Palliative Care Practices in Gynecological Cancers in Asian Countries—A Cross-Sectional Survey by the Federation of Asian Organizations for Radiation Oncology

Abstract

Purpose:

Materials and Methods:

A web-based survey comprising of a 23-item questionnaire was sent to the members of the FARO research committee, FARO council officers, and members representing the national radiation oncology organizations (N = 36) that are a part of FARO.

Results:

All members (100%) responded to the questionnaire. While a majority (76%) of the respondents had both inpatient and outpatient services available for palliative care at their center, only 22% reported having access to specialist palliative care or an attached hospice facility. Among gynecological cancers, cervical cancer was the most common malignancy referred for palliative care (89%), followed by ovarian (64%) and uterine cancer (40%). A combination of palliative radiation and drug therapy (89%) was the most frequently employed treatment modality. Nearly 65% of the respondents reported prescribing strong opioids such as morphine, while 8.3% cited limited or no access to strong opioids. More than 60% of the respondents believed that palliative care was underutilized at their center, and oncologists’ lack of time was cited as the most common barrier (47%) limiting its utilization. Formal training in palliative care for all radiation oncologists (75%), development of palliative care infrastructure (66.7%), and improved access to specialist palliative care (55.6%) were cited as the most important measures that need to be undertaken to facilitate palliative care in the region.

Conclusions:

This survey has identified notable gaps in palliative care practices for gynecological cancers in the FARO region. To effectively integrate comprehensive palliative care into the oncology workflows, efforts must focus on increased training, strengthening the existing infrastructure, and developing research models tailored to the region’s needs.

Keywords

Asia FARO gynecological cancers palliative care survey

Key Message

What is already known on this topic?

Cervical cancer is one of the commonest malignancies across Asia, and a significant proportion of patients present in advanced stages of the disease, requiring palliative care. Although integration of palliative care is essential in cervical cancer management, significant disparities across these regions hinder its availability.

What does this study add?

The study amalgamates the palliative care practices across the Asian countries in patients with advanced incurable cervical cancers and provides insights into developing standardized palliative care across the region.

How might this study affect research, practice, or policy?

Based on this study, a prospective multicentric study has been designed to study the impact of integration of palliative care in the management of advanced cervical cancer in the Federation of Asian Organizations for Radiation Oncology region.

Introduction

Asia is witnessing a rapidly increasing cancer burden and mortality across all cancer sites. The region, comprising mainly of low- and middle-income countries (LMICs), contributes to a significant proportion of the global gynecological cancer burden, especially cervical cancer, and most patients present in advanced stages of the disease.¹ Effective integration of palliative care services into cancer management is, therefore, of utmost importance in this setting.

Palliative management focuses on the care of patients with advanced illness or a significant symptom burden. The integration of palliative care into the care of patients with cancer is associated with reduced symptom burden, increased patient and caregiver satisfaction, reduced rates of depression, and better end-of-life (EOL) quality metrics.² Several studies have demonstrated that palliative care given alongside usual oncologic care in patients with advanced cancer improves survival and quality of life (QoL). Most studies show improved outcomes at a cost lower than that for standard oncologic care alone and a decrease in the rate of aggressive interventions in the last 30 days of life.^3,4 Early integration of palliative care (EIPC) has also been associated with a reduction in the use of chemotherapy near EOL and an increase in enrollment and length of stay in hospice.⁵ In response to the growing body of literature supporting the benefits of palliative care integration to routine oncological care, both the American Society of Clinical Oncology and the Society of Gynecologic Oncology (SGO) released official practice guidelines in 2012 (updated in 2016) and 2015, respectively, encouraging the routine incorporation of palliative services to improve quality of care.^6–8

However, the integration of palliative care to oncology practice in the Asian region is restricted by a number of factors such as limited access to specialist palliative care (including medicines and equipment), lack of formal palliative care training, and oncologist time constraints.⁹ Moreover, palliative care practices are not uniform and vary across different centers. Hence, there is an unmet need for structured integration of palliative care into comprehensive cancer management, especially in patients with gynecological cancers whose palliative care needs are often complex and require a combination of physical, psychosocial, spiritual, and emotional support, in addition to the management of pain and other distressing symptoms.¹⁰ These issues are further compounded by the large prevalence of gynecological cancers, especially cervical cancer, in LMICs and poor socioeconomic conditions.

This survey was conducted to assess the current palliative care practices in advanced gynecological cancers among radiation oncologists across the Federation of Asian Organizations for Radiation Oncology (FARO) region. Founded in 2014 with a mission of fostering the practice of radiation oncology for the benefit of patients with cancer in the region, FARO serves as a federation of 15 national radiation oncology organizations in Asia. These include Bangladesh Society of Radiation Oncology, Chinese Society of Therapeutic Radiation Oncology, Association of Radiation Oncologists of India, Indonesian Radiation Oncology Society, Japanese Society for Therapeutic Radiation Oncology, Korean Society for Radiation Oncology, Malaysian Oncology Society, Philippines Radiation Oncology Society, Singapore Radiological Society, Sri Lanka College of Oncologists, Thai Association of Radiation Oncology, Pakistan Society of Clinical Oncology, Myanmar Society of Radiation Oncology, Mongolian Society of Radiation Oncology, and Nepalese Society of Radiotherapy and Oncology. FARO conducts its research activities through the FARO Research Network (FERN) and its various theme-specific working groups. Based on an initial survey identifying priority areas as agreed upon by FERN members, patterns-of-care surveys were launched across common tumor sites to support the development of prospective collaborative protocols.^11,12 These focus on themes particularly relevant to the Asian region. Hence, collaborative protocols in gynecological, head and neck, and breast cancers were prioritized, with several initiatives launched in 2025. One of the key priorities identified by the Gynecological Working Group was evaluating the integration of palliative care into clinical practice across Asia. To address this, the group designed a survey to identify gaps and barriers, with the goal of informing decisions on how to incorporate standardized palliative care workflows into routine gynecological oncology practice across the region. The survey results will serve as the foundation for a future prospective collaborative protocol within the FERN/FARO framework.

Materials and Methods

A web-based survey consisting of a 23-item questionnaire was designed and distributed to the members of the FARO research committee, FARO council officers, and representatives from national radiation oncology organizations affiliated with FARO (N = 36) in May 2023. All participants were practicing radiation oncologists from the FARO countries, familiar with the prevailing palliative care practices and the unmet needs within their respective organizations. The questionnaire was designed on the basis of two prior surveys conducted within the SGO, aimed at examining perceptions and practices related to palliative care among gynecological oncology practitioners.^13,14 The questionnaire was reviewed by members of the FARO research committee. The questionnaire was structured around four key themes, with specific questions detailed in Table 1.

Table 1.

Survey Questions

S.no.	Question	Response options
1	What is your country of origin?	□ Bangladesh □ China □ India □ Indonesia □ Japan □ South Korea □ Malaysia □ Mongolia □ Myanmar □ Pakistan □ Philippines □ Singapore □ Sri Lanka □ Thailand
2	What is your institutional background?	□ Private □ Government □ Semi-government □ Others, please specify_________________
Existing infrastructure for palliative care
3	What kind of palliative care services are available at your center?	□ Outpatient only □ Outpatient and inpatient palliative ward □ None, services provided along with routine patient care □ Referred to other centers for palliative care □ Do not believe in providing palliative care
4	Is a designated palliative care specialist available at your center?	□ Yes □ No
5	Is a hospice facility available at your center, and if yes, specify the type of facility?	□ Not available □ Yes, it is attached to the hospital □ Private hospice facility □ Government hospice facility □ Hospice facilities run by NGO □ Others, please specify_____________
6	Does your center provide home visit/home care facility?	□ Yes □ No
Palliative care practices within the member nations
7	What is the entry point of palliative care at your center? (Multiple options)	□ We don’t refer patients for palliative care □ At diagnosis □ When all treatment options have been exhausted □ For uncontrolled symptoms □ For end-of-life care □ For psychosocial needs/to discuss goals of care □ Others, if any________________
8	How are palliative care services scheduled at your center?	□ Daily □ Twice a week □ Once a week □ Not available
9	What is the approximate number of patients referred for palliative care every month at your center?	□ Less than 5 □ 5–15 □ 16–25 □ >25 None
10	Where do most of your cancer patients die?	□ At the hospital □ Home □ In other hospitals □ In hospice □ Don’t know
11	Who discusses end-of-life issues with patient/family?	□ Don’t discuss □ Don’t know □ Treating physician □ Palliative care team □ Treating physician along with the palliative care team □ Others, please specify_______________
Palliative care practices in gynecological cancers management
12	What is the approximate number of patients with gynecological cancers referred for palliative care at your center every month?	□ Less than 5 □ 5–15 □ 6–25 □ >25 □ None
13	Is there a designated examination room/space for gynecological cancer patients requiring palliative care?	□ Yes □ No
14	Patients with which of these gynecological malignancies are referred most commonly for palliative care at your center? (Multiple options)	□ Cervical cancer □ Ovarian Cancer □ Uterine Cancer □ Vulvo-vaginal Cancers □ Pelvic sarcomas
15	What are the most common reasons for referral of patients with gynecological cancers to the palliative care clinic? (Multiple options)	□ Pelvic symptoms (pain/bleeding/discharge) □ Intestinal Obstruction □ Ascites □ Bone metastasis □ Fistula □ Psychosocial issues □ Others, please specify_________________
16	What is the most common age group of gynecological cancer patients referred for palliative care at your center?	□ <30 years □ 30–60 years □ >60 years
17	What is the most common treatment modality used in patients with gynecological cancers requiring palliative care? (Multiple options)	□ Drug therapy (Analgesics, laxatives etc.) □ Drug therapy + Local radiation □ Drug therapy + Chemotherapy □ Drug therapy + Targeted therapy □ Others, please specify_______________
18	What are the various palliative radiotherapy schedules used for gynecological cancers at your center? (Multiple options)	□ 30 Gy/ 10 fractions □ 20 Gy/ 5 fractions □ 8/10 Gy single fraction □ Quad Shot □ Any other, please specify________________
19	How often are strong opioids (e.g., morphine) prescribed to gynecological cancer patients in your palliative care practice?	□ Not prescribed □ Not routinely prescribed, only by palliative care specialist □ Commonly prescribed □ Limited or no access to strong opioids
Barriers in the integration of palliative care and measures to fulfill unmet needs
20	In your opinion, what is the status of palliative care utilization at your center?	□ Over utilized □ Underutilized □ Appropriately used □ Not available
21	What do you think are the barriers that limit the utilization of palliative care at your center? (Multiple options)	□ No barriers at our center □ Not enough time □ Limited access to palliative care □ Physician concern or losing patient hope or trust □ Poor reimbursement □ Patient’s or family’s reluctance □ Do not feel the need of providing palliative care services to these patients □ Others please specify_______________
22	Have you received any formal palliative care training during the course of your career?	□ Yes □ No
23	What measures do you think can be undertaken to facilitate palliative care services at your center?	□ Appointment of a designated palliative care specialist/team □ Ensuring adequate access to strong opioids and supportive drugs □ Developing designated palliative care ward and/or hospice facility □ Formal training in palliative care □ Increased awareness about palliative care □ Others, please specify_______________
Additional comments

Existing infrastructure for palliative care

This section focused on assessing the availability of palliative care infrastructure within participants’ centers, including the presence of designated palliative care specialists, hospice facilities, and provision of home-based care.

Palliative care practices within the member nations

Questions in this category aimed to explore the existing workflow of palliative care within respondents’ institutions, as well as the characteristics of patients typically referred for palliative care.

Palliative care practices in gynecological cancer management

This section delved into the specific palliative care practices concerning patients with gynecological cancers, including patient profiles referred for palliative care and commonly employed treatment modalities.

Barriers in the integration of palliative care and measures to fulfill unmet needs

Questions in this segment addressed perceived obstacles in integrating palliative care into routine clinical practice, the perceived need for palliative care within participants’ centers, awareness of and access to formal training in palliative care, and solicited suggestions to enhance palliative care services.

Additionally, respondents were given the provision for additional comments at the end of the survey. A four-week response period was allotted, with two electronic reminders sent to encourage completion. Descriptive statistics were employed to summarize the survey findings.

Results

Overall characteristics

All 36 respondents completed the survey questionnaire (100%). The proportion of responding FARO member nations has been depicted in Figure 1. Majority of the respondents worked in public sector institutions (78%). The overall palliative care practices and demographic profile of the respondents have been enlisted in Table 2.

FIG. 1.

Proportion of responding FARO member nations. FARO, Federation of Asian Organizations for Radiation Oncology.

Table 2. Practices and Demographic Profile of the Respondents

Total number of responses	N = 36 (%)
Institutional background
Public	28 (77.7)
Private	6 (16.7)
Public–private partnership	1 (2.8)
Nongovernment nonprofit	1 (2.8)
Type of available palliative care services
Outpatient only	8 (22.2)
Outpatient and inpatient palliative ward	27 (75)
None, services provided along with routine patient care	0
Referred to other centers for palliative care	1 (2.8)
Do not believe in providing palliative care	0
Availability of a designated palliative care specialist
Yes	8 (22.2)
No	28 (77.8)
Availability of hospice facility
Not available	16 (44.4)
Attached to the hospital	8 (22.2)
Private hospice facility	1 (2.8)
Government hospice facility	3 (8.4)
Hospice facilities run by NGO	8 (22.2)
Home visits or home care facility
Yes	18 (50)
No	18 (50)
Palliative care service schedule
Daily	28 (77.8)
Twice a week	1 (2.8)
Once a week	6 (16.6)
Not available	1 (2.8)
Patients referred for palliative care in a month
<5	4 (11.1)
5–15	7 (19.4)
16–25	4 (11.1)
>25	10 (27.8)
Do not know	11 (30.6)
Patients with gynecological cancer referred for palliative care in a month
<5	20 (55.6)
5–15	9 (25)
16–25	4 (11.1)
>25	3 (8.3)
Most common gynecological malignancies referred for palliative care
Cervical cancer	32 (88.9)
Ovarian cancer	23 (63.9)
Uterine cancer	14 (38.9)
Vulvovaginal cancers	12 (33.3)
Pelvic sarcomas	11 (30.6)
Formal palliative care training
Yes	15 (41.7)
No	21 (58.3)

Existing infrastructure for palliative care

Majority of respondents reported having both inpatient and outpatient palliative care services (75%) available at their center. Regarding hospice facilities, 22% reported having a hospice facility attached to their hospital, while an equal percentage utilized hospice facilities operated by nongovernmental organizations. Notably, 44% of centers reported lacking any hospice facility. Home-based care was provided by 50% of the respondents’ centers. Only 22% respondents reported having access to specialist palliative care.

Palliative care practices within the member nations

The primary entry point for palliative care was either for EOL care (94.4%) or for managing uncontrolled symptoms (83.3%). In addition, a significant proportion (80%) cited psychosocial needs and discussions regarding goals of care as reasons for palliative care referral. Notably, only 39% of respondents indicated that patients were referred to palliative care at the time of diagnosis of advanced cancer (Fig. 2).

FIG. 2.

Most common entry points for palliative care at the respondent’s center.

Palliative care services were available on a daily basis at 78% of the respondents’ centers. However, only 28% reported referring more than 25 patients for palliative care each month. Discussions regarding EOL issues were commonly conducted either by treating the physician alongside the palliative care team (50%) or by treating the physician alone (36%). Regarding the location of patient deaths, approximately 45% of respondents stated that most of their patients died at home, while 25% reported that patient deaths occurred in the hospital.

Palliative care practices in gynecological cancer management

Majority of respondents’ centers (80%) received less than 15 referrals of patients with gynecological cancer per month, with nearly 70% of these patients falling in the age group of 30–60 years. Cervical cancer was the most common gynecological malignancy requiring palliative care (89%), followed by ovarian (64%) and uterine cancer (39%). Pelvic symptoms such as pain and bleeding were the primary reasons for palliative care referral (91.7%), followed by intestinal obstruction (55.6%), bone metastases (55.6%), and fistulae (50%) (Fig. 3).

FIG. 3.

Most common reasons for palliative care referral in patients with gynecological cancers.

The most frequently utilized treatment modality for these patients was a combination of palliative radiation and drug therapy (89%). Approximately two-thirds of respondents (64%) reported prescribing strong opioids such as morphine, while 8.3% cited limited or no access to strong opioids. Regarding palliative radiotherapy schedules, the most commonly used were 30 Gy in 10 fractions (83.3%) and 20 Gy in 5 fractions (72.2%). Additionally, single fraction palliative radiation in 8 or 10 Gy doses was utilized by 44.4% of respondents. Only 55% of centers reported having a designated space for patients with gynecological cancer requiring palliative care.

Barriers in the integration of palliative care and measures to fulfill unmet needs

More than 60% of respondents believed that palliative care was underutilized at their center. Lack of time was the most commonly cited barrier (47%) limiting the utilization of palliative care. Other barriers mentioned included limited access to palliative care services (39%), reluctance on the part of patients or their families (39%), and physician concern about potentially diminishing patient hope or trust (28%) (Fig. 4).

FIG. 4.

Perceived barriers limiting the utilization of palliative care.

Regarding training, only 42% of respondents reported having received formal training in palliative care. A significant majority (75%) believed that providing formal training to all radiation oncologists was the most crucial measure for enhancing palliative care provision in their country. Other suggested measures included establishing dedicated palliative care wards or hospice facilities (66.7%), increasing awareness about palliative care (66.7%), appointing designated palliative care specialists at oncology centers (55.6%), and ensuring adequate access to strong opioids and other supportive drugs (28%) (Fig. 5).

FIG. 5.

Suggested measures to facilitate palliative care services in the FARO region.

Discussion

Studies investigating the integration of palliative care into routine oncology practice consistently demonstrate improvements in QoL and patient-reported outcomes, along with reduced health care costs. Although there are no randomized trials specifically focusing on patients with gynecological malignancies, there are trials involving multiple solid tumor sites that also include gynecological cancers.^15,16 However, a significant proportion of patients either receive palliative care consultations very late in their course or not at all. For example, a retrospective study of patients with ovarian cancer revealed that only 28% of women undergoing treatment for ovarian cancer were referred for palliative care.¹⁷ Our survey also revealed a significant lack of palliative care referrals for patients with gynecological cancer with over 80% of respondents reporting fewer than 15 gynecological palliative care referrals per month. This mirrors earlier findings from a survey conducted within the SGO, where more than half of the respondents felt that palliative care services for gynecological cancers were underutilized at their centers, mainly catering to symptom control.^13,14

Moreover, most respondents indicated that palliative care was primarily initiated for EOL care or uncontrolled symptoms, rather than at the time of diagnosis, reflecting a common challenge in early integration. EIPC has been shown to significantly improve QoL, as demonstrated by Temel et al. in patients with metastatic non-small cell lung cancer and in other studies.^15,18 In a prospective study from India, the authors reported that EIPC in patients with locally advanced cervical cancer resulted in significant improvement in social and emotional well‐being subscales of QoL with EIPC.¹⁹

The survey identified several barriers to the adequate and timely integration of palliative care services. Notably, there exists significant variability in both infrastructure and practices related to palliative care across the FARO region. While a majority of respondents reported having inpatient and outpatient palliative care services at their center, the availability of hospice facilities, specialist palliative care, and home-based care showed considerable gaps. In the United States, 70%−80% of palliative care programs report an inadequate number of outpatient specialists to meet the demand.²⁰ Similar data from Asia are lacking, though studies from India and China have highlighted the absence of national policies or government funding for palliative care.^21,22 While integrated palliative care remains largely inaccessible in LMICs, the Indian state of Kerala has emerged as a model for its integration into the public health care system, with palliative care being incorporated into primary health care since 2008.^23–26

Other important barriers highlighted in the survey include time constraints, limited service availability, and patient and family reluctance. Almost half of the respondents acknowledged not having received any formal training in palliative care. Most gynecological oncology providers face constraints on the time they can allocate to symptom management and palliative care, a challenge particularly pronounced in high-volume centers in developing nations. Across Asia, numerous centers operate well beyond their intended capacity, with some facing an oncologist-to-patient ratio as low as 1 per 500.²⁷ Given the scarcity of specialist palliative care in the region, as emphasized by the survey findings, optimizing palliative care referrals becomes imperative, tailored to fit within the constraints of time and resources. To ensure timely access to specialty palliative care, all cancer centers should establish referral triggers aimed at triaging patients with the greatest need.²⁸

Integrating palliative care clinics within oncology departments of institutions ensures a seamless continuum of care, maximizing the reach of these services to a larger number of patients. It also provides an opportunity for ongoing training and experience in palliative care for health care professionals.²⁹ Radiation oncology departments can play a vital role in this regard by providing palliative radiotherapy and, at the same time, contribute to setting up an appropriate palliative care environment for these patients. To ensure continuum of care, integration models may be incorporated based on the location of care, which could be in the form of an embedded clinic, a free-standing palliative care clinic, home-based palliative care, or palliative care by telehealth. Such integration models may also be based on the referral method, which could be oncologist initiated; guided by clinical judgment or by referral criteria; or automated at the time of diagnosis of advanced cancer or development of symptoms and other triggers.³⁰

Consequently, it is essential for fellows and practicing oncologists to receive adequate training in primary palliative care, a measure strongly advocated by the survey respondents. This could involve incorporating palliative care rotations into radiation oncology curricula, providing certification training for practicing oncologists, and expanding opportunities for training in hospice and palliative medicine. Encouragingly, a variety of educational initiatives have been established in the Asian region to meet this need.

For instance, in Kerala, India, there are multiple training options for physicians and nurses, such as fellowships, shorter certificate courses, and residential programs endorsed by the World Health Organization (WHO).²¹ Similarly, in Bangladesh, Myanmar, and several other Asian countries, the Lien Collaborative for Palliative Care is dedicated to cultivating local expertise through training programs and international leadership initiatives. This collaborative effort allows candidates to learn from established palliative care programs within the region.^9,31 In Mongolia, hundreds of physicians and nurses have completed short palliative care courses since 2007.³²

The survey also shed light on the existing palliative care practices in the FARO region. It revealed that the utilization of palliative radiation and drug therapy was prevalent, underscoring the significance of multimodal approaches tailored to the unique needs of individual patients. Radiotherapy is highly effective in the palliation of local pelvic symptoms such as pain and bleeding. Importantly, it also reduces the requirement of strong opioids for pain management, a crucial consideration in regions with limited access to these medications.^33,34 A study examining factors influencing the use of strong opioids in patients with cancer receiving comprehensive palliative care in India found that palliative radiotherapy was associated with a significantly longer opioid-free interval in patients with advanced cancers.³⁵ Palliative radiotherapy should be utilized and incorporated into the existing palliative care protocols for advanced gynecological cancers (such as the Essential Package of Palliative Care for Women), which currently do not include this modality.³⁶

A high degree of variability was, however, noted in the palliative radiotherapy schedules followed by the survey respondents. Unlike established dose fractionation schedules for palliative radiotherapy in conditions like bone or brain metastases,^37,38 a definitive consensus is lacking regarding the optimal regimen for patients with advanced gynecological cancers.³⁹ Further research is needed to explore various radiotherapy protocols tailored to the palliative care needs of patients with advanced gynecological cancers, particularly within the context of the Asian demographic. Emerging evidence from prospective studies⁴⁰ and ongoing randomized trials (ClinicalTrials.gov ID NCT03997110) in this region suggests promising developments.

The utilization rate of strong opioids among survey respondents was 64%, reflecting a notable advancement in global access to essential medications like morphine. This progress can be attributed, in part, to the WHO’s model of pain management. This model, which recognizes morphine as an essential medicine, has been adopted by numerous countries.^9,41–43 However, access to strong opioids remains uneven, particularly in various parts of Asia. Barriers such as a lack of training among health care workers in opioid prescription, regulatory hurdles, and cultural attitudes further impede the widespread utilization of strong opioids in these regions.^26,42 Increased awareness and effective policy making are vital to ensuring the optimal utilization of these drugs and addressing the challenges faced in accessing them.

This survey emphasizes the need to implement a standardized basic practice workflow across the FARO region to improve palliative care integration for patients with gynecological cancers. A critical step forward involves the formulation and adoption of regionally adapted palliative care guidelines built on shared clinical pathways, including standardized referral triggers and consensus-driven treatment algorithms. For instance, integrating structured palliative care checklists into routine gynecological oncology consultations and establishing automated referral criteria—based on disease stage, symptom burden, or functional decline—can promote consistent and timely access to palliative services across institutions.

There is a dire need for conducting high-quality, context-specific research to support the development of integrated palliative care models tailored to varying resource settings. Such models must be scalable and responsive to the health care infrastructure of each region. Development of the FARO palliative care registry represents one such step that can facilitate systematic collection of data on patient characteristics, treatment regimens, QoL, and access barriers across multiple institutions and countries in the region. Such data can serve as the basis for longitudinal, multicenter research, allowing for the evaluation of changes in referral patterns, care delivery models, treatment outcomes, and health system improvements. Given the relatively lower contribution of Asia and other LMICs to palliative care literature,⁴⁴ prioritizing research initiatives in this region is crucial. The FERN is actively engaged in designing multicentric prospective trials aimed at informing practice and policy across diverse health care systems in the region.¹²

It is important to acknowledge the limitations of this study, including its cross-sectional design. This may have resulted in response or selection bias, temporal ambiguity, and the lack of ability to establish causality between the perceived barriers and prevailing palliative care practices. The sample size and geographical representation may also limit the generalizability of the findings. However, the member nations included in this survey represent a mix of low-, middle-, and high-income regions. Respondents came from diverse institutional backgrounds and reported a wide range of palliative care practices. As such, the findings can be considered reflective of the broader landscape across many Asian countries represented in the survey. Future research employing longitudinal and more comprehensive methodologies could provide deeper insights into the evolving landscape of palliative care in gynecological cancer management in Asian countries.

Conclusions

In conclusion, this survey offers valuable insights into the current landscape of palliative care practices for managing advanced gynecological cancers in Asian countries. Achieving successful integration of comprehensive palliative care into standard oncology care requires substantial efforts in infrastructure development, enhanced training, strengthening the health care workforce in hospice and palliative medicine, and implementing research models tailored to the needs of the FARO region.

Footnotes

Author Disclosure Statement

The authors have no conflicts of interest to disclose.

Funding Information

No funding was received for this article.

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