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:

Clinical Trial

Neoplasms

Esophagus

Follow-Up Studies

Versions (3) ▾

8/26/12
1/9/15
1/9/15

Uploaded on:

January 9, 2015

DOI:

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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

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

StudyEvent: RTOG 1010 Follow-up Form (F1)
1. 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

RTOG Study No.

Case #

Institution Name

Institution No.

Patient Initials

RTOG Patient ID

Amended Data

Yes

Unnamed2

Has a new primary cancer or MDS been diagnosed that has not been previously reported? (MYELODYSPLASTIC SYNDROME)

No (No)

Unknown (Unknown)

Yes (Yes)

New Primary Site

Aml/mds (AML/MDS)

Bcc (BCC)

Bladder (Bladder)

Brain (Brain)

Colorectal (Colorectal)

15 more items in the detailed view.

New Primary Cancer Date (MM/DD/YYYY)

Specify

Unnamed5

Non-Protocol Therapy Type

None (None)

Radiation Therapy (Radiation therapy)

Radiation To Other Sites, Specify (Radiation to other sites)

Surgery (Surgery)

Chemotherapy (Chemotherapy)

3 more items in the detailed view.

Date of Non-protocol therapy (MM/DD/YYYY)

Specify

Toxicities

Grade 3 or 4 Restrictive Cardiomyopathy

Yes

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)

Yes