Docetaxel
Taxane chemotherapy
Low blood counts, infection and sepsis
Hair loss, mouth soreness and fatigue
Numbness / tingling; sometimes lasting
Fluid retention and nail changes
Allergic infusion reaction
SACTCHECK · REGIMEN-SPECIFIC SACT CONSENT
TCHP: docetaxel, carboplatin, trastuzumab and pertuzumab
HER2-positive early breast cancer · before surgery · NCCP 00722 · version 2 · 21-day cycle
PROTOTYPE · GOVERNANCE REVIEW REQUIRED
Patient name
DOB
Hospital no.
Date
Treatment context
Treat HER2-positive early breast cancer as part of a plan intended to reduce the risk of it returning.
Treat HER2-positive early breast cancer as part of a plan intended to reduce the risk of it returning.
Schedule
All four medicines are given by infusion on Day 1 of a 21-day cycle, for six cycles before surgery. Surgery findings guide the postoperative treatment. There is no routine take-home chemotherapy pump.
All four medicines are given by infusion on Day 1 of a 21-day cycle, for six cycles before surgery. Surgery findings guide the postoperative treatment. There is no routine take-home chemotherapy pump.
1. Treatment discussion
Purpose, expected benefit and alternatives explained
Correct HER2 medicine and formulation confirmed
Duration and treatment setting discussed
Heart and other required monitoring explained
Supportive medicines and urgent contact advice discussed
Pregnancy / contraception / breastfeeding discussed where relevant
Common, serious and lasting agent-specific risks discussed below
Companion cancer medicines reviewed using their own information
2. Regimen / agent-specific material risks
Carboplatin
Platinum chemotherapy
Low blood counts, infection and bleeding
Nausea, vomiting and fatigue
Allergic reaction, sometimes after previous exposure
Kidney or electrolyte changes
Trastuzumab
HER2-targeted antibody
Heart pumping-function reduction / heart failure
Infusion or allergic reaction
Diarrhoea and fatigue
Rare serious lung effects
Pertuzumab
HER2-targeted antibody
Diarrhoea and dehydration
Infusion / allergic reaction
Heart pumping-function reduction
Rash and fatigue
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