Nuclear Medicine - University College Hospital, Ibadan.
Lutetium-177 PSMA Therapy Referral Form
Lutetium-177 PSMA therapy is a targeted radiopharaceutical treatment for advanced prostate cancer, specifically designed for patients with metastatic castration-resistant prostate cancer (mCRPC) who have limited treatment options. This innovative therapy works by targeting and destroying cancer cells while minimizing harm to healthy tissue. By doing so, it can help reduce symptoms and improve quality of life. Additionally, Lutetium-177 PSMA therapy can also slow disease progression and improve survival rates.
Patient Name
*
Surname
Name
Hospital/Folder/Case note Number
*
Patient’s Phone Number
*
Patient's Contact Number
Format: (0000) 000-0000.
Referring Clinician
*
Referring Clinician's Telephone Number
*
Mobile phone
Referring Clinician's email address
*
Email
Referring Hospital or Clinic/Speciality
*
Primary Diagnosis
*
Date of diagnosis
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Gleason Score
*
Performance Status
*
Please Select
1
2
3
ECOG
Bilateral Orchidectomy
*
Yes
No
Date
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Chemotherapy
*
Yes
No
Docetaxel
Yes
No
Number of cycles
Please Select
1
2
3
4
5
6
7
8
9
10
Docetaxel
Start date
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Started Docetaxel
End date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Ended Docetaxel
Carbazitaxel
Yes
No
Number of cycles
Please Select
1
2
3
4
5
6
7
8
9
10
Carbazitaxel
Start date
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Started Carbazitaxel
End date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Ended Carbazitaxel
Radiotherapy
*
Yes
No
Number of fractions
Dose
Gray
Site(s)
Radiotherapy
Date(s)
Castrate Resistant
*
Yes
No
Date
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Diagnosed castrate resistant
Any PSMA Scans done ? (Ga-68 PSMA/F-18 PSMA PET or Tc-99m PSMA SPECT)
*
Yes
No
Not sure
Date
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
PSMA scan findings:
Current Medication(s)
*
Other Medical History
*
Upload available results - pathology, imaging and blood work
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit
Should be Empty: