Elsevier

The Lancet Oncology

Volume 8, Issue 5, May 2007, Pages 430-438
The Lancet Oncology

Historical Review
From margins to centre: a review of the history of palliative care in cancer

https://doi.org/10.1016/S1470-2045(07)70138-9Get rights and content

Summary

Palliative care and hospices have developed rapidly since the late 1960s. The pioneering work of Cicely Saunders was instrumental in drawing attention to the end-of-life care needs of patients with advanced malignant disease. Palliative care began to be defined as a subject of activity in the 1970s and came to be synonymous with the physical, social, psychological, and spiritual support of patients with life-limiting illness, delivered by a multidisciplinary team. Palliative care services have developed in many settings and have often been closely related to oncology. The worldwide need for this type of care remains much greater than the available provision, but there are encouraging signs of recognition by policymakers and influential bodies, and interest in palliative care has never been greater. This paper charts the modern history of such care around the world and concludes on some current issues and future challenges.

Introduction

In 1959, Cicely Saunders (figure 1), newly qualified in medicine and working as a research fellow at St Joseph's Hospice in Hackney, London, UK, was engrossed in the preparation of her first major medical publication.1 Writing at the request of the surgeon Ronald Raven, her chapter on “The Management of Patients in the Terminal Stage” was the only important contribution of its kind to a major six-volume series on cancer. At that time, there were only a handful of hospices in the UK, each run by a religious foundation.2 Little published research existed on the subject of caring for dying patients,3 the modern hospice movement was yet to get under way,4 the term palliative care had not come into common use,5 and no professional societies had been formed to promote interest in the subject.6, 7 Furthermore, the emerging specialty of clinical oncology was showing little interest in the care of those dying from cancer. 40 years on, in 1999, the British government appointed a national director to reform and improve cancer services. This so-called cancer tsar was Mike Richards, a breast cancer specialist and professor of palliative medicine.8 He built on the work of the Calman–Hine report9 and the UK Government's Cancer Plan10 to implement a programme of reform to cancer services, which now gives a core place to palliative care, and which, in collaboration with other groups, is also extending to a national strategy for end-of-life care.11

In only four decades, the care of patients with advanced malignant disease and the management of their symptoms during the trajectory of illness has moved from the margins of oncological practice to the very centre of modern cancer care. The way in which this advancement occurred is the subject of a still unfolding history and one which involves the emergence of palliative medicine as a subject of specialisation in a growing number of countries. This worldwide development of palliative care is deeply rooted in the specialty of oncology, which has shaped the conceptual model of palliative care, produced some of its major leaders and innovators, and provided a population of patients with the obvious potential to benefit from a new approach to the management of those with advanced disease.

This article reviews the history of modern hospice and palliative care and concludes with some issues about future development. This Review draws on a programme of original studies (directed by the author) that goes back to 1995 and which now forms part of the work of the International Observatory on End of Life Care at Lancaster University, UK. This programme contains a large and growing oral history collection and associated digital archives and has been responsible for the cataloguing and safe storage of the personal papers of several key figures in the history of the modern hospice movement. Furthermore, the programme includes a major collection of published works, offprints, reports, and grey literature, and has been responsible for extensive bibliographical cataloguing of key works in this specialty.12

Section snippets

Oncological origins of the modern hospice and palliative care

In the 1950s, professional and public interest in cancer was mainly focused on the potential for curative treatment, and a patient dying from cancer was, at best, overlooked and, at worst, abandoned by physicians who told their patients to go home, as there was nothing more that could be done. Concern about the medical neglect of patients dying from cancer was, in part, stimulated by the findings of early research that began to appear in the postwar years, and which marked a shift within the

St Christopher's Hospice

In 1967, Saunders and her colleagues opened the world's first modern hospice in London, UK, where clinical care, teaching, and research were combined within an overall philosophy that was seen as a middle way between too much and too little treatment. St Christopher's Hospice (figure 3) quickly became a source of inspiration to others, and sought to establish itself as a centre of excellence in a new specialty, giving equal weight to clinical care, education, and research.

In the early days, the

Specialisation

As hospices and palliative care in the UK underwent a vigorous period of expansion in the 1980s, three factors conjoined to build a platform for the broad consolidation of this active discipline: a medical association was formed to support its practitioners; a scientific journal was established; and recognition was given to palliative medicine as an area of specialisation.47 By 1985, plans were being developed in the UK for the creation of an association to represent the interests of physicians

Cancer pain

Before the 1970s, pain caused by cancer had received little international attention as either a clinical or a public health problem and was often regarded as an inevitable, not fully controllable, consequence of the disease.51, 52 The spread of modern hospices and palliative care and the increasing number of studies being done on this subject encouraged a small number of pioneering oncologists to organise the first International Symposium on Cancer Pain, held in Venice in 1978.53 Research

International collaboration

From the 1980s, pioneers of hospices and palliative care worked to promote their goals in many countries, increasingly building on international networks of support and collaboration (figure 5).58 In 1976, the First International Congress on the Care of the Terminally Ill was held in Montreal, Quebec, Canada, and was then organised every 2 years thereafter by Balfour Mount and colleagues. In 1980, Josefina Magno and others formed the International Hospice Institute, which, in 1999, became the

Future challenges

In 2006, a detailed picture emerged from the first study to our knowledge ever to attempt an estimate of the global provision of palliative care.87 In total, 115 of the world's 234 countries have established one or more hospice–palliative care services. However, only 35 (15%) of the 234 countries have achieved a measure of integration with other mainstream service providers together with wider policy recognition. Such a picture must be set against the stark realities of global need: 56 million

Search strategy and selection criteria

Information for this Review was found by hand and electronic searches in the English language using the following key words and phrases: “hospice”, “palliative care”, “cancer pain”, “history”, and “international development”. The search was limited to papers published between 1945 and 2007.

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