The primary objective was to find which interventions, if any, were effective in preventing central venous catheter (CVC)-related infections in children with cancer. The secondary objective was to examine the effectiveness of each intervention in the subgroups of (a) implanted venous external catheters, (b) hematologic versus nonhematologic malignancies, and (c) in those receiving hematopoietic stem cell transplantation (HSCT) versus no HSCT.

Databases searched were the Cochrane Central Register of Controlled Trials (2008), MEDLINE (January 1950–January 2009), EMBASE (January 1980–January 2009), and CINAHL (January 1982–March 2009), as were reference lists from relevant articles and international conference proceedings (2004–2008).

Reviews examined were randomized, controlled trials and quasi-randomized, controlled trials of children (younger than 18 years) with cancer who had long-term tunneled CVCs with a CVC infection-prevention intervention other than anticoagulants, systemic antibiotics, and antibiotic lock techniques versus no intervention, placebo, or other intervention to prevent CVC-related infections.

Studies with interventions to treat other catheter-related complications were excluded.

Twenty-eight total references were retrieved.

For dichotomous outcomes, risk ratio and 95% confidence interval (CI) were used to express the estimate of effect; for continuous outcomes, weighted mean differences, standard deviation (SD), and 95% CI were used to summarize the data for each group; and for rare events, rate ratio as a summary statistic and meta-analysis of rate ratios via a generic inverse-variance approach were used.  

The initial total search yielded 876 citations, 216 of which were duplicates. From this, 28 full-text articles were reviewed and three were kept for final analysis. The overall study quality was low.

• After all exclusions, three studies (with 793 participants) were examined.
• Sample range across studies was 103 to 577 patients.
• Patients younger than 22 years with hematologic and nonhematologic malignancies, and one study with HSCT recipients, who had long-term internal or external CVCs were included. Interventions were monthly flushes of 3 mL of prophylactic urokinase-heparin (total doses of 5,000 IU of urokinase) versus heparin alone (total doses of 300 units of heparin); two weekly catheter flushes with urokinase alone (5,000 IU/mL) versus heparin alone (100 units per mL); and transparent catheter dressing changes every 15 days versus every four days (HSCT study).

• Patients were undergoing the active treatment phase of care.
• The study has clinical applicability for pediatrics.

Meta-analysis for the comparison of catheter flushing with urokinase (with or without heparin) versus heparin alone demonstrated an effect on the catheter-associated infection (CAI) rate with the rate ratio of CAI rate = 0.72 (95% CI [0.12, 4.41]) with use of urokinase in adults. One study reviewed reported an incidence of CAI of 2.6 per 1,000 CVC days with urokinase and 3.9 per 1,000 CVC days with heparin (p = 0.04). Studies involving different frequencies of dressing changes were difficult to analyze because adherence to every 14-day change was very low.

There were fewer CAIs with urokinase flushes, with or without heparin versus heparin alone, suggesting that urokinase use in catheter flushes may be beneficial. These findings are limited by the wide CI in findings and the fact that how CAI was defined for this systematic review was not described. No firm conclusions can be drawn from this review regarding urokinase, but the results suggest that further research in this area is warranted, although the difference between the groups was not statistically significant. There were no differences between groups who received dressing changes every 15 days versus every four days regarding the premature removal of the catheter due to infection. Catheter-related infections were not evaluated in the dressing change study, and adherence to the dressing change intervention was poor.

The results highlight need for clear and consistent outcomes definitions to further the research in this area.

Databases searched were AMED, EMBASE, MEDLINE, and PubMed via the Ovid platform and CINAHL via EBSCO.

Search keywords were oncology, chemotherapy, radiotherapy, strength training, aerobic exercise, walking program, physical activity, and fatigue.

Studies were included if they reported 

• An acute or rehab hospital setting
• A controlled trial
• An outcome measure of fatigue
• Sufficient exercise intensity to have a physiologic effect.

Studies were excluded if they reported additional diversional interventions.

Initially, 2,954 studies were retrieved. After exclusions, there was a final set of five studies. The PEDro scale was applied for evaluation of study quality.

• The final five trials included 269 patients with various cancer types.
• Sample sizes ranged from 22 to 104 patients.

• Overall study quality was low, with scores being an average of 4.6 out of 10 possible points.
• Four trials were included in the meta-analysis. Findings for fatigue showed a standardized mean difference of -0.22 (95% confidence interval [-0.62, 0.08]; p = 0.13).
• The most common fatigue measures were the Brief Fatigue Inventory (BFI) and visual analog scale (VAS).
• All interventions involved aerobic exercise.
• There were no between-group effects seen for other symptoms analyzed.

This review showed no significant effect of aerobic exercise interventions for fatigue outcomes in hospitalized patients with cancer. As this study only included hospitalized patients, the findings may not be applicable in other patient groups.

The study was limited by the small number of included trials, with most having small sample sizes.

Effectiveness of exercise for fatigue may vary greatly depending on the phase of care and time in the cancer disease trajectory at which the intervention is provided. Lack of significant positive findings here may be related to the timing of the intervention with all patients in acute or rehabilitation hospitals.

To test the effectiveness of a brief intervention using a cognitive and behaviorally oriented approach on symptoms of fatigue.

Patients were randomly assigned to the intervention or usual care control group. The intervention included three individual face-to-face, sixty-minute sessions that coincided with chemotherapy treatment schedules. These were aimed at clarifying meanings, setting goals, educating patients about cancer-related fatigue, developing and discussing coping strategies, and cognitive restructuring. Sessions were audiotaped to ensure treatment fidelity. Study assessments were performed at baseline (cycle three of chemotherapy), the end of treatment, four weeks after the end of treatment, and nine months after study entry.

• In total, 50 patients (40% male, 60% female) were included.  
• Mean age was 59.1 years (standard deviation = 11.5 years).
• Colorectal cancers were the most common. Multiple other tumor types were included
• Of the patients, 80% had stage III or IV disease, and 76% had at least one other comorbid condition.

• Single site 
• Outpatient 
• United Kingdom

Patients were undergoing the active antitumor treatment phase of care.

The study was a randomized, controlled trial.

• 100-mm visual analog scale (VAS) for global fatigue
• European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30)
• Fatigue outcome measure designed for the study
• Multidimensional Fatigue Inventory (MFI)
• Hospital Anxiety and Depression Scale (HADS)

VAS fatigue scores were significantly lower in the experimental group at Time 2, end of treatment (p = 0.03), but not at any other time point. EORTC physical functioning scores were higher in the experimental group at the end of treatment (p = 0.001) and at four weeks after treatment ended (p = 0.02). There was an overall trend over time favoring the experimental group; however, the trend was not significant and was smaller when data were controlled for medical conditions and HADS scores. No data for the nine-month time after treatment were provided.

Findings suggest that a cognitive-behavioral approach intervention can be beneficial in reducing fatigue during the short term after cancer treatment.

• The study had a small sample size, with less than 100 participants.
• The study had risks of bias due to no blinding and no appropriate attentional control condition.
• Subject withdrawals were 10% or greater. 

Findings suggest that cognitive-behavioral approach interventions to restructure thinking, set goals and coping strategies, and improve self-efficacy may be helpful in reducing fatigue immediately after chemotherapy treatment. This evidence is not strong, given the study limitations here, but the findings are potentially promising.

To test the effectiveness of propolis as a mouthwash to reduce chemotherapy-induced oral mucositis

Patients were randomized to receive a propolis mouth rinse (30% extract) or sterile water placebo rinse. Patients were to swish 5 ml of the rinse in the mouth for 60 seconds, gargle, and expectorate. Rinses were used three times daily for seven days.

• N = 40   
• AGE = Not reported
• MALES: Not reported  
• FEMALES: Not reported
• CURRENT TREATMENT: Combination radiation and chemotherapy
• KEY DISEASE CHARACTERISTICS: Patients with head and neck cancer receiving chemotherapy and radiation therapy

• SITE: Single site   
• SETTING TYPE: Outpatient    
• LOCATION: Iran

PHASE OF CARE: Active antitumor treatment

Double-blind, randomized, controlled trial

World Health Organization (WHO) mucositis grading

By day seven, erythema, wounding, and general mucositis grades were lower in the propolis group (p < 0.006). Mucositis grades were lower in the propolis group.

The findings suggest that propolis mouth rinses may be helpful to manage oral mucositis in patients with head and neck cancer receiving chemotherapy and radiation therapy. Well designed research is needed to confirm these findings.

• Small sample (< 100)
• No demographic information was provided, and the chemotherapy regimens used were not adequately described. There is no information about other aspects of oral care that were used.

This study report has multiple flaws and provided only weak evidence of the potential effectiveness of propolis for the reduction of oral mucositis. Well designed research is needed to further evaluate the potential effects of this intervention.

To study the efficacy of aprepitant in the prevention of chemotherapy-induced nausea and vomiting (CINV) in patients receiving moderately emetogenic chemotherapy (MEC) for colorectal cancer

Patients with advanced or recurrent colorectal cancer were treated with standard MEC regimens including FOLFOX, XELOX, OR FOLFIRI and received either standard antiemetic therapy with 5-HT₃ receptor antagonist (RA) plus dexamethasone or aprepitant regimen including 5-HT₃ RA plus reduced-dose dexamethasone plus aprepitant. Patients were followed from the initiation of chemotherapy through day 5 using patient diaries to record emetic episodes, nausea, or rescue antiemetics in 24-hour intervals.

• N = 117 Japanese and Australian adults with recurrent or advanced colorectal cancer stratified based on Performance status 
• MEAN AGE = 63.48 years in standard group, 66.46 years in aprepitant group
• MALES: 56%, FEMALES: 44%
• CURRENT TREATMENT: Chemotherapy
• KEY DISEASE CHARACTERISTICS: Patients with dvanced or recurrent colorectal cancer receiving MEC

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

PHASE OF CARE: Active antitumor treatment

Multicenter, phase II, open-label, randomized, parallel, comparative study

The outcomes in both groups were analyzed using chi-squared tests for primary end points, secondary end points, and patients characteristics by treatment group. Two-sided sample t tests were used when appropriate. P < 0.05 was considered to be a statistically significant difference.

The percentage of patients with complete response in the overall phase was 79.6% in the standard group versus 79.7% in the aprepitant group. The acute phase was 94.9% complete response in both groups, and the delayed phase was 79.6% versus 79.7%. The overall incidence of adverse events were similar in both groups.

No significant differences existed between the standard treatment and aprepitant regimen in terms of complete suppression of vomiting, nausea, and time to treatment failure. This study demonstrates that aprepitant in combination with a 5-HT₃ RA and reduced dose of dexamethasone is well tolerated and effective for preventing CINV associated with MEC in patients with colorectal cancer.

The addition of aprepitant to standard antiemetic therapy for MEC in patients with colorectal cancer is well tolerated and effective for control of CINV, but the lack of significant difference suggests that the added cost of an additional medication is not warranted.

Patients were enrolled to test vitamin E as prophylaxis against chemotherapy-induced peripheral neuropathy.

Patients were randomly divided into groups assigned to receive chemotherapy treatment with (group I) or without vitamin E supplementation (group II). Group II served as control. Patients assigned to group I received alpha-tocopherol (i.e., vitamin E) orally at a dose of 300 mg per day twice daily during chemotherapy and as long as three months after chemotherapy was completed.

• The total sample consisted of 40 patients treated with six courses of cumulative cisplatin, paclitaxel, or their combination regimens for a nonmyeloid malignancy.
• The final sample size was 31.
• Exclusion criteria included a history of neuropathy, systemic diseases such as diabetes, lupus, HIV, alcohol abuse, and those who had received chemotherapy in the past.

The study had a pilot, randomized, controlled, open label with blind assessment design.

The clinical evaluation of neuropathy was based on a modified Neurologic Symptom Score (NSS) and Neurologic Disability Score (NDS). NSS selected symptoms such as weakness, numbness, or pain, scoring as present (1) or absent (0). Clinical signs (i.e., cranial nerves function; joint position, pin prick, and vibration sensation; muscle strength and deep tendon reflexes) were assessed using a modified version of NDS ranging from 0 (no deficit) to 4 (absence of function/severest deficit). Electrophysiologic examination included motor conduction of ulnar and peroneal nerves. Measures were taken at baseline and repeated after the third and sixth cycles as well as three months after cessation by the same neurologist.

Vitamin E supplementation significantly decreased the incidence of neurotoxicity, with 25% of patients receiving Vitamin E experiencing chemotherapy-induced peripheral neuropathy compared to 73.3% in the control group.

This pilot study with a small sample size and many variables assessed make achieving a statistically significant result by chance alone more likely.

Small sample size

To assess the efficacy and safety of celiac plexus neurolysis in reducing pancreatic cancer pain; to identify adverse effects and differences associated with various techniques of celiac plexus neurolysis

• Databases searched were Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Gateway, and EMBASE. In addition, investigators manually searched reference lists and the proceedings of relevant international professional groups.
• Search keywords were celiac plexus, nerve block, pancreatic cancer, and pain.
• Studies were included if they
  • Involved celiac plexus block implemented through a surgical approach or EUS.
  • Were randomized controlled trials that included a minimum follow-up of four weeks.
  • Were published in English.
  • Dealt with pain secondary to pancreatic cancer.
• Studies were excluded if they were reported in an abstract rather than a full article or if they dealt with pain due to chronic inflammation rather than pain relating to cancer of the pancreas.

The initial search retrieved 102 studies. Investigators reviewed the studies in terms of risk of bias. Investigators performed a meta-analysis on studies that they selected to include.

• The final sample of studies consisted of six studies involving 358 patients.
• Range of sample size, across studies, was 20–137.

• At four weeks, mean pain score difference according to a visual analog scale was –0.42 with 95% confidence interval (CI) –0.71 through –0.13 (p = 0.004) in favor of celiac block. At eight weeks, investigators noted significant heterogeneity.
• Opioid consumption was lower with celiac plexus block, with a mean difference at four weeks of –34.33 (95% CI –44.43 through –24.24, p < 0.00001).
• Adverse events were more likely to occur in control groups. The most common adverse events were diarrhea and constipation. These effects may have been associated with the higher opioid consumption of patients taking placebo.
• The number of studies was insufficient to allow researchers to evaluate the efficacy of different block implementations.

Celiac plexus block appears to be a safe and effective means of reducing bone pain associated with pancreatic cancer. Results show that celiac plexus block has a slight but statistically significant advantage over usual analgesic treatment. Investigators noted that the studies included in the analysis had some identified risk of bias. Three of the studies were blinded; three were not. The studies Arcidiacono et al. reviewed were the same studies that Yan and Myers reviewed in 2007.

Data are insufficient to allow researchers to evaluate the differences between CT-guided and posterior percutaneous celiac plexus block techniques.

Nurses should be aware of celiac plexus block as a means of pain management in patients with cancer of the pancreas. Nurses should advocate for the patient and inform him or her of potential treatment options. Findings of this meta-analysis are based on follow-up at four weeks, and results showed significant heterogeneity at eight weeks. This suggests that efficacy may not be sustainable over the long term. Further research, including long-term follow-up, is needed.

STUDY PURPOSE: To review the evidence for efficacy of music interventions for patients with cancer receiving palliative care and review the neurobiological evidence to explain pathways by which music may have an effect

TYPE OF STUDY: Systematic review

DATABASES USED: PubMed, CINAHL, Plus, Ovid, PsycINFO, PoQuest, and the Cochrane Library

KEYWORDS:  music; music therapy; cancer; oncology; palliative care; pain; anxiety; depression; mood; quality of life; neuroscience; endogenous opioids; dopamine; GABA; 5HT; permutations

INCLUSION CRITERIA: RCT; meta-analysis or systematic review from 1970–2012

EXCLUSION CRITERIA: Not reported

TOTAL REFERENCES RETRIEVED: Not reported

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Not reported

• FINAL NUMBER STUDIES INCLUDED = six studies regarding pain, eight studies for anxiety, four studies regarding quality of life, four studies involving effect on mood, and eight studies exploring the neurobiologic evidence
• SAMPLE RANGE ACROSS STUDIES, TOTAL PATIENTS INCLUDED IN REVIEW = 527 in pain (range: 30–136) and 410 for anxiety (range: 20–136)
• KEY SAMPLE CHARACTERISTICS: Samples included adults and children. Most interventions were done during a diagnostic or other procedure.

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

In the acute pain setting, music had a moderate analgesic effect with SMD of -.059, 95% CI -0.90, -0.27 (p = .0003). Effect for chronic pain is not known and has not been well studied. The study cites results of a Cochrane review of effects of music on anxiety (SMD -11.2, p = .0088). It is noted that effect on anxiety only has been studied in the acute, situational setting. Longer-term effects and application in palliative care are unknown. Review of neurobiologic evidence suggests that music may affect specific pathways that are implicated in the pathophysiology of pain, anxiety, and depression.

Music interventions have a moderate positive effect on procedural pain and acute, situational anxiety.

• This review does not report results of the literature search nor any quality evaluation of manuscripts retrieved. 
• For pain analysis, no description is provided of methods to calculate SMD or any findings regarding heterogeneity. 
• For anxiety, this report just repeats findings from a previous Cochrane review. 
• Although inclusion criteria stated RCT, the authors did include at least one single-group trial in the review.

Music may be helpful to reduce acute anxiety and procedure-related pain. This is a simple intervention nurses could use in a variety of settings. Longer-term effects and effects in different situations are not known.

• FINAL NUMBER STUDIES INCLUDED = 10
• TOTAL PATIENTS INCLUDED IN REVIEW = 488 (62 lost to attrition)
• KEY SAMPLE CHARACTERISTICS: The frequency of intervention and type of intervention varied (Note: 10 studies of 8 different intervention foci.): 70% of the sample studies held intervention sessions once per week for a total of three to eight weeks. Participants with terminal cancer were studies either weekly or bi-weekly until death. The dance movement study held sessions two times per week for six weeks then once weekly for six weeks. One study held a music therapy session during chemotherapy.

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

Depression and anxiety were shown to improve in three of the studies although the interventions were different (music therapy, art therapy, and mindfulness-based art therapy). Other psychological factors also improved: lower ratings of somatic symptoms in an art therapy study and a creative arts study, and psychiatric symptom improvement. Improvements in various measures of quality of life were reported in studies of mindfulness-based art therapy, art therapy, music therapy, creative arts therapy, and dance/movement therapies. Art therapy showed improvements in coping resources and mood states. Music therapy showed improvements in stress and anger. Creative arts therapy showed improvements in specific aspects of the Profile of Mood States (POMS) that were reported: tension-anxiety, depression-dejection, anger-hostility, and confusion-bewilderment.

Evidence reviewed in this study is inconclusive regarding effectiveness of various creative interventions.

• Selected articles using creative psychological interventions did not include writing therapy or drama therapy.  
• Meta-analysis was not possible, although rationale was clearly explained by the writers.
• Only one of the 10 articles was evaluated as having high quality; the remaining were satisfactory.
• Follow-up measures were not included in several studies.
• The number of articles included in the sample was small (n = 10).
• There appear to be discrepancies in accuracy of references to specific studies in the table: example, page 4, last paragraph indicates lack of replicated findings, whereas the table indicates otherwise.
• Specified Creative Psychological Interventions delivered by a qualified therapist were shown to improve well-being on several measures. 

The therapies were implemented by qualified therapists and were varied in nature, although not exhaustive of available therapies. The value of music, art, and movement therapies are shown to effectively reduce symptoms of anxiety and depression and improve quality of life, coping, and mood. Suggestions for further research are offered.

To test the hypothesis that an Acceptance and Commitment Therapy (ACT) group intervention would reduce anxiety and increase positive outcomes among cancer survivors at the re-entry phase

Groups were facilitated by a trained clinical psychologist and oncology social worker and provided in seven weekly two-hour sessions. Participants were assisted in cultivating awareness and acceptance of thoughts and emotions about cancer, disentangling from rigid thoughts and beliefs, clarifying personal values, and committing to pursue activities aligned with those values through experiential exercises, metaphors, discussion, and homework. Study outcomes were measured at 3.5, 2, and 0.5 weeks baseline prior to the intervention, midintervention, one week following the last session, and three months after the last session.

• N = 42   
• MEAN AGE = 53.52 years
• AGE RANGE = 20–70 years
• MALES: 7.1%, FEMALES: 92.9%
• CURRENT TREATMENT: Not applicable
• KEY DISEASE CHARACTERISTICS: Varied cancers; 59.5% had breast cancer. All had completed initial treatment within the past 12 months.
• OTHER KEY SAMPLE CHARACTERISTICS: Ninety-seven percent were Caucasian with an average of a bachelor’s degree and a median income of $41,000–$60,000. All patients demonstrated anxiety on screening tools, and 52% had both anxiety and depression upon study entry.

• SITE: Multi-site   
• SETTING TYPE: Other    
• LOCATION: A community center in Colorado

PHASE OF CARE: Transition phase after active treatment

Quasiexperimental

• State-Trait Anxiety Inventory (STAI)  
• Center for Epidemiological Studies Depression Scale (CESD)
• Short Form 36 Health Survey (SF-36)
• Concerns about recurrence scale
• Revised Impact of Event Scale (IES)
• Orientation to Life Questionnaire
• Participant rating of the value of each session

Anxiety declined following the intervention at immediate postmeasurement (p < 0.001) and three-month follow-up (p < 0.001). Depression symptoms also declined after the intervention (p < 0.001) and at three-month follow-up (p < 0.001). Fear of cancer recurrence decreased (p < 0.05) and at follow-up (p = 0.001).

The findings suggest that the group ACT intervention can help reduce anxiety and depression at healthcare re-entry among cancer survivors.

• Small sample (< 100)
• Risk of bias (no control group)
• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Measurement validity/reliability questionable
• Intervention expensive, impractical, or training needs
• Used a large battery of tests repeatedly over a short period of time—testing effect could be a threat to validity.

The group psychotherapy approach used here may be helpful to patients who are suffering from anxiety and/or depression after completion of initial treatment for cancer. Further research is needed.