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www.thelancet.com/oncology Vol 15 April 2014 e158

Survey fi nds barriers to palliative care at homeTwo research projects commissioned by Marie Curie Cancer Care have drawn attention to shortfalls in community-based palliative care.

In the fi rst, a survey of 1003 family doctors across the UK, 61% stated that their terminally ill patients were not adequately cared for at night and at weekends, and fewer than half believed that these patients had continual access to pain relief. The second, a report based on conversations with terminally ill patients—most of whom had cancer—and carers, off ered persuasive anecdotal support. “Families report witnessing a convoluted process, with a doctor required to be present to prescribe, but not administer pain relief”, wrote the authors. Carers talked of having to chase prescriptions and delays in receiving prescriptions at night.

There are provisions for patients at risk of deterioration to be provided

with anticipatory boxes of pain medications, but they still require a doctor’s instruction and a district nurse to administer the injection. All this takes time. “We know that most people don’t want to die in hospital”, explains Marie Curie’s Phil McCarvill. “If we want to move people out of hospitals into places where they want to be, then we need to improve the quality of all aspects of care that can be provided in the community”.

Part of the problem is the number of diff erent agencies involved in community- based care for terminally ill patients. Most family doctors are not contractually responsible for out-of-hours services (although they do liaise with the doctors who run the services) so a patient requiring assistance outside of offi ce hours will often fi nd themselves transferred to

hospital by a physician who does not know them, despite their wishes to die at home. “There are too many stories of patients who have had plenty of planning and then a crisis happens out of hours and it all breaks down”, Bill Noble, Medical Director at Marie Curie and editor of BMJ Supportive and Palliative Care, told The Lancet Oncology.

Ensuring that on-call specialist palliative care services are widely available—which is by no means currently the case—would go some way to resolving this issue, as would ensuring that services are fl exible and responsive to patients’ wishes. “At the moment, there are a lot of forces that keep someone who is very ill in hospital, and very few that help them get home”, concluded Noble.

Talha Khan Burki

Increase of thyroid cancer in children from Fukushima?The number of children with diag-nosed or suspected thyroid cancer in Fukushima is increasing, according to latest fi gures from a regular health survey started after the nuclear disaster in 2011.

The Fukushima Health Management Survey regularly collects health data for people living in the Fukushima prefecture at the time of the meltdown on March 11, 2011—3 years ago this week. It includes regular thyroid ultras ound in people aged 18 years and younger; 254 280 tests have been done so far (81% of the target population).

The latest fi ne-needle aspiration biop sy and cytology results from the 1490 children undergoing further testing after ultrasound, detected ten cases that were suspicious or malignant, bringing the total to 33 cases of confi rmed and 42 suspected diagnoses of thyroid cancer identifi ed since 2011.

“This indicates a signifi cantly higher incidence than the expected 1–2 per million cases of thyroid cancer in 10 to 14-year-old Japanese children”, commented Kristien Boelaert (University of Birmingham, UK).

“It is unclear whether these fi ndings refl ect the induction of molecular alterations in the childhood thyroid, which is exquisitely sensitive to radiation-induced carcinogenesis, or if they can be attributed to the fi nding of small and potentially incidental lesions due to intensive screening with high-resolution ultrasound”, she said.

David Shaw (University of Basel, Switzerland) said: “To reach any conclusion about an increase in cancer rates related to the disaster, a screening control group in an un aff ected area is required”. He considered it “unfortunate” that this had not been done in Japan.

Boelaert noted that the fi rst recorded cases of thyroid cancer after

the Chernobyl accident occurred 3–4 years after exposure—longer than the Fukushima survey so far—and in people exposed to higher radiation doses. Estimated radiation dose exposure in the 4 months after the Fukushima accident was below 1 mSv in 15 of the 24 children with diagnosed or suspected thyroid cancer who have had results from baseline estimates.

Shinichi Suzuki, who leads the thyroid-screening programme at Fukushima University Medical School, told Japanese press that the team is now analysing cancerous thyroid tissue from the children to look for radiation-induced mutations.

Shaw recommended setting up an internationally accessible biobank of samples from people potentially aff ected by radiation to further understanding of the extent and eff ects of exposure.

Susan Mayor

Published OnlineMarch 14, 2014 http://dx.doi.org/10.1016/S1470-2045(14)70123-8

For the survey of family doctors see http://www.mariecurie.org.uk/en-GB/Media/Press-releases-and-comments/Marie-Curie-Wales-calls-for-around-the-clock-care-for-terminally-ill-/

For the report see http://blog.mariecurie.org.uk/wp-content/uploads/2014/03/S691-Diffi cult-Conversations-report.pdf

Published OnlineMarch 14, 2014 http://dx.doi.org/10.1016/S1470-2045(14)70122-6

For more on the survey see www.fmu.ac.jp/radiationhealth/history/

For the survey results see www.fmu.ac.jp/radiationhealth/results/media/14-2_ThyroidUE.pdf

For Shinichi Suzuki’s comments to Japanese press see ajw.asahi.com/article/0311disaster/fukushima/AJ201402080047

For a more on the biobank see Comment Lancet Oncol 2013; 14: 1042–43

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