E3F05 Non-Protocol Therapy Form Radiation Therapy With or Without Temozolomide in Treating Patients With Low-Grade Glioma Source Form: NCI FormBuilder:


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June 12, 2015

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E3F05 Non-Protocol Therapy Form

INSTRUCTIONS: Use this form to capture the first occurrence of non-protocol anti-tumor therapy per registration step ONLY if patient's disease is still stable or in partial or complete remission and has not progressed/relapsed from protocol therapy. Submit form to the ECOG Coordinating Center; keep a copy for your files. Mark an X in appropriate boxes

Reporting Period
Patient demographics
Data amendment
Non-Protocol Therapy Date
Type(s) of first non-protocol therapy
Non-protocol Chemotherapy
Non-protocol Hormonal Therapy
Non-protocol Immunotherapy (/Biological Response Modifiers)
Non-protocol high dose chemotherapy/stem cell transplant (Autologous or Allogeneic)
Non-protocol Surgery
Non-protocol Radiation Therapy
Other Non-protocol Therapy
Was the non-protocol therapy given for the disease of this protocol (NOTE: Treatment for a second primary in the same organ site would not be considered therapy for disease of this protocol.)