ID
10027
Description
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
Keywords
Versions (2)
- 8/26/12 8/26/12 -
- 3/19/15 3/19/15 - Martin Dugas
Uploaded on
March 19, 2015
DOI
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License
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.
Description
Patient status
Description
Patient's Vital Status (mark one with an X)
Data type
text
Description
Cause of death (if dead)
Data type
text
Alias
- UMLS CUI-1
- C0007465
Description
DeathReason,Specify
Data type
text
Description
CurrentMenopausalStatus
Data type
text
Description
Resumptiondate
Data type
text
Description
Cessationdate
Data type
text
Description
Haspatienthadadocumentedclinicalassessmentforthiscancersincesubmissionofthepreviousfollow-upform?
Data type
boolean
Description
CancerFollow-upStatusDate
Data type
date
Alias
- NCI Thesaurus ObjectClass
- C2991
- UMLS 2011AA ObjectClass
- C0012634
- NCI Thesaurus Property
- C25365
- UMLS 2011AA Property
- C0678257
Description
Hasthepatientbeendiagnosedwithafirstlocal-regionalrecurrence/progressionsincesubmissionofthelastfollow-upform?
Data type
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
Description
ProgressionDate,FirstLocal-Regional
Data type
date
Description
ProgressionSite(s),FirstLocal-Regional
Data type
text
Description
ProgressionAssessmentSource
Data type
text
Description
Hasthepatientbeendiagnosedwithafirstdistantrecurrence/progressionsincesubmissionofthelastfollow-upform?
Data type
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C1269798
Description
ProgressionDate,FirstDistant
Data type
date
Description
ProgressionSite,FirstDistant
Data type
text
Description
Hasanewprimarycancerormyelodysplasticsyndrome(MDS)beendiagnosedthathasnotbeenpreviouslyreported?
Data type
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
Description
Date of diagnosis (M)
Data type
date
Alias
- NCI Thesaurus ValueDomain
- C25164
Description
NewPrimarySite
Data type
text
Description
Adverse event
Alias
- UMLS CUI-1
- C0877248
Description
Hasthepatientexperienced(priortodiagnosisofrecurrenceorsecondprimary)anysevere(Grade>=3),longtermtreatmentrelatedtoxicitythathasnotbeenpreviouslyreported?
Data type
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C1519275
- UMLS CUI-2
- C3537125
Description
IMTCode
Data type
text
Description
CTCAdverseEventTerm
Data type
text
Description
Grade
Data type
float
Description
DateofOnset
Data type
text
Description
Therapy
Description
PastTamoxifenInd
Data type
boolean
Description
CurrentTamoxifenInd
Data type
boolean
Alias
- UMLS CUI-1
- C0039286
Description
Datetamoxifenstarted
Data type
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
Description
TamoxifenDiscontinuedDate
Data type
date
Description
Didthepatientreceiveanyaromataseinhibitors?
Data type
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
Whicharomataseinhibitor?
Data type
text
Description
Other,specify(aromataseinhibitor)
Data type
text
Description
Isthepatientstillreceivingaromataseinhibitor?
Data type
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
Datearomataseinhibitorstarted
Data type
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
Description
Ifpatientdiscontinuedaromataseinhibitorsincelastfollow-up,givedate
Data type
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS CUI-1
- C0011008
Description
Didpatientreceivenon-protocolcancertherapypriortofirstrecurrenceandnotpreviouslyreported?
Data type
boolean
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS CUI-1
- C1518384
- UMLS CUI-2
- C0087111
Description
Non-ProtocolTherapy
Data type
text
Description
Non-ProtocolChemotherapyAdministeredSpecify
Data type
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
Description
Non-ProtocolHormoneTherapyAdministeredSpecify
Data type
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
Description
Non-protocolbiologicresponsemodifiertherapy,specify
Data type
text
Description
Non-ProtocolRadiationTherapyAdministeredSpecify
Data type
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
Similar models
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)