Download Name of Drug(s), Dose(s) and schedule

London Cancer New Drugs Group
Application form for the London Cancer Drugs Fund
THIS APPLICATION MUST BE COMPLETED AND APPROVED BY THE RELEVANT CANCER
NETWORK TEAM BEFORE THE PATIENT IS STARTED ON TREATMENT
Name of Drug(s), Dose(s) and
schedule:
Drug(s)/Regimen used in
combination:
Abiraterone 1000mg orally daily
Indication:
Metastatic castration resistant prostate cancer in
patients who are asymptomatic or mildly
symptomatic after failure of androgen deprivation
therapy in whom chemotherapy is not yet clinically
indicated
Regimen Name (OPCS v 4.6)
Line of treatment
NA
Post androgen deprivation therapy, 2nd or 3rd
line (please specify line of therapy)
With Prednisolone 10mg daily
Estimated Cost of CDF drug treatment (per 28 day Cycle) BNF costs plus VAT at 20%
NB, If patient specific costs are required for local purposes, please enter here:
Enter N/A if section does NOT Apply
£3282
Will this drug be provided to the patient via a homecare provider
Y/N
Please indicate whether the patient meets the following LCNDG CDF criteria
Please
insert
Yes/No
Primary Diagnosis: Malignant neoplasm of the prostate, ICD10 Code C61
Patient has castration-resistant prostate cancer, which is either pathologically confirmed or
clinically confirmed with PSA > 100ng/mL with sclerotic bone metastases
Patient has documented disease progression during or after failure of androgen deprivation
therapy
Patient is asymptomatic or mildly symptomatic, defined as not requiring opiates for disease
related pain
Patient has NO visceral organ disease
Chemotherapy is not clinically indicated at this time
Ventricular ejection fraction > 50% or NYHA Class III or IV heart failure has not been
established.
No moderate or severe hepatic dysfunction or uncontrolled hypertension
ECOG Performance Status < 1 (unless due to longstanding physical disability) without
significant co-morbidity
Treatment agreed at an MDT
This patient’s treatment will be prescribed and managed under the supervision of an
oncologist qualified in the use of systemic anticancer therapy.
Y/N
Number of cycles intended (up to 8 cycles)
Every 28
days
Frequency of
cycles
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Proposed Treatment start date
Patient Details
Patient NHS No.
Registered GP name
Patient Hospital
No.
GP post code
Patient initials
Patient Date of Birth
Patient’s PCT
CDF_Abiraterone CRPC_pre-chemo_V1.0 Feb 2013
3
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The consultant agrees to provide outcome data in relation to this patient’s treatment, on completion of
therapy.
Failure to submit an end of treatment summary will result in suspension of payment to the Trust.
Trust
Contact details of Trust
Oncology Pharmacist
Consultant
Consultant Contact
details (email/phone)
(Block Capitals)
Consultant signature
1. Enter electronic signature
OR
Date of completion
2. Print name & submit e-mail
from Consultant, or with email confirmation of
consultant initiation of
treatment OR
3. Print form, consultant to
sign and Fax (SELCN Only)
Submit completed application form to the Cancer Network Management team
If the form is e-mailed, an electronic copy of the Consultant’s signature is acceptable.
Contact details: [email protected]
Application approved on behalf of Cancer Network Management Team
Approved by Name and Designation
Signature, Date of approval & copy sent to London CDF audit
office
Cancer
Network
Applications to,
e-mail
Applications
to, Fax
Telephone
contact
http://www.selcn.nhs.uk/content/dynamic.asp?id=869&dyna
mic_id=88&sn=Cancer%20Drugs%20Fund%20documents
[email protected]
0207 188 7120
Jacky Turner
0207 188 7090
http://www.nlcn.nhs.uk/interim-cancer-drugs-fund
nclcdfrequests
@nhs.net
Applications not
accepted by Fax
Dermot Ball
0207 685 6212
http://www.nelcn.nhs.uk/content/projects.asp?
projectid=128
btl-tr.icdfnelcn
[email protected]
Applications not
accepted by Fax
North
West
London
http://www.nwlcn.nhs.uk/Healthcare%20Professionals/Refer
ence%20Library/interim-cancer-drug-fund-2010.htm
wms-pct.cancerdrug
[email protected]
Applications not
accepted by Fax
Pauline McCalla
0203 350 4552
South
West
London
Available via individual Trust intranet sites
smpt.ICDFrequests
[email protected]
Applications not
accepted by Fax
Pauline McCalla
0203 350 4552
South
East
London
North
Central
London
North
East
London
Application forms available at
CDF_Abiraterone CRPC_pre-chemo_V1.0 Feb 2013
3
Raj Nijjar
0207 377 7241
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PCT
Bexley
Bromley
Greenwich
Lambeth
Lewisham
Southwark
Barnet
Enfield
Haringey
Camden
Islington
(West Essex)
Barking & Dagenham
City & Hackney
Havering
Newham
Redbridge
Tower Hamlets
Waltham Forest
Brent
Ealing
Hammersmith & Fulham
Harrow
Hillingdon
Hounslow
Kensington & Chelsea
Westminster
Croydon
Kingston
Richmond and Twickenham
Sutton and Merton
Cancer Network
South
East London
North
Central London and West Essex
North
East London
North
West London
South
West London
Wandsworth
CDF_Abiraterone CRPC_pre-chemo_V1.0 Feb 2013
3
Trust
Guy's & St Thomas'
King's College Hospital
Lewisham Healthcare Trust
South London Healthcare @ PRUH
South London Healthcare @ QEW
South London Healthcare @ QMS
Barnet & Chase Farm
North Middlesex
Princess Alexandra Harlow (PAH)
Royal Free
UCLH
Whittington
BHR
Barts and The London
Homerton
Newham
Whipps Cross
Chelsea & Westminster
Ealing
Hillingdon
Imperial
Northwick Park
West Middlesex
Epsom & St Helier
Croydon
Kingston
St Georges
RMH
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