Download BRE2_v2.2_Brentuximab_Hodgkins

National Cancer Drugs Fund Application Form –
Brentuximab
For Hodgkin’s Lymphoma
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
Ver2.1
12 Jan 2015
Added note
Ver2.2
29 Jul 2016
Two new notes added
Change to current version
Criteria
Changes
Note 2
New addition
Note 3
New addition
National Cancer Drugs Fund – Application Form 29 Jul 2016
Brentuximab for Hodgkins Lymphoma
Page 1
National Cancer Drugs Fund Application Form –
Brentuximab
For Hodgkin’s Lymphoma
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 Brentuximab for Hodgkin’s Lymphoma
TICK
All 3 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. Relapsed or refractory CD30+ Hodgkin lymphoma
3. a) Following autologous stem cell transplant (ASCT), OR,
b) Following at least two prior therapies when ASCT or multi-agent
chemotherapy is not a treatment option
NOTE: If a patient has not achieved a partial or complete response after 6 cycles, then
treatment with brentuximab should be discontinued
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
morbidities).
NOTE: Maximum of 16 cycles should be administered
Consultant Approval (email authority)
Patient Consent Obtained (date of letter – copy to be retained on patient file)
National Cancer Drugs Fund – Application Form 29 Jul 2016
Brentuximab for Hodgkins Lymphoma
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*
C81 – Hodgkin Lymphoma
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 29 Jul 2016
Brentuximab for Hodgkins Lymphoma
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