E5103 Radiation Therapy Form Doxorubicin, Cyclophosphamide, and Paclitaxel With or Without Bevacizumab in Treating Patients With Lymph Node-Positive or High-Risk, Lymph Node-Negative Breast Cancer Source Form: NCI FormBuilder:

  1. 8/26/12 8/26/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
  3. 9/20/21 9/20/21 -
Uploaded on:

September 20, 2021

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Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00433511 Treatment - E5103 Radiation Therapy Form - 2543728v1.0

Instructions: Complete this form according to the forms submission schedule. Submit original to the ECOG Coordinating Center; keep a copy for your files.

Reporting Period
Did the patient have protocol-defined radiation therapy as part of protocol treatment?
Radiation therapy not administered reason (if applicable - Note: Information regarding patients that are receiving Radiation Therapy per protocol/physician discretion must be collected on - this form.)
When did the patient start receiving radiation therapy as part of protocol treatment?
Whole Breast, boost (Site All fields must be completed. - Irradiated? 1=no, 2=yes)
Whole Breast, no boost
Partial Breast
Chest Wall (if mastectomy)
Ipsilateral Supraclavicular
Internal Mammary Lymph Nodes
Partial Breast Irradiation
Is patient on Partial Breast Irradiation Protocol Study

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