Elsevier

The Lancet Oncology

Volume 13, Issue 11, November 2012, Pages e492-e500
The Lancet Oncology

Review
Supportive, palliative, and end-of-life care for patients with cancer in Asia: resource-stratified guidelines from the Asian Oncology Summit 2012

https://doi.org/10.1016/S1470-2045(12)70380-7Get rights and content

Summary

The burden of cancer in Asia is high; 6·1 million new cases were diagnosed in the continent in 2008, which accounted for 48% of new cases worldwide. Deaths from cancer are expected to continue to rise because of ageing populations and modifiable risk factors such as tobacco and alcohol use, diet, and obesity. Most patients who are diagnosed with cancer in Asia have advanced disease that is not amenable to curative treatment, which means that they are likely to have pain and other symptoms and psychosocial concerns. These burdens vary with the economic and political situation of the different countries and are affected by such factors as an absence of screening programmes, insufficient cancer diagnostic and treatment services (especially in sparsely populated and rural areas), legal restrictions on access to drugs to relieve pain, and a medical culture in which quality-of-life considerations are undervalued in relation to imperatives to treat. These issues could be ameliorated by increased investment in cancer screening, removal of restrictions on prescription of opioids, and improvements in medical education to increase recognition of treatment futility. Supportive, palliative, and end-of-life care offer the potential to enhance quality of life, improve pain control, and reduce suffering for patients with cancer and their families, and to give patients a dignified death. All patients should have access to such care—in resource-rich regions these services should be integrated into oncology services, whereas in resource-poor regions they should be the main focus of treatment. The form of care should depend on the economic circumstances within and across countries, and recommendations are made across four resource classifications (basic to maximal) to take account of the diversity of settings in Asia.

Introduction

When patients are diagnosed with a life-threatening illness such as cancer, they and their families face uncertainty about the future and anxiety about how to access treatment, the quality of treatment, and its affordability. These concerns include patients' access to supportive, palliative, and end-of-life care meant to enhance their quality of life and reduce suffering throughout the course of the disease and to help them to deal with distressing symptoms and psychological and social challenges.1 Supportive and palliative care should be integrated into comprehensive cancer care; such care is the responsibility of all health professionals who care for patients with cancer. The way such care is organised and delivered, and whether palliative care is labelled as a specialist or accredited discipline, will inevitably vary between countries in Asia.

Palliative and end-of-life care services have expanded substantially during the past few decades throughout the world. In many countries, palliative medicine is well established as a specialist discipline or subdiscipline in medicine, distinct from oncology though with strong links to it. Dame Cicely Saunders led the early development of the modern hospice movement by establishing St Christopher's Hospice in south London, UK, more than 50 years ago, and similar developments rapidly spread to other European countries.2 The initial focus was on improvement of pain control with opioid drugs, which remains one of the central goals of care for patients with advanced and incurable cancer.3 Subsequently, palliative care, in several forms, has spread across most of the world, including to countries in Asia.4 However, many patients in Asia do not receive the supportive, palliative, and end-of-life care that they need.

This Review represents a consensus statement on the optimum supportive, palliative, and end-of-life care for patients in Asia, and was developed at the fourth Asian Oncology Summit, held in Singapore, April 13–15, 2012. The consensus involved a review of guidelines, presentations, and a round-table discussion that included regional and international experts, with audience participation. We do not aim to provide a detailed review of the status of palliative care in all Asian countries. Rather, we provide a brief overview of the epidemiology of cancer and cancer mortality in Asia, with an emphasis on the needs of patients and the challenges facing organisations and governments. We also provide an account of the contribution of supportive care to oncology, and argue for increased integration of palliative care into oncology services.1 Additionally, we present an overview of education in palliative care in Asia. Finally, we make recommendations across four resource classifications (basic to maximal) to take account of the diversity of settings in Asia.

There are differences in how key terms are defined and articulated in practice, but a common understanding is essential to allow for comparisons and benchmarking, and such an approach has been used successfully in other diverse regions such as Europe.5, 6 Use and assessment of services is based on an assumption that everyone shares a common understanding of terms and the aims of supportive, palliative, and end-of-life care. However, most of the evidence shows that terms and their definitions are poorly understood and not agreed upon.7 The terms used are affected by the historical development and nature of health-care systems in different countries and are subject to change over time. For example, in the UK, terms related to palliative care have undergone several transitions, from hospice care and terminal care in the early period of the hospice movement (1960s and 1970s) to palliative care towards the turn of the century (1980–2000); since 2008, end-of-life care has emerged as the preferred term. In this Review, we use the definitions provided in panel 1.

Section snippets

Cancer epidemiology and mortality in Asia

Cancer accounts for about 13% of deaths worldwide. Deaths from cancer are expected to continue to rise, because of ageing populations and modifiable risk factors such as tobacco and alcohol use, diet, and obesity. According to GLOBOCAN,12 about 70% of all cancer deaths in 2008 occurred in low-income and middle-income countries, many of which are in Asia.

The burden of cancer in Asia is high; for example, in 2008, 6·1 million new cases were diagnosed, which accounted for 48% of new cases

The need for palliative care

Most patients who are diagnosed with cancer in Asia have advanced disease that is not amenable to curative treatment, which means that they are likely to have pain and other symptoms and psychosocial concerns. In high-income countries such as Japan, Hong Kong, and Singapore, the quality of oncology services is similar to that in western countries. However, in low-income countries such as Burma, Laos, and Cambodia, many cancer patients are unable to receive even basic anticancer treatment. In

Supportive care in cancer

The essence of supportive and palliative care is the holistic care of the patient. Management is not restricted to the physical complications of the cancer and its treatment but includes the psychological, social, and spiritual needs of the patient (and family carers).21 The aim is to improve the quality of life, irrespective of the stage of the disease (ie, early or late) or the intention of the treatment (ie, curative or palliative). Supportive care has become an integral component of

Integration of palliative care into oncology services

Momentum is building in the development of palliative-care services in Asia. With increasing worldwide recognition of the essential contribution of palliative care to cancer care, many of the early steps in the development of palliative-care services could be skipped or shortened.

The 2012 International Association for Hospice and Palliative Care (IAHPC) report on essential practices in palliative care30 details the list of practices regarded as essential by doctors and nurses in primary care

Palliative care education in Asia

In the past few years, Asian advocates of palliative care have set up associations and societies to promote palliative care, such as the Asia Pacific Hospice Network, which has helped to train health-care professionals in countries with very few resources.4 However, formal professional education in palliative care is not yet fully established in Asia. Most of the health-care professionals who want to be trained in palliative care have to go elsewhere to access suitable courses. Formerly there

The future

The IAHPC list of essential practices in palliative care31 identifies three major components of care: recognition and management of patients' and families' physical, psychological, emotional, and spiritual care needs; care planning and coordination issues; and communication issues. These practices are applicable in any care setting, and the solutions can be varied dependent on local resources (table 3).31, 32, 38

For example, pain management does not always necessitate expensive drugs or other

Search strategy and selection criteria

We searched Medline, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Google Scholar for articles with the terms “supportive care”, “palliative care”, “end-of-life care”, “cancer”, “cancer trends”, “epidemiology”, or “public health”, together with “Asia”, in the title, abstract, or keywords. We also searched the websites of WHO, the Worldwide Palliative Care Alliance, Lien Foundation—Life before Death, the International Association for Hospice and Palliative

References (42)

  • Cancer control: knowledge into action: WHO guide for effective programmes—palliative care

    (2007)
  • L Radbruch et al.

    White Paper on standards and norms for hospice and palliative care in Europe: part 1

    Eur J Palliat Care

    (2009)
  • L Radbruch et al.

    White Paper on standards and norms for hospice and palliative care in Europe: part 2

    Eur J Palliat Care

    (2010)
  • CF von Gunten

    Humpty-Dumpty syndrome

    Palliat Med

    (2007)
  • Welcome to MASCC. Leading supportive care in the 21st century

  • NI Cherny et al.

    ESMO policy on supportive and palliative care

    (2003)
  • End of Life Care Strategy—promoting high quality care for all adults at the end of life

    (2008)
  • GLOBOCAN 2008 fast stats

  • Cancer. Fact sheet No 297

    (2012)
  • Mapping levels of palliative care development: a global update 2011

  • M Wright et al.

    Hospice and palliative care in southeast Asia: a review of developments and challenges in Malaysia, Thailand and the Philippines

    (2010)
  • Cited by (33)

    • Development of Palliative Care Services at a Tertiary Care Teaching Hospital in Pakistan: Retrospective Analysis of Existing Palliative Care Program

      2022, Journal of Pain and Symptom Management
      Citation Excerpt :

      AKUH has lead in innovative and challenging areas by excellence in education, best clinical practices and research. It is one of the few hospitals in Pakistan that has embraced PC and set up a specialty clinical and academic service based on preexisting models.13,29–33 The PC program at AKUH operates as part of the department of Oncology and established as a collaborative effort between the departments of Oncology, Family Medicine, and Pediatrics.

    • Mapping unmet supportive care needs, quality-of-life perceptions and current symptoms in cancer survivors across the Asia-Pacific region: Results from the International STEP Study

      2017, Annals of Oncology
      Citation Excerpt :

      A meeting discussing challenges of supportive cancer care in Asia, convened by the Multinational Association for Supportive Care in Cancer in late 2015, identified the key challenges to be the suboptimal treatment of cancer symptoms and treatment toxicities, limited access to supportive care drugs, under-evaluation (and undervaluing) of supportive care, inadequate understanding of supportive care interventions, and limitations in treatment access [31]. The 2012 Asia Oncology Summit discussed supportive and palliative care in Asia and produced a set of resource-stratified guidelines [32] that can be further considered by health ministries, particularly in resource-poor countries. A recent survey in LMICs in South East Asia (n = 5249) [33] also showed that cancer survivors have major impairments in QoL, particularly those at lower socioeconomic status and younger.

    View all citing articles on Scopus
    View full text