Methadone is a difficult medicine to assess the efficacy at an initial stage because the blood concentration of it varies greatly among individuals and it takes days to reach a steady state and cannot be increased for 7 days. Nevertheless, there are few reports of blood concentration together with effects after administration of methadone about Japanese cancer patients. In this study, we investigated changes in blood concentration and pain score (NRS), and factors that affect blood concentration. Dose per body weight was only correlated with blood concentration of methadone. In the effective cases, NRS decreased chronologically until the 7th day after treatment initiation, and significantly decreased from the 1st day compared to before treatment initiation, but in the ineffective cases, it tended to decrease until the 3rd day, but there was no change thereafter. The blood concentration increased to 110 ng/ml on the 7th day in the effective cases, and in the ineffective cases, it reached the concentration on the 3rd day. Thus there was no correlation between the blood concentration and the drug efficacy. The individual blood concentrations tended to increase slightly or decrease after the 3rd day, but in only one case, it continued to increase. From the above-mentioned, it was shown that the effect could be judged at an early stage, however, since there was a case in which the blood concentration continued to rise until the 7th day, it was considered that the early dose increase within 7 days after initiation should be performed carefully.

Delirium occurs in 30-40% of patients with terminal cancer, and 90% of patients are delirious immediately before death. Symptoms such as agitation and hallucination are often refractory to the standard pharmacological therapy. Also, the medication options for delirium in terminally ill patients are often limited due to a difficulty in swallowing or a lack of intravenous access. We herein report a case series of six patients with terminal cancer whose derilium symptoms were treated by asenapine sublingual tablets during the intervention period by the palliative care team. Asenapine was selected when other antipsychotics were ineffective or unavailable for agitation caused by delirium. All patients suffered dyspnea or choking sensations due to dysphagia or respiratory dysfunction. Sedative effect was observed among all patients without apparent adverse events. Sublingual asenapine could be an option for the management of restlessness due to terminal delirium when both oral and intravenous drug administration routes are not available.

​Objective: The purpose of this study was to clarify the characteristics of physical quality of life (QOL) and activities of daily living (ADL) in patients with advanced cancer undergoing home-visit rehabilitation. Method: In this prospective study, we included 35 patients with advanced cancer undergoing home-visit rehabilitation. Physical QOL was assessed using the Physical Functioning (PF) score on the QLQ-C15, and ADL was assessed using the Barthel Index (BI) and Functional Independence Measure (Motor FIM) scores. Changes in physical QOL and each ADL scores from the start of rehabilitation to 4 weeks later were investigated. Also, patients were divided into two groups according to the PF score and characteristics of physical QOL and ADL between the two groups were explored. Result: PF score was significantly improved after 4 weeks compared to baseline. In the PF score maintenance/improvement group, motor FIM score was significantly improved after 4 weeks compared to baseline. Conclusion: The physical QOL of patients with advanced cancer undergoing home-visit rehabilitation was maintained and improved 4 weeks after the start of rehabilitation. It was suggested that maintaining ADL may lead to maintenance and improvement of physical QOL.

Alkaline phosphatase (ALP) has been measured using a Japan-specific method in Japan. However, the Japan Society of Clinical Chemistry (JSCC) has decided to change to an international standardized method of International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) by the end of fiscal year 2020. The Prognosis in Palliative care Study predictor (PiPS) models were the prognosis predictor methods developed in the UK. The ALP value is included in the test items of PiPS-B of the PiPS models. The international standardization method was not used in previous reports about PiPS in Japan. In this study, we investigated the effect of changing measurement methods of ALP levels on the prognostic value of PiPS using IFCC conversion values. We performed prognostic prediction by PiPS models in 239 consecutive patients admitted to our palliative care unit from March 2019 to March 2021. In 98 PiPS-B calculated patients, the prognosis was recalculated by replacing ALP values with the JSCC recommended conversion values. 5 of 98 patients whose prognosis was “weeks” changed to “months+”. It was suggested that a change in the method of ALP measurement from JSCC to IFCC method may change the “weeks” prognosis prediction by PiPS to a “months+”.

Background: Consideration of cultural aspects is important in medical care. We explored regional differences in cancer and palliative care among Okinawa, Tohoku, and Tokyo metropolitan area. Methods: We conducted a questionnaire survey of physicians involved in cancer medicine from September to November 2020. A total of 11 items related to physician experiences were rated using a 5-point Likert-type scale. Results: Responses were received from 553 physicians (187 in Okinawa, 219 in Tohoku, 147 in the Tokyo metropolitan area). In Okinawa, “When patients die, it is important that all family members are present at the last moment,” “Patients/family members primarily consult the elders of the family about the medical treatments,” “Family members hope the patients die at home, because the soul will not return when they die at the hospital,” “Patients/family members get advice from religious advisors about the medical treatments,” and “Family members wish to take the patient home when he/she is about to die and to confirm death at home” were significantly more frequently observed. In Tohoku, “Patients wish to be hospitalized at a specific season” was significantly more frequently reported. In Tohoku and Okinawa, “Patients hide cancer from neighbors and relatives” and “Elderly patients do not want treatment, because they cover the living expenses and education expenses for their children and grandchildren.” were significantly more frequently experienced. Conclusion: There are regional differences in cancer and palliative care in Japan. Being sensitive to the culture of the region is needed.

Introduction: We report a case of dyspnea in the patient with end-stage heart failure with renal insufficiency, which was refractory and was successfully controlled with intravenous fentanyl. Case: The patient was a 76-year-old man with dilated cardiomyopathy who repeatedly had been in and out of the hospital. He was admitted to the hospital because of heart failure exacerbation and treated with all available heart failure therapies, but his dyspnea was refractory. We implemented the team-based palliative care intervention and used intravenous fentanyl as a substitute for morphine due to renal insufficiency. His dyspnea was relieved in dose-dependent without heart failure recovery. Conclusion: In this case, we used intravenous fentanyl to relieve dyspnea in patients with end-stage heart failure. Under careful observation, fentanyl may be used as an alternative drug to relieve dyspnea in patients with end-stage heart failure.

Pancoast tumor is a relatively rare form of non-small cell lung cancer. Due to its invasion of the brachial plexus, it often causes severe pain and sometimes it is difficult to control the pain. Radiotherapy is often chosen not only for the treatment of the cancer but also for pain relief in Pancoast tumors. However, radiotherapy requires the patient to be kept in a resting supine position, which can cause severe pain during treatment or make it impossible to continue treatment due to pain. In this article, we report our experience with a patient who presented with severe pain in the shoulder and upper extremities due to a Pancoast tumor. Although patient had difficulty in maintaining a resting supine position, continuous cervical epidural anesthesia enabled him to complete radiotherapy under pain control. Despite the risk of infection and bleeding from catheterization, it is important to consider the indication of continuous epidural anesthesia when pain control is poor.

In Japan, there are not many reports of using hydromorphone for patients with renal failure and occurring neurotoxicity such as disturbance of consciousness. This report includes two cases of consciousness disorder such as delirium when hydromorphone was started or increased in patients with renal dysfunction. In the case 1, delirium appeared when hydromorphone dosage was increased from 2.4 mg to 3.6 mg intravenously for cancer pain. After reduction of dosage, consciousness disorder was improved. In the case 2, delirium also appeared when oral hydromorphone started at 2 mg for cough and dyspnea. After discontinuation of hydromorphone, the disturbance of consciousness was improved. In both cases, hydromorphone improved cancer pain, cough, and dyspnea, but it was difficult to continue hydromorphone due to adverse events, and opioid switching was required. Although there are reports of neurotoxicity caused associated with the use of high-dose, long-term hydromorphone in patients with renal failure, neurotoxicity may be shown even with small doses and short-term administration.