Supportive care in cancer: new directions to achieve universal access to psychosocial, palliative, and end-of-life care
Authors: Stein Kaasa, Felicia M Knaul, Faith Mwangi-Powell, Gary Rodin
Journal: The Lancet Global Health (2018)

There is growing international recognition that the relief of suffering and the support of physical and psychological wellbeing are essential components of cancer care. There is also an emerging but robust evidence base for the effectiveness and value of psychosocial and palliative interventions in this population.1Temel JS Greer JA Muzikansky A et al.Early palliative care for patients with metastatic non–small-cell lung cancer.N Engl J Med. 2010; 363: 733-742Crossref PubMed Scopus (4990) Google Scholar, 2Zimmermann C Swami N Krzyzanowska M et al.Early palliative care for patients with advanced cancer: a cluster-randomised controlled trial.Lancet. 2014; 383: 1721-1730Summary Full Text Full Text PDF PubMed Scopus (1101) Google Scholar, 3Lo C Hales S Chiu A et al.Managing Cancer And Living Meaningfully (CALM): randomised feasibility trial in patients with advanced cancer.BMJ Support Palliat Care. 2016; (published online Jan 19.)http://dx.doi.org/10.1136/bmjspcare-2015-000866Crossref PubMed Scopus (39) Google Scholar, 4Akechi T Okuyama T Onishi J et al.Psychotherapy for depression among incurable cancer patients.Cochrane Database Syst Rev. 2008; 2 (CD005537.)Google Scholar Nevertheless, optimal psychosocial and palliative interventions are still not routinely implemented as part of cancer care in most high-income countries5Hannon B Zimmermann C Knaul FM Powell RA Mwangi-Powell FN Rodin G Provision of palliative care in low- and middle-income countries: overcoming obstacles for effective treatment delivery.J Clin Oncol. 2016; 34: 62-68Crossref PubMed Scopus (91) Google Scholar or low-income and middle-income countries,6Knaul FM Farmer PE Bhadelia A Berman P Horton R Closing the divide: the Harvard Global Equity Initiative–Lancet Commission on global access to pain control and palliative care.Lancet. 2015; 386: 722-724Summary Full Text Full Text PDF PubMed Scopus (47) Google Scholar despite the substantial untreated symptom burden at all stages of the disease. This burden is not reflected in survival data and must be calculated in terms of the experience of suffering, the quality of life, and the quality of dying and death of individuals with cancer and their families. The need for psychosocial and palliative interventions and for end-of-life care by patients with cancer has become crucial in recent years because of the confluence of multiple factors. These include the ageing of the population and the increased incidence and prevalence of cancer, new treatment modalities, increasingly prolonged and intensive treatment trajectories in high-income countries, the late presentation of disease in low-income countries, and the increasing mortality from cancer worldwide. The need for supportive care has also exponentially grown because of the dramatic shift in public expectations of cancer care providers in all parts of the world. This has included the desire for truthful and empathic communication between cancer care providers and their patients and families, shared decision making, and attention to the personhood of patients, to the relief of their suffering, and to their psychological and physical wellbeing throughout the trajectory of their disease. Cancer care centres and other centres of medical care in most regions have been inadequately equipped to address these demands and to make person-centred care and shared decision making a reality.5Hannon B Zimmermann C Knaul FM Powell RA Mwangi-Powell FN Rodin G Provision of palliative care in low- and middle-income countries: overcoming obstacles for effective treatment delivery.J Clin Oncol. 2016; 34: 62-68Crossref PubMed Scopus (91) Google Scholar The gap in the provision of supportive care in cancer is not easily or adequately explained by economic factors, since such interventions tend to be the least costly component of cancer care.7Carlson LE Bultz BD Efficacy and medical cost offset of psychosocial interventions in cancer care: making the case for economic analyses.Psychooncology. 2004; 13: 837-849Crossref PubMed Scopus (195) Google Scholar This shortfall is most likely due to the confluence of multiple factors, including: stigma and discomfort with emotional distress, suffering, and dying and death; the tilt in modern medical care towards biology and technology; and health policies and cultural attitudes in many regions that have not supported the ready availability of morphine and other medications essential for pain and symptom control.6Knaul FM Farmer PE Bhadelia A Berman P Horton R Closing the divide: the Harvard Global Equity Initiative–Lancet Commission on global access to pain control and palliative care.Lancet. 2015; 386: 722-724Summary Full Text Full Text PDF PubMed Scopus (47) Google Scholar These obstacles have been difficult to resolve because of inadequate mechanisms to redistribute resources and to support global partnerships and local initiatives in training and education and in the implementation of supportive care in cancer. The relative neglect of supportive care in planning and in resource allocation has been difficult to shift because leaders in psychosocial and palliative care have typically had insufficient influence in the distribution of resources for research or clinical care. Global and regional strategies and solutions must be identified to address the gap in psychosocial, palliative, and end-of-life care in cancer. Key issues include: advocacy, engagement, and partnership with civil society to reduce stigma and to mobilise public support for universal access of individuals with cancer and their families to optimal psychosocial, palliative, and end-of-life care;8Fraser BA Powell RA Mwangi-Powell FN et al.Palliative care development in Africa: lessons from Uganda and Kenya.J Glob Oncol. 2017; (published online June 30.)http://dx.doi.org/10.1200/JGO.2017.010090Google Scholar modifying treatment guidelines and health policy with respect to the integration of psychosocial, palliative, and end-of-life care in cancer and ensuring ready access to morphine and other medications to control pain and other symptoms;6Knaul FM Farmer PE Bhadelia A Berman P Horton R Closing the divide: the Harvard Global Equity Initiative–Lancet Commission on global access to pain control and palliative care.Lancet. 2015; 386: 722-724Summary Full Text Full Text PDF PubMed Scopus (47) Google Scholar identifying crucial research questions and action plans to improve and evaluate the quality, universality, and timeliness of access to psychosocial, palliative, and end-of-life care in cancer;9Hui D Bansal S Strasser F et al.Indicators of integration of oncology and palliative care programs: an international consensus.Ann Oncol. 2015; 26: 1953-1959Crossref PubMed Scopus (86) Google Scholar, 10Harding R Selman L Powell RA et al.Research into palliative care in sub-Saharan Africa.Lancet Oncol. 2013; 14: e183-e188Summary Full Text Full Text PDF PubMed Scopus (95) Google Scholar creating initiatives to educate and train primary, secondary, and tertiary care providers in providing optimal emotional support, effective and empathic communication, symptom control, shared decision making, advance care planning, and end-of-life care; establishing and supporting global and regional partnerships to advance supportive care in cancer; supporting and catalysing national strategies to implement optimal psychosocial, palliative, and end of life care as a standard of care; and strategies to translate lessons from cancer in psychosocial, palliative, and end-of-life care to the range of medical diseases and suffering.5Hannon B Zimmermann C Knaul FM Powell RA Mwangi-Powell FN Rodin G Provision of palliative care in low- and middle-income countries: overcoming obstacles for effective treatment delivery.J Clin Oncol. 2016; 34: 62-68Crossref PubMed Scopus (91) Google Scholar This online publication has been corrected. The corrected version first appeared at thelancet.com/lancetgh on April 11, 2018 This online publication has been corrected. The corrected version first appeared at thelancet.com/lancetgh on April 11, 2018 We declare no competing interests. Correction to Lancet Glob Health 2018; 6 (suppl): S11–12Kaasa S, Knaul FM, Mwangi-Powell F, Rodin G. Supportive care in cancer: new directions to achieve universal access to psychosocial, palliative, and end-of-life care. Lancet Glob Health 2018; 6 (suppl): S11–12—In this Abstract, Faith Mwangi-Powell's affiliation details should have read MWAPO Health Development Group, Nairobi, Kenya. This correction has been made as of April 11, 2018. Full-Text PDF Open Access