NSABP PROTOCOL R-04: REGISTRATION FORM NCT00058474 Radiation Therapy and Either Capecitabine or Fluorouracil With or Without Oxaliplatin Before Surgery in Treating Patients With Resectable Rectal Cancer Source Form: NCI FormBuilder:

  1. 12/18/14 12/18/14 - Martin Dugas
  2. 1/9/15 1/9/15 - Martin Dugas
  3. 6/29/15 6/29/15 -
  4. 9/20/21 9/20/21 -
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September 20, 2021

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Creative Commons BY-NC 3.0 Legacy
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#Not required for patients =70 years if age, For patients < 70 years of age with a serum creatinine > ULN either a measured or a calculated creatinine clearance is required.

Ccrr Module For Nsabp Protocol R-04: Registration Form
Person Completing Form, Last Name
Race Categories (more than one may be marked)
Method of Payment (mark primary method only)
Performance Status
Patient Gender
In the opinion of the investigator, is the patient eligible?
Certificiation Of Eligibility
Method of Evaluation (or)
Method of Evaluation (or)
Method of Evaluation (or)
Method of Evaluation (or)
Method of Evaluation (or)
Method of Evaluation (or)
Staging Of Primary Tumor
Procedure Used to Definitively Stage Primary Tumor
Quality Of Life
Did the patient complete the Quality of Life baseline form?
If the baseline QOL form was not completed, indicate the reason below.
Are there multiple rectal tumors?
Is the tumor fixed to surrounding structures?
Tumor Extension
Clinical T Stage
Regional Lymph Nodes (Evidence of positive >= 1.0 cm)
Intended Operative Procedure
Biopsy specimen
Did the patient have a previous biopsy sample collected in RNAlater
I agree to undergo an additional biopsy so that a sample of my tumor can be collected in RNAlater solution and sent to the NSABP (If no, then how did the patient answer the following question from the consent form:)
I agree to let my doctor release the coded link to my R-04 study identification number so my biopsy sample that was collected in RNAlater may be used in the R-04 study (If yes, then how did the patient answer the following question from the consent form:)
Your blood and tissue samples may be kept by the NSABP for use in future research to learn about, prevent, detect, or treat cancer (My)
I agree to allow my study doctor, or someone approved by my study doctor, to contact me regard future research involving my participation in this study (My study doctor or someone he or she chooses may contact me in the future to ask me to take part in more research)
Eligibility Checklist (This is not a complete list of the eligibility criteria. Please see protocol.)

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