Description:

NCT01196390 RTOG 1010 Maintenance Systemic Treatment Summary Form (SF) Radiation Therapy, Paclitaxel, and Carboplatin With or Without Trastuzumab in Treating Patients With Esophageal Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=870A090F-64E8-A152-E040-BB89AD430551

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=870A090F-64E8-A152-E040-BB89AD430551

Keywords:
Versions (5) ▾
  1. 8/26/12
  2. 1/9/15
  3. 1/9/15
  4. 1/9/15
  5. 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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NCT01196390 RTOG 1010 Maintenance Systemic Treatment Summary Form (SF)

Details

INSTRUCTIONS: Form is submitted 1 week after completion or termination of cycle1-5, cycle 6-10 and cycle 11-13, for a total of 3 submissions. All 3 pages of the form must be submitted. Dates are mm-dd-yyyy unless otherwise specified

Header Module
Amended Data
Assessment
cm
Kg
m2
Reporting Period (WHICH CYCLE IS BEING REPORTED)
Treatment Summary
Dose Modification (Change)
Reason Treatment Ended
5 more items in the detailed view.
Therapy Modification
Toxicities
Was a MUGA/Echocardiogram Performed During This Report Period
Incipient CHF (If yes, did the patient experience defined as asymptomatic >20% decrease in LVEF or a decrease of LVEF >10% below the institutions lower limit of normal and required treatment according to institutional guidelines)
LVEF Status (If a MUGA/echocardiogram was performed during this report period)
3 more items in the detailed view.
Grade 3 or 4 Restrictive Cardiomyopathy (IF ANY ANSWERED YES, REPORT COMPLETELY IN Q#12)
Protocol Specific Adverse Event Evaluation
Any adverse events
CTC AE Grade
CTC AE Attribution Code
SAE report submitted
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