Request Continuation of Funding for Chemotherapy Following a Break in Treatment (SSC 1726)
CHEMOTxB_ver1.0 Request for funding for continuation of Chemotherapy following a treatment break formPatient NHS No: / Trust:
Patient Hospital No: / Patient Blueteq Number (if appropriate):
Patient's Initials and DoB: / GP Postcode:
Choose Consultant: / Consultant Email Address:
(@NHS.net account ONLY)
Consultant Name: / Pharmacy Email Address:
(@NHS.net account ONLY)
Date of Starting Initial Treatment: / Please enter a valid date
Start Date of Last Cycle Administered: / Please enter a valid date
Planned Treatment Re-start Date (if approved):
Applications are valid for 4 weeks from date of approval / Please enter a valid date
PLEASE COMPLETE ALL SECTIONS BELOW / Please complete
CHEMOTHERAPY REGIMEN DETAILS
Chemotherapy Regimen (Full names for all drugs)
Diagnosis
Funding Route Prior to Treatment Break / ¨ Routinely commissioned by NHS England (no prior approval required)
¨ Prior Approval required (i.e. post NICE TA) – provide Blueteq ID………………………
¨ CDF – provide Blueteq ID………………………
¨ IFR – provide ID number…………………………
1. Has there has been a break in treatment of more than 4 weeks beyond the expected cycle length for all systemic anti-cancer therapy (SACT)? / Yes / No
If NO then you do not need to complete the rest of the form as the treatment break is within accepted parameters.
2. Is the patient on systemic immune checkpoint inhibitor therapies where a break in treatment of up to 12 weeks from the previous dose is allowed?
(i.e. currently ipilimumab, pembrolizumab and nivolumab and potentially in the future atezolizumab, durvalumab and avelumab) / Yes / No
If YES then you do not need to complete the rest of the form as the treatment break is within accepted clinical guidelines.
3. Is the patient on chemotherapy where a different maximum duration of treatment break is explicitly documented in the NHS England approval criteria for that specific drug or on the relevant NHS England chemotherapy algorithm? / Yes / No
4. Does the treatment break fit within the relevant NHS England chemotherapy algorithm? / Yes / No / Not applicable (no algorithm at present)
If YES (or N/A) to BOTH then you do not need to complete the rest of the form as the treatment break is within an NHS England chemotherapy algorithm.
TREATMENT BREAK DETAILS
Is the treatment break a treatment strategy planned in advance (other than to allow for holidays or similar)? / Yes / No
Please provide details of rationale for treatment break being planned in advance
Is the treatment break an unplanned extended treatment break in reaction to unforeseen events (e.g. longer than expected recovery from surgery or toxicity)? / Yes / No
Please provide details of rationale for treatment break :
Number of remaining cycles/ duration of treatment intended:
Has the patient’s disease progressed during the treatment break? / Yes / No
Please provide evidence to support this statement
e.g.
Scan result within the past 3-4 months (in line with clinical practice)
Tumour markers
Details of MDT discussion
Requestor Speciality: / Haematology / Oncology / Paediatrics
Completed by:
Date:
Return completed form to
C&C /CDF/Treatment Break Application Formv1