Feinberg, B., Gilmore, J., Haislip, S., Jackson, J., Jain, G., Balu, S., & Buchner, D. (2012). Impact of initiating antiemetic prophylaxis with palonosetron versus ondansetron on risk of uncontrolled chemotherapy-induced nausea and vomiting in patients with lung cancer receiving multi-day chemotherapy. Supportive Care in Cancer : Official Journal of the Multinational Association of Supportive Care in Cancer, 20(3), 615–623.
To examine the risk of uncontrolled chemotherapy-induced nausea and vomiting (CINV) among patients with lung cancer receiving multiday chemotherapy and ondansetron- or palonosetron-initiated prophylactic antiemetic regimens in a community oncology setting
The Georgia Cancer Specialists electronic medical records database was used to identify patients with lung cancer who received multiday cisplatin or carboplatin regimens with ondansetron or palonosetron on day 1 between April 1, 2006, and July 31, 2009. Uncontrolled CINV was identified. Risk for uncontrolled CINV, up to 7 days after last chemotherapy administration, was analyzed at cycle level using logistic regression.
This was a multi-site study based on electronic medical records data from Georgia Cancer Specialist, a community-based practice that included 30 offices and 46 medical oncologists throughout Georgia.
This was a retrospective descriptive study using data from an electronic medical records review.
The rate of uncontrolled CINV events measured from first chemotherapy agent administration of the cycle (start date) through 7 days after the last chemotherapy agent administration (end date) for
Rescue antiemetic after the first day chemotherapy or IV antiemetic after the last chemotherapy administration date were considered as nonprophylactic use.
Among patients with lung cancer receiving multiday chemotherapy cycles, administration of palonosetron on day 1 was associated with a significantly lower risk for uncontrolled CINV events versus ondansetron-initiated chemotherapy cycles.
For the patients receiving multiple day, platinum based chemotherapy for the treatment of lung cancer, every-other-day palonosetron would be an option to lower the risk of the incidence of uncontrolled CINV.
Fegg, M.J., Brandstatter, M., Kogler, M., Hauke, G., Rechenberg-Winter, P., Fensterer, V., . . . Borasio, G.D. (2013). Existential behavioural therapy for informal caregivers of palliative patients: A randomised controlled trial. Psycho-Oncology, 22, 2079–2086.
To evaluate the applicability and effectiveness of existential behavioral therapy (EBT) to informal caregivers of palliative care patients with regards to psychological distress and quality of life when compared with treatment as usual
The intervention was six group sessions totaling 22 hours. The sessions focused on introductions and mindfulness, death, bereavement and mindfulness, activating resources, finding meaning, self-care and stress management, personal values for (re-)orientation, and moving forward. Sessions were administered in small (10 participants or fewer), closed groups by a trained behavioral therapist following a study manual. Evaluations occurred at baseline, pre- and post-intervention, and at 3- and 12-month follow-up (five time points).
EBT showed medium effects at the pre-/immediate post-test evaluation with improvement in anxiety (p 0.006) and on all measures of quality of life (p 0.009, 0.007, < 0.001). At the three-month evaluation, EBT showed no significant effects, with only small effect sizes on one-third of the quality-of-life measure SWLS (p 0.04). However, at the 12-month evaluation, EBT demonstrated medium effects on depression (p 0.04) and QOL-NRS (p 0.002). Interestingly, similar patterns resulted when examining secondary outcomes of affect, with significantly less negative affect demonstrated at post-test (p 0.003), which then was not noted at the three-month evaluation, and at 12 months, significantly less negative affect was measured again (p 0.003). Positive affect, although never significant, always was trending more positive than when compared with controls. High level of satisfaction existed with the group, the therapist, information, mindfulness, and values.
EBT shows promise as an intervention to improve psychological distress and quality of life for carers of patients with cancer at end of life. The effect is greatest immediately following the intervention. Additional work is required with attentional control groups and outpatient patient populations to further support the benefits of this intervention.
Interventions such as EBT that target informal carers of patients with cancer have the potential to relieve distress and improve quality of life for the carer and the patient.
Fay, A.P., Moreira, R.B., Nunes Filho, P.R., Albuquerque, C., & Barrios, C.H. (2016). The management of immune-related adverse events associated with immune checkpoint blockade. Expert Review of Quality of Life in Cancer Care, 1, 89–97.
RESOURCE TYPE: Expert opinion
PHASE OF CARE: Active antitumor treatment
Review article
Literature review of common checkpoint inhibitor adverse and serious adverse events. No evidence quality review was provided.
Research is needed on the management of checkpoint inhibitor therapy toxicities.
Farquhar, M.C., Prevost, A.T., McCrone, P., Brafman-Price, B., Bentley, A., Higginson, I.J., . . . Booth, S. (2014). Is a specialist breathlessness service more effective and cost-effective for patients with advanced cancer and their carers than standard care? Findings of a mixed-method randomised controlled trial. BMC Medicine, 12, 194-014-0194-2.
To evaluate the effects of a specialized breathlessness intervention service compared to usual care
The breathlessness intervention service (BIS) was a multidisciplinary complex intervention including nonpharmacologic and pharmacologic interventions to support patients with advanced disease and dyspnea. The BIS used first-stage interventions such as positioning to reduce the work of breathing, education, individualized exercise plans, relaxation techniques, sleep hygiene, cognitive behavioral therapy approaches, and other supports. Second-stage interventions applied concurrently included opioids, antidepressants, anxiolytics, etc. Patients referred to this service were randomly assigned to the intervention or to a wait-list control group. Study measures were obtained at baseline and after the intervention. Interviews were done before randomization, at two weeks, and at five weeks. The interviews were recorded and transcribed verbatim for analysis. A final qualitative analysis was done from 20 intervention transcripts that were purposefully sampled to obtain a diverse group from those who improved and did not improve.
Randomized, controlled trial
Patients in the intervention group had greater reductions in breathlessness (1.68 versus 0.23 points, p = 0.049). There were no other significant differences in outcomes for patients or caregivers between study groups. Interventions identified as helpful were providing and teaching the use of a handheld fan, encouraging exercise, coaching in breathing techniques and positioning, medication changes, and referrals to other services. Total costs were lower for the intervention group, and a cost effectiveness analysis showed a 66.4% likelihood that the intervention would result in lower cost and better outcomes in terms of reduced distress from breathlessness. Scores for mastery of symptom management did not change significantly.
This complex psychoeducational and pharmacologic intervention was associated with reduced distress from breathlessness. No effects on patient or caregiver distress, anxiety, or depression were found.
Individual interventions such as opioid use have been shown to reduce dyspnea, so it was not possible to determine the relative value and utility of the combined interventions examined here. These study findings suggested that multicomponent, complex interventions to improve symptoms of breathlessness can be cost effective and improve outcomes.
Faria, C., Li, X., Nagl, N., & McBride, A. (2014). Outcomes associated with 5-HT3-RA therapy selection in patients with chemotherapy-induced nausea and vomiting: A retrospective claims analysis. American Health and Drug Benefits, 7, 50–58.
To evaluate the clinical and economic impact of delayed chemotherapy-induced nausea and vomiting (CINV) on patients who received initial and maintenance therapy with the 5-hydroxytryptamine 3 (5HT3) receptor antagonist palonosetron compared to older agents
There was no intervention in this retrospective study; however, the procedure was outlined. Using the OptumInsight® database, researchers evaluated the impact of 5HT3 on chemotherapy-naïve patients. This database provided information on all pharmacy and medical claims for each subject, and records were accessed six months prior to the initial chemotherapy treatment and six months after. Patients were not evaluated if the type of antiemetic changed or if chemotherapy was changed. ICD9 codes and pharmacy charges were monitored for primary or secondary diagnoses of nausea, vomiting, and dehydration. Economic outcomes also were evaluated and calculated.
Retrospective database analysis
No instruments were used, but information extracted from the database included patient and treatment characteristics, nausea, vomiting, Charlson Comorbidity Index scores, antiemetic therapy, and specific 5HT3 use.
Preindex comorbidity scores were lowest in the palonosetron group and highest in the dolasetron group. The overall rate for delayed CINV at cycle 1 was 15.6% for all groups. When compared to palonosetron, patients who received ondansetron (p < 0.002), granisetron (p < 0.001), and dolasetron (p = 0.002) had higher rates of CINV in the second and subsequent cycles of chemotherapy. Dexamethasone was consistently used in the first cycle for all treatment groups. Aprepitant was used most often in the palonosetron group (10.7%) compared to ondansetron (3.6%), granisetron (2.3%), and dolasetron (2.5%).
5HT3 agents were effective in preventing CINV. There were differences in 5HT3 efficacy and cost. Delayed CINV rates increased with subsequent cycles of older 5HT3 agents. Palonosetron showed improvement over time. Similar trends were seen with healthcare resource use.
This study demonstrated cost effectiveness. Medical costs constituted the largest costs. Costs were higher if a patient experienced CINV. Nurses need to use guidelines and risk factors when starting patients on chemotherapy. Using a 5HT3 agent based on the emetogenic potential of chemotherapy is important.
Fares, K.M., Mohamed, S.A., Abd El-Rahman, A.M., Mohamed, A.A., & Amin, A.T. (2015). Efficacy and safety of intraperitoneal dexmedetomidine with bupivacaine in laparoscopic colorectal cancer surgery, a randomized trial. Pain Medicine, 16, 1186–1194.
To investigate the safety and efficacy of intraperitoneal bupivacaine and dexmedetomidine in patients undergoing laparascopic colorectal surgery for postoperative pain management
Patients were randomized to one of three groups: (a) control (intraperitoneal injection of saline), (b) bupivacaine only (125 mg, 0.25%) injection, and (c) combined dexmedetomidine and bupivacaine (bupivacaine 0.25% and 1 mcg/kg dexmedetomidine). After hemostasis was achieved in surgery, intraperitoneal instillation of study drugs was sprayed uniformly into the periotoneal cavity guided by camera. Pain was assessed at baseline and at 2, 3, 6, 8, 12, and 24 hours postoperatively. IV tramadol (100 mg) was given when pain was at least 3 or upon patient request.
The group that received bupivacaine and dexmedetomidine had significantly lower pain at 2, 4, and 24 hours compared to the other study groups (p < 0.03) and needed rescue analgesic much later (p = 0.0002). No difference in time to analgesia existed between study groups 1 and 2. Average overall postoperative tramadol consumption was lower in the group receiving the combined intraperitoneal analgesia (p = 0.001).
Intraperitoneal administration of bupivacaine and dexmedetomidine improved the effectiveness and duration of postoperative analgesia compared to bupivacaine alone or placebo.
Findings showed that loco-regional analgesic administration after laparoscopic colorectal surgery was effective for postoperative analgesia, and the addition of dexmedetomidine to bupivacaine improved efficacy and duration of analgesic effect.
Fares, K.M., Mohamed, S.A., & Abdel-Ghaffar, H.S. (2014). High dose intrathecal morphine for major abdominal cancer surgery: A prospective double-blind, dose-finding clinical study. Pain Physician, 17, 255–264.
To investigate the safety and efficacy of three doses of intrathecal morphine in patients receiving major abdominal surgery
Patients were randomly assigned to receive 0.2 mg, 0.5 mg, or 1 mg of morphine injected into the L3-4 space prior to anesthesia. All patients received the same type of anesthesia and reversal. Vital signs and Visual Analog Scales for pain were assessed at six, 12, 18, 24, 36, 48, and 72 hours postoperatively. At patient request, or for a pain score greater than or equal to 3, rescue analgesia of 100 mg IV tramadol was given.
Double-blinded, randomized trial
The mean time in hours till the first analgesic request was longer in those receiving 0.5 mg (22.13, p < 0.001) and 1 mg (30.83 , p < 0.001) of morphine. Mean total tramadol consumption also was lower in these groups (p < 0.001) with the lowest consumption in those receiving 1 mg (p < 0.04). For the first 18 hours postoperatively, those receiving higher doses of intrathecal morphine had lower pain scores (p < 0.02) than those receiving 0.2 mg. At 24 hours and beyond, there were no significant differences in pain scores among groups. More patients in the higher dose groups developed pruritus (p = 0.01). There were no other significant differences in overall adverse effects between groups. One older patient in the 1 mg dose group developed respiratory depression.
Doses of 0.5 mg and 1 mg intrathecal morphine preoperatively resulted in longer postoperative pain control and less analgesic consumption with nonsignificant differences in adverse effects compared to a dose of 0.2 mg.
The provision of high-dose intrathecal morphine preoperatively resulted in improved postoperative pain control among patients receiving major abdominal surgeries for cancer. Higher doses were associated with better pain outcomes for the first 24–48 hours after surgery. The administration of high-dose intrathecal morphine necessitated careful patient selection and strict postoperative monitoring.
Fallon, M.T., Storey, D.J., Krishan, A., Weir, C.J., Mitchell, R., Fleetwood-Walker, S.M., . . . Colvin, L.A. (2015). Cancer treatment-related neuropathic pain: Proof of concept study with menthol—A TRPM8 agonist. Supportive Care in Cancer, 23, 2769–2777.
To evaluate whether a topical menthol product has clinical benefit for pain of peripheral neuropathy
Patients were given a 1% menthol in aqueous cream and were instructed how to apply it to the affected area and corresponding dermatome region of the spine twice daily. Patients were followed for four to six weeks.
PHASE OF CARE: Late effects and survivorship
Open-label
Eighty-two percent showed an improvement in pain scores (p < 0.001). Significant improvements were observed in some aspects of quantitative sensory testing for mechanical detection threshold, cool stimulus, and warm stimulus. Both walking velocity and cadence improved. No significant changes in hand dexterity or LANSS scores were reported.
The findings suggest that the topical application of menthol can improve symptoms of chronic chemotherapy-induced peripheral neuropathy.
This study is limited by its small sample size and study design, but shows promising proof of concept results related to molecular receptors in sensory nerves that appear to respond to topical menthol. Very few interventions have been shown to prevent or effectively treat chemotherapy-induced peripheral neuropathy, so further research on the use of topical menthol is warranted. Further well designed studies are needed.
Fallon, M., Hoskin, P.J., Colvin, L.A., Fleetwood-Walker, S.M., Adamson, D., Byrne, A., . . . Laird, B.J. (2016). Randomized double-blind trial of pregabalin versus placebo in conjunction with palliative radiotherapy for cancer-induced bone pain. Journal of Clinical Oncology, 34, 550–556.
To determine the effectiveness of pregabalin in conjunction with radiotherapy to treat patients with cancer-induced bone pain (CIBP)
This double-blind randomized study examined the concurrent use of pregabalin with palliative radiotherapy (versus placebo with radiotherapy) to prove the efficacy of use for treatment of CIBP. Patients were given 75 mg pregabalin or placebo twice daily for 35 days. Assessment of analgesia was done every seven days from baseline. If adequate analgesia was not achieved, trial medication was increased incrementally up to 300 mg twice daily. Radiotherapy was given in either one fraction of 8 GY or 20 Gy in five fractions.
No statistically significant differences in average pain, pain intereference, or quality of life were discovered. However, differences in mood and breakthrough pain duration, which was lesser in the pregabalin arm (p = 0.037), were present.
These findings do not support use of pregabalin in patients with CIBP receiving palliative radiotherapy.
Nurses providing care to patients in the outpatient setting are in prime position to conduct further research to determine the efficacy of adjunct medications and/or other treatment modalities used for treatment of CIBP and chronic cancer pain in general. Nurses may serve as principal investigators or coinvestigators in further research to determine the most effective interventions. Nurses may also serve to make recommendations for Putting Evidence into Practice (PEP) in outpatient cancer treatment settings, and in doing so serve as patient advocates. Findings do not support the use of pregabalin for metastatic bone pain in patients with cancer.
Fallon, M., Reale, C., Davies, A., Lux, A.E., Kumar, K., Stachowiak, A., & Galvez, R. (2011). Efficacy and safety of fentanyl pectin nasal spray compared with immediate-release morphine sulfate tablets in the treatment of breakthrough cancer pain: A multicenter, randomized, controlled, double-blind, double-dummy multiple-crossover study. Journal of Supportive Oncology, 9(6), 224–231.
To compare the efficacy and tolerability of fentanyl-pectin spray (FPNS) with that of immediate-release morphine sulfate (IRMS) in the treatment of breakthrough cancer pain (BTCP)
Patients in the study were experiencing 1–4 episodes of BTCP per day while taking at least 60 mg/day of oral morphine or equivalent for BTCP. Patients completing the titration phase continued to the double-blind, double-dummy phase: 10 episodes of BTCP were randomly treated with FPNS and oral capsule placebo (5 episodes) or IRMS and nasal spray placebo (5 episodes). The primary end point was pain intensity (PI) difference from baseline at 15 minutes. Secondary end points were onset PI decrease (≥ 1 point) and time to clinically meaningful pain relief. Safety and tolerability were evaluated by means of adverse events (AEs) and nasal assessments. By-patient and by-episode analysis were completed. Duration of follow-up was a maximum of 14 days in the open-label period.
Randomized, controlled, double-blind, double-dummy, multiple crossover trial
The pain intensity difference associated with FPNS was greater than that associated with IRMS. The difference between the two measures of pain intensity was statistically significant (p < 0.05).
For patients receiving around-the-clock opioid treatment for chronic cancer-related breakthrough pain, FPNS appears to be effective, safe, and well tolerated. The early reduction of pain that FPNS provided either matched or exceeded that provided by IRMS. Compared to IRMS, FPNS provided more complete pain relief. The effects of long-term use of FPNS have not been evaluated; nurses must be aware that long-term effects of FPNS on the nasal mucosa are unknown.