National Cancer Drugs Fund Application Form –

Pazopanib

For Advanced Non-adipocytic Soft Tissue Sarcoma

Instructions to Consultants: Please fill in each section of the form electronically and save the document with your own file name. [If you continue typing the boxes will enlarge to contain the text]. Please send electronically to ______. Please also send copies to your Trust’s link accountant / corporate contracting team.

Security of Patient Identifiable Information: The patient will be identified by their NHS number only. Please do not include any other patient identifiers for confidentiality reasons. All communication must be sent to the Cancer Drugs Fund Office via secure e mail accounts: that is from an nhs.net account to the ______account.

Receipt of Application: The sender of the application will receive an acknowledgement, together with details of the unique Cancer Drugs Fund reference.

Cancer Drugs Fund Policy: To check the status of a particular therapy please check the Cancer Drugs Fund Policy at ______

Applications will be subject to Clinical Audit arrangements.

Approved Treatment Required for Pazopanib for Advanced Non-adipocytic Soft Tissue Sarcoma / TICK
All 4 conditions must be met
1.  Application made by and first cycle of systemic anti-cancer therapy to be prescribed by a consultant specialist specifically trained and accredited in the use of systemic anti-cancer therapy
2.  Histologically confirmed advanced non-adipocytic soft tissue sarcoma
3.  Two previous lines of chemotherapy for advanced soft tissue sarcoma or contraindication or intolerance to chemotherapy
4.  Progression within 6 months of treatment for metastatic disease
Consultant Approval (email authority)
Patient Consent Obtained (date of letter – copy to be retained on patient file)


Proposed Start Date for Therapy (add clinic date)*:

Consultant details* (including signature or email confirmation)
/ Name:
Hospital:
Address:
Post Code:
Telephone:
Nhs.net
Trust Pharmacist -
details of the Trust where the patient will be treated* / Name:
Hospital:
Address:
Post Code:
Telephone:
Nhs.net
Mandatory - NHS No*:
Mandatory – Patients date of birth*
Optional – Hospital No. / NHS No:
DOB:
Hospital No:
Clinical Commissioning Group* / CCG Name:
Patient’s GP*
(name, address, telephone) / Name:
Address:
Post Code:
ICD-10 Code (tick the appropriate box)* / C49 - Malignant neoplasm of other connective and soft tissue
C48 - Malignant neoplasm of retroperitoneum and peritoneum
HRG Code

Completion of items marked with * is mandatory. Failure to complete these items may mean that payment is not made.

National Cancer Drugs Fund – Application Form 1 April 2013 Page 2

Pazopanib for Advanced Non-adipocytic Soft Tissue Sarcoma