ID

755

Description

NSABP PROTOCOL B-35 PATHOLOGIST'S REPORT 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=A01C3BB9-FE93-4CD3-E034-080020C9C0E0

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A01C3BB9-FE93-4CD3-E034-080020C9C0E0

Keywords

Versions (2)
  1. 8/26/12 8/26/12 -
  2. 3/22/15 3/22/15 - Martin Dugas
Uploaded on

August 26, 2012

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License

Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00053898 Pathology - NSABP PROTOCOL B-35 PATHOLOGIST'S REPORT FORM - 2033891v3.0

English

Form PRF (04-30-2002) This form is to be completed by the pathologist and submitted to the NSABP Biostatistical Center within 3 months of randomization. Please mail Form PRF separately from the slides and blocks.

1 forms  
Unnamed1
Description

Unnamed1

First Three Letters of Patient's Last Name
Description

FirstThreeLettersofPatient'sLastName

Data type

text

Patient Study ID
Description

PatientStudyID

Data type

text

Institution Name
Description

InstitutionName

Data type

text

Affiliate Name
Description

AffiliateName

Data type

text

Are data amended? (If Yes, circle the amended items in red.)
Description

AmendedDataInd

Data type

text

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

Unnamed2

Accession Number (enter all that apply 123)
Description

AccessionNumber

Data type

double

Unnamed3
Description

Unnamed3

Pathologic Primary Tumor Size (cm leave blank if not directly measurable)
Description

PathologicPrimaryTumorSize

Data type

double

Alias
NCI Thesaurus ValueDomain
C25209
UMLS 2011AA ValueDomain
C0242485
Is measurement gross or microscopic? (mark one)
Description

DuctalBreastCarcinomainSituMicroscopicGrossSizeDocumentedStatus

Data type

text

Alias
NCI Thesaurus ObjectClass
C2924
UMLS 2011AA ObjectClass
C0007124
NCI Thesaurus Property
C25252
UMLS 2011AA Property
C0205288
NCI Thesaurus Property
C43566
UMLS 2011AA Property
C0439806
NCI Thesaurus Property
C25681
UMLS 2011AA Property
C0456389
NCI Thesaurus Property
C25356
UMLS 2011AA Property
C1301725
NCI Thesaurus ValueDomain
C25688
UMLS 2011AA ValueDomain
C0449438
Estimated Size (cm best guess, if possible)
Description

EstimatedSize

Data type

text

Number of slides with DCIS present
Description

NumberofslideswithDCISpresent

Data type

text

Total slides examined for DCIS
Description

TotalslidesexaminedforDCIS

Data type

text

Unnamed4
Description

Unnamed4

Type DCIS (mark one)
Description

TypeDCIS

Data type

text

Growth Patterns (mark all that apply)
Description

HistologicType

Data type

text

Other, specify
Description

HistologicType,OtherName

Data type

text

Dominant Growth Pattern (mark only one)
Description

HistologicType,Dominant

Data type

text

Other, specify
Description

HistologicType,Dominant,Other

Data type

text

Percent Central Necrosis (% estimated necrotic surface area of DCIS associated with any growth pattern)
Description

PercentCentralNecrosis

Data type

text

Unnamed5
Description

Unnamed5

Nuclear Grade (by SBR criteria; mark highest grade)
Description

NuclearGrade

Data type

text

Unnamed6
Description

Unnamed6

Microcalcifications (mark one)
Description

Microcalcifications

Data type

text

Unnamed7
Description

Unnamed7

Margins of DCIS Resection (after re-excision, if done mark one)
Description

DCIS,MarginResult

Data type

text

Nearest Margin (mm if margins are negative)
Description

SurgicalMarginDistance

Data type

double

Unnamed8
Description

Unnamed8

Pathologist Completing Form (print name signature)
Description

PathologistCompletingForm

Data type

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS 2011AA ValueDomain
C1547383
NCI Thesaurus Property
C40988
UMLS 2011AA Property
C1516308
NCI Thesaurus Property
C25250
UMLS 2011AA Property
C0205197
NCI Thesaurus ObjectClass
C17723
UMLS 2011AA ObjectClass
C0334866
Pathologist's Phone Number
Description

PathologistTelephoneNumber

Data type

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS 2011AA ValueDomain
C0237753
NCI Thesaurus ValueDomain
C25395
UMLS 2011AA ValueDomain
C0039457
NCI Thesaurus ObjectClass
C17723
UMLS 2011AA ObjectClass
C0334866
NCI Thesaurus Property
C40978
UMLS 2011AA Property
C1515258
Date Form Completed
Description

FormCompletionDate,Original

Data type

date

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Similar models

Form PRF (04-30-2002) This form is to be completed by the pathologist and submitted to the NSABP Biostatistical Center within 3 months of randomization. Please mail Form PRF separately from the slides and blocks.

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Unnamed1
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
Item
Are data amended? (If Yes, circle the amended items in red.)
text
C25474 (NCI Thesaurus ObjectClass)
C1511726 (UMLS 2011AA ObjectClass)
C25416 (NCI Thesaurus Property)
C1691222 (UMLS 2011AA Property)
CL.1
Code List
Are data amended? (If Yes, circle the amended items in red.)
CL Item
Yes (Yes)
C49488 (NCI Thesaurus)
C1705108 (UMLS 2011AA)
CL Item
No (No)
C49487 (NCI Thesaurus)
C1298908 (UMLS 2011AA)
Item Group
Unnamed2
AccessionNumber
Item
Accession Number (enter all that apply 123)
double
Item Group
Unnamed3
PathologicPrimaryTumorSize
Item
Pathologic Primary Tumor Size (cm leave blank if not directly measurable)
double
C25209 (NCI Thesaurus ValueDomain)
C0242485 (UMLS 2011AA ValueDomain)
Item
Is measurement gross or microscopic? (mark one)
text
C2924 (NCI Thesaurus ObjectClass)
C0007124 (UMLS 2011AA ObjectClass)
C25252 (NCI Thesaurus Property)
C0205288 (UMLS 2011AA Property)
C43566 (NCI Thesaurus Property)
C0439806 (UMLS 2011AA Property)
C25681 (NCI Thesaurus Property)
C0456389 (UMLS 2011AA Property)
C25356 (NCI Thesaurus Property)
C1301725 (UMLS 2011AA Property)
C25688 (NCI Thesaurus ValueDomain)
C0449438 (UMLS 2011AA ValueDomain)
CL.2
Code List
Is measurement gross or microscopic? (mark one)
CL Item
Gross (Gross)
CL Item
Microscopic (Microscopic)
C25252 (NCI Thesaurus)
C0205288 (UMLS 2011AA)
CL Item
Not Directly Measurable (Not directly measurable)
EstimatedSize
Item
Estimated Size (cm best guess, if possible)
text
NumberofslideswithDCISpresent
Item
Number of slides with DCIS present
text
TotalslidesexaminedforDCIS
Item
Total slides examined for DCIS
text
Item Group
Unnamed4
Item
Type DCIS (mark one)
text
CL.3
Code List
Type DCIS (mark one)
CL Item
Comedo (Comedo)
C26453 (NCI Thesaurus)
C0221228 (UMLS 2011AA)
CL Item
Non-comedo (Non-comedo)
Item
Growth Patterns (mark all that apply)
text
CL.4
Code List
Growth Patterns (mark all that apply)
CL Item
Solid (Solid)
CL Item
Cribriform (Cribriform)
CL Item
Micropapillary (Micropapillary)
CL Item
Papillary (Papillary)
CL Item
Other, specify (Other, specify)
HistologicType,OtherName
Item
Other, specify
text
Item
Dominant Growth Pattern (mark only one)
text
CL.5
Code List
Dominant Growth Pattern (mark only one)
CL Item
Solid (Solid)
C0205208 (NCI Metathesaurus)
CL Item
Cribriform (Cribriform)
C25731 (NCI Thesaurus)
C1621425 (UMLS 2011AA)
CL Item
Micropapillary (Micropapillary)
CL Item
Papillary (Papillary)
CL Item
Other, Specify (Other, specify)
HistologicType,Dominant,Other
Item
Other, specify
text
PercentCentralNecrosis
Item
Percent Central Necrosis (% estimated necrotic surface area of DCIS associated with any growth pattern)
text
Item Group
Unnamed5
Item
Nuclear Grade (by SBR criteria; mark highest grade)
text
CL.6
Code List
Nuclear Grade (by SBR criteria; mark highest grade)
CL Item
Grade 1 (Grade 1)
CL Item
Grade 2 (Grade 2)
CL Item
Grade 3 (Grade 3)
Item Group
Unnamed6
Item
Microcalcifications (mark one)
text
CL.7
Code List
Microcalcifications (mark one)
CL Item
Present, Involving Benign Ducts (Present, involving benign tissue elements)
CL Item
Present, Involving Dcis (Present, involving DCIS)
CL Item
Present, Involving Both Benign Ducts And Dcis (Present, involving both benign tissue elements and DCIS)
CL Item
None (None)
C41132 (NCI Thesaurus)
C0549184 (UMLS 2011AA)
Item Group
Unnamed7
Item
Margins of DCIS Resection (after re-excision, if done mark one)
text
CL.8
Code List
Margins of DCIS Resection (after re-excision, if done mark one)
CL Item
Positive (Positive)
CL Item
Indefinite (Indefinite)
CL Item
Negative (Negative)
CL Item
Unable to evaluate margins (Unable to evaluate margins)
SurgicalMarginDistance
Item
Nearest Margin (mm if margins are negative)
double
Item Group
Unnamed8
PathologistCompletingForm
Item
Pathologist Completing Form (print name signature)
text
C25191 (NCI Thesaurus ValueDomain)
C1547383 (UMLS 2011AA ValueDomain)
C40988 (NCI Thesaurus Property)
C1516308 (UMLS 2011AA Property)
C25250 (NCI Thesaurus Property)
C0205197 (UMLS 2011AA Property)
C17723 (NCI Thesaurus ObjectClass)
C0334866 (UMLS 2011AA ObjectClass)
PathologistTelephoneNumber
Item
Pathologist's Phone Number
text
C25337 (NCI Thesaurus ValueDomain)
C0237753 (UMLS 2011AA ValueDomain)
C25395 (NCI Thesaurus ValueDomain)
C0039457 (UMLS 2011AA ValueDomain)
C17723 (NCI Thesaurus ObjectClass)
C0334866 (UMLS 2011AA ObjectClass)
C40978 (NCI Thesaurus Property)
C1515258 (UMLS 2011AA Property)
FormCompletionDate,Original
Item
Date Form Completed
date
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