Description:

CALGB: 40101 FOLLOW-UP FORM Four Versus Six Cycles of Cyclophosphamide/Doxorubicin or Paclitaxel in Adjuvant Breast Cancer NCT00041119 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A46CA742-FE60-27F9-E034-080020C9C0E0

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A46CA742-FE60-27F9-E034-080020C9C0E0

Keywords:
Versions (2) ▾
  1. 8/26/12
  2. 3/19/15
Uploaded on:

March 19, 2015

DOI:
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License:
Creative Commons BY-NC 3.0 Legacy
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Breast Cancer adjuvant therapy (CALGB 40101 NCT00041119)

INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice. Print text in capital letters. Avoid contact with the edges of the boxes. Circle amended items and check "Amended data" box to the right. If submitting by mail, retain a copy for your records and send the original to the CALGB Statistical Center, Data Operations. If faxing, use an original form for maximum clarity in transmission and fax to 919-416-4990. If submitting electronically, click the Send button when you have completed the PDF version of the form.

Header
Amended data?
Patient status
Patient's Vital Status (mark one with an X)
Cause of death (if dead)
Current Menopausal Status (If premenopausal prior to chemotherapy mark one with an X)
Has patient had a documented clinical assessment for this cancer since submission of the previous follow-up form?
Has the patient been diagnosed with a first local-regional recurrence/progression since submission of the last follow-up form?
Site(s) of first local-regional progression (mark all that apply with an X)
How was this progression information obtained? (mark one with an X)
Has the patient been diagnosed with a first distant recurrence/progression since submission of the last follow-up form?
Has a new primary cancer or myelodysplastic syndrome (MDS) been diagnosed that has not been previously reported?
Adverse event
Has the patient experienced (prior to diagnosis of recurrence or second primary) any severe (Grade >= 3), long term treatment related toxicity that has not been previously reported? (Long-Term Cardiac Toxicity)
Therapy
Did this patient receive any tamoxifen?
Is the patient still receiving tamoxifen?
Did the patient receive any aromatase inhibitors?
Which aromatase inhibitor? (mark one with an X)
Is the patient still receiving aromatase inhibitor?
Did patient receive non-protocol cancer therapy prior to first recurrence and not previously reported? (mark all that apply with an X)
Non-Protocol Therapy

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