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Date of Diagnosis:
Day
Month
Year
 
 

Primary Tumour Site:
(If cancer is bilateral, please fill in a separate form for each cancer)

Mutation status:

Primary Tumor (T)
Type of Tumor
Tumor Size
 
 

Regional Lymph Nodes (N)
Type of Nodes
Number of nodes removed
Number of nodes affected
 
 

Distant Metastasis (M)
Type of Metastasis
Site of Metastasis
 
Site
 

Histology:

ER:

PR:

HER2:

Grade:

If BENGIN:

Axillary nodes:

Radiotherapy:

Systemic Therapy:

Surgery

Alive (NO recurrence) – Date:
Day
Month
Year
 
 

Recurrence – Date:
Day
Month
Year
 
 

Death – Date:
Day
Month
Year