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London Cancer New Drugs Group Application form for the London Cancer Drugs Fund THIS APPLICATION MUST BE COMPLETED AND APPROVED BY THE RELEVANT CANCER NETWORK TEAM BEFORE THE PATIENT IS STARTED ON TREATMENT Name of Drug(s), Dose(s) and schedule: Drug(s)/Regimen used in combination: Abiraterone 1000mg orally daily Indication: Metastatic castration resistant prostate cancer in patients who are asymptomatic or mildly symptomatic after failure of androgen deprivation therapy in whom chemotherapy is not yet clinically indicated Regimen Name (OPCS v 4.6) Line of treatment NA Post androgen deprivation therapy, 2nd or 3rd line (please specify line of therapy) With Prednisolone 10mg daily Estimated Cost of CDF drug treatment (per 28 day Cycle) BNF costs plus VAT at 20% NB, If patient specific costs are required for local purposes, please enter here: Enter N/A if section does NOT Apply £3282 Will this drug be provided to the patient via a homecare provider Y/N Please indicate whether the patient meets the following LCNDG CDF criteria Please insert Yes/No Primary Diagnosis: Malignant neoplasm of the prostate, ICD10 Code C61 Patient has castration-resistant prostate cancer, which is either pathologically confirmed or clinically confirmed with PSA > 100ng/mL with sclerotic bone metastases Patient has documented disease progression during or after failure of androgen deprivation therapy Patient is asymptomatic or mildly symptomatic, defined as not requiring opiates for disease related pain Patient has NO visceral organ disease Chemotherapy is not clinically indicated at this time Ventricular ejection fraction > 50% or NYHA Class III or IV heart failure has not been established. No moderate or severe hepatic dysfunction or uncontrolled hypertension ECOG Performance Status < 1 (unless due to longstanding physical disability) without significant co-morbidity Treatment agreed at an MDT This patient’s treatment will be prescribed and managed under the supervision of an oncologist qualified in the use of systemic anticancer therapy. Y/N Number of cycles intended (up to 8 cycles) Every 28 days Frequency of cycles Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Proposed Treatment start date Patient Details Patient NHS No. Registered GP name Patient Hospital No. GP post code Patient initials Patient Date of Birth Patient’s PCT CDF_Abiraterone CRPC_pre-chemo_V1.0 Feb 2013 3 Page 1 of The consultant agrees to provide outcome data in relation to this patient’s treatment, on completion of therapy. Failure to submit an end of treatment summary will result in suspension of payment to the Trust. Trust Contact details of Trust Oncology Pharmacist Consultant Consultant Contact details (email/phone) (Block Capitals) Consultant signature 1. Enter electronic signature OR Date of completion 2. Print name & submit e-mail from Consultant, or with email confirmation of consultant initiation of treatment OR 3. Print form, consultant to sign and Fax (SELCN Only) Submit completed application form to the Cancer Network Management team If the form is e-mailed, an electronic copy of the Consultant’s signature is acceptable. Contact details: [email protected] Application approved on behalf of Cancer Network Management Team Approved by Name and Designation Signature, Date of approval & copy sent to London CDF audit office Cancer Network Applications to, e-mail Applications to, Fax Telephone contact http://www.selcn.nhs.uk/content/dynamic.asp?id=869&dyna mic_id=88&sn=Cancer%20Drugs%20Fund%20documents [email protected] 0207 188 7120 Jacky Turner 0207 188 7090 http://www.nlcn.nhs.uk/interim-cancer-drugs-fund nclcdfrequests @nhs.net Applications not accepted by Fax Dermot Ball 0207 685 6212 http://www.nelcn.nhs.uk/content/projects.asp? projectid=128 btl-tr.icdfnelcn [email protected] Applications not accepted by Fax North West London http://www.nwlcn.nhs.uk/Healthcare%20Professionals/Refer ence%20Library/interim-cancer-drug-fund-2010.htm wms-pct.cancerdrug [email protected] Applications not accepted by Fax Pauline McCalla 0203 350 4552 South West London Available via individual Trust intranet sites smpt.ICDFrequests [email protected] Applications not accepted by Fax Pauline McCalla 0203 350 4552 South East London North Central London North East London Application forms available at CDF_Abiraterone CRPC_pre-chemo_V1.0 Feb 2013 3 Raj Nijjar 0207 377 7241 Page 2 of PCT Bexley Bromley Greenwich Lambeth Lewisham Southwark Barnet Enfield Haringey Camden Islington (West Essex) Barking & Dagenham City & Hackney Havering Newham Redbridge Tower Hamlets Waltham Forest Brent Ealing Hammersmith & Fulham Harrow Hillingdon Hounslow Kensington & Chelsea Westminster Croydon Kingston Richmond and Twickenham Sutton and Merton Cancer Network South East London North Central London and West Essex North East London North West London South West London Wandsworth CDF_Abiraterone CRPC_pre-chemo_V1.0 Feb 2013 3 Trust Guy's & St Thomas' King's College Hospital Lewisham Healthcare Trust South London Healthcare @ PRUH South London Healthcare @ QEW South London Healthcare @ QMS Barnet & Chase Farm North Middlesex Princess Alexandra Harlow (PAH) Royal Free UCLH Whittington BHR Barts and The London Homerton Newham Whipps Cross Chelsea & Westminster Ealing Hillingdon Imperial Northwick Park West Middlesex Epsom & St Helier Croydon Kingston St Georges RMH Page 3 of