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Policy No.:   D0463 

 

 
 
 

 

Cancer Services   State-wide 
Cancer Chemotherapy  

Policy Directive 
 

Version No.:  1.0 
Approval date:  12/07/2018 

 

  



 
 

INFORMAL COPY WHEN PRINTED Cancer Services   SA Health Approved Cancer Chemotherapy Protocol Register Policy Directive 

 Page 2 of 7 

For Official Use Only-I1A1 
 

 

Contents  
 
1. Policy Statement .................................................................................................................. 3 

2. Roles and Responsibilities .................................................................................................. 3 

3. Policy Requirements............................................................................................................ 4 

4. Implementation &amp; Monitoring ............................................................................................... 5 

5. National Safety and Quality Health Service Standards ....................................................... 6 

6. Definitions ............................................................................................................................ 6 

7. Associated Policy Directives / Policy Guidelines and Resources ....................................... 7 

8. Document Ownership &amp; History .......................................................................................... 7 

  



 
 

INFORMAL COPY WHEN PRINTED Cancer Services   SA Health Approved Cancer Chemotherapy Protocol Register Policy Directive 

 Page 3 of 7 

For Official Use Only-I1A1 
 

 

Cancer Services   State-wide Cancer Chemotherapy Policy 
Directive  
 

1. Policy Statement 

The purpose of this policy is to establish state-wide governance over the development, 
approval and maintenance of cancer chemotherapy protocols and prescribing tools. 
 

1.1 SA Health acknowledges that the safety and quality of medicines in use is an essential 
component of patient care. 
 

1.2 SA Health recognises that robust governance of cancer chemotherapy prescribing 
supports clinicians in providing safe and effective care and enhanced consumer 
outcomes.  
 

1.3 This policy defines a state-wide, quality assured framework for development, approval 
and review of cancer chemotherapy protocols and prescribing tools for use within SA 
Health hospitals and health services. 
 

1.4 This policy outlines the use of eviQ treatments online as the primary resource for adult 
cancer chemotherapy protocols.  

 

2. Roles and Responsibilities 
 

Chief Executive, SA Health, is responsible for:  

? Ensuring SA public hospitals and health services are aware of and comply with the 
principles of this policy.  

 
 Local Health Network Chief Executive Officers will:  
? delegate the day-to-day responsibility for complying with this policy to the relevant senior 

managers and clinicians; 

? ensure the health services under their administration have systems and resources in 
place to ensure adherence to this policy;  

? ensure surveillance of adherence of this policy;  

? ensure surveillance information is reported to SA Health Cancer Drug Committee and 
other appropriate committees. 

 
Executive Directors, Directors, Heads of service/departments and other senior managers will: 

? Promote awareness of the importance of adherence to this policy providing support for 
clinicians and patients;  

? ensure local policies, procedures and resources are implemented to facilitate policy 
implementation, adherence and reporting via the approved process; 

? create an environment where any incident relating to cancer treatment is notified and 
investigated, including implementation of strategies to reduce the likelihood of a similar 
incident occurring. 

 
SA Health Cancer Drug Committee (SAHCDC) will: 

? Provide overarching governance of development, approval and review of cancer 
chemotherapy protocols and prescribing tools and related processes; 

? support SA Health hospitals and health services to implement this policy by provision of 
advice, information and regular updates on the procedures related to development,  
approval and review of cancer chemotherapy protocols and prescribing tools; 

? maintain the SA Health Approved Cancer Chemotherapy Protocol Register. 



 
 

INFORMAL COPY WHEN PRINTED Cancer Services   SA Health Approved Cancer Chemotherapy Protocol Register Policy Directive 

 Page 4 of 7 

For Official Use Only-I1A1 
 

 

All SA Health employees will: 

? adhere to the aims and principles of this policy; 

? ensure that local policies and procedures are followed to ensure organisational 
adherence to this policy. 

 
* This policy does not apply to cancer chemotherapy protocols that are part of an approved 
Clinical Trial. Clinical trial protocols go through a robust governance process overseen by 
Ethics Committees. 

 

3. Policy Requirements 

3.1 All cancer chemotherapy protocols* to be used in SA Health will be reviewed and 
endorsed via the approved state-wide process established by the SA Health Cancer 
Drug Committee. 
(*NB: Clinical trial protocols, including those for paediatric, young adult and adult 
patients, are subject to a separate SA Health Governance Framework and are not 
included under this policy) 

 
3.2 All cancer chemotherapy protocols submitted for inclusion on the SA Health Approved 

Cancer Chemotherapy Protocol Register will be evidence-based and meet all SA 
Health and relevant legislative and professional requirements before endorsement. 
 

3.3 Procedures and guidance for use by LHN s and cancer services to support the 
development, approval and maintenance of cancer chemotherapy protocols for use in 
SA Health will be available. 
 

3.4 All new cancer chemotherapy protocols, amendments to protocols and requests to 
deviate from an aspect of an eviQ protocol will be submitted to the state-wide process 
for approval. 
 

3.5 Cancer chemotherapy protocols for the SA Health Approved Cancer Chemotherapy 
Protocol Register will either be developed by or will be reviewed by an appropriate 
tumour-stream group or group of clinicians with a recognised expertise in the 
therapeutic area before endorsement by the SA Health Cancer Drug Committee. 
 

3.6 The SA Health Approved Cancer Chemotherapy Protocols Register will list cancer 
chemotherapy protocols approved under the state-wide process for use in SA Health 
hospitals and health services. All protocols listed on the register will be regularly 
reviewed, and where necessary, updated or removed. 
 

3.7 Occasional, individual patient use of cancer chemotherapy protocols not on the register 
is facilitated via the Use of a Non-Registered Cancer Chemotherapy Protocol Request 
Form (Single patient use) pathway. 
 

3.8 Procedures and guidance based on best practice will be available for use by LHN s and 
cancer services to support the Non-Registered Cancer Chemotherapy Protocol 
Request Form (Single patient use). 
 

3.9 Use of eviQ treatments online 

3.9.1 eviQ is the primary resource for evidence-based chemotherapy and targeted 
therapy treatment protocols used within SA Health for the treatment of adults. 
 




 
 

INFORMAL COPY WHEN PRINTED Cancer Services   SA Health Approved Cancer Chemotherapy Protocol Register Policy Directive 

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For Official Use Only-I1A1 
 

 

3.9.2 eviQ treatments online is an Australian government, freely available online resource 
of cancer treatment protocols developed by multidisciplinary teams of cancer 
specialists. eviQ provides evidence-based information to support health 
professionals in the delivery of cancer treatments available at the time treatment 
decisions are being made. The eviQ website will be accessed via 
https://www.eviq.org.au. 
  

3.9.3 Cancer chemotherapy protocols that are currently listed on eviQ treatments online  
will go through a streamlined approval process by the SA Health Cancer 
Committee if requested for inclusion on the Approved Cancer Chemotherapy 
Protocols register.. 

3.10 Non-eviQ based cancer chemotherapy protocols 

3.10.1 All cancer chemotherapy protocols that are required for regular use in SA Health 
and not listed on eviQ will be submitted to the state-wide approval and endorsement 
process. 
 

3.10.2 Endorsement for a cancer chemotherapy protocol required for regular use in SA 
Health not listed on eviQ will be supported by evidence of efficacy. 

? This may include, but not be limited to: Internationally recognised cancer 
chemotherapy protocol sources (e.g. British Columbia Cancer Agency (BCCA) 
(Canada), https://www.nccn.org/ (US), Peer-reviewed published journal article. 

? This does not include: article abstract only 

3.11 Chemotherapy prescribing tools used within the LHNs (e.g. pdfs, templates and 
spreadsheets) for approved protocols will be developed, implemented and maintained 
according to a set of clinical governance standards overseen and endorsed by the SA 
Health Cancer Drug Committee.   Standardisation in these processes will support the 
efficient translation to a future statewide electronic chemotherapy prescribing solution. 
 

3.12 All cancer chemotherapy protocols listed on the SA Health Approved Cancer 
Chemotherapy Protocol Register will be regularly reviewed: 
 

? eviQ listed protocols will be reviewed every 3 years or sooner (e.g. new clinical 
evidence/eviQ updates). 

? Protocols not listed on eviQ will be reviewed every 2 years or sooner (e.g. protocol 
is added to eviQ. 
 

4. Implementation &amp; Monitoring 
 

The SA Health Cancer Drug Committee (SAHCDC) will be responsible for overseeing the 
development and updating of the SA Health Approved Cancer Chemotherapy Protocol 
Register, oversight of LHN/cancer service governance on the development of chemotherapy 
prescribing tools and reporting of data including: 

4.1 Annual report on Register changes due to oncology and haematology practice changes. 
 

4.2 Twice-yearly reports on SAHCDC activity to South Australian Medicines Advisory 
Committee (SAMAC). 
 

4.3 Monthly reporting on Use of a Non-Registered Cancer Chemotherapy Protocol Request 
Form (Single patient use) including identification of new protocols required for 





 
 

INFORMAL COPY WHEN PRINTED Cancer Services   SA Health Approved Cancer Chemotherapy Protocol Register Policy Directive 

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For Official Use Only-I1A1 
 

 

development from multiple use of a chemotherapy protocol under this procedure. 
 

4.4 Monthly updates of the SA Health Approved Cancer Chemotherapy Protocol Register. 
 

4.5 Review of all cancer chemotherapy protocols housed on the SA Health Approved 
Cancer Chemotherapy Protocol Register. 
 

4.6 Reports of LHN self-assessments against clinical governance framework for 
development, maintenance and review of chemotherapy prescribing tools. 

 

5. National Safety and Quality Health Service Standards 

 

 

 
 

6. Definitions 
 

Chemotherapy Protocol: A chemotherapy protocol is a document, defining the drugs to be 
used, their dosage, the frequency and duration of treatments, and other information such as 
side-effects, drug interactions, how and when dose modifications are recommended, 
administration details and evidence for effect. Chemotherapy Protocols may be for one drug, 
or for two or more drugs in combination chemotherapy. 

 
Chemotherapy prescribing tool   a system providing a written or electronic version of the 
prescribed chemotherapy regimen which includes dose calculations, frequency, scheduling 
and supportive care medications.   

 
 

National 
Standard 1 

 
Governance 

for Safety 
and Quality 

in Health 
Care 

 

 
 

National 
Standard 2 

 
Partnering 

with 
Consumers 
 
 
 

 
 

National 
Standard 3 

 
Preventing 

&amp; 
Controlling 
Healthcare 
associated 
infections 

 
 

National 
Standard 4 

 
Medication 

Safety 
 
 
 
 

 
 

National 
Standard 5 

 
Patient 

Identification 
&amp; Procedure 

Matching 
 
 

 
 

National 
Standard 6  

 
Clinical 

Handover 
 
 
 

 

 
 

National 
Standard 7 

 
Blood and 

Blood 
Products 

 
 

 

 
 

National 
Standard 8 

 
Preventing 

 &amp; 
Managing 
Pressure 
Injuries 

 

 
 

National 
Standard 9 

 
Recognising &amp; 
Responding to 

Clinical 
Deterioration 

 
 

 
 

National 
Standard 10 

 
Preventing 

Falls &amp; 
Harm from 

Falls 
 
 

? ? ? ? ? ? ? ? ? ? 

 
 

National Standard 
1 
 

Clinical 
Governance 

 
 

National 
Standard 2 

 
Partnering 

with 
Consumers 

 
 
 

 
 

National 
Standard 3 

 
Preventing &amp; 
Controlling 
Healthcare- 
Associated 
Infection 

 
 

National 
Standard 4 

 
Medication 

Safety 
 
 
 
 

 
 

National 
Standard 5 

 
Comprehensiv

e Care 
 
 

 
 

National 
Standard 6 

 
Communic

ating for 
Safety 

 
 
 
 

 
 

National 
Standard 7 

 
Blood 

Management 

 
 

National 
Standard 8 

 
Recognising &amp; 
Responding to 

Acute 
Deterioration 

 
 

? ? ? ? ? ? ? ? 























































































































 
 

INFORMAL COPY WHEN PRINTED Cancer Services   SA Health Approved Cancer Chemotherapy Protocol Register Policy Directive 

 Page 7 of 7 

For Official Use Only-I1A1 
 

 

7. Associated Policy Directives / Policy Guidelines and Resources 
 

eviQ Treatments online https://www.eviq.org.au/ 
 
 

8. Document Ownership &amp; History 

Approval 
Date 

Version Who approved New/Revised Version Reason for Change 

12/07/18  V1.0 SA Health Policy Committee 
Original SA Health Policy Committee 
approved version. 

 

Use full numbers when a substantial change or full review of the policy has taken place.  
Use 1.1, 1.2 etc. when the update is minor in nature eg change in legislation name. 
 
Refer to the  Policy Approval Delegations  for the appropriate approving authority. 
 

Document developed by:  Medicines and Technology Programs (MTP) and Out of Hospital 

Pharmacy Services Department for Health and Ageing 

File / Objective No.: A994472 / 2017-11030 

Next review due:   30/04/2023 (usually 1-5 years  time)  

Policy history: Is this a new policy (V1)?  Y 

 Does this policy amend or update and existing policy?   N 

 If so, which version? 

 Does this policy replace another policy with a different title?  N 

 If so, which policy (title)? 

ISBN No.:                        978-1-76083-027-4     

 

 



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