Description:

E2108 Step 2 Follow-up Form Early Surgery or Standard Palliative Therapy in Treating Patients With Stage IV Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=8E30083E-7422-9EAD-E040-BB89AD430E1D

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=8E30083E-7422-9EAD-E040-BB89AD430E1D

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Versions (3) ▾
  1. 8/27/12
  2. 1/8/15
  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 NCT01242800 Follow-Up - E2108 Step 2 Follow-up Form - 3130846v1.0

INSTRUCTIONS: Complete this form and submit original to the ECOG Coordinating Center according to the forms submission schedule. If the same lesion was assessed more than once during a report period, submit additional forms (record all lesions on each form). If no lesions were assessed during a required report period, code 1=No to answer the question at the top of page 2. Keep a copy for your files. NOTE: Amendments to the site and method fields should be accompanied by amendments to previously submitted forms when applicable

Header
Unnamed2
Unnamed4
On Treatment Report Period
Report Period (Choose one)
Vital Status
Patient's Vital Status
Primary Cause of Death (if applicable)
Section Ii - Reporting Period
Has the patient been diagnosed with first local-regional recurrence (since submission of last follow-up form)
Basis of Diagnosis
Iib - Local-regional Recurrence
Axillary Node(s) and/or Soft Tissue
Infraclavicular Node(s)
Skin of breast
Internal mammary node
Ipsilateral Breast
Supraclavicular Node(s)
Skin of the chest wall
Chest Wall
Skin nodules present?
cm
Ulceration present?
cm
cm
Is direct invasion of tumor into skin present?
cm
Status Of Local-regional Disease
Skin nodules present?
cm
Ulceration present?
cm
cm
Tumor Mobility
Is direct invasion of tumor into skin present?
cm
Asymptomatic tumor in the intact breast present?
cm
Disease Description
Has the patient been diagnosed with first distant progression? (since submission of last follow-up form)
Basis of Diagnosis
Opposite Breast
Distant Lymph Nodes
Distant Skin/subcutaneous Tissue
Bone
Bone Marrow
Lung
Liver
Pleura
Brain
Other CNS
Other
Overall Response Per Recist Criteria - Target, Nontarget And New Lesions
Were circulating tumor cells (CTCs) assessed
Comments

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