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Bilateral Breast Radiotherapy Form (Form 24-BR) 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: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=0162063B-84EB-2286-E044-0003BA3F9857

Link:
https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=0162063B-84EB-2286-E044-0003BA3F9857
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  1. 8/27/12 8/27/12 -
  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 Treatment - Bilateral Breast Radiotherapy Form (Form 24-BR) - 2411259v1.0

BREAST RADIOTHERAPY FORM (Form 24-R) Instructions: Submit this form upon completion of radiotherapy or if radiotherapy was planned and not given. 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 Breast Radiotherapy Form (form 24-r)
This form is being completed for
Did the patient receive intraoperative radiotherapy (IORT)? (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
Did patient start adjuvant postoperative radiotherapy? (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
Postoperative radiotherapy fields (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
Was postoperative radiotherapy boost given? (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)
For those patients who did not start adjuvant radiotherapy, please give reason (CCRR MODULE FOR Breast Radiotherapy Form Form 24-R)

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