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Purpose: Cancer care in Germany during the COVID-19 pandemic was affected by resource scarcity and the necessity to prioritize medical measures. This study explores ethical criteria for prioritization and their application in cancer practices from the perspective of German oncologists and other experts., Methods: We conducted fourteen semi-structured interviews with German oncologists between February and July 2021 and fed findings of interviews and additional data on prioritizing cancer care into four structured group discussions, in January and February 2022, with 22 experts from medicine, nursing, law, ethics, health services research and health insurance. Interviews and group discussions were digitally recorded, transcribed verbatim and analyzed using qualitative content analysis., Results: Narratives of the participants focus on "urgency" as most acceptable criterion for prioritization in cancer care. Patients who are considered curable and those with a high level of suffering, were given a high degree of "urgency." However, further analysis indicates that the "urgency" criterion needs to be further distinguished according to at least three different dimensions: "urgency" to (1) prevent imminent harm to life, (2) prevent future harm to life and (3) alleviate suffering. In addition, "urgency" is modulated by the "success," which can be reached by means of an intervention, and the "likelihood" of reaching that success., Conclusion: Our analysis indicates that while "urgency" is a well-established criterion, its operationalization in the context of oncology is challenging. We argue that combined conceptual and clinical analyses are necessary for a sound application of the "urgency" criterion to prioritization in cancer care., (© 2024. The Author(s).)

Complementary and alternative medicine (CAM) use in children with cancer has a high prevalence. If (parents of) patients bring up the topic of CAM, pediatric oncologists (POs) face considerable challenges regarding knowledge and professional behavior. In this study, we explore German POs' understanding of CAM and related attitudes as well as challenges and strategies related to CAM discussions by means of semi-structured interviews analyzed according to principles of qualitative thematic analysis with parents of children with cancer. We could conduct 14 interviews prior to theoretical saturation. The interviews had a duration of 15-82 min ( M  = 30.8, SD  = 18.2). Professional experience in pediatric oncology was between 0.5 and 26 years ( M  = 13.8, SD  = 7.6). Main themes identified were a heterogeneous understanding and evaluation of CAM, partly influenced by personal experiences and individual views on plausibility; the perception that CAM discussions are a possible tool for supporting parents and their children and acknowledgement of limitations regarding implementation of CAM discussions; and uncertainty and different views regarding professional duties and tasks when being confronted with CAM as a PO. Our interdisciplinary interpretation of findings with experts from (pediatric) oncology, psychology, and ethics suggests that there is need for development of a consensus on the minimal professional standards regarding addressing CAM in pediatric oncology.

Background: A blended learning program to promote the consultation expertise of pediatric oncologists (POs) on complementary and integrative medicine (CIM) was developed and completed by POs as part of a training program. A previous study indicated that POs in Germany were in need of information and training on CIM, and that there were no medical training offers on the subject in Germany., Methods: Evaluation of e-learning (questionnaires) and practically oriented one-day, face-to-face workshops (questionnaires, simulation patients), the workshops were evaluated with regard to changes in quality of physician-patient interaction and with regard of the participants' feedback., Results: 32 POs signed up for the program and completed the e-learning. 22 POs participated in one of the workshops. POs agreed that they had received professionally relevant content during the e-learning. The questionnaires on physician-patient interaction showed neither clear positive nor negative changes concerning the quality of interaction. The feedback from the participants on the workshop was very positive., Conclusion: Following the end of the blended learning program the e-learning was made available again for interested POs. 34 further applications were received for participation in this part of the training program. With around 300 POs in Germany, this shows a high demand for further training offers of this kind as well as a need for further development., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Thieme. All rights reserved.)

Background: The German Cancer Aid set up a priority research programme with the intention to generate high-quality information based on evidence and to make this information easily accessible for health-care professionals and advisors, researchers, patients, and the general public., Summary: The Kompetenznetz Komplementärmedizin in der Onkologie (KOKON) received 2 funding periods within this programme. During the first funding period, KOKON assessed patients' and health-care professionals' informational needs, developed a consulting manual for physicians, developed an education programme for self-help groups, set up a knowledge database, and developed a pilot information website for patients. Funding period 2 continues with work that allows cancer patients and health-care professionals to make informed decisions about complementary and alternative medicine (CAM). For this aim, KOKON evaluates training programmes for physicians (oncology physicians, paediatric oncologists, and general practitioners) and for self-help groups. All training programmes integrate results from an analysis of the ethical, psychological, and medical challenges of CAM in the medical encounter, and the knowledge database is being extended with issues related to CAM for supportive and palliative care. Key Message: A Germany-wide collaborative research project to identify needs, provide information, foster communication, and support decision-making about CAM in oncology is being set up., (© 2019 S. Karger AG, Basel.)

Background: Shared decision-making (SDM) has been advocated as an ethical framework for decision-making in cancer care. According to SDM, patients make decisions in light of their values and based on the available evidence. However, SDM is difficult to implement in cancer care. A lack of applicability in practice is often reported. This empirical-ethical study explores factors potentially relevant to current difficulties in translating the concept of SDM into clinical practice., Methods: This study was conducted with nonparticipant observation of the decision-making process in patients with gastrointestinal cancers for whom the benefit of adjuvant chemotherapy was uncertain according to clinical guidelines. Triangulation of qualitative data analysis was conducted by means of semistructured interviews subsequent to the observation. Observation notes and interview transcripts were analyzed according to the principles of grounded theory., Results: Deviating from the concept of SDM, oncologists initiated a process of eliciting values and medical information prior to conveying information. The purpose of this approach was to select and individualize information relevant to the treatment decision. In doing so, the oncologists observed used two strategies: "biographical communication" and a "metacommunicative approach." Both strategies could be shown to be effective or to fail depending on patients' characteristics such as their view of the physicians' role and the relevance of value-related information for medical decision-making., Conclusion: In contrast to the conceptual account of SDM, oncologists are in need of patient-related information prior to conveying information. Both strategies observed to elicit such information are in principle justifiable but need to be adapted in accordance with patient preferences and decision-making styles., Implications for Practice: This study showed that knowledge of patients' values and preferences is very important to properly adapt the giving of medical information and to further the process of shared decision-making. Shared decision-making (SDM) trainings should consider different strategies of talking about values. The right strategy depends largely on the patient's preferences in communication. To be aware of the role of values in SDM and to be able to switch communicative strategies might prove to be of particular value. A more systematic evaluation of the patient's decision-making preferences as part of routine procedures in hospitals might help to reduce value-related barriers in communication., Competing Interests: Disclosures of potential conflicts of interest may be found at the end of this article., (© AlphaMed Press 2018.)

In recent years, the term "value-based healthcare" has been increasingly used in debates about costs and outcomes of health interventions in cancer care. This paper distinguishes 2 meanings of the term "value" and explores the relevance of both meanings of the word for assessing the "value" of cancer drugs. At the focus of the analysis are value judgments which form an integral part of the assessment of benefit of cancer drugs. The review concludes with a reflection on individual competences and systemic factors which are relevant to decision making about the value of treatment in situations of non-curative cancer., (© 2019 S. Karger AG, Basel.)

Background: Against the background of limited resources, the rise in the cost of therapy as well as in the number of cancer patients fuels the discussion about the necessity to ration, i.e., setting limits to beneficial treatment for cost reasons. Recently, we presented the self-reported prevalence of bedside rationing among German oncologists. Here, we describe oncologists' views on cost containment strategies and their role therein., Methods: We performed an online survey including structured questions and free field sections with the members of the German Society of Hematology and Oncology., Results: In the perception of oncologists, cost considerations and negotiations are gaining in importance and consume considerable working time. This negatively affects job satisfaction in 72% of the 345 respondents. Oncologists are concerned that the quality of care will suffer from rationalization and implicit rationing. They are ambivalent as to who is best suited to decide about resource rationing: 66% support the view that limits for costly procedures should be set by a form of commission; nevertheless, 48% consider physicians as the best decision makers in these situations., Conclusion: We suggest a broad public discussion and an interdisciplinary debate among the oncology community to define and legitimize decisions on rationing by setting explicit criteria., (© 2017 S. Karger GmbH, Freiburg.)

Background: Professional guidelines encourage physicians to provide children with as much information regarding their health as deemed developmentally and emotionally appropriate. However, empirical research indicates that in clinical practice, an open discussion with children about cancer is often lacking. This study explores impeding factors to and possible strategies for open communication of cancer diagnosis to children from the perspectives of parents and physicians., Procedure: Semi-structured interviews were conducted with 18 parents of children with cancer and 10 treating oncologists. The patient sample was obtained from three pediatric units in Romania. Interviews were transcribed verbatim and interpreted using thematic analysis. Inductive open-coding procedures identified participants' accounts regarding their experiences with cancer diagnosis and treatment. Final themes were selected by grouping codes that formed a pattern in the data., Results: An interplay of mainly three different factors-information overload and emotional turmoil, lack of knowledge and skills for disclosing the diagnosis, and assumptions about burdening the child when discussing cancer-restricted parent-patient communication and subsequently affected physician-patient exchanges. Oncologists recommended open communication at diagnosis, but left the final decision to the parents. They adapted their communication style with patients to parents' preference., Conclusions: Although physicians need to respect the wishes of children's legal representatives, they also have a duty to promote patients' best interests. We recommend that physicians employ a proactive stance in ensuring that children with cancer are appropriately informed about their diagnosis. In case of parents' arduous objections to full disclosure, an ethical consultation should be considered., (© 2015 Wiley Periodicals, Inc.)

Background: Survey research indicates that decisions about the provision and limitation of treatment near the end of life in patients with cancer vary considerably., Objectives: The study objectives were to review the evidence on variables associated with explicit decisions about limitation of treatment in patients with cancer and to critically appraise the factors from a clinical ethics perspective., Methods: A search was conducted of studies published in EMBASE, CINAHL, PsycINFO, Assia, Current Contents Medicine, Belit, and Euroethics before February 5, 2014. Eligible studies reported data on explicit treatment limitation in patients with cancer and included a statistical analysis on possibly associated factors. Information on study participants, types of limited treatment, and variables associated with limiting treatment were extracted by two researchers independently. Data synthesis was performed jointly by researchers from oncology, medical ethics, and social sciences., Results: The search yielded 897 publications, of which 7 were relevant for this review. Factors significantly associated with decisions about limitation of treatment could be distinguished in three categories: first, sociodemographic variables such as the ethnic background of patients; second, health- or treatment-related variables including a lack of capacity in patients with cancer; and third, patients' preferences and the role of relatives in decisions about limitation of treatment. Limitations to this study are that the studies lacked a predefined hypothesis and they all had been conducted in Western countries., Conclusion: The identified variables raise ethical issues with regards to possible influence of value judgments underlying decisions about limitation of treatment in end-of-life care.

Background: Decision making in oncology poses intricate ethical questions because treatment decisions should account not only for evidence-based standards but also for the patient's individual values and preferences. However, there is a scarcity of empirical knowledge about patient involvement in oncological decision making., Methods: Direct, nonparticipant observation was used as a qualitative research method to gain an understanding of the interplay between medical expertise and patient participation in oncological decision making. Based on a multiperspective approach, observations were performed in three settings (tumor conference, ward round, and outpatient clinic) in the oncology department of a German university hospital. The observation transcripts were analyzed using central features of qualitative data analysis., Results: Major differences were identified regarding the decision-making processes in the three settings related to the patient's presence or absence. When the patient was absent, his or her wishes were cited only irregularly; however, patients actively advanced their wishes when present. Preselection of treatments by physicians was observed, narrowing the scope of options that were finally discussed with the patient. Dealing with decisions about risky treatments was especially regarded as part of the physician's professional expertise., Conclusion: The study reveals aspects of decision making for cancer patients that have been underexposed in the empirical and theoretical literature so far. Among these are the relevance of structural aspects for the decisions made and the practice of preselection of treatment options. It should be further discussed how far medical expertise reaches and whether therapeutic decisions can be made without consulting the patient., (©AlphaMed Press.)

Rising costs of cancer care and the growing burden of cancer in a world of finite resources seem to make rationing in oncology inevitable. Information is currently lacking about oncologists' strategies in responding to resource constraints and the prevalence of withholding costly treatments. An online survey was offered via e-mail to physician members of the German Society of Hematology and Oncology. Those actively practicing were asked to complete an online questionnaire asking how limited resources were currently affecting their clinical practice. Two-thirds of 345 participating oncologists reported withholding costly treatments in at least some instances. Regarding their rationale, 70% stated that evidence for costly intervention was not convincing enough, and 59% said that they rationed approved treatments because of an unfavorable cost/benefit calculation. Only 29% reported being explicit about their rationing decision if the patient did not know or inquire about the respective intervention. Withholding expensive procedures from individual patients was widespread among the respondents. Oncologists withheld treatments not only if they perceived the scientific evidence to be questionable but also if they perceived reimbursement prospects or the cost/benefit ratio to be unfavorable, a behavior that could be called rationing. Currently this mostly refers to costly procedures with limited additional benefits. Although this result may be interpreted as indicating that oncologists assume responsibility for spending the resources in a justified way, more transparency and an open discussion on cost-effectiveness and the just allocation of costly treatments is needed.

Background: Surveys indicate considerable variation regarding the provision of cancer treatment at the end of life. The variation cannot be fully explained by differences concerning the clinical situation or patients' preferences. The aim of this qualitative study was to explore medical oncologists' experiences with advanced cancer, as well as their views of the relevance of medical and nonmedical criteria for decisions about limiting treatment., Methods: Qualitative in-depth interviews were conducted with physicians working in medical oncology in tertiary care hospitals or district general hospitals in England. Purposive sampling and qualitative analysis were performed., Results: Physicians reported that a number of nonmedical factors influence professional decisions about the offering or limiting of cancer treatment in advanced cancer in addition to medical criteria. Physicians' individual judgments about the benefit of treatment, as well as the amount of their clinical experience, were cited as such factors. In addition, the physicians' perceptions of the patient's age and life circumstances were reported to influence their treatment decisions. Multiprofessional team discussions and the systematic collection of relevant clinical data regarding the outcomes of different treatment approaches in advanced cancer were suggested as strategies to improve the quality of treatment decisions., Conclusion: The findings of this study provide explanations for the variation in treatment in advanced cancer. Making value judgments explicit and gathering more appropriate clinical data on the outcomes of treatment near the end of life are prerequisites for improved ethical and evidence-based treatment decisions in advanced cancer.

Innovations in the drug treatment of cancer patients pose several medical and ethical challenges. The increasing incidence and prevalence of cancer, in combination with the availability of new and usually highly expensive anticancer drugs, are associated with a significant increase in the general costs for the treatment of cancer patients. Therefore, the development of scientific strategies for judgments on benefits is indispensable. In this paper, the authors analyze the benefit assessment and the benefit-risk assessment as a foundation for decisions on prioritization in hematology and oncology. In a first step, regulatory aspects and shortcomings regarding the design of clinical trials in oncology before and after approval of anticancer drugs are identified as factors that contribute to difficulties in establishing the effectiveness of new drugs entering the health care market. The authors will conclude with suggestions for the improvement of benefit-risk analyses and the generation of scientific data necessary for such analyses., (Copyright © 2011 S. Karger AG, Basel.)

Background: Costs for medical care and strategies to handle limited resources in health care are discussed in many European countries. Few empirical studies explore the oncologists' perceptions and views regarding economical aspects in clinical practice., Research Participants and Methods: Semi-structured interviews with physicians working in oncology in Germany and England. For this paper, parts of the transcripts in which interviewees discuss economical aspects of clinical practice were analysed exploratively and according to principles of content analysis., Results: 17 (Germany) and 12 (England) research interviews were analysed. German physicians described different forms of implicit rationing. The effects of economic considerations are judged as predominantly negative. Physicians working in England named concrete situations in which interventions are not performed because of cost considerations. The rationing of medical care was viewed as necessary in light of limited resources. The assignment of allocation decisions on the macro-level was favoured because of the resulting relief for the physician-patient relationship., Conclusions: The narratives of interviewees in both countries differ regarding the perceptions and views on economical aspects in clinical practice. The specific approaches of each health care system towards the allocation of limited resources offer one basis for explanations of these differences., (Copyright © 2011 S. Karger AG, Basel.)

Introduction: In German-speaking countries "breaking bad news" courses are increasingly included in the medical undergraduate curriculum. In this paper we present an instrument (Aufklärungsgesprächbewertungsskala, AGBS) for the evaluation of communication competencies in the context of disclosing the diagnosis of cancer to patients as well as the results of the reliability analysis for this instrument., Methods: Following a systematic literature review we selected the "breaking bad news assessment schedule" (BAS) as a model for developing the AGBS. The checklist was translated into German and modified. Following the use of the instrument in a teaching module for 4th year medical students Cronbach's alpha was calculated for the estimation of internal consistency, the intraclass coefficient (ICC) was used for the estimation of interrater reliability., Results: 58 videotaped interactions between students and simulated patients were used for reliability analysis. The AGBS shows good values with respect to internal consistency (Cronbach's alpha 0.88) and overall interrater reliability (ICC 0.86). Further analysis indicates that the values for interrater reliability differ depending on the communication competencies evaluated when using the AGBS., Conclusion: The AGBS is a reliable instrument which may be used in medical undergraduate courses to evaluate student-simulated patient interaction during the disclosure of cancer diagnosis. The varying values for the interrater reliability in the different parts of the AGBS may serve as a basis for the further development of instruments for the evaluation of communication skills.