This specialist Guidelines summary of the World Health Organization (WHO) report on cancer care covers supportive care, survivorship care, and palliative care, and is intended for use by oncologists working in a secondary care setting.
Please refer to the full report for the complete set of recommendations, including primary prevention of cancer, early diagnosis and screening for cancer, planning cancer control programmes, financing cancer control: challenges and strategies, and effective implementation: improving capacity and capability.
Effective Strategies for Access to High-Quality Pathology and Diagnostic Imaging
- Cancer diagnosis and staging generally require laboratory services, imaging, endoscopy, fine-needle aspiration cytology, core needle biopsy, histopathology, and immunohistochemistry. Histopathology is still the reference standard for final diagnosis of many cancers, and routine haematological and biochemical investigations and tumour marker testing play major roles in the treatment of cancer
- A highly qualified pathology workforce, including biomedical laboratory scientists, can significantly increase the throughput of specimens and thus potentially increase access. Pre- and in-service training increases competence, and the efficacy of short-term expert visitor programmes and telepathology are well documented. Service organisation is particularly important with a limited workforce, and a specimen transport network can allow diagnosis near patients' homes with advanced review at an appropriate laboratory in a tiered network
- The most effective imaging modality for a particular cancer type depends on health system capacity, and an appropriate health technology assessment should be performed before more advanced, complex, and expensive imaging modalities, such as positron emission tomography, are adopted. Additionally, several imaging modalities can be used to guide interventional procedures (for example, fluoroscopy-guided interventions) as well as external irradiation (that is, computed tomography for image-guided radiotherapy). Standards of care should be set, and a well-trained workforce should have the necessary competence to interpret images.
Supportive Care, Survivorship Care, and Palliative Care
- Survivorship and palliative care are critical elements of comprehensive cancer care. Care for late adverse effects of cancer and the psychosocial needs of long-term cancer survivors are increasingly important as treatment improves
- Palliative care—the prevention and relief of physical, psychological, social, or spiritual suffering—of adults and children is essential to optimise their quality of life and maintain their dignity. Palliative care includes end-of-life care, and should continue when treatment is no longer beneficial or possible. Populations that require tailored policies and approaches include disadvantaged groups, the ageing population, and adolescents and young adults who have unique desires and needs, such as maintaining fertility. People with cancer embark on a journey involving complex, long-term integrated care
- Supportive, survivorship, and palliative care should be integrated into broader health services, with clear communication among different levels of care to improve overall outcomes and efficiency.
Supportive Care During Treatment
- Cancer patients at all stages of their disease require supportive services. Distress occurs in 20–50% of cancer patients, and symptoms such as pain, fatigue, and nutritional problems should be systematically evaluated and addressed. Teaching self-help strategies to patients during and after treatment contributes to this approach. A psycho-oncologist should therefore be part of a multidisciplinary team
- Unmanaged depression and fear can worsen tolerance of treatment and discourage treatment completion. Similarly, malnutrition in all its forms (undernutrition, inadequate vitamins or minerals, overweight, obesity) is associated with poorer prognoses, including a greater likelihood of recurrence or death during or after treatment. Poor nutritional status is also associated with increased risks for toxic effects of chemotherapy, lower quality of life, and distress. Early clinical assessment, dietary counselling and, if necessary, nutritional supplements, can improve quality of life and completion of treatment
- The aim of rehabilitation is to reduce the disabling effects of cancer and its treatment and to facilitate early reintegration into social life, particularly for those who have morbidity associated with surgery (for example, amputation) or tumour-related effects such as paralysis or loss of sight.
Survivorship Care After Treatment
- Survivorship care includes prevention and surveillance for recurrent and new cancers, management of long-term toxicity and comorbid conditions, and surveillance and management of psychosocial effects
- Survivorship care should be adapted to the needs, preferences, and resources of each patient and the health system, and be delivered after completion of treatment, coordinated by care teams that include a primary care physician. Particular consideration should be given to children. The cumulative burden of chronic health conditions resulting from cancer and its treatment at early ages is even more significant among survivors of childhood cancer, requiring a comprehensive approach for care transition as they grow from childhood into adulthood. Furthermore, approximately 12% of childhood cancer survivors are expected to carry alterations in cancer-predisposing genes, requiring close long-term follow up and counselling.
Improving Access to Palliative Care
- Palliative care improves the quality of life of patients and families facing life-threatening illness, and may improve survival. It involves preventing and relieving suffering by early identification, assessment, and treatment of physical, psychosocial, and spiritual problems, maintenance of dignity, and controlling symptoms. A novel example of palliation is the provision of self-expanding stents for dysphagia in advanced oesophageal cancer that can be delivered in low- and middle-income countries with a high incidence of this tumour
- Palliative care networks that include home care also reduce overcrowding in hospitals, protect patients' families from financial risk, and reduce costs to healthcare systems by reducing hospital admissions and length of stay
- A competence framework should require at least basic training (≥35 hours) in palliative care for all primary care providers, and intermediate training (≥70 hours) for oncologists and other specialists who care for people with serious illness. Service delivery models should promote appropriate capacity in palliative care, at basic level in home and community health centres, intermediate level in hospitals, and specialist level in cancer centres, with procedures for communication and smooth patient transfer among levels.