Description:

CALGB 40601 RADIATION THERAPY FORM Paclitaxel and Trastuzumab With or Without Lapatinib in Treating Patients With Stage II or Stage III Breast Cancer That Can Be Removed by Surgery Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=3A1E51E7-0B3F-2826-E044-0003BA3F9857

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=3A1E51E7-0B3F-2826-E044-0003BA3F9857

Keywords:
Versions (4) ▾
  1. 8/27/12
  2. 1/9/15
  3. 1/9/15
  4. 7/8/15
Uploaded on:

July 8, 2015

DOI:
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License:
Creative Commons BY-NC 3.0 Legacy
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CALGB 40601 RADIATION THERAPY FORM

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 use black ink.

Header
Are data amended
Patient demographics
Radiation Therapy
Has the patient received radiation therapy to the breast?
Radiation Therapy
Has the patient received elective postmastectomy radiation therapy?
Radiation Therapy
Has the patient received regional nodal radiation therapy?
Has the patient received regional nodal radiation therapy to supraclavicular nodes?
Has the patient received regional nodal radiation therapy to axillary nodes?
Has the patient received regional nodal radiation therapy to internal mammary nodes?
Expected Adverse Events
CTC adverse event term
CTC Adverse Event Term
CTC AE Attribution Code (^2)
CTC AE Attribution Code (^2)
Comments

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