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

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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)

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
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)
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
Comments