ID

9023

Beschreibung

CALGB-31004 OPEN Registration/Randomization Worksheet (SPARE Phase IB) Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B5A21D41-B9DA-D92A-E040-BB89AD4353CA

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B5A21D41-B9DA-D92A-E040-BB89AD4353CA

Stichworte

Versionen (3)
  1. 19.09.12 19.09.12 -
  2. 09.01.15 09.01.15 - 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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Malignant Mesothelioma Registration - CALGB-31004 OPEN Registration/Randomization Worksheet (SPARE Phase IB) - 3342180v1.0

Englisch

A Phase IB/Randomized Phase II Placebo-controlled Study of Linsitinib (OSI-906; NSC #751082) in Combination with Chemotherapy in Previously Treated Malignant Mesothelioma

1 Formulare  
Protocol Administration
Beschreibung

Protocol Administration

Date Informed Consent Signed (MM DD YYYY)
Beschreibung

InformedConsentFormSignedDate

Datentyp

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
HIPAA Authorization Date (MM DD YYYY)
Beschreibung

PatientSignedDischargeMedicalRecordDate

Datentyp

date

Alias
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus Property
C25679
NCI Metathesaurus Property
C0012621
NCI Thesaurus Property-2
C45258
UMLS 2011AA Property
C0025102
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Projected Start Date of Treatment (MM DD YYYY)
Beschreibung

Treatment Begin Date

Datentyp

date

Alias
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus ObjectClass-2
C25631
NCI Thesaurus Property
C25431
UMLS CUI-1
C3173309
NCI Thesaurus Property-2
C25275
NCI Thesaurus ValueDomain
C25164
NCI Thesaurus ValueDomain-2
C25431
Pre-treatment Characteristics
Beschreibung

Pre-treatment Characteristics

Performance Status
Beschreibung

ECOG Performance Status

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25664
UMLS CUI-1
C1520224
NCI Thesaurus Property
C25367
NCI Thesaurus ValueDomain-2
C25491
NCI Thesaurus ObjectClass
C20641
Height (cm)
Beschreibung

Patient Height

Datentyp

float

Maßeinheiten
  • cm
Alias
NCI Thesaurus ValueDomain
C25209
UMLS CUI-1
C0489786
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25347
cm
Weight (kg)
Beschreibung

Patient Weight

Datentyp

float

Maßeinheiten
  • Kg
Alias
NCI Thesaurus ValueDomain
C25209
UMLS CUI-1
C0005910
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25208
Kg
Disease code (mesothelioma)
Beschreibung

MedicalDictionaryforRegulatoryActivitiesTerminologyIdentifierCode

Datentyp

float

Alias
NCI Thesaurus ValueDomain
C25162
UMLS 2011AA ValueDomain
C0805701
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
NCI Metathesaurus ObjectClass
CL104089
NCI Thesaurus ValueDomain-2
C43820
UMLS 2011AA ValueDomain-2
C1140263
Certification Of Eligibility
Beschreibung

Certification Of Eligibility

In the opinion of the investigator, is the patient eligible
Beschreibung

Eligibility for trial

Datentyp

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS CUI-1
C1302261
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25171
Prior Therapy
Beschreibung

Prior Therapy

Prior Cancer Therapies (Mark all that apply with an X.)
Beschreibung

Prior therapy type

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS CUI-1
C1514463
NCI Thesaurus ObjectClass
C25629
NCI Thesaurus ObjectClass-2
C15368
NCI Thesaurus Property
C25365
Number of regimens (Chemotherapy multiple agents systemic)
Beschreibung

PriorMultipleAgentChemotherapyAdministeredCount

Datentyp

float

Alias
NCI Thesaurus ObjectClass
C15632
UMLS 2011AA ObjectClass
C0392920
NCI Thesaurus ObjectClass-2
C25629
UMLS 2011AA ObjectClass-2
C0332152
NCI Thesaurus ObjectClass-3
C17648
UMLS 2011AA ObjectClass-3
C0439064
NCI Thesaurus ObjectClass-4
C1708
UMLS 2011AA ObjectClass-4
C0450442
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
NCI Thesaurus ValueDomain
C25463
UMLS 2011AA ValueDomain
C0750480
Number of regimens (Chemotherapy non-cytotoxic)
Beschreibung

PriorNon-cytotoxicAgentChemotherapyAdministeredCount

Datentyp

float

Alias
NCI Thesaurus ObjectClass
C15632
UMLS 2011AA ObjectClass
C0392920
NCI Thesaurus ObjectClass-2
C25629
UMLS 2011AA ObjectClass-2
C0332152
NCI Thesaurus ObjectClass-3
C83487
UMLS 2011AA ObjectClass-3
C2827065
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
NCI Thesaurus ValueDomain
C25463
UMLS 2011AA ValueDomain
C0750480
Number of regimens (Chemotherapy - NOS)
Beschreibung

PriorChemotherapyRegimenNumber

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ObjectClass
C15632
UMLS 2011AA ObjectClass
C0392920
NCI Thesaurus ObjectClass-2
C25629
UMLS 2011AA ObjectClass-2
C0332152
NCI Thesaurus Property
C15697
UMLS 2011AA Property
C0040808
Number of regimens (Chemotherapy single agent systemic)
Beschreibung

SingleAgentSystemicChemotherapyAdministeredCount

Datentyp

float

Alias
NCI Thesaurus ValueDomain
C25463
UMLS 2011AA ValueDomain
C0750480
NCI Thesaurus ObjectClass
C15756
UMLS 2011AA ObjectClass
C0854619
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
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Ähnliche Modelle

A Phase IB/Randomized Phase II Placebo-controlled Study of Linsitinib (OSI-906; NSC #751082) in Combination with Chemotherapy in Previously Treated Malignant Mesothelioma

1 Formulare
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Protocol Administration
InformedConsentFormSignedDate
Item
Date Informed Consent Signed (MM DD YYYY)
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)
PatientSignedDischargeMedicalRecordDate
Item
HIPAA Authorization Date (MM DD YYYY)
date
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25679 (NCI Thesaurus Property)
C0012621 (NCI Metathesaurus Property)
C45258 (NCI Thesaurus Property-2)
C0025102 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Treatment Begin Date
Item
Projected Start Date of Treatment (MM DD YYYY)
date
C15368 (NCI Thesaurus ObjectClass)
C25631 (NCI Thesaurus ObjectClass-2)
C25431 (NCI Thesaurus Property)
C3173309 (UMLS CUI-1)
C25275 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C25431 (NCI Thesaurus ValueDomain-2)
Item Group
Pre-treatment Characteristics
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)
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)
Patient Height
Item
Height (cm)
float
C25209 (NCI Thesaurus ValueDomain)
C0489786 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25347 (NCI Thesaurus Property)
Patient Weight
Item
Weight (kg)
float
C25209 (NCI Thesaurus ValueDomain)
C0005910 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25208 (NCI Thesaurus Property)
MedicalDictionaryforRegulatoryActivitiesTerminologyIdentifierCode
Item
Disease code (mesothelioma)
float
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
CL104089 (NCI Metathesaurus ObjectClass)
C43820 (NCI Thesaurus ValueDomain-2)
C1140263 (UMLS 2011AA ValueDomain-2)
Item Group
Certification Of Eligibility
Eligibility for trial
Item
In the opinion of the investigator, is the patient eligible
boolean
C38148 (NCI Thesaurus ValueDomain)
C1302261 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25171 (NCI Thesaurus Property)
Item Group
Prior Therapy
Item
Prior Cancer Therapies (Mark all that apply with an X.)
text
C25284 (NCI Thesaurus ValueDomain)
C1514463 (UMLS CUI-1)
C25629 (NCI Thesaurus ObjectClass)
C15368 (NCI Thesaurus ObjectClass-2)
C25365 (NCI Thesaurus Property)
CL.4
Code List
Prior Cancer Therapies (Mark all that apply with an X.)
CL Item
No Previous Exposure To Drug (nos) (No prior therapy)
CL Item
Agents Administered To Control The Replication And/or Spread Of Viruses (Anti-retroviral therapy)
CL Item
Treatment With An Agent That Prevents Or Impairs The Translation Of The Genetic Message For Production Of A Specific Protein (Antisense)
CL Item
High Dose Chemotherapy Combined With Transplantation Of Bone Marrow Cells (Bone marrow transplant)
CL Item
Systemic Chemotherapy With A Regimen Containing Multiple Agents (Chemotherapy multiple agents systemic)
CL Item
Prior Therapy With Agents That Are Not Known To Cause Damage To Cycling Cells (Chemotherapy non-cytotoxic)
CL Item
Non-systemic Chemotherapy Treatment Or Chemotherapy Not Described By Chemotherapy Single Agent Systemic Or Multi-agent Systemic (Chemotherapy (NOS))
CL Item
Systemic Chemotherapy With A Single Agent Regimen (Chemotherapy single agent systemic)
CL Item
Treatment Of Human Disease By Gene Transfer (Gene transfer)
CL Item
Image Directed Local Therapy (Image Directed Local Therapy)
CL Item
Cancer Therapy Which Incorporates Hormonal Manipulation (Hormonal therapy)
CL Item
Drug And/or Immunotherapy (Drug and/or Immunotherapy)
CL Item
Anticancer Treatment With A Live, Replication-competent Virus (Oncolytic virotherapy)
CL Item
Targeted Ionizing Radiation Therapy Utilizing Radioactive Implants Or Seeds (Radiation therapy)
CL Item
Surgical Procedure, Or Operation, With Therapeutic Intent (Surgery)
CL Item
Therapy Nos (Therapy (NOS))
CL Item
Substance Or Group Of Substances Administered To Induce The Immune System To Recognize And Destroy Tumors Or Microorganisms (Vaccine)
CL Item
Hematopoietic Stem Cell Transplantation (Hematopoietic Stem Cell Transplantation)
PriorMultipleAgentChemotherapyAdministeredCount
Item
Number of regimens (Chemotherapy multiple agents systemic)
float
C15632 (NCI Thesaurus ObjectClass)
C0392920 (UMLS 2011AA ObjectClass)
C25629 (NCI Thesaurus ObjectClass-2)
C0332152 (UMLS 2011AA ObjectClass-2)
C17648 (NCI Thesaurus ObjectClass-3)
C0439064 (UMLS 2011AA ObjectClass-3)
C1708 (NCI Thesaurus ObjectClass-4)
C0450442 (UMLS 2011AA ObjectClass-4)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
PriorNon-cytotoxicAgentChemotherapyAdministeredCount
Item
Number of regimens (Chemotherapy non-cytotoxic)
float
C15632 (NCI Thesaurus ObjectClass)
C0392920 (UMLS 2011AA ObjectClass)
C25629 (NCI Thesaurus ObjectClass-2)
C0332152 (UMLS 2011AA ObjectClass-2)
C83487 (NCI Thesaurus ObjectClass-3)
C2827065 (UMLS 2011AA ObjectClass-3)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
PriorChemotherapyRegimenNumber
Item
Number of regimens (Chemotherapy - NOS)
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C15632 (NCI Thesaurus ObjectClass)
C0392920 (UMLS 2011AA ObjectClass)
C25629 (NCI Thesaurus ObjectClass-2)
C0332152 (UMLS 2011AA ObjectClass-2)
C15697 (NCI Thesaurus Property)
C0040808 (UMLS 2011AA Property)
SingleAgentSystemicChemotherapyAdministeredCount
Item
Number of regimens (Chemotherapy single agent systemic)
float
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS 2011AA ValueDomain)
C15756 (NCI Thesaurus ObjectClass)
C0854619 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
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