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London Cancer New Drugs Group Application form to access Cancer Drugs Fund THIS APPLICATION MUST BE COMPLETED AND APPROVED BY YOUR CANCER NETWORK TEAM BEFORE THE PATIENT IS STARTED ON TREATMENT APPLICATION FORM to access Cancer Drug Fund Only fully completed forms will be accepted. This route of funding applies for the list of drugs identified by the London Cancer New Drugs Group for funding when used in accordance with the previously agreed and listed criteria. All eligibility criteria listed below MUST apply to the patient. Definition: A “Near-Off-Label indication” is where the indication is molecularly specific and the indication bears a biological similarity to the indication for which the drug holds a Marketing Authorisation in the UK. NB Where the application to the CDF for a Near Off-label indication does not exactly meet the indications listed below, the application will be assessed individually by the London Cancer Drugs Fund Panel prior to authorisation. Rituximab Dose per m2: Schedule Number of Doses of Rituximab intended Drug(s) used in combination: Please specify Regimen Indication (Insert indication from list in Appendix 1 to this form): Please specify Line of treatment: Please specify Cost of treatment (per Dose) Calculated as 1.75m2 x 375mg = 675mg, inc wastage = 700mg, +VAT @ 20% If Dose differs from above, enter revised Cost per Dose Please indicate whether the patient meets the following LCNDG CDF criteria Patient has confirmed CD20 expression Patient indication is listed in Appendix 1 to this form Patient’s treatment was decided at an appropriate Multidisciplinary Team meeting. This patient’s treatment will be prescribed and managed under the supervision of a haemato- oncologist qualified in the use of systemic anticancer therapy. Primary Diagnosis: ICD10 Code Please specify, See table below £1467 per dose Please insert Yes/No 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 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. CDF_Near_off-Label_Rituximab_V1.5_April_2012 Page 1 of 4 Trust Contact details of Trust Oncology Pharmacist Consultant Consultant Contact details (email/phone) (Block Capitals) Consultant signature Date of completion 1. Enter electronic signature OR 2. Print name & submit e-mail from Consultant, or with e-mail 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 The form may be e-mailed, an electronic copy of the Consultant’s signature is acceptable. Contact details [email protected] Approved by London CDF panel, if applicable & Date Application approved on behalf of Cancer Network Management Team If the form is e-mailed, and electronic copy of the Consultant’s signature is acceptable Contact details: Approved by Name and Designation Signature, Date of approval and copy sent to London CDF Audit Office CDF_Near_off-Label_Rituximab_V1.5_April_2012 Page 2 of 4 Appendix 1 Drug Indication ICD10 Code Rituximab +chemo 2nd or 3rd line Relapsed Refractory Mantle Cell Lymphoma C83.1 1st line HIV associated Castleman’s Disease B21.7 1st line Mantle Cell Lymphoma 1st Line of treatment-Waldenstrom's Macroglobulinaemia (including lymphoplasmacytic lymphomas) C83.1 1st line Splenic Marginal Zone Lymphoma Relapsed DLBCL in patients suitable for consolidation with an Auto transplant C83 DLBCL ( bulky stage I) Nodular Lymphocyte Predominant Hodgkin’s Disease – advanced stage (nb CD20+ve) C83.3 Relapsed MALT lymphoma Resistant Hairy cell leukemia, relapsed/ refractory to either Cladribine or Pentostatin C88.4 Rituximab Rituximab +HyperCVAD/RHDMTX-AraC or R-CHOP Rituximab +/- Chemo Rituximab + Chemo Rituximab + Chemo R-CHOP R-ABVD, RCHOP Rituximab + Chemo Rituximab +/- Chemo PCT Cancer Network 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 South East London North Central London and West Essex North East London North West London South West London Wandsworth CDF_Near_off-Label_Rituximab_V1.5_April_2012 C88 C83.3 C81 C91.4 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 4 Cancer Network Application forms available at Applications to, e-mail Applications to, Fax Telephone contact South East London 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 North Central London http://www.nlcn.nhs.uk/interim-cancer-drugs-fund nclcdfrequests @nhs.net Applications not accepted by Fax Dermot Ball 0207 685 6212 North East London 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 Susan Kilby 0208 407 3929 CDF_Near_off-Label_Rituximab_V1.5_April_2012 Page 4 of 4 Raj Nijjar 0207 377 7241
