Description:

NSABP-B-47 Follow-Up Form (Form F) A Randomized Phase III Trial of Adjuvant Therapy Comparing Chemotherapy Alone (Six Cycles of Docetaxel Plus Cyclophosphamide or Four Cycles of Doxorubicin Plus Cyclophosphamide Followed by Weekly Paclitaxel) to Chemotherapy Plus Trastuzumab in Women With Node- Positive or High-Risk Node-Negative HER2-Low Invasive Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9556F723-E4C3-09D5-E040-BB89AD433F36

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=9556F723-E4C3-09D5-E040-BB89AD433F36

Keywords:
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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Breast Cancer NCT01275677 Follow-Up - NSABP-B-47 Follow-Up Form (Form F) - 3161621v1.0

This paper worksheet may be completed to facilitate the entry of the information in NSABP Coordinator Online. Partially completed online forms may be saved in Coordinator Online. DO NOT SUBMIT THIS WORKSHEET VIA FAX OR MAIL. Follow-up data must be submitted every 6 months through 5 years on study, then every 12 months through year 10. Form F is also required when a protocol event occurs

Header
Vital Status
Patient's Vital Status
Source of Survival Information (if alive)
Primary Cause of Death (if dead)
Was there evidence of recurrence at the time of death
First Recurrence
Has the patient been diagnosed with first recurrence since submission of the last follow-up form (excluding LCIS)
Was the First Recurrence DCIS Alone in the ipsilateral breast following lumpectomy
First Invasive Local Recurrence
Has the patient been diagnosed with first invasive local recurrence since submission of the last follow-up form
Site of first recurrence/progression (s Mark all that apply)
First Local-regional Recurrence
Has the patient been diagnosed with first regional recurrence since submission of the last follow-up form
Site of First Regional Recurrence (s mark all ipsilateral sites that apply)
First Central Nervous System Recurrence
Has the patient been diagnosed with first central nervous system recurrence since submission of the last follow-up form (CNS )
First Distant Recurrence
Has the patient been diagnosed with first distant recurrence since submission of the last follow-up form? (other than CNS recurrence)
New Primary Cancer Or Mds
Has a new primary cancer or MDS been diagnosed that has not been previously reported?
Patient Height And Weight
Was patient height measured since the previous follow-up report
cm
Was patient weight measured since the previous follow-up report
Kg
Late Thrombotic Event
Has the patient been diagnosed with any of the following cardiac events since submission of the last follow-up form? (If yes, Indicate applicable grade in the following table, and provide supporting documentation. The online software will provide a transmittal form that must be printed. Fax this transmittal form with the supporting documentation to 412-622-2111. A Cardiac Report Form Form CR must be submitted via Coordinator Online, and all required documentation must be provided)
Adverse Event
Grade
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