Description:

NSABP Protocol B-42 - Protocol Entry Form Worksheet Letrozole in Treating Postmenopausal Women Who Have Received Hormone Therapy for Hormone Receptor-Positive Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=17AF2627-D64B-3BA6-E044-0003BA3F9857

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=17AF2627-D64B-3BA6-E044-0003BA3F9857

Keywords:
Versions (3) ▾
  1. 12/18/14
  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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Breast Cancer NCT00382070 Registration - NSABP Protocol B-42 - Protocol Entry Form Worksheet - 2494107v1.0

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

Header
Unnamed2
Eligibility Criteria
Race
Race
Person Completing Form, Last Name
Method of Payment (mark primary method only)
Ethnicity
Country of residence
Consent
Patient consents to
Unnamed4
Has the patient authorized the release of Protected Health Information to the NSABP?
Did the patient have a bilateral mastectomy
Type of surgery
Pathologic Lymph Node Assessment
Receptor Status, ER
Receptor Status, PgR
Was HER2 testing performed
HER-2/neu status
Therapy Status
Did this patient receive any tamoxifen?
Is the patient currently receiving an AI
Was the patient on the B-42 Letrozole Registration Program
Unnamed4
In the opinion of the investigator, is the patient eligible?
Has the patient participated in any other NSABP trial
Patient Characteristics
cm
Kg
Cardiac History
Medical Condition
Medications (in the 12 months prior to study entry)
Cardiac History - Other
Has the patient smoked daily for at least 3 months at any time since her breast cancer diagnosis
Does the patient have any first degree relatives who died from heart disease before the age of 55 ("First degree relatives" include parent, children, brothers, and sisters)
Concomitant Medications
Agent Category
Taking at time of randomization?
Continuing after Randomization
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