EDITORIAL

Ensuring access to palliative care for cervical cancer patients

The recently published article by Ooko et al.^[1] brings to attention limited access to palliative care (PC) in a vulnerable group of women diagnosed with advanced uterine cervical cancer (CC) and their families in low- and middle-income countries (LMICs). CC patients are prone to significant physical, psychosocial and spiritual suffering arising from the effects of their disease throughout the illness trajectory, especially among those living in poorer developing countries and the underserved minority populations in higher-income countries.^[2-4] Therefore, PC services should be made available to these patients and their families throughout their illness trajectory regardless of cancer stage. Integrating PC earlier into specific cancer care is showing some positive results compared with standard oncological care alone.^[5]

More than 3 million people, including patients and caregivers, needed PC owing to CC in 2017, of whom 2.6 million were in LMICs.^[4] The most common symptoms found in CC patients are mild to moderate or severe pain, fatigue, malodorous vaginal discharge, bleeding and psychosocial distress.^[3,4] Neuropathic pain caused by direct cancer infiltration into or compression of nerve plexuses located in the pelvis is predominant.^[4] Patients' physical, psychological, social, cultural and spiritual circumstances often modify the perception of pain and suffering. Healthcare providers commonly use medications alone to manage physical pain. However, psychosocial and spiritual care should also form part of the care plan for optimum relief of symptoms.

The World Health Assembly Resolution 67.19 of 2014 called for member states to strengthen and implement PC policies to support the comprehensive strengthening of health systems that integrate evidence-based, cost-effective and equitable services across all healthcare levels, especially at primary healthcare and community/ home-based level.^[6] Since then, the World Health Organization has developed a comprehensive guideline on how to integrate PC into health systems at different levels in a cost-effective practical manner, and established a list of essential medicines, including opioids, for treatment of moderate and severe pain, and other common distressing symptoms in patients with life-threatening illnesses.^[7]

Clinicians caring for CC patient should assess PC needs at the time of cancer diagnosis and incorporate a PC plan into the overall invasive cancer treatment plan. The Essential Package of Palliative Care for Women with Cervical Cancer (EPPCCC) was created by a panel of experts from countries of different income levels, and can be used by healthcare providers with at least basic training in PC at all levels of care to relieve distressing symptoms in CC patients.^[8,9] However, the complexity of advanced CC symptoms^[2-4] may require a more elaborate management approach beyond the scope of EPPCCC to achieve relief for the patient. The Augmented Package of Palliative Care for Women with Cervical Cancer, which includes palliative radiotherapy, palliative surgery, advanced medical therapies, nerve blocks for pain control and psycho-oncology, should be used whenever possible to prevent and/or relieve severe refractory symptoms.^[9,10]

Providing effective, safe, people-centred, timely, equitable and efficient PC for a CC patient and her family requires an interdisciplinary team approach. Members of the team should possess at least basic training in PC that enables them to respond effectively to specific needs according to available resources in their setting.^[7] Teams should also be able to provide service that is supportive and culturally appropriate. While it is critical to ensure that EPPCCC is universally available to all CC patients even in the least-resourced settings,^[8,9] governments and healthcare institutions should also look into making the augmented package available. The augmented package requires the availability of radiotherapy equipment and specialised personnel in radiation oncology, gynaecological oncology, psychiatry, internal medicine and allied medical professions. Efforts to create capacity for training in these disciplines where there is scarcity or where they are not yet available must accompany the effort to make augmented package available.

In conclusion, CC patients and their family caregivers frequently suffer from complex distressing symptoms that may not respond adequately to basic PC as provided with the EPPCCC. Therefore, palliative care services requiring specialised equipment, procedures and personnel should be made available, at least in a referral centre within a region, where they are accessible to a majority of women with CC and their family.

Francis Ooko

Department of Radiation Medicine and Imaging, Faculty of Health Sciences, University of Limpopo, Sovenga, South Africa francis.ooko@ul.ac.za

References

1. Ooko F, Mothiba T, van Bogaert P, et al. Access to palliative care in patients with advanced cancer of the uterine cervix in the low- and middle-income countries: A systematic review. BMC Palliat Care 2023;22:140. https://doi.org/10.1186/s12904-023-01263-9        [ Links ]

2. Bates MJ, Mijoya A. A review of patients with advanced cervical cancer presenting to palliative care services at Queen Elizabeth Central Hospital in Blantyre, Malawi. Malawi Med J 2015;27(3):93-95. https://doi.org/10.4314%2Fmmj.v27i3.4        [ Links ]

3. Kebebew T, Mavhandu-Mudzusi AH, Mosalo A. A cross-sectional assessment of symptom burden among patients with advanced cervical cancer. BMC Palliative Care 2021;20:190.         [ Links ]

4. Krakauer EL, Kwete X, Kane K, et al. Cervical cancer-associated suffering: Estimating the palliative care needs of a highly vulnerable population. JCO Glob Oncol 2021;7:862-872. https://doi.org/10.1200/go.21.00025        [ Links ]

5. Dey T, Mukerjee A, Rai B, et al. Early integration of palliative care in cervical cancer: Experiences from a pilot study. J Fam Med Primary Care 2023;12(2):366. https://doi.org/10.4103/jfmpc.jfmpc_1569_22        [ Links ]

6. World Health Assembly. Resolution WHA67.19. Strengthening of palliative care as a component of comprehensive care throughout the life course. Geneva: WHA, 2014. https://apps.who.int/gb/ebwha/pdf_files/WHA67/A67_R19-en.pdf (accessed 25 September 2023).         [ Links ]

7. World Health Organization. Planning and implementing palliative care services: A guide for programme managers. Geneva: WHO, 2016. https://iris.who.int/bitstream/handle/10665/250584/9789241565417-eng.pdf (accessed 25 September 2023).         [ Links ]

8. Krakauer EL, Kane K, Kwete X, et al. Essential package of palliative care for women with cervical cancer: Responding to the suffering of a highly vulnerable population. JCO Glob Oncol. 2021;7:873-885. https://doi.org/10.1200/go.21.00026        [ Links ]

9. World Health Organization. WHO framework for strengthening and scaling-up services for the management of invasive cervical cancer. Geneva: WHO, 2020. https://www.who.int/publications/i/item/9789240003231 (accessed 27 September 2023).         [ Links ]

10. Krakauer EL, Kane K, Kwete X, et al. Augmented package of palliative care for women with cervical cancer: Responding to refractory suffering. JCO Glob Oncol 2021;7:886-895. https://doi.org/10.1200/go.21.00027        [ Links ]