BREAST RADIOTHERAPY FORM (Form 24-R) Instructions: Submit this form upon completion of radiotherapy or if radiotherapy was planned and not given. Mark your selection with an ?X? in the appropriate box(es). Use minus one (-1) to indicate that an answer is unknown, unobtainable, or not done.

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Ccrr Module For Breast Radiotherapy Form (form 24-r)
PatientStudyID,CoordinatingGroup
Item
Patient ID No. (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
text
Patient Initials
Item
Patient Initials (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
PatientBirthDate
Item
Patient's Date of Birth (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
date
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25275 (NCI Thesaurus Property)
C2745955 (UMLS 2011AA Property)
ParticipatingCenter/Affiliate
Item
Participating Center/Affiliate
text
ParticipatingGroupCode
Item
Center Code
text
C25162 (NCI Thesaurus ValueDomain)
C0805701 (UMLS 2011AA ValueDomain)
Item
This form is being completed for
text
C13717 (NCI Thesaurus ValueDomain)
C1515974 (UMLS 2011AA ValueDomain)
C20989 (NCI Thesaurus Property)
C0031809 (UMLS 2011AA Property)
C12971 (NCI Thesaurus ObjectClass)
C0006141 (UMLS 2011AA ObjectClass)
C25306 (NCI Thesaurus Property-2)
C0441987 (UMLS 2011AA Property-2)
CL.1
Code List
This form is being completed for
CL Item
Left Breast/side (Left breast/side)
CL Item
Right Breast/side (Right breast/side)
Didthepatientreceiveintraoperativeradiotherapy(IORT)?
Item
Did the patient receive intraoperative radiotherapy (IORT)? (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
boolean
Didpatientstartadjuvantpostoperativeradiotherapy?
Item
Did patient start adjuvant postoperative radiotherapy? (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
boolean
Datepostoperativeradiotherapystarted
Item
Date postoperative radiotherapy started (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
text
Datepostoperativeradiotherapyended
Item
Date postoperative radiotherapy ended (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
text
Totalpostoperativedosegivenwithoutboost
Item
Total postoperative dose given without boost (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
text
Item
Postoperative radiotherapy fields (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
text
CL.4
Code List
Postoperative radiotherapy fields (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
CL Item
Breast (Breast)
CL Item
Supraclavicular lymph nodes (Supraclavicular lymph nodes)
CL Item
Internal mammary lymph nodes (Internal mammary lymph nodes)
CL Item
Chest wall (Chest wall)
CL Item
Axilla (Axilla)
CL Item
Other, please specify (Other, please specify)
RTSite,Other
Item
Other, (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
text
Waspostoperativeradiotherapyboostgiven?
Item
Was postoperative radiotherapy boost given? (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
BrachytherapyTotalDose,Boost
Item
Total Dose to Boost Field(s) (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
float
Item
For those patients who did not start adjuvant radiotherapy, please give reason (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
text
CL.6
Code List
For those patients who did not start adjuvant radiotherapy, please give reason (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
CL Item
Patient Refused (Patient refused)
CL Item
Initially Planned, But Physician Later Advised Against (Initially planned, but physician later advised against)
CL Item
Early Recurrence (Early recurrence)
CL Item
Early Death (Early death)
CL Item
Other, Please Specify (Other, please specify)
Other,
Item
Other, (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
text
Investigator Signature
Item
Investigator Signature (/Designee)
text
C25704 (NCI Thesaurus ValueDomain)
C2346576 (UMLS CUI-1)
C25678 (NCI Thesaurus Property)
C17089 (NCI Thesaurus ObjectClass)
Investigator Signature Date
Item
Date
date
C25164 (NCI Thesaurus ValueDomain)
C2346576 (UMLS CUI-1)
C25678 (NCI Thesaurus Property)
C0011008 (UMLS CUI-2)
C25367 (NCI Thesaurus ValueDomain-2)
C17089 (NCI Thesaurus ObjectClass)
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