Description:

FORM 6 - FINAL REPORT NCT00090974 Quality Of Life Companion Study For JMA27 (NCIC-MA.27): A Randomized Phase III Trial Of Exemestane Versus Anastrozole With Or Without Celecoxib In Postmenopausal Women With Receptor Positive Primary Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=ABE51386-B5AC-5668-E034-0003BA12F5E7

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=ABE51386-B5AC-5668-E034-0003BA12F5E7

Keywords:
Versions (3) ▾
  1. 8/26/12
  2. 1/9/15
  3. 7/5/15
Uploaded on:

July 5, 2015

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License:
Creative Commons BY-NC 3.0 Legacy
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FORM 6 - FINAL REPORT NCT00090974

To be submitted within 6 weeks of the patient's death.

Patient Information
Cause Of Death
Primary Cause of Death (check one)
Autopsy
Autopsy?
Disease Status
Status of most recent clinical assessment
Other Malignancies Or Myelodysplastic Syndrome
Has a new primary cancer or MDS been diagnosed that has not been previously reported?
Toxicity Evaluation
Did the patient experience any new or continuing toxicities since the last report?
CTC Adverse Event Term (Code/grade according to NCI Common Toxicity Criteria, Version 2.0)
CTC Adverse Event Category (Code/grade according to NCI Common Toxicity Criteria, Version 2.0)
CTC Adverse Event Attribution Code
Adverse Events
Has the patient experienced a bone fracture since submission of last follow-up form?
Bone Fracture Site, Spinal (Check)
Bone Fracture Site, Wrist (Check)
Bone Fracture Site, Pelvis (Check)
Bone Fracture Site, Hip (Check)
Bone Fracture Site, Femur (Check)
Bone Fracture Site, Tibia (Check)
Bone Fracture Site, Ankle (Check)
Bone Fracture Site, Other (specify) (Check)
Has the patient had a new diagnosis of osteoporosis since submission of last follow-up form?
Cardiovascular Event, Myocardial infarction (Report only events which have occurred since last report or conditions which were present at the time of last report and have worsened since. Report non-ischemic events in the "other" category.)
Cardiovascular Event, Stroke/transient ischemic attack (TIA) (Report only events which have occurred since last report or conditions which were present at the time of last report and have worsened since. Report non-ischemic events in the "other" category.)
Cardiovascular Event, On-going angina (no surgical intervention) (Report only events which have occurred since last report or conditions which were present at the time of last report and have worsened since. Report non-ischemic events in the "other" category.)
Cardiovascular Event, Angina requiring percutaneous transluminal coronary angioplasty (PTCA) (Report only events which have occurred since last report or conditions which were present at the time of last report and have worsened since. Report non-ischemic events in the "other" category.)
Cardiovascular Event, Thromboembolic event (Report only events which have occurred since last report or conditions which were present at the time of last report and have worsened since. Report non-ischemic events in the "other" category.)
Cardiovascular Event, Other (specify) (Report only events which have occurred since last report or conditions which were present at the time of last report and have worsened since. Report non-ischemic events in the "other" category.)
Treatment Given Since Last Report To Ncic Ctg
Is the patient receiving any non-protocol cancer therapy not previously reported?
Non-Protocol Raloxifene Therapy?
Non-Protocol Bisphosphonate Therapy?
Non-Protocol Lipid Lowering Therapy?
Other Non-Protocol Therapy?
Comments
Supporting Documentation
Investigator Signature
Ccrr Module For Form 6 - Final Report

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