Description:

RTOG-0522 I1: Initial Evaluation Form NCT00265941 Radiation Therapy and Cisplatin With or Without Cetuximab in Treating Patients With Stage III or Stage IV Head and Neck Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=F64A912E-BA2D-250A-E034-0003BA3F9857

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=F64A912E-BA2D-250A-E034-0003BA3F9857

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Uploaded on:

September 20, 2021

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Creative Commons BY-NC 3.0 Legacy
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Initial Evaluation Head and Neck Cancer Stage III or IV RTOG-0522 I1 NCT00265941

No Instruction available.

  1. StudyEvent: RTOG-0522 I1: Initial Evaluation Form
    1. No Instruction available.
Header
Amended data
Patient demographics
years
Gender
PERFORMANCE STATUS (ZUBROD)
History of Prior Malignancy (INVASIVE EXCEPT NON-MELANOMATOUS SKIN CANCER)
Prior Treatment
Prior Surgery (FOR HEAD AND NECK CANCER-EXCLUDES DIAGNOSTIC BIOPSY AND NODAL SAMPLING)
Prior Chemotherapy (FOR OTHER REASONS)
Prior Radiation Therapy (FOR HEAD AND NECK CANCER)
Prior therapy that targeted EGFR pathway (Type shown on CRF - "EGRF")
Co-morbidities
Hospitalized for unstable angina and/or CHF in last 6 months
Transmural MI in last 6 months
IV antibiotics at time of registration
COPD exacerbation or other respiratory illness requiring hospitalization or precluding study therapy at registration
Prior allergic reaction to Cisplatin
Prior allergic reaction to C225
Diagnostic Work-up
CT scan of tumor site
MRI result (of tumor site)
PET/CT
PET/CT chest
Chest X-Ray Result
Chest CT
ECHO and/or MUGA
Baseline LVEF
%
Laboratory Tests
ANC
Platelet Count
Hemoglobin
g/dL
Bilirubin
SGOT (AST)
SGPT (ALT)
Serum Creatinine
Creatinine Clearance
Serum Calcium
Corrected Serum Calcium
Ionized Serum Calcium
Magnesium
Primary Site (If site within region cannot be determined, specify region)
Indicate other involved sites within region of origin or extension at study entry (Use previous codetable)
Tumor Measurements At Presentation
Histologic Type
cm
Primary Tumor Laterality
Clinical T Stage
Clinical N Stage (OVERALL)
Clinical N Stage, Right side
Clinical N Stage, Left side
Clinical M Stage
Weight Loss in Previous Six Months
Does the patient have a past history of swallowing problems
How long were swallowing problems apparent (If yes,)
Does the patient currently have swallowing problems
How long have swallowing problems been present (If yes,)
Does the patient have a past history of tube feedings
How long were tube feedings given (If yes,)
Does the patient currently require tube feeding
Is patient dependent on tube feeding for >50% of nutritional support (If yes,)
Smoking History
Does the patient currently smoke (cigarettes)
Number of Cigarettes per day (Need to add this new question to CRF to capture value for current smokers - values need to match existing CDE)
Smoking Discontinued Duration
Protocol Specific Adverse Event Evaluation
CTC Adverse Event Term
Comments

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