Breast Radiotherapy Form (Form 24-R) 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:

  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 - Breast Radiotherapy Form (Form 24-R) - 2073924v3.0

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)?
Did patient start adjuvant postoperative radiotherapy?
Postoperative radiotherapy fields (select all areas that apply)
Was postoperative radiotherapy boost given?
For those patients who did not start adjuvant radiotherapy, please give reason (select one box only)

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