Search

Background: The overall survival rate of advanced cancer patients has improved thanks to the development of modern medical treatments, particularly new and innovative chemotherapeutic agents such as targeted therapies and immune checkpoint inhibitors.Current Concepts: Chemotherapy is administered in neoadjuvant, adjuvant, and palliative settings, and its ultimate goal is to improve overall survival. Chemotherapy has several proven and valuable clinical benefits, but also many side effects that cannot be ignored, especially in patients with poor European Cancer Oncology Group performance status. Therefore, we must carefully weigh and trade off the benefits and harms from many chemotherapy agents. In fact, it can be difficult to determine whether advanced cancer patients really benefit from chemotherapy, which is why a number of value measurement tools such as the American Society Clinical Oncology-Value Framework and the European Society for Medical Oncology-Magnitude of Clinical Benefit Scale have been developed.Discussion and Conclusion: We need to include individual cancer patients in decision-making processes and use appropriate shared decision-making to decide whether or not to administer chemotherapy. Furthermore, we should perform rational trade-offs in consideration of limited health resources.

Purpose In Korea, the “Act on Hospice and Palliative Care and Decisions on Life-sustaining Treatment for Patients at the End of Life” was enacted on February 4, 2018. This study was conducted to analyze the current state of life-sustaining treatment decisions based on National Health Insurance Service (NHIS) data after the law came into force.Materials and Methods The data of 173,028 cancer deaths were extracted from NHIS qualification data between November 2015 and January 2019.Results The number of cancer deaths complied with the law process was 14,438 of 54,635 cases (26.4%). The rate of patient self-determination was 49.0%. The patients complying with the law process have used a hospice center more frequently (28% vs. 14%). However, the rate of intensive care unit (ICU) admission was similar between the patients who complied with and without the law process (ICU admission, 23% vs. 21%). There was no difference in the proportion of patients who had undergone mechanical ventilation and hemodialysis in the comparative analysis before and after the enforcement of the law and the analysis according to the compliance with the law. The patients who complied with the law process received cardiopulmonary resuscitation at a lower rate.Conclusion The law has positive effects on the rate of life-sustaining treatment decision by patient’s determination. However, there was no sufficient effect on the withholding or withdrawing of life-sustaining treatment, which could protect the patient from unnecessary or harmful interventions.

Purpose This study aimed to confirm the decision-making patterns for life-sustaining treatment and analyze medical service utilization changes after enforcement of the Life-Sustaining Treatment Decision-Making Act. Materials and methods Of 1,237 patients who completed legal forms for life-sustaining treatment (hereafter called the life-sustaining treatment [LST] form) at three academic hospitals and died at the same institutions, 1,018 cancer patients were included. Medical service utilization and costs were analyzed using claims data. Results The median time to death from completion of the LST form was three days (range, 0 to 248 days). Of these, 517 people died within two days of completing the document, and 36.1% of all patients prepared the LST form themselves. The frequency of use of the intensive care unit, continuous renal replacement therapy, and mechanical ventilation was significantly higher when the families filled out the form without knowing the patient's intention. In the top 10% of the medical expense groups, the decision-makers for LST were family members rather than patients (28% patients vs. 32% family members who knew and 40% family members who did not know the patient's intention). Conclusion The cancer patient's own decision-making rather than the family's decision was associated with earlier decision-making, less use of some critical treatments (except chemotherapy) and expensive evaluations, and a trend toward lower medical costs.

Background/Aims: The multidisciplinary team (MDT) approach is a cornerstone of clinical oncology. This study investigated the current state of MDT care, in cluding patient satisfaction, in Korea. Methods: We obtained the annual number of cancer patients who have received MDT care since 2014 from the registry of the Health Insurance Review and As sessment Service (HIRA). In addition, patients who received MDT care from Au gust 2014 to May 2017 at four university hospitals were further characterized, and patient satisfaction was measured prospectively using a patient-reported ques tionnaire. Results: The total number of patients who received MDT care increased from 2014 to 2016 (2,113 to 9,998 patients, respectively) in the HIRA Cohort. The type of cancer that most often required MDT was breast cancer (23.8%), followed by col orectal cancer (19.1%). In the Representative Cohort (n = 1,032), MDT was request ed by the surgeon more than half the time (55.7%). The main focus of MDT was decision making for further treatment planning (99.0%). The number of doctors participating in the MDT was usually five (70.0%). After initiating an MDT ap proach, the treatment plan changed for 17.4% of patients. Among these patients, 359 completed a prospective satisfaction survey regarding their MDT care. The overall satisfaction with the MDT approach was very high, with an average score of 9.6 out of 10 points. Conclusions: The application of MDT care is a rapidly growing trend in clini cal oncology, and shows high patient satisfaction. Further research is needed to determine which types of cancer patients could benefit most from MDT, and to enable MDT care to operate more efficiently so that it may expand successfully throughout Korea.

Despite the urgent need to control dementia, an effective treatment has yet to be developed. Along with the Korean government's policy of cooperation between conventional medicine (CM) and Korean medicine (KM), integrative medical services for dementia patients are being provided. This study aimed to compare the integrative medical clinic (IMC) for dementia used by Dongguk University Hospitals (DUH) with other service models and to review the characteristics and treatment outcomes of patients who had visited DUH over the past 5 years. Patients' electronic medical records from May 2015 to June 2020 were searched and their data were analyzed to evaluate the IMC's service model. Patient demographic and clinical characteristics, diagnostic tests, and treatment patterns for CM and KM were collected. The proportion of patients who did not show worsening cognitive function was described in detail. A strength of the DUH integrative medicine clinic is its ability to manage both KM and CM patients in the same space at the same time. Among the 82 patients who visited the clinic during our study period, 56 remained for data analysis after we excluded patients who met the exclusion criteria; nineteen patients had diagnoses of mild cognitive impairment. Among collaboration patterns, the first visit to the IMC had the highest proportion (55.4%). Among diagnosed tests in CM, laboratory tests and neuropsychological tests were used the most. In KM, a heart rate variability test was frequently used. The most common CM treatment prescribed was anticonvulsants, with 22 patients (39.2%) receiving donepezil, whereas the most frequent KM treatments were acupuncture (82.1%) and herbal medicine (78.6%). Twelve patients were followed up with the Mini-Mental State Examination, and 8 demonstrated either no worsening or improved cognition (baseline Mini-Mental State Examination range: 21-26). All 8 patients had mild cognitive impairment including 6 with amnestic, multidomain impairment. This study searched for a way to improve cognitive dysfunction and dementia using an integrative approach, and it shows promising results for mild cognitive impairment. However, more precisely designed follow-up studies are needed to address the present work's limitations of a retrospective study design and a small sample size.

Background As the role of immunotherapies and personalized medicine grow, cancer patients have faced many choices in treatments and have suffered financial toxicity. These challenges brought the need for the value framework (VF) to guide treatment decision making. Methods A survey was taken to 102 oncologists about perception for VF. They were asked about priorities among several considerations when they prescribe cancer drugs. Their views on the need for development and potential implications of VF in Korea were assessed, also. Results The survey shows that 90% of the respondents choose clinical efficacy as the most important value in cancer drugs selection, and the cost of drug was more weighted value in immune checkpoint inhibitors (13.7%). Approximately half (53.9%) answered that they were aware of the existing VFs. Over 90% of respondents agreed with the need for development of a VF for cancer drugs based on Korean healthcare system and further usefulness for decisions about reimbursement issues. Seventy-one percent answered that two representative VFs (American Society Clinical Oncology-VF and European Society for Medical Oncology-Magnitude of Clinical Benefit Scale) should be reflected in value measurement of cancer drugs in Korea. Conclusion The Korean oncologists recognized the necessity for the clinical application of VF. Further discussion between the stakeholders should be followed to alleviate the financial burden through the value-based decision making of cancer drugs., Graphical Abstract

Background/aims Despite increased demand for cancer patient's to make their own decisions based on an adequate understanding of what is involved in chemotherapy, the primary signing agent and the reasons for surrogate signing have not been appropriately evaluated. Methods The ethics committee of the palliative medicine subgroup of the Korean Cancer Study Group designed this study and solid cancer patients to whom chemotherapy was offered, from seven institutions, were evaluated. The details relating to surrogate's signing of chemotherapy consent were evaluated. Then, we analyzed the factors associated with surrogate's signing according to patient's demographics and characteristics related to chemotherapy consent. Results Surrogate's signing was noted for 20.7% (84/405) of patient and over half of surrogate signings were performed by the patients' son or daughter (60.7%). Two main reasons for surrogate signing were patient's incapacity (34.5%) and taking over authorization from patients (33.3%). The factors associated with more frequent surrogate's signing were absence of spouse, lower education level, outpatient, and when residents played a role as a principle provider of chemotherapy consent. Conclusion This study suggests the lack of patients' own decision making for chemotherapy in some situations. This ethical dilemma must be considered for adequately informed decision making for chemotherapy while ensuring the patients' autonomy is maintained.

Terminal lucidity is an unpredictable end-of-life experience that has invaluable implications in preparation for death. We retrospectively evaluated terminal lucidity at a university teaching hospital. Of 338 deaths that occurred during the study period (187 in the ICU and 151 in general wards), terminal lucidity was identified in 6 cases in general wards. Periods of lucidity ranged from several hours to 4 days. After experiencing terminal lucidity, half of the patients died within a week, and the remainder died within 9 days. More attention should be directed toward understanding terminal lucidity to improve end-of-life care in a meaningful way.

Purpose The main purpose of the Life-Sustaining Treatment Decisions Act recently enacted in Korea is to respect the patient’s self-determination. We aimed to investigate the current status and features of patient self-determination after implementation of the law.Materials and Methods Between February 2018 and January 2019, 54,635 cancer deaths were identified from the National Health Insurance Service (NHIS) database. We analyzed the characteristics of decedents who complied with the law process by self-determination compared with decedents with family determination and with decedents who did not comply with the law process.Results In multivariable analysis, patients with self-determination were younger, were less likely to live in rural areas, were less likely to belong to the highest income quintile, were less likely to be treated in general hospitals, and were more likely to show a longer time from cancer diagnosis compared with patients with family determination. Compared with patients who did not comply with the law process, patients with self-determination were younger, lived in Seoul or capital area, were less likely to belong to the highest income quintile, were treated in general hospitals, were less likely to have genitourinary or hematologic malignancies, scored higher on the Charlson comorbidity index, and showed a longer time from cancer diagnosis. Patients with self-determination were more likely to use hospice and less likely to use intensive care units (ICUs) at the end-of-life (EOL).Conclusion Decedents with self-determination were more likely to be younger, reside in the Seoul or capital area, show a longer time from cancer diagnosis, and were less likely to belong to the highest income quintile. They utilized hospice more frequently, and received less ICU care at the EOL.

This study sought to adapt the existing value framework (VF) to produce a reliable and valid Korean oncology VF. Two VFs developed by The American Society of Clinical Oncology (ASCO) and the European Society for Medical Oncology (ESMO) were selected for examination in the present study. Forward and backward translations were conducted for six high-priced drugs indicated for non-small-cell lung cancer and multiple myeloma. Inter-rater reliability was measured based on the intraclass correlation coefficient (ICC) and variation was described using the coefficient of variation. The relative weights of factors critically considered by Korean oncologists were derived following the analytic hierarchy process (AHP), and focus group interviews (FGIs) were used to obtain qualitative data regarding the applications of these two VFs in the Korean setting. The ICCs of the Korean VFs were 0.895 (0.654–0.983) for ASCO and 0.726 (0–0.982) for ESMO translations, suggesting excellent reliability for ASCO and good reliability for ESMO. AHP demonstrated that clinical benefit has the highest priority, which is consistent with the ASCO VF. The FGIs suggested that the result for AHP is acceptable and that both ESMO and ASCO VFs should be used complementarily. Although further evaluation with a larger sample size is needed, the Korean versions of ESMO/ASCO VFs are valid and reliable tools and are acceptable to Korean stakeholders, yet they should be applied with caution.

Purpose This study aimed to validate the Sheffield Profile for Assessment and Referral to Care (SPARC) as an effective tool for screening palliative care needs among Korean cancer patients. Materials and methods The English version of the SPARC was translated by four Korean oncologists and reconciled by a Korean language specialist and a medical oncologist fluent in English. After the first version of the Korean SPARC (K-SPARC) was developed, back-translation into English was performed by a professional translator and bilingual oncologist. The back-translated version was reviewed by the original author (S.H.A.), and modifications were made (ver. 2). The second version of the K-SPARC was tested against other questionnaires, including the Functional Assessment of Cancer Therapy-General (FACT-G) and the Edmonton Symptom Assessment System (ESAS). Results Thirty patients were enrolled in the pilot trial. Fifteen were male, and the median age was 64.5 years. Six patients had an Eastern Cooperative Oncology Group (ECOG) performance status of 2 or more. All patients except one were receiving chemotherapy. Regarding internal consistency, the Cronbach's α scores for physical symptoms, psychological issues, religious and spiritual issues, independency and activity, family and social issues, and treatment issues were 0.812, 0.804, 0.589, 0.843, 0.754, and 0.822, respectively. The correlation coefficients between the SPARC and FACT-G were 0.479 (p=0.007) for the physical domain and -0.130 (p=0.493) for the social domain. Conclusion This pilot study indicates that the K-SPARC could be a reliable tool to screen for palliative care needs among Korean cancer patients. A further study to validate our findings is ongoing.

PURPOSE This study aimed to investigate the prevalence and risk factors of burnout and occupational stress among medical oncologists in Korea. Materials and Methods A survey was conducted of medical oncologists who were members of Korean Society for Medical Oncology (KSMO) using the Korean Occupational Stress Scale, the validated Maslach Burnout Inventory (MBI) and supplemental questions about work and lifestyle factors. RESULTS Among 220 active KSMO members, 111 responses were collected. The median age was 42 years (range, 32 to 63 years). Two-thirds of responders worked 6 days per week and half of them worked a total of 60-80 hours per week. Each medical oncologist treated a median of 90-120 patients per week in outpatient clinics and 20-30 patients per week in patient practices. MBI subscales indicated a high level of emotional exhaustion in 74%, a high level of depersonalization in 86%, and a low level of personal accomplishment in 65%: 68% had professional burnout according to high emotional exhaustion and high depersonalization scores. The risk of burnout was higher for medical oncologists aged from 30-39 than 40-49 years, and unmarried than married. Considering personal accomplishment, females had a higher risk of burnout. The median score of occupational stress was 63 (range, 43 to 88). Having night-duty call was the strongest risk factor on more stress. A higher stress score was associated with a higher prevalence of burnout. CONCLUSION Burnout and occupational stress are quite common amongst Korean medical oncologists. Achieving a healthy work-life balance, ensuring balanced workload distribution, and engaging in proper stress relief solutions are necessary.

Purpose This study was conducted to investigate the current role of medical oncologists in cancer care with a focus on increasing the recognition of medical oncology as an independent specialty. Materials and Methods Questionnaires modified from the Medical Oncology Status in Europe Survey dealing with oncology structure, resources, research, and patterns of care given by medical oncologists were selected. Several modifications were made to the questionnaire after feedback from the insurance and policy committee of the Korean Association for Clinical Oncology (KACO). The online survey was then sent to KACO members. Results A total of 214 medical oncologists (45.8% of the total inquiries), including 71 directors of medical oncology institutions, took the survey. Most institutions had various resources, including a medical oncology department (94.1%) and a department of radiation oncology (82.4%). There was an average of four medical oncologists at each institution. Medical oncologists were involved in various treatments from diagnosis to end-of-life care. They were also chemotherapy providers from a wide range of institutions that treated many types of solid cancers. In addition, 86.2% of the institutions conducted research. Conclusion This is the first national survey in Korea to show that medical oncologists are involved in a wide range of cancer treatments and care. This survey emphasizes the contributions and proper roles of medical oncologists in the evolving health care environment in Korea.

PURPOSE This study was conducted to explore the process and operation of a cancer multidisciplinary team (MDT) after the reimbursement decision in Korea, and to identify ways to overcome the major barriers to effective and sustainable MDTs. MATERIALS AND METHODS Approximately 1,000 cancer specialists, including medical oncologists, surgical oncologists, radiation oncologists, pathologists, and radiologists in general hospitals in Koreawere invited to complete the survey. The questionnaire covered the following topics: organizational structure of MDTs, candidates for consulting, the clinical decision-making initiative, and responsibility for dealing with legal disputes. RESULTS We collected a total of 179 responses (18%) from physicians at institutions where an MDT approach was active. A surgical oncologist (91%), internist (90%),radiologist (89%),radiation oncologist (86%), pathologist (71%), and trainees (20%) regularly participated in MDT operations. Approximately 55% of respondents stated that MDTs met regularly. In cases of a split opinion, the physician in charge (69%) or chairperson (17%) made the final decision, and most (86%) stated they followed the final decision. About 15% and 32% of respondents were "very satisfied" and "satisfied," respectively, with the current MDT's operations. Among 38 institutional representatives, 34% responded that the MDT operation became more active and 18% stated an MDT was newly implemented after the reimbursement decision. CONCLUSION The reimbursement decision invigorated MDT operations in almost half of eligible hospitals. Dissatisfaction regarding current MDTs was over 50%, and the high discordance rates regarding risk sharing suggest that it is necessary to revise the current system of MDTs.

Background: Positive attitudes for end-of-life (EOL) care along with adequate education are key factors for the provision of quality EOL care. This national study was conducted to identify the factors that influence attitudes toward EOL care on medical students. Method: An anonymous survey was designed and administered to fourth-year medical students at all 41 medical schools in Korea. Topics related to EOL care were assessed in classroom teaching, bedside teaching, and feedback experiences during clinical clerkships. Seven questions for self-rated attitudes and affecting factors were analyzed toward EOL care. Results: With a response rate of 49.2%, the median number of topics recognized by the students as having been delivered was 5 of 11 topics in classroom lectures and 1 of 8 topics in clinical experience. Although few (21.2%) participants indicated that they felt ready for EOL care practice, nevertheless, most felt that they should have adequate knowledge of and preparation for clinical competency in EOL care. Several parameters including respondent’s demographics and exposure to EOL care topics in classroom and in bedside teaching influenced the responses to all 7 attitude questions. However, having more than 1 bedside experience was the only factor positively affecting all attitudinal measures. Conclusions: Clinical experience related to EOL care seems to be the utmost priory in fostering positive attitudes and competency among medical students.

Purpose We evaluated the prevalence and characteristics of breakthrough cancer pain (BTcP) in Korean patients admitted with cancer pain. Materials and Methods In-hospital patients with cancer pain completed a questionnaire concerning severity of background cancer pain (BCP), prevalence and treatment for BTcP, sleep disorders, and satisfaction with cancer pain treatment. Medical records showing medications for BCP and BTcP were also evaluated. Results Total 609 patients with controlled BCP enrolled. Mean age of the patients was 59.5 years old, and 59% were male. Of all patients, 177 (29%) complained of BTcP. No clinical characteristic predicted BTcP. Of the 177 patients with BTcP, 56% did not receive treatment for BTcP. Patients with BTcP showed significant association with a sleep disorder and dissatisfaction with pain control, compared to those without BTcP (p < 0.0001 and p=0.0498, respectively). Oxycodone-immediate release was the most commonly used short-acting analgesic, followed by intravenous morphine. Conclusion The prevalence of BTcP was 29% in patients admitted with controlled BCP. Although the patients had well-controlled BCP, BTcP showed association with a lower quality of life in patients with cancer. More medical attention is needed for detection and management of BTcP.

Advanced incurable cancer patients receive palliative chemother apy to prolong their life and improve quality of life. However, physicians should assess the timing to discontin ue the treatment, especially near the final months of life, as palliative chemotherapy may accompany considerable toxicity. Even though there are no clear guidelines regarding the withdrawal timing for anticancer treatment in pal liative setting, it is important clarify the issue for quality of care for advanced cancer patients. Here, we present two patients who received palliative chemotherapy for advanced colon cancer and non-small cell lung cancer, respectively. In both cases, it was jointly determined to stop palliative chemotherapy, and best efforts are made to r elieve troublesome symptoms. The cases and upto-date literature review will highlight the importance of the timing of discontinuation of cancer treatments when changes are being made to the health care system and hospice an d palliative medicine is taking root in Korea.

e19391 Background: Emerging oncology drugs such as targeted agents and immune checkpoint inhibitors (ICIs) have brought dramatic advances in cancer treatment, while rapid rise in the drug cost. In Korea, the policy of expansion of health insurance coverage has improved accessibility to high-priced oncology drugs through their registrations in reimbursement list. However, this made a considerable impact on the financial burden of national health insurance. The objective of this study was to assess the awareness and perceptions of medical oncologists about the value frameworks of cancer drugs in Korea. Methods: We collected the data from survey for 102 medical oncologists at cancer conference. They were asked about prioritization among multiple considerations when they prescribe cancer drugs, The second question was awareness of value frameworks such as American Society of Clinical Oncology (ASCO) value framework and European Society for Medical Oncology Magnitude of Clinical Benefit Scale (ESMO-MCBS). Additionally, potential application of value framework to the decision on reimbursement coverage was included. Results: The majority of respondents (90%) chose clinical efficacy as the most important factor when they selected oncology drug for cancer patients. Safety/tolerability and drug cost were followed as 5.9% and 1%, respectively. Meanwhile, the order of priority of considerations for ICIs treatment was as follows: clinical efficacy (74.5%), drug costs (13.7%), and safety/tolerability (9%). More than half of those questioned (53.9%) were already aware of ASCO value framework and ESMO-MCBS, while 26.5% did not recognize them at all. Over 90% of respondents agreed with the need for development of new value framework tool which can be complementary to current valuation system for oncology drugs. Oncologists responded positively to the necessity of the assessment tool as a criterion for reimbursement registration (84.3%) as well as post-reimbursement re-evaluation (89.2%). Conclusions: Our results suggest that value assessment tool of oncology drug be necessary for providing medical evidences for clinical decision and for determination to health insurance reimbursement in Korea.

Due to an increasing proportion of older individuals and the adoption of a westernized lifestyle, the incidence rate of breast cancer is expected to rapidly increase within the next 10 years in Korea. The National Cancer Screening Program (NCSP) of Korea recommends biennial breast cancer screening through mammography for women aged 40–69 years old and according to individual risk and preference for women above 70 years old. There is an ongoing debate on how to most effectively screen for breast cancer, with many proponents of personalized screening, or screening according to individual risk, for women under 70 years old as well. However, to accurately stratify women into risk categories, further study using more refined personalized characteristics, including potentially incorporating a polygenic risk score (PRS), may be needed. While most breast cancer risk prediction models were developed in Western countries, the Korean Breast Cancer Risk Assessment Tool (KoBCRAT) was developed in 2013, and several other risk models have been developed for Asian women specifically. This paper reviews these models compared to commonly used models developed using primarily Caucasian women, namely, the modified Gail, Breast Cancer Surveillance Consortium, Rosner and Colditz, and Tyrer-Cuzick models. In addition, this paper reviews studies in which PRS is included in risk prediction in Asian women. Finally, this paper discusses and explores strategies toward development and implementation of personalized screening for breast cancer in Korea.

Completing an advance directive offers individuals the opportunity to make informed choices about end-of-life care. However, these decisions could be influenced in different ways depending on how the information is presented. We randomly presented 185 participants with four distinct types of advance directive: neutrally framed (as reference), negatively framed, religiously framed, and a combination. Participants were asked which interventions they would like to receive at the end of life. Between 60% and 70% of participants responded “accept the special interventions” on the reference form. However, the majority (70%–90%) chose “refuse the interventions” on the negative form. With respect to the religious form, 70% to 80% chose “not decided yet.” Participants who refused special life-sustaining treatments were older, female, and with better prior knowledge about advance directives. Our findings imply that the specific content of advance directives could affect decision-making with regard to various interventions for end-of-life care.

To give informed consent, a patient needs to sufficiently understand the information provided by a physician to decide among treatment options. Although shared decision-making is becoming an important aspect of patient-centered care, little is known about decision-making by cancer patients in Korea. This study assessed Korean cancer patients’ understanding of treatment goals and the need to obtain further information after a physician obtained informed consent for radiotherapy. In this prospective study, doctors and patients completed questionnaires independently after informed consent for radiotherapy had been obtained. The questionnaires for the doctors and patients were comprised of matched items regarding treatment aims and the need for further information. The study enrolled 103 cancer patients scheduled for radiotherapy. The proportion of respondents who stated that the intent of treatment was to bring about a cure was 80.6% among the patients (83 of 103 patients) and 53.4% (55 of 103 patients) among the doctors (p = 0.000). The proportion of respondents who believed that the aim was prolongation of life was 16.5 and 1.9%, respectively (p = 0.000). Regarding the need for further information, 42.7% (44/103) of the patients did not want further information because they had faith in the physicians’ medical expertise. Many Korean cancer patients misunderstand the aims of treatment and half of participants do not want further information. Physicians should address whether specific interventions can solve these barriers so that Korean cancer patients can make truly autonomous treatment decisions.

A 36-year-old woman was diagnosed with anaplastic large cell lymphoma (ALCL) by excisional biopsy of a left frontal skin lesion. During the first cycle of chemotherapy (cyclophosphamide, doxorubicin, vincristine, and prednisolone), the patient complained of right ocular pain and inflammation. Cytologic examination using aqueous humor revealed atypical lymphocytes, suggesting intraocular ALCL involvement. Acute angle closure developed in the anterior chamber due to rapid progression of ALCL, causing pupillary block. Laser and surgical interventions were attempted but failed to relieve the pupillary block. Finally, radiation therapy resolved the pupillary block to restore the anterior chamber and normalize intraocular pressure. This is the first case in the English literature of ALCL involving the iris to cause acute secondary angle closure.

Supplemental Digital Content is available in the text, The decision as to whether patients should be admitted to a medical intensive care unit (ICU), in the absence of information concerning survival rates or prognostic factors in survival, is often challenging. We analyzed survival trends in relation to hospital discharge and examined patient and hospital characteristics associated with survival following ICU care, using a sample of nationwide claims data in Korea from 2002 through 2013. The Korean government implements a compulsory social insurance program that covers the country's entire population, and the Korean National Health Insurance Service-National Sample Cohort (NHIS-NSC) data from 2002 based on this program were used for this study. The NHIS-NSC is a stratified random sample of 1,025,340 subjects selected from around 46 million Koreans. We evaluated annual survival trends using the Kaplan-Meier test. Analyses of the relationship between survival and patient and hospital characteristics were performed using Cox regression analyses. Employing a multivariate model, variables were selected using the forward selection method to consider the multicollinearity of variables. A total of 32,553 patients admitted to an ICU between 2002 and 2013 were identified among the eligible beneficiaries. The number of patients who had histories of ICU admission steadily increased throughout the study period, and patients older than 80 years constituted a progressively increasing proportion of ICU admissions, from 7.3% in 2002 to 16.9% in 2007 to 23.1% in 2013. The mean number of mechanical equipment items applied consistently increased, while no difference was observed in the trend for overall 1-year survival in patients following ICU treatment across the study period: the 1-year survival rate ranged from 66.7% (year 2003) to 64.2% (year 2010). Advanced age, cancer, renal failure, pneumonia, and influenza were all associated with heightened risk of mortality within 1 year. Our results should prove useful to older patients and their clinicians in their decisions regarding whether to seek ICU care, with the goals of improving the end-of life care and optimizing resource utilization.

55 Background: This study explored the current state of end-of-life (EoL) care education provided to Korean medical students and their self-rated attitudes toward EoL-related education. Methods: An anonymous survey was given to fourth year medical s tudents and the principle EoL care educators at all 41 Korean medical schools. The medical educators were asked to identify the EoL care-related topics that they usually teach students. Both students and medical educators completed seven items regarding self-perceived attitudes. Results: In total, 23 medical educators (56.1%) and 1,545 medical students (46.3%) responded. Of nine topics related to EoL care, the most frequently taught topics were delivering bad news (100%) and managing physical symptoms (74.1%), whereas setting treatment goals was taught the least frequently (37.0%). Approximately half of the educators taught the withdrawal of life-sustaining devices (59.3%), death and dying (55.6%), and advanced directives (55.6%). When the medical students were dichotomized into groups taught at least six topics (n = 815) versus five or fewer topics (n = 729), the group taught at least six topics expressed more satisfaction with EoL care education and they considered EoL care-related issues during their clerkship rotations. They also had fewer negative answers when they were asked about their readiness to practice EoL care. Conclusions: EoL education is inadequate for Korean medical students. However, medical students who were more fully instructed in this topic reported self-rated competency regarding EoL care-related issues. Further research should develop an education system that provides sufficient knowledge and training in EoL care for Korean medical students.

Purpose The purpose of this study is to evaluate the prescription of essential or futile medications for terminal cancer patients during their final admission. Materials and Methods We conducted a retrospective review of the medical charts of terminally ill cancer patients admitted to the Hemato-oncology Department of two teaching hospitals from March 1, 2007 to December 31, 2009. Essential medications were based on the drugs listed by the International Association for Hospice and Palliative Care, while futile medications were defined when short-term benefit to patients with respect to survival, quality of life, or symptom control was not anticipated. Results A total of 196 patients were included. Among essential medications, strong opioids were the most frequently prescribed drugs during the last admission (62.2% fentanyl, 44.3% morphine), followed by megestrol (46.0%), and metoclopramide (37.2%); 51% of gastric protectors were prescribed with potential futility. Anti-hypertensive and antiglycemic agents were administered to those who experienced arterial blood pressure below 90 mm Hg (47.3%) or presented with a single measurement of fasting glucose below 50 mg/dL (10.7%), respectively. Statins were prescribed to 6.1% (12/196) of patients, and 75% of those prescriptions were regarded as futile. Conclusion Our data suggest that effective prescription of essential medications and withdrawal from futile medications should be actively reconciled for improvement of a patient's end-of-life care.

Recently, extracts from the pericarp of mangosteen, Garcinia mangostana L., exhibited various pharmacological properties such as anti-oxidative, anti-inflammatory, anti-bacterial and chemopreventive activities. Albeit it has diverse application, there is little information about its pharmacokinetic aspects. Thus, the present study was undertaken to develop the simultaneous determination of α- and γ-mangostins (α- and γ-MG), major and active compounds, from extracts for the application of pharmacokinetic studies in mice using combined liquid chromatography–tandem mass-spectrometry and microsampling systems. The intra- and inter-validation, precision, accuracy, stability, recovery and matrix effects of α- and γ-MG were conducted in mouse plasma. Based on the developed analytical methods, pharmacokinetic parameters of α- and γ-MG after intravenous and oral administration of mangosteen extract were calculated. In sample preparation steps, the biological samples were deproteinized by acetonitrile and chromatographic separation was accomplished on a C18 column. The detection was accomplished by multiple-reaction monitoring scanning after electrospray ionization source in the positive ionization mode. The optimized mass transition ion pairs (m/z) for quantitation were 411.062 → 354.900, 397.384 → 340.900, and 808.379 → 527.200 for α- and γ-MG and docetaxel (internal standard), respectively. The total run time was 5 min. The results provided a meaningful basis for the preclinical and clinical application of mangosteen extract.

PURPOSE Platinum-based chemotherapy has conferred a modest but significant survival benefit and the introduction of newer drugs has led to achieve higher response rate in patients with advanced non-small cell lung cancer (NSCLC). We performed a phase II trial in order to evaluate the efficacy and toxicity of combination chemotherapy with vinorelbine (Navelbine) and cisplatin in advanced NSCLC. MATERIALS AND METHODS Patients with previously untreated, unresectable stage IIIB or IV NSCLC with measurable lesion (s) were eligible for entry into the study. NP chemotherapy consisted of intravenous vinorelbine 25 mg/m2, on day 1 and 8, and intravenous cisplatin 80 mg/m2 on day 1; this cycle was repeated every three weeks. RESULTS A total of 33 patients were enrolled in the study between July 1999 and Feb 2000. Of the 30 patients deemed eligible for analysis, thirteen patients achieved a partial response and thirteen showed a stable disease. The overall response rate was 43.3%. The median duration of response was 5.7 months (95% CI: 2.8~8.5 months). The median time to progression was 7.6 months (95% CI: 5.5~9.7 months) and the overall median survival time was 15.1 months (95% CI: 9.8~20.4 months) in the intent-to-treat analysis. Chemotherapy-related grade 3 or 4 toxicities were anemia in 1.5%, leukopenia in 4.5%, nausea/vomiting in 2.3%, alopecia in 13.3%, and neurotoxicity in 3.3%. CONCLUSION The combination of vinorelbine and cisplatin chemotherapy seems to be active and fairly tolerable in patients with advanced NSCLC.

Purpose The HER2 gene encodes a 185-kd transmembrane glycoprotein receptor (p185(HER2)) that has partial homology with the epidermal growth factor receptor (EGFR) and shares intrinsic tyrosine kinase activity. The HER2 gene has been found to be amplified in various human cancers and to be associated with poor prognosis. The authors investigated the correlation between clinicopathologic factors and the overexpression of the p185(HER2) in Korean gastric adenocarcinoma patients, and determined whether the antiproliferative effects of anti- p185(HER2) antibody can also be observed on gastric cancer cell lines that overexpress this growth factor receptor. Materials and methods We evaluated the relationship between p185(HER2) overexpression and clinicopathological features in 94 (M: F=52: 42) gastric adenocarcinoma patients (median age 59 years). Protein expression was analysed by immunohistochemical staining in paraffin embedded tissues with monoclonal antibody for p185(HER2). To explore the role of humanized anti-p185(HER2) monoclonal antibody trastuzumab (Herceptin ) in vitro, the growth curve of Korean gastric cancer cells that overexpress the p185(HER2) protein was studied and a cell cycle analysis was performed. Results p185(HER2) overexpression correlates positively with lymph node metastasis (p=0.002), distant metastasis (p=0.01), AJCC classification (p=0.01), higher relapse rate p=0.001), and a tendential association with the pT stage (p=0.054). p185(HER2) overexpression was found to be more frequent in advanced gastric cancer than early gastric cancer (54.1% vs 24.2%, p=0.008). Patients with overexpression of p185(HER2) were found to have significantly lower relapse-free (p=0.003) and overall survival (p= 0.0004) than patients without overexpression. Among several Korean gastric cancer cell lines, SNU-1, SNU-5, and SNU-620 overexpress p185(HER2). Trastuzumab inhibited the proliferation of p185(HER2) overexpressed Korean gastric cancer cell line by 21% with down-regulation of p185(HER2) protein expression. DNA fluorescence flow cytometry of propidium iodide-stained nuclei showed a reduction in the fraction of the S phase following treatment with trastuzumab. Conclusion S: Taken together, our observations suggest the potential prognostic significance of p185(HER2) overexpression in Korean gastric adenocarcinoma patients and point to the need for further research on this mechanism. This suggests the possible use of p185(HER2) as a therapeutic target in gastric cancer.

Cisplatin-based therapy is associated with various toxicities, including renal failure and neuropathy. However, acute arterial thrombosis is also a possible toxic effect of cisplatin, one that has been documented in a few cases worldwide. Here we present a rare case of ascending aortic thrombosis occurring 9 days after cisplatin-based chemotherapy in a 74-year-old male who was diagnosed with malignant pleural effusion suggestive of non-small cell lung cancer. The patient did not have any predisposing factor for the occurrence of an aortic thrombus before cisplatin-based chemotherapy. Thus, we suggest that the hypercoagulable state occurred secondary to cisplatin-based chemotherapy and was additive to the malignancy itself, causing aortic thrombosis. The patient was treated successfully with low-molecular-weight heparin and warfarin.