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National National Cancer Drugs Fund Application Form – Bevacizumab for Stage IVB, Recurrent, or Persistent Cervical Cancer (1st line treatment) Author(s) David Thomson Owner Chemotherapy Clinical Reference Group Version Control Version Control Date Revision summary Ver0.1 24 Feb 2014 Draft for discussion Ver1.0 27 Feb 2014 Final draft for publication Ver1.1 28 Mar 2014 Update – heading updated Ver1.2 14 Jul 2014 Addition of section re-SACT and monitoring Change to current version Criteria Changes N/A Addition of section re-SACT and monitoring National Cancer Drugs Fund – Application Form 14 July 2014 Bevacizumab for Stage IVB, Recurrent, or Persistent Cervical Cancer – 1st line Page 1 National Cancer Drugs Fund Application Form – Bevacizumab for Stage IVB, Recurrent, or Persistent Cervical Cancer (1st line treatment) 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 Bevacizumab for Stage IVB, Recurrent, or Persistent cervical cancer – 1st line TICK All 8 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 confirmed carcinoma of the cervix. 3. Indication for 1st line palliative chemotherapy. 4. Primary stage IVB, recurrent, or persistent disease not amenable to curative treatment with surgery and/or radiotherapy. 5. Given with Paclitaxel and either Cisplatin or Carboplatin. 6. PS 0 or 1 7. No previous treatment with bevacizumab or other anti-VEGF therapy 8. No contra-indication to the use of bevacizumab 9. Bevacizumab dose to be 15mg/kg every 3 weeks Note: Bevacizumab is ONLY approved for use in combination with combination chemotherapy and is not approved for use as a single agent maintenance therapy Note: Bevacizumab should be discontinued due to toxicity or disease progression, whichever occurs first. 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 Bevacizumab for Stage IVB, Recurrent, or Persistent Cervical Cancer – 1st line 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* C53.9 – Malignant neoplasm of cervix uteri, unspecified 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 Bevacizumab for Stage IVB, Recurrent, or Persistent Cervical Cancer – 1st line Page 3