Having analysed the data of patients of palliative care, it was observed that the referral for palliative care in our set up was low. Going by our hospital registry, only 2.74% of patients were referred for PC. stages of However, more than 2/3rd of the patients presents in advanced cancer and need PC in the trajectory of incurable disease. Oncologists endeavour to treat patients until all cancer directed treatments fail ends up referring the patients for PC in which it is mainly “end of life” care. However, early introduction of PC has shown to improve quality and quantity of life. [7] The early PC has been shown to influence patientrelated outcomes also. [8]
Going by age distribution maximum number of patients (24.2%) were in the age group of 41 to 50 years required PC services. This was relatively younger population. Study from Cipla Palliative care centre, which lies in the western part of India shows that the peak age of patients requiring palliative care were between age of 51 to 60 years. [9]
In India, the need for PC is high, but will be guided by socioeconomic conditions of the country. [10] Approximately 57% of the who came for PC in our study were of low socioeconomic status and needed financial help to support their treatment cost. Similar study from other part of India by Rajmohan and Kumar showed a 82% of patients needing PC were of low socioeconomic status.[11]
Low levels of education are prevalent among patients needing palliative care. In our study a high proportion of patients, that is, 47.1 % were illiterate and 17.9% had their education level till primary school only. A similar study from New Delhi, Capital city of India also had 21% illiterates in need of PC.[12]
In this study, maximum number of patients needing PC were head neck cancer patients which is the number one cancer among males in our hospital. According to a multi-institutional study also 65% of new head and neck cancers with locally advanced disease did not benefit from optimal treatment, resulting in poor survival. [13] The second most leading cancer were breast cancer patients in need of PC which is the most common cancer in women of our hospital. This is in sync with GLOBOCAN 2018 data for India where number of new cases of five most common cancers are Breast cancer (14%), followed by cancer of lip (10.4%), cervix uteri (8.4%), lung (5.9%) and stomach (5%).
Approximately 70% bony metastasis occur in cases of Prostate and breast cancer. [14] Bone is the third most common site of metastasis, after lung and liver.[15] However, in our study the maximum number of patients presented with bony metastasis, followed by liver, lung and brain. This difference in data could be because maximum number of patients who were referred to PC were for pain management. This could also be due to fact that maximum number of patients referred for PC were from Radiotherapy department.
In our study leading symptom of patients in PC was pain (97.4%). The prevalence of pain has been 90–100% among patients in two of the PC OPD clinics in other parts of the country. [16, 17] Cancer pain is perhaps the most feared symptom associated with cancer. Pain is subjective in nature, is difficult to quantify and may vary in intensity. This pain could be due to malignancy itself or due to soft tissue infiltration, nerve compression and bony metastasis. According to Clohysi et al, the most common cause of pain is bony pain in cancer, which is poorly localized, gets worse at night and remains unrelieved by sleep or lying down. [18] About 52.6% patients of needed strong opioids and 37.7% needed weak opioids to control pain. Opioids play important role in treatment of moderate to severe pain because of their rapid effectiveness [19], lack of ceiling effect, and no direct detrimental effects on organ functions.
Geo spatial mapping was done to have an idea from where the patients came. Majority of the patients came from Patna district followed by Muzaffarpur and Samastipur. Patients came from all districts of Bihar, however availability of PC services is in 2 districts only, that also in few of hospitals amongst 38 districts of Bihar. There is a huge gap of access to PC in our state. It is clear that local problems require local solutions. Considering the size of population which requires PC, manyfold efforts have to be made. The state of Kerala has certainly set an example.[20] The other places in country should try to learn from Kerala, not necessarily use the same model but at least try emulating the spread.[21]
Palliative care is an emerging discipline in India and still faces many challenges that have to be overcome.[22] Our study also shows in spite of PC OPD on our Institute, referral of the patients is poor. To sum up a lot needs to be done in this part of the country to build up a structured way of delivering PC starting from raising awareness amongst health care professionals and general public to availability of opioids in every district of Bihar and in the country.