Beschreibung:

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

Stichworte:

Klinische Studie [Dokumenttyp]

Treatment Form

Adenokarzinom

Ösophagus

Versionen (5) ▾

Hochgeladen am:

8. Juli 2015

DOI:

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Lizenz:

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

StudyEvent: RTOG 1010 Maintenance Systemic Treatment Summary Form (SF)
1. 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

RTOG Study No.

Case #

Institution Name

Institution No.

Patient Initials

RTOG Patient ID

Amended Data

Yes

Assessment

Height (CM)

Weight (KG)

BSA (M^2 [BSA must be taken out to the hundredth X.XX])

Reporting Period (WHICH CYCLE IS BEING REPORTED)

Cycle 1 (Cycle 1)

Cycle 2 (Cycle 2)

Cycle 3 (Cycle 3)

Treatment Summary

Agent Name

Date Agent Started (MM DD YYYY)

Date Agent Ended (MM DD YYYY)

Agent Dose (mg)

Total No. of Doses

Agent Total Cumulative Dose (mg)

Dose Modification (Change)

No (No)

Yes, Planned (i.e., The Treatment Was Changed According To Protocol Guidelines) (Yes, planned)

Yes, Unplanned (i.e., The Treatment Change Was Not Part Of Protocol Guidelines) (Yes, unplanned)

Reason Treatment Ended

Adverse Event/side Effects/complications (Adverse Event/Side Effects/Complications)

Alternative Therapy (Alternative therapy)

Death On Study (Death on study)

Disease Progression, Relapse During Active Treatment (Disease progression, relapse during active treatment)

Other (Other)

5 weitere Items in der Detailansicht.

Alternative therapy, specify

Patient off-treatment for other complicating disease, specify

Other specify

Therapy Modification

Details of any treatment modification

Comments

Investigator Signature

Date

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