Cancer services have suffered badly during the pandemic and there is a danger of immunosuppressant drugs dramatically raising the risk to cancer patients requiring chemotherapy. The traditional model requires that a patient receives the maximum tolerated dose (MTD) of chemotherapy on the principle that you kill the cancer before you kill the patient. The Lancet has questioned this dogma and it is very clear from the new data we have using immunotherapy that this concept is simply wrong in solid tumours. WEw have known about low dose treatments for a many years and there are increasing data to show that lower dosing actually achieves better results. The idea is old and put forward as long ago as the 15th century by Paracelsus and is known as Hormesis! Indeed, very much lower doses are needed and the reason this seems to work has been clarified by greater knowledge of the immunological effects on the likes of suppressor cells. Indeed, most new trials in immunotherapy are aiding low dose cyclophosphamide to help the effect. Full dose cyclophosphamide is very toxic but at 50mg orally given every other day (so called metronomic dosing) it is very effective. Given the side-effects are minimal, that out is oral, it is cheap, and it is almost certainly effective, we are missing a golden opportunity to trial this during the crisis. The NHS should be looking for effective therapy that is cheap and not be obsessed by trials using very expensive agents which we can ill afford. Repurposing agents is one very important and easy way to get a result and may well spare many patients the awful side-effects of conventional therapy at maximal dose. At the very least, patients are getting some treatment and will retain hope, as well as possibly getting more
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