S1011 Surgeon's 90-Day Assessment Form Standard Versus Extended LND (#5223) 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 Treatment - S1011 Surgeon's 90-Day Assessment Form Standard Versus Extended LND (#5223) - 3153915v1.0

Instructions: To be completed by attending surgeon. Please complete 90 days after surgery. Surgeons should be provided with this form prior to the surgical event. 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

Was the assessment done
Surgical Complications (Record any events that occurred following hospital discharge to 90 days post-op)
Surgical Complication Grade
Neoadjuvant Treatment Related To This Bladder Cancer
Prior Adjuvant Chemotherapy
Will the patient receive adjuvant chemotherapy (Please complete if the answer was "No" to adjuvant chemotherapy)
Chemotherapy Regimen (Please complete if the answer was "Yes" to adjuvant chemotherapy select all that apply)
Did the patient complete the planned adjuvant therapy (Please indicate "Yes" if the patient completed the planned adjuvant chemotherapy as of this form submission)

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