ID

9250

Beskrivning

F1 Radiation Therapy Oncology Group Phase III Prostate 3D / IMRT Follow-up Form Radiation Therapy in Treating Patients With Stage II Prostate Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=11CEC00B-902D-4DD5-E044-0003BA3F9857

Länk

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=11CEC00B-902D-4DD5-E044-0003BA3F9857

Nyckelord

Versioner (3)
  1. 2012-09-19 2012-09-19 -
  2. 2015-01-09 2015-01-09 - Martin Dugas
  3. 2015-03-21 2015-03-21 - Martin Dugas
Uppladdad den

9 januari 2015

DOI

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Licens

Creative Commons BY-NC 3.0 Legacy
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Prostate Cancer NCT00033631 Follow-Up - F1 Radiation Therapy Oncology Group Phase III Prostate 3D / IMRT Follow-up Form - 2477531v1.0

Engelsk

INSTRUCTIONS: Submit this form at patient's entry on study. Use -1 for unknown or not applicable unless otherwise specified in codetable. All dates to be reported mm-dd-yyyy unless otherwise indicated.

1 Formulär  
Header
Beskrivning

Header

Amended Data
Beskrivning

AmendedData

Datatyp

text

Unnamed2
Beskrivning

Unnamed2

RTOG Study
Beskrivning

RTOGStudy

Datatyp

text

Case #
Beskrivning

Case#

Datatyp

text

Institution Name
Beskrivning

InstitutionName

Datatyp

text

Institution No.
Beskrivning

InstitutionNo.

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
Patient Initials
Beskrivning

Patient Initials

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
RTOG Patient ID
Beskrivning

Trial subject ID RTOG

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
UMLS CUI-2
C1514695
NCI Thesaurus Property
C19778
NCI Thesaurus Property-2
C25364
Unnamed3
Beskrivning

Unnamed3

If this is a revised or corrected form, indicate by checking box.
Beskrivning

CaseReportFormModifiedInd-2

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus ObjectClass
C40988
UMLS 2011AA ObjectClass
C1516308
NCI Thesaurus Property
C25573
Unnamed4
Beskrivning

Unnamed4

PATIENT'S VITAL STATUS
Beskrivning

Patient'sVitalStatus

Datatyp

text

DATE OF LAST CONTACT OR DEATH
Beskrivning

DeathDate/LastContactDate

Datatyp

date

CAUSE OF DEATH (IF DEAD)
Beskrivning

Causeofdeath

Datatyp

text

Due to other cause, specify (cause of death)
Beskrivning

Primary Cause of Death, specify

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C16960
UMLS CUI-1
C0007465
NCI Thesaurus ObjectClass-2
C25251
NCI Metathesaurus ObjectClass
C0007465
NCI Thesaurus Property
C17649
NCI Thesaurus Property-2
C25365
NCI Thesaurus ValueDomain
C25685
HAS THE PATIENT HAD A DOCUMENTED CLINICAL ASSESSMENT FOR PROSTATE CANCER SINCE SUBMISSION OF THE PREVIOUS FOLLOWUP FORM?
Beskrivning

HASTHEPATIENTHADADOCUMENTEDCLINICALASSESSMENTFORPROSTATECANCERSINCESUBMISSIONOFTHEPREVIOUSFOLLOWUPFORM?

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ValueDomain-2
C25180
UMLS 2011AA ValueDomain-2
C1522602
DATE OF LAST CLINICAL ASSESSMENT
Beskrivning

CancerFollow-upStatusDate

Datatyp

date

Alias
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
PERFORMANCE STATUS (ZUBROD 0-4)
Beskrivning

PERFORMANCESTATUS

Datatyp

text

Follow-up PSA Value(s) (Prostate: PSA Measurements)
Beskrivning

Follow-upPSAValue(s)

Datatyp

text

Date of PSA Assessment(s)
Beskrivning

DateofPSAAssessment(s)

Datatyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
HAS THE PATIENT HAD A PROSTATE BIOPSY SINCE SUBMISSION OF THE LAST FOLLOWUP FORM?
Beskrivning

HASTHEPATIENTHADAPROSTATEBIOPSYSINCESUBMISSIONOFTHELASTFOLLOWUPFORM?

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ValueDomain-2
C25180
UMLS 2011AA ValueDomain-2
C1522602
Biopsy Date
Beskrivning

BiopsyDate

Datatyp

date

HAS THE PATIENT DEVELOPED A FIRST PROGRESSION THAT HAS NOT BEEN PREVIOUSLY REPORTED?
Beskrivning

HASTHEPATIENTDEVELOPEDAFIRSTPROGRESSIONTHATHASNOTBEENPREVIOUSLYREPORTED?

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ValueDomain-2
C25180
UMLS 2011AA ValueDomain-2
C1522602
HAS THE PATIENT BEEN DIAGNOSED WITH BIOCHEMICAL RECURRENCE SINCE SUBMISSION OF LAST FOLLOW-UP FORM? (See Protocol Section 11)
Beskrivning

ProgressionInd,Biochemical

Datatyp

text

PSA Value at progression (B)
Beskrivning

ProgressionPSAValue

Datatyp

float

HAS THE PATIENT BEEN DIAGNOSED WITH FIRST LOCAL-REGIONAL RECURRENCE SINCE SUBMISSION OF LAST FOLLOW-UP FORM? (See Protocol Section 11)
Beskrivning

HASTHEPATIENTBEENDIAGNOSEDWITHFIRSTLOCAL-REGIONALRECURRENCESINCESUBMISSIONOFLASTFOLLOW-UPFORM?

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ValueDomain-2
C25180
UMLS 2011AA ValueDomain-2
C1522602
DATE OF FIRST LOCAL-REGIONAL PROGRESSION (LOCAL)
Beskrivning

ProgressionDate,FirstLocal-Regional

Datatyp

date

WHAT WAS THE METHOD USED TO DETERMINE local/regional PROGRESSION (LOCAL)
Beskrivning

WHATWASTHEMETHODUSEDTODETERMINElocal/regionalPROGRESSION

Datatyp

text

HAS THE PATIENT BEEN DIAGNOSED WITH FIRST DISTANT RECURRENCE SINCE SUBMISSION OF THE LAST FOLLOW-UP FORM? (REGIONAL OR)
Beskrivning

HASTHEPATIENTBEENDIAGNOSEDWITHFIRSTDISTANTRECURRENCESINCESUBMISSIONOFTHELASTFOLLOW-UPFORM?

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ValueDomain-2
C25180
UMLS 2011AA ValueDomain-2
C1522602
DATE OF FIRST DISTANT PROGRESSION (REGIONAL OR)
Beskrivning

ProgressionDate,FirstDistant

Datatyp

date

SITE(S) OF FIRST DISTANT PROGRESSION (REGIONAL OR)
Beskrivning

Site(s)ofFirstDistantProgression

Datatyp

text

WHAT WAS THE METHOD USED TO DETERMINE distant PROGRESSION (REGIONAL OR)
Beskrivning

WHATWASTHEMETHODUSEDTODETERMINEdistantPROGRESSION

Datatyp

text

Other, specify (method used to determine distant progression)
Beskrivning

Other,specify(methodusedtodeterminedistantprogression)

Datatyp

text

Unnamed7
Beskrivning

Unnamed7

DID THE PATIENT RECEIVE ANY NON-PROTOCOL PROSTATE CANCER THERAPY SINCE THE LAST FOLLOW-UP (If yes, enter therapy type and date for each therapy delivered during the follow-up period.)
Beskrivning

DIDTHEPATIENTRECEIVEANYNON-PROTOCOLPROSTATECANCERTHERAPYSINCETHELASTFOLLOW-UP

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ValueDomain-2
C25180
UMLS 2011AA ValueDomain-2
C1522602
Non-Protocol Therapy Type
Beskrivning

Non-ProtocolTherapyAdministeredType

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus ObjectClass-2
C25590
UMLS 2011AA ObjectClass
C1518384
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Date of first non-protocol therapy
Beskrivning

Non-ProtocolTherapyDate,First

Datatyp

date

Specify (non-protocol prostate cancer therapy)
Beskrivning

Specify(non-protocolprostatecancertherapy)

Datatyp

text

New Primary Site (HAS A NEW PRIMARY CANCER OR MDS MYELODYSPLASTIC SYNDROME BEEN DIAGNOSED THAT HAS NOT BEEN PREVIOUSLY REPORTED?)
Beskrivning

NewCancerDiagnosisAnatomicSite

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C13717
UMLS 2011AA ValueDomain
C1515974
NCI Thesaurus ObjectClass
C25586
UMLS 2011AA ObjectClass
C0205314
NCI Thesaurus ObjectClass-2
C9305
UMLS 2011AA ObjectClass-2
C0006826
NCI Thesaurus Property
C15220
UMLS 2011AA Property
C0011900
New Primary Cancer Date
Beskrivning

NewPrimaryCancerDate

Datatyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Specify (new primary site)
Beskrivning

Specify(newprimarysite)

Datatyp

text

URINARY INCONTINENCE, Severity Grade (0-3)
Beskrivning

URINARYINCONTINENCE,SeverityGrade

Datatyp

text

URINARY INCONTINENCE, Attribution (Attribution)
Beskrivning

URINARYINCONTINENCE,Attribution

Datatyp

text

Specify if other cause (urinary incontinence, attribution)
Beskrivning

Specifyifothercause(urinaryincontinence,attribution)

Datatyp

text

URINARY INCONTINENCE, AER Begin Date
Beskrivning

URINARYINCONTINENCE,AERBeginDate

Datatyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
URINARY FREQUENCY/URGENCY, Severity Grade (0-3)
Beskrivning

URINARYFREQUENCY/URGENCY,SeverityGrade

Datatyp

text

URINARY FREQUENCY/URGENCY, Attribution (Attribution)
Beskrivning

URINARYFREQUENCY/URGENCY,Attribution

Datatyp

text

Specify if other cause (urinary frequency/urgency, attribution)
Beskrivning

Specifyifothercause(urinaryfrequency/urgency,attribution)

Datatyp

text

URINARY FREQUENCY/URGENCY, AER Begin Date
Beskrivning

URINARYFREQUENCY/URGENCY,AERBeginDate

Datatyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
ERECTILE IMPOTENCE, Severity Grade (0-3)
Beskrivning

ERECTILEIMPOTENCE,SeverityGrade

Datatyp

text

ERECTILE IMPOTENCE, Attribution (see table below)
Beskrivning

ERECTILEIMPOTENCE,Attribution

Datatyp

text

Specify if other cause (erectile impotence, attribution)
Beskrivning

Specifyifothercause(erectileimpotence,attribution)

Datatyp

text

ERECTILE IMPOTENCE, AER Begin Date
Beskrivning

ERECTILEIMPOTENCE,AERBeginDate

Datatyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Unnamed8
Beskrivning

Unnamed8

LATE RADIATION THERAPY ADVERSE EVENTS (Arms 1 and 2 only)
Beskrivning

LATERADIATIONTHERAPYADVERSEEVENTS

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus ValueDomain-2
C25180
UMLS 2011AA ValueDomain-2
C1522602
Late RT Adverse Event Grade
Beskrivning

LateRTAdverseEventGrade

Datatyp

text

Late RT Adverse Event Term
Beskrivning

LateRTAdverseEventTerm

Datatyp

text

BLADDER/OTHER GU Specify (late adverse event)
Beskrivning

BLADDER/OTHERGUSpecify(lateadverseevent)

Datatyp

text

SMALL/LARGE INTESTINE, specify (late adverse event)
Beskrivning

SMALL/LARGEINTESTINE,specify(lateadverseevent)

Datatyp

text

OTHER GI, specify (late adverse event)
Beskrivning

OTHERGI,specify(lateadverseevent)

Datatyp

text

OTHER, specify (late adverse event)
Beskrivning

OTHER,specify(lateadverseevent)

Datatyp

text

Late RT Adverse Event Onset Date
Beskrivning

LateRTAdverseEventOnsetDate

Datatyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Unnamed12
Beskrivning

Unnamed12

COMMENTS
Beskrivning

Comments

Datatyp

text

SIGNATURE
Beskrivning

Signature

Datatyp

text

DATE
Beskrivning

Date

Datatyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Ccrr Module For F1 Radiation Therapy Oncology Group Phase Iii Randomized Study Of Adjuvant Therapy For High Risk Pt3no Prostate Cancer Follow-up Form
Beskrivning

Ccrr Module For F1 Radiation Therapy Oncology Group Phase Iii Randomized Study Of Adjuvant Therapy For High Risk Pt3no Prostate Cancer Follow-up Form

Tillbaka till toppen

Similar models

INSTRUCTIONS: Submit this form at patient's entry on study. Use -1 for unknown or not applicable unless otherwise specified in codetable. All dates to be reported mm-dd-yyyy unless otherwise indicated.

1 Formulär
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Item Group
Header
AmendedData
Item
Amended Data
text
Item Group
Unnamed2
RTOGStudy
Item
RTOG Study
text
Case#
Item
Case #
text
InstitutionName
Item
Institution Name
text
InstitutionNo.
Item
Institution No.
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
Patient Initials
Item
Patient Initials
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Trial subject ID RTOG
Item
RTOG Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1514695 (UMLS CUI-2)
C19778 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
Item Group
Unnamed3
CaseReportFormModifiedInd-2
Item
If this is a revised or corrected form, indicate by checking box.
text
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C40988 (NCI Thesaurus ObjectClass)
C1516308 (UMLS 2011AA ObjectClass)
C25573 (NCI Thesaurus Property)
Item Group
Unnamed4
Item
PATIENT'S VITAL STATUS
text
CL.1
Code List
PATIENT'S VITAL STATUS
CL Item
Alive (Alive)
CL Item
Dead (Dead)
DeathDate/LastContactDate
Item
DATE OF LAST CONTACT OR DEATH
date
Item
CAUSE OF DEATH (IF DEAD)
text
CL.2
Code List
CAUSE OF DEATH (IF DEAD)
CL Item
Due To This Disease (Due to this disease)
CL Item
Due To Protocol Treatment (Due to protocol treatment)
CL Item
Due To Other Cause (Due to other cause, specify)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Primary Cause of Death, specify
Item
Due to other cause, specify (cause of death)
text
C16960 (NCI Thesaurus ObjectClass)
C0007465 (UMLS CUI-1)
C25251 (NCI Thesaurus ObjectClass-2)
C0007465 (NCI Metathesaurus ObjectClass)
C17649 (NCI Thesaurus Property)
C25365 (NCI Thesaurus Property-2)
C25685 (NCI Thesaurus ValueDomain)
Item
HAS THE PATIENT HAD A DOCUMENTED CLINICAL ASSESSMENT FOR PROSTATE CANCER SINCE SUBMISSION OF THE PREVIOUS FOLLOWUP FORM?
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25180 (NCI Thesaurus ValueDomain-2)
C1522602 (UMLS 2011AA ValueDomain-2)
CL.3
Code List
HAS THE PATIENT HAD A DOCUMENTED CLINICAL ASSESSMENT FOR PROSTATE CANCER SINCE SUBMISSION OF THE PREVIOUS FOLLOWUP FORM?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
CancerFollow-upStatusDate
Item
DATE OF LAST CLINICAL ASSESSMENT
date
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
Item
PERFORMANCE STATUS (ZUBROD 0-4)
text
CL.4
Code List
PERFORMANCE STATUS (ZUBROD 0-4)
CL Item
0 (0)
C0919414 (NCI Metathesaurus)
CL Item
1 (1)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
3 (3)
CL Item
4 (4)
CL Item
-1 (-1)
Follow-upPSAValue(s)
Item
Follow-up PSA Value(s) (Prostate: PSA Measurements)
text
DateofPSAAssessment(s)
Item
Date of PSA Assessment(s)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Item
HAS THE PATIENT HAD A PROSTATE BIOPSY SINCE SUBMISSION OF THE LAST FOLLOWUP FORM?
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25180 (NCI Thesaurus ValueDomain-2)
C1522602 (UMLS 2011AA ValueDomain-2)
CL.5
Code List
HAS THE PATIENT HAD A PROSTATE BIOPSY SINCE SUBMISSION OF THE LAST FOLLOWUP FORM?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
BiopsyDate
Item
Biopsy Date
date
Item
HAS THE PATIENT DEVELOPED A FIRST PROGRESSION THAT HAS NOT BEEN PREVIOUSLY REPORTED?
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25180 (NCI Thesaurus ValueDomain-2)
C1522602 (UMLS 2011AA ValueDomain-2)
CL.6
Code List
HAS THE PATIENT DEVELOPED A FIRST PROGRESSION THAT HAS NOT BEEN PREVIOUSLY REPORTED?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
HAS THE PATIENT BEEN DIAGNOSED WITH BIOCHEMICAL RECURRENCE SINCE SUBMISSION OF LAST FOLLOW-UP FORM? (See Protocol Section 11)
text
CL.7
Code List
HAS THE PATIENT BEEN DIAGNOSED WITH BIOCHEMICAL RECURRENCE SINCE SUBMISSION OF LAST FOLLOW-UP FORM? (See Protocol Section 11)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
ProgressionPSAValue
Item
PSA Value at progression (B)
float
Item
HAS THE PATIENT BEEN DIAGNOSED WITH FIRST LOCAL-REGIONAL RECURRENCE SINCE SUBMISSION OF LAST FOLLOW-UP FORM? (See Protocol Section 11)
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25180 (NCI Thesaurus ValueDomain-2)
C1522602 (UMLS 2011AA ValueDomain-2)
CL.8
Code List
HAS THE PATIENT BEEN DIAGNOSED WITH FIRST LOCAL-REGIONAL RECURRENCE SINCE SUBMISSION OF LAST FOLLOW-UP FORM? (See Protocol Section 11)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
ProgressionDate,FirstLocal-Regional
Item
DATE OF FIRST LOCAL-REGIONAL PROGRESSION (LOCAL)
date
Item
WHAT WAS THE METHOD USED TO DETERMINE local/regional PROGRESSION (LOCAL)
text
CL.9
Code List
WHAT WAS THE METHOD USED TO DETERMINE local/regional PROGRESSION (LOCAL)
CL Item
Not Applicable (NOT APPLICABLE)
C48660 (NCI Thesaurus)
C1272460 (UMLS 2011AA)
CL Item
Physical Exam (Physical exam)
CL Item
Pathologic (Pathologic)
C25610 (NCI Thesaurus)
C1521733 (UMLS 2011AA)
Item
HAS THE PATIENT BEEN DIAGNOSED WITH FIRST DISTANT RECURRENCE SINCE SUBMISSION OF THE LAST FOLLOW-UP FORM? (REGIONAL OR)
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25180 (NCI Thesaurus ValueDomain-2)
C1522602 (UMLS 2011AA ValueDomain-2)
CL.10
Code List
HAS THE PATIENT BEEN DIAGNOSED WITH FIRST DISTANT RECURRENCE SINCE SUBMISSION OF THE LAST FOLLOW-UP FORM? (REGIONAL OR)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
ProgressionDate,FirstDistant
Item
DATE OF FIRST DISTANT PROGRESSION (REGIONAL OR)
date
Site(s)ofFirstDistantProgression
Item
SITE(S) OF FIRST DISTANT PROGRESSION (REGIONAL OR)
text
Item
WHAT WAS THE METHOD USED TO DETERMINE distant PROGRESSION (REGIONAL OR)
text
CL.11
Code List
WHAT WAS THE METHOD USED TO DETERMINE distant PROGRESSION (REGIONAL OR)
CL Item
Not Applicable (NOT APPLICABLE)
C48660 (NCI Thesaurus)
C1272460 (UMLS 2011AA)
CL Item
Physical Exam (Physical exam)
CL Item
Pathologic (Pathologic)
C25610 (NCI Thesaurus)
C1521733 (UMLS 2011AA)
CL Item
Radiographic (Radiographic)
CL Item
Nuclear Scan (Nuclear scan)
CL Item
Other, Specify (Other, specify)
Other,specify(methodusedtodeterminedistantprogression)
Item
Other, specify (method used to determine distant progression)
text
Item Group
Unnamed7
Item
DID THE PATIENT RECEIVE ANY NON-PROTOCOL PROSTATE CANCER THERAPY SINCE THE LAST FOLLOW-UP (If yes, enter therapy type and date for each therapy delivered during the follow-up period.)
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25180 (NCI Thesaurus ValueDomain-2)
C1522602 (UMLS 2011AA ValueDomain-2)
CL.12
Code List
DID THE PATIENT RECEIVE ANY NON-PROTOCOL PROSTATE CANCER THERAPY SINCE THE LAST FOLLOW-UP (If yes, enter therapy type and date for each therapy delivered during the follow-up period.)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Non-Protocol Therapy Type
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C15368 (NCI Thesaurus ObjectClass)
C25590 (NCI Thesaurus ObjectClass-2)
C1518384 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
CL.13
Code List
Non-Protocol Therapy Type
CL Item
None (None)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
CL Item
Radiation To Pelvis (Radiation to pelvis)
CL Item
Radiation To Other Sites, Specify (Radiation to other sites, specify)
CL Item
Surgery (Surgery)
C17173 (NCI Thesaurus)
C0038894 (UMLS 2011AA)
CL Item
Chemotherapy (Chemotherapy)
C15632 (NCI Thesaurus)
C0392920 (UMLS 2011AA)
CL Item
Hormones (Hormones)
CL Item
Other Specify (Other, specify)
CL Item
Surgical Procedure Related To Previous Rt, Specify (Surgical procedure related to previous RT, specify)
CL Item
Complementary Alternative Medicine, Specify (Complementary Alternative Medicine, specify)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Non-ProtocolTherapyDate,First
Item
Date of first non-protocol therapy
date
Specify(non-protocolprostatecancertherapy)
Item
Specify (non-protocol prostate cancer therapy)
text
Item
New Primary Site (HAS A NEW PRIMARY CANCER OR MDS MYELODYSPLASTIC SYNDROME BEEN DIAGNOSED THAT HAS NOT BEEN PREVIOUSLY REPORTED?)
text
C13717 (NCI Thesaurus ValueDomain)
C1515974 (UMLS 2011AA ValueDomain)
C25586 (NCI Thesaurus ObjectClass)
C0205314 (UMLS 2011AA ObjectClass)
C9305 (NCI Thesaurus ObjectClass-2)
C0006826 (UMLS 2011AA ObjectClass-2)
C15220 (NCI Thesaurus Property)
C0011900 (UMLS 2011AA Property)
CL.14
Code List
New Primary Site (HAS A NEW PRIMARY CANCER OR MDS MYELODYSPLASTIC SYNDROME BEEN DIAGNOSED THAT HAS NOT BEEN PREVIOUSLY REPORTED?)
CL Item
None (None)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
CL Item
Aml/mds (AML/MDS)
C9441 (NCI Thesaurus)
CL Item
Bcc (BCC)
CL Item
Bladder (Bladder)
C12414 (NCI Thesaurus)
C0005682 (UMLS 2011AA)
CL Item
Brain (Brain)
C12439 (NCI Thesaurus)
C0006104 (UMLS 2011AA)
CL Item
Colorectal (Colorectal)
C13363 (NCI Thesaurus)
C0555952 (UMLS 2011AA)
CL Item
Esophageal (Esophageal)
C37950 (NCI Thesaurus)
C1522619 (UMLS 2011AA)
CL Item
Gastric (Gastric)
C13307 (NCI Thesaurus)
C1704242 (UMLS 2011AA)
CL Item
Liver (Liver)
C12392 (NCI Thesaurus)
C0023884 (UMLS 2011AA)
CL Item
Lung (Lung)
C12468 (NCI Thesaurus)
C0024109 (UMLS 2011AA)
CL Item
Melanoma (Melanoma)
C3224 (NCI Thesaurus)
C0025202 (UMLS 2011AA)
CL Item
Nhl (NHL)
CL Item
Pancreatic (Pancreatic)
C25726 (NCI Thesaurus)
C0030274 (UMLS 2011AA)
CL Item
Renal (Renal)
C25225 (NCI Thesaurus)
C0022646 (UMLS 2011AA)
CL Item
Squamous-skin (Squamous-Skin)
CL Item
Other Hematologic, Specify (Other Hematologic, specify)
CL Item
Other Solid, Specify (Other solid, specify)
CL Item
Unknown Primary (Unknown primary)
NewPrimaryCancerDate
Item
New Primary Cancer Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Specify(newprimarysite)
Item
Specify (new primary site)
text
Item
URINARY INCONTINENCE, Severity Grade (0-3)
text
CL.15
Code List
URINARY INCONTINENCE, Severity Grade (0-3)
CL Item
0 (0)
C0919414 (NCI Metathesaurus)
CL Item
1 (1)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
3 (3)
Item
URINARY INCONTINENCE, Attribution (Attribution)
text
CL.16
Code List
URINARY INCONTINENCE, Attribution (Attribution)
CL Item
Not Applicable (Not applicable)
C48660 (NCI Thesaurus)
C1272460 (UMLS 2011AA)
CL Item
Radiotherapy only (Radiotherapy only)
CL Item
Tumor and Rx (Tumor and Rx)
CL Item
Other cause, specify (Other cause, specify)
CL Item
Unknown (Unknown)
Specifyifothercause(urinaryincontinence,attribution)
Item
Specify if other cause (urinary incontinence, attribution)
text
URINARYINCONTINENCE,AERBeginDate
Item
URINARY INCONTINENCE, AER Begin Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Item
URINARY FREQUENCY/URGENCY, Severity Grade (0-3)
text
CL.17
Code List
URINARY FREQUENCY/URGENCY, Severity Grade (0-3)
CL Item
0 (0)
C0919414 (NCI Metathesaurus)
CL Item
1 (1)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
3 (3)
Item
URINARY FREQUENCY/URGENCY, Attribution (Attribution)
text
CL.18
Code List
URINARY FREQUENCY/URGENCY, Attribution (Attribution)
CL Item
Not Applicable (Not applicable)
C48660 (NCI Thesaurus)
C1272460 (UMLS 2011AA)
CL Item
Radiotherapy only (Radiotherapy only)
CL Item
Tumor and Rx (Tumor and Rx)
CL Item
Other cause, specify (Other cause, specify)
CL Item
Unknown (Unknown)
Specifyifothercause(urinaryfrequency/urgency,attribution)
Item
Specify if other cause (urinary frequency/urgency, attribution)
text
URINARYFREQUENCY/URGENCY,AERBeginDate
Item
URINARY FREQUENCY/URGENCY, AER Begin Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Item
ERECTILE IMPOTENCE, Severity Grade (0-3)
text
CL.19
Code List
ERECTILE IMPOTENCE, Severity Grade (0-3)
CL Item
0 (0)
C0919414 (NCI Metathesaurus)
CL Item
1 (1)
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
3 (3)
Item
ERECTILE IMPOTENCE, Attribution (see table below)
text
CL.20
Code List
ERECTILE IMPOTENCE, Attribution (see table below)
CL Item
Not Applicable (Not applicable)
C48660 (NCI Thesaurus)
C1272460 (UMLS 2011AA)
CL Item
Radiotherapy only (Radiotherapy only)
CL Item
Tumor and Rx (Tumor and Rx)
CL Item
Other cause, specify (Other cause, specify)
CL Item
Unknown (Unknown)
Specifyifothercause(erectileimpotence,attribution)
Item
Specify if other cause (erectile impotence, attribution)
text
ERECTILEIMPOTENCE,AERBeginDate
Item
ERECTILE IMPOTENCE, AER Begin Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Item Group
Unnamed8
Item
LATE RADIATION THERAPY ADVERSE EVENTS (Arms 1 and 2 only)
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25180 (NCI Thesaurus ValueDomain-2)
C1522602 (UMLS 2011AA ValueDomain-2)
CL.21
Code List
LATE RADIATION THERAPY ADVERSE EVENTS (Arms 1 and 2 only)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
Late RT Adverse Event Grade
text
CL.22
Code List
Late RT Adverse Event Grade
CL Item
2 (2)
C66833 (NCI Thesaurus)
C0205448 (UMLS 2011AA)
CL Item
3 (3)
CL Item
4 (4)
CL Item
5 (5)
CL Item
8 (8)
CL Item
9 (9)
CL Item
-1 (-1)
Item
Late RT Adverse Event Term
text
CL.23
Code List
Late RT Adverse Event Term
CL Item
Skin (SKIN)
C12470 (NCI Thesaurus)
C1123023 (UMLS 2011AA)
CL Item
Bladder/other Gu Specify (BLADDER/OTHER GU Specify)
CL Item
Small/large Intestine, Specify (SMALL/LARGE INTESTINE, specify)
CL Item
Other Gi, Specify (OTHER GI, specify)
CL Item
Other, Specify (OTHER, specify)
BLADDER/OTHERGUSpecify(lateadverseevent)
Item
BLADDER/OTHER GU Specify (late adverse event)
text
SMALL/LARGEINTESTINE,specify(lateadverseevent)
Item
SMALL/LARGE INTESTINE, specify (late adverse event)
text
OTHERGI,specify(lateadverseevent)
Item
OTHER GI, specify (late adverse event)
text
OTHER,specify(lateadverseevent)
Item
OTHER, specify (late adverse event)
text
LateRTAdverseEventOnsetDate
Item
Late RT Adverse Event Onset Date
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Item Group
Unnamed12
Comments
Item
COMMENTS
text
Signature
Item
SIGNATURE
text
Date
Item
DATE
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Item Group
Ccrr Module For F1 Radiation Therapy Oncology Group Phase Iii Randomized Study Of Adjuvant Therapy For High Risk Pt3no Prostate Cancer Follow-up Form
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