Description:

NSABP PROTOCOL B-36: FOLLOW-UP FORM Comparison of Two Combination Chemotherapy Regimens in Treating Women With Breast Cancer NCT00087178 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=C89314D7-1DBA-74BA-E034-0003BA12F5E7

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=C89314D7-1DBA-74BA-E034-0003BA12F5E7

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Versions (4) ▾
  1. 8/26/12
  2. 1/9/15
  3. 4/13/15
  4. 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 FOLLOW-UP NSABP B-36 NCT00087178

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  1. StudyEvent: NSABP PROTOCOL B-36: FOLLOW-UP FORM
    1. No Instruction available.
Header
Are data amended (check box if yes, and circle amended items)
Vital Status
Patient's Vital Status
Source of Survival Information (if alive)
Primary cause of Death (if dead)
Was there evidence of recurrence at the time of death?
Cancer Follow-up Status
Has the patient had a documented clinical assessment for this cancer (since submission of the last follow-up form)?
First Local-regional Recurrence
Has the patient been diagnosed with first local-regional recurrence (since submission of the last follow-up form)?
Site(s) of First Local-Regional Recurrence (mark all ipsilateral sites that apply)
First Distant Recurrence
Has the patient been diagnosed with first distant recurrence/progression (since submission of the last follow-up form)?
New Primary Cancer Or Mds
Has a new primary cancer or MDS been diagnosed that has not been previously reported?
Patient data
Has the patient had a menstrual period or vaginal bleeding in the last 12 months?
Has the patient had a hysterectomy?
Has the patient had a bilateral oophorectomy?
Was patient randomized to receive Celecoxib or Placebo?
Did the patient experience any of the following adverse events that have not been previously reported?
Adverse Events
Adverse Event
Grade
Late Adverse Events
Has the patient experienced any severe (Grade >= 3) adverse event, possibly related to the chemotherapy, that has not been previously reported?
Therapy
Did the patient receive any Herceptin treatment (since randomization since last follow-up)
Did the patient receive any systemic hormonal treatment (since randomization since last follow-up)
Tamoxifen
Anastrozole
Exemestane
Letrozole
LHRH agonist
Other, specify

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