Final stage and farewell support. Episode 19

Monika Rachtan
Good afternoon, I am Monika Rachtan. I would like to welcome you to another episode of the programme "Patient First". None of us wants to get cancer, but once upon a time we just experience abdominal pain. We call the emergency room, go to the ED. A doctor comes in and says we probably have advanced cancer. No one is then able to offer us immediate help. The diagnosis takes a long time and the diagnosis is confirmed. Then we go to my guest today, Professor Ewa Kalinka, who is a clinical oncologist. Good morning, Professor.

Ewa Kalinka
Good morning, Madam Editor, good morning to you.

Monika Rachtan
Professor, does a patient diagnosed with advanced cancer have any hope of a cure?

Ewa Kalinka
Ladies and gentlemen, absolutely yes! Clinical oncology is a huge therapeutic field that varies according to a number of important factors. The first, extremely important factor is the patient's general condition. The better the patient's health status, the better the chances of long-term survival despite advanced cancer. Therefore, I appeal, let us not wait until ailments seriously weaken us. It is worth reacting to the first, even small symptoms that appear in our lives. These can be simple things such as abdominal pain, itching of the skin, changes in vision, a new cough, pain when urinating, and many others. Let's not underestimate them, let's not put off visiting the doctor. In Poland, the structure of comprehensive care at the GP is now being promoted.

Monika Rachtan
Does this structure really work?

Ewa Kalinka
This depends on several important factors. The first is the patient's choice of GP.

Monika Rachtan
This is very important.

Ewa Kalinka
This is where the system has no influence, does it?

Monika Rachtan
It is up to us.

Ewa Kalinka
Exactly, and I would strongly encourage you to change your GP if you are dissatisfied with their service. The system promotes patients who enrol with the best doctors because funding depends on the number of patients enrolled.

Monika Rachtan
That is, popular doctors, liked by patients, earn more and are happy.

Ewa Kalinka
Specifically. The family clinic will want to employ the doctors that patients want to be treated by.

Monika Rachtan
Because we often dread these visits to doctors. We go to the GP, the image I have in my mind is a doctor sitting at a desk, stressed, difficult to get to. I imagine a Mr or Mrs doctor with a notebook hurriedly prescribing prescriptions, and we patients have a lot of anxiety about that visit.

Ewa Kalinka
Editor, I also understand these concerns.

Monika Rachtan
Yes.

Ewa Kalinka
This is completely understandable. When health and life become the subject of a visit, emotions come into play. It is important to feel a certain chemistry with our doctor. If such a relationship is lacking, we should consider changing doctors. Doctors have many ways to establish a rapport with the patient from the first moments. I, for example, start the visit by introducing myself and explaining that I am a clinical oncologist and that our visit is to understand the patient's problem. This helps to relieve tension and creates an atmosphere of trust. It is worth choosing a good GP, as you mentioned.

Ewa Kalinka
But there are times when a doctor refuses a patient's requests. If this happens, please ask for it in writing.

Monika Rachtan
Exactly, these situations do happen. We are then left with a written confirmation. Often doctors back down from a refusal when they see that the patient is determined.

Ewa Kalinka
The doctor cannot always order all the tests because he has limitations imposed by the National Health Service.

Monika Rachtan
This is important information.

Ewa Kalinka
Yes, we cannot expect a doctor to order a PET scan that is not always necessary. This test is often performed unnecessarily, lengthening queues for those who really need it. However, recently GPs have been allowed to order CT scans and referrals to specialists at no cost. It is therefore worth asking for reasons for refusal and trying to understand the doctor's decision.

Monika Rachtan
We often have the impression that the doctor does not have time for us because he or she is busy on the computer. Not all patients, especially older patients, understand that the doctor has many administrative responsibilities. This can cause frustration for patients who feel they are being ignored.

Ewa Kalinka
There is a certain dehumanisation of visits due to the use of the computer. The dream would be for the doctor to conduct the visit in the presence of an assistant who would record the information. Modern technology also allows the conversation between doctor and patient to be recorded, which could be helpful. Unfortunately, the health service suffers from a lack of resources, making it difficult to introduce such facilities. Commercial medical facilities can afford to organise visits better, which is a financial issue. Therefore, we need additional investment in the health service to improve the quality of care. It is also important that the patient has the courage to ask questions of the doctor and ask for clarification.

Ewa Kalinka
The patient is entitled to this. Not everyone wants to be involved in the treatment process, but this depends on each patient's preference. It is worth individualising the approach to the patient, taking into account their age, life situation and needs.
Monika Rachtan
The professor mentioned the dehumanisation of medicine resulting from the presence of a computer in the doctor's office. Our podcast is supported by the Institute for Patient Rights and Health Education, which promotes the humanisation of medicine. From the perspective of your speciality, how do you, Professor, understand the humanisation of medicine?

Ewa Kalinka
Looking from my perspective, what the editor mentioned, i.e. the doctor's lack of time, is imposed by the system. Unfortunately, the large number of patients we have to handle each day results in limited time we can devote to each patient. So, we are faced with a difficult choice: is it better to receive 10 patients, devoting enough time to them so that they feel truly included in our care and not just subjected to the treatment we give them, or is it better, however, to receive 20 patients, providing them with the right treatment but giving up this humanitarian aspect of our speciality. I think it is important at the beginning of the contact with the clinical oncologist that the doctor informs the patient what the therapy will be like, that the first conversation is the longest and that it is an opportunity to find out about the patient's state of health, their education, their social situation, their financial situation, and so on.

Monika Rachtan
Because this is really important.

Ewa Kalinka
Did he have a good understanding of how to contact us in case of complications or deterioration of his health? What rights does he have access to, even if the system does not facilitate this, etc., etc.? It should simply be explained to him or her that our next appointments will routinely include questions about events since our last visit. This is why it is useful to write down what they want to tell us, as patients often get stressed in the oncologist's office. This stress is so great that we can see that their eyes want to say a lot, but they cannot express it in words. That is why it is useful to give them a piece of paper and a pencil. Write down everything they want to talk to me about at home. In this way, even a short visit can be extremely informative, as it will satisfy any doubts the patient may have. The patient needs to know that they can always ask for an additional appointment. Of course, this will not always be possible straight away, as we have a specific work rhythm. We have to examine patients, order tests, check the results, order chemotherapy and only then will we have time for a longer conversation with the patient.

Ewa Kalinka
Asking to talk to me for 10 minutes is important, especially if the patient is expecting such a short consultation. It is worthwhile for the doctor to be aware of the patient's needs and to prepare for such a conversation in a way that allows him or her to focus only on the patient, instead of thinking about 20 other things. It is important to remember that both the patient and the doctor in the white coat are human and have their weaknesses.

Monika Rachtan
Of course, we as patients often forget this. And do patients often cry in your professor's office?

Ewa Kalinka
Yes, patients most often cry when they find out they have cancer, which unfortunately carries a certain stigma in society. A cancer patient is often the kind of patient who, if they have a heart attack, will definitely end up in oncology rather than cardiology because they are perceived differently. Hearing the diagnosis is a huge challenge. Imagine one of us getting such a diagnosis.

Monika Rachtan
It's certainly difficult, especially when someone close to you has cancer, not necessarily a husband or parent, but a cousin or neighbour, for example. We hear about someone who has had cancer, but it's not us.

Ewa Kalinka
Exactly. That's why imagining how a person feels when they receive such a diagnosis is important. I am an advocate of giving patients information in a way that is honest but also tailored to their needs. The patient must trust us, they must not be deceived. Very often, other doctors, who are not involved in therapy, put the oncologist in charge of informing the patient.

Monika Rachtan
And what happens to that patient afterwards?

Ewa Kalinka
He is left with an information card, which is taken by his loved one.

Monika Rachtan
I understand.

Ewa Kalinka
I understand that the family wants to protect their loved one. This is understandable. However, the process of informing the patient from the medical world is not always ideal. At the point when the patient has to give informed consent for treatment, they need to be informed why the therapy is necessary. This is the moment when tears appear. Another such moment is when the patient is informed that the treatment has failed.

Monika Rachtan
Because unfortunately it happens, doesn't it?

Ewa Kalinka
Yes, especially for patients with advanced disease. We tell them that we will use different lines of treatment if the first one is not effective. This is a huge shock, especially when we are treating with the intention of curing. Hearing about a relapse is a huge blow. It requires honesty and candour, tailored to the patient's needs. The patient himself will determine how much information he wants to receive.

Monika Rachtan
The professor mentioned that today many cancers can be cured completely, especially when the patient undergoes surgery. The patient gets the good news that the disease has been cured. Of course, he is aware that there is a risk of recurrence, even after a year, but can recurrence also occur after 5 or 10 years?

Ewa Kalinka
Yes, there are some cancers that can recur even after 15 or 20 years. This is especially true of certain subtypes of breast cancer, which are quite common.

Monika Rachtan
These people live under constant stress.

Ewa Kalinka
Exactly, and those mildest subtypes that seem harmless at first can insidiously recur even after many years. This is why aggressive cancers have a faster recurrence, but also why a recurrence can be ruled out more quickly. If an aggressive cancer does not recur within two or three years, the risk of recurrence decreases with each passing month. For tumours with a milder biology, the opposite is unfortunately true.

Monika Rachtan
You also have these discussions with breast cancer patients. It must be a very delicate situation when the patient is already happy about her improvement and you have to make her aware of the possibility of recurrence and the need for regular examinations.

Ewa Kalinka
I try to avoid such formulations, but I encourage patients to have systematic examinations. I do not want to impose excessive checks, because a visit to the oncologist is associated with a lot of stress. Unnecessary examinations only increase the psychological burden on the patient, who lives in constant tension. However, it is worthwhile for the patient to be aware that if new symptoms appear, such as bone pain or other worrying changes, she should consult an oncologist or at least a doctor. Sometimes the symptoms of cancer are not obvious and patients do not associate them.

Monika Rachtan
What symptoms might these be?

Ewa Kalinka
An example is itching of the skin.

Monika Rachtan
This seems to be difficult to link to cancer.

Ewa Kalinka
Another example is darkening urine. How could this be linked to a recurrence of breast cancer? This is why I always encourage people to call if there are any new symptoms, and together with the patient we will assess whether this requires an additional visit. The patient needs to be alert to such signals. However, I do not support routine follow-ups for many years for patients who have a good prognosis. This only adds to their stress and puts a strain on the system, delaying diagnoses for other patients. Our aim as an oncology community is to pass on distant checks to GPs to reduce queues to oncologists.

Monika Rachtan
We talk a lot about the role of GPs in the care of oncology patients. The oncology patient is accompanied by many specialists in the long-term treatment process. Can you go back to systemically treated patients who have already exhausted the available treatment options and the disease recurs?

Ewa Kalinka
It is a really difficult situation when the patient no longer has any treatment options available and the drug programmes are not working. There are clinical trials available in Poland, but I am referring to the situation when all options have been exhausted and the disease returns.

Monika Rachtan
What can be done in such a case?

Ewa Kalinka
The most important thing is to avoid the message that 'there is nothing more we can do, go to the hospice'. Such a message, although true, should be given in an empathetic way because it is a huge blow to the patient. Even if I know that there are no more treatment options, I try to express it in a different way.

Monika Rachtan
What words do you use in such a situation?

Ewa Kalinka
I inform the patient that his body is very weakened, which is a fact. I say that I do not see another line of treatment now, but suggest a follow-up visit in a while.

Monika Rachtan
Do patients return for such visits?

Ewa Kalinka
Unfortunately, some do not return. However, it is important that the patient has the opportunity to contact a doctor who does not close the door. This offers hope. Sometimes after a few months, when the patient is free of treatment, there may be an opportunity for another therapy or to participate in clinical trials. Therefore, I believe that leaving such a gateway is important and fair. However, palliative care and support should be provided to the patient during this time so that they are not left alone.

Monika Rachtan
Where do cancer patients die?

Ewa Kalinka
It depends. Some die in hospitals, some in hospices, but a significant proportion die in their homes. Those who die at home often have the best care from their family. In the last weeks of life, the patient is often unable to care for themselves and is transported to hospital to ensure that they receive adequate nutrition and hydration. A person should not be allowed to die of starvation or dehydration.

Monika Rachtan
Often patients can't eat anymore, can they?

Ewa Kalinka
Precisely. In such cases, hospital care is necessary to ensure that the patient receives adequate nutritional support and pain management.

Monika Rachtan
I recently spoke to a carer of a cancer patient who had already exhausted all treatment options. I asked what they were fighting for now. She said that they are fighting for a dignified death so that the patient does not starve to death. Access to nutritional advice and pain management is not always easy.

Ewa Kalinka
This is unfortunately true. My dream is for the system to automatically activate palliative care at the patient's place of residence when the oncologist determines that there are no more treatment options. Today, it is the patient himself who has to search for and organise this care. Carers and patients often do not know how to deal with such a situation.

Monika Rachtan
What can a nurse do in such a situation?

Ewa Kalinka
The nurse assesses the patient's condition, nutrition, pain level and basic vital signs such as blood pressure or pulse rate. She documents this information and can pass it on to the doctor, who will decide on the next steps. Sometimes the patient does not require immediate medical intervention but, for example, nutritional advice. Then the nurse can communicate these needs to the doctor. Unfortunately, the palliative care system in Poland does not work as it should. Patients often lack access to support in their homes. This should be more proactive and accessible. It is worthwhile so that the patient does not have to seek help alone.
Monika Rachtan
But is it because oncologists are reluctant to support these patients? Because it seems obvious to me that when I leave the clinical oncologist's office, he should write in the chart that the patient needs to be fed properly. However, this is not enough. Has the patient been informed of the possibility of receiving nutritional advice at a specific location, giving a simple street where to go? The specialist cannot come to the patient's home. This is so obvious. When I talk to the professor, I am surprised that this is not happening.

Ewa Kalinka
I too am surprised that this is not happening. Especially as I have the pleasure of working on a daily basis with colleagues who write nutritional advice into information sheets from the first cycle of chemotherapy, even in patients undergoing radical treatment. Greetings, you know who I am talking about. Colleagues who even write in that if there is constipation, increase this or that in the diet. And if there is diarrhoea, eliminate this and that. If there is anaemia, remember there is a lot of iron in kale and other foods. And all this is written in the information sheet. It's a template that you just insert, you just have to remember it. Why don't oncologists do that? Editor, I don't know, I'm not going to try to hypothesise. Part of it is probably due to the fact that we are not fully educated in proper nutrition. We physicians, not only oncologists but others as well, and even more so in adapting nutritional solutions to a patient's changing situation. There are, after all, specialist nutrition clinics. The existence of these counselling centres proves that doctors of other specialities do not have this knowledge.

Ewa Kalinka
We need to set up a dedicated network of nutritional advice clinics to correct these skills gaps in the rest of the health service in these situations. But some basic advice is really easy to type in, and always worthwhile. I spend a great deal of time talking to patients about diet, physical activity, alcohol consumption or reaction to medication. These may seem like secondary questions, but they are very important.

Monika Rachtan
Please answer these questions right away, as patients who listen to us often do not have an oncologist willing to answer such questions. Are patients allowed to drive?

Ewa Kalinka
Can patients drive a car? This depends on the type of medication they are taking, as it is important to remember that some painkillers are considered drugs. Today's drugs of this type are very modern and do not cause a feeling of fogginess or a reduction in perception, reaction time or control of activities requiring mental agility. Nevertheless, when taking any medication, you should look at the leaflet to see if it affects your driving ability. Do not rely solely on the dose of the drug. Obviously, the higher the dose, the greater the risk of affecting driving ability. I have patients who have had their consciousness and mental faculties severely affected after taking a high dose of the drug. Therefore, if the drug contains a warning, you should not drive because a person under the influence of narcotic substances equals a person under the influence of alcohol in terms of the law.

Ewa Kalinka
Therefore, knowing this, one must not knowingly take to the road, as one is then committing a serious offence against oneself and others.

Monika Rachtan
This is very important. Another question relates to the drinking of alcohol by oncology patients.

Ewa Kalinka
Patients may drink alcohol. However, it should always be borne in mind that alcohol is considered a carcinogen, i.e. a substance capable of causing cancer. Nevertheless, the occasional consumption of alcohol, for example at a family dinner, should not significantly affect the patient's wellbeing. The exception is patients who have a high risk of nausea and vomiting, for example due to central nervous system metastases or the use of certain chemotherapeutic drugs. In such cases, alcohol consumption can lead to unpleasant effects. It is also worth checking whether any additional medication you are taking has an interaction with alcohol, as the combination of painkillers with alcohol can be dangerous. If there are no such contraindications, drinking alcohol in moderation is permitted.

Monika Rachtan
That is to say, a glass of wine with dinner at Christmas.

Ewa Kalinka
Yes, there really is no need to worry.

Monika Rachtan
You mentioned painkillers that can be used by oncology patients. It seems that narcotic drugs for healthy people sound controversial. Does a cancer patient really need to take them? When a patient with disseminated cancer and metastases to various organs experiences severe pain, are narcotic drugs the only salvation?

Ewa Kalinka
I am waiting for you to finish this statement, Madam Editor, because this is a typical mistake. One must not wait until the pain becomes unbearable to reach for narcotic drugs. The sooner we start effective pain therapy, the lower the doses of medication are needed. Therefore, we do not wait until the patient is unable to bear the pain to turn on narcotic drugs. Pain is a symptom that has a devastating effect on the patient's condition, affecting appetite, physical activity and general wellbeing. All these factors have a direct impact on life expectancy. Therefore, controlling pain is key to prolonging life. There is no need to be afraid of using opioids if they are necessary. They should be switched on as soon as needed. If a patient is in pain, it means that they are being inadequately treated.

Monika Rachtan
How painful is cancer?

Ewa Kalinka
It can be very painful.

Monika Rachtan
Do patients often say that they are in so much pain that they cry because of the pain?

Ewa Kalinka
Editor, such severe pain is rare. I am not saying never, but it is rare to have sudden pain with cancer. It usually gradually increases from week to week, month to month, year to year. If, at an early stage, the pain is properly treated with therapy, be it pharmacological or radiotherapy, as well as other treatments such as neurolysis of the plexuses, etc., the patient will never experience such severe pain as the editor mentioned, that terrible and unbearable pain. However, it is definitely not worth waiting for the pain to get worse before starting to treat it. This is really a big mistake.

Monika Rachtan
Cancer patients, when they become ill, find out about various outpatient clinics, including a nutritional clinic. One such counselling centre is the pain management counselling centre, which operates within our healthcare system,?

Ewa Kalinka
Yes, it is generally available to all insured persons. What is more, the medicines from this outpatient clinic for cancer patients are largely free of charge.

Monika Rachtan
Who should be asked and at what stage? We already know that at an early stage, because you said that we cannot wait until the pain becomes so unbearable that the patient stops functioning. Who should we ask for information about such a pain clinic if no one has informed us that we can use it?

Ewa Kalinka
Firstly, it is worth being aware of one thing: the oncologist is not able to sense pain. The patient must communicate it, because if he or she does not tell us that he or she is in pain, no matter how severe, we will not know. Therefore, communication is key here, and a list of questions and a pencil so as not to forget it can come in handy. It is not worth procrastinating about the pain. Pain can be more or less intractable in different circumstances. Usually oncologists are good at implementing initial therapies. However, if, despite the oncologist's interventions, these do not work, it is worth considering a pain clinic. Of course, this can be done in parallel with oncological care, without worrying about double-burdening the patient with further outpatient clinics and long waits in the queue. Therefore, as long as oncological treatment effectively controls pain, a pain clinic is not necessary. However, if there are problems with drug treatment or other aspects, it may be necessary to refer the patient to this outpatient clinic.

Monika Rachtan
We know that cancer does not only affect the patient himself, but also those around him. Those close to the patient are also affected. I think that sometimes they feel the pain more than the patient himself, because when the patient is given medication, they are not always fully aware of what is happening, because that moment will come. They are the ones in a lot of pain. Where can they seek help? Is this psycho-oncologist, who is now much talked about, really available on the ward and has an open door for these people?

Ewa Kalinka
Above all, the psycho-oncologist has an open door for patients, and there are indeed many of them. Of course, they must be our priority, because in the whole process of fighting the disease, the patient who is affected is always the most important. There is no doubt in our minds that he or she is the one we should focus our efforts on. What about care for families? Unfortunately, this is not available to the extent that we would like it to be. Of course, if a patient asks us to talk to his or her family, we are open to doing so. However, it is important to remember that such conversations can be very difficult. Often families begin to cry and express their fears and concerns, which can be extremely overwhelming.

Monika Rachtan
Are these situations really happening?

Ewa Kalinka
These situations are rare, but unfortunately they do happen. They are very difficult conversations. This is when I believe that any responsible doctor should honestly tell the patient that, although they are very sorry for the situation, they are not a specialist in psychiatry or psycho-oncology and are not in a position to help in this area. In such cases, help should be sought from a specialist as soon as possible. Unfortunately, this is often a barrier for our patients and their families, because psychiatry in Poland is often perceived badly and they put it down as something for 'lunatics'. This is, unfortunately, a barrier that we need to break down. I would therefore strongly encourage anyone who notices any cancer-related emotional disturbance in themselves or their loved ones to act as soon as possible. The earlier we react, the greater the chance of effective intervention, which may require less medication and therapy. Psychological therapy is very helpful in such situations.

Monika Rachtan
Unfortunately, not everyone can afford it. The professor has already mentioned that access to such assistance for families is limited.

Ewa Kalinka
Yes, unfortunately this is true. There are psychological counselling centres for adults, but unfortunately there are often long queues. This is a serious problem, because in a crisis situation we cannot afford to wait three months for a first appointment with a psychologist. The system is unfortunately not efficient enough in this regard. I do not have a ready-made solution to this problem, but when it comes to psychological care for families affected by cancer, this is an issue that requires much more investment from the health system.
Monika Rachtan
When we have a loved one at home who passes away and we know we can't really do anything anymore, we don't have another line of therapy. We see that this person is getting weaker and weaker, sleeping more and more hours. Or shall I say a little colloquially, should such a patient still be tormented, should we still seek therapy? Because some people think that on this last day they are looking for rescue therapy, especially when it comes to someone we love very much. Or, for example, when a young woman who has recently given birth passes away.

Ewa Kalinka
Yes, I understand perfectly well what you mean, Madam Editor. This is where we come up against the phenomenon and concept of so-called persistent therapy. Persistent therapy is therapy that tires the patient more than it gives them anything. And here, persistent therapy already begins with persistent diagnosis. If the patient is dying, then having to take him or her to yet another CT scan or a check-up gastroscopy or some other examination is really a huge effort for the patient, and can really cause him or her to catch severe pneumonia in some waiting room and die because of it, because the examination alone will not change anything in his or her life. In my opinion, persistence starts at the stage where the patient no longer accepts it. That's basically when the persistence ends. It is not permissible to treat a patient or subject them to various procedures against their will. This is because each of us has the right to decide not to treat ourselves. It is important that this decision is a conscious one, which means that it is not made on the basis of such and such a small nodule, and that the patient can take chemotherapy or not.

Ewa Kalinka
This is not a conscious decision. On the other hand, if the patient is aware that she is in the terminal period and what she wants most is to be at home, in peace and quiet, surrounded by her loved ones, and not to undergo yet another examination or therapy which, as we all know, really has no chance of producing anything. We have to respect the will of such a patient and the most difficult stage, in which the family still very much wants to help and then the patient no longer does, because then we do it against this sick person. And this is a sin that I strongly discourage.

Monika Rachtan
The subject is extremely difficult, but I would like to have at least a few more questions for you at the end of our conversation. He talked about the fact that a great deal of change is happening in oncology in Poland. Changes are currently being made to improve oncology care to a large extent. Of course, it is difficult to say that oncology patients will stop leaving after these changes, because it is impossible. We know that there are more and more of these cancers. We can take care of ourselves, we can live better so that we don't get cancer. But the facts are that many of our listeners will get cancer one day. There are many positive changes that are currently being made in oncology. Which of these do you think will change the face of oncology a little? So we will be talking about this departure in two years' time, when you have introduced all of this and cleaned up this Polish oncology, and we will be saying that patients are leaving with more dignity.

Ewa Kalinka
All the changes that are happening now in oncology are expected to result in speeding up the processes of diagnosis and accessibility to treatment, as well as introducing a new element that is extremely important, that of quality assessment. That is, we will be held accountable by the system in an automatic way for the results of our treatment. How will this affect the terminal period? Madam Editor, it won't affect much, because today all the power is focused on prevention, on education, on treatment and on care during the treatment period of the patient, with a huge role for medical coordinators of this very medical care. But this role does not extend beyond the treatment stage. This role will not provide this care to the patient at home. This care still rests on the shoulders of our colleagues who provide hospice care, palliative care. I imagine that in Poland we still do not have enough decisive people who want to dedicate themselves, dedicate their professional lives to the care of terminally ill patients. And please don't surprise them, because it is very difficult medicine. I think it is the most difficult. Coming to terms with the fact that there is not much more that can be done for this person means that we don't judge this work of ours as particularly effective.

Ewa Kalinka
Somehow we don't see our big role in this patient's life. And I have the utmost respect for the doctors who are dealing with this, because it takes an incredibly strong backbone to endure this. What can we do? We can promote the involvement of palliative medicine, we can promote knowledge and education among PCPs that it is also their responsibility during the dying period of their patient to care for that patient. But these changes, which are to take place especially in the national oncology network in the next few years, in my opinion will unfortunately not change terminal care in a fundamental way.

Monika Rachtan
Myself, I think it's worth thinking about the fact that if these changes don't affect the final stage of the disease, we can do a lot for ourselves by being in good health.

Ewa Kalinka
I agree, definitely.

Monika Rachtan
To move towards a healthy life.

Ewa Kalinka
Preferably as late as possible.

Monika Rachtan
Or preferably not at all.

Ewa Kalinka
This is indeed prevention and health-promoting action. Each of us can make these changes ourselves. There is now overwhelming scientific evidence that appropriate lifestyle changes can effectively reduce the risk of cancer. Of course, diet, avoidance of smoking, alcohol and regular physical activity are known to us as risk factors for heart disease and stroke. However, these changes also have a significant impact on cancer risk, something we often do not realise.

Ewa Kalinka
A prime example is the elimination of cancer through vaccination against HPV. With these vaccinations, we can effectively reduce the incidence of certain cancers. In countries that implemented these vaccinations several years ago, such as Australia and Scandinavia, the number of cases of these diseases has fallen to one or two per year. In our country, unfortunately, we are still talking about thousands of cases.

Monika Rachtan
This is important for patients, and I would like to answer questions that often arise in the context of HPV vaccination. We have already had Professor Pinkas on the programme to talk about these vaccinations. However, some viewers have expressed concerns, suggesting that we have not been informed about the potential complications and side effects of the vaccination. Girls in other countries have allegedly had serious problems after these vaccinations and have even died. What would you, Professor, like to say to those who question the safety of these vaccinations?

Ewa Kalinka
I would like to stress that I respect each person's opinion when it comes to their own health. However, I encourage a considered approach and analysis. If we are already reading the leaflet and considering the side effects, it is worth weighing them against the actual risk of disease not only for girls but also for boys. Vaccination should also be considered for boys. It is worth considering what the chances of contracting this type of cancer are in the absence of vaccination and what the consequences of not vaccinating might be for the child's health. Side effects are present with any type of vaccination, even drinking excessive amounts of water can result in adverse effects. It is important to use common sense and assess the risks of vaccination versus the risks of not vaccinating. This is key and I highly recommend this way of thinking, as HPV vaccination is not the same as standard vaccination against infections.

Ewa Kalinka
We must remember that our infants receive several vaccinations at the same time already in the first year of life, and then no one protests. These are vaccinations against infectious diseases, and here we are talking about protecting the public against cancer. That is why the lack of proportion in the concerns surprises me. However, I respect every parent's choices on this issue.

Monika Rachtan
I would like to ask another question that I found in these comments. I am quoting a patient who wrote a comment here. How is it possible that vaccines used to be worked on for 100 years and it took so long to invent one vaccine, and now every year they prepare another one for us? And how is it that suddenly these vaccines can be developed so quickly? I remind you that this is a patient question.

Ewa Kalinka
Of course, I understand such a question and I take it very seriously, because it comes from a certain common sense. Indeed, the registration of mass and prophylactic vaccinations has taken many years, as we have sought to be as certain as possible about their safety. This is a question more suited to a vaccination expert or a doctor specialising in infectious diseases. In the case of COVID-19, this becomes an example worth discussing. We noticed that it was suddenly possible to develop a vaccine within a year or a little more. This was due to the accelerated registration processes, especially at the US Food and Drug Administration (FTA) and the European Medicines Agency (EMA). It was a response to a particular health need, especially as hundreds of thousands of people were dying from the disease. It is important to understand that people were actually dying from COVID-19, despite current myths. When I hear such claims, it moves me a lot, because I saw these cases with my own eyes. Back then, we were all working not only for the standard 8 hours a day in the laboratories, but in a three-shift system to progress as quickly as possible.

Ewa Kalinka
The registration agencies have been very proactive in pointing out to manufacturers areas that need to be investigated quickly, especially with regard to safety. This is what has happened. Would we have preferred a vaccine to have been in development for 10 years? Of course we would, but how many people would we lose then.

Monika Rachtan
Professor, what are the three most important things our listeners should remember from today's talk?

Ewa Kalinka
The three most important points are: we have the right to expect a good relationship with our doctor, both as a professional and as a human being; we have the right to ask for a change of doctor if we are not satisfied with the care; and it is important to prepare for the conversation with your oncologist so that important issues are not overlooked. Do not delay the use of palliative care as this can shorten life and increase suffering. Palliative care is part of medicine and should not be feared.

Monika Rachtan
Today we have covered a difficult topic, but we believe that we have provided you with valuable knowledge. We want this knowledge to be useful and relevant, because well-informed patients are easier for oncologists to treat.

Ewa Kalinka
Definitely yes. I encourage you to check on the National Health Service website in your area to see how many facilities are available to help your situation. You do not have to stay in one facility if you think you will get better care elsewhere.