Dose-banding (also known as dose-rounding in some countries) has been in operation in most English hospitals for some, but not all, systemic anti-cancer chemotherapy (SACT) drugs for some time. However, the practice has been piecemeal and inconsistent. NHS England has now devised an incentive scheme to drive uptake. It is anticipated that this will result in cost savings, reduced waiting times, and greater flexibility for services.
We have argued in the pages of HPE for wider adoption of dose-banding for several years now. Fundamentally, the use of dose-banding acknowledges that some degree of individualisation of doses is necessary, but argues that doses do not need to be calculated down to the last milligram. For many years, chemotherapy doses were calculated on the basis of body surface area in the belief that this provided an accurate index of organ function.
However, there are numerous sources of error in the calculation. Some readers will recall that distinguished Chicago oncologist, Mark Ratain, was the keynote speaker at HPE LIVE a few years ago. He has famously remarked that being over-focussed on a precise rather than an accurate dose could mean that a consistently wrong dose is always given and that, “Anybody who is worried about rounding a dose by 10% does not understand the intrinsic inaccuracy of the calculation.”
To help with the implementation process, a set of dose-banding tables has been produced together with other guidance. NHS England acknowledges that there is not currently a consensus on doses of drugs or the method of dose-banding to be used.
It notes that, “There is therefore significant potential for the adoption of a single standardised set of doses for a range of SACT drugs across England”. In practice, I suspect that this translates into quite a lot of work for pharmacy departments and oncology pharmacists to educate their prescribers in the principles and practice of dose-banding and to implement the changes.
This should not be a thankless task; there is a body of evidence to support dose-banding and there are some champions within the NHS. In Scotland, where dose-banding is well-established, it is estimated that some 60–70% of all chemotherapy doses are dose-banded, so Scottish colleagues could be approached for their tips for success.
If standardised doses can be taken off the shelf, then it will be easier to provide timely treatment for patients, which could greatly enhance their quality of care.
Standardised doses could be externally procured in future, and this could be advantageous for many reasons but it could leave gaps in the workloads of hospital pharmacy aseptic compounding units. It has been suggested that this could compromise their long-term viability but it could also be an opportunity to improve the safety of other injectable medicines.
Most hospital pharmacies in England have lacked the capacity to prepare other high-risk injectable doses used in their institutions. Here is a chance to put that right – and contribute further to the patient safety agenda.
Dose-banding for SACT is good science and common sense – it is good to see NHS England putting its weight behind it.