by Dr. Vishal Rao
India is witnessing an alarming growth in the incidence of cancer. One in nine people in the country are likely to develop cancer over their lifetime, and the incidence is expected to increase by 12.8% in 2025, compared to 2020. The implication is that most of our families are going to encounter the disease, and inevitably become acquainted with oncologists and healthcare institutions. With a predominantly clinical approach to managing cancer, the relentless onslaught of cases not only causes distress to increasing numbers of patients and caregivers, but also puts us oncologists and the healthcare system under inordinate stress.
There are many reasons that this consideration is important, especially in a country with a ratio of one medical oncologist per 3000 new patients a year. For one, we cannot afford long consultations with such caseloads, even though longer consultation times are proven to lead to better health outcomes. Further, burnout or severe occupation-related distress is experienced by 20%-70% of practicing oncologists worldwide, leading to medical errors, professional misconduct, or leaving medical practice altogether. Reducing the caseload will improve the capacity of the healthcare system to deliver quality care, yielding more positive patient outcomes. This can be achieved by the twin approaches of prevention and palliation.
Not just an apple a day
Up to 50% of cancer cases are preventable, though avoiding cancer altogether is tricky because we are all exposed to the ever-growing list of carcinogens to some degree. We can however take measures appropriate to our risk profiles.
In 2019, risk factors such as tobacco and alcohol use, unhealthy diets, and unsafe sex leading to HPV contributed to almost half of the total number of cancer cases recorded. Modifying our behavior to avoid these risks is certain to reduce the incidence and progression of cancer.
Unnervingly, cancer can also strike those that completely avoid these risks. The genetic (not necessarily hereditary) mutations that cause cancer can be triggered by a number of factors, such as pollutants, diet, stress, and hormones. The good news is that we can mitigate the effect of these factors to some extent by taking measures to build our lifestyles around exercise, good nutrition, attention to mental health, and sufficient sleep. However, the real struggle lies in managing the social determinants of health outside of individual control. Life today is hurried and intense, with crowded living conditions, increasing pollution, financial pressures, uncontrolled consumption, sensationalistic media playing up threats around us and so on. We need to introspect and collaborate as a society to reduce these triggers.
Prevention is also achieved by diagnosing the disease early enough to avoid progression and deaths. Many cancers are curable if diagnosed early, and earlier diagnoses also imply less complex treatment, in turn easing the doctor’s workload.
Research into preventing cancer sees new developments every day, and prevention efforts will go a long way to reduce the burden on the healthcare system.
‘Healing’ vs. ‘Curing’
Palliation enters the picture when the disease has taken root, meaning the attempt now is to cure or manage cancer. Treatment protocols include chemotherapy, immunotherapy, radiation, or surgical measures. Each is accompanied by a host of side effects such as nausea, gastrointestinal distress, fatigue, anxiety and depression. But patients and caregivers experience pain and discomfort well before this point – cancer is so feared that even the idea of undergoing tests to diagnose it can be deeply unsettling. Without external support, they can only look to the already overburdened oncologist to take them through the entire process, from screening to treatment and after.
Just as cancer itself can metastasize beyond a specific organ, its effects cannot be contained to just clinical aspects. They are also felt at wider physical, mental, emotional, social and spiritual levels. Hence, palliative care focuses on the person and their varied needs while clinical care focuses on the disease. Multidisciplinary teams of professionals provide information and support to enhance the quality of lives touched by cancer. The oncologist no longer bears the burden of being the sole source of information and comfort.
The crucial significance of palliation cannot be understated. Early initiation of palliative care has been proven to reduce depression and anxiety because of its holistic, empathetic approach. Patients are also empowered on the clinical front, because palliative care professionals ensure they are well informed of the appropriate use of different medical treatments, can identify their own preferences, and are mentally prepared for possible outcomes.
Early initiation of palliative care can lead to better control of symptoms and survival advantages, even if the cancer is diagnosed at an advanced stage. A study amongst stage IV lung cancer patients found that the median survival for those who received early palliative care was 11.6 months, against 8.9 months for those who received standard medical care. This is despite patients in the former category refusing aggressive medical treatment towards the end of their lives. With better symptom control and awareness of treatment outcomes, palliation spares the healthcare system from repeated treatments that are futile or even worsen the patient’s condition.
It takes a village
Prevention ensures lowered incidence and complications and is best achieved through awareness programmes. Every individual should be aware of the risks and possible symptoms of cancer and be proactive about securing immediate medical attention. Combined with better lifestyles, living conditions and nutrition, this would reduce caseloads for oncologists.
The CAUTION mnemonic serves as a handy tool for individuals to proactively monitor their body for seven potential symptoms
(i) changes in bowel or bladder habits,
(ii) a sore in the body that does not heal,
(iii) unusual bleeding or discharge,
(iv) thickening or lump in a breast or elsewhere in the body,
(v) indigestion or difficulty swallowing,
(vi) obvious changes in a wart or mole,
(vii) nagging cough or hoarseness.
Early diagnosis by a trusted healthcare provider is key to treating and managing cancer more effectively.
When it comes to the range of consequences that accompany cancer diagnoses and treatment, palliation will be key. Being able to identify and understand the varied concerns and requirements that patients and caregivers may have, is a skill in itself, and one that has priorities outside the clinical domain. It would be invaluable having a cadre of professionals dedicated to addressing concerns in a wide range of matters, including effects and appropriateness of treatment, pain management, emotional and spiritual distress, social isolation, nutrition and complementary therapies, and practical financial issues. They could provide invaluable guidance at any stage of the cancer care journey, beginning from screenings all the way to remission or, potentially, to end-of-life care. Without such support, patients and caregivers are often left to their own devices. The earlier that a palliative care team gets involved, the more time that we as doctors can dedicate to effective clinical management.
Everyone stands to gain when oncologists’ caseloads are reduced through prevention and palliation. Systemic efforts are necessary to build awareness of prevention, and capacity to provide palliative care. At the same time, each individual must do what is necessary for their particular positions – starting from the person taking adequate healthy measures to avoid meeting an oncologist, all the way to someone living a fulfilling and pain-free life during and after treatment. Altogether, it would result in better health outcomes across the board.
Dr. Vishal Rao, Group Director for Head & Neck Surgical Oncology and Robotic Surgery at HCG Cancer Centre & Dean at HCG Academics, Bengaluru
(DISCLAIMER: The views expressed are solely of the author and ETHealthworld does not necessarily subscribe to it. ETHealthworld.com shall not be responsible for any damage caused to any person / organisation directly or indirectly.)