S1007 Radiation Therapy Form (S1007RAD) Tamoxifen Citrate, Letrozole, Anastrozole, or Exemestane With or Without Chemotherapy in Treating Patients With Invasive RxPONDER Breast Cancer Source Form: NCI FormBuilder:


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  1. 8/27/12
  2. 1/9/15
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January 9, 2015

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Breast Cancer NCT01272037 Treatment - S1007 Radiation Therapy Form (S1007RAD) - 3139641v1.0

Instructions: Submit this form 1 year post-registration. 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

Has the patient received radiation therapy to the breast?
Whole breast or chest wall
Partial Breast
Tumor bed or chest wall boost
Ipsilateral supraclavicular / axillary apex field
Separate field for internal mammary nodes
Targeted Regions Of Treatment
Breast or chest wall
Level I axilla
Level II axilla
Level III axilla
Supraclavicular fossa
Internal mammary
Partial Breast Irradiation
Partial Breast Irradiation Method

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