Description:

FORM 9 - RECURRENCE AND CONTRALATERAL BREAST CANCER REPORT Quality Of Life Companion Study For JMA27 (NCIC-MA.27): A Randomized Phase III Trial Of Exemestane Versus Anastrozole With Or Without Celecoxib In Postmenopausal Women With Receptor Positive Primary Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=ABE31B86-C179-5457-E034-0003BA12F5E7

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=ABE31B86-C179-5457-E034-0003BA12F5E7

Keywords:
Versions (3) ▾
  1. 8/26/12
  2. 1/9/15
  3. 9/20/21
Uploaded on:

September 20, 2021

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License:
Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00090974 Follow-Up - FORM 9 - RECURRENCE AND CONTRALATERAL BREAST CANCER REPORT - 2058833v3.0

Details

Submit within 6 weeks of the date of diagnosis.

  1. StudyEvent: FORM 9 - RECURRENCE AND CONTRALATERAL BREAST CANCER REPORT
    1. Submit within 6 weeks of the date of diagnosis.
Patient Information
Disease Status
Has the patient been diagnosed with first local-regional recurrence?
Has the patient been diagnosed with first distant recurrence/progression?
Has the patient been diagnosed with contralateral breast cancer? (since submission of the last follow-up form)
Supporting Documentation
Comments
Investigator Signature
Header
Recurrence Table
Site(s) Local-Regional, Ipsilateral Breast (Check)
Site(s) Local-Regional, Chest Wall (Check)
Site(s) Local-Regional, Regional Nodes/axilla (Check)
Site(s) Distant, Lung (Check)
Site(s) Distant, Liver (Check)
Site(s) Distant, Bone (Check)
Site(s) Distant, Central Nervous System (Check)
Site(s) Distant, Bone Marrow (Check)
Site(s) Distant, Ascites (Check)
Site(s) Distant, Pleural Effusion (Check)
Site(s) Distant, First Other, Specify (Check)
Site(s) Distant, Second Other, Specify (Check)
Ccrr Module For Form 9 - Recurrence And Contralateral Breast Cancer Report
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