Description:

CALGB 80702 On-Study Form Oxaliplatin, Leucovorin Calcium, and Fluorouracil With or Without Celecoxib in Treating Patients With Stage III Colon Cancer Previously Treated With Surgery Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=7ADB9225-BFE2-FA4C-E040-BB89AD4369EB

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=7ADB9225-BFE2-FA4C-E040-BB89AD4369EB

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Versions (2) ▾
  1. 8/27/12
  2. 1/9/15
Uploaded on:

January 9, 2015

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License:
Creative Commons BY-NC 3.0 Legacy
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Colorectal Cancer NCT01150045 On-Study - CALGB 80702 On-Study Form - 2970013v1.0

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. Mark an X in the appropriate box for fields with a choice. Print text in capital letters. Avoid contact with the edges of the boxes. If data are amended, circle amended items and check the "Yes" box. If submitting by mail, retain a copy for your records and send the original to the CALGB Statistical Center, Data Operations. If submitting by fax, use an original form for maximum clarity in transmission and fax to 919-416-4990. If submitting electronically, click the Send button when you have completed the PDF version of the form

Header
Are data amended
Unnamed2
Patient Description
Has the patient had any prior cancer diagnosed? (other than colon)
Clinical T Stage (TMN Stage prior to surgery Mark one with an X.)
Clinical N Stage (TMN Stage prior to surgery Mark one with an X.)
Clinical M Stage (TMN Stage prior to surgery Mark one with an X.)
Tnm Stage/surgical Data
Lab Data At Protocol Entry
%
mg/dL
mg/dL
Cardiac Risk Factors
Uncontrolled high blood pressure (systolic blood pressure >150)
Unstable angina
Symptomatic congestive heart failure
History of documented myocardial infarction or cerebrovascular accident
New York Heart Association Class III or IV heart failure
Neurosensory or neuromotor toxicity >= grade 2
History of upper gastrointestinal ulceration, bleeding or perforation within the past 3 yrs
Ongoing treatment with aspirin or NSAIDS including celecoxib (except low-dose aspirin < 100mg/day)
In the past five years prior to the diagnosis of colon cancer, was the patient a regular user of any NSAIDS, aspirin or celecoxib (Regular use is defined as at least two tablets per week, on average for more than 9 months of the year. Please ask the patient this question at time of study entry.)
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