How to Make the most of Palliative Treatment in Cancer Care
The term “palliative care” often brings to mind the image of a terminally ill cancer patient getting physical and emotional support during their final days. This was indeed what palliative care aimed to achieve in its early days, but it is no longer the case. Since its first introduction in Singapore in 1996 and subsequent recognition as a medical subspecialty in 2006, palliative medicine has developed extensively and is now an important part in cancer treatment modalities for patients at all stages.
This article discusses what palliative care is, who it is for, its differences from hospice and end-of-life care, and where, when, how you and your family can benefit from it during the cancer treatment journey. I also include a few commonly asked questions from patients in my practice, to help you understand palliative treatment better.
What is palliative care?
Palliative care is a specialised type of care for people facing a serious health issue. The main goal is to improve their well-being and quality of life through providing relief from symptoms and other challenges related to the illness, most commonly pain. By doing so, it can improve the quality of life of the patients as well as their families. Palliative care is given by a team of specialists, not just one doctor or one nurse.
From the above definition, we can see why palliative treatment is important in cancer care. Cancer at all stages can be life-threatening. As treatment progresses, patients often experience a multitude of symptoms caused not only by cancer itself, but also the side effects of the treatment, including pain, fatigue, nausea, vomiting, loss of appetite, loss of sleep, and more. The role of palliative treatment is to relieve these symptoms in a holistic manner, elevate the quality of life of the patients, their caregivers and families, thereby helping the patient to build up strength and reserve to fight cancer.
In addition to physical distress, the cancer journey can be mentally and emotionally straining for the patients and their loved ones. Palliation can address these issues, with the help of extended members of the care team, such as psychiatrists, social workers and volunteers. Note that palliative treatment does not aim to cure cancer. It can support and therefore be given together with other curative treatments.
Is palliative care for you?
Patients who are unfamiliar with palliative care often say to me, “I don’t know of another cancer patient getting palliative treatment. Do I really need it?” This question is in fact best answered after a collaborative discussion between the patient, the oncologist, and the palliative care team. Below are the important questions to consider when consulting with the palliative care specialist and deciding if this treatment is necessary, and if so, how best to incorporate it with standard care for your case.
Firstly, what are your care goals?
The general goal of palliative treatment is to improve the quality of life and well-being of the patients and their families. Specifically, it can help to:
- Relieve symptoms: In cancer care, common symptoms include pain, nausea, vomiting, indigestion, breathlessness, fatigue, weakness, physical motion limitations, etc..These can be symptoms of the cancer itself, or the side effects of standard cancer treatments you are getting.
- Prevent further symptoms and complications: Known as anticipatory care, this approach in palliative care can help to support the standard curative treatment. When symptoms and complications are kept at bay, patients have more health reserves to battle cancer and heal.
- Provide psychosocial care to the patients and their families: Up to 1 in 4 cancer patients report symptoms of depression during their cancer journey. The complexity of the treatment process, the uncertainty of treatment outcomes, stressful financial matters, day-to-day practical concerns, among many other issues, can take a toll on the mental health of the patients and families. This is where the palliative care team can come in. With their experience in dealing with other cancer patients, ready resources including psychologists, counsellors, social workers, volunteers, contacts of support groups, etc., palliation team can be extended to support your psychological, emotional and even spiritual needs.
As palliative care is highly customisable to the patient’s care goals, the palliation team needs to know your care objectives to work out an effective treatment plan for you, including which specific palliative treatment to get, where to receive it, ie., at home, clinic or elsewhere, how often etc.
With the above overarching objectives of palliative care in mind, think about your specific care needs. What symptoms are you experiencing? How bad are the pain and side effects? What symptoms and complications might occur according to the treatment plan? What does quality of life mean for you and your family? Are you looking for mostly nursing and medical care, or psychological care, day-to-day support, or all of them? You may need to discuss with your oncologist to find out the answers for some of these questions. This is the necessary ‘homework’ to determine how palliative treatment can benefit you.
Secondly, do the benefits outweigh the care burden?
Pain and symptom relief, counselling and mental support are all great, but do they outweigh the burden, in terms of total well-being, financial cost and otherwise? The palliative specialist is there to consult and give advice, but ultimately this question needs to be answered by the patients and their families themselves.
For instance, an esophageal cancer patient has dysphagia, ie., difficulty swallowing. Enteral feeding, ie., tube feeding, provides relief and prevents complications such as aspiration pneumonia, whereby food enters the airway and introduces bacteria into the lungs. However, if the cancer deteriorates, is enteral feeding comfortable and sustainable in the long term? At what point does palliative treatment cease to provide comfort to the patient? Such evaluation needs to be done from time to time as the disease and treatment progress, by the patients and their families. Palliative treatment can then be tailored according to the situation and the patient’s evolving care goals.
Palliative care vs Hospice care
Another question I sometimes hear from patients is “When palliative care is recommended, does it mean cancer treatment has failed and my prognosis is poor?” This question comes from the fact that the two terms palliative care and hospice care are often used interchangeably by the public and misunderstood as the same.
Palliative care indeed has its roots in hospice care, which is why it is commonly associated with care for the terminally ill. But since the hospice movement in London in 1967 that gave birth to hospice care and later on modern palliative care, much has evolved. While the care approach and principles are similar between palliative care and hospice care, there are 2 main distinctions:
- Palliative care can be given to cancer patients with any prognosis, while hospice care is typically given to patients with a prognosis of 6 months or less.
- A patient can receive palliative care alongside curative treatment. Hospice care, however, starts only when a patient has stopped curative treatment and it is clear that the patient will not survive for long.
As illustrated above, palliative care is much broader in scope compared with hospice care. It can be given at any stage of illness. Hospice care, also called end-of-life care, can be seen as a type of palliative care. Knowing such differences will help you better understand your oncologist’s recommendations and seek the right palliative treatment.
Is the cancer doctor also the palliative doctor?
Palliative treatment is provided by a team of multidisciplinary healthcare professionals, not just one doctor. Your primary oncologist is part of the team, who works closely with a palliative care specialist and other team members, to ensure palliation achieves its objective. Let’s get to know them below.
The palliative care specialist is a physician specially trained in palliative medicine and familiar with various aspects of palliative treatment, including pain and symptom management, nutrition care, psychosocial support, rehabilitation, and more.
The other team members are often specialists in their respective fields, such as:
- Occupational therapist
- Respiratory therapist
- Social worker
The cancer patients themselves and their family also form an essential part of the palliative care team. As you can see, the palliative care team can be large and complex. Maintaining effective communication and keeping everyone on the same page is key. The palliative physicians are often skilled in this matter, but the role of the cancer patients and their families are also crucial. Without their inputs, the medical professionals would not be able to tailor the treatment plan to their care needs and doing so in a timely manner.
When should you start palliative care?
We now know that palliative care is not only for terminal cancer cases and it can help to manage the disease in earlier stages. But when exactly should a patient start palliative treatment? Is it when pain and other symptoms are too much to bear?
Studies show that palliative treatment, when combined with standard cancer treatment from an early stage, can improve a patient’s quality of life, reduce distress and the intensity of other symptoms. Early palliative cancer care also reduces unnecessary hospitalisations and treatments due to complications. However, as palliation is highly customised to individuals, when to start the treatment should follow the patient’s care objectives and wishes as well.
In cancer care, experts recommend having the conversation about palliative care early on with the oncologist and palliative specialist, as early as at the point of diagnosis and when cancer treatment is first discussed. Knowing your options and planning ahead can help you decide on the most optimal actions for your situation. During the course of cancer treatment, depending on the intensity of symptoms, responses to therapy, as well as other considerations like patient’s preferences and funding available, you can adapt your treatment plan and start palliative care quickly when you wish to.
What palliative treatments are available for cancer?
The specific therapies used for palliative treatment may sound similar to standard cancer treatment. You could hear the doctors recommending radiation therapy, chemotherapy, and surgery as part of the palliative care plan. However, they differ in the treatment goals. When radiation therapy or chemotherapy is utilised for palliation, the aim is not to cure cancer, but to improve the present symptoms or lower the risk of future complications.
Palliative cancer treatment may include:
- Palliative chemotherapy
- Palliative radiation therapy
- Palliative targeted therapy
- Palliative hormone therapy
- Other treatments depending on the patient’s symptoms, such as physical therapy, respiratory therapy, medications to manage pain and other problems, etc.
Similar to standard cancer treatment, the oncologist and palliative specialist may recommend one or a combination of therapies to achieve palliation goals.
Chemotherapy and radiation therapy are by far the most commonly prescribed therapies in palliative care. For instance, a patient experiences severe pain caused by bone metastasis or a fast growing tumour pressing on the spinal cord nerve. Palliative radiation therapy can help to relieve the pain while lowering the risk of paralysis and paresthesia due to irreversible neurological damage. Note that the pain relief impact from palliative radiotherapy is not instant like with oral or intravenous pain treatment. It often takes up to a couple of weeks to eliminate the cancer cells involved with radiotherapy and for the patient to feel significant pain relief. However, the effect is longer lasting than with oral or IV pain management methods.
Hormone therapy is also quite common, for instance in the form of prescribed corticosteroid – also known as the ‘stress hormone drug’. This type of medication can be prescribed to manage cancer symptoms such as anti-inflammation for brain cancer, treat fatigue, bone pain, nausea, vomiting and loss of appetite for various cancers. Endocrine therapy (ET) is another hormonal therapy used among advanced breast cancer patients for palliative purposes.
For an example of other treatments used in cancer palliative care, we can look at how respiratory therapy might be used for a person with Hodgkin lymphoma. This cancer commonly affects the lymph nodes in the chest and neck areas, such as the thymus. The swollen thymus can press on the airways, making breathing laborious for the patient and leading to serious dyspnea, i.e., shortness of breath (more about lymphoma and its symptoms in our article here). Palliative treatment in this case will call on the support of a respiratory therapist who specialise in addressing breathing issues, helping the patient perform breathing exercises and improving breathing capacity.
Palliative treatment is indispensable for cancer patients who wish to improve their quality of life during the cancer recuperation journey. By relieving pain and other symptoms of cancer and side effects of cancer treatments, it elevates the patient’s well-being, boosting their strength to battle the disease. It is for all stages of cancer and can be received together with standard cancer treatment.
Palliative care has come a long way in Singapore. Under MOH’s national strategy for palliative care, 11,000 healthcare professionals have been trained in this service so far, and more will be. Patients can seek quality palliation service from a wide range of healthcare providers including public hospitals, clinics, community care centres and private service providers. You can also use MediSave for palliative care received in hospital as well as at home.
To make the most of palliative treatment, it is essential for the patients and their families to take a central role in defining their care needs and weighing the options. Once that is discussed, defined and clearly communicated, you will find that the palliative care team – in which your oncologist is an important part – can be your reliable companion every step of the way.