Description:

E5103 24-months Post-Registration Cardiac Function Assessment 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=8C9D1499-1276-D754-E040-BB89AD43467F

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=8C9D1499-1276-D754-E040-BB89AD43467F

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Versions (3) ▾
  1. 8/26/12
  2. 1/9/15
  3. 6/16/15
Uploaded on:

June 16, 2015

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License:
Creative Commons BY-NC 3.0 Legacy
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E5103 24-months Post-Registration Cardiac Function Assessment Form NCT00433511

INSTRUCTIONS: Use this form ONLY when submitting results from the 24 months post-registration cardiac assessment. For any cardiac data obtained prior to the 24-month timepoint, please use the E5103 Cardiac Toxicity Form

Header
Report Period
Patient demographics
Cardiac Function
Has the patient had a documented assessment of cardiac function
Clinical Episode of CHF (requires symptoms associated with a decrease of LVEF to below LLN)
S3 Gallop
Bibasilar Rales
Cardiomegaly
Abnormal ECG
Cardiac Adverse Events
CTC Adverse Event Term
CTC AE Attribution Code
LVEF Information
Has the patient had a documented assessment of LVEF (this report period)
Method of Evaluation
%
%
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