Cancer Treatment Summary (End of Treatment)

Date Prepared: [Date]

Author: [Name, credentials, role, institution, contact]

Care Setting: [outpatient / survivorship transition visit / post-treatment follow-up]

Primary Oncology Contacts:

• Medical Oncology: [Name, phone]
• Radiation Oncology: [Name, phone] (Include only if applicable)
• Surgical Oncology: [Name, phone] (Include only if applicable)
• Other: [Discipline, name, phone] (Include as needed)

Executive Synopsis

[End-of-treatment summary paragraph] (Compose a 4–8 sentence paragraph including: primary cancer diagnosis with site and histology; stage at diagnosis; overall treatment intent; completed treatment modalities with date ranges; best response or current disease status; major complications and ongoing toxicities; and any ongoing therapy or devices.)

Cancer Diagnosis and Staging

Primary Diagnosis: [Primary site, histology/subtype, grade, laterality, date of initial diagnosis]

Basis of Diagnosis: [Biopsy site and date; pathology report reference]

Staging:

• System: [Staging system and edition, e.g., AJCC 8th, FIGO, Ann Arbor]
• Type: [clinical / pathologic / postsurgical]
• Stage: [T category] [N category] [M category] — [Overall stage group]
• Baseline sites of disease: [Anatomic sites present at baseline]
• Baseline tumor markers: [Marker, value, units, date] (Include only if relevant to cancer type)

(If staging is not formally documented, state "Not documented in available record." If an estimate is necessary, label clearly as "Approximate" and specify the basis.)

Biomarkers and Molecular Testing:

• Predictive/prognostic markers: [Markers relevant to tumor type with results, dates, and source lab, e.g., ER/PR/HER2, PD-L1, MSI/MMR]
• Genomic profiling: [Test name/vendor, date, key actionable findings] (Reference full report location; do not reproduce variant tables)
• Germline testing: [Test name/panel, date, key findings] (Reference genetics report)

(If testing was not performed or not applicable, state "Not performed" or "Not applicable.")

Treatment Course

(List all cancer-directed treatments in chronological order. Use generic drug names and expand regimen acronyms. Document cycles planned versus completed, dose reductions/delays with reasons, and clinical trial participation. If a modality was not given, explicitly state "Systemic therapy: none," "Surgery: none," or "Radiation therapy: none.")

Date Range	Modality	Intent	Key Details	Notable Complications or Deviations
[Start date – End date]	[systemic therapy / surgery / radiation / procedure / clinical trial]	[neoadjuvant / adjuvant / definitive / maintenance / palliative]	[Key details per modality]	[Complications, hospitalizations, treatment interruptions, early discontinuation with reasons]

(For systemic therapy details: list agents by generic name, route, schedule, dose units; cycles planned vs completed; dose reductions/delays with reasons; concurrent therapy if applicable. For surgery details: procedure name, anatomic site and laterality, margin status R0/R1/R2, lymph node yield and positivity, pathologic stage updates, reconstruction/devices placed. For radiation details: treated site and laterality, technique/modality, total dose in Gy and fractionation, number of fractions, concurrent systemic therapy.)

Cumulative Dose Summary: [Agent name: cumulative dose in appropriate units] (Include only for agents with dose-dependent late toxicities such as anthracyclines, bleomycin, platinum agents. Label as calculated from specific records if computed. Omit section if not applicable.)

Clinical Trial Participation: [Yes / No / Unknown] (If yes, include protocol name/ID, arm, and date range; note if blinded medications were used)

Complications and Toxicities

(Problem-oriented format; prioritize by severity and ongoing impact. Use "consistent with" for attribution unless causation was explicitly documented. Include grading system if used, e.g., CTCAE.)

• [Problem name]: [Onset date and time course; severity/grade; key diagnostics and interventions; outcome] — Current status: [resolved / improving / persistent]; [current management if ongoing]

(Include hospitalizations/ED visits related to therapy, infections including neutropenic fever, thromboembolism, cardiotoxicity, severe GI toxicity, and treatment-limiting adverse effects. For persistent toxicities, include functional impact and current management.)

Disease Status at End of Treatment

• Response assessment methods: [Imaging modality, pathology, tumor markers, endoscopy, clinical exam with dates] (Name formal response criteria if used, e.g., RECIST 1.1)
• Best response during treatment: [CR / PR / SD / PD / Not assessed] ([Date])
• End-of-treatment status: [NED / CR / PR / SD / PD / Indeterminate] ([Assessment method and date]) (If residual disease exists, note location and brief extent)
• Performance status: [ECOG 0–4 / Karnofsky %] ([Date])
• Weight trend: [Baseline weight/date → End-of-treatment weight/date; % change] (Include only if clinically relevant)
• Indwelling devices: [Port / PICC / ostomy / feeding tube / other] — [in place / removed]; Plan: [removal timing or maintenance plan]

Ongoing Therapy and Medications

(List cancer-directed and high-importance supportive medications only. Do not auto-import the entire medication list.)

• Cancer-directed therapy: [Agent name, dose, route, schedule, start date, planned duration] (e.g., maintenance therapy, endocrine therapy, targeted agent)
• Key supportive medications: [Anticoagulation, steroids with taper plan, prophylactic antimicrobials, chronic pain regimen, other critical medications with doses and durations]

Follow-up Coordination

• Oncology follow-up: [Responsible clinician/team; next appointment date or timeframe; who orders surveillance imaging/labs]
• PCP responsibilities: [Comorbidity management, vaccinations, health maintenance, symptom monitoring]
• Surveillance plan: [Brief summary of imaging/lab/endoscopy schedule and duration, or "See Survivorship Care Plan dated [date]"]
• Escalation instructions:
  • Contact oncology for: [New localized symptoms, medication questions, device issues, mild treatment-related toxicities]
  • Seek emergency care for: [Fever, uncontrolled pain/vomiting, bleeding, new neurologic deficits, chest pain, shortness of breath]
  • After-hours contact: [On-call number or instructions]

Source Documents

(Reference where detailed information can be found; do not reproduce content)

• [Pathology report(s): accession number, date]
• [Operative note(s): date, surgeon]
• [Radiation end-of-treatment summary: date, facility]
• [Imaging reports: modality and dates]
• [Genomic/molecular report(s): vendor/test name, date]
• [Clinical trial documents: protocol ID, enrollment dates] (Include only if applicable)

(Use "Unknown (outside records not received)," "Not documented in available record," or "Not applicable" for missing information to prevent misinterpretation. Avoid inference; include only information explicitly documented in the record.)