Description:

RTOG 1010 Initial Follow-up Form (FS) Radiation Therapy, Paclitaxel, and Carboplatin With or Without Trastuzumab in Treating Patients With Esophageal Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=86E1F1DA-E438-F1B2-E040-BB89AD43175C

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=86E1F1DA-E438-F1B2-E040-BB89AD43175C

Keywords:
Versions (3) ▾
  1. 8/26/12
  2. 1/9/15
  3. 1/9/15
Uploaded on:

January 9, 2015

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License:
Creative Commons BY-NC 3.0 Legacy
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Adenocarcinoma of the Gastroesophageal Junction NCT01196390 Follow-Up - RTOG 1010 Initial Follow-up Form (FS) - 3088118v1.0

Details

INSTRUCTIONS: Submit this form at the appropriate follow-up interval and whenever there is a change in the patient's status. Dates are recorded mm-dd-yyyy unless otherwise specified

Unnamed Module 1
Amended Data
Assessment
Vital Status
Primary Cause of Death
Has the patient had a documented clinical assessment for this cancer?
Current Disease Status
Primary Tumor
Regional lymph nodes
Distant metastasis
Second primary
Method of Evaluation
%
%
Events
Event
10 more items in the detailed view.
Toxicities
Grade 3 or 4 Restrictive Cardiomyopathy
Toxicities
Was a MUGA/Echocardiogram Performed During This Report Period
Incipient CHF (If yes, did the patient experience defined as asymptomatic >20% decrease in LVEF or a decrease of LVEF >10% below the institutions lower limit of normal and required treatment according to institutional guidelines)
LVEF Status (If a MUGA/echocardiogram was performed during this report period)
3 more items in the detailed view.
Protocol Specific Adverse Event Evaluation
Any adverse events
CTC AE Grade
CTC AE Attribution Code
SAE report submitted
Footer Module
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