| 1 | English French  Notes   Complete/Exclude | 
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| 2 | DATE OF LAST CONTACT: | 
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| 3 | TUMOR STATUS: | 
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| 4 | ICD Revision: | 
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| 5 | Place of Death: | 
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| 6 | Care Center at Death: | 
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| 7 | Autopsy: | 
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| 8 | Autopsy Date/Time: | 
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| 9 | Autopsy No: | 
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| 10 | ICD Cause of Death: | 
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| 11 | Cause of Death/Cancer: | 
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| 12 | Date of Death: | 
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| 13 | Path/autopsy: | 
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| 14 | Religion: | 
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| 15 | Marital Status at Dx: | 
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| 16 | Occupation: | 
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| 17 | Last Date: | 
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| 18 | Type of Tobacco user: | 
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| 19 | YR. Quit Tobacco Use: | 
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| 20 | Yrs. of Alcohol Use: | 
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| 21 | Drinks per-day: | 
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| 22 | Yr. Quit Drinking: | 
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| 23 | Family Member with Cancer: | 
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| 24 | Cancer: | 
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| 25 | Primary Surgeon: | 
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| 26 | Managing Physician: | 
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| 27 | Following Physician: | 
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| 28 | Other Physician 3: | 
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| 29 | Other Physician 4: | 
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| 30 | DX Date: | 
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| 31 | Class of Case: | 
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| 32 | Type of Reporting Source: | 
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| 33 | Histology: | 
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| 34 | Dx Facility: | 
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| 35 | Text Histology: | 
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| 36 | Grade: | 
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| 37 | Tumor Marker 2: | 
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| 38 | ICDO-Site: | 
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| 39 | Referring Facility: | 
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| 40 | Laterality: | 
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| 41 | Transfer Facility: | 
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| 42 | DX Confirmation: | 
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| 43 | Primary Payer at Diagnosis: | 
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| 44 | IP/OP status: | 
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| 45 | Screening Result: | 
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| 46 | Screening Date: | 
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| 47 | Presentation at Cancer Conference: | 
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| 48 | Date of Cancer Conference: | 
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| 49 | Referral to Support Services: | 
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| 50 | Site/Gp: | 
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| 51 | Primary Sequence No: | 
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| 52 | Text-Primary Site Title: | 
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| 53 | Text-Dx Proc-PE: | 
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| 54 | Text-Dx Proc-X-ray/scan: | 
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| 55 | Text-Dx Proc-Op: | 
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| 56 | Text-Dx Proc-Lab Tests: | 
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| 57 | Text-Dx Proc-Scopes: | 
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| 58 | Text-Dx Proc-Path: | 
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| 59 | Text Primary Site: | 
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| 60 | Text Dx Proc-Phys.Exam: | 
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| 61 | Text Dx Proc-Xray/Scan: | 
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| 62 | Text Dx Proc-Operation: | 
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| 63 | Text Dx Proc-Lab Tests: | 
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| 64 | Text Dx Proc-Endoscopy: | 
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| 65 | Text Dx Proc-Path/Cyto: | 
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| 66 | Clinical TNM: | 
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| 67 | Clinical T: | 
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| 68 | Pathologic T: | 
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| 69 | Clinical N: | 
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| 70 | Pathologic N: | 
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| 71 | Clinical M: | 
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| 72 | Pathologic M: | 
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| 73 | Clinical Stage Group: | 
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| 74 | Staged By (Clin): | 
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| 75 | Other Stage: | 
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| 76 | Size of Tumor: | 
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| 77 | Positive nodes: | 
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| 78 | Peripheral Blood Inv.: | 
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| 79 | Nodes Examined: | 
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| 80 | Associated with HIV: | 
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| 81 | Extension: | 
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| 82 | Metastasis-1: | 
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| 83 | Lymph Nodes: | 
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| 84 | Metastasis-2: | 
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| 85 | General Summary Stage: | 
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| 86 | Metastasis-3: | 
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| 87 | Dx/Stging/Palliative Proc: | 
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| 88 | Surgery of Primary Site Date: | 
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| 89 | Surgical Approach: | 
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| 90 | Reconstruction/Restoration: | 
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| 91 | - Text Rx-Surgery/No Surgery: | 
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| 92 | - Text Rx-Other Cancer Directed Surgery: | 
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| 93 | Surgical Margins: | 
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| 94 | Reason for No Surgery: | 
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| 95 | Radiation Date: | 
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| 96 | Regional Dose: | 
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| 97 | Radiation tx not administered | 
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| 98 | NA, brachytherapy/radioisotopes administered | 
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| 99 | Dose unknown/unknown if administered | 
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| 100 | Regional Treatment Modality: | 
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| 101 | Reason for No Radiation: | 
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| 102 | Sequence: | 
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| 103 | Radiation Treatment - (either radiation or prophylactic) | 
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| 104 | Target Place: | 
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| 105 | Target Site: | 
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| 106 | Radiation Source: | 
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| 107 | Total due to target: | 
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| 108 | Predominant FXN size: | 
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| 109 | Start Date: | 
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| 110 | Stop Date: | 
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| 111 | - Text Rx-Rad (BEAM): | 
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| 112 | - Text Rx-Rad-Other: | 
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| 113 | Radiation Therapy to CNS DAte: | 
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| 114 | Chemotherapy Date: | 
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| 115 | Reason for No Chemotherapy: | 
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| 116 | Text-Rx-Chemo: | 
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| 117 | Hormone Therapy Date: | 
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| 118 | Reason for No Hormone Therapy: | 
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| 119 | Text-Rx-Hormone: | 
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| 120 | Immunotherapy Date: | 
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| 121 | Text-RX-Immunotherapy: | 
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| 122 | Other Therapy Date: | 
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| 123 | Text-Rx-Other: | 
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| 124 | Protocol Eligibility Status: | 
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| 125 | Protocol Participation: | 
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| 126 | Text Remarks: | 
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| 127 | Physician's Staging: | 
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| 128 | MD: | 
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| 129 | QA Selected: | 
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| 130 | QA Review: | 
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| 131 | QA Date: | 
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| 132 | Recurrence Date: | 
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| 133 | Distant Site 1: | 
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| 134 | Type of 1st Recurrence: | 
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| 135 | Distant Site 2: | 
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| 136 | Distant Site 3: | 
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| 137 | Subsequent Recurrence Date: | 
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| 138 | Type of Subsequent Recurrence: | 
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| 139 | **********  Print Abstract-Brief  ********** | 
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| 140 | Reporting Hospital: | 
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| 141 | Date of First Contact: | 
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| 142 | Histology: | 
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| 143 | Acc/Seq Number: | 
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| 144 | Medical Record Number: | 
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| 145 | Telephone: | 
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| 146 | Type of Reporting Source: | 
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| 147 | Class of Case: | 
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| 148 | Age at Dx: | 
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| 149 | Birthplace: | 
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| 150 | Facility referred from: | 
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| 151 | Facility referred to: | 
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| 152 | Date Dx: | 
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| 153 | Following physician: | 
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| 154 | Primary surgeon: | 
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| 155 | Physician #3: | 
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| 156 | Physician #4: | 
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| 157 | Laterality: | 
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| 158 | Diagnostic confirmation: | 
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| 159 | Tumor size: | 
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| 160 | Extension: | 
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| 161 | Regional lymph nodes positive: | 
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| 162 | Regional lymph nodes examined: | 
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| 163 | Lymph nodes: | 
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| 164 | SEER Summary Stage 2000: | 
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| 165 | Sites of metastases: | 
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| 166 | Clinical TNM: | 
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| 167 | AJCC Stage (Clin): | 
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| 168 | AJCC Stage (Path): | 
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| 169 | FIRST COURSE OF TREATMENT SUMMARY: | 
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| 170 | Dx/Staging/Palliative Proc: | 
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| 171 | Surgery of primary site: | 
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| 172 | Reason for no surgery: | 
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| 173 | Radiation: | 
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| 174 | Reason for no radiation: | 
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| 175 | Hormone Therapy: | 
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| 176 | Immunotherapy: | 
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| 177 | Other treatment: | 
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| 178 | Abstract Date: | 
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| 179 | Abstracter: | 
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| 180 | Date of Last Patient Contact: | 
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| 181 | AVAILABLE CONTACTS | 
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| 182 | ***********DEATH INFORMATION********** | 
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| 183 | Date: | 
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| 184 | Cause of Death/Cancer: | 
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| 185 | ICD Cause: | 
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| 186 | Care Center: | 
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| 187 | ICD Revision: | 
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| 188 | Path/Autopsy (Gross & Micro): | 
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| 189 | State Hospital No: | 
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| 190 | IDCO SITE: | 
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| 191 | GRADE: | 
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| 192 | Sequence Number: | 
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| 193 | DATE of LAST CONTACT: | 
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| 194 | VITAL STATUS: | 
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| 195 | ABSTRACTER: | 
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| 196 | ABSTRACT DATE: | 
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| 197 | Spanish origin: | 
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| 198 | CONTACT NAME | 
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| 199 | Follow-up Status: | 
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| 200 | DATE LAST | 
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| 201 | Site/Gp: | 
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| 202 | PATIENT SUMMARY | 
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| 203 | Date of Last Contact or Death: | 
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| 204 | Autopsy Date/Time: | 
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| 205 | Autopsy #: | 
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| 206 | Cause of Death: | 
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| 207 | Abstract Status: | 
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| 208 | Date Case Completed: | 
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| 209 | Primary Site: | 
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| 210 | Patient Summary/Abstract for: | 
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| 211 | ** PATIENT IDENTIFICATION ** | 
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| 212 | Address at Dx: | 
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| 213 | Accession No: | 
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| 214 | Hospital No: | 
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| 215 | Accession Yr: | 
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| 216 | Primary Sequence No: | 
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| 217 | Phone Residence: | 
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| 218 | Marital Status DX: | 
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| 219 | Agent Orange Exp: | 
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| 220 | Ionizing Rad Exp: | 
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| 221 | Chemical Exp: | 
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| 222 | Asbestos Exp: | 
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| 223 | Persian Gulf Svc: | 
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| 224 | Middle East Svc: | 
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| 225 | Somalia Svc: | 
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| 226 | Comorbidity/Complication #1: | 
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| 227 | Comorbidity/Complication #2: | 
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| 228 | Comorbidity/Complication #3: | 
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| 229 | Comorbidity/Complication #4: | 
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| 230 | Comorbidity/Complication #5: | 
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| 231 | Comorbidity/Complication #6: | 
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| 232 | Primary Surgeon: | 
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| 233 | Following Physician: | 
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| 234 | ** CANCER IDENTIFICATION ** | 
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| 235 | Date DX: | 
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| 236 | Histology: | 
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| 237 | AFIP Submission: | 
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| 238 | Primary Site: | 
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| 239 | ** STAGE OF DISEASE AT DIAGNOSIS ** | 
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| 240 | Clinical TNM: | 
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| 241 | Pathologic TNM: | 
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| 242 | Clinical Stage Group: | 
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| 243 | Pathologic Stage Group: | 
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| 244 | Staged By (Clinical Stage): | 
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| 245 | Staged By (Pathologic Stage): | 
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| 246 | Other Stage: | 
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| 247 | Pathologic Extension: | 
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| 248 | Lymph Nodes: | 
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| 249 | General Summary Stage: | 
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| 250 | Metastasis-1: | 
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| 251 | Metastasis-2: | 
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| 252 | Metastasis-3: | 
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| 253 | ** FIRST COURSE OF TREATMENT ** | 
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| 254 | First Course of Treatment Date: | 
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| 255 | Date of No Treatment: | 
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| 256 | Surgery of Primary (F): | 
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| 257 | Surgery of Primary @Fac (F): | 
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| 258 | Surgical Margins: | 
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| 259 | Scope of LN Surgery (F): | 
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| 260 | Scope of LN Surgery @Fac (F): | 
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| 261 | Surg Proc/Other Site (F): | 
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| 262 | Surg Proc/Other Site @Fac (F): | 
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| 263 | Reason for No Surgery: | 
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| 264 | Regional Dose: | 
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| 265 | Regional Treatment Modality: | 
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| 266 | Chemotherapy: | 
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| 267 | Chemotherapy @Fac: | 
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| 268 | Hormone Therapy: | 
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| 269 | Hormone Therapy @Fac: | 
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| 270 | Immunotherapy: | 
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| 271 | Immunotherapy @Fac: | 
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| 272 | Other Treatment: | 
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| 273 | Other Treatment @Fac: | 
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| 274 | Year Put on Protocol: | 
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| 275 | ** SUBSEQUENT THERAPY ** | 
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| 276 | Subsequent Treatment Date: | 
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| 277 | Surgery of Primary Site: | 
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| 278 | Hema Trans/Endocrine Proc: | 
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| 279 | ** FOLLOW-UP HISTORY ** | 
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| 280 | Cause of Death: | 
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| 281 | 1998 Patient Care Evaluation Study of Prostate Cancer | 
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| 282 | 1998 Patient Care Evaluation Study of Prostate Cancer | 
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| 283 | 8. PRIMARY PAYER AT DIAGNOSIS | 
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| 284 | 9. FAMILY HISTORY OF PROSTATE CANCER | 
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| 285 | 8. PRIMARY PAYER AT DIAGNOSIS | 
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| 286 | 9. FAMILY HISTORY OF PROSTATE CANCER | 
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| 287 | TABLE I - GENERAL INFORMATION | 
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| 288 | 9 4. POSTAL CODE AT DIAGNOSIS......... | 
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| 289 | 9 7. SPANISH ORIGIN................... | 
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| 290 | 18 8. PRIMARY PAYER AT DIAGNOSIS....... | 
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| 291 | 657 9. FAMILY HISTORY OF PROSTATE CANCER | 
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| 292 | 10. CLASS OF CASE | 
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| 293 | 11. SYMPTOMS PRESENT AT INITIAL DIAGNOSIS | 
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| 294 | 12. INITIAL METHODS OF DIAGNOSIS | 
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| 295 | 13. DIAGNOSTIC EVALUATION | 
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| 296 | 14. RESULTS OF MOST RECENT PRE-TREATMENT PSA TEST | 
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| 297 | 18. BEHAVIOR CODE(ICD-O-2) | 
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| 298 | 20. BIOPSY PROCEDURE | 
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| 299 | 21. GUIDANCE OF BIOPSY TO PRIMARY | 
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| 300 | 22. BIOPSY APPROACH FOR PRIMARY | 
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| 301 | 23. BIOPSY OF OTHER THAN PRIMARY | 
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| 302 | 24. DIAGNOSTIC CONFIRMATION | 
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| 303 | ####################    ####################    #################### | 
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| 304 | ####################    ####################    #################### | 
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| 305 | ####################    ####################    #################### | 
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| 306 | ####################    ####################    #################### | 
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| 307 | ####################    ####################    #################### | 
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