(a) for all conditions Please summarise the current status of the patient in terms of quality of life, symptoms etc including any recognised condition-specific QoL / status scores. What is the clinical patient’s current severity? Please use standard scoring systems e.g. WHO, DAS28, 6MW, cardiac index or those applicable to the patients clinical diagnosis. Please include interpretation of the score (b) In case of intervention for Please indicate whether the cancer: intervention is for: -adjuvant / neoadjuvant -1st line relapse (or metastatic) -2nd line relapse -Other (please specify) What is the WHO performance status? Or other recognised status/score How advanced is the cancer? (stage) Describe any metastases: SECTION E: PREVIOUS TREATMENT/INTERVENTIONS Summary of previous Start Stop Name of Reason for stopping* / intervention(s) this patient Date: Date: Intervention Response achieved or has received for the (for drugs include indicate if still condition. name, dose and continuing * Reasons for stopping may frequency of use) include: Course completed No or poor response Disease progression Adverse effects/poorly tolerated (please detail nature of adverse effect/intolerance) Has a previous application been submitted on behalf Delete as appropriate: Yes / No of this patient? SECTION F: EVIDENCE FOR EFFECTIVENESS OF INTERVENTION REQUESTED Delete as appropriate: Yes / No Is the requested intervention licensed for the requested indication in the UK? Governance Drugs- Has the Delete as appropriate: Yes / No Has the Approved NHS trust Drugs and Provider approved the Therapeutics If No, then STOP HERE. requested intervention for use Committee The application requires DTC approval (DTC) through its recognised clinical or equivalent governance arrangements? approved the Evidence MUST be supplied e.g. DTC minutes, a requested letter from the DTC Chairman, if Chairman’s intervention for action has been taken use?
(a) for all conditions Please summarise the current status of the patient in terms of quality of life, symptoms etc including any recognised condition-specific QoL / status scores. What is the patient’s current clinical severity? Please use standard scoring systems e.g. WHO, DAS28, 6MW, cardiac index or those applicable to the patients clinical diagnosis. Please include interpretation of the score (b) In case of intervention for cancer: Please indicate whether the intervention is for: -adjuvant / neoadjuvant -1st line relapse (or metastatic) -2nd line relapse -Other (please specify) What is the WHO performance status? Or other recognised status/score How advanced is the cancer? (stage) Describe any metastases: SECTION E: PREVIOUS TREATMENT/INTERVENTIONS Summary of previous intervention(s) this patient has received for the condition. * Reasons for stopping may include: Course completed No or poor response Disease progression Adverse effects/poorly tolerated (please detail nature of adverse effect/intolerance) Start Date: Stop Date: Name of Intervention (for drugs include name, dose and frequency of use) Reason for stopping* / Response achieved or indicate if still continuing Has a previous application been submitted on behalf of this patient? Delete as appropriate: Yes / No SECTION F: EVIDENCE FOR EFFECTIVENESS OF INTERVENTION REQUESTED Is the requested intervention licensed for the requested indication in the UK? Delete as appropriate: Yes / No Governance Has the Approved NHS Provider approved the requested intervention for use through its recognised clinical governance arrangements? Drugs- Has the trust Drugs and Therapeutics Committee (DTC) or equivalent approved the requested intervention for use? Delete as appropriate: Yes / No If No, then STOP HERE. The application requires DTC approval Evidence MUST be supplied e.g. DTC minutes, a letter from the DTC Chairman, if Chairman’s action has been taken