Description:

Follow-up Form (Form 24-E) 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=B0FA982B-ACAA-0AC1-E034-0003BA12F5E7

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https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=B0FA982B-ACAA-0AC1-E034-0003BA12F5E7
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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 - Follow-up Form (Form 24-E) - 2072392v3.0

SINCE SUBMISSION OF LAST FOLLOW-UP FORM

  1. StudyEvent: Follow-up Form (Form 24-E)
    1. SINCE SUBMISSION OF LAST FOLLOW-UP FORM
Ccrr Module For Follow-up Form (form 24-e)
Documentation of hospital or clinic visit
Patient's Vital Status (select one)
Primary cause of death
Autopsy
Bone densitometry
Performance status at date of this examination or contact
Menstrual status during 3 months prior to follow-up visit (select one)
Was patient pregnant at any time during this follow-up period? If more than one pregnancy, indicate most recent episode. (If pregnant during protocol treatment, complete Form 24-EIU for each pregnancy.)
Did the patient have gynecologic surgery, procedures and/or diagnostic imaging (excluding PAP smear?)
Has the patient attempted to become pregnant during this follow-up period
Method
Has the patient had any clinically significant cardiovascular and/or cerebrovascular events after protocol treatment ended (Report on Form 24-AE if during protocol treatment or up to 12 months after protocol treatment has ended.)
Did the patient have any bone fractures after protocol treatment ended? (Report on Form 24-AE if during protocol treatment or up to 12 months after protocol treatment has ended.)
Has patient experienced any other severe (> grade 3) adverse event(s), (not reported in Q13-16) after protocol treatment ended? (Report on Form 24-AE during protocol treatment or up to 12 months after protocol treatment has ended.)
Was event related to protocol treatment
Was event related to protocol treatment
Was event related to protocol treatment
Has the patient been diagnosed with in situ breast cancer, right side, since the submission of the last Follow-up Form (select one)
Has the patient been diagnosed with in situ breast cancer, left side, since the submission of the last Follow-up Form
Has the patient been diagnosed with in situ cervical cancer since the submission of the last Follow-up Form?
Has the patient been diagnosed with basal cell or squamous cell carcinoma of the skin since the submission of the last Follow-up Form?
Has patient had a suspicious or proven second primary since submission of last Follow-up Form
Specify site below
Has patient had a suspicious or proven recurrence/metastasis or contralateral invasive breast cancer since submission of last Follow-up Form?
Site
Investigation
Are there additional sites
Surgery
Radiation Therapy
Chemotherapy
Endocrine therapy
Other

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