Author(s)
Owner
Version Control
David Thomson
Chemotherapy Clinical Reference Group
Ver3.1
Version Control
Ver3.0
Date
14 Jul 2014
24 Oct 2014
Revision summary
Introduction of version control and addition of section re-SACT and monitoring
Update of criteria 2
2
Change to current version
Criteria Changes
Split into a. and b. to allow for non-histological confirmation
National Cancer Drugs Fund
– Application Form 24 Oct 2014
Radium223 for CRPC
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 the treatment of castration-resistant prostate cancer with bone metastases
All 10 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. a. Histologically/ cytologically confirmed adenocarcimoma of the prostate with two or more bone metastases detected on skeletal scintigraphy OR b. Clinical suspicion of prostate cancer is high due to high PSA value
(>100ng/ml) with two or more bone metastases detected on skeletal scintigraphy
3. PS 0-2
4. Absence of visceral metastases on recent scanning and no previous history of visceral spread
5. Received prior docetaxel, were not healthy enough or declined to receive it
6. Symptomatic disease with regular use of analgesic medication or treatment with external-beam radiation therapy required for cancer related bone pain within the previous 12 weeks
7. No previous hemibody external radiotherapy, systematic radiotherapy with radioisotopes within the previous 24 weeks
8. No malignant lymphadenopathy that is more than 3cm in diameter
9. No imminent or established spinal cord compression
TICK
10. If receiving treatment with abiraterone or enzalutamide, a sufficient trial of
National Cancer Drugs Fund
– Application Form 24 Oct 2014
Radium223 for CRPC
Page 2

treatment with the abiraterone or enzalutamide has been given to relieve bone symptoms before consideration of radium-223
Consultant Approval (email authority)
Patient Consent Obtained (date of letter – copy to be retained on patient file)
National Cancer Drugs Fund
– Application Form 24 Oct 2014
Radium223 for CRPC
Page 3

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:
C61 – Malignant neoplasm of prostate
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 24 Oct 2014
Radium223 for CRPC
Page 4