Editorial
Corbis
Prioritising palliative care
See Comment page 1699 See Article page 1721
For more on Sir Richard Peto’s comment see http:// www.dcp-3.org/
Cure is not always available for patients with cancer, and palliative care, defined by WHO as “an approach that improves the quality of life of patients and their families facing the problems associated with lifethreatening illness”, should always be present. WHO also recommends that palliative care “is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life”, but how early is early enough for palliative care to be integrated into standard treatment, and what is the value of early involvement of palliative care? In today’s Lancet, Camilla Zimmermann and colleagues present the results of a cluster-randomised controlled trial to assess the effect of early outpatient-focused palliative care on several aspects of quality of life in patients with advanced cancer. Notably, eligible patients in this trial have an estimated survival of 6–24 months, while in the real world most patients with cancer are referred to palliative care teams in the last 2 months of their life or never receive such care at all. No significant difference was noted in the primary outcome—functional assessment of chronic illness
therapy and spiritual wellbeing at 3 months. However, as for secondary outcomes, significant advantages for palliative care were identified in terms of change score for functional assessment of chronic illness therapy and spiritual wellbeing at 4 months, quality of life at end of life, and satisfaction with care at 3 months and 4 months. This study suggests that palliative care can be implemented both early and effectively to improve quality of life. Too often, palliative care is de-emphasised in the management of patients with cancer, and cure is pursued by too many physicians. Moreover, palliative care is often a low priority in global cancer targets. However, the time has come for health professionals and health systems to consider palliative options seriously at the earliest stages of the cancer journey, and to enable a shared care model that involves palliative specialists in multidisciplinary treatment of patients. Indeed, as Sir Richard Peto commented on the Disease Control Priorities 3 Twitter feed: “If you want to make striking cancer targets, prioritize palliative care and then talk about prevention.” n The Lancet
Ramon Andrade 3DCIENCIA/Science Photo Library
Management of liver cirrhosis
See Seminar page 1749
For the WHO guidelines see http://www.who.int/hiv/pub/ hepatitis/hepctreatment guidelinespub/en/
1694
Liver cirrhosis is an increasing cause of morbidity and mortality, responsible for more than 1 million deaths annually. In today’s Lancet, a Seminar by Emmanuel Tsochatzis and colleagues describes liver cirrhosis as the fourteenth most common cause of death worldwide. In developed countries, the leading causes of liver cirrhosis are hepatitis C virus (HCV), alcohol misuse, and nonalcoholic liver disease; whereas hepatitis B virus (HBV) is the most common cause in sub-Saharan Africa and most parts of Asia. Hepatocellular carcinoma is the leading cause of death in patients with liver cirrhosis, and management of hepatocellular carcinoma is complicated by liver cirrhosis in more than 80% of patients. More cases of liver cirrhosis are caused by HCV than HBV. On April 9, the first WHO Guidelines for HCV were released to coincide with the European Association for the Study of the Liver (EASL) Congress in London, UK. These guidelines give countries a roadmap for screening and treatment of hepatitis C, with specific guidance on how to start treatment in resource-limited settings. According
to WHO estimates, the prevalence of HCV infection varies substantially by region. For example, east and south Asia have high population HCV prevalence rates (of 3·7% and 3·4%, respectively), which accounts for more than 100 million patients infected with HCV. Several new drugs to treat HCV infection are in development. Recently, the US Food and Drug Administration approved simeprevir and sofosbuvir, and the European Medicines Agency approved sofosbuvir. Criticism has been rightly drawn over the prohibitive cost of these drugs for lowincome and middle-income countries (LMICs). Although these drugs will be offered to LMICs at a discounted price, they are still too expensive for many countries to scale up treatment. To advance treatment and improve quality of care for patients, The Lancet has established a Commission on liver disease in the UK, which is due to report its findings later this year. Further efforts to implement effective treatment of HCV, and to combat liver cirrhosis, in LMICs are badly needed. n The Lancet www.thelancet.com Vol 383 May 17, 2014
Corbis
Prioritising palliative care
See Comment page 1699 See Article page 1721
For more on Sir Richard Peto’s comment see http:// www.dcp-3.org/
Cure is not always available for patients with cancer, and palliative care, defined by WHO as “an approach that improves the quality of life of patients and their families facing the problems associated with lifethreatening illness”, should always be present. WHO also recommends that palliative care “is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life”, but how early is early enough for palliative care to be integrated into standard treatment, and what is the value of early involvement of palliative care? In today’s Lancet, Camilla Zimmermann and colleagues present the results of a cluster-randomised controlled trial to assess the effect of early outpatient-focused palliative care on several aspects of quality of life in patients with advanced cancer. Notably, eligible patients in this trial have an estimated survival of 6–24 months, while in the real world most patients with cancer are referred to palliative care teams in the last 2 months of their life or never receive such care at all. No significant difference was noted in the primary outcome—functional assessment of chronic illness
therapy and spiritual wellbeing at 3 months. However, as for secondary outcomes, significant advantages for palliative care were identified in terms of change score for functional assessment of chronic illness therapy and spiritual wellbeing at 4 months, quality of life at end of life, and satisfaction with care at 3 months and 4 months. This study suggests that palliative care can be implemented both early and effectively to improve quality of life. Too often, palliative care is de-emphasised in the management of patients with cancer, and cure is pursued by too many physicians. Moreover, palliative care is often a low priority in global cancer targets. However, the time has come for health professionals and health systems to consider palliative options seriously at the earliest stages of the cancer journey, and to enable a shared care model that involves palliative specialists in multidisciplinary treatment of patients. Indeed, as Sir Richard Peto commented on the Disease Control Priorities 3 Twitter feed: “If you want to make striking cancer targets, prioritize palliative care and then talk about prevention.” n The Lancet
Ramon Andrade 3DCIENCIA/Science Photo Library
Management of liver cirrhosis
See Seminar page 1749
For the WHO guidelines see http://www.who.int/hiv/pub/ hepatitis/hepctreatment guidelinespub/en/
1694
Liver cirrhosis is an increasing cause of morbidity and mortality, responsible for more than 1 million deaths annually. In today’s Lancet, a Seminar by Emmanuel Tsochatzis and colleagues describes liver cirrhosis as the fourteenth most common cause of death worldwide. In developed countries, the leading causes of liver cirrhosis are hepatitis C virus (HCV), alcohol misuse, and nonalcoholic liver disease; whereas hepatitis B virus (HBV) is the most common cause in sub-Saharan Africa and most parts of Asia. Hepatocellular carcinoma is the leading cause of death in patients with liver cirrhosis, and management of hepatocellular carcinoma is complicated by liver cirrhosis in more than 80% of patients. More cases of liver cirrhosis are caused by HCV than HBV. On April 9, the first WHO Guidelines for HCV were released to coincide with the European Association for the Study of the Liver (EASL) Congress in London, UK. These guidelines give countries a roadmap for screening and treatment of hepatitis C, with specific guidance on how to start treatment in resource-limited settings. According
to WHO estimates, the prevalence of HCV infection varies substantially by region. For example, east and south Asia have high population HCV prevalence rates (of 3·7% and 3·4%, respectively), which accounts for more than 100 million patients infected with HCV. Several new drugs to treat HCV infection are in development. Recently, the US Food and Drug Administration approved simeprevir and sofosbuvir, and the European Medicines Agency approved sofosbuvir. Criticism has been rightly drawn over the prohibitive cost of these drugs for lowincome and middle-income countries (LMICs). Although these drugs will be offered to LMICs at a discounted price, they are still too expensive for many countries to scale up treatment. To advance treatment and improve quality of care for patients, The Lancet has established a Commission on liver disease in the UK, which is due to report its findings later this year. Further efforts to implement effective treatment of HCV, and to combat liver cirrhosis, in LMICs are badly needed. n The Lancet www.thelancet.com Vol 383 May 17, 2014
