Description:

NSABP PROTOCOL B-35: FOLLOW-UP FORM Anastrozole or Tamoxifen in Treating Postmenopausal Women With Ductal Carcinoma in Situ Who Are Undergoing Lumpectomy and Radiation Therapy Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A057E605-C97E-3E81-E034-080020C9C0E0

Link:
https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=A057E605-C97E-3E81-E034-080020C9C0E0
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  1. 8/26/12 8/26/12 -
  2. 3/23/15 3/23/15 - Martin Dugas
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August 26, 2012

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Creative Commons BY-NC 3.0 Legacy
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Breast Cancer NCT00053898 Follow-Up - NSABP PROTOCOL B-35: FOLLOW-UP FORM - 2034205v3.0

Form F35 Submit every 6 months for the first 5 years, every 12 months thereafter, and when a protocol event occurs.

Unnamed1
Are data amended? (If Yes, circle the amended items in red.)
Vital Status
Patient's Vital Status
Source of Survival Information (if alive)
Cause of Death (if dead)
Was there evidence of recurrence at the time of death?
Cancer Follow-up Status
Has the patient had a documented clinical assessment for this cancer since the last follow-up form?
Ipsilateral Breast Tumor Recurrence (ibtr)
Has the patient been diagnosed with an invasive or non-invasive recurrence in the ipsilateral breast that has not been previously reported?
First Local-regional Recurrence
Has the patient been diagnosed with first local-regional recurrence since submission of the last follow-up form? (other than IBTR)
Site(s) Diagnosed (mark all first ipsilateral sites that apply)
First Distant Recurrence
Has the patient been diagnosed with first distant recurrence since submission of the last follow-up form?
New Primary Cancer Or Mds
Has a new primary cancer or MDS been diagnosed that has not been previously reported?
Unnamed2
Unnamed3
Total Mastectomy Not Previously Reported?
Unnamed4
Fracture Not Previously Reported? (mark all that apply)
Unnamed5
Since the last reported follow-up, has the patient had any vaginal hormonal therapy? (e.g., low dose estrogen cream, Vagifem [R], Estring [R])
Since The Last Reported Follow-up, Has The Patient Been Treated With Any Of The Following?
Bisphosphonates (e.g., Actonel [R], Fosamax [R])
Calcitonin (e.g., Miacalcin [R])
Unnamed7
Did patient receive any Tamoxifen/Anastrozole during the past 6 months?
If yes, what percentage of her required pills did she take? (Select the item that best describes her compliance during the 6-month period.)
How was this percentage determined?
Late Adverse Event
Has the patient experienced any severe (Grade =3) adverse event, possibly related to study medication, that has not been previously reported? (If yes, identify CTC Terms, 4-Character Codes, circle highest applicable grades, and attach documentation.)
Unnamed3
Adverse Event
Grade (highest grade this cycle INCLUDE GRADE 0's)

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