Development of WHO guidelines for the management of cancer pain in adults
The World Health Organization is developing new guidelines for the clinical management of cancer pain in adults. The production of these guidelines will be led by WHO’s Department for the Management of Noncommunicable Diseases, Disability, Injury and Violence Prevention (NVI). Previous WHO guidelines on this topic include the 1996 document ‘Cancer Pain Relief, 2nd Edition, with a guide to opiate availability’. In light of new evidence and strong mandates from Member States, new guidelines are needed. More recently, WHO has developed Guidelines on the pharmacological treatment of persisting pain in children with medical illness (2012), but there remains a need for more comprehensive WHO guidelines on pain management and palliative care. New WHO guidelines for the management of cancer pain in adults will be one component to address the priority gaps in WHO guidance in these important areas.
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Zipporah Ali is the Executive Director of Kenya Hospices and Palliative Care Association (KEHPCA) since 2014. She had previously worked as its National coordinator until 2013, and joined in 2007 after working as Senior Medical Officer in Nairobi Hospice from 1998.
After obtaining her MD in Aegen (Ege) University, Turkey, in 1986, she went on to complete a Master’s in Public Health (University of Nairobi, 1999), a Higher Diploma in Palliative Care (Oxford Brookes University, 2002), and a Master’s in Palliative Care in 2015
Dr. Ali is involved in advocacy and creating awareness on pain relief and palliative care in Kenya for both adults and children. She has been instrumental in fostering strong relationships with the Ministry of Health to integrate palliative care into government hospitals. She has been instrumental in developing: the first National Cancer Control Strategy; the National Guidelines for Cancer Management-Kenya; National Palliative Care Guidelines for Kenya; and was also part of the team that developed the ‘Beating Pain’ pocket book by Africa Palliative Care Association.
She has completed the International Pain Policy Fellow program with the International Pain Policy Studies Group as well as the International Palliative Care Leadership Development Initiative at The Institute of Palliative Medicine at the San Diego Hospice.
In 2012, Zipporah was awarded an Honorary Doctor of the University by Oxford Brookes University in recognition of her outstanding contribution in PC both internationally and locally.
Dr Gauhar Afsan studied Medicine in 1990 at Dow Medical college, University of Karachi, and became a fellow in Anaesthesiology of the College of Physicians & Surgeons Pakistan in 1996. She underwent Pain Management Training at Queen’s Medical Centre, Nottingham, UK in 1998.
She is the founder of the first multidisciplinary pain setup (1998) in Pakistan. Over the last 18 years she established pain services mainly for cancer pain & back pain. She has a resolve to continue her contributions to education with busy clinical services. She also started the first pain fellowship program at Aga Khan University in 2006 and currently serves as founding member of Taskforce of National Pain Fellowship Program of Pakistan. She is also one of the pioneer members of the groups that introduced a pain curriculum to undergraduate programs. She has established collaborations with other tertiary care centres to provide optimal pain relief to all. She has been the President of the South Asian Regional Pain Society (SARPS) from 2012-2014. She has made substantive contributions towards WHO guidelines on the Pharmacological treatment of persisting pain in children with medical illness (2012). She resides in Karachi, Pakistan, and currently serves on editorial boards of several national and international peer reviewed journals and is author to more than 70 peer reviewed publications with several international and national grants.
Chioma Asuzu is a clinical psychologist based in the University of Ibadan, Nigeria, specializing in the area of psycho-oncology. She acquired her Bachelors education in nursing before transitioning to psychology with a Master’s degree in Counselling Psychology and a doctorate in Clinical Psychology, all in the University of Ibadan. Additionally, she has a diploma in Cancer Prevention and Control as well as a diploma in Molecular Prevention from the National Cancer Institute in Maryland, USA.
She is primarily employed in the Department of Counselling and Human Developmental Studies, University of Ibadan with teaching, research, and services in clinical psychology. She holds a joint appointment in the Department of Radiation Oncology of the College of Medicine in the University, where she also serves as honorary Psycho-oncologist to the University College Hospital. In the hospital, she leads a weekly psycho-oncology clinic. Part of the work at this clinic includes the assessment of patients for psychological distress and its psychological management with psychotherapy.
Apart from these clinical services, her work also includes teaching, research, community services in psycho-oncology, and holding conferences in the area of cancer prevention and control.
She is the founding President of the Psycho-Oncology Society of Nigeria and the Association for Psycho-Oncology in Africa.
Eduardo Bruera M.D. is Professor of Oncology and Chair of the Department of Palliative, Rehabilitation and Integrative Medicine at The University of Texas MD Anderson Cancer Center since 1999. He resides in Houston, Texas USA. A medical oncologist, Dr. Bruera is a Fellow of the American Association of Hospice & Palliative Medicine. He received his MD from the Universidad de Rosario, Rosario, Argentina in 1979 and has authored over 1000 publications, including peer-reviewed publications, book chapters, abstracts, and books. Dr. Bruera has published multiple research studies and reviews on pain and opioid management. He has edited 2 editions of a major textbook on cancer pain. He is a world-recognized leader in palliative and supportive care and is dedicated to improving patient access to palliative care internationally, particularly in the developing world where he helped in the establishment of palliative care programs in Latin America, India and Europe. Dr. Bruera has trained hundreds of physicians, nurses, and healthcare professionals in the different aspects of clinical delivery of palliative care. He has received numerous national and international awards, he is a member of many medical organizations, and participates on the editorial boards of multiple medical journals.
After graduating from the University of Adelaide Medical School, South Australia, Dr. Cleary trained in Internal Medicine and Medical Oncology at the Royal Adelaide Hospital and then undertook three years of opioid pharmacology research.
Moving to the UW in 1994, he developed a Palliative Care Program, from which he has recently stepped aside as Medical Director. Throughout, he has served as Program Director of Cancer Control at the UW Carbone Cancer Center, with full integration of palliative care. He was the 2004 President of the American Academy of Hospice and Palliative Medicine. He serves as a North American Editor of Palliative Medicine, the Research Journal of the European Association of Palliative Care. He has global connections in Cancer Pain and Palliative Care, evidence by the releases of the Global Opioid Policy Initiative publications for Africa, Asia, the Caribbean and Latin America, India, and the Middle East. Recent grant funding from the National Cancer Institute’s Global Health Program supported a fourth (and African) cohort of the PPSG’s Pain Policy Fellowship. He was co-chair of the Breast Health Global Initiative (BHGI)'s resource stratified guidelines for Palliative Care. Dr. Cleary is a member of the WHO Technical Advisory Group for Palliative Care, the HGEI-Lancet Commission on Palliative Care and co-chair of ASCO's Resource-Stratified Guideline on Palliative Care.
Malcolm Dobbin PhD, MBBS, Dip Obstetrics RANZCOG, MPH, FAFPHM, is a Public Health Physician working as the Senior Medical Advisor for the Real-Time Prescription Monitoring Implementation Taskforce of the Victorian Department of Health and Human Services, Australia, and is Adjunct Senior Research Fellow, Department of Forensic Medicine, Monash Univeristy, where he conducts research on poisoning deaths involving pharmaceutical drugs.
He conducted postgraduate research in social and preventive medicine, investigating the health and nutritional status of Aboriginal children in Victoria, and has a background in emergency medicine, general practice, hospital medicine, drug and alcohol treatment and public health. He worked for ten years in Aboriginal community controlled health services in inner city and remote Australia.
His skills include public health, preventive medicine, health policy, epidemiology and public health research. His areas of interest include addressing the misuse of prescription and over-the-counter drugs, with particular interest in preventing the harm resulting from problematic prescribing, use, and diversion from licit to illicit use of prescription opioids, as well as harm from the misuse of over-the-counter combination analgesics containing codeine. He is also active in the engagement of general practitioners in the identification and management of alcohol and other drug problems in their practice.
Kathleen Foley MD is an attending neurologist emeritus at Memorial Sloan-Kettering Cancer Center in New York City, where she has worked for more than four decades. In 1981, under Dr Foley's leadership, Memorial Sloan Kettering opened the first designated pain service in a cancer setting in the United States. Dr Foley is a professor of neurology, neuroscience, and clinical pharmacology at the Weill Cornell Medical College, and holds the Society of Memorial Sloan Kettering Chair in Pain Research. She is the former medical director of the International Palliative Care Initiative.
In 1995, Dr Foley became director of the Open Society Institute’s Project on Death in America, a $45 million, nine-year project focused on transforming the culture of death in the United States through initiatives in science, the humanities, education, and professional training. Recognizing a critical need for developing leaders and palliative care experts in order to facilitate change in patient care, Dr Foley and her team created leadership programs for physicians, nurses, and social workers around the country, including at Memorial-Sloan Kettering Cancer Center.
As director of the International Palliative Care Initiative at the Open Society Foundations, Dr Foley worked with governments to develop pain and palliative care initiatives and policies. To date, the project has fostered more than 40 leaders from over 30 countries who will lead future palliative care efforts in their respective nations.
She is the past director of the World Health Organization Collaborating Centre at Memorial Sloan-Kettering Cancer Center and has chaired three WHO expert panels resulting in three WHO monographs related to cancer pain and palliative care. She was elected to membership in the Institute of Medicine of the National Academy of Sciences, and has received numerous awards, including the Medal of Honor from the American Cancer Society, the David Karnovsky Award from the American Society of Clinical Oncology, and the Frank Netter Award of the American Academy of Neurology.
Dr Foley received her BS from St. John’s University, and then attended Cornell University Medical College, graduating as a member of the Alpha Omega Alpha Medical Honor society. Dr Foley went on to complete a medical internship and neurology residency at New York Hospital – Cornell Medical Center, followed by a fellowship in neuro-oncology at Memorial Sloan-Kettering Cancer Center.
Harmala Gupta received her BA Honours in Economics from Lady Sri Ram College, Delhi University, in 1973. She gained an MA in International Politics from the School of International Studies, Jawaharlal Nehru University, New Delhi in 1975, and then an MA in Chinese Studies the following year. She was awarded a teaching assistantship at McGill University, Montreal, Canada, to pursue a PhD in Chinese Politics in the Department of Political Science, 1977. She returned to McGill Univeristy in 1987 to complete her PhD thesis. In the same year, however, she was diagnosed with Hodgkin’s Lymphoma, thus was unable to submit her thesis.
Following her experience with cancer, Harmala founded the first cancer support group in India, ‘Cancer Sayhog’, in 1991. She founded ‘CanSupport’ in 1996. CanSupport has pioneered home care for people with terminal cancer in Delhi. It works in collaboration with the Pain & Palliative Care Clinic at the Institute Rotary Cancer Hospital (IRCH) at AIIMS. Under this programme more than 12,000 patients and members of the family have received high quality and appropriate medical, nursing and psychological care. CanSupport also runs a daycare programme for children and adults with cancer, a cancer support group and a telephone helpline for cancer. All its services are free as they are aimed at the most needy.
Harmala is also President of the first national level umbrella organization of cancer support groups in India – Cancer Care India. She is on the governing board of the Rajiv Gandhi Cancer Institute in Delhi and is a fellow of the UICC. She has delivered several talks at international and national conferences, been interviewed by the media and has written extensively on cancer, and received several fellowships and national awards of recognition for her work.
Philip Larkin Is a registered nurse with specialist qualifications and practice in paediatrics, community health and oncology, with over 25 year’s clinical and academic experience in specialist of palliative care, including regional coordinator of services and head of a hospice education department. He currently hold a joint appointment as Professor of Clinical Nursing (Palliative Care) at University College Dublin and Our Lady’s Hospice and Care Services, Dublin combining both a clinical and academic focus essential for the development of palliative care and palliative nursing, in particular. He has been involved in the development of palliative care at a national and international level. He held the Chair of the Irish Association for Palliative Care and in 2015 was elected President of the European Association for Palliative Care - the first nurse to hold this role.
Philip chairs the All-Ireland Institute of Hospice and Palliative Care (AIIHPC). He is a senior faculty member at the UCD School of Nursing, Midwifery and Health Systems and has served as a member the School Senior Management Team and within Academic Council. He provides research support and counsel to a wide range of graduate students undertaking Masters and PhD studies, as well as having a notable teaching portfolio in the discipline of palliative care. He received a lifetime achievement award from Macmillan Cancer Support and the International Journal of Palliative Nursing in recognition of his contributions to the field. He leads the support of clinical staff in complex decision-making and developing key performance indicators (KPI) for practice.
Philip holds a BSc in Community Health from King’s College London, a master in Education in Palliative Care from the University of Huddersfield, UK, and received his PhD in Palliative Care biomedical ethics and law from the Catholic University of Louvain, Belgium.
Diederik Lohman is the Interim Director of the Health and Human Rights Division at Human Rights Watch. He leads the organization’s research and advocacy on palliative care and pain treatment. As part of the project, he has spearheaded advocacy at the U.N. Commission on Narcotic Drugs, the International Narcotics Control Board, the World Health Organization and other international institutions. He has conducted or supervised research on palliative care in Armenia, Guatemala, India, Kenya, Mexico, Morocco, Russia, Senegal and Ukraine and various other countries. He has also conducted extensive research on and written about drug dependence treatment and HIV treatment for drug users, and HIV testing and counseling. Previously, he served as senior researcher for Russia, Ukraine and Belarus with the Europe and Central Asia Division of Human Rights Watch and as its Moscow office director. Diederik holds a Master’s in Russian Studies and Law and is based in Maplewo, New Jersey, USA.
Sébastien Moine is a General Practitioner in a multi-professional primary health care center in a rural area of northern France and a physician in a palliative care mobile team in Compiègne hospital, Picardie. He obtained his MD in 2003, and studied the Ethics of Chronic Illness and End of Life Palliative Care in his Msc. He also holds a postgraduate diploma in Palliative and end of life care, and another in Active learning and Medical Simulation. Sébastien is also a PhD candidate in public health (Health Education and Practices Laboratory, Paris 13 University), and his research concerns developing and evaluating a complex intervention in primary care, aiming to enhance access to palliative care.
Besides of developing educational materials at SimUsanté, a medical simulation center in Amiens University Hospital, Sébastien has a special interest in medical education for health professionals involved in the provision of palliative care in the community.
Sébastien has been participating in various task forces at the French National Authority for Health, regarding palliative care. He is piloting a multidisciplinary task force aiming to implement axis 3 (‘Community palliative care’) of the French Plan for the Development of Palliative Care 2015-2018. He is currently a member of the scientific council of the French Society for Palliative Care (SFAP), and of the executive committee of the European Association for Palliative Care (EAPC) Reference Group in Primary Care.
Dr Hibah Osman is the founder of Balsam and serves as both its Executive and Medical Director. Hibah is a family physician who is American Board Certified in both Family Medicine and Hospice and Palliative Medicine. She has received training in palliative care at the Institute of Palliative Medicine at San Diego Hospice and at Harvard Medical School. Hibah is committed to developing palliative care in Lebanon and the region to insure that palliative care is available and accessible to anyone who needs it. In addition to providing palliative care to patients in Beirut, she has been actively working on raising awareness among policy makers, health providers, and in the community. She has served on the National Committee on Pain Control and Palliative Care at the Ministry of Public Health since 2011 and chairs its Subcommittee on Practice. She also supports hospitals to establish a palliative care culture and palliative care programs. She established the first palliative care consultation service in Lebanon at the American University of Beirut Medical Center (AUBMC) in 2013.
Professor Radbruch is professor of palliative medicine at the University of Bonn and is extensively published, his main research interests being symptom assessment, cancer pain, opioid treatment, fatigue, cachexia and ethical issues in palliative care. He has contributed to guideline development for cancer pain, fatigue, cachexia and palliative care in general both on a national and international level. He is Director of the Department of Palliative Medicine at the University Hospital Bonn, Director of the Palliative Care Centre (Malteser Hospital Bonn/Rhein-Sieg), and Chair of the Board of Directors of the International Association of Hospice and Palliative Care.
He has coordinated the ATOME project (access to opioid medicines in Europe) funded by the 7th Framework programme of the European Union (with WHO and WHO Europe as partners in the consortium) and has chaired the development of the WHO guidelines on ensuring balance in access to controlled medicines in 2010. He has lead or contributed to numerous systematic reviews in palliative care, including alternative application routes for opioids, pharmacological treatment of fatigue in palliative care, cannabinoids in palliative care, and together with Liliana de Lima has led the successful application for inclusion of palliative care medicines in the 19th edition of the Essential Medicines List of the WHO. He is co-author of the German textbook on palliative medicine (Lehrbuch der Palliativmedizin, Schattauer Verlag). He has been editor of the scientific journal ‘Der Schmerz’ since 2004, a member of the Drug Commission of the German Medical Board since 2004, and a member of the Expert Commission of the German Narcotic Control Agency since 2004.
M. R. Rajagopal
M. R. Rajagopal is the director and founder of the Trivandrum Institute of Palliative Sciences, India, a WHO Collaborating Centre for Policy and Training on Access to Pain Relief. Since 1996, he has been working with the WHO Collaborating Center at Madison-Wisconsin and with Government of India to improve opioid availability in India. The work has so far resulted in simplification of narcotic regulations in 13 states in India as well as in uninterrupted availability of oral morphine from the Government Opium and Alkaloid factories in India.
He is Chairman of Pallium India, a charitable trust that he founded in 2003 which aims at improving coverage with quality in palliative care in India, and is a member of the Opioid Availability Committee of Indian Association of Palliative Care.
In 1993, he was one of the founders of Pain and Palliative Care Society (PPCS) in Medical College, Calicut. In 1995, it was recognized as a model demonstration project by the World Health Organisation, known for its suitability to the socio-cultural needs of the country, for its novel training programs and for its roots in the community. Over ten years, it developed into the biggest Palliative Care Centre in the country incorporating a major “Institute of Palliative Medicine” (IPM), with more than 60 link centres in various parts of Kerala.
He was prime mover of the development of National Standards for Palliative Care in India in 2006-2008, and is a member of other health-related committees at international-, national-, and state- level.
Rajagopal holds a Bsc in Zoology (1965) from St Berchman’s College, University of Kerala; an MBBS (1971) from the medical college of Trivandrum, University of Kerala; an MD (Anaesthesiology)(1976) from the All India Institute of Medical Sciences, New Delhi; and an M.N.A.M.S (Anesthesiology) (1977) from the National Board of Examinations, India.
Paul Sebastian has been Director of the Regional Cancer Centre, Trivandrum, India (RCC) since 2009. He completed his MBBS and MS Surgery in 1980 and 1985 respectively from Government Medical College, Trivandrum, India. He received higher training in palliative care from Sir Michael Sobell House, Oxford, UK under Dr. Robert Twycross and from other hospices in the UK.
He significantly contributed to the establishment of the Pain and Palliate Service at the RCC in 1986, one of the first such services in the country based on WHO principles. He has played a major role in making oral morphine available in the RCC and also setting up in-house production facility for liquid morphine.
He was instrumental in developing RCC as a major centre for teaching and training in oncology including palliative care by starting several recognized courses and fellowship programmes. Providing affordable, accessible and equitable cancer care to all is a major interest of his. His research interests include prevention and early detection of cancer, development of simple, low cost treatment strategies for cancer suitable for countries with limited resources and palliative care. For his contributions, he was awarded the Best Doctor Award by the Government of Kerala in 2008.
Nandi Siegfried (Guideline Methodologist)
Nandi Siegfried MBChB, MPH (Hons), FCPHM (SA), DPhil (Oxon) is a public health medicine specialist committed to improving the health of the South African people and global health through evidence-based research. She provides independent consultancy in clinical epidemiology, knowledge translation, and organizational review to national and international organizations. In the last five years she has provided technical support, expert input, and facilitation to several World Health Organization Clinical Guidelines Development processes in the HIV/AIDS and nutritional fields using the GRADE approach. Prior to establishing her own consultancy in 2011, she was co-Director of the South African Cochrane Centre at the Medical Research Council (MRC) and established the MRC Clinical Trials Support initiative. In addition to consulting, she is a Chief Specialist Scientist (part-time) at the MRC, a Research Associate at the University of Cape Town Centre for Infectious Diseases and Epidemiology Research, and an Assistant Clinical Professor in the Department of Epidemiology and Biostatistics at the University of San Francisco, USA. Dr Siegfried enjoys lecturing and continues to provide supervision and mentoring to students and colleagues.
Catherine Stannard, MB ChB, FRCA, FFPMRCA, works at the Pain Clinic in Southmead Hospital, Bristol, in the United Kingdom. She is an acknowledged national and international expert on prescribed opioids and other analgesics for pain (of whatever diagnosis). She is the lead editor of the definitive international textbook on evidence in pain management and is a board member of the International Association of Pain Systematic Reviews and Outcome Evaluation group. She is an active member of the Cochrane Collaboration Pain, Palliative and Supportive Care Group and was NICE guideline group member for Opioids in Palliative Care and Safer Use and Management of Controlled Drugs.
In addition to membership of clinical and policy committees, she has developed and chaired three national clinical and policy collaborative initiatives in the UK:
- Opioids Aware, a resource to support safe prescribing of opioid medicines for acute, cancer and persistent pain.
- Advice to prescribers on the risks of misuse of gabapentin and pregabalin.
- Pain management in secure settings.
She has published and lectured widely on the use and limitations of prescribed medicines for pain relief to a diverse spectrum of clinical and policy audiences. She has experience in written and broadcast media on issues relating to pain and its management generally and use of prescribed medicines in particular.
Professor Turner MBBS, PhD, FRANZCP, is a consultation-liaison psychiatrist with 25 years’ experience in treatment of patients with cancer and their families, across all tumour streams, including expertise in treatment of patients in the terminal phase. She is based in Brisbane at the University of Queensland, where she has worked for twenty years. She has extensive experience in the development of evidence-based clinical practice guidelines, including chairing four working groups. These roles encompass determination of key questions using PICO format, evaluation of evidence and quality, collation into clinically-meaningful recommendations, and engagement in implementation including development of consumer versions. She chairs the Clinical Practice Guidelines Working Group of the International Psycho-Oncology Society and the Cancer Australia working group, convened to revise and update “Clinical Practice Guidelines for the Psychosocial Care of Adults with Cancer”. Based on that work, she chaired a multidisciplinary group that developed “Clinical Guidance for Responding to Suffering in Adults with Cancer”.
Dr Vanderpuye is a radiation and medical oncologist practicing at the National Centre for Radiotherapy and Nuclear Medicine, Korlebu Teaching Hospital, Accra, Ghana, where she has worked the past 15 years.
She took medical training at the Kwame Nkrumah University for Science And Technology, Kumasi , Ghana from 1984-1990 and graduated with an MBChB degree. Her radiation oncology training was under an IAEA fellowship at the Howard University Hospital 1995-1999 and a subsequent UICC fellowship in medical oncology at the University of Chicago 2002-2003. Her main expertise is in management of breast, gynaecological, gastrointestinal and genitourinary cancers with chemotherapy and radiotherapy. She has much experience of pain management with medication and radiotherapy; at least 50% of her patients present with incurable, late-stage disease. She is part of the palliative team at the National Centre, and is a training coordinator for oncology in the postgraduate medical college in Ghana. She is a member of most of the major African oncology societies and currently the Secretary Treasurer-elect for the African Organization for research and training in cancer (AORTIC).
Verna Walker-Edwards graduated in 1988 from the College of Arts Science and Technology with a diploma in Pharmacy. In 1989, she became a registered pharmacist with the Pharmacy Council of Jamaica and has been registered for the past 27 years. Her experiences in the field of pharmacy include community, distribution hospital and regulatory pharmacy. In 2007, she was elected president of the Pharmaceutical Society of Jamaica for two years after serving in several capacities as Secretary, Vice President and a member since 1991. During her tenure, the Society celebrated eighty years as an organization representing the profession of Pharmacy in Jamaica. In 2008, she commenced the International Pain Policy Fellowship, University of Wisconsin, Carbone Cancer Centre, which continued for four years. Her research topic for the Masters programme will be the ‘Pharmacist's role in dispensing opioids for acute and chronic pain’. Verna works in the Standards and Regulation division in the Ministry of Health, Jamaica.