Purpose and Methods: In the WHO guidelines on the management of cancer pain, global standard-dose acetaminophen (APAP) is described as a first-line drug, but there have been few studies comparing the efficacy and safety of APAP with other options in Japan. We retrospectively studied the efficacy and safety of global standard-dose APAP in the management of cancer pain, by comparing 182 patients treated with global standard-dose APAP (1,800-2,400 mg/day) (APAP group) and 86 patients treated with NSAIDs (NSAIDs group) at our clinic. Results: As the result, the management of cancer pain was comparable between the APAP group and the NSAIDs group. Despite the lack of sufficient investigation of concomitant drug such as opioids, etc., global standard-dose APAP was not inferior to NSAIDs in terms of efficacy as a non-opioid analgesic for the treatment of cancer pain. When we compared safety between the APAP group and the NSAIDs group, the incidence of nausea was significantly lower in the APAP group (p<0.01), while the percentage of patients with AST/ALT levels 2.5 times higher than at baseline was comparable in the 2 groups. Conclusion: Based on the above efficacy and safety results, global standard-dose APAP was concluded to be a useful non-opioid analgesic option for the treatment of cancer pain in Japan. Palliat Care Res 2011; 6(2): 133-142

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Background: In order to improve physicians' competence of palliative care, the PEACE project, a palliative care education program for physicians based on the Cancer Control Act, has been conducted throughout the country since 2008. The effectiveness and limitations of the current project management techniques and learning materials have not been determined. This study aimed to explore current problems with the PEACE project and to seek corrective strategies. Method: A workshop was held with 36 participants who had finished PEACE faculty-development programs, and involved brain-storming with physicians. The results of brain-storming sessions were qualitatively analyzed. Results: Most problems identified related to the burden, to the host, of holding the faculty-development program workshop. In addition, some problems related specifically to the individual host site or community involved. Conclusion: One strategy to improve these problems is to incorporate e-Learning to both expand the program and reduce the burden on the host site. In addition, workshop materials could be improved to include additional modules and revised guidelines. Palliat Care Res 2011; 6(2): 143-149

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Advanced cancer patients experience stress and are at risk for developing psychological problems. Early diagnosis and suitable intervention are very important for their quality of life and compliance with chemotherapy. The Hospital Anxiety and Depression Scale (HADS) is one of the most commonly used mood scales; however, HADS has not been validated for use with cancer patients undergoing chemotherapy. The purpose of this study was to validate HADS as a screening tool for psychological distress among cancer patients undergoing chemotherapy. We also identified possible factors contributing to psychological distress and explored the development of original screening tools. Fifty subjects agreed to complete HADS and consult with psychiatric specialists. Possible contributing factors to psychological distress were identified by HADS and logistic regression analysis. The mean score for patients with psychological distress was 20.0 ± 8.93, and for patients without distress was 9.67 ± 6.11; scores for patients with psychological distress were significantly higher. The optimal cutoff point of psychological distress appeared to be 17. This cutoff point was associated with 72.7% sensitivity and 82.1% specificity. The factor “recurrent cancer” (p=0.043) had an odds ratio of 7.24 (1.21-61.2). We verified that HADS is a useful screening tool for cancer patients undergoing chemotherapy. The factor “recurrent cancer” was shown to contribute to psychological distress. Palliat Care Res 2011; 6(2): 150-157

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The purpose of this study was to explore the meaning of the lived experience of having outlook toward self of patients with advanced non-small cell lung cancer receiving standard therapy. Unstructured interviews were conducted with five Co-researchers. The dates were gathered from verbatim interviews, then the transcripts were analyzed using the procedural steps based of phenomenological approach of Colaizzi. As a result, three in five common meanings in their experiences are the following: 1) Life-oriented with their life because of raising awareness of the end of their life, 2) Being as what they are because of knowing what they were for themselves, 3) Being not isolated because they were isolated. When considered based on the above three common meanings, having outlook toward self must be viewed as a searching one's life as being that it starts at the time of raising awareness of mortality and as a one's positive effort to live fully as oneself in later life. Palliat Care Res 2011; 6(2): 222-226

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Purpose: The aim of this qualitative research was to identify the components of the changes in perception experienced by the physicians and nurses concerning the medical care they provide for Hematology Ward patients in the terminal phase. Methods: We performed semi-structured interviews with three physicians and five nurses concerning case conferences about patients in the terminal phase and both qualitatively and descriptively analyzed the data from those interviews. Results: We extracted the category of ‘consciousness of terminal phase’ from subcategories “consciousness about the period of terminal phase” and “change in care where patients’ remaining time is considered.” We also extracted the category ‘team approach’ from subcategories “know the importance of information sharing within the medical care team,” “nurses can play a coordinating role” and “opportunity to know the will of patients and families.” Conclusion: The study showed that the case conferences made physicians and nurses conscious of the terminal phase on the medical ward where patients with various symptoms are mixed. We found that case conferences provided an opportunity for physicians and nurses to become conscious of the needs of the terminally ill, become aware of the importance of information sharing, and perceive the importance of the team approach. Furthermore the case conferences caused the nurses to become more aware of their role in the care of patients in the terminal phase. Palliat Care Res 2011; 6(2): 227-232

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Background: On receiving chemotherapy, extravasation of drugs is a severe problem. The extravasations occur more commonly in patients who are elderly, have a poor performance status, have diabetes mellitus complications or have repeatedly received chemotherapy. Also, cancer patients usually require repeated venous punctures for this treatment. Purpose and methods: For the purpose of evaluating the efficacy and safety of peripherally inserted central catheters (PICCs) for intravenous chemotherapy, we retrospectively reviewed all the cancer patients for whom PICC were inserted for chemotherapy from April 2008 to December 2010. Patients' background, duration of PICC insertion and complications were evaluated in this study. Results: Ten patients (male 4, female 6) were reviewed in this study. The median age was 59 years (17∼69). A total of 13 PICCs were inserted in 10 patients. The most common underlying disease was abdominal rhabdomyosarcoma (n=3, 30%) followed by lung cancer (n=2, 20%) and hematologic tumor (n=2, 20%). The average catheter span was 46 days. Catheter-related infections were seen in 2 cases (15.4%). No phlebitis or thrombosis usually associated with venous route was detected in PICC used for chemotherapy. Conclusions: PICC might reduce patients' discomfort such as repeated venous punctures or complications associated with chemotherapy. We suggest that PICC would be one of the effective tools in chemotherapy. Palliat Care Res 2011; 6(2): 233-236

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It is important to collect patients' and their families' opinions to provide good palliative care. This study aims to analyze the contents of free description provided by the survey for cancer patients and bereaved families, which was performed before the intervention of The Outreach Palliative Care Trial of Integrated Regional Model (OPTIM) study. Requests for and good points of cancer treatment and palliative care were collected and classified. 1,493 advanced cancer patients and 1,658 bereaved families in four areas received the questionnaire, and 271 patients and 550 families filled in the free description. Cancer patients and bereaved families had demands for improved communication with medical staff, improved quality of pain relief, financial support of treatment, more educational activities on palliative care, and improved cooperation within and outside hospitals. Palliat Care Res 2011; 6(2): 237-245

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Purpose: The effectiveness of continuous intravenous infusion of fentanyl for pain due to stomatitis, pharyngitis, and esophagitis after hematopoietic stem cell transplantation (HSCT) was investigated. Methods: Subjects included 15 HSCT patients with pain due to mucosal damage. Continuous intravenous infusion of fentanyl was commenced at a dose of 12.5 μg/hour. Pain was controlled through an increase or decrease in volume as needed. Grade of oral mucosal damage, pain scale, and QOL index such as the number of tooth brushing or gargles were measured at the start of administration of fentanyl and at the time of maximum dosage. Results: The median time to start of fentanyl administration was day 7 after transplantation. The median duration of administration was 12 days. The median maximum dosage of fentanyl was 980 (range, 243.8∼3,010) μg/day, and it was reached at a median of day 5 after administration of fentanyl was started. Compared to that observed at the start of fentanyl administration, the grade of oral mucosal damage was significantly increased at the time of maximum administration. However, pain scale was significantly decreased and QOL index was maintained. Conclusion: Continuous intravenous infusion of fentanyl suppressed the increase of pain when mucosal damage increased, maintained QOL, and possibly contributed to selfcare. Palliat Care Res 2011; 6(2):246-252

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This paper presents the case of a man in his 70's with local advanced bladder cancer with hospital-developed Fournier's gangrene. The patient was hospitalized at the palliative care unit, and drainage with incision of the scrotum for symptom relief was performed to relieve severe pain. The patient experienced pain only during changing of the wound's dressing and no pain at rest after the operation. Furthermore, he reached his birthday and spent time in peace with his family. Fournier's gangrene is the necrotizing fasciitis of perineal and anal lesions, in which inflammation progresses rapidly in wide lesions, and it is associated with a high mortality rate. For Fournier's gangrene in a terminally ill patient, current agreement might depend on the patient's goal of treatment. The drainage provided for spiritual care of the patient and his family as well as pain relief. In conclusion, local drainage for Fournier's gangrene can be feasible as a choice of palliative treatment. Palliat Care Res 2011; 6(2): 340-343

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We experienced a case in which a blood transfusion proved to be effective for the treatment of symptomatic restless legs syndrome that occurred in a patient demonstrating terminal stage cancer with iron-deficiency anemia due to hemorrhaging as a result of carcinomatous peritonitis. The patient was a female in her seventies who suffered from hepatocellular carcinoma. After undergoing blood transfusion, the symptoms of discomfort in her lower limbs dramatically improved. It was thought that it was expected the symptomatic restless leg syndrome was frequently amalgamated, and a positive diagnosis and appropriate treatment were necessary in the terminal stage of cancer. Palliat Care Res 2011; 6(2): 344-349

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Continuous epidural injection of opioid/local anesthetic drugs can be a useful tool to alleviate intractable pain in cancer patients. The use of an epidural catheter, however, always faces with contamination and infection. In order to avoid contamination, an injection port is often implanted in the subcutaneous space and intermittent or continuous injection is employed. The injection port requires an additional cost and a little more time for implantation. Both the cost and the time-requiring procedure may be of problem in the terminally ill cancer patients. We present 3 cases of cancer patients with high risk of catheter contamination treated with continuous epidural injection using catheters elongated through subcutaneous tunnel from the epidural puncture site to the front side of abdominal wall. The risk factors of the patients were; subcutaneous emphysema due to intestinal perforation in a 81 yr male with bladder cancer, local abscess and MRSA infection in a 45 yr female with uterine cancer, and cutaneous tissue disruption in a 51 yr female with lung cancer and multiple metastasis. The duration of epidural analgesia were 22, 26, and 21 days until the patient's death, respectively. Although the risk of epidural catheter contamination and infection was extremely high in all three patients, continuous epidural injection for more than 3 weeks was possible with favorable analgesic effects. Use of an epidural catheter elongated through subcutaneous route from the puncture site to the frontal abdominal wall offers a practical and inexpensive way in patients with intractable pain at least for a few weeks. Palliat Care Res 2011; 6(2): 350-357

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Purpose: We report a patient with opioid-resistant pain in whom favorable pain control could be achieved with burst ketamine therapy. Case: A female in her fifties had been followed up due to pain associated with recurrence in the right thoracic cavity at the thoracotomy site after surgery for mesopharyngeal and hypopharyngeal cancer, free jejuna autograft reconstruction, and permanent tracheotomy. Oral drug administration became impossible due to dysphagia and nausea, and she was admitted because of unfavorable pain control. Although the opioid dose was increased, pain did not improve, and rescue medication was also ineffective. Opioid-resistant pain was suspected, and burst ketamine therapy was performed. The therapy was initiated with the continuous intravenous administration of 100 mg/day ketamine, which was increased to 300 mg/day and 500 mg/day after 24 and 48 hours, respectively, according to the degree of pain, and was continued for 5 days. As analgesic effects of morphine were obtained during ketamine administration, a higher dose of morphine was administered; as a result, a favorable pain control outcome was achieved, and the patient returned home. Conclusion: Burst ketamine therapy may be effective for the treatment of opioid-resistant pain. Palliat Care Res 2011;6(2): 358-364

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