Innovations In Cancer Pain Relief: Technologies, Ethics And Practices

Abstract

We estimate that almost 5 million people worldwide are experiencing unrelieved pain from their cancer. Yet it has been argued that the knowledge and skills required to alleviate cancer pain are now well established. Our study focuses on innovations in cancer pain relief and adopts and inter-disciplinary approach, combining perspectives from sociology, history, bio-ethics and the clinical disciplines. We view "cancer pain" as a multi-faceted phenomenon subject to cultural filters that shape and influence not only how it is perceived, but also its clinical management in different contexts and the extent to which resources are made available to relieve it. We focus on the problem of understanding how innovations in cancer pain relief take place and how they make an impact, It is proposed to analyse this in two case studies: clinical innovation and public health innovation. Each case study will make use of documentary analysis and primary data collected from interviews with key innovators and will incorporate an ethical reflection to establish to what extent the ethical governance of innovation in cancer pain relief can be enhanced in the future. The case study of clinical innovation will focus on the dynamic interplay between clinicians, researchers patient groups and the pharmaceutical industry in generating innovative approaches to cancer pain relief in the form of new drugs and modes of delivery. The case study of public health innovation will examine the variable impact of clinical innovation at the societal and population level, in the context of strategic approaches developed by the World Health Organization. Through the varied roles of clinicians, patient groups, pharmaceutical companies, researchers and health planners, the study will work towards the production of a statement to inform the improved ethical governance of cancer pain relief innovation in the future.

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Summary

Background

Worldwide, we estimate that some 67-80% of cancer patients are currently suffering from under-treated pain. Yet, it has been argued that the knowledge and skills required to alleviate cancer pain are well established. This study will shed light on some of the processes that contribute to this mismatch by addressing cancer pain as a clinical problem, as a public health problem, and in particular as a moral and ethical problem. The study will assess the global development of innovative technologies for cancer pain relief, since 1945, making use of sociological, historical and ethical perspectives. Particular attention will be paid to drivers of innovation, variations in application, links to structural inequalities, and associated cultural and moral meanings.

Research Design

The study will be conducted in two phases. It will be supported by a multi-disciplinary reference group comprising key individuals from the clinical and social sciences of pain, health care ethics, health care policy and the pharmaceutical industry.

Phase one: A narrative history of cancer pain relief since 1945
We will identify key forms of technological innovation in cancer pain relief since 1945. These will include: new pharmaceutical inventions and discoveries; the redeployment of technologies from other areas of health care; and the public health 'technology' of policy and strategic planning.

Phase two: Case studies of innovation
Two case studies of areas of innovation will be carried out. In these, documentary analyses will be complemented by interviews with key innovators, and an analysis of primary data collected in other studies. Each case study will incorporate an ethical component.

· Case study one: clinical innovation.
This will encompass an analysis of key post-war innovations in clinical practice. These are issues of direct importance to the individual patient, including the development of new applications of morphine and related opioids, new modes for their delivery, and the increasing orientation to 'quality of life' as an outcome in their measurement.

· Case study two: public health innovation.
This is concerned with cancer pain relief at a population level, focussing on strategies to minimize or eradicate cancer pain within whole populations, nationally and internationally. It will particularly consider the work of the World Health Organization in identifying cancer pain as a global health problem.

Policy and Academic Implications

This study is unusual in bringing together historical, sociological, clinical and ethical perspectives on how particular ways of managing cancer pain have been adopted. Our approach will allow an understanding of how issues of culture, history and politics are reconciled with consequences and costs of market led innovation. It has the potential to impact upon policy at two levels:

1. It is directly relevant to the UK government's current concerns to improve the quality and availability of cancer services.
2. It will suggest improvements in the way that cancer pain relief technologies are harnessed to relieve suffering in international contexts.

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Contacts

Professor David Clark

Dr Jane Seymour

Dr William Noble

Professor Henk ten Have

Dr Marcia Meldrum

Dr Silvia Paz

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Outputs

Book Chapters

D. Clark "Rise and demise of the Brompton cocktail" in Opioids and pain relief : a historical perspective Ed. Meldrum, Marcia International Association for the Study of Pain

Conference Papers

'Technologies of cancer pain relief 1945-2000: concepts, practices, voices'
Michelle Winslow, David Clark, Jane Seymour, Bill Noble, Henk ten Have, Marcia Meldrum, Silvia Paz
Devices and Designs: Medical Innovation in Historical Perspective', Manchester, July 11-13
http://www.chstm.man.ac.uk/events/innovation/program.htm

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News

Article in the ESRC's The Edge Magazine - Huge Inequalities in Cancer Care Issue 17, Nov 2004, Page 9

http://www.esrc.ac.uk/esrccontent/DownloadDocs/edge_Nov2004.pdf

History of Palliative Care- looking back, taking stock, looking forward
Palliative Care Section
Royal Society of Medicine, London 13 November 2003-11-27

This well attended meeting brought together leading figures in the field of palliaitve care, to reflect on its development to date and to explore issues relating to its progress in the future. Opened by presentations from Sir Kenneth Calman and Professor Michael Richards, the programme also included talks from Professor Irene Higginson, Professor Geoff Hanks, Dr Derek Doyle, Dame Professor Ilora Finaly and Dr Elizabeth Thompson.

Professor David Clark of Lancaster University talked about the modern history of hospice and palliaitve care and drew on the work of the Hospice History Project and also the Sheffield-based IHT study of innovations in cancer pain relief.

Project group Newsletter # 2 October 2003 available here - pdf

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