Description:

S1007 Treatment Form (TX1007) Tamoxifen Citrate, Letrozole, Anastrozole, or Exemestane With or Without Chemotherapy in Treating Patients With Invasive RxPONDER Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=90CA1C57-43D2-A228-E040-BB89AD43458D

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=90CA1C57-43D2-A228-E040-BB89AD43458D

Keywords:
Versions (2) ▾
  1. 8/27/12
  2. 1/8/15
Uploaded on:

January 8, 2015

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License:
Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT01272037 Treatment - S1007 Treatment Form (TX1007) - 3140038v1.0

Instructions: Please complete this form at 6 months, 12 months, 18 months, 24 months, 30 months, 36 months, 4 years, and 5 years after randomization. All dates are MONTH, DAY, YEAR. Explain any blank dates or fields in a Comments section. Place an X in appropriate boxes. Circle AMENDED items in red and write AMENDED across the top of the form

Header
Reporting Period
Status
Vital Status
Has the patient progressed per the definition in Section 10.0 of the protocol
Treatment For This Cycle
Assigned Treatment Arm
Was the patient treated on the assigned arm during this reporting period
Kg
Has the patient received any chemotherapy during this reporting period?
Section Iv - Treatment
Has the patient received any endocrine therapy during this reporting period
Did patient switch type of endocrine therapy during this reporting period
Specify reason for switch in endocrine therapy (If yes)
Specify new type of endocrine therapy given
Specify which Aromatase Inhibitor was given (If Aromatase Inhibitor)
Tamoxifen (If no, Answer Yes or No for each of the following therapies the patient consistently took during this reporting period)
Aromatase Inhibitor (If no, Answer Yes or No for each of the following therapies the patient consistently took during this reporting period)
Specify which Aromatase Inhibitor was given
Other
If the patient was premenopausal at registration, is she currently having regular menstrual periods
Did patient receive Ovarian Function Suppression (OFS) during this reporting period
Ovarian Function Suppression Type (If yes)
Was all endocrine therapy discontinued this reporting period
Concurrent Medications/clinical Trials
Did the patient receive bisphosphonates during this reporting period (select all that apply)
Is the patient currently co-enrolled on another CTEP or NCI-sponsored clinical trial for breast cancer
Comments

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