International Journal of Science Annals, Vol. 5, No. 1-2, 2022 рrint ISSN: 2617-2682; online ISSN: 2707-3637; DOI:10.26697/ijsa SOCIAL AND BEHAVIORAL SCIENCES. Rehabilitation ORIGINAL RESEARCH Significance of Palliative Care for the Quality of Life for Oncology Patients Authors’ Contribution: A – Study design; Nikolov A.1 ABCDEFG , Georgieva L.2 DEFG B – Data collection; C – Statistical analysis; 1 Dental Clinic “Zahnzentrum Rudow“, Germany D – Data interpretation; 2 Medical University – Sofia, Bulgaria E – Manuscript preparation; F – Literature search; Received: 12.10.2022; Accepted: 17.11.2022; Published: 25.12.2022 G – Funds collection Abstract Background and Oncological diseases are one of the biggest problems that can cause irreparable Aim of Study: harm to human health. The significance of various types’ medical care on the quality of life for patients with malignant diseases remains an urgent research problem. The aim of the study: to provide empirical data for the significance of palliative care in supporting the quality of life for patients with gastric cancer. Material and Methods: The study was conducted at the University Hospital of Heidelberg, Germany. A representative sample of the study subjects consisted of 378 patients diagnosed with gastric cancer. Comparative analyzes to approaches in cancer prevention, as well as 5-year survival among patients with gastric cancer in Germany, Bulgaria, Japan, and Singapore were used. Results: The majority of the patients in the study sample from Germany died in their homes or in hospices (91.2%), while only a small proportion died in the hospital (8.7%). Based on the international comparison, we concluded that in Bulgaria, the ongoing treatment and care of terminally ill patients differ significantly in terms of their scope, development level and impact on the patients. The 5-year survival rate for stomach cancer in Bulgaria is 3%, which is much lower than in Asian countries, where there is a significantly higher survival rate for this disease: Singapore 10-30%, Japan 12-35%. Conclusions: The significance of the palliative care to support the quality of life for oncological patients has been constantly increasing in recent years. Systemic and long-term palliative care provides the necessary support for quality of life and can affect the 5-year survival of oncological patients. This is confirmed by our study in Germany, where rates are 28-30%. The authors recommend providing professional, high-quality palliative care as needed to ensure quality of life for patients with malignant diseases. Keywords: palliative care, life quality, 5-year survival, patients, stomach cancer, mortality from gastric cancer Copyright: © 2022 Nikolov A., Georgieva L. Published by Archives of International Journal of Science Annals DOI and UDC DOI https://doi.org/10.26697/ijsa.2022.1-2.4 UDC 616-082:616-006 Conflict of interests: The authors declare that there is no conflict of interests Peer review: Double-blind review Source of support: This research did not receive any outside funding or support Information about Nikolov Alexander (Corresponding Author) – https://orcid.org/0000-0001-5414- the authors: 9378; alexander_nikolov1988@yahoo.de; PhD student, Dental Clinic “Zahnzentrum Rudow“, Berlin, Germany. Georgieva Lidia – https://orcid.org/0000-0002-9320-9203; Doctor of Medical Sciences, MD, Professor, Medical University – Sofia, Sofia, Bulgaria. 39 International Journal of Science Annals, Vol. 5, No. 1-2, 2022 рrint ISSN: 2617-2682; online ISSN: 2707-3637; DOI:10.26697/ijsa Introduction Malignant diseases are one of the biggest problems of Currently, there are departments of palliative medicine our time. In recent years, the frequency of their in over 50 countries around the world, including the occurrence has increased significantly worldwide. USA, Germany, France and the Republic of Bulgaria. In Stomach cancer is the fifth most common cancer in the some countries such as New Zealand, Sweden, Norway, world and the third most common cause of death due to Canada, Australia and Great Britain, there are even cancer. The importance of palliative care for the university departments of palliative medicine and duration and quality of life of gastric cancer patients is specialization of palliative medicine doctors (Deliyski, constantly increasing (Smyth et al., 2020). 2000). It is interesting to note that in Great Britain there Although the quality of their prevention and treatment is an overall very well-developed teaching program in have improved, the morbidity and mortality from gastric this medicine for all professional groups involved in carcinoma in both sexes continues to raise with the palliative care. The integration of palliative medicine is increase in the life expectancy of the population. (Ilic & so advanced in UK healthcare that more than 50% of Ilic, 2022), patients who die from gastric cancer are cared for by Gastric carcinoma cases burden modern society, with specialist palliative care teams (Adolph et al., 2014). both the severity of their course and their high financial In 2020, there are 51 registered palliative and hospice cost for the social system. This fact obliges us to beds per 1 million inhabitants in the UK, 200-day continue to study the essential reasons for this and to try hospices and 370 home care teams complement the to actively counteract them, not only through primary palliative care system. In the United Kingdom, only a and secondary prevention, but also through the short time after the foundation of the hospice “St. prevention of the mental and social impacts of the Christopher” in 1975, the idea of hospice became a disease (Hanauske, 1997). phenomenon, leading to numerous hospices being Stomach cancer is the fifth most common cancer in the founded in the 1970s. Unlike the well-organized system world. It is the third leading cause of death from cancer in Great Britain, in other Western European countries, (after lung cancer and liver cancer), with, according to separate palliative wards and hospices were established statistics from 2020, 750,000 deaths worldwide. It for the first time in the 1980s, and a health system occurs twice as often in men than in women and occurs covering palliative medicine was established at first in in more than half of cases in patients over 75 years of 1990s. age (Lordick et al., 2011). It is difficult to give exact statistics for the different Most of the cases of this carcinoma are caused by factors European countries. In general, it should be noted that such as lifestyle, including poor diet, smoking, obesity, especially in the years from 1990 to 2015, a significant alcohol use and infection with Helicobacter pylori number of palliative and hospice facilities were bacteria (Deliyski, 2000). registered. In Sweden, the number of inpatient units Stomach cancer changes the lives of patients and of their increased from 2 to 22, and in 1994, and in Poland from relatives. The disease and its treatment can burden the 16 (1992) to 83 (1993). In France, their number patient not only physically, but also mentally (Ajani et increased from 6 (1992) to 30 (1994). Norway started al., 2010). Consequences of the disease include family very early with palliative medicine and the training and problems, financial worries, professional and social specialization of medical staff in this field was burdens, early retirement. When stomach cancer is in an strengthened from the beginning on. Another important advanced stage, it most often cannot be removed and the aspect in Norwegian healthcare is the introduction of the treatment of cancer patients is palliative. Palliative care so-called “Supportteam” to support palliative cancer aims to alleviate the mental and physical suffering of the patients. From 1984 to 1996, the number of these patients and are of great importance for the duration and hospital/home teams increased to 210. The first title of quality of life of the patients (Harada et al., 2020). “professor” in the field of palliative medicine took place The word “hospice” comes from the Latin “hospitium” in Norway in 1994, and a year later, the first department and means guests of monasteries. The first hospices date for palliative care was established. In 1989, the back to the Middle Ages, when members of religious European Association for Palliative Care (EAPC) was orders housed dying people, where they cared for them established and in 2004, it had already more than 50,000 until they died. The actual concept of modern hospice collective members. care was built by two medical persons in the 1970s in The World Health Organization (WHO) describes Great Britain – Cecily Saunders and Elizabeth Kübler- palliative medicine as treatment for patients with Ross, who developed hospices with the effective incurable, progressive and advanced disease with a treatment of pain as their main goal. Even at this early limited life expectancy, for whom the main goal is to stage of development of care for dying patients, there is improve the quality of life. This definition limits a developed sensitivity for preserving a dignified life, palliative treatment options not only for malignant which is also related to the treatment of pain and other diseases (in this case stomach cancer), but also excludes symptoms having a direct impact on the patient’s quality many patients with chronic diseases and disabilities. of life in his last days. The first palliative care unit was Although alleviating pain is the task of all physicians, built in 1975 at the Royal Victoria Hospital in Montreal, regardless of the type of disease and how advanced it is, Canada. palliative care clearly aims to mitigate suffering at the end stage, when the focus of treatment is entirely on 40 International Journal of Science Annals, Vol. 5, No. 1-2, 2022 рrint ISSN: 2617-2682; online ISSN: 2707-3637; DOI:10.26697/ijsa increasing and improving the quality of life, not the life countries with Bulgaria as an example, western extension. Focusing on pain control and symptom relief European countries with Germany as an example as well become the primary goal of therapy (Cunningham & as more advanced world Asia countries, in particular Schulick, 2007). Singapore and Japan. Another very essential element of palliative medicine Lastly, we analyzed available statistics about incidence, for patients with stomach cancer is communication with prevention, 5-year survival of stomach cancer in the the seriously ill or dying patient and his relatives. selected countries. Honesty in communication, delivering bad news, and grief support are examples of this. Thirdly, the ability of Results and Discussion the patient to lead as normal life as possible, such as Table 1 presents the results about place of where the carrying out old habits that give him/her pleasure and death of patients occurred. The data is collected in an maintaining contact with relatives, should be noted. own study conducted with gastric cancer patients. The Although palliative care, as defined above, is not limited results show that 345 deaths (91.2%) did not occur at the to the treatment of patients with incurable gastric cancer, hospital. In other words, the majority of the patients died it should be noted that traditionally palliative care is in their homes or in hospices. established in the field of tumor diseases. Palliative care Table 1 does not exclude chemotherapy, radiation therapy Place of Death of Patients with Stomach Cancer and/or surgical therapy. A condition for the implementation of these therapies is, however, that the Patients benefits of these measures are greater than their potential Parameters adverse impact for patients (Kelsen & Atiq, 1993; Scarpi people % et al., 2019). Death occurred at home In summary, palliative medicine is characterized by the 345 91.2 or in a hospice following points (Koizumi et al., 1999): 1. Comprehensive control of the patient’s pain and Death occurred in the 33 8.7 symptoms. hospital 2. Integrating the physical, social and spiritual needs of Total 378 100.0 patients, relatives and the treating team, both during and after illness and death. Although the terms hospice care and palliative care are 3. Accepting death as a part of life. When life ends, often used interchangeably, the main difference between death should neither be hastened nor delayed. Palliative the two should be noted. While palliative care has a medicine rejects euthanasia. broader scope, including patients with various diseases 4. Competence on the important issues of and needing long-term specialized and active general communication and ethics. care for their physical, psychosocial and spiritual The task and aim of palliative medicine are to provide condition, hospice care is focused on patients in the support to the patient suffering from stomach cancer so terminal phase of their illness. It can be summarized that that he has the best possible quality of life until his end. hospice care is part of palliative care with the important This is possible thanks to the cooperation of capable clarification that it includes the preparation of the patient palliative bases with family doctors, social care and and his family on topics related to the end of life and hospital departments, as their main goal is to ensure implies even more intensive care for the physical, optimal round-the-clock treatment of palliative ill psycho-social and mental condition of the patient in the patients. (Kilpatrick & Johnson, 1999; Kitzes & last months of his/her life. This clarification also Anderson, 2003). constructs one of the important moral questions faced by The aim of the study. To provide empirical data for the specialists caring for patients in a terminal stage, namely significance of palliative care for patients with gastric – is it necessary for the patient to know about the cancer. In particular, we focus on the analyses of the role approaching death (Kern at al., 2007; Klaschik, 2009). of palliative care for improvement of the duration and According to the Law on Medical Institutions of the quality of life of stomach cancer patients and discussed Republic of Bulgaria, a hospice is a medical institution potential mitigation of the negative mental and social “in which medical and other specialists carry out long- impacts of the disease. term medical monitoring, supporting treatment prescribed by a doctor for a person with chronic Materials and Methods debilitating diseases and medico-social problems” To address the research question, we used various (Methodist Le Bonheur Healthcare, n. d.). In contrast, in empirical data as well as literature review. countries with better-developed services for terminally Firstly, we performed descriptive statistics of data from ill patients (USA, England, Austria, Germany, etc.), this an own study conducted with a total sample of 378 definition focus on the concept of “hospice care”, which gastric cancer patients at the University clinic in is aimed precisely at the nature of the care itself rather Heidelberg in order to analyze place of death and than the physical location where it is provided. This can potentially palliative care of stomach cancer patients. be the patient’s home or a specialist facility – the right Secondly, we compared prevention approaches as well to decide is in their hands and/or in the hands of the as hospice and palliative care in eastern European family when the patient is unable to decide for himself. 41 International Journal of Science Annals, Vol. 5, No. 1-2, 2022 рrint ISSN: 2617-2682; online ISSN: 2707-3637; DOI:10.26697/ijsa Differences in the handling of the concept itself could be survival rates are typical for Japan (a country with a high considered as an indicator of the degree of development mortality rate from stomach cancer): for advanced (or stagnation) of these concerns in the respective stages (IIIB and IV) it is between 5-17%, for potentially country, as they reveal the way in which a given curable stages (IV-II-IIIA) it is between 18-35%, for phenomenon is thought of in a society (Arvanitis et al., early gastric cancer it is between 78-95%, with Japanese 1990; Klaschik, 2009). authors traditionally reporting higher survival for all Comparing the different prevention approaches in stages (Krastev, 1980). Bulgaria and in the countries of Western Europe, we Table 2 shows that in countries like Japan, where 20 could conclude that in Bulgaria the ongoing treatment years ago the incidence per 100,000 people was 77 only and care of the terminally ill differ significantly in terms with changes in diet, lifestyle, and environment, it has of the scope of the patients, rates of development and dropped to 42 per 100,000. This high survival rate in effect on the patients. Japan is also due to the good palliative care (Japanese The five-year survival rate in patients operated on for Ca Gastric Cancer Association, 2021; Kato & Asaka, ventricles shows significant differences according to the 2012). stage of the disease and is relatively low. The following Table 2 Incidence, Prevention; 5-Year Survival of Stomach Cancer in Selected Countries Incidence Country Preventive measures Screening 5-year survival, % (per 100,000 people) Germany 13 Yes Yes, active 28-30 Bulgaria 14 No No 3 Singapore 37-39.2 Yes Yes, active 10-30* Japan 42 Yes Yes, active 12-35* Note. *1st - stage up to 90%. The 5-year survival rate from stomach cancer in Bulgaria is much lower than countries in Asia, where a Ethical Approval significantly higher incidence per 100,000 population is The study protocol was consistent with the ethical observed. The reasons for this are complex. One of the guidelines of the 1975 Declaration of Helsinki as suspected reasons may be insufficient provision and reflected in a prior approval by the Institution’s Human access to quality post-operative, long-term care and Research Committee. palliative care. Another reason could be the difficult access to the main method of detecting and proving Funding Source gastric carcinoma, such as fibrogastroscopy and video- This research did not receive any outside funding or assisted fibrogastroscopy with biopsy. These highly support. specialized studies require precise, expensive equipment, which is still extremely insufficient in Bulgaria. In References addition, this equipment requires highly specialized Adolph, H., Berberich, H., Besseler, M., Beutel, M., personnel with many years of experience, which Blettner, G., Böhle, E., Bohnenkamp, H., Bruns, G., currently only large oncology centers have. Dietz, A., Dippmann, A. K., Englert, G., Faller, H., This difficult access of the population to such specialists Follmann, M., Gruber, H., Härtl, K., Hasenburg, A., greatly complicates early detection, which subsequently Heckl, U., Heußner, P., Isele, B., … Wickert, M. determines the low 5-year survival rate. Just the opposite (2014). Leitlinienprogramm onkologie: conclusion is necessary for countries like Japan and Psychoonkologische diagnostik, beratung und Singapore, which, despite their high morbidity per behandlung von erwachsenen krebspatienten [Guideline program oncology: Psycho-oncological 100,000 people, are the undisputed champions in early diagnostics, counseling and treatment of adult detection, rapid complex treatment, good palliative care cancer patients]. https://leitlinienprogramm- and many times higher 5-year survival rate (Methodist Le onkologie.de/Leitlinien.7.0.html [in German] Bonheur Healthcare, n. d.). Ajani, J. A., Barthel, J. S., Bekaii-Saab, T., Bentrem, D. J., D’Amico, T. A., Das, P., Denlinger, C., Conclusions Fuchs, C. S., Gerdes, H., Hayman, J. A., Hazard, L., The significance of the palliative care for the quality of Hofstetter, W. L., Ilson, D. H., Keswani, R. N., life with a diagnoses cancer of the stomach constantly Kleinberg, L. R., Korn, M., Meredith, K., increases during the past decades. It is possible that the Mulcahy, M. F., Orringer, M. B., ... Yang, G. good long-term palliative care can influence the 5-year (2010). Gastric cancer. Journal of the National survival rate of the cancer patients. Therefore, additional Comprehensive Cancer Network, 8(4), 378-409. studies on this direction are necessary. By then, provision https://doi.org/10.6004/jnccn.2010.0030 of an increasing, according to the needs, amount of good Arvanitis, M. L., Jagelman, D. G., Fazio, V. W., quality palliative care is recommended. Lavery, I. C., & McGannon, E. (1990). Mortality in patients with familial adenomatous polyposis. 42 International Journal of Science Annals, Vol. 5, No. 1-2, 2022 рrint ISSN: 2617-2682; online ISSN: 2707-3637; DOI:10.26697/ijsa Diseases of the Colon & Rectum, 33(8), 639-642. Health_Administration_and_Po.html?hl=fr&id=7y6 https://doi.org/10.1007/BF02150736 3c8H61UsC&output=html_text Cunningham, S. C., & Schulick, R. D. (2007). Palliative Kitzes, J. A., & Anderson, R. P. (2003). Hospice and management of gastric cancer. Surgical Oncology, palliative care: Concepts and practice (2nd ed.). 16(4), 267-275. Jones & Bartlett Learning. https://doi.org/10.1016/j.suronc.2007.08.004 https://books.google.de/books/about/Hospice_and_ Deliyski, T. S. (2000). Rak na stomakha: Klasyfykatsyia i Palliative_Care.html?id=5UigsyFcm2QC&redir_es lechenye [Stomach cancer: Classification and c=y treatment]. Prima Print; Pleven. https://ilib.mu- Klaschik, E. (2009). Palliativmedizin [Palliative medicine]. pleven.bg/bg/details.php?id=MUPL10003144 [in In S. Husebo & E. Klaschik (Eds.), Palliativmedizin Bulgarian] [Palliative medicine] (pp. 1-45). Springer, Berlin, Japanese Gastric Cancer Association (2021). Japanese Heidelberg. https://doi.org/10.1007/978-3-642- gastric cancer treatment guidelines 2018 (5th ed.). 01549-6_1 [in German] Gastric cancer: Official Journal of the International Koizumi, W., Ujiie, S., & Taguchi, T. (1999). Gastric Gastric Cancer Association and the Japanese carcinoma: A phase II study of capecitabine with Gastric Cancer Association, 24(1), 1–21. new dosing regimen in patients with https://doi.org/10.1007/s10120-020-01042-y advanced/metastatic gastric carcinoma. European Hanauske, A. R. (1997). UFT in gastric cancer: Current Journal of Cancer, 35(Suppl. 4), S148. status and future developments. Oncology (Williston https://doi.org/10.1016/S0959-8049(99)80973-3 Park, N. Y.), 11(9 Suppl. 10), 113–118. Krastev, B. (1980). Rak na stomakha [Stomach cancer]. https://pubmed.ncbi.nlm.nih.gov/9348582/ Medytsyna i fizkultura. https://knizhen- Harada, K., Zhao, M., Shanbhag, N., Baba, H., & pazar.net/products/books/1542514-rak-na-stomaha Ajani, J. A. (2020). Palliative care for advanced [in Bulgarian] gastric cancer. Expert Review of Anticancer Lordick, F., Ott, K., & Sendler, A. (2011). Magen- und Therapy, 20(7), 575-580. adenokarzinome des ösophagogastralen übergangs https://doi.org/10.1080/14737140.2020.1781620 [Gastric cancer and adenocarcinoma of the Ilic, M., & Ilic, I. (2022). Epidemiology of stomach cancer. esophagogastric junction]. Der Chirurg – The World Journal of Gastroenterology, 28(12), 1187- Surgeon, 82, 968-973. 1203. https://doi.org/10.3748/wjg.v28.i12.1187 https://doi.org/10.1007/s00104-011-2127-3 [in Kato, M., & Asaka, M. (2012). Recent development of German] gastric cancer prevention. Japanese Journal of Methodist Le Bonheur Healthcare (n. d.). Corporate Clinical Oncology, 42(11), 987-994. compliance & Privacy new associate training https://doi.org/10.1093/jjco/hys151 [Company program]. Kelsen, D., & Atiq, O. T. (1991). Therapy of upper https://www.methodisthealth.org/ gastrointestinal tract cancers. Current Problems in Scarpi, E., Dall’Agata, M., Zagonel, V., Gamucci, T., Cancer, 15(5), 235-294. Bertè, R., Sansoni, E., Amaducci, E., https://pubmed.ncbi.nlm.nih.gov/1743044/ Broglia, C. M., Alquati, S., Garetto, F., Kern, M., Wessel, H., & Ostgathe, E. (2007). Ambulante Schiavon, S., Quadrini, S., Orlandi, E., palliativbetreuung – einflussfaktoren auf eine Gardini, A. C., Ruscelli, S., Ferrari, D., Pino, M. S., stationäre einweisung am lebensende [Outpatient Bortolussi, R., Negri, F., ... Maltoni, M. (2019). palliative care – factors influencing inpatient Systematic vs. on-demand early palliative care in admission at the end of life]. Zeitschrift für gastric cancer patients: a randomized clinical trial Palliativmedizin – Journal for Palliative Medicine, assessing patient and healthcare service outcomes. 8(4), 155-161. https://doi.org/10.1055/s-2007- Supportive Care in Cancer, 27(7), 2425-2434. 986261 [in German] https://doi.org/10.1007/s00520-018-4517-2 Kilpatrick, A., & Johnson J. A. (Eds.). (1999). Handbook of Smyth, E. C., Nilsson, M., Grabsch, H. I., van health administration and policy. Marcel Dekker. Grieken, N. C., & Lordick, F. (2020). Gastric https://books.google.td/books/about/Handbook_of_ cancer. The Lancet, 396(10251), 635-648. https://doi.org/10.1016/S0140-6736(20)31288-5 Cite this article as: Nikolov, A., & Georgieva, L. (2022). Significance of palliative care for the quality of life for oncology patients. International Journal of Science Annals, 5(1-2), 39–43. https://doi.org/10.26697/ijsa.2022.1-2.4 The electronic version of this article is complete. It can be found online in the IJSA Archive https://ijsa.culturehealth.org/en/arhiv This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited (http://creativecommons.org/licenses/by/4.0/deed.en). 43