Description:

E5204 On-Study 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=089B43F4-F7BD-38D3-E044-0003BA3F9857

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=089B43F4-F7BD-38D3-E044-0003BA3F9857

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Versions (3) ▾
  1. 8/27/12
  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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E5204 On-Study Form NCT00303628

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

Header
Report period
Patient demographics
Baseline Evaluation
ECOG Performance Status (at study entry)
Is patient hypertensive
Is patient on anti-hypertensive therapy
Patient receiving full-dose anticoagulants
Kg
Kg
cm
Diabetes History
Diabetes Mellitus
Is patient insulin dependent
Does patient manage his/her diabetes with oral medications
Pathologic Staging
Histologic Grade (Differentiation) ([From pre-treatment biopsy specimen])
Perforation
Obstruction
Clinical T Stage (Use the staging definitions in Appendix V of the protocol)
Clinical N Stage (Use the staging definitions in Appendix V of the protocol)
Clinical M Stage (Use the staging definitions in Appendix V of the protocol)
Stage Grouping Assessment Method
Pathologic T Stage (Use the staging definitions in Appendix V of the protocol)
Pathologic N Stage (Use the staging definitions in Appendix V of the protocol)
Pathologic M Stage (Use the staging definitions in Appendix V of the protocol)
Biological Markers
Regimen Type Given
Prior Surgery For This Disease
Primary Surgery Type
Was sphincter preserved
Was the tumor fixed to surrounding structures
Was a complete resection done?
Were all lymph nodes suggestive of disease removed?
Baseline Abnormalities
Comments

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