Description:

E5204 Disease Assessment 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: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=089B0CA5-B778-3631-E044-0003BA3F9857

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=089B0CA5-B778-3631-E044-0003BA3F9857

Keywords:
Versions (3) ▾
  1. 8/27/12
  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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E5204 Disease Assessment Form NCT00303628

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

ECOG clinical trial administrative data
Data amendment
Cycle number
On Treatment Report Period (Choose one x)
Vital Status
Patient's Vital Status
Primary Cause of Death (if applicable)
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 a first recurrence since the last Follow-Up Form? (Long-Term)
Site of recurrence (s)
Did a physician make a formal diagnosis of recurrence
Was the recurrence treated by surgery
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