NSABP B-45 Worksheet for Cardiac Safety Monitoring Report 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 Cardiac Safety Monitoring Report Form - 2847086v1.0

This paper worksheet may be completed to facilitate the entry of the required Cardiac Safety Monitoring information in NSABP Coordinator Online. Partially completed worksheets may be saved in Coordinator Online. DO NOT SUBMIT THIS WORKSHEET VIA FAX OR MAIL

Report Period
Time point (for this report)
Did the patient receive any systemic anticancer treatment for documented invasive breast cancer recurrence or second primary cancer prior to this Time Point
Section A: Lvef Assessment
Reason LVEF was Assessed at Other Time Point (If Time Point is Other mark one)
Was LVEF assessment performed at this time point (If Time Point is not Other)
Assessment Type
Section B: Ecg With Qtc Assessment
Has the patient had an EKG (this time point Note: not required 9 months after randomization)
Was QTc assessed
Section C: Cardiac Events
Did the patient experience any of the following cardiac events at the specified time point (mark all that apply)

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