ID

804

Descripción

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

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A46CA742-FE60-27F9-E034-080020C9C0E0

Palabras clave

Versiones (2)
  1. 26/8/12 26/8/12 -
  2. 19/3/15 19/3/15 - Martin Dugas
Subido en

26 de agosto de 2012

DOI

Para solicitar uno, por favor iniciar sesión.

Licencia

Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00041119 Follow-Up - CALGB: 40101 FOLLOW-UP FORM - 2038050v3.0

Inglés

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.

1 formularios  
Unnamed1
Descripción

Unnamed1

CALGB Form
Descripción

CALGBForm

Tipo de datos

text

CALGB Study No
Descripción

CALGBStudyNo

Tipo de datos

text

CALGB Patient ID
Descripción

CALGBPatientID

Tipo de datos

text

From
Descripción

From

Tipo de datos

text

To (date of last contact or death)
Descripción

To

Tipo de datos

text

Amended data?
Descripción

Amendeddata?

Tipo de datos

text

Unnamed2
Descripción

Unnamed2

Patient's Name
Descripción

Patient'sName

Tipo de datos

text

Participating Group
Descripción

ParticipatingGroup

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C17005
UMLS 2011AA ObjectClass
C1257890
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Patient Hospital Number
Descripción

PatientHospitalNumber

Tipo de datos

text

Participating Group Protocol No.
Descripción

ParticipatingGroupProtocolNo.

Tipo de datos

text

Main Member Institution/Adjunct
Descripción

MainMemberInstitution/Adjunct

Tipo de datos

text

Participating Group Patient No.
Descripción

ParticipatingGroupPatientNo.

Tipo de datos

text

Unnamed3
Descripción

Unnamed3

Patient's Vital Status (mark one with an X)
Descripción

Patient'sVitalStatus

Tipo de datos

text

Cause of death (if dead)
Descripción

Causeofdeath

Tipo de datos

text

Describe cause of death (Disease Assessment)
Descripción

DeathReason,Specify

Tipo de datos

text

Has patient had a documented clinical assessment for this cancer since submission of the previous follow-up form?
Descripción

Haspatienthadadocumentedclinicalassessmentforthiscancersincesubmissionofthepreviousfollow-upform?

Tipo de datos

text

How was this progression information obtained? (mark one with an X)
Descripción

ProgressionAssessmentSource

Tipo de datos

text

Date of last clinical assessment (M)
Descripción

CancerFollow-upStatusDate

Tipo de datos

date

Alias
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Has the patient been diagnosed with a first local-regional recurrence/progression since submission of the last follow-up form?
Descripción

Hasthepatientbeendiagnosedwithafirstlocal-regionalrecurrence/progressionsincesubmissionofthelastfollow-upform?

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Date of first local-regional progression (M)
Descripción

ProgressionDate,FirstLocal-Regional

Tipo de datos

date

Site(s) of first local-regional progression (mark all that apply with an X)
Descripción

ProgressionSite(s),FirstLocal-Regional

Tipo de datos

text

Unnamed4
Descripción

Unnamed4

Patient's Name
Descripción

Patient'sName

Tipo de datos

text

CALGB Form
Descripción

CALGBForm

Tipo de datos

text

CALGB Study No
Descripción

CALGBStudyNo

Tipo de datos

text

CALGB Patient ID
Descripción

CALGBPatientID

Tipo de datos

text

From
Descripción

From

Tipo de datos

text

Unnamed5
Descripción

Unnamed5

Has the patient been diagnosed with a first distant recurrence/progression since submission of the last follow-up form?
Descripción

Hasthepatientbeendiagnosedwithafirstdistantrecurrence/progressionsincesubmissionofthelastfollow-upform?

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Date of first distant progression (M)
Descripción

ProgressionDate,FirstDistant

Tipo de datos

date

Site(s) of first distant progression
Descripción

ProgressionSite,FirstDistant

Tipo de datos

text

How was this progression information obtained? (mark one with an X)
Descripción

ProgressionAssessmentSource

Tipo de datos

text

Has a new primary cancer of myelodysplastic syndrome (MDS) been diagnosed that has not been previously reported?
Descripción

Hasanewprimarycancerofmyelodysplasticsyndrome(MDS)beendiagnosedthathasnotbeenpreviouslyreported?

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Date of diagnosis (M)
Descripción

NewPrimaryCancerDate

Tipo de datos

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
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)
Descripción

NewPrimarySite

Tipo de datos

text

Current Menopausal Status (If premenopausal prior to chemotherapy mark one with an X)
Descripción

CurrentMenopausalStatus

Tipo de datos

text

Resumption date
Descripción

Resumptiondate

Tipo de datos

text

Cessation date (M)
Descripción

Cessationdate

Tipo de datos

text

Unnamed6
Descripción

Unnamed6

Patient's Name
Descripción

Patient'sName

Tipo de datos

text

CALGB Form
Descripción

CALGBForm

Tipo de datos

text

CALGB Study No
Descripción

CALGBStudyNo

Tipo de datos

text

CALGB Patient ID
Descripción

CALGBPatientID

Tipo de datos

text

From
Descripción

From

Tipo de datos

text

Unnamed7
Descripción

Unnamed7

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)
Descripción

Hasthepatientexperienced(priortodiagnosisofrecurrenceorsecondprimary)anysevere(Grade>=3),longtermtreatmentrelatedtoxicitythathasnotbeenpreviouslyreported?

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
IMT Code
Descripción

IMTCode

Tipo de datos

text

IMT Code
Descripción

IMTCode

Tipo de datos

text

CTC Adverse Event Term
Descripción

CTCAdverseEventTerm

Tipo de datos

text

CTC Adverse Event Term
Descripción

CTCAdverseEventTerm

Tipo de datos

text

Grade (only 3, 4, 5)
Descripción

Grade

Tipo de datos

double

Grade (only 3, 4, 5)
Descripción

Grade

Tipo de datos

double

Date of Onset (M)
Descripción

DateofOnset

Tipo de datos

text

Date of Onset (M)
Descripción

DateofOnset

Tipo de datos

text

Did patient receive non-protocol cancer therapy prior to first recurrence and not previously reported? (mark all that apply with an X)
Descripción

Didpatientreceivenon-protocolcancertherapypriortofirstrecurrenceandnotpreviouslyreported?

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Non-Protocol Therapy
Descripción

Non-ProtocolTherapy

Tipo de datos

text

Non-protocol chemotherapy, specify
Descripción

Non-ProtocolChemotherapyAdministeredSpecify

Tipo de datos

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
Non-protocol hormonal therapy, specify
Descripción

Non-ProtocolHormoneTherapyAdministeredSpecify

Tipo de datos

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
Non-protocol biologic response modifier therapy, specify
Descripción

Non-protocolbiologicresponsemodifiertherapy,specify

Tipo de datos

text

Non-protocol radiation therapy, specify
Descripción

Non-ProtocolRadiationTherapyAdministeredSpecify

Tipo de datos

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
Unnamed8
Descripción

Unnamed8

Patient's Name
Descripción

Patient'sName

Tipo de datos

text

CALGB Form
Descripción

CALGBForm

Tipo de datos

text

CALGB Study No
Descripción

CALGBStudyNo

Tipo de datos

text

CALGB Patient ID
Descripción

CALGBPatientID

Tipo de datos

text

From
Descripción

From

Tipo de datos

text

Long-term Therapy
Descripción

Long-term Therapy

Did this patient receive any tamoxifen?
Descripción

PastTamoxifenInd

Tipo de datos

text

Is the patient still receiving tamoxifen?
Descripción

CurrentTamoxifenInd

Tipo de datos

text

Date tamoxifen started (if not previously reported)
Descripción

Datetamoxifenstarted

Tipo de datos

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
If patient discontinued tamoxifen since last follow-up, give date (M)
Descripción

TamoxifenDiscontinuedDate

Tipo de datos

date

Did the patient receive any aromatase inhibitors?
Descripción

Didthepatientreceiveanyaromataseinhibitors?

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Which aromatase inhibitor? (mark one with an X)
Descripción

Whicharomataseinhibitor?

Tipo de datos

text

Other, specify (aromatase inhibitor)
Descripción

Other,specify(aromataseinhibitor)

Tipo de datos

text

Is the patient still receiving aromatase inhibitor?
Descripción

Isthepatientstillreceivingaromataseinhibitor?

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Date aromatase inhibitor started (if not previously reported)
Descripción

Datearomataseinhibitorstarted

Tipo de datos

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
If patient discontinued aromatase inhibitor since last follow-up, give date (M)
Descripción

Ifpatientdiscontinuedaromataseinhibitorsincelastfollow-up,givedate

Tipo de datos

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Comments
Descripción

Comments

Comments
Descripción

Comments

Tipo de datos

text

Unnamed9
Descripción

Unnamed9

Completed By (Print or Type Name)
Descripción

CompletedBy

Tipo de datos

text

Date Completed (M)
Descripción

DateCompleted

Tipo de datos

date

Ccrr Module For Calgb: 40101 Follow-up Form
Descripción

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.

1 formularios
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Item Group
Unnamed1
CALGBForm
Item
CALGB Form
text
CALGBStudyNo
Item
CALGB Study No
text
CALGBPatientID
Item
CALGB Patient ID
text
From
Item
From
text
To
Item
To (date of last contact or death)
text
Item
Amended data?
text
CL.1
Code List
Amended data?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item Group
Unnamed2
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 Group
Unnamed3
Item
Patient's Vital Status (mark one with an X)
text
CL.2
Code List
Patient's Vital Status (mark one with an X)
CL Item
Alive (Alive)
CL Item
Dead (Dead)
CL Item
Lost (Lost)
Item
Cause of death (if dead)
text
CL.3
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
CL.4
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
CL.9
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)
CL.5
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
CL.6
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)
CL Item
Axilla (Axilla)
Item Group
Unnamed4
Patient'sName
Item
Patient's Name
text
CALGBForm
Item
CALGB Form
text
CALGBStudyNo
Item
CALGB Study No
text
CALGBPatientID
Item
CALGB Patient ID
text
From
Item
From
text
Item Group
Unnamed5
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)
CL.8
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
CL.9
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)
CL.10
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
CL.11
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 Group
Unnamed6
Patient'sName
Item
Patient's Name
text
CALGBForm
Item
CALGB Form
text
CALGBStudyNo
Item
CALGB Study No
text
CALGBPatientID
Item
CALGB Patient ID
text
From
Item
From
text
Item Group
Unnamed7
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)
CL.12
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
CL.16
Code List
Grade (only 3, 4, 5)
CL Item
3 (3)
CL Item
4 (4)
CL Item
5 (5)
Item
Grade (only 3, 4, 5)
double
CL.16
Code List
Grade (only 3, 4, 5)
CL Item
3 (3)
CL Item
4 (4)
CL Item
5 (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)
CL.17
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
CL.18
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 Group
Unnamed8
Patient'sName
Item
Patient's Name
text
CALGBForm
Item
CALGB Form
text
CALGBStudyNo
Item
CALGB Study No
text
CALGBPatientID
Item
CALGB Patient ID
text
From
Item
From
text
Item Group
Long-term Therapy
Item
Did this patient receive any tamoxifen?
text
CL.19
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
CL.20
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)
CL.21
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
CL.22
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)
CL.23
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)
Item Group
Comments
Comments
Item
Comments
text
Item Group
Unnamed9
CompletedBy
Item
Completed By (Print or Type Name)
text
DateCompleted
Item
Date Completed (M)
date
Item Group
Ccrr Module For Calgb: 40101 Follow-up Form
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