Patient name: DOB: : (//)

Date plan was created: ( Click here to enter a date.) . This summary is provided for educational purposes. Not meant to replace medical chart.

Oncology providers
Provider / Name / Contact information
Medical oncologist / Harmesh R. Naik, MD., Hope Cancer Clinic
14555 Levan Road, Suite 110, Livonia, MI 48154. / Ph: 734-462-2990
Fax: 734-462-3268
Surgeon
Radiation oncologist
Primary MD
Other
Diagnosis details
Diagnosis: Breast cancer. Location: (chooserightleftbilateral)
/ Date of diagnosis (biopsy date) : (//)
Tumor type (chooseInvasive ductal carcinomaDuctal carcinoma in situInvasive lobular carcinomaLobular carcinoma in situUnknownOther) / Stage: (choose01234Unknown) . TNM: T( choose1a1b1c234Xis ) N (choose0123X) M(choose01X).
ER status (choosePositiveNegativeUnknown) / PR status (choosePositiveNegativeUnknown) / Her 2 status (choosePositiveNegativeUnknown)
Lymph nodes (choosePositiveNegativeUnknown). Number: . / Oncotype DX ( ChooseYesNoUnknownNot done ). Score (Choose< 1818-31> 31). 5 yr risk %.
Other:
Breast surgery: ( chooseyesnounknown )
Side: (chooserightleftbilateral) / Type of surgery (chooseBiopsy LumpectomyMastectomyPartial mastectomy) Click here to enter a date.)
Lymph node sampling / (chooseYesNoUnknownNot done) (chooseSentinel nodeAxillary dissectionUnknown) ( Click here to enter a date.)
Lymphedema (chooseYesNoUnknown)
Additional details: Please contact your surgical doctor for additional details.
Chemotherapy: ( chooseyesnounknown )
Regimen (chooseStandard AC x 4Dose dense AC x 4 AC x 4 followed by T x 4dose dense AC x 4 followed by T x 4TACAC---THDC---HClinical trialCAFCMFOther) / Start date: ( Click here to enter a date.)
Details of regimen (Name and dose ) /
WBC growth factor (chooseYesNoUnknown) / Transfusions (chooseYesNoUnknown)
Anthracycline total dose (chooseDoxorubicinEpirubicinMitoxantrone) ( mg/m2)
Start date ( Click here to enter a date.) / End date ( Click here to enter a date.)
Side effects : Hair loss. Nausea/Vomiting. Neuropathy. Low blood count Fatigue. Menopause symptoms. Cardiac. Other
Additional details / complications / comments:
Trastuzumab (Herceptin) therapy: ( chooseyesnounknown )
Start date ( Click here to enter a date.) / End date ( Click here to enter a date.)
Details :
Hormonal therapy: ( chooseyesnounknown )
Drug: ( chooseTamoxifenAnastrozoleLetrozoleExemestaneunknownOther )
Start date (Click here to enter a date.) / End date ( Click here to enter a date.)
Additional details / side effects:
Radiation therapy: ( chooseyesnounknown )
Side: (chooserightleftbilateral) / Radiation dose rads
Start date ( Click here to enter a date.) / End date ( Click here to enter a date.)
Additional details / side effects: Please contact your radiation doctor for additional details.
What to watch for: Promptly report any new symptoms: Example symptoms:
·  New lumps, Bone pain, Chest pain, breathing difficult, cough, Abdominal pain, Persistent headaches
·  Weight loss, loss of appetite, Any other symptoms that are not improving, Unexplained symptoms
Survivorship care: Suggested follow up care for asymptomatic patients: Based on ASCO guidelines
Medical history/physical exam / Every 4 months x 3 years
Every 4-6 months years 4-5 / Annually thereafter
Breast self exam / Monthly if feasible
Mammography / Annually or earlier if suggested by radiologist / (first in six months after RT)
Genetic counseling / Consider if criteria met / Ask your doctor
Colo-rectal cancer screening / Recommended.
Pap smear and pelvic exam / Recommended. / Contact primary MD or Gyn MD.
Skin cancer screening / Recommended / Use sun block in summer.
No smoking /smoking cessation / Recommended- Do not smoke / Michigan Tobacco Quit Line: 1-800-784-8669
Bone density measurement / Oral Calcium and vitamin D / Recommended. / Contact primary MD.
Low fat diet / Recommended / Nutritional consult
Staying active / Recommended / Fall precautions
Report any new symptoms / Recommended
REMEMBER:
Please note that the ASCO guidelines apply to patient who are feeling fine and have no symptoms.
If you are having any symptoms, then you need to contact your physician for proper testing.

Notes:

Have fun!
Enjoy life! / Recommended / Ctr + click on http://hopecancerclinic.net/inspirational/fly_a_kite