Description:

NSABP PROTOCOL B-43: FOLLOW-UP FORM Radiation Therapy With or Without Trastuzumab in Treating Women With Ductal Carcinoma In Situ Who Have Undergone Lumpectomy Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=3991DC1D-88CC-388C-E044-0003BA3F9857

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=3991DC1D-88CC-388C-E044-0003BA3F9857

Keywords:
Versions (2) ▾
  1. 8/26/12
  2. 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 NCT00769379 Follow-Up - NSABP PROTOCOL B-43: FOLLOW-UP FORM - 2679283v1.0

This paper worksheet may be completed to faciliate the entry of the information in NSABP Coordinator Online. Partially completed forms may be saved in Coordinator Online.

Header
Vital Status
Patient's Vital Status
Source of Survival Information (if alive)
Primary Cause of Death
Was there evidence of recurrence at the time of death
Cancer Follow-up Status
Has the patient had a documented clinical assessment for this cancer (since submission of the last follow-up form)
Ipsilateral Breast Tumor Recurrence (ibtr)
Has the patient been diagnosed with an invasive or non-invasive recurrence in the ipsilateral breast that has not been previously reported (or skin of the ipsilateral breast )
IBTR Type
First Local-regional Recurrence
Has the patient been diagnosed with first local-regional recurrence (other than IBTR since submission of the last follow-up form?)
Site(s) of First Local-Regional Recurrence (mark all ipsilateral sites that apply)
First Distant Recurrence
Has the patient been diagnosed with first distant recurrence/progression?
New Primary Cancer Or Mds
Has a new primary cancer or MDS been diagnosed that has not been previously reported?
Mastectomy
Did the patient have total mastectomy?
Location of total mastectomy
Late Thrombotic Event
Has the patient been diagnosed with any of the following cardiac events since submission of the last follow-up form?
CTCAE Term
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