ID
10027
Beschreibung
CALGB: 40101 FOLLOW-UP FORM Four Versus Six Cycles of Cyclophosphamide/Doxorubicin or Paclitaxel in Adjuvant Breast Cancer NCT00041119 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A46CA742-FE60-27F9-E034-080020C9C0E0
Link
Stichworte
Versionen (2)
- 26.08.12 26.08.12 -
- 19.03.15 19.03.15 - Martin Dugas
Hochgeladen am
19. März 2015
DOI
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Lizenz
Creative Commons BY-NC 3.0 Legacy
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Breast Cancer adjuvant therapy (CALGB 40101 NCT00041119)
INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice. Print text in capital letters. Avoid contact with the edges of the boxes. Circle amended items and check "Amended data" box to the right. If submitting by mail, retain a copy for your records and send the original to the CALGB Statistical Center, Data Operations. If faxing, use an original form for maximum clarity in transmission and fax to 919-416-4990. If submitting electronically, click the Send button when you have completed the PDF version of the form.
Beschreibung
Patient status
Beschreibung
Patient's Vital Status (mark one with an X)
Datentyp
text
Beschreibung
Cause of death (if dead)
Datentyp
text
Alias
- UMLS CUI-1
- C0007465
Beschreibung
DeathReason,Specify
Datentyp
text
Beschreibung
CurrentMenopausalStatus
Datentyp
text
Beschreibung
Resumptiondate
Datentyp
text
Beschreibung
Cessationdate
Datentyp
text
Beschreibung
Haspatienthadadocumentedclinicalassessmentforthiscancersincesubmissionofthepreviousfollow-upform?
Datentyp
boolean
Beschreibung
CancerFollow-upStatusDate
Datentyp
date
Alias
- NCI Thesaurus ObjectClass
- C2991
- UMLS 2011AA ObjectClass
- C0012634
- NCI Thesaurus Property
- C25365
- UMLS 2011AA Property
- C0678257
Beschreibung
Hasthepatientbeendiagnosedwithafirstlocal-regionalrecurrence/progressionsincesubmissionofthelastfollow-upform?
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
Beschreibung
ProgressionDate,FirstLocal-Regional
Datentyp
date
Beschreibung
ProgressionSite(s),FirstLocal-Regional
Datentyp
text
Beschreibung
ProgressionAssessmentSource
Datentyp
text
Beschreibung
Hasthepatientbeendiagnosedwithafirstdistantrecurrence/progressionsincesubmissionofthelastfollow-upform?
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C1269798
Beschreibung
ProgressionDate,FirstDistant
Datentyp
date
Beschreibung
ProgressionSite,FirstDistant
Datentyp
text
Beschreibung
Hasanewprimarycancerormyelodysplasticsyndrome(MDS)beendiagnosedthathasnotbeenpreviouslyreported?
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
Beschreibung
Date of diagnosis (M)
Datentyp
date
Alias
- NCI Thesaurus ValueDomain
- C25164
Beschreibung
NewPrimarySite
Datentyp
text
Beschreibung
Adverse event
Alias
- UMLS CUI-1
- C0877248
Beschreibung
Hasthepatientexperienced(priortodiagnosisofrecurrenceorsecondprimary)anysevere(Grade>=3),longtermtreatmentrelatedtoxicitythathasnotbeenpreviouslyreported?
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C1519275
- UMLS CUI-2
- C3537125
Beschreibung
IMTCode
Datentyp
text
Beschreibung
CTCAdverseEventTerm
Datentyp
text
Beschreibung
Grade
Datentyp
float
Beschreibung
DateofOnset
Datentyp
text
Beschreibung
Therapy
Beschreibung
PastTamoxifenInd
Datentyp
boolean
Beschreibung
CurrentTamoxifenInd
Datentyp
boolean
Alias
- UMLS CUI-1
- C0039286
Beschreibung
Datetamoxifenstarted
Datentyp
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
Beschreibung
TamoxifenDiscontinuedDate
Datentyp
date
Beschreibung
Didthepatientreceiveanyaromataseinhibitors?
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschreibung
Whicharomataseinhibitor?
Datentyp
text
Beschreibung
Other,specify(aromataseinhibitor)
Datentyp
text
Beschreibung
Isthepatientstillreceivingaromataseinhibitor?
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Beschreibung
Datearomataseinhibitorstarted
Datentyp
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
- NCI Thesaurus ObjectClass
- C15445
- UMLS 2011AA ObjectClass
- C0279025
- NCI Thesaurus ObjectClass-2
- C1740
- UMLS 2011AA ObjectClass-2
- C0593802
- NCI Thesaurus Property
- C25382
- UMLS 2011AA Property
- C1521801
Beschreibung
Ifpatientdiscontinuedaromataseinhibitorsincelastfollow-up,givedate
Datentyp
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS CUI-1
- C0011008
Beschreibung
Didpatientreceivenon-protocolcancertherapypriortofirstrecurrenceandnotpreviouslyreported?
Datentyp
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C1518384
- UMLS CUI-2
- C0087111
Beschreibung
Non-ProtocolTherapy
Datentyp
text
Beschreibung
Non-ProtocolChemotherapyAdministeredSpecify
Datentyp
text
Alias
- NCI Thesaurus ValueDomain
- C25685
- UMLS 2011AA ValueDomain
- C1521902
- NCI Thesaurus ObjectClass
- C15632
- UMLS 2011AA ObjectClass
- C0392920
- NCI Thesaurus ObjectClass-2
- C25590
- UMLS 2011AA ObjectClass-2
- C1518384
- NCI Thesaurus Property
- C25382
- UMLS 2011AA Property
- C1521801
Beschreibung
Non-ProtocolHormoneTherapyAdministeredSpecify
Datentyp
text
Alias
- NCI Thesaurus ValueDomain
- C25685
- UMLS 2011AA ValueDomain
- C1521902
- NCI Thesaurus ObjectClass
- C15445
- UMLS 2011AA ObjectClass
- C0279025
- NCI Thesaurus ObjectClass-2
- C25590
- UMLS 2011AA ObjectClass-2
- C1518384
- NCI Thesaurus Property
- C25382
- UMLS 2011AA Property
- C1521801
Beschreibung
Non-protocolbiologicresponsemodifiertherapy,specify
Datentyp
text
Beschreibung
Non-ProtocolRadiationTherapyAdministeredSpecify
Datentyp
text
Alias
- NCI Thesaurus ValueDomain
- C25685
- UMLS 2011AA ValueDomain
- C1521902
- NCI Thesaurus ObjectClass
- C15313
- UMLS 2011AA ObjectClass
- C1522449
- NCI Thesaurus ObjectClass-2
- C25590
- UMLS 2011AA ObjectClass-2
- C1518384
- NCI Thesaurus Property
- C25382
- UMLS 2011AA Property
- C1521801
Ähnliche Modelle
INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice. Print text in capital letters. Avoid contact with the edges of the boxes. Circle amended items and check "Amended data" box to the right. If submitting by mail, retain a copy for your records and send the original to the CALGB Statistical Center, Data Operations. If faxing, use an original form for maximum clarity in transmission and fax to 919-416-4990. If submitting electronically, click the Send button when you have completed the PDF version of the form.
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C0439673 (UMLS 2011AA)
C0012634 (UMLS 2011AA ObjectClass)
C25365 (NCI Thesaurus Property)
C0678257 (UMLS 2011AA Property)
C1269798 (UMLS CUI-1)
C1519275 (UMLS CUI-1)
C3537125 (UMLS CUI-2)
C0011008 (UMLS 2011AA ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C0290882 (UMLS 2011AA)
C0246421 (UMLS 2011AA)
C1522602 (UMLS 2011AA ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C15445 (NCI Thesaurus ObjectClass)
C0279025 (UMLS 2011AA ObjectClass)
C1740 (NCI Thesaurus ObjectClass-2)
C0593802 (UMLS 2011AA ObjectClass-2)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C0011008 (UMLS CUI-1)
C1518384 (UMLS CUI-1)
C0087111 (UMLS CUI-2)
C1521902 (UMLS 2011AA ValueDomain)
C15632 (NCI Thesaurus ObjectClass)
C0392920 (UMLS 2011AA ObjectClass)
C25590 (NCI Thesaurus ObjectClass-2)
C1518384 (UMLS 2011AA ObjectClass-2)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C1521902 (UMLS 2011AA ValueDomain)
C15445 (NCI Thesaurus ObjectClass)
C0279025 (UMLS 2011AA ObjectClass)
C25590 (NCI Thesaurus ObjectClass-2)
C1518384 (UMLS 2011AA ObjectClass-2)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
C1521902 (UMLS 2011AA ValueDomain)
C15313 (NCI Thesaurus ObjectClass)
C1522449 (UMLS 2011AA ObjectClass)
C25590 (NCI Thesaurus ObjectClass-2)
C1518384 (UMLS 2011AA ObjectClass-2)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)