Download (Std 3.3) SCP-Aurora Baycare Medical Center (10000095)

Cancer Survivorship Care Plan
DEMOGRAPHICS
Patient Name:
DOB:
Age:
Phone:
HEALTH CARE TEAM
Primary Physician:
Provider Nonsystem
Surgeon:
Plastic Surgeon:
Care Coordinator:
Medical Oncologist:
Radiation Oncologist:
Other:
Ph: None
Ph:
Ph:
Ph:
Ph:
Ph:
Ph:
DIAGNOSIS
Date Diagnosed:
Cancer Staging:
Follicular lymphoma
Primary site: Lymphoid Neoplasms (Bilateral)
Staging method: AJCC 6th Edition
Clinical: Stage II signed by on 4/18/2014 1:18 PM
Pathologic: Stage II signed by on 4/18/2014 1:18 PM
Summary: Stage II
Locations of Disease:
Pathology Markers:
Ann Arbor Stage:
IPI:
LDH at Diagnosis:
{History of solid organ transplant
HIV Positive
HEP B Positive}
Stem Cell Transplant planned not planned
NOTES:
Status {New, Recurrence}
MRN:
TREATMENT SUMMARY
Bone Marrow Biopsy:
Surgical Procedure:
Other Procedure:
Date(s):
Date:
Date:
Location:
Location:
Location:
Chemotherapy/Biotherapy
Treatment
**drop down list of current regimens
Number of
Cycles
**
Radiation:
Body Site:
Field:
Dates Given
Adverse Events
{ONC ADVERSE EVENTS:126616}
{ONC ADVERSE EVENTS:126616}
{ONC ADVERSE EVENTS:126616}
{ONC ADVERSE EVENTS:126616}
{ONC ADVERSE EVENTS:126616}
Date started:
Treatment Location:
Dose:
Date completed:
Adverse Events:
Report any of these symptoms IMMEDIATELY to your Cancer Care Team:
 Shortness of breath
 Chest pain
 Unexplained fevers
 Chills or night sweats
 Any new lumps or bumps (lymphadenopathy)
 Losing weight without trying
 Any new persistent pain
 Progressive weakness or fatigue
 Itching skin
POSSIBLE LATE EFFECTS OF CANCER TREATMENT
Chemotherapy:
You may experience one or more of these long term effects related to your cancer treatment:
Fatigue
Early Menopause
Hot flashes
Neuropathy (numbness and/or tingling or pain to your hands or feet)
Response to Treatment
ONC Treatment Response
Complete, Partial, Stable
Disease, Progression
“Chemo brain” known as cognitive dysfunction
Weight gain
Depression
Anxiety
Sexual dysfunction
Pain to your muscles or joints
Difficulty sleeping
You received an anthracycline (Adriamycin, Doxorubicin). These drugs can cause heart damage which can appear years after treatment has ended. If you have shortness
of breath, irregular heartbeat or any swelling to your feet or ankles, contact your Health Care Provider immediately for evaluation. An echocardiogram (echo), which is a test
that uses ultrasound to take pictures of your heart to see how well it is working, may be ordered after you complete treatment. It is recommended that you have this test done
about 1 year after you finish your treatment, or when your health care provider recommends it
Radiation therapy can cause long-term complications. These side effects generally depend on where you had radiation. If you had radiation to your chest it can lead to lung
damage and difficulty breathing. Chest radiation may also increase the long-term risk for heart disease and heart attack. Although rare, the development of breast cancer is a
particular concern for young women treated with chest radiation.
Neck radiation may increase the later risk for underactive thyroid (hypothyroidism) and thyroid cancer.
Radiation to the pelvic area may increase the risk for infertility, particularly for women.
Important Information for Lymphoma Survivors
It is important to get a mammogram every year beginning at age 40, if you are a woman. If you have had radiation to your chest or armpit, you may need to start getting
mammograms and MRIs earlier, either 5 to7 years after your treatment was finished, or at age 40, whichever comes first.
If you had radiation to your neck area you may need periodic carotid ultrasound, which is a test that looks at the carotid arteries in your neck to see if they are narrowed or
blocked.
If you had radiation to your neck area it is important to have thyroid function tests, which are blood tests that look at how well your thyroid is working. These tests should be
done at every follow-up visit.
If you have had treatment for Hodgkin lymphoma you may need pulmonary function tests (PFTs), which are breathing tests that measure how well your lungs are working.
Vaccinations: It is important that lymphoma survivors receive a flu vaccine every year and a pneumonia vaccine every 5 years.
CANCER SURVEILLANCE PLAN
After your treatment is completed, it is very important to go to all of your scheduled follow-up appointments. During these visits, your health care provider will ask questions
about any symptoms and may do physical exams and order lab tests or imaging tests as needed to look for recurrences, secondary cancers or side effects.
Medical Oncology Follow up/Examination
History and Physical Examination
Frequency
Every 3 months years 1
and 2 after treatment,
Every 6 months years 3-5,
then yearly.
Provider to Contact
Date Due
Blood Tests
CT scan
PET scan
Pre-Treatment Weight:
Post Treatment Weight:
GENERAL SCREENING AND WELLNESS
It is important, and your responsibility to have routine annual physicals by your primary care provider, sometimes in addition to your scheduled cancer surveillance
care plan.
Health Promotion, Prevention and Wellness:
 Maintain a healthy weight
 Adopt a physically active lifestyle (Adults should get a minimum of 30 minutes of “moderate-intensity physical activity” on five days or more each week)
 Consume a healthy plant-based diet with emphasis on fruits, vegetables, legumes and grains.
 Limit consumption of alcohol if you consume alcoholic beverages
 Follow-up with your primary care provider for routine physical examinations, blood pressure, cholesterol and glucose monitoring
 Avoiding direct sun exposure and protect skin with a broad-spectrum sunscreen (sun protection factor (SPF) of 15 or greater, UVA and UVB)
 Routine dental examinations
 Bone health: Speak with your oncologist or primary care provider for recommendations on if and when you should have bone density screening.
If you use tobacco, strongly consider quitting. The Wisconsin Tobacco Quit Line (1-800-QUIT-NOW) provides one-on-one counseling over the phone
or referrals to other programs and services, and is free of charge to Wisconsin residents. If you need help please talk to your health care provider, who
can recommend strategies for quitting smoking, such as counseling, medications and nicotine replacement products.
(NCCN Clinical Practice Guidelines, 2013 and University of Wisconsin Center for Tobacco Research and Intervention)
Tobacco Use: No, Yes past, Yes current
If current cessation counseling provided? Yes, No, Patient declined
Needs/Concerns/Opportunities:
{ONC Needs/Concerns/Opportunities:121914}
Advance Directives
Emotional / Mental Health
Employment
Financial Advice / Assistance
Genetic Risk
Personal Relationships
Prevention / Wellness
Other ***
REFERRALS
Physical / Occupational / Speech Therapy
Pulmonary Rehabilitation
Dietician
Genetic Counselor
Cancer Counseling (psychologist / therapist)
Sexual Health / Fertility
Social Worker
Contemporary Therapies (i.e. yoga, massage, acupuncture)
Financial Counselor
American Cancer Society
Support Group
Five Wishes
Smoking Cessation.
Cancer Survivorship
Other ***
Rehabilitation: {ONC Rehabilitation:121910} Physical, Occupational, Speech, Pulmonary Rehab, PM&R and Dietician
Care Plan Reviewed - Date:
By: