Description:

RTOG 0724 Phase III Cervix Chemo RT (+)/(-) Adjuvant Chemotherapy: Initial Evaluation Form (I1) NCT00980954 Chemotherapy and Pelvic Radiation Therapy With or Without Additional Chemotherapy in Treating Patients With High-Risk Early-Stage Cervical Cancer After Radical Hysterectomy Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=5D016EA3-A43F-2E2A-E044-0003BA3F9857

Link:
https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=5D016EA3-A43F-2E2A-E044-0003BA3F9857
Keywords:
  1. 12/18/14 12/18/14 - Martin Dugas
  2. 1/9/15 1/9/15 - Martin Dugas
  3. 6/16/15 6/16/15 -
  4. 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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RTOG 0724 Phase III Cervix Chemo RT (+)/(-) Adjuvant Chemotherapy: Initial Evaluation Form (I1) NCT00980954

INSTRUCTIONS: All questions must be answered per code table and/or instructions. Record dates as mm-dd-yyyy unless otherwise specified

  1. StudyEvent: RTOG 0724 Phase III Cervix Chemo RT (+)/(-) Adjuvant Chemotherapy: Initial Evaluation Form (I1)
    1. INSTRUCTIONS: All questions must be answered per code table and/or instructions. Record dates as mm-dd-yyyy unless otherwise specified
Header module
Amended Data (INSTRUCTIONS: All questions must be answered per code table and/or instructions. Record dates as mm-dd-yyy unless otherwise specified.)
Assessment
Performance Status (Zubrod)
FIGO staging (CLINICAL AJCC 6TH EDITION)
Pathologic T Stage
Pathologic N Stage
Pathologic M Stage
Type of radical hysterectomy
Histologic Category
Histologic Type
Histologic Grade
HIGH RISK FEATURES
Positive parametrium
Right parametrium
Left parametrium
Positive pelvic nodes
Extracapsular extension
Positive para-aortic nodes (PA)
PA nodes completely resected
If positive PA (para-aortic) nodes, PET/CT negative post-op
Extracapsular extension
Common Iliac Node Dissection
Examinations
PET / PET CT of Para-Aortic Nodes
Baseline Lab Values (hematologic)
1000/uL
g/dL
mg/dL
U/L
mmol/L
Severe Active Comorbidity
Residual gross tumor
Neuroendocrine histology
Does the patient have clinical or radiologic evidence of metastatic disease? (excluding completely resected PA nodes)
History of Prior Malignancy
Prior radiation therapy to the pelvis resulting in overlapping of radiation therapy fields per this protocol
Hospitalized for unstable angina and/or CHF in last 6 months
Transmural MI in last 6 months
Acute bacterial or fungal infection requiring intravenous antibiotics at the time of registration
COPD exacerbation or other respiratory illness requiring hospitalization or precluding study therapy at registration
Patient known to be HIV positive
Is CD4 count => 350 cells/mm
Prior systemic chemotherapy for current study cancer
Prior allergic reaction to carboplatin, cisplatin or paclitaxel
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