Description:

RTOG-0522 F1: Follow-up Form Radiation Therapy and Cisplatin With or Without Cetuximab in Treating Patients With Stage III or Stage IV Head and Neck Cancer NCT00265941 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=F65D686D-87BE-6280-E034-0003BA3F9857

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=F65D686D-87BE-6280-E034-0003BA3F9857

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  1. 9/19/12
  2. 1/9/15
  3. 1/9/15
  4. 4/15/15
  5. 2/5/19
Copyright Holder:
NCI
Uploaded on:

February 5, 2019

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License:
Creative Commons BY-NC 3.0
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Head and Neck Cancer NCT00265941 Follow-Up

Details

No Instruction available.

  1. StudyEvent: RTOG-0522 F1: Follow-up Form
    1. No Instruction available.
Header
Amended data
Current Disease Status And Method Of Determination
PATIENT'S VITAL STATUS
PRIMARY CAUSE OF DEATH
HAS THE PATIENT HAD A DOCUMENTED CLINICAL ASSESSMENT FOR THIS CANCER (SINCE SUBMISSION OF THE PREVIOUS FOLLOW-UP FORM)
Primary tumor (Original study site)
Nodal Disease Right
Nodal Disease Left
Method of Evaluation (see Q5 codetable)
3 more items in the detailed view.
Disease Events
Event (Event Codes: Primary Tumor site under study 11,12; Regional Disease including Lymph Nodes from site under study 21,22,23,24)
Has the patient been diagnosed with first distant recurrence/progression? (SINCE SUBMISSION OF THE PREVIOUS FOLLOW-UP FORM)
Site(s) of distant progression (S use codetable below)
21 more items in the detailed view.
New primary cancer
Has a new primary cancer or MDS been diagnosed that has not been previously reported? (MYELODYSPLASTIC SYNDROME SINCE SUBMISSION OF THE PREVIOUS FOLLOW-UP FORM)
Site(s) of new primary (S USE CODETABLE FROM Q7)
21 more items in the detailed view.
Non-Protocol Therapy
Was any non-protocol therapy given (RELATED TO CANCER UNDER STUDY SINCE SUBMISSION OF THE PREVIOUS FOLLOW-UP FORM)
Non-Protocol Surgery
Non-Protocol Chemotherapy
Non-Protocol Biologic Response Modifier
Non-protocol radiation therapy to primary
Non-protocol radiation therapy to nodes (right)
Non-protocol radiation therapy to nodes (left)
Non-protocol radiation therapy to other sites
Other Non-Protocol Therapy
Was any non-protocol supportive therapy given (Was any non-protocol supportive therapy given since submission of the previous follow-up form)
Type of Supportive Care Given
Swallowing and Tube Feeding
Does the patient currently have swallowing problems
How long have swallowing problems been present (IF YES,)
3 more items in the detailed view.
Does the patient currently require tube feeding (12)
Is patient dependent on tube feeding for >50% of nutritional support (If yes,)
Was a feeding tube inserted during this reporting period (13)
Was a feeding tube discontinued during this reporting period (14)
Was a tracheostomy performed during this reporting period (15)
Was use of a tracheostomy discontinued during this reporting period
Protocol Specific Adverse Event Evaluation
CTC Adverse Event Term
1055 more items in the detailed view.
CTC AE Attribution Code (A. Attribution to Protocol Treatment: See protocol sections 6&7 for definition of "protocol treatment" 1=unrelated; 2=unlikely; 3=possible; 4=probable; 5=definite)
Serious adverse event report submitted (B. Adverse Event report submitted: 1=No; 2=Yes; 9=Unknown)
Protocol Specific Adverse Event Evaluation
New or continuing adverse events (Not reported in Q6)
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