CALGB: 49903 ADVANCED TREATMENT SUMMARY FORM; All Patients Trastuzumab With or Without Tamoxifen in Treating Women With Progressive Stage IV Breast Cancer Source Form: NCI FormBuilder:

  1. 8/26/12 8/26/12 -
  2. 3/20/14 3/20/14 - Martin Dugas
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March 20, 2014

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Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00053339 Treatment - CALGB: 49903 ADVANCED TREATMENT SUMMARY FORM; All Patients - 2054479v3.0

INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice. Print text in capital letters. Avoid contact with the edges of the boxes. Circle amended items and check "Amended data" box to the right. If submitting by mail, retain a copy for your records and send the original to the CALGB Data Management Center. If faxing, use an original form for maximum clarity in transmission and fax to 919-416-4990. If submitting electronically, click the Send button when you have completed the PDF version of the form.

Amended data?
Treatment Cycle Information
Reason Treatment Ended (mark one with an X)
Treatment Schedule - Systemic Therapy
Were there any dose modifications or additions/ omissions to protocol treatment? (mark one with an X)
Treatment Schedule - Other Therapy
Were any optional protocol therapies given?
Was any concurrent non-protocol therapy given during protocol treatment?
indicate below (concurrent non-protocol therapy given during protocol treatment) (mark all that apply with an X)

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