ID

10478

Descripción

NSABP PROTOCOL B-35 ON-STUDY FORM Anastrozole or Tamoxifen in Treating Postmenopausal Women With Ductal Carcinoma in Situ Who Are Undergoing Lumpectomy and Radiation Therapy Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A051F12F-A237-0456-E034-080020C9C0E0 NCT00053898

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A051F12F-A237-0456-E034-080020C9C0E0

Palabras clave

Versiones (3)
  1. 18/12/14 18/12/14 - Martin Dugas
  2. 2/6/15 2/6/15 -
  3. 3/6/15 3/6/15 -
Subido en

3 de junio de 2015

DOI

Para solicitar uno, por favor iniciar sesión.

Licencia

Creative Commons BY-NC 3.0 Legacy
Comentarios del modelo :

Puede comentar sobre el modelo de datos aquí. A través de las burbujas de diálogo en los grupos de elementos y elementos, puede agregar comentarios específicos.

Volver a los comentarios del modelo
Comentarios de grupo de elementos para :

Comentarios del elemento para :

Para descargar modelos de datos, debe haber iniciado sesión. Por favor iniciar sesión o Registrate gratis.

NSABP PROTOCOL B-35 ON-STUDY FORM NCT00053898

Inglés

Form ON (04-30-2002) Submit within 30 days of registration. Attach All applicable Operative Reports and Pathology Reports.

1 formularios  
NSABP administration data
Descripción

NSABP administration data

First Three Letters of Patient's Last Name
Descripción

FirstThreeLettersofPatient'sLastName

Tipo de datos

text

Patient Study ID
Descripción

PatientStudyID

Tipo de datos

text

Institution Name
Descripción

InstitutionName

Tipo de datos

text

Affiliate Name
Descripción

AffiliateName

Tipo de datos

text

Person Completing Form Last Name
Descripción

PersonCompletingForm,LastName

Tipo de datos

text

Person Completing Form First Name
Descripción

PersonCompletingForm,FirstName

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Person Completing Form Phone
Descripción

PersonCompletingForm,Phone

Tipo de datos

text

Alias
NCI Thesaurus ValueDomain
C25704
UMLS 2011AA ValueDomain
C1527021
Are data amended? (If Yes, circle the amended items in red.)
Descripción

AmendedDataInd

Tipo de datos

boolean

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Biopsy results
Descripción

Biopsy results

Fine Needle Aspiration Cytology (Circle Y or N for Yes, No)
Descripción

FineNeedleAspirationCytology

Tipo de datos

text

Core (or Tru Cut) Needle Biopsy (Circle Y or N for Yes, No)
Descripción

Core(orTruCut)NeedleBiopsy

Tipo de datos

text

Incisional Biopsy (Circle Y or N for Yes, No)
Descripción

IncisionalBiopsy

Tipo de datos

text

Excisional Biopsy or Lumpectomy (Circle Y or N for Yes, No)
Descripción

SurgicalProcedureLumpectomyExcisionalBiopsyPerformed

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C15329
UMLS 2011AA ObjectClass
C0543467
NCI Thesaurus Property
C15755
UMLS 2011AA Property
C0024885
NCI Thesaurus Property-2
C38000
UMLS 2011AA Property-2
C0884358
NCI Thesaurus Property-3
C15385
UMLS 2011AA Property-3
C0184921
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Resection of Lumpectomy Margins (Circle Y or N for Yes, No)
Descripción

SurgicalProcedureLumpectomySurgicalMarginExcisionPerformedInd-2

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C15329
UMLS 2011AA ObjectClass
C0543467
NCI Thesaurus Property
C15755
UMLS 2011AA Property
C0024885
NCI Thesaurus Property-2
C38000
UMLS 2011AA Property-2
C0884358
NCI Thesaurus Property-3
C15232
UMLS 2011AA Property-3
C0728940
NCI Thesaurus Property-4
C41227
UMLS 2011AA Property-4
C0229985
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
Sentinel Node Biopsy (Circle Y or N for Yes, No)
Descripción

SentinelNodeBiopsyInd

Tipo de datos

text

Axillary Dissection (Circle Y or N for Yes, No)
Descripción

AxillaryDissectionInd

Tipo de datos

text

DATE OF PROCEDURE (Month, Day, Year)
Descripción

SurgicalProcedurePerformedDate

Tipo de datos

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus Property
C38000
UMLS 2011AA Property
C0884358
NCI Thesaurus ObjectClass
C15329
UMLS 2011AA ObjectClass
C0543467
ACCESSION NUMBER (Pathology Specimen Number)
Descripción

AccessionNumber

Tipo de datos

float

Disease Description
Descripción

Disease Description

Tumor Laterality
Descripción

PrimaryTumorLaterality

Tipo de datos

text

Was the tumor or microcalcification evident on mammogram?
Descripción

Wasthetumorormicrocalcificationevidentonmammogram?

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Was the tumor evident by ultrasound?
Descripción

Wasthetumorevidentbyultrasound?

Tipo de datos

text

Was the tumor palpable?
Descripción

PalpableTumorPresentIndicator

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
NCI Thesaurus ObjectClass
C3262
UMLS 2011AA ObjectClass
C0027651
NCI Thesaurus Property
C25626
UMLS 2011AA Property
C0150312
NCI Thesaurus ObjectClass-2
C25606
UMLS 2011AA ObjectClass-2
C0522499
Were there any breast symptoms? (e.g., pain, nipple discharge or retraction, skin dimpling)
Descripción

Werethereanybreastsymptoms?

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Receptor Status (by Ihc)
Descripción

Receptor Status (by Ihc)

ER Status
Descripción

ERStatus

Tipo de datos

text

PgR
Descripción

PgRStatus

Tipo de datos

text

If unknown, please explain:
Descripción

Ifunknown,pleaseexplain:

Tipo de datos

text

Quality Of Life
Descripción

Quality Of Life

Did the patient complete the Quality of Life baseline form?
Descripción

DidthepatientcompletetheQualityofLifebaselineform?

Tipo de datos

boolean

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If the baseline QOL form was not completed, indicate the reason below. (Protocol Approved Reasons)
Descripción

BaselineQOLIncompleteFormReason

Tipo de datos

text

Alias
NCI Thesaurus ObjectClass
C17047
UMLS 2011AA ObjectClass
C0518214
NCI Thesaurus ObjectClass-2
C25213
UMLS 2011AA ObjectClass-2
C1442488
NCI Thesaurus Property
C19464
UMLS 2011AA Property
C0376315
NCI Thesaurus Property-2
C49160
UMLS 2011AA Property-2
C0205257
NCI Thesaurus ValueDomain
C25638
UMLS 2011AA ValueDomain
C0392360
Other Reason (if applicable)
Descripción

OtherReason(ifapplicable)

Tipo de datos

text

Volver a la parte superior de la página

Similar models

Form ON (04-30-2002) Submit within 30 days of registration. Attach All applicable Operative Reports and Pathology Reports.

1 formularios
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
Alias
Item Group
NSABP administration data
FirstThreeLettersofPatient'sLastName
Item
First Three Letters of Patient's Last Name
text
PatientStudyID
Item
Patient Study ID
text
InstitutionName
Item
Institution Name
text
AffiliateName
Item
Affiliate Name
text
PersonCompletingForm,LastName
Item
Person Completing Form Last Name
text
PersonCompletingForm,FirstName
Item
Person Completing Form First Name
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
PersonCompletingForm,Phone
Item
Person Completing Form Phone
text
C25704 (NCI Thesaurus ValueDomain)
C1527021 (UMLS 2011AA ValueDomain)
AmendedDataInd
Item
Are data amended? (If Yes, circle the amended items in red.)
boolean
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
Item Group
Biopsy results
Item
Fine Needle Aspiration Cytology (Circle Y or N for Yes, No)
text
CL.2
Code List
Fine Needle Aspiration Cytology (Circle Y or N for Yes, No)
CL Item
Y (Y)
CL Item
N (N)
C14562 (NCI Thesaurus)
Item
Core (or Tru Cut) Needle Biopsy (Circle Y or N for Yes, No)
text
CL.3
Code List
Core (or Tru Cut) Needle Biopsy (Circle Y or N for Yes, No)
CL Item
Y (Y)
CL Item
N (N)
C14562 (NCI Thesaurus)
Item
Incisional Biopsy (Circle Y or N for Yes, No)
text
CL.4
Code List
Incisional Biopsy (Circle Y or N for Yes, No)
CL Item
Y (Y)
CL Item
N (N)
C14562 (NCI Thesaurus)
Item
Excisional Biopsy or Lumpectomy (Circle Y or N for Yes, No)
text
C15329 (NCI Thesaurus ObjectClass)
C0543467 (UMLS 2011AA ObjectClass)
C15755 (NCI Thesaurus Property)
C0024885 (UMLS 2011AA Property)
C38000 (NCI Thesaurus Property-2)
C0884358 (UMLS 2011AA Property-2)
C15385 (NCI Thesaurus Property-3)
C0184921 (UMLS 2011AA Property-3)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
CL.5
Code List
Excisional Biopsy or Lumpectomy (Circle Y or N for Yes, No)
CL Item
Y (Y)
CL Item
N (N)
Item
Resection of Lumpectomy Margins (Circle Y or N for Yes, No)
text
C15329 (NCI Thesaurus ObjectClass)
C0543467 (UMLS 2011AA ObjectClass)
C15755 (NCI Thesaurus Property)
C0024885 (UMLS 2011AA Property)
C38000 (NCI Thesaurus Property-2)
C0884358 (UMLS 2011AA Property-2)
C15232 (NCI Thesaurus Property-3)
C0728940 (UMLS 2011AA Property-3)
C41227 (NCI Thesaurus Property-4)
C0229985 (UMLS 2011AA Property-4)
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
CL.6
Code List
Resection of Lumpectomy Margins (Circle Y or N for Yes, No)
CL Item
Y (Y)
CL Item
N (N)
Item
Sentinel Node Biopsy (Circle Y or N for Yes, No)
text
CL.7
Code List
Sentinel Node Biopsy (Circle Y or N for Yes, No)
CL Item
Yes (Y)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (N)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Item
Axillary Dissection (Circle Y or N for Yes, No)
text
CL.8
Code List
Axillary Dissection (Circle Y or N for Yes, No)
CL Item
Yes (Y)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (N)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
SurgicalProcedurePerformedDate
Item
DATE OF PROCEDURE (Month, Day, Year)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C38000 (NCI Thesaurus Property)
C0884358 (UMLS 2011AA Property)
C15329 (NCI Thesaurus ObjectClass)
C0543467 (UMLS 2011AA ObjectClass)
AccessionNumber
Item
ACCESSION NUMBER (Pathology Specimen Number)
float
Item Group
Disease Description
Item
Tumor Laterality
text
CL.9
Code List
Tumor Laterality
CL Item
Left Breast (Left Breast)
CL Item
Right Breast (Right Breast)
Wasthetumorormicrocalcificationevidentonmammogram?
Item
Was the tumor or microcalcification evident on mammogram?
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
Was the tumor evident by ultrasound?
text
CL.11
Code List
Was the tumor evident by ultrasound?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Not Done (Not done)
CL281691 (NCI Metathesaurus)
PalpableTumorPresentIndicator
Item
Was the tumor palpable?
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
C3262 (NCI Thesaurus ObjectClass)
C0027651 (UMLS 2011AA ObjectClass)
C25626 (NCI Thesaurus Property)
C0150312 (UMLS 2011AA Property)
C25606 (NCI Thesaurus ObjectClass-2)
C0522499 (UMLS 2011AA ObjectClass-2)
Werethereanybreastsymptoms?
Item
Were there any breast symptoms? (e.g., pain, nipple discharge or retraction, skin dimpling)
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item Group
Receptor Status (by Ihc)
Item
ER Status
text
CL.14
Code List
ER Status
CL Item
Negative (Negative by IHC)
C25247 (NCI Thesaurus)
C0205160 (UMLS 2011AA)
CL Item
Positive (Positive by IHC)
C25246 (NCI Thesaurus)
C1446409 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Item
PgR
text
CL.15
Code List
PgR
CL Item
Negative (Negative by IHC)
C25247 (NCI Thesaurus)
C0205160 (UMLS 2011AA)
CL Item
Positive (Positive by IHC)
C25246 (NCI Thesaurus)
C1446409 (UMLS 2011AA)
CL Item
Unknown (Unknown)
C17998 (NCI Thesaurus)
C0439673 (UMLS 2011AA)
Ifunknown,pleaseexplain:
Item
If unknown, please explain:
text
Item Group
Quality Of Life
DidthepatientcompletetheQualityofLifebaselineform?
Item
Did the patient complete the Quality of Life baseline form?
boolean
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
Item
If the baseline QOL form was not completed, indicate the reason below. (Protocol Approved Reasons)
text
C17047 (NCI Thesaurus ObjectClass)
C0518214 (UMLS 2011AA ObjectClass)
C25213 (NCI Thesaurus ObjectClass-2)
C1442488 (UMLS 2011AA ObjectClass-2)
C19464 (NCI Thesaurus Property)
C0376315 (UMLS 2011AA Property)
C49160 (NCI Thesaurus Property-2)
C0205257 (UMLS 2011AA Property-2)
C25638 (NCI Thesaurus ValueDomain)
C0392360 (UMLS 2011AA ValueDomain)
CL.17
Code List
If the baseline QOL form was not completed, indicate the reason below. (Protocol Approved Reasons)
CL Item
Patient Does Not Speak English, French, Or Spanish (Patient does not speak English, French, or Spanish)
CL Item
Patient Refused (Patient refused)
CL Item
Other Reason (Other reason)
OtherReason(ifapplicable)
Item
Other Reason (if applicable)
text
Volver a la parte superior de la página 

Contacto

Utilice este formulario para comentarios, preguntas y sugerencias.

Los campos marcados con * son obligatorios.

Ayuda

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial