Key points
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 dosebanded
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.
• Dose standardisation
can reduce the risk
of calculation errors,
decrease preparation
time, and reduce waste.
• Pharmacists play
a critical role in
the preparation of
chemotherapy and
the verification of
prescriptions.
• An analysis of
prescriptions by BOPA
identified 2.3% errors
that could result in
patient harm.
• Up to 70% of
chemotherapy agents
in Scotland are being
administered according
to dose bands.
• Dose banding can
reduce workload on
aseptic departments,
leading to increased
capacity and
productivity on an
increasingly demanding
area of work.
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.
28 | Issue 91 | 2019 | hospitalpharmacyeurope.com