ID
776
Description
NSABP PROTOCOL B-35: REGISTRATION 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=A053033F-8CE7-05B1-E034-080020C9C0E0
Link
Keywords
Versions (2)
- 8/26/12 8/26/12 -
- 3/18/15 3/18/15 - Martin Dugas
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August 26, 2012
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Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00053898 Registration - NSABP PROTOCOL B-35: REGISTRATION FORM - 2033723v3.0
Form A (04-30-2002) Prior to randomization, fax Form A and signed consent to 412-383-2065.
- StudyEvent: NSABP PROTOCOL B-35: REGISTRATION FORM
Description
Unnamed2
Description
InstitutionName
Data type
text
Description
NCIInstitutionNumber
Data type
text
Description
AffiliateName
Data type
text
Description
RegisteredInvestigator
Data type
text
Description
InformedConsentDateSigned
Data type
date
Alias
- NCI Thesaurus ValueDomain
- C25164
- UMLS 2011AA ValueDomain
- C0011008
Description
ProjectedTreatmentBeginDate
Data type
date
Description
PersonCompletingForm,LastName
Data type
text
Description
PersonCompletingForm,FirstName
Data type
text
Alias
- NCI Thesaurus ObjectClass
- C25190
- UMLS 2011AA ObjectClass
- C0027361
- NCI Thesaurus Property
- C25364
- UMLS 2011AA Property
- C0600091
Description
PersonCompletingForm,Phone
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25704
- UMLS 2011AA ValueDomain
- C1527021
Description
PersonCompletingForm,Fax
Data type
double
Description
Unnamed3
Description
PatientName
Data type
text
Description
PatientBirthDate
Data type
date
Alias
- NCI Thesaurus ObjectClass
- C16960
- UMLS 2011AA ObjectClass
- C0030705
- NCI Thesaurus Property
- C25275
- UMLS 2011AA Property
- C2745955
Description
Patient'sSocialSecurityNumber
Data type
text
Description
Unnamed4
Description
RaceCategories
Data type
text
Description
EthnicCategories
Data type
text
Description
Unnamed5
Description
PaymentMethod
Data type
text
Description
Unnamed6
Description
PatientAddress,Country
Data type
text
Description
OtherInd-3
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25704
- UMLS 2011AA ValueDomain
- C1527021
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
PatientAddress,PostalCode
Data type
double
Description
Unnamed7
Description
PerformanceStatus
Data type
text
Description
PatientHeight
Data type
double
Alias
- NCI Thesaurus ObjectClass
- C16960
- UMLS 2011AA ObjectClass
- C0030705
- NCI Thesaurus Property
- C25347
- UMLS 2011AA Property
- C0489786
Description
PatientWeight
Data type
double
Description
Certificate Of Eligibility
Description
PatientEligibilityInd
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
- NCI Thesaurus ObjectClass
- C16960
- UMLS 2011AA ObjectClass
- C0030705
- NCI Thesaurus Property
- C25171
- UMLS 2011AA Property
- C0013893
Description
Stratification Factor
Description
PatientRegistrationAgeYearCount
Data type
double
Alias
- NCI Thesaurus ObjectClass
- C16960
- UMLS 2011AA ObjectClass
- C0030705
- NCI Thesaurus Property
- C25646
- UMLS 2011AA Property
- C1514821
- NCI Thesaurus ValueDomain
- C29848
- UMLS 2011AA ValueDomain
- C0439234
- NCI Thesaurus ValueDomain
- C25463
- UMLS 2011AA ValueDomain
- C0750480
Description
Unnamed8
Description
Eligibility Checklist
Description
VerificationofPostmenopausalStatus
Data type
text
Alias
- NCI Thesaurus Property
- C38008
- UMLS 2011AA Property
- C0687676
- NCI Thesaurus Property
- C3231
- UMLS 2011AA Property
- C0025320
- NCI Thesaurus ObjectClass
- C25171
- UMLS 2011AA ObjectClass
- C0013893
Description
DateofLastSurgeryforBreastCancerTreatment
Data type
text
Description
Surgical Treatment And Pathology
Description
Didthepatientundergolumpectomy?
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
MicroinvasiveCancerInd
Data type
text
Description
DCISInd
Data type
text
Alias
- NCI Thesaurus Property
- C25458
- UMLS 2011AA Property
- C0750484
- NCI Thesaurus ObjectClass
- C2924
- UMLS 2011AA ObjectClass
- C0007124
- NCI Thesaurus Property
- C25527
- UMLS 2011AA Property
- C0205462
Description
ArethefinalmarginsoftheresectedspecimenhistologicallyfreeofDCIS?
Data type
text
Alias
- NCI Thesaurus ObjectClass
- C25508
- UMLS 2011AA ObjectClass
- C0205088
- NCI Thesaurus ObjectClass
- C25563
- UMLS 2011AA ObjectClass
- C0205284
- NCI Thesaurus Property
- C25547
- NCI Thesaurus Property
- C25527
- UMLS 2011AA Property
- C0205462
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
Werethereanyclinicallyormammographicallysuspiciousmassesorclustersofcalcification?
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
Ifitem6isyes,werethesesuspiciousmassesorclustersofcalcificationbiopsied?
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
Ifitem6aisyes,arethemarginshistologicallyfreeofDCIS?
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
Aretheresuspiciouspalpablenodesintheipsilateralorcontralateralaxilla?
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
Aretherepalpablesupraclavicularorinfraclavicularnodes?
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
Isthereabilateralmalignancyoramassormammographicabnormalityintheoppositebreastthatissuspiciousformalignancy?
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
Didthepatienthaveoneormoreipsilateralaxillarynodesorintramammarynodesthatwerepositivefortumoronhistologicexamination?
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
Didthepatientundergomastectomy?
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
Other Treatment
Description
HassystemicorradiationtherapybeengivenforthecurrentDCIS?
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
PriorHormonalTherapyInd
Data type
text
Description
Isthepatientcurrentlytakingraloxifene(Evista[R])orotherselectiveestrogenreceptormodulators(SERMs)?
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
Hasthepatientbeentakinganysexhormonaltherapy,e.g.estrogenorprogesteronereplacementtherapy,oralcontraceptives,androgens,etc.?
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
Ifitem15isyes,wasthistherapydiscontinuedpriortorandomization?
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
Unnamed9
Description
Contraindications
Description
Doesthepatienthaveapriorhistoryofdeepveinthrombosisorpulmonaryembolus?
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
Hasthepatienteverbeendiagnosedwithanon-breastmalignancy?
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
Ifitem17isyes,hasthepatientbeendisease-freeforatleast5years?
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
Ifitem17aisno,wasthediagnosissquamousorbasalcellcarcinomaoftheskinwhichwaseffectivelytreated,carcinomainsituofthecervixthathasbeentreatedbysurgeryalone,orlobularcarcinomainsitu(LCIS)oftheipsilateralorcontralatera
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
PatientTransientIschemicAttackCerebrovascularAccidentPersonalMedicalHistoryInd-2
Data type
text
Alias
- NCI Thesaurus ObjectClass
- C29867
- UMLS 2011AA ObjectClass
- C0679646
- NCI Thesaurus Property
- C50781
- UMLS 2011AA Property
- C0007787
- NCI Thesaurus Property
- C3390
- UMLS 2011AA Property
- C0038454
- NCI Thesaurus Property
- C18772
- UMLS 2011AA Property
- C0262926
- NCI Thesaurus ValueDomain
- C38147
- UMLS 2011AA ValueDomain
- C1512698
Description
Doesthepatienthaveanonmalignantsystemicdisease(cardiovascular,renal,hepatic,etc.)thatwouldprecludeherbeingsubjectedtoprotocoltherapyorwouldpreventprolongedfollow-up?
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
Doesthepatienthaveapsychiatricoraddictivedisorderwhichwouldprecludeobtaininginformedconsent?
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
DoesthepatienthaveapriorhistoryofinvasivebreastcancerorDCIS?
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
Doesthepatienthaveuncontrolledhypertension?
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
Doesthepatienthaveuncontrolleddiabetes?
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
Doesthepatienthaveatrialfibrillation,notcontrolledbymedication?
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
Pre-entry Studies
Description
Hasthepatienthadahistoryandphysicalinthelast6months?
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
Hasthepatienthadabilateralmammogramwithinthepast12months?
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
HysterectomyPerformedInd-3
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C38148
- UMLS 2011AA ValueDomain
- C1512699
- NCI Thesaurus Property
- C38000
- UMLS 2011AA Property
- C0884358
- NCI Thesaurus ObjectClass
- C15256
- UMLS 2011AA ObjectClass
- C0020699
Description
Ifitem27isno,hasthepatienthadapelvicexamwithinthepast12months?
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
Unnamed10
Description
WBC
Data type
text
Description
SGOT(AST)
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
Totalbilirubin
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
Alkalinephosphatase
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
Description
Serumcreatinine
Data type
text
Alias
- NCI Thesaurus ValueDomain
- C25180
- UMLS 2011AA ValueDomain
- C1522602
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Form A (04-30-2002) Prior to randomization, fax Form A and signed consent to 412-383-2065.
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