PAKISTAN ARMED FORCES
MEDICAL JOURNAL (Category X)

A Journal of Army Medical & Dental Corps

Being published since 1956

ISSN (online) 2411-8842
ISSN (print) 0030-9648

VOL 67, No. 3, JUNE 2017

CANCER PAIN AND PALLIATIVE CARE

Editorial

Palliative care is an integral component of cancer care. Developing countries like Pakistan are still struggling with the initiation and implementation of WHO pillars for establishing palliative care services. In Pakistan palliative care is a low priority issue with many other competing health and developmental issues. With the rising rates of cancer incidence, the national cancer plan was initiated in 2002, but the progress is very slow.
The picture of terminally ill cancer patients in Pakistan is appalling. After a protracted and potentially dangerous treatment with chemotherapy, surgery and/or radiotherapy, the breaking of news of incurability of cancer is catastrophic, not only for the despairing patient, but also for the expectant family. The intensity and intractability of the concomitant pain becomes unbearable adding to hopelessness, helplessness and depression. If only pain can be relieved the patient would comfortably pass the remaining days or weeks of his/her life, becomes the only desire of the grief stricken family.
Unfortunately, lack of awareness of the advancement in the techniques and new therapeutic modalities for management of pain is rampant, not only in general public but also in most of the private and public sector hospitals1. In fact most of these hospitals do not have a pain management centre. This results in avoidable acute and severe pain of the terminal cancer patients, who continue to suffer inexorably and die in a miserable state. The situation is by and large fairly manageable to a comfortable transition of the incurable cancer patient to the next world.
During the last decade, even thoughv Pakistan’s health burden has had a shift from communicable to non-communicable diseases, our health systems still lag behind and have nottransitioned from disease oriented to primary care and prevention-oriented2,3. In 2012, an estimated 148,000 people were diagnosed with cancer in Pakistan4. The largest city in Pakistan,Karachi, reported one of the highest incidences for breast cancer in any Asian population with the majority presenting with advance stage4.
In 2012, age-standardized cancer incidence rate of Pakistan was estimated at 111.8 per 100,000people/year with approximately 101,000 persons dying of cancer per year5. Given this, the need for palliative care services in Pakistan cannot be ignored since the majority of patients present to health care facilities with an advanced stage of cancer and require palliation from the beginning.
For the successful implementation of palliative care into health care system, there needs to be an emphasis on education, training and research. In Pakistan, facilities established to provide specialized healthcare needs like oncology care are not accessible to the majority since they are situated in urban cities and are
expensive private sector facilities. Treatment is therefore beyond the reach of the majority6.
With high rates of cancer even within the younger population, in 2002, Pakistan initiated its National Cancer
Control Plan with the primary purpose of cancer control. The plan included building a health system prioritizing pain relief and palliative care alongside prevention and control efforts7. However, despite more than a decade of initiating a plan and recognizing a need for it, the development of palliative care services is far from adequate  and Pakistan still struggles with implementation of the three pillars of palliative care8. According to a recent mapping of palliative care development, Pakistan is classified as a country with isolated palliative care provision5. Pakistan’s ratio of services to population is one of the highest (1:90 million), which is in sharp contrast to the ratio in developed countries like Austria (1:34,000) or Australia (1:67,000) or even other populous Asian countries like India (1:42 million), China (1:8 million), and Indonesia (1:22 million)5.

Institutional Gap
It is extremely unfortunate to record that there is not a single institution in the public sector or private sector offering palliative care to a huge number of terminally ill cancer patients in Pakistan. Majority of the patients suffering with cancer have access only to Government Hospitals with oncology units and radiotherapy centers run by PAEC. Some are treated by NGO based cancer hospitals (such as SKCH) and hospices. Only a minority is treated in private hospitals. However, none of these cancer treating centers / hospitals or any other institution offers ‘palliative care’ to these end-stage terminally ill patients. They are left to the care of inexperienced, untrained and groping for help family members, till their last breath. Many such patients are rushed to the hospitals in gasping state only to die away from their kith and kin.

Palliative Care Service
Palliative care is a multi-disciplinary active total care of patient with life threatening disease when it is no longer responsive to curative or life prolonging treatment. Its primary aim is to promote comfort by alleviating pain and other distressful symptoms. Palliative Care is synonymous with end of life care with an effort to ‘add life to their days, not days to their life’. Palliative care is initially delivered in hospital setting by a team of specialists comprising of pain specialist (usually an anesthesiologist), a psychiatrist, concerned specialist of the primary disease, a rehabilitation specialist and a religious person trained in spiritual counseling. Later, palliative care services can be extended in home settings as the center becomes advanced with additional facilities of human resource and transportation.
The concept of palliative care in Pakistan so far remains limited to the compassionate tender care by the family members to their loved ones suffering from terminal illness. There are no such organized centers of palliative care except some pain clinics which have come up in some hospitals. They are offering relief from pain to a variety of patients; however, the comprehensive approach of palliative care is yet to be developed.
Now some of the hospitals in Pakistan have recently started such services in their hospitals. College of Physicians & Surgeons Pakistan (CPSP) has recently started fellowship in pain medicine. Riphah International University (RIU)is already granting MSc in pain medicine since 2006.

Barriers to Palliative Care
At present in Pakistan, the major barriers to palliative care are an uncommitted government, lack of drugs and an unrecognized specialty. To establish and improve palliative care in Pakistan, two areas that need priority focus are the availability of opioids and education and training in palliative care. Without a palliative care module being incorporated in undergraduate and postgraduate curriculum of medical and nursing colleges, the specialty will not be recognized and services will not grow6.

RECOMMENDATION
Considering the present scope of palliative care there is an immense need of training, teaching and structured services in Pakistan. Palliative care nursing is also in need of development since very few institutions have nurses specialized in palliative care on their oncology team. Most of the nurses are
trained on the job by physicians and some may have attended short courses or workshops.

Reference

1. Bano S, Farhat SM. Report on awareness about cancer in Pakistan. Awareness about cancer in Pakistan, 4th Feb 2013, NAYS Survey http://www.nays.com.pk/nays-survey/
2. Jafar TH, Haaland BA, Rahman A, Razzak JA, Bilger M. Noncommunicable diseases and injuries in Pakistan: strategic priorities. Lancet 2013; 381: 2281-90.
3. Wasay M, Zaidi S, Khan M, Jooma R. Non communicable diseases in Pakistan: burden, challenges and way forward forhealth care authorities. J Pak Med Assoc 2014; 64: 1218-19.
4. http://www.cancerindex.org/Pakistan.
5. Lynch T, Connor S, Clark D. Mapping levels of palliative care development: a global update. J Pain Symp Manage 2013; 45(6): 1094-1106.
6. Nishtar S. Prevention of non-communicable diseases in Pakistan: an integrated partnership-based model. Health Res Policy Syst 2004; 2: 7.
7. Nishtar S, Ahmed A, Bhurgri Y, Mohamud KB, Zoka N. Prevention and control of cancers: National Action Plan forNCD Prevention, Control and Health Promotion in Pakistan. J Pak Med Assoc 2004; 54: S45-56.
8. Shad A, Ashraf MS, Hafeez H. Development of palliative-care services in a developing country: Pakistan. J Pediatr Hematol Oncol 2011; S62-63.



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