National Cancer Drugs Fund Application Form –
Bevacizumab
for low grade gliomas of childhood and young adults
(3rd Line in Combination with Irinotecan)
Author(s)
David Thomson
Owner
Chemotherapy Clinical Reference Group
Version Control
Version Control
Date
Revision summary
Ver0.1
11 Mar 2014
Draft for discussion
Ver1.0
18 Mar 2014
Final draft for publication
Ver1.1
14 Jul 2014
Addition of section re-SACT and monitoring
Ver1.2
12 Jan 2015
Removal of age criteria; addition of SACT compliance
Change to current version
Criteria
Changes
3
Age limit removed
9
New criteria re- SACT compliance
National Cancer Drugs Fund – Application Form 12 January 2015
Bevacizumab for low grade gliomas of childhood and young adults
3rd Line in Combination with Irinotecan
Page 1
National Cancer Drugs Fund Application Form –
Bevacizumab
for low grade gliomas of childhood and young adults
(3rd Line in Combination with Irinotecan)
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.
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.
Approved Treatment Required for Bevacizumab for low grade gliomas of childhood
and young adults – 3rd Line in Combination with Irinotecan
TICK
All 9 conditions must be met
1. Application made by and first cycle of systemic anti-cancer therapy to be prescribed
by a consultant paediatric specialist specifically trained and accredited in the use of
systemic anti-cancer therapy
2. Progressive low grade glioma
3. No previous treatment with either irinotecan or bevacizumab
4. Irinotecan and bevacizumab to be the 3rd or further line of therapy
5. A maximum of 12 months duration of treatment to be used with a re-application
required at 6 months
6. Consent with the parent/guardian to specifically document the unknown long term
toxicity of this combination, particularly on growth and ovarian function
7. To be used within the treating Trust’s governance framework, as Bevacizumab and
Irinotecan are not licensed in this indication in children
8. The treating Trust has to formally agree to comply with full SACT dataset collection
9. In the period immediately prior to the application for irinotecan and bevacizumab,
the appropriate specialist MDT has considered the use of proton beam
radiotherapy.
NOTE: Bevacizumab is ONLY approved for use in combination with combination
chemotherapy and is not approved for use as a single agent maintenance therapy
National Cancer Drugs Fund – Application Form 12 January 2015
Bevacizumab for low grade gliomas of childhood and young adults
3rd Line in Combination with Irinotecan
Page 2
NOTE: Additional data on long term toxicity must be collected by the paediatric oncology
community
Consultant Approval (email authority)
Patient Consent Obtained (date of letter – copy to be retained on patient file)
National Cancer Drugs Fund – Application Form 12 January 2015
Bevacizumab for low grade gliomas of childhood and young adults
3rd Line in Combination with Irinotecan
Page 3
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*
Mandatory - NHS No*:
Mandatory – Patients
date of birth*
Optional – Hospital No.
Clinical Commissioning
Group*
Patient’s GP*
(name, address,
telephone)
Name:
Hospital:
Address:
Post Code:
Telephone:
Nhs.net
NHS No:
DOB:
Hospital No:
CCG Name:
Name:
Address:
Post Code:
ICD-10 Code (please tick
the relevant box)*
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 12 January 2015
Bevacizumab for low grade gliomas of childhood and young adults
3rd Line in Combination with Irinotecan
Page 4