Other Cancer Type - Radiopharmaceuticals
Radiation Therapy Physician Worksheet
(As of 1 July 2018)
This worksheet is to be used for treatment involving Radiopharmaceuticals. If external beam radiation therapy
is being planned for treatment of the liver, please use the appropriate cancer type worksheet. If the request is
for SIRT or Xofigo, please use the appropriate physician worksheet.
Radiopharmaceuticals should be used by or under the control of physicians who are qualified by specific
training and experience in the safe use and handling of radiopharmaceuticals, and whose experience and
training have been approved by the appropriate governmental agency authorized to license the use of
radiopharmaceuticals.
Patient name:
What is the radiation therapy start date (mm/dd/yyyy)? _____ /______ /_______
1.
Which radiopharmaceutical will be used?
Iodine-131 (I-131)
Lutetium-177 (Lu-177 ; Lutathera
®
)
Ibritumomab Tiuxetan (Zevalin
®
)
Strontium-89 (Sr-89)
Samarium-153 (Sm-153)
If Lutetium-177 was selected, please continue to question #2. Otherwise, skip to question #9.
2. What is the site of the primary neuroendocrine tumor?
Appendix
Large bowel
Small bowel
Pancreas
Stomach
Other: __________
3. Has the patient had or will have surgery for the primary tumor?
Yes No
4. Does the patient have metastatic disease?
Yes No
5. Where are the metastases located?
Bone
Brain
Liver
Lung
Lymph nodes
Other: __________
6. Has or will treatment with SBRT or SIRT be given?
Yes No
7. Will the patient be receiving chemotherapy with or following treatment with
Lutetium-177?
Yes No
8. Has the member previously received treatment with Lutetium-177?
Yes No
Continued on next page
