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

APPLICATION FORM to access Interim Cancer Drug Fund
Only fully completed forms will be accepted.
This route of funding applies for the list of drugs identified by the
London Cancer New Drugs for Funding when used in accordance with the previously agreed and listed criteria. All eligibility criteria listed below MUST apply to the patient.
Name of Drug(s), Dose(s) and schedule: / Sunitinib 37.5mg orally Once Daily
Indication: / Unresectable or metastatic pancreatic neuroendocrine tumours (excluding poorly differentiated) with disease progression
Drug(s)/Regimen used in combination: / Single agent / Y/N
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 differentiated tumours) / Y/N
Patient has advanced/metastatic or otherwise unresectable disease. / Y/N
Patient has documented disease progression within the previous 12 months assessed according to RECIST criteria or symptomatic / Y/N
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 tumour / Y/N
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 oncologist qualified in the use of systemic anticancer therapy. / Y/N
Primary Diagnosis: ICD10 Code, Please specify, if not known enter ‘NK’
Number of cycles intended (or until progression) / Frequency of cycles / Every 28 days
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
(Block Capitals) / Consultant Contact details (email/phone)
Date of completion
Consultant signature
1. Enter electronic signature OR
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:
Application approved on behalf of Cancer Network Management Team
Approved by Name and Designation
Signature, Date of approval & copy sent to London CDF audit office
PCT / Cancer Network / Trust
Bexley / South
East London / Guy's & St Thomas'
Bromley / King's College Hospital
Greenwich / Lewisham Healthcare Trust
Lambeth / South London Healthcare @ PRUH
Lewisham / South London Healthcare @ QEW
Southwark / South London Healthcare @ QMS
Barnet / North
Central London and West Essex / Barnet & Chase Farm
Enfield / North Middlesex
Haringey / Princess Alexandra Harlow (PAH)
Camden / Royal Free
Islington / UCLH
(West Essex) / Whittington
Barking & Dagenham / North
East London / BHR
City & Hackney / Barts and The London
Havering / Homerton
Newham / Newham
Redbridge / Whipps Cross
Tower Hamlets
Waltham Forest
Brent / North
West London / Chelsea & Westminster
Ealing / Ealing
Hammersmith & Fulham / Hillingdon
Harrow / Imperial
Hillingdon / Northwick PaArk
Hounslow / West Middlesex
Kensington & Chelsea
Westminster
Croydon / South
West London / Epsom & St Helier
Kingston / Croydon
Richmond and Twickenham / Kingston
Sutton and Merton / St Georges
Wandsworth / RMH
Cancer
Network / Application forms available at / Applications to,
e-mail / Applications to, Fax / Telephone
contact
South
East London / http://www.selcn.nhs.uk/content/dynamic.asp?id=869&dynamic_id=88&sn=Cancer%20Drugs%20Fund%20documents / / 0207 188 7120 / Jacky Turner
0207 188 7090
North
Central London / http://www.nlcn.nhs.uk/interim-cancer-drugs-fund / nclcdfrequests
@nhs.net / Applications not
accepted by Fax / Dermot Ball
0207 685 6212
North
East London / http://www.nelcn.nhs.uk/content/projects.asp?
projectid=128 / btl-tr.icdfnelcn
/ Applications not
accepted by Fax / Raj Nijjar
0207 377 7241
North
West London / http://www.nwlcn.nhs.uk/Healthcare%20Professionals/Reference%20Library/interim-cancer-drug-fund-2010.htm / wms-pct.cancerdrug
/ Applications not
accepted by Fax / Pauline McCalla
0203 350 4552
South
West London / Available via individual Trust intranet sites / smpt.ICDFrequests
/ Applications not
accepted by Fax / Susan Kilby 0208 407 3929

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