Patient NHS No: / Trust:
Patient Hospital No: / Practice Code:
Patient's Initials and DoB: / GP Postcode:
Choose Consultant:
Consultant Name: / * / Other Contact Details: / *
Notification Email Address:(@NHS.net account ONLY)
Treatment Start Date:Please enter a valid date
BY TICKING THESE BOXES AND SUBMITTING THE APPLICATION THE CLINICIAN IS CONFIRMING THE PATIENT MEETS ALL THE CRITERIA BELOW. IT SHOULD BE NOTED THAT THE SACT DATASET WILL BE USED TO MONITOR THAT THESE CRITERIA ARE BEING MET:
Please indicate whether patient meets the following criteria: / Please tick
- I confirm that an 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
- I confirm that the patient has histologically or cytologically documented oestrogen receptor positive and her-2 negative breast cancer
- I confirm that the patient has had no prior treatment with a CDK 4/6 inhibitor unless either palbociclib has had to be stopped within 3 months of its start solely as a consequence of dose-limiting toxicity and in the clear absence of disease progression or ribociclib has been received as part of any compassionate use scheme and the patient meets all the other criteria
- I confirm that the patient has metastatic breast cancer or locally advanced breast cancer not amenable to curative treatment
- I confirm that the patient is male or is female and either post-menopausal or if pre- or peri-menopausal has undergone ovarian ablation or suppression with LHRH agonist treatment
- I confirm that the patient has had no previous hormone therapy for locally advanced or metastatic disease i.e. is hormone therapy naïve for locally advanced/metastatic breast cancer. Previous hormone therapy with anastrazole or letrozole whether as adjuvant therapy or as neoadjuvant treatment is allowed as long as the patient has had a disease-free interval of 12 months or more since completing treatment with anastrazole or letrozole.
- I confirm that ribociclib will only be given in combination with an aromatase inhibitor
- I confirm that the patient hasan ECOG performance status of 0-2
- I confirm that treatment will continue until there is progressive disease or excessive toxicity or until the patient choosesto discontinue treatment, whichever is the sooner
- I confirm that treatment breaks of up to 6 weeks are allowed, but solely to allow toxicities to settle
- I confirm that ribociclibwill be otherwise used as set out in its Summary of Product Characteristics (SPC)
- What is the acquisition cost of the drug including VAT (if applicable)?
Commissioners will complete if cost not known as this will allow us to ensure budgets are allocated appropriately.