London Cancer New Drugs Group

Application form to access Cancer Drugs Fund

THIS APPLICATION MUST BE COMPLETED AND APPROVED BY YOUR CANCER NETWORK TEAM BEFORE THE PATIENT IS STARTED ON TREATMENT

APPLICATION FORM to access 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 Group for funding when used in accordance with the previously agreed and listed criteria. All eligibility criteria listed below MUST apply to the patient.
Definition:
A “Near-Off-Label indication” is where the indication is molecularly specific and the indication bears a biological similarity to the indication for which the drug holds a Marketing Authorisation in the UK.
NB Where the application to the CDF for a Near Off-label indication does not exactly meet the indications listed below, the application will be assessed individually by the London Cancer Drugs Fund Panel prior to authorisation.
Rituximab / Dose per m2: / Schedule
Number of Doses of Rituximab intended
Drug(s) used in combination:
Please specify Regimen
Indication (Insert indication from list in Appendix 1 to this form):
Please specify
Line of treatment:
Please specify
Cost of treatment (per Dose)
Calculated as 1.75m2 x 375mg = 675mg, inc wastage = 700mg, +VAT @ 20% / £1467 per dose
If Dose differs from above, enter revised Cost per Dose
Please indicate whether the patient meets the following LCNDG CDF criteria / Please insert Yes/No
Patient has confirmed CD20 expression / Y/N
Patient indication is listed in Appendix 1 to this form / Y/N
Patient’s treatment was decided at an appropriate Multidisciplinary Team meeting. / Y/N
This patient’s treatment will be prescribed and managed under the supervision of a haemato- oncologist qualified in the use of systemic anticancer therapy. / Y/N
Primary Diagnosis: ICD10 Code Please specify, See table below
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
The form may be e-mailed, an electronic copy of the Consultant’s signature is acceptable.
Contact details
Approved by London CDF panel, if applicable
& Date
Application approved on behalf of Cancer Network Management Team
If the form is e-mailed, and electronic copy of the Consultant’s signature is acceptable
Contact details:
Approved by Name and Designation
Signature, Date of approval and 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 Park
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

Appendix 1

Drug / Indication / ICD10 Code
Rituximab +chemo / 2nd or 3rd line Relapsed Refractory Mantle Cell Lymphoma / C83.1
Rituximab / 1st line HIV associated Castleman’s Disease / B21.7
Rituximab +HyperCVAD/R-HDMTX-AraC or R-CHOP / 1st line Mantle Cell Lymphoma / C83.1
Rituximab +/- Chemo / 1st Line of treatment-Waldenstrom's Macroglobulinaemia (including lymphoplasmacytic lymphomas) / C88
Rituximab + Chemo / 1st line Splenic Marginal Zone Lymphoma / C83
Rituximab + Chemo / Relapsed DLBCL in patients suitable for consolidation with an Auto transplant / C83.3
R-CHOP / DLBCL ( bulky stage I) / C83.3
R-ABVD, RCHOP / Nodular Lymphocyte Predominant Hodgkin’s Disease – advanced stage (nb CD20+ve) / C81
Rituximab + Chemo / Relapsed MALT lymphoma / C88.4
Rituximab +/- Chemo / Resistant Hairy cell leukemia, relapsed/ refractory to either Cladribine or Pentostatin / C91.4

CDF_Near_off-Label_Rituximab_V1.5_April_2012 Page 1 of 4

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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