308 lines
7.9 KiB
Plaintext
308 lines
7.9 KiB
Plaintext
English French Notes Complete/Exclude
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DATE OF LAST CONTACT:
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TUMOR STATUS:
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ICD Revision:
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Place of Death:
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Care Center at Death:
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Autopsy:
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Autopsy Date/Time:
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Autopsy No:
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ICD Cause of Death:
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Cause of Death/Cancer:
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Date of Death:
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Path/autopsy:
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Religion:
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Marital Status at Dx:
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Occupation:
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Last Date:
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Type of Tobacco user:
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YR. Quit Tobacco Use:
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Yrs. of Alcohol Use:
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Drinks per-day:
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Yr. Quit Drinking:
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Family Member with Cancer:
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Cancer:
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Primary Surgeon:
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Managing Physician:
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Following Physician:
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Other Physician 3:
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Other Physician 4:
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DX Date:
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Class of Case:
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Type of Reporting Source:
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Histology:
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Dx Facility:
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Text Histology:
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Grade:
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Tumor Marker 2:
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ICDO-Site:
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Referring Facility:
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Laterality:
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Transfer Facility:
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DX Confirmation:
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Primary Payer at Diagnosis:
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IP/OP status:
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Screening Result:
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Screening Date:
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Presentation at Cancer Conference:
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Date of Cancer Conference:
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Referral to Support Services:
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Site/Gp:
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Primary Sequence No:
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Text-Primary Site Title:
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Text-Dx Proc-PE:
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Text-Dx Proc-X-ray/scan:
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Text-Dx Proc-Op:
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Text-Dx Proc-Lab Tests:
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Text-Dx Proc-Scopes:
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Text-Dx Proc-Path:
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Text Primary Site:
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Text Dx Proc-Phys.Exam:
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Text Dx Proc-Xray/Scan:
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Text Dx Proc-Operation:
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Text Dx Proc-Lab Tests:
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Text Dx Proc-Endoscopy:
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Text Dx Proc-Path/Cyto:
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Clinical TNM:
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Clinical T:
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Pathologic T:
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Clinical N:
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Pathologic N:
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Clinical M:
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Pathologic M:
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Clinical Stage Group:
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Staged By (Clin):
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Other Stage:
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Size of Tumor:
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Positive nodes:
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Peripheral Blood Inv.:
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Nodes Examined:
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Associated with HIV:
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Extension:
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Metastasis-1:
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Lymph Nodes:
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Metastasis-2:
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General Summary Stage:
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Metastasis-3:
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Dx/Stging/Palliative Proc:
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Surgery of Primary Site Date:
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Surgical Approach:
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Reconstruction/Restoration:
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- Text Rx-Surgery/No Surgery:
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- Text Rx-Other Cancer Directed Surgery:
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Surgical Margins:
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Reason for No Surgery:
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Radiation Date:
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Regional Dose:
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Radiation tx not administered
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NA, brachytherapy/radioisotopes administered
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Dose unknown/unknown if administered
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Regional Treatment Modality:
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Reason for No Radiation:
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Sequence:
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Radiation Treatment - (either radiation or prophylactic)
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Target Place:
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Target Site:
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Radiation Source:
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Total due to target:
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Predominant FXN size:
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Start Date:
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Stop Date:
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- Text Rx-Rad (BEAM):
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- Text Rx-Rad-Other:
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Radiation Therapy to CNS DAte:
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Chemotherapy Date:
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Reason for No Chemotherapy:
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Text-Rx-Chemo:
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Hormone Therapy Date:
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Reason for No Hormone Therapy:
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Text-Rx-Hormone:
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Immunotherapy Date:
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Text-RX-Immunotherapy:
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Other Therapy Date:
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Text-Rx-Other:
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Protocol Eligibility Status:
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Protocol Participation:
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Text Remarks:
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Physician's Staging:
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MD:
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QA Selected:
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QA Review:
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QA Date:
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Recurrence Date:
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Distant Site 1:
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Type of 1st Recurrence:
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Distant Site 2:
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Distant Site 3:
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Subsequent Recurrence Date:
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Type of Subsequent Recurrence:
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********** Print Abstract-Brief **********
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Reporting Hospital:
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Date of First Contact:
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Histology:
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Acc/Seq Number:
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Medical Record Number:
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Telephone:
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Type of Reporting Source:
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Class of Case:
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Age at Dx:
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Birthplace:
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Facility referred from:
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Facility referred to:
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Date Dx:
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Following physician:
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Primary surgeon:
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Physician #3:
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Physician #4:
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Laterality:
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Diagnostic confirmation:
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Tumor size:
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Extension:
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Regional lymph nodes positive:
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Regional lymph nodes examined:
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Lymph nodes:
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SEER Summary Stage 2000:
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Sites of metastases:
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Clinical TNM:
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AJCC Stage (Clin):
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AJCC Stage (Path):
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FIRST COURSE OF TREATMENT SUMMARY:
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Dx/Staging/Palliative Proc:
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Surgery of primary site:
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Reason for no surgery:
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Radiation:
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Reason for no radiation:
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Hormone Therapy:
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Immunotherapy:
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Other treatment:
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Abstract Date:
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Abstracter:
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Date of Last Patient Contact:
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AVAILABLE CONTACTS
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***********DEATH INFORMATION**********
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Date:
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Cause of Death/Cancer:
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ICD Cause:
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Care Center:
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ICD Revision:
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Path/Autopsy (Gross & Micro):
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State Hospital No:
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IDCO SITE:
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GRADE:
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Sequence Number:
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DATE of LAST CONTACT:
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VITAL STATUS:
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ABSTRACTER:
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ABSTRACT DATE:
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Spanish origin:
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CONTACT NAME
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Follow-up Status:
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DATE LAST
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Site/Gp:
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PATIENT SUMMARY
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Date of Last Contact or Death:
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Autopsy Date/Time:
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Autopsy #:
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Cause of Death:
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Abstract Status:
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Date Case Completed:
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Primary Site:
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Patient Summary/Abstract for:
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** PATIENT IDENTIFICATION **
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Address at Dx:
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Accession No:
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Hospital No:
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Accession Yr:
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Primary Sequence No:
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Phone Residence:
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Marital Status DX:
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Agent Orange Exp:
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Ionizing Rad Exp:
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Chemical Exp:
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Asbestos Exp:
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Persian Gulf Svc:
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Middle East Svc:
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Somalia Svc:
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Comorbidity/Complication #1:
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Comorbidity/Complication #2:
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Comorbidity/Complication #3:
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Comorbidity/Complication #4:
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Comorbidity/Complication #5:
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Comorbidity/Complication #6:
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Primary Surgeon:
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Following Physician:
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** CANCER IDENTIFICATION **
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Date DX:
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Histology:
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AFIP Submission:
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Primary Site:
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** STAGE OF DISEASE AT DIAGNOSIS **
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Clinical TNM:
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Pathologic TNM:
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Clinical Stage Group:
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Pathologic Stage Group:
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Staged By (Clinical Stage):
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Staged By (Pathologic Stage):
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Other Stage:
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Pathologic Extension:
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Lymph Nodes:
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General Summary Stage:
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Metastasis-1:
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Metastasis-2:
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Metastasis-3:
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** FIRST COURSE OF TREATMENT **
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First Course of Treatment Date:
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Date of No Treatment:
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Surgery of Primary (F):
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Surgery of Primary @Fac (F):
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Surgical Margins:
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Scope of LN Surgery (F):
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Scope of LN Surgery @Fac (F):
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Surg Proc/Other Site (F):
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Surg Proc/Other Site @Fac (F):
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Reason for No Surgery:
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Regional Dose:
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Regional Treatment Modality:
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Chemotherapy:
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Chemotherapy @Fac:
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Hormone Therapy:
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Hormone Therapy @Fac:
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Immunotherapy:
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Immunotherapy @Fac:
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Other Treatment:
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Other Treatment @Fac:
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Year Put on Protocol:
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** SUBSEQUENT THERAPY **
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Subsequent Treatment Date:
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Surgery of Primary Site:
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Hema Trans/Endocrine Proc:
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** FOLLOW-UP HISTORY **
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Cause of Death:
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1998 Patient Care Evaluation Study of Prostate Cancer
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1998 Patient Care Evaluation Study of Prostate Cancer
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8. PRIMARY PAYER AT DIAGNOSIS
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9. FAMILY HISTORY OF PROSTATE CANCER
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8. PRIMARY PAYER AT DIAGNOSIS
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9. FAMILY HISTORY OF PROSTATE CANCER
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TABLE I - GENERAL INFORMATION
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9 4. POSTAL CODE AT DIAGNOSIS.........
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9 7. SPANISH ORIGIN...................
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18 8. PRIMARY PAYER AT DIAGNOSIS.......
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657 9. FAMILY HISTORY OF PROSTATE CANCER
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10. CLASS OF CASE
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11. SYMPTOMS PRESENT AT INITIAL DIAGNOSIS
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12. INITIAL METHODS OF DIAGNOSIS
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13. DIAGNOSTIC EVALUATION
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14. RESULTS OF MOST RECENT PRE-TREATMENT PSA TEST
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18. BEHAVIOR CODE(ICD-O-2)
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20. BIOPSY PROCEDURE
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21. GUIDANCE OF BIOPSY TO PRIMARY
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22. BIOPSY APPROACH FOR PRIMARY
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23. BIOPSY OF OTHER THAN PRIMARY
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24. DIAGNOSTIC CONFIRMATION
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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