1. Patterns of Cancer Patients Referred to Palliative in a Tertiary Hospital in Dammam - Saudi Arabia
Dr. Muteb ABOAWJA, MD
Consultant Family Medicine
Palliatve Care Fellowship
King Faisal Medical City - Abha 1

2. Introduction
Identification of epidemiological patterns of cancer diagnoses in a health care practice is considered a baseline in assessing needs, planning health services and assess control measures.
For cancer patients and their families, pain is perhaps the most frightening for patients and their families. Almost 70% of cancer patients suffer some degree of pain, which usually increases with progress of cancer.
Winslow et al. (2005)

3. Pain as a common symptom among cancer patients receiving palliative care services is progressively increasing at the end of life. Almost 70% of cancer patients experience pain during their course of illness.
Therefore palliative care team is concerned with providing better pain control to improve the quality of life of cancer patients.
World Health Organization (2007): Palliative Care. Geneva, Switzerland: WHO 2007.
Fallon M. (2008): When morphine does not work. Support Care Cancer. 16:771–5

4. Changing trends in incidence rates of malignancy patterns have been observed. Generally, the incidence rates for malignancies are slowly declining in the developed countries, while growing in the developing countries
(Maiti and Gangopadhyay, 2012).

5. The identification of the magnitude and pattern of cancer is the first step in determining clues to the cause(s) of cancer and in having a baseline to plan and assess control measures.
(Deshpande et al., 2012).

6. In Saudi Arabia
There were 15,653 cancer cases registered in Saudi Cancer Registry (2013)*
Cancer burden in the kingdom to increase by 5 to 10 fold**
Frist palliative Care in the kingdom was started in KFSH ,Riyadh bed unit , consult services , outpatient clinics).
92% of Saudi cancer patient suffer from pain.***
*Saudi cancer registry. Overview of cancer incidence In: Cancer Incidence Report Saudi Arabia Saudi Ministry of Health 2016; p. 19
**Ibrahim E, Bin S, Banjar L, Awadalla S, Abomelha MS. Current and future cancer burden in Saudi Arabia: Meeting the challenge.
Hematol Oncol Stem Cell Ther 2008;1:210-5.
***Gray AJ, Ezzat A, Volker S. Developing palliative care services for terminally ill patients in Saudi Arabia. Ann Saudi Med 1995;15:370-7.

7. Service availability Very few centers across the kingdom .
Mostly in tertiary care facilities.
Very limited capacity.
Lack of services also in private sector.
Very late presentation to those centers with advance disease which limit the benefit of palliative care.

8. 1
Dammam 3 2 4 7 5 6

9. Referral pattern of palliative patient in the kingdom
Study conducted in KFSH&RC
1567 referral over 4 years where studied
Referral to PC was done in the last week of life was accounted for 28%of cases.
The median survival from the first referral was 19 days
Survival was shorter if it was initiated by medicine , hematology , and pediatric oncology.
Early referral showed long survival

10. Therefore, this retrospective hospital-based study was conducted to identify epidemiological characteristics and diagnoses of cancer patients referred to palliative care at a tertiary care center in Dammam City, Saudi Arabia.

11. AIM OF THE WORK

12. To identify epidemiological characteristics and diagnoses of cancer patients referred to palliative care unit at a tertiary care center in Dammam, Saudi Arabia.

13. PATIENTS AND METHOD

14. Retrospective study was done on 2610 patients with confirmed advanced non curable cancer disease who are referred to PC unit in Dammam as inpatients.

15. Dammam

17. Since 2008, it has served as a tertiary referral hospital offering specialized medical care in several fields, mainly oncology.
It contains 327 beds, 93 of them for oncology cases including 20 beds for palliative care.

18. Chart review of electronic medical records of patients referred to palliative medicine service at tertiary Hospital in Dammam, between January 2014 and June 2016.
The main variables within collected data comprised year of admission, age, gender, diagnosis, pain score, and discharge condition.

19. Assesses for pain was done two times for each patient
Assesses for pain was done two times for each patient. The 1st time before intervention and 2nd time after one week of intervention or at discharge day if patients going home before seven days
Pain assessment was done using verbal descriptive Scale. 1 2 3

20. Statistical analysis
All data manipulation and analysis were performed using the SPSS (Statistical Package for Social Science).
Descriptive statistics (frequency and percentage) were calculated. The statistical significance of differences was judged at p<0.05.

22. Patients’ characteristics regarding gender

23. Patients’ characteristics regarding age group.

24. Distribution of types of cancer referred to PC

25. the highest proportions of cancer patients attending palliative care services are related to breast, colon and lung.

26. Most Common Cancers among Saudis, 2013 for All Ages
According to (Saudi Cancer Registry Report)

27. Results of the current study revealed a marked decrease in the incidence of medication toxicity among cancer patients, which decreased from 12.9% in 2014 to 5.3% in 2015 then 3.9% in Moreover, pain control was optimal for most patients during their treatment period.

28. Incidence of medication toxicity

29. Morphine consumption in Saudi

30. Opioid consumption Muslim countries
Consumption of opioid analgesics in the fifteen largest Muslim-majority countries ordered by decreasing ACM. The dashed line represents the boundary between “very low consumption” and “virtually nonexistent consumption” based on the data and definitions of Seya et al. (2011). ACM = adequacy of consumption measure. ND = no data. By comparison, the ACM for the US was calculated to be 2.48
Palliative Care in the Muslim-Majority Countries: The Need for More and Better Care Deena M. Aljawi1 and Joe B. Harford. Contemporary and Innovative Practice in Palliative Care,150:2011 *

31. Pain score before and after intervention

32. Our Center vs KFMC Initial Assessment
A. Alsuhail et al. (2015)

33. Our Center vs KFMC After Intervention
A. Alsuhail et al. (2015)

34. pain scores before and after intervention

35. Regarding discharge condition of our patients, about half of them discharged alive from the unit compared to one fourth died in the unit.

36. Patients’ Discharge Condition

37. This high rate of mortality can be explained by the fact that our center is the highest referral center for cancer patients which provides health care for terminal and advance cases.

38. Study Strength and Limitation
This is the first study in Dammam to identify epidemiological characteristics and diagnoses of cancer patients referred to palliative care unit.
Study Strength and Limitation
all patients were inpatient because insufficient record for outpatient
The short period still a limitation.
retrospective nature of the study decreased its accuracy.

39. We have good system for patient record now.
Other new prospective study going on and it includes both inpatients & outpatients.

41. The highest proportions of cancer patients attending palliative care related to breast, colon and lung.
Control of pain and treatment toxicity is quite successful. Nevertheless, about one fourth of them were terminal cases and died in the unit.
The palliative care intervention is very effective to control cancer pain especially moderate to severe pain.
Early referral to palliative care is highly recommended.

42. Further studies are needed to Explore the reasons for the increase of certain types of cancer more than others. Therefore, several researchers reported various risk factors for cancer
Further studies are needed to assess possible effectiveness of early referral to palliative care services early in the disease course.
Therefore, this study should be extended for the coming years and to investigate the reasons that would explain the high proportions of certain types of cancer among attending patients.