IBCSG Long Term Follow-Up Recurrence Form (18-LTF-RC) Source Form: NCI FormBuilder:

  1. 8/26/12 8/26/12 -
  2. 6/20/17 6/20/17 - Martin Dugas
Uploaded on:

June 20, 2017

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Creative Commons BY-NC 3.0
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IBCSG Long Term Follow-Up Recurrence Form (18-LTF-RC)

Complete this form for patients with a proven recurrence. Use minus one (-1) to indicate that an answer is unknown unobtainable or not done

Header Module
Proven Recurrence/Metastasis Or Contralateral Invasive Breast Cancer
Site (Sites of Recurrence Local Regional Distant)
Hormone Receptor Analysis
Was Hormone Receptor Analysis performed (on a recurrence reported during this follow-up period)
day month year
ER Status (select one)
PgR Status (select one)
Footer Module

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