Tailoring cancer treatment plans early on with the strengths of Palliative Care protocols
By Dr. Sunitha Daniel, Advisor, Palliative Care, Karkinos Healthcare
Cancer – the very thought of ever being diagnosed with this disease can freeze our mind and make our world come crashing. It is a complicated disease. The onset of this disease can be predicted only to an extent but even if cancer prediction is done, we see that the treatment has poor outcomes if it is presented at a late stage to the physician.
By the time diagnoses and treatments are initiated, cancer would have spread to other parts of the body causing terminal illness. The ability of this disease to consume a life is rather quick compared to other life-threatening illnesses. This is why diagnosis of cancer at the right stage becomes very important as it has a direct impact on the Quality of Life, cost, and the treatment outcome for a patient.
Over the years, cancer research and treatment has undergone tremendous evolution. And, in the last 20 years, increasing attention has been given to a patient’s Quality of Life, especially in oncology. From a cancer perspective, Quality of Life (QoL) can be defined as a sense of well-being that contains multidimensional factors such as physical, psychological, social, and spiritual wellbeing of a patient. These days the nutritional dimension is also being considered as an important parameter in QoL.
In this context, palliative care is classically defined as an approach that improves the QoL of patients (adults or children) and their families who are facing problems associated with life-threatening illness like cancer. It prevents and relieves suffering through the early identification, correct assessment, and treatment of pain and other problems, whether physical, psychosocial, or spiritual. It is now accepted that the development of palliative care through effective, low-cost approaches is usually the only feasible alternative to respond to the urgent needs of the sick and improve their QoL.
The International Association of Hospice and Palliative Care (2018) has defined Palliative care as the active holistic care of individuals across all ages with serious health-related suffering due to severe illness and especially of those near the end of life.
Changing the approach and application of palliative care to improve QoL
The purpose of palliative care is to relieve the patient from suffering and improve the Quality of Life for both patients and families throughout the illness experience, not just at the end of life. Of those living with cancer, 60% will experience significant pain. Research, knowledge, and experience related to pain alleviation have proved that it is important to deliberate the need and plan for palliative care at a very early stage of cancer treatment to help the patient fight the disease or rather let go off life with dignity. And, today, there is that knowledge to relieve much of the unnecessary suffering and help the patient convalesce with the support from the palliative care department.
A landmark study conducted in a western country proved that palliative care intervention along with standard oncology care at diagnosis of late stage lung cancer improved not just the quality of life of patients but their survival also. The study had two arms of patients , one receiving just the standard oncology treatment and the other with a combination of palliative care and standard oncology care. The arm that received the conventional and palliative care showed significant improvements in survival.
In 1990, the World Health Organization (WHO) enforced guidelines to integrate palliative care into health care systems. This included advice and guidelines to governments on priorities and how to implement national palliative care programs and national cancer control programs where palliative care will be one of the main components of comprehensive cancer care.
Since then, WHO has broadened its approach to palliative care. Whereas before, a disease-specific approach was used, now the similarities and opportunities for cooperation among those working with different diseases are emphasized. The earlier WHO definition of palliative care stressed its relevance to patients not responsive to curative therapy. Today, however, there is wide recognition that the principles of palliative care should be applied as early as possible in the course of any chronic, ultimately fatal illness. The WHO states that this change in thinking emerged from a new understanding that problems at the end of life have their origins at an earlier time in the trajectory of disease. Symptoms not treated at onset become very difficult to manage in the last days of life.
Addressing suffering involves taking care of issues beyond physical symptoms. The WHO approach to palliative care has also been extended, such that, while pain relief is still an important component, it is by no means the only consideration. The physical, emotional, and spiritual needs of the patient are all considered important concerns in palliative care. With the involvement of these disciplinaries, palliative care uses a team approach to support patients and their caregivers. This includes addressing practical needs and providing mental health or bereavement counselling. It offers a support system to help patients live as actively as possible until death.
The American Society of Clinical Oncology (ASCO) also believes that it is the oncologists’ responsibility to care for their patients in a continuum that extends from the moment of diagnosis throughout the course of the illness. ASCO stresses that in addition to appropriate anticancer treatment, palliative care must include symptom control and psycho-social support during all phases of care, including those during the last phase of life.
Advocating Palliative Care by a proficient Tumor Board at Karkinos Healthcare
It is depressing to note that despite knowing the advantages of palliative care, in India, only 2% of the population receive this care. This is why Karkinos Healthcare, while setting up its cancer centers, plans for a palliative care department alongside all other services.
Based on ASCO’s recommendation, Karkinos Healthcare believes that it is the company’s committed responsibility to provide concurrent palliative care alongside usual cancer care to all patients in late stage of cancer.
Generally, palliative care for patients with advanced cancer should be delivered through an interdisciplinary care team. This interdisciplinary team is called the Tumor Board. A Tumor Board is a group of medical oncologists, radiation oncologists, onco-surgeons, onco-nurses, pathologists, radiologists, and in some cases researchers, who meet to discuss treatment options for individual cancer patients. Typically, those involved come from different backgrounds so that various treatment modalities can be discussed and knowledge can be shared to ultimately cure and save the life of the patient. For this reason, Karkinos Healthcare has placed a palliative care physician in the Tumor Board to bring about effective resolutions in a timely manner or from the start of the treatment in advanced cancer patients. This board at Karkinos Healthcare works on evidence-based, cost-effective interventions that can save a life or alleviate pain or simply bring better outcomes to improve QoL on a case-to-case basis.
For newly diagnosed patients with advanced cancer, Karkinos Healthcare’s Tumor Board deliberates the involvement of early palliative care plans, starting early in the diagnosis process and ideally within 8 weeks of diagnosis. The team begins the deliberation with symptom, psychosocial, and spiritual assessments and inquiries about the patient’s understanding of their situation, then frames goals of care and tailors treatment plans that suit the patient.
Karkinos Healthcare’s Tumor Board meets up once a week to do a retrospective analysis and discussion on the ‘goals of care’ for every patient, which entails us to discuss about: knowledge of the illness; cost-effective options for treatment; pain management (use of opioids); planning for the future; etc. While doing all this, the palliative team builds a good rapport and relationship with the patient and the respective family members. It is also important for Karkinos Healthcare to seek referral to other palliative care providers or to be referred by other cancer care providers to our palliative care team.
A palliative care specialist has the required training and license to authorize the use of oral opioids pain medications. Opioids like morphine are pain relievers that are prescribed for severe pain, which is no longer responding to medications of lesser strength. As palliative care specialists are scarce in India, Karkinos Healthcare is training its oncologists in palliative care to be able legally prescribe appropriate opioids for pain management.
Being a digital oncology platform, Karkinos Healthcare makes the best use of digital technologies in palliative care too. The platform provides the scope to organize Virtual Tumor Boards, where the interdisciplinary team are able to discuss on online platforms regardless of their location. This way we ensure that the intervention time is never lost due to non-availability of treating oncologists and support staff. The Command Center established by the technology team of Karkinos Healthcare ensures that the patient at any time is never dropped out of the service. The company strongly believes and envisions in offering end-to-end cancer care services to the patient and not seeing the end of the patient succumbing to the disease.