Breast Cancer Preoperative Treatment Plan

ENDOCRINE THERAPY SURGERY [Insert Practice Name/Info Here] Definitive breast surgery: Aromatase Inhibitor Type: Preoperative None Tamoxifen Date: (____/___/____) Other Lumpectomy Mastectomy Mastectomy/immediate recon Postoperative Both The Treatment removed: #Medication: Plan is a brief record of major aspects of breast cancerendocrine therapy started (or notstart) (___/___/___) lymph nodes # lymph notes positive: Date preoperative treatment. This is to a complete patient history or comprehensive record of intended therapies. Duration: Axillary dissection: Yes (___/___/____) No Sentinel node biopsy: Yes (___/___/____) No Medical oncology provider name: TRASTUZUMAB (HERCEPTIN) THERAPY Notable surgical findings/comments: Patient name: Patient ID: Trastuzumab (Herceptin) planned: Yes No Preoperative planned: Yes No Both Postoperative Radiation therapy planned: Yes No Reconstruction Patient DOB: (___/___/___) Age at diagnosis: Patient phone: Pre-trastuzumab ejection fraction: Date completed: (___/___/___) Date completed: (___/___/___) Type: % (___/___/___) Trastuzumab (Herceptin) prescribed: Yes No Support contact name: Most recent ejection fraction: % (___/___/___) Support contact relationship: Support contact phone: Planned or completed dates of trastuzumab ONCOLOGY TEAM MEMBER(___/___/___) therapy: Start date CONTACTS End date (___/___/___) BASELINE INFORMATION (AT DIAGNOSIS) Provider: Was trastuzumab prematurely stopped (temporarily or permanently)? No Yes (describe): nd Family history: None 2 degree relative 1st degree relative Multiple relatives Name: Site: Left Right Bilateral Tumor type: S Infiltrating ductal Infiltrating lobular Other: Contact Info: IDE EFFECTS OF TREATMENT Baseline side effects of T2 treatment regimen: T4c loss Nausea/Vomitingstatus: positive negative T stage: T1 the T3 T4a T4b Hair T4d Baseline node Low blood count Fatigue Possible Provider: Clinical stage: 0 I symptoms Cardiac symptoms DXOther: II III Oncotype recurrence score (if applicable): Neuropathy Menopause Name: ER status: Positive Negative PR status: Positive Negative HER2 status: Positive Negative Contact Info: Major comorbid conditions: Echocardiogram or MUGA result prior to chemotherapy (if obtained): EF= % Provider: CHEMOTHERAPY TREATMENT PLAN Name: Height: in/cm Pre-treatment weight: lb/kg Contact Info: Pre-Treatment BSA: Date last menstrual period: (_ _/_ _/__ _) Name of regimen: Comments Start Date: (___/___/____) Treatment on clinical trial: Yes No Chemotherapy Drug Name Route Dose Schedule

Postoperative chemotherapy planned? No

Yes (describe):

Was chemotherapy prematurely stopped (temporarily or permanently)?

No Yes (describe):

2008 American Society of Clinical Oncology. All rights reserved. Important caution: this is a summary document whose purpose is to review the highlights of the breast cancer chemotherapy treatment plan for this patient. This does not replace information available in the medical record, a complete medical history provided by the patient, examination and diagnostic information, or educational materials that describe strategies for coping with breast cancer and chemotherapy in detail. Both medical science and an individuals health care needs change, and therefore this document is current only as of the date of preparation. This summary document does not prescribe or recommend any particular medical treatment or care for breast cancer or any other disease and does not substitute for the independent medical judgment of the treating professional.