E1105 On-Study Form NCT00520975 First-Line Chemotherapy and Trastuzumab With or Without Bevacizumab in Treating Patients With Metastatic Breast Cancer That Overexpresses HER-2/NEU Source Form: NCI FormBuilder:

  1. 8/26/12 8/26/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
  3. 6/18/15 6/18/15 -
  4. 9/20/21 9/20/21 -
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September 20, 2021

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Creative Commons BY-NC 3.0 Legacy
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E1105 On-Study Form NCT00520975

INSTRUCTIONS: Use this form to capture the first occurrence of non-protocol anti-tumor therapy per registration step

Reporting Period
Patient demographics
ECOG Performance Status (Day 1 of this cycle)
Data amendment
Pre-registration Evaluation
Carboplatin planned
Menopausal status
g/24 hours
Prior Treatment
Most Extensive Primary Surgery
Prior Hormonal Therapy (in adjuvant or metastatic setting)
Prior Treatment Regimen Type
Prior Radiation Therapy
Prior Taxane Therapy (in the adjuvant or neoadjuvant setting)
Prior Doxorubicin Therapy (in the adjuvant or neoadjuvant setting)
Prior Epirubicin Therapy (in the adjuvant or neoadjuvant setting)
Prior Trastuzumab Therapy (in the adjuvant setting)
Prior Lapatinib Therapy (in the adjuvant or neoadjuvant setting?)
Prior Other Chemotherapy (in the adjuvant or metastatic setting)
Disease Description
ER Status
PgR Status
Her2/neu expression status by immunohistochemistry (DAKO HercepTest)
Local-regional (Sites of Involvement At Study Entry - Record an answer for each site including "Other)
Ipsilateral supraclavicular nodes
Opposite Breast
Distant Lymph Nodes
Distant Skin/subcutaneous Tissue
Bone Marrow
Other CNS
Other (Second)

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