/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/beacon-protocols/,/clinical/cckm-tools/content/beacon-protocols/breast/,

/clinical/cckm-tools/content/beacon-protocols/breast/name-96593-en.cckm

201611306

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Beacon Protocols,Breast

CSC Breast C1-3 FEC (21D1)Followed by C4-6 Docetaxel(21D1)Pertuzumab(21D1)Trastumab(21D1) VER 10-3-16 (HL 5303)

CSC Breast C1-3 FEC (21D1)Followed by C4-6 Docetaxel(21D1)Pertuzumab(21D1)Trastumab(21D1) VER 10-3-16 (HL 5303) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, Breast


CSC BREAST C1-3: FEC (21D:1)/FOLLOWED BY C4-6: DOCETAXEL(21D:1)/PERTUZUMAB(21D:1)/TRASTUZUMAB(21D:1)
VER: 10-3-16 – Properties
Pre-Cycle – 10/25/2016 through 10/31/2016 (7 days), Planned
Day 1, Pre-Cycle – Planned for 10/25/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Neoadjuvant); THERAPY: epirubicin 100 mg/m2 IV Day 1, fluorouracil 500 mg/m2 IV Day 1,
cyclophosphamide 600 mg/m2 IV Day 1; CYCLE LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: pertuzumab 840
mg IV Day 1, trastuzumab 8 mg/kg IV Day 1, DOCEtaxel 75 mg/m2 IV Day 1; CYCLE LENGTH: 21 days; COURSE: 1 cycle followed
by THERAPY: pertuzumab 420 mg IV Day 1, trastuzumab 6 mg/kg IV Day 1, DOCEtaxel 75 mg/m2 IV Day 1; CYCLE LENGTH: 21
days; COURSE: 2 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
Treatment Conditions
Treatment Condition A
Verify patient has obtained pretreatment MUGA or ECHO.
Take Home Medications
aprepitant (EMEND) 80 MG cap
Take 1 cap by mouth one time daily. Take Day 2 and Day 3 of each cycle following chemotherapy., 80 mg, Disp-2 cap, R-2, 1 X
DAILY starting S
dexamethasone (DECADRON) 4 MG tab
Take 2 tabs by mouth one time daily. Take on Days 2, 3, and 4 following chemotherapy., 8 mg, Disp-18 tab, R-0, 1 X DAILY starting
S, Local Printer
ondansetron (ZOFRAN) 8 MG tab
Take 1 tab by mouth every 8 hours as needed for nausea/vomiting., 8 mg, Disp-30 tab, R-5, EVERY 8 HOURS PRN starting S,
Local Printer
Cycle 1 – 11/1/2016 through 11/21/2016 (21 days), Planned
Day 1, Cycle 1 – Planned for 11/1/2016
Treatment Plan Information
Reference Information (1)
BREAST CANCER: Brufman G, et al. Ann Oncol 1997;8(2):155-62.
Reference Information (2)
BREAST CANCER: Gianni L, et al. Lancet Oncol 2012;13(1):25-32.
Reference Information (3)
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ZZtestonc,Andrew [2428787]
11/1/2016 2:56:33 PM Page 1 of 12
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

BREAST CANCER: Schneeweiss A, et al. Ann Oncol 2013;24(9):2278-84.
Reference Information (4)
BREAST CANCER: Bonneterre J, et al. J Clin Oncol 2005;23(12):2686-93.
Treatment Plan Summary
DISEASE: Breast Cancer (Neoadjuvant); THERAPY: epirubicin 100 mg/m2 IV Day 1, fluorouracil 500 mg/m2 IV Day 1,
cyclophosphamide 600 mg/m2 IV Day 1; CYCLE LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: pertuzumab 840
mg IV Day 1, trastuzumab 8 mg/kg IV Day 1, DOCEtaxel 75 mg/m2 IV Day 1; CYCLE LENGTH: 21 days; COURSE: 1 cycle followed
by THERAPY: pertuzumab 420 mg IV Day 1, trastuzumab 6 mg/kg IV Day 1, DOCEtaxel 75 mg/m2 IV Day 1; CYCLE LENGTH: 21
days; COURSE: 2 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC without DIFF, ANC, Creatinine, AST, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for: ANC less than 1000/uL or Platelets less than or equal to 100K/uL or Creatinine
greater than 1.5 X ULN or AST greater than 2 X ULN or Total Bilirubin greater than 1.2 mg/dL.
Treatment Condition A
Verify patient has obtained pretreatment MUGA or ECHO.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
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ZZtestonc,Andrew [2428787]
11/1/2016 2:56:33 PM Page 2 of 12
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Medications
epirubicin (ELLENCE) injection 100 mg/m2 (Treatment Plan)
100 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 15 Minutes
Administer over 15 minutes IV side arm push **vesicant**
fluorouracil (ADRUCIL) injection 500 mg/m2 (Treatment Plan)
500 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 5-15 Minutes
Administer over 5 to 15 minutes.
cyclophosphamide (CYTOXAN) 600 mg/m2 in sodium chloride 0.9 % 250 mL bag
600 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC, Creatinine, AST, Total
Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: fluorouracil, epirubicin and cyclophosphamide for 150 minutes.
Cycle 2 – 11/22/2016 through 12/12/2016 (21 days), Planned
Day 1, Cycle 2 – Planned for 11/22/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Neoadjuvant); THERAPY: epirubicin 100 mg/m2 IV Day 1, fluorouracil 500 mg/m2 IV Day 1,
cyclophosphamide 600 mg/m2 IV Day 1; CYCLE LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: pertuzumab 840
mg IV Day 1, trastuzumab 8 mg/kg IV Day 1, DOCEtaxel 75 mg/m2 IV Day 1; CYCLE LENGTH: 21 days; COURSE: 1 cycle followed
by THERAPY: pertuzumab 420 mg IV Day 1, trastuzumab 6 mg/kg IV Day 1, DOCEtaxel 75 mg/m2 IV Day 1; CYCLE LENGTH: 21
days; COURSE: 2 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC without DIFF, ANC, Creatinine, AST, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for: ANC less than 1000/uL or Platelets less than or equal to 100K/uL or Creatinine
greater than 1.5 X ULN or AST greater than 1.5 X ULN or Total Bilirubin greater than 1.2 mg/dL.
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ZZtestonc,Andrew [2428787]
11/1/2016 2:56:33 PM Page 3 of 12
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
Treatment Medications
epirubicin (ELLENCE) injection 100 mg/m2 (Treatment Plan)
100 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 15 Minutes
Administer over 15 minutes IV side arm push **vesicant**
fluorouracil (ADRUCIL) injection 500 mg/m2 (Treatment Plan)
500 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 5-15 Minutes
Administer over 5 to 15 minutes.
cyclophosphamide (CYTOXAN) 600 mg/m2 in sodium chloride 0.9 % 250 mL bag
600 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC, Creatinine, AST, Total
Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: fluorouracil, epirubicin and cyclophosphamide for 150 minutes.
Cycle 3 – 12/13/2016 through 1/2/2017 (21 days), Planned
Day 1, Cycle 3 – Planned for 12/13/2016
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Neoadjuvant); THERAPY: epirubicin 100 mg/m2 IV Day 1, fluorouracil 500 mg/m2 IV Day 1,
cyclophosphamide 600 mg/m2 IV Day 1; CYCLE LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: pertuzumab 840
mg IV Day 1, trastuzumab 8 mg/kg IV Day 1, DOCEtaxel 75 mg/m2 IV Day 1; CYCLE LENGTH: 21 days; COURSE: 1 cycle followed
by THERAPY: pertuzumab 420 mg IV Day 1, trastuzumab 6 mg/kg IV Day 1, DOCEtaxel 75 mg/m2 IV Day 1; CYCLE LENGTH: 21
days; COURSE: 2 cycles.
Consent
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ZZtestonc,Andrew [2428787]
11/1/2016 2:56:33 PM Page 4 of 12
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC without DIFF, ANC, Creatinine, AST, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for: ANC less than 1000/uL or Platelets less than or equal to 100K/uL or Creatinine
greater than 1.5 X ULN or AST greater than 1.5 X ULN or Total Bilirubin greater than 1.2 mg/dL.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
RN instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 250-500 mL/hr, Intravenous, ONCE, 1 dose Starting when released
Infuse 1000 mL throughout treatment.
Pre-Medications
aprepitant (EMEND) cap 125 mg
125 mg, Oral, ONCE, 1 dose Starting when released
ondansetron (ZOFRAN) tab 24 mg
24 mg, Oral, ONCE, 1 dose Starting when released
dexamethasone (DECADRON) tab 12 mg
12 mg, Oral, ONCE, 1 dose Starting when released
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ZZtestonc,Andrew [2428787]
11/1/2016 2:56:33 PM Page 5 of 12
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Treatment Medications
epirubicin (ELLENCE) injection 100 mg/m2 (Treatment Plan)
100 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 15 Minutes
Administer over 15 minutes IV side arm push **vesicant**
fluorouracil (ADRUCIL) injection 500 mg/m2 (Treatment Plan)
500 mg/m2, Intravenous, ONCE, 1 dose Starting when released, Administer over 5-15 Minutes
Administer over 5 to 15 minutes.
cyclophosphamide (CYTOXAN) 600 mg/m2 in sodium chloride 0.9 % 250 mL bag
600 mg/m2, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes.
Take Home Medications
dexamethasone (DECADRON) 4 MG tab
Take 2 tabs by mouth 2 times daily. Take for 3 days starting morning of day prior to DOCEtaxel., 8 mg, Disp-36 tab, R-0, 2 X DAILY
starting S, Local Printer
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC, Creatinine, AST, Total
Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT: pertuzumab, trastuzumab, and DOCEtaxel for 240 minutes.
Cycle 4 – 1/3/2017 through 1/23/2017 (21 days), Planned
Day 1, Cycle 4 – Planned for 1/3/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Neoadjuvant); THERAPY: epirubicin 100 mg/m2 IV Day 1, fluorouracil 500 mg/m2 IV Day 1,
cyclophosphamide 600 mg/m2 IV Day 1; CYCLE LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: pertuzumab 840
mg IV Day 1, trastuzumab 8 mg/kg IV Day 1, DOCEtaxel 75 mg/m2 IV Day 1; CYCLE LENGTH: 21 days; COURSE: 1 cycle followed
by THERAPY: pertuzumab 420 mg IV Day 1, trastuzumab 6 mg/kg IV Day 1, DOCEtaxel 75 mg/m2 IV Day 1; CYCLE LENGTH: 21
days; COURSE: 2 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
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ZZtestonc,Andrew [2428787]
11/1/2016 2:56:33 PM Page 6 of 12
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify Labs
Verify pretreatment labs have been obtained: CBC without DIFF, ANC, Creatinine, AST, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for: ANC less than 1000/uL or Platelets less than or equal to 100K/uL or Creatinine
greater than 1.5 X ULN or AST greater than 1.5 X ULN or Total Bilirubin greater than 1.2 mg/dL.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity to pertuzumab can occur. For first and second dose, patient should be treated in a location to optimize emergency
care. See Emergency Medications. Patient should be monitored for 30 minutes after the first dose of pertuzumab.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications. Patient must be monitored for one hour after the first dose of trastuzumab.
Hypersensitivity Monitoring (3)
Hypersensitivity to DOCEtaxel can occur. For first and second dose, patient should be treated in a location to optimize emergency
care. See Emergency Medications.
** Rush dextrose primed line with 18mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of DOCEtaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
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ZZtestonc,Andrew [2428787]
11/1/2016 2:56:33 PM Page 7 of 12
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
pertuzumab (PERJETA) 840 mg in sodium chloride 0.9 % 250 mL bag
840 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 60 minutes. Hypersensitivity can occur. For first and second dose patient should be treated in a location to optimize
emergency care. See Emergency Medications. Do NOT administer by rapid push or bolus. Patient must be monitored for 30 minutes
after the first dose of pertuzumab. No additional medications to be administered during observation period.
trastuzumab (HERCEPTIN) 635 mg in sodium chloride 0.9 % 250 mL bag
635 mg (rounded from 635.2 mg = 8 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Give first dose over 90 minutes and subsequent doses over 30 minutes. Hypersensitivity risk. For first and second dose, patient
should be treated in a location to optimize emergency care. See Emergency Medications. Patient must be monitored for one hour
after the first dose of trastuzumab. Trastuzumab should be given prior to any chemotherapy.
DOCEtaxel (TAXOTERE) 75 mg/m2 in dextrose 5 % 100 mL non-PVC bag
75 mg/m2, Intravenous, ONCE, 1 dose Starting when released
For 60 minutes. Hypersensitivity risk. See emergency medications. In non-PVC bag. Infuse through non PVC tubing.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC, Creatinine, AST, Total
Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT:pertuzumab, trastuzumab, and DOCEtaxel for 180 minutes.
Cycle 5 – 1/24/2017 through 2/13/2017 (21 days), Planned
Day 1, Cycle 5 – Planned for 1/24/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Neoadjuvant); THERAPY: epirubicin 100 mg/m2 IV Day 1, fluorouracil 500 mg/m2 IV Day 1,
cyclophosphamide 600 mg/m2 IV Day 1; CYCLE LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: pertuzumab 840
mg IV Day 1, trastuzumab 8 mg/kg IV Day 1, DOCEtaxel 75 mg/m2 IV Day 1; CYCLE LENGTH: 21 days; COURSE: 1 cycle followed
by THERAPY: pertuzumab 420 mg IV Day 1, trastuzumab 6 mg/kg IV Day 1, DOCEtaxel 75 mg/m2 IV Day 1; CYCLE LENGTH: 21
days; COURSE: 2 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
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ZZtestonc,Andrew [2428787]
11/1/2016 2:56:33 PM Page 8 of 12
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify Labs
Verify pretreatment labs have been obtained: CBC without DIFF, ANC, Creatinine, AST, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for: ANC less than 1000/uL or Platelets less than or equal to 100K/uL or Creatinine
greater than 1.5 X ULN or AST greater than 1.5 X ULN or Total Bilirubin greater than 1.2 mg/dL.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity to pertuzumab can occur. For first and second dose, patient should be treated in a location to optimize emergency
care. See Emergency Medications. Patient should be monitored for 30 minutes after the first dose of pertuzumab.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications. Patient must be monitored for one hour after the first dose of trastuzumab.
Hypersensitivity Monitoring (3)
Hypersensitivity to DOCEtaxel can occur. For first and second dose, patient should be treated in a location to optimize emergency
care. See Emergency Medications.
** Rush dextrose primed line with 18mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of DOCEtaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
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ZZtestonc,Andrew [2428787]
11/1/2016 2:56:33 PM Page 9 of 12
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

dexamethasone (DECADRON) 10 MG/ML injection 10 mg
10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
pertuzumab (PERJETA) 420 mg in sodium chloride 0.9 % 250 mL bag
420 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Hypersensitivity can occur. For first and second dose patient should be treated in a location to
optimize emergency care. See emergency medications. Do NOT administer by rapid push or bolus.
trastuzumab (HERCEPTIN) 476 mg in sodium chloride 0.9 % 250 mL bag
476 mg (rounded from 476.4 mg = 6 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Administer over 30
minutes. Patient must be monitored for one hour after the first dose of trastuzumab.
DOCEtaxel (TAXOTERE) 75 mg/m2 in dextrose 5 % 100 mL non-PVC bag
75 mg/m2, Intravenous, ONCE, 1 dose Starting when released
For 60 minutes. Hypersensitivity risk. See emergency medications. In non-PVC bag. Infuse through non PVC tubing.
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC without DIFF, ANC, Creatinine, AST, Total
Bilirubin; CHEMOTHERAPY ROOM APPOINTMENT:pertuzumab, trastuzumab, and DOCEtaxel for 180 minutes.
Cycle 6 – 2/14/2017 through 3/6/2017 (21 days), Planned
Day 1, Cycle 6 – Planned for 2/14/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Breast Cancer (Neoadjuvant); THERAPY: epirubicin 100 mg/m2 IV Day 1, fluorouracil 500 mg/m2 IV Day 1,
cyclophosphamide 600 mg/m2 IV Day 1; CYCLE LENGTH: 21 days; COURSE: 3 cycles followed by THERAPY: pertuzumab 840
mg IV Day 1, trastuzumab 8 mg/kg IV Day 1, DOCEtaxel 75 mg/m2 IV Day 1; CYCLE LENGTH: 21 days; COURSE: 1 cycle followed
by THERAPY: pertuzumab 420 mg IV Day 1, trastuzumab 6 mg/kg IV Day 1, DOCEtaxel 75 mg/m2 IV Day 1; CYCLE LENGTH: 21
days; COURSE: 2 cycles.
Consent
Verify Consent
Verify informed consent has been obtained.
IV Access
Insert and Maintain Peripheral IV
CONTINUOUS Starting when released Until Specified
Peripheral IV Size: RN Discretion
Additional PIV may be inserted as needed for repeat blood sampling or IV medication administration.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
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ZZtestonc,Andrew [2428787]
11/1/2016 2:56:33 PM Page 10 of 12
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

Verify Labs
Verify pretreatment labs have been obtained: CBC without DIFF, ANC, Creatinine, AST, Total Bilirubin.
Treatment Parameters
Hold treatment and notify authorizing prescriber for: ANC less than 1000/uL or Platelets less than or equal to 100K/uL or Creatinine
greater than 1.5 X ULN or AST greater than 1.5 X ULN or Total Bilirubin greater than 1.2 mg/dL.
Verify Medication(s) Taken at Home (1)
Verify that patient has taken dexamethasone and document in a progress note. Notify authorizing prescriber if patient has not taken
medication as prescribed.
Nursing Procedure, Assessment and Monitoring
Hypersensitivity Monitoring (1)
Hypersensitivity to pertuzumab can occur. For first and second dose, patient should be treated in a location to optimize emergency
care. See Emergency Medications. Patient should be monitored for 30 minutes after the first dose of pertuzumab.
Hypersensitivity Monitoring (2)
Hypersensitivity reaction to trastuzumab can occur. For first and second dose, patient should be treated in a location to optimize
emergency care. See Emergency Medications. Patient must be monitored for one hour after the first dose of trastuzumab.
Hypersensitivity Monitoring (3)
Hypersensitivity to DOCEtaxel can occur. For first and second dose, patient should be treated in a location to optimize emergency
care. See Emergency Medications.
** Rush dextrose primed line with 18mL prior to programming start rate for infusion.
** RN to keep emergency medications locked at bedside (diphenhydramine and dexamethasone)
** For first and second doses, titrate up to full infusion rate over a minimum of 15 minutes
** RN to stay at patient’s bedside for a minimum of 15 minutes for first dose. RN to do the same for second dose if adverse reaction
during first dose.
Vital Signs
EVERY 15 MINUTES Starting when released Until Specified
Vital signs to be monitored every 15 minutes for the first hour and then every 30 minutes until infusion complete for the first and
second dose of DOCEtaxel administration. Monitor vital signs every 30 minutes for all subsequent doses if previous doses tolerated.
Flush Venous Access Device per Guidelines
Order details
sodium chloride flush 0.9% 10 mL injection
Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 10 UNIT/ML lock flush injection 1-150 units
1-150 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Flush per VAD guidelines.
heparin 100 UNIT/ML lock flush injection 500 units
500 units, Flush, PRN Starting when released Until Discontinued, flush/line care
Implanted port use ONLY to be used when de-accessing port. Flush per VAD guidelines.
Hydration
sodium chloride 0.9 % infusion
at 20 mL/hr, Intravenous, ONCE, 1 dose Starting when released
To establish line and for flushing.
Pre-Medications
ondansetron (ZOFRAN) tab 8 mg
8 mg, Oral, ONCE, 1 dose Starting when released
Give 30 minutes prior to chemotherapy.
Emergency Medications
diphenhydramine (BENADRYL) injection 25 mg
25 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
diphenhydramine (BENADRYL) injection 50 mg
50 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction, Administer over 1 Minutes
dexamethasone (DECADRON) 10 MG/ML injection 4 mg
4 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
dexamethasone (DECADRON) 10 MG/ML injection 10 mg
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ZZtestonc,Andrew [2428787]
11/1/2016 2:56:33 PM Page 11 of 12
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org

10 mg, Intravenous, PRN, 1 dose Starting when released, infusion reaction
albuterol 2.5 mg/3 mL neb soln
2.5 mg, Nebulization, PRN, 1 dose Starting when released, infusion reaction
Treatment Medications
pertuzumab (PERJETA) 420 mg in sodium chloride 0.9 % 250 mL bag
420 mg, Intravenous, ONCE, 1 dose Starting when released
Administer over 30 to 60 minutes. Hypersensitivity can occur. For first and second dose patient should be treated in a location to
optimize emergency care. See emergency medications. Do NOT administer by rapid push or bolus.
trastuzumab (HERCEPTIN) 476 mg in sodium chloride 0.9 % 250 mL bag
476 mg (rounded from 476.4 mg = 6 mg/kg × 79.4 kg), Intravenous, ONCE, 1 dose Starting when released
Hypersensitivity risk. See emergency medications. Trastuzumab should be given PRIOR to any chemotherapy. Administer over 30
minutes. Patient must be monitored for one hour after the first dose of trastuzumab.
DOCEtaxel (TAXOTERE) 75 mg/m2 in dextrose 5 % 100 mL non-PVC bag
75 mg/m2, Intravenous, ONCE, 1 dose Starting when released
For 60 minutes. Hypersensitivity risk. See emergency medications. In non-PVC bag. Infuse through non PVC tubing.
Follow-Up
MULTIPLE DAY FOLLOW-UP (1)
Care Planning for: {UWONC SURVIVORSHIP PLANNING:7700070}
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ZZtestonc,Andrew [2428787]
11/1/2016 2:56:33 PM Page 12 of 12
Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 11/2016CCKM@uwhealth.org