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CSC GU Concurrent XRT Capecitabine (21D:1-5, 8-12, 15-19) VER 12-1-16 (HL 3249)

CSC GU Concurrent XRT Capecitabine (21D:1-5, 8-12, 15-19) VER 12-1-16 (HL 3249) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Beacon Protocols, GU


CSC GU CONCURRENT XRT CAPECITABINE(21D1-5,8-12,15-19) VER 12-1-16 – Properties
Pre-Cycle – 6/8/2017 through 6/14/2017 (7 days), Planned
Day 1, Pre-Cycle – Planned for 6/8/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Urothelial/Bladder/Penile Cancer (Advanced); THERAPY: capecitabine 1500 mg by mouth twice daily for 5 days/week,
concurrent with radiotherapy; CYCLE LENGTH: 21 days; COURSE: for duration of radiotherapy.
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
ELECTROLYTES
Expected-S Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S Approximate, Expires-S+365, Routine
BUN
Expected-S Approximate, Expires-S+365, Routine
CREATININE
Expected-S Approximate, Expires-S+365, Routine
BILIRUBIN, TOTAL
Expected-S Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S Approximate, Expires-S+365, Routine
ALT/SGPT
Expected-S Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S Approximate, Expires-S+365, Routine
Take Home Medications
prochlorperazine (COMPAZINE) 10 MG tab
Take 1 tab by mouth every 6 hours as needed for nausea/vomiting., 10 mg, Disp-30 tab, R-5, EVERY 6 HOURS PRN starting S,
Local Printer
Cycle 1 – 6/15/2017 through 7/5/2017 (21 days), Planned
Day 1, Cycle 1 – Planned for 6/15/2017
Treatment Plan Information
Reference Information (1)
BLADDER/UROTHELIAL/PENILE CANCER: Patel B, et al. Int J Radiat Oncol Biol Phys 2005;62(5):1332-8.
Treatment Plan Summary
DISEASE: Urothelial/Bladder/Penile Cancer (Advanced); THERAPY: capecitabine 1500 mg by mouth twice daily for 5 days/week,
concurrent with radiotherapy; CYCLE LENGTH: 21 days; COURSE: for duration of radiotherapy.
Consent
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Zztestonc,Jeff J [2507481]
6/15/2017 7:46:50 AM Page 1 of 3
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

Verify Consent
Verify informed consent has been obtained.
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil infusion and to
call with concerns.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): capecitabine (Dispensed Day 1 of each cycle).
Take Home Medications
capecitabine (XELODA) 500 MG tab
Take 3 tabs by mouth 2 times daily. Take on Monday through Friday during radiotherapy for 10 doses., 1,500 mg, Disp-90 tab,
R-0, 2 X DAILY starting S
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC (DIFF if to be done locally) ANC, eletrolytes,
glucose, BUN, creatinine, total bilirubin, AST, ALT, magnesium; RADIOLOGY: Prior to discharge, confirm XRT scheduled, if
applicable.
Cycle 2 – 7/6/2017 through 7/26/2017 (21 days), Planned
Day 1, Cycle 2 – Planned for 7/6/2017
Treatment Plan Information
Treatment Plan Summary
DISEASE: Urothelial/Bladder/Penile Cancer (Advanced); THERAPY: capecitabine 1500 mg by mouth twice daily for 5 days/week,
concurrent with radiotherapy; CYCLE LENGTH: 21 days; COURSE: for duration of radiotherapy.
Consent
Verify Consent
Verify informed consent has been obtained.
Pre-Labs
CBC WITHOUT DIFFERENTIAL
Expected-S+21 Approximate, Expires-S+365, Routine
ABSOLUTE NEUTROPHIL COUNT
Expected-S+21 Approximate, Expires-S+365, Routine
ELECTROLYTES
Expected-S+21 Approximate, Expires-S+365, Routine
GLUCOSE
Expected-S+21 Approximate, Expires-S+365, Routine
BUN
Expected-S+21 Approximate, Expires-S+365, Routine
CREATININE
Expected-S+21 Approximate, Expires-S+365, Routine
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Zztestonc,Jeff J [2507481]
6/15/2017 7:46:50 AM Page 2 of 3
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org

BILIRUBIN, TOTAL
Expected-S+21 Approximate, Expires-S+365, Routine
AST/SGOT
Expected-S+21 Approximate, Expires-S+365, Routine
MAGNESIUM
Expected-S+21 Approximate, Expires-S+365, Routine
Treatment Conditions
Verify Labs
Verify pretreatment labs have been obtained: CBC, ANC.
Treatment Parameters
Hold and notify authorizing prescriber for ANC less than or equal to 1,000/µL or Platelets less than or equal to 100K/µL or Creatinine
greater than ULN.
Nursing Procedure, Assessment and Monitoring
Patient Instructions(1)
Educate/reinforce with patient regarding hand and foot syndrome related to capecitabine or continuous fluorouracil infusion and to
call with concerns.
Treatment Medications
See Take Home Medication(s)
Refer to the take home medications section for the following treatment medication(s): capecitabine (Dispensed Day 1 of each cycle).
Take Home Medications
capecitabine (XELODA) 500 MG tab
Take 3 tabs by mouth 2 times daily. Take on Monday through Friday during radiotherapy for 10 doses., 1,500 mg, Disp-90 tab,
R-0, 2 X DAILY starting S
Follow-Up
DAY 22 FOLLOW-UP
(Day 1 of next cycle) RETURN TO CLINIC for appointment with provider; LABS: CBC (DIFF if to be done locally) ANC, eletrolytes,
glucose, BUN, creatinine, total bilirubin, AST, ALT, magnesium; RADIOLOGY: Prior to discharge, confirm XRT scheduled, if
applicable.
Actions
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Zztestonc,Jeff J [2507481]
6/15/2017 7:46:50 AM Page 3 of 3
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
06/2017CCKM@uwhealth.org