Description:

SOUTHWEST ONCOLOGY GROUP S0221 PACLITAXEL TREATMENT FORM Adjuvant Doxorubicin, Cyclophosphamide, and Paclitaxel in Treating Patients With Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=03583163-D58B-189D-E044-0003BA3F9857

Link:
https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=03583163-D58B-189D-E044-0003BA3F9857
Keywords:
  1. 8/26/12 8/26/12 -
  2. 1/8/15 1/8/15 - Martin Dugas
  3. 6/3/15 6/3/15 -
Uploaded on:

August 26, 2012

DOI:
To request one please log in.
License :
Creative Commons BY-NC 3.0 Legacy
Model comments :

You can comment on the data model here. Via the speech bubbles at the itemgroups and items you can add comments to those specificially.

Itemgroup comments for :

Item comments for :

In order to download data models you must be logged in. Please log in or register for free.

Breast Cancer NCT00070564 Treatment - SOUTHWEST ONCOLOGY GROUP S0221 PACLITAXEL TREATMENT FORM - 2420913v1.0

Instructions: Complete this form if the patient was assigned to Treatment Arm 1 or Arm 3. Submit this form only once, after the patient has completed AC chemotherapy and has recovered from acute toxicity. All dates are MONTH, DAY, YEAR. Place an X in appropriate boxes. Circle AMENDED items in red.

Unnamed1
Disease Status
Vital Status
Treatment Status
Assigned treatment arm
Did the patient start treatment on the assigned arm?
Kg
Were there any dose modifications or additions/omissions to protocol treatment?
Did the patient receive trastuzumab during this treatment period
Unnamed 5
Did the patient experience one or more episodes of Grade 3 or 4 neutropenia?
Did the patient experience one or more episodes of Grade 3 or 4 febrile neutropenia?
Did the patient experience one or more episodes of Grade 3 or 4 anemia?
Comments

Similar models

Please use this form for feedback, questions and suggestions for improvements.

Fields marked with * are required.

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial