ID
804
Beschreibung
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
Stichworte
Versionen (2)
- 26.08.12 26.08.12 -
- 19.03.15 19.03.15 - Martin Dugas
Hochgeladen am
26. August 2012
DOI
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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.
Beschreibung
Unnamed2
Beschreibung
Patient'sName
Datentyp
text
Beschreibung
ParticipatingGroup
Datentyp
text
Alias
- NCI Thesaurus ObjectClass
- C17005
- UMLS 2011AA ObjectClass
- C1257890
- NCI Thesaurus Property
- C25364
- UMLS 2011AA Property
- C0600091
Beschreibung
PatientHospitalNumber
Datentyp
text
Beschreibung
ParticipatingGroupProtocolNo.
Datentyp
text
Beschreibung
MainMemberInstitution/Adjunct
Datentyp
text
Beschreibung
ParticipatingGroupPatientNo.
Datentyp
text
Beschreibung
Unnamed3
Beschreibung
Patient'sVitalStatus
Datentyp
text
Beschreibung
Causeofdeath
Datentyp
text
Beschreibung
DeathReason,Specify
Datentyp
text
Beschreibung
Haspatienthadadocumentedclinicalassessmentforthiscancersincesubmissionofthepreviousfollow-upform?
Datentyp
text
Beschreibung
ProgressionAssessmentSource
Datentyp
text
Beschreibung
CancerFollow-upStatusDate
Datentyp
date
Alias
- NCI Thesaurus ObjectClass
- C2991
- UMLS 2011AA ObjectClass
- C0012634
- NCI Thesaurus Property
- C25365
- UMLS 2011AA Property
- C0678257
Beschreibung
Hasthepatientbeendiagnosedwithafirstlocal-regionalrecurrence/progressionsincesubmissionofthelastfollow-upform?
Datentyp
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschreibung
ProgressionDate,FirstLocal-Regional
Datentyp
date
Beschreibung
ProgressionSite(s),FirstLocal-Regional
Datentyp
text
Beschreibung
Unnamed4
Beschreibung
Unnamed5
Beschreibung
Hasthepatientbeendiagnosedwithafirstdistantrecurrence/progressionsincesubmissionofthelastfollow-upform?
Datentyp
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschreibung
ProgressionDate,FirstDistant
Datentyp
date
Beschreibung
ProgressionSite,FirstDistant
Datentyp
text
Beschreibung
ProgressionAssessmentSource
Datentyp
text
Beschreibung
Hasanewprimarycancerofmyelodysplasticsyndrome(MDS)beendiagnosedthathasnotbeenpreviouslyreported?
Datentyp
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschreibung
NewPrimaryCancerDate
Datentyp
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
Beschreibung
NewPrimarySite
Datentyp
text
Beschreibung
CurrentMenopausalStatus
Datentyp
text
Beschreibung
Resumptiondate
Datentyp
text
Beschreibung
Cessationdate
Datentyp
text
Beschreibung
Unnamed6
Beschreibung
Unnamed7
Beschreibung
Hasthepatientexperienced(priortodiagnosisofrecurrenceorsecondprimary)anysevere(Grade>=3),longtermtreatmentrelatedtoxicitythathasnotbeenpreviouslyreported?
Datentyp
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschreibung
IMTCode
Datentyp
text
Beschreibung
IMTCode
Datentyp
text
Beschreibung
CTCAdverseEventTerm
Datentyp
text
Beschreibung
CTCAdverseEventTerm
Datentyp
text
Beschreibung
Grade
Datentyp
double
Beschreibung
Grade
Datentyp
double
Beschreibung
DateofOnset
Datentyp
text
Beschreibung
DateofOnset
Datentyp
text
Beschreibung
Didpatientreceivenon-protocolcancertherapypriortofirstrecurrenceandnotpreviouslyreported?
Datentyp
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschreibung
Non-ProtocolTherapy
Datentyp
text
Beschreibung
Non-ProtocolChemotherapyAdministeredSpecify
Datentyp
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
Beschreibung
Non-ProtocolHormoneTherapyAdministeredSpecify
Datentyp
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
Beschreibung
Non-protocolbiologicresponsemodifiertherapy,specify
Datentyp
text
Beschreibung
Non-ProtocolRadiationTherapyAdministeredSpecify
Datentyp
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
Beschreibung
Unnamed8
Beschreibung
Long-term Therapy
Beschreibung
PastTamoxifenInd
Datentyp
text
Beschreibung
CurrentTamoxifenInd
Datentyp
text
Beschreibung
Datetamoxifenstarted
Datentyp
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
Beschreibung
TamoxifenDiscontinuedDate
Datentyp
date
Beschreibung
Didthepatientreceiveanyaromataseinhibitors?
Datentyp
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschreibung
Whicharomataseinhibitor?
Datentyp
text
Beschreibung
Other,specify(aromataseinhibitor)
Datentyp
text
Beschreibung
Isthepatientstillreceivingaromataseinhibitor?
Datentyp
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschreibung
Datearomataseinhibitorstarted
Datentyp
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
Beschreibung
Ifpatientdiscontinuedaromataseinhibitorsincelastfollow-up,givedate
Datentyp
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
Beschreibung
Comments
Beschreibung
Unnamed9
Beschreibung
Ccrr Module For Calgb: 40101 Follow-up Form
Ähnliche Modelle
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)