E5103 On-Study Form NCT00433511 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:


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  2. 1/9/15
  3. 6/16/15
  4. 9/20/21
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September 20, 2021

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E5103 On-Study Form NCT00433511

Instructions: Complete this form and submit original to the ECOG Coordinating Center within one week of registrations. Keep a copy for your files.

ECOG clinical trial administrative data
Reporting Period
Patient demographics
Performance status
ECOG Performance Status (Day 1 of this cycle)
Menopausal status (Definitions of Menopausal Status: Postmenopausal: Defined as at least one of the following: 1 age >55 with no spontaneous menses for at least 12 months; or 2 age </=55 with no spontaneous menses within the past 12 months e.g., spontaneously or...)
Pre-registration Evaluation
Prior tamoxifen therapy
Prior raloxifene therapy? (for chemoprevention)
Pre-registration Scans/imaging
Method of Evaluation
Disease Description
Tumor Laterality (NOTE: Submit copies of pathology reports for all diagnostic and therapeutic surgical procedures with E5103 Source Document Tracking Coversheet)
Breast: Surgical Procedures
Most Extensive Primary Surgery
Was sentinel node sampling performed
Was axillary dissection performed?
Breast: Disease Description
Histologic Grade (For breast cancer, a combined histologic grade is used according to SBR/Elston classification)
Nuclear Grade
Receptor Status, ER (as defined by local laboratory; borderline results should be reported as positive)
Receptor Status, PgR
Her2/neu expression status by immunohistochemistry (DAKO HercepTest)
Breast: Surgical Procedures
Breast: Disease Description
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