Cancer cachexia is a multifactorial syndrome defined by ongoing loss of skeletal muscle mass that cannot be fully reversed by conventional nutritional support. Nutritional treatment is a component of nutritional support, as well as symptom palliation and nutritional counseling. Nutritional treatment, exercise, and pharmacological agents are essential for treating cancer cachexia. In our studies at palliative care units, 76% and 73% of advanced cancer patients and bereaved families, respectively, required nutritional support, and nutritional support was also found to have beneficial effects on selected groups of advanced cancer patients. Our studies also indicated that as chronic inflammation is the underlying cause of cancer cachexia the plasma C-reactive protein (CRP) level might be useful as a prognostic marker/biomarker of advanced cancer. It was suggested that nutritional support based on the mechanism responsible for cancer cachexia is useful during the treatment of cancer cachexia although the evidence for this is not robust, and the CRP level is suggested to be a clinically significant index of the response to such treatment.

Rectal irritative symptoms in cancer patients are often refractory to treat and exacerbate their quality of life. We experienced a peadiatric case of rectal irritative symptoms treated by Yokukansan. A 9 year-old boy developed rectal irritative symptoms as itching sensation in rectum caused by relapsed rhabdomyosarcoma in pelvis. Oral Yokukansan, which is common Japanese Kampo medicine for temper tantrum of children, was administered and relieved his symptoms. Yokukansan is known as adjuvant drug for neuropathic pain. It could be one of the adjuvant drugs for refractory symptoms in palliative care setting.

Background: Cancer may have impacts on parents for child rearing. There has been few reports regarding what support is needed for them. The aim of this study is to investigate the needs of support system for cancer patients who have young children. Methods: First, we retrospectively studied records of specialized support for patients who had young children by palliative care team in National Cancer Center Hospital (NCCH) from April 2013 to September 2015. The data was collected from the NCCH electronic medical records. Next, we qualitatively classified the concerns about child-rearing of patients and their family. Results: A total of 131 (Male/Female: 41/90) cases received specialized support for patients who had young children during study period. The average age of patients was 43.3. Top three of primary sites of the patients were gastrointestinal tract, lung and breast. Approximately eighty percent of the patients were in the state of the recurrence and/or progressive cancer. The average age of their young children (n=239) was 9.6 (ages 0-17). The parents’ perceptions of child-related stressors were classified into three subcategories: 1. How to tell children about illness and treatment, 2. How to manage children’s reaction and emotion after having told them about illness, and 3. How to keep the parents’ role of child-rearing. Discussion: We found that patients who have children (age 0-17) have various types of concerns depending on their condition or age of children. Therefore, multi-disciplinary team approach for improving an effective support system was needed.

Food and eating are of great significance to humans, as we are the only creatures that establish relationships and sustain a social network through food and eating. Recent studies revealed that patients with advanced cancer and their family members often experience complicated eating-related distress due to tumors themselves, side effects of cancer treatments, and negative impacts of cancer cachexia. Therefore, we suggested the importance of the integration of palliative, supportive, and nutritional care to alleviate eating-related distress among patients and family members, and the significance of the development of tools to measure their distress in supportive and palliative care settings. No care strategies for eating-related distress experienced by patients and family members have been established, and the development of an interdisciplinary psychosocial approach and integrative care is required. As such, we are planning to start a nutritional support and cancer cachexia clinic in the National Cancer Center, and disseminate a newly developed care program across Japan.

Although palliative sedation therapy (PST) is considered to alleviate intolerable and refractory symptoms in dying patients with advanced cancer, there have been few studies regarding the situation of tertiary cancer center. We conducted a retrospective survey of the medical records of the patients who died between April 2015 and March 2016 at the National Cancer Center Hospital in Japan. PST was conducted in 75 out of 431 patients (17.4%). The patient demographics were as follows: sex (male/female), 48/27; median age, 61 years (range 5-83; 11 patients (14.7%) were aged under 39 years); and primary sites were lung, 18 (24.7%)/ pancreas, 11 (14.7%)/ hematopoietic organs, 11 (14.7%)/ bones and soft tissues, 8 (10.7%)/ and the others, 27 (36.0%). The main target symptoms for PST were dyspnea (38, 50.7%) and delirium (30, 40.0%). The most commonly used sedative agent was midazolam (72, 96.0%). Continuous deep sedation was intended in 61 patients (81.3%) at the death. Median survival from the start of PST were 2 days (range 0-54). The differences between palliative care team (PCT) intervention group and control group were lower age (58 vs. 62.5, P=0.048) and uniformity of initial midazolam dose (5-12 vs. 9.6-25.2 mg/day). Distinctive feature in this study was large proportion of adolescent and young adult patients with rare cancers. PCT might have different approaches to sedation in comparison to non-PCT medical staffs.

Purpose: The purpose of this study was to clarify the current status of Do-Not-Resuscitate discussions (DNRd) with terminally ill cancer patients in Japan and the psychological burden on bereaved families depending on whether or not a DNRd is performed. Method: A multicenter prospective observational study of advanced cancer patients admitted to 23 palliative care units (PCUs) in Japan was conducted, and a questionnaire survey of bereaved families was also conducted after patients died. Result: 1,605 patients were included in the analysis, and 71.4% of patients had a DNRd with doctors before PCU admission, 10.8% at admission, and 11.4% during admission. In contrast, 93.3% of family members had a DNRd with doctors before PCU admission, 48.4% at admission, and 52.1% during admission. Conclusion: Although DNRd was performed between patients and physicians in 72.3% of cases at any point throughout the course of time from before PCU admission to death, there was no evidence of psychological burden such as depression or complicated grief in the bereaved families due to patient participation in DNRd.

Abdominal paracentesis is a standard intervention for symptom relief in patients with ascites; however, there is no established agreement regarding the optimal speed of ascites drainage. This paper presents three cases of rapid manual drainage of ascites (RMDA) conducted during home visits: a 72 year-old male with intractable cirrhosis, a 73 year-old male with malignant ascites secondary to cancer of the pancreatic tail, and a 54 year-old male suffering from malignant ascites due to pancreatic tail cancer with hepatic metastases. Drainage volumes ranged from 1.4 to 3 liters, with procedures taking between 12 to 14 minutes. Post-procedure systolic blood pressures were maintained above 90 mmHg at immediate, 2 (±1) hours, and 24 (±12) hours following the procedure in all cases. No severe adverse events were reported. RMDA may offer a reduced procedural time in the home visit context, lessening patient discomfort and healthcare provider costs. Further studies are needed to evaluate the safety of RMDA in home care settings.

Background: Adolescents and young adults (AYA) with cancer go through various life events during their illness trajectory, and there is often insufficient information on their diseases due to their rarity. Few chances are available for AYA patients to meet and share information with each other. Therefore, at the National Cancer Center Hospital in Japan we hold AYA Hiroba, a monthly get-together for AYA patients to communicate with each other. This study investigated satisfaction and effect with the activity. Methods: We have held the AYA Hiroba activity once a month since May 2016. We asked participants to complete a questionnaire at each session.Results: We held the activity 33 times between May 2016 and May 2019. A total of 130 patients participated, and 97 of them completed the questionnaire, including providing demographic data, since October 2017. The respondent demographics were as follows: sex (male/female), 38/59; median age, 29 years (range 14–39 years); outpatients/inpatients, 31/66; number of sessions attended (1/≥2), 42/55; and cancer type (sarcoma/malignant lymphoma/brain tumor/germ cell tumor/leukemia/melanoma/breast cancer/neuroblastoma/Wilms tumor/lung cancer/cervical cancer/nasopharyngeal cancer/tongue cancer/blank), 45/11/9/7/6/5/3/3/2/1/1/1/1/2). Many attendees perceived the activity favorably: “It was very satisfying” (61.7%), and “It was very helpful” (65%). The feedback was classified into three categories: “interaction with the same generation”, “diversion”, and “getting information”. Discussion: AYA patients have a great need to communicate with each other, and the feedback suggests that AYA Hiroba would be effective in interaction with the same generation, diversion and getting information. Most participants were very satisfied with the program.

Introduction: Intracranial tumors cause various neurological symptoms and neuropathic pain, which are often refractory to opioids. In some of these cases, the combination of Kampo medicines can be effective. Case: The case was a 44-year-old patient who underwent surgery for a suspected papilloma. After resection, pathological examination revealed squamous cell carcinoma, positive for margins, and then, the left intraorbital metastasis was observed. Due to the intracranial invasion of the tumor, he had pain in the second and third branches of the trigeminal nerve in the left face and paresthesia in the second branch of the trigeminal nerve bilaterally (Numerical Rating Scale: NRS 10/10). Hydromorphone was introduced, and the pain was relieved, but the paresthesia remained (NRS 8/10). Both paresthesia and pain worsened during the course of chemotherapy, but MRI showed no tumor progression, thus, the cause of symptom aggravation was diagnosed edema of the tissue around the tumor. Therefore, Goreisan was started, and both paresthesia and pain were relieved. Discussion: Goreisan has been shown to be effective in cerebral edema due to its water-regulating effect by inhibiting aquaporin. In the present case, the reduction of edema in peritumoral tissues by Goreisan may have contributed to the symptomatic relief.

Introduction: In patients receiving opioids, relief of cancer pain by palliative radiation therapy or other means can lead to opioid discontinuation and subsequent withdrawal symptoms, such as agitation, insomnia, and diarrhea, due to opioid-related physical dependence. Appropriate steps should be taken to prevent these symptoms. Case: A 72-year-old man underwent surgery for esophageal cancer. He developed low back pain and right lower limb pain, and was diagnosed with sacral and right iliac bone metastases. His pain was resistant to oxycodone (OXC), so he was simultaneously treated with methadone (MDN) and palliative radiotherapy. His pain gradually decreased, and MDN was tapered and switched to OXC, which was in turn discontinued at 20 mg/day at the patient's strong request. After OXC discontinuation, akathisia, anxiety, and diarrhea appeared as withdrawal symptoms. These were treated with immediate-release OXC, transdermal fentanyl, and suvorexant. Discussion: When discontinuing opioids, dose reduction below 10% per week is recommended, de-escalation to the lowest possible dose should be followed by cessation. In case of withdrawal symptoms, immediate-release opioids may be used, and opioid tapering should be attempted in parallel with symptom control.