Non-Small Cell Lung Cancer Radiation Therapy Physician

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Non-Small Cell Lung Cancer Radiation Therapy Physician
Non-Small Cell Lung Cancer
Radiation Therapy Physician Worksheet
(As of 26 January 2017)
This worksheet is to be used for curative or palliative treatment of non-small cell lung cancer. If the treatment
is for metastases from non-small cell lung cancer, please use the appropriate metastatic worksheet. Patient name:
What is the radiation therapy treatment start date (mm/dd/yyyy)?
1.
_____ / _____ / ______
a. What is the clinical T-stage?
TX
T1
T2
T3
T4
N2
N3
Tis
b. What is the clinical N-stage?
NX
N0
N1
c. Does the patient have distant metastases (stage M1) (i.e. to brain, lung, liver, bone)?
Yes
2.
No
a. What is the treatment intent?
Definitive
Pre-operative (neo-adjuvant)
Post- operative (adjuvant)
Palliation
b. If post-operative (adjuvant) is the treatment intent, then answer the following questions:
i. What is the margin status?
Negative
Positive
ii. Is there gross residual tumor?
Yes
No
iii. Is there evidence of extracapsular extension?
Yes
No
c. If palliation is the treatment intent, what technique will be used for palliation?
External beam radiation therapy (EBRT)
Brachytherapy
If Brachytherapy will be used for palliation, skip forward to question #8.
Continued on next page
Non-Small Cell Lung Cancer
Radiation Therapy Physician Worksheet
(As of 26 January 2017)
3.
What EBRT technique will be used to deliver the radiation therapy?
Select a technique for each applicable phase, and fill in the number of fractions.
Phase 1
Phase 2
Phase 3
Complex (77307)
Complex (77307)
Complex (77307)
3D conformal
3D conformal
3D conformal
Intensity modulated
Intensity modulated
Intensity modulated
radiation therapy (IMRT)
radiation therapy (IMRT)
radiation therapy (IMRT)
Proton beam therapy
Proton beam therapy
Proton beam therapy
Rotational arc therapy
Rotational arc therapy
Rotational arc therapy
Stereotactic body radiation
Stereotactic body radiation
Stereotactic body radiation
therapy (SBRT)
therapy (SBRT)
therapy (SBRT)
Tomotherapy
Tomotherapy
Tomotherapy
Number of fractions: ________
Number of fractions: ________
Number of fractions: ________
4.
Will respiratory motion management be utilized?
Yes
No
5.
Will concurrent chemotherapy be performed?
Yes
No
6.
Will daily image-guided radiation therapy (IGRT) be used?
Yes
No
7.
If brachytherapy will be utilized for palliation, then answer the following questions:
a. Has the patient received EBRT?
Yes
No
b. How many brachytherapy treatments (fractions) will be utilized?
Fractions: ___________
c. How many brachytherapy applications will be utilized?
Applications: _________
Continued on next page
Non-Small Cell Lung Cancer
Radiation Therapy Physician Worksheet
(As of 26 January 2017)
8.
Note any additional information in the space below.

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