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East Midlands Cancer Drug Fund (EMCDF) Application for Bevacizumab (7.5mg/kg ) in combination with Carboplatin and Paclitaxel chemotherapy for patients with advanced (Stage 3c/4) ovarian cancer (including primary peritoneal and fallopian tube cancers) sub-optimally debulked after surgery 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 Propose use in combination with paclitaxel & carboplatin doublet chemotherapy Stage 3c/4 ovarian cancer Residual disease (residual tumour ≥1cm) after initial or delayed (interval) debulking surgery 0 2 Yes 1 3 No Yes Yes No 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) Clinical assessments and cancer antigen 125 (CA-125) measurements before each cycle of chemotherapy, then alternate cycles during bevacizumab monotherapy. CT scan as clinically indicated Maximum duration of bevacizumab 19 cycles (57 weeks). 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-0165-12v2 Written By: Colin Ward Date of Issue: 6th June 2012 Authorised By: CDAG Review Date: June 2014 Page Number: 1 of 1