UICC World Cancer Congress 2006

Objective: Review the issues and challenges of cancer pain management in resource poor settings as well as discuss the some practical solutions.

Methods: Review of Literature, World health Organization and Ministry of Health reports in addition to personal experience. Results: / Findings: Kenya is facing an epidemiological transition characterized by the double burden of communicable and non communicable diseases including cancers. Cancer care initiatives in Kenya like in most Sub-Saharan Africa, take place in the context of inadequate healthcare funding, poor infrastructure, extreme poverty of patients, and minimal educational opportunities in cancer for health care workers. These factors are largely responsible for cancer patients presenting late, usually with intractable pain. The country has fundamental difficulties in distributing drugs due to a myriad of factors including financial, legislative and logistical problems. Morphine and related narcotic analgesics do not reach the cancer patients, most of whom live in the rural areas.

The World Health Organization (WHO) released guidelines for cancer pain relief in 1986. Since then, several controlled studies on effectiveness and practicability of these guidelines have been published. [Sepulveda 2003; Felleiter P 2004, Zech DF 1995; various authors describe inadequate use of these guidelines. [Felleiter P 2004, Joranson 1993]. Kenya is yet to implement a comprehensive management program for cancer. Cancer pain is hardly addressed as a policy issue at national and institutional level despite the priority that the WHO has devoted to the problem over the past decade. There are no national palliative or cancer care policy guidelines. Palliative care is given little attention in the nursing and medical school curriculum. In-service training opportunities in cancer and pain management are few and far apart while resources such as journals, books and access to internet are non existent in nearly all hospitals. Thus only an insignificant number of health workers are familiar with the WHO cancer pain management guidelines. IMPEDIMENTS TO CANCER PAIN RELIEF. Cancer care initiatives in Kenya like in most of the developing world, take place in the background of inadequate infrastructure, poor healthcare administrative systems, the extreme poverty of many patients, under funding of healthcare programs, and minimal educational opportunities for health care staff. Narcotics like Morphine are not easily available, due to legislative and logistical difficulties in supplies. A further impediment to improving cancer pain management in Kenya is that a majority of health care spending, both public and private, goes to curative and preventive efforts. Clearly, these are not the conditions for implementation of WHO cancer pain management guidelines or building specialized cancer pain management programs.

RE-DEFINING THE ROLE OF THE NURSE IN CANCER PAIN MANAGEMENT.

The bulk of the patients in the rural areas including those with cancer consult the nurse as the primary health worker. Nurses, who form the largest bulk of health workers in Kenya serves as the clinicians, pharmacists, social workers, counselors, dieticians and all other roles for which practitioners are not available. Majority of the nurses are not well prepared to play these roles.

Nurses in Kenya play the traditional role of giving analgesics as prescribed though in the districts and rural areas they do prescribe simple analgesics like Paracetamol. The Dangerous Drugs and Narcotics act does not allow them to prescribe opioids even when working in palliative care settings. However in Uganda, a neighboring East African country, whose social, cultural and economic circumstances are similar to Kenya, the strict regulations relating to narcotics have been amended to allow nurses in palliative care settings to prescribe opioids. The developments in Uganda, suggest that expanding nurses' roles with a clear role definition, and supportive regulations will help ease the burden of unnecessary morbidity associated with uncontrolled pain.

BRIDGING THE GAP BETWEEN WHAT IS AND WHAT SHOULD BE.

Aggressive high-tech approaches to pain management are not feasible in developing countries, which are facing an epidemiological transition characterized by the double burden of communicable and non-communicable diseases. WHO has initiated the "community health approach to palliative care for HIV/AIDS and cancer patients in Africa project." The goal of this project is to improve the quality of life of patients and their families in African countries by development of home based palliative care programs with a public health approach that will provide comprehensive care including pain relief. In resource-starved areas with poor healthcare infrastructure, this may be the only feasible means of providing adequate access to palliative care.

For the majority, of the cancer patients, in sub-Saharan Africa including Kenya, key barriers to adequate pain management are not the lack of technology but poverty and health system inequity. The fact that there exists successful hospice programs based in the rural areas, which are funded through charity; to provide home care services, means that, similar models can be replicated in the rest of the country. Furthermore, for the few who can afford, comprehensive cancer care; diagnostics and treatment including chemotherapy, radiotherapy, and surgery, is available from selected private healthcare providers. Cancer pain management should not be seen as a technical issue to be left to the specialists, an issue of benevolence to be dealt with by charitable institutions, or a commodity to be sold by private hospitals. The role of all stake holders, health workers, families, policy makers needs to be redefined and recast in a framework where every cancer patient, everywhere, even the most marginalized, is assured of adequate pain control and is empowered to demand and access this as a right. Bridging the gap between what is known and what is practiced will entail: · Empowering Oncology professional associations and other groups involved in Cancer with advocacy skill to get cancer high in the healthcare agenda. · Securing political support and persuading the law-makers to ensure that legislation will be put in place to empower nurses to prescribe, dispense, and administer Opioid analgesics to patients. · Capacity building for leaders in cancer care to enable them get cancer, and management of associated symptoms including pain adequately addressed in the medical and nursing school curriculum. · Investing sufficient resources in health and allocating these funds equitably among the healthcare priorities, giving cancer care the attention it deserves. · Collaboration with international partners in funding and supporting specific Cancer programs, including but not limited to public and professional education Programs, provision of education materials and screening campaigns.

CONCLUSION.

Cancer pain management should be seen as a global public health problem otherwise efforts to address it will not make much impact in the world. There is need for International support in setting up comprehensive Cancer Management programs in resource poor countries of the developing world.

In the context of the WHO cancer pain relief guidelines, cancer pain is hardly being managed adequately, or regularly for majority of Kenyan cancer patients.

The healthcare scenario in Kenya is such that nurses will continue to play a central role, not only in adapting the WHO guidelines to suit local circumstances, but also in establishing cost effective cancer pain management programs. Though statistics are not available, the number of patients suffering with uncontrolled cancer pain in Kenya and indeed in most of Africa is tragic. The establishment of pain management programs is therefore an urgent and unavoidable humanitarian responsibility. This grave responsibility cannot be met by the nurses in poor countries alone, for it transcends nursing and reflects on the values of society, both locally and globally...[ BMJ editorial, June 2002.]