CALGB 40503 ON-STUDY FORM Tamoxifen or Letrozole With or Without Bevacizumab in Treating Women With Stage III or Stage IV Breast 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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Breast Cancer NCT00601900 On-Study - CALGB 40503 ON-STUDY FORM - 2551476v1.0

INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink.

Are data amended
Patient Characteristics
ECOG Performance Status (Mark one with an X.)
Menstrual period within the last 12 months?
Ovarian Function Suppression Type (If the patient was pre-menopausal)
Disease Description
ER status (Mark one with an X.)
PgR status (Mark one with an X.)
Timing of assay (Mark one with an X.)
Timing of assay (Mark one with an X.)
Site Of Progression Or Recurrence
Sites of Progression (s)
Required Laboratory Values
Urine Protein (Mark one with an X.)
g/24 hours
Immunohistochemistry Kit or Test Type (Mark all that apply with an X.)
FISH Kit or Test Type (Mark all that apply with an X.)
Final Diagnosis with HER2/neu (Mark one with an X.)
Prior Treatment - Systemic Regimens
Prior anthracycline Treatment
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