy delayed
Item
Was this cycle of treatment delayed
boolean
C38148 (NCI Thesaurus ValueDomain)
C1299577 (UMLS CUI-1)
C25477 (NCI Thesaurus Property)
C25472 (NCI Thesaurus Property-2)
C15368 (NCI Thesaurus ObjectClass)
Item
Reason
text
C15368 (NCI Thesaurus ObjectClass)
C25477 (NCI Thesaurus Property)
C25472 (NCI Thesaurus Property-2)
C1511572 (UMLS 2011AA Property)
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
C15368 (NCI Thesaurus ValueDomain-2)
C25476 (NCI Thesaurus ValueDomain-3)
C0205421 (UMLS 2011AA ValueDomain-2)
CL.5
Code List
Reason
CL Item
Adverse Event (Adverse Event)
C41331 (NCI Thesaurus)
C0877248 (UMLS 2011AA)
CL Item
Other, Specify (Other, specify)
TreatmentCycleDelayReasonText
Item
Specify
text
C15368 (NCI Thesaurus ObjectClass)
C25477 (NCI Thesaurus Property)
C25472 (NCI Thesaurus Property-2)
C1511572 (UMLS 2011AA Property)
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25638 (NCI Thesaurus ValueDomain-2)
C0392360 (UMLS 2011AA ValueDomain-2)
C25476 (NCI Thesaurus ValueDomain-3)
C0205421 (UMLS 2011AA ValueDomain-3)
Agent
Item
Agent Name
text
C25364 (NCI Thesaurus Property)
C1521826 (UMLS CUI-1)
C1708 (NCI Thesaurus ObjectClass)
C1708 (NCI Thesaurus ValueDomain)
C42614 (NCI Thesaurus ValueDomain-2)
AgentAdministeredSpecify
Item
Other, specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C1708 (NCI Thesaurus ObjectClass)
C0450442 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
Agent administered during reporting period
Item
Was agent administered
boolean
C38147 (NCI Thesaurus ValueDomain)
C0450442 (UMLS CUI-1)
C1708 (NCI Thesaurus ObjectClass)
C1521801 (UMLS CUI-2)
C25382 (NCI Thesaurus Property)
AgentDoseModifiedIndicator
Item
Treatment dose modified
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C25446 (NCI Thesaurus Property)
C0392747 (UMLS 2011AA Property)
C1708 (NCI Thesaurus ObjectClass)
C0450442 (UMLS 2011AA ObjectClass)
Agent Total Dose
Item
Agent Total Dose
float
C25304 (NCI Thesaurus ValueDomain)
C25379 (NCI Thesaurus Property)
C25488 (NCI Thesaurus ValueDomain-2)
C1708 (NCI Thesaurus ObjectClass)
C2986497 (UMLS CUI-1)
Cytokine Therapy
Item
Did the patient receive cytokine support
boolean
C38148 (NCI Thesaurus ValueDomain)
C20464 (NCI Thesaurus Property)
C1708 (NCI Thesaurus ObjectClass)
C25382 (NCI Thesaurus Property-2)
C0199974 (UMLS CUI-1)
Item
Type
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C20464 (NCI Thesaurus Property)
C0079189 (UMLS 2011AA Property)
C1708 (NCI Thesaurus ObjectClass)
C0450442 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property-2)
C1521801 (UMLS 2011AA Property-2)
CL.9
Code List
Type
CL Item
Filgastrim (Filgastrim)
CL Item
Pegfilgastrim (Pegfilgastrim)
CL Item
Erythropoietin (Erythropoietin)
C20429 (NCI Thesaurus)
C0014822 (UMLS 2011AA)
CL Item
Darbopoietin (Darbopoietin)
CL Item
Other (Other)
AgentCytokineAdministeredSpecify
Item
Specify
text
C25685 (NCI Thesaurus ValueDomain)
C1521902 (UMLS 2011AA ValueDomain)
C20464 (NCI Thesaurus Property)
C0079189 (UMLS 2011AA Property)
C1708 (NCI Thesaurus ObjectClass)
C0450442 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property-2)
C1521801 (UMLS 2011AA Property-2)
PackedRedBloodCellTransfusionReceivedInd-2
Item
Did the patient receive PRBC
boolean
C38147 (NCI Thesaurus ValueDomain)
C25639 (NCI Thesaurus Property)
C15409 (NCI Thesaurus ObjectClass)
C1512698 (UMLS CUI-1)
C1514756 (UMLS CUI-2)
C0199962 (UMLS CUI-3)
PlateletTransfusionAdministeredInd-2
Item
Did the patient receive platelet transfusion
text
C38148 (NCI Thesaurus ValueDomain)
C15366 (NCI Thesaurus ObjectClass)
C25382 (NCI Thesaurus Property)
C1512699 (UMLS CUI-1)
C0086818 (UMLS CUI-2)
C1521801 (UMLS CUI-3)
FreshFrozenPlasmaTransfusionReceiveInd-2
Item
Did the patient receive FFP transfusion
boolean
C38147 (NCI Thesaurus ValueDomain)
C25639 (NCI Thesaurus Property)
C0016709 (NCI Metathesaurus ObjectClass)
C15408 (NCI Thesaurus ObjectClass)
C1512698 (UMLS CUI-1)
C1514756 (UMLS CUI-2)
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