E5103 Epirubicin Supplemental 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:


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  3. 6/8/15
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June 8, 2015

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E5103 Epirubicin Supplemental Form NCT00433511

INSTRUCTIONS: Complete and submit this form at the end of each cycle of Step 1 during the Doxorubicin shortage IF Doxorubicin was not administered due to drug shortage. On the E5103 Treatment Form - Step 1, for Doxorubicin, be sure to record ¿0.0mg¿ for Agent Total Dose, "02=dose held" for Dose Modification and ¿06=alternative therapy for other reason" for Dose Modification Reason

Patient demographics
Data amendment
Treatment period
On Treatment Report Period (Choose one X)
Dose modification
Dose Modification Reason (If a dose modification reason was due to an Adverse Event, please record all AE grades both reportable and non-reportable in the appropriate section on E5103 Adverse Event form.)

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