Description:

SOUTHWEST ONCOLOGY GROUP S0221 AC TREATMENT FORM NCT00070564 Adjuvant Doxorubicin, Cyclophosphamide, and Paclitaxel in Treating Patients With Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=E92C6D7A-4422-6B28-E034-0003BA3F9857

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=E92C6D7A-4422-6B28-E034-0003BA3F9857

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Versions (3) ▾
  1. 8/26/12
  2. 1/8/15
  3. 6/3/15
Uploaded on:

June 3, 2015

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License:
Creative Commons BY-NC 3.0 Legacy
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SOUTHWEST ONCOLOGY GROUP S0221 AC TREATMENT FORM NCT00070564

Instructions: Complete this form if the patient was assigned to Treatment Arm 1 or Arm 3. Submit this form only once, after the patient has completed AC chemotherapy and has recovered from acute toxicity. All dates are MONTH, DAY, YEAR. Place an X in appropriate boxes. Circle AMENDED items in red.

Header
Disease Status
Vital Status
Treatment Status
Assigned treatment arm
Did the patient start treatment on the assigned arm?
Kg
Agent Name
Were there any dose modifications or additions/omissions to protocol treatment?
Adverse event assessment
Did the patient experience one or more episodes of Grade 3 or 4 neutropenia?
Did the patient experience one or more episodes of Grade 3 or 4 febrile neutropenia?
Did the patient experience one or more episodes of Grade 3 or 4 anemia?
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