Description:

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: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=22AFD24B-EC68-5512-E044-0003BA3F9857

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=22AFD24B-EC68-5512-E044-0003BA3F9857

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

September 20, 2021

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

Details

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

Header
Reporting Period
Unnamed2
Header
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
Axilla
Internal Mammary Lymph Nodes
Other
Unnamed2
Partial Breast Irradiation
Method
Is patient on Partial Breast Irradiation Protocol Study
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