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 Born and educated in Australia, Professor Nathan Cherny settled in Israel, where he works as an oncologist and palliative care physician. A pioneer of the integration of the two specialties, he has spearheaded many international projects aimed at improving patient care and access to treatment. Last year he received the much coveted European Society for Medical Oncology (ESMO) Award. Through the EJPC Palliative Care Policy Development Award, he now receives well-deserved recognition from the palliative care community.
How do you feel about having received the 2016 EJPC Palliative Care Policy Development Award?
This is very special. As a doctor working in a small unit in Israel, I feel exhilarated at the idea of being able to extend my outreach, in co-operation with colleagues and professional societies, to enhance the culture of care, to propagate new approaches to care, and to increase the availability of the means to care. This has been part of my professional mission for many years, both with the European Association for Palliative Care (EAPC) and the European Society for Medical Oncology (ESMO). It is extremely validating to see these efforts recognised by my palliative care colleagues.
You are both an oncologist and a palliative medicine physician. At the start of your career, what attracted you to these two specialties?
I was influenced by some critical experiences as a young medical student in Australia. Among these was my own journey with metastatic testicular cancer and the inspirational care I received from my treating physician, the late Dr Tom Sandeman, at the Peter MacCallum Cancer Centre in Melbourne. During my formative years I was also inspired by the works of Dr Elisabeth Kübler-Ross and Dame Cicely Saunders, and the teachings of Professor Peter Singer on the moral dimension of care in medicine. My teachers and mentors in oncology, Max Schwarz, John Zalcberg and Ian Haines, encouraged my deepening interest in palliative care, which was cemented in the years of my fellowship at the Memorial Sloan Kettering Cancer Center in the USA, where I had the great privilege to work side by side with mentors including Kathleen Foley, Russell Portenoy and Nessa Coyle.
What have been the achievements of the ESMO Palliative Care Working Group since its creation in 1999?
The idea of the working group was developed by my colleague Professor Rafi Catane, shortly after we had established an integrated oncology and palliative medicine service at the Shaare Zedek Medical Center in Jerusalem in 1994. We wanted to break down the barriers impeding the uptake of palliative care by oncologists and cancer centres, and Rafi recognised the potential of working within the mainstream oncology framework of the ESMO.
Guided by the Palliative Care Working Group (PCWG), the ESMO has published three policy statements that remain relevant to this day – about the role of the oncologist in delivering palliative care, minimal standards for palliative care in cancer centres, and core elements of palliative care education for oncology trainees.1 A research programme was initiated in 2000. In parallel, the PCWG launched two incentive schemes: a programme for trainee grants in palliative care and the ESMO Designated Centre of Integrated Oncology and Palliative Care programme.2
The criteria for the designated centre programme were derived from the WHO guidelines published in 1990,3 as well as from the experience Rafi Catane and I had gained when creating the integrated oncology and palliative medicine service at Shaare Zedek Medical Center. The underlying philosophy was to create a structured model that could provide a template for developing integrated oncology and palliative care services elsewhere.
The success of the designated centre programme has surpassed all expectations. The ESMO can now boast almost 200 accredited centres providing integrated oncology and palliative care worldwide. Indeed, recent international surveys have highlighted the unique prevalence and strength of this large cohort of centres.4 This has defined a new standard of care for oncology, not only in Europe but around the world. It could not have been achieved without the participation of wonderful oncologists from across Europe dedicated to this project.
Is the integration of palliative care into oncology services complete?
As far as I can see, we still have a long way to go in order to reach the level of integration that I feel would optimally serve our patients. The work of clinicians and researchers in developing an evidence base to demonstrate the advantages of this approach, and thus influence policy and practice, remains critical.
What do you think is needed to make pain relief for cancer pain a reality?
The scandal of undertreated pain in cancer and other life-limiting illnesses remains a global challenge. The Global Opioid Policy Initiative (GOPI)5 set out to evaluate the availability and accessibility of opioids for the relief of cancer pain, makes a small dent in the problem by highlighting the barriers to accessing critical pain medications. There remains so much to be done: raising the expectations of consumers, educating clinicians, addressing fears and stigma, ensuring adequate supplies of affordable medications – to name but a few tasks ahead of us. We also have to confront the limitations of our current therapeutic repertoire: we still need better and more reliable approaches, especially for managing neuropathic pain.
Do you think the 2009 EAPC recommended framework for palliative sedation is generally well understood and adhered to?
I think the EAPC palliative sedation framework6 has stood the test of time. It doesn’t give all of the answers. It does, however, boldly and forthrightly discuss problematic and abusive practices, and sets a path to provide ethical and compassionate care to patients who would otherwise be in dire distress at the end of life. Although I have no way of measuring adherence to it, it has been cited almost 300 times in only six years, so I do believe that it has influenced the formulation of practice guidelines in many countries and institutions – which is exactly what it set out to do.
What are you currently working on?
Inspired by the achievements of the GOPI, the ESMO and WHO – along with the Union for International Cancer Control and the Institute of Cancer Policy at King’s College London – have launched the two sequential projects to address the availability and accessibility of anticancer drugs, first in Europe and subsequently in the rest of the world.7 These projects piggybacked on the methodology and experience that were accrued during the opioid studies, which are now providing important data to address the problem of equity in access to cancer care – a problem prevalent in all but the wealthiest countries in the world.
Thus far these studies have identified that the prohibitive cost of new medications is generating major inequities in the treatment of certain cancers in Europe; and that, in many of the poorest countries in the world, even anticancer medications featuring on the WHO list of essential drugs are often only available at full price – which makes them unaffordable to most – and accessibility is commonly impaired by problems of manufacturing and distribution.
These findings highlight the major public health challenges in the delivery of cancer care in impoverished and developing economies. They also highlight the human consequences of the aggressive pricing policies associated with new anticancer medications in the past 15 years. They challenge us to vigorously address the problems of affordability and sustainability. We need a pricing structure that reflects the actual magnitude of benefit accrued by patients, while still providing adequate rewards and incentives for R&D and marketing.
Another project I am involved in is the ESMO Magnitude of Clinical Benefit Scale (MCBS).8 Its aim is to gain an accurate understanding of how much benefit anticancer medications actually provide. This benefit is often overstated or overestimated because of optimism bias and hype. From my experience in Israel and the USA, overstating or overestimating the benefits of new treatments does not only compromise the integrity and credibility of oncologists and oncology organisations, but can also have harmful consequences, such as the misallocation of limited public funds, disproportionate expectations about new treatments, and harm to patients in terms adverse effects, personal cost and false hopes.
We have designed a first version of the ESMO-MCBS, a well-validated tool stratifying the clinical benefit of new anticancer treatments. The tool is applicable to a range of solid tumours. Based on data from well-structured phase-III clinical trials or meta-analyses, it uses a rational and consistent approach to derive a relative ranking of the benefit that can be anticipated from any new treatment.
I believe this is an important first step in the major ongoing task of assessing value in cancer care, which is essential for the appropriate use of limited public and personal resources. The ESMO-MCBS will help both patients and society.
What advice would you give to your peers and colleagues who want to develop public policy initiatives?
In my experience the most important things are to:
- choose to address a significant problem
- understand the underlying issues that contribute to the problem (which in itself can be an important public health initiative, as with the ESMO studies on the knowledge and attitudes of oncologists in Europe regarding palliative care)
- build alliances with other key interested parties
- set pragmatic and achievable targets
- design robust, manageable projects that can be completed within a reasonable timeframe
- seek critical and constructive expert peer review, and be prepared to listen to criticism.
What is your experience of working in a turbulent and sometimes troubled part of the world?
In my professional life I live in a ‘bubble’ of co-operation and mutual respect between Israelis and Palestinians. Despite the fact that the Shaare Zedek Medical Center is ostensibly an Orthodox Jewish hospital, almost 30% of the resident staff are Palestinians, as are about a quarter of my patients. Every day I see Palestinian doctors treating Jewish Israelis and Jewish doctors treating Palestinians with respect, care and affection. Our care doesn’t stop at the ‘green line’ or the security wall: we have special arrangements for patients to come to from all over the West Bank to receive subsidised care, and we regularly welcome Palestinian physicians and nurses for advanced training in integrated oncology and palliative care. Healthcare breaks boundaries and helps shatter stereotypes. In a country where there is so much ‘demonisation’ across lines of enmity, healthcare, especially palliative care, is a place where we can build bridges of understanding. This is central to my personal mission of promoting peace and understanding in the hope of building the trust needed to end the conflict between our peoples.
Who would you like to dedicate your Award to?
On a personal basis I wish to dedicate this Award to my family: my parents, Dr Jack Cherny and the late Berta Cherny, who nurtured values of caring, service, diligence and integrity, as well as the importance of pushing boundaries; to my wife Nancy and our four children Calanit, Noa, Eitan and Gil; to my brothers Mark and David; and to my extended circles of family and friends who keep my life balanced between work, social engagement, nature and an appreciation of everything life gives us, including – and above all – love and connectedness.
On a more general basis, I dedicate this Award to the ongoing challenge of making the best possible care available and affordable to all, and to the pursuit of peace and understanding between people, especially in the Middle East.
References
1. Cherny NI, Catane R, Kosmidis P. ESMO takes a stand on supportive and palliative care. Ann Oncol 2003; 14: 1335–1337.
2. www.esmo.org/Patients/Designated-Centres-of-Integrated-Oncology-and-Palliative-Care (last accessed 18/05/2016)
3. World Health Organization. Cancer Pain Relief and Palliative Care. Geneva: WHO, 1990.
4. Davis MP, Strasser F, Cherny N, Levan N. MASCC/ESMO/EAPC survey of palliative programs. Support Care Cancer 2015; 23: 1951–1968.
5. www.esmo.org/Policy/Global-Opioid-Policy-Initiative (last accessed 18/05/2016)
6. Cherny NI, Radbruch L; Board of the European Association for Palliative Care. European Association for Palliative Care (EAPC) recommended framework for the use of sedation in palliative care. Palliat Med 2009; 23: 581–593.
7. www.esmo.org/Policy/Anti-Cancer-Medicines-Availability/International-Study (last accessed 18/05/2016)
8. www.esmo.org/Policy/Magnitude-of-Clinical-Benefit-Scale (last accessed 18/05/2016)
2017 nominations
Nominations for the 2017 EJPC Award will open on 1 October 2016. The submission form will be available on the EJPC Award pages of the EJPC website, www.ejpc.eu.com/ejpcaward
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