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SP-0093 ETHICAL VALUES IN MANAGING A DEPARTMENT
S37
JOINT SYMPOSIUM: ESTRO-ECCO: ETHICS IN PROFESSIONAL LIFE SP-0091 ETHIC VALUES: DO THEY BELONG IN A MUSEUM OR YOUR DAILY BRIEFCASE? F. Botturi1 1 Università Cattolica del S. Cuore, Department of Radiation Oncology, Campobasso, Italy 1. The influence the technological mindset The mutual implication of medicine and humanism is not to be taken for granted. Medicine is, to a wide extent, part of a scientific and technological world, thus bearing the influence of its general mindset. It is quite easy, indeed, to conceive the interpersonal and ethical dimension of medicine just as a humanitarian willingness which is applied upon a self-sufficient scientific and technical doing. This comes from the development of the technological world as a highly complex and specialized structure which is becoming more and more autonomous when it comes to its organization and purposes. This epistemological and sociological situation looks like a justification for the common separation between scientific and technological systems on one side and the ethical assessment on the other. Along the same lines, we meet a growing feeling of unruliness of those systems by individual subjects and a significant degree of inefficacy of ethical decisions on self-sufficient structures and processes. Within this kind of experience, human relationships become a marginal appendix of practices which follow objective rules. Interpersonal relationships receive then some consideration as preconditions for an increased efficiency of those practices, but not as an essential component of the competence they demand. 2. The inevitable responsibility of action Such a representation, though, is only deceptively plausible: it conceals the “knot” of personal action, i.e. the fact that the single, concrete action is the real center around which the different systems are effectually knotted together. Our actions aren’t just a tool to build relationships between different systems, but they are rather deliberate and free acts, actual choices between the possibilities which are offered by the various systems we are involved in. Thus, it’s only through our actions that the scientific knowledge and the technical procedures acquire a responsible destination, a cultural significance and a practical connection to their ends which are related to actual human beings. Seen in this perspective, health itself, which is the purpose of every medical action, is objectively and ultimately about the person as a whole and her research for a “healthy” destination. This doesn’t mean that medical actions should leave behind the objectivity of a clinical perspective, which methodically selects the relevant diagnostic and therapeutic features; it rather means that medical actions shouldn’t lose from sight an anthropologically wide sense of health. By operating in this way the physician fully expresses an ability of “evaluation” which is not just scientific and technical, but also anthropological and moral. 3. Ethics of compassion and care Any illness points to a need for health which signifies a wider desire of “healthiness” of the human condition, a strain towards the destination of the person. Within this perspective, the therapist can always recognize that she always shares with the patient the problem of the “proper functioning” of human life as such. Then, being receptive towards the other person doesn’t look anymore like a humanitarian ornament upon a neutral scientific and technical praxis, but rather an expression of the deep sense of the medical act itself. That is an ethical dimension which is internal to the medical practice and by taking it seriously the physician isn’t adding something external to her profession, but she is rather living it to its full human meaning and avoiding the risk of alienation within an abstract practice of her competence. A sincere reception of others comes, then, from the recognition of a shared condition and expresses an “ethics of compassion” for humanity and an “ethics of care” where the physician is engaged as a human being. SP-0092 ETHIC VALUES IN THE DISSEMINATION OF SCIENCE J.Overgaard Aarhus University Hospital, Aarhus, Denmark Abstract not received
ESTRO 31
SP-0093 ETHICAL VALUES IN MANAGING A DEPARTMENT B. Van Daele1, K. Haustermans2 1 AZ St Maria, Management, Halle, Belgium 2 UZ Leuven, Radiation Oncology, Leuven, Belgium In this lecture an overview will be given of the different challenges and ethical questions a chair of a department is confronted with on a daily basis. A frame work will be presented to classify these (see figure): on one side there is the ethical dimension with three domains being the community related aspects, the psychologically related aspects and the existentially related aspects of ethical values, on the other side the chairmanship dimension with “vision and goals” and “leadership aspects”. For each crossing of axes examples are given. An attempt will be made to offer an “ethical language” which can be used when discussing these topics. Currently a big debate is ongoing regarding delivering affordable cancer care in high-income countries (see figure). With the increase in cancer burden and the increasing costs of cancer treatment it is clear that in the not too far future the challenge will be how to collectively deliver reasonably priced cancer care to all citizens. From a cultural-philosophical point of view, some interesting thoughts on potential solutions can be found in the book “Medical Nemesis: the expropriation of health” by Ivan Illich. The author states that the medical establishment and industrialization have become a major threat to health. He refers to the Greek mythology as a metaphor to clarify his ideas : Nemesis represents divine vengeance upon mortals who infringe on those prerogatives the gods guard for themselves. Nemesis was the inevitable punishment for attempts to be a hero rather than a human being. She took the shape of a goddess that represented nature’s response to hubris. Hubris is illustrated by Prometheus who stole the fire from the gods and brought it to mankind. As punishment, Zeus chained Prometheus to a mountain where every day, an eagle would come and eat his liver. From Illich’s point of view, all cultures over time have been struggling with pain, sickness an death. Although the human answer historically could be found in a mixture of religion, culture, lifestyle and medicine, it is not until the 20th century that people started to believe that “modern medicine” was on its way to cure all diseases and to overcome pain. Everybody must have access to this new religion that guarantees victory over pain and illness and over death as a painful killer. Consequently, no price is too high to conquer all diseases. Illich calls this phenomenon structural iatrogenesis resulting in the alienation of people from their own sickness and death. Besides he also has a thesis on medical iatrogenesis (disease caused by medical intervention itself) and social iatrogenesis (persisting unhealthy social conditions with illness as an alibi). It is now time to review the health-care system. This review should not reinforce the present medicalisation of life but should instead focus on the recovery of a personal responsibility for health care. A new definition of health should help us with the ability to cope with pain, illness and death. This should be achieved in a “convivial way”: in harmony with the person’s autonomy and the medical world. From a more pragmatic point of view, we will refer to a Dutch commission which developed in 1991 a conceptual framework that can be used as a tool for making choices in reimbursement for health care. The so called “Funnel of Dunning” reveals 5 criteria for care programs to be reimbursed by the government or social insurance : necessity, effectiveness, efficiency, individual or social responsibility and degree of discomfort of sickness. From the position of the chair of a department, one has to face on a daily basis the conflicts of priorities responsibility towards the management, towards the staff and towards the patients (see figure). These conflicts are not easy to handle and even more difficult to resolve. A leader is frequently confronted with the choice “quit or manage” and as such is vulnerable to burnout. Organizations should be made aware of this and should create an environment in which leaders are protected against this phenomenon.
S38
ESTRO 31
tolerance of late adverse effects after a PBRT schedule, whether hypofractionated or not, may be greater than n after the same schedule delivered to the whole breast, even if tissue e damage per unit volume is the same. For example, a given density of o fibrosis restricted to a partial (eg. boost) volume may be better tolerated than the same density of fibrosis affecting the whole breastt. Overall treatment time is not expected to impact on late adverse e effects, other than by modifying the severity of effects conse equential to acute skin reactions. An impact of treatment time on tumour control in the adjuvant setting has not been formally testted, but cannot be ruled out. Finally, it is likely that the clinical effeccts of current single dose intraoperative radiotherapy schedules remaiin explicable in terms of current models of tumour and normal tissue responses. r SP-0096 EVIDENCE OF VOLUME EFFECTS FOR NORMA AL TISSUE AND TUMOUR RESPONSES E. Van Limbergen University Hospital Gasthuisberg, Leuven, Be elgium Abstract not received SP-0097 IORT UPDATE: WHAT ARE THE LIMITS OF TOTA AL DOSE AND VOLUME? R. Orecchia1, M.C. Leonardi1 1 European Institute of Oncology, Radiation Th herapy, Milan, Italy
SP-0094 ETHIC VALUES AND SCIENTIFIC SOCIETIES M. Baumann1 1 TU Dresden Med. Faculty Carl Gustav Carus, Radiation n Oncology, Dresden, Germany The general aim of scientific societies is to advance science by research and education, as well as dissemination an nd discussion of results. Medical scientific societies regularly add the aim to promote the quality of treatment of specific disease in the best interest of patients. Such aims of medical scientific societiies establish a particular and privileged role not only in the scientificc community but also among patients, policy makers and the general public. p Although not always easy to differentiate, this role is fundame entally different from that of professional or lobbyist organizations, and d mandates firm foundation on and strict adherence to ethical values. The T contribution will review the special status of medical scientific soccieties and gives examples how these values should impact on govern nance, structure and activities of medical scientific societies.
SYMPOSIUM: HYPOFRACTONATION BREAST RADIOTHERAPY
AND
PARTIAL
SP-0095 HYPOFRACTIONATION AND PBRT: WHAT DO WE NEED N TO THINK ABOUT? N. Somaiah1, J. Yarnold2 1 The Royal Marsden NHS Foundation Trust, Radiothera apy, Sutton, United Kingdom 2 The Royal Marsden NHS Foundation Trust & Institute of o Cancer Research, Radiotherapy, Sutton, United Kingdom Randomised trials testing whole breast radiotherapy delivered using once-daily fractions of 2.7 - 3.3 Gy show the fraction nation sensitivity of breast cancer to be comparable to that of late adverse effects recorded by clinicians and patients up to 10 years post-treatment. The fractionation sensitivities of normal and malignant tissues t over this range of fraction sizes are not expected to change when hypofractionation is used for partial breast radiotherapy (PBRT), at least when once-daily fractions are delivered. Wh hen twice-daily fractions of the same size are used, a greater effect of the second fraction must be taken into account when using iso-e effect formulae, such as the linear-quadratic model. The magnitude of o this effect is better quantified for normal tissues than for tumou urs. The clinical
IntraOperative RadioTherapy (IORT) consistts of a high single dose delivered under direct and visual ispection of o the tumor. The goal is to improve local control and reduce toxicity since there is less volume of irradiated healthy tissue. In addition, there is no interval between surgery and radiotherapy. The results publisshed in the literature are still preliminary, and there are only few datta that allow to compare this approach with the conventional one. Due to the strict selection criteria and the well standardized technica al approach is also very difficult to find results evaluating the efffect of dose and treated volume in terms of local control and side effects. The great majority of patients had unifocal disease with a tumo or size smaller than 2-2.5 cm. The dose of 20 Gy given as sole treatm ment has been assessed in the TARGIT-A trial (the only randomized tria al available to day). After a relatively short period of follow-up the difference d between local recurrence rates in the two arms was 0.25% 0 (not significant). Unpublished data coming from the ELIOT ra andomized trial (21 Gy in single shoot) seem to be more selective with h respect the tumor size, with a statistical equivalence limited to sm maller tumors. Very few patients were treated with IORT at different dose levels (from 16 to 24 Gy) and this limited number doesn't allow any statistical considerations, even the rate of local failure e seems to remain stable varying the dose. The addition of a IORT T boost dose with EBRT produced very good results (in some series very close to 100% at 5years) in terms of local control, indipendently from the IORT dose (from 10 to 20 Gy), the EBRT dose (from 37 to 54 Gy) and the tumor size (these series included patients with T1 1 up to T3 tumors). The heterogeneity among the combined sched dules used in different institutions seems to be indipendent by a stratification of patients according to the risk categories. More data a can be considered with respect the dose and the related toxicitiess, even the incidence of acute and late effects doesn't differ from the e historical series treated with conventional fractionation. In the alrready mentioned TARGIT trial no difference has been observed also o for adverse effects or complications in the two arms. Moderate fibrrosis is the most frequent effect with an incidence close to 30% for 24 Gy G single dose, decreasing to 25% with smaller doses (20-21 Gy). Combined treatment of IORT plus EBRT is expected to cause more neggative effects than IORT alone, with a difference of about 4%. A casse of grade IV acute skin ulcer was experienced with this com mbination. Because the development of fibrosis is progressive the lack of long term data is limiting in order to evaluate this aspect. In n these cases the treated volume could have a strong impact,mainlyy in case of combined treatment. Another factor that should be co onsidered is also the time lapse between surgery and IORT and the following EBRT, with shorter time possibly increasing the highest grades off toxicity.
JOINT SYMPOSIUM: ESTRO-ECCO: ETHICS IN PROFESSIONAL LIFE SP-0091 ETHIC VALUES: DO THEY BELONG IN A MUSEUM OR YOUR DAILY BRIEFCASE? F. Botturi1 1 Università Cattolica del S. Cuore, Department of Radiation Oncology, Campobasso, Italy 1. The influence the technological mindset The mutual implication of medicine and humanism is not to be taken for granted. Medicine is, to a wide extent, part of a scientific and technological world, thus bearing the influence of its general mindset. It is quite easy, indeed, to conceive the interpersonal and ethical dimension of medicine just as a humanitarian willingness which is applied upon a self-sufficient scientific and technical doing. This comes from the development of the technological world as a highly complex and specialized structure which is becoming more and more autonomous when it comes to its organization and purposes. This epistemological and sociological situation looks like a justification for the common separation between scientific and technological systems on one side and the ethical assessment on the other. Along the same lines, we meet a growing feeling of unruliness of those systems by individual subjects and a significant degree of inefficacy of ethical decisions on self-sufficient structures and processes. Within this kind of experience, human relationships become a marginal appendix of practices which follow objective rules. Interpersonal relationships receive then some consideration as preconditions for an increased efficiency of those practices, but not as an essential component of the competence they demand. 2. The inevitable responsibility of action Such a representation, though, is only deceptively plausible: it conceals the “knot” of personal action, i.e. the fact that the single, concrete action is the real center around which the different systems are effectually knotted together. Our actions aren’t just a tool to build relationships between different systems, but they are rather deliberate and free acts, actual choices between the possibilities which are offered by the various systems we are involved in. Thus, it’s only through our actions that the scientific knowledge and the technical procedures acquire a responsible destination, a cultural significance and a practical connection to their ends which are related to actual human beings. Seen in this perspective, health itself, which is the purpose of every medical action, is objectively and ultimately about the person as a whole and her research for a “healthy” destination. This doesn’t mean that medical actions should leave behind the objectivity of a clinical perspective, which methodically selects the relevant diagnostic and therapeutic features; it rather means that medical actions shouldn’t lose from sight an anthropologically wide sense of health. By operating in this way the physician fully expresses an ability of “evaluation” which is not just scientific and technical, but also anthropological and moral. 3. Ethics of compassion and care Any illness points to a need for health which signifies a wider desire of “healthiness” of the human condition, a strain towards the destination of the person. Within this perspective, the therapist can always recognize that she always shares with the patient the problem of the “proper functioning” of human life as such. Then, being receptive towards the other person doesn’t look anymore like a humanitarian ornament upon a neutral scientific and technical praxis, but rather an expression of the deep sense of the medical act itself. That is an ethical dimension which is internal to the medical practice and by taking it seriously the physician isn’t adding something external to her profession, but she is rather living it to its full human meaning and avoiding the risk of alienation within an abstract practice of her competence. A sincere reception of others comes, then, from the recognition of a shared condition and expresses an “ethics of compassion” for humanity and an “ethics of care” where the physician is engaged as a human being. SP-0092 ETHIC VALUES IN THE DISSEMINATION OF SCIENCE J.Overgaard Aarhus University Hospital, Aarhus, Denmark Abstract not received
ESTRO 31
SP-0093 ETHICAL VALUES IN MANAGING A DEPARTMENT B. Van Daele1, K. Haustermans2 1 AZ St Maria, Management, Halle, Belgium 2 UZ Leuven, Radiation Oncology, Leuven, Belgium In this lecture an overview will be given of the different challenges and ethical questions a chair of a department is confronted with on a daily basis. A frame work will be presented to classify these (see figure): on one side there is the ethical dimension with three domains being the community related aspects, the psychologically related aspects and the existentially related aspects of ethical values, on the other side the chairmanship dimension with “vision and goals” and “leadership aspects”. For each crossing of axes examples are given. An attempt will be made to offer an “ethical language” which can be used when discussing these topics. Currently a big debate is ongoing regarding delivering affordable cancer care in high-income countries (see figure). With the increase in cancer burden and the increasing costs of cancer treatment it is clear that in the not too far future the challenge will be how to collectively deliver reasonably priced cancer care to all citizens. From a cultural-philosophical point of view, some interesting thoughts on potential solutions can be found in the book “Medical Nemesis: the expropriation of health” by Ivan Illich. The author states that the medical establishment and industrialization have become a major threat to health. He refers to the Greek mythology as a metaphor to clarify his ideas : Nemesis represents divine vengeance upon mortals who infringe on those prerogatives the gods guard for themselves. Nemesis was the inevitable punishment for attempts to be a hero rather than a human being. She took the shape of a goddess that represented nature’s response to hubris. Hubris is illustrated by Prometheus who stole the fire from the gods and brought it to mankind. As punishment, Zeus chained Prometheus to a mountain where every day, an eagle would come and eat his liver. From Illich’s point of view, all cultures over time have been struggling with pain, sickness an death. Although the human answer historically could be found in a mixture of religion, culture, lifestyle and medicine, it is not until the 20th century that people started to believe that “modern medicine” was on its way to cure all diseases and to overcome pain. Everybody must have access to this new religion that guarantees victory over pain and illness and over death as a painful killer. Consequently, no price is too high to conquer all diseases. Illich calls this phenomenon structural iatrogenesis resulting in the alienation of people from their own sickness and death. Besides he also has a thesis on medical iatrogenesis (disease caused by medical intervention itself) and social iatrogenesis (persisting unhealthy social conditions with illness as an alibi). It is now time to review the health-care system. This review should not reinforce the present medicalisation of life but should instead focus on the recovery of a personal responsibility for health care. A new definition of health should help us with the ability to cope with pain, illness and death. This should be achieved in a “convivial way”: in harmony with the person’s autonomy and the medical world. From a more pragmatic point of view, we will refer to a Dutch commission which developed in 1991 a conceptual framework that can be used as a tool for making choices in reimbursement for health care. The so called “Funnel of Dunning” reveals 5 criteria for care programs to be reimbursed by the government or social insurance : necessity, effectiveness, efficiency, individual or social responsibility and degree of discomfort of sickness. From the position of the chair of a department, one has to face on a daily basis the conflicts of priorities responsibility towards the management, towards the staff and towards the patients (see figure). These conflicts are not easy to handle and even more difficult to resolve. A leader is frequently confronted with the choice “quit or manage” and as such is vulnerable to burnout. Organizations should be made aware of this and should create an environment in which leaders are protected against this phenomenon.
S38
ESTRO 31
tolerance of late adverse effects after a PBRT schedule, whether hypofractionated or not, may be greater than n after the same schedule delivered to the whole breast, even if tissue e damage per unit volume is the same. For example, a given density of o fibrosis restricted to a partial (eg. boost) volume may be better tolerated than the same density of fibrosis affecting the whole breastt. Overall treatment time is not expected to impact on late adverse e effects, other than by modifying the severity of effects conse equential to acute skin reactions. An impact of treatment time on tumour control in the adjuvant setting has not been formally testted, but cannot be ruled out. Finally, it is likely that the clinical effeccts of current single dose intraoperative radiotherapy schedules remaiin explicable in terms of current models of tumour and normal tissue responses. r SP-0096 EVIDENCE OF VOLUME EFFECTS FOR NORMA AL TISSUE AND TUMOUR RESPONSES E. Van Limbergen University Hospital Gasthuisberg, Leuven, Be elgium Abstract not received SP-0097 IORT UPDATE: WHAT ARE THE LIMITS OF TOTA AL DOSE AND VOLUME? R. Orecchia1, M.C. Leonardi1 1 European Institute of Oncology, Radiation Th herapy, Milan, Italy
SP-0094 ETHIC VALUES AND SCIENTIFIC SOCIETIES M. Baumann1 1 TU Dresden Med. Faculty Carl Gustav Carus, Radiation n Oncology, Dresden, Germany The general aim of scientific societies is to advance science by research and education, as well as dissemination an nd discussion of results. Medical scientific societies regularly add the aim to promote the quality of treatment of specific disease in the best interest of patients. Such aims of medical scientific societiies establish a particular and privileged role not only in the scientificc community but also among patients, policy makers and the general public. p Although not always easy to differentiate, this role is fundame entally different from that of professional or lobbyist organizations, and d mandates firm foundation on and strict adherence to ethical values. The T contribution will review the special status of medical scientific soccieties and gives examples how these values should impact on govern nance, structure and activities of medical scientific societies.
SYMPOSIUM: HYPOFRACTONATION BREAST RADIOTHERAPY
AND
PARTIAL
SP-0095 HYPOFRACTIONATION AND PBRT: WHAT DO WE NEED N TO THINK ABOUT? N. Somaiah1, J. Yarnold2 1 The Royal Marsden NHS Foundation Trust, Radiothera apy, Sutton, United Kingdom 2 The Royal Marsden NHS Foundation Trust & Institute of o Cancer Research, Radiotherapy, Sutton, United Kingdom Randomised trials testing whole breast radiotherapy delivered using once-daily fractions of 2.7 - 3.3 Gy show the fraction nation sensitivity of breast cancer to be comparable to that of late adverse effects recorded by clinicians and patients up to 10 years post-treatment. The fractionation sensitivities of normal and malignant tissues t over this range of fraction sizes are not expected to change when hypofractionation is used for partial breast radiotherapy (PBRT), at least when once-daily fractions are delivered. Wh hen twice-daily fractions of the same size are used, a greater effect of the second fraction must be taken into account when using iso-e effect formulae, such as the linear-quadratic model. The magnitude of o this effect is better quantified for normal tissues than for tumou urs. The clinical
IntraOperative RadioTherapy (IORT) consistts of a high single dose delivered under direct and visual ispection of o the tumor. The goal is to improve local control and reduce toxicity since there is less volume of irradiated healthy tissue. In addition, there is no interval between surgery and radiotherapy. The results publisshed in the literature are still preliminary, and there are only few datta that allow to compare this approach with the conventional one. Due to the strict selection criteria and the well standardized technica al approach is also very difficult to find results evaluating the efffect of dose and treated volume in terms of local control and side effects. The great majority of patients had unifocal disease with a tumo or size smaller than 2-2.5 cm. The dose of 20 Gy given as sole treatm ment has been assessed in the TARGIT-A trial (the only randomized tria al available to day). After a relatively short period of follow-up the difference d between local recurrence rates in the two arms was 0.25% 0 (not significant). Unpublished data coming from the ELIOT ra andomized trial (21 Gy in single shoot) seem to be more selective with h respect the tumor size, with a statistical equivalence limited to sm maller tumors. Very few patients were treated with IORT at different dose levels (from 16 to 24 Gy) and this limited number doesn't allow any statistical considerations, even the rate of local failure e seems to remain stable varying the dose. The addition of a IORT T boost dose with EBRT produced very good results (in some series very close to 100% at 5years) in terms of local control, indipendently from the IORT dose (from 10 to 20 Gy), the EBRT dose (from 37 to 54 Gy) and the tumor size (these series included patients with T1 1 up to T3 tumors). The heterogeneity among the combined sched dules used in different institutions seems to be indipendent by a stratification of patients according to the risk categories. More data a can be considered with respect the dose and the related toxicitiess, even the incidence of acute and late effects doesn't differ from the e historical series treated with conventional fractionation. In the alrready mentioned TARGIT trial no difference has been observed also o for adverse effects or complications in the two arms. Moderate fibrrosis is the most frequent effect with an incidence close to 30% for 24 Gy G single dose, decreasing to 25% with smaller doses (20-21 Gy). Combined treatment of IORT plus EBRT is expected to cause more neggative effects than IORT alone, with a difference of about 4%. A casse of grade IV acute skin ulcer was experienced with this com mbination. Because the development of fibrosis is progressive the lack of long term data is limiting in order to evaluate this aspect. In n these cases the treated volume could have a strong impact,mainlyy in case of combined treatment. Another factor that should be co onsidered is also the time lapse between surgery and IORT and the following EBRT, with shorter time possibly increasing the highest grades off toxicity.