ID

9130

Beschrijving

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

Trefwoorden

Versies (2)
  1. 27-08-12 27-08-12 -
  2. 09-01-15 09-01-15 - Martin Dugas
Geüploaded op

9 januari 2015

DOI

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Licentie

Creative Commons BY-NC 3.0 Legacy
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Cervical Cancer NCT00057928 Pre-Study - SOUTHWEST ONCOLOGY GROUP S0227 ADVANCED CERVICAL CARCINOMA PRESTUDY FORM - 2056878v3.0

Engels

No Instruction available.

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

Header

SWOG Patient ID
Beschrijving

SWOGPatientID

Datatype

text

SWOG Study No.
Beschrijving

SWOGStudyNo.

Datatype

text

Registration Step
Beschrijving

RegistrationStep

Datatype

text

Patient Initials (L, F M)
Beschrijving

Patient Initials

Datatype

text

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

InstitutionName

Datatype

text

Physician (Groups Other than SWOG)
Beschrijving

RegisteredInvestigator

Datatype

text

Group Name
Beschrijving

ParticipatingGroupName

Datatype

text

Study No.
Beschrijving

Particip.GroupProtocolNumber

Datatype

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.)
Beschrijving

PatientStudyID,ParticipatingGroup

Datatype

text

Disease Description At Diagnosis
Beschrijving

Disease Description At Diagnosis

Date of definitive histologic diagnosis of primary tumor
Beschrijving

PrimaryTumorDiagnosisDate

Datatype

date

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

StageGrouping

Datatype

text

Histologic grade at diagnosis (check highest grade)
Beschrijving

HistologicGrade

Datatype

text

Histologic type at diagnosis (check all that apply)
Beschrijving

HistologicType

Datatype

text

Other, specify
Beschrijving

HistologicType,OtherVariant

Datatype

text

Prior Treatment Related To This Cancer
Beschrijving

Prior Treatment Related To This Cancer

Primary Surgery
Beschrijving

PriorSurgeryInd

Datatype

boolean

Primary Surgery Date
Beschrijving

PrimarySurgeryDate

Datatype

date

Radiation therapy
Beschrijving

PriorRTInd

Datatype

boolean

Persistent disease after radiation therapy
Beschrijving

ResidualDiseaseStatus

Datatype

boolean

Persistent disease after radiation therapy
Beschrijving

ResidualDiseaseStatus

Datatype

boolean

Prior Chemotherapy
Beschrijving

PriorChemotherapyInd

Datatype

text

Yes, specify agents
Beschrijving

Non-ProtocolChemotherapyType

Datatype

text

Other treatment, specify
Beschrijving

PriorChemotherapyRegimen,OtherAgent

Datatype

text

Disease Description At Study Entry
Beschrijving

Disease Description At Study Entry

Disease status at study entry (If recurrent disease)
Beschrijving

DiseaseStatus

Datatype

text

date of first recurrence
Beschrijving

ProgressionDate,First

Datatype

date

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

DiseaseSite

Datatype

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
Beschrijving

DiseaseSite,LymphNodes

Datatype

text

Other, specify
Beschrijving

PrimarySite,Other

Datatype

text

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

PrimaryTumorSize

Datatype

float

Comments
Beschrijving

Comments

Comments
Beschrijving

Comments

Datatype

text

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

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

Terug naar het begin van de pagina

Similar models

No Instruction available.

1 Formulieren
  1. StudyEvent: SOUTHWEST ONCOLOGY GROUP S0227 ADVANCED CERVICAL CARCINOMA PRESTUDY FORM
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Datatype
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
CL.1
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
CL.2
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
CL.3
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
CL.8
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
CL.9
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)
CL.10
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
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