ID
804
Description
CALGB: 40101 FOLLOW-UP FORM Four Versus Six Cycles of Cyclophosphamide/Doxorubicin or Paclitaxel in Adjuvant Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A46CA742-FE60-27F9-E034-080020C9C0E0
Link
Keywords
Versions (2)
- 8/26/12 8/26/12 -
- 3/19/15 3/19/15 - Martin Dugas
Uploaded on
August 26, 2012
DOI
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License
Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00041119 Follow-Up - CALGB: 40101 FOLLOW-UP FORM - 2038050v3.0
INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice. Print text in capital letters. Avoid contact with the edges of the boxes. Circle amended items and check "Amended data" box to the right. If submitting by mail, retain a copy for your records and send the original to the CALGB Statistical Center, Data Operations. If faxing, use an original form for maximum clarity in transmission and fax to 919-416-4990. If submitting electronically, click the Send button when you have completed the PDF version of the form.
Description
Unnamed2
Description
Patient'sName
Data type
text
Description
ParticipatingGroup
Data type
text
Alias
- NCI Thesaurus ObjectClass
- C17005
- UMLS 2011AA ObjectClass
- C1257890
- NCI Thesaurus Property
- C25364
- UMLS 2011AA Property
- C0600091
Description
PatientHospitalNumber
Data type
text
Description
ParticipatingGroupProtocolNo.
Data type
text
Description
MainMemberInstitution/Adjunct
Data type
text
Description
ParticipatingGroupPatientNo.
Data type
text
Description
Unnamed3
Description
Patient'sVitalStatus
Data type
text
Description
Causeofdeath
Data type
text
Description
DeathReason,Specify
Data type
text
Description
Haspatienthadadocumentedclinicalassessmentforthiscancersincesubmissionofthepreviousfollow-upform?
Data type
text
Description
ProgressionAssessmentSource
Data type
text
Description
CancerFollow-upStatusDate
Data type
date
Alias
- NCI Thesaurus ObjectClass
- C2991
- UMLS 2011AA ObjectClass
- C0012634
- NCI Thesaurus Property
- C25365
- UMLS 2011AA Property
- C0678257
Description
Hasthepatientbeendiagnosedwithafirstlocal-regionalrecurrence/progressionsincesubmissionofthelastfollow-upform?
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
ProgressionDate,FirstLocal-Regional
Data type
date
Description
ProgressionSite(s),FirstLocal-Regional
Data type
text
Description
Unnamed4
Description
Unnamed5
Description
Hasthepatientbeendiagnosedwithafirstdistantrecurrence/progressionsincesubmissionofthelastfollow-upform?
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
ProgressionDate,FirstDistant
Data type
date
Description
ProgressionSite,FirstDistant
Data type
text
Description
ProgressionAssessmentSource
Data type
text
Description
Hasanewprimarycancerofmyelodysplasticsyndrome(MDS)beendiagnosedthathasnotbeenpreviouslyreported?
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
NewPrimaryCancerDate
Data type
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
Description
NewPrimarySite
Data type
text
Description
CurrentMenopausalStatus
Data type
text
Description
Resumptiondate
Data type
text
Description
Cessationdate
Data type
text
Description
Unnamed6
Description
Unnamed7
Description
Hasthepatientexperienced(priortodiagnosisofrecurrenceorsecondprimary)anysevere(Grade>=3),longtermtreatmentrelatedtoxicitythathasnotbeenpreviouslyreported?
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
IMTCode
Data type
text
Description
IMTCode
Data type
text
Description
CTCAdverseEventTerm
Data type
text
Description
CTCAdverseEventTerm
Data type
text
Description
Grade
Data type
double
Description
Grade
Data type
double
Description
DateofOnset
Data type
text
Description
DateofOnset
Data type
text
Description
Didpatientreceivenon-protocolcancertherapypriortofirstrecurrenceandnotpreviouslyreported?
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
Non-ProtocolTherapy
Data type
text
Description
Non-ProtocolChemotherapyAdministeredSpecify
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25685
- UMLS 2011AA ValueDomain
- C1521902
- NCI Thesaurus ObjectClass
- C15632
- UMLS 2011AA ObjectClass
- C0392920
- NCI Thesaurus ObjectClass
- C25590
- UMLS 2011AA ObjectClass
- C1518384
- NCI Thesaurus Property
- C25382
- UMLS 2011AA Property
- C1521801
Description
Non-ProtocolHormoneTherapyAdministeredSpecify
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25685
- UMLS 2011AA ValueDomain
- C1521902
- NCI Thesaurus ObjectClass
- C15445
- UMLS 2011AA ObjectClass
- C0279025
- NCI Thesaurus ObjectClass
- C25590
- UMLS 2011AA ObjectClass
- C1518384
- NCI Thesaurus Property
- C25382
- UMLS 2011AA Property
- C1521801
Description
Non-protocolbiologicresponsemodifiertherapy,specify
Data type
text
Description
Non-ProtocolRadiationTherapyAdministeredSpecify
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25685
- UMLS 2011AA ValueDomain
- C1521902
- NCI Thesaurus ObjectClass
- C15313
- UMLS 2011AA ObjectClass
- C1522449
- NCI Thesaurus ObjectClass
- C25590
- UMLS 2011AA ObjectClass
- C1518384
- NCI Thesaurus Property
- C25382
- UMLS 2011AA Property
- C1521801
Description
Unnamed8
Description
Long-term Therapy
Description
PastTamoxifenInd
Data type
text
Description
CurrentTamoxifenInd
Data type
text
Description
Datetamoxifenstarted
Data type
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
Description
TamoxifenDiscontinuedDate
Data type
date
Description
Didthepatientreceiveanyaromataseinhibitors?
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
Whicharomataseinhibitor?
Data type
text
Description
Other,specify(aromataseinhibitor)
Data type
text
Description
Isthepatientstillreceivingaromataseinhibitor?
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
Datearomataseinhibitorstarted
Data type
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
- NCI Thesaurus ObjectClass
- C15445
- UMLS 2011AA ObjectClass
- C0279025
- NCI Thesaurus ObjectClass
- C1740
- UMLS 2011AA ObjectClass
- C0593802
- NCI Thesaurus Property
- C25382
- UMLS 2011AA Property
- C1521801
Description
Ifpatientdiscontinuedaromataseinhibitorsincelastfollow-up,givedate
Data type
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
Description
Comments
Description
Unnamed9
Description
Ccrr Module For Calgb: 40101 Follow-up Form
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INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice. Print text in capital letters. Avoid contact with the edges of the boxes. Circle amended items and check "Amended data" box to the right. If submitting by mail, retain a copy for your records and send the original to the CALGB Statistical Center, Data Operations. If faxing, use an original form for maximum clarity in transmission and fax to 919-416-4990. If submitting electronically, click the Send button when you have completed the PDF version of the form.
C1705108 (UMLS 2011AA)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C0439673 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C0012634 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
C1522602 (UMLS 2011AA ValueDomain)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C1522602 (UMLS 2011AA ValueDomain)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C1522602 (UMLS 2011AA ValueDomain)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C0011008 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C1522602 (UMLS 2011AA ValueDomain)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
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)
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)
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)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C0011008 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
C0290882 (UMLS 2011AA)
C0246421 (UMLS 2011AA)
C1522602 (UMLS 2011AA ValueDomain)
C1298908 (UMLS 2011AA)
C1705108 (UMLS 2011AA)
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)
C0011008 (UMLS 2011AA ValueDomain)