Three Years of Bidirectional, Home-Based Opioid Route Management in Advanced Cervical Cancer with Coexisting Causes of Route Failure: A Case Report.

Oral administration is preferred for cancer pain, and when it fails the switch to a parenteral or transdermal route is usually made once and in one direction. We describe a woman with recurrent cervical cancer managed at home for approximately three years in whom several causes of route failure coexisted-short bowel syndrome with a stoma (impairing enteral absorption of sustained-release opioids), profound cachexia (impairing subcutaneous absorption), and recurrent indwelling-device infections (threatening vascular access)-so that the opioid route had to be changed repeatedly and in both directions. Delivery moved from oral, to continuous subcutaneous patient-controlled analgesia (PCA), to an existing central venous port when subcutaneous absorption failed, back to oral hydromorphone, then to transdermal and transmucosal fentanyl when tablets were recovered undissolved from the stoma, and finally back to intravenous PCA with hydromorphone and ketamine as bony metastatic pain emerged. Each transition followed an identifiable event and was accomplished at home through physician-pharmacist-visiting-nurse collaboration, including home therapeutic drug monitoring. Analgesia and an active quality of life were largely maintained. When multiple causes of route failure coexist, opioid route selection cannot be a single fixed decision; a flexible, bidirectional and anticipatory approach to route management is central to home-based palliative care.