ID

9404

Beskrivning

NSABP PROTOCOL B-39: Chemotherapy Report Radiation Therapy in Treating Women Who Have Undergone Surgery For Ductal Carcinoma In Situ or Stage I or Stage II Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=E6F98A67-4163-1881-E034-0003BA3F9857

Länk

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=E6F98A67-4163-1881-E034-0003BA3F9857

Nyckelord

Versioner (2)
  1. 2012-08-26 2012-08-26 -
  2. 2015-01-09 2015-01-09 - Martin Dugas
Uppladdad den

9 januari 2015

DOI

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Licens

Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00103181 Treatment - NSABP PROTOCOL B-39: Chemotherapy Report - 2295346v3.0

Engelsk

This form is to be submitted for all patients, including those who do not receive adjuvant chemotherapy.

1 Formulär  
Part 1. Patient Treatment Plan Based On Information Provided At Patient Registration
Beskrivning

Part 1. Patient Treatment Plan Based On Information Provided At Patient Registration

NSABP Patient ID
Beskrivning

Patient ID NSABP

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25337
UMLS CUI-1
C2348585
NCI Thesaurus ObjectClass
C16960
UMLS CUI-2
C1513905
NCI Thesaurus Property
C25364
NCI Thesaurus Property-2
C15818
Patient Initials
Beskrivning

Patient Initials

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Date of Registration
Beskrivning

PatientRegistrationDate

Datatyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C16960
UMLS 2011AA ObjectClass
C0030705
NCI Thesaurus ValueDomain-2
C25367
NCI Thesaurus Property
C25646
UMLS 2011AA Property
C1514821
Intention to Administer Chemotherapy
Beskrivning

ChemotherapyIntentAdminstrationInd-2

Datatyp

boolean

Alias
NCI Thesaurus ValueDomain
C38147
UMLS 2011AA ValueDomain
C1512698
NCI Thesaurus ObjectClass
C15632
UMLS 2011AA ObjectClass
C0392920
NCI Thesaurus Property
C25409
UMLS 2011AA Property
C1533734
NCI Thesaurus Property-2
C25725
UMLS 2011AA Property-2
C1283828
Assigned Treatment
Beskrivning

Protocol Treatment Arm

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C15368
NCI Thesaurus ObjectClass-2
C42651
UMLS CUI-1
C1522541
NCI Thesaurus Property
C32141
NCI Thesaurus Property-2
C25426
NCI Thesaurus ValueDomain
C25284
Treatment Plan
Beskrivning

BreastProtocolPlannedTreatmentType

Datatyp

text

Alias
NCI Thesaurus ObjectClass
C25320
UMLS 2011AA ObjectClass
C1507394
NCI Thesaurus ObjectClass-2
C12971
UMLS 2011AA ObjectClass-2
C0006141
NCI Thesaurus Property
C15368
NCI Thesaurus Property-2
C25619
UMLS 2011AA Property
C1301732
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
Part 2. To Be Completed By Institution
Beskrivning

Part 2. To Be Completed By Institution

Did patient receive adjuvant chemotherapy? (If no, remaining questions do not apply.)
Beskrivning

Didpatientreceiveadjuvantand/orneoadjuvantchemotherapyforbreastcancer?

Datatyp

boolean

Chemotherapy Treatment Start Date
Beskrivning

Chemotherapy Start Date

Datatyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS CUI-1
C1302181
NCI Thesaurus ObjectClass
C15632
UMLS CUI-2
C3173309
NCI Thesaurus ValueDomain-2
C25431
NCI Thesaurus Property
C25382
Chemotherapy Treatment End Date (date of last dose)
Beskrivning

ChemotherapyAdministeredEndDate

Datatyp

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
NCI Thesaurus ObjectClass
C15632
UMLS 2011AA ObjectClass
C0392920
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Adjuvant Chemotherapy (mark all types of chemotherapy patient received)
Beskrivning

AdjuvantChemotherapyAdministeredType

Datatyp

text

Alias
NCI Thesaurus ValueDomain
C25284
UMLS 2011AA ValueDomain
C0332307
NCI Thesaurus ObjectClass
C15632
UMLS 2011AA ObjectClass
C0392920
NCI Thesaurus ObjectClass-2
C2140
UMLS 2011AA ObjectClass-2
C0001552
NCI Thesaurus Property
C25382
UMLS 2011AA Property
C1521801
Tillbaka till toppen

Similar models

This form is to be submitted for all patients, including those who do not receive adjuvant chemotherapy.

1 Formulär
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Item Group
Part 1. Patient Treatment Plan Based On Information Provided At Patient Registration
Patient ID NSABP
Item
NSABP Patient ID
text
C25337 (NCI Thesaurus ValueDomain)
C2348585 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C1513905 (UMLS CUI-2)
C25364 (NCI Thesaurus Property)
C15818 (NCI Thesaurus Property-2)
Patient Initials
Item
Patient Initials
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
PatientRegistrationDate
Item
Date of Registration
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C16960 (NCI Thesaurus ObjectClass)
C0030705 (UMLS 2011AA ObjectClass)
C25367 (NCI Thesaurus ValueDomain-2)
C25646 (NCI Thesaurus Property)
C1514821 (UMLS 2011AA Property)
ChemotherapyIntentAdminstrationInd-2
Item
Intention to Administer Chemotherapy
boolean
C38147 (NCI Thesaurus ValueDomain)
C1512698 (UMLS 2011AA ValueDomain)
C15632 (NCI Thesaurus ObjectClass)
C0392920 (UMLS 2011AA ObjectClass)
C25409 (NCI Thesaurus Property)
C1533734 (UMLS 2011AA Property)
C25725 (NCI Thesaurus Property-2)
C1283828 (UMLS 2011AA Property-2)
Item
Assigned Treatment
text
C15368 (NCI Thesaurus ObjectClass)
C42651 (NCI Thesaurus ObjectClass-2)
C1522541 (UMLS CUI-1)
C32141 (NCI Thesaurus Property)
C25426 (NCI Thesaurus Property-2)
C25284 (NCI Thesaurus ValueDomain)
CL.2
Code List
Assigned Treatment
CL Item
Group 1: Whole Breast Irradiation (Group 1: Whole Breast Irradiation)
CL Item
Group 2: Partial Breast Irradiation (Group 2: Partial Breast Irradiation)
Item
Treatment Plan
text
C25320 (NCI Thesaurus ObjectClass)
C1507394 (UMLS 2011AA ObjectClass)
C12971 (NCI Thesaurus ObjectClass-2)
C0006141 (UMLS 2011AA ObjectClass-2)
C15368 (NCI Thesaurus Property)
C25619 (NCI Thesaurus Property-2)
C1301732 (UMLS 2011AA Property)
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
CL.3
Code List
Treatment Plan
CL Item
Wbi Without Chemotherapy (WBI without chemotherapy)
CL Item
Chemotherapy Followed By Wbi (Chemotherapy followed by WBI)
CL Item
Pbi Without Chemotherapy (PBI without chemotherapy)
CL Item
Pbi Followed By Chemotherapy (PBI followed by chemotherapy)
Item Group
Part 2. To Be Completed By Institution
Didpatientreceiveadjuvantand/orneoadjuvantchemotherapyforbreastcancer?
Item
Did patient receive adjuvant chemotherapy? (If no, remaining questions do not apply.)
boolean
Chemotherapy Start Date
Item
Chemotherapy Treatment Start Date
date
C25164 (NCI Thesaurus ValueDomain)
C1302181 (UMLS CUI-1)
C15632 (NCI Thesaurus ObjectClass)
C3173309 (UMLS CUI-2)
C25431 (NCI Thesaurus ValueDomain-2)
C25382 (NCI Thesaurus Property)
ChemotherapyAdministeredEndDate
Item
Chemotherapy Treatment End Date (date of last dose)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
C15632 (NCI Thesaurus ObjectClass)
C0392920 (UMLS 2011AA ObjectClass)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
Item
Adjuvant Chemotherapy (mark all types of chemotherapy patient received)
text
C25284 (NCI Thesaurus ValueDomain)
C0332307 (UMLS 2011AA ValueDomain)
C15632 (NCI Thesaurus ObjectClass)
C0392920 (UMLS 2011AA ObjectClass)
C2140 (NCI Thesaurus ObjectClass-2)
C0001552 (UMLS 2011AA ObjectClass-2)
C25382 (NCI Thesaurus Property)
C1521801 (UMLS 2011AA Property)
CL.5
Code List
Adjuvant Chemotherapy (mark all types of chemotherapy patient received)
CL Item
Anthracyclines (Anthracyclines)
CL Item
Taxanes (Taxanes)
CL Item
Other (Other)
C17649 (NCI Thesaurus)
C0205394 (UMLS 2011AA)
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