Download National Cancer Drugs Fund Application Form – Cetuximab for

National Cancer Drugs Fund Application Form –
Cetuximab
for Metastatic Colorectal Cancer
(3rd or Subsequent Line as a Single Agent Treatment in
Patients Not Treated to Progression Under NICE TA176)
Author(s)
David Thomson
Owner
Chemotherapy Clinical Reference Group
Version Control
Version Control
Date
Revision summary
Ver2.0
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
Page 1
Cetuximab for Metastatic Colorectal Cancer
3rd and Subsequent Line as a Single Agent Treatment in Patients Not Treated to Progression Under NICE
TA176
National Cancer Drugs Fund Application Form –
Cetuximab
for Metastatic Colorectal Cancer
(3rd or Subsequent Line as a Single Agent Treatment in Patients Not Treated to
Progression Under NICE TA176)
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 Cetuximab for Metastatic Colorectal Cancer – 3rd
and Subsequent Line as a Single Agent Treatment in Patients Not Treated to
Progression Under NICE TA176
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. a) 3rd line indication
b) 4th line indication
4. Patients with wild-type RAS
5. Performance status of 0 or 1
6. Response to previous Cetuximab in the context of NICE TA176 and
discontinuation at 16 weeks for consideration of surgery (and therefore not
treated to disease progression)
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)
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
Page 2
Cetuximab for Metastatic Colorectal Cancer
3rd and Subsequent Line as a Single Agent Treatment in Patients Not Treated to Progression Under NICE
TA176
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
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
Page 3
Cetuximab for Metastatic Colorectal Cancer
3rd and Subsequent Line as a Single Agent Treatment in Patients Not Treated to Progression Under NICE
TA176