Given the unique skills of anaesthesiologists in pain management and regional anaesthesia, the role of anaesthesiologists is increasing in the care of cancer patients.
The global burden of cancer is increasing. Currently, about 11 million people develop cancer and 6.2 million people die every year. This represents a greater than 15 per cent increase since 1990 in both incidence and mortality. Worldwide, 12 per cent of deaths are due to cancer, which is the third leading cause of death following infections and cardiovascular diseases. In the industrialised world, one in four people die from cancer. In the US, the lifetime risk of developing cancer is an astounding 41 per cent. Cancer incidence in the developed world is twice that in the developing world. This is due to the earlier onset of tobacco epidemic, earlier exposure to occupational carcinogens and the western diet and lifestyle. Worldwide, one-third of new cases are preventable while another third are amenable to early detection and treatment. Pain and palliative care strategies enhance quality of life but access to these services is limited.
Pain management and palliative cancer care are the areas where anaesthesiologist can have significant impact worldwide.
Trends in cancer cases
By 2020, the global cancer burden is expected to rise by 50 per cent due to increasing age of populations and rising trends in cancer risk factors. In the developed world, this explosion of cancer cases is beginning to happen due to the confluence of two trends.
The first is the fact that cancer strikes people over the age of 50 with greater frequency than it does youth. Both the incidence and mortality for cancer rises dramatically in people over the age of 50, and by age 60 that rate increases with each additional year.
The second trend, in the US in particular, is that the population is rapidly ageing due to the so called "baby boom generation" which began after the World War II. In 2008, the US population over the age of 50 will be about 91 million and by 2025 that number will rise to 130 million-a 42 per cent increase in 17 years or about one generation.
While mortality rates for cancer in the developed world have begun to decline, the increased number of cases will have dramatic implications for healthcare delivery systems within the first quarter of the 21st century. Currently in the US, cancer has surpassed cardiac disease as the leading cause of death of individuals under the age of 85.
Cancer in the developing world
By 2020, new cancer cases will grow from 11 million to 15 million per year and over 75 per cent of the new cases will be in the developing world. These countries will have only 5 per cent of the treatment resources. While cancer is a major problem worldwide, there are marked geographical differences in incidence and type. The most common cancers worldwide are breast, colorectal, prostate, cervical with the most lethal being lung, stomach and liver. Preventing cancer is easier, cheaper and more effective than treating it. To transfer medical technology "as it is" to developing countries is difficult and usually economically impossible.
While prevention and treatment are desirable, most cases are diagnosed late with surgical resection being the only realistic treatment possible. Of India's 1 billion people, for example, the incidence of cancer is 1 million per year with 80 per cent deemed incurable at the time of diagnosis.
Chemotherapy and radiation therapy are costly and are not widely available in most developing countries. Palliative care is a key priority but access to those services is also restricted since narcotic access is limited in many developing countries to prevent misuse of drugs. More than half of all cancer deaths occur in developing countries. Resources for diagnosis and treatment of cancer in developing countries are limited or non-existent.
Cancer treatment disparities
Tremendous disparities exist worldwide in the way cancer is treated. In the developed world, modern surgery, radiation and chemotherapy, often in combination with personalised and molecularly targeted approaches, have prolonged the time taken for cancer treatment. In the developing world, cancer is generally detected at a very advanced stage. As a result, the treatment would be limited only to palliative care to relieve suffering.
The WHO estimates over 50 per cent of cancer patients worldwide suffer unrelieved pain. It is estimated that 1 million people experience cancer pain in India alone every year.
The simple implementation of known pain and symptom control techniques using narcotic analgesics could improve the lives of many patients dying of cancer. However, a major problem in developing world is simply obtaining and distributing narcotic analgesics.
For many years, the WHO has advanced its "pain ladder" approach to pain management in the cancer patient. According to this approach, if pain occurs, there should be prompt oral administration of drugs in the following order: nonopioids (aspirin and paracetamol); then, as necessary, mild opioids (codeine); then strong opioids such as morphine, until the patient is free of pain. To calm fears and anxiety, additional drugs-"adjutants"-should be used. To maintain freedom from pain, drugs should be given "by the clock", that is every 3-6 hours, rather than "on demand". This three-step approach of administering the right drug in the right dose at the right time is inexpensive and felt to be 80-90 per cent effective.
Anaesthetic and surgical intervention on appropriate nerves may provide further pain relief if drugs are not wholly effective. The use of such interventional techniques for pain management has been advocated by some a fourth step on ladder. This so-called fourth step on the ladder of interventional pain management has been poorly studied but could be more applicable than previously understood.
Local anaesthetics are more widely available than opioids, especially in some parts of the developing world and the skills required to provide nerve blocks are easily acquired by anaesthesiologist. The most useful interventional pain management procedures are celiac plexus block, epidural infusions, vertebroplasty, intra-thecal neurolytic blocks and intrathecal pumps.
Opioid availability is a major impediment to providing cancer pain relief in the developing world. In India, the Narcotic Drugs Act of 1985 produced stringent rules to prevent misuse and resulted in severe shortages of narcotics for care.
By 2004, 8 of 25 states amended their laws to liberalise the availability of narcotic analgesics. However, narcotic availability needs improvement at the local level in all countries. Worldwide data regarding the availability and use of narcotics has been compiled by researchers at the University of Wisconsin and demonstrate dramatic differences in the availability of these drugs, especially in developing nations.
A shining example of what can be done in palliative care comes from India. In the state of Kerala, which has a population of 30 million, 30,000 new cancer cases are adding every year. Kerala liberalised their narcotic access in 2000. Cancer care is provided in six hospitals and one Regional Cancer Center. Cancer treatment is available on payment. However, most patients can afford limited treatment. The average daily income is US$ 0.25 and average daily cost of palliative care is US$ 1.
The Pain and Palliative Care Society, led by Dr M R Rajogopal, an anaesthesiologist who is the father of palliative care in India, developed a network of 33 palliative care clinics throughout Kerala. They provide outpatient treatment with home support with volunteer community assistance.
In 2000, they treated 6,000 new patients or about 25 per cent of cancer patients in Kerala. They provided free service and discovered that narcotic diversion was minimal and successfully brought palliative care services to villages and people who needed it most. More needs to be done; Dr Rajogopal estimates that currently less than 1 per cent of India's 1.6 million people suffering from cancer pain get relief in Kerala since restrictive laws and fears limit narcotic availability in other states. In 2007, India's Health Minister, Dr Anbumani Ramadoss, intervened with the Parliament to increase its national cancer plan's budget for palliative care, thanks largely to the efforts of physicians like Dr Rajogopal and others.
In summary, cancer is becoming an increasing health problem worldwide as world population ages and western lifestyles encroach upon developing nations with limited resources. Anaesthesiologists can have important roles not only in the OR and ICU where patients are treated, but also in pain centres and the community where improved palliative care and pain management can impact the lives of millions suffering from this disease.
Cancer and the anaesthesiologist
The unique skills of anaesthesiologists in pain management; regional anaesthesia, airway management and critical care make them important members of the healthcare team treating cancer patients. The functions of anaesthesiologist include management of the patient undergoing surgical and diagnostic procedures, management in the Intensive Care Unit (ICU), and management of cancer pain and delivering palliative care services.
During surgical anaesthesia, the anaesthesiologist must always be concerned about the airway. The highest prevalence of difficult airways, known, suspected and unrecognised, occur in cancer patients, especially those with head and neck malignancies. Additionally, chemotherapy can adversely affect cardiac, pulmonary and renal function. Radiation therapy can also have adverse effects on heart, lungs and the airway. The patient's age and history, concurrent disease also influence the outcome. In the ICU, the use of mechanical ventilation for post-operative ventilation is commonplace. Non-invasive ventilatory support is commonly used as a bridge to reintubation and intubation can be avoided in up to half of properly selected patients using mask and pressure support ventilation.
Additional useful strategies in treating cancer are to minimise invasive monitoring; provide good pain management with regional anaesthesia and epidural techniques as needed. Special attention should also be paid to prevention of ICU acquired infections such as Catheter Related Blood Stream Infections (CRBIS) and Ventilator Associated Pneumonias (VAP), which increase length of stay and morbidity in some patient populations. Care bundles for managing all patients receiving ventilatory support and requiring invasive venous access have been shown to reduce these infections.
Pain management and palliative cancer care are the areas where anaesthesiologist can have significant impact in the care of patients worldwide. It is estimated that 50 per cent of all cancer patients experience pain at some point of their illness; 70-80 per cent of all advanced cancer patients experience pain, 50 per cent moderate to severe pain, and 30 per cent severe pain. Pain management and palliative care are closely related-hence this tremendous role for anaesthesiology.
Thomas W Feeley is Division Head of Anaesthesiology & Critical Care and VP for Medical Operations at UT MD Anderson Cancer Center. He has served in this capacity for the past ten years and coordinates the medical operations of the institution to ensure high quality and safe patient care.