Description:

FORM 5S - SHORT FOLLOW-UP 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=ABE490D9-DEFA-56EC-E034-0003BA12F5E7

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=ABE490D9-DEFA-56EC-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 5S - SHORT FOLLOW-UP REPORT NCT00090974

Canadian Centres: When completed please mail to:National Cancer Institute of Canada, Clinical Trials Group, Queen's University, 82-84 Barrie Street, Kingston, Ontario, K7L 3N6

Patient Information
Month Of Report
Month of report (circle one)
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?
Investigations
Imaging site
Method of Evaluation
Toxicity Evaluation
Did the patient experience any new or continuing toxicities of protocol treatment 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
Treatment Given Since Last Report To Ncic Ctg
Raloxifene Therapy
Bisphosphonate Therapy
Lipid-lowering Therapy
Is the patient receiving any non-protocol cancer therapy not previously reported? (Cancer Therapy)
Adverse Events
Has the patient experienced a bone fracture since last report?
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 last report?
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.)
Comments
Supporting Documentation
Investigator Signature
Ccrr Module For Form 5s - Short Follow-up Report

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