[Intensity modulated radiotherapy for head and neck cancers: ethics and patients selection]

Intensity modulated radiotherapy (IMRT) allows a better coverage of the target volume and a better saving of organs at risk with a decrease of toxicity in head and neck cancers. It requires more human labor and materials compared to conformational radiotherapy. If they are insufficient, a selection of the patients receiving IMRT may be necessary, raising an ethical problem.

We collected the motives guiding the choice of the technique of radiotherapy for head and neck cancers during a month of physicists' shortage.

Nineteen patients received IMRT and eight conformational radiotherapy. Conformational irradiation was chosen in palliative and postsurgery treatments, to reduce delay, in laryngeal tumors and re-irradiation. IMRT was preferred for complex target volumes and the localizations at risk of important xerostomia following conformational radiotherapy. These choices were confronted with the bioethics criteria of Beauchamp and Childress. The beneficence justified the use of IMRT or conformational radiotherapy depending on the circumstances. The non-maleficence attempted to decrease the toxicity with IMRT. Justice was questioned by the selection. The autonomy of patients was not totally respected in the choice.

To help in the choice of the patients receiving an IMRT in a crisis situation, we proposed a hierarchical organization of selection criteria: complex volumes close to critical organs at risk, localization with high risk of xerostomia, long life expectancy and postoperative delay constraints.