Geographical variation in the use of fluorouracil in the treatment of early breast cancer within england

Background: In April 2019, the European Society of Medical Oncology published guidelines1 for management of Early Breast Cancer (EBC) which concluded that fluorouracil can be omitted from anthracycline based regimens as it does not add efficacy and increases toxicity Additionally, the European Medicines Agency has recommended2 that all patients starting fluorouracil based chemotherapy must be tested for dihydropyrimidine dehydrogenase (DPD), which will further increase costs, and may delay treatment for some patients Objectives: To: • Quantify use of fluorouracil containing chemotherapy for treatment of EBC within England-and determine any geographical variation • Estimate potential pharmacy capacity improvements from universal guideline adoption • Estimate the impact on DPD testing if the guidance was followed Methods: The SACT Dataset3,4 from April 2018 was analysed Filtered for: Diagnosis of 'Breast cancer', Treatment intent of 'adjuvant', 'neo-adjuvant' or 'curative' and Treatment including epirubicin or doxorubicin To estimate the capacity impact, it was assumed patients received 3 cycles of FEC (9 syringes) aspart of the FEC-T regime and that this would be replaced by 4 cycles of EC (8 syringes) To estimate the impact on DPD testing, it was assumed patients received 6 cycles of FEC chemotherapy (patient numbers would be 1/6 fluorouracil doses) Both give the most conservative estimates Results: 108 NHS Organisations in England between April 2018 and August 2019 administered 38,807 doses of anthracycline and 18,729 (48 3%) administrations of fluorouracil 13 organisations recorded no fluorouracil use, and 18 recorded fluorouracil in more than 95% of patients receiving an anthracycline The median percentage of doses given containing fluorouracil was 65 0% Use of fluorouracil by Cancer Alliance ranged from 1 76%-94 9% (median: 38 5%) Of the 20 English Cancer Alliances, three gave less than 5% of patients fluorouracil Fluorouracil use fell in 17 Alliances from April to August 2019 compared to a year earlier (mean change in percentage fluorouracil use of 15 5 percentage points) Overall reduction of 1323 fluorouracil doses (χ2 p<0 001) Seven Alliances gave less than 5% of patients fluorouracil in this period Discussion/Conclusion: We conservatively estimate that at least 4624 dose units could be avoided annually compared to 2018/19, creating much needed capacity for other treatments Additionally, at least 2312 DPD tests per year in England could be avoided The utilisation of fluorouracil in the treatment of EBC within England varies This may be leading to unnecessary toxicity and additional costs for the NHS Variation was present prior to publication of the guidance and in some areas, there was rapid change associated with the timing of publication, however, wide variation remains We would encourage a more universal approach to the adoption of treatment guidelines to ensure equitable care across the NHS As a result of the SARS-CoV-2 pandemic, chemotherapy intensity may have reduced, and further analysis is recommended Incomplete data from September 2019 onwards hinders further analysis