ID

9417

Descrição

FORM 5M - MINIMAL FOLLOW-UP REPORT Quality Of Life Companion Study For JMA27 (NCIC-MA.27): A Randomized Phase III Trial Of Exemestane Versus Anastrozole With Or Without Celecoxib In Postmenopausal Women With Receptor Positive Primary Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=ABF3BD71-F788-63E3-E034-0003BA12F5E7

Link

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=ABF3BD71-F788-63E3-E034-0003BA12F5E7

Palavras-chave

Versões (2)
  1. 26/08/2012 26/08/2012 -
  2. 09/01/2015 09/01/2015 - Martin Dugas
Transferido a

9 de janeiro de 2015

DOI

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Licença

Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00090974 Follow-Up - FORM 5M - MINIMAL FOLLOW-UP REPORT - 2064122v3.0

Inglês

USA Centres: Send CRFs to CTSU.

1 Formulários  
  1. StudyEvent: FORM 5M - MINIMAL FOLLOW-UP REPORT
    1. USA Centres: Send CRFs to CTSU.
Patient Information
Descrição

Patient Information

Patient Study ID, Coordinating Group
Descrição

PatientStudyID,CoordinatingGroup

Tipo de dados

text

Patient Initials (first - middle - last)
Descrição

Patient Initials

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Patient Medical Record Number
Descrição

PatientMedicalRecordNumber

Tipo de dados

text

Investigator Name
Descrição

InvestigatorName

Tipo de dados

text

Institution Name
Descrição

InstitutionName

Tipo de dados

text

Registered Investigator (NCI Investigator #)
Descrição

RegisteredInvestigator

Tipo de dados

text

Status
Descrição

Status

Date of Last Contact or Death (yyyy mmm dd)
Descrição

DeathDate/LastContactDate

Tipo de dados

date

Patient's Vital Status
Descrição

Patient'sVitalStatus

Tipo de dados

text

Primary Cause of Death
Descrição

PrimaryCauseofDeath

Tipo de dados

text

Due to other cause, describe primary cause of death
Descrição

DeathReason,Specify

Tipo de dados

text

Due to other cause, describe primary cause of death
Descrição

DeathReason,Specify

Tipo de dados

text

Has the patient been diagnosed with first local-regional recurrence? (since submission of the last follow-up form)
Descrição

ProgressionInd,FirstLocal-Regional

Tipo de dados

boolean

Date of First Local-Regional Progression (yyyy mmm dd)
Descrição

ProgressionDate,FirstLocal-Regional

Tipo de dados

date

Has the patient been diagnosed with first distant recurrence/progression?
Descrição

ProgressionInd,FirstDistant

Tipo de dados

boolean

Date of First Distant Progression (yyyy mmm dd)
Descrição

ProgressionDate,FirstDistant

Tipo de dados

date

Has the patient been diagnosed with contralateral breast cancer? (since submission of the last follow-up form)
Descrição

Hasthepatientbeendiagnosedwithcontralateralbreastcancer?

Tipo de dados

boolean

Alias
NCI Thesaurus ValueDomain
C38148
UMLS 2011AA ValueDomain
C1512699
Date of Diagnosis of Contralateral Breast Cancer (yyyy mmm dd)
Descrição

ContralateralBreastCancerDiagnosisDate

Tipo de dados

date

Alias
NCI Thesaurus ObjectClass
C12971
UMLS 2011AA ObjectClass
C0006141
NCI Thesaurus ObjectClass-2
C9305
UMLS 2011AA ObjectClass-2
C0006826
NCI Thesaurus ObjectClass-3
C25307
UMLS 2011AA ObjectClass-3
C0441988
NCI Thesaurus Property
C15220
UMLS 2011AA Property
C0011900
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Other Malignancies Or Myelodysplastic Syndrome
Descrição

Other Malignancies Or Myelodysplastic Syndrome

Has a new primary cancer or MDS been diagnosed that has not been previously reported?
Descrição

NewPrimaryCancerInd

Tipo de dados

boolean

Date of diagnosis (yyyy mmm dd)
Descrição

NewPrimaryCancerDate

Tipo de dados

date

Alias
NCI Thesaurus ValueDomain
C25164
UMLS 2011AA ValueDomain
C0011008
Malignancy Type
Descrição

MalignancyType

Tipo de dados

text

Site(s) of New Primary
Descrição

NewPrimarySite

Tipo de dados

text

Describe (new primary cancer or MDS)
Descrição

NewPrimaryDiagnosis

Tipo de dados

text

Header
Descrição

Header

Patient Study ID, Coordinating Group
Descrição

PatientStudyID,CoordinatingGroup

Tipo de dados

text

Patient Initials (first - middle - last)
Descrição

Patient Initials

Tipo de dados

text

Alias
NCI Thesaurus ValueDomain
C25191
UMLS CUI-1
C2986440
NCI Thesaurus ObjectClass
C16960
NCI Thesaurus Property
C25536
Comments
Descrição

Comments

COMMENTS
Descrição

Comments

Tipo de dados

text

Investigator Signature
Descrição

Investigator Signature

Investigator Signature
Descrição

InvestigatorSignature

Tipo de dados

text

Alias
NCI Thesaurus Property
C25678
UMLS 2011AA Property
C1519316
NCI Thesaurus ObjectClass
C17089
UMLS 2011AA ObjectClass
C0035173
Person Completing Form, Last Name
Descrição

PersonCompletingForm,LastName

Tipo de dados

text

Person Completing Form, First Name
Descrição

PersonCompletingForm,FirstName

Tipo de dados

text

Alias
NCI Thesaurus ObjectClass
C25190
UMLS 2011AA ObjectClass
C0027361
NCI Thesaurus Property
C25364
UMLS 2011AA Property
C0600091
Form Completion Date, Original (yyyy mmm dd)
Descrição

FormCompletionDate,Original

Tipo de dados

date

Ccrr Module For Form 5m - Minimal Follow-up Report
Descrição

Ccrr Module For Form 5m - Minimal Follow-up Report

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Similar models

USA Centres: Send CRFs to CTSU.

1 Formulários
  1. StudyEvent: FORM 5M - MINIMAL FOLLOW-UP REPORT
    1. USA Centres: Send CRFs to CTSU.
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de dados
Alias
Item Group
Patient Information
PatientStudyID,CoordinatingGroup
Item
Patient Study ID, Coordinating Group
text
Patient Initials
Item
Patient Initials (first - middle - last)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
PatientMedicalRecordNumber
Item
Patient Medical Record Number
text
InvestigatorName
Item
Investigator Name
text
InstitutionName
Item
Institution Name
text
RegisteredInvestigator
Item
Registered Investigator (NCI Investigator #)
text
Item Group
Status
DeathDate/LastContactDate
Item
Date of Last Contact or Death (yyyy mmm dd)
date
Item
Patient's Vital Status
text
CL.1
Code List
Patient's Vital Status
CL Item
Alive (Alive)
CL Item
Dead (Dead)
Item
Primary Cause of Death
text
CL.2
Code List
Primary Cause of Death
CL Item
Due To This Disease (Due to this disease)
CL Item
Due To Protocol Treatment (Due to protocol treatment)
CL Item
Cardiovascular death (specify) (Cardiovascular death (specify))
CL Item
Due To Other Cause, Specify (Due to other cause, describe primary cause of death)
DeathReason,Specify
Item
Due to other cause, describe primary cause of death
text
DeathReason,Specify
Item
Due to other cause, describe primary cause of death
text
ProgressionInd,FirstLocal-Regional
Item
Has the patient been diagnosed with first local-regional recurrence? (since submission of the last follow-up form)
boolean
ProgressionDate,FirstLocal-Regional
Item
Date of First Local-Regional Progression (yyyy mmm dd)
date
ProgressionInd,FirstDistant
Item
Has the patient been diagnosed with first distant recurrence/progression?
boolean
ProgressionDate,FirstDistant
Item
Date of First Distant Progression (yyyy mmm dd)
date
Hasthepatientbeendiagnosedwithcontralateralbreastcancer?
Item
Has the patient been diagnosed with contralateral breast cancer? (since submission of the last follow-up form)
boolean
C38148 (NCI Thesaurus ValueDomain)
C1512699 (UMLS 2011AA ValueDomain)
ContralateralBreastCancerDiagnosisDate
Item
Date of Diagnosis of Contralateral Breast Cancer (yyyy mmm dd)
date
C12971 (NCI Thesaurus ObjectClass)
C0006141 (UMLS 2011AA ObjectClass)
C9305 (NCI Thesaurus ObjectClass-2)
C0006826 (UMLS 2011AA ObjectClass-2)
C25307 (NCI Thesaurus ObjectClass-3)
C0441988 (UMLS 2011AA ObjectClass-3)
C15220 (NCI Thesaurus Property)
C0011900 (UMLS 2011AA Property)
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
Item Group
Other Malignancies Or Myelodysplastic Syndrome
NewPrimaryCancerInd
Item
Has a new primary cancer or MDS been diagnosed that has not been previously reported?
boolean
NewPrimaryCancerDate
Item
Date of diagnosis (yyyy mmm dd)
date
C25164 (NCI Thesaurus ValueDomain)
C0011008 (UMLS 2011AA ValueDomain)
MalignancyType
Item
Malignancy Type
text
NewPrimarySite
Item
Site(s) of New Primary
text
NewPrimaryDiagnosis
Item
Describe (new primary cancer or MDS)
text
Item Group
Header
PatientStudyID,CoordinatingGroup
Item
Patient Study ID, Coordinating Group
text
Patient Initials
Item
Patient Initials (first - middle - last)
text
C25191 (NCI Thesaurus ValueDomain)
C2986440 (UMLS CUI-1)
C16960 (NCI Thesaurus ObjectClass)
C25536 (NCI Thesaurus Property)
Item Group
Comments
Comments
Item
COMMENTS
text
Item Group
Investigator Signature
InvestigatorSignature
Item
Investigator Signature
text
C25678 (NCI Thesaurus Property)
C1519316 (UMLS 2011AA Property)
C17089 (NCI Thesaurus ObjectClass)
C0035173 (UMLS 2011AA ObjectClass)
PersonCompletingForm,LastName
Item
Person Completing Form, Last Name
text
PersonCompletingForm,FirstName
Item
Person Completing Form, First Name
text
C25190 (NCI Thesaurus ObjectClass)
C0027361 (UMLS 2011AA ObjectClass)
C25364 (NCI Thesaurus Property)
C0600091 (UMLS 2011AA Property)
FormCompletionDate,Original
Item
Form Completion Date, Original (yyyy mmm dd)
date
Item Group
Ccrr Module For Form 5m - Minimal Follow-up Report
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