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 schedule: / Axitinib 5mg orally Twice daily
Drug(s)/Regimen used in combination: / single agent
Indication: / As an option for advanced renal cell carcinoma (RCC) after failure of prior treatment with TKI or cytokine.
Regimen Name (OPCS v 4.6) / NA
Line of treatment / 2nd line / Y/N
Prior therapy / Cytokine
TKI / Y/N
Y/N
Estimated Cost of CDF drug treatment (per 28 day Cycle) BNF costs plus VAT at 20% / £4220
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
Primary Diagnosis: Malignant neoplasm of the kidney, except renal pelvis, ICD10 CodeC64 / Y/N
Patient has histologically or cytologically confirmed renal cell carcinoma / Y/N
Patient has failed on 1st line cytokineor one line of treatment with a Tyrosine Kinase Inhibitor / Y/N
An assessment of potential need for co-administration with inhibitors or inducers of CYP3A4/5 and, to a lesser extent, CYP1A2, CYP2C19, and uridine diphosphate-glucuronosyltransferase (UGT) 1A1, will be undertaken in this patient and doses adjusted accordingly. / Y/N
No severe liver impairment / Y/N
ECOG Performance Status 1 (unless due to longstanding physical disability) without significant co-morbidity / Y/N
Treatment agreed at anMDT / 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
Number of cycles intended (up to 8 cycles) / Frequency of cycles / Every 28 days
Proposed Treatment start date
Patient Details
Patient NHS No. / Registered GP name
PatientHospital 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
Cancer
Network / Application forms available at / Applications to,
e-mail / Applications to, Fax / Telephone
contact
South
East London / / / 0207 188 7120 / Jacky Turner
0207 188 7090
North
Central London / / nclcdfrequests
@nhs.net / Applications not
accepted by Fax / Dermot Ball
0207 685 6212
North
East London /
projectid=128 / btl-tr.icdfnelcn
/ Applications not
accepted by Fax / Raj Nijjar
0207 377 7241
North
WestLondon / / 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 / Pauline McCalla
0203 350 4552
PCT / Cancer Network / Trust
Bexley / South
East London / Guy's & St Thomas'
Bromley / King's CollegeHospital
Greenwich / Lewisham Healthcare Trust
Lambeth / South LondonHealthcare @ PRUH
Lewisham / South LondonHealthcare @ QEW
Southwark / South LondonHealthcare @ 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
WalthamForest
Brent / North
WestLondon / ChelseaWestminster
Ealing / Ealing
Hammersmith & Fulham / Hillingdon
Harrow / Imperial
Hillingdon / NorthwickPark
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

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