CALGB Form

CALGB Study No

CALGB Patient ID (Disease Description)

Amended data?

Patient's Name

Participating Group

Patient Hospital Number

Participating Group Protocol No.

Main Member Institution/Adjunct

Participating Group Patient No.

First positive biopsy date (M)

Most extensive primary surgery (mark one with an X)

Date of most extensive primary surgery (if required, used date of last re-excision)

Sentinel node biopsy?

Sentinel node biopsy date (M)

Sentinel node biopsy results (per protocol)

Was axillary dissection performed?

Date of axillary dissection (M)

Total number of lymph nodes examined (if sentinel node biopsy and axillary node dissection were performed, enter the total number of nodes examined)

Granulocytes

Total bilirubin (mg/dl)

Creatinine (mg/dl)

Platelet count

Bilirubin upper limit of institutional laboratory normal (mg/dl)

Calculated creatinine clearance (mL/min)

% LVEF

% Lower limit of institutional normal LVEF

Tumor laterality (mark one with an X)

Receptor status, ER (If measured in fmols/mg cytosol protein >=10 is positive. If other measures are used apply institutional standards; borderline results should be reported as positive)

Receptor status, PgR

Pathologic primary tumor size (cm)

Histologic grade (combined histologic grade is used according to SRE/Elston classification)

Total number of positive lymph nodes (If sentinel node biopsy and axillary node dissection were performed, enter the sum of positive nodes)

T (TNM classification)

N (TNM classification)

M (TNM classification) (Prior Systemic Therapy)

Prior breast cancer prevention therapy?

If Yes, what type (prior breast cancer prevention therapy) (mark all that apply with an X)

Other, specify (prior breast cancer therapy)

Completed By (Print or Type Name)

Date Completed