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The opportunity for a patient with advanced cancer to travel abroad may, for some, be a life affirming event during a dark period in their life. For others, what they hoped to be a time of joy may become an unmitigated disaster if they become unwell while away from the safety net of local cancer services. The rise of low budget airlines and cheaper foreign travel has led to an increase in the number of people travelling by air. Health professionals are more likely to face requests by patients to advise them on travel plans. Although foreign travel is an unrealistic goal for some patients, appropriate forward planning and proactive management can allow some patients to make an important journey abroad. This paper looks at the practical issues facing cancer patients who intend to travel overseas and offers practical advice on considerations that need to be made.
Foreign travel is no longer the exclusive preserve of the adventurous and wealthy. The growth of budget airlines and cheap package holidays has opened up the possibility of global travel to many people. Furthermore, demographic changes have resulted in more people having to travel to foreign countries in order to visit family and friends. As more people seek to fly abroad, it is inevitable that greater numbers with disability or illness, including cancer, will also be considering flying to their destination.
Foreign travel is not without its risks and a much longed for holiday can become a costly nightmare should things go wrong. Patients will often turn to their healthcare professionals for guidance when planning a journey. The needs of each patient will be unique and appropriate arrangements must reflect individual circumstances, the country of destination and the mode of travel. It is important for healthcare professionals to be aware of the potential pitfalls facing patients with cancer embarking on foreign travel and to have access to reliable and up‐to‐date information.
The patient will be committing valuable time, effort and finances into their holiday. A multidisciplinary assessment as to whether the patient is actually well enough to undertake the journey is essential. Assessment must take into consideration the patient's physical capabilities (including the stability and severity of symptoms), the distances involved, the mode of travel and the country of destination. Multi‐professional assessment may be required for those cancer patients with pre‐existing comorbidities—for example, heart failure, respiratory disease. When there is uncertainty regarding the patient's ability to travel by aircraft, sanction must be sought from the relevant airline medical officer (see “The importance of planning”). Travel to certain destinations may be precluded if the patient is unable to receive the necessary immunisations (see “Immunisations”)
It may be necessary to advise a delay to the planned journey if the patient has recently completed, is currently undergoing, or due to start certain treatments such as chemotherapy.
The patient may be unrealistic regarding their capability to travel. False expectations may be born out of a lack of understanding regarding the true nature of their illness. Alternatively, the patient may be denying the seriousness of their condition. Such situations require sensitive handling and excellent communication.
For a patient with advanced cancer, a holiday may represent more than “taking a break” and there can be any number of reasons for the choice of destination.1 If the patient is deemed too ill to make their intended journey, the healthcare professional should be prepared to discuss alternatives rather than simply giving a negative response. For example:
Additional expenditure may be incurred in order to facilitate the safe travel of a patient with ongoing healthcare needs. The resultant financial cost may prove prohibitive and such issues may require further exploration (see appendix 1).
Commercial air travel is one of the safest modes of transport and problems specifically related to a patient's cancer are rare. However, the environment within the cabin can be challenging; humidity is relatively low and conditions are often noisy and cramped with long periods of sitting.2,3,4
Modern jet aircraft have a cruising altitude approaching 39 000 feet, which is more fuel‐efficient and avoids much of the turbulence experienced at lower altitudes.5 Although cabin pressure is maintained at a more modest 5000–8000 feet, passengers will be subjected to prolonged periods at reduced atmospheric pressure.2,3,4,5,6,7 The fall in atmospheric pressure has two main effects:
At 8000 feet the partial pressure of oxygen falls to the equivalent of breathing 15.1% oxygen at sea level.5 The volume of gas expansion can be in excess of 30%.5 Most people have the capacity to compensate for such changes with little difficulty. However, for some individuals with an underlying healthcare need, these changes can be problematic. The suitability of flying as a mode of transport must be carefully considered if any of the following apply to a patient2,4,5,7,8:
The British Thoracic Society recommends that patients planning to fly, who have a resting sea level oximetry between 92–95% with additional risk factors (such as lung cancer, chronic lung or cardiac disease), should undergo hypoxic challenge testing as part of the pre‐flight assessment.5 Patients with a current closed pneumothorax should not travel on commercial aircraft while those with a previous pneumothorax will need a chest x ray confirming resolution before flight.5
Going on holiday is generally considered a positive experience, yet it is not without possible complications. The multidisciplinary team should assess the patient's capabilities ahead of the journey. Such assessment, together with knowledge of the chosen destination and itinerary, will aid identification of potential problem areas and facilitate anticipatory planning. All stages of the journey must be considered.
The patient should travel with a written summary of their condition that includes:
Such written information should be in English and translated into the language of the country of destination. Copies of both should be kept in the patient's possession at all times.
The patient may be in receipt of benefits to which they remain entitled during their time abroad. The local benefits office will be able to give advice and additional information is available on the website for the Department for Work and Pensions (www.dwp.gov.uk).
If it were anticipated that medical care would be required while abroad, it would be prudent to contact the appropriate health care professional in the country of destination before travelling and forward an up‐to‐date summary of the patient's condition. Information about cancer services within a particular country can be obtained through the relevant high commission, embassy or consulate. The Hospice Information Service supplies the contact details of hospices and specialist palliative care units throughout the world (www.hospiceinformation.info).
Some patients may be tempted to partake in some of the numerous complementary/alternative therapies practised throughout the world. The authors advise extreme caution. It would be difficult for the patient to establish whether a practitioner is adequately trained, has appropriate insurance or whether they are affiliated to a governing body. Furthermore, some herbal remedies may contain substances that interact with the patient's prescribed medication. The patient should not take such remedies without discussing the matter with their cancer specialist.
For patients requiring long‐term oxygen therapy, prior arrangement with the destination country is essential for adequate supplies to be organised. The patient's UK oxygen provider should be able to arrange for supplementary oxygen to be available at the destination, although there may be a charge.5,9 It is important to confirm that all such arrangements are in place before travelling. The patient should obtain details as to whom to contact, both at the country of destination and in the UK, in the event of problems arising regarding the supplementary oxygen supply. It may be necessary for the patient to supply their own oxygen tubing, adaptors, masks/nasal cannula as required.
It is usual for the patient to make appropriate arrangements regarding travelling to and from the airport, including the availability of supplementary oxygen as required. If the patient is unable to travel by car or taxi, the services of a private ambulance may be necessary.
The airport terminal can be a very stressful environment for those with a healthcare need.10 To minimise potential problems, the patient should give plenty of notice to the airline as to what level of assistance is required. At the time of booking, the patient should clarify:
Arrangements will also need to be made if supplementary oxygen is required within the terminal, including at stopovers.
Medical equipment may not be allowed onto the aircraft without the prior authorisation from the airline medical officer (AMO). Such authorisation should be obtained in writing, which can then be produced on demand. Medical equipment should travel in the patient's hand luggage, as should any additional supplies required, such as syringes, batteries and spare parts.
The airline has a duty of care to all their passengers and will seek to minimise the risk of possible disruption, such as having to make an unscheduled landing to obtain medical treatment. There is neither the skill nor the facilities on commercial aircraft to care for seriously ill people for extended periods of time, and airline staff may refuse to carry passengers whom they feel are too unwell.4,8 The AMO will assess the suitability of individuals to travel based on information received from the patient. Further information may be requested from the patient's general practitioner or cancer specialist. The AMO may only authorise travel when special arrangements are in place with regards to seating, provision of an escort and in‐flight oxygen.
Slightly more legroom than standard may be obtained from an aisle seat, which would also give easier opportunity to walk around the plane. Some airlines have designated seating for people with disabilities. Seating options can be discussed when booking the flight.
If it is likely that the patient will require long periods reclining in their chair or would benefit from additional legroom, then first class travel may be deemed necessary (particularly over longer journeys). The patient will have to meet the additional cost of upgrading. Provision for the patient to travel on a stretcher can often be made but since one stretcher can accommodate the space of up to nine economy class seats, cost may be prohibitive.8
Flight attendants are trained in first aid and strive to be as helpful as possible, but they are not authorised to give assistance with personal or medical care, or operate medical equipment. The AMO may stipulate that if the patient requires such support, they travel in the company of an escort. The nature of the escort depends on the type of care required8—for example:
In situations where an escort is deemed necessary, the escort must be seated next to the patient. When the escort is a healthcare professional, the patient is expected to meet the costs incurred.
Although commercial aircraft have an emergency oxygen supply, it is intended solely for an in‐flight emergency. If there is likelihood that a patient will require supplementary oxygen during the flight it is imperative that they discuss their needs fully with the airline at the time of booking.
There is little consistency between airlines regarding the provision of in‐flight oxygen. Most airlines are able to supply supplementary oxygen but charges (where made) vary widely; some airlines expect payment for an additional seat, to which the oxygen cylinders are secured. Supplementary in‐flight oxygen is usually delivered at flow rates ranging from 2–8 litres per minute, but the maximum flow rate varies between airlines and should be clarified before booking. Some airlines allow a patient to travel with their own oxygen supply, but in limited quantities. The use of supplementary oxygen during take off and landing may be subject to further restriction.9 The policies and procedures of individual airlines can be found on their respective websites. The healthcare provision of many major airlines are summarised on the British Lung Foundation website (www.britishlungfoundation.org).
The AMO may request written information from the patient's general practitioner or specialist detailing the need for in‐flight oxygen, whether required continuously or intermittently and the flow rate (at altitude).
The standard of healthcare and its provision varies greatly throughout the world, not only between countries but also within countries. For example, patients staying within an urbanised area of a developed country may well be able to access a wide range of healthcare services (possibly at a cost). However, if the destination is to a remote location, even within a developed country, then healthcare provision may be very basic. An important part of planning a journey abroad is to ascertain the level of healthcare services available. The relevant high commission, embassy or consulate will be able to provide details.
The level of emergency medical cover available to UK citizens abroad varies but is essentially of three types11:
The Department of Health booklet “Health Advice for Travellers” is widely available at post offices and travel agents. It provides details on how to access health care when abroad and how to obtain an EHIC (and form E112); an updated version can be found on their website (www.dh.gov.uk/travellers).
Because our healthcare system is largely “free at the point of delivery”, it is easy for UK citizens to underestimate the financial costs accrued when receiving medical treatment while abroad. Even within countries that have a reciprocal agreement with the UK, costs can run into thousands of pounds for treatment received. Costs can escalate dramatically if the services of an air ambulance are required (in excess of £30000 from the USA, up to £12000 from the Balearics).12 If death occurs while the patient is abroad, the family are expected to meet the costs of repatriation. Therefore, comprehensive travel insurance is strongly recommended for those patients who wish to travel abroad.
Even though a patient with advanced cancer may be deemed fit enough to travel by their doctor, there may still be difficulty in obtaining travel insurance as the patient is considered more likely to make a claim.13 Added difficulty may occur if the destination country has expensive healthcare, or if the journey involves a long flight.
Insurance companies will consider applications for cover on an individual basis. This may involve the completion of a health questionnaire, the request of information from the patient's doctor, and possibly an independent medical examination. The patient must provide full details regarding their condition and treatment when applying for travel insurance as any omission may invalidate the policy if a subsequent claim is made.
There may be a wide variation in the level of cover (if any) offered and premiums can also vary widely, so it is necessary to “shop around”. It is important that the patient is clear as to what the policy offers (some may exclude claims related to their cancer) and the amount of excess to be paid. Cancerbackup provides details of insurance companies which have previously provided cover for patients with cancer (www.cancerbackup.org.uk).
Any escort may need to travel with the same level of insurance as the patient. Medical equipment that is accompanying the patient should also be fully insured.
General healthcare advice that is appropriate to all travellers often has particular relevance for those with cancer, due to their increased susceptibility to the risks encountered. Often, relatively simple measures and precautions can prevent much distress.
The association between venous thromboembolism and long haul travel has been the subject of much speculation. Patients with advanced cancer are highly prothrombotic and sitting in cramped conditions for a prolonged period of time is likely to represent an increased risk.5,14,15,16 General advice includes drinking plenty of non‐alcoholic drinks, taking a short walk every 1–2 h, and performing leg exercises regularly. There are no specific guidelines for thromboprophylaxis in cancer patients during flights. It is the opinion of the authors that anti‐embolic stockings and aspirin should be considered in all at risk patients. Patients considered at a greater risk—for example, because of recent surgery, fracture, hormonal therapy or chemotherapy—should be considered for prophylactic low molecular weight heparin, although this may raise practical difficulties.
Sufferers of lymphoedema may find their condition is exacerbated by air travel as a result of prolonged inactivity. A pre‐flight assessment by a lymphoedema specialist would be beneficial. Restrictive clothing should be avoided and compression garments worn as instructed.
If lymphoedema affects the lower limbs the patient should be advised to wear shoes that can accommodate any swelling of the feet. Shoes should not be removed during the flight (there may be difficulty getting them back on). Some form of footwear should be worn at all times, including when bathing in the sea.
If lymphoedema affects the upper limbs the patient should avoid wearing rings or wristwatches on the affected limb. The patient should also avoid carrying heavy luggage. Vaccinations should not be injected into the affected limb.
Special care should be taken to avoid sunburn and insect bites. It may be considered necessary for the patient to travel with a supply of antibiotics in the event of infection. The Lymphoedema Support Network produces an informative leaflet on the “Do's and Don'ts” when planning holidays and travel (www.lymphoedema.org/lsn).
Diarrhoea and vomiting can be debilitating to individuals who are generally in good health, but can be devastating to the patient with advanced cancer. Food and water can be contaminated in a variety of ways but risks can be reduced significantly by taking relatively simple precautions:
Even limited exposure to strong sunlight can cause sunburn and heat exhaustion. Patients should be advised to stay out of the sun during the hottest part of the day (11.00–15.00) and to drink plenty of non‐alcoholic drinks. Some patients may be more sensitive to the direct effects of the sun due to chemotherapy regimens, radiotherapy or lymphoedema. High‐factor sun block (SPF 15 or higher) is recommended, as is the wearing of loose, cotton clothing.
A number of countries have diseases that are transmitted through insect bites, but any bite can lead to subsequent infection. The risk of insect bites may be increased with certain types of holidays (for example, camping), holidaying at certain times of the year (for example, high summer), at certain times of day (for example, at dusk) or at particular locations (for example, lakesides, wooded areas).
If the risk of insect bites is deemed to be high, the patient should be encouraged to use an approved insect repellent (preferably containing DEET (diethltouamide)) and keeping as much of their body covered with appropriate clothing. A “knock‐down” insecticide spray may provide further protection. The use of a mosquito net should also be considered.
Immunisation against certain diseases may be essential or recommended when travelling to certain countries. Whether a patient is able to receive certain vaccines may influence their travel destination.
There are three main types of vaccine:17
Live attenuated vaccines are best avoided in patients who are immunocompromised. Inactivated vaccines and detoxified toxins are safe to give but may be less effective in people with a weakened immunity.17
Causes for a patient being immunocompromised include:
Patients who have received high dose chemotherapy, stem cell or bone marrow transplantation may have lost the immunity from previous vaccinations and will require revaccination 6 months after the completion of their cancer treatment.17
Patients who have undergone a splenectomy will have lower resistance to certain types of infection and should be vaccinated against pneumococcus, Haemophilus, influenza type b, and meningococcus.16 It may be considered necessary for a splenectomy patient to travel with a ready supply of antibiotics. Malaria can pose particular problems for patients who have undergone a splenectomy and travel to malarial areas is best avoided.
There are no restrictions on the carriage of either “over‐the‐counter” medications or prescription drugs (not controlled) out of the UK. However, there is a range of considerations that the patient needs to address before travelling in order to minimise potential problems:
Additional considerations and arrangements must be made for patients travelling with controlled drugs. The Home Office stipulates the maximum doses of controlled drugs that an individual may export out of the UK. If the quantity of controlled drug does not exceed the maximum amount specified, a covering letter from the prescribing doctor (on headed notepaper) will be sufficient to permit the carriage of drug out of, or into, the UK. Up‐to‐date lists can be obtained at www.drugs.gov.uk (drug laws and licensing link).
In order to carry quantities of a controlled drug greater than the maximum stipulated by the Home Office, the prescribing doctor must make an application for a Personal Import/Export Licence. Application forms may be downloaded from the www.drugs.gov.uk (drug laws and licensing link).
It usually takes 14 days to issue a Personal Licence, although it is possible to speed up the process if necessary.
Diamorphine is illegal in most countries and permission must be sought from the relevant ministry of health before it can be taken into that country or a licence issued. In circumstances where the patient is seeking repatriation to a foreign country, it may be necessary to convert to an alternative opioid.
A Personal Licence has no standing outside the UK and will merely allow travellers to pass through UK customs unhindered. It has no influence on permitting entry of controlled drugs into the country of destination. Individual countries may have strict guidelines regarding the import of controlled drugs. Patients are strongly advised to obtain the relevant authorisation by contacting the appropriate high commission, embassy or consulate before embarking on their journey. If possible, such authorisation should be obtained in writing in order to show to the local customs service. If written authorisation is not forthcoming, a letter from the prescribing doctor on official notepaper to include details of the prescription with a contact address and telephone number may prove helpful.8
The diagnosis of advanced cancer does not absolutely preclude the patient from travelling abroad. However, minimising potential risks and dealing with the bureaucracy can be a daunting and frustrating experience. Many of the complexities can be overcome by a combination of careful planning and good communication.
The patient will often turn to a healthcare professional for advice, although the healthcare professional themselves may be unsure as to how to take the issue forward. Developing a resource pack based on up‐to‐date sources of information (see appendix 2) and selected references cited in this article would be a suitable starting point.
The financial costs can be prohibitive and the patient needs to be aware of all the costs they may incur and not just the “brochure price”. It is advisable that the additional costs are looked into before making a firm booking.
Allow as much time as possible when planning a trip abroad. With so many people and organisations to liaise with, communication will be more effective if it is not rushed. There are occasions when time is a luxury that the patient does not have and the use of a checklist will help to organise and speed up the process.
For the patient, a trip abroad at the end of their life often represents more than a holiday. Any decision to dissuade the patient from travelling should not be made lightly, and certainly not on the grounds that it would be “too difficult to arrange”. However, supporting the patient may involve pointing out the unsuitability of the proposed trip based on many factors including the patient's general health, the arduousness of the journey and the lack of suitable healthcare. When the patient's illness is very advanced, the energy and time they will expend on planning and undertaking their journey may be more appropriately directed elsewhere. This is a time for sensitive communication, to explore the underlying motivations and discuss realistic alternatives.
AMO - airline medical officer
DEET - diethltouamide
EEA - European Economic Area
IHIC - European Health Insurance Card
POSSIBLE ADDITIONAL EXPENSES (WHEN TRAVELLING WITH A HEALTHCARE NEED)
USEFUL SOURCES OF INFORMATION
British Lung Foundation
08458 505020 (Help‐line)
Provides a range of information on planning holidays in the UK and abroad for people with respiratory illness. Includes guidance for organising oxygen when going abroad. Also details the policies and procedures of many major airlines regarding the supply of in‐flight oxygen and the available assistance for passengers with disability
0808 800 1234 (Help‐line)
Provides information on all aspects of cancer, including a wide range of issues relating to travel.
Department of Health (DoH)
0800 555 777 (Literature Line)
The comprehensive booklet “Health Advice For Travellers” is widely available at Post Offices and travel agents and can also be ordered from the literature line. An updated version of “Health Advice For Travellers” is available on the DoH website.
The DoH also contributes to the travel pages on CEEFAX (page 460) which includes general health advice for travellers and updated overseas health warnings and immunisation advice.
Follow the links “Drug laws and licensing” “Licensing” “Personal Licenses” to obtain:
Foreign and Commonwealth Office
Follow the link “Travel Advice” for up‐to‐date information about many countries including risks and hazards.
Hospice Information Service
0870 903 3903
Information and contact details of palliative care services around the world, as well as in the UK.
Provides holiday and travel information including the booklet “Flying home – or on holiday”
Lymphoedema Support Network
020 7351 4480
Provides detailed information on lymphoedema for both the patient and healthcare professional.
Produces the factsheet “Holidays and travel”
Macmillan Cancer Relief
Provides practical support through the Macmillan nurse service and a number of self help and support groups.
Macmillan will also consider the awarding of a one‐off grant to help offset such expenses as travel costs.
National Travel Health Network and Centre
Funded by the Department of Health. Aims to improve the quality of travel health advice available to healthcare professionals.
Contains a wide range of links to alternative sources of information including “Health Information for International Travel” (the ‘Yellow book') which contains a summary of health risks in various countries and the required/advised immunisations.
Conflict of interest: none stated