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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
FORM to access Interim
Cancer Drug Fund
2
Name of Drug(s), APPLICATION
Dose(s) and
Eribulin
1.23 forms
mg/m
(equivalent
to 1.4 mg/m2 eribulin
Only
fully
completed
will
be
accepted.
schedule:
This route of funding
appliesintravenously
for the list of drugson
identified
mesylate)
Daysby1the
and 8 of every 21London Cancer New Drugs for Funding when used in accordance with the previously agreed and
day cycle.
listed criteria. All eligibility criteria listed below MUST apply to the patient.
Indication:
Locally advanced or metastatic breast cancer who have
progressed after at least two chemotherapeutic regimens for
advanced disease. Prior therapy should have included an
anthracycline and a taxane unless patients were not suitable
for these treatments.
Drug(s)/Regimen used in
combination:
Regimen Name (OPCS v 4.6)
Line of treatment
Y/N
Single agent
Not available
3rd or subsequent line (Please specify)
Estimated Cost of CDF drug treatment (per Cycle) BNF costs plus VAT at 20%
NB, If patient specific costs are required for local purposes, please enter here:
(Rounded to the nearest vial size, plus VAT at 20%)- Enter N/A if section does NOT Apply
£2254 per cycle
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 breast ICD10 Code C50
Positive diagnosis of advanced or metastatic Breast Cancer
Previous treatment with anthracycline or patient unsuitable for treatment with
anthracycline
Previous treatment with taxane or patient unsuitable for treatment with taxane
Patient has received at least two chemotherapeutic regimens for advanced disease.
Patient has progressed within 6 months of last chemotherapy
Patient has ECOG performance status < 2
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
Y/N
Number of cycles intended (or until
progression)
Proposed Treatment start date
3 weekly
Frequency of
cycles
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Patient Details
Patient NHS No.
Registered GP name
Patient Hospital No.
GP post code
Patient initials
Patient Date of Birth
Patient’s PCT
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)
CDF_Eribulin_mBr_V1.1_ April 2012
Page 1 of 3
Consultant signature
1. Enter electronic signature OR
Date of completion
2. Print name & submit e-mail from
Consultant, or with e-mail
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]
PCT
Cancer Network
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
South
East London
North
Central London and West Essex
North
East London
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
North
West London
Epsom & St Helier
Croydon
Kingston
St Georges
South
West London
Wandsworth
RMH
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
CDF_Eribulin_mBr_V1.1_ April 2012
Page 2 of 3
Cancer
Network
Application forms available at
Applications to,
e-mail
Applications
to, Fax
Telephone
contact
South
East London
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
North
Central London
http://www.nlcn.nhs.uk/interim-cancer-drugs-fund
nclcdfrequests
@nhs.net
Applications not
accepted by Fax
Dermot Ball
0207 685 6212
North
East London
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
Susan Kilby 0208
407 3929
CDF_Eribulin_mBr_V1.1_ April 2012
Page 3 of 3
Raj Nijjar
0207 377 7241