PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY:
|
|
|
- Janice Hunt
- 5 years ago
- Views:
Transcription
1 PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY: Nintedanib-Docetaxel PATIENT DETAILS PATIENT S SURNAME/FAMILY NAME: PATIENT S FIRST NAME(S): DATE OF BIRTH: NHS NUMBER: (or other identifier) HOSPITAL NAME/STAMP: MALE FEMALE SPECIAL REQUIREMENTS: (e.g. other language/other communication method) RESPONSIBLE HEALTH PROFESSIONAL: Name: NAME OF PROPOSED COURSE OF TREATMENT (include brief explanation if medical term not clear) Nintedanib and docetaxel for the treatment of non-small cell lung cancer (NSCLC). Nintedanib capsules are taken orally twice a day on days 2 to 21, and docetaxel is given intravenously on day 1, every 21 days for up to 6 cycles. Followed by nintedanib capsules alone taken orally twice a day, treatment is supplied every 28 days. Treatment is continued until disease progression or unacceptable toxicity. WHERE THE TREATMENT WILL BE GIVEN: outpatient day unit/case inpatient other: STATEMENT OF HEALTH PROFESSIONAL (to be filled in by health professional with appropriate knowledge of proposed procedure, as specified in the hospital/trust s consent policy) I have explained the procedure/treatment to the patient. In particular, I have explained: all relevant boxes THE INTENDED BENEFITS CURATIVE to give you the best possible chance of being cured. DISEASE CONTROL/PALLIATIVE the aim is not to cure but to control or shrink the disease. The aim is to improve both quality of life and survival. ADJUVANT therapy given after surgery to reduce the risk of the cancer coming back. NEO-ADJUVANT therapy given before surgery/radiotherapy to shrink the cancer, allow radical treatment and reduce the risk of the cancer coming back. Page 1 of 5
2 STATEMENT OF HEALTH PROFESSIONAL (continued) SIGNIFICANT, UNAVOIDABLE OR FREQUENTLY OCCURRING RISKS COMMON SIDE EFFECTS: More than 10 in every 100 (>10%) people have one or more of the side effects listed: Nintedanib: Diarrhoea, skin changes (rash or red, dry, itchy skin), sore mouth, feeling sick (nausea) and being sick (vomiting), loss of appetite, bruising or bleeding, tiredness and feeling weak (fatigue), bruising or bleeding, abdominal (tummy) pain, numbness or tingling in the hands or feet, and changes in the way the liver works. Nintedanib and docetaxel: An increased risk of getting an infection from a drop in white blood cells - it is harder to fight infections and you can become very ill. If you have a severe infection this can be life threatening. Contact you doctor or hospital straight away if: your temperature goes over 37.5 C (99.5 F) or over 38 C (100.4 F), depending on the advice given by your chemotherapy team you suddenly feel unwell (even with a normal temperature) Docetaxel: Hair loss, diarrhoea, sore hands and feet, sore mouth and ulcers, taste changes, anaemia (low number of red blood cells), bruising or bleeding, tiredness and feeling weak (fatigue), skin changes, nail changes, numbness or tingling in the hands and feet, fluid retention (you may notice you gain weight and/or your ankles and legs swell), rash, allergic reactions, and watery eyes. OCCASIONAL SIDE EFFECTS: Between 1 and 10 in every 100 (1-10%) people have one or more of these effects: Nintedanib: Dehydration, and abscesses. Docetaxel: Feeling sick (nausea) and being sick (vomiting), pain in the joints or muscles, lung changes (causing breathlessness), and changes in eyesight. OTHER RISKS: Docetaxel may leak outside of the vein while it is being given; this is called extravasation. If this happens when you re having docetaxel it can damage the tissue around the vein. Tell the nurse straight away if you have any stinging, pain, redness or swelling around the vein. Extravasation is not common but if it happens it s important that it s dealt with quickly. Potential side-effects with the anti-sickness medication may include: constipation, headaches, indigestion, difficulty sleeping, and agitation. Cancer can increase your risk of developing a blood clot (thrombosis), and having treatment with anti-cancer medicines may increase this risk further. A blood clot may cause pain, redness and swelling in a leg, or breathlessness and chest pain - you must tell your doctor straight away if you have any of these symptoms. Some anti-cancer medicines can damage women s ovaries and men s sperm. This may lead to infertility in men and women and/or early menopause in women. Some anti-cancer medicines may damage the development of a baby in the womb. It is important not to become pregnant or father a child while you are having treatment and for at least 3 months after nintedanib treatment and up to 6 months after docetaxel treatment. Nintedanib may affect how well hormonal contraceptives work. It is important to use effective contraception during and for 3 months after treatment with nintedanib treatment and up to 6 months after docetaxel treatment. You can talk to your doctor or nurse about this. A confirmed negative pregnancy test is required for women of childbearing potential before starting treatment with nintedanib. Very rarely complications of treatment with anticancer medicines can be life-threatening or even result in death. The risks are different for every individual. You can talk to your doctor or nurse about what this means for you. Page 2 of 5
3 STATEMENT OF HEALTH PROFESSIONAL (continued) ANY OTHER RISKS: I have discussed what the treatment is likely to involve (including inpatient / outpatient treatment, timing of the treatment, blood and any additional tests, follow-up appointments etc) and location. I have discussed the intended benefits and risks of any available alternative treatments (including no treatment) and any particular concerns of this patient. THE FOLLOWING LEAFLET HAS BEEN PROVIDED: Information leaflet for nintedanib-docetaxel and/or for the individual drugs. 24 hour chemotherapy service contact details Other, please state: STATEMENT OF INTERPRETER (where appropriate) INTERPRETER BOOKING REFERENCE (if applicable): I have interpreted the information above to the patient to the best of my ability and in a way in which I believe s/he can understand. Page 3 of 5
4 STATEMENT OF PATIENT Please read this form carefully. If your treatment has been planned in advance, you should already have your own copy of the form which describes the benefits and risks of the proposed treatment. If not, you will be offered a copy now. If you have any further questions, do ask we are here to help you. You have the right to change your mind at any time, including after you have signed this form. I agree to the procedure and course of treatment described on this form. I understand that you cannot give me a guarantee that a particular person will perform the procedure. The person will, however, have appropriate training and experience. I understand that any procedure in addition to those described on this form will only be carried out if it is necessary to save my life or to prevent serious harm to my health. I have been told about additional procedures which may become necessary during my treatment. I have listed below any procedures which I do not wish to be carried out without further discussion: Patient s signature: A witness should sign below if the patient is unable to sign but has indicated his or her consent. Young people/children may also like a parent to sign here (see notes). Parent s/witness signature: COPY ACCEPTED BY PATIENT: YES / NO (please circle) CONFIRMATION OF CONSENT (health professional to complete when the patient attends for treatment, if the patient has signed the form in advance) On behalf of the team treating the patient, I have confirmed with the patient that s/he has no further questions and wishes the procedure to go ahead. IMPORTANT NOTES: (tick if applicable) See also advance decision to refuse treatment Patient has withdrawn consent (ask patient to sign /date here) FURTHER INFORMATION FOR PATIENTS CONTACT DETAILS (if patient wishes to discuss options later): Contact your hospital team if you have any questions about cancer and treatment. Cancer Research UK can also help answer your questions about cancer and treatment. If you want to talk in confidence, call our information nurses on freephone , Monday to Friday, 9am to 5pm. Alternatively visit for more information. These forms have been produced by Guy s and St. Thomas NHS Foundation Trust as part of a national project to support clinicians in ensuring all patients are fully informed when consenting to SACT. The project is supported by Cancer Research UK. This does not mean you are taking part in a clinical trial. Page 4 of 5
5 GUIDANCE FOR HEALTH PROFESSIONALS (to be read in conjunction with the hospital s consent policy) WHAT A CONSENT FORM IS FOR This form documents the patient s agreement to go ahead with the investigation or treatment you have proposed. It is not a legal waiver if patients, for example, do not receive enough information on which to base their decision, then the consent may not be valid, even though the form has been signed. Patients are also entitled to change their mind after signing the form, if they retain capacity to do so. The form should act as an aide-memoir to health professionals and patients, by providing a checklist of the kind of information patients should be offered, and by enabling the patient to have a written record of the main points discussed. In no way, however, should the written information provided for the patient be regarded as a substitute for face-to-face discussions with the patient. THE LAW ON CONSENT See the Department of Health s Reference guide to consent for examination or treatment 2nd Edition for a comprehensive summary of the law on consent (also available at WHO CAN GIVE CONSENT Everyone aged 16 or over is presumed to have the capacity to give consent for themselves, unless the opposite is demonstrated. If a child under the age of 16 has sufficient understanding and intelligence to enable him or her to understand fully what is proposed, then he or she will have capacity to give consent for himself or herself. Young people aged 16 and 17, and younger children with capacity, may therefore sign this form for themselves, but may like a parent to countersign as well. If the child is not able to give consent for himself or herself, someone with parental responsibility may do so on their behalf and a separate form is available for this purpose. Even where a child is able to give consent for himself or herself, you should always involve those with parental responsibility in the child s care, unless the child specifically asks you not to do so. If a patient has the capacity to give consent but is physically unable to sign a form, you should complete this form as usual, and ask an independent witness to confirm that the patient has given consent orally or non-verbally. WHEN NOT TO USE THIS FORM If the patient is 18 or over and lacks the capacity to give consent, you should use an alternative form (form for adults who lack the capacity to consent to investigation or treatment) instead of this form. A patient lacks capacity if they have an impairment of the mind or brain or disturbance affecting the way their mind or brain works and they cannot: understand information about the decision to be made retain that information in their mind use or weigh this information as a part of their decision making process, or communicate their decision (by talking, using sign language or any other means) You should always take all reasonable steps (for example involving more specialist colleagues) to support a patient in making their own decision, before concluding that they are unable to do so. Relatives cannot be asked to sign a form on behalf of an adult who lacks capacity to consent for themselves, unless they have been given the authority to do so under a Lasting Power of Attorney or as a court deputy. INFORMATION Information about what the treatment will involve, its benefits and risks (including side-effects and complications) and the alternatives to the particular procedure proposed, is crucial for patients when making up their minds. The courts have stated that patients should be told about significant risks which would affect the judgement of a reasonable patient. Significant has not been legally defined, but the GMC requires doctors to tell patients about significant, unavoidable or frequently occurring risks. In addition if patients make clear they have particular concerns about certain kinds of risk, you should make sure they are informed about these risks, even if they are very small or rare. You should always answer questions honestly. Sometimes, patients may make it clear that they do not want to have any information about the options, but want you to decide on their behalf. In such circumstances, you should do your best to ensure that the patient receives at least very basic information about what is proposed. Where information is refused, you should document this on the consent form or in the patient s notes. REFERENCES 1. Summary of Product Characteristics (SPCs) for individual drugs: 2. Cancer Research UK: about-cancer/cancers-in-general/treatment/cancer-drugs/ 3. Macmillan Cancer Support, Cancer Information: macmillan.org.uk/cancerinformation/cancertreatment/ Treatmenttypes/Chemotherapy/Chemotherapy.aspx 4. Guy s and St. Thomas NHS Foundation Trust, Chemotherapy consent forms. Page 5 of 5
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY:
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY: Carboplatin-Etoposide PATIENT DETAILS PATIENT S SURNAME/FAMILY NAME: PATIENT S FIRST NAME(S): DATE OF BIRTH: NHS NUMBER: (or other identifier) HOSPITAL
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY:
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY: Docetaxel-EC PATIENT DETAILS PATIENT S SURNAME/FAMILY NAME: PATIENT S FIRST NAME(S): DATE OF BIRTH: NHS NUMBER: (or other identifier) HOSPITAL NAME/STAMP:
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY:
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY: Docetaxel-Oxaliplatin- Fluorouracil (FLOT) PATIENT DETAILS PATIENT S SURNAME/FAMILY NAME: PATIENT S FIRST NAME(S): DATE OF BIRTH: NHS NUMBER: (or other
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY:
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY: FEC-P PATIENT DETAILS PATIENT S SURNAME/FAMILY NAME: PATIENT S FIRST NAME(S): DATE OF BIRTH: NHS NUMBER: (or other identifier) HOSPITAL NAME/STAMP: MALE
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY:
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY: BEP (5 day) PATIENT DETAILS PATIENT S SURNAME/FAMILY NAME: PATIENT S FIRST NAME(S): DATE OF BIRTH: NHS NUMBER: (or other identifier) HOSPITAL NAME/STAMP:
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY:
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY: Gemcitabine- Carboplatin PATIENT DETAILS PATIENT S SURNAME/FAMILY NAME: PATIENT S FIRST NAME(S): DATE OF BIRTH: NHS NUMBER: (or other identifier) HOSPITAL
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY:
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY: Oxaliplatin- Fluorouracil (FOLFOX) PATIENT DETAILS PATIENT S SURNAME/FAMILY NAME: PATIENT S FIRST NAME(S): DATE OF BIRTH: NHS NUMBER: (or other identifier)
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY:
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY: Irinotecan- Capecitabine (CAPIRI) PATIENT DETAILS PATIENT S SURNAME/FAMILY NAME: PATIENT S FIRST NAME(S): DATE OF BIRTH: NHS NUMBER: (or other identifier)
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY:
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY: Cisplatin- Capecitabine- Trastuzumab PATIENT DETAILS PATIENT S SURNAME/FAMILY NAME: PATIENT S FIRST NAME(S): DATE OF BIRTH: NHS NUMBER: (or other identifier)
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY:
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY: Niraparib PATIENT DETAILS PATIENT S SURNAME/FAMILY NAME: PATIENT S FIRST NAME(S): DATE OF BIRTH: NHS NUMBER: (or other identifier) HOSPITAL NAME/STAMP:
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY:
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY: Everolimus PATIENT DETAILS PATIENT S SURNAME/FAMILY NAME: PATIENT S FIRST NAME(S): DATE OF BIRTH: NHS NUMBER: (or other identifier) HOSPITAL NAME/STAMP:
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY:
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY: Dabrafenib-Trametinib PATIENT DETAILS PATIENT S SURNAME/FAMILY NAME: PATIENT S FIRST NAME(S): DATE OF BIRTH: NHS NUMBER: (or other identifier) HOSPITAL
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY:
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY: Pembrolizumab PATIENT DETAILS PATIENT S SURNAME/FAMILY NAME: PATIENT S FIRST NAME(S): DATE OF BIRTH: NHS NUMBER: (or other identifier) HOSPITAL NAME/STAMP:
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY:
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY: Bevacizumab + Chemotherapy PATIENT DETAILS PATIENT S SURNAME/FAMILY NAME: PATIENT S FIRST NAME(S): DATE OF BIRTH: NHS NUMBER: (or other identifier) HOSPITAL
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY:
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY: Atezolizumab PATIENT DETAILS PATIENT S SURNAME/FAMILY NAME: PATIENT S FIRST NAME(S): DATE OF BIRTH: NHS NUMBER: (or other identifier) HOSPITAL NAME/STAMP:
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY:
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY: Pazopanib PATIENT DETAILS PATIENT S SURNAME/FAMILY NAME: PATIENT S FIRST NAME(S): DATE OF BIRTH: NHS NUMBER: (or other identifier) HOSPITAL NAME/STAMP:
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY:
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY: Sunitinib PATIENT DETAILS PATIENT S SURNAME/FAMILY NAME: PATIENT S FIRST NAME(S): DATE OF BIRTH: NHS NUMBER: (or other identifier) HOSPITAL NAME/STAMP:
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY:
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY: Axitinib PATIENT DETAILS PATIENT S SURNAME/FAMILY NAME: PATIENT S FIRST NAME(S): DATE OF BIRTH: NHS NUMBER: (or other identifier) HOSPITAL NAME/STAMP:
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY:
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY: Ponatinib PATIENT DETAILS PATIENT S SURNAME/FAMILY NAME: PATIENT S FIRST NAME(S): DATE OF BIRTH: NHS NUMBER: (or other identifier) HOSPITAL NAME/STAMP:
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY:
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY: Cabozantinib PATIENT DETAILS PATIENT S SURNAME/FAMILY NAME: PATIENT S FIRST NAME(S): DATE OF BIRTH: NHS NUMBER: (or other identifier) HOSPITAL NAME/STAMP:
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY:
PATIENT AGREEMENT TO SYSTEMIC ANTI- CANCER THERAPY: Zoledronic acid PATIENT DETAILS PATIENT S SURNAME/FAMILY NAME: PATIENT S FIRST NAME(S): DATE OF BIRTH: NHS NUMBER: (or other identifier) HOSPITAL NAME/STAMP:
Patient identifier/label: Page 1 of 7 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM EC-T: EPIRUBICIN / CYCLOPHOSPHAMIDE - DOCETAXEL
Patient identifier/label: Page 1 of 7 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM EC-T: EPIRUBICIN / CYCLOPHOSPHAMIDE - DOCETAXEL Patient s surname/family name Patient s first names Date of birth
Patient identifier/label: Page 1 of 6 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM CISPLATIN + ETOPOSIDE ORAL/INTRAVENOUS
Patient identifier/label: Page 1 of 6 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM CISPLATIN + ETOPOSIDE ORAL/INTRAVENOUS Patient s surname/family name Patient s first names Date of birth Hospital
Patient identifier/label: Page 1 of 6 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM CHOP 21 +/- RITUXIMAB. Patient s first names.
Patient identifier/label: Page 1 of 6 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM CHOP 21 +/- RITUXIMAB Patient s surname/family name Patient s first names Date of birth Hospital Name: Guy s Hospital
PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM FERRERI / IELSG PROTOCOL. Patient s first names. Date of birth
Page 1 of 6 FORM FERRERI / IELSG PROTOCOL Patient s surname/family name Patient s first names Date of birth Hospital Name: Guy s Hospital St. Thomas Hospital King s College Hospital Lewisham Hospital NHS
Patient identifier/label: Page 1 of 6 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM CYTARABINE (HIGH DOSE)
Patient identifier/label: Page 1 of 6 CYTARABINE Patient s surname/family name Patient s first names Date of birth Hospital Name: Guy s Hospital St. Thomas Hospital King s College Hospital Lewisham Hospital
Patient identifier/label: Page 1 of 6 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM ABVD. Patient s first names.
Patient identifier/label: Page 1 of 6 Patient s surname/family name Patient s first names Date of birth Hospital Name: Guy s Hospital St. Thomas Hospital King s College Hospital Lewisham Hospital NHS number
Patient identifier/label: Page 1 of 5 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM BEVACIZUMAB. Patient s first names. Date of birth.
Patient identifier/label: Page 1 of 5 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM BEVACIZUMAB Patient s surname/family name Patient s first names Date of birth Hospital Name: NHS number (or other
Patient identifier/label: Page 1 of 5 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM CABOZANTINIB. Patient s first names.
Patient identifier/label: Page 1 of 5 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM CABOZANTINIB Patient s surname/family name Patient s first names Date of birth Hospital Name: NHS number (or other
Patient identifier/label: Page 1 of 6 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM ZOLEDRONIC ACID. Patient s first names.
Patient identifier/label: Page 1 of 6 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM ZOLEDRONIC ACID Patient s surname/family name Patient s first names Date of birth NHS number (or other identifier)
Patient's surname/family name. Patient's first names. Date of birth. Responsible health professional. Job title. NHS number (or other identifier)
Page 1 of7 Patient's surname/family name Department of Health THE ROYAL MARSDEN NHS FOUNDATION TRUST Robotic-assisted Laparoscopic Prostatectomy (RALP) Patient Agreement to Investigation or Treatment Patient's
Paclitaxel (Taxol) and carboplatin
Paclitaxel (Taxol) and carboplatin Paclitaxel (Taxol) and carboplatin This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may
Department of Clinical Haematology. Chemotherapy. Information for patients. Page 1 of 12
Department of Clinical Haematology Chemotherapy Information for patients Page 1 of 12 You may find this booklet helpful if you or someone close to you is going to have chemotherapy. It explains: what chemotherapy
Patient agreement to investigation or treatment. Emergency Spinal Discectomy/Decompression. Patient details (or pre-printed label)
CONSENT FORM 1 (VI) Patient agreement to investigation or treatment Emergency Spinal Discectomy/Decompression Patient details (or pre-printed label) Patient s surname/family name..... Patient s first names..
Weekly standard dose. Paclitaxel (Taxol) and carboplatin
paclitaxel (taxol) and carboplatin Paclitaxel (Taxol) and carboplatin This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may
Patient agreement to investigation or treatment. Spinal Injections. Patient details (or pre-printed label) Patient s surname/family name...
CONSENT FORM 1(VII) Patient agreement to investigation or treatment Spinal Injections Patient details (or pre-printed label) Patient s surname/family name..... Patient s first names.. Date of birth. Responsible
Carboplatin & weekly paclitaxel (Taxol) (for anal cancer) Carboplatin and weekly paclitaxel (Taxol) (for anal cancer)
Carboplatin & weekly paclitaxel (Taxol) (for anal cancer) Carboplatin and weekly paclitaxel (Taxol) (for anal cancer) The possible benefits of treatment vary; for some people chemotherapy may reduce the
Bevacizumab (Avastin ) treatment for Neurofibromatosis Type 2 (NF2) Information for patients
Bevacizumab (Avastin ) treatment for Neurofibromatosis Type 2 (NF2) Information for patients This booklet has been written to give you more information about bevacizumab (commonly known as Avastin). This
Pentostatin (Nipent )
Pentostatin (Nipent ) Pentostatin (Nipent ) This leaflet is offered as a guide to you and your family. Your treatment will be fully explained by your doctor or nurse, who will be happy to answer any questions.
Cisplatin and Capecitabine
Cisplatin and Capecitabine Cisplatin and Capecitabine This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk
Docetaxel (Taxotere) with GCSF
Docetaxel (Taxotere) with GCSF Docetaxel (Taxotere) with GCSF for hormone This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy
Gemcitabine and carboplatin (Breast)
Gemcitabine and carboplatin (Breast) Gemcitabine and carboplatin (Breast) This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy
Haematology. C = Cyclophosphamide (pronounced sigh clo fos fa mide)
Haematology CEPP Chemotherapy This information is about CEPP chemotherapy, which is a treatment for Lymphoma. Lymphoma is a cancer of the lymphatic system - a network of glands in the body that helps to
Tamoxifen Tamoxifen. Your treatment Your doctor or nurse clinician has prescribed for you a treatment which includes the hormonal therapy tamoxifen.
Tamoxifen Tamoxifen This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people hormonal therapy may reduce the risk of cancer coming back, for others
Fitting of an Intrauterine Device (IUD)
PLEASE PRINT WHOLE FORM DOUBLE SIDED ON YELLOW PAPER Patient Information to be retained by patient affix patient label What is an IUD? An IUD is a small T-shaped plastic and copper device that is put into
Gemcitabine and Cisplatin (urology)
Gemcitabine and Cisplatin Gemcitabine and Cisplatin (urology) This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce
Cisplatin and gemcitabine (GI)
Cisplatin and gemcitabine (GI) Cisplatin and gemcitabine (GI) This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce
Laparoscopic radical nephrectomy
PLEASE PRINT WHOLE FORM DOUBLE SIDED ON YELLOW PAPER Patient Information to be retained by patient affix patient label What is a laparoscopic radical nephrectomy? This is a procedure which involves removal
ChIVPP. ChIVPP. Day 1 to 14 Chlorambucil tablets Procarbazine capsules Prednisolone tablets
ChIVPP ChIVPP This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk of the cancer coming back, for others
Haematology. R - CEPP Chemotherapy
Haematology R - CEPP Chemotherapy This information is about R-CEPP chemotherapy, which is a treatment for Lymphoma. Lymphoma is a cancer of the lymphatic system a network of glands in the body that helps
Vinblastine (Lymphoma)
Vinblastine (Lymphoma) Vinblastine (Lymphoma) This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk of the
Perjeta Contains the active ingredient pertuzumab (rch)
Perjeta Contains the active ingredient pertuzumab (rch) Consumer Medicine Information What is in this leaflet This leaflet answers some common questions about Perjeta. It does not contain all the available
Myocet. Myocet. Myocet is given into the vein (intravenously) through a fine tube (cannula) as an infusion over 1 hour.
Myocet Myocet This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk of the cancer coming back, for others
Gemcitabine and carboplatin (Lung)
Gemcitabine and carboplatin (Lung) Gemcitabine and carboplatin (Lung) This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may
Brentuximab vedotin. Brentuximab vedotin
Brentuximab vedotin Brentuximab vedotin This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk of the cancer
Mitomycin C given by injection into a vein. Cisplatin and hydration (fluids) via a drip over 6 or 18 hours.
Cisplatin & Mitomycin C Cisplatin & Mitomycin C This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk of the
Consumer Medicine Information March 2009
March 2009 50 (oxaliplatin 50mg power for injection vial) 100 (oxaliplatin 100mg power for injection vial) What is in this leaflet? This leaflet answers some common questions about Powder for injection.
ABVD. by infusion over 30 minutes. You will have treatment on Day 1 and Day 15 (this is one cycle) for 2, 3 or 6 cycles.
ABVD ABVD This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk of the cancer coming back, for others it may
Eloxatin Oxaliplatin concentrated solution for injection
Eloxatin Oxaliplatin concentrated solution for injection Consumer Medicine Information Please read this leaflet before you are given this medicine. What is in this leaflet This leaflet answers some common
Epirubicin. Epirubicin
Epirubicin Epirubicin This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk of the cancer coming back, for
Oral Etoposide (Lymphoma)
Oral Etoposide (Lymphoma) Oral Etoposide (Lymphoma) This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk
Capecitabine (Xeloda) tablets
Capecitabine (Xeloda) tablets This is used with radiotherapy to treat colorectal cancer Information for patients Chemotherapy Name Hospital No Your consultant is Important Advice Always carry your chemotherapy
Vinorelbine (Oral) Oral Vinorelbine
Oral Vinorelbine Vinorelbine (Oral) This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk of the cancer coming
Dexamethasone is used to treat cancer. This drug can be given in the vein (IV), by mouth, or as an eye drop.
Dexamethasone Other Names: Decadron About This Drug Dexamethasone is used to treat cancer. This drug can be given in the vein (IV), by mouth, or as an eye drop. Possible Side Effects (More Common) Increased
Pemetrexed (Alimta )
Pemetrexed (Alimta ) Pemetrexed (Alimta ) This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk of the cancer
Capecitabine (Xeloda )
1 Capecitabine (Xeloda ) This fact sheet is for anyone diagnosed with pancreatic cancer who would like to find out more about capecitabine chemotherapy to treat pancreatic cancer. It provides information
Gemcitabine and carboplatin (Lung)
Gemcitabine and carboplatin (Lung) Gemcitabine and carboplatin (Lung) This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may
Gemcitabine (Gemzar )
1 Gemcitabine (Gemzar ) This fact sheet is for anyone diagnosed with pancreatic cancer who would like to find out more about gemcitabine chemotherapy to treat pancreatic cancer. It provides information
Myeloma Haematology and Transplant Unit MPT
MPT Myeloma Haematology and Transplant Unit MPT This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk of the
Paclitaxel (Taxol) Paclitaxel is given into the vein (intravenously) through a fine tube (cannula) as an infusion over 1 hour.
Paclitaxel (Taxol) Paclitaxel (Taxol) This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk of the cancer
Eribulin (Halaven ) Treatment is given on Day 1 and Day 8 of a 21-day cycle.
Eribulin (Halaven ) Eribulin (Halaven ) This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk of the cancer
The treatment is given every 3 weeks for 6 to 8 cycles.
R-CVP R-CVP This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk of the cancer coming back, for others it
Bendamustine. Bendamustine. Your treatment Your doctor or nurse clinician has prescribed a course of treatment with bendamustine.
Bendamustine Bendamustine This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk of the cancer coming back,
Diagnostic and therapeutic pleural aspiration
PLEASE PRINT WHOLE FORM DOUBLE SIDED ON YELLOW PAPER Patient Information to be retained by patient Diagnostic and therapeutic pleural aspiration affix patient label Who is this leaflet for? This leaflet
Treatment FLAG. An information guide
TO PROVIDE THE VERY BEST CARE FOR EACH PATIENT ON EVERY OCCASION Treatment FLAG An information guide Treatment FLAG This leaflet is offered as a guide to you and your family. The possible benefits of treatment
West Suffolk Hospital
For staff use only: Patient Details: First names: Hospital no: (Use hospital identification label) West Suffolk Hospital Patient information leaflet Carpal Tunnel Syndrome 2-3 Patient agreement to investigation
Myeloma Haematology and Transplant Unit CTD1
CTD1 Myeloma Haematology and Transplant Unit CTD1 This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk of
Your treatment. 240 BEP 3 Days Page 1 of 6
BEP - 3 Days BEP - 3 Days This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk of the cancer coming back,
VIDE. Vincristine given via intravenous (IV) infusion over 10 minutes Etoposide & doxorubicin given together via IV infusion over 4 hours
VIDE VIDE This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk of the cancer coming back, for others it may
For the Patient: Olaparib tablets Other names: LYNPARZA
For the Patient: Olaparib tablets Other names: LYNPARZA Olaparib (oh lap' a rib) is a drug that is used to treat some types of cancer. It is a tablet that you take by mouth. Tell your doctor if you have
VDC IE. Your treatment You will have 14 cycles of VDC IE given every 2 to 3 weeks.
VDC IE VDC IE This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk of the cancer coming back, for others
High dose melphalan conditioning for autologous transplant (inpatient) Palatine treatment centre
High dose melphalan conditioning for autologous transplant (inpatient) High dose melphalan conditioning for autologous transplant (inpatient) Palatine treatment centre This leaflet is offered as a guide
Pemetrexed (Alimta ) and cisplatin
Pemetrexed (Alimta ) and cisplatin Pemetrexed (Alimta ) and cisplatin This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may
Abemaciclib (Verzenios ) Abemaciclib (Verzenios )
Abemaciclib (Verzenios ) Abemaciclib (Verzenios ) Abemaciclib is a targeted (biological) therapy. This group of drugs block the growth and spread of cancer. They target and interfere with processes in
GCVP. Cyclophosphamide by injection Vincristine by short infusion. Gemcitabine by infusion over 30 minutes
GCVP GCVP This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk of the cancer coming back, for others it may
Fluorouracil (5FU) Speak to our specialist nurses on our free Support Line
1 Fluorouracil (5FU) This fact sheet is for anyone diagnosed with pancreatic cancer who would like to find out more about Fluorouracil (5-FU) chemotherapy to treat pancreatic cancer. It provides information
For the Patient: Fludarabine injection Other names: FLUDARA
For the Patient: Fludarabine injection Other names: FLUDARA Fludarabine (floo-dare-a-been) is a drug that is used to treat many types of cancer. It is a clear liquid that is injected into a vein. Tell
Intravenous anti-cancer treatment
Intravenous anti-cancer treatment Information for patients Chemotherapy Name Hospital No Your consultant is Anti-cancer treatment is the term used to describe medicines used to treat cancer including chemotherapy.
Nivolumab. Nivolumab
Nivolumab Nivolumab This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary: for some people immunotherapy may reduce the risk of the cancer coming back, for
Oral cyclophosphamide in ovarian cancer
Oral cyclophosphamide in ovarian cancer Oral cyclophosphamide in ovarian cancer This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy
Eribulin (Halaven ) Treatment is given on Day 1 and Day 8 of a 21-day cycle.
Eribulin (Halaven ) Eribulin (Halaven ) This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk of the cancer
IVAC IVAC (Lymphoma) 1277 IVAC (Lymphoma) Page 1 of 6
IVAC IVAC (Lymphoma) This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk of the cancer coming back, for
Haematology. The other 2 drugs, folinic acid and GCSF, help to reduce the side effects of the treatment.
Haematology CODOX-M Chemotherapy This information is about CODOX-M chemotherapy, which is a treatment for Burkitts Lymphoma. Lymphoma is a cancer of the lymphatic system - a network of glands in the body
Cisplatin and radiotherapy to the
Cisplatin and radiotherapy to the head and neck Cisplatin and radiotherapy to the head and neck This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some
DHAP DHAP Your treatment dexamethasone Possible side effects
DHAP DHAP This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk of the cancer coming back, for others it may