Description:

E1105 Treatment Form NCT00520975 First-Line Chemotherapy and Trastuzumab With or Without Bevacizumab in Treating Patients With Metastatic Breast Cancer That Overexpresses HER-2/NEU Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=17256C2D-9F93-4AD8-E044-0003BA3F9857

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=17256C2D-9F93-4AD8-E044-0003BA3F9857

Keywords:
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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E1105 Treatment Form NCT00520975

INSTRUCTIONS: Complete this form at the end of each cycle (1 cycle = 3 weeks), and at required follow-ups if specified by the Long-Term Follow-Up Form (to report late adverse events).

Header
On Treatment
On Treatment Report Period (since start of treatment)
Section I - Vital Status
Vital Status
Primary Cause of Death (if applicable)
Patient Charastics
Kg
Therapy Administered
Dose modification
Dose Modification Reason
mg/dL
Adverse Event (If chemotherapy was modified for adverse event, mark all that apply)
Adverse Event (If trastuzumab was modified for adverse event, mark all that apply)
Adverse Event (If bevacizumab/placebo was modified for adverse event, mark all that apply)
Section Vi - Non-protocol Therapy
Was any non-protocol therapy given during protocol treatment (not previously reported)

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