Description:

E5103 Treatment Form - Step 2 (Arm D ONLY) NCT00433511 Doxorubicin, Cyclophosphamide, and Paclitaxel With or Without Bevacizumab in Treating Patients With Lymph Node-Positive or High-Risk, Lymph Node-Negative Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=3C897B97-5BB5-5817-E044-0003BA3F9857

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=3C897B97-5BB5-5817-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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E5103 Treatment Form - Step 2 (Arm D ONLY) NCT00433511

Details

INSTRUCTIONS: Complete this form at the end of each cycle (1 cycle =3 weeks). Submit original to the ECOG Coordinating Center. Keep a copy for your files. Refer to forms packet for submission schedule

Header module
Reporting Period
On Treatment Report Period (ARM D ONLY)
6 more items in the detailed view.
Therapy Administered
Kg
Dose modification
Dose Modification Reason (* If a dose modification reason represents a qualifying Grade CTCAE, report the event on the E5103 Adverse Event Form.)
3 more items in the detailed view.
Adverse Event (Instruction: If Bevacizumab dose was modified for adverse event, mark an 'X' for all that apply:)
6 more items in the detailed view.
Non-protocol Therapy
Was any non-protocol cancer therapy given during protocol treatment (not previously reported - * Bisphosphonate Therapy will NOT be considered non-protocol therapy.)
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