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 Shortages of life-saving cancer medicines for children are frequent
and can complicate typical treatment protocols, creating substantial
ethical challenges, the doctors write in the Journal of the National
Cancer Institute.
“Curability, prognosis, and the incremental importance of a
particular drug to a given patient’s outcome are the critical
factors to consider when deciding how to allocate scarce life-saving
drugs,” Dr. Yoram Unguru of Johns Hopkins University in Baltimore
and colleagues write in the commentary.
While shortages may occur for a variety of reasons, they are
particularly common for generic injected medicines and happen
frequently in the U.S., the authors note. There are about 265 drugs
currently in short supply in the U.S., down from a peak of 320 as of
September 2014.
The first response to a shortage should be to maximize efficiency
and minimize waste in using available supplies, the authors argue.
After that, when there is no longer enough medicine to go around,
clinicians should consider curability based on evidence that points
to survival odds, taking into account how well a medicine works for
a particular tumor type as well as individual patient
characteristics.
Doctors might, for example, consider skipping one drug in short
supply when there is another widely available medicine that could
produce similar survival odds, even if the alternative drug doesn’t
necessarily offer children as much time before symptoms worsen.
When the chances of survival are widely different, it may be
clear-cut to give the child with better odds the medicine. But when
survival odds are similar, for instance the difference between 70
percent and 80 percent, this is no longer an ideal way to ration
scare chemotherapy, argue the authors, who declined to be
interviewed.
Tumor type also matters.
For example, if injectable methotrexate is in short supply, it makes
more sense to prioritize children with acute lymphoblastic leukemia
(ALL) over kids with bone malignancies known as osteosarcoma because
more evidence points to the effectiveness of this drug for ALL, the
authors argue.
Phase of treatment is important, too.
A child recently diagnosed with ALL, for example, may have a larger
disease burden and a greater need for chemotherapy than another kid
who has already been in treatment for a while and is taking medicine
to help prevent tumors from returning.
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In addition, kids who need only a small amount of medicine for a
course of treatment might get priority over children who would need
larger quantities, the authors suggest.
Clinicians should consider this ethical framework for rationing
scarce cancer drugs in the absence of a nationwide policy spelling
out the best way to dole out chemotherapy during a shortage, the
authors conclude.
“In discussing curability, prognosis and importance of a particular
drug to outcome, it is important to note that these thoughtful
authors consider both the absolute expected survival rate and the
incremental impact of the agent on survival,” said Dr. Reshma Jagsi,
a researcher in oncology and medical ethics at the University of
Michigan in Ann Arbor who wasn’t involved in the commentary.
“Also noteworthy is the fact that they do not advocate prioritizing
treatment between two children whose chances of survival are
similar,” Jagsi added by email.
This ethical framework also makes a crucial distinction between
prognosis and curability, said Dr. Jill Beck, a researcher in
pediatric oncology at the University of Nebraska Medical Center who
wasn’t involved in the study.
“Curability is the chance that a child will be cured of their cancer
with the current treatment,” Beck said by email. “Prognosis is very
similar to curability, although looks at the chance of survival as
opposed to cure. Some children may be cured of their cancer, but
still not survive due to complications of the therapy.”
SOURCE: http://bit.ly/VFCL0c Journal of the National Cancer
Institute, online January 29, 2016.
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