Download National Cancer Drugs Fund Application Form – Pertuzumab For

National Cancer Drugs Fund Application Form –
Pertuzumab
For Advanced Breast 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.
Approved Treatment Required for Pertuzumab for Advanced Breast Cancer
TICK
All 6 conditions must be met
1. Locally advanced or metastatic breast cancer
2. HER-2 3+ or FISH positive
3. PS 0 or 1
4. No Prior adjuvant HER2 therapy or completed more than 12 months prior to
Mets
5. No prior treatment with chemotherapy or HER2 therapy for metastatic disease
6. To be given as first line treatment in combination with docetaxel and
trastuzumab
NOTE: not to be used beyond first disease progression
Consultant Approval (email authority)
Patient Consent Obtained (date of letter – copy to be retained on patient file)
National Cancer Drugs Fund – Application Form 1 April 2013
Pertuzumab for Advanced Breast Cancer
Page 1
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*
C50 – Malignant neoplasm of breast
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 1 April 2013
Pertuzumab for Advanced Breast Cancer
Page 2