Download Exceptional Circumstances Submission Form

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)
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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]
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