Integration of oncology and palliative care

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Published: 5 Dec 2013
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Dr James Cleary - University of Wisconsin School of Medicine and Public Health, Madison, USA

Dr James Cleary talks to ecancer at the 2013 Indian Cancer Congress about the importance of incorporating palliative care from diagnosis to end-of-life care, not only end-of-life care.

I talked about the integration of oncology and palliative care and actually how important palliative care is as an essential component of cancer care. This is not something that when cancer care finishes we actually say oncology should no longer be involved; we’re actually saying palliative care is probably critical from the point of diagnosis. An Institute of Medicine report in 2001 looked at the skills that make up palliative care: communication skills, treatment of symptoms related to disease, treatment of symptoms related to therapy, psychosocial care and then end of life care. Most people think that palliative care is just end of life care but we’re actually saying it covers the whole gamut, so how we break bad news, how we share transitions, progression of disease, how we actually then tell someone near the end of life that they’re dying. These are all skills that not only palliative care physicians should have but medical oncologists should have.

Are some of these issues particularly pressing in India?

India has particular issues and the particular issues that they have at the moment are that oncology is growing so they have a real opportunity to restyle or rework oncology in a way that palliative care is integrated very well. I think palliative care has come to the scene late in the United States, earlier in the United Kingdom; Europe has been a very speedy adapter of recent times but India has a real opportunity to say palliative care is part of oncology care now. And it’s delightful that at the first Indian Cancer Conference they’ve actually chosen to devote a full day to palliative care. They’re also addressing psycho-oncology; they’re addressing issues that many other countries actually took a long while to get to so it’s a real opportunity. But they also have challenges and one of the big challenges in India at the moment is the lack of opioids; you can’t really have a good palliative care programme without access to opioids. Despite being one of the major producers of opium in the world, India has very, very low consumption of morphine. They’re down into the range of 0.2mg per person per year and this compares with European countries that are consuming somewhere between 100-200mg of morphine per person per year. There is some misuse of and diversion of opioids in India but in actual fact it’s very hard to divert medical morphine in India because there’s just so little.

Why are these problems happening?

If one looks at the diagrams in actual fact India consumed decent amounts up until 1984 and then there was new legislation brought in which actually brought in policy restrictions, penalties that made it very, very difficult… well, not so difficult… yes, it is difficult. You need four licences to be able to prescribe morphine and distribute morphine in a state so the very fact that you have to go through that makes it a real barrier. The centres that can do it, most of the morphine that’s prescribed is done in Kerala which has most of the palliative care programmes in India at the present time. There is a growing movement, particularly led by the Indian Association for Palliative Care, to improve palliative care around the country and there is now legislation before the parliament which will repeal the current legislation and change the Narcotic Control Act to actually make it a smoother process to prescribe opioids. They’re removing the obligation from the states to control it, it will become a federal rule together working with the states. So we’re hoping this goes up in the winter session of parliament in December of this year.