Description:

CALGB-40502 Follow-Up Form NCT00785291 Paclitaxel, Paclitaxel Albumin-Stabilized Nanoparticle Formulation, or Ixabepilone With or Without Bevacizumab in Treating Patients With Stage IIIC or Stage IV Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=51FC17F4-984D-0C38-E044-0003BA3F9857

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=51FC17F4-984D-0C38-E044-0003BA3F9857

Keywords:
Versions (4) ▾
  1. 8/27/12
  2. 1/8/15
  3. 1/9/15
  4. 6/21/15
Uploaded on:

June 21, 2015

DOI:
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License:
Creative Commons BY-NC 3.0 Legacy
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CALGB-40502 Follow-Up Form NCT00785291

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 complete the form electronically. After entering all data, click the "Print and/or Submit to CALGB" button located at the bottom of the last page of the form. Retain a copy of the form for your records. Submit supporting documentation by fax (919-416-4990) or mail. If data are amended, circle amended items, check the "Yes" box, and submit by fax or mail

Header
Are data amended
Patient demographics
Vital Status
Patient's vital status (Mark one with an X. If the patient is lost, follow instructions on form C-1742 and in the CALGB Policies and Procedures chapter 8 to have Data Operations change a patient's survival status to: "Confirmed lost to follow-up")
Primary cause of death (Mark one with an X.)
Has the patient had a documented clinical assessment for this cancer (during this reporting period?)
Notice Of Progression
Has the patient been diagnosed with first local-regional recurrence (since submission of the last follow-up form?)
Site of First Local-Regional Progression (s)
Has the patient been diagnosed with first distant recurrence/progression? (since submission of the last follow-up form?)
How was this progression information obtained? (Mark one with an X.)
How was this progression information obtained? (Mark one with an X.)
Non-protocol Therapy
Did the patient receive additional therapy? (during this reporting period)
Long-term Adverse Events
Has the patient experienced (prior to diagnosis of recurrence or second primary) any severe (Grade >=3), long term toxicity that has not been previously reported (If yes complete the section below)
CTC Adverse Event Term
CTC AE Attribution Code
Notice Of Progression
Has a new primary cancer or MDS been diagnosed that has not been previously reported? (myelodysplastic syndrome)
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