Description:

Paclitaxel, Cisplatin, and Radiation Therapy With or Without Cetuximab in Treating Patients With Locally Advanced Esophageal Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=2A16F93C-C68B-2E25-E044-0003BA3F9857

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=2A16F93C-C68B-2E25-E044-0003BA3F9857

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Versions (4) ▾
  1. 9/19/12
  2. 1/9/15
  3. 6/21/15
  4. 8/4/15
Uploaded on:

August 4, 2015

DOI:
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License:
Creative Commons BY-NC 3.0 Legacy
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Initial Evaluation Form Esophageal Cancer RTOG NCT00655876

Details

No Instruction available.

  1. StudyEvent: I1: Radiation Therapy Oncology Group Phase III Esophagus Initial Evaluation Form
    1. No Instruction available.
Module 1
AMENDED DATA
Patient status assessment
years
Performance Status (Zubrod)
History of Prior Malignancy (except non melanomatous skin cancer)
Kg
Extent of Dysphagia
Oral alimentation
Nasogastric tube feeding
Ostomy feeding
Intravenous hyperalimentation
Other
Estimate of daily caloric intake
Prior Treatment
Prior Surgery (for esophageal cancer excludes diagnostic biopsy)
Prior chemotherapy (for study cancer)
Prior chemotherapy (for other reasons)
Prior radiation therapy (to chest)
Prior therapy that targeted EGFR pathway
Prior platinum based and/or paclitaxel based therapy
Study Cancer
Site of study cancer
Histologic Type
Cervical esophagus
Invasion into the trachea or major bronchi
Evidence of tracheoesophageal fistule
Esophageal Tumor Clinical T Stage
Is the tumor proximal thoracic
Clinical N Stage
Clinical M Stage
Celiac lymph nodes
Cervical lymph nodes
Supraclavicular lymph nodes
Laboratory Tests
g/dL
1000/ul
1000/uL
mg/dL
U/L
U/L
mg/dL
mg/dL
Diagnosis Work-up
History and Physical
CT scan or MRI of the chest or abdomen
Endoscopic biopsy of esophageal tumor
EKG
Bronchoscopy
PET/CT
Co-morbidties
Hospitalized for unstable angina and/or CHF in last 6 months
Transmural MI in last 6 months
IV antibiotics at time of registration
COPD exacerbation or other respiratory illness requiring hospitalization or precluding study therapy at registration
Prior allergic reaction to cisplatin
Prior allergic reaction to C225
Prior allergic reaction to taxol
Prior severe infusion reaction to a monocolonal antibody
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