banding for several intravenous anticancer
agents, National Health Service (NHS) England
has formed Medicines Optimisation and
Chemotherapy Clinical Reference Groups with
the aim to uniformise prescription practices
across the entire region based on previously
approved dose bands. The implementation efforts
of these reference groups are being encouraged
by NHS England via a Commissioning for Quality
and Innovation initiative (CQUIN) scheme, which
releases funding upon demonstration of
improvements in quality from the participating
trusts. 1
Currently, there are pre-determined dose bands
for 54 chemotherapy agents in England. NHS
England’s Medicines Optimisation Intelligence
Group is responsible for collecting data to support
this implementation, and specific measurement
tools and recommendations have been developed
by the Chemotherapy Dose Standardisation
Steering Group to measure the impact of this
initiative. NICE is closely collaborating with NHS
England to widen the implementation of dose
standardisation for chemotherapy drugs,
providing specific guidance on drug sourcing and
supply, as well as contracting and tendering. In
addition, NICE provides recommendations for the
identification of waste during the preparation
process, and for the measurement of the impact
of dose banding on the patients’ experience with
their treatment, as well as on staff satisfaction
and the financial impact on Trusts. 1
Benefits of dose banding and ready-to-use
products
The benefits of chemotherapy dose
standardisation are obvious, most notably the
time-saving and cost-reducing benefits. In
England, the costs incurred by the NHS with
chemotherapy amount to approximately £1.5
billion, of which 80% represent anticancer
medicines. In addition, these costs seem to grow
by approximately 8% every year, which
significantly contributes to the financial burden
of the health system. With the implementation
of discrete dose bands, the administered doses
of conventional chemotherapy agents are actually
about 6% of the calculated dose for the patient;
for biological agents, which are traditionally
much more expensive, it is approximately 10%. 1
An analysis of costs and parenteral
chemotherapy drug use following dose
standardisation in a tertiary oncology centre in
England showed a reduction in approximately
£100,000 per month on 17 dose-banded drugs,
despite an increase in the number of prescribed
doses during the same period of time. These
encouraging results were accompanied by
a reduction of approximately 10% in the total
workload associated with drug compounding,
ultimately increasing the capacity and
productivity of the centre’s aseptic compounding
unit. 3
Dose banding can also reduce patients’ waiting
times because the ready-to-use drugs can be
administered on any day that fits their schedules.
Moreover, this practice allows patients to receive
their treatment at facilities closer to their
residence, given that no special compounding
units are required for drug preparation. From the
perspective of health care providers, dose banding
results in reductions in the time spent with drug
preparation and minimises dose calculation
errors. Dose banding also prevents time-
consuming changes in prescriptions and allows
for a rapid dispensation through the use of
pre-prepared doses. Financial efficiency can be
further improved by outsourcing standardised
pre-filled bags of chemotherapy agents for
infusion. For commissioners, the uniformisation
of doses at the national or regional level
contributes to reduced costs arising from the
reuse of doses that are not used due to changes
in doses during treatment or due to cancellation
of the treatment, and from the reduction in
incomplete vial usage during the preparation
process. 1
In addition to these proven benefits, the
available evidence suggests that the use of dose
bands does not seem to have a negative impact
on the toxicity associated with chemotherapy
drugs or on clinical outcomes for patients. 1
A retrospective study conducted in France in
2012 to compare the pharmacokinetic profiles
of chemotherapy drugs, administered at regular
fixed doses and as dose bands, showed no
differences in drug exposure between the two
dosing approaches. 4 Another study in England
showed the feasibility of the dose banding
strategy for five anticancer drugs in paediatric
patients with ages ranging from 1 month to
18 years, based on pharmacokinetic parameters. 5
The future of dose standardisation in
oncology
The standardisation of doses of intravenous
cytotoxic chemotherapy agents was initially
proposed to improve pharmacy capacity and
reduce medication errors and wastage. However,
further optimisation of the administration of
anticancer drugs can potentially contribute to
a more efficient oncology unit. In addition to
dose bandings, the use of solvents, volume and
labelling of chemotherapy agents can also be
subject to uniformisation, which can potentially
minimise the risks posed by these toxic drugs to
both patients and staff. In the future, a partial or
full automation of the drug preparation process
may represent an advancement in terms of
improvements in drug management since the
number of patients diagnosed with cancer
continues to increase every year. Formal
evaluation of the feasibility, consistency, quality
control and assurance of validated dose banding
procedures in routine practice are also needed in
order to demonstrate a reduction of the financial
pressure placed on health systems due to
non-standardised dosing.
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HHE 2019 | hospitalhealthcare.com
References
1 National Institute for
Health and Care Excellence.
Chemotherapy dose
standardization. February 2018.
www.nice.org.uk/advice/ktt22
(accessed February 2019).
2 British Oncology Pharmacy
Association. Medicines
Optimisation, Safety and
Clinical Pharmacy Workforce
Plan. January 2015. www.
bopawebsite.org/sites/default/
files/publications/Clinical_
pharmacy_workforce_final2015.
pdf (accessed February 2019).
3 Chatelut E et al. Dose banding
as an alternative to body
surface area-based dosing of
chemotherapeutic agents.
Br J Cancer 2012;107(7):1100–6.
4 Finch M, Masters N.
Implications of parenteral
chemotherapy dose
standardisation in a tertiary
oncology centre. J Oncol Pharm
Pract 2018:1078155218812943.
5 White-Koning M. Investigating
the potential impact of dose
banding for systemic anti-cancer
therapy in the paediatric setting
based on pharmacokinetic
evidence. Eur J Cancer
2018;91:56–67.