UICC World Cancer Congress 2006

Considerable knowledge exists in dealing with pain and the many symptoms that affect cancer patients. However there are a multitude of barriers that unless recognised and negotiated will continue to hinder symptom relief. There are various assessment criteria and drugs formulated but often these may not factor in several issues that affect the developing world.

ISSUES THAT AFFECT CANCER SYMPTOM MANAGEMENT

It is a normal line of enquiry for clinicians to ask patients about the symptoms they are suffering as a result of cancer. However, the manner of which the presence or severity of symptoms are reported may depend on several factors. In hoping for a cure, many patients may feel that pain and other symptoms are a necessary evil and ‘worth it', if cure is still the goal. In developing countries, there is still a great deal of deference given to doctors and the reporting of symptoms may be seen as ‘burdening' the doctor. Patients may even feel that pain and other symptoms are a necessary part of the cancer experience. There are various assumptions and perceptions that may interfere with effective symptom control. Injections are much better than oral medications, drips and nutritional support are always needed are common examples.

There is then the multitude of issues that affect the use of opioids. Addiction, tolerance, dose requirements, hastening or a precursor of dying are common issues. Unfortunately, a concern is that many clinicians are just as ignorant as the patients and families they serve. Many patients are simply ignorant that many of the symptoms they experience may be alleviated through simple means.

Medicine has to operate within the cultural environment of the community it serves. Hence the significance of cancer symptoms need to be understood within the cultural context of the patients and their families. The family may play an important role in deciding the course of treatment both at home and in hospital. Some patients may want to be awake for religious considerations and suffer pain rather than risk a reduction in consciousness with pain relief. Delirium may be mistaken for possession of spirits. The use of traditional and alternative practises must be understood in their context of use rather than be rejected outright as ‘unproven' therapy. Even the words and language used in the description of illness and symptoms may play a pivotal role rendering communication skills a crucial skill for anyone involved in patient care. In many respects, the media may play a role in both the raising and destroying of hope but often without due evidence of either.

The cancer journey may well be accompanied by a parallel journey into the spiritual domain for the patient. In many communities, religion may be the dominant factor in decision making. This may even affect healthcare workers, in deference to their clinical upbringing. Hence the patient's pain and suffering may well be attributed as a test of faith, a necessary passage and that relief may be associated with increased servitude. The clinician thus needs to carefully seek for not just physical symptoms but also psychosexual, spiritual and existential issues. These itself may be taboo topics within the community but perhaps not to the patient.

The right of a patient for self determination and autonomy may vary in developing countries than in developed nations and there may be a case for working in terms of family autonomy to effect good symptom relief rather than separate the rights of patients and families. In some communities, there is a challenge to adequately assess symptoms when the patient may not have full insight into their condition of the family prohibits the disclosure of illness to the patient.

Whereas there are still challenges to improve the relief of symptoms such as weakness and anorexia, the dissemination of current knowledge of pain and symptom control to doctors in developing countries has been poor. Pain and palliative care are seen as a luxury for inclusion into medical curriculum. Hence whereas in some areas, cancer pain is slowly being addressed, issues dealing with neuropathic pain, cachexia-anorexia, bowel obstruction are hardly dealt with appropriately. Even less are symptoms that are in the non physical domain. The availability and expense of drugs may also be factor. Although morphine remains the gold standard in cancer pain relief and is cheap, many factors seek to obstruct its effective use.

In the age of globalisation, clinicians may be aware of advancements in symptoms relief through new but expensive drugs. However their use may reduce the scarce resources available for patient care. The influence of pharmaceutical marketing and ‘education' and ‘western' orientated research may affect clinical prescribing and decision making. There is hardly any promotion of effective, cheap and generic medications.

For many doctors in developing countries, where resources may be limited, there may be burgeoning ethical considerations. Issues of aims of treatment, rights of patients and their families, resources and their own morality may all impact on their approach to delivering good symptom management.

Addressing symptom control would not be complete without acknowledging organisational, resource and legislative factors. Fear of misuse of opioids rather than cancer pain relief require appropriate information to be channelled to authorities to enable patient access to pain relief drugs. For healthcare providers, the treatment and curative aspects of cancer care may be thought of as more important than providing pain, symptom control, palliative care, rehabilitation or bereavement support. Hence resources and infrastructure are concentrated in curative treatment with its accompanying appendages whilst community and palliative care remedies are scarcely thought of, albeit perhaps through ignorance.

MODELS OF APPROACH

Although education may be a generic prescription to improve and sensitive both clinicians and patients to the possibilities of improving pain and symptom controls, there are several ways in making inroads into the problems.

In many communities, the growth of palliative care has been through its impact into not just the alleviation of symptoms but also in its approach in dealing with the whole experience of cancer. Combined with a more rational approach to the use of resources and allowing greater information and participation of patients and families to clinical decision making allows a more pragmatic approach to symptom control. A better appreciation of hopes and understanding the rationale for patient's preference for alternative / traditional remedies is also helpful. This current development of palliative care needs to be encourages and nourished.

Increasingly patient support and cancer survivor groups have been used to talk to patients with cancer. Their experience and understanding are able to provide a more grounded advice and approach that may have greater appeals to certain patient populations. In dealing with cancer, it is imperative that healthcare systems appreciate that dealing with cancer not only require physicians but may be greatly enhanced with involving a multidisciplinary team. Such an initiative may not necessarily be at high expenses as costs may be saved with better symptom control. If a multidisciplinary team is unrealistic, a multi-skilled person would still be a great asset.

Finally a case must be made for greater and broad education for both the medical and general public as a whole. It is only with greater appreciation that much of cancer symptoms may be helped and a healthcare system that is geared for it would pain and symptom control be gradually improved.

CONCLUSION

Improvement in cancer symptom control may be improved in developing countries by adopting fairly simple measures. These involve attitudinal changes, better communication, greater access to simple but effective drugs, education and the dissemination of simple and easily understood information. All efforts at education needs to be encouraged but through respecting the inherent values of the community. The models of care currently available in resource rich countries are simply not transferable to developing countries but simple but effective models can be implemented. Whilst there may be examples of successes in developing countries, their emphasis on service development rather than research, audit and documentation ensures that such success stories remain hidden from the world at large.