Download East Midlands Cancer Drug Fund (EMCDF)

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