Description:

NSABP PROTOCOL B-39: FOLLOW-UP FORM NCT00103181 Radiation Therapy in Treating Women Who Have Undergone Surgery For Ductal Carcinoma In Situ or Stage I or Stage II Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=E6FAF17E-75C9-2EDC-E034-0003BA3F9857

Link:
https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=E6FAF17E-75C9-2EDC-E034-0003BA3F9857
Keywords:
  1. 8/26/12 8/26/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
  3. 7/5/15 7/5/15 -
Uploaded on:

July 5, 2015

DOI:
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License :
Creative Commons BY-NC 3.0 Legacy
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NSABP PROTOCOL B-39: FOLLOW-UP FORM NCT00103181

Submit every 6 months for the first 5 years, every 12 months thereafter, and when a protocol event occurs.

Header
Are data amended? (check box if yes, and circle amended items)
Vital Status
Patient's Vital Status
Source of Survival Information (if alive)
Primary Cause of Death (if dead)
Was there evidence of recurrence at the time of death?
Type of Evidence (if yes,)
Cancer Follow-up Status
Has the patient had a documented clinical assessment for this cancer (since submission of the last follow-up form?)
First Local-regional Recurrence
Has the patient been diagnosed with first local-regional recurrence (since submission of the last follow-up form?)
Site(s) of First Local-Regional Recurrence (mark all ipsilateral sites that apply)
First Distant Recurrence
Has the patient been diagnosed with first distant recurrence/progression (since submission of the last follow-up form?)
New Primary Cancer Or Mds
Has a new primary cancer or MDS been diagnosed that has not been previously reported?
Since the last follow-up, has the patient received any adjuvant hormonal therapy? (prior to cancer recurrence or second primary cancer)
Has the patient undergone total mastectomy of the ipsilateral breast that was not previously reported on Form F?
In-breast Tumor Recurrence
LOCATION OF IBTR
TREATMENT OF IBTR
NSABP breast cancer protocol
Is this patient also enrolled in another NSABP breast cancer protocol?

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