ID
9331
Description
NSABP-B-47 Medical Conditions and Lifestyle Questionnaire Form - Follow-up (Form MCL-F) A Randomized Phase III Trial of Adjuvant Therapy Comparing Chemotherapy Alone (Six Cycles of Docetaxel Plus Cyclophosphamide or Four Cycles of Doxorubicin Plus Cyclophosphamide Followed by Weekly Paclitaxel) to Chemotherapy Plus Trastuzumab in Women With Node- Positive or High-Risk Node-Negative HER2-Low Invasive Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=96C1751F-BD70-2B10-E040-BB89AD433A9B
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Mots-clés
Versions (3)
- 27/08/2012 27/08/2012 -
- 11/08/2014 11/08/2014 - Martin Dugas
- 09/01/2015 09/01/2015 - Martin Dugas
Téléchargé le
9 janvier 2015
DOI
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Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT01275677 Quality of Life - NSABP-B-47 Medical Conditions and Lifestyle Questionnaire Form - Follow-up (Form MCL-F) - 3165236v1.0
INSTRUCTIONS TO THE INSTITUTION This questionnaire should be completed by all patients. Evaluations should be carried out according to schedule, even if the patient discontinues protocol therapy (Patients who experienced breast cancer recurrence, invasive contralateral breast cancer, or second non-breast primary cancer excluding squamous or basal cell skin cancers or new in situ carcinomas of any site do not need to fill out this form [Protocol Section 8.4]) A clinical staff member should complete page 1, print the patient's initials and NSABP Patient ID at the top of Page 2 through 3, and give the questionnaire to the patient for completion. After the patient has completed the questionnaire, verify that the date the questionnaire was completed is recorded at the top of page 2 and fax all 3 pages to the NSABP Biostatistical Center at (412) 622-2115. If all efforts to administer the scheduled MCL-F form fail or if a woman declines to complete the scheduled questionnaire for any reason, a B-47 QMD form should be submitted instead (Protocol Section 8.3.4)
Description
Time Point
Description
CaseReportFormPersonCompleteType
Type de données
text
Alias
- NCI Thesaurus ValueDomain
- C25284
- UMLS 2011AA ValueDomain
- C0332307
- NCI Thesaurus Property
- C25190
- UMLS 2011AA Property
- C0027361
- NCI Thesaurus ObjectClass
- C40988
- UMLS 2011AA ObjectClass
- C1516308
- NCI Thesaurus Property-2
- C25250
- UMLS 2011AA Property-2
- C0205197
Description
AssessmentPeriodType
Type de données
text
Alias
- NCI Thesaurus ValueDomain
- C25284
- UMLS 2011AA ValueDomain
- C0332307
- NCI Thesaurus ObjectClass
- C20989
- UMLS 2011AA ObjectClass
- C0031809
- NCI Thesaurus Property
- C25616
- UMLS 2011AA Property
- C1948053
Description
QualityofLifeCompleteAssessmentDate
Type de données
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
- NCI Thesaurus ObjectClass
- C17047
- UMLS 2011AA ObjectClass
- C0518214
- NCI Thesaurus Property
- C25250
- UMLS 2011AA Property
- C0205197
- NCI Thesaurus Property-2
- C25367
Description
Section 1 - Lifetime Medical Conditions
Description
ChronicDiseasePresentType
Type de données
text
Alias
- NCI Thesaurus ValueDomain
- C25284
- UMLS 2011AA ValueDomain
- C0332307
- NCI Thesaurus Property
- C25626
- UMLS 2011AA Property
- C0150312
- NCI Thesaurus ObjectClass
- C2991
- UMLS 2011AA ObjectClass
- C0012634
- NCI Thesaurus ObjectClass-2
- C14141
- UMLS 2011AA ObjectClass-2
- C0205191
Description
DiseaseorDisorderPhysicianCareAssessmentAssessmentInd-3
Type de données
boolean
Alias
- NCI Thesaurus ObjectClass
- C2991
- UMLS 2011AA ObjectClass
- C0012634
- NCI Thesaurus Property
- C25741
- UMLS 2011AA Property
- C0031831
- NCI Thesaurus Property-2
- C25217
- UMLS 2011AA Property-2
- C1516048
- NCI Thesaurus Property-3
- C61488
- UMLS 2011AA Property-3
- C1947933
- NCI Thesaurus ValueDomain
- C38148
- UMLS 2011AA ValueDomain
- C1512699
Description
PatientMedicalConditionTherapyInd-2
Type de données
boolean
Alias
- NCI Thesaurus ValueDomain
- C38147
- UMLS 2011AA ValueDomain
- C1512698
- NCI Thesaurus ObjectClass
- C16960
- UMLS 2011AA ObjectClass
- C0030705
- NCI Thesaurus Property
- C25261
- UMLS 2011AA Property
- C0205476
- NCI Thesaurus Property-2
- C25457
- UMLS 2011AA Property-2
- C0348080
Description
PersonDiseaseorDisorderActivityRestrictionAssessmentInd-3
Type de données
boolean
Alias
- NCI Thesaurus ObjectClass
- C25190
- UMLS 2011AA ObjectClass
- C0027361
- NCI Thesaurus Property
- C25367
- NCI Thesaurus Property-2
- C43431
- UMLS 2011AA Property
- C0441655
- NCI Thesaurus Property-3
- C2991
- UMLS 2011AA Property-2
- C0012634
- NCI Thesaurus Property-4
- C53452
- UMLS 2011AA Property-3
- C0443288
- NCI Thesaurus ValueDomain
- C38148
- UMLS 2011AA ValueDomain
- C1512699
Description
Section 2 - Alcohol And Tobacco Usage
Description
AlcoholConsumptionNumber
Type de données
float
Alias
- NCI Thesaurus ValueDomain
- C25337
- UMLS 2011AA ValueDomain
- C0237753
- NCI Thesaurus ObjectClass
- C2190
- UMLS 2011AA ObjectClass
- C0001962
- NCI Thesaurus Property
- C25340
- UMLS 2011AA Property
- C0457083
Description
Smoking history
Type de données
text
Alias
- NCI Thesaurus ValueDomain
- C25284
- UMLS CUI-1
- C1519384
- NCI Thesaurus ObjectClass
- C17934
- NCI Thesaurus Property
- C18772
Similar models
INSTRUCTIONS TO THE INSTITUTION This questionnaire should be completed by all patients. Evaluations should be carried out according to schedule, even if the patient discontinues protocol therapy (Patients who experienced breast cancer recurrence, invasive contralateral breast cancer, or second non-breast primary cancer excluding squamous or basal cell skin cancers or new in situ carcinomas of any site do not need to fill out this form [Protocol Section 8.4]) A clinical staff member should complete page 1, print the patient's initials and NSABP Patient ID at the top of Page 2 through 3, and give the questionnaire to the patient for completion. After the patient has completed the questionnaire, verify that the date the questionnaire was completed is recorded at the top of page 2 and fax all 3 pages to the NSABP Biostatistical Center at (412) 622-2115. If all efforts to administer the scheduled MCL-F form fail or if a woman declines to complete the scheduled questionnaire for any reason, a B-47 QMD form should be submitted instead (Protocol Section 8.3.4)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1513905 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C15818 (NCI Thesaurus Property-2)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass-2)
C25364 (NCI Thesaurus Property)
C25191 (NCI Thesaurus ValueDomain)
C21541 (NCI Thesaurus ValueDomain-2)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass)
C0805701 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA ObjectClass)
C19464 (NCI Thesaurus Property)
C0376315 (UMLS 2011AA Property)
C25409 (NCI Thesaurus Property-2)
C1533734 (UMLS 2011AA Property-2)
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25551 (NCI Thesaurus ValueDomain-2)
C1517741 (UMLS 2011AA ValueDomain-2)
C0027361 (UMLS 2011AA ObjectClass)
C19464 (NCI Thesaurus Property)
C0376315 (UMLS 2011AA Property)
C25409 (NCI Thesaurus Property-2)
C1533734 (UMLS 2011AA Property-2)
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C25509 (NCI Thesaurus ValueDomain-2)
C1279901 (UMLS 2011AA ValueDomain-2)
C0237753 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C19464 (NCI Thesaurus Property)
C0376315 (UMLS 2011AA Property)
C25409 (NCI Thesaurus Property-2)
C1533734 (UMLS 2011AA Property-2)
C0680532 (UMLS CUI-1)
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)
C0332307 (UMLS 2011AA ValueDomain)
C25190 (NCI Thesaurus Property)
C0027361 (UMLS 2011AA Property)
C40988 (NCI Thesaurus ObjectClass)
C1516308 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property-2)
C0205197 (UMLS 2011AA Property-2)
C0205394 (UMLS 2011AA)
C0332307 (UMLS 2011AA ValueDomain)
C20989 (NCI Thesaurus ObjectClass)
C0031809 (UMLS 2011AA ObjectClass)
C25616 (NCI Thesaurus Property)
C1948053 (UMLS 2011AA Property)
C0011008 (UMLS 2011AA ValueDomain)
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C25367 (NCI Thesaurus Property-2)
C0332307 (UMLS 2011AA ValueDomain)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C2991 (NCI Thesaurus ObjectClass)
C0012634 (UMLS 2011AA ObjectClass)
C14141 (NCI Thesaurus ObjectClass-2)
C0205191 (UMLS 2011AA ObjectClass-2)
C0006826 (UMLS 2011AA)
C0018802 (UMLS 2011AA)
C0011570 (UMLS 2011AA)
C0011849 (UMLS 2011AA)
C0010068 (UMLS 2011AA)
C0022646 (UMLS 2011AA)
C2991 (NCI Thesaurus-3)
C0012634 (UMLS 2011AA-4)
C0023884 (UMLS 2011AA)
C2991 (NCI Thesaurus-3)
C0012634 (UMLS 2011AA-4)
C2709248 (UMLS 2011AA)
C2991 (NCI Thesaurus-3)
C0012634 (UMLS 2011AA-4)
C0029408 (UMLS 2011AA)
C0003811 (UMLS 2011AA)
C0003873 (UMLS 2011AA)
C0040132 (UMLS 2011AA)
C2991 (NCI Thesaurus-3)
C0012634 (UMLS 2011AA-4)
C0041582 (UMLS 2011AA)
C0012634 (UMLS 2011AA ObjectClass)
C25741 (NCI Thesaurus Property)
C0031831 (UMLS 2011AA Property)
C25217 (NCI Thesaurus Property-2)
C1516048 (UMLS 2011AA Property-2)
C61488 (NCI Thesaurus Property-3)
C1947933 (UMLS 2011AA Property-3)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25261 (NCI Thesaurus Property)
C0205476 (UMLS 2011AA Property)
C25457 (NCI Thesaurus Property-2)
C0348080 (UMLS 2011AA Property-2)
C0027361 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus Property)
C43431 (NCI Thesaurus Property-2)
C0441655 (UMLS 2011AA Property)
C2991 (NCI Thesaurus Property-3)
C0012634 (UMLS 2011AA Property-2)
C53452 (NCI Thesaurus Property-4)
C0443288 (UMLS 2011AA Property-3)
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C2190 (NCI Thesaurus ObjectClass)
C0001962 (UMLS 2011AA ObjectClass)
C25340 (NCI Thesaurus Property)
C0457083 (UMLS 2011AA Property)
C1519384 (UMLS CUI-1)
C17934 (NCI Thesaurus ObjectClass)
C18772 (NCI Thesaurus Property)