Health-Related Suffering and Palliative Care in Breast Cancer

Purpose of Review
Breast cancer continues to be the most frequently diagnosed cancer in women and the leading cause of cancer death worldwide. By the suffering that it causes in various domains of life, breast cancer seriously impacts the quality of life of affected individuals and causes a major burden of suffering in the community. The objectives of the review were to understand the health-related suffering in patients with breast cancer and to identify the scope of palliative care in improving the quality of life of patients with breast cancer.

Recent Findings
Breast cancer causes suffering in physical, psychological, social, financial, and spiritual domains of the lives of the patient and family. Management of breast cancer with surgery, chemotherapy, and radiation could have adverse effects, such as pain, nausea and vomiting, fatigue, shortness of breath, depression, and constipation. Both cancer and its treatment can impact the psychosocial and spiritual well-being of the patient and family members. Integrating palliative care into existing breast cancer treatment programs seems to be the best approach to diminish these sufferings.

In addition to pain and other physical symptoms, breast cancer can cause major psychological, social, and spiritual suffering. In the context of developing countries, out-of-pocket expenditure can cause major financial destruction which can impact generations. Integration of palliative care to breast cancer treatment is essential.

Essential Package of Palliative Care for Women With Cervical Cancer: Responding to the Suffering of a Highly Vulnerable Population

Women with cervical cancer, especially those with advanced disease, appear to experience suffering that is more prevalent, complex, and severe than that caused by other cancers and serious illnesses, and approximately 85% live in low- and middle-income countries where palliative care is rarely accessible. To respond to the highly prevalent and extreme suffering in this vulnerable population, we convened a group of experienced experts in all aspects of care for women with cervical cancer, and from countries of all income levels, to create an essential package of palliative care for cervical cancer (EPPCCC). The EPPCCC consists of a set of interventions, medicines, simple equipment, social supports, and human resources, and is designed to be safe and effective for preventing and relieving all types of suffering associated with cervical cancer. It includes only inexpensive and readily available medicines and equipment, and its use requires only basic training. Thus, the EPPCCC can and should be made accessible everywhere, including for the rural poor. We provide guidance for integrating the EPPCCC into gynecologic and oncologic care at all levels of health care systems, and into primary care, in countries of all income levels.

Augmented Package of Palliative Care for Women With Cervical Cancer: Responding to Refractory Suffering

The essential package of palliative care for cervical cancer (EPPCCC), described elsewhere, is designed to be safe and effective for preventing and relieving most suffering associated with cervical cancer and universally accessible. However, it appears that women with cervical cancer, more frequently than patients with other cancers, experience various types of suffering that are refractory to basic palliative care such as what can be provided with the EPPCCC. In particular, relief of refractory pain, vomiting because of bowel obstruction, bleeding, and psychosocial suffering may require additional expertise, medicines, or equipment. Therefore, we convened a group of experienced experts in all aspects of care for women with cervical cancer, and from countries of all income levels, to create an augmented package of palliative care for cervical cancer with which even suffering refractory to the EPPCCC often can be relieved. The package consists of medicines, radiotherapy, surgical procedures, and psycho-oncologic therapies that require advanced or specialized training. Each item in this package should be made accessible whenever the necessary resources and expertise are available.

“Hanging in a balance”: A qualitative study exploring clinicians’ experiences of providing care at the end of life in the burn unit

Although the culture in burns/critical care units is gradually evolving to support the delivery of palliative/end of life care, how clinicians experience the end of life phase in the burn unit remains minimally explored with a general lack of guidelines to support them.

To explore the end of life care experiences of burn care staff and ascertain how their experiences can facilitate the development of clinical guidelines.

Interpretive-descriptive qualitative approach with a sequential two phased multiple data collection strategies was employed (face to face semi-structured in-depth interviews and follow-up consultative meeting). Thematic analysis was used to analyze the data.

The study was undertaken in a large teaching hospital in Ghana. Twenty burn care staff who had a minimum of 6 months working experience completed the interviews and 22 practitioners participated in the consultative meeting.

Experiences of burn care staff are complex with four themes emerging: (1) evaluating injury severity and prognostication, (2) nature of existing system of care, (3) perceived patient needs, and (4) considerations for palliative care in burns. Guidelines in this regard should focus on facilitating communication between the patient and family and staff, holistic symptom management at the end of life, and post-bereavement support for family members and burn care practitioners.

The end of life period in the burn unit is poorly defined coupled with prognostic uncertainty. Collaborative model of practice and further training are required to support the integration of palliative care in the burn unit.

Access to Radiotherapy for Cancer treatment (ARC) Project’: Guidance for low and middle-income countries establishing safe and sustainable radiotherapy services

Efforts to improve access to cancer care, including radiotherapy services in low and middle-income countries (LMICs) is challenging. Many radiotherapy initiatives in LMICs have failed to fully deliver on their promise because of multi-faceted barriers at the systems, organisational and patient levels, leading to significant wastage of scarce resources. Greater guidance on how to assess and build LMICs’ readiness for establishing sustainable radiotherapy services is needed to improve cancer care outcomes in LMICs. 𝗔𝗶𝗺: The ‘𝗔ccess to 𝗥adiotherapy for 𝗖ancer treatment (ARC) Project’ aimed to provide practical guidance to LMICs on establishing safe and sustainable radiotherapy services. 𝗠𝗲𝘁𝗵𝗼𝗱𝘀: The mixed qualitative methods ARC Project involved a: systematic review; and two-part qualitative study. The systematic review synthesised strategies adopted by LMICs to improve access to cancer treatment and palliative care. Semi-structured interviews undertaken with global radiotherapy experts explored perceived facilitators and barriers to establishing sustainable radiotherapy services in LMICs. The mid-point meta-inference of the systematic review and semi-structured interview data generated a draft list of requirements, which was circulated to global experts during the second part-of the qualitative study. The final meta-inference was undertaken following the completion of the three studies. 𝗙𝗶𝗻𝗱𝗶𝗻𝗴𝘀: The systematic review identified that comparatively few studies have focused specifically on improving radiotherapy in LMICs, with no research evaluating effectiveness. The semi-structured interviews identified three key facilitators to establishing sustainable radiotherapy services in LMICs, namely: committing to a vision of improving cancer care; making it happen and sustaining a safe service; and leveraging off radiotherapy to strengthen integrated cancer care. The mid-point meta-inference generated 42 potential requirements, which were organised into four readiness domains: commitment (n=13); cooperation (n=7); capacity (n=17); and catalyst (n=5). The participant validation confirmed 37 of the generated requirements as relevant for inclusion in a radiotherapy service development readiness self-assessment guide for use by LMICs. The end-point meta-inference of the ARC Project’s integrated data presented the ‘𝗥𝗘adiness 𝗦𝗘lf-𝗔ssessment (RESEA) Guide’, with 120 questions that may help LMICs at macro and meso level to determine and create action plans to improve their readiness to establish radiotherapy services. 𝗖𝗼𝗻𝗰𝗹𝘂𝘀𝗶𝗼𝗻𝘀: The ARC Project has identified a complex combination of facilitators and barriers that influence the establishment of sustainable radiotherapy services in LMICs. It has developed a RESEA Guide to provide support for LMICs seeking to establish sustainable radiotherapy services. Further work is needed to evaluate the acceptability and feasibility of the RESEA Guide and inform further refinements.

Barriers and facilitators to implementation of cancer treatment and palliative care strategies in low- and middle-income countries: systematic review.

To appraise improvement strategies adopted by low- and middle-income countries to increase access to cancer treatments and palliative care; and identify the facilitators and barriers to implementation.A systematic review was conducted and reported in accordance with PRISMA statement. MEDLINE, CINAHL, and the Cochrane Library databases were searched. Bias was assessed using the Standards for Quality Improvement Reporting Excellence, and evidence graded using the Australian National Health and Medical Research Council system.Of 3069 articles identified, 18 studied were included. These studies involved less than a tenth (n?=?12, 8.6%) of all low- and middle-income countries. Most were case reports (58%), and the majority focused on palliative care (n?=?11, 61%). Facilitators included: stakeholder engagement, financial support, supportive learning environment, and community networks. Barriers included: lack of human resources, financial constraints, and limited infrastructure.There is limited evidence on sustainable strategies for increasing access to cancer treatments and palliative care in low- and middle-income countries. Future strategies should be externally evaluated and be tailored to address service delivery; workforce; information; medical products, vaccines, and technologies; financing; and leadership and governance.