ID

6211

Beschreibung

CALGB: 49907 ON-STUDY FORM Comparison of Combination Chemotherapy Regimens in Treating Older Women Who Have Undergone Surgery for Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A50D7D2E-A557-3317-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A50D7D2E-A557-3317-E034-080020C9C0E0

Stichworte

Versionen (1)
  1. 18.12.14 18.12.14 - Martin Dugas
Hochgeladen am

18. Dezember 2014

DOI

Für eine Beantragung loggen Sie sich ein.

Lizenz

Creative Commons BY-NC 3.0 Legacy
Modell Kommentare :

Hier können Sie das Modell kommentieren. Über die Sprechblasen an den Itemgruppen und Items können Sie diese spezifisch kommentieren.

Zurück zu Modell Kommentaren
Itemgroup Kommentare für :

Item Kommentare für :

Um Formulare herunterzuladen müssen Sie angemeldet sein. Bitte loggen Sie sich ein oder registrieren Sie sich kostenlos.

ON-STUDY FORM (CALGB 49907)

Englisch

Continue on next page

1 Formulare  
  1. StudyEvent: CALGB: 49907 ON-STUDY FORM
    1. Continue on next page
Header
Beschreibung

Header

Alias
UMLS CUI-1
C1320722
CALGB Form
Beschreibung

CALGBForm

Datentyp

text

CALGB Study No
Beschreibung

CALGBStudyNo

Datentyp

text

CALGB Patient ID (Disease Description)
Beschreibung

CALGBPatientID

Datentyp

text

Amended data?
Beschreibung

Amendeddata?

Datentyp

text

Patient's Name
Beschreibung

Patient'sName

Datentyp

text

Participating Group
Beschreibung

ParticipatingGroup

Datentyp

text

Alias
NCI Thesaurus ObjectClass
C17005
UMLS 2011AA ObjectClass
C1257890
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Patient Hospital Number
Beschreibung

PatientHospitalNumber

Datentyp

text

Participating Group Protocol No.
Beschreibung

ParticipatingGroupProtocolNo.

Datentyp

text

Main Member Institution/Adjunct
Beschreibung

MainMemberInstitution/Adjunct

Datentyp

text

Participating Group Patient No.
Beschreibung

ParticipatingGroupPatientNo.

Datentyp

text

Surgical Procedures
Beschreibung

Surgical Procedures

First positive biopsy date (M)
Beschreibung

FirstPositiveBiopsyDate

Datentyp

date

Most extensive primary surgery (mark one with an X)
Beschreibung

PrimarySurgeryType

Datentyp

text

Date of most extensive primary surgery (if required, used date of last re-excision)
Beschreibung

PrimarySurgeryDate

Datentyp

date

Sentinel node biopsy?
Beschreibung

Sentinelnodebiopsy?

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
Sentinel node biopsy date (M)
Beschreibung

SentinelNodeBiopsyDate

Datentyp

date

Sentinel node biopsy results (per protocol)
Beschreibung

SentinelNodeBiopsyResults

Datentyp

text

Was axillary dissection performed?
Beschreibung

AxillaryDissectionInd

Datentyp

text

Date of axillary dissection (M)
Beschreibung

AxillaryDissectionDate

Datentyp

date

Total number of lymph nodes examined (if sentinel node biopsy and axillary node dissection were performed, enter the total number of nodes examined)
Beschreibung

Totalnumberoflymphnodesexamined

Datentyp

double

Laboratory
Beschreibung

Laboratory

Granulocytes
Beschreibung

GRANULOCYTES

Datentyp

text

Total bilirubin (mg/dl)
Beschreibung

Totalbilirubin

Datentyp

double

Alias
NCI Thesaurus ValueDomain
C25209
UMLS 2011AA ValueDomain
C0242485
Creatinine (mg/dl)
Beschreibung

Lab,Renal,Creatinine

Datentyp

double

Platelet count
Beschreibung

Plateletcount

Datentyp

double

Bilirubin upper limit of institutional laboratory normal (mg/dl)
Beschreibung

Bilirubinupperlimitofinstitutionallaboratorynormal

Datentyp

double

Alias
NCI Thesaurus ValueDomain
C25209
UMLS 2011AA ValueDomain
C0242485
Calculated creatinine clearance (mL/min)
Beschreibung

Calculatedcreatinineclearance

Datentyp

double

% LVEF
Beschreibung

%LVEF

Datentyp

text

% Lower limit of institutional normal LVEF
Beschreibung

%LowerlimitofinstitutionalnormalLVEF

Datentyp

double

Pathology
Beschreibung

Pathology

Alias
UMLS CUI-1
C0030664
Tumor laterality (mark one with an X)
Beschreibung

PrimaryTumorLaterality

Datentyp

text

Receptor status, ER (If measured in fmols/mg cytosol protein >=10 is positive. If other measures are used apply institutional standards; borderline results should be reported as positive)
Beschreibung

ERStatus

Datentyp

text

Receptor status, PgR
Beschreibung

PgRStatus

Datentyp

text

Pathologic primary tumor size (cm)
Beschreibung

PathologicPrimaryTumorSize

Datentyp

double

Alias
NCI Thesaurus ValueDomain
C25209
UMLS 2011AA ValueDomain
C0242485
Histologic grade (combined histologic grade is used according to SRE/Elston classification)
Beschreibung

HistologicGrade

Datentyp

text

Total number of positive lymph nodes (If sentinel node biopsy and axillary node dissection were performed, enter the sum of positive nodes)
Beschreibung

Totalnumberofpositivelymphnodes

Datentyp

double

T (TNM classification)
Beschreibung

T(TNMclassification)

Datentyp

double

N (TNM classification)
Beschreibung

N(TNMclassification)

Datentyp

double

M (TNM classification) (Prior Systemic Therapy)
Beschreibung

M(TNMclassification)

Datentyp

double

Prior breast cancer prevention therapy?
Beschreibung

Priorbreastcancerpreventiontherapy?

Datentyp

text

Alias
NCI Thesaurus ValueDomain
C25180
UMLS 2011AA ValueDomain
C1522602
If Yes, what type (prior breast cancer prevention therapy) (mark all that apply with an X)
Beschreibung

IfYes,whattype(priorbreastcancerpreventiontherapy)

Datentyp

text

Other, specify (prior breast cancer therapy)
Beschreibung

Other,specify(priorbreastcancertherapy)

Datentyp

text

Completed By (Print or Type Name)
Beschreibung

CompletedBy

Datentyp

text

Date Completed
Beschreibung

DateCompleted

Datentyp

date

Zum Seitenanfang zurückkehren

Ähnliche Modelle

Continue on next page

1 Formulare
  1. StudyEvent: CALGB: 49907 ON-STUDY FORM
    1. Continue on next page
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Header
C1320722 (UMLS CUI-1)
CALGBForm
Item
CALGB Form
text
CALGBStudyNo
Item
CALGB Study No
text
CALGBPatientID
Item
CALGB Patient ID (Disease Description)
text
Item
Amended data?
text
CL.1
Code List
Amended data?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Patient'sName
Item
Patient's Name
text
ParticipatingGroup
Item
Participating Group
text
C17005 (NCI Thesaurus ObjectClass)
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
PatientHospitalNumber
Item
Patient Hospital Number
text
ParticipatingGroupProtocolNo.
Item
Participating Group Protocol No.
text
MainMemberInstitution/Adjunct
Item
Main Member Institution/Adjunct
text
ParticipatingGroupPatientNo.
Item
Participating Group Patient No.
text
Item Group
Surgical Procedures
FirstPositiveBiopsyDate
Item
First positive biopsy date (M)
date
Item
Most extensive primary surgery (mark one with an X)
text
CL.2
Code List
Most extensive primary surgery (mark one with an X)
CL Item
Partial Mastectomy/lumpectomy/excisional Biopsy (Partial mastectomy/lumpectomy/excisional biopsy)
CL Item
Mastectomy, Nos (Mastectomy, NOS)
PrimarySurgeryDate
Item
Date of most extensive primary surgery (if required, used date of last re-excision)
date
Item
Sentinel node biopsy?
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.3
Code List
Sentinel node biopsy?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
SentinelNodeBiopsyDate
Item
Sentinel node biopsy date (M)
date
Item
Sentinel node biopsy results (per protocol)
text
CL.4
Code List
Sentinel node biopsy results (per protocol)
CL Item
Negative (Negative)
C25247 (NCI Thesaurus)
C0205160 (UMLS 2011AA)
CL Item
Positive (Positive)
C25246 (NCI Thesaurus)
C1446409 (UMLS 2011AA)
Item
Was axillary dissection performed?
text
CL.5
Code List
Was axillary dissection performed?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
AxillaryDissectionDate
Item
Date of axillary dissection (M)
date
Totalnumberoflymphnodesexamined
Item
Total number of lymph nodes examined (if sentinel node biopsy and axillary node dissection were performed, enter the total number of nodes examined)
double
Item Group
Laboratory
GRANULOCYTES
Item
Granulocytes
text
Totalbilirubin
Item
Total bilirubin (mg/dl)
double
C25209 (NCI Thesaurus ValueDomain)
C0242485 (UMLS 2011AA ValueDomain)
Lab,Renal,Creatinine
Item
Creatinine (mg/dl)
double
Plateletcount
Item
Platelet count
double
Bilirubinupperlimitofinstitutionallaboratorynormal
Item
Bilirubin upper limit of institutional laboratory normal (mg/dl)
double
C25209 (NCI Thesaurus ValueDomain)
C0242485 (UMLS 2011AA ValueDomain)
Calculatedcreatinineclearance
Item
Calculated creatinine clearance (mL/min)
double
%LVEF
Item
% LVEF
text
%LowerlimitofinstitutionalnormalLVEF
Item
% Lower limit of institutional normal LVEF
double
Item Group
Pathology
C0030664 (UMLS CUI-1)
Item
Tumor laterality (mark one with an X)
text
CL.6
Code List
Tumor laterality (mark one with an X)
CL Item
Left (Left)
C25229 (NCI Thesaurus)
C0205091 (UMLS 2011AA)
CL Item
Right (Right)
C25228 (NCI Thesaurus)
C0205090 (UMLS 2011AA)
CL Item
Bilateral (Bilateral)
Item
Receptor status, ER (If measured in fmols/mg cytosol protein >=10 is positive. If other measures are used apply institutional standards; borderline results should be reported as positive)
text
CL.7
Code List
Receptor status, ER (If measured in fmols/mg cytosol protein >=10 is positive. If other measures are used apply institutional standards; borderline results should be reported as positive)
CL Item
Negative (Negative)
C25247 (NCI Thesaurus)
C0205160 (UMLS 2011AA)
CL Item
Positive (Positive)
C25246 (NCI Thesaurus)
C1446409 (UMLS 2011AA)
Item
Receptor status, PgR
text
CL.8
Code List
Receptor status, PgR
CL Item
Negative (Negative)
C25247 (NCI Thesaurus)
C0205160 (UMLS 2011AA)
CL Item
Positive (Positive)
C25246 (NCI Thesaurus)
C1446409 (UMLS 2011AA)
PathologicPrimaryTumorSize
Item
Pathologic primary tumor size (cm)
double
C25209 (NCI Thesaurus ValueDomain)
C0242485 (UMLS 2011AA ValueDomain)
Item
Histologic grade (combined histologic grade is used according to SRE/Elston classification)
text
CL.9
Code List
Histologic grade (combined histologic grade is used according to SRE/Elston classification)
CL Item
Well Differentiated (Low)
C14171 (NCI Thesaurus)
C0205615 (UMLS 2011AA)
CL Item
Moderately Differentiated (Intermediate)
C14162 (NCI Thesaurus)
C0205616 (UMLS 2011AA)
CL Item
Poorly Differentiated (High)
C14167 (NCI Thesaurus)
C0205617 (UMLS 2011AA)
Totalnumberofpositivelymphnodes
Item
Total number of positive lymph nodes (If sentinel node biopsy and axillary node dissection were performed, enter the sum of positive nodes)
double
T(TNMclassification)
Item
T (TNM classification)
double
N(TNMclassification)
Item
N (TNM classification)
double
M(TNMclassification)
Item
M (TNM classification) (Prior Systemic Therapy)
double
Item
Prior breast cancer prevention therapy?
text
C25180 (NCI Thesaurus ValueDomain)
C1522602 (UMLS 2011AA ValueDomain)
CL.10
Code List
Prior breast cancer prevention therapy?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
If Yes, what type (prior breast cancer prevention therapy) (mark all that apply with an X)
text
CL.11
Code List
If Yes, what type (prior breast cancer prevention therapy) (mark all that apply with an X)
CL Item
Tamoxifen (Tamoxifen)
C855 (NCI Thesaurus)
C0039286 (UMLS 2011AA)
CL Item
Raloxifene (Raloxifene)
C1518 (NCI Thesaurus)
C0244404 (UMLS 2011AA)
CL Item
Other, Specify (Other, specify)
Other,specify(priorbreastcancertherapy)
Item
Other, specify (prior breast cancer therapy)
text
CompletedBy
Item
Completed By (Print or Type Name)
text
DateCompleted
Item
Date Completed
date
Zum Seitenanfang zurückkehren 

Kontakt

Benutzen Sie dieses Formular für Rückmeldungen, Fragen und Verbesserungsvorschläge.

Mit * gekennzeichnete Felder sind notwendig.

Hilfe

Benötigen Sie Hilfe bei der Suche? Um mehr Details zu erfahren und die Suche effektiver nutzen zu können schauen Sie sich doch das entsprechende Video auf unserer Tutorial Seite an.

Zum Video