Development of Specialist Palliative Care in Indian Cancer Care Setting: A Personal Journey of Three Decades

HISTORY OF SPECIALIST PALLIATIVE CARE DEVELOPMENT IN ONCOLOGY

In the early 1950s, the first origins of palliative care provision to patients with cancer was observed in Brompton Hospital and the Royal Marsden Hospital, UK. In those days, terminally ill patients with cancer pain received a cocktail called as the “Brompton Cocktail.” This cocktail was a mixture of morphine hydrochloride, cocaine hydrochloride, alcohol, and chloroform water. Dr. Robert Twycross, who was then working as a research fellow at St. Christopher's Hospice UK, concluded that it was the oral morphine in the Brompton cocktail that provided relief from cancer pain and advocated using oral morphine for cancer pain management. The first hospital palliative care team for the terminally ill was established in 1976 at St. Thomas's Hospital London, and by mid-1980s, many cancer treatment centers across the UK had multidisciplinary palliative care teams. Marie Curie Memorial Foundation and MacMillan Organisation were instrumental in setting up palliative care units across cancer treatment centers in the UK. In the United Kingdom, in the year 1987, palliative medicine was recognized as a medical specialty, in 1989, the first post of palliative medicine consultant was created, and the first formal training in palliative medicine began in 1995. These developments in palliative care were mirrored in Western Europe, Northern America, and Australia.[1]

The cancer pain received very little attention until the 1970s, and the International Association for Study of Pain was founded in 1973, and the first international symposium on cancer pain management was held in Venice in 1978. This was the first time when physicians and oncologists had discussions on means to relieve cancer pain, factors contributing to the poor management of cancer pain and legal barriers for opioid use.[2] In 1982, the World Health Organization (WHO) initiated Cancer Pain Program, which with the help of cancer pain specialists and pharmaceutical manufacturers developed a global program for cancer pain relief. Through this program, three-step analgesic ladder was developed and WHO recommended using strong opioids and adjuvants for cancer pain management.[3]

PERSONAL EXPERIENCE OF SPECIALIST PALLIATIVE CARE DEVELOPMENT IN ONCOLOGY

In 1985, I joined as an Assistant Professor in the Department of Anesthesiology, Critical Care and Pain. This was my initial exposure to cancer pain and palliative care. Although there was concurrent hospice movement by Dr. D'Souza in Mumbai and community palliative care movement by Dr. Rajagopal in Kerala, the first oncology palliative care was provided through Tata Memorial Centre in the mid-late 1980s. During those days, advanced cancer patients with severe pain used to receive a tablet called A and O (aspirin and opium) prepared by Haffkine Institute, Mumbai, which was exclusively available in Tata Memorial Centre for cancer pain management. In 1986-1987, we initiated discussions with Food and Drug Administration of Maharashtra and pharmaceutical industry to make morphine available at Tata Memorial Centre. In 1987, we were able to get the license to procure, store, and dispense oral morphine for cancer pain. Intractable cancer pain was managed with neurolytic blocks using phenol and absolute alcohol.

My keen interest in cancer pain and palliative care, motivated me to join National Cancer Institute of Milan, Italy in 1988. I was trained under Dr. Vittorio Ventafridda and worked both at hospital and community palliative care setting. I had the pleasure of doing joint home visits on the weekends with Dr. Ventafridda. I fondly cherish my drives through the pristine beauty of the suburbs of Milan and the authentic Italian cuisines offered by the families of the patients during these home visits. During this time, I witnessed the momentous rise of palliative care movement in Europe. The European Association of Palliative Care (EAPC) was formed in 1988 in Milan and Dr. Vittorio Ventafridda became its first president. I attended the first EAPC conference and I had the great privilege of meeting and spending time with Dame Cecily Saunders, Elizabeth Kubler-Ross, Robert Twycross, Balfour Mount, and Augusto Caraceni.

Dr. N S Sawant and Dr. Sushila Shah former heads of Department of Anesthesiology, Critical Care and Pain were very supportive of starting the Pain and Palliative Care unit at Tata Memorial Hospital.

In 1990, I along with Sister Rathnamani, started the first palliative care outpatient department (OPD) in Tata Memorial Centre, Mumbai. We used to make time from our busy work schedules and run OPDs to cater for the pain and palliative care needs of our patients. In 1992, I joined the pain and palliative care fellowship at the Memorial Sloan-Kettering Cancer Centre (MSKCC). During those days, in MSKCC, I had the privilege of working with world palliative care leaders such as Kathleen Foley, Subash Jain, Nessa Coyle, and Nathan Cherny. I equipped myself with the use of intravenous opioid infusions, epidural and intrathecal analgesia and various neurolytic procedures. After my return to India, from 1992 to 1996, I continued to run palliative care outpatient clinics. From 1996 onwards, Dr. Mary Ann Muckaden from radiation oncology joined hands with us to take forward the specialized oncology palliative care program in Tata Memorial Centre.

In the last two decades, along with my core clinical and administrative responsibilities, I continued to maintain an active interest in cancer pain and palliative care by working closely with the hospital Pain and Palliative Care Departments. We were able to influence the Medical Council of India (MCI) to recognize palliative medicine as the medical subspecialty and in the year 2010, MCI recognized palliative medicine as a medical subspecialty. With our continued work with MCI, in 2012, MCI granted permission to start country's first MD program in Palliative Medicine. In the year 2015, the country's first two students of MD palliative medicine graduated from Tata Memorial Centre and the Department of Palliative Medicine at Tata Memorial Centre is now an MCI recognized department. At present as the Government of India Nominee for the Postgraduate Committee of MCI, I continue to assist many cancer treatment centers across India to establish specialist palliative care training programs.

REFLECTIONS ON MY PALLIATIVE CARE JOURNEY

The last three decades of my cancer pain and palliative care journey was very remarkable and fulfilling. Integration of the formative experiences and its profound influences has led me to the person I am and the practitioner I have become. The exposure and experience of palliative care have created in me a passionate desire to ensure that the process of cancer care is managed with great sensitivity, empathy, and compassion. In the last three decades, palliative care in India has grown leaps and bounds. However, specialist palliative care provision is restricted to the only handful of cancer treatment centers in India. It will be my personal endeavor through MCI to promote and develop specialist palliative care training programs across India.