E3F05 Long-Term Follow-up Form Radiation Therapy With or Without Temozolomide in Treating Patients With Low-Grade Glioma Source Form: NCI FormBuilder:

  1. 8/26/12 8/26/12 -
  2. 1/8/15 1/8/15 - Martin Dugas
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January 8, 2015

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Creative Commons BY-NC 3.0 Legacy
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Brain and Central Nervous System Tumors NCT00978458 Follow-Up - E3F05 Long-Term Follow-up Form - 2900961v1.0

INSTRUCTIONS: After patient is off treatment, complete this form for each required follow-up report period (see forms submission schedule). Submit original to the ECOG Coordinating Center. Keep a copy for your files. NOTE: This form is required at the specified report periods regardless of whether new information is available

Off Treatment Report Period (since registration choose one)
Vital Status
Patient's Vital Status
Primary Cause of Death (if applicable)
Section Ii - Reporting Period
Section Iv - Notice Of New Primary
Has a new primary cancer or MDS been diagnosed that has not been previously reported?
Section Iii - Disease Follow-up Status
Has the patient had a documented clinical assessment for this cancer (this reporting period)
Has the patient developed a first progression that has not been previously reported? (CNS or relapse)
Did a physician make a formal diagnosis of progressive disease? (CNS)
Section V - Adverse Events
Has the patient experienced any severe (Grade = 3) long term toxicity that has not been previously reported? (prior to diagnosis of CNS progression/relapse NOTE: Do not report adverse events occurring after start of non-protocol therapy.)
Section Vi - Non-protocol Therapy Prior To Progression
Has the patient received any non-protocol cancer therapy prior to first progression (CNS not previously reported)

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