S1011 Prestudy Form (#8218) Standard or Extended Pelvic Lymphadenectomy in Treating Patients Undergoing Surgery for Invasive Bladder Cancer 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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Bladder Cancer NCT01224665 Pre-Study - S1011 Prestudy Form (#8218) - 3152929v1.0

Instructions: Submit this form within 7 days of 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. ELIGIBILITY VERIFICATION: Each of the fields below corresponds to a criterion in Section 5 and must be completed for patient to be eligible

Patient And Disease Description
Zubrod Performance Status Score (see section 10.5 of the protocol)
Disease Description
Clinical T Stage
Bimanual Exam Result
Histologic Type (Please select all that apply based on TURBT or biopsy; pure squamous cell carcinoma or pure adenocarcinoma not eligible)
Type of Variant Histology (if selected please specify)
Laboratory Values
Laboratory Values1
Prior Treatment Related To This Cancer
Prior Neoadjuvant Chemotherapy
Neoadjuvant Treatment Related To This Bladder Cancer
Chemotherapy Regimen (select all that apply)

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