Description:

S1011 Prestudy Form (#8218) Standard or Extended Pelvic Lymphadenectomy in Treating Patients Undergoing Surgery for Invasive Bladder Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=93990004-B6E8-D71A-E040-BB89AD433C84

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=93990004-B6E8-D71A-E040-BB89AD433C84

  1. 8/26/12 8/26/12 -
  2. 1/9/15 1/9/15 - Martin Dugas
Uploaded on:

January 9, 2015

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Creative Commons BY-NC 3.0 Legacy
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Bladder Cancer NCT01224665 Pre-Study - S1011 Prestudy Form (#8218) - 3152929v1.0

Instructions: Submit this form within 7 days of registration. All dates are MONTH, DAY, YEAR. Explain any blank fields or blank dates in the Comments section. Place an X in appropriate boxes. Circle AMENDED items in red and write AMENDED across top of form. ELIGIBILITY VERIFICATION: Each of the fields below corresponds to a criterion in Section 5 and must be completed for patient to be eligible

Header
Patient And Disease Description
Zubrod Performance Status Score (see section 10.5 of the protocol)
cm
Kg
Disease Description
Clinical T Stage
Bimanual Exam Result
Histologic Type (Please select all that apply based on TURBT or biopsy; pure squamous cell carcinoma or pure adenocarcinoma not eligible)
Type of Variant Histology (if selected please specify)
Laboratory Values
%
Laboratory Values1
mg/dL
Prior Treatment Related To This Cancer
Prior Neoadjuvant Chemotherapy
Neoadjuvant Treatment Related To This Bladder Cancer
Chemotherapy Regimen (select all that apply)
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