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8310

Beschreibung

Lung Cancer - Treatment Summary Form Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=DE329218-46CF-3E0C-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=DE329218-46CF-3E0C-E034-0003BA12F5E7

Stichworte

Versionen (3)
  1. 19.09.12 19.09.12 -
  2. 08.01.15 08.01.15 - Martin Dugas
  3. 09.01.15 09.01.15 - Martin Dugas
Hochgeladen am

9. Januar 2015

DOI

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Creative Commons BY-NC 3.0 Legacy
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    Treatment - Lung Cancer - Treatment Summary Form - 2263415v3.0

    Englisch

    No Instruction available.

    1 Formulare  
    1. StudyEvent: Lung Cancer - Treatment Summary Form
      1. No Instruction available.
    Crf Header
    Beschreibung

    Crf Header

    Coordinating Group Protocol No.
    Beschreibung

    Protocol ID Coordinating Group

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337 (undefined)
    UMLS CUI-1
    C3274381 (Clinical Trial Registry Identifier)
    NCI Thesaurus ObjectClass
    C25320 (undefined)
    UMLS CUI-2
    C1711341 (Group Coordinator)
    NCI Thesaurus Property
    C25462 (undefined)
    NCI Thesaurus Property-2
    C25364 (undefined)
    Coordinating Group Code
    Beschreibung

    Coordinating Group Code

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25162 (undefined)
    UMLS CUI-1
    C1711341 (Group Coordinator)
    NCI Thesaurus ObjectClass
    C17005 (undefined)
    UMLS CUI-2
    C0805701 (Code)
    NCI Thesaurus ObjectClass-2
    C25462 (undefined)
    NCI Thesaurus Property
    C25364 (undefined)
    Protocol Title
    Beschreibung

    Protocol Title

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191 (undefined)
    UMLS CUI-1
    C2986303 (Study Protocol Document Version Public Title)
    NCI Thesaurus ObjectClass
    C25320 (undefined)
    NCI Thesaurus Property
    C42774 (undefined)
    Patient Study ID
    Beschreibung

    Patient Study ID

    Datentyp

    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)
    Institution/Affiliate
    Beschreibung

    Institution Name

    Datentyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C25454 (undefined)
    UMLS CUI-1
    C1301943 (Institution name)
    SNOMED
    398321007
    NCI Thesaurus ObjectClass-2
    C21541 (undefined)
    NCI Thesaurus Property
    C25364 (undefined)
    NCI Thesaurus ValueDomain
    C25191 (undefined)
    NCI Thesaurus ValueDomain-2
    C21541 (undefined)
    Other Patient ID
    Beschreibung

    Trial subject ID Participating Group

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337 (undefined)
    UMLS CUI-1
    C2348585 (Clinical Trial Subject Unique Identifier)
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    UMLS CUI-2
    C2347449 (Participating Clinical Study Organization)
    NCI Thesaurus Property
    C25608 (undefined)
    NCI Thesaurus Property-2
    C25364 (undefined)
    Participating Group Code
    Beschreibung

    ParticipatingGroupIdentifierCode

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25162 (undefined)
    UMLS 2011AA ValueDomain
    C0805701 (Code)
    NCI Thesaurus ObjectClass
    C25608 (undefined)
    UMLS 2011AA ObjectClass
    C0679823 (Participation)
    NCI Thesaurus ObjectClass-2
    C17005 (undefined)
    UMLS 2011AA ObjectClass-2
    C1257890 (Population Group)
    SNOMED
    389109008
    LOINC
    LA12078-4
    NCI Thesaurus Property
    C25364 (undefined)
    UMLS 2011AA Property
    C0600091 (Identifier)
    SNOMED
    118522005
    LOINC
    LP31795-5
    Patient Name (initials acceptable)
    Beschreibung

    Patient Name

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191 (undefined)
    UMLS CUI-1
    C1299487 (Patient name)
    SNOMED
    371484003
    NCI Thesaurus ObjectClass
    C16960 (undefined)
    NCI Thesaurus Property
    C25364 (undefined)
    Lung: Treatment Plan
    Beschreibung

    Lung: Treatment Plan

    First Date (any modality of) Protocol Therapy Was Given
    Beschreibung

    Treatment Start Date

    Datentyp

    date

    Alias
    NCI Thesaurus ObjectClass
    C15368 (undefined)
    NCI Thesaurus ObjectClass-2
    C25509 (undefined)
    UMLS CUI-1
    C3173309 (Date treatment or therapy started)
    LOINC
    LP262646-5
    NCI Thesaurus Property
    C25431 (undefined)
    NCI Thesaurus Property-2
    C25275 (undefined)
    NCI Thesaurus ValueDomain
    C25164 (undefined)
    NCI Thesaurus ValueDomain-2
    C25431 (undefined)
    Last Date (any modality of) protocol therapy was given
    Beschreibung

    Treatment End Date

    Datentyp

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164 (undefined)
    UMLS CUI-1
    C1531784 (Date treatment stopped)
    SNOMED
    413947000
    NCI Thesaurus ObjectClass
    C15368 (undefined)
    NCI Thesaurus Property
    C25275 (undefined)
    NCI Thesaurus Property-2
    C25496 (undefined)
    Reason Treatment Ended
    Beschreibung

    Off Treatment Reason

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25638 (undefined)
    UMLS CUI-1
    C1518544 (Off Treatment)
    NCI Thesaurus ObjectClass
    C25601 (undefined)
    UMLS CUI-2
    C0566251 (Reason and justification)
    SNOMED
    288830005
    NCI Thesaurus Property
    C25365 (undefined)
    Alternative Therapy (Specify)
    Beschreibung

    Off-treatmentAlternativeReasonSpecify

    Datentyp

    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
    C25415 (undefined)
    UMLS 2011AA Property
    C1523987 (Alternative)
    LOINC
    LA30091-5
    NCI Thesaurus Property-2
    C25365 (undefined)
    UMLS 2011AA Property-2
    C0678257 (Description)
    LOINC
    LP6800-9
    Complicating Disease (Specify)
    Beschreibung

    Off Treatment Reason, specify

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685 (undefined)
    UMLS CUI-1
    C1518544 (Off Treatment)
    NCI Thesaurus ObjectClass
    C25601 (undefined)
    UMLS CUI-2
    C0566251 (Reason and justification)
    SNOMED
    288830005
    NCI Thesaurus Property
    C25365 (undefined)
    UMLS CUI-3
    C1521902 (To specify)
    NCI Thesaurus Property-2
    C25455 (undefined)
    Other (specify)
    Beschreibung

    Off Treatment Reason, specify

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685 (undefined)
    UMLS CUI-1
    C1518544 (Off Treatment)
    NCI Thesaurus ObjectClass
    C25601 (undefined)
    UMLS CUI-2
    C0566251 (Reason and justification)
    SNOMED
    288830005
    NCI Thesaurus Property
    C25365 (undefined)
    UMLS CUI-3
    C1521902 (To specify)
    Lung: Treatment Schedule - Systemic Therapy
    Beschreibung

    Lung: Treatment Schedule - Systemic Therapy

    Total Number of Cycles Given
    Beschreibung

    Total number of cycles

    Datentyp

    float

    Alias
    NCI Thesaurus Property
    C25304 (undefined)
    UMLS CUI-1
    C2045831 (chemotherapeutics regimen total number of cycles ordered)
    NCI Thesaurus ObjectClass
    C15368 (undefined)
    NCI Thesaurus ValueDomain
    C25463 (undefined)
    NCI Thesaurus Property-2
    C25379 (undefined)
    Were there any dose modifications or additions/omissions to protocol treatment?
    Beschreibung

    Dose Modification

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25180 (undefined)
    UMLS CUI-1
    C1707811 (Dose Modification)
    NCI Thesaurus ObjectClass
    C25256 (undefined)
    NCI Thesaurus Property
    C25572 (undefined)
    NCI Thesaurus ValueDomain-2
    C25572 (undefined)
    Lung: Treatment Schedule - Radiation Therapy
    Beschreibung

    Lung: Treatment Schedule - Radiation Therapy

    Total Dose to Lung (cGy)
    Beschreibung

    Total Dose to Lung

    Datentyp

    float

    Alias
    NCI Thesaurus ObjectClass
    C15313 (undefined)
    UMLS CUI-1
    C2169193 (radiation therapy pattern total dose (___cGy))
    NCI Thesaurus Property
    C12468 (undefined)
    UMLS CUI-2
    C0024109 (Lung)
    SNOMED
    39607008
    LOINC
    LP7407-2
    NCI Thesaurus Property-2
    C25382 (undefined)
    NCI Thesaurus ValueDomain
    C25304 (undefined)
    NCI Thesaurus ValueDomain-2
    C25488 (undefined)
    Were there any unscheduled interruptions in radiation therapy?
    Beschreibung

    Unscheduled Interruptions in Radiation Therapy

    Datentyp

    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)
    RT Interruptions Reason (Specify)
    Beschreibung

    Radiation Therapy Interruptions Reason

    Datentyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704 (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)
    UMLS CUI-3
    C0566251 (Reason and justification)
    SNOMED
    288830005
    Comments
    Beschreibung

    Comments

    Comments
    Beschreibung

    Research Comments

    Datentyp

    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)
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    Ähnliche Modelle

    No Instruction available.

    1 Formulare
    1. StudyEvent: Lung Cancer - Treatment Summary Form
      1. No Instruction available.
    Name
    Typ
    Description | Question | Decode (Coded Value)
    Datentyp
    Alias
    Item Group
    Crf Header
    Protocol ID Coordinating Group
    Item
    Coordinating Group Protocol No.
    text
    C25337 (NCI Thesaurus ValueDomain)
    C3274381 (UMLS CUI-1)
    C25320 (NCI Thesaurus ObjectClass)
    C1711341 (UMLS CUI-2)
    C25462 (NCI Thesaurus Property)
    C25364 (NCI Thesaurus Property-2)
    Coordinating Group Code
    Item
    Coordinating Group Code
    text
    C25162 (NCI Thesaurus ValueDomain)
    C1711341 (UMLS CUI-1)
    C17005 (NCI Thesaurus ObjectClass)
    C0805701 (UMLS CUI-2)
    C25462 (NCI Thesaurus ObjectClass-2)
    C25364 (NCI Thesaurus Property)
    Protocol Title
    Item
    Protocol Title
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2986303 (UMLS CUI-1)
    C25320 (NCI Thesaurus ObjectClass)
    C42774 (NCI Thesaurus Property)
    Patient Study ID
    Item
    Patient Study ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C2348585 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25462 (NCI Thesaurus Property)
    C25364 (NCI Thesaurus Property-2)
    Institution Name
    Item
    Institution/Affiliate
    text
    C25454 (NCI Thesaurus ObjectClass)
    C1301943 (UMLS CUI-1)
    C21541 (NCI Thesaurus ObjectClass-2)
    C25364 (NCI Thesaurus Property)
    C25191 (NCI Thesaurus ValueDomain)
    C21541 (NCI Thesaurus ValueDomain-2)
    Trial subject ID Participating Group
    Item
    Other Patient ID
    text
    C25337 (NCI Thesaurus ValueDomain)
    C2348585 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C2347449 (UMLS CUI-2)
    C25608 (NCI Thesaurus Property)
    C25364 (NCI Thesaurus Property-2)
    ParticipatingGroupIdentifierCode
    Item
    Participating Group Code
    text
    C25162 (NCI Thesaurus ValueDomain)
    C0805701 (UMLS 2011AA ValueDomain)
    C25608 (NCI Thesaurus ObjectClass)
    C0679823 (UMLS 2011AA ObjectClass)
    C17005 (NCI Thesaurus ObjectClass-2)
    C1257890 (UMLS 2011AA ObjectClass-2)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    Patient Name
    Item
    Patient Name (initials acceptable)
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1299487 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25364 (NCI Thesaurus Property)
    Item Group
    Lung: Treatment Plan
    Treatment Start Date
    Item
    First Date (any modality of) Protocol Therapy Was Given
    date
    C15368 (NCI Thesaurus ObjectClass)
    C25509 (NCI Thesaurus ObjectClass-2)
    C3173309 (UMLS CUI-1)
    C25431 (NCI Thesaurus Property)
    C25275 (NCI Thesaurus Property-2)
    C25164 (NCI Thesaurus ValueDomain)
    C25431 (NCI Thesaurus ValueDomain-2)
    Treatment End Date
    Item
    Last Date (any modality of) protocol therapy was given
    date
    C25164 (NCI Thesaurus ValueDomain)
    C1531784 (UMLS CUI-1)
    C15368 (NCI Thesaurus ObjectClass)
    C25275 (NCI Thesaurus Property)
    C25496 (NCI Thesaurus Property-2)
    Item
    Reason Treatment Ended
    text
    C25638 (NCI Thesaurus ValueDomain)
    C1518544 (UMLS CUI-1)
    C25601 (NCI Thesaurus ObjectClass)
    C0566251 (UMLS CUI-2)
    C25365 (NCI Thesaurus Property)
    CL.1
    Code List
    Reason 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
    Adverse Event/side Effects/complications (Adverse Event/Side Effects/Complications)
    CL Item
    Death On Study (Death on study)
    CL Item
    Patient Withdrawal Or Refusal After Beginning Protocol Therapy (Patient withdrawal/refusal after beginning protocol therapy)
    CL Item
    Patient Withdrawal Or Refusal Before Beginning Protocol Therapy (Patient withdrawal/refusal prior to beginning protocol therapy)
    CL Item
    Alternative Therapy (Alternative therapy)
    CL Item
    Patient Off-treatment For Other Complicating Disease (Patient off-treatment for other complicating disease)
    CL Item
    Other (Other)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    Off-treatmentAlternativeReasonSpecify
    Item
    Alternative Therapy (Specify)
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C25601 (NCI Thesaurus ObjectClass)
    C1518544 (UMLS 2011AA ObjectClass)
    C25415 (NCI Thesaurus Property)
    C1523987 (UMLS 2011AA Property)
    C25365 (NCI Thesaurus Property-2)
    C0678257 (UMLS 2011AA Property-2)
    Off Treatment Reason, specify
    Item
    Complicating Disease (Specify)
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1518544 (UMLS CUI-1)
    C25601 (NCI Thesaurus ObjectClass)
    C0566251 (UMLS CUI-2)
    C25365 (NCI Thesaurus Property)
    C1521902 (UMLS CUI-3)
    C25455 (NCI Thesaurus Property-2)
    Off Treatment Reason, specify
    Item
    Other (specify)
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1518544 (UMLS CUI-1)
    C25601 (NCI Thesaurus ObjectClass)
    C0566251 (UMLS CUI-2)
    C25365 (NCI Thesaurus Property)
    C1521902 (UMLS CUI-3)
    Item Group
    Lung: Treatment Schedule - Systemic Therapy
    Total number of cycles
    Item
    Total Number of Cycles Given
    float
    C25304 (NCI Thesaurus Property)
    C2045831 (UMLS CUI-1)
    C15368 (NCI Thesaurus ObjectClass)
    C25463 (NCI Thesaurus ValueDomain)
    C25379 (NCI Thesaurus Property-2)
    Item
    Were there any dose modifications or additions/omissions to protocol treatment?
    text
    C25180 (NCI Thesaurus ValueDomain)
    C1707811 (UMLS CUI-1)
    C25256 (NCI Thesaurus ObjectClass)
    C25572 (NCI Thesaurus Property)
    C25572 (NCI Thesaurus ValueDomain-2)
    CL.2
    Code List
    Were there any dose modifications or additions/omissions to protocol treatment?
    CL Item
    Yes, Planned (i.e., The Treatment Was Changed According To Protocol Guidelines) (Yes, planned)
    CL Item
    Yes, Unplanned (i.e., The Treatment Change Was Not Part Of Protocol Guidelines) (Yes, unplanned)
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    Item Group
    Lung: Treatment Schedule - Radiation Therapy
    Total Dose to Lung
    Item
    Total Dose to Lung (cGy)
    float
    C15313 (NCI Thesaurus ObjectClass)
    C2169193 (UMLS CUI-1)
    C12468 (NCI Thesaurus Property)
    C0024109 (UMLS CUI-2)
    C25382 (NCI Thesaurus Property-2)
    C25304 (NCI Thesaurus ValueDomain)
    C25488 (NCI Thesaurus ValueDomain-2)
    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.3
    Code List
    Were there any unscheduled interruptions in radiation therapy?
    CL Item
    Yes, Due To Toxicity (Yes, due to toxicity)
    CL Item
    Yes, For Other Reasons, Specify (Yes, for other reasons, specify)
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    Radiation Therapy Interruptions Reason
    Item
    RT Interruptions Reason (Specify)
    text
    C25704 (NCI Thesaurus ValueDomain)
    C1522449 (UMLS CUI-1)
    C15313 (NCI Thesaurus ObjectClass)
    C1512900 (UMLS CUI-2)
    C25542 (NCI Thesaurus Property)
    C0566251 (UMLS CUI-3)
    Item Group
    Comments
    Research Comments
    Item
    Comments
    text
    C25704 (NCI Thesaurus ValueDomain)
    C0947611 (UMLS CUI-1)
    C15319 (NCI Thesaurus ObjectClass)
    C25393 (NCI Thesaurus Property)
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