ONCOLOGY
Chemotherapy dose
standardisation and optimisation
Standardisation of doses of intravenous 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
Kiran Channa
MRPharmS MFRPSI
Clinical Team Lead
Pharmacist: Medicine,
Worcestershire Acute
Hospitals NHS Trust, UK
The dosing of chemotherapy agents involves
a delicate balance between the desired efficacy
and the drug’s acceptable toxicity. Traditionally,
the doses of anticancer drugs were calculated
according to body weight or surface area, but in
2018, the National Institute for Health and Care
Excellence (NICE) released a position statement
supporting dose standardisation, or dose banding,
for intravenous chemotherapy drugs for adults
with cancer. This standardisation and
optimisation of doses in oncology brings benefits
to hospitals, as well as health care providers and
patients.
Dose standardisation for intravenous
chemotherapy agents
The objective of having standardised doses in the
treatment of cancer is to facilitate the preparation
of intravenous chemotherapy agents within
hospital pharmacy aseptic units, and also the
administration in the oncology ward. The
chemotherapy schedule for a patient with cancer
is often complex and involves multiple drugs
and dose adjustments as part of a regimen that
is tailored to each individual case. With dose
standardisation, the doses of intravenous
anticancer drugs are approximated to pre-
determined standard doses and clustered in dose
ranges or bands, which can significantly reduce
preparation time, mitigate the risk of calculation
errors, and reduce waste resulting from left-over
drugs. 1
The chemotherapy drugs purchased in bulk by
a particular hospital can then be standardised to
match the recommended pre-defined dose bands
and prepared as single-serve doses in advance,
provided these drugs show long-term
physicochemical stability after compounding
(that is, greater than 30 days). Alternatively,
pre-compounded products can be acquired.
This dose standardisation process involves, in
general; the approval of basic practices for the
definition of dose bands by the local oncology
and hematology departments; the approval of
national or regional dose banding tables by local
formulary committees; the prescription and
dispensing of the approved drugs according to the
doses listed in these tables; and the establishment
of uniform practices for the purchase of ready-to-
administer products. 1
The role of the pharmacist in the
administration of chemotherapy agents is critical,
ranging from the verification of the prescription
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to the preparation of the drug(s) to be
administered. The verification of prescriptions,
which might involve a specific number and
type of checks for each prescription, and the
reconciliation of systemic anticancer agents,
must be carried out by accredited professionals,
according to standards defined by the British
Oncology Pharmacy Association (BOPA). 2
Prescription errors can be particularly
dangerous in this setting. An analysis of
prescriptions for chemotherapy agents against
BOPA standards in England, Scotland and Wales
identified errors in 2.3% of prescriptions during
the mandatory prescription verification process,
which could potentially result in medical
intervention or hospitalisation, or even serious
injury or death. In addition to prescription
verification, pharmacists are responsible for
reviewing all the medicines taken by a patient
who is about to initiate chemotherapy in order
to minimise the risk of adverse effects of the
treatment such as toxicities or reduced efficacy
owing to presence of comorbidities or the use of
concomitant and/or alternative medicines that
can interact with the conventional anticancer
agents. Together with nurses trained in oncology,
pharmacists can also provide counselling to
patients and follow up on the use of any
medicines, ensuring adherence to the treatment. 2
Given the toxicity of these drugs and the
significant investment in time and money
from the institutions and staff, it is of utmost
importance that all health care professionals
involved in chemotherapy patients with cancer
adhere to the standards for dose banding defined
by their organisations. Regular quality audits
should be conducted at all levels of involvement,
and any deficiencies should be promptly
communicated and corrected. 2
Implementation of dose standardisation for
chemotherapy agents
Chemotherapy dose bands have been gradually
implemented at several hospital trusts in England
for the past ten years, although at variable pace.
However, some level of heterogeneity has been
observed in terms of processes used for dose
banding and the drugs included in the bands.
In Scotland, where dose standardisation is now
established, 60–70% of all chemotherapy agents
are currently being administered according to
pre-specified dose bands. 1
In order to promote the adoption of dose