Palliative Care in the Caribbean Through the Lens of Women with Breast Cancer: Challenges and Opportunities

Background

Across the Caribbean, too many women are presenting with advanced breast cancer and dying with little or no access to palliative care. No comprehensive assessment of current capacity to deliver palliative care in the region exists, largely due to limited data. We assess the challenges in delivering palliative care for breast cancer patients in the Caribbean, highlighting the needs and experiences of low-income women through emblematic patient narratives.

Recent Findings

There is an urgent need to improve access to palliative care and pain relief throughout the region. Challenges include insufficient healthcare infrastructures to support cancer care, tremendous unmet need for palliative care, pervasive opiophobia resulting in limited access to opioids for pain relief, patients’ reluctance to engage with clinical care, and the widespread use of complementary and alternative medicines prior to the acceptance of conventional care.

Summary

There is an urgent need to improve access to palliative care and pain relief for cancer patients in the Caribbean. Strong regional collaboration, provider and patient education, improved access to opioids, and innovative models for palliative care that reflect the culture and resources available in the region have the potential to measurably improve palliative care delivery.

     

Survey on patients' satisfaction with opioid rescue guidance by pharmacists

To examine the influence of drug therapy guidance by pharmacists on the use of a rescue dose (RD) for opioid analgesics (opioids) and pain as well as drug therapy guidance in cancer pain treatment, we conducted a patient satisfaction survey. The subjects were 56 cancer patients undergoing opioid therapy in hospitals belonging to the Symptom Control Research Group (SCORE-G). The survey period was 2 months (from November 1 until December 31, 2006). Drug therapy guidance regarding the use of RD was performed twice in each patient to evaluate the patients' satisfaction. RD was prescribed in 87.8% of the patients in the first guidance and in 80.5% in the second guidance periods. The proportion of patients who used RD significantly increased from 63.8% to 87.5%. Five items significantly improved in the second guidance period: "marked analgesic effects," "satisfaction with current treatment," "correct understanding of RD usage," "relief through RD," and "appropriate use of RD." On comprehensive evaluation following the second round of guidance, 81% of the patients reported overall satisfaction, and 78% reported the usefulness of guidance in pain treatment. These results suggest that positive guidance by pharmacists increases patients' satisfaction. In providing guidance, it was important to confirm the characteristics and side effects of opioids as well as the necessity of RD to patients accurately and repeatedly.     

The management of cancer pain

The experience of pain in cancer is widely accepted as a major threat to quality of life, and the relief of pain has emerged as a priority in oncology care. Pain is associated with both the disease as well as treatment, and management is essential from the onset of early disease through long-term survivorship or end-of-life care. Effective relief of pain is contingent upon a comprehensive assessment to identify physical, psychological, social, and spiritual aspects and as a foundation for multidisciplinary interventions. Fortunately, advances in pain treatment and in the field of palliative care have provided effective treatments encompassing pharmacological, cognitive-behavioral, and other approaches. The field of palliative care has emphasized that attention to symptoms such as pain is integral to quality cancer care.     

An attitude survey on the medical use of narcotics for cancer pain relief

Narcotic medications are the major drug therapy for cancer pain relief. A clinical use of fentanyl patches and oxycodone extended-release tablets has recently become available, which led to more choices of narcotics to be used medically. On the other hand, palliative care systems have not yet been fully established by medical institutions. The management of symptoms including pain, therefore, actually has to be performed by "care doctors" involved in cancer care. We conducted a survey on the medical use of narcotics for 500 people, including cancer patients and their family members. The result showed that the recognition rate of morphine used for cancer pain relief was 88%, while the recognition rate of narcotics for medical use other than morphine available for cancer pain relief was 20%. The most acceptable dosage form of narcotics was a skin patch, followed by an oral preparation. A response percentage that the dosage form of medical narcotics should be selectable by users was 93%.     

Pain: impediments and suggestions for solutions

Pain is a common and devastating symptom of cancer that can be effectively controlled with currently available pharmacological and non-pharmacological therapies. Unfortunately, there continue to be reports that half of patients with cancer have inadequate relief of their pain with devastating effects on their quality of life and functional status. Systematic efforts to understand and eliminate the barriers to effective pain control are essential if we are to make pain assessment and management an integral part of cancer care. Documented impediments are related to health care professionals; patients, families, and the public; and the health care, reimbursement, and drug regulatory systems. A research agenda that focuses on closing the gap between current knowledge and practice is essential to assuring that people with cancer are no longer subjected to the agony of unrelieved pain.     

Cancer relief in India

In India, 80% of all patients with cancer are first seen in the terminal phase of their illness. At that point, their terrible suffering and pain forces them to go their doctor for some relief. There is then no hope of cure, but with effective palliative care measures, there is hope of relief of symptoms and some restoration of quality of life.
Gilly Burn, an English cancer nurse, started an independent voluntary organization in March 1990 called Cancer Relief India (CRI). During her third visit to India, where she has travelled extensively and lectured to health professionals and others, Gilly had a dream on a train. She awoke with the idea of founding a charity to provide better cancer and palliative care in a land with relatively few resources, in need of cancer expertise.     

Improving cancer pain management in Malaysia

Within Malaysia's otherwise highly accessible public healthcare system, palliative medicine is still an underdeveloped discipline. Government surveys have shown that opioid consumption in Malaysia is dramatically lower than the global average, indicating a failure to meet the need for adequate pain control in terminally ill patients. Indeed, based on daily defined doses, only 24% of patients suffering from cancer pain receive regular opioid analgesia. The main barriers to effective pain control in Malaysia relate to physicians' and patients' attitudes towards the use of opioids. In one survey of physicians, 46% felt they lacked knowledge to manage patients with severe cancer pain, and 64% feared effects such as respiratory depression. Fear of addiction is common amongst patients, as is confusion regarding the legality of opioids. Additional barriers include the fact that no training in palliative care is given to medical students, and that smaller clinics often lack facilities to prepare and stock cheap oral morphine. A number of initiatives aim to improve the situation, including the establishment of palliative care departments in hospitals and implementation of post-graduate training programmes. Campaigns to raise public awareness are expected to increase patient demand for adequate cancer pain relief as part of good care.     

Ibandronate: its role in metastatic breast cancer

Bisphosphonates are the most effective agents for treating and/or preventing complications of bone metastases and are the standard of care in this setting. Currently, four bisphosphonates are available for metastatic bone disease (MBD): clodronate, pamidronate, zoledronic acid, and ibandronate. Although all four of these bisphosphonates have been shown to reduce the incidence of skeletal-related events in patients with bone metastases, there are substantial differences among these agents in their potency, dose and route of administration, and side effects. Ibandronate and zoledronic acid, the two newer aminobisphosphonates, appear to have similar biochemical efficacies when phase III trial data are compared. Both agents were equally effective in reducing markers of bone resorption in the only prospective comparative trial carried out to date, but no data on relative clinical efficacy are available from head-to-head comparisons. Both the oral and i.v. formulations of ibandronate have also shown long-term efficacy in managing metastatic bone pain (MBP), but the onset of action of standard bisphosphonate treatment is not sufficient when rapid relief of pain is required. Because of its favorable renal safety profile, i.v. ibandronate can be administered daily for 3 days, as a so-called "loading dose." This dosing regimen has allowed rapid and effective relief of MBP without the unwanted side effects associated with opioids and other analgesics. Ibandronate is thus an effective, flexible, and well-tolerated bisphosphonate that can meet the varying requirements of patients with MBD.     

'Futile care': what to do when your patient insists on chemotherapy that likely won't help

While there is no generally accepted medical definition of "futile care," many factors may play a role in the delivery of chemotherapy to patients who are unlikely to benefit. In this review, we consider the roles of both the patient and the physician in driving the provision of "futile care" and offer practical steps the oncologist can take to avoid it.     

中国癌痛控制战略的实施现状与展望

简介我国癌症疼痛控制战略的实施现状及其可能的发展前景。我国自1990年推广实施WHO癌症疼痛三阶梯治疗方案,癌痛治疗状况虽发生一些改善,但是受益的癌症疼痛患者所占比例并不高。WHO认为一个国家的吗啡消耗量是评价该国癌痛改善状况的一个重要指标。中国的吗啡消耗量仍特别低,为了达到“让中国癌症患者不痛”的目标,非常需要做好以下诸项工作:更新用麻醉药观念,消除阿片类药物“成瘾恐惧”的心理束缚;改变不合理的处方习惯,认知哌替啶不适于为癌症患者缓解慢性疼痛;麻醉药品管理要保证医疗需求;大力开展医务人员培训工作,加大宣传力度,进一步推广规范三阶梯治疗原则;在应用镇痛效果好、副作用少的新药的同时,要改善对廉价即释吗啡片的供应。控制癌痛是医生的神圣职责,需要做出不懈的努力。     

Single-dose half-body irradiation for palliation of multiple bone metastases from solid tumors. Final Radiation Therapy Oncology Group report

This is the final analysis of Protocol #78-10 which explored increasing single-doses of half-body irradiation (HBI) in patients with multiple (symptomatic) osseous metastases. When given as palliation, HBI was found to relieve pain in 73% of the patients. In 20% of the patients the pain relief was complete; over two thirds of all patients achieved better than 50% pain relief. The HBI pain relief was dramatic with nearly 50% of all responding patients doing so within 48 hours and 80% within one week from HBI treatment. Furthermore, the pain relief was long-lasting and continued without need of retreatment for at least 50% of the remaining patient's life. These results compare favorably with those obtained by the Radiation Therapy Oncology Group (RTOG) using several conventional daily fractionated schemes on similar patients in a prior study (RTOG #74-02). HBI achieves pain relief sooner and with less evidence of pain recurrence in the irradiated area than conventionally treated patients. The most effective and safest of the HBI doses tested were 600 rad for the upper HBI and 800 rad for the lower or mid-HBI. Increasing doses beyond these levels did not increase pain relief, duration of relief, or achieved a faster response; however, the increase in dose was associated with a definite increase in toxicity. Single-dose HBI was well tolerated with no fatalities seen among 168 treated patients. A comprehensive premedication program has proven to decrease the acute radiation syndrome to very acceptable levels. There were excellent responses found in practically all tumors treated, but especially breast and prostate among which over 80% of all patients experienced pain relief, 30% in a complete fashion. Single-dose HBI emerges as one of the safest, fastest, and more effective palliative tools for intractable cancer pain in modern radiation oncology.     

Efforts to prevent adverse events in the United States--health care risk management and a fresh perspective on adverse events prevention

Not causing adverse events is never-ceasing issue in the health care field. However, the advances and greater specialization of medical technologies and the increasing number of elderly people, are all factors in the occurrence of adverse events. At the same time, greater efficiency is now demanded in the health care field, and the problem of preventing adverse events has become tougher than ever before. Given the situation, a fresh perspective on attempts to prevent adverse events may be important. One hint for such a new perspective is the health care risk management that is widely practiced in the health care field in the United States. This was introduced in the mid-1970s to counter the disputes and lawsuits at the time, but over the years the focus has shifted to the importance of prevention, and is now recognized as a means to work toward the assurance of quality of health care. Hints are also found in the suggestions related to adverse events prevention. In "To Err Is Human," published in November 1999 in the United States, includes proposals to "respect human limits in process design" and "promote effective team functioning," which are just the approaches we should adopt for a new perspective. I would also like to draw attention to the idea that there should be investigations into "developing effective mechanisms for identifying and dealing with unsafe practitioners" and the importance of "protecting voluntary reporting systems" that is mentioned. Adopting American methods unchanged to the health care system in Japan may not be appropriate, but the way of thinking and know-how from health care risk management, as well as the suggestions for adverse events prevention will provide us new perspectives on adverse events prevention, from which we should work toward a system of more efficient, and high-quality adverse events prevention.     

晚期消化系统肿瘤疼痛患者大剂量吗啡治疗的临床护理研究

目的探讨晚期消化系统肿瘤疼痛患者大剂量吗啡治疗及护理的临床疗效。方法选择2010年6月至2013年6月接受大剂量吗啡治疗的晚期消化系统肿瘤疼痛患者34例,所有患者均给予大剂量吗啡静脉输液泵输入治疗,起始剂量为为口服剂量的30%,效果不显著者适当增加吗啡剂量,吗啡剂量220⁵50mg/d,对患者进行静脉输注泵、输液管、镇痛、不良反应等护理,观察疗效。结果疼痛完全缓解18例(52.9%),部分缓解16例(47.1%),疼痛缓解有效率为100%。在治疗过程中,出现轻微头昏嗜睡、恶心呕吐、血压降低、呼吸抑制、便秘、幻觉谵妄、欣快感等不良反应,经对症治疗、减少吗啡剂量以及时间延长后,不良反应均显著减轻或消失。结论晚期消化道肿瘤疼痛患者使用大剂量吗啡治疗与护理,能有效缓解患者极度疼痛,提高生活质量,值得临床推广应用。     

Radiation therapy in bone metastases from lung cancer

The record of 73 patients with 153 sites of bone metastases from a lung cancer treated by radiation have been reviewed to evaluate the effectiveness of pain relief. Radiation therapy for bone metastases was found to be very effective. Sufficient symptomatic improvement was achieved in 94% of all patients, while 63% obtained almost complete pain relief that was sustained until death. Onset of a symptomatic response to radiotherapy was within less than 20 Gy in total dose in more than 80% of all patients. There were no significant differences in the frequency of pain relief among the various histological types of primary lung tumors.     

Radiation therapy of osseous metastasis

Palliative irradiation for bone metastasis is very effective. In more than 80% of the patients the effective pain relief can be obtained by the administration of 20-30 Gy in total dose. A review of the literature as well as our clinical experiences indicates that within wide ranges no optimal radiation schedule or dose exist for reducing pain in bone metastasis. The most important purpose of radiotherapy is not the pain relief bt the prevention of the fracture and the spinal palsy. Therefore, the method and schedule of the radiotherapy should be decided in due consideration of the location of the primary lesion and its extension, the location and extent of the bone metastasis, and the general condition of the patient.     

Home hospice care for the blood cancer patients

In order to clarify the clinical characteristics along with the practical care that we provided, 21 terminally ill blood cancer patients who died at home from July 1 in 2003 to May 31 in 2010 were analyzed and compared with 733 non-blood cancer patients. The patients'characteristics such as age, gender and the home death frequency did not show a significant difference. The home care period for blood cancer patients showed that it tended to be a short duration, but not a statistically-significant difference. For the cases of longer period of more than 15 days at home, focus lists at each phase based on total suffering classification did not show significant differences between the two groups. The frequency of strong opioid usage was significantly lower in the blood cancer patients, whereas a strong opioid was used for pain relief in multiple myeloma cases. As a preliminary report, firstly, although frequency of hematological malignancy in home hospice care is low, the care was not difficult by comparison with that of the non-hematological malignancies. Secondly, the main issue of symptom control was a pain relief, and fentanyl patch was the first-choice strong opioid without the need of opioid rotation because relief of dyspnea was few. Thirdly, in the multiple myeloma, the pain relief was the most important issue that was compared with in other blood cancer patients. And fourthly, although the hemorrhage was a big focus in case of leukemia, it didn't force to cease the home care.     

Intrathecal drug delivery for the management of cancer pain: a multidisciplinary consensus of best clinical practices

A substantial number of patients with cancer suffer considerable pain at some point during their disease, and approximately 25% of cancer patients die in pain. Providing effective pain management for patients with severe pain that impacts quality of life can present the oncologist or palliative care specialist with complex clinical challenges that often require multifaceted therapeutic measures. This paper presents multidisciplinary consensus-based recommendations for the treatment of intractable cancer pain using intrathecal drug delivery systems, which offer rapid and effective pain relief with less toxicity relative to oral or parenteral administration. Intrathecal drug delivery systems can be highly effective in a variety of patient settings, including cases of refractory pain, diminished performance status, poor tolerability of oral medications, polyanalgesia for complex pain, and inadequate dosing due to addiction concerns. The use of implantable or external systems is discussed, as well as implantation procedures, drug titration recommendations, and management of potential side effects.The authors offer a newly developed algorithm for delivering intraspinal analgesia in patients with cancer.The intent is that increased understanding of available options for truly effective pain management in the oncology and palliative care arena and the benefits of multidisciplinary cooperation will translate into genuine improvements in patient quality of life and a measurable decrease in the number of patients who suffer needlessly in their final days.     

Patient-Controlled Analgesia for Cancer Pain: A Long-Term Study of Inpatient and Outpatient Use

The safety and efficacy of patient-controlled analgesia for the long-term control of cancer pain was tested prospectively. Respiratory rates, mental status, and pain relief were recorded at baseline and compared with those during the study period. Patients had a lower analgesic demand (i.e., self-administered less morphine during the nighttime); specifically, dosing declined48% from the daytime level. Respiratory rates did not change appreciably during the study and no cases of significant respiratory depression were encountered. Patients self-administered sufficient morphine to produce adequate but not complete pain relief in almost all trials. Pain relief was safely achieved by both intravenous and subcutaneous routes of administration in both the inpatient and outpatient settings. Mean 24-h morphine use stayed relatively constant even for patients receiving more than 2 weeks of treatment. In conclusion, patient-controlled analgesia is effective and safe therapy for the long-term control of severe cancer pain.     

如何提高“三级阶梯止痛法”的疗效与安全性

目的力求癌痛治疗效果与安全性的统一。方法按三级阶梯止痛疗法的用药原则：①实行“目标”（无痛）治疗,不计较用药剂量;②预防大剂量止痛药物的副反应;③效果评价标准兼顾“缓解程度”和“生存质量”的统一。结果90例中、重度癌痛患者中,完全缓解达67％,中度缓解达29％,显著有效率（完全缓解＋中度缓解）为96％;癌痛综合征逐步消除;生存质量分值由治疗前平均29分．三天后升至42分;哌替啶过量所致呼吸抑制即时恢复。结论①三级阶梯止痛疗法仅为指导原则,具体病人还需在用药量和安全性之间摸索“最佳交叉点”;②医源性痛苦（不一定疼痛）、癌痛综合征和癌痛三者需同步处理;③逐步用“生存质量”标准取代“缓解程度”,可使癌痛治疗效果有质的提高。     

The importance of psycho-oncology

Cancer patients not only exhibit physical care problems, but also have various psychological, social, and existential problems which cause stress that can induce psychological disorders. Psychological distress causes suffering in patients and negatively impacts their treatment. Therefore, appropriate interventions are required. Family caregivers also suffer from mental and physical burdens that cause poor health, leading them to being called "second order patients," and necessitating their own treatment and care. Thus, cancer treatment involves biological and humanistic approaches. Psycho-oncology deals with the humanistic aspects of cancer treatment to help reduce the psychological burden of patients. Bereavement is one of the most stressful events that a family experiences. Intervention is sometimes needed for mental, physical, and social reactions to grief in the family. Bereavement care, "postvention," is considered effective for reducing the family's stress.