Description:

E1105 Cardiac Toxicity Form NCT00520975 First-Line Chemotherapy and Trastuzumab With or Without Bevacizumab in Treating Patients With Metastatic Breast Cancer That Overexpresses HER-2/NEU Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=171FF705-FB7F-3F20-E044-0003BA3F9857

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=171FF705-FB7F-3F20-E044-0003BA3F9857

Keywords:
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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E1105 Cardiac Toxicity Form NCT00520975

INSTRUCTIONS: Complete this form and submit original to the ECOG Coordinating Center within one week of registration. Keep a copy for your files

Header
Patient demographics
Data amendment
On Treatment
On Treatment Report Period (Choose one x)
Off Treatment
Off Treatment Report Period (since registration)
Cardiovascular assessment
Has the patient had a documented assessment of cardiac function
Method of Evaluation (LVEF)
%
%
S3 Gallop (Specify whether any of the following adverse events have occurred during this report period record an answer for each event listed below)
Dyspnea on exertion, orthopnea or paroxysmal noctural dyspnea
Basilar Rales
Cardiomegaly
Clinical Episode of CHF (defined as having 2 or more of the above events)
Abnormal ECG
Comments

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