REVIEW
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, precompounded
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 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
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
26 | Issue 91 | 2019 | hospitalpharmacyeurope.com