Every day, patients with cancer across the country are being denied access to adequate pain control. Relieving needless suffering is what we should be focusing our energy on.
— Kathleen M. Foley, MD
Kathleen M. Foley, MD, began her life’s work in cancer pain management at a time when suffering was a universally accepted consequence of the disease. Since then, Dr. Foley’s tireless work in the clinic and public forum has advanced not only the clinical treatment of cancer pain, but also the global awareness that relieving pain is an undeniable human rights issue.
“I graduated from Cornell Medical School in 1969, and following my residency in neurology at New York Hospital, Jerome Posner, MD, who was Chair of the Neurology Department at Memorial Sloan-Kettering Cancer Center (MSKCC), offered me a fellowship to study cancer pain. I confessed I knew nothing about cancer pain, and he wonderfully remarked, ‘Don’t worry; no one else does either.’” Dr. Foley recalled.
Establishes Nation’s First Cancer Pain Clinic
In 1975, when Dr. Foley joined the Department of Neurology at MSKCC, the modern pharmacology of treating pain was still in its infancy. “I began working with Dr. Raymond Houde, a clinical pharmacologist known for his studies of analgesics, to develop a clinical research program on cancer pain,” Dr. Foley said. The collaborative effort paid off: Within 2 years, Dr. Foley and her associates had created the nation’s first pain clinic within a cancer center.
Building on that success, Dr. Foley expanded her research into areas that would capture the scope and intensity of undertreated cancer pain. “We wanted to quantify the prevalence of cancer pain and define the neurologic pain syndromes that occurred in the cancer patient population,” Dr. Foley said, explaining that the nascent field of neuro-oncology was quickly gaining traction at MSKCC. “We then developed a robust analgesics study group that combined basic and clinical research along with a pain physician and oncology nurse training program.”
Access to Medical Opioids Is Critical
Dr. Foley’s early work in pain predated pain assessment tools and imaging technologies such as CT and MRI scans; thus, the etiology of pain remained somewhat obscure. Drug delivery methods were also limited, further hampering aggressive pain control. “At that time, patients with severe pain were being managed with intramuscular morphine on an as-needed basis; there was no oral morphine available in the United States,” Dr. Foley said.
The barriers to medical opioids became evident to Dr. Foley, and much of her initial work focused on establishing a scientific basis for morphine in managing cancer pain. “Using research data, our group argued strongly for the wide availability of oral morphine for cancer patients with pain. We also formed the concept of a continuum of opioid responsiveness in which some patients required higher doses of opioids. This may seem intuitive today, but it was a breakthrough concept in the early days of pain management,” Dr. Foley stressed.
Dr. Foley explained that the foundation of the new pain program at MSKCC was based on the natural experiment of treating thousands of patients with cancer. “Our clinical research was able to dispel the myths of opioid addiction and prove that pain stimuli rather than tolerance alone dictate the need to increase the dose of opioids,” Dr. Foley said. “As our work continued, it became very clear that although undertreated pain was a major issue, a more holistic approach was needed when caring for patients with cancer. It took a while, but in 1996 we broadened our reach and effectiveness in managing the symptoms related to cancer treatment by launching the Pain and Palliative Care Service at MSKCC.”
Tackling End-of-life Care
Even prior to establishing MSKCC’s Palliative Care Service, Dr. Foley had begun to expand her horizons, seeing undertreatment of cancer pain as but one part of the often problematic way in which our culture at large views the process of illness. “In 1994, I led an initiative funded by the philanthropist George Soros called the Project on Death in America. Our primary goal was to advance palliative care and translate our existing knowledge into clinical care,” Dr. Foley said.
“We chose this very in-your-face name for the Project because we wanted to directly attack the issue of end-of-life care. Armed with a $45 million grant, we supported community efforts to improve care of the dying and review policy measures that affect end-of-life care. We also built leadership teams that helped advance the growth of this underserved field,” Dr. Foley noted, adding that the data after more than 9 years show that the initiatives supported by the program have been enormously successful.
Debate over Physician-assisted Suicide
Since the mid-1990s, discussions on what constitutes the best end-of-life care have included the debate on whether physician-assisted suicide is medically and ethically appropriate. Although physician-assisted suicide seemed an unavoidable subject for the Project on Death in America, Dr. Foley said, “Our board members had strongly diverse opinions on the issue, but we made a collective decision not to address physician-assisted suicide, as too many other initiatives needed our attention and resources.”
However, Dr. Foley did have a personal interest in physician-assisted suicide. “Throughout my career, patients who were in severe pain have asked me to end their lives. But when I relieved their pain, they no longer wanted to die. Therefore, I felt that lack of care was the main driver behind most suicide requests,” Dr. Foley said.
Multiple debates on physician-assisted suicide ensued, most notably in two New England Journal of Medicine articles and an ASCO forum in which Marcia Angell, MD, argued in favor of the practice. Dr. Foley and Herbert Hendin, MD, in their 2002 book, The Case against Assisted Suicide: For the Right to End-of-life Care, reasoned that patients in terrible pain “are making an anguished cry for help and a very ambivalent request to die.”
“The debates got a bit contentious, but I learned a lot about tolerance. More importantly, every day, patients with cancer across the country are being denied access to adequate pain control. Relieving needless suffering is what we should be focusing our energy on,” Dr. Foley said.
Pain Management: A Global Issue
Dr. Foley is the Medical Director of the International Palliative Care Initiative, another George Soros–funded project to help address the lack of pain control around the world, especially in developing nations where arcane sociopolitical and regulatory barriers obstruct access to opioids. “These initiatives are happening in Central and Eastern Europe and in sub-Saharan Africa. We’ve been fortunate to have a major funding boost from the Global Access to Pain Relief Initiative. So again, fast forward 11 years and palliative care is now on the global public health policy agenda,” Dr. Foley said.
Dr. Foley acknowledged that progress in creating access to opioid analgesics in many regions of the world has been slow. “However, awareness of the problem is growing. For instance, in a very forceful statement, the World Health Organization (WHO) stated that access to morphine is a human rights issue. WHO estimates that about 5 billion people worldwide are denied basic pain relief. That is a staggering statistic.”
On a singularly riveting note, Dr. Foley cited a video on the website Stop Torture in Health Care (http://www.stoptortureinhealthcare.org). Vlad, a young patient with cancer in the Ukraine, is paralyzed and bedridden, dying in excruciating pain because the law prohibits prescribing more than 50 mg of morphine per day, when doctors have determined that he needs at least 2,000 mg for adequate relief. Vlad subsequently died in agonizing pain.
“The tragedy here is that Vlad was cared for by a loving mother and had everything in place to ensure a decent life before death—except enough morphine, which he was denied simply because the government has set an artificial level based on absolutely no evidence,” Dr. Foley said.
Various experts in the field of pain control debate whether “torture” is actually taking place in health services around the world. Asked if Vlad’s situation was torture, Dr. Foley replied unequivocally, “If one has something that can relieve someone’s suffering and it is being willfully denied, yes, I call that torture.”
Dr. Foley continues her daily work to advance the treatment of pain and palliative care and to increase global awareness that access to pain relief is a basic human right. ■
Disclosure: Dr. Foley reported no potential conflicts of interest.