HOPE CANCER CLINIC, 14555 LEVAN RD., SUITE 110, LIVONIA, MI 48154.
PHONE: 734-462-2990; FAX: 734-462-3268. WWW.HOPECANCERCLINIC.NET
Patient name:
DOB: : (
/
Date plan was created: ( Click here to enter a date.)
purposes. Not meant to replace medical chart.
Provider
Medical oncologist
/
)
. This summary is provided for educational
Oncology providers
Name
Harmesh R. Naik, MD., Hope Cancer Clinic
14555 Levan Road, Suite 110, Livonia, MI 48154.
Contact information
Ph: 734-462-2990
Fax: 734-462-3268
Surgeon
Radiation oncologist
Primary MD
Other
Diagnosis: Breast cancer. Location: (choose)
Diagnosis details
Date of diagnosis (biopsy date) : (
Tumor type (choose)
ER status (choose)
PR status (choose)
Lymph nodes (choose). Number:
.
/
/
)
Stage: (choose) . TNM: T( choose ) N (choose) M(choose).
Her 2 status (choose)
Oncotype DX ( Choose ). Score (Choose). 5 yr risk
%.
Other:
Breast surgery: ( choose )
Side: (choose)
Type of surgery (choose) Click here to enter a date.)
Lymph node sampling
(choose) (choose)
( Click here to enter a date.)
Lymphedema (choose)
Additional details: Please contact your surgical doctor for additional details.
Regimen (choose)
Details of regimen (Name and dose )
Chemotherapy: ( choose )
Start date: ( Click here to enter a date.)
WBC growth factor (choose)
Anthracycline total dose (choose)
Start date ( Click here to enter a date.)
Side effects :
Hair loss.
Nausea/Vomiting.
Menopause symptoms.
Cardiac.
Other
Additional details / complications / comments:
Transfusions (choose)
(
mg/m2)
End date ( Click here to enter a date.)
Neuropathy.
Low blood count
Fatigue.
Trastuzumab (Herceptin) therapy: ( choose )
Start date ( Click here to enter a date.)
End date ( Click here to enter a date.)
Details :
BREAST CANCER MANAGEMENT , TREATMENT SUMMARY AND SURVIVORSHIP CARE PLAN.
This template was created by: Harmesh Naik, MD. (2012 short version).
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HOPE CANCER CLINIC, 14555 LEVAN RD., SUITE 110, LIVONIA, MI 48154.
PHONE: 734-462-2990; FAX: 734-462-3268. WWW.HOPECANCERCLINIC.NET
Hormonal therapy: ( choose )
Drug: ( choose )
Start date (Click here to enter a date.)
Additional details / side effects:
End date ( Click here to enter a date.)
Radiation therapy: ( choose )
Radiation dose
rads
Start date ( Click here to enter a date.)
End date ( Click here to enter a date.)
Additional details / side effects: Please contact your radiation doctor for additional details.
Side: (choose)


What to watch for: Promptly report any new symptoms: Example symptoms:
New lumps, Bone pain, Chest pain, breathing difficult, cough, Abdominal pain, Persistent headaches
Weight loss, loss of appetite, Any other symptoms that are not improving, Unexplained symptoms
Survivorship care: Suggested follow up care for asymptomatic patients: Based on ASCO guidelines
Annually thereafter
Medical history/physical exam Every 4 months x 3 years
Breast self exam
Every 4-6 months years 4-5
Monthly if feasible
Genetic counseling
Annually or earlier if suggested by
radiologist
Consider if criteria met
Colo-rectal cancer screening
Recommended.
Pap smear and pelvic exam
Recommended.
Skin cancer screening
Recommended
No smoking /smoking
cessation
Bone density measurement /
Oral Calcium and vitamin D
Low fat diet
Recommended- Do not smoke
Recommended.
Michigan Tobacco Quit
Line: 1-800-784-8669
Contact primary MD.
Recommended
Nutritional consult
Staying active
Recommended
Fall precautions
Report any new symptoms
Recommended
Mammography
(first in six months after RT)
Ask your doctor
Contact primary MD or
Gyn MD.
Use sun block in summer.
REMEMBER:
Please note that the ASCO guidelines apply to patient who are feeling fine and have no symptoms.
If you are having any symptoms, then you need to contact your physician for proper testing.
Notes:
Have fun!
Enjoy life!
Recommended
Ctr + click on http://hopecancerclinic.net/inspirational/fly_a_kite
BREAST CANCER MANAGEMENT , TREATMENT SUMMARY AND SURVIVORSHIP CARE PLAN.
This template was created by: Harmesh Naik, MD. (2012 short version).
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