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6
Once cancer is diagnosed, the patient may require medical
treatment and specialized care for months, and often years.
The principal modes of therapy – surgery, radiotherapy and
chemotherapy – may be given alone or in combination. Strong
emphasis is now placed on the development of specialized
cancer centres in which evidence-based multimodality thera-
py is applied, subject to evaluation by appropriately designed
trials. After successful treatment, specific rehabilitation may
be needed.
When cancer treatment is not curative, maintaining the high-
est possible quality of life is paramount. For many patients,
supportive and palliative care are essential and this often
involves a range of professional services that extends beyond
the discipline of oncology.
SURGICAL ONCOLOGY
Fig. 6.5 Contrast-enhanced magnetic resonance imaging (MRI) of an intraductal papillary mucinous
tumour of the pancreas in an adult patient who was subsequently treated by total pancreatectomy.
1 = common bile duct; 2 = pancreatic duct with multiple dilations caused by the presence of tumour tis-
sue; R = right, L = left.
REFERENCES WEBSITES
1. Vetto J, ed. (1999) Current Practice and Therapy in advances in the management of breast cancer during the Society of Surgical Oncology (USA):
Surgical Oncology, Hagerstown, MD, Lippincott Williams & twentieth century. Eur J Cancer, 35: 1963-1973. http://www.surgonc.org
Wilkins Publishers. 6. Berry DP, Maddern GJ (2000) Other in situ ablative European Society for Surgical Oncology:
2. Feig BW, Berger DH, Fuhrman GM, eds (1998) The M.D. techniques for unresectable liver tumours. Asian J Surg, 23: http://www.esso-surgeonline.be/
Anderson Surgical Oncology Handbook, Hagerstown, MD, 22-31.
World Federation of Surgical Oncology Society:
Lippincott Williams & Wilkins Publishers. 7. Luck AJ, Maddern GJ (1999) Intraoperative abdominal http://www.wfsos.com/
3. Mion F, Grozel L, Boillot O, Paliard P, Berger F (1996) ultrasonography. Br J Surg, 86: 5-16.
On-line Medical Dictionary (CancerWeb):
Adult cirrhotic liver explants: precancerous lesions and unde- 8. Partensky C, Maddern GJ (1999) Pancreatectomy after http://cancerweb.ncl.ac.uk/omd/
tected small hepatocellular carcinomas. Gastroenterology, neoadjuvant chemoradiation for potentially resectable
111: 1587-1592. exocrine adenocarcinoma of the pancreas. In: Mornex F,
4. Bremers AJ, Rutgers EJ, van de Velde CJ (1999) Cancer Mazeron, JJ, Droz, JP, Marty, M eds, Concomitant
surgery: the last 25 years. Cancer Treat Rev, 25: 333-353. Chemoradiation: Current Status and Future, Paris, Elsevier.
5. Fisher B (1999) From Halsted to prevention and beyond:
delivered using tight beams to well depends on the type of radiation used and
SUMMARY defined areas in the body. This allows for is increased in the presence of oxygen.
the treatment of deep-seated tumours Many tumours are hypoxic, simply
> Radiotherapy is fundamental to the opti- with minimal radiation being delivered to because they have outgrown their blood
mal management of cancer patients; its surrounding normal tissue. Although the supply (Invasion and metastasis, p119)
efficacy is affected by technical (the
majority of treatments given in this way and this renders such tumours more
nature and delivery of the beam) and
biological factors (tumour susceptibility use X- or gamma rays, ionizing radiation resistant to radiation damage. Different
modulated by hypoxia and drugs). can also be given by electron beam accel- techniques to overcome this problem,
erators or particle accelerators. such as the use of hyperbaric oxygen,
> Provision of radiotherapy services is The biological basis for the therapeutic hypoxic cell sensitizers and neutron radia-
central to national cancer control strate- effect of radiation has been examined tion, have had only limited success. It is
gies, requiring long-term planning and extensively in both cell culture and animal
appropriate assessment of health care tumours. Although there are correlations
resources. from the laboratory, most clinical radio-
therapy regimens are based on experi-
> Without recourse to sophisticated tech-
ence rather than biological modelling.
nology, effective radiotherapy for many
cancers can be comprehensively provid- There is considerable heterogeneity bet-
ed at moderate cost. ween tumours which defies rigid predic-
tion.
Cell survival curves after the administra-
tion of different doses of radiation have
been used to explore the best way to
enhance selectivity between normal and
It is estimated that 50% of all patients who malignant cells. Radiation causes pro-
are diagnosed with cancer in the world found DNA damage which is then repaired Fig. 6.6 Schematic drawing of the inside of a lin-
ear accelerator, indicating the wave-guide in which
would currently benefit at some stage of in most cells (Carcinogen activation and electrons are accelerated before hitting a target.
their illness from radiotherapy. This could DNA repair, p89). The amount of damage ©Varian Medical Systems.
be either as part of radical therapy with
curative intent or as palliation for pain or
other symptoms. The delivery of radio-
therapy requires long-term planning in the
construction of facilities as well as spe-
cialized doctors, physicists and techni-
cians [1]. In many parts of the world facil-
ities are very poor, even though upgrading
is well within many health service budg-
ets. The increasing reliability of modern
equipment together with the reducing
costs of the associated sophisticated
computer planning facilities should result
in considerable global improvement over
the next decade.
Radiobiology
Radiotherapy is defined as the use of ion-
izing radiation for the treatment of malig-
nant disease. Modern high energy X-ray
machines deliver radiation which is up to
one hundred times more penetrating than
the X-rays used for diagnosis and can be Fig. 6.7 A patient being prepared for treatment on a modern linear accelerator. © Varian Medical Systems.
Radiotherapy 277
The cobalt source is housed in a lead box
Equipment Energy 50% depth dose Approximate with a shutter, which is opened electrical-
(depth at which electron beam machine cost ly. The only mechanical failure to be
ionization is 50%) (million US$)
addressed involves malfunction of the
shutter mechanism. However there are
Orthovoltage 50-250 KeV 4 cm 0.2 problems with radiological protection as
Cobalt 1.25 MeV 9 cm 0.6 the sources need to be changed every five
years because of radioactive decay. There
Linear accelerator 4-20 MeV 15 cm 1.0 have also been several bizarre incidents in
Particle accelerator 4-20 MeV 5-20 cm 20 - 50 developing countries where stolen cobalt
heads have been sold for scrap metal
Table 6.4 Characteristics of radiotherapy equipment. resulting in highly radioactive home and
office furniture.
Linear accelerators (Fig. 6.7) are now the
likely that as more is understood about ated at the target site (the site at which “gold standard” for radiotherapy provi-
the molecular genetics of cancer, the X-rays are generated by electron bom- sion. Electrons are accelerated down a lin-
effects of radiation will be more accurate- bardment). Even with elaborate water ear wave-guide of about a metre in length
ly predictable. This will allow for more tai- cooling systems, target degradation and then hit a target where their kinetic
lored and appropriate radiation schedules occurs rapidly at higher voltages. energy is transferred into X-rays. Such
and doses, with better efficacy and less Although the penetration of such low volt- machines can reliably produce beams of
toxicity. age beams is only 1-4 cm, they are effec- up to 20MeV energy. These beams pass
tive at treating superficial cancers of the directly through the skin surface causing
Equipment skin and for palliating bone metastases. little or no skin reaction. In order to deliv-
Radiotherapy equipment is complex and The application of multiple orthovoltage er maximal quantities of radiation to deep
varied [2]. The penetrating power of a fields was used to treat deep tumours in tumours while keeping normal tissue dose
radiotherapy beam is defined in terms of the past, but severe skin reactions and the low it is necessary to use more than one
its energy and is measured in electron large volume of normal tissue irradiated beam. The amount of energy given up by
volts (eV). The simplest type of equipment posed severe problems. each beam diminishes as it penetrates.
is a low energy orthovoltage machine that Isotope-based radiotherapy using gamma With modern equipment and computer
basically represents an enhanced diag- ray-emitting sources produces beams planning facilities, excellent dose distribu-
nostic X-ray machine. It can produce a with a higher energy. Initially radium was tion can usually be achieved in most parts
beam of up to 250KeV. The problem in the source used, but this was superseded of the body using three fields. The charac-
using a standard X-ray tube to produce a by cobalt. Cobalt machines produce an teristics of the radiation produced and the
beam of higher energy is the heat gener- energy of 1.25 MeV and are very reliable. approximate equipment costs are shown
in Table 6.4.
The process by which the volume to be
Tumour Total Dose Duration of No. of fractions
irradiated is identified by the radiothera-
(Gy) treatment (weeks) (dose (Gy) per fraction) pist is called “planning”. Information is
taken from clinical examination, plain X-
rays, computed tomography (CT) and
Prostate cancer 64 6 32 (2) magnetic resonance imaging (MRI) scans
and used to identify the target high dose
Glioblastoma 60 6 30 (2) volume. A simulator (a diagnostic appara-
Oesophageal cancer 60 6 30 (2) tus with the same characteristics as a
treatment machine) is used to check the
Laryngeal cancer 60 6 30 (2) anatomical relationships. In many situa-
tions, computed tomography planning sys-
Pituitary tumour 50 5 25 (2)
tems allow direct marking of the volume
Lung cancer 50 4 20 (2.5) on a computed tomography scan.
For small volume, very accurate fields,
Hodgkin disease 40 4 20 (2)
such as those used for laryngeal or pitu-
Bone metastases 8 1 1 (8) itary tumours, some form of patient immo-
bilization shell is required. This is a thin
Table 6.5 Radiotherapy treatment appropriate to particular cancers. perspex mask made to fit each patient
A B C
Fig. 6.8 Conformal radiotherapy to a pleural mesothelioma. A The calculated dose distribution in the axial or transverse view. B An example of one Beam's Eye
View (BEV). The BEV at this particular gantry angle has a crescent shape that conforms to the target volume. C Different Beam's Eye Views (BEVs) that are
delivered in one conformal X-ray arc field. ©Varian Medical Systems
Radiotherapy 279
CANCER EDUCATION IN about cancer, and provides a series of tant that medical students should be
MEDICAL COURSES model curricula. appropriately educated about cancer. The
The continued orientation of most medical joint UICC/WHO statement (Undergrad-
student curricula around traditional uate education in cancer, UICC/WHO
The Edinburgh Declaration of 1988 (World department-discipline areas rather than Workshop, Geneva, 1981), to the effect
Conference on Medical Education, Lancet community or patient needs inhibits the that “in most countries there is a signifi-
2:464, 1988) aimed to change the charac- development of clinical service-based inte- cant gap between the actual cure rates of
ter of medical education so that “it truly grated teaching. It also inhibits the incor- various cancers and the maximum cure
reflects the defined needs of the society poration of new knowledge about cancer rates obtaining through utilizing current
in which it is situated”. The total burden of biology and epidemiology and improved available knowledge”, is sobering. An
cancer on the global community and the cancer treatments into medical student important first step in the reform of med-
health care professions is increasing. education. Medical educators stress the ical student cancer education is the
These realities are prompting increased importance of medical students' experi- appointment of a cancer education com-
efforts in cancer control, and medical stu- ence as a major determinant of lifetime mittee or co-ordinator in all medical
dent cancer education must be an integral approaches to cancer. Initial perspectives schools. A reorganization of the existing
part of this effort. The International Union may not be greatly affected by postgradu- syllabus with the introduction of prob-
Against Cancer (UICC) monograph ate training. For many doctors, their only lem-based learning relating to cancer
(Robinson E et al., Cancer Education for formal cancer education is that gained as a biology, cancer prevention, diagnosis,
undergraduate medical students : curricu- medical student, partly because cancer treatment and symptom control, would
la from around the world, UICC, Geneva management and control does not fall rectify many of the deficiencies identified
1994) describes global concerns about squarely on any of the individual postgrad- in surveys of medical student cancer edu-
the status of medical student education uate educational bodies. It is clearly impor- cation.
ing the chance of tumour eradication, the vaginal vault. In this way a pear-shaped Side effects of radiotherapy
provided no metastases are present. deposition of high intensity radiation is Most patients tolerate radiotherapy relatively
delivered over a two- to three-day period. well. Problems arise from the intrinsic sensi-
Brachytherapy More sophisticated after-loading systems tivity of normal tissue inevitably included in
This literally means “short distance treat- are available in which the isotope, in the the treatment volume. Mucous membranes
ment” and is used to describe techniques form of cobalt or iridium beads, is inserted became oedematous and painful, skin reac-
where radioactive sources are placed into guides by a hydraulic system. This tion leads in extreme cases to ulceration and
directly through or in contact with a tumour. reduces unwanted exposure of staff and rel- scarring. Abdominal radiation causes enteri-
Such systems for the treatment of cervical atives to radiation. tis and diarrhoea. The general acute effects
cancer are very effective. This cancer is Iridium 191 wires are flexible and can be of radiation include radiation sickness and
common in many parts of the developing inserted directly into tumours of the tongue, general debility. Good nursing care with
world and, if better education could result in buccal mucosa, anus and breast. This gives drugs to control sickness, headaches, diar-
earlier presentation, more women would be a very high dose of radiation precisely to the rhoea and oedema can effectively control
curable by this relatively low-tech proce- tumour. The wires remain in position for most problems. The delivery of high quality
dure. Basically rods of caesium or other iso- three to five days and the results are often radiotherapy requires teamwork between a
tope are placed directly into the uterus with as good as found with more expensive range of professionals to maximize its bene-
further radioactive material inserted into external radiotherapy systems. fits and reduce the severity of its side effects.
REFERENCES WEBSITES
1. Porter A, Aref A, Chodounsky Z, Elzawawy A, Treatment in Developing Countries, New Mexico: Los International Society of Radiology:
Manatrakul N, Ngoma T, Orton C, Van't Hooft E, Sikora K Alamos Laboratories. http://www.isradiology.org
(1999) A global strategy for radiotherapy: a WHO consulta- The Royal College of Radiologists (UK):
tion. Clin Oncol (R Coll Radiol ), 11: 368-370. 4. Van Dyk F, Battista J (1996) Cobalt 60: an old modali-
http://www.rcr.ac.uk
ty, a renewed challenge. Curr Oncol 3: 23-34.
2. Price P, Sikora K, eds (2000) Treatment of Cancer, 4th European Association and Congress of Radiology:
Edition, London, Chapman and Hall. 5. Royal College of Radiologists (1998) Equipment, http://www.eurorad.org
Workload and Staffing for Radiotherapy in the UK, London
3. Borras C, Stovall J, eds (1993) Design Requirements for Cancer BACUP (UK): Understanding Radiotherapy:
Megavoltage Radiotherapy X-Ray Machines for Cancer http://www.cancerbacup.org.uk/info/radiotherapy.htm
nation chemotherapy became standard. New drugs have been launched and new
SUMMARY During the 1950s and 1960s, major combinations put together. However,
strides were made in the treatment of many challenges remain (Table 6.6).
> The efficacy of chemotherapy varies leukaemias, lymphomas and choriocarci- Despite many new agents becoming avail-
markedly depending upon the malignan-
nomas with many patients being com- able, often at great cost, the gains in
cy. Some, such as testicular seminoma,
leukaemias and malignant lymphomas
pletely cured. New drugs were discovered terms of cure rates have been small.
are highly responsive, while minimal following extensive screening pro- Fashions for high dose chemotherapy with
response tumours include those of the grammes – the vinca alkaloids from the
brain (glioblastoma), lung and pancreas. periwinkle, the anthracyclines from fungi
and platinum drugs from experiments on
> WHO has identified a list of essential the effects of electric currents on bacteri-
anticancer drugs. al growth. The 1970s and 1980s brought
effective drug combinations for testicular
> Drugs are typically used in combination, cancer and many childhood malignancies.
based on and progressively improved by
Thus chemotherapy is now given in the
randomized trials.
setting of paediatric malignancy, germ cell
> Inherent or induced drug resistance limits tumours (Cancers of the male reproduc-
efficacy. tive tract, p208) and some types of lym-
phoma (Lymphoma, p237) with curative
> Most currently-used drugs inhibit DNA intent. Chemotherapy may be adminis-
synthesis and/or cell division, inducing tered prior to surgery (neoadjuvant) to
apoptosis. Drugs that target tumour- facilitate resection and prevent metasta-
specific signalling pathways, including sis or after surgical debulking (adjuvant)
the tryrosine kinase inhibitor Gleevec to reduce the risk of distant relapse.
for stromal tumours and acute myeloid
Adjuvant chemotherapy for breast and
leukaemia, are being developed.
colon cancer was proven to be beneficial
> New approaches include gene therapy in large-scale randomized trials followed
and novel strategies for immunotherapy, by sophisticated meta-analyses [1]. The
but clinical results thus far are largely value of chemotherapy in improving the
disappointing. quality of life of patients, by palliating Fig. 6.9 Chemotherapeutic drugs for injection
symptoms and pain, even in the absence may be available as ampoules (as shown) or
of survival advantage, is evident. ready-prepared in a syringe.
CHEMOTHERAPY High complete response High complete response Low complete response
The use of chemotherapy to treat cancer High cure Low cure Low cure
began in 1943 following the observation of
leukopenia (reduction in number of leuko-
cytes) in military personnel exposed to Hodgkin disease Acute myeloid leukaemia Non small cell lung cancer
mustard gas after an explosion of a battle- Acute lymphoblastic leukaemia Breast cancer Colon cancer
ship in Bari harbour. This alkylating agent
was adapted for intravenous use and pro- Testicular cancer Ovarian cancer Stomach cancer
duced dramatic but short-lived responses
Choriocarcinoma Small cell lung cancer Prostate cancer
in patients with lymphoma and leukaemia.
Other agents, such as the folic acid and Childhood cancer Sarcoma Pancreatic cancer
pyrimidine inhibitors, followed and the
Burkitt lymphoma Myeloma Glioblastoma
armamentarium rapidly grew. It was rec-
ognized that drug resistance developed
when single agents were used, so combi- Table 6.6 Chemotherapy for advanced cancer: the current situation.
6-MERCAPTOPURINE
6-THIOGUANINE
METHOTREXATE
ALKYLATING AGENTS
Inhibits dihydrofolate
reductase Cross-link DNA
5-FLUOROURACIL PROCARBAZINE
HYDROXYUREA ANITIBIOTICS
ETOPOSIDE
Inhibits topoiso-
merase II
RNA
L-ASPARAGINASE
PROTEINS
Deaminates L-asparagine
VINCA ALKALOIDS
TAXANES
Stabilize microtubules
Fig. 6.12 Summary of the mechanisms and sites of action of selected cancer chemotherapeutic drugs.
REFERENCES WEBSITES
1. Early Breast Cancer Trialists' Collaborative Group 9. Sotomayor EM, Borrello I, Tubb E, Rattis FM, Bien H, Lu Drug Information: a guide to prescription and over-the-
(1992) Systemic treatment of early breast cancer by hor- Z, Fein S, Schoenberger S, Levitsky HI (1999) Conversion counter medications (USA):
monal, cytotoxic, or immune therapy. 133 randomised tri- of tumor-specific CD4+ T-cell tolerance to T-cell priming http://www.nlm.nih.gov/medlineplus/druginformation.
als involving 31,000 recurrences and 24,000 deaths among through in vivo ligation of CD40. Nat Med, 5: 780-787. html
75,000 women. Lancet, 339: 71-85. 10. Diehl L, den Boer AT, Schoenberger SP, van der Voort US Food and Drug Administration Oncology Tools website:
2. NCI/ASCO (1998) Integrating economic analysis into EI, Schumacher TN, Melief CJ, Offringa R, Toes RE (1999) http://www.fda.gov/cder/cancer/
cancer clinical trials: the National Cancer Institute- CD40 activation in vivo overcomes peptide-induced periph- American Society of Clinical Oncology:
American Society of Clinical Oncology Economics eral cytotoxic T-lymphocyte tolerance and augments anti- http://www.asco.org
Workbook. J Natl Cancer Inst Monogr, 1-28. tumor vaccine efficacy. Nat Med, 5: 774-779.
3. Sikora K, Advani S, Koroltchouk V, Magrath I, Levy L, 11. Boon T, van der Bruggen P (1996) Human tumor anti-
Pinedo H, Schwartsmann G, Tattersall M, Yan S (1999) gens recognized by T lymphocytes. J Exp Med, 183: 725-
Essential drugs for cancer therapy: a World Health 729.
Organization consultation. Ann Oncol, 10: 385-390. 12. Rosenberg SA (1999) A new era for cancer
4. McGuire W, Neugut AI, Arikian S, Doyle J, Dezii CM immunotherapy based on the genes that encode cancer
(1997) Analysis of the cost-effectiveness of paclitaxel as antigens. Immunity, 10: 281-287.
alternative combination therapy for advanced ovarian can- 13. Gilboa E (1999) The makings of a tumor rejection anti-
cer. J Clin Oncol, 15: 640-645. gen. Immunity, 11: 263-270.
5. Sikora K (1999) Developing a global strategy for can- 14. Hersey P (2002) Advances in non-surgical treatment
cer. Eur J Cancer, 35: 24-31. of melanoma. Expert Opin Investig Drugs, 11:75-85.
6. Sikora K (1998) Cancer. In: Marinker M, Peckham,M 15. Nguyen T, Thomas WD, Zhang XD, Sanders J, Hersey
eds, Clinical futures, London, BMJ Books, 74-95. P (2000) Immunologically mediated tumor cell apoptosis.
7. Hersey P (2003) Principles in immunotherapy of The role of TRAIL in T cell and cytokine mediated respons-
melanoma. In: Thompson JF, Morton DL, Kroon, BBR eds, es to melanoma. Forum (Genova ), 10: 243-252.
Textbook of Melanoma: Pathology, Diagnosis and 16. O'Regan RM, Jordan VC (2002) The evolution of
Management, Martin Dunitz. tamoxifen therapy in breast cancer: selective oestrogen-
8. Lanzavecchia A (1998) Immunology. Licence to kill. receptor modulators and downregulators. Lancet Oncol, 3:
Nature, 393: 413-414. 207-214.
Rehabilitation 293
cer and its associated disability. Finally, rehabilitation for terminal cancer
Frequently, community resources, family patients may focus on family training for
and friends need to be mobilized for a safe Interdisciplinary rehabilitation team basic care-giving, bowel and bladder
discharge of the patient from hospital. The issues, skin care, pain control, and pallia-
social worker is familiar with agencies and tive care measures.
charities that can provide financial assis- Physiatrist (rehabilitation physician) Cancer rehabilitation can be performed in
tance as well as equipment and services, Primary care physician, medical oncolo- various settings depending on the extent
if needed. gist, surgeon, radiation oncologist of the cancer and the extent of the dis-
The case manager can assist patients with ability. For ambulatory patients with focal
home health and equipment referrals, Rehabilitation nurse weaknesses, physical and occupational
obtain insurance approvals for inpatient Physical therapist therapists can improve mobility and self-
rehabilitation hospitalization, and address care issues. For patients requiring hospi-
questions regarding insurance coverage. Occupational therapist talization, a comprehensive interdiscipli-
The chaplain can provide supportive spiri- Speech therapist nary team may be used to coordinate
tual services to patients and their families mobility, self-care, cognitive, nutritional
who are having a difficult time coping with Nutritionist and patient care issues prior to discharge
the uncertainty of their disease. Case manager
and return home. For advanced cancer
It is feasible for knowledgeable primary patients, the same interdisciplinary team
care physicians, oncologists, or surgeons Social worker can help teach family members and carers
to coordinate appropriate rehabilitation how to move and care for the patient,
Chaplain
care. However the time and resources enabling the patient to spend quality time
necessary to put together the appropriate Table 6.13 in familiar surroundings.
rehabilitation team are often not available. Outpatient therapies can be obtained in
the office, clinic or therapy gym. Inpatient
The context of cancer rehabilitation ing active ongoing treatment to limit the rehabilitation can occur in a rehabilitation
As previously stated, cancer rehabilitation adverse physical affects of the treatment unit that is part of a general hospital or
should occur throughout the course of the and also provide the patient with an active can occur in a free standing rehabilitation
disease to lessen and prevent disability. A role that he/she can play in the recovery hospital with cancer patient experience.
rehabilitation programme can be pre- process. Rehabilitation frequently occurs Due to extensive medical issues in
scribed prior to surgery or treatment to after surgery or chemotherapy when the advanced cancer patients, it is beneficial
improve conditioning or toleration of the effects of disease and treatment have led to have ready access to surgical and med-
treatment. Specific therapies may be pre- to deconditioning or specific functional ical consultants as well as medical oncol-
scribed to maintain strength or range of deficits. Rehabilitation for advanced can- ogists for urgent assistance. End-stage
motion in an area that may be adversely cer patients with significant tumour bur- cancer rehabilitation can be given in the
affected by proposed treatments. A reha- den may focus on therapies designed to rehabilitation unit, palliative care unit or
bilitation programme is often initiated dur- improve basic mobility and self-care. hospice. At any stage of disease, quality of
life is the goal of cancer rehabilitation,
which can also be arranged at home as
long as it is safe for the patient and family.
Rehabilitation interventions
Occupational therapy for training in activities of daily living such as bathing, grooming,
dressing, toileting.
Speech therapy for cognitive assessment and training, swallowing evaluation and treat-
ment.
Joint injections, trigger point injections, botulism toxin injections for symptom control.
Table 6.14
Rehabilitation 295
REFERENCES WEBSITE
1. Garden FH, Gillis TA (1996) Principles of Cancer Disabilities. In: Levin V ed., Cancer in the Nervous System. American Academy of Physical Medicine and
Rehabilitation. In: Braddom RL, Buschbacher R.M. eds, 2nd Edition, Oxford University Press. Rehabilitation:
Physical Medicine and Rehabilitation, Philadelphia, http://www.aapmr.org/
Saunders, 1199-1214. 4. Conference Report (2001) Cancer Rehabilitation in the
New Millenium (Supplement). Cancer, 92: 970-1048.
2. World Health Organization (1980) International
Classification of Impairments, Disabilities, and Handicaps, 5. WHO QOL Group (1998) The World Health Organization
Geneva, WHO. Quality of Life Assessment (WHO QOL): development and
3. Levin V, Gillis TA, Yadav R, Guo Y (2002) Rehabilitation general psychometric properties. Soc Sci Med, 46: 1569-
of Patients with Neurological Tumours and Tumour-related 1585.
1984 1999
Fig. 6.21 Worldwide morphine consumption nearly tripled between 1984 and 1999, largely as a result of increasing emphasis by WHO on the need to use mor-
phine in the treatment of cancer-related pain.
existing clinical science. Whether or not unspoken, or rarely articulated: cant that these outcomes themselves
appropriate patients are referred to spe- - Does the adoption of a recognized strat- may be the key tool for change: such
cialist palliative care services, as should egy for cancer pain relief run the risk of change must come from within the com-
be the case in difficult situations, damaging the spiritual fabric of our socie- munity. However, wise leadership from
depends on referral patterns and this fact ty, of destroying our way of thinking about senior administrators and clinicians can
may impede the delivery of optimum pal- the meaning of life, of suffering, of death? have dramatic consequences.
liative care. - When we are so short of resources, why The challenge now in achieving better lev-
The obstacles to the achievement of a should we spend so much time, money els of global cancer pain relief is a more
“good” level of cancer pain relief commu- and trouble on pain treatment in those appropriate understanding of the psycho-
nity-wide in all countries, but especially who can no longer work, instead of trying logical matrix within which the means to
developing countries, include not only the to cure more people? relieve that pain must operate. Awareness
diffusion of knowledge regarding cancer - Why is cancer pain relief still so poor in of the total ecological matrix – with its his-
pain relief, policy change concerning drug the West, even in prestigious cancer cen- torical, social, economic, psychological
availability, and education of health pro- tres? and spiritual components – is essential if
fessionals and the public, but also more These matters need discussion in situa- cancer pain relief is to be achieved. In
subtle and sensitive issues. There are tions of trust, and in an atmosphere of some respects, psychological and spiritual
countless examples of delays in imple- partnership. development in some so-called developing
mentation which are only explicable in It is essential that those seeking to intro- countries is far in advance of the rest of
terms of cultural factors which must be duce the WHO approach to pain relief are the globe – and there is a need for all to
respected and understood. deeply aware of the personal, cultural and recognize exchange-in-partnership as the
Some of these profound issues are spiri- spiritual context into which this new most promising means of advance for the
tual and philosophical, and are felt espe- mode of thinking and acting is to be intro- third millennium.
cially keenly in developing countries. duced. The beneficial outcomes to the Those working in the policy area of
Questions such as the following may be patients and their families are so signifi- health care and with patients should
REFERENCES WEBSITES
1. Doyle D, Hanks GW, MacDonald N, eds (1997) Oxford 9. Gomez-Batiste X, Fontanals MD, Roca J, Borras JM, The Macmillan Cancer Relief charity, UK:
Textbook of Palliative Medicine, 2nd Edition, Oxford, Viladiu P, Stjernsward J, Ruis E (1996) Catalonia WHO http://www.macmillan.org.uk/framed.html
Oxford University Press. demonstration project on palliative care implementation National Hospice and Palliative Care Organization, USA:
2. World Health Organization (1986). Cancer Pain Relief 1990-1995: Results in 1995. J Pain Symptom Management, http://www.nhpco.org/
and Palliative Care, Geneva, WHO. 12: 73-78.
International Association of Hospice and Palliative Care, USA:
3. World Health Organization (1996). Cancer Pain Relief 10. International Narcotics Control Board (1999) Report http://www.hospicecare.com
and Palliative Care, Geneva, WHO. of the International Narcotics Control Board for 1999,
American Pain Foundation:
Vienna, United Nations Publications.
4. World Health Organization (1998). Symptom Relief in http://www.painfoundation.org/
Terminal Illness, Geneva, WHO. Education for Physicians on the End of Life Care (EPEC):
http://www.epec@ama-assn.org
5. Higginson I, ed. (1993) Clinical Audit in Palliative Care,
Oxford, Radcliffe Medical Press. The WHO Collaborating Center for Policy and
Communications:
6. World Health Organization (2002). National Cancer http://www.medsch.wisc.edu/painpolicy
Control Programmes: Policies and Management
Guidelines, 2nd Edition, Geneva, WHO. Cancer Pain Release (publication of the WHO global com-
munications programme to improve cancer pain control
7. American Medical Association Institute of Ethics and palliative and supportive care):
(1999) EPEC Project. Education for Physicians on End of http://www.whocancerpain.wisc.edu/
Life Care, Chicago.
8. Field MJ, Cassel CK, eds (1997) Approaching Death:
Improving Care at the End of Life (Committee on Care at
the End of Life, Division of Health Care Services, Institute
of Medicine), Washington, D.C., National Academy Press.