Diagnosis: Breast Cancer Stage:

Protocol: Doxorubicin & Cyclophosphamide (AC)

Ht: 165 cm Wt:63 kg BSA: 1.7 m²
Before each cycle : CBC & diff, platelets, creatinine & LFT 1. 2. 3. 4.
May proceed with doses printed if ANC > 1.0 x 109/L, platelets > 100 x 109/L, serum creatinine< 1.5mg/dl,
and bilirubin < 1.2 mg/dl
Dose modification for:

Hematology Other Toxicity ___________________________.

1. Emest 8 mg IV 30 minutes before chemotherapy
2. Dexamethasone 8 mg IV 30 minutes before CTX
3. Gupison 20mg PO 1X3X3days
4. Lorazepam 2mg tab 1/2 tab X1X5days at night
5. Esomak tab 40mg 1X1X5days+ Plasil 10mg tab 1X3X5days PR

Chemotherapy :

DOXORUBICIN 60mg/m2 (100 %) = 100 mg IV push.

CYCLOPHOSPHAMIDE 600 mg /m2 (100 %) = 1000 mg IV over 30 minutes.

Cycle Date due Remarks Date given

1 10/10/12 ‫ وشراء الثرمومتر‬K‫التأكد من عمل االيكو واألشعة الطبقية‬
2
3
4
The regimen is repeated every 3 weeks. Protocol infusion time: 60 minutes

Name & Sig. of Physician: Date: Pharmacist: Nurse :

Post chemotherapy medication:

Dexamethasone 8 mg Po on Days 2 and 3
Diagnosis: Breast Cancer Stage:
Protocol: Docetaxel
Ht: _______ cm Wt: _______ kg BSA: _______ m²

Before each cycle : CBC & diff, platelets & LFT 1. 2. 3. 4.

May proceed with doses printed if ANC > 1.0 x 109/L, platelets > 100 x 109/L, and LFT's are
within reference ranges.

Dose modification for:

Hematology Other Toxicity

____________________________.

Premedications:

Dexamethasone 8 mg PO BID for 3 days, starting one day prior to treatment.

Chemotherapy :

DOCETAXEL 75 mg/m2 (________ %) = _________mg IV over 1 hour. (Use non-PVC bag).

Cycle Date due Remarks Date given

4
Repeat cycle every 3 weeks Protocol infusion time: 60 minutes

Post chemotherapy medication:

Dexamethasone 8 mg PO BID one day before chemotherapy and on days 1 and 2

2
Diagnosis: Breast Cancer Stage:
Protocol: Docetaxel (neoadjuvant)
Ht: _______ cm Wt: _______ kg BSA: _______ m²
Before each cycle : CBC & diff, platelets & LFT 1. 2. 3. 4.

May proceed with doses printed if ANC > 1.0 x 109/L, platelets > 100 x 109/L, and LFT's are within
reference ranges.

Dose modification for:

Hematology Other Toxicity

____________________________.

Premedications:

Dexamethasone 8 mg PO BID for 3 days, starting one day prior to treatment.

Chemotherapy :

DOCETAXEL 100 mg/m2 (________ %) = _________mg IV over 1 hour. (Use non-PVC bag).

Cycle Date due Remarks Date given

1
2
3
4
Repeat cycle every 3 weeks Protocol infusion time: 60 minutes

Name & Sig. of Physician: Date: Pharmacist: Nurse :

3
Post chemotherapy medication:
Dexamethasone 8 mg PO BID one day before chemotherapy and on days 1 and 2

Diagnosis: Breast Cancer Stage :

Protocol: Trastuzumab & Docetaxel
Ht: _______ cm Wt: _______ kg BSA: _______ m²
1Before each cycle : CBC & diff, platelets & LFT 21. 32. 43. 54. 65. 76.
9 9
May proceed with doses printed if ANC > 1.0 x 10 /L, platelets > 100 x 10 /L and LFT's are
within reference ranges.
Dose modification for:
Hematology Other Toxicity
______________________________.

Premedications:
1. Clemastine 2mg IV 30 minutes before chemotherapy
2. Paracetamol 500mg, 2 tablets PO 30 minutes before chemotherapy
3. Dexamethasone 8 mg PO BID for 3 days, starting one day prior to treatment

Chemotherapy :
Cycle 1 :
TRASTUZUMAB 8 mg/kg (________ %) =__________mg IV over 90 minutes on Day 1
(Observe for 60 minutes post infusion

DOCETAXEL 75 mg/m2 (________ %) = _________mg IV over 1 hour on Day 1 (Use non-PVC

bag).

Cycles 2-6 :
TRASTUZUMAB 6 mg/kg (________ %) =__________mg IV over 30 minutes on Day 1
(Observe for 30 minutes post infusion)

DOCETAXEL 75 mg/m2 (________ %) = _________mg IV over 1 hour on Day 1 (Use non-PVC

bag).

4
 Cycle Date due Remarks Date given
1
2
3
4
5
6
This regimen is repeated every 3 weeks Protocol infusion time: 120 minutes

Name & Sig. of Physician: Date: Pharmacist: Nurse :

Post chemotherapy medication:

Dexamethasone 8 mg PO BID one day before chemotherapy and on days 1 and 2

Diagnosis: Breast Cancer Stage:

Protocol: Paclitaxel
Ht: _______ cm Wt: _______ kg BSA: _______ m²

Before each cycle : CBC & diff, platelets & LFT 1. 2. 3. 4.

May proceed with doses printed if ANC > 1.0 x 109/L, platelets > 100 x 109/L, and LFT's are
within reference ranges.

Dose modification for:

Hematology Other Toxicity

____________________________.

5
Premedications:
1. Clemastine 2 mg IV given 30 minutes prior to Paclitaxel
2. Ranitidine 50 mg IV given 30 minutes prior to Paclitaxel
3. Dexamethasone 20 mg IV given 30 minutes prior to Paclitaxel

Chemotherapy :

PACLITAXEL 175 mg/m2 (________ %) = _________mg IV over 3 hours. (Use non-PVC bag).

Cycle Date due Remarks Date given

1
2
3
4

Name & Sig. of Physician: Date: Pharmacist: Nurse :

Diagnosis: Breast Cancer Stage:

Protocol: Paclitaxel (weekly)

Ht: _______ cm Wt: _______ kg BSA: _______ m²
May proceed with doses printed if ANC > 1.0 x 10 /L, platelets > 100 x 109/L, and LFT's are
9

within reference ranges.

Dose modification for:
Hematology Other Toxicity
____________________________.

Premedications:
1. Clemastine 2 mg IV given 30 minutes prior to Paclitaxel
2. Ranitidine 50 mg IV given 30 minutes prior to Paclitaxel
3. Dexamethasone 8 mg IV given 30 minutes prior to Paclitaxel

6
 Chemotherapy
Week 1 :
PACLITAXEL 80 mg/m2 (________ %) = _________mg IV over 1 hour. (Use non-PVC bag)

Week Date due Remarks Date given

1
2
3
4
5
6
7
8
9
10
11
12
Protocol infusion time: 120 minutes

Name & Sig. of Physician: Date: Pharmacist: Nurse :

Diagnosis: Breast Cancer Stage :

Protocol: Trastuzumab & Paclitaxel (adjuvant)
Ht: _______ cm Wt: _______ kg BSA: _______ m²
8Before each cycle : CBC & diff, platelets & LFT 91. 102. 113. 4.
May proceed with doses printed if ANC > 1.0 x 10 /L, platelets > 100 x 10 /L and LFT's are
9 9

within reference ranges.

7
Dose modification for:
Hematology Other Toxicity
______________________________.

Premedications:
3. Clemastine 2 mg IV given 30 minutes prior to Paclitaxel
4. Ranitidine 50 mg IV given 30 minutes prior to Paclitaxel
3. Dexamethasone 20 mg IV given 30 minutes prior to Paclitaxel

Chemotherapy :
Cycle 1 :
TRASTUZUMAB 8 mg/kg (________ %) =__________mg IV over 90 minutes on Day 1
(Observe for 60 minutes post infusion

PACLITAXEL 175 mg/m2 (________ %) = _________mg IV over 3 hours. (Use non-PVC bag).

Cycles 2-4 :
TRASTUZUMAB 6 mg/kg (________ %) =__________mg IV over 30 minutes on Day 1
(Observe for 30 minutes post infusion)

PACLITAXEL 175 mg/m2 (________ %) = _________mg IV over 3 hours. (Use non-PVC bag).

Cycle Date due Remarks Date given

1
2
3
4
This regimen is repeated every 3 weeks Protocol infusion time: 300 minutes
Diagnosis: Breast Cancer Stage:
Protocol: Docetaxel & Cyclophosphamide (TC)
Ht: _______ cm Wt: _______ kg BSA: _______ m²
Before each cycle : CBC & diff, platelets, creatinine & LFT 1. 2. 3. 4.
May proceed with doses printed if ANC > 1.0 x 109/L, platelets > 100 x 109/L, serum
creatinine< 1.5mg/dl, and bilirubin < 1.2 mg/dl
Dose modification for:

Hematology Other Toxicity

___________________________.

8
Premedications:
6. Ondansetron 8 mg IV 30 minutes before chemotherapy
2. Dexamethasone 8 mg PO BID for 3 days, starting one day prior to treatment.

Chemotherapy :

DOCETAXEL 75 mg/m2 (________ %) = _________mg IV over 1 hour. (Use non-PVC bag).

CYCLOPHOSPHAMIDE 600 mg /m2 (_______ %) = _________ mg IV over 30 minutes.

Cycle Date due Remarks Date given

1
2
3
4
The regimen is repeated every 3 weeks. Protocol infusion time: 2 hours

Diagnosis: Breast Cancer Stage:

Protocol: 5-FU-Epirubicin-Cyclophosphamide followed by Docetaxel (FEC-T)
Ht: _______ cm Wt: _______ kg BSA: _______ m²
12Before each cycle: CBC & diff, creatinine, and
131. 142. 153.
LFT
May proceed with doses printed if ANC > 1.5 x 109/L, Platelets > 100 x 109/L and LFT's are
within reference ranges.

9
Premedications:
1. Ondansteron 8 mg IV, 30 minutes before chemotherapy on Day 1
2.Dexamethasone 8 mg IV/PO on Day 1, then 8 mg IV/PO on Days 2 and 3

Dose modification for:

Hematology Other Toxicity
____________________________.

Chemotherapy :
5-FLUOROURACIL 500 mg/m2/day(______%) = ______ mg IV slow push on Day 1
EPIRUBICIN 100 mg/m2 (_____%) = ______ mg IV slow push on Day 1
CYCLOPHOSPHAMIDE 500 mg /m2 (_______ %) = _______ mg IV over 30 minutes on Day 1.

Cycle Date due Remarks Date given

1
2
3
The regimen is repeated every 3 weeks Protocol infusion time: 2 hours

Name & Sig. of Physician: Date: Pharmacist: Nurse :

Page 1 of 2

Diagnosis: Breast Cancer Stage:

Protocol: 5-FU-Epirubicin-Cyclophosphamide followed by Docetaxel (FEC-T)
Ht: _______ cm Wt: _______ kg BSA: _______ m²

Before each cycle : CBC & diff, platelets & LFT 161. 172. 183.

May proceed with doses printed if ANC > 1.0 x 109/L, platelets > 100 x 109/L, and LFT's are
within reference ranges.

Dose modification for:

10
 Hematology Other Toxicity
____________________________.

Premedications:
Dexamethasone 8 mg PO BID for 3 days, starting one day prior to treatment.

Chemotherapy :

DOCETAXEL 100 mg/m2 (________ %) = _________mg IV over 1 hour. (Use non-PVC bag).

Cycle Date due Remarks Date given

Repeat cycle every 3 weeks Protocol infusion time: 2 hours

Name & Sig. of Physician: Date: Pharmacist: Nurse :

Page 2 of 2

Diagnosis: Metastatic Breast Cancer Stage: IV

Protocol: Gemicitabine
Ht: _______ cm Wt: _______ kg BSA: _______ m²
201. 212. 234. 256.
19Before dose : CBC, creatinine and bilirubin 223. 245.

May proceed with doses printed if ANC > 1.0 x 109/L and platelets > 100 x 109/L

Premedications:
Metoclopramide 10 mg IV / PO Days 1 , 8 and 15

11
Dose modification for:

Hematology Other Toxicity

_____________________________.

Chemotherapy :
GEMCITABINE 1000 mg/m2 ( _______%) = _________ mg IV over 30 minutes Days 1 , 8
and 15

Cycle Date due Remarks Date given

1
2
3
4
5
6
The regimen is repeated every 4 weeks. Protocol infusion time : 40 minutes

Name & Sig. of Physician: Date: Pharmacist: Nurse :

12