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The allocation of funding for new anticancer treatments within the UK has not kept pace with demand. Clinicians find themselves restricted in the use of licensed drugs which they feel are in the best interests of individual patients. Against this, health authorities have a duty to ensure that scarce resources are used equitably to meet the needs of the local population as a whole. Differential levels of funding for new treatments across the country have led to concerns about rationing by postcode. This paper outlines an approach to the prioritization of new treatment for advanced cancer developed jointly by clinicians and health authorities in South London. The approach involves evidence reviews and consensus meetings. Existing and new treatments are rated on a four-point ‘relative effectiveness scale’, which takes account of the impact of the treatment on quality of life and on survival. The strength of evidence supporting each effectiveness rating is also classified. Health Authorities have used these ratings to determine overall funding levels, while leaving decisions on individual patients to the relevant Trusts. © 2000 Cancer Research Campaign

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Objective. Colorectal cancer is the second largest cause of death from malignant disease in Western countries. Although surgical resection is the preferred treatment in early disease, chemotherapy has an important role to play both as an adjunct to surgery and in the palliation of advanced disease. For many years 5-fluorouracil (5-FU) has been the only cyto toxic drug with significant activity in this condition and, recently, considerable effort has been directed toward enhancing its activity and finding better, alternative agents. Recently, raltitrexed (Tomudex; Zeneca Pharmaceuticals), the first of a new class of cytotoxic drugs, the selective, direct, thymidylate synthase inhibitors, received its first regulatory ap proval for the first-line treatment of advanced colo rectal cancer. The purpose of this review is to con sider the efficacy, toxicity, and resource implications of using this new antineoplastic agent, alongside developments that have been made in the more effective use of fluoropyrimidines, and the place of drug treatment in the management of colorectal cancer. Data Sources. A variety of sources were used, including manual and on-line (Medline and Pharm- line) literature searching. Approved and other drug names were used as primary search terms, linked with colorectal cancer where limitation was required. The medical information department of Zeneca Pharma ceuticals also was used where appropriate. Study Selection. Particular attention was di rected to randomized clinical trials, but nonrandom ized and preclinical studies were considered where appropriate. Conclusions. Although colorectal cancer is in herently resistant to cytotoxic chemotherapy, such treatment now has an established role as an adjunct to surgery and in the palliation of advanced disease. The optimum 5-FU- based regimen has yet to be estab lished with certainty, although in advanced disease a four-times-weekly, 5-day regimen of 5-FU and low- dose folinic acid is probably the best of those fully evaluated to date. Raltitrexed seems to be as effective as this combination while having definite advantages in terms of toxicity and the resources required for its preparation and administration, although it remains to be seen to what extent these and other resource benefits will be offset by its higher cost and how its efficacy and tolerability will compare with other 5-FU- based regimens in ongoing clinical trials.

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Objectives. To determine the extent of change in intravenous (IV) chemotherapy workload in recent years, the availability of specialist pharmacy and nursing staff to carry out this work and the service implications of any mismatch between these two parameters. To determine the volume of chemotherapy currently administered for metastatic colorectal cancer (MCRC) to allow assessment of the possible workload implication of a switch to oral fluoropyrimidine therapy. Design. An anonymous postal survey of pharmacist members of the British Oncology Pharmacy Association (BOPA) and their nursing colleagues. Response. 0f 104 questionnaires distributed, 54 were returned (response rate 51.9%). Data summary. Ninety-three per cent of pharmacists reported an increase averaging 178% (range 15]/500%) in the volume of IV chemotherapy being prepared by their units over the last five years, with the average unit currently producing 896 (range 110]/5000) doses each month. Pharmacist and nurse recruitment difficulties were also reported almost universally. The combination of these two factors led to reported problems for both staff and patients, with a majority of nursing and pharmacy staff noting increased staff stress and prolonged patient waiting times. A significant minority of departments have already taken, generally undesirable, steps to address a significant imbalance between chemotherapy workload and service capacity, including restricting clinical trial activity and other aseptic dispensing work. Conclusions. Rapid expansion in the use of IV cytototoxic chemotherapy has resulted in pharmacy and nursing services facing severe pressure. Imaginative solutions are necessary if safe and efficient services are to be maintained. These may include increased use of oral fluorpyrimidines for the first-line treatment of MCRC, which this survey indicates accounts for about 10% of IV chemotherapy administered in the UK.

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