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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