Form:Canary: PASS Follow-up v3.0


CDE IDCDE Description
* 421EDRN Participant ID (Go To: 1219)
* 1219Date of contact (MM/DD/YYYY): (Go To: 423)
* 423EDRN Protocol ID (Go To: 422)
* 422EDRN Site ID (Go To: 929)
* 929EDRN Staff ID of the person who collected the data: (Go To: 2176)
* 2176Visit code (Go To: 578)
 
Permissible Values (value):Y1V06 (20)
 
 Y1V12 (21)
 
 Y2V06 (22)
 
 Y2V12 (23)
 
 Y3V06 (24)
 
 Y3V12 (25)
 
 Y4V06 (26)
 
 Y4V12 (27)
 
 Y5V06 (28)
 
 Y5V12 (29)
 
 Y6V12 (51)
 
 Y7V12 (53)
 
 Y8V12 (55)
 
 Y9V12 (57)
 
 Y10V12 (59)
* 578Age at specimen collection (Go To: 4546)
* 4546Has the participant had a biomarker test performed? (Go To: 3298)
 
Permissible Values (value):No (0)
 
 Yes (1) (Go To: 3214)
 
 Unknown (99)
* 3214Number of subform loops to record 2: (Go To: 3201)
 
Permissible Values (value):1 (1)
 
 2 (2)
 
 3 (3)
 
 4 (4)
 
 5 (5)
 
 6 (6)
 
 7 (7)
 
 8 (8)
 
 9 (9)
 
 10 (10)
   3201Line number or identifier 2 (system-generated): (Go To: 4547)
* 4547Prostate biomarker test name: (Go To: 4548)
 
Permissible Values (value):4Kscore (1)
 
 ConfirmMDx (2)
 
 Decipher (3)
 
 Oncotype DX for Prostate Cancer (GPS) (4)
 
 PCA3 (5)
 
 Prolaris (6)
 
 Prostate Health Index (PHI) (7)
 
 Select MDx (8)
 
 Other, specify: (97)
 
 Unknown (99)
   4548Biomarker test name (Other, specify): (Go To: 4551)
* 4551Date of biomarker test (MM/DD/YYYY) (Go To: 4549)
* 4549Biomarker test result: (Go To: 3163)
   3163Loop-specific comments 2: (Go To: 3298)
* 3298Biopsy since last study contact? (Go To: 2178)
 
Permissible Values (value):No (0)
 
 Yes (1) (Go To: 973)
 
 Unknown/refused (9)
* 973Date of prostate biopsy (MM/DD/YYYY): (Go To: 3299)
* 3299Any infection, bleeding, or urinary retention as a result of the procedure? (Go To: 2178)
 
Permissible Values (value):No (0)
 
 Yes (1)
 
 Unknown/refused (9)
* 2178Since your last routine study contact, have you been told by a doctor that you have any of the following genitourinary conditions? (Check all that apply.) (Go To: 2199)
 
Permissible Values (value):No (0)
 
 [Males only] BPH (Benign prostatic hypertrophy) (1)
 
 [Males only] Prostatitis (an inflamed prostate) (3)
 
 Unknown/refused (99)
* 2199Treatment for genitourinary condition: (Go To: 1576)
 
Permissible Values (value):Medication (1)
 
 Surgery (3)
 
 None (44)
 
 Other, specify: (97) (Go To: 2198)
* 2198Treatment for genitourinary condition (Other, specify): (Go To: 1576)
* 1576American Urological Association (AUA) symptom score: (Go To: 1691)
* 1691Quality of life due to urinary symptoms: (Go To: 1045)
 
Permissible Values (value):Delighted (0)
 
 Pleased (1)
 
 Mostly satisfied (2)
 
 Mixed (3)
 
 Mostly dissatisfied (4)
 
 Unhappy (5)
 
 Terrible (6)
 
 Not collected (90)
* 1045Performance status (Which of the following options would you say describes your current performance status?) (Go To: 2190)
 
Permissible Values (value):Fully active, able to carry on all pre-disease performance without restriction (0)
 
 Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work (1)
 
 Ambulatory and capable of all selfcare but unable to carry out any work activities. Up and about more than 50% of waking hours (2)
 
 Capable of only limited selfcare, confined to bed or chair more than 50% of waking hours (3)
 
 Completely disabled. Cannot carry on any selfcare. Totally confined to bed or chair (4)
* 2190Have your smoking habits changed since your last routine study contact? (Go To: 2196)
 
Permissible Values (value):No (0)
 
 Yes (1) (Go To: 1299)
 
 Unknown/refused (9)
* 1299Currently smoke at least one cigarette a day? (Do you currently smoke cigarettes regularly, at least one a day?) (Go To: 1325)
 
Permissible Values (value):No (0) (Go To: 1298)
 
 Yes (1)
 
 Unknown/refused (9)
* 1298Age quit smoking cigarettes? (How old were you when you permanently quit smoking cigarettes?) (Go To: 1325)
* 1325Average number of cigarettes smoked per day? (During the time you have smoked, on average, how many cigarettes did you smoke per day?) (Go To: 2196)
* 2196Has your alcohol use changed since your last routine study contact? (Go To: 1334)
 
Permissible Values (value):No (0)
 
 Yes (1) (Go To: 1329)
 
 Unknown/refused (9)
   1329On average, how many glasses of wine do you drink? Count a four-ounce glass of wine as one drink. (Go To: 1330)
 
Permissible Values (value):None (4)
 
 <1 per week (5)
 
 1-6 per week (6)
 
 1-2 per day (7)
 
 3-5 per day (8)
 
 6+ per day (9)
   1330On average, how many glasses/cans of beer do you drink? Count a twelve-ounce can as one beer. (Go To: 1331)
 
Permissible Values (value):None (4)
 
 <1 per week (5)
 
 1-6 per week (6)
 
 1-2 per day (7)
 
 3-5 per day (8)
 
 6+ per day (9)
   1331On average, how many shots of hard liquor or mixed drinks do you drink? Count one shot (1 1/2 ounces) or one mixed drink as one drink. (Go To: 1334)
 
Permissible Values (value):None (4)
 
 <1 per week (5)
 
 1-6 per week (6)
 
 1-2 per day (7)
 
 3-5 per day (8)
 
 6+ per day (9)
* 1334New primary cancer [other than basal/squamous cell skin cancer] confirmed by a doctor since last routine study contact? (Have you been diagnosed with a new primary cancer [other than basal/squamous cell skin cancer] since your last routine study contact?) (Go To: 1295)
 
Permissible Values (value):No (0)
 
 Yes (1) (Go To: 1343)
 
 Unknown/refused (9)
* 1343Cancer type/location (Go To: 2148)
 
Permissible Values (value):Bladder (1)
 
 Bone (2)
 
 Brain (3)
 
 Breast (4)
 
 Colon (6)
 
 Esophagus (7)
 
 Head & neck (mouth, nose, and throat) (8)
 
 Kidney (9)
 
 Liver (10)
 
 Leukemia (11)
 
 Lung (12)
 
 Lymphoma, including Hodgkins (13)
 
 Pancreas (15)
 
 Rectum (17)
 
 Skin (melanoma, no basal or squamous) (18)
 
 Stomach (19)
 
 Thyroid (20)
 
 Testis (24)
 
 Other, specify: (97) (Go To: 1335)
 
 Unknown/refused (999)
* 1335Cancer type/location (Other,specify): (Go To: 2148)
* 2148Primary cancer treatment(s) received: (Go To: 1295)
 
Permissible Values (value):Chemotherapy (1)
 
 Radiation therapy (2)
 
 Surgery (3)
 
 Hormone therapy (4)
 
 Cryotherapy (5)
 
 Unknown/refused (9)
 
 None (44)
 
 Other, specify: (97) (Go To: 2150)
* 2150Primary cancer treatment(s) received: (Other, specify) (Go To: 1295)
* 1295Weight [in pounds] (What is your current weight [in pounds]? (Go To: 979)
* 979Date of digital rectal exam (DRE) (MM/DD/YYYY): (Go To: 976)
* 976Digital rectal exam results: (Go To: 975)
 
Permissible Values (value):Normal (1)
 
 Abnormal, clearly suspicious for cancer (6)
 
 Unknown/refused (99)
* 975Prostate T-Stage, Clinical (Go To: 2179)
 
Permissible Values (value):T0 (2)
 
 T1a (4)
 
 T1b (5)
 
 T1c (6)
 
 T2a (8)
 
 T2b (9)
 
 T2c (10)
 
 T3a (12)
 
 T3b (13)
 
 T4 (14)
 
 TX (15)
* 2179Prostate N-Stage, Clinical: (Go To: 1694)
 
Permissible Values (value):NX (1)
 
 N0 (2)
 
 N1 (5)
* 1694Prostate M-Stage, Clinical : (Go To: 1360)
 
Permissible Values (value):MX (1)
 
 M0 (2)
 
 M1 (3)
 
 M1a (4)
 
 M1b (5)
 
 M1c (6)
* 1360Have any of your first degree blood relatives (biological parents, siblings, children) been diagnosed with cancer [other than basal/squamous cell skin cancer] since your last routine study contact? [Not including half-siblings, step-siblings, or step-children.] (Go To: 1097)
 
Permissible Values (value):No (0)
 
 Yes (1) (Go To: 3143)
 
 Unknown/refused (9)
* 3143Number of relative´s cancers to record: (Go To: 3202)
 
Permissible Values (value):1 (1)
 
 2 (2)
 
 3 (3)
 
 4 (4)
 
 5 (5)
 
 6 (6)
 
 7 (7)
 
 8 (8)
 
 9 (9)
 
 10 (10)
* 3202Line number or identifier 3 (system-generated): (Go To: 1351)
* 1351Relative type (mother, brother, etc) (Go To: 1311)
 
Permissible Values (value):Brother (1)
 
 Sister (2)
 
 Son (3)
 
 Daughter (4)
 
 Father (5)
 
 Mother (6)
 
 Refused (88)
 
 Unknown (99)
* 1311First primary cancer: (Go To: 1430)
 
Permissible Values (value):Bladder (1)
 
 Bone (2)
 
 Brain (3)
 
 Breast (4)
 
 Cervix (5)
 
 Colon (6)
 
 Esophagus (7)
 
 Head & neck (mouth, nose, and throat) (8)
 
 Kidney (9)
 
 Liver (10)
 
 Leukemia (11)
 
 Lung (12)
 
 Lymphoma, including Hodgkins (13)
 
 Ovary (14)
 
 Pancreas (15)
 
 Prostate (16)
 
 Rectum (17)
 
 Skin (melanoma, no basal or squamous) (18)
 
 Stomach (19)
 
 Thyroid (20)
 
 Uterus (21)
 
 Endometrium (22)
 
 Testis (24)
 
 Vagina (26)
 
 Gall bladder (40)
 
 Mesothelioma (42)
 
 Multiple myeloma (44)
 
 Fallopian tube (45)
 
 Primary peritoneal cancer (46)
 
 Refused (88)
 
 Other, specify: (97) (Go To: 1310)
 
 Unknown (99)
* 1310Cancer type/Location (Other, specify) (Go To: 1430)
   1430Relative´s age when diagnosed (Go To: 1317)
   1317Subsequent primary cancer(s): (Go To: 3272)
 
Permissible Values (value):None (0)
 
 Bladder (1)
 
 Bone (2)
 
 Brain (3)
 
 Breast (4)
 
 Cervix (5)
 
 Colon (6)
 
 Esophagus (7)
 
 Head & neck (mouth, nose, and throat) (8)
 
 Kidney (9)
 
 Liver (10)
 
 Leukemia (11)
 
 Lung (12)
 
 Lymphoma, including Hodgkins (13)
 
 Ovary (14)
 
 Pancreas (15)
 
 Prostate (16)
 
 Rectum (17)
 
 Skin (melanoma, no basal or squamous) (18)
 
 Stomach (19)
 
 Thyroid (20)
 
 Uterus (21)
 
 Endometrium (22)
 
 Testis (24)
 
 Vagina (26)
 
 Gall bladder (40)
 
 Mesothelioma (42)
 
 Multiple myeloma (44)
 
 Fallopian tube (45)
 
 Primary peritoneal cancer (46)
 
 Refused (88)
 
 Other (95)
 
 Unknown (99)
   3272Loop-specific comments 5: (Go To: 1097)
   1097Comments (do not include any participant identifiers) (Go To: End of Form)