Originally published as JCO Early Release 10.1200/JCO.2008.19.9455 on December 1 2008

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Cultural Challenges in Caring for Our Patients in Advanced Stages of Cancer

Guido Biasco

Department of Hematology and Oncology Sciences L & A Seràgnol, University of Bologna, S. Orsola-Malpighi Hospital, Bologna; Academy of Sciences of Palliative Medicine, Bentivoglio, Italy

Antonella Surbone

Department of Medicine, New York University Medical School, New York, NY

To the Editor:

The August 10, 2008, issue of Journal of Clinical Oncology is entirely dedicated to palliative medicine. European Journal of Cancer also published in May 2008 an issue entitled "Palliative Medicine: The Art and the Science." Editorial choices underline how oncology is concerned with palliative and end-of-life care, not only in terms of progress in symptom control, but also in regard to basic science aspects and the many medical, psychological, social, and ethical ramifications of this field of medicine. All articles in JCO are extremely interesting, as they contribute to clarifying key issues and encourage discussion toward the establishment of common guidelines.

A few points, however, may benefit from further clarification. First, is palliative medicine a specialty or an aggregate of different specialties? Supportive care, palliative care, and end-of-life care are sometimes used as if they were interchangeable terms. Though at times overlapping, they denote different domains.¹ The use of nonuniform language can easily generate confusion, given that diverse terminologies refer to different areas of expertise. The need for multidisciplinary teams, for example, is widely acknowledged in this field of medicine as a means of integrating medical and psychosocial care, yet different teams require different disciplinary expertise. Supportive care may be provided by an internist or oncologist; palliative care often requires anestheologists or other specialists in pain management; and end-of-life care entails particular expertise in assessing and responding to the spiritual and religious concerns and needs of dying cancer patients. Different terms thus refer to special areas of research and intervention in different stages and phases of the patient's illness.

Second, it is important to clarify how teams are best composed and to what extent different sociocultural contexts and local logistics influence the way in which problems are managed most effectively. For example, the choice of hospice or home care may not depend so much on individual preference as on service availability, geographic closeness to specialized centers, and various socioeconomic factors. The use of clear terminology also helps in deciding the composition of different teams and in identifying roles and responsibilities within them.² It is critical that the team leader have a clear, broad, and flexible outlook regarding the spectrum of problems involved. The operational modalities of each team within different local facilities also need to be defined clearly in order for working groups to have a tangible effect on the quality of care delivered to cancer patients. Reaching a balance between ideal and feasible goals is often a delicate, complex process, especially if we consider that competing expertises may correspond to competing interests within groups and institutions.

The JCO and European Journal of Cancer issues demonstrate that we have greatly advanced in our ability to control symptoms such as pain, fatigue, and malnutrition. Now we need to improve our ability to positively affect other aspects of our cancer patients’ suffering during the advanced stages of their illness. This is a difficult task, as there are many barriers to overcome. Yet, if we consider that real progress in today's medicine came about when molecular biologists and clinicians began to speak to and understand each other, we can foresee how progress in palliative medicine will be achieved when technical advances, new skills, adequate financial resources, effective policy changes, and social, emotional, psychological, and spiritual support for patients and their caregivers that support the dignity of both are fully integrated.

Achieving this goal requires balancing clinical art with science while paying due attention to cross-cultural differences that influence patients’ and physicians’ attitudes toward health care matters.^3-5 After proper cultural assessment of each patient, the team may suggest the most appropriate approach to accompany patients and assist them in their decision-making process. Though the importance of cultural sensitivity for oncologists is now increasingly recognized and teaching and training in cultural competence are mandatory in some countries, we also need to develop culturally competent health care systems to address effectively different social, racial, and cultural realities of the communities for which they provide care.^4-6

Palliative and end-of-life care for a patient born and living in an Anglo-Saxon country may be different from that of a patient in a Latin or Islamic country, as patients’ relationships with individual physicians and with institutions, preferences and practices of truth telling, attitudes toward screening, prevention and clinical trials, decision-making styles, and end-of-life choices are all subject to cultural variability.^4,6 Additional research on how cultural diversity influences patients’ and families’ preferences in regard to palliative care in oncology is needed to meet the needs of different communities and individual patients. So-called tailored therapy, a favorite concept in today's medical oncology, can also be applied to our approach to the incurable stages of cancer. In the end, a tailored approach is made possible through rediscovering the human essence of "being with our patients" as they move toward the end of their lives. Stern adherence to scientific methods cannot fully encompass the depth and breadth of our tasks in supportive, palliative, and end-of-life care.

AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The author(s) indicated no potential conflicts of interest.

NOTES

published online ahead of print at www.jco.org on December 1, 2008

REFERENCES

1. Fallon M, Smyth J: Terminology: The historical perspective, evolution and current usage—Room for confusion? Eur J Cancer 8:1069-1071, 2008

2. Pellegrino ED: Emerging ethical issues in palliative care. JAMA 279:1521-1522, 1998[Free Full Text]

3. Kagawa-Singer M, Blackhall LJ: Negotiating cross-cultural issues at the end of life. JAMA 286:2993-3001, 2001[Abstract/Free Full Text]

4. Betancourt JR: Cross-cultural medical education: Conceptual approaches and frameworks for evaluation. Acad Med 78:560-569, 2003[Medline]

5. Surbone A: Cultural aspects of communication in cancer care. Recent Results Cancer Res 168:91-104, 2006[CrossRef][Medline]

6. Wilson-Stronks A, Galvez E: Hospitals, language and culture: A snapshot of the nation. Oakbrook Terrace, IL, The Joint Commission and The California Endowment, 2007. http://www.jointcommission.org/NR/rdonlyres/E64E5E89-5734-4D1D-BB4D-C4ACD4BF8BD3/0/hlc_paper.pdf

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This Article Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Save to my personal folders Download to citation manager Rights & Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Biasco, G. Articles by Surbone, A. Search for Related Content PubMed PubMed Citation Articles by Biasco, G. Articles by Surbone, A. Social Bookmarking                            What's this?