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Abstract Background Under-diagnosis of pain is a serious problem in cancer care. Accurate pain assessment by physicians may form the basis of effective care. The aim of this study is to examine the association between late referral to a Palliative Care Team (PCT) after admission and the under-diagnosis of pain by primary physicians. Methods This retrospective study was performed in the Teikyo University teaching-hospital for a period of 20 months. We investigated triads composed of 213 adult cancer inpatients who had coexisting moderate or severe pain at the initial PCT consultation, 77 primary physicians, and 4 palliative care physicians. The outcome of the present study was the under-diagnosis of pain by primary physicians with routinely self-completed standard format checklists. The checklists included coexisting pain documented independently by primary and palliative care physicians at the time of the initial PCT consultation. Under-diagnosis of pain was defined as existing pain diagnosed by the palliative care physicians only. Late referral to PCTs after admission was defined as a referral to the PCT at ≥20 days after admission. Because the two groups displayed significantly different regarding the distributions of the duration from admission to referral to PCTs, we used 20 days as the cut-off point for “late referral.” Results Accurate pain assessment was observed in 192 triads, whereas 21 triads displayed under-diagnosis of pain by primary physicians. Under-diagnosis of pain by primary physicians was associated with a longer duration between admission and initial PCT consultation, compared with accurate pain assessment (25 days versus 4 days, p Conclusions Under-diagnosis of pain by primary physicians was associated with late referral to PCTs. Shortening the duration from admission to referral to PCTs, and increasing physicians’ awareness of palliative care may improve pain management for cancer patients.

Abstract Background Continual collaboration between physicians and hospital-based palliative care teams represents a very important contributor to focusing on patients' symptoms and maintaining their quality of life during all stages of their illness. However, the traditionally late introduction of palliative care has caused misconceptions about hospital-based palliative care teams (PCTs) among patients and general physicians in Japan. The objective of this study is to identify the factors related to physicians' attitudes toward continual collaboration with hospital-based PCTs. Methods This cross-sectional anonymous questionnaire-based survey was conducted to clarify physicians' attitudes toward continual collaboration with PCTs and to describe the factors that contribute to such attitudes. We surveyed 339 full-time physicians, including interns, employed in a general acute-care hospital in an urban area in Japan; the response rate was 53% (N = 155). We assessed the basic characteristics, experience, knowledge, and education of respondents. Multiple logistic regression analysis was used to determine the main factors affecting the physicians' attitudes toward PCTs. Results We found that the physicians who were aware of the World Health Organization (WHO) analgesic ladder were 6.7 times (OR = 6.7, 95% CI = 1.98-25.79) more likely to want to treat and care for their patients in collaboration with the hospital-based PCTs than were those physicians without such awareness. Conclusion Basic knowledge of palliative care is important in promoting physicians' positive attitudes toward collaboration with hospital-based PCTs.

Paternalistic decision-making continued in the past, not only in cancer care. It has since been replaced by self-determination by the patient. As the concept of advanced care planning has spread, the importance of shared decision-making between healthcare professionals and patients has been recognized. In addition, family participates in the process with Key Role in Japan. Decisions are sometimes painful, especially with advanced cancer. Families provide emotional support to the patient and participate in decision-making as an advocate when it is difficult to make decisions. Furthermore, barriers and coping with that in Japan are also mentioned. When patients have unrealistic hopes, healthcare providers can express their concerns while taking care not to deny their wishes. Patients with dementia are what they are. For patients who avoid decision-making, it is important to assess their current physical pain symptoms and emotional burden. Suffering reduces energy of the patient and can prevent thinking about the future. Future issues need to address ethical aspects and overcome clinical challenges.

Opioids are effective in cancer pain management. However, adverse effects such as opioid-induced constipation(OIC) cause significant reductions in the quality-of-life of cancer patients. In addition, this treatment sometimes also results in inadequate pain relief. It is estimated that from 50-90% of cancer patients receiving opioids suffer from OIC. The mechanism of exogenous opioids on gastrointestinal opioid receptors is known to lead to bowel dysfunction: including motility, secretion and coordination of the sphincter function. The Rome Ⅳ criteria is widely used for the definition of OIC. Imaging, which is not routinely performed, is useful for diagnosing the severity and they also help in choosing the most appropriate laxatives. Additionally, the bowel function index (BFI)can help to distinguish between opioid-treated patients with or without constipation. Unfortunately, the effective Japanese scale for the BFI remains to be elucidated. Primary treatment with stimulants and osmotic laxatives often demonstrates limited effectiveness. New agents, such as peripherally acting mu-opioid receptor antagonists(PAMORA), which have a potent competitive antagonist action, are therefore needed to improve the treatment of such patients. PAMORA should be observed carefully for the diarrhea when the duration of opioid therapy is prolonged prior to PAMORA initiation. Pharmacologically, this diarrhea might be associated with the onset of peripheral withdrawal symptoms.

In 2010s, several opioids became available in Japan, including methadone, tapentadol and hydromorphone. Methadone was approved in September 2012 by Japanese regulatory authority. Since methadone is positioned as so-calledstep 4 opioidin Japan, it must be prescribed as alternative opioid switched from another of 60mg/day or greater equivalent dose of oral morphine. Diversity of pharmacokinetics among individuals and various drug interactions require close monitoring of adverse events. In spite of these cautions, unique characteristics such as inhibiting N-methyl-D-aspartate(NMDA)and in- ducing internalization/degradation of mu-delta opioid receptor heterodimers underline the value of methadone in opioid switching. Tapentadol, a dual-acting opioid which inhibits noradrenaline(norepinephrine)reuptake, was approved in Japan in March 2014. In a double-blind randomized study comparing with oxycodone, tapentadol showed relatively better tolerability. Advantages such as having no active metabolites and minimal drug interactions also ease the administration of tapentadol to the patients with comorbidities. Hydromorphone, approved in March 2017, has a profile similar to morphine. Higher potency than morphine lead to less production of 3-glucronide metabolite(H3G)which accumulates in patients with renal failure and causes neurotoxicity. Because there is no concluding evidence about effect of hydromorphone on dyspnea or tolerability in patients with renal insufficiency, organized studies are still needed. We expect these "new in Japan" opioids contribute to long-term, stable pain control for patients with cancer.

Pain is classified as either nociceptive pain, which results from a nociceptor stimulation, or neuropathic pain, which results from a lesion of the neural pathway. Clinically, in many cases, pain consists of a single origin but multiple origins are also possible. In this paper, we outline an assessment and strategy for nociceptive pain in cancer. The onset time, location, feature, strength, and etiology were included as categories for the assessment of pain. Furthermore, we added a psychosocial assessment to the physical assessment, which ensured comprehensive pain evaluation. We performed the investigation according to the WHO method for cancer pain relief. According to the effects and adverse effects, we chose a non-opioid analgesic and an opioid analgesic as medications. However, nonpharmacological therapy, such as radiotherapy and nerve block, is not a concern with the WHO analgesic ladder. It is important that a multi-disciplinary team, which includes physicians, nurses, physiotherapists, and pharmacists, support the patients to manage their pain by themselves through the knowledge of the factors affecting their pain and the medication methods for easing it when it gets worse. Although we cannot ease pain completely, it is important to define the goal of treatment with patients and to examine the strategy for maximum pain relief.

Cancer-related pain affects approximately 90% of those in all stages of the disease. Pain is both a sensation and an emotional experience, and thus it has been defined as total pain. The type of cancer pain management decided upon depends on the underlying pathophysiological mechanisms, which are classified as nociceptive(somatic and visceral), neuropathic, and idiopathic. Pain management as part of routine cancer care has been forcefully advanced by the World Health Organization( WHO)-analgesic ladder. The clinical application of pain management should be employed only after a complete and comprehensive assessment and evaluation. The present overview article focuses on nonsteroidal anti-inflammatory drugs (NSAIDs), opioids and adjuvant analgesia.

This paper reviews current cancer pain management guidelines, the challenge of managing pain across the care settings hospital to home. This also presents up-to-date information on the medications and strategies and the expansion of the World Health Organization's (WHO) analgesic ladder with several classes of drugs that are currently used to treat cancer pain: (1) non-steroidal anti-inflammatory drugs (NSAIDs), (2) opioid analgesics with opioid rotation and the control for side effect of opioid, (3) adjuvant analgesics including ketamine.

Seventy-nine terminal patients with gynecological cancer treated in the past 5 years in our hospital or their families were interviewed on where those patients died and the reason why they chose to die in the place. Fifty-two patients (65.8%) died at our hospital, 18 patients (22.8%) at other hospitals, 5 (6.3%) at other hospice and 4 (5.1%) at home. The 52 patients who died at our hospital were asked why they chose to die there. 42 of them (80.8%) wanted care at our hospital to the death. 10 (20.2%) had no time to think of home care or other institutions because of the sudden change of the condition. The 18 patients who died at other institutions were also asked about the reason. 9 of them (50%) wanted to die in their hometown or close to their home. 5 of them (27.8%) were referred to other hospitals due to brain metastasis or the necessity of undergoing dialysis. 2 of them (11.1%) were referred to the institutions which provide long-term care. 2 of them (11.1%) were brought into a nearby emergent care hospital and died after the sudden change of the condition. The palliative care ward in our university hospital can provide continued relationship with cancer patients. We had time to talk enough with carcinoma patients and their family in the ward, which widened choices of their death place, including home death.

As a medical advisor specialized in palliative care, I think the following points should be considered regarding management of patients after discharge from a tertiary hospital: 1. Information that we should get before the interview and examination, 2. Assessment of symptoms, 3. Medications for the management of pain, 4. Supportive care to cope with psychosocial problems derived from the management of physical symptoms, 5. Help to continue with activities of daily life and to cope with the cancer at home, and 6. Characterize of the medical advisor as a member of an interdisciplinary team.

Diseases, details of interventions, medical cares provided and the condition of use and services of local medical institutions were investigated in the home care support activities during the period from November 1997 to March 2003. We intervened in 1,309 patients. 70% of them were terminal patients with malignant tumor. Interventions were mostly consultations about the life under medical care, guidance about HPN/tube feeding, consultations about nursing and coordination with local medical institutions. 422 of them were under care of family doctors. 502 of them used visiting nursing. 70% of the patients under care of the hospital required high-tech home care and home hospice care. The 5-year activities indicate that nurses who support home care at the hospitals providing acute medical care are expected to 1. serve as the consultation contact for patients and families, 2. support the life under medical care in consultation with internal and external related professionals, 3. use social resources, 4. serve as the contact for providing the logistic support under an emergent situation or under the lack of care-giving capabilities, 5. provide guidance for the safe use of high-tech home medical care by patients/families at the discharge, 6. communicate or coordinate with local medical institutions for continued care/nursing and 7. develop/support the flexible and convenient distribution system of medical equipment and medical materials/drugs or the 24-hour healthcare support system jointly with private enterprises.

We report a case of recurrent breast cancer with chronic renal failure in a 58-year-old female. She could be treated on an outpatient basis under good general condition for most of her remaining life by chemoradiotherapy in combination with hemodialysis. Modification of the chemoradiotherapy procedures and collaboration of medical staff including the doctor in charge of home medical care and her family was indispensable in keeping her hospital stay as short as possible.