Download VAN1_v2.2_Vandetanib_MTC

National Cancer Drugs Fund Application Form –
Vandetanib
For the 1st Line Treatment of Medullary Thyroid Cancer
Author(s)
David Thomson
Owner
Chemotherapy Clinical Reference Group
Version Control
Version Control
Date
Revision summary
Ver0.1
10 Mar 2013
Draft for discussion
Ver1.0
01 Apr 2013
Final draft for publication
Ver1.1
10 May 2013
Update – addition of criteria 1.
Ver2.0
18 Mar 2014
Update – criteria aligned with those of Cabozantinib.
Ver2.1
14 Jul 2014
Addition of section re-SACT and monitoring
Ver2.2
29 Jul 2016
Addition of new criteria
Change to current version
Criteria
Changes
3
New addition
National Cancer Drugs Fund – Application Form 29 Jul 2016
Vandetanib for Medullary Thyroid Cancer
Page 1
National Cancer Drugs Fund Application Form –
Vandetanib
For the 1st Line Treatment of Medullary Thyroid Cancer
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 Vandetanib for Medullary Thyroid Cancer
TICK
All 4 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, unresectable, locally advanced or metastatic
medullary thyroid cancer
3. 1st line indication
4. Progressive and symptomatic disease
5. No previous tyrosine kinase therapy unless intolerant of cabozantinib within 3
months of starting therapy and toxicity which cannot be managed by dose
delay or dose modification and in the absence of disease progression on
cabozantinib
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
Vandetanib for Medullary Thyroid Cancer
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*
C73 – Malignant neoplasm of thyroid gland
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
Vandetanib for Medullary Thyroid Cancer
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