ID

9130

Beschreibung

SOUTHWEST ONCOLOGY GROUP S0227 ADVANCED CERVICAL CARCINOMA PRESTUDY FORM S0227 Comparison of Cisplatin Combined With Either Paclitaxel or Gemcitabine in Treating Patients With Recurrent, Persistent, or Metastatic Cervical Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A9C2988B-9167-372F-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A9C2988B-9167-372F-E034-0003BA12F5E7

Stichworte

  1. 27.08.12 27.08.12 -
  2. 09.01.15 09.01.15 - Martin Dugas
Hochgeladen am

9. Januar 2015

DOI

Für eine Beantragung loggen Sie sich ein.

Lizenz

Creative Commons BY-NC 3.0 Legacy

Modell Kommentare :

Hier können Sie das Modell kommentieren. Über die Sprechblasen an den Itemgruppen und Items können Sie diese spezifisch kommentieren.

Itemgroup Kommentare für :

Item Kommentare für :

Um Formulare herunterzuladen müssen Sie angemeldet sein. Bitte loggen Sie sich ein oder registrieren Sie sich kostenlos.

Cervical Cancer NCT00057928 Pre-Study - SOUTHWEST ONCOLOGY GROUP S0227 ADVANCED CERVICAL CARCINOMA PRESTUDY FORM - 2056878v3.0

No Instruction available.

  1. StudyEvent: SOUTHWEST ONCOLOGY GROUP S0227 ADVANCED CERVICAL CARCINOMA PRESTUDY FORM
    1. No Instruction available.
Header
Beschreibung

Header

SWOG Patient ID
Beschreibung

SWOGPatientID

Datentyp

text

SWOG Study No.
Beschreibung

SWOGStudyNo.

Datentyp

text

Registration Step
Beschreibung

RegistrationStep

Datentyp

text

Patient Initials (L, F M)
Beschreibung

Patient Initials

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Institution / Affiliate
Beschreibung

InstitutionName

Datentyp

text

Physician (Groups Other than SWOG)
Beschreibung

RegisteredInvestigator

Datentyp

text

Group Name
Beschreibung

ParticipatingGroupName

Datentyp

text

Study No.
Beschreibung

Particip.GroupProtocolNumber

Datentyp

float

Pt. ID (Instructions: All dates are MONTH, DAY, YEAR. Explain any blank fields or blank dates in the Comments section at the end of the form. Place an X in appropriate boxes. Circle AMENDED items in red.)
Beschreibung

PatientStudyID,ParticipatingGroup

Datentyp

text

Disease Description At Diagnosis
Beschreibung

Disease Description At Diagnosis

Date of definitive histologic diagnosis of primary tumor
Beschreibung

PrimaryTumorDiagnosisDate

Datentyp

date

Alias
NCI Thesaurus ObjectClass
C3262
UMLS 2011AA ObjectClass
C0027651
NCI Thesaurus Property
C15220
UMLS 2011AA Property
C0011900
Stage at diagnosis (FIGO, select one)
Beschreibung

StageGrouping

Datentyp

text

Histologic grade at diagnosis (check highest grade)
Beschreibung

HistologicGrade

Datentyp

text

Histologic type at diagnosis (check all that apply)
Beschreibung

HistologicType

Datentyp

text

Other, specify
Beschreibung

HistologicType,OtherVariant

Datentyp

text

Prior Treatment Related To This Cancer
Beschreibung

Prior Treatment Related To This Cancer

Primary Surgery
Beschreibung

PriorSurgeryInd

Datentyp

boolean

Primary Surgery Date
Beschreibung

PrimarySurgeryDate

Datentyp

date

Radiation therapy
Beschreibung

PriorRTInd

Datentyp

boolean

Persistent disease after radiation therapy
Beschreibung

ResidualDiseaseStatus

Datentyp

boolean

Persistent disease after radiation therapy
Beschreibung

ResidualDiseaseStatus

Datentyp

boolean

Prior Chemotherapy
Beschreibung

PriorChemotherapyInd

Datentyp

text

Yes, specify agents
Beschreibung

Non-ProtocolChemotherapyType

Datentyp

text

Other treatment, specify
Beschreibung

PriorChemotherapyRegimen,OtherAgent

Datentyp

text

Disease Description At Study Entry
Beschreibung

Disease Description At Study Entry

Disease status at study entry (If recurrent disease)
Beschreibung

DiseaseStatus

Datentyp

text

date of first recurrence
Beschreibung

ProgressionDate,First

Datentyp

date

Site of disease at study entry (check all that apply)
Beschreibung

DiseaseSite

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C3262
UMLS 2011AA ObjectClass
C0027651
NCI Thesaurus Property
C25341
UMLS 2011AA Property
C0450429
NCI Thesaurus ObjectClass-2
C12971
UMLS 2011AA ObjectClass-2
C0006141
Lymph nodes, specify
Beschreibung

DiseaseSite,LymphNodes

Datentyp

text

Other, specify
Beschreibung

PrimarySite,Other

Datentyp

text

Clinical size of tumor at study entry (if microscopic, enter 0)
Beschreibung

PrimaryTumorSize

Datentyp

float

Comments
Beschreibung

Comments

Comments
Beschreibung

Comments

Datentyp

text

Ccrr Module For Southwest Oncology Group S0227 Advanced Cervical Carcinoma Prestudy Form
Beschreibung

Ccrr Module For Southwest Oncology Group S0227 Advanced Cervical Carcinoma Prestudy Form

Ähnliche Modelle

No Instruction available.

  1. StudyEvent: SOUTHWEST ONCOLOGY GROUP S0227 ADVANCED CERVICAL CARCINOMA PRESTUDY FORM
    1. No Instruction available.
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Header
SWOGPatientID
Item
SWOG Patient ID
text
SWOGStudyNo.
Item
SWOG Study No.
text
RegistrationStep
Item
Registration Step
text
Patient Initials
Item
Patient Initials (L, F M)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
InstitutionName
Item
Institution / Affiliate
text
RegisteredInvestigator
Item
Physician (Groups Other than SWOG)
text
ParticipatingGroupName
Item
Group Name
text
Particip.GroupProtocolNumber
Item
Study No.
float
PatientStudyID,ParticipatingGroup
Item
Pt. ID (Instructions: All dates are MONTH, DAY, YEAR. Explain any blank fields or blank dates in the Comments section at the end of the form. Place an X in appropriate boxes. Circle AMENDED items in red.)
text
Item Group
Disease Description At Diagnosis
PrimaryTumorDiagnosisDate
Item
Date of definitive histologic diagnosis of primary tumor
date
C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C15220 (NCI Thesaurus Property)
C0011900 (UMLS 2011AA Property)
Item
Stage at diagnosis (FIGO, select one)
text
Code List
Stage at diagnosis (FIGO, select one)
CL Item
Refer To Figo Staging For Specific Gynecologic Cancer (IA)
CL Item
Refer To Figo Staging For Specific Gynecologic Cancer (IB)
CL Item
Refer To Figo Staging For Specific Gynecologic Cancer (IIA)
CL Item
Refer To Figo Staging For Specific Gynecologic Cancer (IIB)
CL Item
Refer To Figo Staging For Specific Gynecologic Cancer (IIIA)
CL Item
Refer To Figo Staging For Specific Gynecologic Cancer (IIIB)
CL Item
Refer To Figo Staging For Specific Gynecologic Cancer (IVA)
CL Item
Refer To Figo Staging For Specific Gynecologic Cancer (IVB)
Item
Histologic grade at diagnosis (check highest grade)
text
Code List
Histologic grade at diagnosis (check highest grade)
CL Item
Grade 1-well Differentiated (1)
CL Item
Grade 2-moderately Differentiated (2)
CL Item
Grade 3-poorly Differentiated (3)
CL Item
Grade Unknown (unknown)
Item
Histologic type at diagnosis (check all that apply)
text
Code List
Histologic type at diagnosis (check all that apply)
CL Item
Adenosquamous (Adenosquamous)
CL Item
Squamous Cell Carcinoma (Squamous cell carcinoma)
C2929 (NCI Thesaurus)
C0007137 (UMLS 2011AA)
CL Item
Adenocarcinoma, Unspecified (Adenocarcinoma, unspecified)
CL Item
Other, Specify (Other, specify)
HistologicType,OtherVariant
Item
Other, specify
text
Item Group
Prior Treatment Related To This Cancer
PriorSurgeryInd
Item
Primary Surgery
boolean
PrimarySurgeryDate
Item
Primary Surgery Date
date
PriorRTInd
Item
Radiation therapy
boolean
ResidualDiseaseStatus
Item
Persistent disease after radiation therapy
boolean
ResidualDiseaseStatus
Item
Persistent disease after radiation therapy
boolean
Item
Prior Chemotherapy
text
Code List
Prior Chemotherapy
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes, specify agents)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Non-ProtocolChemotherapyType
Item
Yes, specify agents
text
PriorChemotherapyRegimen,OtherAgent
Item
Other treatment, specify
text
Item Group
Disease Description At Study Entry
Item
Disease status at study entry (If recurrent disease)
text
Code List
Disease status at study entry (If recurrent disease)
CL Item
Metastatic disease at presentation (Metastatic disease at presentation)
CL Item
Recurrent disease following complete response to primary surgery and/or RT (Recurrent disease following complete response to primary surgery and/or RT)
CL Item
Primary Gyn Disease Continues To Be Present Following Initial Treatment (Persistent disease despite primary surgery and/or RT)
ProgressionDate,First
Item
date of first recurrence
date
Item
Site of disease at study entry (check all that apply)
text
C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C12971 (NCI Thesaurus ObjectClass-2)
C0006141 (UMLS 2011AA ObjectClass-2)
Code List
Site of disease at study entry (check all that apply)
CL Item
Bladder (Bladder)
C12414 (NCI Thesaurus)
C0005682 (UMLS 2011AA)
CL Item
Bone (Bone)
C12366 (NCI Thesaurus)
C0262950 (UMLS 2011AA)
CL Item
Cervix (Cervix)
C12311 (NCI Thesaurus)
C0007874 (UMLS 2011AA)
CL Item
Colon (Colon)
C12382 (NCI Thesaurus)
C0009368 (UMLS 2011AA)
CL Item
Cns/brain (CNS/Brain)
CL Item
Endometrium (Endometrium)
C12313 (NCI Thesaurus)
C0014180 (UMLS 2011AA)
CL Item
Liver (Liver)
C12392 (NCI Thesaurus)
C0023884 (UMLS 2011AA)
CL Item
Lung (Lung)
C12468 (NCI Thesaurus)
C0024109 (UMLS 2011AA)
CL Item
Ovary (Ovary)
C12404 (NCI Thesaurus)
C0029939 (UMLS 2011AA)
CL Item
Peritoneum (Peritoneum)
C12770 (NCI Thesaurus)
C0031153 (UMLS 2011AA)
CL Item
Pleura (Pleura)
C12469 (NCI Thesaurus)
C0032225 (UMLS 2011AA)
CL Item
Skin (Skin)
C12470 (NCI Thesaurus)
C1123023 (UMLS 2011AA)
CL Item
Uterus (Uterus)
C12405 (NCI Thesaurus)
C0042149 (UMLS 2011AA)
CL Item
Ascites (Ascites)
C2885 (NCI Thesaurus)
C0003962 (UMLS 2011AA)
CL Item
Parametrial Involvement (Parametrial involvement)
CL Item
Pleural Effusion (Pleural effusion)
C3331 (NCI Thesaurus)
C0021071 (UMLS 2011AA)
CL Item
Lymph Nodes, Specify (Lymph nodes, specify)
CL Item
Other, Specify (Other, specify)
DiseaseSite,LymphNodes
Item
Lymph nodes, specify
text
PrimarySite,Other
Item
Other, specify
text
PrimaryTumorSize
Item
Clinical size of tumor at study entry (if microscopic, enter 0)
float
Item Group
Comments
Comments
Item
Comments
text
Item Group
Ccrr Module For Southwest Oncology Group S0227 Advanced Cervical Carcinoma Prestudy Form

Benutzen Sie dieses Formular für Rückmeldungen, Fragen und Verbesserungsvorschläge.

Mit * gekennzeichnete Felder sind notwendig.

Benötigen Sie Hilfe bei der Suche? Um mehr Details zu erfahren und die Suche effektiver nutzen zu können schauen Sie sich doch das entsprechende Video auf unserer Tutorial Seite an.

Zum Video