Two approaches to pediatric cancer, two different philosophies

Torn between doing the most good or the least harm is not an enviable position for physicians to find themselves and there are no easy answers to these ethical questions, according to an article published online Dec. 18 in the Journal of the American College of Radiology.

Authors Benjamin Farnia, a fourth-year student with the Department of Radiation Oncology at University of Texas MD Anderson Cancer Center in Houston, and colleagues asserted that the difference in approach between providers in North American and Europe is evident in one scenario: treating pediatric soft-tissue sarcoma rhabdomyoscarcoma (RMS).

When studying the treatment of the eye cancer in children, the North American approach operates from a principle of beneficence. As such, clinicians base decisions on attempting to minimize disease recurrence through initial radiation, which often comes with increased patient vulnerability to treatment sequelae.

European clinicians, on the other hand, aim to prevent harsh treatment side effects by avoiding radiation upfront and using chemotherapy instead, which often comes with increased disease recurrence.

The authors looked to analyze both approaches ethically and to provide a glimpse into the tradeoffs with each approach and to help clinicians provide guidance to parents in the face of the controversy.

“We hope to establish that ethical analysis is an important resource to address challenges that arise when professional practices and perspectives differ across groups of physicians, and in this case, regional borders, in the management of cancer patients,” the authors wrote.

For the analysis, the researchers examined the ethical foundation for both treatment approaches. Using principles set forth by a previous study, the team examined the approaches in light of the following:

• Respect for autonomy (respecting patients’ decisions)
• Nonmaleficence (avoiding causing harm)
• Beneficence (relieving or preventing harm and providing benefits)
• Justice (distributing benefits, risks and costs equally)

Farnia and colleagues found that the North American approach operated from a “fiduciary obligation to protect and promote the health-related interests of their patients.”

Survival rates of the North American approached ranged between 96 and 100 percent and by initiating radiation therapy upfront, they decrease the chances for recurrence of the disease and for salvage therapy, the authors wrote. Additionally, the North American approach looks to avoid the increase of metastatic disease down the road. The authors cited an additional study that showed distant metastasis rates as high as 15 percent in patients who did not receive upfront radiation.

The European approach has a survival rate between 85 and 88 percent and works to emphasize the potential for damaging after effects of aggressive treatment by using chemotherapy instead of radiation upfront. Radiation is used if the disease returns.

“Both approaches are based on well-established ethical principles, evidence, and clinical experience. Thus, both approaches currently appear to have legitimacy and should be included in the informed consent process,” the authors concluded.  “However, if treatment-related toxicity is reduced through improvements in radiation delivery, the North American approach could emerge as ethically superior.”