[Influence of the Timing of Cessation of or Withholding Chemotherapy and End-of-Life Care at Home in Patients with Incurable Solid Cancers-An Interim Report of the Results of the Questionnaire Survey among Home Care Physicians in Japan].

BACKGROUND: The study analyzed data obtained using a questionnaire on the potential discriminative characteristics of patients with an incurable solidcancer who receivedor didnot receive palliative chemotherapy during end-of-life care at home. From the standpoint of regional palliative care, we aimed to investigate the influence of the timing of cessation of or withholding chemotherapy andend -of-life care at home in patients with incurable solidcancers. We plannedthe project to obtain scientific evidence about the timing of cessation of or withholding chemotherapy. METHODS: The study included all patients with solidcancers treatedwith or without palliative chemotherapy who diedat home in 2016 in Japan. We distributed postcards of the invitation to participate in the questionnaire survey to more than 2000 home care physicians in Japan. The questionnaires administeredto home care physicians were registeredin website surveys from May to November 2017. The questionnaire data were analyzed using nonparametric methods. RESULTS: We previously obtained information from 576 patients at 170 medical facilities from May to August 2017. As we continue the study, we release an interim report of the questionnaire survey among home care physicians. Of the patients, from the time of diagnosis of the incurable solid cancer, 40% hadreceivedchemotherapy and6 0% hadnot. CONCLUSION: The 60% of patients who didnot undergo chemotherapy since diagnosis were a problem to our projects. However, as we continue the questionnaire survey, we would like to analyze the data from the returned questionnaires.

[The Influence of the Timing of Ceasing or Withholding Chemotherapy in Home-Based End-of-Life Care in Patients with Incurable Solid Cancer - Release of an Interim Report of the Questionnaire Survey to Home Care Doctors in Japan].

BACKGROUND: The study analyzes a questionnaire on the potential discriminative characteristics of patients with incurable solidcancer, who either receivedor didnot receive palliative chemotherapy while receiving home-basedend -of-life care. From the standpoint of regional palliative care, we sought to investigate the influence of the timing of when chemotherapy was ceasedor withheldin home-basedend -of-life care in patients with incurable solidcancer. We plannedthe project to obtain scientific evidence about the timing of ceasing or withholding chemotherapy. PATIENTS AND METHODS: The study includes all patients with solidcancer treatedwith or without palliative chemotherapy andwho diedat home in 2016 in Japan. We delivereda postcardof invitation to participate in the questionnaire to more than 2,000 home care doctors in Japan. The questionnaires were registeredas online surveys from May to November 2017. The questionnaire data were analyzed using nonparametric methods. RESULTS: We obtained information from 576 patients at 170 medical facilities from May to August 2017, but the study is currently ongoing; hence, we have released an interim report of the questionnaire results. Among the patients, 40%receivedchemotherapy and 60%didnot since the time of the first incurable solidcancer diagnosis. CONCLUSION: The majority 60% of patients not receiving chemotherapy was a setback to our project. However, as the questionnaire survey continues, we wouldlike to analyze these data after collecting more results.

Early Response of Esophageal Cancer to Neoadjuvant Chemotherapy with Docetaxel-Cisplatin-5-Fluorouracil Represents Sensitivity: A Phase II Study.

AIM: The aim of this study was to assess the response rate and find improvements. PATIENTS AND METHODS: Fifty-five patients with esophageal cancer were enrolled. Neoadjuvant chemotherapy (one or two courses) consisted of 60 mg/m(2)docetaxel on day 1, 70 mg/m(2)cisplatin on day 1 and continuous infusion of 5-fluorouracil at 600 mg/m(2)/day on day 1-5. All patients were examined for clinical response by computed tomography and endoscopy at each course. RESULTS: Grade 3/4 hematological toxicity was observed in 63.6% and grade 3/4 non-hematological toxicity in 41.8% of patients. The clinical response rate was 71% and histological complete response rate was 7.8%. We divided patients into three groups by clinical response to the first course of chemotherapy: partial response (PR), incomplete response (IR) and stable disease (SD). The final clinical response rate in those with SD to the first course was significantly lower (vs. those with PR p<0.001, vs. IR p<0.001). CONCLUSION: A high response rate was obtained and tolerability was good. Moreover, the presence of sensitivity to therapy was reflected in the initial clinical response.

A phase II study of bevacizumab with modified OPTIMOX1 as first-line therapy for metastatic colorectal cancer: the TCOG-GI 0802 study.

BACKGROUND: Although bevacizumab plus FOLFOX is a standard treatment for metastatic colorectal cancer, oxaliplatin must be withdrawn in many patients because of cumulative neurotoxicity. We postulated that a reduced dose of oxaliplatin and modified treatment schedule would prolong the time to treatment failure and evaluated bevacizumab combined with a modified OPTIMOX1 regimen (mOPTIMOX1, oxaliplatin dose: 85 mg/m(2)). METHODS: Eligible patients had a histologically confirmed diagnosis of metastatic colorectal cancer and a performance status of 0-1. Patients were excluded if they had grade 1 or higher peripheral sensory neuropathy or had previously received chemotherapy for metastatic colorectal cancer. Patients received bevacizumab plus mFOLFOX6 every 2 weeks for 6 cycles, followed by 12 cycles of a simplified biweekly regimen of leucovorin and fluorouracil (sLV5FU2) plus bevacizumab. Oxaliplatin was then reintroduced, and bevacizumab plus mFOLFOX6 was continued until progressive disease. RESULTS: The median duration of disease control was 11.7 months (95 % confidence interval [CI], 9.7-13.5 months). The median overall survival was 23.1 months (95 % CI, 18.8-27.9 months). The overall response rate according to both the RECIST and WHO criteria was 51.3 %. The most common grade 3 or 4 toxicities were neutropaenia (32.5 %), hypertension (17.5 %), leukocytopaenia, sensory neuropathy, and diarrhoea (10.0 %). There were no treatment-related deaths. CONCLUSIONS: Bevacizumab plus mFOLFOX6 was well tolerated, and patients could continue chemotherapy for longer than with conventional FOLFOX regimens. This regimen might be an effective treatment option for patients with metastatic colorectal cancer.

Early measurement of urinary N-acetyl-ß-glucosaminidase helps predict severe hyponatremia associated with cisplatin-containing chemotherapy.

BACKGROUND: Although cisplatin is a widely used anticancer drug for treating various types of cancer, its clinical application is limited by severe systemic toxicities, such as nephropathy, hematologic toxicity, and gastrointestinal toxicity. There are no reliable and validated biomarkers to predict adverse events caused by cisplatin. METHODS: Sixty-six patients who underwent cisplatin-containing first-line chemotherapy between June 2010 and November 2013 were retrospectively analyzed. Data on urinary N-acetyl-ß-glucosaminidase activities measured 24-48 h after cisplatin infusion were retrieved, and adverse events during the first course of chemotherapy were recorded according to the Common Terminology Criteria for Adverse Events version 4.0. RESULTS: Patient characteristics were: male/female 60/6, median age 65 (range 36-78) years, esophageal/gastric/other cancer 60/4/2, chemotherapy regimen docetaxel-cisplatin-fluorouracil/fluorouracil-cisplatin/S-1-cisplatin 54/8/4, cisplatin dose (mg/sm) 60/70/80 16/43/7. Grade 3/4 adverse events were leukopenia (40.9%), neutropenia (54.4%), febrile neutropenia (37.9%), hyponatremia (28.8%), and acute kidney injury (37.9%). Patients with 20 units/gram creatinine or higher urinary N-acetyl-ß-glucosaminidase developed statistically lower minimum serum sodium concentration (median 126 vs. 134 mEq/L, p = 0.0053). There were no significant correlations between urinary N-acetyl-ß-glucosaminidase and the development of other severe adverse events. CONCLUSION: Early significant increase in urinary N-acetyl-ß-glucosaminidase predicts subsequent development of severe hyponatremia after cisplatin-containing chemotherapy.

Key components of chemotherapy for thymic malignancies: a systematic review and pooled analysis for anthracycline-, carboplatin- or cisplatin-based chemotherapy.

PURPOSE: Thymic malignancies, comprising thymoma and thymic carcinoma, are rare. Consequently, optimal chemotherapy for advanced thymic malignancies remains controversial. Platinum-based chemotherapy is currently the consensus treatment based on the results of single-arm phase II trials and retrospective investigations. However, comparison of cisplatin-based and carboplatin-based chemotherapy has yet to be undertaken; the effectiveness of the addition of anthracycline also remains uncertain. METHODS: In the present study, clinical trials and retrospective data regarding platinum-based chemotherapy were analyzed. The endpoint was the response rate to each chemotherapy. For advanced thymoma, we compared platinum with anthracycline-based chemotherapy and platinum with non-anthracycline-based chemotherapy. For advanced thymic carcinoma, anthracycline-based versus non-anthracycline-based chemotherapy and carboplatin-based versus cisplatin-based chemotherapy were compared. This analysis included a retrospective study of response of advanced thymic carcinoma to irinotecan and cisplatin in our institution. RESULTS: The response rate for the 314 patients from 15 studies with advanced thymoma, including both prospective and retrospective data, was 69.4% [95% confidence interval (CI) 63.1-75.0%] for platinum with anthracycline-based chemotherapy and 37.8% (95% CI 28.1-48.6%; p < 0.0001) for platinum with non-anthracycline-based chemotherapy. The response rates after anthracycline-based and non-anthracycline-based chemotherapy for advanced thymic carcinoma were similar (41.8 vs. 40.9%; p < 0.91), whereas the response rates after cisplatin-based and carboplatin-based chemotherapy for advanced thymic carcinoma differed significantly (53.6 vs. 32.8%; p = 0.0029) in 206 patients from 10 studies. CONCLUSIONS: Platinum with anthracycline-based chemotherapy is an optimal combination for advanced thymoma. For advanced thymic carcinoma, cisplatin-based chemotherapy may be superior to carboplatin-based chemotherapy.

Biweekly irinotecan plus cisplatin versus irinotecan alone as second-line treatment for advanced gastric cancer: a randomised phase III trial (TCOG GI-0801/BIRIP trial).

PURPOSE: We compared biweekly irinotecan plus cisplatin (BIRIP) with irinotecan alone as the second-line chemotherapy (SLC) for advanced gastric cancer (AGC). METHODS: Patients with metastatic or recurrent gastric cancer refractory to S-1-based first-line chemotherapy were randomly assigned to receive BIRIP (irinotecan 60mg/m(2) plus cisplatin 30mg/m(2), every 2weeks) or irinotecan alone (irinotecan 150mg/m(2), every 2weeks). The primary end-point was to show the superiority of BIRIP to irinotecan in terms of progression free survival (PFS). RESULTS: 130 patients were enrolled. PFS was significantly longer in the BIRIP group (3.8months [95% confidence interval (CI) 3.0-4.7]) than in the irinotecan group (2.8months [2.1-3.3]; hazard ratio 0.68, 95% CI 0.47-0.98; P=0.0398). Median overall survival was 10.7months in the BIRIP group and 10.1months in the irinotecan group (HR 1.00, 95% CI 0.69-1.44, P=0.9823). The objective response rate was 22% in the BIRIP group and 16% in the irinotecan group (P=0.4975). However, the disease control rate was significantly better in the BIRIP group (75%) than in the irinotecan group (54%, P=0.0162). The incidences of grade 3 or worse adverse events did not differ between the two groups. Any grade elevation of serum creatinine was more common in the BIRIP group (25% versus 8%, P=0.009), but any grade diarrhoea (17% versus 42%, P=0.002) was more common in the irinotecan group. CONCLUSION: BIRIP significantly prolonged PFS as compared with irinotecan alone and was tolerated as SLC, but did not demonstrate the survival benefit in this trial.

[The current status of home palliative care for patients with advanced cancer at the Jikei University School of Medicine].

Medical oncologists are involved in cancer chemotherapy as well as end-of-life care. Recently, an increased number of patients with advanced cancer have expressed their preference to receive palliative care at their home during the end-of-life period, and several home medical care providers have aimed to provide such a service. The number of cancer patients who wish to receive home palliative care has also increased at our institution. We reviewed the characteristics of advanced cancer patients who received chemotherapy and who eventually received homecare from 2012 to 2014. The total number of patients was 22. Of these, 9 had breast cancer(40.9%)and 8 had colorectal cancer(36.4%). The median age was 68(range 36-90) years. Half of these patients died at home. The median duration of homecare to death was 64.5(range 12-252)days. Approximately 70% of patients were able to remain at home for over a month, but 3 patients died within 2 weeks at home and 1 patient returned to the hospital after 10 days of homecare due to disease progression. While palliative care in the home setting is valued by many cancer patients in the end-of-life period, close monitoring is needed for patients with rapidly progressing disease.

Complete response of esophageal small cell carcinoma amrubicin treatment.

Small cell carcinoma of the esophagus (SmCCE) is a rare and aggressive disease known to have a poor prognosis. SmCCE patients are generally treated with a chemotherapeutic regimen for small cell lung cancer. Salvage therapy for patients with relapsed or refractory tumors has not yet been established. A 63-year-old man with extensive SmCCE was treated with chemotherapy consisting of cisplatin (CDDP) and irinotecan (CPT-11). After the second course of CPT-11/CDDP, the celiac lymph node increased in size. Amrubicin (AMR) as second-line chemotherapy was started. The patient had a complete response after the fifth course of AMR, resulting in an 8-month progression-free survival after initial administration. This case suggests that, as in small cell lung cancer, AMR is effective for SmCCE.

[A case of stage IV b pancreatic cancer in which a catheter-related infection caused by epidural/subcutaneous reservoir therapy affected palliative home-based care].

We report the case of a patient with a stage IV b pancreatic cancer in which epidural/subcutaneous reservoir therapy was effective for pain control. However, a catheter-related infection caused by methicillin-resistant Staphylococcus aureus (MRSA)was occurred. In recent years, the number of cancer patients desiring palliative home-based care in Japan has increased. Epidural/subcutaneous reservoir therapy is often offered to relieve refractory pain, and to reduce the side effects of systemic administration of opioids, such as drowsiness, in homecare patients. We believe that this patient may have been able to continue home-based care if the catheter-related infection did not occur, because a significant improvement was calculated in the pain level by the numerical rating scale(NRS)observed. It is important to establish and share common strict guidelines between hospital doctors and general practitioners for the management of the subcutaneous catheter and reservoir therapy in order to prevent catheter-related infections over a long period.

[Usefulness of subarachnoid phenol-glycerin block therapy for enabling cancer patients with refractory anal pain to proceed to home-based care].

In recent years, the number of cancer patients and their families desiring palliative home-based care in Japan has increased. Subarachnoid phenol-glycerin block therapy is offered to relieve refractory anal pain in cancer patients, and to reduce the side effects of systemic administration of opioids, such as drowsiness. The effects of phenol-glycerin, which is a medicine used for neurodegenerative diseases, lasted for 1 week to 3 months. Eight patients with this manipulation showed a significant improvement in their pain level, calculated by the numerical rating scale(NRS). Five of these patients could proceed to homebased care. It is important to establish common guidelines for the management of phenol-glycerin. The participation of pharmacists in the palliative care team will contribute to further growth of home-based care.

Possible clinical cure of metastatic breast cancer: lessons from our 30-year experience with oligometastatic breast cancer patients and literature review.

BACKGROUND: Metastatic breast cancer (MBC) is generally incurable. However, 10-20-year relapse-free survival of MBC is approximately 2%, implying that at least a small subset of MBC patients achieve prolonged survival. We therefore analyzed long-term outcome in a particular subset, i.e., oligometastatic breast cancer (OMBC). METHODS: Data of OMBC subjects (N = 75) treated in our institution from April 1980 to March 2010 were retrospectively analyzed. OMBC was identified as: one or 2 organs involved with metastatic lesions (excluding the primary lesion resectable by surgery), fewer than 5 lesions per metastasized organ, and lesion diameter less than 5 cm. Patients were generally treated with systemic chemotherapy first, and those who achieved complete response (CR) or partial response (PR) were further treated, if applicable, with local therapy (surgical or radiation therapy) to maintain CR or to induce no evidence of clinical disease (NED), with additional systemic therapy. RESULTS: Median follow-up duration was 103 (6-329) months. Single or 2 organs were involved in, respectively, 44 (59%) and 31 (41%) cases with metastatic lesions, 48% of which were visceral. In cases where effects of systemic therapy, possibly in combination with other treatments, were evaluated (N = 68), CR or PR was achieved in 33 (48.5%) or 32 (47.1%), respectively, with overall response rate (ORR: CR + PR) of 95.6% (N = 65). In cases receiving multidisciplinary treatment (N = 75), CR or NED (CR/NED), or PR was induced in 48 (64.0%) or 23 (30.7%) cases, respectively, with ORR (CR/NED + PR) of 94.7% (N = 71). CR rates (60.5%) with systemic therapy and CR/NED rates (79.5%) with multidisciplinary treatment were significantly better in subjects with a single involved organ than in those with two involved organs (P = 0.047 and 0.002, systemic only or multidisciplinary treatments, respectively). Medians estimated by Kaplan-Meier method were: overall survival (OS) of 185.0 months and relapse-free interval (RFI) of 48.0 months. Estimated outcomes were: OS rates (OSR) of 59.2% at 10 years and 34.1% at 20 years, and relapse-free rates (RFR) of 27.4% at 10 years and 20 years. No disease progression was observed after 101.0 months as RFR. Cases with single organ involvement (N = 44) showed significantly better outcomes (OSR of 73% at 10 years and 52% at 20 years, RFR of 42% at 10 years and 20 years). Those who received local therapies (N = 35) also showed better prognosis: OSR of 82% at 10 years and 53% at 20 years, RFR of 38% at 10 years and 20 years. Three cases (4%) survived for their lifetime without relapse after achieving CR or NED, our definition of clinical cure. Multivariate analysis revealed factors favoring better prognosis as: none for OS, and single organ involvement with metastasis, administration of local treatment, and shorter disease-free interval (DFI) (P = 0.030, 0.039, and 0.042, respectively) for RFR. Outcomes in OMBC in literature were OSR of 35-73% at 10 years and 26-52% at 20 years, and RFR of 27-42% at 10 years and 26-42% at 20 years. CONCLUSIONS: The present analyses clearly indicate that OMBC is a distinct subgroup with long-term prognosis superior to MBC, with reasonable provability for clinical cure. Further prospective studies to better characterize OMBC are warranted to improve prognosis in MBC.

[Home medical support at Jikei Medical University].

A clinical clerkship of home care has been introduced to third-year medical students since 1998 at our university. Visiting nurses from the regional visiting nursing stations would give actual trainings at patient's home to a lot of medical students every year. For the improvement of medical education, it is not sufficient to give actual trainings to the students from visiting nurses. Then what we can do for visiting nurses about the role of the medical University was to offer and introduce the programs of cardiac and respiratory assessment as lifelong learning for the visiting nurses. After these programs were finished, two kinds of questionnaires were given to all participants to examine the necessity and scheduling of these program: 1 ) The first questionnaires after the programs was of cardiac and respiratory assessment, 2 ) The second questionnaires was for the participants with the experience of these programs, 3 ) Last questionnaires was for all visiting nurses about our 41 regional visiting nursing stations to promote the new programs(eight programs: home hospice care and opioids, PEG for the nutrition, ICLS, management of respirator at home, management of IVH port, ECG, foreign body of the airway, and the anatomy of organs)for lifelong learning. 1 ) A total of 7 2 visiting nurses participated in our programs for about one year recently, and 100% of these attendants returned questionnaires. After the programs, almost all of visiting nurses agreed that these programs were meaningful for them and it should be continued. 2 ) A total of 2 10 visiting nurses participated in our programs for the past 5 years. Fifty seven percent(57. 1%)of visiting nurses returned questionnaires. After the programs, a lot of visiting nurses agreed that these programs were meaningful for them and it should be continued. 3 ) Nearly 50 percent (47. 8% or 213/446)of visiting nurses from 41 visiting nursing stations returned questionnaires. A lot of visiting nurses expressed that they would like to participate in the subject of hospice care and opioids, PEG for the nutrition, ICLS and management of respirator at home as new programs. For the role of the medical University to promote a home care, it is necessary to support a community-based home care with educational issues at the university and to offer the new program mentioned previously as lifelong learning with practical and essential issues for medical staffs at patients' homes.

[Strontium-89 therapy and subarachnoid phenol block successfully eliminated intractable pain of metastasis in the patient with advanced urachal carcinoma].

We report a case of a 39-year-old man with intractable multifocal pain caused by metastatic urachal carcinoma to the bone. The patient underwent a partial cystectomy in May 2008, and lung metastasis occurred 9 months after the surgery. He then received salvage chemotherapy, but developed metastasis to the liver, brain, and bone. He was hospitalized due to a shoulder pain, a lower back pain, buttocks pain, numbness in both legs, and drop foot in right leg. MRI revealed metastases to the spine, and lumbar spinal canal stenosis with cauda equina compression. Even a combination of fentanyl-patch, oral acetaminophen, gabapentin and paroxetine was not effective for pain control. Strontium-89 therapy and subarachnoid phenol block successfully eliminated intractable pain. The patient could be discharged from hospital and received a palliative care at home for a short period of time.

[Usefulness of epidural catheter with the subcutaneous reservoir for cancer pain control in homecare service].

The epidural block therapy is offered to reduce one of the side effects of systemic administration of opioids such as drowsiness. Hence, it is necessary to set a subcutaneous reservoir to prevent a catheter-related infection for a long period of time. One hundred twenty five patients with this manipulation during the year 2004 to 2010 showed a significant improvement in their pain level calculated by Numerical Rating Scale(NRS). However only 30 cases could be proceed to the homecare. There was one case of catheter-related infection in 30 homecare cases. It is useful to establish the common strict guidelines between hospital doctors and general practitioners for the management of the epidural catheter with subcutaneous reservoir.

Phase II study of S-1 as first-line treatment for elderly patients over 75 years of age with advanced gastric cancer: the Tokyo Cooperative Oncology Group study.

PURPOSE: This prospective multicenter phase II study was carried out to investigate the efficacy, safety and pharmacokinetics of S-1 monotherapy in elderly patients over 75 years of age, with unresectable advanced or recurrent gastric cancer. METHODS: Patients had measurable or evaluable lesions according to the Japanese Classification of Gastric Carcinoma. S-1 (25-60 mg determined by the body surface area and creatinine clearance) was given orally, twice daily. A course of treatment consisted of 4-week administration followed by a 2-week rest period, and the patients received repeated courses. RESULTS: Thirty-three patients were enrolled. Pharmacokinetics of S-1 was studied in six patients, and the maximum plasma concentrations of respective metabolites after S-1 administration were found to be similar to those reported for younger cancer patients. The overall response rate in 33 patients was 21.2% (95% CI, 10.7-37.8%), and median progression-free survival was 3.9 months, with a median overall survival of 15.7 months. Frequently noted adverse events include leukopenia, neutropenia, anemia, anorexia, and fatigue. As for serious adverse events, relatively higher frequencies of anemia (9%) and anorexia (12%) of grade 3 severity were found, but there were no grade 4 episodes. CONCLUSIONS: The results suggest that S-1 monotherapy is safe and useful for elderly patients with unresectable advanced or recurrent gastric cancer when the dose is selected with caution, taking into account renal function.

Second-line chemotherapy with biweekly paclitaxel after failure of fluoropyrimidine-based treatment in patients with advanced or recurrent gastric cancer: a report from the gastrointestinal oncology group of the Tokyo cooperative oncology group, TCOG GC-0501 trial.

OBJECTIVE: A multicenter trial was conducted to evaluate the efficacy and safety of paclitaxel every 2 weeks in patients with advanced or recurrent gastric cancer who had previously received fluoropyrimidine-based chemotherapy. METHODS: The subjects were patients with gastric cancer who had disease progression or recurrence while receiving fluoropyrimidine-based chemotherapy. All patients had adequate major organ functions with an Eastern Cooperative Oncology Group performance status (PS) of 0-2. Paclitaxel 140 mg/m(2) was administered intravenously on days 1 and 15 of a 4-week cycle. The primary endpoint was the response rate. Secondary endpoints were progression-free survival (PFS), overall survival and safety. RESULTS: Response was assessable in 40 of 41 enrolled patients. Their median age was 63 (range: 48-77) years, and PS was 0 in 22 patients, 1 in 13 and 2 in 5. Previous treatment included S-1 (1 M tegafur-0.4 M gimestat-1 M otastat potassium) monotherapy in 32 patients and S-1-based combination therapy in 5. The median number of administered courses of paclitaxel was 3.5 (1-14). The response rate was 17.5% (95% confidence interval: 7.3-32.8%, partial response: 7, stable disease: 21, progressive disease: 10 and not evaluable: 2). The disease control rate was 70.0%, the median PFS was 111 days and the median overall survival was 254 days. Major adverse events of Grade 3 or 4 were neutropenia (27.5%), anemia (12.5%), diarrhea (2.5%) and sensory neuropathy (2.5%). CONCLUSIONS: Biweekly paclitaxel seemed to be one of the useful chemotherapies after failure of fluoropyrimidine-based treatment in patients with advanced or recurrent gastric cancer.

[Conditions required for home death--analysis of nine outpatients received chemotherapy].

Although a cancer patient to die at home has been arranged much easier due to a change in homecare service environment, the patient to die at home is not always possible. In the present study, we reviewed an outpatient who received chemotherapy and eventually died. We analyzed a relationship between the locations of their death and factors which influenced their final places using medical records. With a total of nine dead patients, five patients died at either home or hospital close to their home. In order to prevent a death at University hospital, the following points were important: First, doctors should ask patients which location they want to die at the beginning of the terminal stage. Second, home care doctors should start visiting patients before the end-of-life.

[Usefulness of epidural catheter with distal subcutaneous reservoir for cancer pain control].

When an effective pain relief cannot be achieved by systemic administration of analgesics, neuraxial opioid therapy such as epidural (EPI) and subarachnoid (SA) catheters should be offered. During the period of 2004 to 2008, EPI (117 patients) and SA (1 patients) with an epidural catheter with subcutaneous reservoir also showed a significant improvement in their pain level calculated by numerical rating scale (NRS). Two cases of infection were caused by a subcutaneous reservoir, however, no serious infections, such as epidural abscess, were observed. Long-term catheter trouble occurred in 15 patients (12.8%) which was considered to be the catheter obstruction caused by epidural fibrosis. It is necessary to establish the common guidelines between hospital doctors and general practitioners to prevent the incidence of the catheter troubles and infections.

[A case of an advanced pancreatic cancer (stage IVb) outpatient who could not maintain a home-based care until her death].

The number of cancer patients and their families desiring home-based care has been increasing over the last few years. We reported a patient, a 40-year old female patient with advanced pancreatic cancer (T4N3M1, Stage IVb). Once we had switched from a systemic administration of opioid to an epidural administration via a subcutaneous reservoir for her extreme pain, she was given relief from her severe pain and was able to be discharged. Although against her wishes, she had to be taken back into hospital due to both an inappropriate management of the subcutaneous reservoir by the general practitioners and her spiritual (existential) pain. Public support systems are urgently needed to be established for patients who continue to receive a home-based care.