Ver2.1
Author(s)
Owner
Version Control
Version Control
Ver2.0
David Thomson
Chemotherapy Clinical Reference Group
Date
14 Jul 2014
04 Nov 2015
Revision summary
Introduction of version control and addition of section re-SACT and monitoring
Minor editorial change
Change to current version
Criteria Changes
3 and 4 Criteria 3 becomes criteria 4 and vice versa
National Cancer Drugs Fund
– Application Form 04 November 2015
Bosutinib for Chronic Phase Chronic Myeloid Leukaemia
Intolerance to Dasatinib and Nilotinib
Page 1

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 Bosutinib for Chronic Phase Chronic Myeloid
Leukaemia – Intolerance to Dasatinib and Nilotinib
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. Chronic phase chronic myeloid leukaemia
3. Significant intolerance to nilotinib (Grade 3 or 4 events)
4. Significant intolerance to dasatinib (Grade 3 or 4 adverse events) (if Dasatinib accessed via its current approved CDF indication)
Consultant Approval (email authority)
Patient Consent Obtained (date of letter – copy to be retained on patient file)
TICK
National Cancer Drugs Fund
– Application Form 04 November 2015
Bosutinib for Chronic Phase Chronic Myeloid Leukaemia
Intolerance to Dasatinib and Nilotinib
Page 2

Proposed Start Date for Therapy (add clinic date)*:
Consultant details*
(including signature or email confirmation)
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)
ICD-10 Code*
Name:
Hospital:
Address:
Post Code:
Telephone:
Nhs.net
Name:
Hospital:
Address:
Post Code:
Telephone:
Nhs.net
NHS No:
DOB:
Hospital No:
CCG Name:
Name:
Address:
Post Code:
C92.1 – Chronic myeloid leukaemia (CML), BCR/ABL-positive
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 04 November 2015
Bosutinib for Chronic Phase Chronic Myeloid Leukaemia
Intolerance to Dasatinib and Nilotinib
Page 3