Question 1: Purpose of therapy
Indicate purpose of therapy:
- Induction (frontline)
- Consolidation/intensification after achieving first CR/Cri
- Maintenance/ continuation after achieving first CR/Cri
- Reinduction after fist disease relapse or later relapse
- Consolidation/intensification after disease relapse, after achieving second or later CR/CRi
- Maintenance/continuation after disease relapse, after achieving second or later CR/Cri
- Other (Go to question 2. If not, proceed to question 3.)
Question 2: Specify Other
Specify other purpose of therapy.
Question 3-4: Date line of therapy started
Indicate known or unknown. If known, report the date (YYYY-MM-DD) when therapy was started in Question 4.
Question 5-6: Date line of therapy stopped
Indicate known or unknown. If known, report the date (YYYY-MM-DD) when therapy was stopped in Question 5.
Question 7: Was Mylotarg™ given with combination chemotherapy as part of this line of therapy?
Indicate yes or no. If yes, move to Question 8. If no, move to question 10.
Question 8: Specify systemic therapy.
Check all therapies that apply to this line of therapy. If other, check “other systemic therapy” and move to question 9.
Question 9: Specify other therapy.
Indicate therapy that was used in combination with Mylotarg™ that was not listed.
Question 10: Height used for Mylotarg™ dose.
Indicate height used for dosage and check unit of measurement (inches or centimeters).
Question 11: Body weight used for Mylotarg™ use.
Indicate weight used for dosage and check unit of measurement (pounds or kilograms).
Questions 12: Specify the number of instances Mylotarg™ was administered as a part of this line of therapy.
Indicate the number of instances Mylotarg™ was used. CIBMTR also recommends to attach the medication administration record.
Questions 13-32: Instance.
Specify date dose administered (YYYY-MM-DD) for each instance. Specify dose administered (mg/mg 2) for each instance.
Question 33: Total Mylotarg™ dose given as part of this line of therapy
Indicate known or unknown. If known, go to question 34. If unknown, skip to question 35.
Question 34: Mylotarg™ dose
Indicate Mylotarg™ dose given as part of this line of therapy in mg/m 2.
Question 35: Best response to line of therapy
Indicate best response to line of therapy:
- Complete remission (CR): ALL of the following criteria without progression for at least four weeks: <5% blasts in the bone marrow, no blasts with Auer rods, no extramedullary disease, ANC of > 1,000/uL, platelets >1000,000/uL
- Complete remission with incomplete hematologic recovery (Cri): All CR criteria except for neutropenia (<1,000/uL) and/or thrombocytopenia (<100,000/uL)
- No complete remission
Question 36: Date Assessed
Indicate date of assessment (YYYY-MM-DD).
Repeat questions 1-36 for each line of therapy and submit the form.
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