Palliative care in cancer: Ensuring quality of life alongside active cancer treatment

Let us start with a mental game. Imagine that you have been diagnosed with cancer, for which chemotherapy and radiation are required. You have already started chemotherapy, and the unpleasant side effects have begun – nausea, vomiting, exhaustion. You can barely get out of bed. Inevitably, along with these physical discomforts come various worries about the outcome of the treatments, the prognosis, and the multidimensional consequences to your life. Will I make it? Will I survive, and if I do, will I be the same as before? Practical concerns also arise: I cannot work, will I be able to take enough time off? How will I cope with the costs of my treatment, which may be offered free, but still come with many indirect expenses? And what about my loved ones – my children, my partner, my parents? Will they be able to cope with this? I do not want to be a burden, but I need them. As far as going out is concerned, I should forget it – there is no room for taking risks that might delay treatments.

According to the World Health Organization (WHO), in 2022, it was estimated that there were 20 million new cancer cases and 9.7 million deaths due to the disease worldwide. Statistically, one in five individuals will develop cancer during their lifetime, with roughly one in nine men and one in 12 women dying from the disease^[1]. Concerning palliative care, according to WHO, it seems that globally, only 14% of patients who need it have access to it^[2]. Cancer remains one of the most challenging medical conditions – while advances in research have led to impressive breakthroughs in early detection and treatment, the unpleasant truth is that not all cancers can be cured. For the majority of patients, the diagnosis of cancer marks the beginning of a journey that involves managing symptoms, enduring treatment side effects, and confronting mental and psychological issues. Thus, the significant role of palliative care is highlighted as an intervention that ensures quality of life alongside therapies aiming to extend survival.

Historically, palliative care originated form the hospice movement, linked to Dame Cicely Saunders, who established St. Christopher’s Hospice for the terminally ill patients in 1967, and Elizabeth Kübler-Ross, who published her significant work, On death and dying, in 1969. Nowadays, palliative care in oncology is not narrowed to end-of-life care; rather, it constitutes an integral component of comprehensive cancer treatment. The main goal is to alleviate physical symptoms such as pain, fatigue, dyspnea, and constipation, which may be caused by the disease and its treatment. Beyond symptom management, palliative care addresses the psychological, social, and spiritual dimensions that compose the burden of cancer diagnosis. Moreover, palliative care encompasses the support of the patient’s primary caregivers and family, who are significantly burdened throughout the course of the illness.

Research has consistently featured the value of early integration of palliative care in cancer care. According to published data, palliative care improves the quality of life and reduces distressing somatic symptoms, thus improving patients’ comfort, increasing adherence to treatment, and allowing them to tolerate aggressive cancer treatments^[3]. Moreover, the delivery of psychological support and counseling lessens the emotional burden of cancer distress addressing psychological conditions as anxiety and depression, which worsen the patients’ experience of illness^[4]. Studies have shown that palliative care may even extend survival – the Temel study (2010) indicated that patients who received palliative care lived longer than those who received standard oncology care alone^[5]. Furthermore, early palliative care promotes effective communication between patients, their caregivers, and healthcare providers. It contributes to clarifying goals of treatment, addressing patients’ needs and preferences about their care, thus resulting in effective decision-making^[6]. Finally, in an era where health economics play a substantial role in guiding policy, early integration of palliative care seems to be cost-effective, as it reduces hospitalizations, emergency department visits, and aggressive, vain interventions^[7].

Unfortunately, despite the evidence, palliative care remains underutilized in oncology. There is still limited awareness of the role and significance of palliative care among both healthcare providers and patients, who falsely equate it with end-of-life care and cessation of active treatment. Consequently, the referrals to palliative care services are limited and delayed until the final days of illness trajectory. Delayed referral to palliative care services is observed in Greece healthcare services as well. It is worth mentioning that until recently, palliative care had not been formally integrated into the National Health System. Fortunately, in December 2022, palliative care was integrated into the National Health System with the passing of a bill that included the creation of an institutional framework for the operation of a comprehensive palliative care delivery system. Since then, only a few steps have been taken as the provision of palliative care in Greece continues to be fragmentary and does not receive sufficient state support, while the number of available structures is minimal and disproportionate to the population in need.

To fully integrate palliative care into the National Health System, several steps are necessary. Oncologists should receive training on the basic palliative care principles, maybe as a part of their specialty acquisition training. Patients who are diagnosed with advanced or high-burden cancers should be timely referred to palliative care services. In addition, policymakers and healthcare institutions must prioritize establishing new and funding already existing palliative care services. Last but not least, research is of outmost importance to develop efficient and even innovative palliative care models.

The present issue has the recent position paper by the Palliative Care Working Group of the Hellenic Society of Medical Oncology (HeSMO), which underscores the urgent need for integrating palliative care into Greece’s oncology landscape. The paper highlights the benefits of early palliative interventions and addresses key challenges in Greece, advocating for comprehensive education, multidisciplinary team, and policy reforms to ensure equitable access to high-quality palliative care^[8].

Now is the most appropriate time to reflect on what constitute success in oncology. Prolonging survival and increasing disease-free survival and response rates are measurable goals, but they are not enough without ensuring the quality of life and comfort of patients throughout the course of the disease. By integrating timely palliative care, we address the patient in a holistic way as a unique entity with multiple needs. Especially, oncologists are entrusted with the important role of setting a paradigm of holistic care. After all, if we were cancer patients, wouldn’t we hope for this kind of care?