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8229

Descrizione

T1 Radiation Therapy Oncology Group Phase III Prostate 3D / IMRT Radiotherapy Form Radiation Therapy in Treating Patients With Stage II Prostate Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=11E22AA5-BFC0-32E2-E044-0003BA3F9857

collegamento

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=11E22AA5-BFC0-32E2-E044-0003BA3F9857

Keywords

versioni (2)
  1. 20/09/12 20/09/12 -
  2. 09/01/15 09/01/15 - Martin Dugas
Caricato su

9 gennaio 2015

DOI

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Licenza

Creative Commons BY-NC 3.0 Legacy
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    Prostate Cancer NCT00033631 Treatment - T1 Radiation Therapy Oncology Group Phase III Prostate 3D / IMRT Radiotherapy Form - 2478411v1.0

    Inglese

    Submit this form at the completion of protocol therapy. Use -1 for unknown or not applicable unless otherwise specified in the codetable. Dates are recorded mm-dd-yyyy unless otherwise specified. A copy much be submitted to RTOG HQ and the ITC.

    1 moduli  
    Module 1
    Descrizione

    Module 1

    RTOG Study No.
    Descrizione

    Protocol ID RTOG

    Tipo di dati

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337 (undefined)
    UMLS CUI-1
    C3274381 (Clinical Trial Registry Identifier)
    NCI Thesaurus ObjectClass
    C25320 (undefined)
    UMLS CUI-2
    C1514695 (Radiation Therapy Oncology Group)
    LOINC
    LA4303-9
    NCI Thesaurus Property
    C19778 (undefined)
    NCI Thesaurus Property-2
    C25364 (undefined)
    Case #
    Descrizione

    Case#

    Tipo di dati

    text

    Institution
    Descrizione

    Institution Name

    Tipo di dati

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191 (undefined)
    UMLS CUI-1
    C1301943 (Institution name)
    SNOMED
    398321007
    NCI Thesaurus ObjectClass
    C21541 (undefined)
    NCI Thesaurus ValueDomain-2
    C21541 (undefined)
    NCI Thesaurus Property
    C25364 (undefined)
    Institution No.
    Descrizione

    Institution Number

    Tipo di dati

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337 (undefined)
    UMLS CUI-1
    C1301943 (Institution name)
    SNOMED
    398321007
    NCI Thesaurus ObjectClass
    C21541 (undefined)
    UMLS CUI-2
    C0805701 (Code)
    NCI Thesaurus Property
    C25364 (undefined)
    Participant's Initials
    Descrizione

    Patient Initials

    Tipo di dati

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191 (undefined)
    UMLS CUI-1
    C2986440 (Person Initials)
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    NCI Thesaurus Property
    C25536 (undefined)
    Participant's I.D. No.
    Descrizione

    Patient Study ID

    Tipo di dati

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337 (undefined)
    UMLS CUI-1
    C2348585 (Clinical Trial Subject Unique Identifier)
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    NCI Thesaurus Property
    C25462 (undefined)
    NCI Thesaurus Property-2
    C25364 (undefined)
    If this is a revised or corrected form, indicate by checking box.
    Descrizione

    CaseReportFormModifiedInd-2

    Tipo di dati

    text

    Alias
    NCI Thesaurus ValueDomain
    C38147 (undefined)
    UMLS 2011AA ValueDomain
    C1512698 (Yes or No Response)
    NCI Thesaurus ObjectClass
    C40988 (undefined)
    UMLS 2011AA ObjectClass
    C1516308 (Case Report Form)
    NCI Thesaurus Property
    C25573 (undefined)
    RADIATION THERAPY START DATE
    Descrizione

    Radiation Therapy Start Date

    Tipo di dati

    date

    Alias
    NCI Thesaurus ObjectClass
    C15313 (undefined)
    UMLS CUI-1
    C1522449 (Therapeutic radiology procedure)
    SNOMED
    53438000
    LOINC
    LA4351-8
    NCI Thesaurus Property
    C25431 (undefined)
    UMLS CUI-2
    C0808070 (Start Date)
    NCI Thesaurus Property-2
    C25275 (undefined)
    NCI Thesaurus ValueDomain
    C25164 (undefined)
    NCI Thesaurus ValueDomain-2
    C25367 (undefined)
    RADIATION THERAPY END DATE
    Descrizione

    Radiation Therapy End Date

    Tipo di dati

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164 (undefined)
    UMLS CUI-1
    C1522449 (Therapeutic radiology procedure)
    SNOMED
    53438000
    LOINC
    LA4351-8
    NCI Thesaurus ObjectClass
    C15313 (undefined)
    UMLS CUI-2
    C0806020 (End date)
    SNOMED
    454551000124105
    LOINC
    MTHU008302
    NCI Thesaurus Property
    C25275 (undefined)
    NCI Thesaurus Property-2
    C25496 (undefined)
    ELAPSED DAYS
    Descrizione

    RadiationTherapyTotalDayCount

    Tipo di dati

    float

    Alias
    NCI Thesaurus ObjectClass
    C15313 (undefined)
    UMLS 2011AA ObjectClass
    C1522449 (Therapeutic radiology procedure)
    SNOMED
    53438000
    LOINC
    LA4351-8
    NCI Thesaurus Property
    C25304 (undefined)
    UMLS 2011AA Property
    C0439810 (Total)
    SNOMED
    255619001
    LOINC
    LP21089-5
    NCI Thesaurus Property-2
    C25301 (undefined)
    UMLS 2011AA Property-2
    C0439228 (day)
    SNOMED
    258703001
    NCI Thesaurus ValueDomain
    C25301 (undefined)
    UMLS 2011AA ValueDomain
    C0439228 (day)
    SNOMED
    258703001
    NCI Thesaurus ValueDomain-2
    C25463 (undefined)
    UMLS 2011AA ValueDomain-2
    C0750480 (Count)
    TOTAL FRACTIONS
    Descrizione

    Total Number of Fractions

    Tipo di dati

    float

    Alias
    NCI Thesaurus Property
    C25304 (undefined)
    UMLS CUI-1
    C1522449 (Therapeutic radiology procedure)
    SNOMED
    53438000
    LOINC
    LA4351-8
    NCI Thesaurus ObjectClass
    C15313 (undefined)
    UMLS CUI-2
    C1264633 (Fraction of)
    SNOMED
    103398007
    NCI Thesaurus ValueDomain
    C25463 (undefined)
    UMLS CUI-3
    C0750480 (Count)
    NCI Thesaurus Property-2
    C25514 (undefined)
    TOTAL DOSE (Gy)
    Descrizione

    Radiation Therapy Total Dose

    Tipo di dati

    float

    Alias
    NCI Thesaurus ValueDomain
    C25304 (undefined)
    UMLS CUI-1
    C2169193 (radiation therapy pattern total dose (___cGy))
    NCI Thesaurus ObjectClass
    C15313 (undefined)
    NCI Thesaurus ValueDomain-2
    C25488 (undefined)
    NCI Thesaurus Property
    C25382 (undefined)
    Performance Status (Zubrod 0-4)
    Descrizione

    PerformanceStatus

    Tipo di dati

    text

    WERE THERE ANY UNSCHEDULED INTERRUPTIONS IN RADIATION THERAPY?
    Descrizione

    Unscheduled Interruptions in Radiation Therapy

    Tipo di dati

    text

    Alias
    NCI Thesaurus ValueDomain
    C25180 (undefined)
    UMLS CUI-1
    C1522449 (Therapeutic radiology procedure)
    SNOMED
    53438000
    LOINC
    LA4351-8
    NCI Thesaurus ObjectClass
    C15313 (undefined)
    UMLS CUI-2
    C1512900 (Interruption)
    NCI Thesaurus Property
    C25542 (undefined)
    Specify RT interruption reason
    Descrizione

    Radiation Therapy Interruption Reason

    Tipo di dati

    text

    Alias
    NCI Thesaurus ObjectClass
    C15313 (undefined)
    UMLS CUI-1
    C1522449 (Therapeutic radiology procedure)
    SNOMED
    53438000
    LOINC
    LA4351-8
    NCI Thesaurus Property
    C25594 (undefined)
    UMLS CUI-2
    C3538832 (Reason for Treatment Interruption)
    NCI Thesaurus Property-2
    C25211 (undefined)
    NCI Thesaurus Property-3
    C25542 (undefined)
    NCI Thesaurus ValueDomain
    C25685 (undefined)
    REASON RADIATION THERAPY TREATMENT ENDED
    Descrizione

    TreatmentDiscontinuedType

    Tipo di dati

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284 (undefined)
    UMLS 2011AA ValueDomain
    C0332307 (Type - attribute)
    SNOMED
    261664005
    NCI Thesaurus ObjectClass
    C15368 (undefined)
    NCI Thesaurus Property
    C25484 (undefined)
    UMLS 2011AA Property
    C1444662 (Discontinued)
    SNOMED
    410546004
    Alternative therapy, specify
    Descrizione

    Alternative therapy, specify

    Tipo di dati

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685 (undefined)
    UMLS CUI-1
    C0949216 (Alternative Therapies)
    NCI Thesaurus ObjectClass
    C15368 (undefined)
    NCI Thesaurus ObjectClass-2
    C25415 (undefined)
    NCI Thesaurus Property
    C25382 (undefined)
    Other complicating disease, specify
    Descrizione

    Off-TreatmentConditionSpecify

    Tipo di dati

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685 (undefined)
    UMLS 2011AA ValueDomain
    C1521902 (To specify)
    NCI Thesaurus ObjectClass
    C25601 (undefined)
    UMLS 2011AA ObjectClass
    C1518544 (Off Treatment)
    NCI Thesaurus Property
    C25457 (undefined)
    UMLS 2011AA Property
    C0348080 (Condition)
    SNOMED
    260905004
    LOINC
    LP185404-3
    Other, specify
    Descrizione

    Off-TreatmentOtherReasonSpecify

    Tipo di dati

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685 (undefined)
    UMLS 2011AA ValueDomain
    C1521902 (To specify)
    NCI Thesaurus Property
    C17649 (undefined)
    UMLS 2011AA Property
    C0205394 (Other)
    SNOMED
    74964007
    LOINC
    LP21049-9
    NCI Thesaurus ObjectClass
    C25601 (undefined)
    UMLS 2011AA ObjectClass
    C1518544 (Off Treatment)
    NCI Thesaurus Property-2
    C25365 (undefined)
    UMLS 2011AA Property-2
    C0678257 (Description)
    LOINC
    LP6800-9
    Type of Radiation Therapy Administered (Which modality was used to treat this patient)
    Descrizione

    Radiation Therapy Type

    Tipo di dati

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284 (undefined)
    UMLS CUI-1
    C1522449 (Therapeutic radiology procedure)
    SNOMED
    53438000
    LOINC
    LA4351-8
    NCI Thesaurus ObjectClass
    C15313 (undefined)
    UMLS CUI-2
    C0683312 (Categories)
    LOINC
    MTHU018876
    NCI Thesaurus Property
    C25382 (undefined)
    Comments
    Descrizione

    Research Comments

    Tipo di dati

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704 (undefined)
    UMLS CUI-1
    C0947611 (Comment)
    LOINC
    LP72293-1
    NCI Thesaurus ObjectClass
    C15319 (undefined)
    NCI Thesaurus Property
    C25393 (undefined)
    Signature of person completing form
    Descrizione

    Responsible Person Signature

    Tipo di dati

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704 (undefined)
    UMLS CUI-1
    C1550483 (data entry person)
    NCI Thesaurus ObjectClass
    C25190 (undefined)
    NCI Thesaurus ObjectClass-2
    C25657 (undefined)
    NCI Thesaurus Property
    C25678 (undefined)
    Date form completed, original
    Descrizione

    Form Completion Date

    Tipo di dati

    date

    Alias
    NCI Thesaurus ObjectClass
    C19464 (undefined)
    UMLS CUI-1
    C1549507 (Report completion date/time)
    NCI Thesaurus Property
    C25250 (undefined)
    NCI Thesaurus Property-2
    C25604 (undefined)
    NCI Thesaurus ValueDomain
    C25164 (undefined)
    NCI Thesaurus ValueDomain-2
    C25367 (undefined)
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    Similar models

    Submit this form at the completion of protocol therapy. Use -1 for unknown or not applicable unless otherwise specified in the codetable. Dates are recorded mm-dd-yyyy unless otherwise specified. A copy much be submitted to RTOG HQ and the ITC.

    1 moduli
    Name
    genere
    Description | Question | Decode (Coded Value)
    Tipo di dati
    Alias
    Item Group
    Module 1
    Protocol ID RTOG
    Item
    RTOG Study No.
    text
    C25337 (NCI Thesaurus ValueDomain)
    C3274381 (UMLS CUI-1)
    C25320 (NCI Thesaurus ObjectClass)
    C1514695 (UMLS CUI-2)
    C19778 (NCI Thesaurus Property)
    C25364 (NCI Thesaurus Property-2)
    Case#
    Item
    Case #
    text
    Institution Name
    Item
    Institution
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1301943 (UMLS CUI-1)
    C21541 (NCI Thesaurus ObjectClass)
    C21541 (NCI Thesaurus ValueDomain-2)
    C25364 (NCI Thesaurus Property)
    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)
    Patient Initials
    Item
    Participant's Initials
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2986440 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25536 (NCI Thesaurus Property)
    Patient Study ID
    Item
    Participant's I.D. No.
    text
    C25337 (NCI Thesaurus ValueDomain)
    C2348585 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25462 (NCI Thesaurus Property)
    C25364 (NCI Thesaurus Property-2)
    CaseReportFormModifiedInd-2
    Item
    If this is a revised or corrected form, indicate by checking box.
    text
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C40988 (NCI Thesaurus ObjectClass)
    C1516308 (UMLS 2011AA ObjectClass)
    C25573 (NCI Thesaurus Property)
    Radiation Therapy Start Date
    Item
    RADIATION THERAPY START DATE
    date
    C15313 (NCI Thesaurus ObjectClass)
    C1522449 (UMLS CUI-1)
    C25431 (NCI Thesaurus Property)
    C0808070 (UMLS CUI-2)
    C25275 (NCI Thesaurus Property-2)
    C25164 (NCI Thesaurus ValueDomain)
    C25367 (NCI Thesaurus ValueDomain-2)
    Radiation Therapy End Date
    Item
    RADIATION THERAPY END DATE
    date
    C25164 (NCI Thesaurus ValueDomain)
    C1522449 (UMLS CUI-1)
    C15313 (NCI Thesaurus ObjectClass)
    C0806020 (UMLS CUI-2)
    C25275 (NCI Thesaurus Property)
    C25496 (NCI Thesaurus Property-2)
    RadiationTherapyTotalDayCount
    Item
    ELAPSED DAYS
    float
    C15313 (NCI Thesaurus ObjectClass)
    C1522449 (UMLS 2011AA ObjectClass)
    C25304 (NCI Thesaurus Property)
    C0439810 (UMLS 2011AA Property)
    C25301 (NCI Thesaurus Property-2)
    C0439228 (UMLS 2011AA Property-2)
    C25301 (NCI Thesaurus ValueDomain)
    C0439228 (UMLS 2011AA ValueDomain)
    C25463 (NCI Thesaurus ValueDomain-2)
    C0750480 (UMLS 2011AA ValueDomain-2)
    Total Number of Fractions
    Item
    TOTAL FRACTIONS
    float
    C25304 (NCI Thesaurus Property)
    C1522449 (UMLS CUI-1)
    C15313 (NCI Thesaurus ObjectClass)
    C1264633 (UMLS CUI-2)
    C25463 (NCI Thesaurus ValueDomain)
    C0750480 (UMLS CUI-3)
    C25514 (NCI Thesaurus Property-2)
    Radiation Therapy Total Dose
    Item
    TOTAL DOSE (Gy)
    float
    C25304 (NCI Thesaurus ValueDomain)
    C2169193 (UMLS CUI-1)
    C15313 (NCI Thesaurus ObjectClass)
    C25488 (NCI Thesaurus ValueDomain-2)
    C25382 (NCI Thesaurus Property)
    Item
    Performance Status (Zubrod 0-4)
    text
    CL.1
    Code List
    Performance Status (Zubrod 0-4)
    CL Item
    0 (Fully active, able to carry on all pre-disease performance without restriction (Karnofsky 90 - 100))
    C0919414 (NCI Metathesaurus)
    CL Item
    1 (Restricted in physically strenuous activity but ambulatory (K 70 - 80))
    CL Item
    2 (Ambulatory and capable of all selfcare but unable to carry out any work activities (K 50 - 60))
    C66833 (NCI Thesaurus)
    C0205448 (UMLS 2011AA)
    CL Item
    3 (Capable of only limited selfcare, confined to bed or chair more than 50% of waking hours (K 30 - 40))
    CL Item
    4 (Completely disabled (K 10 - 20))
    Item
    WERE THERE ANY UNSCHEDULED INTERRUPTIONS IN RADIATION THERAPY?
    text
    C25180 (NCI Thesaurus ValueDomain)
    C1522449 (UMLS CUI-1)
    C15313 (NCI Thesaurus ObjectClass)
    C1512900 (UMLS CUI-2)
    C25542 (NCI Thesaurus Property)
    CL.2
    Code List
    WERE THERE ANY UNSCHEDULED INTERRUPTIONS IN RADIATION THERAPY?
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes, Due To Toxicity (Yes, due to toxicity)
    CL Item
    Yes, Due To Other Reason (Yes, due to other reason)
    Radiation Therapy Interruption Reason
    Item
    Specify RT interruption reason
    text
    C15313 (NCI Thesaurus ObjectClass)
    C1522449 (UMLS CUI-1)
    C25594 (NCI Thesaurus Property)
    C3538832 (UMLS CUI-2)
    C25211 (NCI Thesaurus Property-2)
    C25542 (NCI Thesaurus Property-3)
    C25685 (NCI Thesaurus ValueDomain)
    Item
    REASON RADIATION THERAPY TREATMENT ENDED
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C15368 (NCI Thesaurus ObjectClass)
    C25484 (NCI Thesaurus Property)
    C1444662 (UMLS 2011AA Property)
    CL.3
    Code List
    REASON RADIATION THERAPY TREATMENT ENDED
    CL Item
    Treatment Completed Per Protocol Criteria (Treatment completed per protocol criteria)
    CL Item
    Disease Progression, Relapse During Active Treatment (Disease progression, relapse during active treatment)
    CL Item
    Toxicity/side Effects/complications (Toxicity/side effects/complications)
    CL Item
    Death On Study (Death on study)
    CL Item
    Patient Withdrawal Or Refusal After Beginning Protocol Therapy (Patient withdrawal or refusal after beginning protocol therapy)
    CL Item
    Patient Withdrawal Or Refusal Prior To Beginning Protocol Therapy (Patient withdrawal or refusal prior to beginning protocol therapy)
    CL Item
    Alternative Therapy (Alternative therapy)
    CL Item
    Other Complicating Disease (Other complicating disease)
    CL Item
    Other (Other)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    Alternative therapy, specify
    Item
    Alternative therapy, specify
    text
    C25685 (NCI Thesaurus ValueDomain)
    C0949216 (UMLS CUI-1)
    C15368 (NCI Thesaurus ObjectClass)
    C25415 (NCI Thesaurus ObjectClass-2)
    C25382 (NCI Thesaurus Property)
    Off-TreatmentConditionSpecify
    Item
    Other complicating disease, specify
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C25601 (NCI Thesaurus ObjectClass)
    C1518544 (UMLS 2011AA ObjectClass)
    C25457 (NCI Thesaurus Property)
    C0348080 (UMLS 2011AA Property)
    Off-TreatmentOtherReasonSpecify
    Item
    Other, specify
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C17649 (NCI Thesaurus Property)
    C0205394 (UMLS 2011AA Property)
    C25601 (NCI Thesaurus ObjectClass)
    C1518544 (UMLS 2011AA ObjectClass)
    C25365 (NCI Thesaurus Property-2)
    C0678257 (UMLS 2011AA Property-2)
    Item
    Type of Radiation Therapy Administered (Which modality was used to treat this patient)
    text
    C25284 (NCI Thesaurus ValueDomain)
    C1522449 (UMLS CUI-1)
    C15313 (NCI Thesaurus ObjectClass)
    C0683312 (UMLS CUI-2)
    C25382 (NCI Thesaurus Property)
    CL.4
    Code List
    Type of Radiation Therapy Administered (Which modality was used to treat this patient)
    CL Item
    3d Conformal (3D conformal)
    CL Item
    Imrt (IMRT)
    Research Comments
    Item
    Comments
    text
    C25704 (NCI Thesaurus ValueDomain)
    C0947611 (UMLS CUI-1)
    C15319 (NCI Thesaurus ObjectClass)
    C25393 (NCI Thesaurus Property)
    Responsible Person Signature
    Item
    Signature of person completing form
    text
    C25704 (NCI Thesaurus ValueDomain)
    C1550483 (UMLS CUI-1)
    C25190 (NCI Thesaurus ObjectClass)
    C25657 (NCI Thesaurus ObjectClass-2)
    C25678 (NCI Thesaurus Property)
    Form Completion Date
    Item
    Date form completed, original
    date
    C19464 (NCI Thesaurus ObjectClass)
    C1549507 (UMLS CUI-1)
    C25250 (NCI Thesaurus Property)
    C25604 (NCI Thesaurus Property-2)
    C25164 (NCI Thesaurus ValueDomain)
    C25367 (NCI Thesaurus ValueDomain-2)
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