PALLIATIVE CARE &
SUPPORTIVE THERAPY

Palliative care is specialised medical care focused on relieving the symptoms, pain, and stress of serious illness — delivered alongside curative or active treatment, not instead of it.

“Palliative care is not the end of treatment; it is the infrastructure that helps patients endure and complete it.”

• What Palliative Care Is

  A formal, team-based discipline addressing physical symptoms, psychological distress, spiritual concerns, and practical needs — for patients and families at every stage of cancer.

• What Palliative Care Is Not

  Not hospice care. Not "comfort care only". Not a substitute for active treatment. It runs concurrently with curative and life-prolonging therapy from the point of diagnosis.

• Supportive Therapy — The Broader Term

  Supportive therapy encompasses all non-disease-directed interventions: anti-emetics, nutritional support, growth factors, rehabilitation, and psychological care — even during curative treatment.

• Primary vs Specialist Palliative Care

  Primary palliative care is delivered by all oncologists and nurses (basic symptom management). Specialist palliative care is delivered by dedicated teams for complex symptom needs or difficult care decisions.

The most critical distinction in supportive oncology: hospice is a type of palliative care, but palliative care is far broader than hospice.

Supportive therapy is a coordinated set of clinical services addressing every dimension of patient wellbeing throughout the illness.

• Physical Symptom Management

  Pain control, nausea management, fatigue, dyspnoea, and treatment of functional decline — with the goal of maintaining treatment tolerability and quality of life.

• Nutritional Support

  Dietetic assessment, high-protein supplementation, enteral or parenteral feeding when needed, and specific management of cancer cachexia.

• Psychological & Psychiatric Care

  Routine distress screening, individual psychotherapy, pharmacological treatment of anxiety and depression, couple and family therapy, and anticipatory grief support.

• Social & Practical Support

  Social work services for financial, employment, and housing concerns; caregiver respite; care coordination across settings; and advance care planning assistance.

• Rehabilitation

  Physiotherapy, occupational therapy, speech and language therapy, and structured exercise — before, during, and after cancer treatment.

The landmark Temel et al. trial (NEJM 2010) randomised metastatic NSCLC patients to standard care vs early palliative care from diagnosis.

• 11.6 moMedian Survival — Early PC Groupvs 8.9 months in the standard care group — a significant survival advantage.
• ↓ DepressionLower Clinical Depression RatesPatients receiving early palliative care had significantly less depression.
• ↓ Aggressive EOL TxLess Aggressive End-of-Life TreatmentFewer received high-intensity chemotherapy in the last weeks of life.
• ASCO EndorsedGuideline RecommendationASCO recommends palliative care integration from diagnosis for advanced cancer.

Cancer pain is the symptom patients fear most and the one most amenable to effective management. Undertreatment remains a global problem.

“Effective pain management is not a luxury — it is a fundamental component of cancer care and a patient right.”

• WHO Analgesic Ladder

  Step 1: non-opioids (paracetamol, NSAIDs) for mild pain. Step 2: mild opioids (codeine, tramadol) for moderate pain. Step 3: strong opioids (morphine, oxycodone, fentanyl) for severe pain. Adjuvants added at any step.

• Interventional Pain Approaches

  Coeliac plexus block for pancreatic pain, intrathecal drug delivery, palliative radiotherapy for bone pain, surgical fixation of pathological fractures, and ketamine infusions for refractory neuropathic pain.

Supportive therapy for treatment toxicity is the infrastructure that allows effective cancer treatment to be delivered safely and completely.

Malnutrition directly impacts treatment tolerance, surgical outcomes, immune function, and survival. Early nutritional intervention is more effective than late-stage management.

“Cancer cachexia cannot be fully reversed by increasing caloric intake alone — it requires specific metabolic and nutritional intervention.”

• Cancer Cachexia

  A complex metabolic syndrome: involuntary weight loss, muscle wasting (sarcopenia), reduced appetite, and systemic inflammation. Common in pancreatic, gastric, lung, and head and neck cancers. Directly associated with worse outcomes and greater toxicity.

• Nutritional Interventions

  Early dietetic assessment and personalised planning; high-calorie/high-protein supplementation; enteral nutrition (NG or PEG tube) when oral intake is severely impaired; parenteral nutrition when GI tract cannot be used.

• Timing Is Critical

  Routine nutritional screening at diagnosis, regular dietetic assessment, and proactive intervention before significant weight loss has occurred are the standard at comprehensive cancer centres.

Clinically significant anxiety and depression are substantially more prevalent in cancer patients than in the general population. Left unaddressed, psychological distress worsens pain perception, impairs treatment adherence, and worsens clinical outcomes.

• Psychological Interventions

  CBT for anxiety and depression; supportive-expressive group therapy; mindfulness-based stress reduction; couple and family therapy; pharmacological treatment (antidepressants, anxiolytics) where indicated; anticipatory grief work.

• Spiritual & Existential Care

  Addresses meaning, legacy, values, and fears — for patients of all faiths and none. Research shows patients with attended spiritual needs have better quality of life, less depression, and more peaceful end-of-life experiences.

Structured rehabilitation improves surgical outcomes, reduces fatigue, maintains function during treatment, and addresses late treatment effects in survivors.

1. 1

   Prehabilitation

   Physical conditioning, nutritional optimisation, and psychological preparation before major surgery or treatment. Even brief prehabilitation improves post-operative recovery and shortens hospital stay.

2. 2

   During Active Treatment

   Structured aerobic and resistance exercise to reduce fatigue and maintain muscle mass; respiratory physiotherapy; lymphoedema management; speech and language therapy for head/neck/oesophageal cases.

3. 3

   Survivorship Rehabilitation

   Addresses late treatment effects: post-chemotherapy cognitive changes, persistent fatigue, cardiovascular effects of anthracyclines, post-surgical deficits, and sexual health impacts in patients achieving remission.

Patients with documented goals-of-care conversations are less likely to receive aggressive end-of-life treatments that do not align with their wishes, more likely to die in their preferred setting, and — in some studies — live longer.

• Understand Diagnosis & Prognosis

  Clarify what the patient understands about their cancer current stage, trajectory, and treatment options.

• Identify Patient Values

  What matters most right now — maintaining function, being at home, minimising side effects, or extending life?

• Clarify Treatment Goals

  Is the goal cure, life prolongation, symptom control, or preservation of quality of life? These may change over time.

• Set Treatment Intensity Limits

  What level of side effects or intervention is the patient willing to accept? What are the lines they do not want crossed?

• Advance Care Planning

  Document treatment preferences and wishes in an advance directive or living will so they guide care if the patient cannot speak for themselves.

Palliative care is an evolving relationship that adapts to the patients changing needs throughout the illness — not a single event.

1. 1

   Initial Comprehensive Assessment

   Symptoms, pain, functional status, nutritional state, psychological wellbeing, social situation, spiritual concerns, and understanding of diagnosis — assessed jointly with the patient and family.

2. 2

   Symptom Management Initiation

   Pain medications optimised or started. Anti-emetics, anxiolytics, and supportive medications introduced. Referrals to dietitian, physiotherapist, psychologist, or social worker made as needed.

3. 3

   Ongoing Review and Adaptation

   Regular reviews — aligned to treatment cycles during active therapy, more frequent in advanced disease — adapt the plan as the patients condition evolves.

4. 4

   Goals-of-Care Conversations

   At key junctures — diagnosis of advanced disease, progression, or when options narrow — structured conversations guide treatment decisions and care planning.

5. 5

   Transition to Comfort-Focused Care

   When disease progresses beyond active treatment, the palliative care team ensures symptoms are controlled, the patient's wishes are honoured, and the family is supported through and beyond the patient's death.

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