Description:

S1011 Follow-Up Form (#56311) Standard or Extended Pelvic Lymphadenectomy in Treating Patients Undergoing Surgery for Invasive Bladder Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9339E952-BB3F-996A-E040-BB89AD43480C

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9339E952-BB3F-996A-E040-BB89AD43480C

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Versions (2) ▾
  1. 8/26/12
  2. 1/9/15
Uploaded on:

January 9, 2015

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License:
Creative Commons BY-NC 3.0 Legacy
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Bladder Cancer NCT01224665 Follow-Up - S1011 Follow-Up Form (#56311) - 3152339v1.0

Instructions: Please submit at each follow up after completion of treatment until relapse or progression, at time of relapse or progression, and at protocol-specified intervals after relapse or progression. Also submit at time of diagnosis of second primary. All dates are MONTH, DAY, YEAR. Answer all questions and explain any blank fields or blank dates in the Comments section. Place an X in appropriate boxes. Circle AMENDED items in red

Header
Vital Status
Vital Status
Has the patient had a documented clinical assessment for this cancer (since submission of the previous follow-up form)
Has the patient developed a first relapse or progression that has not been previously reported
Site(s) of Relapse or Progression (select all that apply)
Has a new primary cancer or MDS been diagnosed that has not been previously reported? (myelodysplastic syndrome)
Has the patient received any non-protocol cancer therapy not previously reported (prior to progression/relapse)
Has the patient experienced (prior to treatment for progression or relapse or a second primary, and prior to non-protocol treatment) any severe (grade >=3) long term toxicity that has not been previously reported?
Comments