Home chemotherapy for children with cancer.

A program was established in which the parents of children with cancer were trained to administer intravenous chemotherapy to the children in their homes. The main objectives of this program (Home Intravenous Chemotherapy by Parents [HICP]) were to improve the quality of life for children with cancer and their parents and to decrease the cost of medical care for these children by decreasing the number of clinic visits and hospital stays intended solely for the administration of chemotherapy. Twenty-four months of experience with this program indicates that with a close communication network and a good working relationship among a home care organization (HCO), the parents of the patient, a pediatric oncology nurse, and an attending pediatric oncologist, many chemotherapeutic agents can be safely administered to these children by their parents in their homes. The patients and their parents are enthusiastic about this program because of the valuable time saved and the increased participation in care. In addition, this program greatly decreased the cost of medical care for these children.     

Home chemotherapy in the Department of surgery, Higashi Sapporo Hospital

It is widely accepted that home chemotherapy improves the quality of life (QOL) of patients. Its purpose is to prevent the growth of the tumor rather than to reduce it is size, that is long NC, and to lessen the symptoms. The most important thing is side-effect-free treatment, because the patient is usually in the home. For this reason, the patient him/herself must be familiar with the side effects and emergency situations. Evaluation of home chemotherapy is very difficult, because the amount of anticancer drug is reduced or optimized for the individual patient. Thus, evaluation depends not only on tumor size, but also on QOL, lessening of symptoms, satisfaction or dissatisfaction with the treatment, and the philosophy of life of patients. This approach is being put to greater and greater use to maintain the QOL of patients, and to reduce the hospital costs. In the future, new anticancer drugs that have fewer side effects and stronger anticancer action are desirable.     

Home anti-cancer chemotherapy with continuous infusion of 5-FU combined with low-dose cisplatin injection via implantable venous port with portable balloon pump

Home anti-cancer chemotherapy was performed for patients with advanced cancer of the digestive plantable venous port placed beneath the skin via the subclavian vein. 128 patients under 75 years old (enrolled: 6 patients with esophageal, 65 with gastric, 44 with colorectal, 5 with cholangio, 5 with pancreatic, one with hepatic and one with ileal cancer) were treated. Continuous intravenous infusion of 5-FU (300-400 mg/body/day) combined with low-dose injection of cisplatin (5 mg/body/day) was continued for 10 days, and repeated 3 times for 6 weeks. The response rate was 23.6% in 72 patients with valuation of tumor mass. In 83 patients for whom a tumor marker evaluation was also performed, an effect was seen in 30.1%. No severe side effects such as renal dysfunction were observed, and no special infusions were needed. Therefore, a quality of life was maintained in which bathing was possible and patients were released from the hospital. Hyperalimentation through the venous port, and palliation during the terminal stage, is easily accomplished. It is useful method for surgery, chemotherapy and palliative therapy in the treatment of cancer.     

The future of chemotherapy at home--from outpatient chemotherapy to chemotherapy at home

Chemotherapy for colorectal cancer has changed greatly. A continuous systemic chemotherapy like FOLFOX or FOLFIRI became a standard. It is necessary to get sufficient knowledge and technique of chemotherapy for an infusion port system and a portable pump system. The risk management aspect is very important. Both strict and steady drug mixing and an administration system are necessary. It is also important to make a 24-hour surveillance system for any unusual conditions. The hospital as a whole must come to grips with these problems. The chemotherapy at an outpatient clinic or home will become a standard in the near future because it preserves the patients' QOL.     

Home care in Sapporo

We established a clinic specialized in home care in Sapporo in July 2001. In these 2 years we have provided medical home care service to 160 patients, and 97 are still receiving regular service. At first we accepted any patients living within 16 km from the clinic. However, bad traffic conditions in winter made it difficult to visit patients living in districts far away from the clinic. Therefore, we planned a network of home care physicians in Sapporo. Now 12 home care physicians hold monthly meetings. In Sapporo, meetings of home care related workers are organized in each ward, as suggested by the Sapporo Medical Association. There is a relatively good supply of home care related services and resources, including availability of an important number of visiting nurses. Patients being taken care of at home who present an acute exacerbation of symptoms are relatively easily accepted by acute hospitals. But those who have difficulties in continuing home care due to a sudden change in family conditions are not easily accepted by nursing hospitals. Recently, the number of group homes and lodging houses for elderly persons has markedly increased in Sapporo. It might have some problems in medical support in the near future.     

Rationalization of adjuvant chemotherapy by induction chemotherapy

An induction chemotherapy, before any local treatment, allows to precise the chemosensitivity of the primary tumor. These data may help to improve indication and type of a further adjuvant chemotherapy. However there are many biological differences between different sites of the same tumor and along the time, without or after treatment. It is thus impossible to be sure that a chemotherapeutic regimen effective as first treatment on the primary will be equally active on micro-metastases some months later. Many questions in this field will be answered only by controlled studies and careful observations.     

Home chemotherapy by concomitant UFT + Leucovorin (po.) in postoperative colorectal cancer patients assessed with Dukes D and curability C colorectal cancer

Concomitant treatment with 5-fluorouracil (5-FU) and Leucovorin (LV) is positioned as the standard chemotherapy against colorectal cancer. We noted the action of LV to enhance the effect of biochemical modulation by 5-FU, and made an attempt at home chemotherapy with UFT + LV by oral administration, in consideration to the convenience of patients. SUBJECTS: The subjects of this study were 24 post-operative patients who had been assessed with Dukes D and curability C colorectal cancer with measurable metastatic lesions and who could tolerate chemotherapy. METHODS: 1 course of treatment consisted of 2 weeks of UFT at 300-400 mg/m2/day and LV at 15 mg/body/day followed by 2 weeks of drug withdrawal. The administration was conducted for 4 courses or more as the target. Unless serious adverse reaction occurred, dose increase of UFT was allowed. RESULTS: The efficacy rate in the 22 patients who were assessable was 22.7%. There were 11 NC patients, accounting for half (50%) of the subjects. This home chemotherapy is expected to become an alternative chemotherapy against colorectal cancer in the future, because the treatment does not require hospitalization and has less impact on the QOL of patients.     

Regional chemotherapy

Regional chemotherapy is an interesting treatment option in patients with advanced pancreatic cancer but cannot be considered standard treatment, and it should not be performed outside controlled clinical trials. The real value of regional chemotherapy must be evaluated in larger, randomized trials. New drug combinations may reduce the observed side effects and improve tumor response. Gene therapy with p53 and K-ras modulated herpesviruses may become a palliative treatment option and can be administered easily by regional chemotherapy techniques [23].     

Intraperitoneal chemotherapy

A fact that the Second International Conference of Intracavitary Chemotherapy was held at Sandiego in 1988 clearly suggests that the intraperitoneal chemotherapy attracts again the attention as a new administration route aimed at complete cure and useful modality against refractory intraabdominal cancer. Basic problems (peritoneal circulation, importance of peritoneal clearance, conditions required for ip infusion and penetration depth from the tumor surface) are described. As to ip infusion of CDDP, pharmacokinetic characteristics (iv vs ip), the difference of ultrafiltrable Pt. value (chemical assay vs biological assay) and clinical notes are reviewed. Several clinical trials now on going (CDDP-STS combination, CDDP-STS-Angiotensin II, CHPP and IPCP) are introduced. Finally the future direction of intraperitoneal chemotherapy is discussed.     

Hepatic-arterial chemotherapy

The liver is a common site of metastases from cancers from most sites, but particularly from the gastrointestinal tract, since the portal vein drains into the liver. About half of all patients with colorectal cancer develop liver metastases. The response of liver metastases to systemic combination chemotherapy has improved, but the 2-year survival is only 25-30%. Hepatic-arterial infusion of chemotherapy produces higher response rates, with a 2-year survival of 50-60%. In patients who can undergo liver resection followed by hepatic-arterial infusion, the 2-year survival is 85%. This review summarises the anatomical basis, pharmacokinetic background, and cost-effectiveness of this procedure. We discuss the phase II and phase III studies of hepatic-arterial infusion therapy, with a focus on liver metastases from colorectal cancer.