Concomitant Medications Form (Form 24-CCM) Brain Function in Premenopausal Women Receiving Tamoxifen With or Without Ovarian Function Suppression for Early-Stage Breast Cancer on Clinical Trial IBCSG-2402 Source Form: NCI FormBuilder:

  1. 8/26/12 8/26/12 -
  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 NCT00659373 Treatment - Concomitant Medications Form (Form 24-CCM) - 2072606v3.0

CONCOMITANT MEDICATIONS FORM (Form 24-CCM) Instructions: This form is to be completed: -> Prior to starting any protocol therapy (Tamoxifen, Exemestane, OFS), and -> On the same schedule as the Follow-Up Form (24-E) (every 3 months in Year 1, every six months in Years 2-5) (during Tamoxifen, Exemestane, OFS), and -> At 6 and 12 months after the last dose of all protocol therapy (Tamoxifen, Exemestane, OFS). -> No CCM Forms are required after first relapse/recurrence. Use minus one (-1) to indicate that an answer is unknown, unobtainable, or not done.

Ccrr Module For Concomitant Medications Form (form 24-ccm)
Did patient receive any of the concomitant medications listed in the Concomitant Medication Code box below
Concomitant Medication
Primary Reason
Route of Administration

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