Conclusions

The evidence that has emerged during the production of this chapter shows that people with advanced cancer can be construed as "survivors." The general palliative care literature tends to "frame" these same people as "dying" but in many ways that is incorrect except in the final stages of physical deterioration. An alternative is to view these people and their family caregivers as "cancer survivors." Increasingly cancer patients will live for longer periods with the knowledge of their advanced disease and the threat ofrecurrence. These represent both physical and psychological challenges for individuals. This chapter has reviewed the consequences of physical impairment, changes to appearance, functional limitations and psychological sequelae. There has been a tendency in my view to seek to identify pathology instead of recognizing the profound adaptations required and the resilience of many cancer survivors. The chapter has also reviewed the social impact for patients and family members.

Many patients and family are fortunate to receive high quality, comprehensive and well-coordinated multidisciplinary cancer care. The development of specialist palliative care services and hospice programs throughout the world have made dramatic improvements to the lives of those who are able to access these services but in most countries these people remain the minority. Calls to extend the principles of palliative care to all cancer patients who may benefit have been made.81 This requires a radical shift in the organization, management and funding of these services so they become part of standard oncology provision. They also need to be made available in flexible formats in response to differing social circumstances and preferences about place of care. These new ways of extending the remit of supportive palliative care rather than merely focusing on terminal care have been proposed to be health enhancing.82 They require new ways of thinking from government agencies, major cancer charities and of course, support from the communities in which they are embedded. We need to look to exciting new models of community-based nonprofessional palliative care emerging from less well-resourced countries such as India.83

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