1
Palliative Care on Cancer Patients at Sanglah General Hospital, Denpasar Bali*
IGAA Jayanthi Wulan Utami1, Putu Anda Tusta Adiputra2 1
Undergraduate Student Faculty of Medicine Udayana University 2
Oncology Division, Surgery Department Sanglah General Hospital / Faculty of Medicine Udayana University
*Has been presented on The 23rd Asia Pacific Cancer Conference (APCC) 2015
ABSTRACT
Background: Palliative care is a treatment option for cancer patients who have entered the final stage / terminal phase. Often cancer patients die in a state of pain. Palliative care in cancer patients can improve the quality of life of cancer patients. Palliative care in Indonesia has been running more than a decade but the development of this field is not as fast as other fields.
Methods: The data was collected using retrospective method by looking at the secondary data obtained from Sanglah Hospital in 2013. As well as by reviewing the literature study based on the results of an assessment of the literature that the validity has been tested and issues relevant to the topic.
Results: There were a number of 122 cancer patients who received palliative care at the Central General Hospital (RSUP) Sanglah in 2013 with the ratio of men and women was 1: 1.65. Cervical cancer was the type of cancer that affects most patients receiving palliative care in 2013. While based on the classification of age, the age group 41-60 years was the age group in which most patients received palliative care at Sanglah Hospital in 2013.
Conclusions: Palliative care in cancer patients at RSUP Sanglah was done comprehensively and focused not only to the general state of the patient but also on the patient's psychosocial approach to form holistic treatments to improve the quality of life of cancer patients.
1
Palliative Care on Cancer Patients at Sanglah General Hospital, Denpasar Bali*
IGAA Jayanthi Wulan Utami1, Putu Anda Tusta Adiputra2 1
Undergraduate Student Faculty of Medicine Udayana University 2
Oncology Division, Surgery Department Sanglah General Hospital / Faculty of Medicine Udayana University
*Has been presented on The 23rd Asia Pacific Cancer Conference (APCC) 2015
ABSTRACT
Background: Palliative care is a treatment option for cancer patients who have entered the final stage / terminal phase. Often cancer patients die in a state of pain. Palliative care in cancer patients can improve the quality of life of cancer patients. Palliative care in Indonesia has been running more than a decade but the development of this field is not as fast as other fields.
Methods: The data was collected using retrospective method by looking at the secondary data obtained from Sanglah Hospital in 2013. As well as by reviewing the literature study based on the results of an assessment of the literature that the validity has been tested and issues relevant to the topic.
Results: There were a number of 122 cancer patients who received palliative care at the Central General Hospital (RSUP) Sanglah in 2013 with the ratio of men and women was 1: 1.65. Cervical cancer was the type of cancer that affects most patients receiving palliative care in 2013. While based on the classification of age, the age group 41-60 years was the age group in which most patients received palliative care at Sanglah Hospital in 2013.
Conclusions: Palliative care in cancer patients at RSUP Sanglah was done comprehensively and focused not only to the general state of the patient but also on the patient's psychosocial approach to form holistic treatments to improve the quality of life of cancer patients.
2
INTRODUCTION
Cancer is a group of diseases characterized by abnormal cell growth and uncontrolled.1 Cancer is a chronic disease that can be caused by both external factors (tobacco, viruses, chemicals, and radiation) and internal factors (gene mutations, hormones, immune conditions, and metabolic disorders). Those causal factors can initiate or trigger the growth of cancer cells.
Based on data from the Centers for Diseases Control and Prevention (CDC), cancer is the second leading cause of death in the United States. One in four deaths in the United States are caused by this disease. According to the United States Cancer Statistics, approximately 1,575 people per day died of cancer in the United States in 2010.2 In Indonesia, cancer is the 7th leading cause of death based on the Basic Health Research (RISKESDAS) conducted by the National Health Department of Indonesia in 2007.3
The choice of therapy for cancer varies depending on the stage of the disease. Treatment performed can be surgery, radiation therapy, chemotherapy, hormonal therapy, targeted therapy as well as biological therapy.4 Cancers often cause various complaints and the treatment given was often yielding side effects for cancer patients. Therefore, cancer patients are sometimes also given treatment to relieve symptoms caused. Curing a cancer patients often are not possible. If the cancer has metastasized to other organs or if treatment is not successful then the cancer can be classified into advanced or terminal cancer. For cancer patients diagnosed with advanced cancer, cancer treatment will be focused on palliative care.
In Indonesia, palliative care has evolved in Surabaya and Jakarta since 1992.5 Currently, there have been six health centers that provide palliative care, i.e. 2 in Jakarta, as well as each one in Surabaya, Denpasar Bali, Yogyakarta and Makassar South Sulawesi.5.6
Sanglah General Hospital is the main referral hospital in Denpasar. As a main hospital, Sanglah Hospital provides palliative care for cancer patients. But unfortunately until now, the field of palliative care is still not much recognized as other treatments. In fact, some studies suggest that palliative care can improve the quality of life of cancer patients.7 Unfortunately, there is still little interest in palliative care research.8 Especially very few research on how palliative care in Indonesia and Bali occurred.
Based on the background described above, it can be formulated several problems, namely how palliative care in cancer patients at RSUP Sanglah and how the characteristics of cancer patients who receive palliative care Sanglah Hospital in Denpasar.
In terms of theoretical research, it is expected that this research can be useful in terms of reference for the development of subsequent research and development of science in the field of health, especially in the field of palliative care.
RESEARCH METHOD AND SAMPLE
3 Samples were taken from the Central
General Hospital (RSUP) Sanglah as a government referral for doing palliative care services. Samples taken are cancer patients who receive care by a team of Poli Palliative Sanglah Hospital in 2013. The inclusion criteria for the search of samples in this study were patients with cancer who undergo inpatient or outpatient treatment at Sanglah Hospital who were diagnosed based on physical examination, imaging, and histopathologic. While exclusion criteria were cancer patients undergoing inpatient or outpatient treatment at Sanglah Hospital who did not get palliative care.
DATA ANALYSIS
Once the necessary data collected, data processing and arrangement is done in a systematic and logical manner. Data analysis used is descriptive argumentative data analysis. The formulation of the problem, research objectives, and the discussion was analyzed then connected to draw general conclusions. The collected data were grouped by gender, age, and type of cancer.
RESULTS
Patient data used is cancer patients data who were hospitalized at Sanglah Hospital and received palliative care by 2013. Characteristics of patients sought was based on the patient's gender, age of the patient, as well as the type of cancer that suffered by the patient. Of the 122 cancer patients who were treated by a team of Palliative at RSUP Sanglah, as much as 38% (46 people) male and 62% (76 people) were female. Ratio of male and female patients, were up to 1: 1.65.
By age group, cancer patients who receive palliative care in 2013 aged <18 years as much as 1.6% (2 people), aged 18-40 years of as much as 16.4% (20 people), patients aged 41-60 years were 59% (72) and patients aged> 60 years were 22% (28). Based on the type of cancer, most cancer patients who received palliative care was that of cervical cancer by 41 patients. Nasopharyngeal cancer were 17, 11 lung cancer patients, 9 patients with breast cancer, 5 patients with ovarian cancer, 5 patients with pancreatic cancer, prostate cancer 3 patients, 2 patients with colon cancer, penile cancer 1 patient, as well as other types of cancer (sinus and nasal cancer, thyroid gland cancer, malignant melanoma, non-Hodgkin lymphoma, etc.) 28 patients.
Bar Chart 1. Cancer Patients Getting Palliative Care at Sanglah General Hospital
4
Jenis Kanker Jumlah Pasien (%)
Cervical cancer 41 (33.6 %)
Nasopharinx cancer 17 (14 %)
Lung cancer 11 (9 %)
Breast cancer 9 (7.5%)
Ovarium cancer 5 (4%)
Pancreatic cancer 5 (4%)
Prostate cancer 3 (2,5 %)
Colon cancer 2 (1,6 %)
Penile cancer 1 (0,08 %)
Other types of cancer
(Nasal and sinus cancer, Thyroid cancer, melanoma maligna, limpoma non-hodgkin, etc)
28 (23 %)
[image:5.595.98.514.457.741.2]Bar Chart 2. Cancer Patient who Receive Palliative Care at Sanglah General Hospital Based on Age Group
Table 1. Cancer Patient Getting Palliative Care at Sanglah General Hospital BaseType of Cancer
(1,64%)
(16,39%)
(59%)
5
DISCUSSION
1. Palliative Care on Cancer Patients in Sanglah Central General Hospital
According to WHO, palliative care is defined as an approach that aims to improve the quality of life of patients and their families in dealing with the problems associated with life-threatening illness, by preventing and relieving suffering through early identification and assessment and treatment of pain and other problems-both physical , psychosocial and spiritual.9,10 Palliative care improve the quality of life of cancer patients not only by freeing the patient from pain, but also from the spiritual and psychosocial support that may be needed by patients since the beginning of the diagnosis until the death of the patient. Palliative care helps the patient to appreciate life and accept death as a natural process, so as to improve the quality of life of patients holistically and also can provide a positive influence for cancer disease suffered by the patients. Palliative care in Sanglah General Hospital was conducted by a team of multi-disciplinary specialists from as many as 13 doctors and 2 nurses as care performer. Palliative care given to cancer patients varies according to the patient's complaints. If the patient does not have complaints, follow-up of patients is still being done every day. The aspects that are assessed include pain assessment, effectiveness of treatment, and the patient's general condition.
For pain management, WHO has developed a three-step ladder for cancer pain management in adults.11,12 When pain is felt by the patient, the treatment sequence starting from the class
nonopioids (aspirin and paracetamol); then if it has not sufficiently followed by mild opioids (codeine); and strong opioids such as morphine, until the patient felt pain free. To dampen anxiety, the patient may also be given an additional form of adjuvant drugs. To achieve pain relief, treatment should be administered in a manner "by the clock" ie, every 3 to 6 hours, and not only when necessary. If the approach to the way this is done at the right time and dose then 80% -90% can overcome pain effectively.12 Unlike in pediatric patients, pain management just made up the second ladder.
2. Characteristics of the Cancer Patients Getting Palliative Care at Sanglah Hospital in 2013
6
CONCLUSION
Palliative care in cancer patients at RSUP Sanglah was done comprehensively, not just focused on the reduction of pain, the effectiveness of treatment, and the patient's general condition, but treatment is also done in terms of patient’s psychosocial to form holistic treatments to improve the quality of life of cancer patients. Cancer patients who receive palliative care at Sanglah Hospital in 2013 as many as 122 people with a ratio of men and women about 1: 1.65. Cervical cancer is a type of cancer that affects most patients receiving palliative care at Sanglah Hospital in 2013. While based on age, the age group 41-60 years is the age group in which most patients received palliative care at Sanglah Hospital in 2013.
REFERENCES
1. American Cancer Society. Cancer Facts & Figures 2012. Atlanta: American Cancer Society; 2012. 2. World Health Organization. The
Global Burden of Disease: 2004 Update. Geneva: World Health Organization; 2008.
3. Disease Statistics Data in Indonesia [Internet] 2010. [cited 2013 November
20]. Available from :
http://www.riskesdas.litbang.depkes.g o.id/
download/TabelRiskesdas2010.pdf 4. American Society of Clinical
Oncology [Internet] [updated April 2013; cited 2013 November 24].
Available from :
http://www.cancer.net/all-about- cancer/treating-cancer/caring-symptoms-cancer-and-its-treatment
5. Bruera E, Higginson IJ, Ripamonti C, Von Gunten C. Textbook of Palliative Medicine. London: Hodder Arnold; 2006
6. Kim A, Fall P, Wang D. Palliative Care: Optimizing Quality of Life. The Journal of The American Osteophatic Association.
7. Bakitas M, Lyons KD; Hegel MT, Balan S, Brokaw FC, Seville J, Hull JG, Li Z, Tosteson TD, Byock IR, Ahles TA. Effects of a Palliative Care Intervention on Clinical Outcomes in Patients With Advanced CancerThe Project ENABLE II Randomized
Controlled Trial.
JAMA. 2009;302(7):741-749.
8. MacDonald N. Palliative Care-An Essential Component of Cancer Control. Canadian Medical Association. June 30 1998; 158 (13) 9. Guidelines & Protocols Advisory
Committee Palliative Care for the Patient with Incurable Cancer or Advanced Diseases. Family Practice Oncology Network and the Guidelines
and Protocols Advisory
Committee. 2010
10. Eguchi K. Development of Palliative Medicine for Cancer Patients in Japan: From Isolated Voluntary Effort to Integrated Multidisciplinary Network. Jpn J Clin Oncol, vol. 40, 2010, p.870-875; 17
11. Eldridge L. Lung Cancer [Internet] 2012. [Updated 2012 October 2; Cited 2013 November 24]. Available from :
http://lungcancer.about.com/od/treatm entoflungcancer/f/palliativechemo.htm
1
Palliative Care on Cancer Patients at Sanglah General Hospital, Denpasar Bali*
IGAA Jayanthi Wulan Utami1, Putu Anda Tusta Adiputra2 1
Undergraduate Student Faculty of Medicine Udayana University 2
Oncology Division, Surgery Department Sanglah General Hospital / Faculty of Medicine Udayana University
*Has been presented on The 23rd Asia Pacific Cancer Conference (APCC) 2015
ABSTRACT
Background: Palliative care is a treatment option for cancer patients who have entered the final stage / terminal phase. Often cancer patients die in a state of pain. Palliative care in cancer patients can improve the quality of life of cancer patients. Palliative care in Indonesia has been running more than a decade but the development of this field is not as fast as other fields.
Methods: The data was collected using retrospective method by looking at the secondary data obtained from Sanglah Hospital in 2013. As well as by reviewing the literature study based on the results of an assessment of the literature that the validity has been tested and issues relevant to the topic.
Results: There were a number of 122 cancer patients who received palliative care at the Central General Hospital (RSUP) Sanglah in 2013 with the ratio of men and women was 1: 1.65. Cervical cancer was the type of cancer that affects most patients receiving palliative care in 2013. While based on the classification of age, the age group 41-60 years was the age group in which most patients received palliative care at Sanglah Hospital in 2013.
Conclusions: Palliative care in cancer patients at RSUP Sanglah was done comprehensively and focused not only to the general state of the patient but also on the patient's psychosocial approach to form holistic treatments to improve the quality of life of cancer patients.
2
INTRODUCTION
Cancer is a group of diseases characterized by abnormal cell growth and uncontrolled.1 Cancer is a chronic disease that can be caused by both external factors (tobacco, viruses, chemicals, and radiation) and internal factors (gene mutations, hormones, immune conditions, and metabolic disorders). Those causal factors can initiate or trigger the growth of cancer cells.
Based on data from the Centers for Diseases Control and Prevention (CDC), cancer is the second leading cause of death in the United States. One in four deaths in the United States are caused by this disease. According to the United States Cancer Statistics, approximately 1,575 people per day died of cancer in the United States in 2010.2 In Indonesia, cancer is the 7th leading cause of death based on the Basic Health Research (RISKESDAS) conducted by the National Health Department of Indonesia in 2007.3
The choice of therapy for cancer varies depending on the stage of the disease. Treatment performed can be surgery, radiation therapy, chemotherapy, hormonal therapy, targeted therapy as well as biological therapy.4 Cancers often cause various complaints and the treatment given was often yielding side effects for cancer patients. Therefore, cancer patients are sometimes also given treatment to relieve symptoms caused. Curing a cancer patients often are not possible. If the cancer has metastasized to other organs or if treatment is not successful then the cancer can be classified into advanced or terminal cancer. For cancer patients diagnosed with advanced cancer, cancer treatment will be focused on palliative care.
In Indonesia, palliative care has evolved in Surabaya and Jakarta since 1992.5 Currently, there have been six health centers that provide palliative care, i.e. 2 in Jakarta, as well as each one in Surabaya, Denpasar Bali, Yogyakarta and Makassar South Sulawesi.5.6
Sanglah General Hospital is the main referral hospital in Denpasar. As a main hospital, Sanglah Hospital provides palliative care for cancer patients. But unfortunately until now, the field of palliative care is still not much recognized as other treatments. In fact, some studies suggest that palliative care can improve the quality of life of cancer patients.7 Unfortunately, there is still little interest in palliative care research.8 Especially very few research on how palliative care in Indonesia and Bali occurred.
Based on the background described above, it can be formulated several problems, namely how palliative care in cancer patients at RSUP Sanglah and how the characteristics of cancer patients who receive palliative care Sanglah Hospital in Denpasar.
In terms of theoretical research, it is expected that this research can be useful in terms of reference for the development of subsequent research and development of science in the field of health, especially in the field of palliative care.
RESEARCH METHOD AND SAMPLE
3 Samples were taken from the Central
General Hospital (RSUP) Sanglah as a government referral for doing palliative care services. Samples taken are cancer patients who receive care by a team of Poli Palliative Sanglah Hospital in 2013. The inclusion criteria for the search of samples in this study were patients with cancer who undergo inpatient or outpatient treatment at Sanglah Hospital who were diagnosed based on physical examination, imaging, and histopathologic. While exclusion criteria were cancer patients undergoing inpatient or outpatient treatment at Sanglah Hospital who did not get palliative care.
DATA ANALYSIS
Once the necessary data collected, data processing and arrangement is done in a systematic and logical manner. Data analysis used is descriptive argumentative data analysis. The formulation of the problem, research objectives, and the discussion was analyzed then connected to draw general conclusions. The collected data were grouped by gender, age, and type of cancer.
RESULTS
Patient data used is cancer patients data who were hospitalized at Sanglah Hospital and received palliative care by 2013. Characteristics of patients sought was based on the patient's gender, age of the patient, as well as the type of cancer that suffered by the patient. Of the 122 cancer patients who were treated by a team of Palliative at RSUP Sanglah, as much as 38% (46 people) male and 62% (76 people) were female. Ratio of male and female patients, were up to 1: 1.65.
By age group, cancer patients who receive palliative care in 2013 aged <18 years as much as 1.6% (2 people), aged 18-40 years of as much as 16.4% (20 people), patients aged 41-60 years were 59% (72) and patients aged> 60 years were 22% (28). Based on the type of cancer, most cancer patients who received palliative care was that of cervical cancer by 41 patients. Nasopharyngeal cancer were 17, 11 lung cancer patients, 9 patients with breast cancer, 5 patients with ovarian cancer, 5 patients with pancreatic cancer, prostate cancer 3 patients, 2 patients with colon cancer, penile cancer 1 patient, as well as other types of cancer (sinus and nasal cancer, thyroid gland cancer, malignant melanoma, non-Hodgkin lymphoma, etc.) 28 patients.
Bar Chart 1. Cancer Patients Getting Palliative Care at Sanglah General Hospital
4
Jenis Kanker Jumlah Pasien (%)
Cervical cancer 41 (33.6 %)
Nasopharinx cancer 17 (14 %)
Lung cancer 11 (9 %)
Breast cancer 9 (7.5%)
Ovarium cancer 5 (4%)
Pancreatic cancer 5 (4%)
Prostate cancer 3 (2,5 %)
Colon cancer 2 (1,6 %)
Penile cancer 1 (0,08 %)
Other types of cancer
(Nasal and sinus cancer, Thyroid cancer, melanoma maligna, limpoma non-hodgkin, etc)
28 (23 %)
[image:11.595.98.514.457.741.2]Bar Chart 2. Cancer Patient who Receive Palliative Care at Sanglah General Hospital Based on Age Group
Table 1. Cancer Patient Getting Palliative Care at Sanglah General Hospital BaseType of Cancer
(1,64%)
(16,39%)
(59%)
5
DISCUSSION
1. Palliative Care on Cancer Patients in Sanglah Central General Hospital
According to WHO, palliative care is defined as an approach that aims to improve the quality of life of patients and their families in dealing with the problems associated with life-threatening illness, by preventing and relieving suffering through early identification and assessment and treatment of pain and other problems-both physical , psychosocial and spiritual.9,10 Palliative care improve the quality of life of cancer patients not only by freeing the patient from pain, but also from the spiritual and psychosocial support that may be needed by patients since the beginning of the diagnosis until the death of the patient. Palliative care helps the patient to appreciate life and accept death as a natural process, so as to improve the quality of life of patients holistically and also can provide a positive influence for cancer disease suffered by the patients. Palliative care in Sanglah General Hospital was conducted by a team of multi-disciplinary specialists from as many as 13 doctors and 2 nurses as care performer. Palliative care given to cancer patients varies according to the patient's complaints. If the patient does not have complaints, follow-up of patients is still being done every day. The aspects that are assessed include pain assessment, effectiveness of treatment, and the patient's general condition.
For pain management, WHO has developed a three-step ladder for cancer pain management in adults.11,12 When pain is felt by the patient, the treatment sequence starting from the class
nonopioids (aspirin and paracetamol); then if it has not sufficiently followed by mild opioids (codeine); and strong opioids such as morphine, until the patient felt pain free. To dampen anxiety, the patient may also be given an additional form of adjuvant drugs. To achieve pain relief, treatment should be administered in a manner "by the clock" ie, every 3 to 6 hours, and not only when necessary. If the approach to the way this is done at the right time and dose then 80% -90% can overcome pain effectively.12 Unlike in pediatric patients, pain management just made up the second ladder.
2. Characteristics of the Cancer Patients Getting Palliative Care at Sanglah Hospital in 2013
6
CONCLUSION
Palliative care in cancer patients at RSUP Sanglah was done comprehensively, not just focused on the reduction of pain, the effectiveness of treatment, and the patient's general condition, but treatment is also done in terms of patient’s psychosocial to form holistic treatments to improve the quality of life of cancer patients. Cancer patients who receive palliative care at Sanglah Hospital in 2013 as many as 122 people with a ratio of men and women about 1: 1.65. Cervical cancer is a type of cancer that affects most patients receiving palliative care at Sanglah Hospital in 2013. While based on age, the age group 41-60 years is the age group in which most patients received palliative care at Sanglah Hospital in 2013.
REFERENCES
1. American Cancer Society. Cancer Facts & Figures 2012. Atlanta: American Cancer Society; 2012. 2. World Health Organization. The
Global Burden of Disease: 2004 Update. Geneva: World Health Organization; 2008.
3. Disease Statistics Data in Indonesia [Internet] 2010. [cited 2013 November
20]. Available from :
http://www.riskesdas.litbang.depkes.g o.id/
download/TabelRiskesdas2010.pdf 4. American Society of Clinical
Oncology [Internet] [updated April 2013; cited 2013 November 24].
Available from :
http://www.cancer.net/all-about- cancer/treating-cancer/caring-symptoms-cancer-and-its-treatment
5. Bruera E, Higginson IJ, Ripamonti C, Von Gunten C. Textbook of Palliative Medicine. London: Hodder Arnold; 2006
6. Kim A, Fall P, Wang D. Palliative Care: Optimizing Quality of Life. The Journal of The American Osteophatic Association.
7. Bakitas M, Lyons KD; Hegel MT, Balan S, Brokaw FC, Seville J, Hull JG, Li Z, Tosteson TD, Byock IR, Ahles TA. Effects of a Palliative Care Intervention on Clinical Outcomes in Patients With Advanced CancerThe Project ENABLE II Randomized
Controlled Trial.
JAMA. 2009;302(7):741-749.
8. MacDonald N. Palliative Care-An Essential Component of Cancer Control. Canadian Medical Association. June 30 1998; 158 (13) 9. Guidelines & Protocols Advisory
Committee Palliative Care for the Patient with Incurable Cancer or Advanced Diseases. Family Practice Oncology Network and the Guidelines
and Protocols Advisory
Committee. 2010
10. Eguchi K. Development of Palliative Medicine for Cancer Patients in Japan: From Isolated Voluntary Effort to Integrated Multidisciplinary Network. Jpn J Clin Oncol, vol. 40, 2010, p.870-875; 17
11. Eldridge L. Lung Cancer [Internet] 2012. [Updated 2012 October 2; Cited 2013 November 24]. Available from :
http://lungcancer.about.com/od/treatm entoflungcancer/f/palliativechemo.htm
