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National Cancer Drugs Fund Application Form – Cetuximab for Metastatic Colorectal Cancer (1st Line in Combination with Irinotecan Based Chemotherapy) 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 Cetuximab for Metastatic Colorectal Cancer – 1st Line in Combination with Irinotecan Based Chemotherapy 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. Metastatic colorectal cancer 3. 1st line indication 4. Patients with wild-type KRAS 5. Given in combination with Irinotecan-based combination chemotherapy 6. Not eligible for NICE TA176 approved indications (including patients who have not progressed despite receiving the NICE approved 16 weeks treatment) 7. No previous treatment with Cetuximab NOTE: Cetuximab is not approved for use with oxaliplatin-based combination or single agent fluoropyrimidine chemotherapy Note: No treatment breaks of more than 4 weeks beyond the expected cycle length are allowed (to allow any toxicity of current therapy to settle or in the case of intercurrent comorbidities) Note: If excessive toxicity with irinotecan, cetuximab can be continued with a fluoropyrimidine alone until disease progression only. Consultant Approval (email authority) National Cancer Drugs Fund – Application Form 1 April 2013 Cetuximab for Metastatic Colorectal Cancer 1st Line in Combination with Irinotecan Based Chemotherapy Page 1 Patient Consent Obtained (date of letter – copy to be retained on patient file) National Cancer Drugs Fund – Application Form 1 April 2013 Cetuximab for Metastatic Colorectal Cancer 1st Line in Combination with Irinotecan Based Chemotherapy Page 2 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 (please tick the relevant box)* C18 - Malignant neoplasm of colon C19 - Malignant neoplasm of rectosigmoid junction C20 - Malignant neoplasm of rectum 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 Cetuximab for Metastatic Colorectal Cancer 1st Line in Combination with Irinotecan Based Chemotherapy Page 3