Efficacy and Safety of Three-dimensional Conformal Radiotherapy for Macroscopic Vascular Invasion of Hepatocellular Carcinoma.

Chemotherapy is insufficient to treat macroscopic vascular invasion (MVI) of hepatocellular carcinoma (HCC). We retrospectively investigated the treatment outcomes of patients who underwent three-dimensional conformal radiotherapy (3D-CRT) for HCC MVI and analyzed prognostic factors by multivariate analysis using a Cox proportional hazard model. Sixty-five patients were studied. MVI sites were the portal vein (n=48 patients), portal and hepatic veins (n=8), and hepatic vein (n=9). The median irradiation dose was 50 Gy. The median survival time (MST) was 7.5 months. Performance status 2 or 3, modified albumin-bilirubin grade 2b or 3, and massive/diffuse type were poor prognostic factors. Nineteen patients (29%) with a treatment effect of 3 or 4 (≥ 50% of tumor necrosis or regression) at the irradiation sites according to the Response Evaluation Criteria in Cancer of the Liver showed longer survival than those with an effect of 1 or 2 (MST 18.7 vs. 5.9 months, p<0.001). No treatment-related death occurred. The hepatic function reserve was preserved in more than 70% of patients. 3D-CRT controlled HCC MVI safely and was suggested to be a good treatment option.

Development of a Systematic Approach to Consultation Record Data from Cancer Consultation and Support Centers.

The purpose of this study is to extract features and structure them using text mining and to analyze changes over time on consultation records accumulated in a cancer consultation and support center database from 2009 to 2018. The text-mining approach worked effectively under conditions of expanding data, and a co-occurrence network revealed patterns and trends in the content of consultations.

[The Effect of Using Regional Cooperation Critical Pathway for Cancer Patients].

We conducted a questionnaire survey of cancer patients and medical institutions to examine the usage status and problems of the regional cooperation critical pathway (cooperation path). In a survey of medical institutions, 65% of respondents said that using a cooperation path was beneficial, which was a significant increase from the previous survey in 2014. According to a survey on workload, about 30% of doctors felt that the workload increased in 2018 as well as in 2014. On the other hand, hospital profits increased at twice as many medical institutions compared to 2014. According to surveys of cancer patients, 80% of patients said that they were happy to use the cooperation path. However, a small percentage of patients disagreed with the use of the cooperation path. In this questionnaire survey, it was found that not only doctors but also patients understand the merits of the cooperation path.

Geriatric Screening for Hospitalized Older Adults with Cancer: A Survey of the Japanese Association of Clinical Cancer Centers.

Objective Geriatric screening followed by a more detailed assessment and intervention is recommended for older adults with cancer. However, little is known regarding how the geriatric screening covered by Japanese health insurance is used for hospitalized older cancer patients. We surveyed all hospitals in Japanese Association of Clinical Cancer Centers (JACCC) to explore the current use of this approach. Methods The JACCC member hospitals specialize in cancer care from prevention, through diagnosis and treatment, to palliative care. We mailed paper questionnaires to the presidents of the hospitals in December 2019 and collected them by February 2020. The survey requested general hospital information and asked whether (and how) such geriatric screening for hospitalized older adults with cancer was conducted. Results Twenty-six of 32 hospitals completed the survey (81%). Fourteen hospitals are cancer centers, while the remaining 12 hospitals are general hospitals which care of both cancer and non-cancer patients. Eleven hospitals (42%) performed geriatric screening and the most common use of the results was for "early discharge planning" and for "applying for long-term care insurance." Most clinicians rated the screening "somewhat" or "a little" helpful and found it most helpful for "meeting patient-post discharge needs". The most frequently reported barrier to implementation was a "lack of leadership to improve the care of older adults." Conclusion Geriatric screening was used at less than half of the major cancer centers and hospitals in Japan. One feasible solution to this problem is to establish an interprofessional workgroup at each hospital with the shared goal of providing high-quality care for this population.

[Tolerability of Definitive Chemoradiotherapy in Elderly Patients with Esophageal Cancer].

Definitive chemoradiotherapy(CRT)for esophageal cancer is the standard treatment and alternative to surgery. However, the tolerability of CRT in elderly patients is not well known. In this study, we retrospectively analyzed 60 patients with esophageal cancer who were treated with CRT(5-FU 700 mg/m2, cisplatin 70 mg/m2, radiation 60 Gy)at our hospital between January 2015 and September 2017. The patients were divided into 2 groups: an elderly group comprising 16 patients aged >75 years and a non-elderly group comprising 44 patients aged <74 years. The relative dose intensity of cisplatin in the elderly group was significantly lower than that in the non-elderly group. Radiotherapy was successfully executed in both groups. More patients in the elderly(25%)than the non-elderly group(7%)developed pneumonitis, and all patients who developed severe pneumonitis in the elderly group died. Application of definitive CRT and irradiation methods in elderly patients with a subpleural reticular shadow should be carefully considered before initiating therapy.

[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.

[Continuous Subcutaneous Injection Therapy in End-of-Life Symptoms of Cancer and Non-Cancer Patients].

The significance of continuous subcutaneous injection(CSI)therapy was assessed in end-of-life symptoms of cancer and non-cancer home hospice patients. In a retrospective analysis of 106 advanced cancer patients who underwent opioid CSI therapy, the most frequent symptom was pain(65%), followed by dyspnea(46%), seizure(8%), ileus(8%), and other uncontrolled end-of-life symptoms(23%). The median oral morphine equivalent daily opioid dose was 90 mg(2.5-1,920 mg)and the median duration of CSI administration was 3 days(1-350 days). Eighty-six percent of the patients underwent adjunct therapy to opioids, such as midazolam, octreotide, and haloperidol, in the management of cancer pain and non-pain cancer symptoms. In 5 non-cancer patients with systemic vascular disease, various symptoms required opioid CSI in the endof- life days. CSI with adjunct therapy to opioids can be effective in the treatment of end-of-life symptoms in both cancer and non-cancer patients.

[Cancer Disease Trajectory and the Contribution of Artistic Outreach Activity to Palliative Care].

The purpose of this article is to show some unintentional aspects of palliative supports offered by the community. The activities of the Opera Ehime, an amateur opera group, play an important role in palliative and grief care. This community is also committed to providing supportive care for home hospice cancer patients through an outreach music program that offers patients connection with others and reduces isolation. Assessment by the coordinator includes determiningthe patients' preferences and the relevance of music throughout their lives. Then, the coordinator predicts the cancer trajectory and invites patients to participate in the home hospice concert at any stage of their illness. These activities are an effective form of supportingcancer care for patients to promote wellness and improve physical and emotional well-being, as well as quality of life.

[Awareness about medical expenses and certifications of eligibility for limited health insurance payments for chemotherapy among clinicians at the Ehime Cancer Care Network Priority Hospitals (Ehime Cancer Kyoten Hospitals)].

The "Cancer Chemotherapy and its Management" subcommittee at the Ehime Cancer Care Network Priority Hospitals (Ehime Cancer Kyoten Hospitals)with a focus on medical expenses associated with chemotherapy, surveyed awareness among 98 clinicians regarding certifications of eligibility for Limited Health Insurance Payments during cancer treatment. This committee also lists social and clinical problems encountered at the Ehime Cancer Care Network Priority Hospitals. In our survey, 78% of clinicians were consulted about medical expenses associated with chemotherapy and were actively involved in resolving medical expense problems and resulting correspondences. However, only 38% of clinicians could explain the details of the Japanese guideline on the catastrophic cap and the certifications of eligibility for Limited Health Insurance Payments. This knowledge deficit was more pronounced in younger residents. From our analyses of the awareness about medical expenses among clinicians, we recommend the establishment of the following systems for the management of cancer patients. First, establish a reporting system and early consultation on the catastrophic cap and the certifications of eligibility before initiating cancer treatment. Second, education regarding medical expenses should be mandatory for clinicians, especially for young residents. Third, patients with cancer suffering in the interval of the medical expense and the social system should be relieved with new systems.

[Support for cancer caregivers during the palliative, hospice, and bereavement phases: the role of family physicians].

The family caregivers of cancer patients are at an increased risk of physical and mental morbidity. The purpose of this study is to capture the needs of the caregivers before and during the years after the loss of the patient. A survey was conducted among 229 consecutive advanced cancer patients in our family clinic. Seventy percent of the patients died in their homes, the median overall survival was 15.1 months, and the median survival time was 3 months from the beginning of the coordination with oncologists. While 28%of the patients received the best possible supportive care alone and 50%of them were admitted after the cessation of chemotherapy, in 22%of the patients, the coordination with oncologists began during the chemotherapy phase. During times of active cancer treatment, the caregivers were provided with various types of support from the family physicians. In the post-death bereavement phase, 124 caregivers were admitted to our family care clinic. The family physician can play an important role in aiding the caregivers during the palliative, hospice, and bereavement phases.

[Effective methods of organizing complex information in advanced cancer patients].

Advanced cancer patients often present with variable clinical information documenting widespread lesions and treatment histories. For health care providers, organizing and managing this information is crucial. In our ambulatory and home palliative/ hospice care practice, two visual tools are used: 1 ) a one-page line diagram which shows the Edmonton Labeled Visual Information System (ELVIS) and a schematic demarcation of dermatomes shown as distinct segments, and 2 ) a one-page summary report containing various graphs displaying the transition of clinical variables which appear to be predictive of survival. These concise visual representations of cancer information can be beneficial for summarizing or reviewing the disease and its clinical course, and in the transfer of patient information to other institutions. They may also serve as an aid to improve information recall in cancer patients, as well as to provide both the patients and their caregivers with information about cancer trajectories so that they can set appropriate goals, priorities, and expectations of care.

[Genetic counseling and practice of hereditary cancers at Shikoku Cancer Center].

Although the progress in understanding human genetics regarding cancer has been applied to the medical practice of treating hereditary cancers in developed western countries, it is not widely implemented in Japan. We started treating hereditary cancers at NHO Shikoku Cancer Center in November 2000. Our institution has a multidisciplinary team that provides medical care and genetic counseling for patients with hereditary cancers, and their relatives. The team consists of doctors from several related departments, and paramedics including a genetic counselor who participated as of 2009. Medical care of patients with hereditary cancers should not be separated from general oncological practice, but incorporate all medical professionals, including doctors of related departments and paramedic. We have attempted to identify patients with hereditary cancer and their family members and relatives at high risk; we followed them up and provided risk-reducing therapies for them at our cancer center. Here we present the framework of our practice in treating hereditary cancers. We discuss appropriate goals and future perspectives in the field of hereditary cancer in Japan.

Validation analysis of Japanese histological classification of breast cancer using the National Summary of Hospital Cancer Registry 2007, Japan.

Using the National Summary of Hospital Cancer Registry 2007, Japan, (HCRJ) from 219 local core cancer hospitals (LCCH) that had registered more than 29 breast cancers, we validated the Japanese classification of breast cancer (JCBC). In JCBC, most invasive ductal carcinomas (IDC) are subclassified as papillotubular carcinoma (coded as 850031 in the HCRJ) or scirrhous carcinoma (850033). Because of the confusing criterion that IDC with substantial ductal carcinoma in situ (DCIS) is papillotubular carcinoma, pathological T (pT)1 might be overestimated as pT2-3 by measuring the tumor size to include DCIS at LCCH where papillotubular carcinoma is diagnosed correctly. The LCCH were divided based on the difference between the proportion of papillotubular carcinoma to scirrhous carcinoma (PPS), that is, the proportion of 850031 cases to the sum of 850031 and 850033 cases at each LCCH (mean: 45.6%), and the PPS of the LCCH whose in-house histological classification was the origin of JCBC (standard PPS [StPPS]: 42.3%), into G5 (PPS within StPPS ± 5%), L5 (PPS < StPPS-5%), HL (StPPS + 15% ≥ PPS > StPPS + 5%), and HH (PPS > StPPS + 15%). On pT2-3, the proportion of N1-3 cases to N0 in G5 and HL was significantly lower than that in L5. The averages of the proportion at each LCCH of G5 and HL were also significantly lower than that of L5. Meanwhile, on pT1, the proportions and averages were not significantly different among the groups. The frequent overestimation of pT in G5 and HL explains their lower frequency of lymph nodal metastasis on pT2-3, leaving the frequency on pT1 unchanged. The JCBC has spoiled the accuracy of pTNM.

A case of small undifferentiated intramucosal gastric cancer with lymph node metastasis.

Early gastric cancer (EGC) has a favorable prognosis after surgical gastrectomy. For intramucosal EGC with little risk of lymph node metastasis, endoscopic mucosal resection (EMR) is an accepted treatment method. Herein we document a noteworthy case of small undifferentiated gastric cancer with nodal metastasis. A 60-year-old Japanese woman underwent gastrectomy with D2 lymph node dissection for the treatment of EGC in the lower gastric body. Histological examination revealed that signet-ring cell carcinoma was located in approximately one-third of the superficial portion of the mucosal layer, with a tumor size of 13 mm. No lymphatic invasion, venous invasion, or fibrosis was observed in the submucosal layer. This case had nodal metastasis and was finally diagnosed as stage IB (T1N1M0) according to the Japanese Classification of Gastric Carcinoma (JCGC). The patient is alive without recurrence 6 years after treatment.

Multicenter prospective study on efficacy and safety of octreotide for inoperable malignant bowel obstruction.

OBJECTIVE: The aim of this study was to evaluate the efficacy and safety of octreotide for malignant bowel obstruction in a multicenter study. METHODS: Terminally ill patients diagnosed with inoperable malignant bowel obstruction were treated with octreotide 300 microg/day. The primary endpoint was the overall improvement rate of subjective abdominal symptoms. The degrees of nausea, vomiting, abdominal pain, distension, anorexia, fatigue, thirst and overall quality of life were evaluated by the self-rating scores selected from the MD Anderson Symptoms Inventory and Kurihara's Face Scale. RESULTS: Forty-nine patients were enrolled in the study, and 46 patients received study treatment, including 17 gastric, 13 colorectal, 7 ovarian and other cancers. The median survival time was 25 days. The number of vomiting episodes significantly correlated with the MD Anderson Symptoms Inventory nausea and vomiting scores (P< 0.001) before octreotide treatment. Of 43 patients evaluable for efficacy, the scores of all the MD Anderson Symptoms Inventory items except abdominal pain and the number of vomiting episodes improved during the first 4 days of octreotide treatment (P< 0.0062). The MD Anderson Symptoms Inventory scores were decreased in 59-72% of patients, and overall quality-of-life scores improved in 56% of patients. No serious adverse events were observed. CONCLUSIONS: The high improvement rate in abdominal symptoms suggested the efficacy of octreotide in terminally ill patients with malignant bowel obstruction.

Present situation of pTNM classification in Japan: questionnaire survey of the pathologists of Gan-shinryo-renkei-kyoten Byoin (local core cancer hospitals) on pTNM classification.

pTNM classification is the most important element of surgical pathology. Internationally, the International Union against Cancer (UICC)-TNM is the standard TNM classification. In the present study questionnaires about the pTNM were sent to the pathology divisions of 288 institutions designated as Gan-shinryo-renkei-kyoten Byoin (local core cancer hospitals) on the basis of the Cancer Control Act. The questionnaire consisted mainly of questions about the TNM. There were 78 respondents, including 70 qualified pathology specialists, with a mean of 18.4 years of experience. The recognition rate of the important basic rules of the UICC-TNM were as follows: 'When in doubt, select the lower': 63.6% (49/77); 'Direct invasion to a lymph node is an N component': 61.0% (47/77); 'Only the extension of an invasive cancer is a T component': 45.5% (35/77). Few respondents knew the UICC criteria for judging whether multiple pulmonary lesions represent metastatic or multiple primary lesions. Only 26 (36.4%) of 77 pathologists were informed about cTNM routinely, suggesting that neither pathologists nor clinicians possess adequate knowledge about pTNM classification in many institutions. It is recommended that pathologists be informed about the rules and importance of pTNM through education, the revised Japanese classification of cancers, and self-assessment of their own institutes.

[Local communication system between hospitals, clinics and nursing homes and their team approaches are essential in a consistent medical care for cancer patients].

Designated cancer care hospitals are responsible for constructing a local communication system between hospitals, clinics and nursing homes. Their team approaches are essential in a consistent medical care for cancer patients. Clinical pathway sheets shared by them will promote their collaboration and keep the consistency of medical care. Counseling and supporting section, palliative care unit and palliative care team in the designated cancer care hospital play an important role improving the quality of medical care for cancer patients.

[Team approach for treatment of patients with cancer, how to cooperate with staffs of other medical institutions--a recent trend in Japan].

For the team approach to patients with cancer both of consistency of medical services and patient's satisfaction are important. Japanese health care reform planning prescribes an establishment of a section which accepts patient's consultation and provides proper advice or information. Technology of the internet is also promising for team approaches with staffs of other medical institutions as well as the patient support section in the cancer centers.