Download 1st Line in Combination with Gemcitabine

National Cancer Drugs Fund Application Form –
Albumin bound Paclitaxel nanoparticles
for advanced adenocarcinoma of the pancreas
(1st Line in Combination with Gemcitabine)
Author(s)
David Thomson
Owner
Chemotherapy Clinical Reference Group
Version Control
Version Control
Date
Revision summary
Ver0.1
11 Mar 2014
Draft for discussion
Ver1.0
18 Mar 2014
Final draft for publication
Change to current version
Criteria
Changes
N/A
N/A – version 1.0
National Cancer Drugs Fund – Application Form 18 March 2014
Albumin bound Paclitaxel nanoparticles for advanced adenocarcinoma of the pancreas ver1.0
1st Line in Combination with Gemcitabine
Page 1
National Cancer Drugs Fund Application Form –
Albumin bound Paclitaxel nanoparticles
for advanced adenocarcinoma of the pancreas
(1st Line in Combination with Gemcitabine)
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.
Approved Treatment Required for Albumin bound Paclitaxel nanoparticles for
advanced adenocarcinoma of the pancreas – 1st Line in Combination with
Gemcitabine
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. Histologically or cytologically confirmed adenocarcinoma of the pancreas
3. Stage IV disease (patients with locally advanced disease are ineligible)
4. PS 0 or 1
5. No previous chemotherapy for advanced disease
6. No previous chemotherapy for early disease unless given as a radiation sensitiser
at least 6 months previously
Consultant Approval (email authority)
Patient Consent Obtained (date of letter – copy to be retained on patient file)
National Cancer Drugs Fund – Application Form 18 March 2014
Albumin bound Paclitaxel nanoparticles for advanced adenocarcinoma of the pancreas ver1.0
1st Line in Combination with Gemcitabine
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 (please tick
the relevant box)*
HRG Code
25.9 - Malignant neoplasm of pancreas, unspecified
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 18 March 2014
Albumin bound Paclitaxel nanoparticles for advanced adenocarcinoma of the pancreas ver1.0
1st Line in Combination with Gemcitabine
Page 3