Complete this form for patients with a proven recurrence. Use minus one (-1) to indicate that an answer is unknown unobtainable or not done

Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Header Module
C1320722 (UMLS CUI-1)
Hospital Admission Ordinal Number
Item
Visit number
integer
C25337 (NCI Thesaurus ValueDomain)
C16696 (NCI Thesaurus ObjectClass)
C25385 (NCI Thesaurus Property)
C1549755 (UMLS CUI [1])
International Breast Cancer Study Group Identifier Number
Item
IBCSG Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
C25530 (NCI Thesaurus Property-2)
C4037772 (UMLS CUI [1,1])
C1512890 (UMLS CUI [1,2])
Protocol International Breast Cancer Study Group Identifier Number
Item
IBCSG Study No.
text
C25337 (NCI Thesaurus ValueDomain)
C25320 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
C25530 (NCI Thesaurus Property-2)
C3274381 (UMLS CUI [1,1])
C1512890 (UMLS CUI [1,2])
Randomization Number
Item
Randomization No.
text
C16960 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus ValueDomain)
C25196 (NCI Thesaurus Property)
C2986235 (UMLS CUI [1])
Institution Identifier Number
Item
Institution Code Number
text
C25337 (NCI Thesaurus ValueDomain)
C21541 (NCI Thesaurus ObjectClass)
C25364 (NCI Thesaurus Property)
C1301943 (UMLS CUI [1,1])
C0805701 (UMLS CUI [1,2])
Institution Name
Item
Institution Name
text
C25191 (NCI Thesaurus ValueDomain)
C21541 (NCI Thesaurus ObjectClass)
C21541 (NCI Thesaurus ValueDomain-2)
C25364 (NCI Thesaurus Property)
C1301943 (UMLS CUI [1])
Item Group
Proven Recurrence/Metastasis Or Contralateral Invasive Breast Cancer
C0679254 (UMLS CUI-1)
Item
Site (Sites of Recurrence Local Regional Distant)
integer
C13717 (NCI Thesaurus ValueDomain)
C38155 (NCI Thesaurus Property)
C4872 (NCI Thesaurus ObjectClass)
C4055130 (UMLS CUI [1,1])
C0678222 (UMLS CUI [1,2])
Code List
Site (Sites of Recurrence Local Regional Distant)
CL Item
Chest Wall (1)
C0205076 (UMLS CUI-1)
CL Item
Scar (2)
C0241158 (UMLS CUI-1)
CL Item
Breast Tissue (3)
C1521747 (UMLS CUI-1)
CL Item
Breast Scar / Skin (4)
C4029865 (UMLS CUI-1)
CL Item
Chest Wall / Outside Breast (5)
C0205157 (UMLS CUI-1)
C0006141 (UMLS CUI-2)
CL Item
Ipsi Axillary Nodes (6)
C0729594 (UMLS CUI-1)
C0441989 (UMLS CUI-2)
CL Item
Ipsi Axilla (7)
C0004454 (UMLS CUI-1)
C0441989 (UMLS CUI-2)
CL Item
Ipsi Internal Mammary Nodes (8)
C0542554 (UMLS CUI-1)
C0441989 (UMLS CUI-2)
CL Item
Ipsi Infraclavicular Nodes (9)
C0229743 (UMLS CUI-1)
C0441989 (UMLS CUI-2)
CL Item
Ipsi Supraclavicular Nodes (10)
C0229730 (UMLS CUI-1)
C0441989 (UMLS CUI-2)
CL Item
Specify Site (11)
C0449695 (UMLS CUI-1)
Breast Carcinoma Recurrent Disease
Item
Specify (If yes, submit page 2 of this form and specify recurrence site)
text
C25685 (NCI Thesaurus ValueDomain)
C38155 (NCI Thesaurus Property)
C4872 (NCI Thesaurus ObjectClass)
C0278493 (UMLS CUI [1])
Recurrence date
Item
Date of diagnosis of recurrent/metastatic disease (day month year)
date
C14174 (NCI Thesaurus ObjectClass)
C14173 (NCI Thesaurus ObjectClass-2)
C2991 (NCI Thesaurus ObjectClass-3)
C25536 (NCI Thesaurus Property)
C15220 (NCI Thesaurus Property-2)
C25164 (NCI Thesaurus ValueDomain)
C0807712 (UMLS CUI [1])
Item Group
Hormone Receptor Analysis
C0523374 (UMLS CUI-1)
Estrogen Receptor Progesterone Receptor Analysis
Item
Was Hormone Receptor Analysis performed (on a recurrence reported during this follow-up period)
boolean
C25391 (NCI Thesaurus ObjectClass)
C17069 (NCI Thesaurus ObjectClass-2)
C17075 (NCI Thesaurus ObjectClass-3)
C38000 (NCI Thesaurus Property)
C38147 (NCI Thesaurus ValueDomain)
C0523374 (UMLS CUI [1])
Breast Carcinoma Recurrent Disease
Item
Specify (If yes, submit page 2 of this form and specify recurrence site)
text
C25685 (NCI Thesaurus ValueDomain)
C38155 (NCI Thesaurus Property)
C4872 (NCI Thesaurus ObjectClass)
C0278493 (UMLS CUI [1])
Specimen Collected Date
Item
Date Specimen collected
date
C25164 (NCI Thesaurus ValueDomain)
C19157 (NCI Thesaurus ObjectClass)
C25452 (NCI Thesaurus Property)
C25275 (NCI Thesaurus Property-2)
C1317250 (UMLS CUI [1])
Estrogen Receptor Positive
Item
ER % Positive (Results of immunohistochemistry IHC: Percent of positive cells use 0-100)
float
C25337 (NCI Thesaurus ValueDomain)
C0279754 (UMLS CUI [1,1])
Progesterone Receptor Positive
Item
PR % Positive (Results of immunohistochemistry IHC: Percent of positive cells use 0-100)
float
C25337 (NCI Thesaurus ValueDomain)
C17075 (NCI Thesaurus ObjectClass)
C25554 (NCI Thesaurus Property)
C0279759 (UMLS CUI [1])
Item
ER Status (select one)
integer
C3262 (NCI Thesaurus ValueDomain)
C17069 (NCI Thesaurus ObjectClass)
C25688 (NCI Thesaurus ValueDomain-2)
C25554 (NCI Thesaurus Property)
C1516974 (UMLS CUI [1])
Code List
ER Status (select one)
CL Item
Negative (1)
C0205160 (UMLS CUI-1)
CL Item
Positive (2)
C1446409 (UMLS CUI-1)
CL Item
Unknown (3)
C0439673 (UMLS CUI-1)
Item
PgR Status (select one)
integer
C25284 (NCI Thesaurus ValueDomain)
C17075 (NCI Thesaurus ObjectClass)
C0678257 (NCI Metathesaurus Property)
C1514471 (UMLS CUI [1])
Code List
PgR Status (select one)
CL Item
Negative (1)
C0205160 (UMLS CUI-1)
CL Item
Positive (2)
C1446409 (UMLS CUI-1)
CL Item
Unknown (3)
C0439673 (UMLS CUI-1)
Item Group
Footer Module
C2825232 (UMLS CUI-1)
Investigator Signature
Item
Investigator/Designee Signature
text
C25704 (NCI Thesaurus ValueDomain)
C25678 (NCI Thesaurus Property)
C17089 (NCI Thesaurus ObjectClass)
C25479 (NCI Thesaurus Property-2)
C2346576 (UMLS CUI [1])
Investigator Signature Date
Item
Investigator Signature Date
date
C25164 (NCI Thesaurus ValueDomain)
C25678 (NCI Thesaurus Property)
C25367 (NCI Thesaurus ValueDomain-2)
C17089 (NCI Thesaurus ObjectClass)
C2346576 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])

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