ID

675

Descrição

CALGB: 49808 TREATMENT SUMMARY FORM HERCEPTIN VS OBSERVATION Combination Chemotherapy, Surgery, and Radiation Therapy With or Without Dexrazoxane and Trastuzumab in Treating Women With Stage III or Stage IV Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9E35395C-8C3D-227A-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9E35395C-8C3D-227A-E034-080020C9C0E0

Palavras-chave

Versões (2)
  1. 26/08/2012 26/08/2012 -
  2. 12/03/2015 12/03/2015 - Martin Dugas
Transferido a

26 de agosto de 2012

DOI

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Licença

Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00016276 Treatment - CALGB: 49808 TREATMENT SUMMARY FORM HERCEPTIN VS OBSERVATION - 2032660v3.0

Inglês

No Instruction available.

1 Formulários  
  1. StudyEvent: CALGB: 49808 TREATMENT SUMMARY FORM HERCEPTIN VS OBSERVATION
    1. No Instruction available.
Unnamed1
Descrição

Unnamed1

CALGB Form
Descrição

CALGBForm

Tipo de dados

text

CALGB Study No
Descrição

CALGBProtocolNumber

Tipo de dados

text

CALGB Patient ID
Descrição

CALGBPatientID

Tipo de dados

text

Amended data?
Descrição

AmendedDataInd

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C25474
UMLS 2011AA ObjectClass
C1511726
NCI Thesaurus Property
C25416
UMLS 2011AA Property
C1691222
Unnamed2
Descrição

Unnamed2

Patient's Name
Descrição

Patient'sName

Tipo de dados

text

Participating Group
Descrição

ParticipatingGroup

Tipo de dados

text

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

PatientHospitalNumber

Tipo de dados

text

Participating Group Protocol No.
Descrição

ParticipatingGroupProtocolNo.

Tipo de dados

text

Main Member Institution/Adjunct
Descrição

MainMemberInstitution/Adjunct

Tipo de dados

text

Participating Group Patient No.
Descrição

ParticipatingGroupPatientNo.

Tipo de dados

text

Treatment Plan
Descrição

Treatment Plan

Is patient taking Herceptin?
Descrição

IspatienttakingHerceptin?

Tipo de dados

text

Initial dose this reporting period (Total dose in mg Herceptin if randomized)
Descrição

Initialdosethisreportingperiod

Tipo de dados

text

Last date protocol therapy was given
Descrição

ProtocolTreatmentAdministeredEndDate

Tipo de dados

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus ObjectClass
C42651
UMLS 2011AA ObjectClass
C0442711
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Number of completed weeks during this reporting period
Descrição

Numberofcompletedweeksduringthisreportingperiod

Tipo de dados

text

Reason Treatment Ended (mark one with an X)
Descrição

ReasonTreatmentEnded

Tipo de dados

text

Reason Treatment Ended Other, specify
Descrição

ReasonTreatmentEndedOther,specify

Tipo de dados

text

Treatment Schedule - Systemic Therapy
Descrição

Treatment Schedule - Systemic Therapy

Were there any dose modifications or additions/ omissions to protocol treatment? (mark one with an X)
Descrição

Werethereanydosemodificationsoradditions/omissionstoprotocoltreatment?

Tipo de dados

text

Were any optional protocol therapies given?
Descrição

Wereanyoptionalprotocoltherapiesgiven?

Tipo de dados

text

Optional Protocol Therapy Name
Descrição

OptionalProtocolTherapyName

Tipo de dados

text

Were any non-protocol therapies given during protocol treatment?
Descrição

Wereanynon-protocoltherapiesgivenduringprotocoltreatment?

Tipo de dados

text

Concurrent Non-Protocol Chemotherapy?
Descrição

ConcurrentNon-ProtocolChemotherapyInd

Tipo de dados

text

Concurrent Non-Protocol Hormonal Therapy?
Descrição

ConcurrentNon-ProtocolHormonalTherapyInd

Tipo de dados

text

Concurrent Non-Protocol Biologic Response Modifier Therapy?
Descrição

ConcurrentNon-ProtocolBRMInd

Tipo de dados

text

Concurrent Non-Protocol Radiation Therapy?
Descrição

ConcurrentNon-ProtocolRTInd

Tipo de dados

text

Concurrent Non-Protocol High Dose Chemotherapy/Autologous Stem Cell Transplant?
Descrição

ConcurrentNon-ProtocolHDC/ASCTInd

Tipo de dados

text

Did this patient receive any tamoxifen?
Descrição

PastTamoxifenInd

Tipo de dados

text

Did patient begin taking tamoxifen during this reporting period? (If Yes)
Descrição

Didpatientbegintakingtamoxifenduringthisreportingperiod?

Tipo de dados

text

If Yes, date tamoxifen started
Descrição

IfYes,datetamoxifenstarted

Tipo de dados

text

Is the patient still receiving tamoxifen?
Descrição

CurrentTamoxifenInd

Tipo de dados

text

If patient discontinued tamoxifen since last follow-up, give date.
Descrição

Ifpatientdiscontinuedtamoxifensincelastfollow-up,givedate.

Tipo de dados

text

Comments
Descrição

Comments

Comments
Descrição

Comments

Tipo de dados

text

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Similar models

No Instruction available.

1 Formulários
  1. StudyEvent: CALGB: 49808 TREATMENT SUMMARY FORM HERCEPTIN VS OBSERVATION
    1. No Instruction available.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
Alias
Item Group
Unnamed1
CALGBForm
Item
CALGB Form
text
CALGBProtocolNumber
Item
CALGB Study No
text
CALGBPatientID
Item
CALGB Patient ID
text
Item
Amended data?
text
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
CL.1
Code List
Amended data?
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item Group
Unnamed2
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
Treatment Plan
Item
Is patient taking Herceptin?
text
CL.2
Code List
Is patient taking Herceptin?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Initialdosethisreportingperiod
Item
Initial dose this reporting period (Total dose in mg Herceptin if randomized)
text
ProtocolTreatmentAdministeredEndDate
Item
Last date protocol therapy was given
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C15368 (NCI Thesaurus ObjectClass)
C42651 (NCI Thesaurus ObjectClass)
C0442711 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
Numberofcompletedweeksduringthisreportingperiod
Item
Number of completed weeks during this reporting period
text
Item
Reason Treatment Ended (mark one with an X)
text
CL.3
Code List
Reason Treatment Ended (mark one with an X)
CL Item
Not applicable (Not applicable)
CL Item
Treatment completed per protocol criteria (Treatment completed per protocol criteria)
CL Item
Disease progression/relapse during active treatment (Disease progression/relapse during active treatment)
CL Item
Toxicity/side effects/complications (Toxicity/side effects/complications)
CL Item
Death on study (Death on study)
CL Item
Patient withdrawal or refusal after beginning protocol therapy (Patient withdrawal or refusal after beginning protocol therapy)
CL Item
Patient withdrawal or refusal prior to beginning protocol therapy (Patient withdrawal or refusal prior to beginning protocol therapy)
CL Item
Alternative therapy (Alternative therapy)
CL Item
Other complicating disease (Other complicating disease)
CL Item
Other, specify (Other, specify)
ReasonTreatmentEndedOther,specify
Item
Reason Treatment Ended Other, specify
text
Item Group
Treatment Schedule - Systemic Therapy
Item
Were there any dose modifications or additions/ omissions to protocol treatment? (mark one with an X)
text
CL.4
Code List
Were there any dose modifications or additions/ omissions to protocol treatment? (mark one with an X)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes, Planned (Yes, planned)
CL Item
Yes, Unplanned (Yes, unplanned)
Item
Were any optional protocol therapies given?
text
CL.5
Code List
Were any optional protocol therapies given?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
OptionalProtocolTherapyName
Item
Optional Protocol Therapy Name
text
Item
Were any non-protocol therapies given during protocol treatment?
text
CL.6
Code List
Were any non-protocol therapies given during protocol treatment?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Concurrent Non-Protocol Chemotherapy?
text
CL.7
Code List
Concurrent Non-Protocol Chemotherapy?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Concurrent Non-Protocol Hormonal Therapy?
text
CL.8
Code List
Concurrent Non-Protocol Hormonal Therapy?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Concurrent Non-Protocol Biologic Response Modifier Therapy?
text
CL.9
Code List
Concurrent Non-Protocol Biologic Response Modifier Therapy?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Concurrent Non-Protocol Radiation Therapy?
text
CL.10
Code List
Concurrent Non-Protocol Radiation Therapy?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Concurrent Non-Protocol High Dose Chemotherapy/Autologous Stem Cell Transplant?
text
CL.11
Code List
Concurrent Non-Protocol High Dose Chemotherapy/Autologous Stem Cell Transplant?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Did this patient receive any tamoxifen?
text
CL.12
Code List
Did this patient receive any tamoxifen?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Item
Did patient begin taking tamoxifen during this reporting period? (If Yes)
text
CL.13
Code List
Did patient begin taking tamoxifen during this reporting period? (If Yes)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
IfYes,datetamoxifenstarted
Item
If Yes, date tamoxifen started
text
Item
Is the patient still receiving tamoxifen?
text
CL.14
Code List
Is the patient still receiving tamoxifen?
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
Ifpatientdiscontinuedtamoxifensincelastfollow-up,givedate.
Item
If patient discontinued tamoxifen since last follow-up, give date.
text
Item Group
Comments
Comments
Item
Comments
text
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