Download National Cancer Drugs Fund Application Form – Panitumumab for

National Cancer Drugs Fund Application Form –
Panitumumab
for Metastatic Colorectal Cancer
(1st Line in Combination with FOLFOX4/ FOLFOX6 or
OxMdG Chemotherapy)
Author(s)
David Thomson
Owner
Chemotherapy Clinical Reference Group
Version Control
Version Control
Date
Revision summary
Ver3.0
14 Jul 2014
Introduction of version control and addition of section re-SACT
and monitoring
Change to current version
Criteria
Changes
N/A
Introduction of version control and addition of section re-SACT and monitoring
National Cancer Drugs Fund – Application Form 14 July 2014
Panitumumab for Metastatic Colorectal Cancer
1st Line in Combination with FOLFOX Chemotherapy
Page 1
National Cancer Drugs Fund Application Form –
Panitumumab
for Metastatic Colorectal Cancer
(1st Line in Combination with FOLFOX4/ FOLFOX6 or OxMdG 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.
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.
Approved Treatment Required for Panitumumab for Metastatic Colorectal Cancer –
1st Line in Combination with the following regimens: FOLFOX4 or FOLFOX6 or
OxMdG Chemotherapy
TICK
All 6 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 RAS
5. Given in combination with the FOLFOX4 or FOLFOX6 or OxMdG chemotherapy
regimens
6. No previous treatment with Panitumumab or Cetuximab
NOTE: Panitumumab is not approved for use as 1st line treatment with other oxaliplatinbased regimens, irinotecan-based combinations, or upfront single agent fluoropyrimidine
chemotherapy and is not approved for use in any line of therapy after 1st line treatment.
Specifically in this setting panitumumab is not to be used with capecitabine and oxaliplatin
combinations.
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)
National Cancer Drugs Fund – Application Form 14 July 2014
Panitumumab for Metastatic Colorectal Cancer
1st Line in Combination with FOLFOX Chemotherapy
Page 2
Note: If excessive toxicity with oxaliplatin, panitumumab can be continued with a
fluoropyrimidine alone until disease progression only.
Note: Not to be used with capecitabine and oxaliplatin combinations
Consultant Approval (email authority)
Patient Consent Obtained (date of letter – copy to be retained on patient file)
National Cancer Drugs Fund – Application Form 14 July 2014
Panitumumab for Metastatic Colorectal Cancer
1st Line in Combination with FOLFOX Chemotherapy
Page 3
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 14 July 2014
Panitumumab for Metastatic Colorectal Cancer
1st Line in Combination with FOLFOX Chemotherapy
Page 4