Online Exclusive Article

Hospice and Palliative Care: Development and Challenges in China

Yijin Wu

Linzi Li

Hang Su

Xueli Yao

Wen Ma

cancer, palliative care, China, developments, challenges
CJON 2016, 20(1), E16-E19. DOI: 10.1188/16.CJON.E16-E19

Background: Terminally ill patients can benefit from palliative care, including relief from physical and emotional suffering, improved quality of life, and longer survival rates. However, despite marked development in other countries, palliative care is still in its infancy in China.

Objectives: The general population and healthcare professionals in China have yet to realize the importance of palliative care services. This article describes the status of palliative care services in China, the historic development of palliative care, and the barriers to its advancement.

Methods: The status quo of hospice and palliative care in China is reviewed, and suggestions are provided on how nurses can improve their abilities to care for patients with cancer at the end of life.

Findings: A significant amount of work is needed in China to meet the standards of international palliative care societies. Palliative care training for nurses is still very limited. Nurses and other health providers who are engaged in palliative care should be well trained regarding the principles and procedures of palliative care to ensure quality care.

Jump to a section

    Palliative care is a multidisciplinary approach to health care for terminally ill patients, the purpose of which is to provide patients with relief from pain and physical and/or mental stress caused by a serious illness—whatever the diagnosis (Adler, Goldfinger, Kalman, Park, & Meier, 2009). The overarching aim of such treatment is to improve the quality of life for patients and their families. Generally speaking, palliative care can improve health-related quality of life in three ways: (a) relieving physical and emotional suffering, (b) improving and strengthening the process of doctor–patient and nurse–patient communication and decision making, and (c) ensuring coordinated and continuous care across multiple healthcare settings (e.g., hospital, home, hospice, long-term care facility) (Khosla, Patel, & Sharma, 2012).

    China is the most populous country in the world, with roughly 1.37 billion people (Infoplease, 2015), and has the largest low–middle class in the world. Cancer causes 21% of all deaths in China (McNamee, 2014). It has long been recognized that palliative care provides better pain management and symptom control for patients with advanced illness in developed countries. Unfortunately, aggressive treatment of patients with advanced-stage cancer is prevalent in China, which largely results from the influence of traditional Chinese cultural values and ethics. This poses problems for the development of palliative care in China; therefore, this article aims to present a comprehensive discussion of the historic background, the current developments, and the challenges faced in the context of palliative care in China.

    History of Palliative Care in China

    In China, hospice and palliative care is an emerging specialty. In 1988, the first research center for palliative care was established in Tianjin Medical University. This was followed two years later by the first hospice and palliative facility. One of the most important steps in the development of palliative care was the establishment of the Chinese Association for Hospice and Palliative Care in 1993; this can be considered as a milestone in the history of palliative care in China. Three years later, the Chinese Journal of Hospice and Palliative Care was founded, which largely promoted the development of hospice and palliative care in Chinese academic settings. In 1998, funded by philanthropist Li Jiacheng, China’s first free hospice facility was established at the First Affiliated Hospital of Shantou University to provide palliative care for patients with end-stage cancer. To date, 32 hospice units have been established across China with the assistance of the Li Jiacheng Foundation (Li, 2014). In 2004, the Ministry of Health further stipulated that the existence of hospice and palliative care be one of the accreditation standards for general hospitals (Su, 2013). This accelerated the establishment of palliative care centers throughout Chinese hospitals. Despite the increasing awareness of the importance of hospice and palliative care for patients with terminal cancer, palliative care remains relatively underdeveloped in China. To date, 32 hospices and about 120 palliative care facilities exist in private and public hospitals throughout China, according to the Chinese Association for Life Care (Liu, 2011). Although many advances have been made in hospice and palliative care, China lags far behind Western countries because of the lack of the comprehensive understanding of the advantages of hospice and palliative care.

    The Need for Palliative Care in China

    In China, along with the rapid development of the economy and a remarkable improvement of living standards, the spectrum of diseases also has changed. The development of chronic and other noncommunicable diseases is closely related to social behaviors and living habits. A survey by Wei and Gao (2009) showed that malignancies, cardiovascular disease, and cerebrovascular disease have become the top three causes of death in China. The number of patients with cancer annually in China is around 3.07 million, with more than 2.2 million deaths from cancer each year (Cai, 2015). About 3 million new cases of cancer are diagnosed each year, with 80% diagnosed as advanced disease (Zhang, 2013; Zhao, Dai, Chen, & Li, 2010). The incidence of moderate to severe pain was reported as 46% among all patients with cancer in China, with 85% of patients with advanced diseases having moderate to severe pain (Hu, Qui, Mei, Ran, & Zhang, 2010). Liu (2011) reported that 90% of patients with late-stage cancer who reported pain were not receiving help to relieve their suffering.

    By 2020, an estimated 5.5 million new patients with cancer will be diagnosed annually in China (Chen, 2008). China is faced with an increasing number of patients with cancer and, therefore, the need for palliative care becomes urgent. The aging population in China also is an important factor that increases stress on the healthcare delivery system. The Xinhua News Agency (2014) reported that about 202 million people are aged 60 years or older in China. With the increasing age of the population, the need for hospice care is becoming more and more urgent, bringing great challenges to the government and society.

    Challenges to the Advancement of Palliative Care

    Opioid availability: A large number of Chinese physicians are unaware or do not take advantage of analgesics to relieve pain in patients who are dying (Sun & Zhou, 2007). They do not fully understand the effects of analgesic drugs and lack experience in their clinical application. Some physicians believe that opioids may make patients die faster and, therefore, they promote opiophobia (the fear of prescribing opiate painkillers) (Furrow, 2001) in patients and prefer using radiation and/or chemotherapy as a substitute to control the pain (Li, Davis, & Gamier, 2011). The reasoning is that radiation and/or chemotherapy can keep the cancer from spreading or kill the cancer cells and, to some extent, relieve the pain and suffering caused by cancer. At the same time, many patients and their families consider pain to be an inevitable part of the cancer journey and worry about addiction issues associated with analgesic drugs. Others believe that, if pain killers are taken in the early stages of cancer treatment, the pain reduction will not be as effective at the end of the patient’s life.

    Historically, the attitudes of the medical profession and the general population toward opioids are largely influenced by the Opium Wars of 1839–1842 and 1856–1860 and concerns about opioid addiction and respiratory depression (Fang, 2007). Although morphine is recommended by the World Health Organization (WHO) as a useful medication to relieve pain in patients with cancer, morphine use in China remains at a low level compared to the number of patients (Su, 2013). The medical use of opioids, such as morphine, is regulated by the State Food and Drug Administration in China, and the amount of opioids dispensed to patients with cancer depends on the stage of disease. For example, patients with a diagnostic certificate, an official document that can be used to prove that the patient suffers from cancer, can obtain a prescription for pain killers for 15 days at most (Wang, Li, Yu, Gu, & Xu, 2002). Despite improvements in access to opioids for patients with cancer in China, barriers to its accessibility and availability remain a challenging problem for the development of pain-management strategies and palliative care services.

    Cultural and social biases: In China, the general population and medical practitioners have many misunderstandings about palliative care and feel that patients receiving palliative care service are just waiting to die, or that palliative care provides euthanasia in a disguised form, which goes against Chinese filial duty. Confucian culture holds that filial piety is the foundation of all virtues. Therefore, once a patient with cancer is transferred to a hospital, the family members, although aware that the curative treatment is futile, will ask doctors to treat the disease at all costs. Pressured by the family’s good will and abetted by reluctance to give up on their patients, oncologists usually continue anticancer therapy by providing different kinds of anticancer treatments, such as radiation therapy, chemotherapy, surgery, and maintenance therapy until the patient dies (Wang et al., 2004). However, for some patients with advanced-stage cancer, these treatments will not cure or relieve the disease but, rather, worsen the physical and emotional suffering and even hasten the patient’s death and increase the cost of care. Transfer of a patient to a palliative care unit in a hospital or an organization for palliative care delivery often is rejected by the patient and family members who view the move as abandonment by the doctors (Li, Xing, Chen, Dong, & Wu, 2013).

    In addition, the general population has a bias against hospice facilities, which hinders the development of palliative care programs. The first palliative care facility in China, Song Tang Hospice, has been relocated seven times since it was first established in West Beijing in 1987 (Lu, 2014). Lu (2014) reported that the residents living near the hospice thought that it was a hospital for the dying and the last stop before the cemetery, bringing bad omens for their lives. In addition, death and dying is a deeply emotional and cultural event in most Asian cultures (Barclay, Blackhall, & Tulsky, 2009), as evidenced by the fact that the general population in China is unwilling to discuss death and palliative care, considering it unlucky or a bad omen if they even talk about these topics. Such discussions are considered an abandonment of hope and, even worse, of the patient.

    Education and policy: Palliative care is a multidisciplinary specialty involving medicine, nursing, psychology, sociology, ethics, and philosophy. It requires personnel that are highly competent and have superb medical and nursing skills and a commitment to working on a multidisciplinary palliative care team. In developed countries, professionals engaging in palliative care must be well trained and often are certified in the specialty. In contrast, palliative care teams in China lag far behind those in developed countries, which severely restricts the development of high quality and comprehensive palliative care.

    To date, the Chinese government and the citizens have demonstrated an unfavorable attitude toward palliative care. As previously mentioned, this attitude is influenced by Chinese cultural and social values regarding the end of life. The government does not allocate funds for palliative care, and no policies to support hospice and palliative care development exist. Citizens in modern society are not willing to discuss palliative care or hospice and deem it as an unfortunate or a bad sign if they openly discuss these topics.

    The Chinese government’s family planning policy also has led to a major demographic shift in that China will significantly increase in the proportion of the older adult population and produce a relative decrease in the number of younger people who will be able to act as caregivers. In addition, a growing fragmentation of the extended family, with members seeking jobs outside of their community, is resulting in fewer family members being available to care for those who are aging or ill (Hsiao, 1984). The shortage of trained professionals, including social workers and volunteers who can provide the care, is a big challenge for the advancement of palliative care in China. Under the influence of the Chinese traditional culture (e.g., the philosophy of life and death), fewer volunteers are in place to deliver palliative care and insufficient numbers of other professionals, including social workers, psychologists, and legal consultants, exist.

    Medical model and cost for cancer treatment: The medical community in China still adopts the traditional biomedical model, which is considered to be a disease- or doctor-centered approach, and views health care as the treatment of physical symptoms in a quantifiable way, where cure is characterized by objective indicators. The biomedical mode neglects the context of the patient’s symptoms because it pays little attention to the social, emotional, and functional aspects of the patient’s health. This biomedical model also misleads patients into thinking that the doctor can cure all diseases. The medical model in China should transition from a biomedical model to a biopsychosocial model, which is beneficial to the advancement of palliative care delivery. A biopsychosocial model is a helpful way to comprehensively approach the treatment of physical symptoms, such as pain, and other psychosocial symptoms in patients with cancer in all stages of the disease process (Novy & Carrier, 2014).

    As far as the medical cost for cancer treatment, the total cost for care of a patient with cancer from diagnosis to death is around 300,000 yuan ($50,000) (Cancer Foundation of China, 2006). However, the average annual per capita income in China is about $7,000 (Wang, 2015). Making it more difficult, palliative care is not covered by the current healthcare system. No financial budget exists for palliative care services from the Ministry of Health, and no policies and stipulations on medical reimbursement are in place for palliative care expenses. The main reason why palliative care cannot get financial support from the government is that patients engaged in palliative care will not get curative treatment.

    Future Plans for Palliative Care in China

    More professional training and continuing education is needed in China. Continuing education should be involved in the palliative care curricula for doctors, nurses, and volunteers, which could be a useful way to improve medical professionals’ awareness and knowledge of palliative care. Extensive medical education about appropriate drugs use, such as dose titration; side effect management; and distinguishing the concepts of tolerance, withdrawal, and psychological dependence, could play a significant role in improving the practice of pain control and may increase the appropriate use of opioids (Wang et al., 2002). Healthcare providers should understand when to begin palliative care and be willing to switch to palliative care, when necessary, for their patients.

    As far as patients and their families are concerned, misconceptions about hospice and palliative care should be corrected by means of public health education, which could further contribute to changing the public’s attitude toward palliative care delivery. Given that talking about death is one of the great taboos in Chinese culture, medical education about death and palliative care is significant for patients with cancer, their families, and the general population.

    A strong collaboration between the Chinese government, the Chinese Association for Palliative Care, and WHO should be made to ensure the steady and healthy development of palliative care. Attempts should be made to introduce advanced experiences from Western developed countries, particularly the biopsychosocial model, to address symptoms at the end of life and adhere to the Chinese national condition. The government should fully recognize the advantages of palliative care services and formulate supporting guidelines and policies to further develop palliative care services. Given the ethnic and cultural diversity in China, each province will need to issue specific policies about palliative care that are compatible with the cultural and ethnic background of the region. According to a government report (Central People’s Government of the People’s Republic of China, 2015), China would be able to develop sound welfare and service systems for people with disabilities or serious illnesses. This would shed light on further development of palliative care in China.

    Implications for Nursing

    Although palliative care involves participants from different fields, the majority of the work will be managed by the medical staff, particularly by nurses. Because oncologists are burdened with outpatient consultations and clinical surgery in China, nurses play a leading role in caring for terminally ill patients. However, palliative care training for nurses is still very limited. To fully advance the development of palliative care in China, well-trained nurses are urgently needed. Nurses engaged in palliative care should be well educated about the principles and procedures of palliative care to ensure quality care. In addition, much work, such as nursing communication, psychosocial care service, and medical knowledge, is needed to improve nurses’ abilities to care for patients at the end of life.

    Conclusion

    In this article, the authors have discussed some issues concerning the development and improvement of palliative care in the context of Chinese culture. The discussion suggests that, although palliative care plays an important role in social civilization and development, palliative care is still in its infancy in China. Factors such as social-cultural bias, healthcare policy, and professionalism lead to slow progression of the development of palliative care in China. This indicates the urgency and importance to increase awareness of palliative care services. The authors hope that the discussion in this article will draw more attention—nationally and internationally—to the development of palliative care in China.

    References

    Adler, E.D., Goldfinger, J.Z., Kalman, J., Park, M.E., & Meier, D.E. (2009). Palliative care in the treatment of advanced heart failure. Circulation, 120, 2597–2606.

    Barclay, J.S., Blackhall, L.J., & Tulsky, J.A. (2009). Communication strategies and cultural issues in the delivery of bad news. Journal of Palliative Medicine, 10, 954–977.

    Cai, Q.Y. (2015, April 16). The global outbreak of cancer and China ranking the first. Retrieved from http://www.ynxxb.com/Content/2015-4/16/N166776999753

    Cancer Foundation of China. (2006). The science and practice of China. Retrieved from http://bit.ly/1SuZNAD

    Central People’s Government of the People’s Republic of China. (2015). Report on the work of the government 2015. Retrieved from http://on.china.cn/1PFRa3z

    Chen, L.Y. (2008, April 13). The incidence and mortality of lung cancer being the highest among malignant cancers in China. Retrieved from http://bit.ly/1O088t6

    Fang, D. (2007). Epidemiological status of cancer. Retrieved from http://www.ikcw.com

    Furrow, B.R. (2001). Pain management and provider liability: No more excuses. Journal of Law, Medicine and Ethics, 29, 28–51.

    Hsiao, W.C. (1984). Transformation of healthcare in China. New England Journal of Medicine, 310, 932–936.

    Hu, Q., Qui, H., Mei, N., Ran, F.M., & Zhang, A.H. (2010). Survey of cancer pain and its treatment. Cancer Research on Prevention and Treatment, 37, 1433–1435. doi:1002-0772(2010).02-0037-02

    Infoplease. (2015). World’s 50 most populous countries. Retrieved from http://bit.ly/1SuZHJl

    Khosla, D., Patel, F.D., & Sharma, S.C. (2012). Palliative care in India: Current progress and future needs. Indian Journal of Palliative Care, 18, 149–154. doi:10.4103/0973-1075.105683

    Li, J., Davis, M.P., & Gamier, P. (2011). Palliative medicine: Barriers and developments in mainland China. Current Oncology Reports, 13, 290–294. doi:10.1007/s11912-011-0169-9

    Li, X., Xing, Y.F., Chen, Z.H., Dong, M., & Wu, X.Y. (2013). Palliative care in urban areas of China. Lancet Oncology, 14, e399.

    Li, X.L. (2014). The study on palliative care service from the perspective of public health. (Unpublished master’s dissertation.) Heilongjiang University, Harerbin, China

    Liu, Y. (2011, March 29). China’s cancer patients. China Daily. Retrieved from http://bit.ly/1muNvfF

    Lu, M. (2014, May 8). Palliative care center being forced to relocate seven times during 27 years. Retrieved from http://epaper.dfdaily.com/dfzb/html/ 2014-05/08/node_2.htm

    McNamee, D. (2014). Commission suggests improvements to cancer care in China, India and Russia. Retrieved from http://www.medicalnewstoday.com/articles/275401.php

    Novy, D.M., & Carrier, J.A. (2014). The biopsychosocial model in cancer pain. Current Opinion in Supportive and Palliative Care, 8, 117–123. doi:10.1097/SPC.000000-0000000046

    Su, Y.G. (2013). A comparative study on the hospice care between U.K. and China. (Unpublished doctoral dissertation.) Shandong University, Jinan, China.

    Sun, G.Y., & Zhou, L. (2007). Current situation of medical education on oncology in China. Research on Medical Education, 6, 1048–1049.

    Wang, X.S., Di, L.J., Reyes, C.C., Guo, H., Liu, S.J., & Cleeland, C.S. (2004). End-of-life care in urban areas of China: A survey of 60 oncology clinicians. Journal of Pain and Symptom Management, 27, 125–132. doi:10.1016/j.painsymp.man.2003.06.002

    Wang, X.S., Li, T.D., Yu, S.Y., Gu, W.P., & Xu, G.W. (2002). China: Status of pain and palliative care. Journal of Pain and Symptom Management, 24, 177–179. doi:10.1016/S0885-3924(02)00435-9

    Wang, Z.Y. (2015). The average annual per capital income being beyond $7000. Retrieved from http://finance.sina.com.cn/hy/20150321/150121775557.shtml

    Wei, Z.H., & Gao, Y.L. (2009). Death analysis on heart and cerebrovascular diseases of the residents in Beijing. Journal of Cardiovascular and Pulmonary Diseases, 28, 377–380.

    Xinhua News Agency. (2014). Statistical communique of the People’s Republic of China on the 2006 national economic and social development. Retrieved from http://news.xinhuanet.com/fortune/2014-02/24/c_119477349_6.htm

    Zhang, P.Y. (2013). The empirical principles and practice of Prf. Daizhao Zhang on advanced stage of the geriatric oncology. (Unpublished doctoral dissertation.) China Academy of Traditional Chinese Medicine, Beijing, China.

    Zhao, P., Dai, M., Chen, W., & Li, N. (2010). Cancer trends in China. Japanese Journal of Clinical Oncology, 40, 281–285.

    About the Author(s)

    Yijin Wu, MD, is a doctoral candidate in the Center for Clinical Neurolinguistics at Shandong University in Jinan; Linzi Li, MD, is an attending doctor in the Department of Gynecology and Obstetrics at the Tancheng Maternal and Child Health Hospital in Linyi; Hang Su, MD, PhD, is a postdoctoral researcher at the School of Foreign Languages at Beihang University; and Xueli Yao, MD, PhD, is a lecturer and Ma Wen, MD, PhD, is a professor, both in the Center for Clinical Neurolinguistics at Shandong University, all in China. The authors take full responsibility for the content of the article. The research was funded by a grant (IFYT 1508) from Innovation Foundation of Young Talent Team at Shandong University. The content of this article has been reviewed by independent peer reviewers to ensure that it is balanced, objective, and free from commercial bias. No financial relationships relevant to the content of this article have been disclosed by the independent peer reviewers or editorial staff. Wen can be reached at mawen@sdu.edu.cn, with copy to editor at CJONEditor@ons.org. (Submitted January 2015. Revision submitted March 2015. Accepted for publication May 16, 2015.)

     

    References

    Adler, E.D., Goldfinger, J.Z., Kalman, J., Park, M.E., & Meier, D.E. (2009). Palliative care in the treatment of advanced heart failure. Circulation, 120, 2597–2606.
    Barclay, J.S., Blackhall, L.J., & Tulsky, J.A. (2009). Communication strategies and cultural issues in the delivery of bad news. Journal of Palliative Medicine, 10, 954–977.
    Cai, Q.Y. (2015, April 16). The global outbreak of cancer and China ranking the first. Retrieved from http://www.ynxxb.com/Content/ 2015-4/16/N166776999753
    Cancer Foundation of China. (2006). The science and practice of China. Retrieved from http://bit.ly/1SuZNAD
    Central People’s Government of the People’s Republic of China. (2015). Report on the work of the government 2015. Retrieved from http://on.china.cn/1PFRa3z
    Chen, L.Y. (2008, April 13). The incidence and mortality of lung cancer being the highest among malignant cancers in China. Retrieved from http://bit.ly/1O088t6
    Fang, D. (2007). Epidemiological status of cancer. Retrieved from http://www.ikcw.com
    Furrow, B.R. (2001). Pain management and provider liability: No more excuses. Journal of Law, Medicine and Ethics, 29, 28–51.
    Hsiao, W.C. (1984). Transformation of healthcare in China. New England Journal of Medicine, 310, 932–936.
    Hu, Q., Qui, H., Mei, N., Ran, F.M., & Zhang, A.H. (2010). Survey of cancer pain and its treatment. Cancer Research on Prevention and Treatment, 37, 1433–1435. doi:1002-0772(2010).02-0037-02
    Infoplease. (2015). World’s 50 most populous countries. Retrieved from http://bit.ly/1SuZHJl
    Khosla, D., Patel, F.D., & Sharma, S.C. (2012). Palliative care in India: Current progress and future needs. Indian Journal of Palliative Care, 18, 149–154. doi:10.4103/0973-1075.105683
    Li, J., Davis, M.P., & Gamier, P. (2011). Palliative medicine: Barriers and developments in mainland China. Current Oncology Reports, 13, 290–294. doi:10.1007/s11912-011-0169-9
    Li, X., Xing, Y.F., Chen, Z.H., Dong, M., & Wu, X.Y. (2013). Palliative care in urban areas of China. Lancet Oncology, 14, e399.
    Li, X.L. (2014). The study on palliative care service from the perspective of public health. (Unpublished master’s dissertation.) Heilongjiang University, Harerbin, China
    Liu, Y. (2011, March 29). China’s cancer patients. China Daily. Retrieved from http://bit.ly/1muNvfF
    Lu, M. (2014, May 8). Palliative care center being forced to relocate seven times during 27 years. Retrieved from http://epaper .dfdaily.com/dfzb/html/ 2014-05/08/node_2.htm
    McNamee, D. (2014). Commission suggests improvements to cancer care in China, India and Russia. Retrieved from http://www .medicalnewstoday.com/articles/275401.php
    Novy, D.M., & Carrier, J.A. (2014). The biopsychosocial model in cancer pain. Current Opinion in Supportive and Palliative Care, 8, 117–123. doi:10.1097/SPC.000000-0000000046
    Su, Y.G. (2013). A comparative study on the hospice care between U.K. and China. (Unpublished doctoral dissertation.) Shandong University, Jinan, China.
    Sun, G.Y., & Zhou, L. (2007). Current situation of medical education on oncology in China. Research on Medical Education, 6, 1048–1049.
    Wang, X.S., Di, L.J., Reyes, C.C., Guo, H., Liu, S.J., & Cleeland, C.S. (2004). End-of-life care in urban areas of China: A survey of 60 oncology clinicians. Journal of Pain and Symptom Management, 27, 125–132. doi:10.1016/j.painsymp.man.2003.06.002
    Wang, X.S., Li, T.D., Yu, S.Y., Gu, W.P., & Xu, G.W. (2002). China: Status of pain and palliative care. Journal of Pain and Symptom Management, 24, 177–179. doi:10.1016/S0885-3924(02)00435-9
    Wang, Z.Y. (2015). The average annual per capital income being beyond $7000. Retrieved from http://finance.sina.com.cn/hy/20150321/150121775557.shtml
    Wei, Z.H., & Gao, Y.L. (2009). Death analysis on heart and cerebrovascular diseases of the residents in Beijing. Journal of Cardiovascular and Pulmonary Diseases, 28, 377–380.
    Xinhua News Agency. (2014). Statistical communique of the People’s Republic of China on the 2006 national economic and social development. Retrieved from http://news.xinhuanet.com/fortune/2014-02/24/c_119477349_6.htm
    Zhang, P.Y. (2013). The empirical principles and practice of Prf. Daizhao Zhang on advanced stage of the geriatric oncology. (Unpublished doctoral dissertation.) China Academy of Traditional Chinese Medicine, Beijing, China.
    Zhao, P., Dai, M., Chen, W., & Li, N. (2010). Cancer trends in China. Japanese Journal of Clinical Oncology, 40, 281–285.