Submit this form when a patient falls to start bevacizumab or when bevacizumab treatment has ended.

Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header
Patient Initials
Item
Patient Initials (Last, First Middle)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Patient ID NSABP
Item
NSABP Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1513905 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C15818 (NCI Thesaurus Property-2)
Institution Name
Item
Institution Name
text
C25191 (NCI Thesaurus ValueDomain)
C1301943 (UMLS CUI-1)
C21541 (NCI Thesaurus ObjectClass)
C21541 (NCI Thesaurus ValueDomain-2)
C25364 (NCI Thesaurus Property)
Affiliate Name
Item
Affiliate Name
text
C21541 (NCI Thesaurus ObjectClass)
C1510825 (UMLS CUI-1)
C25413 (NCI Thesaurus ObjectClass-2)
C25364 (NCI Thesaurus Property)
C25191 (NCI Thesaurus ValueDomain)
C21541 (NCI Thesaurus ValueDomain-2)
Person Completing Form Last Name
Item
Person Completing Form Last Name
text
C25190 (NCI Thesaurus ObjectClass)
C1550483 (UMLS CUI-1)
C25657 (NCI Thesaurus ObjectClass-2)
C1301584 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25551 (NCI Thesaurus Property-2)
C25191 (NCI Thesaurus ValueDomain)
Person Completing Form First Name
Item
Person Completing Form First Name
text
C25190 (NCI Thesaurus ObjectClass)
C1550483 (UMLS CUI-1)
C25657 (NCI Thesaurus ObjectClass-2)
C1443235 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C25509 (NCI Thesaurus Property-2)
C25191 (NCI Thesaurus ValueDomain)
Person Completing Form Phone
Item
Person Completing Form Phone
text
C25337 (NCI Thesaurus ValueDomain)
C1550483 (UMLS CUI-1)
C25190 (NCI Thesaurus ObjectClass)
C1515258 (UMLS CUI-2)
C25657 (NCI Thesaurus ObjectClass-2)
C25395 (NCI Thesaurus Property)
Data amended
Item
Are data amended? (check box if yes, and circle amended items)
boolean
C38148 (NCI Thesaurus ValueDomain)
C0680532 (UMLS CUI-1)
C25474 (NCI Thesaurus ObjectClass)
C25416 (NCI Thesaurus Property)
Item Group
BEVACIZUMAB TREATMENT
Agent Start Date
Item
Begin Date (if patient failed to start, code=00 00 0000)
date
C25164 (NCI Thesaurus ValueDomain)
C1521826 (UMLS CUI-1)
C25431 (NCI Thesaurus ValueDomain-2)
C0808070 (UMLS CUI-2)
C1708 (NCI Thesaurus ObjectClass)
C25275 (NCI Thesaurus Property)
DoseEndDate
Item
End Date (if patient failed to start, code=00 00 0000)
date
C25164 (NCI Thesaurus Property)
C0011008 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C25488 (NCI Thesaurus ObjectClass)
C0178602 (UMLS 2011AA ObjectClass)
C25551 (NCI Thesaurus ObjectClass-2)
C1517741 (UMLS 2011AA ObjectClass-2)
Number of Doses, Total
Item
Total Number of Doses Received (enter "0" if never started)
float
C25304 (NCI Thesaurus Property)
C0178602 (UMLS CUI-1)
C25463 (NCI Thesaurus ValueDomain)
C0750480 (UMLS CUI-2)
C1708 (NCI Thesaurus ObjectClass)
C25256 (NCI Thesaurus Property-2)
Item
Treatment Discontinued Type (select primary reason)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C15368 (NCI Thesaurus ObjectClass)
C25484 (NCI Thesaurus Property)
C1444662 (UMLS 2011AA Property)
Code List
Treatment Discontinued Type (select primary reason)
CL Item
Protocol Mandated Discontinuation (Protocol Mandated Discontinuation)
CL Item
Completed Per Protocol (Completed per protocol)
CL Item
Alternative Therapy (Alternative Therapy)
CL Item
Physician Withdrawal (Physician withdrawal)
CL Item
Patient Withdrawal Or Refusal (Patient withdrawal or refusal)
CL Item
Death, Recurrence, Or Second Primary Cancer (Death, recurrence, or second primary cancer)
CL Item
Other Adverse Event/side Effects/complications (Other Adverse Event/Side Effects/Complications)
CL Item
Other, Specify (Other, specify)
CL Item
Adverse Event/side Effects/complications (Toxicity/Side effects)
CL Item
Death, Recurrence, Or Second Primary Cancer (Death, recurrence, or second primary cancer)
CL Item
Patient Withdrawal Or Refusal (Patient withdrawal or refusal)
CL Item
Physician Withdrawal (Physician withdrawal)
CL Item
Alternative Therapy (Alternative Therapy)
CL Item
Treatment Completed Per Protocol Criteria (Completed per protocol)
CL Item
Other (Other reason, specify)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
Other,specify(reasontreatmentended)
Item
Other reason, specify
text
Item
Adverse events which require discontinuation of bevacizumab
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C41331 (NCI Thesaurus ObjectClass)
C0877248 (UMLS 2011AA ObjectClass)
C15368 (NCI Thesaurus Property)
Code List
Adverse events which require discontinuation of bevacizumab
CL Item
Grade 4 Acute Infusion Reaction Or Allergic Reaction/hypersensitivity (Grade 4 Acute infusion reaction or Allergic reaction/hypersensitivity)
CL Item
Grade 3 Or 4 Hemorrhage (Grade 3 or 4 Hemorrhage)
CL Item
Grade 2, 3, Or 4 Visceral Or Peripheral Arterial Ischemia (Grade 2, 3, or 4 Visceral or peripheral arterial ischemia)
CL Item
Grade 2, 3, Or 4 Cardiac Ischemia/infarction (Grade 2, 3, or 4 Cardiac ischemia/infarction)
CL Item
Grade 2, 3, Or 4 Cns Cerebrovascular Ischemia (Grade 2, 3, or 4 CNS cerebrovascular ischemia)
CL Item
Grade 4 Thrombosis/thrombus/embolism (Grade 4 Thrombosis/Thrombus/Embolism)
CL Item
Grade 4 Intra-abdominal Abscess/infection (Grade 4 Intra-abdominal abscess/Infection)
CL Item
Grade 2, 3, Or 4 Wound Complication, Non-infectious (Grade 2, 3, or 4 Wound complication, non-infectious)
CL Item
Grade 4 Proteinuria (Grade 4 Proteinuria)
CL Item
Grade 4 Hypertension (Grade 4 Hypertension)
CL Item
Other Clinically Significant Grade 4 Ae Related To Bevacizumab (Other clinically significant Grade 4 AE related to Bevacizumab)
CL Item
Grade 1, 2, 3, Or 4 Gi Perforation, Gi Leak, Or Gi Fistula (Grade 1, 2, 3, or 4 GI perforation, GI leak, or GI fistula)
Item Group
Comments
Research Comments
Item
Comments
text
C25704 (NCI Thesaurus ValueDomain)
C0947611 (UMLS CUI-1)
C15319 (NCI Thesaurus ObjectClass)
C25393 (NCI Thesaurus Property)

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