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National National Cancer Drugs Fund Application Form – Trifluridine and Tipiracil for metastatic Colorectal Cancer Author(s) David Thomson Owner Chemotherapy Clinical Reference Group Version Control Version Control Date Revision summary Ver1.0 29 Jul 2016 New form following NICE FAD and interim funding Ver1.1 18 Aug 2016 Clarification of treatment criteria Change to current version Criteria Changes 3 Clarification to indicate that patients relapsing during or within 6 months of completing adjuvant chemotherapy can have this adjuvant line of treatment counted as one line of treatment for metastatic colorectal cancer National Cancer Drugs Fund – Application Form 18 Aug 2016 Trifluridine and Tipiracil for metastatic Colorectal Cancer Page 1 National Cancer Drugs Fund Application Form – Trifluridine and Tipiracil for metastatic Colorectal Cancer 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. BY TICKING THESE BOXES AND SUBMITTING THE APPLICATION THE CLINICIAN IS CONFIRMING THE PATIENT MEETS ALL THE CRITERIA BELOW. IT SHOULD BE NOTED THAT THE SACT DATASET WILL BE USED TO MONITOR THAT THESE CRITERIA ARE BEING MET. Approved Treatment Required for Trifluridine and Tipiracil for metastatic Colorectal Cancer TICK All 5 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. Metastatic Colorectal Cancer 3. Failed at least 2 prior regimens for advanced/metastatic disease. Those patients relapsing during or within 6 months of completing adjuvant chemotherapy can count the adjuvant line of treatment as one line of therapy for advanced/metastatic disease 4. Not considered a candidate for all other available therapies 5. PS 0 or 1 Consultant Approval (email authority) Patient Consent Obtained (date of letter – copy to be retained on patient file) National Cancer Drugs Fund – Application Form 18 Aug 2016 Trifluridine and Tipiracil for metastatic Colorectal Cancer 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 relevant box)* C18 - Malignant neoplasm of colon C19 - Malignant neoplasm of rectosigmoid junction C20 - Malignant neoplasm of rectum HRG Code 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 Aug 2016 Trifluridine and Tipiracil for metastatic Colorectal Cancer Page 3