Download National Cancer Drugs Fund Application Form – Trastuzumab

National Cancer Drugs Fund Application Form –
Trastuzumab Emtansine (Kadcyla)
For the treatment of HER2-positive locally advanced/unresectable or
metastatic (Stage IV) breast cancer who previously received trastuzumab
and a taxane, separately or in combination
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 the treatment of HER2-positive locally advanced/
unresectable or metastatic (Stage IV) breast cancer
TICK
All 7 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. Progression of her-2 positive locally advanced or metastatic breast cancer
3. Progression during or after the most recent treatment for advanced stage
disease or within 6 months of completing treatment for early stage disease
4. Previous treatment with a taxane
5. Previous treatment with trastuzumab
6. PS 0 or 1
7. Left ventricular ejection fraction of 50% or more
To minimise the risk of errors due to the similarity of the product name Trastuzumab
Emtansine (Kadcyla) with that of Trastuzumab (Herceptin) the recommendations in
the Risk Minimisation Plan educational material from the manufacturer should be
followed when prescribing, dispensing and administering the product
Consultant Approval (email authority)
Patient Consent Obtained (date of letter – copy to be retained on patient file)
National Cancer Drugs Fund – Application Form 03 February 2014
Trastuzumab Emtansine for metastatic 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 03 February 2014
Trastuzumab Emtansine for metastatic breast cancer
Page 2