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897

Beschrijving

SOUTHWEST ONCOLOGY GROUP S0500 Prestudy Form Treatment Decision Making Based on Blood Levels of Tumor Cells in Women With Metastatic Breast Cancer Receiving Chemotherapy Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=07D022D9-F34F-20A8-E044-0003BA3F9857

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=07D022D9-F34F-20A8-E044-0003BA3F9857

Trefwoorden

Versies (2)
  1. 26-08-12 26-08-12 -
  2. 09-01-15 09-01-15 - Martin Dugas
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26 augustus 2012

DOI

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Creative Commons BY-NC 3.0 Legacy
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    Breast Cancer NCT00382018 Pre-Study - SOUTHWEST ONCOLOGY GROUP S0500 Prestudy Form - 2436725v1.0

    Engels

    No Instruction available.

    1 Formulieren  
    1. StudyEvent: SOUTHWEST ONCOLOGY GROUP S0500 Prestudy Form
      1. No Instruction available.
    Unnamed1
    Beschrijving

    Unnamed1

    SWOG Patient ID
    Beschrijving

    PatientSouthwestOncologyGroupIdentifierNumber

    Datatype

    double

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus Property
    C25699
    UMLS 2011AA Property
    C1519429
    SWOG Study No.
    Beschrijving

    ProtocolSWOGIdentifierNumber

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C25320
    UMLS 2011AA ObjectClass
    C1507394
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus Property
    C25699
    UMLS 2011AA Property
    C1519429
    Registration Step
    Beschrijving

    RegistrationStepNumber

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C25646
    UMLS 2011AA ObjectClass
    C1514821
    NCI Thesaurus Property
    C16154
    UMLS 2011AA Property
    C1704379
    NCI Thesaurus ValueDomain
    C16154
    UMLS 2011AA ValueDomain
    C1704379
    Patient Initials (L, F M)
    Beschrijving

    PatientInitialsName

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25536
    UMLS 2011AA Property
    C1555582
    Institution/Affiliate
    Beschrijving

    CombinedInstitutionName

    Datatype

    text

    Alias
    NCI Thesaurus ObjectClass
    C25454
    UMLS 2011AA ObjectClass
    C0205195
    NCI Thesaurus ObjectClass
    C21541
    UMLS 2011AA ObjectClass
    C0018704
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    NCI Thesaurus ValueDomain
    C21541
    UMLS 2011AA ValueDomain
    C0018704
    Physician (Participating Group:)
    Beschrijving

    RegisteredInvestigatorName

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    NCI Thesaurus ObjectClass
    C17089
    UMLS 2011AA ObjectClass
    C0035173
    NCI Thesaurus ObjectClass
    C25644
    Group Name
    Beschrijving

    GroupName

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25191
    UMLS 2011AA ValueDomain
    C1547383
    NCI Thesaurus ObjectClass
    C17005
    UMLS 2011AA ObjectClass
    C1257890
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    Participating Group Study No.
    Beschrijving

    ProtocolParticipatingIdentifierNumber

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C25320
    UMLS 2011AA ObjectClass
    C1507394
    NCI Thesaurus Property
    C25608
    UMLS 2011AA Property
    C0679823
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    Participating Group Patient ID (Instructions: All dates are MONTH, DAY, YEAR. Explain any blank fields or blank dates in the Comments section. Place an X in appropriate boxes. Circle AMENDED items in red and write AMENDED across the top of the form.)
    Beschrijving

    PatientParticipatingIdentifierNumber

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25608
    UMLS 2011AA Property
    C0679823
    NCI Thesaurus Property
    C25364
    UMLS 2011AA Property
    C0600091
    Patient Characteristics
    Beschrijving

    Patient Characteristics

    Performance Status
    Beschrijving

    PerformanceStatusAssessmentEasternCooperativeOncologyGroupScale

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25664
    UMLS 2011AA ValueDomain
    C0349674
    NCI Thesaurus Property
    C25367
    NCI Thesaurus ValueDomain
    C25491
    UMLS 2011AA ValueDomain
    C1512162
    NCI Thesaurus ObjectClass
    C20641
    UMLS 2011AA ObjectClass
    C1518965
    Date of CT scan or MRI of the chest or abdomen
    Beschrijving

    MagneticResonanceImagingComputedTomographyDiagnosticImagingChestAbdominalCavityAssessmentDate

    Datatype

    date

    Alias
    NCI Thesaurus ObjectClass
    C16502
    UMLS 2011AA ObjectClass
    C0011923
    NCI Thesaurus ObjectClass
    C17204
    UMLS 2011AA ObjectClass
    C0040405
    NCI Thesaurus ObjectClass
    C16809
    UMLS 2011AA ObjectClass
    C0024485
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    NCI Thesaurus Property
    C25389
    UMLS 2011AA Property
    C0817096
    NCI Thesaurus Property
    C12664
    UMLS 2011AA Property
    C0230168
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    Date of whole body bone scan
    Beschrijving

    BoneScanMedicalImagingEntireSkeletalSystemAssessmentDate

    Datatype

    date

    Alias
    NCI Thesaurus ObjectClass
    C17646
    UMLS 2011AA ObjectClass
    C0203668
    NCI Thesaurus ObjectClass
    C16831
    NCI Thesaurus Property
    C20989
    UMLS 2011AA Property
    C0031809
    NCI Thesaurus Property
    C25497
    UMLS 2011AA Property
    C0439751
    NCI Thesaurus Property
    C12788
    UMLS 2011AA Property
    C0037253
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    HER-2/neu status
    Beschrijving

    HER2/neuStatusType

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus ObjectClass
    C17756
    UMLS 2011AA ObjectClass
    C0242957
    NCI Thesaurus Property
    C25365
    UMLS 2011AA Property
    C0678257
    Does the patient have brain metastases
    Beschrijving

    BrainMetastasisPresentInd-2

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    NCI Thesaurus Property
    C25626
    UMLS 2011AA Property
    C0150312
    NCI Thesaurus ObjectClass
    C12439
    UMLS 2011AA ObjectClass
    C0006104
    NCI Thesaurus ObjectClass
    C19151
    UMLS 2011AA ObjectClass
    C0027627
    Has the patient had stable disease since the completion of radiotherapy to the brain
    Beschrijving

    MetastaticBrainMalignantNeoplasmStableDiseasePriorRadiationTherapyPresentInd-2

    Datatype

    text

    Alias
    NCI Thesaurus ObjectClass
    C18213
    UMLS 2011AA ObjectClass
    C0677946
    NCI Thesaurus ObjectClass
    C14174
    UMLS 2011AA ObjectClass
    C0036525
    NCI Thesaurus ObjectClass
    C12439
    UMLS 2011AA ObjectClass
    C0006104
    NCI Thesaurus ObjectClass
    C9305
    UMLS 2011AA ObjectClass
    C0006826
    NCI Thesaurus Property
    C25626
    UMLS 2011AA Property
    C0150312
    NCI Thesaurus Property
    C15313
    UMLS 2011AA Property
    C1522449
    NCI Thesaurus Property
    C25629
    UMLS 2011AA Property
    C0332152
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Date of completion of radiotherapy to the brain
    Beschrijving

    RadiationTherapyMetastaticBrainMalignantNeoplasmAdministrationEndDate

    Datatype

    date

    Alias
    NCI Thesaurus ObjectClass
    C15313
    UMLS 2011AA ObjectClass
    C1522449
    NCI Thesaurus Property
    C14174
    UMLS 2011AA Property
    C0036525
    NCI Thesaurus Property
    C12439
    UMLS 2011AA Property
    C0006104
    NCI Thesaurus Property
    C9305
    UMLS 2011AA Property
    C0006826
    NCI Thesaurus Property
    C25409
    UMLS 2011AA Property
    C1533734
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    Does the patient have leptomeningeal disease
    Beschrijving

    MetastaticNeoplasmLeptomeningesPresentInd-2

    Datatype

    text

    Alias
    NCI Thesaurus ObjectClass
    C3262
    UMLS 2011AA ObjectClass
    C0027651
    NCI Thesaurus ObjectClass
    C14174
    UMLS 2011AA ObjectClass
    C0036525
    NCI Thesaurus Property
    C25626
    UMLS 2011AA Property
    C0150312
    NCI Thesaurus Property
    C32979
    UMLS 2011AA Property
    C0228126
    NCI Thesaurus ValueDomain
    C38147
    UMLS 2011AA ValueDomain
    C1512698
    Height (CM)
    Beschrijving

    PatientHeightMeasurement

    Datatype

    double

    Maateenheden
    • cm
    Alias
    NCI Thesaurus ValueDomain
    C25209
    UMLS 2011AA ValueDomain
    C0242485
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25347
    UMLS 2011AA Property
    C0489786
    cm
    Weight (KG)
    Beschrijving

    PatientWeightMeasurement

    Datatype

    double

    Maateenheden
    • Kg
    Alias
    NCI Thesaurus ValueDomain
    C25209
    UMLS 2011AA ValueDomain
    C0242485
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C25208
    UMLS 2011AA Property
    C0043100
    Kg
    Menopausal Status
    Beschrijving

    Menopausal Status

    Menopausal Status
    Beschrijving

    PatientMenopauseCategory

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25372
    UMLS 2011AA ValueDomain
    C0683312
    NCI Thesaurus ObjectClass
    C16960
    UMLS 2011AA ObjectClass
    C0030705
    NCI Thesaurus Property
    C3231
    UMLS 2011AA Property
    C0025320
    NCI Thesaurus ValueDomain
    C3231
    UMLS 2011AA ValueDomain
    C0025320
    Disease Description
    Beschrijving

    Disease Description

    ER Result
    Beschrijving

    EstrogenReceptorSummaryResult

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C42614
    UMLS 2011AA ValueDomain
    C0027365
    ER Time
    Beschrijving

    EREvaluationType

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus Property
    C25214
    UMLS 2011AA Property
    C0220825
    NCI Thesaurus ObjectClass
    C17069
    UMLS 2011AA ObjectClass
    C0034804
    Other, specify
    Beschrijving

    EREvaluationSpecify

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    NCI Thesaurus Property
    C25214
    UMLS 2011AA Property
    C0220825
    NCI Thesaurus ObjectClass
    C17069
    UMLS 2011AA ObjectClass
    C0034804
    PgR Result
    Beschrijving

    PgRResultType

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus Property
    C20200
    UMLS 2011AA Property
    C1274040
    NCI Thesaurus ObjectClass
    C17075
    UMLS 2011AA ObjectClass
    C0034833
    PgR Time
    Beschrijving

    PgREvaluationType

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    NCI Thesaurus Property
    C25214
    UMLS 2011AA Property
    C0220825
    NCI Thesaurus ObjectClass
    C17075
    UMLS 2011AA ObjectClass
    C0034833
    Other, specify
    Beschrijving

    PgREvaluationSpecify

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    NCI Thesaurus Property
    C25214
    UMLS 2011AA Property
    C0220825
    NCI Thesaurus ObjectClass
    C17075
    UMLS 2011AA ObjectClass
    C0034833
    Date of initial diagnosis of primary tumor
    Beschrijving

    FirstBiopsyPositiveDate

    Datatype

    date

    Alias
    NCI Thesaurus ObjectClass
    C15189
    UMLS 2011AA ObjectClass
    C0005558
    NCI Thesaurus ObjectClass
    C25509
    UMLS 2011AA ObjectClass
    C1279901
    NCI Thesaurus Property
    C25246
    UMLS 2011AA Property
    C1446409
    NCI Thesaurus Property
    C25275
    UMLS 2011AA Property
    C2745955
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ValueDomain
    C25367
    Date progressive, recurrent or metastatic disease first diagnosed (Note: Involvement of regional nodes or locally advanced disease at original diagnosis is not regarded as metastatic disease.)
    Beschrijving

    DiseaseRecurrenceDate

    Datatype

    date

    Alias
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ValueDomain
    C25367
    NCI Thesaurus Property
    C3352
    UMLS 2011AA Property
    C0034897
    NCI Thesaurus ObjectClass
    C2991
    UMLS 2011AA ObjectClass
    C0012634
    Involved sites at time of entry (select all involved sites)
    Beschrijving

    SWOGDiseaseInvolvedSite

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C13717
    UMLS 2011AA ValueDomain
    C1515974
    NCI Thesaurus Property
    C25341
    UMLS 2011AA Property
    C0450429
    NCI Thesaurus ObjectClass
    C2991
    UMLS 2011AA ObjectClass
    C0012634
    Other sites, specify
    Beschrijving

    SWOGDiseaseInvolvedLocationSpecify

    Datatype

    text

    Alias
    NCI Thesaurus ObjectClass
    C25699
    UMLS 2011AA ObjectClass
    C1519429
    NCI Thesaurus ObjectClass
    C2991
    UMLS 2011AA ObjectClass
    C0012634
    NCI Thesaurus Property
    C25341
    UMLS 2011AA Property
    C0450429
    NCI Thesaurus Property
    C25547
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    NCI Thesaurus ValueDomain
    C2991
    UMLS 2011AA ValueDomain
    C0012634
    Prior Treatment Related To This Cancer
    Beschrijving

    Prior Treatment Related To This Cancer

    Other therapy, specify
    Beschrijving

    SWOGPriorTherapyAdministrationSpecify

    Datatype

    text

    Alias
    NCI Thesaurus ObjectClass
    C25699
    UMLS 2011AA ObjectClass
    C1519429
    NCI Thesaurus ObjectClass
    C25629
    UMLS 2011AA ObjectClass
    C0332152
    NCI Thesaurus ObjectClass
    C15368
    NCI Thesaurus Property
    C25409
    UMLS 2011AA Property
    C1533734
    NCI Thesaurus ValueDomain
    C25685
    UMLS 2011AA ValueDomain
    C1521902
    Radiation (select one)
    Beschrijving

    SWOGRTAdministeredType

    Datatype

    text

    Alias
    NCI Thesaurus ObjectClass
    C15313
    UMLS 2011AA ObjectClass
    C1522449
    NCI Thesaurus Property
    C25382
    UMLS 2011AA Property
    C1521801
    Has the patient had any of the following prior treatments? (select ALL that apply)
    Beschrijving

    SWOGPriorTherapyAdministeredType

    Datatype

    text

    Alias
    NCI Thesaurus ObjectClass
    C25699
    UMLS 2011AA ObjectClass
    C1519429
    NCI Thesaurus ObjectClass
    C25629
    UMLS 2011AA ObjectClass
    C0332152
    NCI Thesaurus ObjectClass
    C15368
    NCI Thesaurus Property
    C25409
    UMLS 2011AA Property
    C1533734
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    Has the patient had any of the following prior treatments? (select ALL that apply)
    Beschrijving

    SWOGPriorTherapyAdministeredType

    Datatype

    text

    Alias
    NCI Thesaurus ObjectClass
    C25699
    UMLS 2011AA ObjectClass
    C1519429
    NCI Thesaurus ObjectClass
    C25629
    UMLS 2011AA ObjectClass
    C0332152
    NCI Thesaurus ObjectClass
    C15368
    NCI Thesaurus Property
    C25409
    UMLS 2011AA Property
    C1533734
    NCI Thesaurus ValueDomain
    C25284
    UMLS 2011AA ValueDomain
    C0332307
    Number of prior chemotherapy regimens
    Beschrijving

    PriorChemotherapyRegimenNumber

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25337
    UMLS 2011AA ValueDomain
    C0237753
    NCI Thesaurus ObjectClass
    C15632
    UMLS 2011AA ObjectClass
    C0392920
    NCI Thesaurus ObjectClass
    C25629
    UMLS 2011AA ObjectClass
    C0332152
    NCI Thesaurus Property
    C15697
    UMLS 2011AA Property
    C0040808
    Date of completion of adjuvant chemotherapy
    Beschrijving

    AdjuvantChemotherapyAdministeredCompleteDate

    Datatype

    date

    Alias
    NCI Thesaurus ObjectClass
    C15632
    UMLS 2011AA ObjectClass
    C0392920
    NCI Thesaurus ObjectClass
    C2140
    UMLS 2011AA ObjectClass
    C0001552
    NCI Thesaurus Property
    C25382
    UMLS 2011AA Property
    C1521801
    NCI Thesaurus ValueDomain
    C25164
    UMLS 2011AA ValueDomain
    C0011008
    NCI Thesaurus ValueDomain
    C25250
    UMLS 2011AA ValueDomain
    C0205197
    Comments
    Beschrijving

    Comments

    Comments
    Beschrijving

    ResearchCommentsText

    Datatype

    text

    Alias
    NCI Thesaurus ValueDomain
    C25704
    UMLS 2011AA ValueDomain
    C1527021
    NCI Thesaurus ObjectClass
    C15319
    NCI Thesaurus Property
    C25393
    UMLS 2011AA Property
    C0282411
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    1 Formulieren
    1. StudyEvent: SOUTHWEST ONCOLOGY GROUP S0500 Prestudy Form
      1. No Instruction available.
    Name
    Type
    Description | Question | Decode (Coded Value)
    Datatype
    Alias
    Item Group
    Unnamed1
    PatientSouthwestOncologyGroupIdentifierNumber
    Item
    SWOG Patient ID
    double
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25699 (NCI Thesaurus Property)
    C1519429 (UMLS 2011AA Property)
    ProtocolSWOGIdentifierNumber
    Item
    SWOG Study No.
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C25320 (NCI Thesaurus ObjectClass)
    C1507394 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25699 (NCI Thesaurus Property)
    C1519429 (UMLS 2011AA Property)
    RegistrationStepNumber
    Item
    Registration Step
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C25646 (NCI Thesaurus ObjectClass)
    C1514821 (UMLS 2011AA ObjectClass)
    C16154 (NCI Thesaurus Property)
    C1704379 (UMLS 2011AA Property)
    C16154 (NCI Thesaurus ValueDomain)
    C1704379 (UMLS 2011AA ValueDomain)
    PatientInitialsName
    Item
    Patient Initials (L, F M)
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25536 (NCI Thesaurus Property)
    C1555582 (UMLS 2011AA Property)
    CombinedInstitutionName
    Item
    Institution/Affiliate
    text
    C25454 (NCI Thesaurus ObjectClass)
    C0205195 (UMLS 2011AA ObjectClass)
    C21541 (NCI Thesaurus ObjectClass)
    C0018704 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C21541 (NCI Thesaurus ValueDomain)
    C0018704 (UMLS 2011AA ValueDomain)
    RegisteredInvestigatorName
    Item
    Physician (Participating Group:)
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    C17089 (NCI Thesaurus ObjectClass)
    C0035173 (UMLS 2011AA ObjectClass)
    C25644 (NCI Thesaurus ObjectClass)
    GroupName
    Item
    Group Name
    text
    C25191 (NCI Thesaurus ValueDomain)
    C1547383 (UMLS 2011AA ValueDomain)
    C17005 (NCI Thesaurus ObjectClass)
    C1257890 (UMLS 2011AA ObjectClass)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    ProtocolParticipatingIdentifierNumber
    Item
    Participating Group Study No.
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C25320 (NCI Thesaurus ObjectClass)
    C1507394 (UMLS 2011AA ObjectClass)
    C25608 (NCI Thesaurus Property)
    C0679823 (UMLS 2011AA Property)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    PatientParticipatingIdentifierNumber
    Item
    Participating Group Patient ID (Instructions: All dates are MONTH, DAY, YEAR. Explain any blank fields or blank dates in the Comments section. Place an X in appropriate boxes. Circle AMENDED items in red and write AMENDED across the top of the form.)
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25608 (NCI Thesaurus Property)
    C0679823 (UMLS 2011AA Property)
    C25364 (NCI Thesaurus Property)
    C0600091 (UMLS 2011AA Property)
    Item Group
    Patient Characteristics
    Item
    Performance Status
    text
    C25664 (NCI Thesaurus ValueDomain)
    C0349674 (UMLS 2011AA ValueDomain)
    C25367 (NCI Thesaurus Property)
    C25491 (NCI Thesaurus ValueDomain)
    C1512162 (UMLS 2011AA ValueDomain)
    C20641 (NCI Thesaurus ObjectClass)
    C1518965 (UMLS 2011AA ObjectClass)
    CL.1
    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)
    MagneticResonanceImagingComputedTomographyDiagnosticImagingChestAbdominalCavityAssessmentDate
    Item
    Date of CT scan or MRI of the chest or abdomen
    date
    C16502 (NCI Thesaurus ObjectClass)
    C0011923 (UMLS 2011AA ObjectClass)
    C17204 (NCI Thesaurus ObjectClass)
    C0040405 (UMLS 2011AA ObjectClass)
    C16809 (NCI Thesaurus ObjectClass)
    C0024485 (UMLS 2011AA ObjectClass)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    C25389 (NCI Thesaurus Property)
    C0817096 (UMLS 2011AA Property)
    C12664 (NCI Thesaurus Property)
    C0230168 (UMLS 2011AA Property)
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    BoneScanMedicalImagingEntireSkeletalSystemAssessmentDate
    Item
    Date of whole body bone scan
    date
    C17646 (NCI Thesaurus ObjectClass)
    C0203668 (UMLS 2011AA ObjectClass)
    C16831 (NCI Thesaurus ObjectClass)
    C20989 (NCI Thesaurus Property)
    C0031809 (UMLS 2011AA Property)
    C25497 (NCI Thesaurus Property)
    C0439751 (UMLS 2011AA Property)
    C12788 (NCI Thesaurus Property)
    C0037253 (UMLS 2011AA Property)
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    Item
    HER-2/neu status
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C17756 (NCI Thesaurus ObjectClass)
    C0242957 (UMLS 2011AA ObjectClass)
    C25365 (NCI Thesaurus Property)
    C0678257 (UMLS 2011AA Property)
    CL.2
    Code List
    HER-2/neu status
    CL Item
    Negative (Negative)
    C25247 (NCI Thesaurus)
    C0205160 (UMLS 2011AA)
    CL Item
    Positive (Positive)
    C25246 (NCI Thesaurus)
    C1446409 (UMLS 2011AA)
    Item
    Does the patient have brain metastases
    text
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    C25626 (NCI Thesaurus Property)
    C0150312 (UMLS 2011AA Property)
    C12439 (NCI Thesaurus ObjectClass)
    C0006104 (UMLS 2011AA ObjectClass)
    C19151 (NCI Thesaurus ObjectClass)
    C0027627 (UMLS 2011AA ObjectClass)
    CL.3
    Code List
    Does the patient have brain metastases
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    Item
    Has the patient had stable disease since the completion of radiotherapy to the brain
    text
    C18213 (NCI Thesaurus ObjectClass)
    C0677946 (UMLS 2011AA ObjectClass)
    C14174 (NCI Thesaurus ObjectClass)
    C0036525 (UMLS 2011AA ObjectClass)
    C12439 (NCI Thesaurus ObjectClass)
    C0006104 (UMLS 2011AA ObjectClass)
    C9305 (NCI Thesaurus ObjectClass)
    C0006826 (UMLS 2011AA ObjectClass)
    C25626 (NCI Thesaurus Property)
    C0150312 (UMLS 2011AA Property)
    C15313 (NCI Thesaurus Property)
    C1522449 (UMLS 2011AA Property)
    C25629 (NCI Thesaurus Property)
    C0332152 (UMLS 2011AA Property)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    CL.4
    Code List
    Has the patient had stable disease since the completion of radiotherapy to the brain
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    RadiationTherapyMetastaticBrainMalignantNeoplasmAdministrationEndDate
    Item
    Date of completion of radiotherapy to the brain
    date
    C15313 (NCI Thesaurus ObjectClass)
    C1522449 (UMLS 2011AA ObjectClass)
    C14174 (NCI Thesaurus Property)
    C0036525 (UMLS 2011AA Property)
    C12439 (NCI Thesaurus Property)
    C0006104 (UMLS 2011AA Property)
    C9305 (NCI Thesaurus Property)
    C0006826 (UMLS 2011AA Property)
    C25409 (NCI Thesaurus Property)
    C1533734 (UMLS 2011AA Property)
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    Item
    Does the patient have leptomeningeal disease
    text
    C3262 (NCI Thesaurus ObjectClass)
    C0027651 (UMLS 2011AA ObjectClass)
    C14174 (NCI Thesaurus ObjectClass)
    C0036525 (UMLS 2011AA ObjectClass)
    C25626 (NCI Thesaurus Property)
    C0150312 (UMLS 2011AA Property)
    C32979 (NCI Thesaurus Property)
    C0228126 (UMLS 2011AA Property)
    C38147 (NCI Thesaurus ValueDomain)
    C1512698 (UMLS 2011AA ValueDomain)
    CL.5
    Code List
    Does the patient have leptomeningeal disease
    CL Item
    No (No)
    C49487 (NCI Thesaurus)
    C1298908 (UMLS 2011AA)
    CL Item
    Yes (Yes)
    C49488 (NCI Thesaurus)
    C1705108 (UMLS 2011AA)
    PatientHeightMeasurement
    Item
    Height (CM)
    double
    C25209 (NCI Thesaurus ValueDomain)
    C0242485 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25347 (NCI Thesaurus Property)
    C0489786 (UMLS 2011AA Property)
    PatientWeightMeasurement
    Item
    Weight (KG)
    double
    C25209 (NCI Thesaurus ValueDomain)
    C0242485 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C25208 (NCI Thesaurus Property)
    C0043100 (UMLS 2011AA Property)
    Item Group
    Menopausal Status
    Item
    Menopausal Status
    text
    C25372 (NCI Thesaurus ValueDomain)
    C0683312 (UMLS 2011AA ValueDomain)
    C16960 (NCI Thesaurus ObjectClass)
    C0030705 (UMLS 2011AA ObjectClass)
    C3231 (NCI Thesaurus Property)
    C0025320 (UMLS 2011AA Property)
    C3231 (NCI Thesaurus ValueDomain)
    C0025320 (UMLS 2011AA ValueDomain)
    CL.6
    Code List
    Menopausal Status
    CL Item
    Pre (<6 Mo Since Lmp And No Prior Bilateral Ovariectomy And Not On Estrogen Replacement) (Pre (< 6 mo since LMP and no prior bilateral ovariectomy and not on estrogen replacement))
    CL Item
    Post (prior Bilateral Ovariectomy Or >12 Mo Since Lmp With No Prior Hysterectomy And Not Currently Receiving Therapy With Lh-rh Analogs [e.g., Zoladex]) (Post (prior bilateral ovariectomy OR > 12 mo since LMP with no prior hysterectomy and not currently receiving therapy with LH-RH analogs [e.g. Zoladex]))
    CL Item
    Above Categories Not Applicable And Age <50 (Above not applicable AND age < 50)
    CL Item
    Above Categories Not Applicable And Age >= 50 (Above not applicable AND age >=50)
    Item Group
    Disease Description
    Item
    ER Result
    text
    C42614 (NCI Thesaurus ValueDomain)
    C0027365 (UMLS 2011AA ValueDomain)
    CL.7
    Code List
    ER Result
    CL Item
    Negative (Negative)
    C25247 (NCI Thesaurus)
    C0205160 (UMLS 2011AA)
    CL Item
    Positive (Positive)
    C25246 (NCI Thesaurus)
    C1446409 (UMLS 2011AA)
    CL Item
    Not Done (Never Done or Unknown)
    CL281691 (NCI Metathesaurus)
    Item
    ER Time
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C25214 (NCI Thesaurus Property)
    C0220825 (UMLS 2011AA Property)
    C17069 (NCI Thesaurus ObjectClass)
    C0034804 (UMLS 2011AA ObjectClass)
    CL.8
    Code List
    ER Time
    CL Item
    At Initial Primary Diagnosis (At initial primary diagnosis)
    CL Item
    At Disease Recurrence (At disease recurrence)
    CL Item
    Other (Other)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    EREvaluationSpecify
    Item
    Other, specify
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C25214 (NCI Thesaurus Property)
    C0220825 (UMLS 2011AA Property)
    C17069 (NCI Thesaurus ObjectClass)
    C0034804 (UMLS 2011AA ObjectClass)
    Item
    PgR Result
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C20200 (NCI Thesaurus Property)
    C1274040 (UMLS 2011AA Property)
    C17075 (NCI Thesaurus ObjectClass)
    C0034833 (UMLS 2011AA ObjectClass)
    CL.9
    Code List
    PgR Result
    CL Item
    Negative (Negative)
    C25247 (NCI Thesaurus)
    C0205160 (UMLS 2011AA)
    CL Item
    Positive (Positive)
    C25246 (NCI Thesaurus)
    C1446409 (UMLS 2011AA)
    CL Item
    Never Done Or Unknown (Never Done or Unknown)
    Item
    PgR Time
    text
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    C25214 (NCI Thesaurus Property)
    C0220825 (UMLS 2011AA Property)
    C17075 (NCI Thesaurus ObjectClass)
    C0034833 (UMLS 2011AA ObjectClass)
    CL.10
    Code List
    PgR Time
    CL Item
    At Initial Primary Diagnosis (At initial primary diagnosis)
    CL Item
    At Disease Recurrence (At disease recurrence)
    CL Item
    Other (Other)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    PgREvaluationSpecify
    Item
    Other, specify
    text
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C25214 (NCI Thesaurus Property)
    C0220825 (UMLS 2011AA Property)
    C17075 (NCI Thesaurus ObjectClass)
    C0034833 (UMLS 2011AA ObjectClass)
    FirstBiopsyPositiveDate
    Item
    Date of initial diagnosis of primary tumor
    date
    C15189 (NCI Thesaurus ObjectClass)
    C0005558 (UMLS 2011AA ObjectClass)
    C25509 (NCI Thesaurus ObjectClass)
    C1279901 (UMLS 2011AA ObjectClass)
    C25246 (NCI Thesaurus Property)
    C1446409 (UMLS 2011AA Property)
    C25275 (NCI Thesaurus Property)
    C2745955 (UMLS 2011AA Property)
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25367 (NCI Thesaurus ValueDomain)
    DiseaseRecurrenceDate
    Item
    Date progressive, recurrent or metastatic disease first diagnosed (Note: Involvement of regional nodes or locally advanced disease at original diagnosis is not regarded as metastatic disease.)
    date
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25367 (NCI Thesaurus ValueDomain)
    C3352 (NCI Thesaurus Property)
    C0034897 (UMLS 2011AA Property)
    C2991 (NCI Thesaurus ObjectClass)
    C0012634 (UMLS 2011AA ObjectClass)
    Item
    Involved sites at time of entry (select all involved sites)
    text
    C13717 (NCI Thesaurus ValueDomain)
    C1515974 (UMLS 2011AA ValueDomain)
    C25341 (NCI Thesaurus Property)
    C0450429 (UMLS 2011AA Property)
    C2991 (NCI Thesaurus ObjectClass)
    C0012634 (UMLS 2011AA ObjectClass)
    CL.11
    Code List
    Involved sites at time of entry (select all involved sites)
    CL Item
    Local-regional (Local-regional)
    C25388 (NCI Thesaurus)
    C1947913 (UMLS 2011AA)
    CL Item
    Ipsilateral Supraclavicular Nodes (ipsilateral supraclavicular nodes)
    CL Item
    Opposite Breast (Opposite breast)
    CL Item
    Distant Lymph Nodes (Distant nodes)
    CL Item
    Distant Skin/subcutaneous Tissue (Distant skin/subcutaneous tissue)
    CL Item
    Bone (Bone)
    C12366 (NCI Thesaurus)
    C0262950 (UMLS 2011AA)
    CL Item
    Bone Marrow (Bone marrow)
    CL Item
    Lung (Lung)
    C12468 (NCI Thesaurus)
    C0024109 (UMLS 2011AA)
    CL Item
    Pleura (Pleura)
    CL Item
    Liver (Liver)
    C12392 (NCI Thesaurus)
    C0023884 (UMLS 2011AA)
    CL Item
    Brain (Brain)
    CL Item
    Other Cns (Other CNS)
    CL Item
    Other (Other sites)
    C17649 (NCI Thesaurus)
    C0205394 (UMLS 2011AA)
    SWOGDiseaseInvolvedLocationSpecify
    Item
    Other sites, specify
    text
    C25699 (NCI Thesaurus ObjectClass)
    C1519429 (UMLS 2011AA ObjectClass)
    C2991 (NCI Thesaurus ObjectClass)
    C0012634 (UMLS 2011AA ObjectClass)
    C25341 (NCI Thesaurus Property)
    C0450429 (UMLS 2011AA Property)
    C25547 (NCI Thesaurus Property)
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    C2991 (NCI Thesaurus ValueDomain)
    C0012634 (UMLS 2011AA ValueDomain)
    Item Group
    Prior Treatment Related To This Cancer
    SWOGPriorTherapyAdministrationSpecify
    Item
    Other therapy, specify
    text
    C25699 (NCI Thesaurus ObjectClass)
    C1519429 (UMLS 2011AA ObjectClass)
    C25629 (NCI Thesaurus ObjectClass)
    C0332152 (UMLS 2011AA ObjectClass)
    C15368 (NCI Thesaurus ObjectClass)
    C25409 (NCI Thesaurus Property)
    C1533734 (UMLS 2011AA Property)
    C25685 (NCI Thesaurus ValueDomain)
    C1521902 (UMLS 2011AA ValueDomain)
    Item
    Radiation (select one)
    text
    C15313 (NCI Thesaurus ObjectClass)
    C1522449 (UMLS 2011AA ObjectClass)
    C25382 (NCI Thesaurus Property)
    C1521801 (UMLS 2011AA Property)
    CL.13
    Code List
    Radiation (select one)
    CL Item
    Extensive Radiation (Extensive RT)
    C16230 (NCI Thesaurus)
    C1517030 (UMLS 2011AA)
    CL Item
    Limited Radiation (Limited RT)
    CL Item
    Not Otherwise Specified (Not otherwise specified)
    CL006269 (NCI Metathesaurus)
    Item
    Has the patient had any of the following prior treatments? (select ALL that apply)
    text
    C25699 (NCI Thesaurus ObjectClass)
    C1519429 (UMLS 2011AA ObjectClass)
    C25629 (NCI Thesaurus ObjectClass)
    C0332152 (UMLS 2011AA ObjectClass)
    C15368 (NCI Thesaurus ObjectClass)
    C25409 (NCI Thesaurus Property)
    C1533734 (UMLS 2011AA Property)
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    CL.14
    Code List
    Has the patient had any of the following prior treatments? (select ALL that apply)
    CL Item
    Surgery (Surgery)
    C17173 (NCI Thesaurus)
    C0038894 (UMLS 2011AA)
    CL Item
    Gene Transfer (Gene transfer)
    C20185 (NCI Thesaurus)
    C1517499 (UMLS 2011AA)
    CL Item
    Anti-retroviral Therapy (Anti-retroviral therapy)
    CL Item
    Antisense (Antisense)
    CL Item
    Oncolytic Virotherapy (Oncolytic virotherapy)
    CL Item
    Vaccine (Vaccine)
    C923 (NCI Thesaurus)
    C0042210 (UMLS 2011AA)
    Item
    Has the patient had any of the following prior treatments? (select ALL that apply)
    text
    C25699 (NCI Thesaurus ObjectClass)
    C1519429 (UMLS 2011AA ObjectClass)
    C25629 (NCI Thesaurus ObjectClass)
    C0332152 (UMLS 2011AA ObjectClass)
    C15368 (NCI Thesaurus ObjectClass)
    C25409 (NCI Thesaurus Property)
    C1533734 (UMLS 2011AA Property)
    C25284 (NCI Thesaurus ValueDomain)
    C0332307 (UMLS 2011AA ValueDomain)
    CL.14
    Code List
    Has the patient had any of the following prior treatments? (select ALL that apply)
    CL Item
    Surgery (Surgery)
    C17173 (NCI Thesaurus)
    C0038894 (UMLS 2011AA)
    CL Item
    Gene Transfer (Gene transfer)
    C20185 (NCI Thesaurus)
    C1517499 (UMLS 2011AA)
    CL Item
    Anti-retroviral Therapy (Anti-retroviral therapy)
    CL Item
    Antisense (Antisense)
    CL Item
    Oncolytic Virotherapy (Oncolytic virotherapy)
    CL Item
    Vaccine (Vaccine)
    C923 (NCI Thesaurus)
    C0042210 (UMLS 2011AA)
    PriorChemotherapyRegimenNumber
    Item
    Number of prior chemotherapy regimens
    text
    C25337 (NCI Thesaurus ValueDomain)
    C0237753 (UMLS 2011AA ValueDomain)
    C15632 (NCI Thesaurus ObjectClass)
    C0392920 (UMLS 2011AA ObjectClass)
    C25629 (NCI Thesaurus ObjectClass)
    C0332152 (UMLS 2011AA ObjectClass)
    C15697 (NCI Thesaurus Property)
    C0040808 (UMLS 2011AA Property)
    AdjuvantChemotherapyAdministeredCompleteDate
    Item
    Date of completion of adjuvant chemotherapy
    date
    C15632 (NCI Thesaurus ObjectClass)
    C0392920 (UMLS 2011AA ObjectClass)
    C2140 (NCI Thesaurus ObjectClass)
    C0001552 (UMLS 2011AA ObjectClass)
    C25382 (NCI Thesaurus Property)
    C1521801 (UMLS 2011AA Property)
    C25164 (NCI Thesaurus ValueDomain)
    C0011008 (UMLS 2011AA ValueDomain)
    C25250 (NCI Thesaurus ValueDomain)
    C0205197 (UMLS 2011AA ValueDomain)
    Item Group
    Comments
    ResearchCommentsText
    Item
    Comments
    text
    C25704 (NCI Thesaurus ValueDomain)
    C1527021 (UMLS 2011AA ValueDomain)
    C15319 (NCI Thesaurus ObjectClass)
    C25393 (NCI Thesaurus Property)
    C0282411 (UMLS 2011AA Property)
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