Download East Midlands Cancer Drug Fund (EMCDF)

East Midlands Cancer Drug Fund (EMCDF)
Application for Peptide Receptor Radionuclide Therapy (i.e. Lutetium177
Octreotate or Yttrium90 octreotide/octreotate for Progressive Symptomatic
Inoperable well-differentiated Neuro-endocrine Tumours
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
Histologically confirmed well differentiated NET
Octreotide scintigraphy or Gallium-68 Octreotate PET scan at
least as high as that in normal liver tissue
Treatment with PRRT has been documented at a dedicated
neuroendocrine MDT
This patient’s treatment will be managed under the
supervision of a clinician competent in the use of radionuclide
agents as anti-cancer therapy.
Pancreatic NET
Progressed or symptoms not controlled, despite or not
suitable for other systemic therapy.
Other NET
Progressed or symptoms not controlled following prior
somatostatin analogue therapy
0
2
Yes
Yes
1
3
No
No
Yes
No
Yes
No
Yes
No
Yes
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)
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-0177-12
Written By: Colin Ward
Date of Issue: 6th December 2012
Authorised By: CDAG
Review Date: December 2014
Page Number: 1 of 1