Description:

Lung Cancer - Advanced Disease Follow Up Form Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=99CD59C5-A8E5-3FA4-E034-080020C9C0E0

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=99CD59C5-A8E5-3FA4-E034-080020C9C0E0

Keywords:
Versions (3) ▾
  1. 9/19/12
  2. 1/9/15
  3. 1/9/15
Uploaded on:

January 9, 2015

DOI:
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License:
Creative Commons BY-NC 3.0 Legacy
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Follow-Up - Lung Cancer - Advanced Disease Follow Up Form - 2019424v2.31

(Information contained in this section is optional and may be included at the discretion of the group; for example: preprinted labels or electronically populated fields may be used)

Crf Header
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Vital Status
Primary Cause of Death
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Has the patient had a documented clinical assessment for this cancer? (since submission of the previous follow-up form)
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Has the patient developed a first progression (or relapse) that has not been previously reported?
Lung: Non-protocol Therapy
Is the patient receiving any non-protocol cancer therapy not previously reported?
Non-Protocol Hormonal Therapy? (includes medical and surgical)
Non-Protocol Chemotherapy
Non-Protocol Immunotherapy?
Non-Protocol Biologic Response Modifier?
Non-Protocol High Dose Chemotherapy/Autologous Stem Cell Transplant
Non-Protocol Radiation Therapy?
Non-Protocol Surgery?
Other Non-Protocol Therapy
Tbd
Has a new primary cancer or MDS been diagnosed that has not been previously reported? (myelodysplastic syndrome)
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Has the patient experienced (prior to diagnosis of recurrence or second primary) any severe (Grade >=3), long term toxicity that has not been previously reported
Allows Documentation Of Any Additional Cooments

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