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Pre-Printed Orders for Take-Home Chemotherapy
 

Customize pre-printed order forms

Contact the Drug Formulary Team at drugformulary@cancercare.on.ca for information about customizing the forms for your centre.

Pre-printed orders are protocol-specific forms that simplify and standardize the prescribing process. Our pre-printed order forms for take-home chemotherapy prescriptions may reduce dosing, transcription and omission errors related to handwritten and verbal take-home chemotherapy orders.

  • Recommended Criteria of a Pre-Printed Order: Oral Chemotherapy Take Home Prescriptions
  • Disclaimer

    These pre-printed orders are available as a reference for the development of institution-specific pre-printed orders. The user is responsible for adapting the materials accurately. Prescribers must use clinical assessment and judgment to ensure that the treatment and doses are appropriate for their patients. 

    Forms: Regimen-Specific, by Type of Cancer

    Adrenal | Breast | CNS (central nervous system) | Gastrointestinal | GIST (gastrointestinal stromal tumours) | Gynecological | Head and Neck | Leukemia | Lung | Lymphoma | MDS (myelodysplastic syndrome) | Myelofibrosis | Multiple Myeloma | Neuroendocrine | Primary Unknown| Prostate | Renal cell | Sarcoma | Skin

    Adrenal

    Regimen code Drug names (non-IV drugs in bold)
    CAPEGEMC capecitabine , gemcitabine
    CISPDOXOETOPMTTN mitotane , cisplatin, doxorubicin, etoposide
    MTTN mitotane

    Breast

    Regimen code Drug names (non-IV drugs in bold)
    ANAS anastrozole
    CAPE capecitabine
    CAPE+TRAS capecitabine , trastuzumab
    CAPEDOCE capecitabine , docetaxel
    CAPELAPA capecitabine, lapatinib
    CM(PO) cyclophosphamide, methotrexate
    CMF(PO) cyclophosphamide, methotrexate, fluorouracil
    CMF(PO)+TRAS cyclophosphamide methotrexate, fluorouracil, trastuzumab
    DENO denosumab
    ETOP(PO) etoposide
    EVEREXEM everolimus, exemestane
    EXEM exemestane
    FLVS fulvestrant
    GOSE goserelin
    LETR letrozole
    LPRL leuprolide (Lupron®)
    LPRL leuprolide (Eligard®)
    MEDR medroxyprogesterone 
    MEGE megestrol
    TMXF tamoxifen

    CNS (central nervous system)

    Regimen code Drug names (non-IV drugs in bold)
    CCV lomustine, cisplatin, vincristine
    ETOP(PO) etoposide
    LOMU lomustine
    PCV procarbazine , lomustine , vincristine
    PROC procarbazine
    TMZL temozolomide
    TMZL(RT) temozolomide (concurrent with radiotherapy)

    Gastrointestinal

    Regimen code Drug names (non-IV drugs in bold)
    CAPE capecitabine
    CAPE(RT) capecitabine (concurrent with radiotherapy)
    CAPE+BEVA capecitabine , bevacizumab
    CAPECISP±TRAS capecitabine , cisplatin ± trastuzumab
    CAPECISP(RT) capecitabine , cisplatin (concurrent with radiotherapy)
    CAPECRBP capecitabine , carboplatin
    CAPEGEMC capecitabine , gemcitabine
    ECARBOX epirubicin, carboplatin, capecitabine
    ECX epirubicin, cisplatin, capecitabine
    EOX epirubibin, oxaliplatin, capecitabine
    REGO regorafenib
    SORA sorafenib
    XELOX±BEVA capecitabine , oxaliplatin ± bevacizumab

    GIST (gastrointestinal stromal tumours)

    Regimen code Drug names (non-IV drugs in bold)
    IMAT imatinib
    REGO regorafenib
    SUNI sunitinib

    Gynecological

    Regimen code Drug names (non-IV drugs in bold)
    ETOP(PO) etoposide
    MEDR medroxyprogesterone
    MEGE megestrol
    TMXF tamoxifen

    Head and Neck

    Regimen code Drug names (non-IV drugs in bold)
    CAPE capecitabine
    ERLO erlotinib
    GEFI gefitinib
    VAND

    Leukemia

    Regimen code Drug names (non-IV drugs in bold)
    BOSU bosutinib (CML)
    CHLO chlorambucil (CLL)
    CVP(PO)±R cyclophosphamide , vinCRIStine, prednisone , ± riTUXimab (CLL)
    CVP±R cyclophosphamide, vinCRIStine, prednisone , ± riTUXimab (CLL)
    DASA dasatinib (CML)
    DASA dasatinib (ALL)
    DEXA(HD) dexamethasone
    FC(PO)±R fludarabine, cyclophosphamide , ± riTUXimab (CLL)
    FLUD(PO)±R fludarabine , ± riTUXimab (CLL)
    HYDR hydroxyurea (CML)
    IBRU ibrutinib (CLL)
    IFNA(SC) interferon alfa (hairy cell leukemia)
    IMAT
    IMAT imatinib (CML)
    NILO nilotinib (CML)
    PRED(HD) prednisone

    Lung

    Regimen code Drug names (non-IV drugs in bold)
    AFAT afatinib
    CERI ceritinib
    CISPETOP(PO) cisplatin, etoposide
    CRIZ crizotinib
    DENO denosumab
    ERLO erlotinib
    ETOP(PO) etoposide
    GEFI

    Lymphoma

    Regimen code Drug names (non-IV drugs in bold)
    BEACOPP bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, prednisone, procarbazine
    CEOP±RITU cyclophosphamide, etoposide , vincristine, prednisone ± rituximab
    CEP lomustine, etoposide, prednisone
    CEPIOP±RITU cyclophosphamide, epirubicin, vincristine, prednisone ± rituximab
    CEPP±RITU cyclophophamide, etoposide, procarbazine, prednisone ± rituximab
    CHLO chlorambucil
    CHLO+RITU chlorambucil , rituximab
    CHLVPP chlorambucil , vinblastine, procarbazine, prednisone
    CHOEP±RITU cyclophosphamide, doxorubicin, vincristine, etoposide, prednisone ± rituximab
    CHOP±R cyclophosphamide, doxorubicin, vincristine, prednisone ± rituximab
    CNOP cyclophosphamide, mitoxantrone, vincristine, prednisone
    COPP cyclophosphamide, vincristine, procarbazine, prednisone
    CVP±R cyclophosphamide, vincristine, prednisone ± rituximab
    CVP(PO)±R cyclophosphamide , vincristine, prednisone ± rituximab
    CYCL(PO) cyclophosphamide
    DHAP dexamethasone , cytarabine, cisplatin
    EPOCH±RITU etoposide, prednisone , vincristine-cyclophosphamide, doxorubicin ± rituximab
    ESHAP etoposide, methylprednisolone/ dexamethasone , cytarabine, cisplatin
    FC(PO)±R fludarabine, cyclophosphamide +/- rituximab
    FLUD(PO)±R fludarabine ± rituximab
    GDP±RITU gemcitabine, dexamethasone , cisplatin ± rituximab
    IBRU ibrutinib
    IFNAZIDO interferon alfa-2b, zidovudine
    MTRX(PO)
    VRNS vorinostat

    MDS (myelodysplastic syndrome)

    Regimen code Drug names (non-IV drugs in bold)
    LENA

    Myelofibrosis

    Regimen code Drug names (non-IV drugs in bold)
    RUXO

    Multiple Myeloma

    Regimen code Drug names (non-IV drugs in bold)
    BMP bortezomib, melphalan, prednisone                         
    BORTDEXALENA bortezomib-dexamethasone-lenalidomide
    CYBORD bortezomib, cyclophosphamide, dexamethasone
    CYBORP bortezomib, cyclophosphamide, prednisone
    CYCL(PO) cyclophosphamide
    DEXA(PO) dexamethasone
    DEXALENA dexamethasone, lenalidomide
    DEXAPOMA dexamethasone, pomalidomide
    LENA(MNT) lenalidomide
    MELPPRED melphalan, prednisone
    MPT melphalan, prednisone, thalidomide
    THAL

    Neuroendocrine

    Regimen code Drug names (non-IV drugs in bold)
    CAPETMZL capecitabine, temozolomide
    CISPETOP(PO) cisplatin, etoposide
    EVER everolimus
    OCTR octreotide
    SUNI

    Primary Unknown

    Regimen code Drug names (non-IV drugs in bold)
    CRBPPACL+ETOP

    Prostate

    Regimen code Drug names (non-IV drugs in bold)
    ABIRPRED abiraterone, prednisone
    BICA bicalutamide
    BICABSRL bicalutamide, buserelin
    BICAGOSE bicalutamide, goserelin
    BICALPRL bicalutamide, leuprolide (Lupron®)
    BICALPRL bicalutamide, leuprolide (Eligard®)
    BICATRIP bicalutamide, triptorelin
    BSRL buserelin
    CABAPRED cabazitaxel, prednisone
    DENO denosumab
    DGRL degarelix
    DOCEPRED docetaxel, prednisone
    ENZL enzalutamide
    FLTM flutamide
    GOSE goserelin
    HCKETO hydrocortisone, ketoconazole
    LPRL leuprolide (Lupron®)
    LPRL leuprolide (Eligard®)
    NLTM nilutamide
    MXNTPRED mitoxantrone, prednisone
    TRIP

    Renal cell

    Regimen code Drug names (non-IV drugs in bold)
    AXIT axitinib
    CAPEGEMC capecitabine , gemcitabine
    EVER everolimus
    PAZO pazopanib
    SORA sorafenib
    SUNI

    Sarcoma

    Regimen code Drug names (non-IV drugs in bold)
    IMAT imatinib
    PAZO

    Skin

    Regimen code Drug names (non-IV drugs in bold)
    DABR dabrafenib
    TRAM trametinib
    VEMU vemurafenib
    VISM
    Last modified: Fri, Jul 24, 2015
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