Case Summary Format

The following is a sample Case Report Format used to submit BCS Case Summaries Please adhere to the suggestions below. You may alter the format but include as much of the indicated content as possible.

Patient Name:

Diagnosis (as verified by biopsy):

History

• History of present illness with presenting symptoms
• Significant medical history especially previous cancer diagnosis
• Treatment interventions (method, dates, response, treating facility, primary providers)
• Complete list of over the counter and prescription medications
• Medical Records which are particularly helpful are:
  • Operative Reports
  • Discharge Summaries
  • Radiation Oncology, Surgical Oncology, Chemotherapy treatment notes
  • Laboratory Reports if critical in following disease progression (tumor markers, IgG, etc)
• Current Status of the patient

Pathology

• All anatomic pathology, cytology, immunology reports to verify the sites of involvement of the cancer
• Bone marrow aspirate and biopsy reports
• Documents must have patient's name, specimen number, date, and treatment facility

Radiology

• All diagnostic reports surrounding initial diagnosis and subsequent restaging of disease Special attention will be paid to: Reports of pre and post conventional treatment imaging studies
• Reports of pre and post CAM intervention
• If clinical course extends for years, provide reports of selected, representative studies
• If disease recurrence occurs, include all reports surrounding re-evaluation
• Contact Information: Patient name, address, and phone number (all locations if patient has more than one residence
• Primary Care Provider and treating facilities names, addresses, and phone numbers throughout conventional and CAM treatment regimens
• If the patient is no longer living, please verify family member's willingness to consent to the NCIevaluation process

Please include a copy of the Medical Records Release Authorization form signed by the patient or family member.