ASCO Templates for Use in Practice

Several versions of the breast cancer treatment plan and summary templates are provided below.

1. Breast Cancer Adjuvant Treatment Plan and Summary templates: these forms include a plan component, to be completed prior to chemotherapy treatment, and a summary to be completed following chemotherapy. The Breast Cancer Survivorship Plan can be added as a third page. Choose any of the following formats:

• Breast Cancer Adjuvant Treatment Plan and Summary (New 11.09)- Modifiable Microsoft Word document: this version is best printed and filled in by hand.
  
• Breast Cancer Adjuvant Treatment Plan and Summary (New 11.09)- Microsoft Word form: this form is best completed by typing in content electronically. The completed template can be saved and/or printed.
  
• Breast Cancer Adjuvant Treatment Plan and Summary (New 11.09)- Microsoft Excel: spreadsheet with text fields and drop down menus, to be completed electronically. The completed template can be saved and/or printed.

2. Breast Cancer Adjuvant Treatment Summary only templates: this template includes all of the elements of the treatment plan and summary but is intended to be completed in total at the end of chemotherapy.  The Breast Cancer Survivorship Plan can be added as a third page.

• Breast Cancer Adjuvant Treatment Summary (New 01.08)- Modifiable Microsoft Word document: this version is best printed and filled in by hand.

3. Breast Cancer Survivorship Plan: a modifiable document that provides a customized plan for breast cancer survivorship care based on ASCO’s guideline. The Plan can be added to a breast cancer treatment plan and summary template.

• Breast Cancer Survivorship Plan (New 11.09)- Modifiable Microsoft Word document: this version is best printed and filled in by hand.
• Breast Cancer Survivorship Plan (New 11.09)- Microsoft Word form: this form is best completed by typing in content electronically. The completed template can be saved and/or printed.

4. Breast Cancer Preoperative Plan only template: this templates includes a plan component to be completed prior to surgery. The Breast Cancer Adjuvant Treatment summary template can be modified for summary documentation at the end of therapy. The Breast Cancer Survivorship Plan can be added as a third page.

• Breast Cancer Preoperative Plan (New 07.22)- Modifiable Microsoft Word document: this version is best printed and filled in by hand.

Development Team Roster

Related ASCO Resources

American Society of Clinical Oncology 2006 Update of the Breast Cancer Follow-up and Management Guideline in the Adjuvant Setting
This page includes the guideline abstract and links to the full text of the guideline and Breast Cancer Surveillance Flow Sheet.

ASCO Patient Guide: Follow-Up Care for Breast Cancer
A patient guide based on ASCO's breast cancer follow-up care guideline.

Information About Use of Treatment Plan and Summaries

The treatment summary is not intended to be, and should not be considered, a substitute for written or verbal communication, physical examination and history, or review of the complete medical record. Because the treatment summary will summarize parts of your patient’s medical record and treatment plan, it should be treated as confidential and used or disclosed only in accordance with federal and state privacy laws.

No single treatment plan or summary can be appropriate for all patients. Treating oncologists assume responsibility for tailoring the treatment summary to meet individual patient’s needs.

Use of the treatment summary is entirely voluntary. Use of this tool does not imply ASCO’s endorsement of any specific treatment or any product. ASCO is not responsible for any inaccurate or inappropriate use of the treatment summary.