Items to Include in 223Ra-Dichloride Therapy Checklist and Consultation Note
| Item | Reason |
|---|---|
| Documentation of bone scan demonstrating uptake in osseous metastatic disease | Required by package insert; if there is no uptake on bone scan, therapeutic radionuclide will not localize in suspected areas of metastatic disease |
| Documentation of no visceral metastatic disease | Required by package insert; therapeutic radionuclide treats not visceral metastatic disease but osseous metastatic disease, given its mechanism of localization (guidelines suggest CT of chest, abdomen, and pelvis before therapy) |
| Documentation of complete blood count with differential counts | Required by package insert and serves as baseline before other therapies, given potential myelosuppression of this therapy |
| Plan or order for follow-up laboratory analysis before planned upcoming therapies | Required by package insert; some lab tests may be organized by clinician who refers patient, but where to find this information should be known before upcoming doses are ordered (these lab tests are needed at least 1 wk before each planned treatment) |
| Documentation of Eastern Cooperative Oncology Group or Zubrod performance status | Helpful for future reference before starting therapy |
| Review of patient continence of urine and stool | Helpful when giving directed radiation safety instructions (therapy excreted mostly via gastrointestinal tract and, to lesser degree, urinary tract) |
| Review of such factors as home situation, travel, and occupational considerations | Helpful when giving directed radiation safety instructions |
| Review of side effects, with recommendation for relevant as-needed medications | Should be done for any medical therapy as part of consent |
| Plan for follow-up weight measurements and documentation of patient weight | Helpful to know ahead of time because doses are weight-based and patient weight may vary because of a variety of circumstances during therapy |
| Signed consent form | Should be done for any medical therapy as part of consent and understanding of potential risks and benefits |
| Radiation safety instructions | Should be done for any radionuclide therapy |
| Completed written directive for sixth therapy | Should be done for any medical therapy (ensure updated weight is used for calculation) |