SAMPLE. Survivorship Care Plan for Lymphoma (Diffuse Large B-Cell) General Information. Care team

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1 SAMPLE This Survivorship Care Plan will facilitate cancer care following active treatment. It may include important contact information, a treatment summary, recommendations for follow-up care testing, a directory of support services and resources, and other information. [1] Survivorship Care Plan for Lymphoma (Diffuse Large B-Cell) Prepared by: Claire M Pace on 6/25/2012 at St Johnsbury, Vermont-rris Cotton Cancer Center General Information Patient Name Mary A. Smith Medical record number Phone (home) Date of birth 4/8/1970 Age at diagnosis 40 Gender Female Support contact David Smith, Care team Hematologist/oncologist Dr. Howard, Radiation oncologist Dr. Jones, Primary care physician Dr. White, OB-GYN Nurse/nurse practitioner Claire Pace--Radiation Oncology, Coordination of care June Davis, Nurse Practitioner- Hematology/Oncology Anna Right, Speech Language Pathology Charlene Gates, Endocrinology Dr. Taggart, Counselor Wendy Wilson, Surgeon Dr. Innes,

2 Background Information Diagnosis date 1/18/2010 Solid organ transplant Family history/predisposing conditions Signs and symptoms H/o of hashimoto's thyroiditis Swelling of her neck with difficulty breathing Other health concerns Hashimoto's thyroiditis, hypothyroid, Clark II melanoma 3/2007 Biopsy site Histology New or recurrent cancer diagnosis HIV status Hepatitus B status Thyroid, Excisional/Incisional Large B cell lymphoma of the thyroid New Negative Negative Staging study Date Findings Bone marrow biopsy 1/15/2010 Negative CT C/A/P 12/31/2009 Thyroid mass PET/CT 1/11/2010 Hypermetabolic activity anterior neck LDH CD20 rmal Positive Number of extranodal sites involved 0 Ann Arbor staging Location(s) disease IE thyroid/neck Treatment Plan & Summary Patient's height 68 in Pre-Treatment Post-Treatment Patient's weight 157 lb 147 lb Patient's BSA 1.85 m² 1.79 m² Patient's BMI ECOG performance status 0 (Asymptomatic) 0 (Asymptomatic) Comments Mary presented with a large anterior neck mass 12/27/2009 that grew rapidly and created the feeling of airway constriction. Imaging demonstrated some deviation of the trachea to the right. Mary experienced nausea controlled with Ativan as well as diarrhea. She needed to be treated with IV fluids due to dehydration at her local ER after cycle 2. She developed alopecia (hair loss) from chemotherapy. Otherwise she tolerated treatment well.

3 Ā Regimen CHOP Cyclophosphamide (Cytoxan) 750 mg/m² iv d1 Doxorubicin (Adriamycin) 50 mg/m² iv d1 Vincristine (Oncovin) 1.4 mg/m² (max 2 mg) iv d1 Prednisone 100 mg po qd d1-5 Q3w x 6-8 cycles Treatment on clinical trial Therapeutic agents # cycles % dose reduction Cyclophosphamide 3 0 Doxorubicin 3 0 Vincristine 3 0 Prednisone 3 0 Biologic therapy Planned: Yes, Administered: Yes, 1/25/2010-3/3/2010 Chemotherapy intent Curative Number of planned cycles 3 Chemotherapy treatment period 1/25/2010-3/3/2010 Response to chemo/immunotherapy Reason for stopping chemotherapy Treatment-related hospitalization(s) Serious toxicities during treatment Ongoing toxicities Radiation therapy Final response to radiation Stem cell transplant Complete Completed therapy Dehydration due to diarrhea 3060 cgy Administered to mediastinum and supraclavicular, 4/30/2010-5/28/2010 Complete t planned Follow-up Care Surveillance First 2 years Years 3-5 Coordinating provider Hematology - oncology visits every 3 to 6 months every 6 months Dr. Howard Lab tests every 3 to 6 months every 6 months Dr. Howard Imaging every 6 months yearly Dr. Howard Radiation Oncology visits every 6 months once a year Dr. Jones/Claire Pace Endocrinology every year every year Dr. Taggart

4 Needs or concerns Prevention & wellness Emotional or mental health Speech and language therapy Endocrinology Age appropriate screening and immunization need to continue once a year with your primary physician. You need to see your dermatologist at least yearly for a full skin exam. Protection of skin from sun with sun screen/ protective clothing ongoing Referral has been made to Wendy Wilson given the family stressors that you are experiencing. You have seen Charlene Gates for a swallow study during your radiation. Continue swallow exercises and contact her if you have difficulty with your exercises or with swallowing. You need to see Dr. Taggart in endocrinology once a year. Referrals provided Smoking cessation counselor Fertility specialist or endocrinologist Comments t applicable t applicable You have had radiation to your neck. Please do stretching exercises daily to prevent restriction in neck movement.

5 Second Cancers Caused by Cancer Treatment Survivors of non-hodgkin lymphoma (NHL) are at increased risk of developing some second cancers, but less so than patients who were treated for Hodgkin disease. Overall, NHL survivors get new cancers about 15% more often than most people (the general population). Increased risks of malignant melanoma, lung cancer, and kidney cancer have been seen in patients who had been treated for NHL. Survivors of NHL are also at risk for several other cancers such as: Kaposi sarcoma Cancers of the head/neck area (this includes the tongue, floor of the mouth, throat, and voice box) Colon cancer Thyroid cancer Bone and soft tissue cancer Bladder cancer Leukemia Hodgkin disease Radiation therapy increases the risk of breast cancer in women who were treated before age 25. Mesothelioma, a rare cancer of the outer lining of the lung, is also increased in those who were treated with radiation. A higher risk of bladder cancer has only been seen in those who were treated with chemotherapy. The drug cyclophosphamide (Cytoxan ), especially if used in higher doses, is linked to bladder cancer. Low-dose total body irradiation (TBI), which was once used to treat NHL, has been linked to an increased risk of leukemia. The risk of leukemia is also higher in those treated with chemotherapy, with the highest risk seen in those treated with both radiation and chemotherapy. Patients who had autologous bone marrow transplants (meaning the patient's own bone marrow was used -- not someone else's) are also at increased risk for developing acute myelogenous leukemia (AML) and an early form of leukemia called myelodysplastic syndrome (MDS). Treatment-related second cancer risk lasts a long time after NHL, up to 30 years after diagnosis. Those who were diagnosed and treated at younger ages (20 years old and younger) have a higher risk than those who were older (70 or older) when they were found to have NHL. Follow-up care Since there is an increased risk for a second cancer following treatment for NHL, survivors should get careful follow-up. Your doctors should be looking for the development of any of the above mentioned cancers as well as the recurrence of NHL. All patients should be encouraged to avoid tobacco smoke American Cancer Society. All Rights Reserved. End tes te 1: Important caution. This is a summary document whose purpose is to review the highlights of the cancer chemotherapy treatment plan for this patient. This does not replace information available in the medical record, a complete medical history provided by the patient, examination and diagnostic information, or educational materials that describe strategies for coping with cancer and adjuvant chemotherapy in detail. Both medical science and an individual s health care needs change, and therefore this document is current only as of the date of preparation. This summary document does not prescribe or recommend any particular medical treatment or care for cancer or any other disease and does not substitute for the independent medical judgment of the treating professional.