Ethical challenges in oncology, explored through a series of vignettes

The specialty of medical oncology poses many ethical dilemmas to the practicing physician. In this article, we have chosen to focus on three of those challenges, presenting them in the form of vignettes. The first dilemma deals with the difficulties physicians encounter secondary to the rising cost of cancer therapies when choosing and communicating about treatment plans with patients. The second scenario addresses difficulties associated with communicating prognosis to cancer patients, and the third challenge focuses on cancer treatment strategies for patients nearing the end of life.

"Well, I think there is great variation...": a qualitative study of oncologists' experiences and views regarding medical criteria and other factors relevant to treatment decisions in advanced cancer

BACKGROUND

Surveys indicate considerable variation regarding the provision of cancer treatment at the end of life. The variation cannot be fully explained by differences concerning the clinical situation or patients' preferences. The aim of this qualitative study was to explore medical oncologists' experiences with advanced cancer, as well as their views of the relevance of medical and nonmedical criteria for decisions about limiting treatment.

METHODS

Qualitative in-depth interviews were conducted with physicians working in medical oncology in tertiary care hospitals or district general hospitals in England. Purposive sampling and qualitative analysis were performed.

RESULTS

Physicians reported that a number of nonmedical factors influence professional decisions about the offering or limiting of cancer treatment in advanced cancer in addition to medical criteria. Physicians' individual judgments about the benefit of treatment, as well as the amount of their clinical experience, were cited as such factors. In addition, the physicians' perceptions of the patient's age and life circumstances were reported to influence their treatment decisions. Multiprofessional team discussions and the systematic collection of relevant clinical data regarding the outcomes of different treatment approaches in advanced cancer were suggested as strategies to improve the quality of treatment decisions.

CONCLUSION

The findings of this study provide explanations for the variation in treatment in advanced cancer. Making value judgments explicit and gathering more appropriate clinical data on the outcomes of treatment near the end of life are prerequisites for improved ethical and evidence-based treatment decisions in advanced cancer.

Structure and function of the oncologic boards in Greece. Description of the institutional and scientific frame; objective problems and difficulties

PURPOSE

Oncology boards should constitute a routine in all hospitals that are dealing with the care of cancer patients. Unfortunately the procedure which should be followed to deal with this health problem has some deficiencies.

METHODS

A literature review has recently been attempted, searching Internet databases by using key words such as oncologic board, medical legislation and medical ethics.

RESULTS

Current mentality suggests that hiding the truth from the patient is wrong and unethical. However, in the Greek society, this is not the case as it seems not right to adopt foreign practices, i.e. to disclose directly to the patient all information relevant to his health status, the intended therapy and possible outcome. Instead, ambiguous information pass onto relatives who in turn bear the burden of informing the patient.

CONCLUSIONS

The best solution would be the integration of the positive elements of the patient's awareness and the beneficial effects of the involvement of the Greek family in the general care of the cancer patient.

Reporting of funding sources and conflict of interest in the supportive and palliative oncology literature

CONTEXT

The reporting of funding support and conflict of interest has not been examined in the supportive/palliative oncology literature.

OBJECTIVES

We examined the frequency of funding and conflict of interest reporting and various study characteristics associated with such reporting.

METHODS

We systematically searched MEDLINE PubMed, PsycInfo, EMBASE, ISI Web of Science, and CINAHL for original studies related to palliative care and cancer in the first six months of 2004 and 2009. For each article, we reviewed the study design, research topic, journal type, and reporting of funding and conflict of interest.

RESULTS

Three hundred forty-four (41%) and 504 (59%) of 848 articles were from 2004 and 2009, respectively. Five hundred two of 848 (59%) studies reported no funding sources, whereas 216 (26%), 70 (8%), 34 (4%), and 26 (3%) reported one, two, three, and four or more sources, respectively. Key funding sources included governmental agencies (n=182/848, 21%), philanthropic foundations (n=163/848, 19%), university departments (n=76/848, 9%), and industry (n=27/848, 3%). Conflict of interest was not reported in 436 of 848 (51%) studies, and only 94 of 848 (11%) explicitly stated no conflict of interest. Other than extramural funding, conflict of interest reporting of any kind was extremely rare (mostly less than 1%). Conflict of interest reporting increased between 2004 and 2009 (39% vs. 55%, P<0.001). Both funding and conflict of interest reporting were associated with prospective studies, larger sample sizes, nontherapeutic studies, North American authors, and publication in palliative care/oncology journals (P≤0.008 for all comparisons).

CONCLUSION

A majority of supportive/palliative oncology studies did not report funding sources and conflict of interest, raising the need for standardization.

Implementing a systematic approach to meeting patients' cancer and fertility needs: a review of the Fertile Hope Centers Of Excellence program

PURPOSE

National guidelines recommend patients with cancer of reproductive age be informed of their risk for infertility resulting from cancer treatment. Despite existing technologies to preserve fertility, many patients report not receiving timely information about fertility risk, and oncology providers report multiple barriers to discussing or referring patients on this topic.

METHODS

Nine cancer centers have been recognized as Fertile Hope Centers of Excellence, a designation awarded to cancer centers with an institutionalized approach to addressing fertility issues. Individual semistructured interviews were conducted with each of these centers to identify strengths of and challenges to their approaches.

RESULTS

All institutions had procedures for the provision of topical professional and patient education and for notification of patients. Notification methods varied widely, from use of customized consent forms to highly automated electronic alerts for providers. Referral routines and enactment of institutional policies also differed. Key components of successful programs emerged, including the value of internal champions, affiliation with complementary programs, and resource sharing.

CONCLUSION

The programs described provide examples of systems that can be assembled in different types of clinical settings, depending on the availability of resources and infrastructure. As institutions develop programs, metrics to evaluate notification systems, in particular, as well as the supportive program components, should be used so identification of best practices can continue. Widespread adoption of programs that incorporate the baseline elements identified will not only comply with national guidelines but also address patients' reproductive needs and fundamentally affect future quality of life.

Letting the cat out of the bag: shifting practices of cancer disclosure in Singapore

INTRODUCTION

Communication between patients and physicians is crucial in the disclosure of cancer diagnosis. Although westernisation of Asian societies has resulted in increased awareness of patient autonomy, the family continues to play an important influencing role in the disclosure process. Therefore, in this study, we aimed to characterise the experience of physicians with the disclosure of cancer diagnosis in a westernised Asian population.

METHODS

Oncologists at a tertiary hospital were approached to participate in this study. Information pertaining to the extent and approach to disclosure was collated. Logistic regression analysis was performed to characterise factors pertaining to the willingness of physicians to fully disclose a diagnosis of cancer.

RESULTS

In all, 25 oncologists (mean age 38 years; 72% men) responded to the survey. A majority of oncologists disclosed a cancer diagnosis directly to the patient over the first few visits. The main reason behind partial or non-disclosure was family objection. Ordinal logistic regression analysis showed that family resistance was the only significant predictor of reluctance to disclose a cancer diagnosis (p = 0.01).

CONCLUSION

In this pilot study, contrary to previous reports, we found that oncologists were more likely to disclose a diagnosis of cancer to the patient first, that they do not accede fully to the family's request for non-disclosure and that family resistance was the only significant predictor of reluctance to disclose a diagnosis of cancer.

Shared decision making in oncology practice: what do oncologists need to know?

BACKGROUND

There is growing interest by patients, policy makers, and clinicians in shared decision making (SDM) as a means to involve patients in health decisions and translate evidence into clinical practice. However, few clinicians feel optimally trained to implement SDM in practice, and many patients report that they are less involved than they desire to be in their cancer care decisions. SDM might help address the wide practice variation reported for many preference-sensitive decisions by incorporating patient preferences into decision discussions.

METHODS

This paper provides a perspective on how to incorporate SDM into routine oncology practice to facilitate patient-centered communication and promote effective treatment decisions. Oncology practice is uniquely positioned to lead the adoption of SDM because of the vast number of preference-sensitive decisions in which SDM can enhance the clinical encounter.

RESULTS

Clinicians can facilitate cancer decision making by: (a) determining the situations in which SDM is critical; (b) acknowledging the decision to a patient; (c) describing the available options, including the risks, benefits, and uncertainty associated with options; (d) eliciting patients' preferences; and (e) agreeing on a plan for the next steps in the decision-making process.

CONCLUSION

Given recent policy movements toward incorporating SDM and translating evidence into routine clinical practice, oncologists are likely to continue expanding their use of SDM and will have to confront the challenges of incorporating SDM into their clinical workflow. More research is needed to explore ways to overcome these challenges such that both quality evidence and patient preferences are appropriately translated and incorporated into oncology care decisions.

Ethical dilemmas in the care of cancer patients near the end of life

By definition, an ethical dilemma involves the need to choose from among two or more morally acceptable options or between equally unacceptable courses of action, when one choice prevents selection of the other. Advances in medicine, increasing economic stress, rise of patient self-determination and differing values between healthcare workers and patients are among the many factors contributing to the frequency and complexity of ethical issues in healthcare. In the cancer patient near the end of life, common ethical dilemmas include those dealing with artificial nutrition and hydration, truth-telling and disagreements over management plans. It would stand the clinician in good stead to be aware of these issues and have an approach toward dealing with such problems. In addition, organisations have a responsibility to ensure that systems are in place to minimise its occurrence and ensure that staff are supported through the process of resolving dilemmas and conflicts that may arise.

Ethical issues at the interface of clinical care and research practice in pediatric oncology: a narrative review of parents' and physicians' experiences

BACKGROUND

Pediatric oncology has a strong research culture. Most pediatric oncologists are investigators, involved in clinical care as well as research. As a result, a remarkable proportion of children with cancer enrolls in a trial during treatment. This paper discusses the ethical consequences of the unprecedented integration of research and care in pediatric oncology from the perspective of parents and physicians.

METHODOLOGY

An empirical ethical approach, combining (1) a narrative review of (primarily) qualitative studies on parents' and physicians' experiences of the pediatric oncology research practice, and (2) comparison of these experiences with existing theoretical ethical concepts about (pediatric) research. The use of empirical evidence enriches these concepts by taking into account the peculiarities that ethical challenges pose in practice.

RESULTS

Analysis of the 22 studies reviewed revealed that the integration of research and care has consequences for the informed consent process, the promotion of the child's best interests, and the role of the physician (doctor vs. scientist). True consent to research is difficult to achieve due to the complexity of research protocols, emotional stress and parents' dependency on their child's physician. Parents' role is to promote their child's best interests, also when they are asked to consider enrolling their child in a trial. Parents are almost never in equipoise on trial participation, which leaves them with the agonizing situation of wanting to do what is best for their child, while being fearful of making the wrong decision. Furthermore, a therapeutic misconception endangers correct assessment of participation, making parents inaccurately attribute therapeutic intent to research procedures. Physicians prefer the perspective of a therapist over a researcher. Consequently they may truly believe that in the research setting they promote the child's best interests, which maintains the existence of a therapeutic misconception between them and parents.

CONCLUSION

Due to the integration of research and care, their different ethical perspectives become intertwined in the daily practice of pediatric oncology. Increasing awareness of what this means for the communication between parents and physicians is essential. Future research should focus on efforts that overcome the problems that the synchronicity of research and care evokes.

KRAS and colorectal cancer: ethical and pragmatic issues in effecting real-time change in oncology clinical trials and practice

Systemic therapy has led to a median survival time for patients with advanced colorectal cancer (CRC) almost fourfold longer than that expected with best supportive care, an outcome achieved through combining chemotherapeutic and targeted biologic agents. Although the latter can include anti-epidermal growth factor receptor antibodies, such as cetuximab and panitumumab, we now have strong evidence that patients whose tumors harbor mutated KRAS will not benefit from this class of agent. Acceptance of the reliability and importance of the KRAS data took several years to evolve, however, for a variety of reasons. The timeline from the presentation and publication of small, retrospective phase II studies to widespread acceptance of the KRAS predictive value and changes in behavior-specifically, modifications of ongoing national trials in advanced/metastatic CRC, changes in national guidelines and practice patterns, and adjustments to the labeled indications for the monoclonal antibodies-was lengthy. In this commentary, we discuss whether or not the process of data disclosure regarding KRAS status and treatment of advanced CRC patients was effective in permitting timely decisions regarding ongoing publicly funded clinical trials and whether or not such decisions were rational and ethical. The overall goals are to highlight lessons learned regarding early disclosure of clinical trial results, as well as vetting and adoption of new scientific data, and to propose modifications for handling similar situations in the future.

What patients value when oncologists give news of cancer recurrence: commentary on specific moments in audio-recorded conversations

PURPOSE

Recommendations for communicating bad or serious news are based on limited evidence. This study was designed to understand patient perspectives on what patients value when oncologists communicate news of cancer recurrence.

STUDY DESIGN AND METHODS

Participants were 23 patients treated for a gastrointestinal cancer at a tertiary U.S. cancer center within the past 2 years, who had semistructured qualitative interviews in which they listened to audio recordings of an oncology fellow discussing news of cancer recurrence with a standardized patient. Participants paused the audio recording to comment on what they liked or disliked about the oncologist's communication.

RESULT

Three themes were identified that refine existing approaches to discussing serious news. The first theme, recognition, described how the oncologist responded to the gravity of the news of cancer recurrence for the patient. Participants saw the need for recognition throughout the encounter and not just after the news was given. The second theme, guiding, describes what participants wanted after hearing the news, which was for the oncologist to draw on her biomedical expertise to frame the news and plan next steps. The third theme, responsiveness, referred to the oncologist's ability to sense the need for recognition or guidance and to move fluidly between them.

CONCLUSION

This study suggests that oncologists giving news of cancer recurrence could think of the communication as going back and forth between recognition and guidance and could ask themselves: "Have I demonstrated that I recognize the patient's experience hearing the news?" and "Have I provided guidance to the next steps?"

[Rationalization, rationing, prioritization: terminology and ethical approaches to the allocation of limited resources in hematology/oncology]

The field of oncology with its numerous high-priced innovations contributes considerably to the fact that medical progress is expensive. Additionally, due to the demographic changes and the increasing life expectancy, a growing number of cancer patients want to profit from this progress. Since resources are limited also in the health system, the fair distribution of the available resources urgently needs to be addressed. Dealing with scarcity is a typical problem in the domain of justice theory; therefore, this article first discusses different strategies to manage limited resources: rationalization, rationing, and prioritization. It then presents substantive as well as procedural criteria that assist in the just distribution of effective health benefits. There are various strategies to reduce the utilization of limited resources: Rationalization means that efficiency reserves are being exhausted; by means of rationing, effective health benefits are withheld due to cost considerations. Rationing can occur implicitly and thus covertly, e.g. through budgeting or the implementation of waiting periods, or explicitly, through transparent rules or policies about healthcare coverage. Ranking medical treatments according to their importance (prioritization) is often a prerequisite for rationing decisions. In terms of requirements of justice, both procedural and substantive criteria (e.g. equality, urgency, benefit) are relevant for the acceptance and quality of a decision to limit access to effective health benefits.

[Benefit-risk evaluation of new drugs as a basis for decisions on prioritization in hematology/oncology: methodical challenges and problem-solving strategies]

Innovations in the drug treatment of cancer patients pose several medical and ethical challenges. The increasing incidence and prevalence of cancer, in combination with the availability of new and usually highly expensive anticancer drugs, are associated with a significant increase in the general costs for the treatment of cancer patients. Therefore, the development of scientific strategies for judgments on benefits is indispensable. In this paper, the authors analyze the benefit assessment and the benefit-risk assessment as a foundation for decisions on prioritization in hematology and oncology. In a first step, regulatory aspects and shortcomings regarding the design of clinical trials in oncology before and after approval of anticancer drugs are identified as factors that contribute to difficulties in establishing the effectiveness of new drugs entering the health care market. The authors will conclude with suggestions for the improvement of benefit-risk analyses and the generation of scientific data necessary for such analyses.

Does it matter whether investigators intend to benefit research subjects?

There has been long-standing, albeit largely implicit, debate over whether investigator intentions are relevant to the ethical appropriateness of clinical research. Some commentators argue that whether investigators intend to collect generalizable knowledge or to benefit subjects is central to the ethics of clinical research. Others do not even mention investigator intentions when evaluating what makes clinical research ethical. To shed light on this debate, the present paper considers the reasons why investigator intentions might be ethically relevant. This analysis reveals that investigator intentions are related to, but distinct from three ethical requirements: whether subjects understand that they are contributing to a project to help others, whether the included interventions have an appropriate risk/benefit ratio, and whether subjects' interests are adequately protected. Provided these three requirements are satisfied, the ethical appropriateness of clinical research does not depend on what intentions investigators have in conducting it.

Ethics of mandatory research biopsy for correlative end points within clinical trials in oncology

Clinical investigators in oncology are increasingly interested in using molecular analysis of cancer tissue to understand the biologic bases of response or resistance to novel interventions and to develop prognostic and predictive biomarkers that will guide clinical decision making. Some scientific questions of this nature can only be addressed, or may best be addressed, through the conduct of a clinical trial in which research biopsies are obtained from all participants. However, trial designs with mandatory research biopsies have raised ethical concerns related to the risk of harm to participants, the adequacy of voluntary informed consent, and the potential for misunderstanding among research participants when access to an experimental intervention is linked to the requirement to undergo a research biopsy. In consideration of the ethical and scientific issues at stake in this debate, the Cancer and Leukemia Group B Ethics Committee proposes guidelines for clinical trials involving mandatory research biopsies. Any cancer clinical trial that requires research biopsies of participants must be well designed to address the scientific question, obtain the biopsy in a way that minimizes risk, and ensure that research participants are fully informed of the risks, rationale, and requirements of the study, as well as of treatment alternatives. Further guidelines and discussions of this issue are specified in this position paper. We feel that if these principles are respected, an informed adult with cancer can both understand and voluntarily consent to participation in a clinical trial involving mandatory research biopsy for scientific end points.

Paternalism in practice: informing patients about expensive unsubsidised drugs

Recent research conducted in Australia shows that many oncologists withhold information about expensive unfunded drugs in what the authors of the study suggest is unacceptable medical paternalism. Surprised by the Australian results, we ran a version of the study in New Zealand and received very different results. While the percentages of clinicians who would prescribe the drugs described in the scenarios were very similar (73-99% in New Zealand and 72-94% in Australia depending on the scenario) the percentage who would not discuss expensive unfunded drugs was substantially lower in New Zealand (6.4-11.1%) than it was in Australia (28-41%). This seems surprising given the substantial similarities between the two countries, and the extensive interaction between their medical professions. We use the contrast between the two studies to examine the generalisability of the Australian results, to identify influences on clinicians' decisions about what treatment information to give patients, and so the tendency towards medical paternalism and, more pragmatically, about how such decisions might be influenced.