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8512

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GOG-0252 Port Complications (Form PCF) Bevacizumab and Intravenous or Intraperitoneal Chemotherapy in Treating Patients With Stage II, Stage III, or Stage IV Ovarian Epithelial Cancer, Fallopian Tube Cancer, or Primary Peritoneal Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=6362EF9C-F4F7-7D80-E040-BB89AD433D31

Länk

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=6362EF9C-F4F7-7D80-E040-BB89AD433D31

Nyckelord

  1. 2012-09-19 2012-09-19 -
  2. 2015-01-09 2015-01-09 - Martin Dugas
Uppladdad den

9 januari 2015

DOI

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Creative Commons BY-NC 3.0 Legacy

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    Fallopian Tube Cancer NCT00951496 Toxicity - GOG-0252 Port Complications (Form PCF) - 2840248v1.0

    Summarize port complications which occurred during delivery of this cycle of IP therapy or caused a delay or missed IP cycle.

    Header Module
    Beskrivning

    Header Module

    Date form originally completed
    Beskrivning

    Form Completion Date

    Datatyp

    date

    Alias
    NCI Thesaurus ObjectClass
    C19464
    UMLS CUI-1
    C1549507
    NCI Thesaurus Property
    C25250
    NCI Thesaurus Property-2
    C25604
    NCI Thesaurus ValueDomain
    C25164
    NCI Thesaurus ValueDomain-2
    C25367
    Date form amended
    Beskrivning

    Amendment date

    Datatyp

    date

    Alias
    NCI Thesaurus ObjectClass
    C19464
    UMLS CUI-1
    C0680532
    NCI Thesaurus Property
    C25250
    UMLS CUI-2
    C0011008
    NCI Thesaurus Property-2
    C25416
    NCI Thesaurus ValueDomain
    C25164
    NCI Thesaurus ValueDomain-2
    C25367
    Person amending form, last name
    Beskrivning

    Person Amending Form

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C0680532
    NCI Thesaurus ObjectClass
    C25190
    UMLS CUI-2
    C1547383
    NCI Thesaurus Property
    C25364
    Patient Initials
    Beskrivning

    Patient Initials

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C2986440
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25536
    Patient Study ID
    Beskrivning

    Patient Study ID

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C2348585
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus Property
    C25462
    NCI Thesaurus Property-2
    C25364
    Person Completing Form, Last Name
    Beskrivning

    Person Completing Form Last Name

    Datatyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C25190
    UMLS CUI-1
    C1550483
    NCI Thesaurus ObjectClass-2
    C25657
    UMLS CUI-2
    C1301584
    NCI Thesaurus Property
    C25364
    NCI Thesaurus Property-2
    C25551
    NCI Thesaurus ValueDomain
    C25191
    Ovarian Cancer Surgery
    Beskrivning

    Ovarian Cancer Surgery

    Current Cycle Number
    Beskrivning

    Cycle Number Chemotherapeutics

    Datatyp

    integer

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C2045829
    NCI Thesaurus Property
    C25471
    NCI Thesaurus ObjectClass
    C15368
    NCI Thesaurus Property-2
    C25379
    Date of complication
    Beskrivning

    IntraperitonealRouteofAdministrationAdverseEventDate

    Datatyp

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus Property
    C41331
    UMLS 2011AA Property
    C0877248
    NCI Thesaurus ObjectClass
    C38258
    UMLS 2011AA ObjectClass
    C1522583
    Port Complications
    Beskrivning

    Port Complications

    Were there complications related to the port
    Beskrivning

    IntraperitonealRouteofAdministrationAdverseEventInd-2

    Datatyp

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus Property
    C41331
    UMLS 2011AA Property
    C0877248
    NCI Thesaurus ObjectClass
    C38258
    UMLS 2011AA ObjectClass
    C1522583
    Were there complications related to the port
    Beskrivning

    IntraperitonealRouteofAdministrationAdverseEventType

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus Property
    C41331
    UMLS 2011AA Property
    C0877248
    NCI Thesaurus ObjectClass
    C38258
    UMLS 2011AA ObjectClass
    C1522583
    Cultures positive
    Beskrivning

    SurgicalProcedureCultureProcedurePositiveFindingComplicationInd-2

    Datatyp

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C15329
    UMLS 2011AA ObjectClass
    C0543467
    NCI Thesaurus Property
    C25300
    UMLS 2011AA Property
    C0430400
    NCI Thesaurus Property-2
    C38758
    UMLS 2011AA Property-2
    C1514241
    NCI Thesaurus Property-3
    C2959
    UMLS 2011AA Property-3
    C0009566
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Organism (was)
    Beskrivning

    SurgicalProcedureCultureProcedurePositiveFindingComplicationText

    Datatyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C15329
    UMLS 2011AA ObjectClass
    C0543467
    NCI Thesaurus Property
    C25300
    UMLS 2011AA Property
    C0430400
    NCI Thesaurus Property-2
    C38758
    UMLS 2011AA Property-2
    C1514241
    NCI Thesaurus Property-3
    C2959
    UMLS 2011AA Property-3
    C0009566
    NCI Thesaurus ValueDomain
    C25704
    UMLS 2011AA ValueDomain
    C1527021
    Access device replaced or revised
    Beskrivning

    IntraperitonealRouteofAdministrationMedicalDeviceReplacementInd-2

    Datatyp

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus Property
    C16830
    UMLS 2011AA Property
    C0025080
    NCI Thesaurus Property-2
    C53610
    UMLS 2011AA Property-2
    C0559956
    NCI Thesaurus ObjectClass
    C38258
    UMLS 2011AA ObjectClass
    C1522583
    Was IP chemotherapy regimen stopped prematurely
    Beskrivning

    OffTreatmentIntraperitonealChemotherapyAdministeredInd-2

    Datatyp

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus ObjectClass
    C25601
    UMLS 2011AA ObjectClass
    C1518544
    NCI Thesaurus Property
    C25382
    UMLS 2011AA Property
    C1521801
    NCI Thesaurus ObjectClass-2
    C15581
    UMLS 2011AA ObjectClass-2
    C0281548
    Was IP chemotherapy regimen stopped prematurely
    Beskrivning

    OffTreatmentIntraperitonealChemotherapyReason

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25638
    UMLS 2011AA ValueDomain
    C0392360
    NCI Thesaurus ObjectClass
    C25601
    UMLS 2011AA ObjectClass
    C1518544
    NCI Thesaurus ObjectClass-2
    C15581
    UMLS 2011AA ObjectClass-2
    C0281548
    NCI Thesaurus Property
    C25365
    UMLS 2011AA Property
    C0678257
    Grade
    Beskrivning

    CommonToxicityCriteriaAdverseEventReportingGrade

    Datatyp

    float

    Alias
    NCI Thesaurus ObjectClass
    C49704
    UMLS 2011AA ObjectClass
    C1516728
    NCI Thesaurus Property
    C25651
    UMLS 2011AA Property
    C0700287
    NCI Thesaurus ValueDomain
    C18000
    UMLS 2011AA ValueDomain
    C0919553
    NCI Thesaurus Property-2
    C25365
    UMLS 2011AA Property-2
    C0678257
    Attempted port replacement
    Beskrivning

    IntraperitonealRouteofAdministrationMedicalDeviceAttemptReplacementInd-2

    Datatyp

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C38258
    UMLS 2011AA ObjectClass
    C1522583
    NCI Thesaurus Property
    C16830
    UMLS 2011AA Property
    C0025080
    NCI Thesaurus Property-2
    C53610
    UMLS 2011AA Property-2
    C0559956
    NCI Thesaurus Property-3
    C39769
    UMLS 2011AA Property-3
    C1516084
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Other specify
    Beskrivning

    OffTreatmentIntraperitonealChemotherapyReasonSpecify

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    NCI Thesaurus ObjectClass
    C25601
    UMLS 2011AA ObjectClass
    C1518544
    NCI Thesaurus ObjectClass-2
    C15581
    UMLS 2011AA ObjectClass-2
    C0281548
    NCI Thesaurus Property
    C25365
    UMLS 2011AA Property
    C0678257
    Footer Module
    Beskrivning

    Footer Module

    Comments
    Beskrivning

    Research Comments

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS CUI-1
    C0947611
    NCI Thesaurus ObjectClass
    C15319
    NCI Thesaurus Property
    C25393

    Similar models

    Summarize port complications which occurred during delivery of this cycle of IP therapy or caused a delay or missed IP cycle.

    Name
    Typ
    Description | Question | Decode (Coded Value)
    Datatyp
    Alias
    Item Group
    Header Module
    Form Completion Date
    Item
    Date form originally completed
    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)
    Amendment date
    Item
    Date form amended
    date
    C19464 (NCI Thesaurus ObjectClass)
    C0680532 (UMLS CUI-1)
    C25250 (NCI Thesaurus Property)
    C0011008 (UMLS CUI-2)
    C25416 (NCI Thesaurus Property-2)
    C25164 (NCI Thesaurus ValueDomain)
    C25367 (NCI Thesaurus ValueDomain-2)
    Person Amending Form
    Item
    Person amending form, last name
    text
    C25191 (NCI Thesaurus ValueDomain)
    C0680532 (UMLS CUI-1)
    C25190 (NCI Thesaurus ObjectClass)
    C1547383 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    Patient Initials
    Item
    Patient Initials
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2986440 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25536 (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)
    Person Completing Form Last Name
    Item
    Person Completing Form, Last Name
    text
    C25190 (NCI Thesaurus ObjectClass)
    C1550483 (UMLS CUI-1)
    C25657 (NCI Thesaurus ObjectClass-2)
    C1301584 (UMLS CUI-2)
    C25364 (NCI Thesaurus Property)
    C25551 (NCI Thesaurus Property-2)
    C25191 (NCI Thesaurus ValueDomain)
    Item Group
    Ovarian Cancer Surgery
    Cycle Number Chemotherapeutics
    Item
    Current Cycle Number
    integer
    C25337 (NCI Thesaurus ValueDomain)
    C2045829 (UMLS CUI-1)
    C25471 (NCI Thesaurus Property)
    C15368 (NCI Thesaurus ObjectClass)
    C25379 (NCI Thesaurus Property-2)
    IntraperitonealRouteofAdministrationAdverseEventDate
    Item
    Date of complication
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C41331 (NCI Thesaurus Property)
    C0877248 (UMLS 2011AA Property)
    C38258 (NCI Thesaurus ObjectClass)
    C1522583 (UMLS 2011AA ObjectClass)
    Item Group
    Port Complications
    IntraperitonealRouteofAdministrationAdverseEventInd-2
    Item
    Were there complications related to the port
    boolean
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C41331 (NCI Thesaurus Property)
    C0877248 (UMLS 2011AA Property)
    C38258 (NCI Thesaurus ObjectClass)
    C1522583 (UMLS 2011AA ObjectClass)
    Item
    Were there complications related to the port
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C41331 (NCI Thesaurus Property)
    C0877248 (UMLS 2011AA Property)
    C38258 (NCI Thesaurus ObjectClass)
    C1522583 (UMLS 2011AA ObjectClass)
    Code List
    Were there complications related to the port
    CL Item
    Abdominal Pain Sufficient To Prevent Treatment (Abdominal pain sufficient to prevent treatment)
    CL Item
    Abscess In Abdomen Or Pelvis By Ct Or Surgically Drained (Abscess in abdomen or pelvis by CT or surgically drained)
    CL Item
    Bowel Complication Not Requiring Surgery (Bowel complication not requiring surgery)
    CL Item
    Bowel Complication Requiring Surgery (Bowel complication requiring surgery)
    CL Item
    Cellutitis Surrounding Port (Cellutitis surrounding port)
    CL Item
    Dyspnea With Ip Chemotherapy Infusion (Dyspnea with IP chemotherapy infusion)
    CL Item
    Fever, Abdominal Pain, And Hospitalization Suspected To Be Peritonitis (Fever, abdominal pain, and hospitalization suspected to be peritonitis)
    CL Item
    Leaking Of Ascites Or Chemotherapy Out Vagina Or Wound (Leaking of ascites or chemotherapy out vagina or wound)
    CL Item
    Reflux Of Fluid Or Leaking Of Fluid Around Port Pocket (Reflux of fluid or leaking of fluid around port pocket)
    CL Item
    Removal Of Port Required (Removal of port required)
    CL Item
    Unable To Access Port With Huber Needle (Unable to access port with huber needle)
    CL Item
    Unable To Infuse Ip Chemotherapy (i.e., Blocked Catheter) (Unable to infuse IP chemotherapy (i.e., blocked catheter))
    SurgicalProcedureCultureProcedurePositiveFindingComplicationInd-2
    Item
    Cultures positive
    boolean
    C15329 (NCI Thesaurus ObjectClass)
    C0543467 (UMLS 2011AA ObjectClass)
    C25300 (NCI Thesaurus Property)
    C0430400 (UMLS 2011AA Property)
    C38758 (NCI Thesaurus Property-2)
    C1514241 (UMLS 2011AA Property-2)
    C2959 (NCI Thesaurus Property-3)
    C0009566 (UMLS 2011AA Property-3)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    SurgicalProcedureCultureProcedurePositiveFindingComplicationText
    Item
    Organism (was)
    text
    C15329 (NCI Thesaurus ObjectClass)
    C0543467 (UMLS 2011AA ObjectClass)
    C25300 (NCI Thesaurus Property)
    C0430400 (UMLS 2011AA Property)
    C38758 (NCI Thesaurus Property-2)
    C1514241 (UMLS 2011AA Property-2)
    C2959 (NCI Thesaurus Property-3)
    C0009566 (UMLS 2011AA Property-3)
    C25704 (NCI Thesaurus ValueDomain)
    C1527021 (UMLS 2011AA ValueDomain)
    IntraperitonealRouteofAdministrationMedicalDeviceReplacementInd-2
    Item
    Access device replaced or revised
    boolean
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C16830 (NCI Thesaurus Property)
    C0025080 (UMLS 2011AA Property)
    C53610 (NCI Thesaurus Property-2)
    C0559956 (UMLS 2011AA Property-2)
    C38258 (NCI Thesaurus ObjectClass)
    C1522583 (UMLS 2011AA ObjectClass)
    OffTreatmentIntraperitonealChemotherapyAdministeredInd-2
    Item
    Was IP chemotherapy regimen stopped prematurely
    boolean
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C25601 (NCI Thesaurus ObjectClass)
    C1518544 (UMLS 2011AA ObjectClass)
    C25382 (NCI Thesaurus Property)
    C1521801 (UMLS 2011AA Property)
    C15581 (NCI Thesaurus ObjectClass-2)
    C0281548 (UMLS 2011AA ObjectClass-2)
    Item
    Was IP chemotherapy regimen stopped prematurely
    text
    C25638 (NCI Thesaurus ValueDomain)
    C0392360 (UMLS 2011AA ValueDomain)
    C25601 (NCI Thesaurus ObjectClass)
    C1518544 (UMLS 2011AA ObjectClass)
    C15581 (NCI Thesaurus ObjectClass-2)
    C0281548 (UMLS 2011AA ObjectClass-2)
    C25365 (NCI Thesaurus Property)
    C0678257 (UMLS 2011AA Property)
    Code List
    Was IP chemotherapy regimen stopped prematurely
    CL Item
    Abdominal Pain (Abdominal pain)
    CL Item
    Bowel Complication (Bowel complication)
    CL Item
    Disease Progression (Disease progression)
    C17747 (NCI Thesaurus)
    C0242656 (UMLS 2011AA)
    CL Item
    Fluid Out Vagina Or Wound (Fluid out vagina or wound)
    CL Item
    Nausea/vomiting/dehydration (Nausea/vomiting/dehydration)
    CL Item
    Neuropathy (Neuropathy)
    C4731 (NCI Thesaurus)
    C0031117 (UMLS 2011AA)
    CL Item
    Other (Other)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    CL Item
    Patient Refusal (Patient refusal)
    CL Item
    Port Complication (Port complication)
    CL Item
    Renal/metabolic (Renal/metabolic)
    CommonToxicityCriteriaAdverseEventReportingGrade
    Item
    Grade
    float
    C49704 (NCI Thesaurus ObjectClass)
    C1516728 (UMLS 2011AA ObjectClass)
    C25651 (NCI Thesaurus Property)
    C0700287 (UMLS 2011AA Property)
    C18000 (NCI Thesaurus ValueDomain)
    C0919553 (UMLS 2011AA ValueDomain)
    C25365 (NCI Thesaurus Property-2)
    C0678257 (UMLS 2011AA Property-2)
    IntraperitonealRouteofAdministrationMedicalDeviceAttemptReplacementInd-2
    Item
    Attempted port replacement
    boolean
    C38258 (NCI Thesaurus ObjectClass)
    C1522583 (UMLS 2011AA ObjectClass)
    C16830 (NCI Thesaurus Property)
    C0025080 (UMLS 2011AA Property)
    C53610 (NCI Thesaurus Property-2)
    C0559956 (UMLS 2011AA Property-2)
    C39769 (NCI Thesaurus Property-3)
    C1516084 (UMLS 2011AA Property-3)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    OffTreatmentIntraperitonealChemotherapyReasonSpecify
    Item
    Other specify
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C25601 (NCI Thesaurus ObjectClass)
    C1518544 (UMLS 2011AA ObjectClass)
    C15581 (NCI Thesaurus ObjectClass-2)
    C0281548 (UMLS 2011AA ObjectClass-2)
    C25365 (NCI Thesaurus Property)
    C0678257 (UMLS 2011AA Property)
    Item Group
    Footer Module
    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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