To investigate the use of a web-based cognitive training intervention for subjective and objective cognitive complaints in breast cancer survivors

HAPPYneuron Pro^© (Scientific Brain Training, Villeurbanne Cedex, France) is a customized 12-task training program of 6 cognitive domains (attention, processing speed, learning, memory, working memory, problem solving) involving 10 levels of difficulty. The program required a minimum commitment of 30 minutes a day for 5 days a week for 6 weeks.

• N = 157   
• MEAN AGE = 54.77 years (SD = 8.62)
• FEMALES: 100%
• CURRENT TREATMENT: Not applicable
• KEY DISEASE CHARACTERISTICS: Breast cancer
• OTHER KEY SAMPLE CHARACTERISTICS: Recruited from existing cohort of 682 breast cancer survivors with subjective cognitive complaints and Internet access

• SITE: Single site   
• SETTING TYPE: Outpatient    
• LOCATION: Aarhus University Hospital, Denmark

PHASE OF CARE: Late effects and survivorship

Randomized, waitlist controlled, pretest–post-test design

• Paced Auditory Serial Addition Test (PASAT)-primary outcome working memory 
• Cognitive Failures Questionnaire (CFQ)-secondary outcome perceived cognitive function
• Neuropsychologic battery for other cognitive outcomes: Rey Auditory Verbal Learning Test (RAVLT) (verbal memory and learning), Digit Span Forward and Backward (working memory), letter fluency test
• 20 Question Test, and cognitive estimation task (CET) (executive function)
• Wechsler Adult Intelligence Scale (WAIS) (premorbid intelligence estimate)
• Beck Depression Inventory (depression)
• Whiteley-7 subscale from Common Mental Disorders Questionnaire (somatization, illness worrying, and conviction)
• SCL-ANX4 from Symptoms Checklist-92 of the Common Mental Disorders–Screening Questionnaire (anxiety)
• Likert-type scale rating of self-reported benefit from the intervention

Web-based cognitive training did not improve function for the PASAT-measured domain of working memory or the CFQ-measured secondary outcome of perceived cognitive function. Improvement was demonstrated for cognitive function on two other neuropsychologic measures for verbal learning (RAVLT) (F [2, 272.1] = 3.2, p = 0.043) and working memory (digit span backward) (F [2, 272.6] = 3.3, p = 0.04).

Primary and secondary outcomes were not achieved, but web-based cognitive training was associated with improvement onone test of verbal learning and one test of working memory. Further study with instruments validated for phone administration may be warranted.

• Risk of bias (no blinding)
• Risk of bias (no appropriate attentional control condition)
• Measurement validity/reliability questionable
• Not all measures were validated for phone administration.
• No webcam access to assure no cheating by participants

The web-based cognitive training intervention was well received by participants and not burdensome to administer in terms of costs. Small improvements were noted for some cognitive measures in the intervention group, and further study may be warranted.

To determine whether a profile-tailored cognitive-behavioral therapy (CBT) treatment program was more effective than either standard CBT or usual care in changing outcomes for patients with cancer-related pain.

Patients received standard CBT, profile-tailored CBT, or usual care. Therapy group sessions ranged from 5 to 50 minutes.

Standard CBT is comprehensive CBT that evaluates thoughts, feelings, and behaviors. It uses six to eight treatment strategies to teach patients to understand the relationship among pain, suffering, and emotions; to use symptom-coping skills, problem solving, relaxation, and self control; and to modify cognitive distortions associated with emotional distress.

Profile-tailored CBT matches patients’ scores on the Biobehavioral Pain Profile (BPP) to specific CBT modules, environmental influences, loss of control, healthcare avoidance, past and current experience, physiologic responsivity, and thoughts of disease progression.

RNs received a two-day training course to deliver the intervention.

• The study was comprised of 131 patients who were experiencing cancer-related chronic pain for more than six weeks that was associated with disease progression, adjuvant therapy, or surgical exploration.
• Mean patient age was 52 years.
• Of the patients, 72% were female, 63% were Caucasian, and 35% were African American.
• Patients had at least one elevated score on the BPP.
• The most common diagnoses were lymphoma and breast, colon, and lung cancers.

The study was conducted at one inpatient and three outpatient cancer centers in the southeastern United States.

Patients were undergoing the active treatment phase of care.

This was a randomized, controlled trial.

• Brief Pain Inventory (BPI)
• Profile of Mood States (POMS)
• Karnofsky Performance Status Score (KPS)
• Medical Outcomes Study–Short Form Health Survey (MOS-SF)
• Katz Index of Independence in Activities of Daily Living (ADL)

Short-term outcome:  Based on the BPI, interference with sleep improved from baseline to immediately postintervention for the profile-tailored CBT group.

Between-group comparison of the treatment effect over the entire study found treatment effects for interference of pain with mood and sleep. Response to the intervention decreased with time.

• Poor retention was noted, with only 28 patients completing the study.
• The final sample size was very small.
• Other concepts were measured, such as fatigue, pain, bowel patterns, symptom distress, quality of life (QOL), and better KPS.
• RNs required a two-day training course to deliver the intervention.
• Space is needed to provide the intervention.

Participants received standard cognitive-based therapy, profile-tailored cognitive-based therapy, or usual care. Those in both therapy groups received 5- to 50-minute sessions. Standard cognitive-based therapy includes comprehensive cognitive and behavioral therapy that evaluates thoughts, feelings, and behaviors. It uses six to eight treatment strategies to teach patients to understand the relationship between pain, suffering, and emotions; to use symptom coping skills, problem-solving, relaxation, and self control; and to modify cognitive distortions associated with emotional distress. Profile-tailored cognitive-behavioral therapy (CBT) matched patient scores on the Biobehavioral Pain Profile (BPP) to specific CBT modules:  environmental influences, loss of control, health care avoidance, past and current experience, physiological responsitivity, and thoughts of disease progression.

• In total, 131 participants were included.
• Mean age was 52 years.
• Of the participants, 72% were female, 63% were Caucasian, and 35% were African American.
• Participants were experiencing cancer-related chronic pain for longer than 6 weeks, which was associated with disease progression, adjuvant therapy, or surgical exploration.
• Participants had at least one elevated score on the BPP.
• Most common diagnoses were breast, colon, and lung cancer and lymphoma.

One inpatient and three outpatient cancer centers in the Southeastern United States

Participants were undergoing the active treatment phase of care.

The study was a randomized trial.

Profile of Mood States (POMS) Symptom Distress Scale

No significant effects on fatigue were found.

• The study had poor retention. Only 28 patients completed the study; the end sample was very small.
• No intention-to-treat analysis was performed.
• Registered nurses received a two-day training course to deliver the intervention.
• Space to provide the intervention.

To investigate the effects of changing from floconazole to posaconazole on the incidence of invasive fungal disease (IFD) and survival

Data were obtained from medical records for analysis. From 2008 to March 2011, primary antifungal prophylaxis was fluconazole 100–200 mg daily. In 2011, prophylaxis was changed to posaconazole 200 mg three times per day. Fungal prophylaxis in most cases was done only during neutropenia. Wards were not equipped with HEPA filters. Bacterial prophylaxis with ciprofloxacin was used during neutropenia in 80%–90% of patients. In 283 patients, comparison of results with posaconazole versus fluconazole was done.

• N = 328   
• MEDIAN AGE = 59 years
• AGE RANGE = 21–85 years
• MALES: 55.1%, FEMALES: 44.9%
• CURRENT TREATMENT: Chemotherapy, other
• KEY DISEASE CHARACTERISTICS: Eighty-seven percent had acute myeloid leukemia, 29% had allogeneic hematopoietic cell transplantation (HCT), and 43.5% had nonallogeneic HCT.

• SITE: Multi-site   
• SETTING TYPE: Not specified    
• LOCATION: Sweden

PHASE OF CARE: Active antitumor treatment

Retrospective cohort comparison

IFD was defined according to the revised 2008 European Organization for Research and Treatment of Cancer (EORTC) definitions.

The incidence of IFD was signficantly lower at day 100 and at the end of patient follow-up (p < 0.01). The incidence of aspergillosis (p = 0.01) and invasive candidiasis (p < 0.05) were also lower in those given posaconazole. Antifungal therapy was more common in the fluconazole group (p < 0.01). There was no difference in overall survival at day 100 or at the end of follow-up.

The use of posaconazole for primary antifungal prophylaxis was more effective for reduction in IFD compared to fluconazole.

• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Unintended interventions or applicable interventions not described that would influence results
• Key sample group differences that could influence results
• No subgroup analysis according to HCT type
• No information on whether colony-stimulating factors were used

Posaconazole was shown to be more effective than fluconazole for the prevention of IFD in high-risk patients; however, the retrospective nature and other design factors limit the validity of this study. A variety of research is aimed at the determination of the most effective antifungal agents for prophlyaxis. Additional research is needed to determine if specific antifungals are more effective overall.

RESOURCE TYPE: Evidence-based guideline

• PHASE OF CARE: Multiple phases of care
• APPLICATIONS: Palliative care 

Not clearly listed in article. Article focused on the consensus points and education points. Prior to those sections, a general section regarding the literature was included.

• BTCP is not the same as background pain or end-of-dose pain.
• Assess pain for evidence of BTCP using algorithm such as the one by Davies et al. Recommend assessment of pain using 1–10 scale. Studies of the outcomes in patients who are assessed and managed using the assessment tools needs to be completed.
• Manage pain by considering the cause of the pain. Optimize control of background analgesia and background pain before trying to treat BTCP.
• The most common approach to manage BTCP in Canada includes the use of traditional short-acting opioids.
• Using up to 20% of total daily opioid dose to treat BTCP is reasonable. Consider using different formulations for background and breakthrough pain.
• Transmucosal fentanyl formulations are beneficial over traditional methods. Pharmacologic properties of the fentanyl formulation should be matched with the characteristics of the BTCP. Never use transmucosal fentanyl formulations in opioid-naïve patients. Injectable fentanyl and sufentanil can be used sublingually or intranasally in the inpatient setting; not recommended in outpatient setting.
• Concerns regarding opioid abuse and dependence should not prevent clinicians from using opioids in patients with a life expectancy less than three months.

• Developed for use in Canada and may not be generalizable to areas outside Canada

Understanding BTCP is vital for nurses to adequately manage pain. Nurses need to be aware of the available guidelines since they are usually at the sharp end of managing pain. With this knowledge, nurses can educate patients and families regarding the proper use of medications to manage pain, specifically BTCP.

RESOURCE TYPE: Expert opinion

• DATABASES USED: None
• INCLUSION CRITERIA: None
• EXCLUSION CRITERIA: None

PHASE OF CARE: Active antitumor treatment

Expert opinion

Literature review of common checkpoint inhibitors adverse events. No quality review provided.

Further education needs to be available on the toxicity profile related to immune checkpoint inhibitors, and obtaining a detailed personal and family history of autoimmune diseases, other comorbidies, concurrent medications, PE, and medications of patients is important prior to starting therapy.

To evaluate the effectiveness of guaraná in fatigue and depression in 36 patients with breast cancer undergoing adjuvant radiotherapy.

Patients were randomized to 75 mg guaraná daily or placebo for two weeks, and then switched to the opposite treatment for the last two weeks of radiotherapy. Randomization was centralized by a pharmacist.

• The final sample size was 36 patients.
• Mean age was 59 years for the experimental group and 57 years for the control group.
• All participants were women.
• Patients were diagnosed with early stage breast cancer for which adjuvant radiotherapy was indicated.

Patients were recruited at Faculdade de Medicina da Fundação do ABC.

The study was a randomized, controlled crossover trial.

• Patients completed the Chalder Fatigue Scale, the Brief Fatigue Inventory (BFI), and the Beck Depression Inventory (BDI) Scale II.
• These assessments were conducted immediately before first radiotherapy, at switching, and right before the start of the last radiotherapy treatment.

No significant differences existed between the two groups on any of the scales. In addition, no side effects were reported from the guaraná.

This study showed no effect from guaraná on fatigue for this population.

The study used patients who reported no fatigue at the beginning of the study.

A currently fatigued population may be worth exploring with guaraná. Patients using guaraná for fatigue should be educated about the research findings.

To present physiotherapy modalities applied for lymphedema therapy through a systematic literature review

Databases searched were Latin American and Caribbean Literature (LILACS), PubMed, and SciELO, covering periods from 1981–2009, 1951–2009, and 2001–2004, respectively. Also, data from physiotherapy textbooks were surveyed. Search keywords were post mastectomy lymphedema, physiotherapy upper limb lymphedema, complex decongestive physiotherapy, and manual lymphatic drainage. Inclusion and exclusion criteria were not described.

No description was provided of the total number of studies reviewed initially, of how identified articles were assessed, or hwo studies were selected and evaluated. 

• Nineteen studies were included in the report.
• The sample range across studies was 3–537.
• All samples included women with lymphedema post-breast cancer treatment.

Physiotherapy used for lymphedema treatment includes complex decongestive therapy (CDT), pneumatic compression (PC), high-voltage electrical stimulation (HVES), and laser therapy. Better results are obtained with combined techniques. CDT is the most used protocol, and its association with PC has demonstrated efficacy. The new techniques HVES and laser demonstrate satisfactory results.

CDT has the strongest scientific support. Its application together with PC has demonstrated efficacy, and new techniques with satisfactory results are being studied, such as HVES and laser therapy. Combined physiotherapy techniques produce the most beneficial effects.

Clinicians should select the best combination based on a detailed assessment of individual cases.

To evaluate the effectiveness of guarana in the treatment of the fatigue and depression of patients with breast cancer who are undergoing adjuvant radiation therapy

Guarana, a plant native to the central Amazon, is known for its stimulant properties. The study involved three phases. Investigators randomized patients at the start of adjuvant radiation treatment (RT) to either guarana or placebo (phase 1). Halfway through RT, crossover occurred from placebo to guarana and vice versa (phase 2). Protocol terminated at end of the 28th RT (phase 3) for both groups. Assessments occurred three times, once at the start of each phase. The total time of the trial was 35 days. A dose of 75 mg/day guarana was administrated.

• The sample was comosed of 36 participants. In Group A, 17 participants received guarana first, then switched to placebo. In Group B, 19 received placebo first then switched to guarana.
• Mean patient age in Group A was 59 years; in Group B, 57 years.
• All participants were female and had infiltrating ductal breast cancer. All patients had undergone mastectomy and were receiving adjuvant RT. Authors state that most participants had stage I or II cancer, but they do not provide a table of sample characteristics. 

• Single site
• Outpatient
• Brazil

Active treatment

Double-blind randomized design with crossover

• Chalder Fatigue Scale (CFS)
• Brief Fatigue Inventory (BFI), in Portuguese
• Beck Depression Inventory-II (BDI-II), validated in Portuguese

• Authors reported no statistically significant differences between the guarana- and placebo-treated group, on any of the measures of fatigue or depression.
• Authors reported no significant differences within groups over time or in different treatment arms, placebo or guarana.
• Authors noted no toxic effects of guarana.
• Participants in neither group had significant fatigue or depression at the start of the trial. Showing the improvement of a nonexistent symptom is impossible, according to the so-called floor effect.

Findings did not support the use of guarana for the treatment of depression or fatigue in cancer patients.

• The study had a small sample, with fewer than 30 participants. Conclusions drawn from such a small sample may not be valid.
• The study was likely underpowered in regard to detecting group differences.
• Participants did not demonstrate significant symptoms at baseline. A better course may be to select either patients at risk for fatigue and depression or a sample of individuals already presenting with such symptoms, to see if treatment results in improvement.

Due to the limitations noted, this study does not support valid nursing conclusions.

To investigate if providing tailored information to patients with advanced head and neck cancer decreases patients' symptoms of anxiety and depression

Patients at one study site received the intervention, and patients at another study site did not receive the intervention and were treated as a control group. The tailored information used was a multimedia tool that included a patient booklet; interactive computer software; computer animation describing cancer spread, staging, and surgical procedures; and a take-home DVD. The purpose of the packet was to educate patients about diagnostic and adjuvant procedures, nutrition, and speech and swallowing practice. Another component was a database. The database could receive and store patient input and could print information that could be given to the patient. The intervention was provided at the hospital by a nurse who was available to address patients' questions and concerns. The control intervention was usual care provided by a nurse practitioner who provided verbal information and pamphlets and met with some patients in an ad hoc manner. Data were collected at baseline. Outcomes were assessed at three months and six months.

• The study reported on a sample of 96 patients.
• Mean patient age was 59.8 years. The age range was 19–87 years.
• The sample was 75% male and 25% female.
• All patients had stage III or IV primary or recurrent head and neck cancer.
• Most patients received combination radiation and chemotherapy.
• The education level of the groups varied significantly, with patients in the control group having a much higher level of education.
• About half of the sample was employed.

• Multisite 
• Setting not specified
• Montréal, Canada

Active antitumor treatment

Nonrandomized controlled trial

• Distress Thermometer
• Hospital Anxiety and Depression Scale (HADS)

Over time, anxiety was lower in the intervention group (p = 0.001), and there was a significant group-by-time effect (p = 0.025). Anxiety did not decline in the control group over time. Over time, depression declined in both groups (p = 0.001), and there were no group differences in depression. Findings were grouped by low, borderline, and high anxiety levels according to HADS results. In the low-anxiety group, patients reported lower levels of anxiety over time than did controls (p = 0.003). In the borderline group, there were no significant differences between study groups. Among those who had clinical levels of anxiety at baseline, patients had lower levels of anxiety at three months (p = 0.014) and six months (p = 0.005). Among those with clinical depression in the control group, depression initially increased at three months and then decreased toward baseline,

Findings demonstrate that the providing information can have an effect on anxiety. It cannot be determined if the nature of the multimodal intervention was a critical factor or whether providing information in any form would be helpful, since there was no random patient assignment and patients in the control group received information in an inconsistent, ad hoc manner.

• The study had a small sample size, with fewer than 100 participants.
• The study had baseline sample and group differences of import.
• The study had a risk of bias due to no control group, no blinding, no random assignment, and no appropriate attentional control condition.
• Baseline data were obtained after the intervention was given.

Findings suggest that providing information to patients may help reduce patients' anxiety but not their symptoms of depression. This study used a package of information; such a package may be a practical means of ensuring that the information patients receive is consistent. Multiple limitations in this study prevent the drawing of firm conclusions about the effectiveness of the method studied.