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An ethical way to choose which kids get chemo during a shortage?

When chemotherapy is in short supply, doctors should choose kids to receive treatment based on which patients have the best odds of being cured by the drugs, argues a group of oncologists.
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 US, 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.
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.”

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