PALLIATIVE MEDICINE AND THE MEDICAL ONCOLOGIST

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PAIN AND PALLIATIVE CARE

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PALLIATIVE MEDICINE AND THE MEDICAL ONCOLOGIST Defining the Purview of Care Nathan I. Cherny, MBBS, FRACP, and Raphael Catane, MD

The division of cancer care into an initial trial of primary antitumor therapies followed by hospice or palliative care for patients who have progressive disease is anachroni~tic.'~~ Because the goals of medical oncology extend beyond the reduction of tumor burden and the deferral of death to incorporate a qualitative dimension, there is need for a continuum in patient care in which both primary therapies and palliative interventions are integrated according to the clinical circumstances of the patient. For most patients, it is the medical oncologist who assumes the role of the physician primarily responsible for the provision and coordination of cancer care. This role is enormously challenging and it demands a wide range of cognitive, clinical, and interpersonal skills (Table 1). Traditionally, the study and practice of medical oncology have focused on the development and implementation of primary anticancer therapies. By virtue of these endeavors, along with measures to provide for early diagnosis, substantial improvements in long- and short-term survival have been achieved for a number of cancers such as the germ cell tumors, lymphomas, early stage breast and colorectal cancer, and the 1e~kemias.I~~ More sobering, however, are the observations that the cure rate for cancer remains less than 50%, and that cancer continues to account for over 25% of all adult deaths.135Many patients are not cured, and for them the issues regarding the quality of their remaining time are critical, regardless of the clinical course of their illness or the duration of survival. ~~~

From the Department of Medical Oncology, Shaare Zedek Medical Center, Jerusalem, Israel

HEMATOLOGY/ONCOLOGY CLINICS OF NORTH AMERICA

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VOLUME 10 * NUMBER 1 FEBRUARY 1996

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Table 1. THE CLINICAL ROLES OF THE MEDICAL ONCOLOGIST Preventative oncology Counseling Diet Cigarette smoking Alcohol Environmental Screening Diagnostic evaluation Primary evaluation of the patient with suggestive clinical findings Cancer staging Physiologic staging Goals of care appropriate to tumor type and stage and patient physiologic staging Communication Disclosure full and partial Treatment counseling Prognostic counseling Eliciting advance directives Patient and family support Psychologic support Advance directives

Antitumor therapies Indications Selection of optimal therapeutic modality Safe administration Prevention and management of adverse effects Symptom control Physical symptoms Psychological symptoms Complications of cancer Complications of treatment Optimization of social supports Care of the dying patient Physical symptoms Psychological symptoms

WORLD HEALTH ORGANIZATION RECOMMENDATIONS ON THE INTEGRATION OF PALLIATIVE MEDICINE AND MEDICAL ONCOLOGY

An expert committee of the World Health Organization on cancer pain and palliative care has emphasized the need for the integration of efforts directed at maintaining the patient’s quality of life in all stages of cancer treatment.137Their report emphasized that factors causing patient distress exist from the time of diagnosis, and that palliative interventions are needed concurrently with efforts to control the underlying cancer. This holds true for patients undergoing both curative and palliative anticancer treatments. The need for palliative intervention from an early stage of cancer care is supported by symptom prevalence data. Portenoy et allo1surveyed symptom prevalence and distress using the Memorial Symptom Assessment Scale (MSAS) among 246 patients receiving active treatment (123 inpatients, 123 outpatients). Regardless of tumor types, 40% to 80% experienced lack of energy, pain, drowsiness, dry mouth, insomnia, or symptoms indicative of psychological distress such as worrying, sadness, or nervousness. Of these, pain and asthenia were most frequently rated as highly distressing. The mean number of symptoms per patient was 11.5 (k6.0, range 0 to 25). Inpatients, and those with Karnofsky Performance Status ( U S ) less than or equal to 80, had more symptoms than did outpatients or those with KPS greater than

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Disease progression increases the number of factors diminishing quality of life as well as the prevalence and severity of physical and psychological symptoms. Surveys of patients with advanced cancer have identified a very high prevalence of pain,12,33, 35, 38, 40* 55, 72* lz6 fatigue, 35, 38* generalized weakness, dyspnea, delirium, nausea, and vomiting.33* 40, 62, 72, lo8,lz6 Other studies in this patient population indicate that psychiatric disturbances occur in greater than 60%,’7,85the most common being l7 Finally, proadjustment disorders, depression, anxiety, and de1iri~m.l~. gressive and advanced cancer is commonly compounded by specific cancer-related complications that require expert management to maintain a modicum of patient comfort (Table 2). Recently, a comprehensive taxonomy of the factors that may contribute to suffering in patients with advanced cancer has been developed (Table 3).21This classification emphasizes the interrelatedness of the distress of the patient, family, and health care providers and the varied contributions of physical, psychological, existential, and social distress. It is proposed that familiarity with the range of factors that may contribute to patient suffering can facilitate assessment and intervention.

Table 2. COMMON COMPLICATIONS OF ADVANCED CANCER Neurologic Tumor infiltration Peripheral nerve Cranial nerve Nerve plexus Spinal cord Leptomeninges Brain Paraneoplastic Pulmonary Airway obstruction Pleural effusion Superior vena cava (SVC) compression Diffuse pulmonary metastases Hemoptysis Musculoskeletal Bone pain Pathologic fractures Gastrointestinal Obstruction Oropharyngeal Esophageal Gastric outlet Small bowel Large bowel Pancreatic duct Bleeding Ascites

Hepatobiliary Obstruction Infiltration Genitourinary Obstruction Ureteric Bladder outlet Bleeding Metabolic Hypercalcemia Hyponatremia Cachexia Anasarca Vascular Obstruction Venous Lymphatic Thrombosis Ischemia Hemorrhage

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Table 3. TAXONOMY OF FACTORS THAT MAY CONTRIBUTE TO SUFFERING IN PATIENTS WITH ADVANCED CANCER ~~~~~

~

~

Factors Contributing to Patient Distress Physical Symptoms pain lack of energy feeling drowsy dry mouth lack of appetite nausea feeling bloated change in the way food tastes numbness/tingling in hands/feet constipation cough swelling of arms or legs itching weight loss weight gain diarrhea dizziness problems with sexual interest or activity shortness of breath vomiting problems with urination difficulty swallowing Psychological Symptoms anxiety depression sleep disturbance irritability impaired concentration nightmares delirium

Existential Concerns disrupted or distorted personal integrity changes in body image changes in physical, intellectual, social, and professional function diminished attractiveness as a person or as a sexual partner increased dependency distress from retrospection unfulfilled aspirations deprecation of the value of previous achievements remorse from unresolved guilt distress from future concerns separation hopelessness futility and meaninglessness concern about death religious concerns illness as a punishment fears of divine retribution fear of a void Empathic Suffering from the Distress of the Family Distress Related to Health Care Services communication availability personal and cultural sensitivity excessive candor or inadequate information lack of services or availability exhausted, uncommitted, or ineffectual services expense

Factors Contributing to Distress in the Family Members of Patients Empathic Suffering from the Distress of the Patient Physical lllness symptoms disability therapy Family Dynamic family stability intrafamily conflict or inability to work cohesively Impending Bereavement loss the ending of their life as they have known it finding a way to living together in anticipation of death role changes Burdens of Care physical psychological performance anxiety in providing comfort or administering medication I

conflict anxiety about emergencies such as pain, dyspnea, or bleeding aesthetic toileting or wound care financial cost of care, lost income, insurance concerns Conflicts adequate relief of distressing symptoms versus preservation of alertness and avoiding the hastening of death duty to care for a loved-one versus duty to care for oneself and one’s other responsibilities Distress Related to Health Care Setvices (same as above) Psychological (same as above) Existential Concerns (same as above) Table continued on opposite page

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Table 3 (Continued). TAXONOMY OF FACTORS THAT MAY CONTRIBUTE TO SUFFERING IN PATIENTS WITH ADVANCED CANCER

Factors Contributing to Distress Among Health Care Providers Empathic Suffering from the Distress of the Patient Empathic Suffering from the Distress of the Family Physical lllness symptoms disability therapy Burdens of Care emotional distress frequent life and death decisions frequent exposure to death frequent exposure to profound emotional distress patient-related high consumer expectations (patient and family) severe patient dependency (physical, emotional) severe patient debilitation severe patient distress (physical emotional) aesthetic severe patient disfigurement or odor inadequate resources inadequate training to manage the prevailing patient and family problems inadequate assistance excessive workload

Conflict with colleagues (substantive or style) with patient 2 family (substantive or style) with self decision making in ambiguous circumstances duty to care for a patient versus duty to care for oneself and one’s other responsibilities Psychological anxiety depression sleep disturbance substance abuse ExistentialConcerns distress from retrospection deprecation of the value of previous achievements guilt about limitations of therapeutic efficacy distress from future concerns futility meaninglessness concerns about death

Adapted from Cherny NI, Coyle N. Foley KM: Suffering in the advanced cancer patient: A definition and taxonomy. J Palliat Care 10(2):57-70,1994; with permission.

ONCOLOGY, HOSPICE, AND PALLIATIVE MEDICINE-THE DIVISION OF LABOR

The development of integrated care of this kind requires familiarity with a range of therapeutic options, appropriate patient evaluation, and a collaborative therapeutic relationship with the patient and other members of an interdisciplinary care team. For the purpose of care planning and goal setting, the natural history of cancer can be divided into five phases (Table 4). The status of the patient in this continuum influences who will carry the responsibility for the coordination and Table 4. FIVE PHASES IN THE NATURAL HISTORY OF CANCER 1. 2. 3. 4. 5.

Diagnostic-ambulatory or inpatient Curative primary therapy Ambulatory palliative therapy Sedentary palliative therapy-interactional Sedentary palliative therapy-noninteractional

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implementation of palliative interventions. The medical oncologist is almost always the coordinating health care provider during the diagnostic work-up, attempts at curative therapy, and the phase of ambulatory palliation during which the patient continues to attend the cancer clinic. During this latter phase, community-based nursing and medical providers are often introduced to augment supportive care outside of the health care institution and in anticipation of diminished mobility. When the patient is no longer ambulatory, the decision to care for the patient at home, in a nursing home, at an inpatient palliative care facility (hospice), or in an acute care hospital is influenced by the nature and severity of the prevailing clinical problems, the extent of homebased medical and nursing resources, the prevailing community facilities, and patient preference.%,57 The role of the medical oncologist in coordinating care at this stage is determined by similar considerations. In some instances, the oncologist will remain the primary provider of palliative care until the patient dies (see the article by Cherny, Coyle, and Foley elsewhere in this issue). In other instances, there is a smooth transition of care, with community supportive services playing a progressively greater role and the oncologist becoming a supportive figure. By maintaining continuity in care, the oncologist can avoid the patient’s feelings of abandonment that can magnify patient and family distress.106 PALLIATIVE MEDICINE IN ROUTINE MEDICAL ONCOLOGY

The enhanced awareness of palliation as a critical goal of oncologic care has been reflected in recent development in policy, research, practice, and education. Policy

The effectiveness of palliative interventions can be evaluated by measuring the impact of therapies on quality of life (QoL) and symptom prevalence and distress. QoL has been endorsed as a critical study outcome for the evaluation of cancer treatments by the National Cancer Institute Southwest Oncology Group?O the National Cancer Institute of and the European Organization for Research and Treatment of Cancer.’ Validated research tools to evaluate QoL,’, ’O0*’I2 symptom prevalence and distress,”” 43, 86 and other parameters are widely available (see the article by Ingham and Portenoy elsewhere in this issue). Incorporation of these parameters into clinical research studies is an increasingly important consideration in competitive funding situations. Research

Until recently, the research literature was characterized by the very few studies in which symptom control and QoL endpoints were system-

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atically evaluated. This paucity of data has confounded attempts to make a definitive conclusion about the palliative value of chemotherapy and radiotherapy in many noncurable malignancies?,81 Since the landmark publication of the Australian breast cancer study comparing continuous versus intermittent chemotherapy using a QoL outcome in addition to survival,3O the prevalence of such studies has grown (Table 5). This trend is reflected in a recent survey of supportive care activities at National Cancer Institute (NCI)-designated cancer centers (n = 51); 24 of the 39 responding centers reported participation in research programs in supportive care.32 Oncologists have played a major role in the development of improved strategies in the prevention and management of chemotherapy nausea and vomiting.52Additionally, a smaller number of medical oncologists have involved themselves in projects addressing the management of other specific physical and psychologic symptoms,2*,88, 89 oncologistpatient communication,36and cancer-related complications such as hyper~alcemia~~ and malignant effusion^.^, 16, 63 The results of many aspects of this research are reviewed in subsequent articles in this issue. Practice

The two largest cancer centers in the United States-Memorial Sloan-Kettering Cancer Center and the University of Texas MD Anderson Cancer Center-have taken the lead in developing specialized clinical and research services in the evaluation of pain and other physical Table 5. RECENT CLINICAL STUDIES THAT INCORPORATE EITHER QUALITY OF LIFE OR SYMPTOM PREVALENCE AND SEVERITY OUTCOME EVALUATION

References Lung Breast Prostate Colorectal Gastric Melanoma Pancreatic Renal Head and neck Laryngeal Brain metastases Support groups Anemia Bone pain Anorexia Enteral feeding Nausea and vomiting Supportive psychotherapy Mastectomy versus lumpectomy

6, 11, 46, 54, 58, 61, 65, 75, 77, 87, 104, 109, 127 18, 44, 47, 60, 84, 115, 123, 129, 132 66, 91, 105 4, 42, 48, 67, 68, 76, 82, 111, 114 41, 117 31, 98, 122 39,110, 120 96 10, 15 74 94 107 19, 69, 121 103, 124, 125 64, 99, 119 113 23 49,50 45

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symptoms and of the psychological manifestations of cancer. Several other centers provide specialist services in cancer pain (Johns Hopkins, Mayo Clinic, Yale University Hospital) and palliative medicine (Cleveland Clinic, Fox Chase Cancer Center). In at least one center (Vanderbilt University Medical Center), the medical oncologists themselves have taken the lead in developing an integrated medical oncology and palliative medicine service. Education

Two recent surveys have emphasized the need for substantial improvement in training medical oncologists in the management of pain and other symptoms. The ECOG study of physician knowledge and attitudes toward cancer pain highlighted extensive knowledge deficits among medical oncologists.12sEighty-six percent of responding oncologists believed that the majority of patients with pain are undermedicated; 50% rated pain management in their own practice as fair, poor, or very poor; and only 27% evaluated their training in the management of pain during residency or fellowship programs as better than fair. Responses to a case scenario demonstrated pervasive knowledge deficits in analgesic therapeutics. The findings of this physician survey were reflected in a survey of pain outcomes among 1308 outpatients treated by these same physicians, which found that 42% of the patients with pain were not given adequate analgesic therapy.28 A survey of burnout among 598 oncologists by Whippen and Cane110s'~~ found that 56% of medical oncologists felt some degree of burnout, and that feelings of frustration and a sense of failure are commonplace. The stress of providing palliative care for incurable and terminal patients was cited as a major contributing factor. These data prompted an editorial in the Journal of Clinical Oncology by the thenpresident of the American Society of Clinical Oncology (ASCO) that called for better preparation of medical oncologists for this aspect of clinical responsibility.*ASCO has since published curriculum guidelines and a teaching module for the training of cancer specialists in cancer pain assessment and treatment.5 SHORTCOMINGS IN THE CURRENT SITUATION

Despite the progress of recent years, substantial deficiencies remain. These are reflected in the widespread public perception that the prevailing cancer care services are unable to provide adequate relief of patient suffering, and that in some circumstances this situation may render death the preferred option.7,131 In one survey of public attitudes toward cancer and pain, 57% of respondents endorsed the statement that a painful death can be expected with cancer, and 69% endorsed the statement that cancer pain can be so bad that a person with cancer might

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consider suicide.70Indeed, uncontrolled physical and psychological symptoms, lack of a supportive care framework, or the anticipation of these conditions, are major contributing factors to suicidal ideation among cancer patients.13 In a retrospective survey of the charts of 90 patients with advanced cancer, 20% of patients had expressed the view that suicide could be an option "somewhere in the future" if pain and other symptoms were uncontrolled, or if they became an excessive burden on their families.33 Despite evidence that the vast majority of cancer pain can be adequately controlled with systemic analgesic therapy, many patients continue to endure poorly relieved pain as demonstrated by the ECOG data (see previous statements)28and an analysis of 13 published reports (that together described almost 2000 patients in routine care) indicating that 50% to 80% did not have adequate pain control.12 A survey of 1400 physicians and nurses at five major hospitals in different parts of the United States found that there was commonly a failure to provide adequate pain relief for dying patients; 81% of the physician and nurse respondents agreed that "the most common form of narcotic abuse in caring for dying patients is undertreatment of pain."116 Surveys indicate that medical practitioners are generally ill equipped to treat pain: they often do not believe their patients when they report it?; they have difficulties in assessing itz8,lZ8,133; many do not know how to treat itz8,lz8, 133; and its treatment is not given high p r i ~ r i t y . ~29 " ~The ~ , limited number of comprehensive cancer centers that have allocated resources to the development of symptom control or psychooncologic services, or to promote research in these fields, and the small representation of these issues at the annual ASCO meetings78,8o suggest that they are of relatively low priority to much of the cancer establishment. With regard to education, there is as yet no data on the extent to which the guidelines on cancer pain education have been implemented and, in fact, their incorporation within the curriculum is not required for program accreditation. Additionally, there are still no formal guidelines or requirements for the education of cancer specialists in the management of the other physical or psychological symptoms widely prevalent in patients with cancer. PALLIATIVE MEDICINE AS A SPECIALTY

The development of palliative medicine as a specialty discipline has contributed to the evolution of cancer medicine by emphasizing the QoL dimension of cancer care, providing a model of clinical practice, systematizing a diffuse knowledge base, and creating new body of accessible medical literature. Palliative medicine is a specialty in evolution. Although born of the hospice movement, it has evolved to increasingly incorporate the care issues of patients with early-stage cancer and AIDS and other chronic organic illnesses, such as motor-neuron disease

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and cardiac, respiratory, or renal 95, 11* thus recognizing that suffering is not exclusive to dying cancer patients. The scientific and clinical knowledge base of palliative medicine is eclectic, and it is characterized by an interdisciplinary synthesis of knowledge and skill. For example, recent advances in the management of cancer pain have been made by oncologists, neurologists, radiotherapists, nuclear medicine physicians, surgeons, nurses, anesthesiologists, neurosurgeons, palliative care physicians, physiatrists, psychologists, and psychiatrists (Table 6 ) . Similar interdisciplinary synthesis is observed in the contemporary literature on the management of physical symptoms including dyspnea, cough, fatigue, anorexia, nausea and vomiting, and gastrointestinal or genitourinary luminal obstruction (see the articles by Dudgeon and Rosenthal; Fainsinger; Watanabe and Bruera; Lichter; and Shike elsewhere in this issue). For the medical oncologist an enhanced familiarity with palliative medicine can extend the clinician's therapeutic repertoire, diminish the stress of caring for patients who have incurable cancer, improve patient outcome, and provide new avenues for clinical research and reward. Palliative medicine is clinically and intellectually challenging. It is an interface among the disciplines of oncology (medical, surgical, and radiation), psychiatry, clinical ethics, and clinical pharmacology. It encourages and, indeed, necessitates interdisciplinary practice, and it offers scope for basic and clinical research to elucidate symptom pathogenesis and improved management strategies.79,8o It has been suggested that increased knowledge and participation in palliative medicine may diminish the risk of burnout among medical oncologists? FACILITATING INTEGRATION OF PALLIATIVE MEDICINE INTO ONCOLOGIC CARE

The furtherance of medical oncologist awareness, knowledge, practice, and research in palliative medicine will require an elevation of the Table 6. CANCER PAIN AS AN EXAMPLE OF INTERDISCIPLINARY CONTRIBUTIONS IN PALLIATIVE MEDICINE Discipline

Oncologists Neurologists Radiotherapists Nuclear medicine Surgeons Nurses Anesthesiologists Neurosurgeons Palliative care physicians Physiatrists Psychologists and psychiatrists Clinical pharmacologists

Contributions

Bisphosphates and gallium for bone pain Management of neuropathic pain High-fraction radiotherapy for bone pain Radiopharmaceuticals Surgical management of spinal cord compression Pain assessment, patient education Spinal analgesia, nerve block techniques Cordotomy, myelotomy, spinal cord decompression Subcutaneous opioid administration, management of adverse opioid effects Orthotics Cognitive and behavioral approaches Transdermal delivery systems

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relative priority of palliation as a goal of cancer care. This, in turn, will need to be reflected in resources allocation, program development, and clinical practice. Elevating the Priority of Palliation

This process requires a paradigm shift at all levels of the cancer medicine infrastructure. The groundswell approach to development of palliative medicine and hospice facilities has made limited inroads into the routine care of cancer patients. Given the current infrastructure for career development and resource allocation for clinical and research programs in medical oncology, initiatives from the major organs of our profession will be required to raise the priority of palliative medicine. The NCI policy on the incorporation of QoL outcome assessment93and the development of guidelines for the management of cancer pain by the Department of Health and Human Services3are excellent models for initiatives of this ilk. Appropriate future steps may include (1)the incorporation of clinical and research programs in palliative medicine as a criterion for the accreditation of a cancer center as a "comprehensive cancer center"; (2) the incorporation of clinical training in palliative medicine as an accreditation criterion for oncology training programs; (3) the development of clinical practice guidelines or standards of care for the management of other physical and psychological symptoms in cancer patients; and (4)enhancing the priority for the publication of palliative medicine research in the major specialty journals. Development of Clinical Programs

Individual institutions are encouraged to develop expert services to provide a clinical service and role models and to conduct clinical and basic research in the palliative care of cancer patients. Experience can be drawn from hospitals and cancer centers that have successfully integrated such programs.20,59, 73, 92, 130, 136 Services should incorporate clinical resources to address problems related to physical and psychologic symptoms. The routine evaluation and charting of pain and other common symptoms using a simple screening tool such as the Memorial Symptom Assessment Scale (MSAS)lO'can help problem identification and outcome monitoring. Research

The evaluation of qualitative parameters such as QoL or symptom prevalence and distress should be incorporated into virtually all phase 11, 111, and IV studies. Because tumor shrinkage in phase I studies is

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observed in less than 5% of incorporation of qualitative outcome assessment may improve the yield from these studies. Furthermore, the clinical trials expertise that exists in the oncology community should be used to address specific symptom control problems (such as dyspnea, nausea, and delirium) or complications of cancer (such as neoplastic plexopathies or bowel obstruction). Education

The curriculum of fellowship programs must reflect the degree to which QoL issues are central to the care of cancer patients. Incorporation of skill development in communication, counseling, symptom control, psychooncology, management of neoplastic complications, terminal care, and self-care is recommended. Research training should include the use of QoL and symptom prevalence tools in clinical research. The major texts and journals of palliative medicine and psychooncology should be among the recommended reading for fellows and clinicians (see Appendix). The Individual Clinician

All oncologists can focus their attention on the palliative needs of their own patients. Practice guidelines, journals, consultants, and other resources are available to help the oncologist address these issues. Physicians can remind themselves, their colleagues, and their students to think about physical and psychological symptom control and patient support at all stages of the illness and not just in the terminal phase. Oncologists can develop relationships with local hospice organizations to ensure close cooperation and smooth transition with continuity of care for patients referred for hospice care. Those involved with teaching can emphasize the evaluation and management of physical and psychological symptoms, communication skills, attitudes, and the care of dying patients. SUMMARY

The fusion of palliative medicine and medical oncology, in practice and in education, can provide a better standard of patient care, reduce the risk of oncologist burnout, and increase the likelihood of patient family and physician satisfaction. There need be no gulf between these disciplines, and only together do they represent truly comprehensive cancer care. The realization of this fusion will require the participation of individual clinicians, program directors, and the policy makers for cancer centers, professional organizations, and the health care regulatory authorities. It is a logical next step in the evolution of medical oncology.

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130. Walsh D, Gombeski WJ, Goldstein P, et al: Managing a palliative oncology program: The role of a business plan. Journal of Pain and Symptom Management 9109-118, 1994 131. Wanzer SH, Federman DD, Adelstein SJ, et al: The physician’s responsibility toward hopelessly ill patients-a second look. N Engl J Med 120:844-849, 1989 132. Watanabe T, Adachi I, Tajima K, et al: Improving the quality of life during chemoendocrine therapy for metastatic breast cancer: A randomized comparison of tamoxifen (TAM) vs medroxyprogesterone acetate (MPA) in combination with doxorubicin (ADM) plus cyclophosphamide (CPA) [meeting abstract 901. Proc Annu Meet Am Soc Clin Oncol 1372, 1994 133. Weissman DE, Gutmann M, Dahl JL: Physician cancer pain education: A report from the Wisconsin Cancer Pain Initiative. Joumal of Pain and Symptom Management 6:445448, 1991 134. Whippen DA, Canellos GP: Burnout syndrome in the practice of oncology: Result of a random survey of 1000 oncologists. J Clin Oncol 9:1916-1920, 1991 1995 135. Wingo PA, Tong T, Bolden S Cancer statistics, 1995. Ca Cancer J Clin 45%-30, 136. Woodruff RK, Jordan L, Eicke JP, et al: Palliative care in a general teaching hospital. 2. Establishment of a service. Med J Aust 155:662465, 1991 137. World Health Organization: Cancer Pain Relief and Palliative Care. Geneva, World Health Organization, 1990

Address reprint requests to Nathan I. Chemy, MBBS, FRACP Department of Medical Oncology Shaare Zedek Medical Center Jerusalem, Israel 91031

Recommended Reading in Palliative Medicine

Major Texts 1. Doyle D, Hanks GW, MacDonald N (eds): Oxford Textbook of Palliative Medicine, Oxford, Oxford University Press, 1993 2. Holland JC, Rowland JH (eds): Handbook of Psychooncology. New York, Oxford University Press, 1989 Handbooks and Monographs 1. Agency for Health Care Policy and Research: Cancer Pain Management Panel: Management of Cancer Pain. Washington, DC, US Dept of Health and Human Services, Clinical Practice Guideline No. 9,1994 2. Billings JA (ed): Outpatient Management of Advanced Cancer. Philadelphia, JB Lippincott, 1985 3. Saunders C, Baines M (eds): Living With Dying: The Management of Terminal Illness, ed 2. Oxford, Oxford University Press, 1989 4. Twycross RG, Lack SA: Therapeutics in Terminal Cancer, ed 2. Edinburgh, Churchill Livingstone, 1990

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5. Walsh TD (ed): Symptom Control. London, Blackwell, 1989 6. Woodruff R Palliative Medicine. Melbourne, Asperula, 1993 Journals 1. Journal of Pain and Symptom Management 2. Journal of Palliative Care 3. Palliative Medicine 4. Supportive Care in Cancer 5. Psychooncology