Raptis, E., Vadalouca, A., Stavropoulou, E., Argyra, E., Melemeni, A., & Siafaka, I. (2014). Pregabalin vs. opioids for the treatment of neuropathic cancer pain: A prospective, head-to-head, randomized, open-label study. Pain Practice, 14, 32–42.
To determine the efficacy and safety of increasing opioid doses versus increasing doses of an adjuvant for patients with definite neuropathic cancer pain (i.e., neuropathic pain that occurred as a result of the disease, the treatment, or both). The goal was to achieve a 30% or more decrease in the visual analog scale (VAS) score compared to baseline.
One hundred and twenty patients were divided via simple randomization into two groups. Baseline data were collected on all 120 patients (i.e., VAS score, meds, and full assessment). The first group was prescribed a starting dose of pregabalin at 75 mg per day and titrated up by 75 mg every third day as needed up to 600 mg per day divided into two doses, until adequate pain relief was achieved or adverse effects were noted. The second group was given 25 mcg per hour fentanyl patch and increased by 25 mcg per hour every 72 hours up to a max dose of 150 mcg per hour until adequate pain relief was achieved or adverse events were noted. Both groups had rescue oral morphine as needed.
Changes in VAS scores showed no difference between groups, but the percentage change in these scores showed a significant reduction for the patients on pregabalin (-58% versus -50%). A greater percentage of patients on pregabalin achieved the study primary endpoint of at least a 30% reduction in pain VAS score (73.3% with pregabalin, 36.7% with fentanyl, p < .0001). No significant difference was seen in the proportion of patients needing rescue medication.
For these patients with neuropathic pain, no significant differences were seen in efficacy of adjuvant pregabalin versus increasing opioid medication for pain control.
I find the results of this study to be useful for oncology professionals working with patients with neuropathic cancer pain, whether from the disease, the treatment, or both. A similar study using tramadol versus pregabalin for neuropathic cancer pain may be of value.
Rapp, S.R., Case, L.D., Peiffer, A., Naughton, M.M., Chan, M.D., Stieber, V.W., . . . Shaw, E.G. (2015). Donepezil for irradiated brain tumor survivors: A phase III randomized placebo-controlled clinical trial. Journal of Clinical Oncology, 33, 1653–1659.
To evaluate the effects of 24 weeks of donepezil versus placebo on objectively measured cognitive function starting at least six months after whole- or partial-brain irradiation
This clinical trial tested donepezil at 5 mg daily for six weeks followed by 10 mg daily for 18 weeks compared to a placebo. Study outcome measurements were collected before randomization, and 12 and 24 weeks after randomization.
PHASE OF CARE: Late effects and survivorship
Randomized, double-blinded, placebo-controlled trial
Self-reported adherence to the dose was approximately 92%, which did not differ between groups. The donepezil group reported more diarrhea (25%, p = 0.005) than the control. At baseline, both groups had poorer verbal memory, motor speed and dexterity, attention, and executive function compared to population norms. There was no improvement in overall cognitive function with 24 weeks of donepezil, but improvements were found for individual measures of memory (p = 0.007, 0.027) and motor speed and dexterity (p = 0.016). Donepezil showed greater improvement in overall cognitive function for patients with poorer cognitive function at baseline (p = 0.01).
For patients who received whole or partial brain irradiation, 24 weeks of donepezil improved memory and motor and speed dexterity. Greater improvements in multiple cognitive domains, including significant improvement in overall cognitive function, were found for patients with poorer cognitive function at baseline.
For patients who receive partial- or whole-brain irradiation for primary brain tumors or brain metastases, donepezil may improve memory and motor speed and dexterity. Patients with poorer cognitive function may have greater benefit, including improvement in overall cognitive function. Educate patients about the risk for diarrhea and appropriate management.
Rapoport, B.L., Chasen, M.R., Gridelli, C., Urban, L., Modiano, M.R., Schnadig, I.D., . . . Navari, R.M. (2015). Safety and efficacy of rolapitant for prevention of chemotherapy-induced nausea and vomiting after administration of cisplatin-based highly emetogenic chemotherapy in patients with cancer: Two randomised, active-controlled, double-blind, phase 3 trials. Lancet Oncology, 16, 1079–1089.
To assess the safety and efficacy of 180 mg rolapitant for the prevention of chemotherapy-induced nausea and vomiting (CINV) in patients with cancer who receive moderately or highly emetogenic chemotherapy (HEC)
Patients who had a KPS of 60 or higher, were expected to live at least four months, and had adequate bone marrow and liver and kidney function were randomly assigned to receive 180 mg of rolapitant versus placebo, which looked exactly like the rolapitant.
PHASE OF CARE: Active antitumor treatment
This article describes two randomized, double-blind, active-control studies.
In both studies (and in the pooled results), treatment with rolapitant resulted in a significantly increased number of patients experiencing a complete response in the delayed phase. The pooled studies found significant difference in the acute phase (first 24 hours). In the overall phase, complete response was significantly more frequent in the first study and in the results of the pooled studies. No significant differences were observed between study groups with respect to daily living as measured by the FLI-E questionnaire.
Oral rolapitant taken once daily before chemotherapy in combination with a 5-HT3 receptor antagonist and dexamethasone is superior to 5-HT3 receptor antagonist and corticosteroid alone.
The study participants were enrolled prior to recommendations for the addition of an NK1 receptor antagonist to standard care and the use of dexamethasone to HEC.
As now accepted, the addition of an NK1 receptor antagonist reduces CINV experienced by patients receiving HEC. Patient education regarding adherence to medications and correct timing can help them prevent what is often the most worrisome side effect.
Rapoport, B.L., Jordan, K., Boice, J.A., Taylor, A., Brown, C., Hardwick, J.S., … Schmoll, H.J. (2010). Aprepitant for the prevention of chemotherapy-induced nausea and vomiting associated with a broad range of moderately emetogenic chemotherapies and tumor types: A randomized, double-blind study. Supportive Care in Cancer, 18, 423–431.
To determine the efficacy, safety, and tolerability of aprepitant for the prevention of chemotherapy-induced nausea and vomiting (CINV) in patients receiving moderately emetogenic chemotherapy (MEC) regimens and to determine if aprepitant would provide a complete response at preventing CINV in the first 5 days (120 hours) following chemotherapy
Patients naïve to moderately or highly emetogenic chemotherapy (HEC) and scheduled to receive a single dose of MEC agent, were enrolled in the study. Group one received an aprepitant triple-therapy regimen; group two received a control regimen that included a placebo 1 hour prior to chemotherapy, ondansetron (same dosing as aprepitant group), and dexamethasone on day 1, and, on days 2 and 3, placebo once daily and ondansetron twice daily (by mouth).
Studies were conducted at multiple sites in the United States, Mexico, Canada, Chile, Brazil, Peru, Colombia, Panama, Hong Kong, Australia, South Africa, France, Germany, Israel, and Russia.
Patients were in active treatment.
The study was a phase III, prospective, randomized, gender-stratified, double-blind trial.
Patients recorded the time and date of nausea, retching, and vomiting episodes in diaries. Nausea was assessed daily using a 100-mm horizontal visual analogue scale (VAS). If a rescue drug was used, the drug name and date and time of administration was recorded. Common Terminology of Adverse Events, version 3.0 (CTAE v 3.0) was used to assign toxicity grades to all laboratory test results and adverse events.
The aprepitant regimen provided significantly more vomiting-free time. Better control with an aprepitant–containing, triple antiemetic regimen was seen for those receiving MEC (nonanthracycline and cyclophosphamide [AC] or AC).
Aprepitant was effective in preventing chemotherapy-associated vomiting in patients receiving a broad range of MEC and should be considered as part of a standard antiemetic regimen.
Rapoport, B., Chua, D., Poma, A., Arora, S., Wang, Y., & Fein, L.E. (2015). Study of rolapitant, a novel, long-acting, NK-1 receptor antagonist, for the prevention of chemotherapy-induced nausea and vomiting (CINV) due to highly emetogenic chemotherapy (HEC). Supportive Care in Cancer, 23, 3281–3288.
To evaluate the safety and efficacy of four different doses of rolapitant for the prevention of chemotherapy-induced nausea and vomiting (CINV) associated with cisplatin-based, highly emetogenic chemotherapy
Eligible patients were randomized to receive rolapitant at 9, 22.5, 90 or 180 mg or no rolapitant (active control) administered two hours before the first dose of chemotherapy on day 1 of cycle 1 with cisplatin greater than 70 mg/m2. Patients also received Zofran® at 32 mg IV and Decadron® at 20 mg orally 30 minutes before chemotherapy. Dexamethasone was administered at 8 mg orally twice daily on days 2, 3, and 4.
Phase 2, randomized, double-blinded, active-controlled, parallel-group, dose-ranging study
Rolapitant was well tolerated and was associated with greater complete response rates than the placebo group. Rolapitant at 180 mg achieved a statistically significant improvement compared to the active control group in the acute (87.6% and 66.7%, respectively, p = 0.001) and delayed (63.6% and 48.9%, respectively, p = 0.045) phases. Complete response rates across all phases of CINV were consistently higher for all other rolapitant dose groups compared to the active control group except the 9 mg group in the acute phase. However, this did not achieve statistical significance. Rolapitant also was statistically superior to the active control in other key secondary efficacy variables including less emesis in the acute and delayed phases and less nausea in the acute and delayed phases. Rolapitant at 90 and 180 mg doses significantly improved quality of life compared to the control group. The incidence of serious adverse events was similar in all treatment groups.
All doses of rolapitant were well tolerated and were associated with greater compete response rates than the active control (except 9 mg in the acute phase). Rolapitant at 180 mg demonstrated a clinical statistically significant effect in preventing CINV in the overall, acute, and delayed phases for patients receiving highly emetogenic chemotherapy.
In this study, rolapitant at 180 mg was safe, well tolerated, and effective in controlling CINV in all phases when given in combination with dexamethasone and a 5HT3 receptor antagonist for patients receiving highly emetogenic chemotherapy.
Rapoport, B., Schwartzberg, L., Chasen, M., Powers, D., Arora, S., Navari, R., & Schnadig, I. (2016). Efficacy and safety of rolapitant for prevention of chemotherapy-induced nausea and vomiting over multiple cycles of moderately or highly emetogenic chemotherapy. European Journal of Cancer, 57, 23–30.
To explore the efficacy and safety of rolapitant in preventing chemotherapy-induced nausea and vomiting (CINV) over multiple cycles of moderately emetogenic chemotherapy (MEC) or highly emetogenic chemotherapy (HEC)
Patients were stratified by gender to receive either 180 mg oral rolapitant or placebo approximately 1–2 hours before receiving either MEC or HEC. All patients received a 5-HT3 antiemetic and dexamethasone. Patients receiving MEC were given 2 mg oral granisetron on days 1–3 and 20 mg dexamethasone on day 1. Patients receiving HEC (e.g., cisplatin-based chemotherapy) were given 10 mc/kg granisetron intravenously and oral 20 mg dexamethasone on day 1 and 8 mg twice daily on days 2–4. Patients receiving taxanes were given dexamethasone per the package insert.
Patients were given a diary to record all episodes of nausea, vomiting, and use of rescue drugs for five days post chemotherapy administration during cycle 1. For subsequent cycles, patients were asked two CINV assessment questions on days 6–8: (a) Have you had any episodes of vomiting or retching since your chemotherapy started in this cycle? and (b) Have you had any nausea since your chemotherapy started in this cycle that interfered with normal daily life? Assessments of safety variables, such as adverse events, vital signs, physical and neurological exams, electrocardiograms, and clinical lab values, were assessed during all cycles.
Compared to the control group, more patients receiving rolapitant reported no emesis or interfering nausea in cycles 2 (p = 0.006), 3 (p < 0.001), 4 (p = 0.001), and 5 (p = 0.021) when compared to the control group. Time to first emesis was significantly longer for the rolapitant group in cycles 1–6 (p < 0.001). The incidence of treatment-related adverse events were only slightly lower in the rolapitant (5.5%) than the control group (6.8%) during cycles 2–6.
Oral rolapitant was effective in protecting against CINV over multiple cycles of MEC and HEC. Rolapitant was well tolerated and demonstrated no increased frequency of adverse effects and no cumulative toxicity over multiple cycles.
Women were disproportionately high in the MEC study largely because of the high number of patients with breast cancer receiving AC chemotherapy.
The findings support the possible benefits of adding rolapitant to the therapy of patients receiving MEC and HEC.
Raphael, M.F., den Boer, A.M., Kollen, W.J., Mekelenkamp, H., Abbink, F.C., Kaspers, G.J., . . . Tissing, W.J. (2014). Caphosol, a therapeutic option in case of cancer therapy-induced oral mucositis in children?: Results from a prospective multicenter double blind randomized controlled trial. Supportive Care in Cancer, 22, 3–6.
To evaluate if Caphosol™ is effective to treat oral mucositis (OM) in pediatric patients who received chemotherapy or hematopoietic stem cell transplant (HSCT)
A sample of 33 patients between 4–18 years old was assigned to Caphosol or placebo. All patients received standard local supportive care, in addition to Caphosol study or 0.9% sodium chloride (NaCl) placebo mouth rinse. All patients were instructed to use the study mouthwash four times daily during their OM period. Primary study outcome was defined as the number of days with OM greater than grade 1. Secondary outcomes were pain and analgesic use.
Chi-square or t-test was used for analysis. The number of days with mucositis greater than grade 1 did not differ significantly between the two study groups (p = 0.154). No significant differences were found between Caphosol and placebo for all the outcome measures except days of pain and tube feeding requirement. Placebo was associated with significantly fewer days of pain (p = 0.035) . The need for tube feeding was significantly higher in the Caphosol group.
Therapeutic use of Caphosol was not beneficial in the treatment of pediatric patients with cancer therapy-induced OM.
Although this study was a double-blind, randomized, controlled trial, the significantly small sample size was problematic. The authors concluded that Caphosol was not effective in practice; however, it is not conclusive because of the significantly high risk for type II errors. A study with a larger sample size is required to assess the efficacy of Caphosol.
Rao, R.D., Michalak, J.C., Sloan, J.A., Loprinzi, C.L., Soori, G.S., Nikcevich, D.A., . . . North Central Cancer Treatment Group. (2007). Efficacy of gabapentin in the management of chemotherapy-induced peripheral neuropathy: A phase 3 randomized, double-blind, placebo-controlled, crossover trial (N00C3). Cancer, 110, 2110–2118.
The purpose of the study was to evaluate the effect of gabapentin on chemotherapy-induced peripheral neuropathy (CIPN).
Patients were assigned to either one of two groups: gabapentin followed by placebo or placebo followed by gabapentin. Doses of both capsules were incrementally increased during the course of three weeks to a target does of 2,700 mg. Patients were treated for six weeks and then had a two-week washout period. After the washout period, patients were treated for another six weeks in the crossover. The sample size was determined by power analysis and study measures were obtained weekly.
The study was conducted at multiple outpatient settings in the north-central region of the United States.
The McGill pain rating questionnaire at six weeks indicated lower pain in the gabapentin-treated groups. No other differences were noted between groups at any point in time during the study. On the numerical scale, a slight reduction in pain was seen in all participants. Improvement was highest in patients who had higher baseline average pain and in those currently in active chemotherapy treatment. Most frequent adverse events were dizziness and fatigue and no differences in adverse events were noted based on gabapentin treatment.
The findings failed to demonstrate any benefit in using gabapentin for CIPN.
The findings do not support the use of gabapentin for the management of CINV.
Rao, M.R., Raghuram, N., Nagendra, H.R., Gopinath, K.S., Srinath, B.S., Diwakar, R.B., . . . Varambally, S. (2009). Anxiolytic effects of a yoga program in early breast cancer patients undergoing conventional treatment: A randomized controlled trial. Complementary Therapies in Medicine, 17(1), 1–8.
To compare effects of a 24-week yoga program with those of a supportive therapy control intervention in patients with early breast cancer
Prior to surgery, patients were assessed and randomly assigned to the yoga program intervention or control condition. All patients received 50 cGy of radiation therapy over six weeks and were prescribed six cycles of standard chemotherapy with the same schedule. Patients in both groups received alpraxolam 0.5 mg once daily for one week following chemotherapy for the first one to two chemotherapy cycles. Patients in the yoga group had four in-person sessions during the perioperative period and were to undergo three in-person sessions per week for six weeks during radiotherapy treatment, with self-practice on the remaining days. During chemotherapy, patients had in-person sessions during visits (one per 21 days) and in-person sessions with a trainer every 10 days. The instructor monitored self-practice through telephone calls and house visits. The control intervention was brief supportive therapy with education, including 15-minute counseling sessions every 10 days during treatment by a social worker. All patients were asked to maintain daily diaries of symptoms, medication, and diet intake, and for those in the yoga group, their frequency and duration of yoga practice.
Patients were undergoing the active treatment phase of care.
A randomized controlled trial design was used.
Sixty-one percent of patients initially randomized dropped out of the study. Approximately half of these patients decided to leave the study after initial surgery, and the rest of the dropouts were removed from the study because they did not end up receiving the same expected adjuvant treatment sequence. Anxiety declined over time in all patients, and overall ANOVA did not show a significant group and time effect. Post hoc analysis showed that the yoga group had significantly lower anxiety immediately postsurgery and midway through radiation therapy (p < 0.05) and midway through chemotherapy (p < 0.001). Analysis of overall symptom distress showed a significant effect of the yoga group over time for reduction in symptom distress (p = 0.001). Post hoc testing showed a significant decrease in trait anxiety in the yoga group compared to controls at several time points in the study (p < 0.01). The effect size for state anxiety was 0.33. Anxiety and symptom distress were strongly correlated at all phases of treatment, with r ranging from 0.49 to 0.73 (p < 0.05).
Anxiety decreased over time in all patients. The yoga intervention was associated with a significantly greater reduction in anxiety at several time points in the treatment schedule, immediately following surgery, midway through radiation therapy, and midway through chemotherapy.
Yoga as provided in this study, with individual instructor-directed sessions and patient self-guided practice expectations, had a mild effect in reducing anxiety over time during various phases of cancer treatment. Guided sessions were done at scheduled visits for treatment, suggesting that this can be a practical way to facilitate patient participation. Patients may find yoga helpful to reduce stress and anxiety.
Rao, R.D., Flynn, P.J., Sloan, J.A., Wong, G.Y., Novotny, P., Johnson, D.B., . . . Loprinzi, C.L. (2008). Efficacy of lamotrigine in the management of chemotherapy-induced peripheral neuropathy: A phase 3 randomized, double blind, placebo-controlled trial, N01C3. Cancer, 112, 2802–2808.
Patients were randomized to either lamotrigine or placebo. Sixty-three patients were randomized to lamotrigine and 62 to placebo. The dose was escalated from 25 mg at bedtime to 150 mg twice daily, a regimen that continued for two weeks. Ten weeks after drug initiation, patients tapered off lamotrigine or placebo over a four-week period.
Phase III randomized, double-blind, placebo-controlled trial
A total of 125 patients enrolled, but only 80 completed the study. Authors observed no significant differences between the two groups in the pain scale or the ENS.
Lamotrigine was not effective in relieving chemotherapy-induced peripheral neuropathy.