Loco-regional chemotherapy at the outpatient clinic for gastric cancer patients with home enteral nutrition

In over the 10 years from 2000-2010, 21 gastric cancer patients received loco-regional chemotherapy with home enteral nutrition (HEN) at an outpatient clinic because of insufficient oral intake. These loco-regional chemotherapy regimens consisted of 5 intra-aortic chemotherapies, 4 hepato-arterial infusions and 12 intra-peritoneal chemotherapies. Five out of 8 cases that had measurable lesions showed PR, and 3 cases revealed PD. The patients received HEN with peptide central formula, 400-1,200 kcal/day in night time. The average duration of HEN was 12.9 months. The post-operative nutritional management was needed for continuation and securing of outpatient chemotherapy. The author reported an experience of the outpatient loco-regional chemotherapy with HEN for the gastric cancer patients who could not eat a sufficient volume of food.     

Home enteral nutrition for gastrectomy patients to provide "seamless nutritional support"

Gastrectomy patients are always likely to face malnutrition because of a small volume intake, chemotherapy, recurrence of cancer, etc. Authors achieved "Seamless Nutritional Support" for gastrectomy patients using jejunostomy. We applied jejunostomy using a NCJ kit for 244 gastrectomy patients during the gastrectomy operation. Forty four patients did the night time home EN using jejunostomy. The patients maintained a good QOL because of this nutritional support at home. Sixty percent of the patients were performed outpatient chemotherapy with home EN. They could continue the chemotherapy safely on the basis of nutritional care.     

Our outpatient cases for home anti-cancer chemotherapy

We report our outpatient cases for home anti cancer chemotherapy. A total of 97 patients with advanced and recurrent cancer (22 with breast, 20 gastric, 29 colonic, 12 rectal, 1 hepatic, 3 cholangio, 4 pancreatic, 2 duodenal, 2 ovarian and 2 malignant lymphomas) were performed at an outpatient clinic or provided home anti-cancer chemotherapy since December 1996. Of these patients, 9 patients were provided home anti-cancer chemotherapy, 56 patients had died, and 41 patients are alive and undergoing continuous therapy. The response rates revealed effective results in these diseases. No severe side effects were seen, and they underwent treatment at an outpatient clinic easily. The treatment of outpatients for home anti-cancer chemotherapy was effective and maintained the patient's QOL. However, it was important to establish early an exclusive therapy room, training of expert nurses and good staff.     

Hospice and palliative care in the outpatient department

In the medical environment, information disclosure to patients and respect of autonomy have spread rapidly. Today, many terminally-ill cancer patients wish to spend as much time at home as possible. In such situations the patient who has been informed that curative treatments are no longer expected to be beneficial can now hope to receive home care and visiting care from hospice/palliative care services. The essential concepts of hospice/palliative care are symptom management, communication, family care and a multidisciplinary approach. These concepts are also important in the outpatient department. In particular, medical staff need to understand and utilize management strategies for common symptoms from which terminally-ill cancer patients suffer (ex. cancer pain, anorexia/fatigue, dyspnea, nausea/vomiting, constipation, hypercalcemia and psychological symptoms). They also need to know how to use continuous subcutaneous infusion for symptom management in the patients last few days. The present paper explains the clinical practices of hospice/palliative care in the outpatient department. Also discussed is support of individual lives so that maximum QOL is provided for patients kept at home.     

Toward effective cancer home therapy--from the nurses point of view]

Home cancer therapy is part of the palliative care intended to enhance the Quality of Life for patients. This treatment in the home should be maintained at the hospital level. The home could be called a "Hospital without walls." Cancer patients, both in the terminal and late stages prefer treatment in their own homes regardless of severity except patients whose cancer is in the early stage. Home treatment primarily relates itself to pain control, TPN, chemotherapy, and symptom control. Our hospital started Home Care Service in 1989, and has since continued work for 18 cancer patients with 122 home visits. Patients in the late stage receiving mostly chemotherapy were treated on an outpatient basis. From August 1990 through July 1991 the patients receiving chemotherapy were 28 in number. Informed consent is essential whenever chemotherapy is involved. Drugs used at home are mostly vescicant or irritant types, in which the route of administration plays a crucial part. But most home cases are given ip treatment. In this process, major efforts have been directed toward flexibility, efficiency, and optimality in providing a support system that responds effectively to multifaceted needs of the community. Clear findings ascertained so far from our experience in this pilot study are as follows. The most urgent needs are 1. Creation of a support system a. A Discharge Planning and Team approach. b. 24-hour support service and emergency care c. A medical and welfare network in the community 2. Education and Training 3. Informed consent 4. Nursing Manual 5. Extensive use of public health insurance, in order to achieve balanced cost sharing.     

Present status of home therapy cancer patients using an infusor

We started a department of medical oncology and the risk management system of cancer chemotherapy since April in 2004. After that, chemotherapy administration increased steadily in numbers, especially on an outpatient basis. For reliable venous access, we made active use of a central venous Port (more than 60% of cases) as a rout of administration. Fifty five patients with advanced colorectal cancer were treated by FOLFIRI or FOLFOX regimen from April 2005 to June 2006. Two hundred sixty four cycles of FOLFIRI and 276 cycles of FOLFOX were administered. One hundred sixteen cycles (44%) and 117 cycles (42%) were performed through home therapy, respectively. Twenty five out of 55 patients could shift to home therapy using an infusor. Nine out of 30 patients wanted to continue on an inpatient basis, because their private insurance for medical care did not support the outpatient chemotherapy.     

Present and future home therapy in advanced stage of pancreatic cancer

We describe the present and future directions of home therapy in pancreatic cancer patients according to the chemotherapy and best supportive care. Chemotherapy in an outpatient clinic is widely supported by the use of gemcitabine, and useful because of mild adverse effect, good clinical benefit response and survival benefit. Since there is no secondary chemotherapy agent after gemcitabine treatment failure, best supportive care is essential. Control of blood glucose level, ascites and pain are also important. Now pain control and home therapy are easy to perform because of the development of various useful opioid agents.     

At home management of aplastic phase following high-dose chemotherapy with stem-cell rescue for hematological and non-hematological malignancies

Background: After high-dose chemotherapy with autologous stem-cell support long hospital stays in the aplastic phase are expensive, lead to increased risk of hospital infections and to increasing pressure on available hospital beds. We developed a home care regimen that allows patients to be at home for most of the aplastic period, without daily hospital visits.Patients and methods: Between October 1995 and December 1997, transfer of supportive care to the home setting took place in three phases for patients undergoing high-dose chemotherapy with stem-cell transplant for malignant lymphoma (one course of BEAM), breast cancer or germ-cell cancer (three courses of tCTC). In the inpatient cohort, the supportive care designed for at home use was administered in the hospital until neutrophile recovery to 0.5 × 109/l. In the second, outpatient cohort, patients were discharged the day after stem-cell reinfusion but the supportive care was delivered daily in hospital. The third, home care cohort, consisted of patients who were discharged the day after stemcell reinfusion, after which specialized home care professionals delivered all supportive care including transfusions and parenteral antibiotics at home, with once weekly check-up in hospital by the transplant physician.Results: Forty-two patients were treated with 81 cycles of high-dose chemotherapy (11, 18 and 13 patients and 17, 40 and 24 courses in the inpatient, outpatient and home care cohorts respectively). Inpatients were hospitalized in the aplastic phase for a median of 14 days. Patients in the outpatient cohort were at home in the aplastic phase for a median of six days (with a median of six days in hospital), and in the home care cohort for a median of 10 days (with a median of 1.5 days in hospital). Unscheduled readmissions and hospital visits were frequent in the outpatient and home care cohorts, mostly due to fever, central indwelling catheter malfunctioning or chemotherapy-related toxicity. However, patients could usually be discharged again after observation and treatment. No infectious deaths or unexpected emergencies occurred in the outpatient or home care cohort. Neither was there any suggestion of an increased number of fevers, infections, or other complications.Conclusions: At home management in the aplastic phase after high-dose chemotherapy and stemcell transplant by community-based professionals is feasible without signs of increased toxicity or infections.presently at Diakonessenhuis Leiden     

The role of the outpatient clinic in chemotherapy for patients with unresectable or recurrent gastric cancer

BACKGROUND: Recently, outpatient chemotherapy centers have become popular in Japan. To clarify the actual conditions of outpatient clinics, we surveyed entire clinical courses of chemotherapy in patients with unresectable or recurrent gastric cancer. METHODS: From the medical records of 64 patients with unresectable or recurrent gastric cancer with no prior chemotherapy, we obtained data on overall survival, non-hospitalized survival, the number of and reasons for attendance at the outpatient clinic and hospitalization, and medical conditions at discharge. RESULTS: The median follow-up time was 520 days, the median survival time was 353 days, and the median non-hospitalized survival time was 282 days. Patients attended the outpatient clinic 1917 times in total; 145 (8%) of these were unplanned visits for accidental disease, disease progression, or toxicity. Patients were hospitalized 291 times in total: 110 (38%) of hospitalizations were unplanned or emergencies because of disease progression or toxicity. Patients were discharged 290 times in total; in 56 of these discharges (19%) unresolved medical problems remained, such as toxicity, total parenteral nutrition, or symptoms related to cancer. Three patients (5%) died from treatment-related leucopenia and thrombocytopenia. CONCLUSIONS: Patients with unresectable and recurrent gastric cancer were treated at outpatient clinics for periods up to 80% longer than the entire clinical course of chemotherapy. However, there were some unplanned or emergency hospitalizations and some patients still experienced medical problems at discharge. The role of the outpatient clinic is very important to chemotherapy for patients with unresectable or recurrent gastric cancer.     

A case report of a terminally ill patient who died of cancer at home under pain control

Ninety percent of patients we handle at our visiting nurse group are last stage cancer patients. We report a terminally ill cancer patient who died at home under a high dose of powerful opioids to control pain. The patient was a 69-year-old woman with colorectal cancer. She lived together with her husband and their elder son's family. Even though the patient's condition dramatically shifted time to time, we could maintain a good QOL of the patient till her death at home. After the outpatient chemotherapy treatment began, we confirmed the patient's colorectal cancer had spread to her bones. We started using powerful opioids for pain control and the patient was eventually transferred to home hospice care. Then, the patient suffered a self destruction of the cutis metastasis layer and the disease caused broken bones on her left thigh. We however continued on providing home care service because of the patient's strong desire to stay home even if the family's concern as a care giver had multiplied. We increased the frequency of home visits and telephone calls in order to give medical and spiritual support for both the patient and her family. As a result, we could keep the patient's good QOL up to the time of her death. Based on the experiences through taking care of the patient, we strongly felt that the timing of proper guidance for the peaceful death to the family, a communication method or a communication system and telephone call visits were very important, in addition to controlling the condition of illness in order to keep up a good QOL for both the patient and her family.     

Chemotherapy of Borrmann's type IV diffuse carcinoma of the stomach

Because of the great difficulty in detection of early lesion of Borrmann type 4 diffuse (scirrhous) gastric cancer, diagnosis is frequently given to the patients with far advanced, widely spread cancer invasion in the stomach which is not infrequently associated with peritonitis carcinomatosa. Accordingly, cancer chemotherapy should be of great importance. We have designed UFTM chemotherapy (a combination of UFT and Mitomycin C) for gastric cancer on the basis of pharmacodynamics of UFT. Twenty-one patients with Borrmann type 4 gastric cancer were treated with UFTM therapy. Of 21 patients, 14 (66.7%) patients experienced clinical responses. Fifty percent survival time after initiation of therapy was 11 months for the responders and 5.7 months for the non-responders. Overall fifty percent survival time was 8.4 months. It is considered that one of the keypoints of chemotherapy for Borrmann type 4 gastric cancer will be the complete treatment of metastatic lesion in the peritoneum which will become lethal to the patients later. Further, discussion was widely made on the treatment of Borrmann type 4 diffuse (scirrhous) gastric cancer.     

A Trial of Chemotherapy for Lung Cancer in Short-Term Hospitalization

Recently the number of patients with lung cancer who receivechemotherapy has been increasing rapidly. Therefore it has becomedifficult to treat all patients with advanced lung cancer onthe basis of accurate protocol in long-term hos-pitalization.Accordingly we tried to treat patients within one week in eachof a number of chemotherapy protocols (short-term hospitalization)and to follow them in the outpatient department. We were ableto accept 61 admissions of 38 patients for chemotherapy fromJune to December 1985. Thus it was possible to take care ofmore than three times as many patients as could be cared forby long-term hospitalization for chemotherapy. Three patientscould not be discharged within one week and eight had to bereadmitted because of leucopenia, thrombocytepenia, or dehydration.It was considered to be possible to decrease the number of suchpatients by more careful and appropriate hydration and to detectthem by appropriate intervals of examination in the outpatientdepartment. We concluded that short-term hospitalization isone of the methods which can make chemotherapy of lung cancermore effective.     

A case of advanced gastric cancer with long-term survival treated by chemotherapy and surgical cytoreduction

A 74-year-old man was revealed to have type 3 gastric cancer with lymph-node metastasis in the third group (N 3) and liver metastasis (H 1). Since we regarded a curative operation as impossible, we started preoperative chemotherapy using TS-1 plus irinotecan hydrochloride (CPT-11) on the premise that we would perform surgical cytoreduction after the chemotherapy. After two courses of chemotherapy, both the primary lesion and the liver metastasis were reduced in size, and the paraaortic lymph-nodes disappeared. Subsequently, a distal gastrectomy (D 0, curability C) was performed. The patient has been receiving postoperative chemotherapy using TS-1 and paclitaxel as an outpatient for 2.3 years. Although there is not enough evidence to support the benefit of surgical cytoreduction, chemotherapy combined with surgical cytoreduction would improve the survival time without deterioration of quality of life (QOL) in patients with advanced gastric cancer. This combined therapy should be considered as one of the promising strategies for advanced gastric cancer.     

Outpatient chemotherapy and oncology network : Onco Pays-de-la-Loire experiment

Many regulatory rules related to home-based care for cancer patients issued during the recent years. More precisely, the French Plan cancer and the December 2004 < arrêté > aim at < facilitating home-based chemotherapy by injection > only < within the framework of a network of health in oncology >, this in order to improve the quality of care and quality of life of patients. In this context, the Onco Pays-de-la-Loire network launched a project with centralised preparations of chemotherapy administred at home. We describe in this study the first results of this experiment. 41 patients have been treated and 224 cytotoxic drugs sended since january 2007 (56 % with trastuzumab, 19 % with gemcitabin, 13 % with methotrexate and 12 % with fluorouracil). No major problem was detected, 1,9 % of the preparations were destroyed. Satisfaction of outpatient healthcare professionals was good. A comparison of estimated costs revealed reductions in costs for outpatient chemotherapy. These first results validate the interest of cancer treatment at home for this kind of patients, and show the importance of nurse and pharmaceutical coordination.     

Modified pharmacokinetic modulating chemotherapy for progressive gastric cancer accompanied by peritoneal dissemination

Peritoneal dissemination is a major event in the development of gastric cancer. However, most patients with it have been excluded from clinical studies because they rarely have measurable lesions. We conducted an analysis to evaluate the efficacy and feasibility of modified pharmacokinetic modulating chemotherapy, for gastric cancer patients with peritoneal dissemination. Between May 2002 and April 2004, 10 patients were treated by modified pharmacokinetic modulating chemotherapy. This analysis was based on 10 consecutive chemotherapy-naive patients with confirmed peritoneal dissemination. This therapy regimen was repeated with a weekly schedule of MTX 100 mg/body, given as intraarterial infusion 1 h prior to a 24-hr infusion of 5-FU 500 mg/body. Simultaneously, enteric-coated tegafur/uracil (400 mg) was administered every day. The one-year overall survival rate was 50. 0%. The median survival time was 311 days. Grade 1 stomatitis and Grade 1/2 oral dryness were involved in 40% of the cases. No patient had to discontinue this therapy because of complications. Objective improvement of ascites was seen in all patients, and all patients could be treated at outpatient clinics. This regimen may be well-tolerated and of clinical benefit for patients with peritoneal dissemination of gastric cancer.     

Our outpatient cases for home anti-cancer chemotherapy using a CV port and a portable pump system

We report our outpatient cases for home anti-cancer chemotherapy using a CV port and a portable pump system. A total of 119 patients with advanced and recurrent cancer were performed at an outpatient clinic or provided home anti-cancer chemotherapy since December 1996 until December 2005. Of these patients, 18 patients were provided home anti-cancer chemotherapy using a CV port and a portable pump system (5 with gastric, 4 colonic, 2 rectal, 1 lung, 1 hepatic, 1 duodenal, 2 breast, and 2 pancreatic). Fifteen patients had died, and 3 patients are alive and undergoing continuous therapy. The response revealed 3 cases with partial response, 13 cases with no change and 2 cases with progressive disease. No severe side effects were seen, and no troubles of catheter and port were experienced as well. Not only the treatment of outpatients for home anti-cancer chemotherapy was effective and maintained the patient's QOL, but also contributed to a marked decrease of medical costs compared to admission therapy.     

A case report of delay in switching from inpatient treatment to home-based care due to changes in pain and other symptoms following chemotherapy

The number of cancer patients and their families desiring home-based care has been increasing. A support system for home-based care is urgently needed for a patient who continues to receive cancer chemotherapy. We introduce a patient for whom the decision to switch from inpatient treatment to home-based care was delayed because of changes in various symptoms associated with chemotherapy. We also examined the factors that resulted in a 7-month hospitalization until the symptoms had abated with third-line chemotherapy, chemotherapy regimens and pain control during the hospital stay, and an optimal timing for proceeding to home care.     

Outpatient chemotherapy for advanced lung cancer]

We reviewed the records of outpatient chemotherapy for advanced lung cancer in our institution. Thirty-two patients received 122 courses of cisplatin-free chemotherapy as outpatient treatments. Before outpatient treatment, every patient received the first chemotherapy as an inpatient treatment and the dose of cytotoxic drugs was reduced accordingly when side effects were judged to be untolerable. Only 1 patient needed hospitalization because of pneumonia with grade IV neutropenia. The overall response included partial responses (PR) 18%, no change (NC) 55%, progressive disease (PR) 11% and the median survival from the start of outpatient chemotherapy was 384 days. The monthly average cost of medical care per inpatient was more than three times as high as that of outpatients. Cisplatin-free chemotherapy for advanced lung cancer should be given as outpatient treatment not only to maintain the quality of life of patients, but also to restrain the total cost of medical care and to use hospital beds efficiently.     

Home chemotherapy

We report the case of a male gastric cancer patient who had undergone outpatient chemotherapy with TAXOTAL+TS-1 for adrenal and lung metastases.The disease was in progress.Next, we performed home chemotherapy with TAXOL.However, this chemotherapy also was not effective either.Therefore, the patient was started on Campto with the premedication including NaseaOD, GasterD and Decadron.The 17-course was performed in the period of 12 months.However, his condition did not improve.He experienced delirium and was hospitalized and the chemotherapy was discontinued.Later, his disease was advanced further and he died.Because of our close relationship with the general hospital, this patient had undergone home chemotherapy as long as 13 months, so that if a seamless cooperation was insured, chemotherapy could have been more safely and effectively performed at the patient's home.This study suggests that home chemotherapy is an important treatment modality.