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SACTCHECK · REGIMEN-SPECIFIC SACT CONSENT

Pembrolizumab + pemetrexed + carboplatin

First-line metastatic non-squamous NSCLC without EGFR or ALK alterations · NCCP 00568 · version 5 · 21-day cycle

PROTOTYPE · GOVERNANCE REVIEW REQUIRED
Patient name
DOB
Hospital no.
Date
Treatment context
The combination aims to control metastatic non-squamous lung cancer. Your team checks cancer markers, your health and your preferences. Chemotherapy and immunotherapy work in different ways.
Schedule
Induction: all three medicines on Day 1 every 21 days for up to four cycles. Maintenance: carboplatin stops; pembrolizumab and pemetrexed may continue every 21 days while appropriate.

1. Treatment discussion

Purpose, expected benefit and alternatives explained
Indication, medicines, sequence and duration confirmed
Blood tests and any individually indicated heart checks discussed
Support medicines and phase changes explained
Fertility, contraception and breastfeeding discussed where relevant
Common, serious and lasting drug-specific risks discussed below
Urgent symptoms and local contact details confirmed

2. Regimen / agent-specific material risks

Pembrolizumab

Immunotherapy
Immune inflammation of lungs, bowel, liver, kidneys, glands, skin and other organs
Serious infusion reactions
Effects can develop after treatment ends

Pemetrexed

Chemotherapy
Low blood counts and infection
Fatigue, nausea, mouth soreness and rash
Kidney toxicity; folate and B12 supplementation are required

Carboplatin

Chemotherapy
Low blood counts, infection or bleeding
Nausea and vomiting
Allergic reactions
Kidney, hearing and nerve effects

Discuss expected benefit, alternatives and important short- and longer-term risks. Tell the team about all medicines, existing illnesses, pregnancy possibility and symptoms that matter to you.

Individual aim / benefit, alternatives, material risks and questions:

3. Consent confirmation

Expected benefit, important risks and reasonable alternatives discussed
Patient questions invited and answered; patient-specific material risks / priorities considered
Emergency contact / toxicity advice and written information offered where appropriate
Patient understands consent is voluntary and may be withdrawn
Patient / person giving consent
Date
Clinician obtaining consent
Date