London Cancer New Drugs Group

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

Only fully completed forms will be accepted.

Name of Drug(s), Dose(s) and schedule: / mFOLFOX- Oxaliplatin 85mg/m2 IV D1, 5-Flourouracil 400mg/m2 IV D1, Calcium folinate 350mg IV D1, 5-Fluorouracil 2400mg/m2 IV D 1 over 46hrs every 2 weeks
Indication: / Pancreatic Cancer
Drug(s)/Regimen used in combination: / See above
Regimen Name (OPCS v 4.6) / mFOLFOX
(listed as Oxaliplatin +Modified de Gramont in OPCS list)
Line of treatment / 2nd line
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 pancreas, ICD10 Code -C25 / Y/N
Histologically and cytologically confirmed measurable metastatic adenocarcinoma of the pancreas / Y/N
Documented disease progression following gemcitabine based chemotherapy in the advanced setting / Y/N
PS 1 / Y/N
This patient’s treatment will be managed under the supervision of an oncologist, competent in the use of systemic anti-cancer therapy / Y/N
Number of cycles intended (or until progression) / Frequency of cycles / 2 weekly
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
Enter electronic signature OR
Print name & submit e-mail from Consultant, or with e-mail confirmation of consultant initiation of treatment OR
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
West London / / 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
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

CDF FOLFOX 2nd line pancreas v1.0, June 2012Page 1 of 3