Description:

E5103 Disease and Vital Status Form 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=22AFE3B9-AE28-56F9-E044-0003BA3F9857

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=22AFE3B9-AE28-56F9-E044-0003BA3F9857

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

June 8, 2015

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License:
Creative Commons BY-NC 3.0 Legacy
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E5103 Disease and Vital Status Form NCT00433511

Instructions: After patient is off treatment, complete this form for each required follow-up report period (see forms submission schedule). Submit original to the ECOG Coordinating Center; Keep a copy for your files.

ECOG clinical trial administrative data
Off Treatment
Off Treatment Report Period (since registration)
Data amendment
Breast: Vital Status
Patient's Vital Status (*IMPORTANT: As soon as a grade 5 adverse event is reported, it is necessary to submit ALL outstanding data in addition to the adverse event form and AdEERS report.)
Primary Cause of Death (if applicable)
Section II - Reporting Period
Section Iii - New Primary Cancers
Has a new primary cancer or MDS been diagnosed that has not been previously reported?
Notice Of First Distance Recurrence
Was first distant recurrence previously reported
Section V - Disease Follow-up Status
Has the patient had a documented clinical assessment for this cancer?
Method of Evaluation
Result
Iib - Local-regional Recurrence
Has the patient been diagnosed with first local-regional recurrence (since submission of the last follow-up form)
Axilla (Sites of local recurrence code all; all sites refer to the same side as the original primary 1=no, 2=yes)
Axillary Node(s)
Infraclavicular Node(s)
Internal mammary node
Ipsilateral Breast
Supraclavicular Node(s)
Basis of Diagnosis
Iic - Distance Recurrence
Has the patient been diagnosed with first distant recurrence/progression? (since submission of the last follow-up form)
Section Iv - Treatment
Hormonal therapy (given this reporting period)
Did patient switch type of hormonal therapy during this report period (If yes:)
Specify new type of adjuvant hormonal therapy administered (If yes:)
Adjuvant Hormonal Therapy Administered Type (If no: - Initial)
Is hormonal therapy continuing
Did patient receive Ovarian Function Suppression (OFS) during this follow-up period?
Specify type (If yes:)
Is LHRH agonist continuing from a previous reporting period (If LHRH agonist:)
Section Viii - Non-protocol Therapy Prior To Recurrence
Has the patient received any non-protocol cancer therapy prior to first recurrence (not previously reported)
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