Question 103: Was lymphodepleting therapy given prior to the infusion? (does not include lines of therapy given for disease treatment, bridging therapy, or maintenance)

Lymphodepleting therapy is given to destroy lymphocytes and T cells.

Do not report bridging therapy in this section. Bridging therapy, therapy given after leukapheresis up until the initiation of lymphodepleting chemotherapy for the purpose of disease control or management, should be reported on the disease specific form if applicable.

Do not report therapy given to treat disease, it should be reported on the disease specific form if applicable

Question 104-105: Specify lymphodepleting drugs:

The form lists each drug by the generic name.

For each drug listed, checking the box will indicate it was given as part of the lymphodepleting therapy used prior to the cellular therapy infusion. Report the total dose of each drug that was actually given. Do not report the prescribed dose or the daily dose. The pharmacy record or Medication Administration Record (MAR) should be used for determining the exact total dose given.

The “other drug” category should only be used if the drug is not one of the listed options. If more than one “other” drug is prescribed, list the generic name of the drugs in the space provided and attach a copy of the source document using the attachment feature in FormsNet3SM.

Question 106: Total dose:

Report the total dose that was actually given of the drug selected in question 104. Drug doses can be reported with one decimal place.

Question 107: Date started:

Report the date (YYYY-MM-DD) the drug was administered. If the exact date is unknown, please view General Instructions, General Guidelines for Completing Forms for more information on reporting partial and unknown dates.

Last modified: May 21, 2020

Need more help with this?
Don’t hesitate to contact us here.

Was this helpful?

Yes No
You indicated this topic was not helpful to you ...
Could you please leave a comment telling us why? Thank you!
Thanks for your feedback.