Cancer pain & palliative care

Cancer pain & palliative care

Cancer is one of the 10 leading causes of death in India. Out of some 10 lakh newly diagnosed cancer patients every year, more than 50 per cent are in...

Cancer is one of the 10 leading causes of death in India. Out of some 10 lakh newly diagnosed cancer patients every year, more than 50 per cent are in the advanced stages.

Over seven lakh people succumb to the disease every year. It is estimated that in India, there are nearly 1.5-2 million cancer cases at any given point of time. Anyone living with a history of cancer, from the moment of diagnosis through the remainder of life, is a cancer survivor. There are several million Indians living with and beyond a diagnosis of cancer.

World Cancer Day is marked on February 4 to raise awareness of cancer and to encourage its prevention, detection, and treatment. It is led by the International Union against Cancer (UICC), a global consortium of 350 cancer-fighting organisations in over 90 countries. World Cancer Day targets the public through global communications marking, and encourages policy makers and UICC member organisations to make cancer a political priority.

Lack of awareness among healthcare workers, policymakers and indeed patients and their relatives are important reasons contributing to poor pain control in cancer patients.

According to the Human Rights Watch Publication in 2009, the three main obstacles to improving pain management and palliative care in cancer patients are:

The failure to train doctors: Most doctors in India do not know how to assess or treat severe pain because the government does not include such instruction in Medical Curriculum.

Poor integration of palliative care into health services: National cancer control programmes do not contain meaningful palliative care components, with the result that palliative care has second-tier status and does not receive adequate public funding.

Restrictive drug regulations: Many Indian States have excessively strict narcotics regulations that make it very difficult for hospitals and pharmacies to get morphine.

In 1998, the Central Government recommended that States adopt modified regulations, but more than half of India's States have not done so. Tamil Nadu enacted the modified regulations in 2002, removing a major barrier to pain treatm

Breast cancer
With some 150,000 new cases being diagnosed every year, the incidence of breast cancer has overtaken cervical cancer to become the most common cancer affecting women. Due to lack of awareness and absence of an organised population based breast screening programme, more than 60 per cent of breast cancers in India present in the advanced stage and most succumb within a year of being diagnosed.

Although introduction of an organised nationwide population based breast screening programme using mammography is the best proven way of detecting cancers in the impalpable stage in the community, it is not a viable option for mass screening in India.

Reasons being - enormous costs involved, huge variation in mammographic reporting and the fact that the vast majority of breast cancers in India are diagnosed in younger women (between 30 – 50 years), where screening mammography is less effective.

Clinical breast examination (CBE), where trained healthcare workers examine the breasts of women is relatively simple, inexpensive and there is considerable circumstantial evidence to show that it is a viable option undertaking population based Breast cancer Screening in India.

Interestingly, the National Family Health Survey (NFHS) released by the Union Government for the years 2015 – 2016 revealed that only 11.1 per cent of women in Urban Telangana and 8.1 per cent in rural Telangana underwent CBE.

A significantly lower number of women in the neighbouring Andhra Pradesh, i.e. only 4.9 per cent in Urban Andhra Pradesh and 5.2 per cent in rural Andhra Pradesh underwent CBE. These statistics are similar across the country.

Since 2012, in an effort to find an ‘Indian solution’ to early detection of Breast Cancer in India, Ushalakshmi Breast Cancer Foundation (UBF), a not for profit organisation based out of Hyderabad has been implementing a large scale population based Breast Cancer Screening Programme spread across 3700 villages in 120 economically backward mandals of 15 districts in Telangana and Andhra Pradesh in partnership with the erstwhile Government of Undivided Andhra Pradesh (2012 - 2014), and more recently, in partnership with Governments of Telangana and Andhra Pradesh and Telangana and Andhra Pradesh Mahila Samatha Societies (2014- 2015).

Around 3,600 Health Care Workers were empowered about the importance of breast awareness and early signs of breast cancer over the past four years through well-researched audio visual aids. They have also been trained to perform CBE, a screening tool to detect early breast cancer.

Some 200,000 underprivileged women underwent screening (2012 – 2017) by way of CBE and those diagnosed with early breast cancers through this initiative have been referred for free treatment through the Arogyasree Scheme.

Impressed with the successful implementation of this large scale population based breast cancer screening programme in the Telugu States, in April 2016, I was invited to be part of a high powered Steering Committee set up by Ministry of Health, Government of India. The Steering Committee’s unanimous decision played a pivotal role in getting CBE incorporated into National Cancer Screening Guidelines.

In November 2016, I was appointed as member of the Technical Advisory Group (TAG) set up by Ministry of Health, which is providing training material and guidance in implementing the programme across the nation.

If valuable lives are to be saved from breast cancer ‘tsunami’ in India, there is an urgent need for a paradigm change in strategy to ensure early detection of breast cancer. The population based Breast Cancer Screening Programme being implemented in Telangana and Andhra Pradesh has a potential to be replicated throughout India and can indeed revolutionise the delivery of breast cancer care in India.

Women from the marginalised communities all across the country can be empowered about importance of early detection of breast cancer in addition to being screened to detect breast cancer in the early stages, the two essential tools to save scores
of lives.

Is there a solution?
There is a great untapped potential for pharma industry involved in manufacturing Chemotherapy drugs to associate with hospitals (Government and Private) delivering cancer services. The pharmaceutical industry have established links with these hospitals as cancer medicines are stocked in the hospital pharmacy.

Palliative Care Services can be developed in these hospitals through a partnership between the hospitals and pharma industry. The Corporate Social Responsibility (CSR) initiative could have the hospital provide space and develop training programmes and the pharma industry can invest in the day to day running costs of the Palliative Care Centre. The Centre could have both the name of the hospital and the pharmaceutical company involved in providing the service.

An MOU can be drawn out for a fixed term of say 10 years so that there is no interruption in the service. This is perhaps one solution that will make a beginning in the development of a service so badly needed in our country. The introduction of palliative care throughout India at tertiary, secondary, and primary health facilities as well as in the community is urgently needed to prevent the gross and unnecessary suffering of millions of people throughout the country.

Clearly, it must never be forgotten that ‘the good of the patient’ should be the highest priority for the doctor. The hospital and the pharma industry. I shall conclude with a quote from Sir James Kalnan, Professor of Royal Postgraduate Medical School, Hammersmith in London – “One can only cure sometimes, relieve often, but it is most important to be able to comfort the patient always”.

Can we prevent breast cancer?
Strictly speaking, one cannot prevent breast cancer. However, lifestyle changes have been shown in studies to decrease breast cancer risk even in those at high risk of developing breast cancer. The following are steps one can take to lower the risk:

  • Weight control: Being overweight or obese increases the risk of breast cancer. This is especially true if obesity occurs later in life, particularly after menopause.
  • Physical activity: which, in turn, helps prevent breast cancer. For most healthy adults, at least 150 minutes of aerobic activity per week is essential (30 mts /day for at least five days a week). Brisk walking/swimming are the best exercises.
  • Breast-feeding: Breast feeding reduces the risk of developing breast cancer and evidence is accumulating to suggest that breast feeding helps reducing risk of developing uterine and ovarian cancer. The longer breast-feeding is done, the greater the protective effect.
  • Limit dose and duration of hormone therapy: Combination hormone therapy for more than three to five years increases the risk of breast cancer. If a lady is taking hormone therapy for menopausal symptoms, it is important to ask the doctor about other options. One may be able to manage post menopausal symptoms with nonhormonal therapies, such as physical activity. If one decides that the benefits of short-term hormone therapy outweigh the risks, one should use the lowest dose that works for a short period of time.
  • Avoid exposure to radiation: Medical-imaging methods, such as computerised tomography, use high doses of radiation, which have been linked with breast cancer risk. It is important to reduce exposure by having such tests only when absolutely necessary.
  • Limit alcohol: The more alcohol one drinks, the greater the risk of developing breast cancer. If one chooses to drink alcohol — it is important to limit oneself to no more than one drink a day.
  • Don't smoke: Accumulating evidence suggests a link between smoking and breast cancer risk, particularly in premenopausal women. In addition, not smoking is one of the best things you can do for your overall health.

For a healthy diet, it is important to:

  • eat a variety of different foods and to eat the right amount to have a healthy weight
  • eat plenty of foods rich in fibre and at least five portions of fruit and vegetables a day
  • limit foods that contain a lot of fat, especially animal (saturated) fat
  • limit sugary food and drinks and lower salt intake
  • drink around two litres of fluids a day (such as water, herbal tea, tea, coffee or low calorie drinks)

Breast Awareness: is about becoming familiar with the breasts and the way they change throughout a woman's life. It is a concept that encourages women to know how their breasts look and feel normally so that they gain confidence about noticing any change which might help detect breast cancer early.

BREAST AWARENESS, as a concept, is gaining increasing acceptance world over.

  • Changes that one should be aware of
  • A change in size - it may be that one breast has become noticeably larger or noticeably lower
  • A nipple has become inverted (pulled in) or changed its position or shape
  • A rash on or around the nipple
  • Blood stained discharge from one or both nipples
  • Puckering or dimpling of the skin
  • A swelling under the armpit or around the collarbone (where the lymph nodes are)
  • A lump or thickening in the breast that feels different from the rest of the breast tissue
  • Constant pain in one part of the breast or in the armpit.

Dr P Raghu Ram is a Padma Shri awardee, Director, KIMS-Ushalakshmi Centre for Breast Diseases & CEO, Ushalakshmi Breast Cancer Foundation, Hyderabad.

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