Description:

CALGB 40302 ON STUDY FORM NCT00390455 Fulvestrant With or Without Lapatinib in Treating Postmenopausal Women With Stage III or Stage IV Breast Cancer That is Hormone Receptor-Positive Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=F593450E-7E56-42E1-E034-0003BA3F9857

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=F593450E-7E56-42E1-E034-0003BA3F9857

Keywords:
Versions (3) ▾
  1. 12/18/14
  2. 1/9/15
  3. 6/16/15
Uploaded on:

June 16, 2015

DOI:
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License:
Creative Commons BY-NC 3.0 Legacy
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CALGB_40302_ONSTUDY_FRM NCT00390455

INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink.

Header
Are data amended
Patient demographics
Patient Characteristics
Post menopausal
Is patient on ovarian suppression with GnRH-A agonist
Did the patient participate in a first line hormone
Was there a clinical response >= 6 months? (If yes, )
What was the response? (If yes, )
Disease Description
ER status (Mark one with an X.)
PgR status (Mark one with an X.)
Timing of assay (Mark one with an X.)
Timing of assay (Mark one with an X.)
Site Of Progression Or Recurrence
Site of progression (s)
Prior Systemic Therapy
Prior adjuvant hormonal therapy (Do not include steroids given with chemotherapy.)
Prior endocrine therapy for metastasis or recurrence (Do not include steroids given with chemotherapy.)
Prior adjuvant chemotherapy (Include pre-op chemotherapy at diagnosis.)
Prior chemotherapy for metastasis or recurrence
Prior adjuvant high dose chemotherapy/Autologous stem cell transplant (HDC/ASCT )
Prior HDC/ASCT for metastasis or recurrence
Prior Aromatase Inhibitors therapy?
Prior adjuvant trastuzumab?
Prior immunotherapy for metastasis or recurrence
Prior adjuvant other therapy
Prior other therapy for metastasis or recurrence
Prior Systemic Regimens
Prior treatment regimen type
Required Laboratory Values
1000/uL
1000/uL
mg/dL
mg/dL
%
HER2/neu Final Diagnosis (Mark one with an X)
Marker Test Method (Mark one with an X)
IHC Lab Value
FISH lab value
ng/ml

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