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:


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  1. 8/26/12
  2. 1/8/15
  3. 6/3/15
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June 3, 2015

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E5103 Treatment Form - Step 2 (Arm D ONLY) NCT00433511

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)
Therapy Administered
Dose modification
Dose Modification Reason (* If a dose modification reason represents a qualifying Grade CTCAE, report the event on the E5103 Adverse Event Form.)
Adverse Event (Instruction: If Bevacizumab dose was modified for adverse event, mark an 'X' for all that apply:)
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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