CANCER PAIN AND PALLIATIVE CARE

Abstract

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 though
Pakistan’s health burden has had a shift from
communicable to non-communicable diseases,
our health systems still lag behind and have not
transitioned 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
100,000 people/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
EDITORIAL
Open Access Editorial
Cancer Pain And Palliative Care Pak Armed Forces Med J 2017; 67(2): 349-51
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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
Cancer Pain And Palliative Care Pak Armed Forces Med J 2017; 67(2): 349-51
351
the job by physicians and some may have
attended short courses or workshops.