Description:

CALGB: 40101 TRASTUZUMAB MONITORING FORM Four Versus Six Cycles of Cyclophosphamide/Doxorubicin or Paclitaxel in Adjuvant Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=FD4BCDD9-1BFD-6EE8-E034-0003BA3F9857

Lien:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=FD4BCDD9-1BFD-6EE8-E034-0003BA3F9857

Mots-clés:

D016430

Treatment Form

C50

26/08/2012 26/08/2012 -
09/01/2015 09/01/2015 - Martin Dugas
21/06/2015 21/06/2015 -

Téléchargé le:

9 janvier 2015

DOI:

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Licence :

Creative Commons BY-NC 3.0 Legacy

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Breast Cancer NCT00041119 Treatment - CALGB: 40101 TRASTUZUMAB MONITORING FORM - 2322062v1.0

Détails

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.

1 Formulaires

StudyEvent: CALGB: 40101 TRASTUZUMAB MONITORING 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.

Header

CALGB Form

CALGB Study No

CALGB Patient ID

Are data amended

Yes

Unnamed2

Patient Initials

Patient Hospital No

Institution/Affiliate

Participating Group

Participating Group Study No

Participating Group Patient ID

Testing Results

Did the patient receive trastuzumab?

Yes

Trastuzumab Agent Not Administration Specify

Date trastuzumab started

Date trastuzumab discontinued

Reason for ending trastuzumab treatment

Completed Per Protocol Criteria (Completed per protocol criteria)

Cardiac Adverse Event (Cardiac adverse event)

Other Cardiac Adverse Event (Other cardiac adverse event)

Non-cardiac Adverse Event (Non-cardiac adverse event)

Other (Other)

Other, specify

Footer

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Date Form Completed

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