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Background: In response to the rapid aging population and increasing number of cancer patients, discussions on dignified end-of-life (EoL) decisions are active around the world. Therefore, this study aimed to identify the differences in EoL care patterns between types of hospice used for cancer patients., Methods: In this population-based cohort study, the Korean National Health Insurance Service cohort data containing all registered cancer patients who died between 2017 and 2021 were used. A total of 408,964 individuals were eligible for analysis. The variable of interest, the type of hospice used in the 6 months before death, was classified as follows: (1) Non-hospice users; (2) Hospital-based hospice single users; (3) Home-based hospice single users; (4) Combined hospice users. The outcomes were set as patterns of care, including intense care and supportive care. To identify differences in care patterns between hospice types, a generalized linear model with zero-inflated negative binomial distribution was applied., Results: Hospice enrollment was associated with less intense care and more supportive care near death. Notably, those who used combined hospice care had the lowest probability and frequency of receiving intense care (aOR: 0.18, 95% CI: 0.17-0.19, aRR: 0.47, 95% CI: 0.44-0.49), while home-based hospice single users had the highest probability and frequency of receiving supportive care (Prescription for narcotic analgesics, aOR: 2.95, 95% CI: 2.69-3.23, aRR: 1.45, 95% CI: 1.41-1.49; Mental health care, aOR: 3.40, 95% CI: 3.13-3.69, aRR: 1.35, 95% CI: 1.31-1.39)., Conclusion: Our findings suggest that although intense care for life-sustaining decreases with hospice enrollment, QoL at the EoL actually improves with appropriate supportive care. This study is meaningful in that it not only offers valuable insight into hospice care for terminally ill patients, but also provides policy implications for the introduction of patient-centered community-based hospice services., (© 2024. The Author(s).)

Importance: Although hospice care has been covered by health insurance for the purpose of improving the quality of life of patients with terminal cancer as well as their caregivers, few studies have evaluated the outcomes of the policy to cover home-based hospice care services., Objective: To investigate the changes in the place of death of patients with cancer after the introduction of insurance-covered, home-based hospice care services in Korea., Design, Setting, and Participants: This cohort study used data from February 1, 2018, to December 31, 2021, from the Causes of Death Statistics database, released annually by Statistics Korea, which contains information on all deaths in the country. Individuals who died of cancer, a representative hospice-eligible disease, were assigned to the case group, and those who died of dementia, a non-hospice-eligible disease, were assigned to the control group. A total of 218 522 individuals constituted the study population., Exposure: Because the Korean Health Insurance Service had begun covering home-based hospice care services on September 1, 2020, and the last follow-up date was December 31, 2021, the follow-up periods for before and after intervention were 31 months and 16 months, respectively (preintervention period: February 1, 2018, to August 31, 2020; postintervention period: September 1, 2020 to December 31, 2021)., Main Outcomes and Measures: The place of death was categorized as a binary variable according to whether it was the person's own home or not. Comparative interrupted time-series models with segmented regression were applied to analyze the time trend and its change in outcomes., Results: Of the 218 522 deaths eligible for the analysis (mean [SD] age at death, 78.6 [8.8] years; 130 435 men [59.7%]), 207 459 were due to cancer, and 11 063 were due to dementia. Immediately after the introduction of home-based hospice care, the rate of home deaths was 24.5% higher for patients with cancer than for those with dementia (estimate, 1.245 [95% CI, 1.030-1.504]; P = .02). The difference in the level change between cancer deaths and dementia deaths, on intervention, was more pronounced for those living in rural areas (estimate, 1.320 [95% CI, 1.118-1.558]; P = .001). In addition, a higher educational level was associated with a larger difference in the immediate effect size due to home-based hospice care (low educational level: estimate, 1.205 [95% CI, 1.025-1.416]; P = .02; middle educational level: estimate, 1.307 [95% CI, 0.987-1.730], P = .06; high educational level: estimate, 1.716 [95% CI, 0.932-3.159]; P = .08)., Conclusions and Relevance: In this cohort study exploring the changes in the place of death for patients with cancer after the insurance mandates for home-based hospice care in Korea, the probability of patients with cancer dying in their own homes increased after the intervention. This finding suggests the need to broaden the extent of home-based hospice care to honor the autonomy of individuals with terminal illness and improve their quality of death.

Background: Cancer survival rates are increasing; however, studies on dyslipidemia as a comorbidity of cancer are limited. For efficient management of the disease burden, this study aimed to understand new-onset dyslipidemia in medically underserved areas (MUA) among cancer survivors > 19 years., Methods: This study used 11-year (2009-2019) data from the Korean National Health Insurance Service sample cohort. Cancer survivors for five years or more (diagnosed with ICD-10 codes 'C00-C97') > 19 years were matched for sex, age, cancer type, and survival years using a 1:1 ratio with propensity scores. New-onset dyslipidemia outpatients based on MUA were analyzed using the Cox proportional hazards model., Results: Of the 5,736 cancer survivors included in the study, the number of new-onset dyslipidemia patients was 855 in MUA and 781 in non-MUA. Cancer survivors for five years or more from MUA had a 1.22-fold higher risk of onset of dyslipidemia (95% CI = 1.10-1.34) than patients from non-MUA. The prominent factors for the risk of dyslipidemia in MUA include women, age ≥ 80 years, high income, disability, complications, and fifth-year cancer survivors., Conclusions: Cancer survivors for five years or more from MUA had a higher risk of new-onset dyslipidemia than those from non-MUA. Thus, cancer survivors for five years or more living in MUA require healthcare to prevent and alleviate dyslipidemia., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background/aims: The use of a self-expandable metal stent (SEMS) is recommended for unresectable malignant biliary obstruction (MBO). Stent-related adverse events might differ according to the position of the stent through the ampulla of Vater (AOV). We retrospectively evaluated SEMS patency and adverse events according to the position of the SEMS., Methods: In total, 280 patients who underwent endoscopic SEMS placement due to malignant distal biliary obstruction were analyzed retrospectively. Suprapapillary and transpapillary SEMS insertions were performed on 51 patients and 229 patients, respectively., Results: Between the suprapapillary group (SPG) and transpapillary group (TPG), the stent patency period was not significantly different (median [95% confidence interval]: 107 days [82.3 to 131.7] vs 120 days [99.3 to 140.7], p=0.559). There was also no significant difference in the rate of adverse events. In subgroup analysis, the stent patency for an MBO located within 2 cm from the AOV was found to be significantly shorter than that for an MBO located more than 2 cm from the AOV in the SPG (64 days [0 to 160.4] vs 127 days [82.0 to 171.9], p<0.001) and TPG (87 days [52.5 to 121.5] vs 130 [97.0 to 162.9], p<0.001). Patients with an MBO located within 2 cm from the AOV in both groups had a higher percentage of duodenal invasion (SPG: 40.0% vs 4.9%, p=0.002; TPG: 28.6% vs 2.9%, p<0.001) than patients with an MBO located more than 2 cm from the AOV., Conclusions: The SPG and TPG showed similar results in terms of stent patency and rate of adverse events. However, patients with an MBO located within 2 cm from the AOV had a higher percentage of duodenal invasion with shorter stent patency than those with an MBO located more than 2 cm from the AOV, regardless of stent position.

Considering the rapid growth in the number of cancer survivors, the successful management of their health behaviors requires further attention. However, there are lack of information about cancer survivors' health behaviors and the risk of mortality using Korean cohort data. This study aimed to examine the effects of health behavior changes on mortality among cancer survivors and to develop a validated nomogram. This cohort study was conducted using claims data. Data from adult cancer survivors from the National Health Insurance Service-National Sample Cohort, conducted between 2002 and 2015, were included. Individuals who were alive for five years after their cancer diagnosis were defined as cancer survivors. Cox proportional-hazards regression was used to estimate the target associations. Discrimination (Harrell's C-index) and calibration (Hosmer-Lemeshow test) were employed to validate the nomogram. Data from 9300 cancer survivors were used for analysis. Compared to non-smokers, those who started or quit smoking had a higher risk of all-cause mortality. Those who were physically inactive had a higher risk of all-cause mortality than those who were continuously active. In the nomogram, the C-index value was 0.79 in the training data and 0.81 in the testing data. Hosmer-Lemeshow test was not significant, demonstrating a good fit. We found that individuals with unhealthy behaviors had a higher risk of mortality, thereby highlighting the importance of managing health behaviors among cancer survivors. The development of a validated nomogram may provide useful insights regarding official policies and existing practices in healthcare systems, which would benefit cancer survivors. Our study could provide the evidence to inform the priority of guideline for managing the health behavior among cancer survivors., (© 2022. The Author(s).)

Background and Aim: Results have been mixed and uncertainty still remains regarding the impact of statin adherence on premature deaths. Thus, we investigated the association between statin adherence and risks of all-cause, cancer, and cardiovascular mortality among dyslipidemia patients in South Korea., Methods and Results: We used data from the National Health Insurance Service (NHIS) National Sample Cohort for the years 2003-2013, which included data on 107,954 middle-aged and elderly dyslipidemia patients. Among these patients, a time-dependent Cox proportional hazards model was used to estimate the hazard ratios (HRs) of all-cause, cancer, and cardiovascular mortality depending on proportion of days covered (PDC) by statin medication. A total of 3073 (2.85%) individuals died within the study period. Of these individuals, 1143 (1.06%) died from cancer, and 687 (0.64%) died from cardiovascular diseases. Relative to good medication adherence (>80%), moderate (50-80%) (hazard ratio [HR]: 1.28, 95% confidence interval [CI]: 1.14-1.43) and poor (<50%) (HR: 1.58, 95% CI: 1.41-1.78) adherence were associated with increased risk of all-cause mortality. Poor adherence was also associated with increased risk of cancer (HR: 1.33, 95% CI: 1.16-1.52) and cardiovascular (HR: 1.27, 95% CI: 1.06-1.51) mortality., Conclusion: Such findings reveal that relative to good statin adherence, moderate and/poor adherence is associated with increased risks of all-cause, cancer, and cardiovascular mortality. Clinicians should assess for dyslipidemia, link statin adherence problems to potential mortality risk, and monitor outcomes in both medication adherence and disease complications., Competing Interests: Declaration of competing interest All authors declare that they have no conflict of interest., (Copyright © 2020 The Italian Diabetes Society, the Italian Society for the Study of Atherosclerosis, the Italian Society of Human Nutrition and the Department of Clinical Medicine and Surgery, Federico II University. Published by Elsevier B.V. All rights reserved.)

The number of cancer survivors is increasing as a consequence of improved therapeutic options. Many families are suffering from the resultant financial burden. Our study aims to determine the total medical cost for 5 years after the initial diagnosis of childhood cancers. A customized dataset from the Korean National Health Insurance Claims Database was requested for this study. A total of 7317 patients were selected to determine the total medical cost. The costs are presented as the 2% trimmed mean value to exclude extreme costs. The medical costs were further classified according to cancer type, treatment phase, and socioeconomic status. Multiple linear regression analyses were performed. The average total medical cost per patient is 36.8 million Korean Wons or 32,157 United States Dollars. Analysis of socioeconomic status revealed that the higher income group demonstrated higher medical expenditure when compared to other groups. Analysis of the treatment phase showed that costs associated with the early phase of treatment are the highest, especially in the first 3 months after initial diagnosis. To alleviate the financial burden and reduce the socioeconomic disparities associated with medical care and costs, a better understanding of the current experience of patients and their families is required.

Background: Psychiatric disorders are common in patients with cancer. The impact of both psychiatric disorders and psychiatric treatment on mortality in patients with cancer needs to be established., Materials and Methods: Nationwide claims data were analyzed. To investigate the association between psychiatric disorders and mortality, 6,292 male and 4,455 female patients with cancer who did not have a record of psychiatric disorders before cancer onset were included. To examine the association between psychiatric treatment and mortality, 1,467 male and 1,364 female patients with cancer were included. Incident psychiatric disorder and receipt of psychiatric treatment within 30 days from the onset of a psychiatric disorder were the main independent variables. Dependent variables were all-cause and cancer-related mortality. Cox proportional hazards regression with time-dependent covariates was used., Results: The onset of psychiatric disorders was associated with a significantly increased risk of mortality in both male (all-cause hazard ratio [HR]: 1.55; cancer-related HR: 1.47) and female patients with cancer (all-cause HR: 1.50; cancer-related HR: 1.44) compared with patients with cancer without psychiatric disorders. Both male and female patients who received psychiatric treatment within 30 days of diagnosis of a psychiatric disorder had a lower risk of cancer-related mortality (males, HR: 0.73; females, HR: 0.71) compared with patients with cancer with psychiatric disorders who did not receive psychiatric treatment., Conclusion: Patients with cancer with newly diagnosed psychiatric disorders had a higher mortality rate. Among these, those who received psychiatric treatment showed lower rates of mortality. Thus, early detection and early treatment of psychiatric disorders in patients with cancer is needed., Implications for Practice: The current study supplements the body of evidence supporting the association of psychiatric disorders onset and treatment with cancer outcomes. Patients with cancer showed an increased risk of both all-cause and cancer-related mortality upon psychiatric disorder onset. Among patients with newly diagnosed psychiatric disorders, those who received psychiatric treatment showed lower cancer-related mortality. Thus, raising awareness of both the risk of psychiatric disorders and the positive effects of psychiatric treatment on cancer outcomes is necessary among patients with cancer, caregivers, and oncologists. Furthermore, it is necessary to adopt a multidisciplinary approach, encouraging patients with cancer to undergo a neuropsychological assessment of their mental health status and receive appropriate and timely psychological interventions., (© AlphaMed Press 2020.)

Purpose: A new type of linear accelerator (linac) was recently introduced into the market by a major manufacturer. Our institution is one of the early users of this preassembled and preconfigured dual-layer multileaf collimator (MLC), ring-gantry linac - Halcyon™ (1st version). We performed a set of full acceptance testing and commissioning (ATC) measurements for three Halcyon machines and compared the measured data with the standard beam model provided by the manufacturer. The ATC measurements were performed following the guidelines given in different AAPM protocols as well as guidelines provided by the manufacturer. The purpose of the present work was to perform a risk assessment of the ATC process for this new type of linac and investigate whether the results obtained from this analysis could potentially be used as a guideline for improving the design features of this type of linac., Methods: AAPM's TG100 risk assessment methodology was applied to the ATC process. The acceptance testing process relied heavily on the use of a manufacturer-supplied phantom and the automated analysis of electronic portal imaging device (EPID) images. For the commissioning process, a conventional measurement setup and process (e.g., use of water tank for scanning) was largely used. ATC was performed using guidelines recommended in various AAPM protocols (e.g., TG-106, TG-51) as well as guidelines provided by the manufacturer. Six medical physicists were involved in this study. Process maps, process steps, and failure modes (FMs) were generated for the ATC procedures. Failure modes and effects analysis (FMEA) were performed following the guidelines given in AAPM TG-100 protocol. The top 5 and top 10 highest-ranked FMs were identified for the acceptance and commissioning procedures, respectively. Quality control measures were suggested to mitigate these FMs., Results: A total of 38 steps and 88 FMs were identified for the entire ATC process. Fourteen steps and 34 FMs arose from acceptance testing. The top 5 FMs that were identified could potentially be mitigated by the manufacturer. For commissioning, a total of 24 steps and 54 potential FMs were identified. The use of separate measurement tools that are not machine-integrated has been identified as a cause for the higher number of steps and FMs generated from the conventional ATC approach. More than half of the quality control measures recommended for both acceptance and commissioning could potentially be incorporated by the manufacturer in the design of the Halcyon machine., Conclusion: This paper presents the results of FMEA and quality control measures to mitigate the FMs for the ATC process for Halcyon machine. Unique FMs that result from the differences in the ATC guidelines provided by the vendor and current conventional protocols, and the challenges of performing the ATC due to the new linac features and ring-gantry design were highlighted for the first time. The FMs identified in the present work along with the suggested quality control measures, could potentially be used to improve the design features of future ring-gantry type of linacs that are likely to be preassembled, preconfigured, and heavily reliant on automation and image guidance., (© 2019 American Association of Physicists in Medicine.)

Objectives: Family members are often cancer patients' primary source of social and emotional support and make a major contribution to how well patients manage their illness. We compared the prevalence of depression in the family members of cancer patients and the general population., Methods: This study used the data from the fourth, fifth, and sixth rounds of the Korea National Health and Nutrition Examination Survey. The variable of interest was the presence of a cohabitating cancer patient in the family and the dependent variable was the presence of diagnosed depression., Results: The odds of having medically diagnosed depression in those with a cohabitating cancer patient in the family were significantly higher than among those who did not have cancer patients in their families (odds ratio [OR], 1.56; 95% confidence interval [CI], 1.12 to 2.17; p=0.009). The OR for females was 1.59, and this increase was statistically significant (95% CI, 1.09 to 2.31; p=0.02)., Conclusions: We need to invest more effort into diagnosing and managing depression in the family members of cancer patients. This will have an impact both on their quality of life and on the well-being of patients, as supporters and caregivers play an instrumental role in helping patients manage their illness.

Background: Although the prevalence of cancer is increasing, it is no longer synonymous with death. The number of cancer survivors is estimated to be increasing due to development in medical treatments and social programs; cancer survivors are increasingly returning to work after long-term unemployment. Thus, we examined the quality of life (QOL) and the factors associated with return of cancer survivors to the workplace., Materials and Methods: This study was performed using the 2008 Community Health Survey administered by the Korea Centers for Disease Control and Prevention (N=548). We used Chi-square tests to compare demographic variables based on self-perceived health status, and analysis of variance (ANOVA) to compare QOL scores among groups. We also performed a mixed-model analysis of the relationship between QOL and factors at the workplaces of cancer survivors., Results: Based on the results of our study, the overall QOL of cancer survivors was associated with 'mutual respect', 'free emotional expression', occupation, and age. Moreover, different trends of QOL according to self-perceived health were identified on additional analysis. In the 'bad' self-perceived health group, QOL was significantly different according to income. The QOL of cancer survivors in the low-income group was lower than in the other groups. Conversely, the 'normal' group had a lower QOL caused by 'no mutual respect' and "no free emotional expression" in the workplace. The QOL in the 'good' group based on self-perceived health was higher in the younger age group., Conclusions: There may be a significant relationship between QOL and workplace factors for cancer survivors, although further study is needed to investigate this relationship in detail. This may facilitate formulation of policy and efforts to prevent and manage the decline in the QOL of cancer survivors returning to work.

Background: Biliary partially covered self-expandable metal stents (PC-SEMS) offer prolonged relief of symptoms of biliary obstruction but may induce complications including pancreatitis, cholecystitis and migration., Aims: To assess efficacy and safety of the ComVi partially covered self-expandable metal stents as primary palliative treatment of distal malignant biliary obstruction., Methods: Seventy patients (mean age 69.2 years) with distal malignant biliary strictures were prospectively included and underwent endoscopic retrograde cholangio-pancreatography and partially covered self-expandable metal stents placement. Follow-up was done for 12 months. self-expandable metal stents patency, survival and complication-rate after partially covered self-expandable metal stents placement were evaluated., Results: Overall median survival time was 190 days (30-856). Forty-four patients (62.8%) died after median 175.5 days (30-614) without signs of stent dysfunction; 37 patients (52.8%) were alive after 6 months without signs of self-expandable metal stents occlusion. Survival rapidly dropped between 8 and 12 months after treatment. Survival was not influenced by sex (P = 0.1) or type of neoplasia (P = 0.178). Median survival was longer (254 days [44-836]) in patients who underwent chemotherapy (P < 0.0001). Partially covered self-expandable metal stents occlusion had 24 (35.7%) patients 154 days (35-485) after treatment. Median survival after re-treatment was 66 days (13-597). Cholecystitis occurred in one patient (1.7%)., Conclusions: The ComVi partially covered self-expandable metal stents is effective for palliation of biliary obstruction secondary to distal malignant biliary strictures. Self-expandable metal stents patency during follow-up is satisfactory without significant complications., (Copyright © 2012 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Background: The purpose of this study was to develop a single measure of cancer burden (SMCB), which can prioritize cancer sites by considering incidence and mortality., Materials and Methods: Incidence data from 1999 to 2010 were obtained from the Korea Central Cancer Registry. Mortality data from 1999 to 2010 were obtained from Statistics Korea. The SMCB was developed by adding incidence and mortality scores. The respective scores were given such that incidence and mortality were classified by ten ranges of equal intervals., Results: According to the SMCB in 2010, stomach cancer ranked 1st in males with 20 points, and colorectal cancer was 2nd with 11 points. Breast cancer and thyroid cancer were joint 1st with 11 points for females. The SMCB for females was less than that for males. The burden of stomach cancer was 1st in males from 1999-2010. The incidences of lung cancer and liver cancer decreased, whereas thyroid cancer and colon cancer increased during the period. Breast cancer and thyroid cancer burden showed tendencies to increase in females. Comparison of SMCB with disability-adjusted life years (DALY) and socioeconomic costs in 2005 showed that the top five cancer sites were similar, but there were differences in the size of the cancer burden., Conclusions: The SMCB indicated that the burdens of stomach cancer in males and thyroid and breast cancers in females were large. The single measure showed an advantage, reflected as the equivalent dimensions of incidence and mortality, whereas DALY and economic costs showed tendencies to reflect premature death.

A multileaf collimator (MLC) model, "MATMLC," was developed to simulate MLCs for Monte Carlo (MC) dose calculations of intensity-modulated radiation therapy (IMRT). This model describes MLCs using matrices of regions, each of which can be independently defined for its material and geometry, allowing flexibility in simulating MLCs from various manufacturers. The free parameters relevant to the dose calculations with this MLC model included MLC leaf density, interleaf air gap, and leaf geometry. To commission the MLC model and its free parameters for the Varian Millennium MLC-120 (Varian Oncology Systems, Palo Alto, CA), we used the following leaf patterns: (1) MLC-blocked fields to test the effects of leaf transmission and leakage; (2) picket-fence fields to test the effects of the interleaf air gap and tongue-groove design; and (3) abutting-gap fields to test the effects of rounded leaf ends. Transmission ratios and intensity maps for these leaf patterns were calculated with various sets of modeling parameters to determine their dosimetric effects, sensitivities, and their optimal combinations to give the closest agreement with measured results. Upon commissioning the MLC model, we computed dose distributions for clinical IMRT plans using the MC system and verified the results with those from ion chamber and thermoluminescent dosimeter measurements in water phantoms and anthropomorphic phantoms. This study showed that the MLC transmission ratios were strongly dependent on both leaf density and the interleaf air gap. The effect of interleaf air gap and tongue-groove geometry can be determined most effectively through fence-type MLC patterns. Using the commissioned MLC model, we found that the calculated dose from the MC system agreed with the measured data within clinically acceptable criteria from low- to high-dose regions, showing that the model is acceptable for clinical applications.