What should be included in a SOAP note for a cancer patient being treated with etoposide and carboplatin?

SOAP Note for Cancer Patients on Etoposide and Carboplatin

Subjective

Essential symptom assessment at each visit:

• Bleeding or bruising – assess for petechiae, epistaxis, gingival bleeding, or easy bruising indicating thrombocytopenia 1
• Infection symptoms – fever, chills, sore throat, cough, dysuria indicating neutropenia 1
• Dyspnea or chest tightness – critical for detecting anaphylactic reactions (higher risk in children with concentrated infusions) 1
• Neuropathy symptoms – numbness, tingling, weakness (less common with carboplatin than cisplatin) 2
• Nausea/vomiting severity – grade and frequency since last visit 2
• Performance status changes – ability to perform daily activities, time spent in bed 3
• Leg swelling or pain – venous thromboembolism occurs in 12.5% with oral etoposide regimens 4

Objective

Pre-treatment laboratory requirements (before EVERY cycle):

• Complete blood count with differential – mandatory before each cycle 1
  • Platelet count ≥100,000/mm³ required to proceed 5
  • Absolute neutrophil count (ANC) ≥1,000/mm³ required to proceed 5
  • Hemoglobin level 1
• Comprehensive metabolic panel – check before each 3-week cycle 5
  • Creatinine clearance calculation using Cockcroft-Gault equation 5
  • Consider formal GFR measurement (Chromium-51 EDTA) in elderly or low muscle mass patients 5
• Vital signs – blood pressure (hypotension risk with rapid infusion), heart rate, temperature 1
• Physical examination findings:
  • Skin examination for petechiae, ecchymoses 1
  • Mucous membrane assessment for bleeding 1
  • Lung auscultation for bronchospasm 1
  • Neurologic examination for peripheral neuropathy 2

Dose modifications based on renal function:

• Carboplatin dosing: Target AUC 5 in patients with any renal impairment using Calvert formula 5
• Etoposide dosing: Reduce dose for renal dysfunction as 50% is renally cleared 5

Assessment

Cancer type and treatment indication:

• Small cell lung cancer (extensive stage): Carboplatin-etoposide is standard first-line therapy with median survival 9-10 months 6
• Poorly differentiated neuroendocrine carcinoma: Disease control rate 74.5% first-line, 69.2% second/third-line 4
• Germ cell tumors: Carboplatin 400 mg/m² day 1 plus etoposide 120 mg/m² days 1-3 every 4 weeks for 3-4 cycles 7

Performance status assessment:

• PS 0-2: Proceed with combination chemotherapy 6
• PS 3-4: Consider best supportive care only or single-agent therapy 6
• PS ≥3 in elderly SCLC: Shorter progression-free survival (3.1 vs 4.6 months) and overall survival (5.1 vs 7.7 months) compared to PS 2 3

Toxicity grading:

• Grade 3-4 myelosuppression: Most common toxicity occurring in 49% of patients 4
• Febrile neutropenia risk: Higher in patients with prior radiotherapy 8
• Anaphylactic reaction risk: Manifested by chills, fever, tachycardia, bronchospasm, dyspnea, hypotension 1

Prognostic factors:

• Liver metastases: Correlate with worse progression-free survival and overall survival on multivariable analysis 4

Plan

Treatment Administration

Standard dosing regimens:

• Small cell lung cancer: Carboplatin AUC 5 day 1 + etoposide 100 mg/m² days 1-3, every 3 weeks for 4-6 cycles 5
• Neuroendocrine carcinoma: Carboplatin 300 mg/m² day 1 + etoposide 120 mg/m² days 1-3, every 3 weeks 4
• Germ cell tumors (good-risk): Carboplatin 400 mg/m² day 1 + etoposide 120 mg/m² days 1-3, every 4 weeks for 3 cycles 7
• Germ cell tumors (poor-risk): Same regimen for 4 cycles every 21 days 7

Preparation and administration:

• Carboplatin: Dilute to final concentration 0.2-0.4 mg/mL with 5% dextrose or 0.9% sodium chloride 1
• Etoposide: Dilute to 0.2-0.4 mg/mL; concentrations >0.4 mg/mL may precipitate 1
• Infusion rate: Administer over 30-60 minutes to prevent hypotension 1
• Avoid rapid IV injection – hypotension risk 1

Oral vs IV etoposide:

• Oral etoposide dose: Two times the IV dose rounded to nearest 50 mg 1
• Comparable efficacy: Disease control rate 69.8% oral vs 80.8% IV (p=0.237) 4
• Venous thromboembolism: Higher with oral etoposide (12.5% vs 1.7%, p=0.04) 4

Supportive Care

Prophylactic G-CSF administration:

• Strongly recommended in patients with PS ≥3 to improve progression-free survival (5.2-6.1 months with G-CSF) 3
• Consider in all patients with prior radiotherapy due to significantly higher leukopenia risk (p=0.01) 8
• NCCN recommendation: Encourage G-CSF use in cases of neutropenia risk 2

Antimicrobial prophylaxis:

• Pneumocystis, fungal, and viral prophylaxis due to severe immunosuppression 5

Antiemetic therapy:

• Carboplatin causes less nausea/vomiting than cisplatin 2

Monitoring for anaphylaxis:

• Immediate termination of infusion if chills, fever, tachycardia, bronchospasm, dyspnea, or hypotension occur 1
• Treatment: Pressor agents, corticosteroids, antihistamines, or volume expanders 1

Treatment Modifications

Hold treatment if:

• Platelet count <50,000/mm³ 1
• Absolute neutrophil count <500/mm³ 1
• Active infection with fever 3

Dose reduction required for:

• Renal impairment (adjust both carboplatin and etoposide) 5, 1
• Grade 3-4 myelosuppression in prior cycle 1

Post-Treatment Surveillance

Timing of reassessment:

• Tumor markers and imaging: 4-8 weeks after last cycle 7
• Germ cell tumors: Complete surgical resection of residual disease essential; 30% have teratoma or viable tumor at post-chemotherapy surgery 7
• Retroperitoneal lymph node dissection: Full bilateral template dissection, not limited "pick-up" lymphadenectomy 7

Safety Precautions

Handling precautions:

• Wear impervious gloves when handling vials 9
• Skin contact: Immediately wash thoroughly with soap and water 9
• Mucous membrane contact: Flush immediately and thoroughly with water 9

Storage and stability:

• Diluted solutions: Stable 96 hours (0.2 mg/mL) or 24 hours (0.4 mg/mL) at room temperature 1
• Discard solutions: 8 hours after preparation 9
• Avoid plastic devices: Acrylic or ABS devices may crack with undiluted etoposide 1

Treatment Duration

Standard course: 4-6 cycles unless disease progression or unacceptable toxicity occurs 5

Discontinuation criteria:

• Disease progression on imaging 5
• Unacceptable toxicity despite dose modifications 5
• Patient refusal or declining performance status 6