NSABP B-45 Worksheet for Thyroid Function Monitoring Form Studying Biological Markers of Fatigue in Women With Residual Invasive Breast Cancer Enrolled on Clinical Trial NSABP-B-45 Source Form: NCI FormBuilder:

  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 NCT00914043 On-Study - NSABP B-45 Worksheet for Thyroid Function Monitoring Form - 2847070v1.0

This paper worksheet may be completed to facilitate the entry of Thyroid Function information (TSH) information in NSABP Coordinator Online. Partially completed worksheets may be saved in Coordinator Online. DO NOT SUBMIT THIS WORKSHEET VIA FAX OR MAIL

Tsh Assessment
Time point (for this report)
Was TSH assessed at this time point
Tsh Assessment1
Was the patient being treated with sunitinib/placebo at the time of this assessment
Was the patient being treated with levothyroxine at the time of this assessment
Was levothyroxine initiated as a result of this assessment (If no)
Levothyroxine Dose (if either question is marked yes)
Tsh Assessment2
Did the patient receive any systemic anticancer treatment for documented invasive breast cancer recurrence or second primary cancer prior to this Time Point
Reason TSH was Assessed at Other Time Point (When Other Time Point applies)

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