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ID

8887

Beskrivning

Chemotherapy checklist Genetic Testing or Clinical Assessment in Determining the Need for Chemotherapy in Women With Breast Cancer That Involves No More Than 3 Lymph Nodes Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=1968DCB8-C8AB-7156-E044-0003BA3F9857

Länk

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=1968DCB8-C8AB-7156-E044-0003BA3F9857

Nyckelord

  1. 2012-08-26 2012-08-26 -
  2. 2015-01-09 2015-01-09 - Martin Dugas
Uppladdad den

9 januari 2015

DOI

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Licens

Creative Commons BY-NC 3.0 Legacy

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    Breast Cancer NCT00433589 Treatment - Chemotherapy checklist - 2499056v1.0

    No Instruction available.

    1. StudyEvent: Chemotherapy checklist
      1. No Instruction available.
    Header
    Beskrivning

    Header

    Patient Birth Date
    Beskrivning

    Birth Date

    Datatyp

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS CUI-1
    C0421451
    NCI Thesaurus ObjectClass
    C16960
    NCI Thesaurus ValueDomain-2
    C25367
    NCI Thesaurus Property
    C25155
    Patient Hospital Number
    Beskrivning

    Patient Hospital No

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C0421459
    NCI Thesaurus Property
    C16960
    NCI Thesaurus Property-2
    C25364
    NCI Thesaurus ObjectClass
    C16696
    Institution Name
    Beskrivning

    Institution Name

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C1301943
    NCI Thesaurus ObjectClass
    C21541
    NCI Thesaurus ValueDomain-2
    C21541
    NCI Thesaurus Property
    C25364
    Institution No.
    Beskrivning

    Institution Number

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS CUI-1
    C1301943
    NCI Thesaurus ObjectClass
    C21541
    UMLS CUI-2
    C0805701
    NCI Thesaurus Property
    C25364
    Physician of Record
    Beskrivning

    Investigator Name

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS CUI-1
    C2826892
    NCI Thesaurus Property
    C25364
    NCI Thesaurus ObjectClass
    C17089
    NCI Thesaurus ObjectClass-2
    C25644
    Header
    Beskrivning

    Header

    Date Chemotherapy Began
    Beskrivning

    Chemotherapy Start Date

    Datatyp

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS CUI-1
    C1302181
    NCI Thesaurus ObjectClass
    C15632
    UMLS CUI-2
    C3173309
    NCI Thesaurus ValueDomain-2
    C25431
    NCI Thesaurus Property
    C25382
    Chemotherapy
    Beskrivning

    ChemotherapyAdministrationIndicator

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25180
    UMLS 2011AA ValueDomain
    C1522602
    NCI Thesaurus ObjectClass
    C15632
    UMLS 2011AA ObjectClass
    C0392920
    NCI Thesaurus Property
    C25409
    UMLS 2011AA Property
    C1533734
    Performance Status
    Beskrivning

    ECOG Performance Status

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25664
    UMLS CUI-1
    C1520224
    NCI Thesaurus Property
    C25367
    NCI Thesaurus ValueDomain-2
    C25491
    NCI Thesaurus ObjectClass
    C20641
    Has the patient had a baseline LVEF measured by MUGA scan or echocardiogram within the past 3 months?
    Beskrivning

    LVEFAssessmentPerformedInd-2

    Datatyp

    boolean

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus ObjectClass
    C25367
    NCI Thesaurus Property
    C38000
    UMLS 2011AA Property
    C0884358
    Left Ventricular Ejection Fraction at Rest (%)
    Beskrivning

    HeartLVEFTestPercentageValue

    Datatyp

    float

    Måttenheter
    • %
    Alias
    NCI Thesaurus ObjectClass
    C12727
    UMLS 2011AA ObjectClass
    C0018787
    NCI Thesaurus Property
    C25294
    UMLS 2011AA Property
    C0022885
    NCI Thesaurus Property-2
    C37946
    UMLS 2011AA Property-2
    C2700377
    NCI Thesaurus ValueDomain
    C25613
    UMLS 2011AA ValueDomain
    C0439165
    NCI Thesaurus ValueDomain-2
    C25712
    UMLS 2011AA ValueDomain-2
    C1522609
    %
    Does the patient have swallowing problems following treatment
    Beskrivning

    SwallowingFunctionDeficitReactionInd-3

    Datatyp

    boolean

    Alias
    NCI Thesaurus ObjectClass
    C25518
    UMLS 2011AA ObjectClass
    C0542341
    NCI Thesaurus ObjectClass-2
    C38028
    UMLS 2011AA ObjectClass-2
    C0011167
    NCI Thesaurus Property
    C25637
    UMLS 2011AA Property
    C0443286
    NCI Thesaurus Property-2
    C37940
    UMLS 2011AA Property-2
    C0011155
    NCI Thesaurus ValueDomain
    C38148
    UMLS 2011AA ValueDomain
    C1512699
    Date Informed Consent Signed
    Beskrivning

    InformedConsentFormSignedDate

    Datatyp

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ValueDomain-2
    C25367
    NCI Thesaurus ObjectClass
    C16468
    UMLS 2011AA ObjectClass
    C0009797
    NCI Thesaurus Property
    C25679
    Assigned Treatment Arm
    Beskrivning

    Protocol Treatment Arm

    Datatyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C15368
    NCI Thesaurus ObjectClass-2
    C42651
    UMLS CUI-1
    C1522541
    NCI Thesaurus Property
    C32141
    NCI Thesaurus Property-2
    C25426
    NCI Thesaurus ValueDomain
    C25704
    Chemotherapy Type
    Beskrivning

    ChemotherapyAdministeredText

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS 2011AA ValueDomain
    C1527021
    NCI Thesaurus ObjectClass
    C15632
    UMLS 2011AA ObjectClass
    C0392920
    NCI Thesaurus Property
    C25382
    UMLS 2011AA Property
    C1521801
    Chemotherapy Regimen
    Beskrivning

    ChemotherapyRegimenType

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus ObjectClass
    C15632
    UMLS 2011AA ObjectClass
    C0392920
    NCI Thesaurus Property
    C15697
    UMLS 2011AA Property
    C0040808
    Other, specify
    Beskrivning

    OtherChemotherapyAgentAdministrationSpecify

    Datatyp

    text

    Alias
    NCI Thesaurus ObjectClass
    C17649
    UMLS 2011AA ObjectClass
    C0205394
    NCI Thesaurus ObjectClass-2
    C15632
    UMLS 2011AA ObjectClass-2
    C0392920
    NCI Thesaurus ObjectClass-3
    C1708
    UMLS 2011AA ObjectClass-3
    C0450442
    NCI Thesaurus Property
    C25409
    UMLS 2011AA Property
    C1533734
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    Comments
    Beskrivning

    Comments

    Date
    Beskrivning

    Investigator Signature Date

    Datatyp

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS CUI-1
    C2346576
    NCI Thesaurus Property
    C25678
    UMLS CUI-2
    C0011008
    NCI Thesaurus ValueDomain-2
    C25367
    NCI Thesaurus ObjectClass
    C17089
    Investigator Signature
    Beskrivning

    Investigator Signature

    Datatyp

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS CUI-1
    C2346576
    NCI Thesaurus Property
    C25678
    NCI Thesaurus ObjectClass
    C17089

    Similar models

    No Instruction available.

    1. StudyEvent: Chemotherapy checklist
      1. No Instruction available.
    Name
    Typ
    Description | Question | Decode (Coded Value)
    Datatyp
    Alias
    Item Group
    Header
    Birth Date
    Item
    Patient Birth Date
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0421451 (UMLS CUI-1)
    C16960 (NCI Thesaurus ObjectClass)
    C25367 (NCI Thesaurus ValueDomain-2)
    C25155 (NCI Thesaurus Property)
    Patient Hospital No
    Item
    Patient Hospital Number
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0421459 (UMLS CUI-1)
    C16960 (NCI Thesaurus Property)
    C25364 (NCI Thesaurus Property-2)
    C16696 (NCI Thesaurus ObjectClass)
    Institution Name
    Item
    Institution Name
    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)
    Investigator Name
    Item
    Physician of Record
    text
    C25191 (NCI Thesaurus ValueDomain)
    C2826892 (UMLS CUI-1)
    C25364 (NCI Thesaurus Property)
    C17089 (NCI Thesaurus ObjectClass)
    C25644 (NCI Thesaurus ObjectClass-2)
    Item Group
    Header
    Chemotherapy Start Date
    Item
    Date Chemotherapy Began
    date
    C25164 (NCI Thesaurus ValueDomain)
    C1302181 (UMLS CUI-1)
    C15632 (NCI Thesaurus ObjectClass)
    C3173309 (UMLS CUI-2)
    C25431 (NCI Thesaurus ValueDomain-2)
    C25382 (NCI Thesaurus Property)
    Item
    Chemotherapy
    text
    C25180 (NCI Thesaurus ValueDomain)
    C1522602 (UMLS 2011AA ValueDomain)
    C15632 (NCI Thesaurus ObjectClass)
    C0392920 (UMLS 2011AA ObjectClass)
    C25409 (NCI Thesaurus Property)
    C1533734 (UMLS 2011AA Property)
    Code List
    Chemotherapy
    CL Item
    Not Planned (Not planned)
    CL Item
    Planned (Planned)
    C25619 (NCI Thesaurus)
    C1301732 (UMLS 2011AA)
    Item
    Performance Status
    text
    C25664 (NCI Thesaurus ValueDomain)
    C1520224 (UMLS CUI-1)
    C25367 (NCI Thesaurus Property)
    C25491 (NCI Thesaurus ValueDomain-2)
    C20641 (NCI Thesaurus ObjectClass)
    Code List
    Performance Status
    CL Item
    Fully Active, Able To Carry On All Pre-disease Performance Without Restriction. (0)
    CL Item
    Restricted In Physically Strenuous Activity But Ambulatory And Able To Carry Out Work Of A Light Or Sedentary Nature, E.g., Light Housework, Office Work. (1)
    CL Item
    Ambulatory And Capable Of All Selfcare But Unable To Carry Out Any Work Activities. Up And About More Than 50% Of Waking Hours. (2)
    CL Item
    Capable Of Only Limited Selfcare, Confined To Bed Or Chair More Than 50% Of Waking Hours. (3)
    CL Item
    Completely Disabled. Cannot Carry On Any Selfcare. Totally Confined To Bed Or Chair. (4)
    CL Item
    Dead (5)
    LVEFAssessmentPerformedInd-2
    Item
    Has the patient had a baseline LVEF measured by MUGA scan or echocardiogram within the past 3 months?
    boolean
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C25367 (NCI Thesaurus ObjectClass)
    C38000 (NCI Thesaurus Property)
    C0884358 (UMLS 2011AA Property)
    HeartLVEFTestPercentageValue
    Item
    Left Ventricular Ejection Fraction at Rest (%)
    float
    C12727 (NCI Thesaurus ObjectClass)
    C0018787 (UMLS 2011AA ObjectClass)
    C25294 (NCI Thesaurus Property)
    C0022885 (UMLS 2011AA Property)
    C37946 (NCI Thesaurus Property-2)
    C2700377 (UMLS 2011AA Property-2)
    C25613 (NCI Thesaurus ValueDomain)
    C0439165 (UMLS 2011AA ValueDomain)
    C25712 (NCI Thesaurus ValueDomain-2)
    C1522609 (UMLS 2011AA ValueDomain-2)
    SwallowingFunctionDeficitReactionInd-3
    Item
    Does the patient have swallowing problems following treatment
    boolean
    C25518 (NCI Thesaurus ObjectClass)
    C0542341 (UMLS 2011AA ObjectClass)
    C38028 (NCI Thesaurus ObjectClass-2)
    C0011167 (UMLS 2011AA ObjectClass-2)
    C25637 (NCI Thesaurus Property)
    C0443286 (UMLS 2011AA Property)
    C37940 (NCI Thesaurus Property-2)
    C0011155 (UMLS 2011AA Property-2)
    C38148 (NCI Thesaurus ValueDomain)
    C1512699 (UMLS 2011AA ValueDomain)
    InformedConsentFormSignedDate
    Item
    Date Informed Consent Signed
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25367 (NCI Thesaurus ValueDomain-2)
    C16468 (NCI Thesaurus ObjectClass)
    C0009797 (UMLS 2011AA ObjectClass)
    C25679 (NCI Thesaurus Property)
    Protocol Treatment Arm
    Item
    Assigned Treatment Arm
    text
    C15368 (NCI Thesaurus ObjectClass)
    C42651 (NCI Thesaurus ObjectClass-2)
    C1522541 (UMLS CUI-1)
    C32141 (NCI Thesaurus Property)
    C25426 (NCI Thesaurus Property-2)
    C25704 (NCI Thesaurus ValueDomain)
    ChemotherapyAdministeredText
    Item
    Chemotherapy Type
    text
    C25704 (NCI Thesaurus ValueDomain)
    C1527021 (UMLS 2011AA ValueDomain)
    C15632 (NCI Thesaurus ObjectClass)
    C0392920 (UMLS 2011AA ObjectClass)
    C25382 (NCI Thesaurus Property)
    C1521801 (UMLS 2011AA Property)
    Item
    Chemotherapy Regimen
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C15632 (NCI Thesaurus ObjectClass)
    C0392920 (UMLS 2011AA ObjectClass)
    C15697 (NCI Thesaurus Property)
    C0040808 (UMLS 2011AA Property)
    Code List
    Chemotherapy Regimen
    CL Item
    3 Month Anthracycline Based (3 month anthracycline based)
    CL Item
    6 Month/cycle Anthracycline Based (6 month/cycle anthracycline based)
    CL Item
    6 Month/cycle Non-anthracycline Regimen (6 month/cycle non-anthracycline regimen)
    CL Item
    Carboplatin And Paclitaxel (Carboplatin and Paclitaxel)
    CL Item
    Cisplatin And Docetaxel (Cisplatin and Docetaxel)
    CL Item
    Cisplatin And Gemcitabine (Cisplatin and Gemcitabine)
    CL Item
    Cisplatin And Vinorelbine (Cisplatin and Vinorelbine)
    CL Item
    Dose Dense Anthracycline (doxorubicin) And Cyclophosphamide (ac) Therapy (dose dense AC)
    CL Item
    Dose Dense Anthracycline (doxorubicin) And Cyclophosphamide (ac) Followed By A Taxane (dose dense AC followed by a taxane)
    CL Item
    5-fluorouracil, Epirubicin, Cyclophosphamide (fec) (FEC)
    CL Item
    Intravenous Cyclophosphamide, Methotrexate, And Fluorouracil (cmf) (IV CMF)
    CL Item
    Oral Cyclophosphamide, Methotrexate And 5-fluorouracil (cmf) (Oral CMF)
    CL Item
    Other (Other)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    CL Item
    Other Regimen Given As Part Of A Ctsu Adjuvant Therapy Protocol (other regimen given as part of a CTSU adjuvant therapy protocol)
    CL Item
    Standard Anthracycline And Cyclophosphamide (ac) Therapy (standard AC)
    CL Item
    Standard Anthracycline (doxorubicin) And Cyclophosphamide (ac) Followed By A Taxane (standard AC followed by a taxane)
    CL Item
    Doxorubicin, Cyclophosphamide, And Docetaxel (tac) (TAC)
    OtherChemotherapyAgentAdministrationSpecify
    Item
    Other, specify
    text
    C17649 (NCI Thesaurus ObjectClass)
    C0205394 (UMLS 2011AA ObjectClass)
    C15632 (NCI Thesaurus ObjectClass-2)
    C0392920 (UMLS 2011AA ObjectClass-2)
    C1708 (NCI Thesaurus ObjectClass-3)
    C0450442 (UMLS 2011AA ObjectClass-3)
    C25409 (NCI Thesaurus Property)
    C1533734 (UMLS 2011AA Property)
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    Item Group
    Comments
    Investigator Signature Date
    Item
    Date
    date
    C25164 (NCI Thesaurus ValueDomain)
    C2346576 (UMLS CUI-1)
    C25678 (NCI Thesaurus Property)
    C0011008 (UMLS CUI-2)
    C25367 (NCI Thesaurus ValueDomain-2)
    C17089 (NCI Thesaurus ObjectClass)
    Investigator Signature
    Item
    Investigator Signature
    text
    C25704 (NCI Thesaurus ValueDomain)
    C2346576 (UMLS CUI-1)
    C25678 (NCI Thesaurus Property)
    C17089 (NCI Thesaurus ObjectClass)

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