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East Midlands Cancer Drug Fund (EMCDF) Application for Brentuximab for Histologically confirmed CD30-positive relapsed or refractory classical Hodgkin’s lymphoma PATIENT PERSONAL DETAILS Patient Name: Date of Birth: NHS Number: Primary Care Trust: GP Name & Practice Details: Please note that all personal information will be removed prior to the consideration by the EMCDF panel DETAILS OF REQUESTER (include referring clinician contact details in the event of query or need for clarification) Name: Designation: Trust: Contact phone number: Secure email for correspondence: Provider Trust Chemotherapy Lead Yes No (or equivalent) Support: Name of Trust Chemotherapy Lead (or equivalent): CLINICAL DETAILS 0 2 ECOG Performance status Lack of chemo responsiveness to Autologous SCT (stem cell transplant) ie refractory or relapse Failed at least two prior multi-agent chemotherapy regimens in patients who are not ASCT candidates Patient has a life expectancy of > 3 months not eligible or unable to participate in a clinical trial of brentuximab vedotin because of location / trial availability / patient choice 1 3 Yes No Yes No Yes Yes No No CONSENT I confirm that this Request has been discussed in full with the patient and that the patient is aware that they are consenting for the Cancer Drugs Fund Panel to access confidential clinical information held by clinical staff involved with their care about them as a patient to enable full consideration of this funding request Signature of Requester: Date: MONITORING RESPONSE How will the benefits of the procedure/treatment be measured? (incl. frequency of assessments) The efficacy of treatment will be monitored using standard imaging techniques (predominantly CT scanning). The standard for patients on treatment is by 12 weeks of treatment and subsequent imaging every 12 weeks after this. What ‘stopping’ criteria will be in place to decide when the treatment is ineffective? Treatment is continuous & indefinite until tumour progression or toxicity means drug is stopped. Please note that regular updates on response to treatment will be requested by the Cancer Drugs Fund Panel and/or EMSCG, a response is mandatory. E-mail completed application forms to [email protected] Document Code: EMCN-DC-0146-12 Written By: C Ward Date of Issue: 22nd March 2012 Authorised By: EMCDAG Review Date: April 2014 Page Number: 1 of 1