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East Midlands Cancer Drug Fund (EMCDF)
Application for Bevacizumab (7.5mg/kg ) in combination with
Carboplatin and Paclitaxel chemotherapy for patients with advanced
(Stage 3c/4) ovarian cancer (including primary peritoneal and fallopian
tube cancers) sub-optimally debulked after surgery
PATIENT PERSONAL DETAILS
Patient Name:
Date of Birth:
NHS Number:
Primary Care Trust:
GP Name & Practice Details:
Please note that all personal information will be removed prior to the consideration by the
EMCDF panel
DETAILS OF REQUESTER
(include referring clinician contact details in the event of query or need for clarification)
Name:
Designation:
Trust:
Contact phone
number:
Secure email for correspondence:
Provider Trust Chemotherapy Lead
 Yes
 No
(or equivalent) Support:
Name of Trust Chemotherapy Lead
(or equivalent):
CLINICAL DETAILS
ECOG Performance status
Propose use in combination with paclitaxel & carboplatin
doublet chemotherapy
Stage 3c/4 ovarian cancer
Residual disease (residual tumour ≥1cm) after initial or
delayed (interval) debulking surgery
0
2
Yes
1
3
No
Yes
Yes
No
No
CONSENT
I confirm that this Request has been discussed in full with the patient and that the patient is
aware that they are consenting for the Cancer Drugs Fund Panel to access confidential
clinical information held by clinical staff involved with their care about them as a patient to
enable full consideration of this funding request
Signature of Requester:
Date:
MONITORING RESPONSE
How will the benefits of the procedure/treatment be measured?
(incl. frequency of assessments)
 Clinical assessments and cancer antigen 125 (CA-125) measurements before each
cycle of chemotherapy, then alternate cycles during bevacizumab monotherapy.
 CT scan as clinically indicated
Maximum duration of bevacizumab 19 cycles (57 weeks).
What ‘stopping’ criteria will be in place to decide when the treatment is ineffective?
1. Clinical and radiological evidence of progression
2. Drug toxicity
Please note that regular updates on response to treatment may be requested by the Cancer
Drugs Fund Panel and/or EMSCG
E-mail completed application forms to [email protected]
Document Code: EMCN-DC-0165-12v2
Written By: Colin Ward
Date of Issue: 6th June 2012
Authorised By: CDAG
Review Date: June 2014
Page Number: 1 of 1