Wednesday, February 13, 2013

Palliative Care: a Realistic Goal in 'War on Cancer'

In the last 40 years since President Nixon launched the ‘War Against Cancer’, we have achieved a lot in the terms of understanding the biology of variety of cancers but when it comes to cure let us evaluate our successes. After worth of several billions of dollars of research where are we?  Let us first understand the parameters that define ‘cure’ in biomedical terminology. The National Cancer Institute (NCI) defines ‘cure’ as “to heal or restore health”. Many people mistake “5year diseasefree survival rates” - an end point used in many clinical trials, as cure rates. Although 5year diseasefree survival is a quick end point that can easily be measured as a parameter of success of a therapeutic agent, an ideal definition of cure would be when the annual death rate of posttreatment cancer patients is the same as the normal population adjusted for the same age, in other words, when the cancer does not come back and people die due to some other reason in while they are cancer-free.

As per above definition of cure, what we have been able to achieve is indeed a “significant increase in the ‘disease-free survival’ for majority of cancers” which is not a small feat by any measures. However, it is still far behind the original goal of finding a complete cure when Nixon declared the “war on cancer” in 1971. Just one government organization, NCI, has spent approximately $90 billion on research and treatment during in these 40 years, let alone other government funding agencies and pharmaceutical industry. Despite our best efforts, truth of the matter is that approximately a third of patients diagnosed with cancer in highincome countries, let alone third world countries like India, will not be ‘cured’ and will ultimately succumb to complications caused by cancer.

So what we could and should do about it? ………While continuous research and development efforts to develop new therapeutic modalities to treat cancer must go on, it is equally, if not more, important to understand the immediate needs of the cancer patients that can help improve the quality of their remaining lives. We should start talking about living with cancer as the “new normal.”  Legendary Cancer Biologist and Nobel Laureate Dr. Harold Varmus, also Director of NCI, recently suggested including a new and probably more realistic goal in the field of cancer research, “making cancer a disease you can live with and go to work with.” He went on to say, “We have many, many patients with lethal cancers who are actually feeling pretty good and are working full time and enjoying their families. As long as their symptoms can be kept under control by radiotherapy and drugs that control symptoms and other modalities, we’re doing right by our patients.”

Sounds reasonably good! Well, people live with diabetes, cardiac disease, many genetic conditions, so why can’t they live with cancer and resume their normal lives as with other diseases? Yes they can, but to ensure this happens in the life of every cancer patient, one of the most important aspects of cancer management is palliative care which has to play a very critical role in here, unfortunately which is most ignored and underdeveloped field so far. For those who are new to this, palliative care (from Latin palliare, to cloak) is medical care provided by a team of physicians, nurses and social workers that specializes in the relief of the pain, symptoms and stress of a serious illness such as cancer. While in recent years, medical researchers and healthcare providers in the west have recognized the importance of this growing field of medicine and already have started focusing in this direction, copycats counterparts in developing countries such as in India are still busy wasting their scarce resources in repeating basic research in cancer biology, in which they are anyways 50 years behind the international level.

Immediate development of basic infrastructure to support palliative care facilities for cancer patients should certainly be top priority for government healthcare agencies in India, where these patients are anyways deprived of basic care for their disease because of lack of dedicated cancer hospitals, oncologists, and new generation targeted (personalized) therapies to treat their cancers. It is quite understandable that governments in developing countries too busy struggling with corruption, bureaucracy, and lack of basic infrastructure to fight seasonal flu, and malaria, can’t provide their citizens the luxury of cancer treatments, but what they could do easily is to ensure the rest of the life of a cancer patient goes smoothly and without pain. The paradoxes of a so-called ‘growing economic power’ India can well be noticed by pathetic state of cancer care in following example. In my native place Lucknow, a vibrant mid-size city of 2.4 million people, located in North India, you can easily pick-up a juicy cheeseburger at McDonald, famous single malt whiskey Glenfiddich at any hour of the day from hundred odd joints, but if you have a family member/friend suffering from unbearable cancer pain, and looking for morphine, you have only one medical store/pharmacy in the whole city, and you are indeed lucky if you find this shop open at the hour of need and morphine is available there at that time. No doubt, cancer patients in India deserve a more peaceful and painless last days of their lives, and a dignified death which can only be ensured in palliative care centers (currently nonexistent) especially designed to meet the needs of terminally ill cancer patients.  

To understand the increasing role of palliative care in cancer management even in best places on earth, please read this article which explains needs, current status, and future directions of this new discipline in oncology:

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