[Ethical stakes in palliative care in radiation oncology]. / Enjeux éthiques de la pratique des soins à visée palliative en oncologie radiothérapique.

In 2021, the Ethics Commission of the SFRO has chosen the issue of the practice of palliative care in radiotherapy oncology. Radiation oncology plays a central role in the care of patients with cancer in palliative phase. But behind the broad name of palliative radiotherapy, we actually find a large variety of situations involving diverse ethical issues. Radiation oncologists have the delicate task to take into account multiple factors throughout a complex decision-making process. While the question of the therapeutic indication and the technical choice allowing it to be implemented remains central, reflection cannot be limited to these decision-making and technical aspects alone. It is also a question of being able to create the conditions for a singularity focused care and to build an authentic care relationship, beyond technicity. It is through this daily ethical work, in close collaboration with patients, and under essential conditions of multidisciplinarity and multiprofessionalism, that our fundamental role as caregiver can be deployed.

[Research ethics: French regulations and applications in radiation oncology]. / Éthique de la recherche : réglementations françaises et applications en oncologie radiothérapie.

French regulations about research ethics are based on the so-called Jardé law, which defines researches involving human beings. Researches involving human beings require the submission of research protocols to a committee for protection of persons with a precise list of documents to submit for a favourable opinion. This law describes different categories of researches and determines the ethical procedures to apply before setting up a research protocol. This issue of categorisation is central and must be taken into account by researchers from the beginning of the research process. Researches considered as not involving human beings also require a set of ethical precautions focused on patients' information and the collection of their non-opposition (due to the application of the General Data Protection Regulation adopted by the European Parliament). Thus, many regulations exist and they require a real work for researchers to meet these requirements in research ethics. This article aims to summarise French regulations. Selected examples are specifically taken into the field of radiation oncology research.

Ethical considerations related to radiosensitivity and radiosusceptibility.

Purpose: The potential for individual radiosensitivity and radiosusceptibility testing, both in clinical practice and in systems of radiological protection, raises complex ethical considerations which must be addressed both in relation to the scientific research looking at the issues themselves, and in relation to any systems of safety and protection which are then proposed for introduction.Methods: This paper uses ethical principles for radiological protection derived by the ICRP together with other biomedical principles, to identify and evaluate some of the ethical issues associated with radiosensitivity testing.Results and conclusions: Although the evaluation is not exhaustive, it illustrates a range of different ethical aspects that would need to be considered, prior to making recommendations for how the field might better address these challenges in its future development.

[Limits of technique: Ethical issues]. / Limites de la technique : enjeux éthiques.

Radiation oncology departments are paradigmatic examples of the general evolution of medicine towards an ever more important presence of technology. The distance to the body or our radical dependence on the machine are concrete factors conditioning care practices in radiotherapy. Thus, an essential question appears: can technique be seen as a real limit for our primary function of care in radiation oncology? It is also necessary to consider the postures this question could lead to: the real risk of finding legitimacy in our sole function of technicians. If technique can be seen as a possible hindrance to our care role, it also appears that technique can create unexpected spaces, where radiation oncologists can express their own definition of care with patients. It is time for our community to take into account this specific aspect of the technologic issue in order to attest the reality of its limits and possibilities. A collective reflection on the ethics of technique, and more broadly on the ethics of care practices in radiation oncology appears relevant.

Common error pathways seen in the RO-ILS data that demonstrate opportunities for improving treatment safety.

PURPOSE: The Radiation Oncology Incident Learning System (RO-ILS) receives event reports from facilities across the country. This effort extracted common error pathways seen in the data. These pathways, expressed as fault trees, demonstrate the need for, and opportunities for, preventing these errors and/or limiting their propagation to treatment. METHODS AND MATERIALS: As of the third quarter of 2016, 2344 event reports had been submitted to RO-ILS and reviewed. A total of 396 of the reports judged highest priority were rereviewed and assigned up to 3 keywords to classify events. Based on patterns among the keyword assignments, the data were further aggregated into pathways leading to 3 general error types: "problematic plan approved for treatment," "wrong shift instructions given to therapists," and "wrong shift performed at treatment." Fault trees were created showing how different errors at different stages in the treatment process combine to flow into these general error types. RESULTS: A total of 173 of the 396 (44%) events were characterized as belonging to 1 of these 3 general error types. Ninety-nine events were defined as "problematic plan approved for treatment," 40 as "wrong shift instructions given to therapists," and 34 as "wrong shift performed at treatment." Seventy-six of these events (44%) resulted in incorrectly delivered treatment. Event discovery was by therapists (n = 76), physicists (n = 45), physicians (n = 23), dosimetrists (n = 15), or not identified (n = 9); 5 events were found as a result of the patient questioning the staff. For the event type "problematic plan approved for treatment," 64 of the 99 (65%) events were attributable to physician error: incorrect target or dosing pattern prescribed. CONCLUSIONS: Data extracted from RO-ILS event reports demonstrate common error pathways in radiation oncology that propagate all the way to treatment. Additional study and coordination of efforts is needed to develop and share best practices to address the sources of these errors and curtail their propagation.

The rise of reimbursement-based medicine: the case of bone metastasis radiation treatment.

It has been hypothesised that the reimbursement system pertaining to radiotherapy is influencing prescription practices for patients with cancer with bone metastases. In this paper, we present and discuss the results of an empirical study that was undertaken on patient records, referred to radiotherapy for the treatment of bone metastases, in a medium-size city, in southern Brazil, during the period of March 2006 to March 2014. Our findings seem to confirm this hypothesis: after a change in the reimbursement method, radiation prescriptions were adapted accordingly, in order to maximise profits. Once such patients become highly vulnerable due to their diagnoses, they also become susceptible to a subtle form of exploitation; physicians let patients believe that more radiation will be better for their health, and they do so despite knowing otherwise, and as it seems, out of pecuniary interests.

Clinical Research Ethics: Considerations for the Radiation Oncologist.

Consideration of clinical research ethics in radiation oncology is underexplored relative to other areas of oncology. A number of ethical challenges related to informed consent, randomization, conflicts of interest, and scientific validity and social value are shared with other areas of medicine, although their exact inflections are specific to radiation oncology. In addition, there are unique concerns in radiation oncology arising from the rapid evolution and uneven distribution of radiation technologies; the greater unfamiliarity of the general public and research oversight committees in regard to radiation oncology clinical practice; and the high complexity of managing most radiation oncology research, much of which is carried out in high-acuity multidisciplinary oncologic settings. To produce the best research, adherence to the highest ethical standards should be pursued as an integral component of all radiation oncology research.

Ethics in the Legal and Business Practices of Radiation Oncology.

Ethical issues arise when a professional endeavor such as medicine, which seeks to place the well-being of others over the self-interest of the practitioner, meets granular business and legal decisions involved in making a livelihood out of a professional calling. The use of restrictive covenants, involvement in self-referral patterns, and maintaining appropriate comity among physicians while engaged in the marketplace are common challenges in radiation oncology practice. A paradigm of analysis is presented to help navigate these management challenges.

Bridging Innovation and Outreach to Overcome Global Gaps in Radiation Oncology Through Information and Communication Tools, Trainee Advancement, Engaging Industry, Attention to Ethical Challenges, and Political Advocacy.

An evolving paradigm in global outreach in radiation oncology has been the implementation of a more region-specific, needs-based approach to help close the gap in radiation services to low- and middle-income countries through the use of innovative tools in information and communication technology. This report highlights 4 information and communication technology tools in action today: (1) the NCCN Framework for Resource Stratification of NCCN guidelines, (2) ASTRO e-Contouring, (3) i.treatsafely.org, and (4) ChartRounds.com. We also render special consideration to matters related to global outreach that we believe require distinct attention to help us meet the goals established by the 2011 United Nations׳ Declaration on noncommunicable diseases: (1) trainee advancement toward careers in global health, (2) ethical challenges of international outreach, (3) critical importance of political advocacy, and (4) collaboration with Industry.

Integrity of the National Resident Matching Program for Radiation Oncology: National Survey of Applicant Experiences.

PURPOSE: The aim of this study was to examine the experiences of radiation oncology applicants and to evaluate the prevalence of behaviors that may be in conflict with established ethical standards. METHODS AND MATERIALS: An anonymous survey was sent to all 2013 applicants to a single domestic radiation oncology residency program through the National Resident Matching Program (NRMP). Questions included demographics, survey of observed behaviors, and opinions regarding the interview and matching process. Descriptive statistics were presented. Characteristics and experiences of respondents who matched were compared with those who did not match. RESULTS: Questionnaires were returned by 87 of 171 applicants for a 51% response rate. Eighty-two questionnaires were complete and included for analysis. Seventy-eight respondents (95.1%) reported being asked at least 1 question in conflict with the NRMP code of conduct. When asked where else they were interviewing, 64% stated that this query made them uncomfortable. Forty-five respondents (54.9%) reported unsolicited post-interview contact by programs, and 31 (37.8%) felt pressured to give assurances. Fifteen respondents (18.3%) reported being told their rank position or that they were "ranked to match" prior to Match day, with 27% of those individuals indicating this information influenced how they ranked programs. Half of respondents felt applicants often made dishonest or misleading assurances, one-third reported that they believed their desired match outcome could be improved by deliberately misleading programs, and more than two-thirds felt their rank position could be improved by having faculty from their home institutions directly contact programs on their behalf. CONCLUSIONS: Radiation oncology applicants report a high prevalence of behaviors in conflict with written NRMP policies. Post-interview communication should be discouraged in order to enhance fairness and support the professional development of future radiation oncologists.

Ethical analysis as a tool for addressing treatment controversies: radiotherapy timing in children with orbital rhabdomyosarcoma as a case example.

PURPOSE: The treatment of orbital rhabdomyosarcoma is a topic of debate between North American and European clinicians, with the utility of radiation therapy as part of initial management in question. Despite differences in philosophy, the dominant North American approach of upfront radiation and the dominant European approach of radiation only in the event of recurrence yield a similar rate of overall survival. We sought to identify the ethical arguments for each approach. METHODS: Established moral principles and appeals in contemporary medical ethics were utilized to identify the ethical arguments supporting each treatment approach. The potential for technologic advances to alter the analysis was considered. RESULTS: Emphasizing the principle of beneficence, the North American approach seeks to reduce recurrence rates. In contrast, the European approach seeks to avoid radiation-induced sequelae, emphasizing the principle of nonmaleficence. 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. However, if treatment-related toxicity is reduced through improvements in radiation delivery, the North American approach could emerge as ethically superior. CONCLUSIONS: Ethical analysis can aid in addressing challenges that arise when professional practices and perspectives differ in the management of cancer patients.

[Strategy for technical evaluation in radiation oncology: methodological and ethical aspects, the French society for radiation oncology's opinion]. / Quelle technique pour quelle tumeur ? Enjeux éthiques et méthodologiques, point de vue de la SFRO.

Evidence-based medicine is a paradigm founded on a hierarchy of research design, accepted as a dogma. Applied to radiation oncology, and specifically to radiotherapy technical comparisons, evidence-based medicine implies methodological and ethical problems. The concept of "incremental" evolution and the dosimetric evidence are proposed as an acceptable alternative to comparative clinical trials if total dose, time, fractionation, and target volumes are not modified. For other situations, either randomized comparative trials or observational studies are needed. When randomized comparative trials are not possible, observational studies, whose validity can be enhanced by appropriate methodology, must be considered as a valid method.

Shared decision-making and patient control in radiation oncology: implications for patient satisfaction.

BACKGROUND: Shared decision-making (SDM) has been linked to important health care quality outcomes. However, to the authors' knowledge, the value of SDM has not been thoroughly evaluated in the field of radiation oncology. The objective of the current study was to determine the association between SDM and patient satisfaction during radiotherapy (RT). The authors also explored patient desire for and perception of control during RT, and how these factors relate to patient satisfaction, anxiety, depression, and fatigue. METHODS: A cross-sectional survey of 305 patients undergoing definitive RT was conducted. Patients self-reported measured variables during the last week of RT. Relationships between variables were evaluated using chi-square analyses. RESULTS: Among study participants, 31.3% of patients experienced SDM, 32.3% perceived control in treatment decisions, and 76.2% reported feeling very satisfied with their care. Patient satisfaction was associated with perceived SDM (84.4% vs 71.4%; P < .02) and patient-perceived control (89.7% vs 69.2%; P < .001). Furthermore, the perception of having control in treatment decisions was associated with increased satisfaction regardless of whether the patient desired control. Increased anxiety (44.0% vs 20.0%; P < .02), depression (44.0% vs 15.0%; P < .01), and fatigue (68.0% vs 32.9%; P < .01) were reported in patients who desired but did not perceive control over their treatments, compared with those who both desired and perceived control. CONCLUSIONS: The findings of the current study emphasize the value of SDM and patient-perceived control during RT, particularly as it relates to patient satisfaction and psychological distress. Regardless of a patient's desire for control, it is important to engage patients in the decision-making process.

[The future of radiation oncology: technology, ethical considerations and economical aspects]. / La radio-oncologie de demain: comment concilier l'éthique, le développement technique et les aspects économiques?

We are facing a real technical revolution in radiation oncology. The radiation oncologist is pushed by the industry to implement rapidly new and "high-tech" therapeutic modalities. All of the technical improvements are obviously aiming at an increase in the therapeutic index. However, one should be cautious before implementing on a large scale those technical innovations as no one really knows neither what the possible impact is on medical outcome (efficacy, toxicity and risk), nor what the economical consequences will be. It is our duty as radiation oncologists to make a comprehensive estimation of the impacts in order to be able to set up guidelines for use that are both ethical and in respectful of human dignity.