ID

9296

Description

SOUTHWEST ONCOLOGY GROUP S0221 FOLLOW UP FORM Adjuvant Doxorubicin, Cyclophosphamide, and Paclitaxel in Treating Patients With Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A678C302-20D3-50A8-E034-0003BA0B1A09

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A678C302-20D3-50A8-E034-0003BA0B1A09

Keywords

Versions (3)
  1. 8/26/12 8/26/12 -
  2. 3/20/14 3/20/14 - Martin Dugas
  3. 1/9/15 1/9/15 - Martin Dugas
Uploaded on

January 9, 2015

DOI

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License

Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00070564 Follow-Up - SOUTHWEST ONCOLOGY GROUP S0221 FOLLOW UP FORM - 2050216v3.0

English

No Instruction available.

1 forms  
  1. StudyEvent: SOUTHWEST ONCOLOGY GROUP S0221 FOLLOW UP FORM
    1. No Instruction available.
Administrative documentation
Description

Administrative documentation

Alias
UMLS CUI
C1320722
SWOG Patient ID
Description

SWOGPatientID

Data type

text

SWOG Study No.
Description

SWOGStudyNo.

Data type

text

Registration Step
Description

RegistrationStep

Data type

text

Patient Initials (L, F M)
Description

Patient Initials

Data type

text

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

InstitutionName

Data type

text

Physician
Description

RegisteredInvestigator

Data type

text

Participating Group Name
Description

ParticipatingGroupName

Data type

text

Participating Group Study No.
Description

ParticipatingGroupProtocolNumber

Data type

float

Participating Group Patient ID
Description

Trial subject ID Participating Group

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
UMLS CUI-2
C2347449
NCI Thesaurus Property
C25608
NCI Thesaurus Property-2
C25364
Vital Status
Description

Vital Status

Vital Status
Description

Vital Status

Data type

integer

Alias
UMLS CUI
C1148433
Date of last contact or death
Description

Last Contact Date

Data type

date

Alias
UMLS CUI
C0585085
Disease Follow Up Status
Description

Disease Follow Up Status

Has the patient had a documented clinical assessment for this cancer since submission of the previous follow-up form?
Description

CancerFollow-upStatusInd

Data type

boolean

Date of Last Clinical Assessment
Description

CancerFollow-upStatusDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Thesaurus Property
C25365
UMLS 2011AA Property
C0678257
Notice Of Progression - Adjuvant
Description

Notice Of Progression - Adjuvant

Has the patient developed a first relapse or progression that has not been previously reported
Description

DiseaseRelapseProgressionInd-3

Data type

boolean

Alias
NCI Thesaurus ObjectClass
C2991
UMLS 2011AA ObjectClass
C0012634
NCI Thesaurus Property
C38155
UMLS 2011AA Property
C0277556
NCI Thesaurus Property-2
C15220
UMLS 2011AA Property-2
C0011900
NCI Thesaurus Property-3
C19987
UMLS 2011AA Property-3
C0242656
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
If Yes, Date of Relapse or Progression:
Description

IfYes,DateofRelapseorProgression:

Data type

text

Site(s) of relapse or progression
Description

DiseaseProgressionRelapseSiteText

Data type

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
NCI Thesaurus Property
C25341
UMLS 2011AA Property
C0450429
NCI Thesaurus Property-2
C18265
NCI Thesaurus ObjectClass
C17747
UMLS 2011AA ObjectClass
C0242656
Notice Of New Primary
Description

Notice Of New Primary

Has a new primary cancer, opposite breast cancer, or myelodysplastic syndrome (MDS) been diagnosed that has not been previously reported?
Description

NewPrimaryCancerInd

Data type

boolean

Date of Diagnosis
Description

NewPrimaryCancerDate

Data type

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
New Primary Site
Description

NewPrimarySite

Data type

text

Non-protocol Treatment
Description

Non-protocol Treatment

Alias
UMLS CUI
C1518384
Has the patient received any non-protocol cancer therapy (prior to progression/relapse) not previously reported?
Description

Non-Protocol Therapy

Data type

boolean

Alias
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus ObjectClass-2
C25590
NCI Thesaurus Property
C25629
NCI Thesaurus Property-2
C19987
NCI Thesaurus Property-3
C25409
NCI Thesaurus ValueDomain
C38148
UMLS CUI
C1518384
Date of First Non-Protocol Therapy (If Yes,)
Description

Non-ProtocolTherapyFirstAdministeredDate

Data type

date

Alias
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus ObjectClass-2
C25590
UMLS 2011AA ObjectClass
C1518384
NCI Thesaurus Property
C25509
UMLS 2011AA Property
C1279901
NCI Thesaurus Property-2
C25382
UMLS 2011AA Property-2
C1521801
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ValueDomain-2
C25367
Agent
Description

Agent Name

Data type

string

Alias
NCI Thesaurus Property
C25364
NCI Thesaurus ObjectClass
C1708
NCI Thesaurus ValueDomain
C1708
NCI Thesaurus ValueDomain-2
C42614
UMLS CUI
C0729502
Long Term Toxicity
Description

Long Term Toxicity

Has the patient experienced any severe long term toxicity that has not been previously reported?
Description

LateAdverseEventInd

Data type

boolean

Toxicities and Grades
Description

CTCAdverseEventTerm

Data type

text

Comments
Description

Comments

Alias
UMLS CUI
C0947611
Comments
Description

Comments

Data type

string

Alias
UMLS CUI
C0947611
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Similar models

No Instruction available.

1 forms
  1. StudyEvent: SOUTHWEST ONCOLOGY GROUP S0221 FOLLOW UP FORM
    1. No Instruction available.
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Administrative documentation
C1320722 (UMLS CUI)
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
text
ParticipatingGroupName
Item
Participating Group Name
text
ParticipatingGroupProtocolNumber
Item
Participating Group Study No.
float
Trial subject ID Participating Group
Item
Participating Group Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C2347449 (UMLS CUI-2)
C25608 (NCI Thesaurus Property)
C25364 (NCI Thesaurus Property-2)
Item Group
Vital Status
Item
Vital Status
integer
C1148433 (UMLS CUI)
CL.1
Code List
Vital Status
CL Item
Alive (1)
CL Item
Dead (0)
Last Contact Date
Item
Date of last contact or death
date
C0585085 (UMLS CUI)
Item Group
Disease Follow Up Status
CancerFollow-upStatusInd
Item
Has the patient had a documented clinical assessment for this cancer since submission of the previous follow-up form?
boolean
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 Group
Notice Of Progression - Adjuvant
DiseaseRelapseProgressionInd-3
Item
Has the patient developed a first relapse or progression that has not been previously reported
boolean
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C38155 (NCI Thesaurus Property)
C0277556 (UMLS 2011AA Property)
C15220 (NCI Thesaurus Property-2)
C0011900 (UMLS 2011AA Property-2)
C19987 (NCI Thesaurus Property-3)
C0242656 (UMLS 2011AA Property-3)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
IfYes,DateofRelapseorProgression:
Item
If Yes, Date of Relapse or Progression:
text
DiseaseProgressionRelapseSiteText
Item
Site(s) of relapse or progression
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
C25341 (NCI Thesaurus Property)
C0450429 (UMLS 2011AA Property)
C18265 (NCI Thesaurus Property-2)
C17747 (NCI Thesaurus ObjectClass)
C0242656 (UMLS 2011AA ObjectClass)
Item Group
Notice Of New Primary
NewPrimaryCancerInd
Item
Has a new primary cancer, opposite breast cancer, or myelodysplastic syndrome (MDS) been diagnosed that has not been previously reported?
boolean
NewPrimaryCancerDate
Item
Date of Diagnosis
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
NewPrimarySite
Item
New Primary Site
text
Item Group
Non-protocol Treatment
C1518384 (UMLS CUI)
Non-Protocol Therapy
Item
Has the patient received any non-protocol cancer therapy (prior to progression/relapse) not previously reported?
boolean
C15368 (NCI Thesaurus ObjectClass)
C25590 (NCI Thesaurus ObjectClass-2)
C25629 (NCI Thesaurus Property)
C19987 (NCI Thesaurus Property-2)
C25409 (NCI Thesaurus Property-3)
C38148 (NCI Thesaurus ValueDomain)
C1518384 (UMLS CUI)
Non-ProtocolTherapyFirstAdministeredDate
Item
Date of First Non-Protocol Therapy (If Yes,)
date
C15368 (NCI Thesaurus ObjectClass)
C25590 (NCI Thesaurus ObjectClass-2)
C1518384 (UMLS 2011AA ObjectClass)
C25509 (NCI Thesaurus Property)
C1279901 (UMLS 2011AA Property)
C25382 (NCI Thesaurus Property-2)
C1521801 (UMLS 2011AA Property-2)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25367 (NCI Thesaurus ValueDomain-2)
Agent Name
Item
Agent
string
C25364 (NCI Thesaurus Property)
C1708 (NCI Thesaurus ObjectClass)
C1708 (NCI Thesaurus ValueDomain)
C42614 (NCI Thesaurus ValueDomain-2)
C0729502 (UMLS CUI)
Item Group
Long Term Toxicity
LateAdverseEventInd
Item
Has the patient experienced any severe long term toxicity that has not been previously reported?
boolean
CTCAdverseEventTerm
Item
Toxicities and Grades
text
Item Group
Comments
C0947611 (UMLS CUI)
Comments
Item
Comments
string
C0947611 (UMLS CUI)
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