NSABP Protocol B-43 - Protocol Entry Form Worksheet Radiation Therapy With or Without Trastuzumab in Treating Women With Ductal Carcinoma In Situ Who Have Undergone Lumpectomy Source Form: NCI FormBuilder:


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  2. 1/9/15
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January 9, 2015

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Breast Cancer NCT00769379 Registration - NSABP Protocol B-43 - Protocol Entry Form Worksheet - 2679593v1.0

Submit every 6 months from date of randomization for the first 5 years; yearly thereafter, and when a protocol event occurs. Fax Form F to 412-622-2111

Person Completing Form, Last Name
Method of Payment (mark primary method only)
Country of Residence (if not USA)
Receptor Status
Receptor Status, ER
Receptor Status, PgR
Nuclear Grade
Plan for hormonal therapy
Patient Characteristics
Did patient consent to future contact about more research?
Has the patient authorized the release of Protected Health Information to the NSABP?
In the opinion of the investigator, is the patient eligible?
Determination Of Pre-entry Menopausal Status
Prior documented bilateral oophorectomy
History of at least 12 months without spontaneous menstrual bleeding
Age 55 or older with a prior hysterectomy
Age 54 or younger with a prior hysterectomy without oophorectomy (or in whom the status of the ovaries is unknown), with a documented FSH level demonstrating confirmatory elevation in the lab's postmenopausal range
Is the patient postmenopausal
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