Clinical Form (Form 24-B) Brain Function in Premenopausal Women Receiving Tamoxifen With or Without Ovarian Function Suppression for Early-Stage Breast Cancer on Clinical Trial IBCSG-2402 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 NCT00659373 On-Study - Clinical Form (Form 24-B) - 2074000v3.0

Clinical Form (Form 24-B) Instructions: This form should reflect the status of the patient and disease at randomization. Please submit within one (1) month of randomization. Mark your selection with an ?X? in the appropriate box(es). Use minus one (-1) to indicate that an answer is unknown, unobtainable, or not done.

Ccrr Module For Clinical Form (form 24-b)
Initial Data
Race (Non-North American) (Non-North American Centers select one)
Race (Ethnicity)
Premenopausal determination
Menstruation (select one)
Has the patient had a hysterectomy? (D M Y )
History of diabetes?
Has patient ever been pregnant, regardless of outcome?
Was patient pregnant at diagnosis?
Primary Disease
Tumor Laterality
Predominant site of primary right breast/side
Predominant site of primary left breast/side
Required Clinical Investigations
Chest X-ray or chest CT
Right mammogram (PA and lateral views)
Left mammogram (PA and lateral views)
Bone Scan
Bone densitometry
Alkaline Phosphatase
Peripheral WBC Count x 10^9/l
Peripheral Platelet Count x 10^9/l
Hemoglobin g/l
Performance status at randomization (Karnofsky 90-100)
Family History
Any known female blood relative(s) diagnosed with breast cancer or ovarian cancer?
Relative (unnamed)
Diagnosed with breast cancer
Diagnosed with ovarian cancer
Any known male blood relatives diagnosed with breast cancer?

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