Impacts of Subtype on Clinical Feature and Outcome of Male Breast Cancer: Multicenter Study in Korea (KCSG BR16-09) / Journal of the Korean Cancer Association, 대한암학회지

Purpose@#The treatment of male breast cancer (MBC) has been extrapolated from female breast cancer (FBC) because of its rarity despite their different clinicopathologic characteristics. We aimed to investigate the distribution of intrinsic subtypes based on immunohistochemistry, their clinical impact, and treatment pattern in clinical practice through a multicenter study in Korea. @*Materials and Methods@#We retrospectively analyzed clinical data of 248 MBC patients from 18 institutions across the country from January 1995 to July 2016. @*Results@#The median age of MBC patients was 63 years (range, 25 to 102 years). Among 148 intrinsic subtype classified patients, 61 (41.2%), 44 (29.7%), 29 (19.5%), and 14 (9.5%) were luminal A, luminal B, human epidermal growth factor receptor 2, and triple-negative breast cancer, respectively. Luminal A subtype showed trends for superior survival compared to other subtypes. Most hormone receptor-positive patients (166 patients, 82.6%) received adjuvant endocrine treatment. Five-year completion of adjuvant endocrine treatment was associated with superior disease-free survival (DFS) in patients classified with an intrinsic subtype (hazard ratio [HR], 0.15; 95% confidence interval [CI], 0.04 to 0.49; p=0.002) and in all patients (HR, 0.16; 95% CI, 0.05 to 0.54; p=0.003). @*Conclusion@#Distribution of subtypes of MBC was similar to FBC and luminal type A was most common. Overall survival tended to be improved for luminal A subtype, although there was no statistical significance. Completion of adjuvant endocrine treatment was associated with prolonged DFS in intrinsic subtype classified patients. MBC patients tended to receive less treatment. MBC patients should receive standard treatment according to guidelines as FBC patients.

A Multicenter, Prospective, Observational Study to Evaluate Ethanol-Induced Symptoms in Patients Receiving Docetaxel Chemotherapy / Journal of the Korean Cancer Association, 대한암학회지

Purpose@#Several previous studies and case reports have reported ethanol-induced symptoms in patients receiving anticancer drugs containing ethanol. Most docetaxel formulations contain ethanol as a solvent. However, there are insufficient data on ethanol-induced symptoms when docetaxel-containing ethanol is administered. The primary purpose of this study was to investigate the frequency and pattern of ethanol-induced symptoms during and after docetaxel administration. The secondary purpose was to explore the risk factors for ethanol-induced symptoms. @*Materials and Methods@#This was a prospective, multicenter, observational study. The participants filled out ethanol-induced symptom questionnaire on the day of chemotherapy and the following day. @*Results@#Data from 451 patients were analyzed. The overall occurrence rate of ethanol-induced symptoms was 44.3% (200/451 patients). The occurrence rate of facial flushing was highest at 19.7% (89/451 patients), followed by nausea in 18.2% (82/451 patients), and dizziness in 17.5% (79/451 patients). Although infrequent, unsteady walking and impaired balance occurred in 4.2% and 3.3% of patients, respectively. Female sex, presence of underlying disease, younger age, docetaxel dose, and docetaxel-containing ethanol amount were significantly associated with the occurrence of ethanol-induced symptoms. @*Conclusion@#The occurrence of ethanol-induced symptoms was not low in patients receiving docetaxel-containing ethanol. Physicians need to pay more attention to the occurrence of ethanol-induced symptoms and prescribe ethanol-free or low-ethanol-containing formulations to high-risk patients.

The Development of a Tool for Assessment of Spiritual Distress in Cancer Patients

Purpose@#This study was conducted to develop a scale to measure spiritual distress in cancer patients. @*Methods@#A total of 69 preliminary items for the spiritaul distress assessment tool (SDAT) were compiled, based on a literature review, selection of empirically relevant items through concept analysis of hybrid models, confirmation of content validity by experts, cognitive interviews, and a pretest. Self-administered questionnaires were collected between April 1 and July 31, 2018, from 225 cancer patients at four medical institutions and one nursing home. The data were analyzed using item analysis, exploratory factor analysis, convergent and discriminant validity, and Pearson correlation for criterion validity. Reliability was tested by Cronbash’s α coefficient. @*Results@#The final version of the SDAT consisted of 20 items. Five-factors, loss of peace, burden of family, avoidance of confronting death, guilt and remorse, regret for not being able to apololgize and forgive were extracted, and showed 62.8% of total variance. The factors were confirmed through convergent and discriminant validity. Criterion validity was confirmed by functional assessment chronic illness therapy spiritual well-being scale 12 (FACIT-Sp12). The overall Cronbach’s α was .91, and the coefficients of each subscale ranged from .78~.83. @*Conclusion@#The SDAT for cancer patients is valid and reliable. It is suggested that the tool can be used to measure spiritual distress in cancer patients.

Survey of Opioid Risk Tool Among Cancer Patients Receiving Opioid Analgesics

Background@#The risk of opioid-related aberrant behavior (OAB) in Korean cancer patients has not been previously evaluated. The purpose of this study is to investigate the Opioid Risk Tool (ORT) in Korean cancer patients receiving opioid treatment. @*Methods@#Data were obtained from a multicenter, cross-sectional, nationwide observational study regarding breakthrough cancer pain. The study was conducted in 33 South Korean institutions from March 2016 to December 2017. Patients were eligible if they had cancer-related pain within the past 7 days, which was treated with strong opioids in the previous 7 days. @*Results@#We analyzed ORT results of 946 patients. Only one patient in each sex (0.2%) was classified as high risk for OAB. Moderate risk was observed in 18 males (3.3%) and in three females (0.7%). Scores above 0 were primarily derived from positive responses for personal or familial history of alcohol abuse (in men), or depression (in women). In patients with an ORT score of 1 or higher (n = 132, 14%), the score primarily represented positive responses for personal history of depression (in females), personal or family history of alcohol abuse (in males), or 16–45 years age range. These patients had more severe worst and average pain intensity (proportion of numeric rating scale ≥ 4: 20.5% vs. 11.4%, P < 0.001) and used rescue analgesics more frequently than patients with ORT scores of 0. The proportion of moderateor high-risk patients according to ORT was lower in patients receiving low doses of longacting opioids than in those receiving high doses (2.0% vs. 6.6%, P = 0.031). Moderate or high risk was more frequent when ORT was completed in an isolated room than in an open, busy place (2.7% vs. 0.6%, P = 0.089). @*Conclusions@#The score of ORT was very low in cancer patients receiving strong opioids for analgesia. Higher pain intensity may associate with positive response to one or more ORT item.

Clinical Practice Guideline for Care in the Last Days of Life / 한국호스피스완화의료학회지

A clinical practice guideline for patients in the dying process in general wards and their families, developed through an evidence-based process, is presented herein. The purpose of this guideline is to enable a peaceful death based on an understanding of suitable management of patients’ physical and mental symptoms, psychological support, appropriate deci-sion-making, family care, and clearly-defined team roles. Although there are limits to the available evidence regarding medical issues in patients facing death, the final recommendations were determined from expert advice and feedback, considering values and preferences related to medical treatment, benefits and harms, and applicability in the real world. This guideline should be applied in a way that takes into account specific health care environments, including the resources of medical staff and differences in the available resources of each institution. This guideline can be used by all medical institutions in South Korea.

Validity and Reliability of Korean Version of Simplified Nutritional Appetite Questionnaire in Patients with Advanced Cancer: A Multicenter, Longitudinal Study / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: Malnutrition and a loss of muscle mass are frequent in cancer patients and have a negative effect on clinical outcome. Nutrition risk screening aims to increase awareness and allow early recognition and treatment of cancer cachexia. Therefore, screenings should be brief, inexpensive, highly sensitive, and have good specificity. Simplified Nutritional Appetite Questionnaire (SNAQ) is a simple screening tool including four questions, and validated to predict weight loss within 6 months in community-dwelling adults and nursing home residents. Our study aimed to translate the SNAQ into Korean, and to assess the validity and reliability of the translated screening tool in advanced cancer patients. MATERIALS AND METHODS: The SNAQ was translated into Korean according to linguistic validation. The internal consistency of the SNAQ was evaluated by Cronbach's alpha coefficient. Test-retest reliability was evaluated using the intraclass correlation coefficient. Concurrent validity was evaluated by measuring the Pearson's correlation coefficient between the SNAQ and Mini-Nutritional Assessment (MNA) and Patient-Generated Subjective Global Assessment (PG-SGA). RESULTS: In the 194 patients included in full analysis set, cancer stage was predominantly metastatic (98.5%), the mean age was 60 years (range, 23 to 81 years), and the mean body mass index was 24 kg/m² (range, 15.6 to 39.6 kg/m²). According to MNA score ≤ 11, 57 patients (29.4%) were malnourished. The mean score (±standard deviation) of the Korean version of the SNAQ was 13.8±2.5 with a range of 6-19. Cronbach's alpha coefficient was 0.737, and intraclass correlation coefficient was 0.869. The SNAQ was moderately correlated with MNA (r=0.404, p 5% of the original bodyweightwithin 6 months occurred in 46 of the 186 patients (24.7%). SNAQ score ≤ 14 predicted > 5% weight loss with a sensitivity of 56.5% and a specificity of 44.3%. CONCLUSION: The Korean version of the SNAQ had high validity and reliability. SNAQ is useful for the screening tool for advanced cancer patients. The SNAQ had a limitation to predict impending weight loss in advanced cancer patients.

Feasibility Study of Physician Orders for Life-Sustaining Treatment for Patients with Terminal Cancer / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: Physician Orders for Life-Sustaining Treatment (POLST) form is a legal document for terminally ill patients to make medical decisions with physicians near the end-of-life. A multicenter prospective study was conducted to evaluate the feasibility of POLST administration in actual oncological practice. MATERIALS AND METHODS: Patients with terminal cancer, age ≥ 20 years, and capable of communicating were eligible. The primary endpoint was the completion rate of POLST. Data about physicians' or patients' barriers were also collected. RESULTS: From June to December 2017, 336 patients from seven hospitals were eligible. Median patient age was 66 years (range, 20 to 94 years); 52.7% were male; and 60.4% had poor performance status. Primary cancer sites were hepato-pancreato-biliary (26.2%), lung (23.2%), and gastrointestinal (19.9%). Expected survival duration was 10.6±7.3 weeks, with 41.2% receiving hospice care, 37.9% showing progression after cancer treatment, and the remaining patients were under active treatment (15.8%) or initially diagnosed with terminal cancer (5.1%). POLST forms were introduced to 60.1% of patients, and 31.3% signed the form. Physicians' barriers were reluctance of family (49.7%), lack of rapport (44.8%), patients' denial of prognosis (34.3%), lack of time (22.7%), guilty feelings (21.5%), and uncertainty about either prognosis (21.0%) or the right time to discuss POLST (16.6%). The patients' barriers were the lack of knowledge/understanding of POLST (65.1%), emotional discomfort (63.5%), difficulty in decision-making (66.7%), or denial of prognosis (14.3%). CONCLUSION: One-third of patients completed POLST forms, and various barriers were identified. To overcome such barriers, social engagement, education, and systematic support might be necessary.

Prospective Validation of The Korean Cancer Study Group Geriatric Score (KG)-7, a Novel Geriatric Screening Tool, in Older Patients with Advanced Cancer Undergoing First-line Palliative Chemotherapy / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: The purpose of this study was to prospectively validate the Korean Cancer Study Group Geriatric Score (KG)-7, a novel geriatric screening tool, in older patients with advanced cancer planned to undergo first-line palliative chemotherapy. MATERIALS AND METHODS: Participants answered the KG-7 questionnaire before undergoing geriatric assessment (GA) and first-line palliative chemotherapy. The performance of KG-7 was evaluated by calculating the sensitivity (SE), specificity (SP), positive and negative predictive value (PPV and NPV), balanced accuracy (BA), and area under the curve (AUC). RESULTS: The baseline GA and KG-7 results were collected from 301 patients. The median age was 75 years (range, 70 to 93 years). Abnormal GA was documented in 222 patients (73.8%). Based on the ≤ 5 cut-off value of KG-7 for abnormal GA, abnormal KG-7 score was shown in 200 patients (66.4%). KG-7 showed SE, SP, PPV, NPV, and BA of 75.7%, 59.7%, 84.4%, 46.0%, and 67.7%, respectively; AUC was 0.745 (95% confidence interval, 0.687 to 0.803). Furthermore, patients with higher KG-7 scores showed significantly longer survival (p=0.006). CONCLUSION: KG-7 appears to be adequate in identifying patients with abnormal GA prospectively. Hence, KG-7 can be a useful screening tool for Asian countries with limited resources and high patient volume.

Initial Assessment and Care Planning in Palliative Hospice Care: Focus on Assessment Tools / 한국호스피스완화의료학회지

For hospice palliative care that provides comprehensive and general care, it is necessary to use assessment tools to objectively list issues and detail care plans. The initial assessment is a process of establishing an overall direction of care by identifying the patient's symptoms, social and spiritual issues and palliative care needs on the admission day or within one day of admission. This process is also used to identify the patients' and families' awareness of the illness, prognosis, treatment options and if the Physician Orders for Life-Sustaining Treatment (POLST) has been drafted. Consisting of 13 simple questions regarding the physical, mental, social, and spiritual domains, the Needs at the End-of-Life Screening Tool (NEST) is recommended as an initial assessment tool. Using specific assessment tools, a care plan is established for the issues identified in the initial assessment within three days of admission. A multidisciplinary assessment tool can be helpful in the physical domain. The psychosocial domain evaluates psychological distress, anxiety and depression. The social domain examines an ability to make decisions, understanding of the socioeconomic circumstance, family relationship, and death preparedness. A spiritual evaluation is also important, for which the Functional Assessment of Chronic Illness Therapy-Spiritual WellBeing Scale (FACIT-Sp) or the Spiritual Health Inventory (SHI) can be used. The use of an assessment tool could not only contribute to pain mitigation a better quality of life for patients, but also provide systematic training for a multidisciplinary team; And the process itself could be a stepping stone for the better care provision.

Surrogate decision making of chemotherapy consent: do we really provide informed consent of chemotherapy for patients?

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.@*CONCLUSIONS@#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.

Experiences and Opinions Related to End-of-Life Discussion: From Oncologists' and Resident Physicians' Perspectives / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: The aims of this study were to explore how oncologists and resident physicians practice end-of-life (EOL) discussions and to solicit their opinions on EOL discussions as a means to improve the quality of EOL care. MATERIALS AND METHODS: A survey questionnaire was developed to explore the experiences and opinions about EOL discussions among oncologists and residents. Descriptive statistics, the t test, and the chisquare test were performed for the analyses. RESULTS: A total of 147 oncologists and 229 residents participated in this study. The study respondents reported diverse definitions of “terminal state,” and mostrespondents tried to disclose the patient's condition to the patient and/or family members. Both groups were involved in EOL care discussions, with a rather low satisfaction level (57.82/100). The best timing to initiate discussionwas consideredwhen metastasis or disease recurrence occurred orwhen withdrawal of chemotherapy was anticipated. Furthermore, the study respondents suggested that patients and their family members should be included in the EOL discussion. Medical, legal, and ethical knowledge and communication difficulties along with practical issues were revealed as barriers and facilitators for EOL discussion. CONCLUSION: This study explored various perspectives of oncologists and resident physicians for EOL discussion. Since the Life-Sustaining-Treatment Decision-Making Act will be implemented shortly in Korea, now is the time for oncologists and residents to prepare themselves by acquiring legal knowledge and communication skills. To achieve this, education, training, and clinical tools for healthcare professionals are required.

A Qualitative Study of Physicians' Perspectives on Non-Cancer Hospice-Palliative Care in Korea: Focus on AIDS, COPD and Liver Cirrhosis / 한국호스피스완화의료학회지

PURPOSE: From August 2017, hospice-palliative care (HPC) will be provided to patients with acquired immunodeficiency syndrome (AIDS), chronic obstructive pulmonary disease (COPD), and liver cirrhosis in Korea. To contribute to building a non-cancer (NC) hospice-palliative care model, NC specialists were interviewed regarding the goals, details, and provision methods of the model. METHODS: Four physicians specializing in HPC of cancer patients formulated a semi-structured interview with questions extracted from literature review of 85 articles on NC HPC. Eleven NC disease specialists were interviewed, and their answers were analyzed according to the qualitative content analysis process. RESULTS: The interviewees said as follows: It is difficult to define endstage NC patients. HPC for cancer patients and that for NC patients share similar goals and content. However, emphasis should be placed on alleviating other physical symptoms and emotional care rather than pain control. Timing of the care provision should be when patients are diagnosed as “end stage”. Special issues should be considered for each NC disease (e.g., use of anti-retroviral drugs for AIDS patients, oxygen supply for COPD patients suffering from dyspnea, liver transplantation for patients with liver cirrhosis) and education should be provided to healthcare professionals. NC patients tend to negatively perceive HPC, and the government's financial assistance is insufficient. CONCLUSION: It is necessary to define end-stage NC patients through in-depth discussion to minimize issues that will likely accompany the expansion of care recipients. This requires cooperation between medical staff caring for NC patients and HPC givers for cancer patients.

Symptom Features of Terminally Ill Cancer Patients and Depression of Family Caregivers / 한국호스피스완화의료학회지

PURPOSE: There has been very little study on the associations between patient's symptoms themselves and family caregiver (FC)'s depression in the palliative phase. This cross-sectional study was to investigate the relationship between symptom features of terminally ill cancer patients and their FC's depression. METHODS: We performed a multicenter survey using the MD Anderson symptom inventory and the Hospital Anxiety and Depression Scale. A total of 293 patient-FC pairs were recruited from seven tertiary medical centers. A multivariate regression analysis was applied for identifying the relevant factors associated with FC depression and for estimating adjusted depression score of FCs. RESULTS: Among various psychosocial factors, low FC quality of life, low social support, spouse, and more caregiving time were significantly associated with FCs' depression. According to the presence of FCs' depression, there were significant differences in some symptom characteristics of patients. Even after adjusting for the relevant confounders, depression scores were lower in FCs caring for patients who had negative symptoms (loss of appetite, P=0.005; drowsiness, P=0.024; and dry mouth, P=0.043) than in FCs caring for patients who had not. FCs caring for patients with severe appetite loss had lower depression scores than those with not severe one (P=0.039). CONCLUSION: Our result suggests that patient's symptom characteristics might be helpful when evaluating a FC's depression.

Korean Treatment Guidelines for Metastatic Prostate Cancer Developed by the Korean Association for Clinical Oncology / 대한내과학회지

The management of advanced prostate cancer has evolved rapidly. Androgen deprivation therapy, via surgical or medical castration, is the first-line therapy for hormone-naïve metastatic prostate cancer. For approximately a decade, docetaxel-based chemotherapy was the only approved agent to show a survival benefit for castration-resistant prostate cancer. However, over the last 5 years, significant advances in the field have led to the approval of several new agents with different mechanisms of action, such as the new androgen pathway inhibitors abiraterone and enzalutamide, a new cytotoxic agent, cabazitaxel, and new bone-seeking agents such as radium-223, which have all been associated with improved quality of life and pain palliation and an increase in survival. However, there has been no Korean treatment guideline for metastatic prostate cancer which is developed based on thorough search for relevant articles, including recently developed agents, and adequate review and assessment of evidences, and thus, a guideline adequate for domestic circumstance is eagerly needed. Experts from the Genitourinary Oncology Committee of the Korea Cancer Study Group developed clinical recommendations for the treatment of metastatic prostate cancer based on 19 key questions. The Korean Association for Clinical Oncology, the Korean Prostate Society, the Korean Urological Oncology Society, and the Korean Society of Pathologists reviewed and endorsed the guidelines. These are the first Korean treatment guidelines developed specifically for metastatic prostate cancer.

Pancreatic Metastasis from Invasive Ductal Carcinoma of the Breast / 대한내과학회지

Pancreatic metastases from primary breast cancer are very rare. We report a case of pancreatic metastasis from invasive ductal carcinoma 13 years after the initial diagnosis of breast cancer. When the pancreatic mass was discovered, it was believed to be a primary pancreatic cancer due to the long interval from the initial diagnosis of breast cancer to metastasis. However, it was confirmed as metastatic breast cancer based on the pathology after surgical removal. Follow-up imaging has shown no recurrence.

Feasibility and Efficacy of Eribulin Mesilate in Korean Patients with Metastatic Breast Cancer: Korean Multi-center Phase IV Clinical Study Results / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: Eribulin mesilate was approved for the treatment of patients with locally advanced or metastatic breast cancer (MBC), who had received at least two chemotherapeutic regimens, including anthracycline and taxane. On the other hand, the efficacy and safety information of eribulin in Korean patients is limited by the lack of clinical trials. MATERIALS AND METHODS: In this multicenter, open-label, single-arm, phase IV study, locally advanced or MBC patients were enrolled between June 2013 and April 2014 from 14 centers in Korea. One point four mg/m2 dose of eribulin was administered on days 1 and 8 of every 21 days. The primary endpoint was the frequency and intensity of the treatment emergent adverse event. The secondary endpoint was the disease control rate, which included the rate of complete responses, partial responses, and stable disease. RESULTS: A total of 101 patients received at least one dose of eribulin and were included in the safety set. The patients received a total of 543 treatment cycles, with a median of three cycles (range, 1 to 31 cycles). The most common adverse event was neutropenia (91.1% of patients, 48.3% of cycles). The frequent non-hematological adverse events included alopecia, decrease in appetite, fatigue/asthenia, and myalgia/arthralgia. The peripheral neuropathy of any grade occurred in 27 patients (26.7%), including grade 3 in two patients. Disease control rate was 52.7% and 51.3% of patients in the full analysis set and per-protocol set, respectively. CONCLUSION: This study demonstrated the feasible safety profile and activity of eribulin in Korean patients with MBC.

Factors Associated with Care Burden among Family Caregivers of Terminally Ill Cancer Patients / 한국호스피스완화의료학회지

PURPOSE: It is important to alleviate care burden for terminal cancer patients and their families. This study investigated the factors associated with care burden among family caregivers (FCs) of terminally ill cancer patients. METHODS: We analyzed data from 289 FCs of terminal cancer patients who were admitted to palliative care units of seven medical centers in Korea. Care burden was assessed using the Korean version of Caregiver Reaction Assessment (CRA) scale which comprises five domains. A multivariate logistic regression model with stepwise variable selection was used to identify factors associated with care burden. RESULTS: Diverse associating factors were identified in each CRA domain. Emotional factors had broad influence on care burden. FCs with emotional distress were more likely to experience changes to their daily routine (adjusted odds ratio (aOR), 2.54; 95% confidence interval (CI), 1.29~5.02), lack of family support (aOR, 2.27; 95% CI, 1.04~4.97) and health issues (aOR, 5.44; 2.50~11.88). Family functionality clearly reflected a lack of support, and severe family dysfunction was linked to financial issues as well. FCs without religion or comorbid conditions felt more burdened. The caregiving duration and daily caregiving hours significantly predicted FCs' lifestyle changes and physical burden. FCs who were employed, had weak social support or could not visit frequently, had a low self-esteem. CONCLUSION: This study indicates that it is helpful to understand FCs' emotional status and family functions to assess their care burden. Thus, efforts are needed to lessen their financial burden through social support systems.

Prerequisite for Korean Advance Directives: From the View of Healthcare Providers

PURPOSE: The purpose of this study was to explore the main prerequisite for Korean Advance Directives [KAD] to ensure their better use. METHODS: Data were collected from two focus group interviews and individual email responses. Study participants were 5 doctors and 6 nurses. All interview data were transcribed and analyzed using qualitative content analysis. RESULTS: Three main themes emerged; establishing a philosophy of KAD, protocol to practice KAD, and the KAD document itself. A philosophy is needed to ensure individual needs, consensus to practice AD and identify principle agents. The core of protocol was found to be as follows; 1) process, 2) premise, 3) procedure, 4) contextual preparation, 5) timing, 6) feasibility. Component and feasibility need to be established for the document itself. CONCLUSION: For a positive acceptance of KAD in Korean society, a culture sensitive, reality based, and user friendly AD needs to be developed.

A Case of Gastric Cancer Presenting Acute Disseminated Intravascular Coagulation Palliated with Combination Chemotherapy of Irinotecan and Cisplatin

Acute disseminated intravascular coagulation (DIC) associated with gastric cancer is not common and has short survival of 1 to 3 weeks. Systemic chemotherapy in spite of hematologic unstability for gastric cancer may prolong survival time. A 47-year-old woman who complained of dyspnea, vaginal bleeding and easy bruisibility was diagnosed to stage IV gastric cancer with acute disseminated intravascular coagulation based on the laboratory data. She also had multiple bone metastases and bone marrow involvement. This is the first case treated with combination chemotherapy of irinotecan and cisplatin for advanced gastric cancer complicated by disseminated intravascular coagulation at the time of diagnosis. With systemic chemotherapy, some of the bleeding symptoms and the DIC process improved, even not completely recovered. However the patient died of disease progression and survival time was 12 weeks.

A case of latex fruit syndrome caused by spinach and eggplant / 대한내과학회지

Spinach (Spinacia oleracea) is a widely consumed vegetable, but rarely causes allergic reactions. Spinach contains plenty of histamine derivatives, so it is sometimes difficult to distinguish food allergy from pharmacologic effect of histamine itself in susceptible individuals. Latex exhibits strong cross reactivity with proteins from different fruits, vegetables, and grains, which is called as latex fruit syndrome. A 27 year old female visited emergency room with hives, facial swelling, dyspnea and palpitation immediately after meal. She had been suffering from latex allergy and had experienced an episode of anaphylaxis after eating eggplant 5 months earlier. Skin prick test with spinach extract was positive. Specific IgE to spinach antigens was detected by ELISA. ELISA inhibition test revealed that there is cross reactivity between latex and spinach. Two IgE binding components were detected between 22kD and 36kD, and another two between 16kD and 22kD on IgE-immunoblot analysis.