Pembrolizumab in combination with chemotherapy with or without bevacizumab [PEMB22]

For the treatment of persistent, recurrent or metastatic cervical cancer in patients whose tumour PD-L1 expression test results have a combined positive score (CPS) of 1 or more where the following criteria have been met:

1. This application is being made by and the first cycle of systemic anti-cancer therapy with pembrolizumab in combination with chemotherapy will be prescribed by a consultant specialist specifically trained and accredited in the use of systemic anti-cancer therapy.
2. The patient has a histologically- or cytologically confirmed diagnosis of cervical carcinoma. Please mark below which histology applies to this patient:

• squamous carcinoma
• adeno-squamous carcinoma
• adenocarcinoma

3. The patient’s tumour has been tested by an approved and validated test for PD-L1 expression as measured by the combined positive score (CPS) test and the result is 1 or more. Please document the actual CPS test result for PD-L1 expression below: PD-L1 expression with the CPS test: _______

Note

Note: patients with tumours with a CPS test result of <1 or who have not had a CPS test are not eligible for treatment with pembrolizumab.

4. The current disease status as to whether the patient has persistent locoregional disease with or without distant metastases or recurrent locoregional disease with or without distant metastases or has presented with distant metastatic spread. Please mark below which scenario applies to this patient:

• persistent locoregional disease without distant metastatic spread
• persistent locoregional disease with distant metastatic spread
• recurrent locoregional disease without distant metastatic spread
• recurrent locoregional disease with distant metastatic spread
• first presentation with distant metastatic spread

5. The patient’s disease is currently not amenable to curative treatment (such as with surgery or radiotherapy or chemoradiotherapy).
6. The type of treatment previously received by this patient for the cervical cancer: Please mark below the type of treatment received by this patient:

• chemoradiotherapy and surgery
• radiotherapy and surgery
• chemoradiotherapy only
• neoadjuvant chemotherapy followed by chemoradiotherapy
• radiotherapy only
• surgery only
• none

7. I confirm that the patient has either not been previously treated with any systemic chemotherapy or has only received chemotherapy whether specifically used as a radio-sensitising agent or received neoadjuvant chemotherapy prior to chemoradiotherapy.
8. The cytotoxic chemotherapy partner with the pembrolizumab is a combination chemotherapy with either paclitaxel plus cisplatin or paclitaxel plus carboplatin (AUC 5mg/mL/min).

Note

Note: a maximum of 6 cycles of cytotoxic chemotherapy is to be administered.

9. Whether or not bevacizumab is also to be given in combination with chemotherapy and pembrolizumab: Please mark below whether bevacizumab is also to be given:

• yes, bevacizumab is also being given
• no, bevacizumab is not being administered

Note

Note: bevacizumab can be continued in combination with pembrolizumab beyond completion of chemotherapy if the patient is benefiting from treatment. Note: if after completing the course of pembrolizumab (see criterion 13) and the patient is still benefitting from treatment, the patient and the clinician have the option to continue with the bevacizumab as monotherapy until disease progression. Note: if bevacizumab is to be given with pembrolizumab and chemotherapy, there is no need to complete a separate blueteq form for the use of bevacizumab in cervical cancer.

10. The patient has not received any prior antibody treatment which targets PD-1 or PD-L1 or PD-L2 or CD137 or OX40 or anti-cytotoxic T-lymphocyte-associated antigen-4 (CTLA-4) for this cervical cancer indication.
11. The patient will be treated with a fixed dose of pembrolizumab following the licenced dosing schedules as shown below • 395mg every 3 weeks, or 790mg every 6 weeks if given via subcutaneous injection • 200mg every 3 weeks, or 400mg every 6 weeks if given via intravenous infusion
12. Treatment with pembrolizumab will be stopped at whichever of the following events occurs first: disease progression or unacceptable toxicity or withdrawal of patient consent or after 2 years of treatment (or after 35 x 3-weekly cycles or its equivalent if 6-weekly pembrolizumab is used).
13. The patient has an ECOG performance status (PS) of 0 or 1.
14. The patient has no symptomatically active brain metastases or leptomeningeal metastases.
15. Where a treatment break of more than 12 weeks beyond the expected 3 or 6 weekly cycle length is needed, a treatment break approval form will be completed, which MUST be approved before treatment with pembrolizumab is recommenced.
16. Pembrolizumab will be otherwise used as set out in its Summary of Product Characteristics (SPC).

NHS funded From: 12 March 2024

Additional information

Form version: -

CDF Managed Access: NA

NICE Technology Appraisal: TA939 (13 December 2023)

Current Form Version

Note

The data on this page was produced using version 1.387 of the CDF list, downloaded from NHS England’s website on 24 February 2026 at 11:00.

If NHS England has published a new version of the CDF List but this site has not yet accessed that, this form may be out of date. Additionally, if any update has occurred without NHS England noting it as a change, this page will be out of date.

Older Form Versions

There are previous versions of this form. These may not all be available on this site.

• PEMB22_prior_to_cdf_1.361
• PEMB22_prior_to_cdf_1.387