Description:

RTOG 1010 Follow-up Form (F1) 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=867B6E62-3E34-C9D2-E040-BB89AD4349E3

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=867B6E62-3E34-C9D2-E040-BB89AD4349E3

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 Follow-up Form (F1) - 3085847v1.0

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? (since submission of the previous follow-up form)
Current Disease Status
Primary Tumor
Regional lymph nodes
Distant metastasis
Second primary
Method of Evaluation
Events
Event
Performance Status
Unnamed2
Has a new primary cancer or MDS been diagnosed that has not been previously reported? (MYELODYSPLASTIC SYNDROME)
New Primary Site
Unnamed5
Non-Protocol Therapy Type
Toxicities
Grade 3 or 4 Restrictive Cardiomyopathy
Incipient CHF (Defined as asymptomatic >20% decrease in LVEF or a decrease of LVEF >10% below the institutions lower limit of normal who are judged to require treatment according to institutional guidelines)
Protocol Specific Adverse Event Evaluation
Any adverse events
CTC AE Grade
CTC AE Attribution Code
SAE report submitted
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