E5204 Long-Term Follow-up Form NCT00303628 Combination Chemotherapy With or Without Bevacizumab in Treating Patients Who Have Had Surgery for Stage II or Stage III Rectal Cancer Source Form: NCI FormBuilder:


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

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E5204 Long-Term Follow-up Form NCT00303628

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

Off Treatment Report Period (since initial registration - Choose one x)
Data amendment
Vital Status
Patient's Vital Status
Primary Cause of Death (if applicable)
Section II - Reporting Period
Notice Of New Primary (including Second Colon Primary)
Has a new primary cancer or myelodysplastic syndrome been diagnosed that has not been previously reported (MDS)
Disease Follow-up Status
Has the patient had a documented clinical assessment for this cancer (since submission of the previous follow-up form)
Notice Of Recurrence
Has the patient been diagnosed with first recurrence since submission of the last follow-up form?
Site of recurrence (s)
Did a physician make a formal diagnosis of recurrence
Was the recurrence treated by surgery
Adverse Events
Has the patient experienced any severe long term toxicity that has not been previously reported (prior to diagnosis of progression/relapse)
Non-protocol Therapy
Has the patient received any non-protocol cancer therapy prior to first recurrence (not previously reported)

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