ID
775
Description
CALGB: 40101 PRE-STUDY ELIGIBILITY CHECKLIST Four Versus Six Cycles of Cyclophosphamide/Doxorubicin or Paclitaxel in Adjuvant Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A4CFBF75-6AD3-69D3-E034-080020C9C0E0
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Keywords
Versions (3)
- 8/26/12 8/26/12 -
- 7/8/15 7/8/15 -
- 7/8/15 7/8/15 -
Uploaded on
August 26, 2012
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License
Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00041119 Eligibility - CALGB: 40101 PRE-STUDY ELIGIBILITY CHECKLIST - 2039130v3.0
INSTRUCTIONS: Complete all information on this form. Do not leave any entries blank.
- StudyEvent: CALGB: 40101 PRE-STUDY ELIGIBILITY CHECKLIST
Description
Unnamed2
Description
Patient'sName
Data type
text
Description
ParticipatingGroup
Data type
text
Alias
- NCI Thesaurus ObjectClass
- C17005
- UMLS 2011AA ObjectClass
- C1257890
- NCI Thesaurus Property
- C25364
- UMLS 2011AA Property
- C0600091
Description
PatientHospitalNumber
Data type
text
Description
ParticipatingGroupProtocolNo.
Data type
text
Description
MainMemberInstitution/Adjunct
Data type
text
Description
ParticipatingGroupPatientNo.
Data type
text
Description
Unnamed3
Description
Histologicallyconfirmedinvasivecarcinomaofthebreast
Data type
text
Description
Undergoneeithermodifiedradicalmastectomyorlumpectomy
Data type
text
Description
NegativetumormarginsforinvasivecancerandDCISincaseofmastectomyorlumpectomy
Data type
text
Description
Nolocallyadvancedbreastcancer,inflammatorybreastcancerormetastaticbreastcancer
Data type
text
Description
Noinvolvementofdermallymphaticsonpathology
Data type
text
Description
"High-risk"node-negativebreastcancer
Data type
text
Description
Negativesentinelnodebiopsy,and/oranaxillarydissectionwhereatleast6lymphnodesareremovedandfoundtobenegative
Data type
text
Description
Nopreviouschemotherapyorhormonaltherapy(exceptfortamoxifenasdescribedintheprotocol)forthismalignancy
Data type
text
Description
Age>=18years
Data type
text
Description
CTCPerformancestatus0-1
Data type
text
Description
Non-pregnantandnon-nursing
Data type
text
Description
Noactivecongestiveheartfailurenormyocardialinfarctionwithin6monthspriortoregistration
Data type
text
Description
Disease-freeofpriorinvasivemalignanciesfor>5yearsexceptforcurativelytreatedbasalcellorsquamouscellcarcinomaoftheskinorcarcinomainsituofthecervix
Data type
text
Description
Willingtostopexogenoushormonetherapy,includingoralcontraceptives,post-menopausalhormonereplacementtherapy,andraloxifene
Data type
text
Description
Discontinuedtamoxifenattimeofenrollmenttostudyiftamoxifenhasbeenreceivedasbreastcancerpreventiveagent,orastreatmentforthismalignancyfor<=4weeks.
Data type
text
Description
Datetamoxifenstarted
Data type
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
Description
Datetamoxifendiscontinued
Data type
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
Description
MeetsALLofthefollowinglaboratorycriteriacompletedwithin16daysbeforeregistration
Data type
text
Description
ANC>=1000/mcL
Data type
text
Description
Dateobtained(ANC)
Data type
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
Description
Platelets>=100,000/mcL
Data type
text
Description
Dateobtained(Platelets)
Data type
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
Description
Creatinine<=2.0mg/dL
Data type
text
Description
Dateobtained(Creatinine)
Data type
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
Description
TotalBilirubin<1.5xupperlimitsofnormaloflaboratory
Data type
text
Description
Dateobtained(TotalBilirubin)
Data type
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
Description
ULN(TotalBilirubin)
Data type
text
Description
<=84dayssincelastmajorbreastsurgery
Data type
text
Description
Ccrr Module For Calgb: 40101 Pre-study Eligibility Checklist
Similar models
INSTRUCTIONS: Complete all information on this form. Do not leave any entries blank.
- StudyEvent: CALGB: 40101 PRE-STUDY ELIGIBILITY CHECKLIST
C1257890 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
C0011008 (UMLS 2011AA ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)