NSABP PROTOCOL B-39: Chemotherapy Report Radiation Therapy in Treating Women Who Have Undergone Surgery For Ductal Carcinoma In Situ or Stage I or Stage II Breast Cancer Source Form: NCI FormBuilder:



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  2. 1/9/15 1/9/15 - Martin Dugas
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January 9, 2015


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Breast Cancer NCT00103181 Treatment - NSABP PROTOCOL B-39: Chemotherapy Report - 2295346v3.0

This form is to be submitted for all patients, including those who do not receive adjuvant chemotherapy.

Part 1. Patient Treatment Plan Based On Information Provided At Patient Registration
Intention to Administer Chemotherapy
Assigned Treatment
Treatment Plan
Part 2. To Be Completed By Institution
Did patient receive adjuvant chemotherapy? (If no, remaining questions do not apply.)
Adjuvant Chemotherapy (mark all types of chemotherapy patient received)

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