E1105 Quality of Life Assessment Form First-Line Chemotherapy and Trastuzumab With or Without Bevacizumab in Treating Patients With Metastatic Breast Cancer That Overexpresses HER-2/NEU NCT00520975 Source Form: NCI FormBuilder:

  1. 8/26/12 8/26/12 -
  2. 1/8/15 1/8/15 - Martin Dugas
  3. 3/25/15 3/25/15 - Martin Dugas
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March 25, 2015

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Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00520975 Quality of Life

INSTRUCTIONS: After patient is off treatment, complete this form for each required follow-up report period (see forms submission schedule).

On Treatment Report Period (Maintenance 1 cycle = 3 weeks)
Quality of life
I have a lack of energy.
I have pain.
I have nausea.
I have certain areas of my body where I experience significant pain
I have been short of breath.
I worry that my condition will get worse
I am content with the quality of my life right now
Because of my physical condition, I have trouble meeting the needs of my family.
I am bothered by side effects of treatment.
I have numbness or tingling in my hands
I have numbness or tingling in my feet
I feel discomfort in my hands
I feel discomfort in my feet

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