To determine the effectiveness of nerve blocks to control pain in patients with end-stage pancreatic cancer pain

Patients were randomized to two groups, the sham and nerve block groups. Visual Analog Scale (VAS) pain scores, pain duration, reduction of other analgesics, and quality of life scores (measured by the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire [EORTC QLQ-C30]) were obtained before and three months after intervention.

• N = 100  
• MEAN AGE = 65.5 years
• MALES: Unknown, FEMALES: Unknown 
• KEY DISEASE CHARACTERISTICS: Unresectable or inoperable carcinoma of the pancreas by CT or EUS; stage determined by the 2010 American Joint Committee on Cancer (AJCC) manual; presence of midabdominal pain at a minimum of two days per week for at least one hour per day; INR 1.5; platelets greater than 50,000; life expectancy greater than three months
• OTHER KEY SAMPLE CHARACTERISTICS: Age had to be greater than 18; excluded if unable to sign consent; excluded if patient had previous blocks; excluded if patient had chronic pancreatitis

• SITE: Not stated/unknown    
• SETTING TYPE: Not specified    
• LOCATION: Not specified; approved by Soochow University Ethical Committee in China

• PHASE OF CARE: End-of-life care
• APPLICATIONS: Elder care, palliative care 

Sham-controlled, randomized, controlled trial

• Visual Analog Scale (VAS)
• European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30)

This study presents a potential additional intervention in combination with pain medication in patients with end-stage pancreatic cancer-associated pain. Additional potential benefits could be the improvement of physical and emotional function, fatigue, insomnia, and loss of appetite. This study would have to be replicated with a larger sample size to prove efficacy.

• Findings not generalizable
• Other limitations/explanation: Follow-up period was limited to three months; location of tumor was not identified; prior therapies not identified; less generalizable sample size 100

This type of therapy presents a potential intervention in combination with pain medication for pain control in end-stage pancreatic cancer based on this randomized, controlled trial. After-care of a patient with a nerve block would require training. An assessment of the adjustment of other medicinal treatments would be required at baseline in this intervention.

This study intended to test the effectiveness of a comprehensive menopausal assessment (CMA) on symptom relief, quality of life, and sexual functioning.

Participants were randomized by age (≤55 and >55) and tamoxifen use (current vs. not used). The CMA was delivered by a trained nurse practitioner with a specialty in family and women’s health over a 4-month period and focused on structured symptom assessment of hot flashes, vaginal dryness, and stress urinary incontinence. After assessment, patients were provided with individualized education and counseling, psychosocial support, referrals, and individualized follow-up. Specific pharmacologic and behavioral interventions for the target symptoms were implemented to control symptoms based on treatment protocols developed by the NP and the study physician. The intervention group returned for a 2-month follow-up visit. The usual care group received a telephone call 2 months after baseline to ask about therapies used to manage their symptoms. Data was collected at baseline and 4 months. The usual care group was then able to take part in the CMA but no further data was collected.

• The study enrolled 42 women with breast cancer.

• SITE:  Single site    
• SETTING TYPE : Outpatient    
• LOCATION: California/community recruitment

PHASE OF CARE: Late effects and survivorship

This was a randomized, controlled trial.

• Menopausal Symptom Scale Score (adapted from the Breast Cancer Prevention Trial Symptom Checklist)
• Vitality Scale from the RAND 36-item Health Survey (aka Medical Outcomes Study SF-36)
• Sexual Summary Scale from the Cancer Rehabilitation Evaluation (CARES)

97% of women in the study reported hot flashes at baseline, with no difference between groups. There was a significant difference in the menopause symptom scale (p=.0004), with women in the intervention group showing the most improvement in symptoms. There was no difference between groups in QOL (p=.77). The CMA group had significantly better sexual functioning at follow-up compared to the usual care group (p=.02). No specific data on improvement in hot flashes was provided. Only the overall symptom scale was reported.

CMA is an effective intervention to improve/reduce the number of menopausal symptoms in breast cancer survivors and to improve sexual function for these women.

Limitations of the study included:

• Small sample (< 100)
• Risk of bias (no blinding)
• Intervention expensive, impractical, or training needs
• Requires a specially trained nurse practitioner for the intervention

A nurse-led intervention to target menopausal symptoms is an effective way to reduce these symptoms in women who are survivors of breast cancer. However, the intervention may be too expensive or impractical given the training requirements of the intervention nurse and institutional guidelines on billable appointments.

To evaluate the effects of prophylaxis with levofloxacin in relapsed/refractory acute myeloid leukemia (AML)

Data were obtained from medical records of patients with relapsed or refractory AML admitted from 2006–2015. Standard levofloxacin prophylaxis was begun in 2013 with 500 mg once daily on day 1 of chemotherapy and continued until neutrophil recovery. Cohorts who received levofloxacin were compared to a cohort that did not receive prophylaxis.

• N = 145   
• MEDIAN AGE = 58–59 years
• AGE RANGE = 18–84 years
• MALES: 67%, FEMALES: 33%
• CURRENT TREATMENT: Chemotherapy
• KEY DISEASE CHARACTERISTICS: All had relapsed AML and were undergoing re-induction chemotherapy.
• OTHER KEY SAMPLE CHARACTERISTICS: Patients on broad spectrum antibiotics or who were receiving other prophylaxis were excluded. Eighteen percent had previously undergone hematopoietic cell transplantation.

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

PHASE OF CARE: Active antitumor treatment

Retrospective cohort comparison

Febrile neutropenia (FN) was defined as an oral temperature of 38.3 C or greater with and absolute neutrophil count less than 500 cells/mm³

A lower rate of bacteremia existed in the prophylaxis group, but the difference was not significant. The time to onset of bacteremia from onset of neutropenia was delayed in the prophylaxis group compared to others (p = 0.012). No differences in drug-resistant organisms existed between cohorts, or in the incidence of FN. In the prophylaxis group, the frequency of gram-negative organism–related infections was lower.

Levofloxacin prophylaxis reduced the number of overall infections and the prevalence of gram-negative infections in patients being treated for relapsed or refractory AML.

• Risk of bias (no blinding)
• Risk of bias (no random assignment)

The findings suggest that antibiotic prophylaxis is beneficial for patients undergoing re-induction chemotherapy for relapsed or refractory AML.

Patients chewed five to six pieces of fluoride-containing, sugar-free gum, sweetened with xylitol per day for 20 minutes per piece from the first day of chemotherapy to three days after course of treatment. Both groups practiced standard oral care, consisting of brushing teeth with a soft toothbrush and rinsing with sodium bicarbonate rinse.

• The study reported on 145 children ages 5–18 years. The gum group had 73 patients, and the control group had 72 patients.
• All patients were scheduled to receive chemotherapy associated with at least a 30% rate of grade 3–4 oral mucositis according to the World Health Organization (WHO) oral mucositis grading scale.

The study was conducted between March 1999 and December 2002.

This was a randomized, controlled trial.

Researchers recorded the WHO grade of mucositis within first 21 days, time to development of grade 3–4 mucositis, incidence of any grade of mucositis, incidence of pain using a 70-point visual analogue scale, number of days of total parenteral nutrition, incidence of abdominal symptoms, and incidence of septicemia.

No significant differences were found between arms for severe mucositis endpoints.

Patients receiving less toxic regimens had a decrease in WHO grade 1–4 oral mucositis of 49% in the gum group and 72% in the control group (p = 0.03).
 

• This study did not achieve adequate sample size according to power analysis.
• Eight children discontinued using the gum because of nausea.
• Chlorhexidine and fungizone were widely used in both arms.

Participants in the treatment group received infusions of calcium gluconate and magnesium sulfate (1 g) before and after oxaliplatin. The chemotherapy protocol consisted of combination oxaliplatin, 5-fluourouracil (5-FU), and leucovorin. Three regimens of oxaliplatin were used: 85 mg/m² every two weeks, 100 mg/m² every two weeks, or 130 mg/m² every three weeks.

A total of 161 patients were enrolled in the study, with 96 placed in the treatment group and 65 in the control group.

The study had a retrospective design.

Toxicity was graded every one to two weeks by staff according to the National Cancer Institute's Common Terminology Criteria for Adverse Events and an oxaliplatin-specific neurotoxicity scale that assessed paresthesias.

Paresthesias, trismus, cramps, limb pain, and diarrhea were significantly less frequent in the treatment group. Pharyngolaryngeal dysesthesia were never reported in the treatment group versus 9% in the control group. In addition, less grade 3 toxicity was reported in the treatment group compared to the control group. At the end of oxaliplatin therapy, 65% of participants in the treatment group had no evidence of chemotherapy-induced peripheral neuropathy (CIPN) compared to 37% in the control group. By the end of treatment, 20% of patients in the treatment group showed evidence of CIPN versus 45% in the control group. Patients with grade 2 or 3 neurotoxicity at the end of treatment with oxaliplatin (85 mg/m²) recovered more rapidly from CIPN than those in the control group.

• The study was retrospective and not randomized or blinded.
• Staff who performed the assessments may have been biased in reporting.
• More patients who received either FOLFOX 4 or FOLFOX 6 regimens were included in the treatment group, making results more open to bias and placebo effect.

To compare the effectiveness of orally administered red morphine drops (RMD) and subcutaneous morphine (SCM) in patients with advanced lung cancer

Patients were randomized to two groups. Group 1 received oral RMD and a subcutaneous injection of isotonic saline. Group 2 received a placebo oral RMD and a subcutaneous injection of morphine. All injections were given in the leg in a location without edema. Patients were instructed to hold the RMD or placebo RMD solution in their mouths as long as possible before swallowing. The study preparations included a) morphine hydrochloride at 2 g, ethanol 96% at 5 g, cochenille tincture PhD.48 10 g, purified water up to 100 g (one drop corresponded to 0.6 mg morphine), b) ethanol 96% at 5 g, cochenille tincture PhD.48 10 g and purified water up to 100 g, c) injectable morphine 20 mg/ml, and d) isotonic saline. Measurements were taken at baseline and five, 10, 15, 20, 30, and 60 minutes after medication administration. Patients were not allowed to take any opioid within four hours prior to the experiment.

• N = 20  
• MEAN AGE = 69 years (range = 42–84 years)
• MALES: 10%, FEMALES: 90%
• KEY DISEASE CHARACTERISTICS: Lung cancer
• OTHER KEY SAMPLE CHARACTERISTICS: Terminally ill patients receiving opioids for pain; resting dyspnea of at least 3 on 0–10 Visual Analog Scale at rest

• SITE: Single site    
• SETTING TYPE: Not specified  
• LOCATION: Denmark

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

Double-dummy randomized, controlled trial

• Visual Analog Scale (VAS) 0–10 to assess the severity of dyspnea
• Respiratory rate
• Oxygen saturation
• Pulse rate

There was no significant difference in dyspnea between the two groups. Both RMD and SCM showed a significant decrease in dyspnea (time p = 0.0451, and treatment p < 0.0001). In addition, RMD and SCM were associated with significant decreases in pulse rate (p = 0.0410). Although it was not statistically significant, patients receiving SCM showed a more rapid decline in dyspnea. Patients in the RMD group received 3.3%–8.6% of their total 24-hour opioid dose. Patients in the SCM group received 1.5%–5.5% of their total 24-hour opioid dose.

Both RMD and SCM improved dyspnea in terminally ill patients.

• Small sample (< 30)
• Baseline sample/group differences of import
• Risk of bias (no blinding)
• Key sample group differences that could influence results
• Other limitations/explanation: Primarily women in the sample; baseline dyspnea was 1 higher in the RMD group

RMD is a reasonable alternative to SCM and should be considered as part of patient preference at the end of life. Subcutaneous administration may provide more rapid relief. It is noteworthy that opioid use relieves dyspnea for patients receiving regular opioids for pain management. The most effective dosage of RMD is not yet known. Additional research to understand the pharmacokinetics of RMD is needed.

To assess the effects of psychosocial interventions on quality of life and mood symptoms in patients diagnosed with cancer within the past 12 months

• Databases searched, up to January 2011, were Cochrane Central Register, MEDLINE EMBASE, CINAHL, and PsycINFO.
• Authors provided an extensive listing of keywords and specific search strategies.
• To be included, studies had to
  • Be randomized controlled trials (RCTs) or quasi-RCTs involving interpersonal dialog between a trained helper and individual newly diagnosed patients with cancer.
  • Measure quality of life and general psychological distress.
  • Include control groups that received standard care only.
• Authors excluded trials involving a combination of psychosocial and pharmacologic interventions, as well as group- and couples-based interventions.

• A total of 3,272 references were retrieved.
• Quality evaluation used criteria specified in the review for random allocation and allocation concealment, blinding, loss to follow-up, and assessment of reporting bias.

• Authors chose 30 trials to include, with 20 included in the meta-analysis.
• The sample range across studies was 17–558, with a total sample across studies of 5,155.
• All studies involved patients diagnosed within the past 12 months only.
• Disease types included breast, colon, gastric, skin, prostate, and testicular cancers as well as, in some mixed trials, a few others.
• All participants were adult patients.

Multiple phases of care

• Anxiety outcomes were evaluated in four studies, depression outcomes were evaluated in six studies, and mood measures were evaluated in eight studies.
• Analysis of studies involving mood measures resulted in a standard mean difference (SMD) of –0.81 (95% CI, 1.44, –0.18, p = 0.01) in favor of the intervention.
• Analysis of quality-of-life outcomes showed mixed results with cognitive behavioral therapy, positive findings in favor of psychoeducational interventions (SMD = 0.29, 95% CI, 0.05, 0.54, p = 0.02), and no significant effects of counseling. Nurse-delivered interventions showed a significant positive effect (SMD = 0.23, 95% CI, 0.04, 0.43, p = 0.02) for quality of life. Interventions provided by a psychologist; general practitioner; and combined nurse, social worker, or others did not demonstrate significant effects.
• No meta-analysis addressed the outcomes of anxiety or depression only.
• Many studies were of relatively low quality, and the studies included substantial heterogeneity.

Findings suggest that psychosocial interventions have a positive impact on quality of life among newly diagnosed patients with cancer. Psychoeducational interventions and nurse-delivered interventions demonstrate a small significant effect across combined trials. Overall evidence does not indicate that individual psychosocial interventions are effective at improving the mood- and quality-of-life–related symptoms of patients newly diagnosed with cancer.

A small number of studies in meta-analysis related to mood changes. Effect sizes in mood changes were small, and study samples comprised high heterogeneity, demonstrating that findings should be interpreted with some caution in terms of clinical relevance.

The fact that nurse-delivered psychosocial interventions demonstrated a positive and statistically significant effect is promising, although the effect size was small. This finding provides some support for interventions delivered by nurses rather than by other healthcare professionals. Other studies have reported this finding. Nurses may be uniquely positioned to provide such interventions: Their knowledge base includes both physiologic and psychosocial components of the cancer experience, and individual interventions can simultaneously and effectively address physical and psychosocial symptom management. The findings of this study provide general support for the effectiveness of psychoeducational interventions.

The MEDLINE database was searched through June 2004 to identify experimental and quasiexperimental studies of exercise (cardiovascular and/or resistance training) during and following cancer treatment.

Twenty-six published studies, reflecting 18 experimental or quasiexperimental trials of exercise during cancer treatment and eight studies of exercise after cancer treatment, were identified. Of the 18 trials during treatment, 14 used some type of cardiovascular training; two used mixed training with cardiovascular, resistance, and flexibility exercise; and two applied a structured resistance training program. Of the eight trials of exercise after cancer treatment, all used cardiovascular or cardiovascular plus resistance training. The duration of the intervention ranged from two to 28 weeks, and the frequency of the exercise intervention ranged from daily to two times per week.

Outcomes were fatigue, health-related quality of life, symptom distress, psychological distress, body composition, physical exercise capacity (maximal oxygen consumption), immunologic parameters, and muscle strength. Treatment evaluated cardiovascular and/or resistance exercise.

• Most of the studies were conducted in women with breast cancer or in samples with mixed solid tumors; single studies in patients with prostate cancer, colorectal cancer, and hematologic malignancies were noted.
• Sample sizes ranged from five to 155 participants.
• Average participant age ranged from 19 to 77 years.

Five of 18 studies of exercise during cancer treatment specifically found improvements in fatigue, and most of these studies were in women with breast cancer. Of note, a trial of resistance training three times per week in men with prostate cancer undergoing androgen depletion therapy showed improvements in fatigue after a 12-week program. Of the eight studies of exercise following cancer treatment, none reported statistically significant improvements in fatigue, but there were improvements in functional status, quality of life, psychological distress, strength, and capacity.

Although recent evidence supports the use of resistance exercise during cancer management as an exercise mode to counteract adverse effects of the disease and treatment, most of the studies were conducted using cardiovascular training. Promising results in terms of fatigue and other outcomes of a short-term resistance exercise program on patients diagnosed with prostate cancer and undertaking androgen-depletion therapy have been reported.

To evaluate the effectiveness of a the telehealth-delivered exercise intervention on symptoms among breast cancer survivors

Patients were randomized to the telehealth intervention or usual care. After baseline assessment, those in the study group received instructions on how to access the private area of the system. The intervention consisted of three sessions per week of exercise following recommendations of the American College of Sports Medicine for cancer survivors. Each session was delivered online. The system allowed participants to send messages and set up video conferencing, participants to write questions or comments, and research staff to comment and monitor performance remotely. Participants received phone calls from research staff if needed. The intervention lasted eight weeks. Usual care patients received basic written recommendations for exercise. After six months, they were offered the opportunity to participate in the telehealth program. Assessments were done at baseline, at completion, and at six months.

• N = 72   
• MEAN AGE = 48.3 years
• FEMALES: 100%
• CURRENT TREATMENT: Not applicable
• KEY DISEASE CHARACTERISTICS: All had breast cancer and previous surgery. Most also had previous radiotherapy and chemotherapy.
• OTHER KEY SAMPLE CHARACTERISTICS: Most had surgery within the last 12 months.

• SITE: Single site   
• SETTING TYPE: Home    
• LOCATION: Spain

• PHASE OF CARE: Late effects and survivorship

• Randomized, controlled trial

• EORTC Cancer Core Quality of Life (EORTC QLQ-C30) and EORTC Breast Cancer Quality of Life (QLQ-BR23)
• Brief Pain Inventory (BPI)
• Handgrip strength
• Isometric abdominal and back strength 
• Sit-to-stand test for lower body strength
• Piper Fatigue Scale (PFS)

After the intervention, the telehealth group reported lower pain severity (p = 0.001) and interference (p = 0.045). The telehealth group reported improved total fatigue perception compared to controls (p = 0.001). This improvement was maintained at the six month follow-up (ES d = –0.75, p = 0.002). Adherence rate for exercise sessions was 93.9%. Muscle strength and quality of life (QOL) were also improved in the telehealth group compared to controls. There were no technical issues or adverse effects of the intervention observed.

An online exercise and interaction approach was effective in reducing pain and fatigue and improving QOL and muscle strength. The program had good patient adherence.

• Small sample (< 100)
• Risk of bias (no blinding)
• Risk of bias (no appropriate attentional control condition)
• Intervention was expensive and impractical, or training needs existed.
• Baseline pain and type of pain are not reported.  
• Baseline fatigue was lower among the intervention group.
• Authors noted that a large number of staff were involved in the provision of this program, which may limit the ability to sustain this type of program.

The online delivery of an interactive exercise intervention was shown to be effective. An Internet-based intervention may be a useful alternative to traditional approaches to deliver such interventions, particularly in the setting of barriers such as distance and time. The comparative costs for staff time to deliver and maintain this type of intervention need to be evaluated.

The objective of this study was to investigate whether a handheld fan reduces the sensation of breathlessness in patients with dyspnea.

Room temperature and humidity were controlled, and the fan was directed to either face or leg for five minutes. This was followed by a 10-minute washout followed by repeat intervention, as crossover dyspnea scores were collected at baseline, at completion of each 5-minute intervention, and after 10-minute washout of each intervention. Additional data collected included pulse rate and oxygen saturation after each 5-minute use of the fan and each 10-minute washout.

• The study reported on a sample of 49 participants.
• The mean age was 71.3 years, with a range of 33–90 years.
• Of the sample, 27 were females and 23 were males.
• Diagnoses included chronic obstructive pulmonary disease (26), lung cancer (primary or secondary) (11), asthma (8), heart disease (15), bronchiectasis (7), pneumonitis (4), other (20), and multiple diagnoses (26).
• Other key characteristics included patients in the United Kingdom with refractory breathlessness.
• Patients were permitted to be on opioids, corticosteroids, and sedatives.
• Exclusion criteria included use of continuous or short-burst oxygen during the study period and hemoglobin less than 10 gm/dl.

The study was conducted in an inpatient medical center and a hospice setting in the United Kingdom.

• Patients were undergoing end-of-life and palliative care.
• The study has clinical applicability for late effects and survivorship.

The study had a randomized, controlled, crossover design.

Visual analogue scale (VAS) 10 cm for dyspnea was used. Anchors were no shortness of breath to worst shortness of breath. VAS calculations were performed by a noninvestigator.

Only eight participants perceived benefits of the fan to the face at the conclusion of 5 minutes, but 19 participants perceived benefit at the end of the 10-minute washout. The eight who initially perceived benefit did register reduction in benefit during the washout period. A significant difference in VAS scores was seen between the two treatment arms with reduction in breathlessness when the fan was directed to the face (p = 0.003).

Use of a fan pointed at the face may reduce the sensation of breathlessness in a controlled temperature and humidity environment.

• Washout period of 10 minutes did not appear adequate because the benefit of the fan on the face for some resulted in sustained reduction of dyspnea at the end of 10 minutes. Because washout time may have been incomplete, the results of the second arm of the study may have been biased, and no actual control period in the study existed. 
• The study had a relatively small sample size of less than 100.
• Results were found with temperature and humidity control, not just fan use.

Handheld fans are inexpensive and easy and permit empowerment of patient initiation of symptom management. This study suggests that this intervention, in a controlled temperature and humidity condition, will decrease the sensation of dyspnea. Patients may continue to experience benefit from the intervention even after its discontinuation, so it may be extremely helpful as bridge management when awaiting onset of an intervention such as a pharmacologic agent.