London Cancer Networks

London Cancer New Drugs Group Application form for the London Cancer Drugs Fund THIS APPLICATION MUST BE COMPLETED AND APPROVED BY THE RELEVANT CANCER NETWORK TEAM BEFORE THE PATIENT IS STARTED ON TREATMENT Name of Drug(s), Dose(s) and Sunitinib 37.5mg orally Once Daily schedule: Indication: Unresectable or metastatic pancreatic neuroendocrine tumours (excluding poorly differentiated) with disease progression Drug(s)/Regimen used in Single agent Y/N combination: Regimen Name (OPCS v 4.6) Sunitinib Line of treatment 1st or 2nd or 3rd line, please specify Estimated Cost of CDF drug treatment (per Cycle) BNF costs plus VAT at 20% £2825 per 28 days NB, If patient specific costs are required for local purposes, please enter here: Enter N/A if section does NOT Apply Will this drug be provided to the patient via a homecare provider Y/N Please indicate whether the patient meets the following LCNDG CDF criteria Please insert Yes/No Patient has pathologically confirmed pancreatic neuroendocrine tumour (excluding poorly Y/N differentiated tumours) Patient has advanced/metastatic or otherwise unresectable disease. Y/N Patient has documented disease progression within the previous 12 months assessed Y/N according to RECIST criteria or symptomatic Patient has ECOG Performance Status < 1 Y/N No previous treatment with tyrosine kinase or VEGF inhibitors Y/N Patient has received less than 3 previous systemic regimens for pancreatic endocrine Y/N tumour The treatment has been agreed by a specialist NET MDT Y/N This patient’s treatment will be prescribed and managed under the supervision of an Y/N oncologist qualified in the use of systemic anticancer therapy. Primary Diagnosis: ICD10 Code, Please specify, if not known enter ‘NK’ Number of cycles intended (or until Frequency Every 28 days progression) of cycles Proposed Treatment start date

Patient Details Patient NHS No. Registered GP name Patient Hospital No. GP post code Patient initials Patient Date of Birth

Patient’s PCT

The consultant agrees to provide outcome data in relation to this patient’s treatment, on completion of therapy. Failure to submit an end of treatment summary will result in suspension of payment to the Trust. Trust Contact details of Trust Oncology Pharmacist Consultant Consultant Contact details (email/phone) (Block Capitals)

CDF_Sunitinib_pNET_V1.1_ April 2012 Page 1 of 3 Consultant signature 1. Enter electronic signature OR Date of completion 2. Print name & submit e-mail from Consultant, or with e-mail confirmation of consultant initiation of treatment OR 3. Print form, consultant to sign and Fax (SELCN Only)

Submit completed application form to the Cancer Network Management team If the form is e-mailed, an electronic copy of the Consultant’s signature is acceptable.

Contact details: [email protected]

PCT Application approvedCancer Network on behalf of CancerTrust Network Management Team Bexley Guy's & St Thomas' ApprovedBromley by Name and Designation King's College Hospital Greenwich South Lewisham Healthcare Trust Signature,Lambeth Date of approvalEast London& copy sent to LondonSouth CDF London audit Healthcare office @ PRUH Lewisham South London Healthcare @ QEW Southwark South London Healthcare @ QMS Barnet Barnet & Chase Farm Enfield North Middlesex Haringey North Princess Alexandra Harlow (PAH) Camden Central London and West Essex Royal Free Islington UCLH (West Essex) Whittington Barking & Dagenham BHR City & Hackney Barts and The London Havering Homerton Newham North Newham Redbridge East London Whipps Cross Tower Hamlets Waltham Forest Brent Chelsea & Westminster Ealing Ealing Hammersmith & Fulham Hillingdon Harrow North Imperial Hillingdon West London Northwick PaArk Hounslow West Middlesex Kensington & Chelsea Westminster Croydon Epsom & St Helier Kingston Croydon Richmond and Twickenham South Kingston Sutton and Merton West London St Georges Wandsworth RMH

Cancer Applications to, Applications Telephone Network Application forms available at e-mail to, Fax contact http://www.selcn.nhs.uk/content/dynamic.asp? South Jacky Turner id=869&dynamic_id=88&sn=Cancer%20Drugs%20Fund [email protected] 0207 188 7120 East London 0207 188 7090 %20documents CDF_Sunitinib_pNET_V1.1_ April 2012 Page 2 of 3 North nclcdfrequests Applications not Dermot Ball http://www.nlcn.nhs.uk/interim-cancer-drugs-fund Central London @nhs.net accepted by Fax 0207 685 6212 Raj Nijjar North http://www.nelcn.nhs.uk/content/projects.asp? btl-tr.icdfnelcn Applications not 0207 377 7241 East London projectid=128 [email protected] accepted by Fax

http://www.nwlcn.nhs.uk/Healthcare North wms-pct.cancerdrug Applications not Pauline McCalla %20Professionals/Reference%20Library/interim-cancer- West London [email protected] accepted by Fax 0203 350 4552 drug-fund-2010.htm

South smpt.ICDFrequests Applications not Susan Kilby 0208 Available via individual Trust intranet sites West London [email protected] 407 3929 accepted by Fax

CDF_Sunitinib_pNET_V1.1_ April 2012 Page 3 of 3