• FINAL NUMBER STUDIES INCLUDED = 6
• TOTAL PATIENTS INCLUDED IN REVIEW = 812
• KEY SAMPLE CHARACTERISTICS: Five studies (two ongoing at the time of publication) were designed to investigate cognitive behavioral training (CBT). One study involved an intervention based on CBT. A meta-analyses was conducted for two of the studies for which the authors provided additional data. Participants were primarily female, and the mean age range was 49.2–60.4 years.

PHASE OF CARE: Late effects and survivorship

The authors indicated that there was insufficient evidence to recommend these interventions and concluded that future research involving CBT interventions for CRCD are unlikely to yield different findings. However, this systematic review and meta-analysis is limited because CBT and neuropsychological interventions and instruments differed, resulting in the inability to pool results.

• The meta-analysis was conducted on only two studies.
• More studies with long-term follow-up periods are needed to draw conclusions about the efficacy of CBT. Additional information regarding intervention descriptions, subject characteristics, and the instruments used for outcome measures are necessary to complete this review for comparison.

The authors indicated that additional research using CBT for CRCD is unlikely to indicate efficacy. However, this review was limited by the limited number of studies reviewed, its lack of longitudinal timepoints, and the differences between the CRCD interventions.  

To demonstrate the potential benefits of topical mometasone furoate (MF) for the prevention of acute radiation reactions with a primary measure/endpoint being the mean modified Radiation Therapy Oncology Group (RTOG) score

• MF and diprobase were applied daily to the irradiated sites from day 1 for five weeks during breast radiation therapy (three weeks radiation therapy [RT], two weeks post-RT).

• Patients received 40 Gy of radiation therapy in 15 fractions in three weeks.
• Some patients received an electron boost of 10 Gy in five fractions.

• Assessments occurred at baseline and on days 8, 15, 21, 29, 36, and 43.

• N = 99
• MEAN AGE = 59.5 years
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: All patients had breast cancer.
• OTHER KEY SAMPLE CHARACTERISTICS: Included nonsmokers, ex-smokers, and smokers; bra cup sizes A–E were included; 72% also received chemotherapy

• SITE: Multi-site
• SETTING TYPE: Outpatient
• LOCATION: United Kingdom

• PHASE OF CARE: Active antitumor treatment

Double-blinded, randomized, controlled trial

• Modified RTOG for skin dermatitis
• Dermatology Life Quality Index (DLQI)
• Hospital Anxiety and Depression Scale (HADS)
• Erythema measurement by reflectance spectrophotometry

• Mean RTOG scores were lower for patients using MF than for those using diprobase (p = 0.046).
• Patients using MF experienced lower scores than those using diprobase for the time till maximum RTOG score (statistically insignificant).
• 4.8% of the patients using MF reached an RTOG of 2.5 versus the 15.5% of patients using diprobase who reached the same score. On a week-to-week basis, the difference in average scores between the groups in was not significantly different.
• The odds ratio of having a lower RTOG score associated with MF use was 2.38 (p = 0.18).

• Higher erythema values were seen in patients using diprobase versus MF. Over the course of the study period, the average treatment difference between groups was significantly better for those using MF (p = 0.012).

• Patients in the MF group experienced higher anxiety and depression scores at baseline than those in the diprobase group.

• Diprobase was associated with increased DLQI scores between weeks 2 and 3, but these scores gradually fell.
• MF was associated with increased DLQI scores till week 5, but this score fell thereafter.
• DLQI scores were worse for those using diprobase.

This study demonstrated that MF cream may be beneficial in reducing the severity of acute radiation skin reactions when compared to diprobase cream applied daily to the irradiated area on the breast during three weeks of RT and two weeks post-RT.

• Small sample (< 100)
• Baseline sample/group differences of import
• Measurement validity/reliability questionable
• Intervention expensive, impractical, or training needs
• Subject withdrawals ≥ 10%
• Other limitations/explanation: It is not clear whether intensity-modulated radiation therapy was used, which impacts the development of radiodermatitis. A slightly higher percentage of participants in the diprobase group also received chemotherapy, which could have affected the results in this group negatively. The chemotherapy agents that participants received were not described.

The findings of this study demonstrated that the use of MF cream was more effective than an aqueous cream for the prevention of severe radiodermatitis in women receiving radiation therapy for breast cancer. Mixed results have been seen in various studies using different topical corticosteroids, suggesting that specific steroid selection is important. Overall findings suggest that it may be important to begin topical treatment use prior to radiation rather than using steroids for the treatment of radiodermatitis after it has developed. The optimal schedule for the use of such treatments has not been determined, and it has varied across studies.

Women with ovarian cancer scheduled for treatment with carboplatin or paclitaxel-based chemotherapy were randomized to receive either IV premedication with amifostine 740 mg/m² or placebo for 30 minutes. Data were collected at baseline, after each cycle of chemotherapy, and at three and six months after completion of chemotherapy.

The sample consisted of 71 women with advanced ovarian cancer.

The study was a double-blind, randomized, placebo-controlled study.

• Measurements included vibration perception thresholds and vibration disappearance thresholds before cycle 4 and after the end of treatment. Secondary objectives were patella and Achilles tendon reflexes and two-point discrimination.
• Sensory symptoms, fine global motor activities, and quality of life were collected via questionnaire.
• Toxicity was reported according to the National Cancer Institute's Common Terminology Criteria for Adverse Events (NCI-CTCAE).

Thirty-seven women received amifostine and 34 received the placebo infusion. A significant protective effect of amifostine was found in vibration, two-point discrimination, and deep tendon reflexes. No significant differences were observed for single sensory or motor symptoms; however, amifostine improved sensory neuropathy according to the NCI-CTCAE criteria. Inconsistent results were reported in regard to quality of life.

• The study sample size may have been too small to detect group differences.
• Inconsistencies were present regarding the assessment of sensory neurotoxicity, the neurologic assessment of vibration thresholds, and quality of life.
• There were inter-observer variances with vibration sense measurement.

To assess the effectiveness of a short-term breathlessness support service in facilitating breathlessness mastery in patients with advanced disease

• N = 105 (53 assigned to the breathlessness support service, and 52 assigned to the standard care group)  
• AVERAGE AGE = 67 years
• MALES: 58%, FEMALES: 42%
• KEY DISEASE CHARACTERISTICS: Patients were included if they experienced refractory breathlessness on exertion or rest despite optimum treatment of their underlying disease; advanced diseases including cancer, chronic obstructive pulmonary disease (COPD), chronic heart failure, interstitial lung disease, and motor neuron disease were included; willing to participate in home physiotherapy and occupational therapy; able to provide informed consent
• OTHER KEY SAMPLE CHARACTERISTICS: Patients were excluded if they experienced breathlessness of unknown etiology, had a primary diagnosis of chronic hyperventilation syndrome, were completely homebound despite the offer of free clinic transport, or were within two weeks of treatment for an acute exacerbation.

• SITE: Multi-site    
• SETTING TYPE: Multiple settings    
• LOCATION: South London

• PHASE OF CARE: End-of-life care
• APPLICATIONS: Palliative care 

This was a single-blinded, randomized, controlled trial. Research nurses and interviewers were blinded to the treatment allocation. Participants, the trial coordinator, and the trial administrator were aware of the treatment allocation.

• Chronic Respiratory Disease Questionnaire (CRDQ)
• London Chest Activity of Daily Living (LCADL) scale
• EQ-5D and EQ Visual Analog Scale (VAS)
• Palliative Care Outcome Scale (PCOS)
• Hospital Anxiety and Depression Scale (HADS)
• Spirometry to assess pulmonary function
• Pulse oximetry to assess oxygen saturation
• Severity of breathlessness in the previous 24 hours on a numeric scale (0–10)

An integrative approach to managing breathlessness within a support service improves patient mastery of breathlessness.

• Findings not generalizable
• Other limitations/explanation: One limitation of the study was a possible placebo effect because participants were not blinded to their specific treatment groups. The authors also suggested that although nurse researchers were blinded to the intervention groups, they may have been able to determine which treatment group participants were assigned based on the existence of breathlessness equipment in their homes (thereby potentially biasing their interviews). In addition, the authors noted that their inclusion and exclusion criteria prevented the inference of study results to patients in the last month of life. Finally, the authors noted that the short-term nature of outcome follow-up restricted their assessment of care costs and long-term survival.

Additional research and education on the structure and process of an integrative breathlessness support service for patients with advanced cancer is warranted.

To evaluate the effects of yogurts made with different types of lactic acid bacteria (LAB) on the gastrointestinal system.

Participants were recruited via advertisement. Consenting patients were assigned using stratified randomization by defecation frequencies to receive one of three types of yogurt.

• Type A: plant-derived LAB—Lactobacillus plantarum—SN35N (95%) with SN13T (5%)
• Type B: plant-derived LAB—Lb. plantarum—SN13T (98%) with SN35N (2%)
• Type C: animal-derived LAB—Lb. lactis A6 (86.1%), Streptococcus thermophilus 510 (13.8%), and Lb. bulgaricus C6 (0.1%)

Participants consumed 100 g of yogurt daily for a six-week period. Data were collected from clinic visits at two-week intervals.

• The study reported on a sample of 68 patients aged 21 to 65 years.
• The sample comprised 49 women and 19 men.
• Patients were healthy adults with some complaints of intestinal health, such as constipation, diarrhea, abdominal pain, and bloating.

Hiroshima, Japan

This was a randomized, double-blind study.

Bristol Stool Form Scale

• No statistical difference existed between the study types (groups A and B) and the control (group C).
• Total cholesterol decreased significantly in all individuals from 214.3 mg/dl at baseline to 203.2 mg/dl at six weeks (p = 0.012) in group B, but not in groups A and C.
• No participants reported any significant adverse events resulting from yogurt intake during the trial.
• No abnormal changes in urine analysis or serum biochemical parameters were observed during the study.

In healthy adults, Lb. plantarum SN13T may improve serum lipid levels and liver function. Actual effects in relieving constipation are unclear.

• The sample size was small (fewer than 100).
• The study did not include patients with cancer.

Effects in relieving constipation are unclear in healthy adults. Additional studies are warranted that include a larger sample and patients with cancer.

The intervention was autogenic training (AT), a type of meditation, with mental exercises:

• Heaviness of limbs
• Warmth of limbs
• Calm regular heartbeat
• Easy breathing
• Abdominal warmth
• Cooling of forehead

Measurements were taken at baseline and at the end of two monthly periods. Patients were observed for evidence of meditative state. Group 1 (control) received one home visit, and group II (intervention) received one home visit plus two months of AT intervention.

The study reported on a sample of 31 women with early-stage breast cancer.

A randomized controlled trial design was used.

• Hospital Anxiety and Depression Scale (HADS)
• T and B cell markers
• Unpaired t tests
• Calculations of blood results and HADS scores were made of mean and standard deviation.

Results showed a p value of 0.0027 between groups for anxiety. T and B cell markers remained similar in both groups. The AT group reported improved HADS anxiety levels (t = 2.00, p = 0.092). There was no statistical difference in HADS scores for patients within the group.

• The study had a small sample of women with early-stage breast cancer.
• Specialized education was needed to provide the AT.
• The authors state a limitation may be that only 7 of 16 patients in the experimental group achieved a meditative state.

To evaluate the effectiveness of aprepitant, dexamethasone, and palonosetron in the prevention of nausea and vomiting in patients with breast cancer receiving an initial cycle of doxorubicin and cyclophosphamide (AC)

Patients were asked to keep a diary recording the number and timing of any episodes of vomiting or retching, frequency and timing of use of rescue antiemetics, degree of nausea using a four-point categorical scale, and notation of other medications taken. The patients were called by a study coordinator at 24, 48, 72, 96, and 120 hours after starting chemotherapy to assist the patients in the completion of the diary.

• The study consisted of 36 participants.
• The median age of patients was 53 years.
• All of the patients were female with a diagnosis of breast cancer.
• All of the patients were chemotherapy naïve with Karnofsky performance statuses of 60 or more
• Patients were scheduled to receive their first course of chemotherapy with cyclophosphamide (≥ 500 mg/m²) and doxorubicin (60 mg/m²) .

The study was conducted at a single outpatient setting at Lahey Clinic Medical Center in Burlington, MA.

• All patients were in active treatment.
• The study has clinical application to elderly care.

This was a prospective trial.

Patients recorded in diaries the number and timing of any episodes of vomiting or retching, frequency and timing of rescue antiemetic use, and degree of nausea using a four-point categorical scale.

• Eighteen patients (50%) achieved a complete response during the 120-hour study period.
• Acute (≤ 24 hours) and delayed (24–120 hours) complete response rates were 81% and 61%, respectively.
• No emesis rates for the acute, delayed, and overall study periods were 97%, 94%, and 92%, respectively.

The aprepitant, dexamethasone, and palonosetron appeared to be well tolerated and effective at preventing emesis, with no emesis rates ranging from 92%–97% during the study period. However, 50% of patients still developed some degree of nausea and took antiemetic rescue medications, highlighting the need for  further improvement in chemotherapy-induced nausea and vomiting (CINV) control in patients with breast cancer receiving AC.

• The study had a small sample size of fewer than 100 patients.
• Current guidelines suggest the use of a 5-HT₃ receptor antagonist, dexamethasone, and aprepitant prior to treatment with an anthracycline and cyclophosphamide (AC) and then aprepitant alone on days 2 and 3. According to the large, phase-III trial that supports the use of the current suggested premedication regimen, approximately half of the patients will achieve a complete response (CR). This study yielded a 50% CR rate. The authors did try to compare the regimen in this study to the regimen used in the phase-III trial. To more fully assess the combinations, a large, randomized controlled trial would need to be done to compare the regimens.

AC is a common treatment regimen for breast cancer and is highly emetogenic. Further studies exploring ways to better control nausea in this patient population, including the use of nonpharmacologic strategies, are needed.

To confirm the differential time course of action noted with a neurokinin 1 (NK1) receptor antagonist (RA) compared to a 5-HT₃ RA in the setting of cisplatin-based chemotherapy using the database from three large, phase III trials

Multivariate logistic regression models were used to assess the impact of the first emesis at different time intervals of aprepitant regimens compared to control regimens using a modified intent-to-treat approach. The endpoint was the frequency of first emesis during distinct time intervals from administration of chemotherapy through 120 hours postadministration.

The trials reported on a total of 2,383 patients.

The mean age range of patients was 52–59 years.

• In the Aprepitant group, the mean age of patients in study 1 was 56 years, the mean age of patients in study 2 was 59 years, and the mean age of patients in study 3 was 53 years.
• In the Control group, the mean age of patients in study 1 was 56 years, the mean age of patients in study 2 was 59 years, and the mean age of patients in study 3 was 52 years.

The percentage of the sample that was male was not reported but assumed to range from 0%–65%. The percentage of females ranged from 35%–100%.

• In the Aprepitant group, study 1 was 42% female, study 2 was 39% female, and study 3 was 99.5% female.
• In the Control group, study 1 was 43% female, study 2 was 35% female, and study 3 was 100% female.

In study 1 and study 2, primary cancer diagnoses were respiratory, urogenital, digestive, and other. In study 3, primary diagnosis was breast cancer.

The majority (59%–80%) were Caucasian.

A total of 1,527 patients were receiving cisplatin-based HEC and 856 were receiving anthracycline plus cyclophosphamide-based moderately emetogenic chemotherapy (MEC).

All patients were in active treatment.

This was a post-hoc analysis.

Measurement instruments and methods were not specified in this article.

With cisplatin-based, highly emetogenic chemotherapy (HEC), the aprepitant regimen was associated with a lower incidence of first vomiting compared to the standard regimen beginning at the 15–18 hour interval and beyond. This lowered incidence was maintained until the 48–60 hour interval, with the first vomiting incidence reduced by 38%–77%.

With anthracycline-cyclophosphamide-based MEC, the first vomiting incidence was markedly lower, as early as the 3–6 hour interval. This effect was maintained up to the 9–12 hour interval, with the first vomiting incidence reduced by 38%–61%.

Emesis induced by cisplatin is biphasic with the initial peak within 2 hours of cisplatin and the second peak starting 16–18 hours and lasting 48 hours after cisplatin. 5-HT₃ medications appear to be most effective in the first 12 hours after cisplatin while NK1-sensitive mechanisms appear to be more effective up to 60 hours after cisplatin.

Anthracycline and cyclophosphamide agents display a monophasic emesis pattern; therefore, better emetic control is noted with NK1-dependent medications much earlier in the treatment cycle.

No discussion was included on how data was collected within each study.

Cisplatin-based regimens require 5-HT₃-dependent medications within the first 12 hours and NK1-dependent medications thereafter.  Anthracycline- and cyclophosphamide-based regimens appear to be sensitive to both 5-HT₃- and NK1-dependent medications.

To prospectively determine the frequency of delayed nausea and vomiting with irinotecan-based chemotherapy following day 1 prophylaxis with a 5-HT₃ receptor antagonist and dexamethasone

All patients received irinotecan-based chemotherapy. All patients received a standard antiemetic regimen prior to chemotherapy consisting of dexamethasone (8 mg oral or IV) and a 5-HT₃ receptor antagonist (8 mg IV or 24 mg oral ondansetron, 100 mg IV or oral dolasetron, and 1 mg IV or 2 mg oral granisetron) given immediately prior to the start of chemotherapy only. No routine antiemetics were prescribed after day one for prophylaxis or delayed emesis. Palonosetron was not permitted in this study. All patients received a prescription for rescue therapy, only to be used during the first 120 hours. Patients were monitored for 120 hours after the initiation of irinotecan by the study coordinator who called at timed intervals to assist patients in completing diaries. During this study, patients only were observed on their first cycle of the irinotecan-based chemotherapy.

• This study consisted of 44 patients.
• The median age was 61 years with a range of 39-79 years.
• The sample was 84% male and 16% female.
• Patients had been diagnosed with colorectal cancer.
• All patients were receiving irinotecan-based chemotherapy (38 patients received a FOLFIRI regimen, five patients, received irinotecan in combination with cetuximab, and only one patient received irinotecan alone).
• One patient had a history of motion sickness, and three of the seven female patients (43%) had a history of morning sickness.
• To be included in the study, patients had to be older than 18 years of age and have European Cooperative Oncology Group Performance Status of 0–2.
• Patients with history of moderate to severe nausea or any vomiting with prior chemotherapy were not eligible.

The study was conducted at multiple outpatient settings through the St. Elizabeth’s Medical Center in Boston, MA; Holy Family Hospital in Methuen, MA; and the Institute for Radiology and Oncology of Serbia.

• All patients were in active treatment.
• This study has application to late effects and survivorship.

This was a prospective, observational study.

• Patient diaries were used to record the frequency and timing of vomiting or retching episodes and the use of rescue meds (1–5 retches over 5 minutes was counted as a single emetic episode).
• A four-point categorical scale was used to assess the extent of nausea experienced in the preceding 24-hour period (0 = none, 1 = mild [did not interfere with normal daily life], and 3 = severe [patients bedridden because of nausea]). 
• Complete control was defined as no emesis, no nausea, and no use of rescue antiemetics.
• Complete response was defined as no emesis and no use of rescue antiemetics.

• The majority (89%) of the 44 patients enrolled in the study had no emesis during the overall period, 9% experienced vomiting or retching during the delayed period, and 7% vomited during the first 24 hours after irinotecan administration.
• Fifteen patients (34%) experienced delayed nausea (mild in 11 patients, moderate in 4 patients). Six patients (14%) took rescue antiemetics during the delayed period.
• Delayed and overall complete response rates were 86% (acute), 82% (delayed), and 77% (overall).
• Complete control was 86% (acute), 64%(acute), and 59%(delayed).
• Achieving a complete response during the acute period predicted for a high likelihood of attaining a complete response during the delayed period (95%).

The results of the study showed efficacy in reducing or controlling delayed nausea and vomiting during the 24-hour period following administration of a camptothecin analogue, a moderately ematogenic  antineoplastic agent, when dexamethasone and a 5-HT₃ receptor antagonist was used as prophylaxis for acute chemotherapy-induced nausea and vomiting (CINV).

• The sample size was small.
• The sample was primarily male. No comparative control group and the male-to-female ratio may have affected results because of gender imbalance with a larger male population.

The use of dexamethasone and a 5-HT₃ receptor antagonist prior to administration of a camptothecin analogue is recommended in the literature and has been shown to be beneficial in controlling acute CINV, which contributes in reducing delayed nausea and vomiting.

To evaluate the efficacy and safety of IV palonosetron in preventing chemotherapy-induced nausea and vomiting (CINV) in patients with cancer who had incomplete control of CINV during their previous cycle of low-emetogenic chemotherapy (LEC)

A baseline clinical assessment was performed including demographics, history, physical exam, labs, and urinalysis, within 14 days of treatment. On day 1, eligible patients received an IV bolus injection of 0.25 mg palonosetron 30 minutes before their scheduled LEC regimen. Patients were then monitored 30 minutes after administration of LEC for any adverse reactions. Outcomes were recorded in patient diaries over a 120-hour period at the end of study visits on days 6, 7, or 8 after LEC administration. Investigators assessed presence of nausea and its severity and intensity, the number of emetic episodes, complete control rate, and the complete response rate for the acute phase (0–24 hours), delayed phase (24–120 hours), and overall response (0–120 hours). 

• The study reported on 34 participants.
• The mean age of the participants was 64.7 years (SD = 13.77 years).
• The sample was 31% male and 69% female.
• Patients had histologically or cytologically confirmed cancer
• The sample was 83% Caucasian, and the mean Karnofsky Performance Status score was 82.8. 
• All patients had received prior LEC that had induced vomiting or at least moderate nausea.
• Most patients (77.8%) consumed no alcohol.

This was a mutlisite study conducted in clinical settings at 10 centers in the United States.

• Patients were in active Treatment.
• This study has application to late effects and survivorship.

This was a prospective, single-arm, descriptive study.

• Patient diaries were used to record of the number of emetic events, use of rescue antiemetics, and measure of nausea on a 4-point Likert-type scale with 0 = no nausea to 3 = severe nausea.
• Complete response was defined as no nausea, vomiting, or need for rescue antiemetics.
• An end-of-study visit was conducted on day 6, 7, or 8.

The majority of patients (94.1%) required no rescues antiemetics in the postchemotherapy phase. In the acute postchemotherapy phase, 88.2% of patients experienced complete response. In the delayed phase, 67% experienced complete response. On two treatment-emergent adverse events occurred. Complete control rate was also noted in the acute and delayed phases. Overall, 73.5% of patients did not require rescue medications.

Palonosetron was effective in preventing CINV in both the acute and delayed postchemotherapy phases and was well tolerated in this group of patients who had a history of CINV with LEC. Unfortunately, type of cancer was not reported.

• The sample was small with fewer than 100 patients.
• No control group was included.
• Patients were receiving various chemotherapy regimens.

In patients with a history of CINV while receiving LEC, palonosetron can be considered a useful antiemetic option for acute and delayed post chemotherapy phases. A randomized study should be considered with a focus on specific LEC regimens. Nurses should note that 73% of patients did not require rescue antiemetics; however, 27% patients did need them.