S1007 Off-Protocol Notice Form - Step 1 Tamoxifen Citrate, Letrozole, Anastrozole, or Exemestane With or Without Chemotherapy in Treating Patients With Invasive RxPONDER Breast Cancer Source Form: NCI FormBuilder:

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

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Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT01272037 Off Treatment - S1007 Off-Protocol Notice Form - Step 1 - 3141184v1.0

Instructions: Submit this form if the patient will not continue on study and register to Step 2, within 2 weeks after the decision not to proceed. 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 at the top of the form

Oncotype Dx Recurrence Score
Was the Oncotype DX Recurrence Score obtained
Off Protocol Reason
Off Protocol Reason (select one)
Planned Treatment
What treatment is planned for the patient (select all that apply)
For Patients Participating In The Quality Of Life And Economic Analysis Substudy
For patients participating in the Quality of Life and Economic Analysis substudy, was the S1007 Health-Related Quality of Life Questionnaire: Observational Study Form completed per protocol section 14.8?
Vital Status

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