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National Cancer Drugs Fund Application Form – Albumin bound Paclitaxel nanoparticles for advanced adenocarcinoma of the pancreas (1st Line in Combination with Gemcitabine) Author(s) David Thomson Owner Chemotherapy Clinical Reference Group Version Control Version Control Date Revision summary Ver0.1 11 Mar 2014 Draft for discussion Ver1.0 18 Mar 2014 Final draft for publication Change to current version Criteria Changes N/A N/A – version 1.0 National Cancer Drugs Fund – Application Form 18 March 2014 Albumin bound Paclitaxel nanoparticles for advanced adenocarcinoma of the pancreas ver1.0 1st Line in Combination with Gemcitabine Page 1 National Cancer Drugs Fund Application Form – Albumin bound Paclitaxel nanoparticles for advanced adenocarcinoma of the pancreas (1st Line in Combination with Gemcitabine) Instructions to Consultants: Please fill in each section of the form electronically and save the document with your own file name. [If you continue typing the boxes will enlarge to contain the text]. Please send electronically to ______________________. Please also send copies to your Trust’s link accountant / corporate contracting team. Security of Patient Identifiable Information: The patient will be identified by their NHS number only. Please do not include any other patient identifiers for confidentiality reasons. All communication must be sent to the Cancer Drugs Fund Office via secure e mail accounts: that is from an nhs.net account to the ____________ account. Receipt of Application: The sender of the application will receive an acknowledgement, together with details of the unique Cancer Drugs Fund reference. Cancer Drugs Fund Policy: To check the status of a particular therapy please check the Cancer Drugs Fund Policy at _________________ Applications will be subject to Clinical Audit arrangements. Approved Treatment Required for Albumin bound Paclitaxel nanoparticles for advanced adenocarcinoma of the pancreas – 1st Line in Combination with Gemcitabine TICK All 6 conditions must be met 1. Application made by and first cycle of systemic anti-cancer therapy to be prescribed by a consultant specialist specifically trained and accredited in the use of systemic anti-cancer therapy 2. Histologically or cytologically confirmed adenocarcinoma of the pancreas 3. Stage IV disease (patients with locally advanced disease are ineligible) 4. PS 0 or 1 5. No previous chemotherapy for advanced disease 6. No previous chemotherapy for early disease unless given as a radiation sensitiser at least 6 months previously Consultant Approval (email authority) Patient Consent Obtained (date of letter – copy to be retained on patient file) National Cancer Drugs Fund – Application Form 18 March 2014 Albumin bound Paclitaxel nanoparticles for advanced adenocarcinoma of the pancreas ver1.0 1st Line in Combination with Gemcitabine Page 2 Proposed Start Date for Therapy (add clinic date)*: Consultant details* (including signature or email confirmation) Name: Hospital: Address: Post Code: Telephone: Nhs.net Trust Pharmacist details of the Trust where the patient will be treated* Mandatory - NHS No*: Mandatory – Patients date of birth* Optional – Hospital No. Clinical Commissioning Group* Patient’s GP* (name, address, telephone) Name: Hospital: Address: Post Code: Telephone: Nhs.net NHS No: DOB: Hospital No: CCG Name: Name: Address: Post Code: ICD-10 Code (please tick the relevant box)* HRG Code 25.9 - Malignant neoplasm of pancreas, unspecified Completion of items marked with * is mandatory. Failure to complete these items may mean that payment is not made. National Cancer Drugs Fund – Application Form 18 March 2014 Albumin bound Paclitaxel nanoparticles for advanced adenocarcinoma of the pancreas ver1.0 1st Line in Combination with Gemcitabine Page 3