Instructions: Submit this form at the completion of chemotherapy. All dates are MONTH, DAY, YEAR. Explain any blank fields or blank dates in the Comments section. Place an X in appropriate boxes. Circle AMENDED items in red and write AMENDED across top of form
Instructions: Submit this form at the completion of chemotherapy. All dates are MONTH, DAY, YEAR. Explain any blank fields or blank dates in the Comments section. Place an X in appropriate boxes. Circle AMENDED items in red and write AMENDED across top of form
Chemotherapy Regimen (select one; if drugs were substituted or omitted during treatment because of toxicity, indicate the initial planned regimen)
CL Item
Docetaxel And Cyclophosphamide (Docetaxel and cyclophosphamide)
CL Item
5-fu, Doxorubicin (or Epirubicin), And Cyclophosphamide (5-FU, doxorubicin (or epirubicin), and cyclophosphamide)
CL Item
Doxorubicin (or Epirubicin) And Cyclophosphamide (ac/ec) Followed By Paclitaxel (Doxorubicin (or epirubicin) and cyclophosphamide (AC/EC) followed by paclitaxel)
CL Item
Doxorubicin (or Epirubicin) And Cyclophosphamide (ac/ec) Followed By Weekly Paclitaxel X 12 (Doxorubicin (or epirubicin) and cyclophosphamide (AC/EC) followed by weekly paclitaxel x 12)
CL Item
5-fu, Doxorubicin (or Epirubicin) And Cyclophosphamide Followed By Docetaxel (q 3 Weeks, 4 Cycles Each) (5-FU, doxorubicin (or epirubicin) and cyclophosphamide followed by docetaxel (q 3 weeks, 4 cycles each))
CL Item
5-fu, Doxorubicin (or Epirubicin) And Cyclophosphamide Followed By Docetaxel (3 Cycles Each) (5-FU, doxorubicin (or epirubicin) and cyclophosphamide followed by docetaxel (3 cycles each))
CL Item
Dose Dense Doxorubicin And Cyclophosphamide Followed By Dose Dense Paclitaxel (q 2 Weeks, 4 Cycles Each) (Dose dense doxorubicin and cyclophosphamide followed by dose dense paclitaxel (q 2 weeks, 4 cycles each))
CL Item
Docetaxel, Doxorubicin, And Cyclophosphamide (6 Cycles) (Docetaxel, doxorubicin, and cyclophosphamide (6 cycles))
CL Item
5-fu, Doxorubicin (or Epirubicin) And Cyclophosphamide (fac) Followed By Weekly Paclitaxel X 12 (5-FU, doxorubicin (or epirubicin) and cyclophosphamide (FAC) followed by weekly paclitaxel x 12)
CL Item
Weekly Paclitaxel X 12 Followed By 5-fu, Doxorubicin (or Epirubicin) And Cyclophosphamide (fac) (Weekly paclitaxel x 12 followed by 5-FU, doxorubicin (or epirubicin) and cyclophosphamide (FAC))
CL Item
Other Regimen Given As Part Of A Ctsu Adjuvant Therapy Protocol (other regimen given as part of a CTSU adjuvant therapy protocol)
CL Item
Other Chemotherapy Regimen (Other chemotherapy regimen)
AdjuvantChemotherapyRegimenSpecify
Item
specify study number and treatment arm (other regimen given as part of a CTSU adjuvant therapy protocol)