Description:

CALGB: 40101 TREATMENT SUMMARY SUBSET FORM Four Versus Six Cycles of Cyclophosphamide/Doxorubicin or Paclitaxel in Adjuvant Breast Cancer NCT00041119 Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A46C8094-22BA-26B0-E034-080020C9C0E0

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A46C8094-22BA-26B0-E034-080020C9C0E0

Keywords:

Breast Neoplasms

8/26/12 8/26/12 -
4/24/15 4/24/15 - Martin Dugas

Uploaded on:

April 24, 2015

DOI:

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License :

Creative Commons BY-NC 3.0 Legacy

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Breast Cancer Treatment CALGB 40101 NCT00041119

INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice. Print text in capital letters. Avoid contact with the edges of the boxes. Circle amended items and check "Amended data" box to the right. If submitting by mail, retain a copy for your records and send the original to the CALGB Statistical Center, Data Operations. If faxing, use an original form for maximum clarity in transmission and fax to 919-416-4990. If submitting electronically, click the Send button when you have completed the PDF version of the form.

StudyEvent: CALGB: 40101 TREATMENT SUMMARY SUBSET FORM
1. INSTRUCTIONS: Complete and submit this form as required by the protocol. Information in the upper right box must be completed for this form to be accepted. For optimal accuracy use black ink. Mark an X in the appropriate box for fields with a choice. Print text in capital letters. Avoid contact with the edges of the boxes. Circle amended items and check "Amended data" box to the right. If submitting by mail, retain a copy for your records and send the original to the CALGB Statistical Center, Data Operations. If faxing, use an original form for maximum clarity in transmission and fax to 919-416-4990. If submitting electronically, click the Send button when you have completed the PDF version of the form.

Header

CALGB Form

CALGB Study No

CALGB Patient ID

Cycle start date

Cycle end date (M)

Amended data?

Yes

No

Patient's Name

Participating Group

Patient Hospital Number

Participating Group Protocol No.

Main Member Institution/Adjunct

Participating Group Patient No.

Completed By (Print or Type Name)

Date Completed (M)

Breast cancer treatment

Current cycle number

BSA

Total dosage for this cycle, Doxorubicin

mg

Total dosage for this cycle, Cyclophosphamide

mg

Total dosage for this cycle, Paclitaxel

mg

Dose adjustments (mark one with an X)

Reduced (1)

Delayed (2)

Reduced And Delayed (3)

Reason for adjustment (Reasons for dose adjustment)

Not Satisfactorily Recovered From Hematologic Toxicity (1)

Grade 3 Or 4 Fatigue (2)

Grade 2 Or 3 Anaphylaxis/hypersensitivity (3)

Grade 3 Or 4 Diarrhea/nausea (4)

7 more items in the detailed view.

Specify (reason for adjustment) (if applicable)

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