The U.S. is currently experiencing an all too common shortage of chemotherapy drugs and, in absence of any national advisory statements from the government, doctors have developed their own guidelines for rationing the much-needed cancer drugs. These new guidelines were recently published in the Journal of the National Cancer Institute.
There are currently around 265 different drugs that are in short supply within the U.S. and many of them are chemotherapy treatments. This is a recurring problem, so the guidelines that were published at the end of January are most likely going to see regular use.
The guidance is broken into two main parts. Step one includes various strategies for easing a shortage, minimizing waste, and improving efficient use of chemotherapy drugs. Step two is a far more sensitive subject—patient prioritization.
Many of the guidelines for improving efficiency and waste reduction are fairly straightforward. Doctors are advised not to over-order or hoard chemotherapy drugs, for instance, since this would result in medication that expires before it can be used. Another approach is that if a certain drug is not available at a patient’s hospital, but can be found at another institution, the patient should be transferred rather than see their treatment plan altered. Parallels are drawn to natural disasters and there is further advice to use shortages as a way to raise attention to the problem and push for policy improvements to avoid future recurrences.
When it comes to deciding which patients will be treated and which ones will not, the determining factors will be curability, prognosis, relative importance of drug to tumor type and outcome, and which phase of treatment a patient is in. It makes utilitarian sense to prioritize treatment for patients with the best chances of success, but things are less clear-cut when dealing with two patients who have similar survival odds. In this case, the patient who has a shorter prognosis—and therefore more urgent need—would be favored. However, not all chemotherapy drugs are equally effective against all tumor types. Sarcomas respond differently to some treatments than non-Hodgkin’s lymphoma, for instance, and how the tumor matches the treatment is going to be taken into account.
Another key distinction is that doctors will need to keep in mind the difference between curability and prognosis. Although the chance a cancer can be cured is closely aligned with the chance of survival, the two do not always match up. Some patients may be curable, but would be unlikely to survive due to complications of the therapy itself, other damage already suffered from the cancer, or other factors.
It is important to remember that this guidance is just that—guidance. These policies are a proposed framework to help doctors and medical staff better make decisions, not hard-and-fast rules. There is still a heavy reliance on a doctor’s personal evaluation and judgment that will ultimately determine how they respond to the current drug shortages.
Sources for Today’s Article:
“A Matter of Life or Death: Pediatric Oncologists Issue Guidance for Allocating Scarce Chemotherapy Drugs,” Journal of the National Cancer Institute JNCI.J, 2016; 108 (6): djv392 doi: http://dx.doi.org/10.1093/jnci/djv392.