A 45-year-old farmer diagnosed with stage 4 stomach cancer was brought to my OPD on a stretcher. He could not even sit in a wheelchair. His abdomen was distended, his legs were swollen, and he was writhing in pain. His family members, visibly distressed, had traveled nearly 100 km to see me, desperate for relief.
I checked his medical records. He had undergone chemotherapy for some time, but it had been ineffective. For pain relief, he had been taking diclofenac injections daily—a temporary solution that barely scratched the surface of his suffering. After the initial assessment, I instructed my nurse to administer an injection. I moved on to my inpatient rounds.
An hour later, I returned to find him fast asleep. His family, misty-eyed and grateful, shared that he hadn’t slept in more than a week because of the pain. They asked me the name of this “magic injection.” I smiled and replied, “That’s Morphine.”
The next day, he was discharged with a prescription for morphine tablets. Two weeks later, I saw him through a video consultation. He was resting well, his pain controlled, and he continued on the same medication. Though he did not live long enough for his next consultation, his family later told me they were immensely grateful that his final days were pain-free.
The Reality of Cancer Pain in Rural India
Cancer pain is unlike any other. It is searing, relentless, and unforgiving, especially when cancer erodes into bones and nerves. Painkillers like paracetamol and diclofenac barely touch it. Yet, these are often the only medications rural patients receive.
More than 65% of India’s population lives in rural areas—places where access to cancer care is limited, and pain management is practically nonexistent. While government schemes have made chemotherapy, surgery, and radiotherapy more accessible, pain management remains a neglected domain.
Primary healthcare providers are often untrained in recognizing and managing severe cancer pain. Many patients are left to travel long distances to tertiary cancer centers, bearing the cost and the emotional burden of transporting a loved one in agony. This journey—often 100 km or more—is not just exhausting; it is dehumanizing.
Urban vs. Rural Divide in Cancer Care
Most tertiary cancer centers are clustered in Tier 1 cities, making them practically inaccessible for many rural families. By the time many rural patients reach these hospitals, the cancer is already at an advanced stage, and the journey back for repeated consultations becomes unbearable. As a result, many choose to stay at home, often enduring pain in silence.
A recent study published in the British Medical Journal found that rural patients were more likely to seek palliative or alternative therapies compared to urban patients. It also noted that urban patients had a higher rate of treatment completion and better pain management. Despite the higher incidence of breast cancer in urban women, mortality was significantly higher among rural women, highlighting the stark contrast in care.
The Complex Nature of Cancer Pain
Cancer pain is caused by various factors, such as the tumor pressing on a nerve, the tumor eroding into the bone, etc. Thus opioids like morphine alone are not the panacea for all cancer pain. One might need medicines that stabilise nerve signals, or even injections near nerves that might block them from carrying pain, known as nerve blocks. One may also need additional medications to strengthen bones and prevent bone loss, such as bisphosphonates. Effective management of the cancer itself through chemotherapy or radiotherapy is often required to reduce pain.
To manage this complexity, rural patients require access to trained oncologists or specialists in pain and palliative care. A study showed that pain and symptom control were grossly inadequate in rural India due to the lack of trained manpower.
The Need for Opioid Access and Trained Professionals
Many hospitals at the taluk level lack experts trained in pain management and access to oral opioid painkillers. Severe pain cases are frequently referred to large urban centers, forcing families to endure extended travel hours and substantial financial costs. For patients already battling late-stage cancer, this is a burden too heavy to carry.
The solution to this silent suffering is straightforward: We need to integrate pain management as a priority for cancer care from day one of treatment. It should begin the moment cancer is diagnosed, not as an afterthought. We must also train primary healthcare providers. Sensitizing doctors at primary health centers to recognize severe cancer pain and refer promptly for pain management therapy can be a game-changer.
We must also decentralize opioid access, because they are a mainstay of treatment for various types of cancer pain. Oral morphine should be available at taluk hospitals, not just tertiary care centers.
Ending the Silent Suffering
Cancer pain should not be a death sentence in itself. The real solution is not just in delivering morphine but in delivering dignity. A comprehensive approach that includes pain management, cancer control, and palliative care—right at the doorstep of rural patients—is the need of the hour.
Patients in rural areas should not have to travel hundreds of kilometers to find relief. They deserve access to opioid pain medications, nerve blocks, and palliative care—close to home. They deserve to die with dignity, not in pain.
To bridge this gap, the government should consider establishing Comprehensive Cancer Centers in Tier 2 and Tier 3 cities with integrated facilities for chemotherapy, surgery, radiotherapy, and pain and palliative care. These centers would bring cancer treatment closer to home for rural patients, alleviating the emotional and financial burdens of long-distance travel and ensuring that cancer care is accessible, humane, and complete.
Pain may be a part of cancer, but suffering should not be. By decentralizing cancer care, we can end the silent suffering that thousands endure every single day.
Edited by Christianez Ratna Kiruba
Image by Christianez Ratna Kiruba
