Cyprus is the third largest island in the Mediterranean Sea and joined the European Union in 2004. It was a former British colony, which achieved independence in 1960 and is situated south of Turkey and west of Syria and Lebanon.
Its Cypriot population in 2010 was estimated to be 800,000. There are a number of non-Cypriots currently living in Cyprus. Most of them are British migrants and several overseas workers from Vietnam, Philippines, and Sri Lanka. Cyprus also hosts refugees from some Middle East countries. Therefore, the total population of Cyprus as of the end of 2010 was slightly under 1 million.1
CYPRUS HEALTH SYSTEM
Cyprus health system is of good standards. Life expectancy is high at 79 years for men and about 82 years for women. Infant mortality is low at 5 infant deaths per 1000 of the population. Further, crude death rate is at 6.9 persons per 1000 of the population.1
Government hospitals are located in all major cities. Smaller government-run hospitals and clinics are present in other areas of the island. There are also a number of private hospitals and clinics run by medical practitioners. All medical practitioners were trained overseas as there is no medical school in Cyprus.
Medical care is provided by the government medical services and the private medical sector. The government medical services can be used by anyone who chooses to be treated at a public medical institution. The government medical services provide treatment free of charge for all patients with cancer. Patients with cancer, who opt to have their treatment in the private sector, can get all the oncology drugs free from the government pharmacies. European citizens residing permanently in Cyprus are entitled to receive essential medical care in government hospitals provided they hold the European health insurance card. The members of the family of the holder of the card are similarly entitled.
Every year in Cyprus, more than 2000 people are diagnosed with cancer. There are approximately 15,000 patients with cancer in Cyprus at any one time (Table 1).
There are currently 3 centers in Cyprus offering services to patients with cancer , the 2 Oncology Departments at the Nicosia and Limassol General Hospitals and the Bank of Cyprus Oncology Center in Nicosia. There are also a number of private oncologists, practicing medical oncology and hematology and they are mostly situated in Nicosia.
The Nicosia and the Limassol General Hospital have Oncology and Hematology departments offering the following services (except radiotherapy):
- Hormone therapy
- Inpatient service
- Outpatient service
The Bank of Cyprus Oncology Center was created after an agreement, signed in 1992, between the Cyprus Government and the Bank of Cyprus. The agreement provided for the following:
- Usage of a donation by the Bank of Cyprus, of about 12 million Euros, for the construction and equipping of the center.
- Provision by the Government of land next to Makarios Hospital in Nicosia.
- Financing of annual operating expenses by the Government.
The center provides the following services:
- Hormone therapy
- Diagnostic examinations including blood tests and radiologic investigations
- Inpatient service
- Outpatient service
In all 3 oncology units supportive care and some palliation is offer at the end of life to patients with cancer. Patients with cancer, and their families, may opt for the patient to stay in 1 of these oncology units, where they can receive specialist pain and symptom relief, or they may wish to self-refer or be referred to 1 of the 2 organizations providing the full range of palliative care cancer services.3 There are no private palliative-care services available.
There are no specialist palliative-care services for children or for patients with other life threatening illnesses such as acquired immunodeficiency syndrome.
Palliative care in Cyprus is divided mainly between charities and oncology departments. General hospitals and private clinics have very limited impact on palliative-care services. Services are diverse, reflecting wide variation in the density of the population of Cyprus.
There are currently 2 major nongovernmental organizations (NGOs) providing palliative-care services in Cyprus: The Cyprus Anti-Cancer Society and the Cyprus Association of Cancer Patients and Friends (PASYKAF). Over the last couple of years 2 new NGOs providing only palliative hospice care were established in Cyprus, 1 in Paphos, the Friends of the Paphos Hospice and 1 in Limassol, the Friends for Life (Table 2).
Cyprus Anti-cancer Society (ACS)4
The ACS was established in 1971 and in 1976 the society established a hospice in Nicosia (Arodaphnousa), which was dedicated to nursing patients dying of cancer. In 2000 the hospice was officially recognized as a palliative-care center and is now an 18-bed inpatient facility. The patients do not pay for the services provided, such as doctors, nurses, drugs, physiotherapy, psychosocial support, food etc. The Arodaphnousa Hospice has increased the number of patients treated each year in the inpatient unit by reducing unnecessary and lengthy inpatient stays. Once symptoms are controlled patients are able to return home, only returning for inpatient treatment if needed.
The society offers home-care service (medical and nursing care, psychosocial support, and physiotherapy) and has also day-care centers where a range of other services which can include music and art therapy, aromatherapy, reflexology, massage, hairdressing, and manicure are being provided. Free transportation is also provided for patients to oncology centers to access treatment or consultation in Nicosia from Larnaca, Limassol, and Paphos. Over the last 5 to 10 years the society developed a multiprofessional palliative-care team that offers up to dated palliative-care service in all towns.
Patients, or their families, can self-refer to the society. Gradually, since the mid-1990s, as links have improved with the oncology centere, more patients are referred by oncologists.
Cyprus Association of Cancer Patients and Friends (PASYKAF)5
The Cyprus Association of Cancer Patients and Friends (PASYKAF) is a NGO and depends mainly on fundraising events and public donations to maintain the provision of the services. The association has also charity shops in Limassol, Larnaca, and Paphos. It was first established in 1986. The services are provided in every district of Cyprus and are all free of charge.
The main objectives of the association are:
- To promote public awareness regarding prevention and early detection of cancer.
- To educate health care professionals in oncology and palliative care.
- To provide services to improve the quality of life for patients and their families.
The association has the following services:
- Home Care: It is provided to patients who require nursing and medical support in the comfort of their own home. Support provided may involve short episodes of care during any stage of therapy. For patients who have advanced disease the aim of care delivery is to promote comfort by relieving pain and other distressing symptoms. Maintaining dignity and patient autonomy is an integral part of their care commitment.
- Day Care: Patients enjoy a social and activity group, which provides companionship, friendship, and support. Activities include music, exercises, craftwork, and excursions.
- Psychology and Social Support: Patients and relatives are offered group support, self-help or individual therapy and guidance during the course of the illness and in bereavement.
- Physiotherapy: Home-care team is complemented by the provision of physiotherapy that assists in the rehabilitation of patients after therapy or simply to promote well-being and quality of life. Practical aids are also loaned, such as wheelchairs, pressure relieving mattresses, etc.
- Lymphoedema Service: For patients who have received treatments such as surgery or radiotherapy and potentially can experience swelling of limbs, they provide information, advice, and treatment/management.
- Post Mastectomy Support: After breast surgery ladies can receive advice and be provided with a choice of prosthesis and underwear.
- Transport Service: For those who experience difficulty in finding transport to attend their oncology appointment there is a free bus service that operates Monday to Friday. This service is available in all districts.
Owing to the demand for patient services, today the Cyprus Association of Cancer Patients and Friends uses a team of doctors, nurses, psychologists, physiotherapists, and social workers supported by professional administrators and communicators. Both organizations (ACS and PASYKAF) are being partially funded by the Ministry of Health.
The Friends of the Paphos Hospice6
It is a small voluntary organization, based in Paphos and is a member of the worldwide Hospice movement. It is run by a volunteer committee of trustees, who receive no payment for their time.
Their objective is to provide “palliative, respite, and terminal care” to any persons in need, due to a life-limiting, untreatable illness or condition—without regard to their race, religion, or ability to pay.
It operates since April of 2006 at a private hospital in Paphos, where the organization established its own independent hospice unit. At the moment there are 4 beds available, with occupancy running at around 70%. The number of beds is directly related to the cost and availability of the specialist nursing staff, which are required to provide the 24/7 palliative care. They also take advantage of offers of help from volunteer nurses, carers, and therapists who regularly assist at the hospice.
More than half of the patients have been Greek Cypriots, whereas the others were British and other expatriates. According to their website up to December of 2010 they cared for more than 420 patients.
Their fundingis purely voluntary and entirely charitable—no Government or other official funding is received—the generosity of individual people, organizations, clubs, groups, and they hope local businesses, enables them to provide the comforting environment within which very sick people can receive palliative care. The funding is 100% transparent, all donations are receipted, and their annual accounts are audited, and available on request to donors.
Friends of Life (Limassol)7
Friends for Life' is a registered charitable association that was established in Limassol in 2007. It consists of a group of people who have known and been emotionally affected by someone with a terminal illness, whether it was a relative, a friend, or a colleague.
It provides hospice care for people in Limassol and is at present the only hospice care in the district. They have 3 designated beds at a private clinic and provide:
- Two weeks respite to give carers and families a break
- Symptom control
- Some day care and
- End of life care
The funds needed to run the hospice comes from 2 charity shops, events and donations (Table 2).
To implement effectively the World Health Organization analgesic ladder is of major importance to have available all the medication needed in all 3 steps. In Cyprus the health professionals have at present most of the medications needed to implement all 3 steps. Unfortunately in some countries although the knowledge is available there is only the availability of analgesics for the first 2 steps of the ladder and there is lack of the step 3 analgesics, principally morphine. That is causing a great amount of suffering to the patients and their families and creates frustration to the health professionals (Table 3).
In Cyprus the following drugs are available:
- Paracetamol and propoxyphene (not available after the 1/1/10)
Where necessary, opioids are given by injection and syringe drivers are used for pain relief mainly in home-care patients. The pharmaceutical services in Cyprus are currently examining the possibility of introducing a fast releasing form of oxycodone and methadone for patients with cancer.
At present, my feeling is that we are not ready to handle more opioids than we already have. There is a risk of having too much without knowing exactly what to do with them. There is a lot of basic education that needs to be done especially in the medical profession.
BARRIERS TO EFFECTIVE CANCER PAIN MANAGEMENT (NOT ONLY IN CYPRUS)
It is tragic that despite the availability of straight-forward and cost-effective therapies the management of cancer pain remains still a subject to discuss.
There are a number of factors that we are well documented why pain is not treated appropriate: There are knowledge deficits, beliefs and attitudes by health care providers, by the health care system and by the patient and/or family members. What are the obstacles to pain relief that are mainly seen in Cyprus?
By Healthcare Professionals
Two very important things have to be mentioned: There is no medical school in Cyprus and that assessment and treatment of pain in Cyprus is done mainly by the Oncologists. The obstacles are:
- Lack of medical education related to pain (during medical school training)
- Lack of knowledge (ignorance) or understanding of pain physiology and management
- Inadequate knowledge of medications or other treatment options
- Lack of or inadequate pain assessment (psychosocial issues and severity of pain)
- False judgment of patient
- Concerns about side effects (fear of addiction and tolerance)
- Inadequate access to nondrug techniques for pain relief
- Under treatment
- Little censure for inadequate attention to pain
- Inadequate time-busy clinics
- Access to opioids is not regarded as a problem in Cyprus
- The interdisciplinary team: Role of registered nurse, medical doctor, social worker, pharmacists etc. not existing
By the health care system
- Confusion regarding drug safety
- Restrictive regulation of controlled substances
- Problems of availability of opioids
- Time constrains
- Reluctant to get new drugs into the country
PATIENTS AND FAMILIES
- Reluctance to report pain
- Reluctance to take pain medications
- Poor adherence with the prescribed analgesic regimen
- Concerns about addiction/tolerance/side effects
- Lack of knowledge regarding use of pain medications
- Caregiver burden
To overcome all these we should never stop our efforts educating health care professionals and patients.
CHANGES IN THE PALLIATIVE CARE IN CYPRUS OVER THE LAST COUPLE OF YEARS
ACS and PASYKAF have “matured.” Their health personal has gained more experience providing advice and support for patients and carers with complex problems. This may include emotional support, advice on pain and symptom control, and help to deal with spiritual questions. They are able to assess the palliative-care needs of the patient and can refer him/her to other services to make sure the needs are met. Both NGO's extended their services into the whole Cyprus going into remote villages.
Both associations-funded training programs, such as distance learning courses in palliative care at degree and diploma level for doctors and nurses. They have also organized short seminars and conferences for doctors, nurses, and physiotherapists in different aspects of palliative care such as pain relief, wound management, lymphoedema care; and short courses in psychosocial, communication and bereavement issues, symptom control, and breast cancer.
It was a matter of concern and sadness that there was a lack of hospice care in Limassol and Paphos area. It meant that many patients, who should be receiving hospice care in more suitable and close to their house surroundings, pass away either in the Arodaphnousa hospice in Nicosia or in hospitals. That need was recently covered by the 2 newly established charity organizations in Limassol and Paphos that are providing hospice care. They helped a number of patients to spend the last days of their life in an environment away from the hospital. They also made, especially for the Limassol Oncology Department, where there is a bed shortage, more acute care beds available for other patients.
However, the establishment of these services is not without its critics, many of whom have cited the following problems: lack of service planning, lack of objective evaluation, limited vision, lack of communication etc. The criticism relates to the emergence of hospices through the fundraising efforts of local groups rather than a planned service from the Ministry of Health. This may lead to an imbalance of provision and may influence the evolution of future services. The Ministry of Health appointed at the end of 2010 a team of health professionals that will assess all cancer services in Cyprus and prepare a strategic plan that will include palliative care, hospice services etc.
Unfortunately efforts by 2 oncologists and the Ministry of Health, 2 years ago, to unite the 2 main NGO's (ACS and PASYKAF) failed for a number of reasons. However, it is encouraging that between the health professionals of the 2 associations there is cooperation in a number of medical issues.
Over the last 20 years palliative care in Cyprus made many positive advances. However, there is place for more to be done. Below are summarized some of the points that we have to work on.
- Continuous improvement of the palliative-care services (plan clinical audits, expand and improve the care in the small hospices in Limassol/Paphos and established 1 in Larnaca/Famagusta area or dedicated beds for terminally ill patients in the local hospital, necessity of 24-hours medical cover in the home-care teams—at present they cover from morning up to 18.00)
- Continue to contact and educate general practitioners, medical doctors, and nurses and raise awareness of the importance and possibilities of palliative care
- Improve the communication between home-care teams and oncologists
- Postgraduate training should be facilitated and encouraged. General practitioners should be sent for a palliative care course or visiting a hospice in Cyprus or overseas.
- Maintain and improving cooperation with the existing international network of palliative care organizations
- Change the curriculum of the nursing school to include more palliative care
- Get knowledge about invasive techniques
- Government funding to take over the rising costs of the palliative care teams of the charity organizations
- Promotion of service to encourage referrals
- Get all palliative care associations together—under an umbrella.
PATIENT AND FAMILY
- Current, accurate information
- Use available resources
- Involve family and caregivers
- Know patient knowledge base
- Address patient priorities first
- Small doses of useful information (eg, side effects)
- Individualize to patient (social, education level)
The Ministry of Health is planning introducing a new health system for the island. Palliative-care services must respond to the changes in management brought about by changes to the Health System, with both purchasers and providers reexamining their patterns of cancer care.
Cyprus is due soon to have a medical school. Palliative medicine should be one of the topics, which should be covered during medical student training. It is recommended that a designated member of the medical school staff take responsibility for implementing the syllabus and coordinating teaching to ensure a systematic approach to the subject.
There are encouraging signs in the management of terminally ill cancer patients in Cyprus. For example, there have been significant advances in symptom palliation, particularly in pain control, and the professions involved in cancer care have improved their knowledge and sharpened their emphasis on maximizing the quality of life of patients with cancer. There is still a lot of room for improvement, so the efforts should never stop. It is therefore mandatory to review again and again palliative-care services to ensure that these benefits are made available to all patients with cancer. Discussion locally and nationally with purchasers, providers, and professional bodies should continue.
All palliative care associations should work together under an official body such as a Palliative Care Committee or a Cyprus Association of Palliative Care. If the Ministry of health does not take the initiative then either the Cyprus Oncological Society or even the palliative care associations themselves should do that. Greater leadership will be needed from individual health professionals, organizations, the government, international bodies etc. The size and complexity of the task is huge but is worth trying.
Good care for patients with cancer, including the relief of pain at the end of life and the opportunity for a dignified death, should be regarded as basic human rights to which everyone should have access when the time comes.9