ID

6211

Descripción

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

Palabras clave

Versiones (1)
  1. 18/12/14 18/12/14 - Martin Dugas
Subido en

18 de diciembre de 2014

DOI

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Licencia

Creative Commons BY-NC 3.0 Legacy
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ON-STUDY FORM (CALGB 49907)

Inglés

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1 formularios  
  1. StudyEvent: CALGB: 49907 ON-STUDY FORM
    1. Continue on next page
Header
Descripción

Header

Alias
UMLS CUI-1
C1320722
CALGB Form
Descripción

CALGBForm

Tipo de datos

text

CALGB Study No
Descripción

CALGBStudyNo

Tipo de datos

text

CALGB Patient ID (Disease Description)
Descripción

CALGBPatientID

Tipo de datos

text

Amended data?
Descripción

Amendeddata?

Tipo de datos

text

Patient's Name
Descripción

Patient'sName

Tipo de datos

text

Participating Group
Descripción

ParticipatingGroup

Tipo de datos

text

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

PatientHospitalNumber

Tipo de datos

text

Participating Group Protocol No.
Descripción

ParticipatingGroupProtocolNo.

Tipo de datos

text

Main Member Institution/Adjunct
Descripción

MainMemberInstitution/Adjunct

Tipo de datos

text

Participating Group Patient No.
Descripción

ParticipatingGroupPatientNo.

Tipo de datos

text

Surgical Procedures
Descripción

Surgical Procedures

First positive biopsy date (M)
Descripción

FirstPositiveBiopsyDate

Tipo de datos

date

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

PrimarySurgeryType

Tipo de datos

text

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

PrimarySurgeryDate

Tipo de datos

date

Sentinel node biopsy?
Descripción

Sentinelnodebiopsy?

Tipo de datos

text

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

SentinelNodeBiopsyDate

Tipo de datos

date

Sentinel node biopsy results (per protocol)
Descripción

SentinelNodeBiopsyResults

Tipo de datos

text

Was axillary dissection performed?
Descripción

AxillaryDissectionInd

Tipo de datos

text

Date of axillary dissection (M)
Descripción

AxillaryDissectionDate

Tipo de datos

date

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

Totalnumberoflymphnodesexamined

Tipo de datos

double

Laboratory
Descripción

Laboratory

Granulocytes
Descripción

GRANULOCYTES

Tipo de datos

text

Total bilirubin (mg/dl)
Descripción

Totalbilirubin

Tipo de datos

double

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

Lab,Renal,Creatinine

Tipo de datos

double

Platelet count
Descripción

Plateletcount

Tipo de datos

double

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

Bilirubinupperlimitofinstitutionallaboratorynormal

Tipo de datos

double

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

Calculatedcreatinineclearance

Tipo de datos

double

% LVEF
Descripción

%LVEF

Tipo de datos

text

% Lower limit of institutional normal LVEF
Descripción

%LowerlimitofinstitutionalnormalLVEF

Tipo de datos

double

Pathology
Descripción

Pathology

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

PrimaryTumorLaterality

Tipo de datos

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)
Descripción

ERStatus

Tipo de datos

text

Receptor status, PgR
Descripción

PgRStatus

Tipo de datos

text

Pathologic primary tumor size (cm)
Descripción

PathologicPrimaryTumorSize

Tipo de datos

double

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

HistologicGrade

Tipo de datos

text

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

Totalnumberofpositivelymphnodes

Tipo de datos

double

T (TNM classification)
Descripción

T(TNMclassification)

Tipo de datos

double

N (TNM classification)
Descripción

N(TNMclassification)

Tipo de datos

double

M (TNM classification) (Prior Systemic Therapy)
Descripción

M(TNMclassification)

Tipo de datos

double

Prior breast cancer prevention therapy?
Descripción

Priorbreastcancerpreventiontherapy?

Tipo de datos

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)
Descripción

IfYes,whattype(priorbreastcancerpreventiontherapy)

Tipo de datos

text

Other, specify (prior breast cancer therapy)
Descripción

Other,specify(priorbreastcancertherapy)

Tipo de datos

text

Completed By (Print or Type Name)
Descripción

CompletedBy

Tipo de datos

text

Date Completed
Descripción

DateCompleted

Tipo de datos

date

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1 formularios
  1. StudyEvent: CALGB: 49907 ON-STUDY FORM
    1. Continue on next page
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
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
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