Databases searched were PubMed, EMBASE, and Cochrane Collaboration.

Search keywords were intrathecal pump for pain, intrathecal infusion, spinal infusion, intrathecal drug delivery system, spinal pump, and intrathecal therapy.

Studies were included in the review if they

• Involved long-term use of intrathecal infusion implants for chronic pain.
• Provided a minimum of three-months follow up.
• Reported on patients with no previous spinal surgery.
• Used any study design.

Studies were excluded if they

• Lacked clear delivery system documentation or used mixed delivery systems.
• Were case reports, technical reports, surveys, or pump evaluations.

The initial search yielded 812 references; 59 of these were reviewed. A final sample of 20 studies was included. Of these, one randomized trial and four observational studies involved cancer pain. Study quality was evaluated using Agency for Healthcare Research and Quality (AHRQ) criteria for observational studies and Cochrane criteria for randomized controlled trials (RCTs).

For cancer-related pain, the final sample of five studies involved 482 patients with refractory pain and end-stage disease. Samples ranged from 35–202. Five systematic reviews also were included in the review; however, none of these specifically addressed cancer-related pain.

Overall, moderate quality level evidence was found with cancer-related pain. Three out of five of the studies showed 30% or greater pain relief at three months, and four out of five studies showed 50% or greater pain relief at three months. All studies showed improvement in both nociceptive and neuropathic pain control. Studies showed reduced complications with opioids. Complications occurred related to devices, the surgical implant procedure, or other procedure-related aspects in three studies. In one study, miscalculation of pump refill dates resulted in severe pain among five patients.

Long-term efficacy and safety of the intrathecal approach in terminal cancer is justified, and data supports the use of chronic intrathecal morphine for treatment of intractable malignant pain. Problems and complications can occur. Device-related complications and the need for surgical revision appear to have occurred at higher rates in earlier studies compared to more recent studies, which reflects ongoing improvements in techniques and education. Initial assessments of cost effectiveness suggest that cost savings are achieved after two years in comparison to systemic therapy in noncancer pain.

Patient selection and experience with implanted devices are important considerations in decision making for use of intrathecal pain management. Patient and caregiver self-care education is key to the safety and efficacy of this approach.

To evaluate the clinical effect of a newly developed lozenge containing polaprezinc for the prevention of oral mucositis in patients who received conditioning high-dose chemotherapy for hematopoietic stem cell transplantation (HSCT) compared to a polaprezinc (zinc-L-carnosine) suspension in a sodium alginate solution that has been shown to be effective in the prevention of oral mucositis in patients who received radiotherapy or high-dose chemotherapy

Patients were pretreated with either polaprezinc suspension during January 2013 and December 2014 or polaprezinc lozenge during January 2015 and December 2016 for the prevention of oral mucositis. The control group consisted of patients who received high-dose chemotherapy without any premedication during March 2006 and February 2011. The incidence and severity of oral mucositis and its associated symptoms, such as oral pain, were reviewed from medical records and compared among the three groups. The severity of adverse events was graded according to the Common Terminology Criteria for Adverse Events (CTCAE), version 3.0.

• N = 66
• AGE RANGE = 19–70 years
• MALES: Not given  
• FEMALES: Not given 
• CURRENT TREATMENT: Chemotherapy
• KEY DISEASE CHARACTERISTICS: Acute myeloid leukemia, acute lymphoblastic leukemia, acute promyelocytic leukemia, myelodysplastic, natural killer/T-cell lymphoma, diffuse large B-cell lymphoma, mantle cell lymphoma, follicular lymphoma, Hodgkin lymphoma

• SITE: Single site   
• SETTING TYPE: Inpatient    
• LOCATION: Japan

PHASE OF CARE: Active antitumor treatment

Retrospective cohort comparison

CTCAE, version 3.0

The results showed grade 2 and grade 3 oral mucositis in the no-premedication control group. The polaprezinc suspension group and the polaprezinc lozenge group showed less incidence of grade 2 mucositis, and the overall average grade of oral mucositis was 0.6 for the suspension group and lozenge group. No statistical difference existed in the average grade or incidence rate of oral mucositis between the suspension group and lozenge group.

The newly developed lozenge containing polaprezinc for the prevention of oral mucositis was shown to be highly effective in the prevention of moderate to severe oral mucositis in patients receiving high-dose chemotherapy for HSCT. There was some question about the efficacy of the lozenge preparation when compared to the suspension.

• Small sample (< 100)
• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Key sample group differences that could influence results 
• Measurement/methods not well described
• Intervention expensive, impractical, or training needs

Gender was not clearly identified, and the method of evaluating the grade of mucositis was not clearly described. The lozenge is not a readily available product, developed and compounded for this study. The product has promise if the study is replicated as randomized, controlled trial.

To evaluate the effect of implementation of institutional guidelines (12 mg dexamethasone alone) for low-emetic risk chemotherapy with docetaxel and to estimate the cost savings for all low-emetic risk chemotherapies in a year

All patients with breast cancer received either four courses of FEC therapy  (500 mg/m² 5-fluorouracil, 100 mg/m² epirubicin, and 500 mg/m² cyclophosphamide) or EC therapy (100 mg/m² epirubicin and 600 mg/m² cyclophosphamide, every 21 days) followed by adjuvant docetaxel therapy (70–75 mg/m²) every 21 days for four cycles.

Before implementation of the institutional antiemetic guidelines, group one (41 patients, 151 courses) received 4 mg ondansetron plus 8 mg IV dexamethasone 30 minutes before treatment with docetaxel.

After implementation of the guidelines, group two (56 patients, 205 courses) received 12 mg dexamethasone only. In both groups, 4 mg oral dexamethasone was given twice a day on days 2 and 3 of docetaxel therapy for prevention of docetaxel-related fluid retention.

Effectiveness and adverse effects were compared between groups. With patients who received dexamethasone and ondansetron, investigators evaluated incidence of nausea, vomiting, and adverse reactions with docetaxel retrospectively in the medical records. 

Additionally, a cost minimization analysis was performed to assess the economic impact of implementing institutional antiemetic guidelines. The cost comparison looked at 4 mg ondansetron + 8 mg dexamethasone + 100 ml normal saline versus 12 mg dexamethasone + 100 ml normal saline plus the time to prepare the antiemetic guidelines, attending committee, and change order sets.

• The study reported on 97 patients (41 in group one and 56 in group two).
• The mean age in group one was 50.2 years (SD = 11.6 groups). The mean age in group two was 50.8 years (SD = 8.9 years).
• The percentage of males and females was not indicated.
• All patients were diagnosed with breast cancer.
• No significant characteristic differences were observed between the groups before or after implementation of the institutional guidelines.

This study was conducted at a single site, the National Hospital Organization Kyushu Cancer Center (NKCC) in Fukuoka, Japan.

All patients were in active treatment. This study has applications for late effects and treatment.

This was a retrospective cohort study.

The Common Terminology Criteria for Adverse Events, version 3.0, was used to grade adverse drug reactions.

• Overall, 97 patients were observed during 356 treatments either before or after implementation of the institutional guidelines (ondansetron + 8 mg dexamethasone versus 12 mg dexamethasone alone).
• Nausea (19.5% in group one versus 16.1% in group two) and vomiting (2.4% in group one versus 0% in group two) occurred in both groups; however, no significant differences in the incidence of emesis were found between the two groups.
• Although anticipated to be higher in the dexamethasone group, no differences were found between the groups in incidence of constipation (34.1% in group one versus 30.4% in group two) or insomnia (17.1% in group one versus 17.9% in group two).
• The cost of ondansetron + 8 mg dexamethasone ($68) decreased to $7.50 with 12 mg dexamethasone.
• Considerable savings occurred between the two groups when ondansetron was eliminated from the low risk antiemetic guidelines.

Dexamethasone alone (12 mg) appeared to be as effective in preventing nausea and vomiting as ondansetron and dexamethasone (8 mg) in low-risk emetic chemotherapy with docetaxel, and it was more cost effective.

• This was not a prospective, randomized, or blinded study
• Outcomes were only evaluated with adjuvant docetaxel therapy for patients with breast cancer and not with other low-emetic risk drugs.
• Adverse reactions caused from the antiemetics were evaluated from medical records.
• Whether 12 mg of dexamethasone is optimal could not be determined from the study.

The use of 12 mg dexamethasone alone for low-risk ematogenic antineoplastic therapies such as docetaxel is recommended in the literature, has shown reasonable effectiveness for preventing nausea and vomiting, and is economically advantageous.

To investigate whether polaprezinc is effective in preventing oral mucositis (OM) in patients receiving high-dose chemotherapy and radiation followed by hematopoietic stem cell transplantation (HSCT)

The treatment group received polaprezinc alginate (P-AG) solution rinses four times per day for one month after transplantation. The control group received an azulene oral rinse four times per day for one month after transplantation.

• N = 36 (25 treatment, and 11 control)   
• AGE RANGE = 15–66 years
• MALES: 40% (treatment); 64% (control); 47% (overall), FEMALES: 60% (treatment); 36% (control); 53% (overall)
• KEY DISEASE CHARACTERISTICS: Hematologic malignancies

• SITE: Single site    
• SETTING TYPE: Multiple settings    
• LOCATION: Medium-sized university hospital in Japan

• PHASE OF CARE: Active antitumor treatment
• APPLICATIONS: Pediatrics and elder care  

Retrospective study

• National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE)
• The amount of analgesia used was recorded.  
• Parametric and nonparametric statistics (T test, chi-square, Mann-Whitney, and P value of < 0.05 for significance)

P-AG decreased the incidence of grade 2 or greater OM. The average grade of OM was lower in the P-AG group. There was a decrease in the amount of moderate to severe pain.

P-AG might be effective in lowering the incidence and severity of OM in patients receiving high-dose chemotherapy and radiation followed by HSCT.

• Small sample (< 30)
• Small sample (< 100)
• Baseline sample/group differences of import
• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Findings not generalizable

P-AG may help in the prevention of OM, but additional study is warranted before a practice change is recommended.

To investigate the effect of a deep breathing intervention, incorporated within conventional nursing care, on tension-anxiety and fatigue experienced by Japanese women with gynecologic cancer undergoing adjuvant chemotherapy for the first time.

To reduce tension-anxiety and fatigue through deep breathing that incorporated elements of exercise.

The deep breathing intervention was initiated for patients in the intervention group. Each patient received 15 minutes of guidance from the researcher using a DVD and pamphlets. The intervention was performed with nursing assistance pre- and postchemotherapy, with the latter given on the second, fourth, and sixth days. The control group received treatment with the usual chemotherapy and nursing care.

• The study was comprised of 23 women.
• Mean age was 53.6 years (standard deviation [SD] = 9.4 years) in the intervention group and 61.7 years (SD = 9.8 years) in the control group.
• All patients were diagnosed with gynecologic cancers, including uterine (54.5%), ovarian, cervical, and peritoneal carcinomatosis. Cancer stage ranged from I (54.5%) to III.
• Patients were included in the study if they had a recent diagnosis, were postoperative and receiving their first administration of adjuvant chemotherapy, were literate in Japanese, and were willing to participate.
• Patients were excluded if they were younger than 20 years and had received recent psychological treatment (including medication and psychotherapy) and/or recent asthma treatment.

• Single site
• Inpatient
• Osaka, Japan

• Patients were undergoing the active treatment phase of care.
• The study has clinical applicability for late effects and survivorship.

The study used a randomized, controlled trial design.

• Profile of Mood States (POMS)–Short Form (Japanese version):  tension-anxiety and fatigue subscales assessed pre- and posttherapy
• Cancer Fatigue Scale (CFS), subscales of subjective fatigue:  physical, affective, and cognitive assessed pre- and posttherapy

There were no statistically significant differences between groups in terms of age, diagnosis, or cancer clinical stage or treatment type (p > 0.05). Prechemotherapy data showed no significant differences between the intervention and control groups in the previously mentioned measurement tools. The postchemotherapy tension-anxiety scores were lower in the intervention group (p = 0.01). Both groups showed significant reductions in tension-anxiety scores (both p = 0.00). The postchemotherapy physical and total fatigue scores of the intervention group were significantly lower than those of the control group (physical, p = 0.04; total, p = 0.04).

The study demonstrated that the tension-anxiety and fatigue scores of patients undergoing chemotherapy for gynecologic cancers were lowered when the nurses assisted them with deep breathing for a short period in addition to providing conventional nursing care provided pre- and postchemotherapy. The prominent features of the study were that it used a program that combined three deep breathing techniques and was of short duration (10 minutes).

• The study had a small sample size, with less than 30 patients.
• The nurse-to-patient ratio for teaching was 1:1.
• The study was limited to patients with gynecologic cancer and had a limited time period evaluated for fatigue (fatigue can worsen as chemotherapy continues). 
• The study needs to be reproducible in different facilities and with a larger sample size. 
• The study lacked an attentional control.

These are very simple exercises that can be taught to patients and be performed even while they are receiving chemotherapy. In addition to usual nursing care, nurses can contribute to reducing patients’ tension-anxiety and fatigue by assisting them in performing deep breathing.

To determine the efficacy of sennoside-based regimens on the proportion of total days with at least one bowel movement (BM) per day.

During phase I, the first 30 consecutive eligible patients admitted to the ward received docusate plus sennosides (DS) for management of constipation. Dosing was as follows.

• Opioid-naive patients received docusate sodium 200 mg BID.
• For those on opioids or had no BM in 48 hours, the starting dose or next dose was docusate 200 mg BID plus sennosides 17.2 mg every bedtime.
• If patients had no BM in the next 48 hours, they received docusate sodium 200 mg TID plus sennosides 17.2 mg BID.
• If patients had no BM in the next 24 hours, they received docusate sodium 200 mg TID plus sennosides 17.2 mg TID.
• If patients still had no BM after 24 hours, they received docusate sodium 200 mg TID plus sennosides 25.8 mg TID. 

During phase II, the next 30 eligible patients with constipation received sennosides only. Dosing was as follows.

• Patients received sennosides 17.2 mg every bedtime.
• For those on opioids or had no BM in 48 hours, the starting dose or next dose was sennosides 17.2 mg BID.
• If patients had no BM in the next 24 hours, they received sennosides 17.2 mg TID.
• Finally, if patients had no BM after 24 hours, they received sennosides 25.8 mg TID.

Rescue laxatives included lactulose, a suppository, or enema as needed. Only 12 days of bowel protocol were abstracted from the medical record.

• The study reported on a sample of 60 patients.
• Mean patient age was 59.1 years (SD = 14.8, range 24–87) in the DS group and 62.9 years (SD =13.9, range 25–85) in the sennosides group.
• The sample comprised 45 women and 15 men.
• Fourteen patients in the sennosides group had genitourinary cancer, and seven patients in the DS group had breast cancer. 
• Eighty percent of patients were on opioids and 72% were admitted for symptom control.

• Single site
• Inpatient
• Vancouver Center of British Columbia Cancer Agency in Canada

• Patients were undergoing the active treatment phase of care.
• The study has clinical applicability to end-of-life and palliative care.

This was a nonrandomized, nonblinded, sequential cohort study.

Nursing chart review

• The mean study observation period was eight days (range 5–12 days).
• Eighty percent of patients in the sennosides group had a BM on at least 40% of days compared with 60% of the DS group (p = 0.09). However, if patients not taking opioids were excluded, the sennosides group had better results (76% versus 50% of days) than the DS group (not significant).
• Fifty-seven percent of patients in the DS group required additional interventions (lactulose, suppositories, or enemas) compared to 40% in the sennosides group.
• Twenty-seven percent of patients in the sennosides group reported diarrhea compared to 13% in the DS group.

Sennosides only produced more BMs than DS.

• The study had a small sample size (fewer than 100).
• The design was not randomized.
• More patients with genitourinary cancer were recruited in the sennosides group than the DS group, and 90% of patients in the DS group were receiving opioids; therefore, an even comparison in diagnosis was not reflected.
• The dosage of sennosides was higher overall in the sennosides group than the DS group, which could have influenced the results as well.
• Conclusions were based on a chart review, which was performed to look at side effects, versus interview. Data may have been lost if patients were not asked or side effects were not recorded.

Adding a stool softener such as docusate does not necessarily produce superior results than those seen with a laxative alone. However, additional randomized, double-blind studies should be conducted before conclusions and evidence into practice are drawn. The usefulness of this study is questionable because of its design and execution issues.

To determine if honey swished, held, and swallowed reduced the severity of radiation-induced oral mucositis (ROM)

Honey and placebo gel were provided in 5 mL packets to be taken after salt/bicarbonate oral rinses four times a day after meals and after radiotherapy or approximately the same time on non-treatment days. Participants were to pour the product into their mouth, circulate it for 30 seconds, and swallow. Subjects were instructed not to eat, drink, or rinse their mouth for 30 minutes following swallowing the honey or placebo. Treatment started on the first day of radiation and continued for seven days following the last radiation treatment. Visits to the oral oncology/dentistry department were scheduled weekly until mucositis was resolved. During each visit, an oral examination was done for mucositis severity rating, a brief questionnaire was conducted, and weight was obtained. Unused treatment medication was collected at the last visit to measure compliance.

• N = 81  
• MEAN AGE: Honey arm: 56.8 years, placebo arm: 59.5 years
• MALES: Honey arm: 81%, placebo arm: 84%; FEMALES: Honey arm: 19%, placebo arm: 16%
• KEY DISEASE CHARACTERISTICS: Head and neck cancer—hypopharynx, larynx, nasopharynx, oral cavity, oropharynx
• OTHER KEY SAMPLE CHARACTERISTICS: Radiation therapy of ≥ 50 Gy; 62% had concurrent chemotherapy; Caucasian

• SITE: Multi-site 
• SETTING TYPE: Outpatient 
• LOCATION: Vancouver and Sudbury, Canada

• PHASE OF CARE: Active antitumor treatment

• Double-blind, randomized, placebo-controlled, investigator-initiated

• Sialometry and mucositis severity scales from the Radiation Therapy Oncology Group (RTOG)
• World Health Organization (WHO) Oral Mucositis Scale

There were no differences found between the treatment and placebo arms for any of the three outcome assessment scales of mucositis for quality of life, symptom scores, or sialometry. Both the honey (35%) and placebo (43%) groups had lower than expected rates of ≥ grade 3 mucositis.

The honey, when used as directed in this study, did not significantly decrease the severity of ROM. The treatment and placebo groups were well matched, and the blinding was effective. The dropout rate was high (honey: 57%, placebo: 52%, those receiving concurrent chemotherapy: 59%). Most of the dropouts were related to nausea. Patients receiving radiation only had a dropout rate of 48%. Only 48 patients had complete weekly mucositis assessments.

• Small sample (< 100)
• Subject withdrawals ≥ 10%
• Other limitations/explanation: The initial plan for the study was to enroll 180 subjects. The study was terminated at planned interim analysis when 106 patients had been recruited.

There have been varied outcomes in studies of honey for the treatment of mucositis. Differences in methodology could explain at least part of the variability. In this study, the subjects tolerated the honey poorly because of nausea and gagging, and a couple patients experienced a burning sensation. The authors referenced a study from New Zealand in which a honey mouthwash was used because undiluted honey caused extreme nausea, vomiting, and stinging sensations. Potential reasons for the lack of efficacy seen could be that the mucositis tools may not have had adequate sensitivity to reveal any clinical difference between or the osmotic effect of the honey and placebo. Also, Christian areas like Canada, New Zealand, and Great Britain, where honey does not have any special significance, may differ from Muslim areas that have the Koran’s references to honey’s healing powers.

To assess whether anesthetizing the skin with buffered lidocaine before performing breast lymphoscintigraphy reduces pain

Patients were randomly assigned to the control group without lidocaine or the experimental group in which the procedure was preceded by lidocaine injection. Patients were asked to rate their pain levels before and immediately after injections for the procedure. All patients received two injections and were were masked from knowing whether one of them was lidocaine.

• N = 49   
• MEAN AGE = 61.4 years
• AGE RANGE = 34–87 years
• FEMALES: 100%
• CURRENT TREATMENT: Not applicable
• KEY DISEASE CHARACTERISTICS: Breast cancer

• SITE: Single site   
• SETTING TYPE: Outpatient    
• LOCATION: Rhode Island

• PHASE OF CARE: Diagnostic

• Randomized, controlled trial

• 0–10 numeric pain rating scale

No difference in preprocedure pain levels existed between groups. Those who received lidocaine reported less of an increase in pain postprocedure. No difference in lymph node detection existed between groups.

Administration of local anesthetic prior to breast lymphoscintigraphy was associated with lower pain severity after the procedure.

• Small sample (< 100)
• Risk of bias (no blinding)
• Limited reporting of statistical results and methods

Authors point out that local anesthesia prior to lymphoscintigraphy is not common practice, due to the assumption that any benefit would be outweighed by the pain associated with additional needle sticks. Some patients may feel significant pain during this procedure, and findings from this study suggest an approach to reduce pain with this experience. Authors discuss the findings in terms of the rationale for using a buffered lidocaine solution and implications for practical application and needed lymph node visualization.

To compare the risk of chemotherapy-induced nausea and vomiting (CINV) events for various 5-HT₃ receptor antagonists (RAs) in patients who received moderately (MEC) or highly emetogenic chemotherapy (HEC) by evaluating hospital or emergency department (ED) admissions

Patients with breast cancer who received adjuvant chemotherapy with cyclophosphamide within four months after surgery and patients with lung cancer who were initiated on carboplatin or cisplatin-based chemotherapy within the study time frame (January 1, 2005, through June 20, 2008) were identified using the PharMetrics database. CINV events associated with hospital and ED admissions were extracted using claims with ICD-9-CM codes for nausea, vomiting, or dehydration.  

In each cohort, patients were stratified into two groups, one consisting of patients initiated and maintained on palonosetron as the only 5-HT₃ RA antiemetic, the other with patients who were initiated on one of the older 5-HT₃ RAs and maintained on the same agent or alternated throughout the study duration between the older 5-HT₃ RA and palonosetron, either as single agents or in combinations. The use of aprepitant and dexamethasone was used in both cohorts.

The study consisted of 4,868 patients with breast cancer and 7,106 patients with lung cancer (5,414 treated with carboplatin, 1,692 treated with cisplatin).

The median age in all cohorts ranged from 53–65 years.

The breast cancer cohort was 100% female.

The carboplatin-treated lung cancer cohort was 46.5% female and 53.5% male.

The cisplatin-treated lung cancer cohort was 40.3% female and 59.7% male.

The patients in the breast cancer and carboplatin-treated lung cancer cohorts were considered to be treated with moderately emetogenic chemotherapy (MEC). The cisplatin-lung cancer cohort was considered to be treated with highly emetogenic chemotherapy (HEC). The authors did control for differences in age, Charlson comorbidity index (CCI) score, gender (lung cancer cohorts), cyclophosphamide dose per square meter per cycle (breast cancer cohort), and cisplatin and carboplatin treatment days (lung cancer cohorts).

Site and setting type was not indicated. Data was analyzed using pooled patient information from PharMetrics database.

• Patients were in active treatment.
• This study has application to elderly care.

This was a retrospective data analysis.

• Patient comorbidities for the six-month baseline period prior to the study index date were calculated using the CCI.
• The study population was selected using the PharMetrics database.

Based on the results presented by the authors, patients with breast or lung cancer treated with HEC or MEC, when initiated and maintained on palonosetron throughout chemotherapy, experienced significantly reduced risk of hospital- and ED-associated CINV events compared to patients who received other 5-HT₃ RA-based regimens. In all three cohorts, the p value was < 0.0001. The results of the data analysis do show superiority of palensetron in reducing such events, but a number of variables and limitations may impact the results.

Antiemetic regimens containing palonosetron may be more effective in reducing severe, uncontrolled CINV than other 5-HT₃ agents; however, firm conclusions cannot be drawn because of study design limitations and risks of bias.

• No appropriate control group was included.
• The lead author was a paid consultant to Easai, Inc., the marketer of oalonosetron in the USA. Easai, Inc was also the sponsor of the study. The other authors are employees of Easai, Inc. This has the potential to lead to further selection bias of the patient population.
• A large variable that was unaccounted for was the varying doses of chemotherapy. 
  • The average dose of cyclophosphomide used in the breast cancer cohort was on the lower end of dosing. Cyclophosphomide is typically given in a dose of 300-600 mg/m² as adjuvant therapy to patients with breast cancer depending on the selected regimen. The average dose used in patients in this study was 414 mg.
  • Only 19% of patients treated with cisplatin were treated with guideline recommended triplet antiemetic therapy.
• Though an effort was made to control for comorbid conditions in the cohorts, variables such as differences in chemotherapy doses were not a part of the analysis.

The study is helpful because it was an analysis of a large group of patients. It also seeks to provide meaningful conclusions for patients. Although identifying interventions for the reduction of CINV in patients can aid in quality of life and ability to receive treatment in a timely manner, looking at the significance of CINV reduction in preventing serious events such as ED visits or hospitalizations is also important.

Potential patients were referred to a highly experienced palliative care physiotherapist clinic. Patients were seen by the physiotherapist at three sessions, each lasting as long as 90 minutes. Intervention consisted of breathing retraining, simple relaxation techniques, activity pacing, and psychosocial support.

The study reported on a sample of 30 patients with non-small cell lung cancer, small cell lung cancer, or mesothelioma (pleural effusion excluded) who experienced breathlessness not less than one month after completion of any active treatment; 68 patients were referred, 17 did not fulfill the criteria, 4 declined, and 2 were too ill to treat. Forty-five entered the study, and 15 deteriorated or died before completion. The median age was 71 years; 24 were men, and 6 were women.

The study was conducted in an outpatient clinic in the United Kingdom.

• Uncontrolled study
• Nonrandomized
• Referred patients

Tools completed by the therapist at each visit

• Current Respiratory Symptoms—adapted from two scales (Medical Research Council and Respiratory Symptom Questionnaire); patients were asked to score how often they were breathless, ranging from most or all the time to less than once a week
• Functional Capacity Scale adapted from above tools; patients scored their ability to climb hills or stairs without breathlessness to experiencing breathlessness at rest
• Sputum production scale

Self-assessment tools completed by patients at baseline and following the intervention (four to six weeks)

• Rotterdam symptom checklist
• VAS: breathing at worst and at best in the proceeding 24 hours as well as distress caused by breathlessness (0–10 where 10 = extreme distress)
• Things that improve breathing (in the clinic, patients were taught techniques and coping strategies likely to improve their feeling of breathlessness); the patients were asked to score 20 helpful strategies at baseline and at the last visit on a VAS (1–10 where 10 = extremely helpful).
• Quality-of-life questionnaire
• Therapist recorded patients’ verbatim comments in free narrative form and added own comments.

Statistical analysis of baseline data on 12 patients who were unable to complete the study compared to 30 patients who completed the study showed significantly lower Functional Capacity Scale scores (p = 0.04) at first assessment. For patients who completed the study, a highly significant (p < 0.001) change in frequency of reported breathlessness was found. A decrease existed in reported breathlessness, from 97% reporting it at least once or twice a day, 73% several times a day, and 27% most of the time to 27% experiencing dyspnea several times a day and 3% most of the time at the final visit. A statistically significant change was seen between study entry and completion (p < 0.001) in functional capacity. Overall, 19 improved function, 9 remained stable, and 2 deteriorated.

No change in sputum production was found.

Rotterdam symptom checklist:

Significant changes were seen in the physical distress scores and activity levels (no p value given). Change in psychological distress scores were borderline.

Degree of breathlessness:

Significant improvement (p < 0.001) was found in all three parameters—breathing at best, breathing at worst, and distress caused by breathlessness.

Intervention strategies:

On study entry, patients were asked to score 20 strategies that were likely to improve feelings of breathlessness. Examples of interventions include activity pacing, abdominal breathing, slowing down, relaxation exercises, not worrying, accepting the situation, and positive thinking.

Patients reported that all of the techniques they learned were helpful and improved breathlessness. Patients reported that massage and the use of bronchodilator drugs were not helpful.

Quality of life:

Significant improvements were seen in decrease in time spent lying down (p = 0.02), improved bodily strength (p = 0.03), and increase in things that made patients happy (p = 0.04). Patients reported an increased ability to do things and improved quality of life.

Qualitative data:

The following themes were extracted from the narrative data: difficulty adjusting, issues around death, effects of treatments, and therapies’ impact on daily life.

The study was uncontrolled. A major limitation of the study is that it is a nonrandomized trial of referred patients. Impossible to know are the implied bias in patients who were referred or the true effect of the intervention without a control group. It was based on a prior study, with the time period shortened because of the loss of patients in the earlier study’s sample.