Pertuzumab
HER2-targeted antibody
Diarrhoea and dehydration
Infusion / allergic reaction
Heart pumping-function reduction
Rash and fatigue
SACTCHECK · REGIMEN-SPECIFIC SACT CONSENT
Pertuzumab + trastuzumab maintenance
HER2-positive metastatic breast cancer · maintenance · NCCP 00726 · version 3a · 21-day cycle
PROTOTYPE · GOVERNANCE REVIEW REQUIRED
Patient name
DOB
Hospital no.
Date
Treatment context
This maintenance treatment continues HER2 blockade to help control metastatic or unresectable recurrent HER2-positive breast cancer after chemotherapy.
This maintenance treatment continues HER2 blockade to help control metastatic or unresectable recurrent HER2-positive breast cancer after chemotherapy.
Schedule
Pertuzumab and trastuzumab are given by infusion every 21 days after the chemotherapy phase of the metastatic treatment plan. Duration depends on benefit, tolerance and the agreed plan; this is not a fixed one-year adjuvant course.
Pertuzumab and trastuzumab are given by infusion every 21 days after the chemotherapy phase of the metastatic treatment plan. Duration depends on benefit, tolerance and the agreed plan; this is not a fixed one-year adjuvant course.
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
Trastuzumab
HER2-targeted antibody
Heart pumping-function reduction / heart failure
Infusion or allergic reaction
Diarrhoea and fatigue
Rare serious lung effects
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Patient understands consent is voluntary and may be withdrawn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