Example of an End-of-Treatment Consultation Note: Breast Cancer

Date of note: April 12, 2005

Name: Jane Doe Age: 39

Date of tissue diagnosis of cancer: August 4, 2004

Diagnosis: Breast cancer

Stage of cancer: T1N1M0 Stage II

Pathologic findings: 1.5 cm. infiltrating ductal cancer in the left breast, moderately differentiated, ER positive, PR negative, Her2Neu negative; 3 of 10 nodes positive for metastatic cancer

Initial treatment plan:

  • Surgery: Lumpectomy and axillary dissection

  • Radiation therapy: 6 weeks of radiation therapy to the left breast

  • Chemotherapy: 4 cycles of AC followed by Taxol; dose-dense regimen

Treatment received (specify dates, location, and providers):

Surgery performed as planned by Dr. David Smith at Happy Valley Hospital on 8/23/04.

Chemotherapy administered by Dr. Mary Scott at Westside Oncology Center from 9/15/04 to 2/1/05. Patient received full dose as specified in published protocol Citron et al., JCO, 2003, CALGB 9751 trial, doxorubicin 60 mg/m2 and cyclophosphamide 600 mg/m2 q 2 weeks × 4 cycles followed by paclitaxel 175 mg/m2 q 2 weeks × 4 cycles. Total dose of doxorubicin was 240 mg/m2.

Radiation therapy was given to the left breast by Dr. Mark Schwartz at Happy Valley Hospital from 2/15/05 to 4/6/05.

Dr. Scott initiated therapy with tamoxifen on 4/12/05.

Unusual or unexpected toxicities during treatment:

There were some treatment delays due to neutropenia and patient required blood transfusions on two occasions.

Expected short- and long-term effects of treatment:

Patient has some fatigue and alopecia at this time, but these are likely to recover over the next 3–6 months. The patient became amenorrheic after the first two cycles of chemotherapy and has severe hot flashes at this time

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