07 December 2016

Supportive care for cancer patients remains inadequate

Pain relief and other forms of supportive care for cancer patients are insufficient, researchers report at the ESMO ASIA 2016 Congress in Singapore. They also highlight that side-effects to chemotherapy must be treated efficiently and that doctors should ensure end-of-life treatment meets patients’ expectations.
Despite existing recommendations on the need for early supportive care interventions for cancer patients (1,2,3) researchers are still reporting inadequate efforts to address pain, anxiety and other side effects of cancer treatment.
A study from India presented at ESMO Asia 2016 shows that, for patients on government-funded health schemes, medical care for the toxic effects of chemotherapy is often highly restricted and this delays cancer treatment cycles. Drugs are often not fully funded so patients have to pay for them out of their own pocket. If they cannot afford to do this, then their supportive care is inadequate and they will suffer side effects from cancer drugs. This means they are unlikely to adhere to treatment for subsequent chemotherapy cycles.
“The majority of patients treated under government schemes had poor quality of supportive care while on chemotherapy,” said lead author Assistant Professor Himanshu Patel, a clinical pharmacist, JSS College of Pharmacy, JSS University, Mysore, India.
“We found its use was highly restricted, leading to side effects such as vomiting and infections, meaning the rescheduling of chemotherapy cycles for many patients.There’s an urgent need for better treatment policies from government,” he said.
Supportive care such as pain relief, antibiotics and drugs to prevent nausea is recommended for advanced cancer patients undergoing chemotherapy by ESMO (1,2) and the World Health Organisation (3), among others.
The study by Dr Patel (4) included interviews about supportive care with 850 patients over six months. Researchers reviewed what support was used including pain-relief, antibiotics and protein supplements.
Results showed that access to drugs proven to be more effective in treating nausea and vomiting was highly restricted for patients on government-funded schemes in India. The same was true for medications to reduce infection risk and boost white blood cell production in patients undergoing chemotherapy, as well as protein supplements.  
To relieve cancer-related pain, four in five participants were prescribed tramadol, with access to morphine and other more effective painkillers limited.
Privately-insured patients did not face the same limited access as those on government-funded schemes, which often did not cover out-of-pocket costs. 
Patel said: “Public cancer care schemes should follow guidelines and include adjuvant treatments in their budgets, according to international recommendations.”

Cure or symptom relief: what do cancer patients expect from treatment?
Patients’ expectations from palliative chemotherapy as well as their concerns as treatment progresses are explored in another study (5) reported at the ESMO Asia 2016 Congress.
Results found that expectations among patients changed as care progressed. Nearly a third (n=11) on first line treatment expected a cure whereas later line patients said they anticipated an ordinary life with controlled symptoms. All patients put drug toxicity as their top concern, although anxiety around disease progression increased as patients advanced through treatment.
Lead author Nobumichi Takeuchi, director of medical oncology, Ina Central Hospital, Ina, Japan, said: “Oncologists should assist end-of-life patients to focus on positive experiences such as a family event so they don’t lose hope. The patient should drive this process with medical staff guiding and encouraging them with a questionnaire to identify their expectations.”

Persistent pain care as important as acute for wellbeing
Cancer pain and how to prioritise its treatment is the focus of a study (6) which evaluated the difference in quality of life (QoL) and demand for pain relief. Researchers compared the experiences of patients with background cancer pain (BCP) - persistent pain lasting at least 12 hours - and breakthrough cancer pain (BTcP) where patients experience brief but severe flare-ups of discomfort.
Results found that patients with uncontrolled BCP had a lower QoL than those with BTcP. Those with moderate or severe BCP experienced sleep disorders and dissatisfaction with pain control compared with BTcP patients (p<0 .0001="" among="" cancer="" demand="" different="" for="" groups="" not="" p="0.082).</p" pain="" significantly="" the="" though="" three="" treament="" vs="" was="">
Lead author Assistant Professor Sun Kyung Baek, a medical oncologist, Kyung Hee University Hospital, Seoul, Republic of Korea, said: “Pain is one of the most feared symptoms in cancer patients and impacts significantly on their well-being. Physicians should be aware of and control background pain first, even though acute pain also has a negative impact on quality of life .”
A total of 1,841 patients were recruited including those experiencing high (n=496) to moderate (n=736) pain, and BTcP (n=609). They completed a questionnaire on their experiences including pain severity, treatment, and satisfaction with how their cancer pain was dealt with.
Commenting on the results of these studies, Dr Grace Yang, a consultant at the National Cancer Centre, Singapore, said: “The findings from these studies highlight the need to improve both the effectiveness of, as well as access to, supportive care measures that can relieve cancer-related symptoms and treatment-related side effects.
“This will improve patient quality of life, enable cancer therapy to be administered, and is aligned with the expectations of patients themselves.” 

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