NICE Issues an Advice on Chemotherapy Dose Standardisation

It is a new topic for the 2018 update of medicines optimisation

In February 2018, the NICE has published a document on Key therapeutic topic [KTT22] that summarises the evidence-base on chemotherapy dose standardisation. It is a key therapeutic topic which has been identified to support medicines optimisation. It is not a formal NICE guidance. It is a new topic for the 2018 update of medicines optimisation.

Chemotherapy dose standardisation, where hospital trusts move to a system of dose banding, has the potential to offer considerable benefits for patients, providers and commissioners.

NHS England's Medicines Optimisation and Chemotherapy Clinical Reference Groups are co-ordinating a national approach to chemotherapy dose standardisation with the objective that all NHS England commissioned providers of chemotherapy move to prescribing and supplying a range of intravenous anticancer therapy in accordance with a nationally approved set of dose bands.

Evidence context

Chemotherapy dose standardisation is a system where doses of intravenous anticancer therapy calculated on an individualised basis are rounded up or down to predetermined standard doses.

Historically, intravenous chemotherapy doses have been calculated for individual patients based on weight or body surface area. This has led to a large number of similar, but not identical, products being made as bespoke orders within compounding units. These small product differences significantly increase time and costs of preparation and costs of drug wastage. There is no robust evidence to suggest that standardised doses affect toxicity or clinical outcomes.

It is estimated that NHS England spends approximately 1.5 billion GBP on the routine commissioning of chemotherapy, with medicine costs being the largest proportion of this spend (80%). There is also a high rate of annual growth in these costs of approximately 8% per year.

Standardisation of chemotherapy doses, where hospital trusts move to a system of dose banding, offers an avenue for achieving improved value in this area and benefits for patients, providers and commissioners. The discrete dose bands lie within 6% of the patient's calculated dose for standard chemotherapy drugs and 10% for biological drugs. Available products can then be standardised to match the recommended doses. 

Implementation of chemotherapy dose banding has been taking place, to variable degrees, in hospital trusts within England for the previous 10 years, and most providers of chemotherapy will already be dose banding to some extent. However, there is still considerable variation in both the methods of dose banding used and the range of drugs that dose banding has been applied to. An NHS England survey of NHS Providers found that 90% of the 94 trusts who responded were dose banding at least 1 intravenous anticancer therapy. But for the 20 most commonly dose-banded drugs, on average just 30% of trusts were dose banding. In Scotland, where dose banding of intravenous anticancer therapy has been established for a number of years, it has been estimated that 60–70% of all intravenous anticancer therapy is administered as dose-banded preparations.

There are currently 54 chemotherapy drugs with approved dose-banding tables.

Alongside standardised doses, the next step of the initiative is to standardise chemotherapy products by diluent, volume and labelling. This is the precursor to accessing ready to administer chemotherapy from the generic and NHS manufacturers.

NICE's position statement  supporting chemotherapy dose standardisation outlines how NICE is working with NHS England to support the project, and to ensure that NICE processes, tools and resources are suitably aligned.

The NICE shared learning example on chemotherapy production: reducing patient waiting times and increasing efficiency that describes how one trust identified and addressed service inefficiencies. Implementation of changes including dose banding, and use of outsourced pre-filled bags reduced the daily waiting times of people attending clinics for injected chemotherapy.