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Tukysa (tucatinib)
We can help with your prescription. Read the “Prescription Guide”.
You can access this medicine even if it's not approved in your country. Learn how.
Tukysa (tucatinib) is a medication used in combination with trastuzumab and capecitabine for the treatment of adult patients with advanced, unresectable or metastatic HER2-positive breast cancer.
Tukysa (tucatinib) has been approved by FDA (USA) and EMA (Europe) in different pack sizes. We can help you gain access to both the USA and European versions of this medicine.
Disease Indications
Breast Cancer
Manufacturer
Seattle Genetics
Usage
Oral
Medicine approved by
-
European Medical Agency (EU)
-
Food and Drug Administration (USA)
-
Health Canada
-
Therapeutic Goods Administration (AUS)
-
Swissmedic (CH)
Patients helped
- Over 1.2 million patients reached
- More than 11,000 patients helped
- 100% successful deliveries to 88 countries
We can help with your import documents
We are experts in import regulations. Scroll below to download the import guide for your country.
FREQUENTLY ASKED QUESTIONS
We help you access approved medicines that are not approved or available in your country of residence.
Legal
We help you access approved medicines that are not approved or available in your country of residence.
Legal
Finances
Payment
- Your permanent residence is outside the European Union
- You take the medicines with you, unused within 90 days after purchase
- You have a full original receipt (which we provide you)
Unfortunately, we are unable to help with VAT refunds following delivery or collection from our partner pharmacies outside of the Netherlands.
- If you are residing within the European Union and you are not a company
- If you are coming to Amsterdam, Luxembourg or Dusseldorf to pick up your order
In case of pick up, you may be eligible for a VAT tax refund if you live outside the European Union.
Price
Reimbursement
- That you want to import an approved medicine from abroad
- The lack of reasonable treatment options available in your country (if you can, include a letter from a doctor confirming this) - no alternative to the treatment.
- That the medicine has already been approved in another country (state the name of the country)
- That your treating doctor states that this medicine is the best option for you (include a copy of the prescription in the letter to the healthcare insurance company)
Ordering and shipping
Ordering
- Name of the patient
- Contact details of patient(email and phone number)
- Copy of patient’s ID
- Contact details of the Doctor (name, address, email and phone number)
- Shipping address
- Copy of the doctor's prescription
Shipping: We can deliver to the patient's residence, a pharmacy, or doctor's office / hospital, but this depends on the country. If you’re not sure what the right choice is for you, please get in touch with our Patient Support Team and we can help you work out your exact requirements.
Once we have received this information, one of our Patient Support Team members will then check your prescription and contact you to follow up on your order. Please note that other documents may be needed for import, we will guide you through the ordering process.
Generally not, but we do provide you with an invoice after you make the payment that you may send to your medical insurance company so they can reimburse you. In some limited circumstances, we do accept insurance. Contact us for more details.
As part of our protocols we might reach out to your treating doctor for verification or information updates. By sending us your prescription you allow us to do so.
- Patient's name and date of birth
- Name of the medicine and dosage
- Required quantity
- Doctor's name and signature
- Doctor's registration number and/or stamp
Ideally, the prescription should be issued in English. Alternatively, a translation (unofficial is sufficient) must be provided.
Please be aware that your doctor may be contacted by one of our team members or by the processing pharmacy in order to verify the prescription.
Shipping
Please be aware that due to the COVID-19 situation worldwide and the country lockdowns, we will sometimes experience delays in shipping.
For EMA approved medicines with prescriptions from within the Schengen zone, you can pick the medicines up from our partner pharmacy in Amsterdam, Luxembourg or Dusseldorf. For non-EMA approved medicines, with prescriptions from within the Schengen zone, you can pick the medicines up in our partner pharmacy in Dusseldorf. If you have requested to collect your medicines, you will receive a notification when the medicines are in the pharmacy and ready for you.
There are also options to deliver the medicines to other countries. Please get in touch with our Patient Support Team to discuss which other pick-up and delivery options may be suitable for you.
- Copy of the ID/passport of the patient
- Copy of the ID/passport of the person who is coming to pick up the medicines
- Letter signed by the patient stating that he/she authorises this person to pick up the medicines on his/her behalf
- Step 1 - Customs may need to check the package to verify its contents. In order to streamline this step, we include a letter for customs with information about the contents. Any additional questions will be answered by everyone.org as and when we are contacted by customs.
- Step 2 - In some countries, there are additional questions from the medical regulatory agencies (i.e. the FDA, EMA, etc). We provide them with all the necessary information based on the information provided by the patient, such as: the prescription, copy of ID and a letter from the treating doctor to show that the medicines are for personal use.
- Step 3 - Customs fees. In some cases, the recipient will be requested to pay taxes and duties. These should be arranged by the patient or receiver and are not covered by everyone.org unless stated otherwise.
Please be aware that the import of the medicines always requires customs clearance and active cooperation from the importing party. We will help and guide you but are dependent on your cooperation and responsiveness.
About us
- Complete the enquiry form on our Contact Us page
- Send an email: [email protected]
- Call us on:
- +31 20 808 4414 (EU)
- +1 646 381 0675 (US)
- +61 28 417 2910 (AUS)
Others
Available medicines
Medicine approval
The respective national and regional agencies, such as the Food and Drugs Administration (FDA) in the USA or the European Medical Authority (EMA) for the European Union assess these applications and make a decision on whether to approve new medicines. The review process is based on evaluation of the evidence provided by the company. Every agency uses a slightly different process.
- Phase I - performed in a small number of healthy volunteers or very sick patients with lack of treatment options, designed to study the effects of the medicine in the human body.
- Phase II - larger number of patients, designed to evaluate the safety and efficacy of the medicine and to determine if different dosages of the treatment have different effects.
- Phase III - large number of patient groups, designed to confirm the safety and efficacy of the medicine.
- Phase IV - after the medicine has received regulatory approval, designed to evaluate the long-term effects.
Updates
Finances
Payment
- Your permanent residence is outside the European Union
- You take the medicines with you, unused within 90 days after purchase
- You have a full original receipt (which we provide you)
Unfortunately, we are unable to help with VAT refunds following delivery or collection from our partner pharmacies outside of the Netherlands.
- If you are residing within the European Union and you are not a company
- If you are coming to Amsterdam, Luxembourg or Dusseldorf to pick up your order
In case of pick up, you may be eligible for a VAT tax refund if you live outside the European Union.
Price
Reimbursement
- That you want to import an approved medicine from abroad
- The lack of reasonable treatment options available in your country (if you can, include a letter from a doctor confirming this) - no alternative to the treatment.
- That the medicine has already been approved in another country (state the name of the country)
- That your treating doctor states that this medicine is the best option for you (include a copy of the prescription in the letter to the healthcare insurance company)
Ordering and shipping
Ordering
- Name of the patient
- Contact details of patient(email and phone number)
- Copy of patient’s ID
- Contact details of the Doctor (name, address, email and phone number)
- Shipping address
- Copy of the doctor's prescription
Shipping: We can deliver to the patient's residence, a pharmacy, or doctor's office / hospital, but this depends on the country. If you’re not sure what the right choice is for you, please get in touch with our Patient Support Team and we can help you work out your exact requirements.
Once we have received this information, one of our Patient Support Team members will then check your prescription and contact you to follow up on your order. Please note that other documents may be needed for import, we will guide you through the ordering process.
Generally not, but we do provide you with an invoice after you make the payment that you may send to your medical insurance company so they can reimburse you. In some limited circumstances, we do accept insurance. Contact us for more details.
As part of our protocols we might reach out to your treating doctor for verification or information updates. By sending us your prescription you allow us to do so.
- Patient's name and date of birth
- Name of the medicine and dosage
- Required quantity
- Doctor's name and signature
- Doctor's registration number and/or stamp
Ideally, the prescription should be issued in English. Alternatively, a translation (unofficial is sufficient) must be provided.
Please be aware that your doctor may be contacted by one of our team members or by the processing pharmacy in order to verify the prescription.
Shipping
Please be aware that due to the COVID-19 situation worldwide and the country lockdowns, we will sometimes experience delays in shipping.
For EMA approved medicines with prescriptions from within the Schengen zone, you can pick the medicines up from our partner pharmacy in Amsterdam, Luxembourg or Dusseldorf. For non-EMA approved medicines, with prescriptions from within the Schengen zone, you can pick the medicines up in our partner pharmacy in Dusseldorf. If you have requested to collect your medicines, you will receive a notification when the medicines are in the pharmacy and ready for you.
There are also options to deliver the medicines to other countries. Please get in touch with our Patient Support Team to discuss which other pick-up and delivery options may be suitable for you.
- Copy of the ID/passport of the patient
- Copy of the ID/passport of the person who is coming to pick up the medicines
- Letter signed by the patient stating that he/she authorises this person to pick up the medicines on his/her behalf
- Step 1 - Customs may need to check the package to verify its contents. In order to streamline this step, we include a letter for customs with information about the contents. Any additional questions will be answered by everyone.org as and when we are contacted by customs.
- Step 2 - In some countries, there are additional questions from the medical regulatory agencies (i.e. the FDA, EMA, etc). We provide them with all the necessary information based on the information provided by the patient, such as: the prescription, copy of ID and a letter from the treating doctor to show that the medicines are for personal use.
- Step 3 - Customs fees. In some cases, the recipient will be requested to pay taxes and duties. These should be arranged by the patient or receiver and are not covered by everyone.org unless stated otherwise.
Please be aware that the import of the medicines always requires customs clearance and active cooperation from the importing party. We will help and guide you but are dependent on your cooperation and responsiveness.
About us
- Complete the enquiry form on our Contact Us page
- Send an email: [email protected]
- Call us on:
- +31 20 808 4414 (EU)
- +1 646 381 0675 (US)
- +61 28 417 2910 (AUS)
Others
Available medicines
Medicine approval
The respective national and regional agencies, such as the Food and Drugs Administration (FDA) in the USA or the European Medical Authority (EMA) for the European Union assess these applications and make a decision on whether to approve new medicines. The review process is based on evaluation of the evidence provided by the company. Every agency uses a slightly different process.
- Phase I - performed in a small number of healthy volunteers or very sick patients with lack of treatment options, designed to study the effects of the medicine in the human body.
- Phase II - larger number of patients, designed to evaluate the safety and efficacy of the medicine and to determine if different dosages of the treatment have different effects.
- Phase III - large number of patient groups, designed to confirm the safety and efficacy of the medicine.
- Phase IV - after the medicine has received regulatory approval, designed to evaluate the long-term effects.
Updates
Tukysa (tucatinib)
Package
Tablets
Where can we deliver?
We have delivered medicines to more than 88 countries. Check if we have sent medicines to yours.
We currently can’t ship medicines to - contact us for alternative options.
Make an enquiry to receive information about the different options of obtaining for a patient in .
We haven’t shipped medicines to yet. You can count on us to make it happen.
Make an enquiry to receive information about the cost, shipping time and import details for .
Yes, we have successfully delivered medicines to .
Make an enquiry to receive information about the cost, shipping time and import details for .
PICK-UP IN PERSON FROM A PARTNER PHARMACY
We can arrange for you to pick up this medicine from our partner pharmacy in Luxembourg. Read more.
Pick-up from Luxembourg.
Depending on your particular circumstance, this option can be cheaper and require less paperwork than direct delivery. You can ask someone else to pick up the medicine on your behalf.
In some cases, medicines can be picked up from partner pharmacies in Amsterdam (the Netherlands) or Dusseldorf (Germany).
Tell our Patient Support Team if you’re interested in pick-up options for your order.
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What is Tukysa (tucatinib) for?
Tukysa (tucatinib) is a prescription medicine used to treat breast cancer that has spread to areas near the breast (locally advanced) or metastatic (has spread to other parts of the body, including the brain) and when it is HER2-positive.
It is used with two other medicines, capecitabine and trastuzumab, and is used after one or more prior anti-HER2-based regimens has been tried.
How effective is Tukysa (tucatinib) for breast cancer?
The approval of Tukysa (tucatinib) for breast cancer was based on a clinical study of 612 people with advanced HER2-positive breast cancer, with or without brain metastases. Tukysa was compared with placebo when added to capecitabine and trastuzumab.
According to the study results published:
More patients had their tumors shrink vs placebo
Tukysa with capecitabine and trastuzumab shrank tumor size in more patients than capecitabine and trastuzumab.
Better overall survival vs placebo
More time without breast cancer growing or spreading vs placebo
For more details refer to the prescribing information at the bottom of the page.
The average length of time that patients lived without their disease getting worse was increased with 39%:
- from 5.6 months with placebo
- to 7.8 months with Tukysa
Reduced risk of developing new brain lesions
Which side effects can I expect with Tukysa (tucatinib)?
The most common side effects of Tukysa (which may affect more than 1 in 5 people) in people with HER2-positive breast cancer listed in the official prescribing information are diarrhea, palmar-plantar erythrodysesthesia, nausea (feeling sick), fatigue (feeling tired), hepatotoxicity (liver problems), vomiting, stomatitis (inflammation of the mouth), decreased appetite, abdominal (belly) pain, headache, anemia (low number of red blood cells), and rash.
Please note this is not intended to be a comprehensive guide. Consult your treating doctor and the prescribing information at the bottom of the page for full details of side effects.
How is Tukysa (tucatinib) taken?
Administration: take Tukysa tablets by mouth 2 times a day and about 12 hours apart, in combination with trastuzumab and capecitabine tablets.
Dosage: 300mg.
Please note this is not intended to be a treatment plan. For a personalised treatment plan, consult your doctor. For more details, you can also reference the full prescribing information at the bottom of the page.
Frequently Asked Questions about Tukysa (tucatinib)
How does Tukysa (tucatinib) work?
Tukysa (tucatinib) is a type of medicine called a tyrosine kinase inhibitor. It targets the enzyme human epidermal growth factor receptor 2 (HER2). HER2 is found on the surface of breast cells and, when overactive, stimulates the growth of cancer cells.
Tukysa can inhibit HER2, which may help stop tumors from growing and cancer from spreading.
For more details about the way Tukysa (tucatinib) works, consult your doctor or see the prescribing information at the bottom of the page. This is not intended to be a comprehensive scientific explanation.
What are some contraindications to taking Tukysa (tucatinib)?
Tukysa (tucatinib) can interact with other drugs, which may affect effects of treatment or lead to serious adverse reactions:
- Strong CYP3A/Moderate CYP2C8 Inducers: avoid concomitant use.
- Strong or Moderate CYP2C8 Inhibitors: avoid concomitant use. Increase monitoring for TUKYSA toxicity with moderate CYP2C8 inhibitors.
- CYP3A Substrates: avoid concomitant use of TUKYSA where minimal concentration changes may lead to serious or life-threatening toxicities. If concomitant use is unavoidable, decrease the CYP3A substrate dosage.
- P-gp Substrates: consider reducing the dosage of P-gp substrates where minimal concentration changes may lead to serious or life-threatening toxicity.
What is the most important information you should know about Tukysa (tucatinib)?
Tukysa (tucatinib) can cause serious side effects. Pay special attention to new or worsening symptoms as they may be related to:
- Diarrhea
- Liver problems (hepatotoxicity)
Tukysa may cause harm to your unborn baby. You should use effective birth control (contraception) during treatment with Tukysa and for at least 1 week after the last dose.
For a comprehensive list of side effects and adverse reactions please refer to the official prescribing information.
Where has Tukysa (tucatinib) been approved?
Tukysa (tucatinib) in combination with trastuzumab and capecitabine was approved to treat advanced HER2-positive breast cancer by:
- The Food and Drug Administration (FDA), USA, on April 17, 2020.
- Swissmedic, Switzerland, on May 12, 2020.
- Health Science Authority, Singapore on May 19, 2020.
- Health Canada, Canada, on June 3, 2020.
- Therapeutic Goods Administration (TGA), Australia, on August 12, 2020.
- The European Medicines Agency (EMA), Europe on February 18, 2021.
Please note that this medicine may have also been approved in other regions than the ones we’ve listed. If you have a question about its approval in a specific country feel free to contact our support team.
References
1. Full prescribing information [FDA]: Tukysa (tucatinib)[PDF]
Seattle Genetics, April 17, 2020
2. Breast Cancer HER2 Status
American Cancer Society, last checked on August 18, 2020
3. FDA Approves First New Drug Under International Collaboration, A Treatment Option for Patients with HER2-Positive Metastatic Breast Cancer
FDA press release, April 17, 2020
4. Seattle Genetics Announces the Approval of TUKYSA™ (tucatinib) in Switzerland for the Treatment of Patients with Metastatic HER2-Positive Breast Cancer
Seattle Genetics press release, May 12, 2020
5. New drug approvals
Health Science Authority Singapore, last checked on Sep 2, 2020
6. Tukysa (tucatinib) product monograph [PDF]
Health Canada, last checked on Sep 2, 2020
7. Seattle Genetics Announces TUKYSA® (tucatinib) Approved Within Months for All Countries Participating in FDA’s Project Orbis Initiative
Seattle Genetics press release, Aug 12, 2020
8. EU approves Tukysa combo for advanced HER2-positive breast cancer
Press release, Feb 2021
The Food and Drug Administration (FDA), USA approval of Tukysa (tucatinib) for the treatment of patients with HER2-positive metastatic breast cancer was based on the data of Study HER2CLIMB (NCT02614794).1
HER2CLIMB was a randomized, international, multi-center study that involved 480 patients with advanced forms of HER2-positive breast cancer. Patients had received previous treatment with trastuzumab, pertuzumab, and ado-trastuzumab emtansine (T-DM1). Patients were given either tucatinib 300 mg or placebo tablets twice daily, for treatment cycles of 21 days. During the first two weeks of each cycle, patients took capecitabine tablets twice daily. On every first day of each cycle, they received trastuzumab injections. Patients were treated until disease progression or unacceptable toxicity.2
Results
The major efficacy outcome measure was progression-free survival (PFS), or the amount of time when there was no growth of the tumor. The secondary outcome measures were overall survival (OS) and overall response rate (ORR), meaning complete or partial tumor remission.2
The median PFS in patients in the Tukysa (tucatinib) group was 7.8 months [95% CI; 7.5, 9.6], compared to 5.6 months in patients in the placebo group [95% CI; 4.2, 7.1].3
Tucatinib significantly improved the overall survival. The median OS duration of patients receiving tucatinib was 21.9 months [95% CI; 18.3, 31], compared to 17.4 months in patients that received placebo [95% CI; 13.6, 19.9].3
Additionally, patients treated with tucatinib had increased ORR: 40.6 [95% CI; 35.3, 46.0] versus 22.8 [95% CI; 16.7, 29.8] in placebo-treated patients.3
Please refer to the summary of product characteristics below and in the resource section for comprehensive information about the safety and effectiveness of Tukysa (tucatinib) for the approved indication.1
References
1. Full prescribing information [FDA]: Tukysa (tucatinib) [PDF]
Seattle Genetics, April 17, 2020
2. A Study of Tucatinib vs. Placebo in Combination With Capecitabine & Trastuzumab in Patients With Advanced HER2+ Breast Cancer (HER2CLIMB)
Clinical Trial NCT02614794, last updated on July 21, 2020
3. Tucatinib, Trastuzumab, and Capecitabine for HER2-Positive Metastatic Breast Cancer
Murthy RK, New England Journal of Medicine, Feb 13, 2020
Tukysa (tucatinib) price in other currencies*
| Package | Euro | Australian dollars | Canadian dollar | New Zealand dollar | Nigerian naira | Singapore dollar | Pound sterling | United States dollar |
|---|---|---|---|---|---|---|---|---|
| 88 tablets of 50 mg (EU) | 3224 EUR | 5334 AUD | 4887 CAD | 5875 NZD | 5764125 NGN | 4634 SGD | 2720 GBP | 3508 USD |
| 84 tablets of 150 mg (EU) | 9083 EUR | 15026 AUD | 13765 CAD | 16550 NZD | 16235647 NGN | 13055 SGD | 7663 GBP | 9882 USD |
| 60 tablets of 150 mg (US) | 18900 EUR | 31266 AUD | 28642 CAD | 34436 NZD | 33781293 NGN | 27163 SGD | 15945 GBP | 20563 USD |
*The prices listed above are based on the cheapest package size and strength everyone.org has access to. Please make an enquiry for more specific pricing. The prices listed above are a guide only, we operate in Euros.
Tukysa (tucatinib) treatment costs
The cost for a monthly or yearly treatment of Tukysa (tucatinib) depends on your prescription requirements which includes the dosage in mg and medicine type (Tablets).
The price of the medicines you see on sale is the cost set by the manufacturer. In addition, shipping costs and a Named Patient support fee will apply.
Make an enquiry and we will help you calculate the total price to buy Tukysa (tucatinib) online and have it delivered where you live. From your side, we’ll simply need a prescription from your treating doctor. In some countries we might also need an import license. Our Patient Support team will guide you throughout the process.
Tukysa (tucatinib) price and additional costs
The price of Tukysa (tucatinib)
The base cost of each medicine is set by the manufacturer. Generally, our Named Patient support fee, shipping costs and any local tax (if applicable) are not included in the product price that is displayed on our website unless stated otherwise.
Our Named Patient support fee
everyone.org provides access to Tukysa (tucatinib) on the Named Patient import basis, which means that we work on behalf of the patient in cooperation with their treating doctor. Our Named Patient support fee covers sourcing, logistics and following up to make sure that the order is received safely and in perfect condition. The Named Patient support fee is tiered relative to the cost of the medicine.
Shipping costs
The shipping prices are dependent on the type of shipping necessary for the particular medicine (regular or cold chain) and upon the destination country. The shipping fees may include the shipping from our supplier to our partner pharmacy as well as the shipping costs to deliver the medicine to the patient’s country of residence. The shipping fee might also include the cost of special packaging, such as coolboxes, cool packs and data loggers, as well as transport insurance to guarantee that you receive your medicine in good order.
You can read a detailed overview of prices and costs here.
Payment methods when you buy Tukysa (tucatinib)
When you buy Tukysa (tucatinib), you can make the payment by bank transfer or by credit card. Payments are fully encrypted and secure. When paying by credit card, you can pay online once you have received your order confirmation. Please be aware that a 2.8% fee applies when paying by credit card.
Tukysa (tucatinib) reimbursement
It might be possible for you to claim the cost of Tukysa (tucatinib) via your country's healthcare system. Some countries have a government fund providing financial assistance for citizens to access lifesaving medical treatment abroad. The best thing would be to check with your country's own health ministry. We also highly recommend checking out local patient blogs, communities and patient organisations to find out more about your options.
Medical insurance
Generally, we do not support medical insurance, but we do provide you with an invoice after you make the payment that you may send to your medical insurance company so they can reimburse you. In some limited circumstances, we do accept insurance. Contact us for more details. You can pay by bank transfer or credit card.
Crowdfunding
Crowdfunding might also be an option for you. It is a means of raising funds by using an online platform to group together many small donations from friends, family and others, in order to help you afford medical treatment. Here are some crowdfunding platforms where you can seek support: GoFundMe, GiveForward, FundRazr and Watsi.
Room temperature shipping
For this medication, standard shipping applies. This means that a consistent room temperature of 15 to 25°C is maintained during transit.
Your order will be shipped to you by our partner couriers, such as DHL, UPS and specialised cold chain couriers. If you would like your order to be shipped by a specific courier, please inform us when you place the order.
Our standard delivery time varies from 5 to 10 working days.
The shipping cost depends on the medicine and the destination country. After making an enquiry, you will receive a detailed quote that includes the shipping costs.
You can also pick up your medicine from our partner pharmacy in Amsterdam or our partner pharmacy in Luxembourg after the order has been paid for.
Four steps to access the medicines you need
How and where to access and buy Tukysa: You can access Tukysa from everyone.org if the drug has not been approved or is not available in your country.
-
Step 1
You send a request for your medicine online
Submit a request for a specific medicine, or a general request, and your Patient Support Manager will contact you within 24 hours. They will be there to support and guide you in anyway possible to help you get the medicine you need.
-
Step 2
We verify your prescription and medical details
Since we help patients access medicines not available in their home country, our first step is to check that the medicine you need is not currently available in your home country. Next we will also verify that you have a prescription from a doctor in your home country for the medicine you need.
-
Step 3
We source your medicine
Once we have verified your prescription and medical details, our expert sourcing team will work with our global network of suppliers to find you the best price. Once we have found you the lowest possible cost for your medicine, we will present you with a final offer for your approval.
-
Step 4
We deliver your medicine
After you have accepted our offer, our experienced logistics team will arrange all the shipping and transportation of your medicine. We will work hard to keep you informed at every step along the way and get your medicine to you quickly and safely. To date we have successfully delivered packages to over 75 countries around the world.
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Disclaimer
We do our best to ensure the accuracy, currency, and completeness of the information provided here, but we can't guarantee it. Medicine information can change over time. The absence of a warning for a given medicine or combination of medicines should not be interpreted as confirmation that it’s safe, effective, or suitable for every patient. Always talk to your treating doctor before starting any treatment.
