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Breast Cyclophosphamide (21D1) Fluorouracil (21D1) Methotrexate (21D1) (1806 VER: 10-1-15)

Breast Cyclophosphamide (21D1) Fluorouracil (21D1) Methotrexate (21D1) (1806 VER: 10-1-15) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Preprinted Paper Orders


VER: 09-27-16 (1806 VER: 10-1-15) Page 1 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Title: Cyclophosphamide/Fluorouracil/Methotrexate (CMF)
Disease Group: Breast
Disease: Breast Cancer (Adjuvant/Advanced)

Therapy: methotrexate 40 mg/m2 IV Day 1.
fluorouracil 600 mg/m2 IV Day 1,
cyclophosphamide 600 mg/m2 IV Day 1

Cycle Length: 21 days Course: 8 cycles or until disease progression

Reference(s): Bonadonna G, et al. BMJ 2005;330(7485):217, Zambetti M, et al. Ann Oncol 1996;7(5):481-5,
Gion M, et al. Eur J Cancer 1991;27(8):996-1002, Tannock I, et al. J Clin Oncol 1988;6(9):1377-87.

Allergies:  NKDA  Other ____________________________

Height _________cm Weight __________kg BSA ________m
2


Cycle _______ Starting with:  Day 1 (date) ___________

Pre labs:
• Obtain CBC without DIFF, ANC, Creatinine, AST, Total Bilirubin
 Other:


Treatment Conditions:
• Verify Informed consent obtained Day 1 of each cycle.
• Verify the following labs have been obtained: CBC, ANC, Creatinine
• Hold and notify provider for: ANC ≤ 1000/µL or Platelets ≤ 100K/µL or Creatinine > ULN

Nursing Procedure, Assessment and Monitoring:
• Instruct patient to drink 8 to 10 (8 ounce) glasses of water day prior to, day of and for two days after treatment.
• Flush/Line Care per Institution standards

Hydration/Fluids: sodium chloride 0.9% IV administer 1000 mL throughout chemotherapy

Premedications/Antiemetics: (May substitute formulary equivalent)
Give prior to chemotherapy (*indicates preferred antiemetic regimen):
 *ondansetron (Zofran) 16 mg by mouth once. PO preferred – may give 8 mg IV if unable to tolerate PO.
 *dexamethasone (Decadron) 10 mg by mouth once. PO preferred – may give 10 mg IV if unable to tolerate
PO.
 fosaprepitant (Emend) 150 mg IV once.
 aprepitant (Emend) 125 mg by mouth once.
 palonosetron (Aloxi) 0.25 mg IV once.
 Other:



VER: 09-27-16 (1806 VER: 10-1-15) Page 2 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Treatment Medications for Day 1: (in order of administration)
Dose modifications from previous day/cycle?  No  Yes – list which drugs and indicate dose reduction below:





• methotrexate (Trexall) ____________mg (40 mg/m2) IV push once. IV push rate 10 mg/minute.

• fluorouracil (Adrucil) _____________ mg (600 mg/m2) IV push once. IV push rate 5 to 15 minutes.

• cyclophosphamide (Cytoxan) __________ mg (600 mg/m2) IV once over 30 to 60 minutes.





Other Orders for Day 1:










Take Home Medications - (Prescribe Cycle 1, Day 1: Review for adequate supply during treatment)
• ondansetron (Zofran) 8 mg tablet, Disp. #30, Refills: 5
Take 1 tablet (8 mg) by mouth every 8 hours as needed for nausea/vomiting.

• ranitidine (Zantac) 150 mg tablet, Disp. #60, Refills: 5
Take 1 tablet (150 mg) by mouth two times daily.

 aprepitant (Emend) 80 mg capsule, Disp. #2, Refills: 5
Take 1 capsule by mouth once daily for two days following chemotherapy.
(Prescribe only if patient received aprepitant as a premedication)

 Other:



VER: 09-27-16 (1806 VER: 10-1-15) Page 3 of 3
Copyright © 2016 University of Wisconsin Hospitals and Clinics Authority Contact: CCKM@uwhealth.org
Follow Up
• Chemotherapy: Day 1 every 21 days

• Labs:
 Other:





• Procedures/Imaging/Scans:
















• Other Orders:















MD Signature_________________________________________ Pager______________
Date __________________Time___________________

Order Verification:
RN Signature: __________________________ Date: ___________ Time: __________ Pager #: ________
RPh Signature: _________________________ Date: ___________ Time: __________ Pager #: ________