308 lines
13 KiB
Plaintext
308 lines
13 KiB
Plaintext
English French Notes Complete/Exclude
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25. GLEASON'S SCORE FOR BIOPSY, LOCAL RESECTION, OR SIMPLE PROSTATECTOMY
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26. GLEASON'S SCORE FOR RADICAL PROSTATECTOMY
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18. BEHAVIOR CODE (ICD-O-2)
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10. CLASS OF CASE................:
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11. SYMPTOMS PRESENT AT INITIAL DIAGNOSIS:
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659 LOWER BACK PAIN..............
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660 TROUBLE URINATING............
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12. INITIAL METHOD OF DIAGNOSIS:
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661 CLINICAL DX WITH BONE LESION.
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662 CLINICAL DX BY RECTAL EXAM...
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664 DIGITAL TRANSRECTAL BIOPSY...
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665 INCIDENTAL FINDING IN TURP FOR BENIGN DISEASE...........
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666 NEEDLE BIOPSY, NOS...........
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667 PERINEAL BIOPSY..............
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669 TRUS GUIDED BIOPSY...........
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13. DIAGNOSTIC EVALUATION:
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671 BONE MARROW ASPIRATION.......
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672 BONE SCAN....................
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675 CT SCAN OF ABDOMEN...........
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676 CT SCAN OF PELVIS............
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679 PELVIC LYMPH NODE DISSECTION.
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683 ULTRASOUND OF ABDOMEN........
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684 14. RESULTS OF MOST RECENT PRE- TREATMENT PSA TEST...........
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16. PRIMARY SITE (ICD-O-2).......: C61.9
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18. BEHAVIOR CODE (ICD-O-2)......:
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141 20. BIOSPY PROCEDURE.............
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21. GUIDANCE OF BIOPSY TO PRIMARY: Not guided, no biopsy
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22. BIOPSY APPROACH FOR PRIMARY..: No biopsy
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21. GUIDANCE OF BIOPSY TO PRIMARY: Unknown/death cert only
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22. BIOPSY APPROACH FOR PRIMARY..: Unknown/death cert only
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142 21. GUIDANCE OF BIOSPY TO PRIMARY
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145 22. BIOSPY APPROACH FOR PRIMARY..
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146 23. BIOSPY OF OTHER THAN PRIMARY.
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26 24. DIAGNOSTIC CONFIRMATION......
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25. GLEASON'S SCORE FOR BIOPSY, LOCAL RESECTION, OR SIMPLE PROSTATECTOMY:
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Surgery codes not 02 through 40
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GLEASON SCORE................: 99 Unknown, not reported, or NA
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GLEASON SCORE................:
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623 GLEASON SCORE................
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26. GLEASON'S SCORE FOR RADICAL PROSTATECTOMY:
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Surgery codes not 50 through 70
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623.3 GLEASON SCORE................
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27. SIZE OF TUMOR (mm)
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28. REGIONAL NODES EXAMINED
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29. REGIONAL NODES POSITIVE
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30. AJCC CLINICAL STAGE (cTNM)
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31. AJCC PATHOLOGIC STAGE (pTNM)
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32. STAGED BY
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TABLE III - EXTENT AND STAGE OF DISEASE
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29 27. SIZE OF TUMOR (mm).....
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33 28. REGIONAL NODES EXAMINED
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32 29. REGIONAL NODES POSITIVE
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30. AJCC CLINICAL STAGE (cTNM):
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31. AJCC PATHOLOGIC STAGE (pTNM):
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32. STAGED BY:
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19 CLINICAL STAGE.........
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89 PATHOLOGIC STAGE.......
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33. DATE OF FIRST COURSE TREATMENT.:
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685 34. EXPECTED MGT/WATCHFUL WAITING..
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35. DATE OF NON CA-DIRECTED SURGERY:
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36. NON CANCER-DIRECTED SURGERY....:
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37. DATE OF CANCER-DIRECTED SURGERY:
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38. LENGTH OF STAY AFTER SURGERY...: 88 NA
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38. LENGTH OF STAY AFTER SURGERY...: 99 Unknown
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686 38. LENGTH OF STAY AFTER SURGERY...
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39. SURGICAL APPROACH..............:
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40. TYPE OF CANCER-DIRECTED SURGERY:
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41. SURGICAL MARGINS...............:
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42. SCOPE OF LYMPH NODE SURGERY....:
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43. TYPE OF LYMPH NODE SURGERY:
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44. SURGERY OF OTHER REGIONAL SITE(S), DISTANT SITE(S),
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OR DISTANT LYMPH NODE(S).......:
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45. NUMBER OF LYMPH NODES REMOVED..:
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47. COMPLICATIONS FOLLOWING SURGICAL FIRST COURSE OF TREATMENT:
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PERMANENT RECTAL INJURY........: NA, no surgery
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THROMBOEMBOLISM................: NA, no surgery
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URETHRAL STRICTURE.............: NA, no surgery
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48. POSTOPERATIVE DEATH W/I 30 DAYS: NA, no surgery
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PERMANENT RECTAL INJURY........: Unknown
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URETHRAL STRICTURE.............: Unknown
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48. POSTOPERATIVE DEATH W/I 30 DAYS: Unknown
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689 PERMANENT RECTAL INJURY........
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691 URETHRAL STRICTURE.............
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441 48. POSTOPERATIVE DEATH W/I 3O DAYS
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49. DATE RADIATION STARTED.........:
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50. RADIATION THERAPY..............:
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51. RADIATION FACILITY.............:
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52. INTERSTITIAL RADIATION/BRACHYTHERAPY ADMINISTERED:
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OTHER INTERSTITIAL, NOS........:
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53. ROUTE OF INTERSTITIAL RADIATION/
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BRACHYTHERAPY ADMINISTERED.....:
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54. EXTERNAL RADIATION ADMINISTERED:
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DISTANT METASTATIC SITES.......:
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PROSTATE & PELVIC NODES........:
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PROSTATE & PARA-AORTIC NODES...:
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PROSTATE REGION ONLY...........:
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OTHER EXTERNAL SITES, NOS......:
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55. TYPE OF EXTERNAL RADIATION
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56. TOTAL EXTERNAL RAD DOSE (cGy) INCLUDING BOOST:
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PELVIC NODES...................:
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PARA-AORTIC NODES..............:
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57. COMPLICATIONS FOLLOWING RADIATION FIRST COURSE OF TREATMENT:
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ACUTE GASTROINTESTINAL.........:
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ACUTE GASTROURINARY............:
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CHRONIC REQUIRING SURGERY OR
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PROLONGED HOSPITALIZATION......:
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URETHRAL OR BLADDER............:
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692 51. RADIATION FACILITY.............
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631 OTHER INTERSTITIAL, NOS........
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693 53. ROUTE OF INTERSTITIAL RADIATION/ BRACHYTHERAPY ADMINISTERED.....
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636 DISTANT METASTATIC SITES.......
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634 PROSTATE & PELVIC NODES........
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635 PROSTATE & PARA-AORTIC NODES...
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633 PROSTATE REGION ONLY...........
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637 OTHER EXTERNAL SITES, NOS......
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694 55. TYPE OF EXTERNAL RADIATION ADMINISTRATION.................
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639 PELVIC NODES...................
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640 PARA-AORTIC NODES..............
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695 ACUTE GASTROINTESTINAL.........
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696 ACUTE GASTROURINARY............
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698 CHRONIC REQUIRING SURGERY OR PROLONGED HOSPITALIZATION......
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699 URETHRAL OR BLADDER............
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58. DATE OF ORCHIECTOMY............: 00/00/0000
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699.1 58. DATE OF ORCHIECTOMY............
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59. DATE EXOGENOUS HT BEGAN........:
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60. HORMONE THERAPY................:
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61. EXOGENOUS HORMONE AGENTS ADMINISTERED:
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LUTEINIZING HORMONES...........:
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PROGESTATIONAL AGENTS..........:
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646 LUTEINIZING HORMONES...........
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645 PROGESTATIONAL AGENTS..........
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62. DATE CHEMOTHERAPY STARTED......:
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64. DATE OF FIRST RECURRENCE
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65. TYPE OF FIRST RECURRENCE
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64. TYPE OF FIRST RECURRENCE
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65. DATE OF FIRST RECURRENCE
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70 64. DATE OF FIRST RECURRENCE
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71 65. TYPE OF FIRST RECURRENCE
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66. DATE OF LAST CONTACT OR DEATH
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67. VITAL STATUS
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68. CANCER STATUS
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69. COMPLETED BY
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70. CLINICAL REVIEW BY CA COMMITTEE
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66. DATE OF LAST CONTACT OR DEATH..:
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15 67. VITAL STATUS...................
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68. CANCER STATUS..................:
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81 69. COMPLETED BY...................
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82 70. CLINICAL REVIEW BY CA COMMITTEE
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8. PRIMARY PAYER AT DIAGNOSIS.......:
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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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LOWER BACK PAIN.................:
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TROUBLE URINATING...............:
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12. INITIAL METHODS OF DIAGNOSIS:
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CLINICAL DX W BONE LESION.......:
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CLINICAL DX BY RECTAL EXAM......:
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DIGITAL TRANSRECTAL BIOPSY......:
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INCIDENTAL FINDING IN TURP FOR BENIGN DISEASE..................:
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NEEDLE BIOPSY, NOS..............:
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PERINEAL BIOPSY.................:
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TRUS GUIDED BIOPSY..............:
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13. DIAGNOSTIC EVALUATION:
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BONE MARROW ASPIRATION..........:
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BONE SCAN.......................:
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CT SCAN OF ABDOMEN..............:
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CT SCAN OF PELVIS...............:
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PELVIC LYMPH NODE DISSECTION....:
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ULTRASOUND OF ABDOMEN...........:
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14. RESULTS OF MOST RECENT PRE-
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TREATMENT PSA TEST...............:
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15. DATE OF INITIAL DIAGNOSIS........:
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16. PRIMARY SITE (ICD-O-2)...........:
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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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GLEASON SCORE...................:
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27. SIZE OF TUMOR (mm)...............:
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28. REGIONAL NODES EXAMINED..........:
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29. REGIONAL NODES POSITIVE..........:
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30. AJCC CLINICAL STAGE (cTNM):
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31. AJCC PATHOLOGIC STAGE (pTNM):
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32. STAGED BY:
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33. DATE OF FIRST COURSE TREATMENT...:
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34. EXPECTED MGT/WATCHFUL WAITING....:
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35. DATE OF NON CA-DIRECTED SURGERY..:
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36. NON CANCER-DIRECTED SURGERY......:
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37. DATE OF CANCER-DIRECTED SURGERY..:
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38. LENGTH OF STAY AFTER SURGERY.....:
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39. SURGICAL APPROACH................:
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40. TYPE OF CANCER-DIRECTED SURGERY..:
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41. SURGICAL MARGINS.................:
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42. SCOPE OF LYMPH NODE SURGERY......:
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43. TYPE OF LYMPH NODE SURGERY:
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44. SURGERY OF OTHER REGIONAL SITE(S), DISTANT SITE(S),
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45. NUMBER OF LYMPH NODES REMOVED....:
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47. COMPLICATIONS FOLLOWING SURGICAL FIRST COURSE OF TREATMENT:
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PERMANENT RECTAL INJURY.........:
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URETHRAL STRICTURE..............:
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48. POSTOPERATIVE DEATH W/I 30 DAYS..:
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49. DATE RADIATION STARTED...........:
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50. RADIATION THERAPY................:
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51. RADIATION FACILITY...............:
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52. INTERSTITIAL RADIATION/BRACHYTHERAPY ADMINISTERED:
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OTHER INTERSTITIAL, NOS.........:
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53. ROUTE OF INTERSTITIAL RADIATION/
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BRACHYTHERAPY ADMINISTERED.......:
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54. EXTERNAL RADIATION ADMINISTERED:
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DISTANT METASTATIC SITES........:
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PROSTATE & PELVIC NODES.........:
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PROSTATE & PARA-AORTIC NODES....:
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PROSTATE REGION ONLY............:
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OTHER EXTERNAL SITES, NOS.......:
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55. TYPE OF EXTERNAL RADIATION
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56. TOTAL EXTERNAL RAD DOSE (cGy) INCLUDING BOOST:
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PELVIC NODES....................:
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PARA-AORTIC NODES...............:
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57. COMPLICATIONS FOLLOWING RADIATION FIRST COURSE OF TREATMENT:
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ACUTE GASTROINTESTINAL..........:
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ACUTE GASTROURINARY.............:
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PROLONGED HOSPITALIZATION.......:
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URETHRAL OR BLADDER.............:
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58. DATE OF ORCHIECTOMY.............:
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59. DATE EXOGENOUS HT BEGAN.........:
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60. HORMONE THERAPY.................:
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61. EXOGENOUS HORMONE AGENTS ADMINISTERED:
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LUTEINIZING HORMONES............:
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PROGESTATIONAL AGENTS...........:
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62. DATE CHEMOTHERAPY STARTED........:
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64. DATE OF FIRST RECURRENCE.........:
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65. TYPE OF FIRST RECURRENCE.........:
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66. DATE OF LAST CONTACT OR DEATH....:
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67. VITAL STATUS.....................:
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68. CANCER STATUS....................:
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69. COMPLETED BY.....................:
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70. REVIEWED BY CANCER COMMITTEE.....:
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ROADS TO FORDS
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7 PLACE OF BIRTH.............
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9 SPANISH ORIGIN.............//^S X=
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Non-Spanish, non-Hispanic
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48 AGENT ORANGE EXPOSURE......//^S X=AOE
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50 IONIZING RADIATION EXPOSURE//^S X=IRE
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52 CHEMICAL EXPOSURE..........
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61 ASBESTOS EXPOSURE..........
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51 PERSIAN GULF SERVICE.......//^S X=PGS
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55 MIDDLE EAST SERVICE........//^S X=MES
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56 SOMALIA SERVICE............//^S X=SS
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Reporting Hospital..........:
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Marital status at Dx........:
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Patient address at Dx.......:
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Patient address at Dx - Supp:
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City/town at Dx.............:
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State at Dx.................:
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Postal code at Dx...........:
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County at Dx................:
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Census Tract................:
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Following physician.........:
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Primary surgeon.............:
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Primary payer at Dx.........:
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Type of reporting source....:
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Class of Case................:
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Facility referred from.......:
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Facility referred to.........:
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Date of First Contact........:
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Date Dx......................:
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Dx Facility..................:
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Histology/Behavior Code......:
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AFIP submission..............:
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Diagnostic Confirmation......:
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Presentation at Cancer Conf..:
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Place of birth.............:
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Spanish origin.............:
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Agent Orange exposure......:
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Ionizing radiation exposure:
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Chemical exposure..........:
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Asbestos exposure..........:
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Persian Gulf service.......:
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Middle East service........:
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Somalia service............:
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Usual Occupation...........:
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Usual Industry.............:
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Tobacco History............:
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Alcohol History............:
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Family History of Cancer...:
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Family Member with Cancer..:
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PREVIOUS HISTORY OF CANCER
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Previous History of Cancer.....:
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1///Unknown if BRM therapy administered
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Patient Care Evaluation Studies of Cancer of the Prostate
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DATE OF ADMISSION
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ACCESSION/SEQUENCE NUMBER.:
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CLASS OF CASE.............:
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9ZIP CODE..................
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BIRTHDATE.................:
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18PRIMARY PAYER AT DIAGNOSIS
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1DATE OF ADMISSION.........
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1.1DATE OF DISCHARGE.........
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METHOD OF DIAGNOSIS
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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#################### #################### ####################
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