Download PER2_ver1.0 National Cancer Drugs Fund Application Form

PER2_ver1.0 National Cancer Drugs Fund Application Form – Pertuzumab for the neoadjuvant treatment of locally
advanced, inflammatory or early breast cancer at high risk of recurrence.
Patient NHS No:
Trust:
Patient Hospital No:
Practice Code:
Patient's Initials and DoB:
GP Postcode:
Choose Consultant:
Consultant Name:
*
Notification Email Address:
Other Contact Details:
*
(@NHS.net account ONLY)
Treatment Start Date:
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:
Please indicate whether patient meets the following criteria:
Please tick
1. I confirm that an application has been made and the first cycle of systemic anti -cancer therapy will be
prescribed by a consultant specialist specifically trained and accredited in the use of systemic anti-cancer
therapy.
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
6. I confirm that the patient has received no prior treatment with chemotherapy or HER2 therapy for this
breast cancer
Yes
No
7. I confirm that pertuzumab will be given in combination with docetaxel-containing chemotherapy plus
intravenous trastuzumab
Yes
No
Yes
No
2. I confirm that treatment is being given with neoadjuvant intent
3. I confirm that the patient has newly diagnosed locally advanced, inflammatory or early breast cancer at
high risk of recurrence (i.e must have stage T2-T4b and M0 disease)
4. I confirm that the patient has HER2 3+ by IHC or FISH/CISH positive disease
5. I confirm that the patient has a baseline LVEF greater than or equal to 55%
8. I can confirm that the patient will receive a maximum of 4 cycles of pertuzumab if given with single agent
docetaxel chemotherapy plus trastuzumab as part of sequential anthracycline/docetaxel regimen OR
maximum of 6 cycles of pertuzumab only if given with combination of docetaxel and carboplatin
chemotherapy plus trastuzumab
Please indicate below the maximum number of cycles of pertuzumab it is planned for the patient to receive:
4 cycles
6 cycles
9. I confirm the licensed dose and frequency of pertuzumab will be used.
10. What is the acquisition cost of the drug including VAT (if applicable)?
£ per month:
Commissioners will complete if cost not known as this will allow us to ensure budgets are allocated
appropriately.
Yes
No