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Application form and decision aid to add a treatment to the approved EoE Cancer Drug Fund list Only fully completed forms will be accepted Name of Consultant Requesting Contact Email Trust base Cancer Network Date Information on proposed treatment: Name of proposed CDF Drug, Dose & Schedule: Drugs used in combination (do not include routine premeds). Dose & schedule: Licensed Indication: Proposed Indication: Line of treatment: Average/median number of cycles (from trials): Total number of cycles intended: Frequency of Cycles: Cost per cycle (including VAT) (Use 1.8m2 /70kg): Cost for entire treatment course (Avg no of cycles from trials X cost per cycle) (including VAT) (Use 1.8m2 /70kg):: Expected number if patients per year per 100,000 population: Addition of treatment to be added to EOE CDF list supported by which NSSGs/ networks in EoE (list): Information on patient specific eligibility criteria which will be used on master form: Please enter Y to confirm 1. Treatment agreed by MDT 2. 3. 4. 5. 6. 7. 8. 9. 10. Example eligibility criteria ECOG 0 to 1 without significant comorbidities (suggestion) – but essential to have some performance status criteria Treatment agreed by MDT (essential) Simple response measures will be repeated and reviewed every cycle (suggestion) Complex imaging will be repeated and reviewed every 3 months(suggestion) Therapy will be discontinued at the first evidence of disease progression on RECIST criteria or on the development of new or progressive symptoms (suggestion) 234823832 Page 1 of 2 April 2012 Information on clinical effectiveness: Has the drug been reviewed by NICE and rejected on the basis of lack of evidence of cost effectiveness but stated as clinically effective? Yes / No If no: is NICE pending? Yes / No Has the drug been rejected by NICE on the basis of lack of clinical evidence? Has the drug been rejected by NICE on the basis that the manufacturer did not provide evidence submission? Yes / No Has the drug been reviewed by LCNDG for the requested indication? Is the drug part of a trial? Is there another reason for the request? (expand as needed): Yes / No If yes: state NICE guidance reference If yes: application is unlikely to be approved If yes: application is unlikely to be approved Yes / No State outcome and colour code assigned Yes / No If yes: application is unlikely to be approved Yes / No If yes: please state in full below Clinical Data supporting submission: (expand as needed and include information on overall survival, progression-free survival and improved quality of life where possible): Please note all completed forms must be emailed to: [email protected] Information on progression of application (EoE use only): Application sent to EoE CDF for consideration: Date received by EoE Date reviewed How reviewed (clinical panel / meeting etc) Summary of comments Outcome Name Designation Date EOE CDF List No. (year/next number) On approved list and on website (date) Local networks informed (date) Application Outcome: Approved / rejected (delete) Please note all completed forms must be emailed to: [email protected] 234823832 Page 2 of 2 April 2012