Objectives: To clarify the preferences for survival time (ST) or quality of life (QOL) in the treatments for advanced cancer. Method: Patients with breast cancer, oncologists, and healthcare-providers including nurses, pharmacists and medical clerks were asked to anonymously complete a survey: The survey included questions regarding 1) priority among treatment options for a fictitious cancer patient, 2) preference of treatment aggressiveness for fictitious cancer patients by age group, 3) preference of treatment among options, with different weight on ST and QOL. Results: 1) Cancer patients' priority regarding ST and QOL was clearer than healthcare providers. 2) Oncologists tended to prioritize ST than cancer patients and other medical staffs in elderly patients. 3) Patients and oncologists tended to prioritize ST, whereas and other medical staffs prioritized QOL. Conclusion: Cancer patients and healthcare providers may have different perception regarding a treatment goal, which should be recognized in the practice of oncology.

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Background: Patients having thoracic esophagectomy, a standardized treatment for esophageal cancer patients in Japan, are known to have various postsurgical signs and symptoms for a period of time. The current status of nursing interventions at outpatients need to be clarified. Purpose: This study aimed at identifying the nurses' interventions for cancer patients at the outpatient setting who previously had thoracic radical esophagectomy. Methods: Patients who had esophagectomy at a cancer center hospital in Japan were prospectively observed and interviewed by outpatient nurses between January 2009 and December 2010. Their documented responses in medical record were prospectively investigated and were qualitatively analyzed via content analysis method. This study was approved by the study hospital's research ethics committee. Results and discussion: The data analysis of nursing interventions for 66 patients yielded 372 extracts, 12 categories, and 74 codes. Nurses were assessing patients' signs and symptoms affected by postsurgical changes, and were utilizing patients' active self-monitoring skills. The results also showed the significance of facilitating postsurgical recovery in relation to nutritional intake and physical activity in patients' daily life. Implications: Based upon the study results, the development of a systematic program is underway, which facilitates esophageal cancer patients' postsurgical recovery.

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Purpose: We evaluated decision-making regarding their end-of-life (EOL) care planning near death of cancer patients. Methods: We characterized EOL decision-making using the medical records of 52 patients of death from cancer, and preference of physicians or surgeons based on semi-structured interviews. Results: For 49 (94%) out of 52 patients, physicians discussed EOL care planning near death with family, whereas family made decision regarding EOL care planning near death in 48 (92%) of patients in the last hours or days of life. Four patients (8%) made their own decisions regarding EOL care planning near death. The median number of days between discussion regarding EOL care planning near death and actual patient death was 4 days. The most common reason for the inability of the patients to make the decision themselves was because their condition had deteriorated. With regard to EOL care policy, all 52 patients requested that resuscitation not be attempted, this was the same for patients who made EOL-decision themselves and those who did not. Eight out of 15 physicians (53%) answered that they discussed EOL care planning near death with family, whereas any physician did not answered that they discuss EOL care planning near death with patients. Conclusion: For the vast majority of patients, their family made decisions regarding EOL care planning near death because physicians preferred to discuss this planning with them instead of with the patients. Such discussions generally occurred when the patient’s death was imminent. All patients and their family preferred that resuscitation not be attempted.

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Purpose: To investigate the significance of a program to enhance the communication of university hospital nurses with cancer patients who search for meaning of life by analyzing changes after the intervention. Methodology: This was a pre/post intervention comparison study. Participants were 24 nurses. Murata's program for enhancing spiritual care-giving skills was employed for intervention, which consists of a lecture and discussion, followed by 3 sessions of 4 hours each (1 per month). The questionnaire of Morita et al. evaluating practices and attitudes toward terminal cancer patients was completed at four stages, which were before intervention, 1 months after, 3 months after, and 6 months after intervention. Data were analyzed using SPSS ver.21. This study was approved by Keio University ethics board. Results and Discussion: Participants were 23 females and a male, being aged 20 to 50 years with 3 to 33 years (average 12.5±8.2 years) of clinical experience. Positive attitude changes were noted at the four stages for "increased Confidence about communicating with terminal patients" and "decreased Sense of Helplessness" (p<0.05).The "Positive Appraisal" score changed between before and after 6 month (p<0.05). The "Self－Reported Practice" score showed a switch towards a positive attitude. These results suggested that intervention increased confidence in communicating and helped university hospital nurses to assist their patients.

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Objective: To investigate the perception of the prevalence of mental diseases in breast cancer patients and the therapeutic approach to depression undertaken by oncologists. Method: Self-reported questionnaires were sent to 352 breast cancer specialists. The survey contains 11 categories to elicit the perception and identification of mental illnesses in patients, diagnostic procedure, and details of antidepressant prescribed. Logistic regression was used to explore the association of oncologists' characteristics and management of depression in breast cancer patients. Results: Survey response rate was 31.3%. Ninety percent of the oncologists perceived the prevalence of depression to be less than 20%, while half believed that the proportion was less than 5%. The most commonly-used medication for the treatment of depression was BZDs (41.5% [n=39]), followed by Selective Serotonin Reuptake Inhibitors (SSRIs) (30.9% [n=29]). Benzodiazepines (BZDs) were most frequently prescribed (41.5%) despite its known ineligible dependency, followed by Selective Serotonin Reuptake Inhibitors (SSRIs) (30.9%). Choice of BZDs was significantly associated with the career length of oncologists (Odds Ratio [OR]=8.20), and safety of drug (OR=5.57). Contrarily, prescription of SSRIs was associated with efficiency of drug (OR=7.07). Conclusion: Relative to anxiety and insomnia, a lower awareness regarding depression was common among study oncologists. In addition, the quality of care varied among these oncologists. It is necessary to improve both the awareness and management of mental illnesses in order to enhance the total clinical care of breast cancer patients.

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Purpose: To identify the nature of personal growth of family primary caregivers after bereavement and to explore the association between such growth and the experience of caring for a terminally ill cancer patient at home. Methods: A self-administered questionnaire survey was mailed to 112 bereaved family primary caregivers who, with assistance from a palliative care service, had cared for a terminally ill cancer patient at home. The main outcomes were measured using the After Bereavement Growth Inventory, previously developed. Results: Responses from 73 questionnaires were analyzed (effective response rate, 66%). The post-bereavement growth score was significantly higher among the study group than among the general population who had experienced bereavement due to illness-related death. Multiple regression analysis revealed that post-bereavement growth was more likely to occur among those family members who, "at the time they chose to provide home palliative care, intended to care for a patient at home until the time of death" and when "the patient desired home palliative care", those who "felt a deepening of their bond with the patient", and those who "felt the death was peaceful". Conclusion: Our findings suggest that for primary family caregiver's to experience personal growth after bereavement, medical professionals should support patients' preference of place at the end of life and caregivers' preparation for the expected home death, respect the family's bond with the patient, and through appropriate symptom management in home palliative care to maintain the patient's sense of peacefulness until the end of life.

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Purpose: This study aimed to evaluate the effect of continuous patient education on pain control in outpatients based on changes in pain intensity scores and occurrence of opioid-related adverse effects. Methods: The education intervention was conducted in the following phases; 1) interview at the first visit for opioid introduction, 2) telephone follow-up at home 3 to 7 days after introducing opioid analgesics, and 3) interview at the next visit. Pain intensity scores; frequency of rescue dose; and occurrence of adverse opioid-related effects such as constipation, nausea, and drowsiness were compared among the three intervention phases. Results: When comparing data at phase 2 and 3 with those at phase 1, daily maximum pain score decreased significantly, frequency of rescue dose and opioid dosage increased significantly, and occurrence rates of constipation decreased. Conclusion: Continuous patient education by pharmacist intervention based on not only patient visit interviews but also telephone communication on non-visiting days can improve the pain intensity scores and reduce the rate of opioid-related adverse effects for cancer outpatients.

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The purposes of this study were to describe nurses’ difficulty with cancer care and explore factors related to the difficulty of cancer care. Self－reported questionnaires were distributed to 512 nurses who are engaged in cancer care at Tohoku University Hospital. Responses from 344 (67％) nurses were subjected to analysis. The results revealed that nurses felt that “communication” was the most difficult aspect of cancer nursing followed by “hospital system and regional alliances” and “knowledge and skill.” Nurses did not feel that “collaboration with doctors” “disclosure and explanation of disease” or “death and dying” had particularly high levels of difficulty, however, their levels of difficulty could be improved. Greater difficulty with cancer care was reported by nurses working on the general ward and nurses with limited cancer care experience in the last year. Communication skill training,education (especially for less experienced nurses), expansion of palliative care, and restructuring of discharge planning and regional collaboration systems might contribute to decreasing nurses’ difficulty with cancer care.

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Background: Rehabilitation and palliative care for advanced/terminal cancer patients share a same goal of enhancing patients' quality of life (QOL). Aim: The aim of this study was to identify the patients' narratives during the rehabilitation session, by analyzing words reflecting their ideas and hopes. Method: Out of forty-seven advanced/terminal patients' narratives during the rehabilitation session from April through September in 2011, the rehabilitation therapists recollected the impressive words. Then, the words were grouped into four categories of "total pain" concept by their meanings. Result: Out of a total of 215 words identified, 60% was grouped into physical aspect, 14% into psychological, 10% into social, 7% into spiritual and 9% into mixed aspects. Discussion: If rehabilitation therapists only deal with physical aspects of enhancing their QOL, 40% of patients' wishes will be ignored. Conclusion: Rehabilitation for advanced/terminal cancer patients might need multidimensional interventions with a concept of "total pain".

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Introduction: We report three cases of women who developed secondary lower-extremity lymphedema after surgery for endometrial cancer. The cancer stage was 2 as per the International Society of Lymphology risk stratification. Case Reports: We performed intensive lymphdrainage of two-phase complex decongestive physiotherapy in each case during a 1-week hospitalization period. The average leg circumference at discharge improved to 92～96% from baseline. Case 1: After primary treatment, a 35-year-old woman presented with temporarily poor self lymphatic drainage during maintenance therapy, and her leg circumference progressively enlarged. However, the patient received reeducation for self lymphatic drainage and outpatient service for lymphedema regularly. Since then, the leg lymphedema has improved. Case 2: A 63-year old woman improved to 92% of baseline and continued an excellent self lymphatic drainage, maintaining 83% with her depression recovered 2.5 years after this hospitalization. Case 3: This case involved a 70-year-old woman in whom maintenance therapy progressed well without aggravation of lymphedema; however, she died in 1.2 years after the first phase treatment due to cancer recurrence. Discussion: Intensive care under short-term hospitalization (for one week) for lower-extremity lymphedema was effective. However, there was one patient in whom self lymphatic drainage became poor. The patients required long-term care for maintenance therapy after primary treatment.

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Introduction: This is the first report about an outpatient who was successfully switched from oxycodone to methadone without any serious problems in Japan. Case report: A man in his 60s who was diagnosed as advanced pancreatic cancer with multiple bone and liver metastases. Since he complained severe cancer pain in spite of taking oxycodone 40mg/day, he was referred to the palliative care team. After discussion about switching from oxycodone to methadone in the palliative care team and obtaining informed consent from him, it was decided to prescribe methadone in the outpatient setting. During induction of methadone, a palliative care certified nurse (CN) played important roles about explanation of futures, pharmacodynamics, pharmacokinetics and side effects, education how to take, monitoring of analgesic and side effects and supports to patient anxieties about methadone. His dose titration of methadone was completed for 15 days, and his adequate dose was decided as 20 mg/day finally. After titration of methadone, pain relief could be achieved. Conclusion: Although methadone has a possibility to improve management of cancer pain, it has some serious problems, such as respiratory depression, QT interval prolongation and others due to unsuitable use. Therefore, patients with prescription of methadone must be educated, monitored and supported by special medical staff with much experiences and knowledge about cancer pain, opioid therapy and methadone. CNs may play important role to keep safety and resolve patients and families’ anxieties for prescription of methadone.

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Introduction: The use of methadone in Japan is limited to cases being switched from the preceding use of strong opioids; the stop-and-go strategy is recommended in which the previously used opioid analgesic is discontinued and methadone is initiated at its full estimated dosage. Case: Refractory cancer pain due to an iliolumbar syndrome was temporarily exacerbated by the stop-and-go switching to methadone from morphine along with ketamine. Pain relief was achieved upon readministration and concomitant use of morphine with methadone after approximately two weeks. Discussion: Through examining this case, we believe that a stepwise switching strategy, rather than the stop-and-go strategy, could be more useful. Considering that overdosage may cause side effects, it is safer to initiate methadone with a small dose. However, more studies need to be conducted to decide whether the establishment of the initial dosage and dosage adjustment should be made more flexible to avoid pain intensification. Further investigation is required on whether the concomitant use of adjuvant analgesics such as ketamine, which similar to methadone is an NMDA receptor antagonist, should be continued when switching to methadone.

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Alleviating fatigue of a patient with advanced cancer often meets troubles, for which medication is restricted. We experienced two cases with cancer-related fatigue, in which 4,000mg of taurine a day was administered orally and the improvement of the Cancer Fatigue Scale (CFS) score was identified as a result. There hasn't been any literature reporting the effect of taurine to cancer-related fatigue yet. However, taurine has been known as a medicine with various effects for quite a long time, and it is possible that it will be recognized as one of the medicines effective for cancer-related fatigue.

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Introduction: The regional palliative care support center (PCSC) has set the following palliative care goals for correction of misunderstanding and prejudice of the general community against palliative care, home care and home death of cancer patients: practice palliative care early after diagnosis, educate the community to understand palliative care and build a regional palliative care cooperation system. Method: This study reviewed four years (2009-2012) of data from the PCSC. Outcome data of the patients were collected during outpatient care, inpatient care, and in-home care that were supported by the PCSC. The PCSC managed palliative care based on patient conditions and symptoms in the early stage after diagnosis. The PCSC worked to spread the idea and importance of palliative care to the general community and health care professionals of the region, and also worked to promote the regional palliative care cooperation. Result: These efforts led to an increase in the number of first center visit of patients, especially introduction patients, and an extension of the period of treatments of both tumor department and palliative care department. These outcomes resulted in an increase in the rate of in-home care transitions, the length of in-home care and the number of deaths at home. These results suggest that the place of appropriate medical and caregiving treatments and the place of death are converting into home gradually from hospital.

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Background: The authors, in collaboration with a nursing college and healthcare organizations, initiated a project, "Tama District (a suburban area in Tokyo) End-of-life Care Networking" for nurses, in order to provide networking opportunities for nurses who would like to work together in their local community. A survey was conducted to identify those nurses' needs before initiating this project. Result: The first networking meeting was held based upon the survey results, and 39 nurses participated. The participants were from 14 hospitals, six home-visit nursing stations, and one home care support office in a northern area of Tama District and its surrounding areas in Tokyo. After having this meeting, it was identified that these nurses were highly motivated in providing better end-of-life care, and they had strong desires to network together and to exchange information about challenges and opportunities in their practice. Conclusion: Future issues and implications included the following: (1) Providing continuous opportunities for nurses with such meetings, and refining and updating programs to meet their needs; (2) Facilitating face-to-face relationships among individual nurses in this local community in order to facilitate better collaboration; (3) Initiating local activities that may improve and enhance nursing practice for patients and families who have health issues in their daily life.

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A recently licensed opioid, Abstral^®, a rapid-acting sublingual tablet of fentanyl, is different from other opioids in its complicated usage. The points to consider are; a careful titration grounded on the assessment whether the increase of base or rescue is appropriate, setting up the tentative upper limit suitable for the baseline opioid, the differentiation of the concept between the rescue dose and the additional dose, instruction to the medical stuff as well as patients and family and cost benefit balance. Taking account of these points, we recommend introducing Abstral^® in our hospital to patients who have difficulty in swallowing or other gastrointestinal function only in the wards. The palliative care team, the department of pharmacy and the division of nursing collaborated to let the medical stuff know these concerns and introduced a license system in which only those doctors who receive an intensive course on the use of Abstral^® can prescribe it. At the same time, we gave a lecture for the nurses and other medical stuff repeatedly (ten times) so as to include as many as possible. A monitoring system of Abstral^® prescription is also established in our hospital.

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