STUDY PURPOSE: Literature review with goals to synthesize current studies and update findings in order to obtain a current, comprehensive estimate of the benefits of pain education.

TYPE OF STUDY: Systematic review

DATABASES USED: PubMed

YEARS INCLUDED: 1987 to March 2014

INCLUSION CRITERIA: Keywords: cancer AND pain AND patient AND education. MeSH terms: pain, pain management, patient education as topic, self-care methods, health knowledge, attitudes, practice, and neoplasms. 

EXCLUSION CRITERIA: No specific exclusion criteria.

TOTAL REFERENCES RETRIEVED: 37

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Criteria used to evaluate: Pain experience, patient satisfaction, and patients’ communication skills and decision making.

FINAL NUMBER STUDIES INCLUDED: 44

TOTAL PATIENTS INCLUDED IN REVIEW: 6,308

SAMPLE RANGE ACROSS STUDIES: 30-970

KEY SAMPLE CHARACTERISTICS: Patients with cancer

PHASE OF CARE: Multiple phases of care

Pain experience: 85% of the studies reported that PEP (Pain Education Programs) significantly improved knowledge and beliefs, 52% of studies showed a statistically significant reduction in pain intensity when using PEP, but none of the studies (except one) showed that the intervention had any clear benefits on QOL.

Patient satisfaction: 90% of patients believed that PEP was helpful and 78% said that PEP made them more involved in pain management. 

Patients’ communication skills and decision making: Communication with clinicians was the most frequently developed behavior, and those patients who scored higher in active communication reported better pain relief and fewer barriers to pain management.

Research indicates a growing interest in therapeutic education of patients with cancer pain. PEP objectives have shifted from a focus on improving patients’ knowledge about pain management to enhancing their communication skills and attitudes. Additional research is warranted to better evaluate PEP effectiveness.

• Limited search
• No quality evaluation
• High heterogeneity
• Only English or French

PEP has been proven to increase patient knowledge of pain management, so it would be wise to increase training for nurses to conduct these interventions properly.

To investigate the effect of bone pain education on pegfilgrastim-related bone pain in patients with breast cancer receiving chemotherapy and pegfilgrastim. Patients were either shown a general video or specific bone pain video and then bone pain was assessed using patient surveys that asked about bone pain severity and location, medications usage, and information from adverse reporting.

Patients were randomized 1:1 to view either a generalized education video on chemotherapy side effects or a video on bone pain following chemotherapy and pegfilgrastim.

• N = 300   
• AGE: Older than 18 years
• FEMALES: 100%
• CURRENT TREATMENT: Chemotherapy, other
• KEY DISEASE CHARACTERISTICS: Stage I-III newly diagnosed patients with breast cancer 
• OTHER KEY SAMPLE CHARACTERISTICS: Planning on getting four cycles of neoadjuvant or adjuvant chemotherapy with pegfilgrastim support starting in cycle 1. Pegfilgrastim was given within 72 hours of chemotherapy. All received a 6 mg dose of pegfilgrastim and all were English speaking.

• SITE: Multi-site   
• SETTING TYPE: Outpatient    
• LOCATION: 48 community oncology clinics in the United States

• PHASE OF CARE: Active anti-tumor treatment
• APPLICATIONS: Elder care

Randomized single-blind study

• Severity of pain by a 0-10 scale
• Location of pain noted on a body map
• Both videos were developed by oncology nurses and oncologists but professionally produced by Amgen
• Adverse effects were graded using the CTCAE standards
• Medication logs
• Every patient watched the video at least twice and could take the video home. The videos did not replace existing patient education.  
• Area under the curve was used to capture both the magnitude and duration of pain in a single continuous measure.

Patient-reported maximum bone pain was similar in both groups. General versus specific C1 3.2 versus 3.5 (p = 0.3479); across all cycles, 4.1 versus 4.6 (p = 0.2196). Other measures of bone pain were also similar between groups. 

Bone pain was highest in C1 and then decreased and remained stable in subsequent cycles. Bone pain medication usage was also similar between the two groups with the highest usage in C1. 

The only area that showed significance was in the 65-75 age group. Maximum bone pain for general video was 2.9 versus 4.6 (p = 0.0599); mean bone pain was 1.3 versus 2.6 (p = 0.0220) and AUC was 5.3 versus 10.9 (p = 0.018).

The bone pain-specific education did not improve patient’s perception of bone pain reported in this patient population. However, this study did provide information on the prevalence, timing, severity, and location of pegfilgrastim-related bone pain. This may help focus future research on treatments for bone pain.

• Unintended interventions or applicable interventions not described that would influence results
• Key sample group differences that could influence results
• Measurement validity/reliability questionable
• Findings not generalizable
• Other limitations/explanation: Pain is highly subjective and could be influenced by other factors. It is difficult to predict and assess. Supplemental teaching was not standardized between sites. Age also could influence patient’s perception of pain.  
• The videos were only two minutes in length, which may not have been significant to generate a meaningful difference in reported pain. The videos may have been too similar.
• No control for patients watching video at home for other distractions. No pain management counseling given.

The major nursing implication is that pain is highest in C1. It is important to educate patients so they do not stop pegfilgrastim treatments due to pain. They need to know the amount of pain decreased is subsequent cycles. Education must always be individualized to be effective. Videos do not replace one-on-one teaching, but new educational methods need to be developed. More research is needed in different patient populations and on specific treatment experiences.

STUDY PURPOSE: To summarize the evidence-base of psychological interventions for women with metastatic breast cancer by mode of delivery and to synthesize data regarding core intervention elements and context factors.

TYPE OF STUDY: Systematic review

DATABASES USED: Medline, PsycINFO, CINAHL, SCOPUS

YEARS INCLUDED: Inception to May 2016

INCLUSION CRITERIA: Articles published or in press in a peer-reviewed journal between database inception to May 2016. Intervention targeted adult woman with a diagnosis of MBC or recurrent breast cancer. Studies including woman with MBC as part of a larger sample with other cancers if data could be extracted about MBC patients. The therapies were psychotherapeutic. Outcomes included survival, distress, coping, QOL, or somatic symptoms. All studies were RCT, quasi-RCT, or feasibility RCT in English.

EXCLUSION CRITERIA: Grey literature

TOTAL REFERENCES RETRIEVED: 740

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Meta-analysis (PRISMA) and a review protocol was developed.

FINAL NUMBER STUDIES INCLUDED: 15 RCTs across 23 articles

TOTAL PATIENTS INCLUDED IN REVIEW: 1,638

SAMPLE RANGE ACROSS STUDIES: 37 to 235

KEY SAMPLE CHARACTERISTICS: Age, years since MBC diagnosis, English speaking, race, partnership, education, employment

PHASE OF CARE: Multiple phases of care     

APPLICATIONS: Palliative care

Overall interventions improved distress in 8 of 13 RCTs, coping in 4 of 5 RCTs, and pain in 4 of 5 RCTs. No evidence of survival benefit was found. For remaining outcomes the evidence was either insufficient or too mixed to draw conclusions. Group programs had the strongest evidence base for efficacy. Individual and low-intensity therapy had insufficient evidence to form conclusions. Group interventions had longest intervention duration and lowest uptake and adherence. Low-intensity interventions had shortest duration and highest uptake and adherence. Disparities in uptake, adherence, and reach were evident with demographic profiles of age, race, language, and partnered woman (young, White, English-speaking, married women).

There remains a parity of psychological interventions for women with MBC. Those that exist have an inconsistent evidence base across the range of patient-reported outcomes. Further research is needed to evaluate accessible delivery formats that ensue efficacy as well as uptake and adherence. There were only five new articles from the last systematic review in 2013.

• Limited number of studies included
• High heterogeneity
• Outcomes varied between studies and used multiple different follow-up assessment tools.

More research is needed on the psychological therapies used in MBC patients in regards to survival, distress, coping, QOL, pain, fatigue, and sleeping, all of which contribute to depression. There is little research on this population and their psychologic concerns, particularly in minority populations. It is important that nurses reach a broader range of women with MBC. Research is also needed on how to deliver more accessible evidence-based interventions.

STUDY PURPOSE: To review in literature the effectiveness of sympathetic blocks in clinical trials. Both, neurolytic blocks of sympathetic as celiac plexus block (CPB) and superior hypogastric plexus block (SHPB), used for visceral abdominal pain in patients with pancreatic and gynaecologic cancer

TYPE OF STUDY: Systematic review

DATABASES USED: MedLine, Embase, and Cochrane Central Register of Controlled Trials

YEARS INCLUDED: Through February 2014

INCLUSION CRITERIA: Trials, both; neurolytic blocks of sympathetic as celiac plexus block (CPB) and superior hypogastric plexus block (SHPB), compared to analgesia or placebo, adult cancer patients and English language

EXCLUSION CRITERIA: Double publications, other clinical indications related, if only complications from sympathetic blocks reported

TOTAL REFERENCES RETRIEVED: 121

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Eligible trials were analyzed using the GRADE system

FINAL NUMBER STUDIES INCLUDED: 27 clinical trials 

TOTAL PATIENTS INCLUDED IN REVIEW: Not specified

SAMPLE RANGE ACROSS STUDIES: Sample range from 20 to 137

KEY SAMPLE CHARACTERISTICS: Pancreatic cancer for the CPB and pelvic pain related to gynecologic cancer for SHPB all of them requiring analgesia for their pain

PHASE OF CARE: Not specified or not applicable     
APPLICATIONS: Palliative care

CPB versus analgesia significantly decreased pain intensity, use of opioids, and reported less side-effect and better quality of life. SHPB versus morphine was more effective in only one RCT with 50 patients with gynecologic cancer that resulted in decrease in pain and less morphine.

Both, neurolytic blocks techniques, are sure and with few complications. Both are effective to reduce pain and to decrease use of opioids, less data is available from SPHB. Individual complete assessment in each patient is needed before deciding the technique to be done.

• Mostly low quality/high risk of bias studies
• High heterogeneity
• Low sample sizes
• No intention to treat analysis

No evidence can indicate the use of one or the other of the neurolytic blocks. Although celiac plexus block (CPB) seems recommended for pancreatic cancer pain, best timing for the technique is still uncertain. For superior hypogastric plexus block (SHPB) only after personalized evaluation in each case.

STUDY PURPOSE: Review the available evidence in literature to determine the effectiveness on the use of peripheral nerve blocks to treat cancer pain in adult patients.

TYPE OF STUDY: Systematic review

DATABASES USED: PubMed, EMBASE, and Cochrane

YEARS INCLUDED: All available data through February 2014

INCLUSION CRITERIA: No experimental studies of effectiveness of peripheral nerve blocks, adult patients with chronic cancer pain, data includes pain level outcomes, English language.

EXCLUSION CRITERIA: Double publications, management of postoperative pain, studies involving non-cancer patients, lack of pain assessment, experimental studies.

TOTAL REFERENCES RETRIEVED: 155

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Only case reports were used in the systematic review. No randomized controlled trials were retrieved.

FINAL NUMBER STUDIES INCLUDED: 16 

TOTAL PATIENTS INCLUDED IN REVIEW: 79

SAMPLE RANGE ACROSS STUDIES: The cancer diagnoses were identified, but not limited to, thoracic, tongue, renal, breast, lung, and ovarian. Some cases involved metastasis.

KEY SAMPLE CHARACTERISTICS: Patients with cancer, different diagnoses

PHASE OF CARE: Not specified or not applicable     
APPLICATIONS: Palliative care

Majority of cases yielded adequate pain relief with few side effects reported.

No conclusion can be made based on the lack of formal evidence. Greater than four types of nerve blocks were included in the 16 reviews.

• Limited number of studies included
• High heterogeneity
• Limited evidence

Although pain control is reported with peripheral nerve blocks, lack of sufficient evidence exists to support this intervention in practice based on this review.

Aim of the study was to investigate the effect of transdermal fentanyl (TDF) as an adjuvant to paravertebral block (PVB) for pain control after breast cancer surgery.

Trial included 50 females scheduled for mastectomy that were randomly allocated into one of two equal groups. The transdermal (TDF group) used transdermal fentanyl patches (TFPs) 25 mcg per hour applied 10 hours preoperative, then PVB with 20 ml of bupivacaine 0.25% was done before induction of general anesthesia. The PVB group used placebo patches in addition to PVB. Postoperative pain was assessed with a visual analog scale (VAS) score up to 48 hours. IV morphine 0.1 mg/kg was given when the VAS is ≥ 3 or on patient request. There was no significant difference between the two groups regarding age, weight, ASA class, and duration of anesthesia and surgery. The primary outcome measures were the time to first request for analgesia and the total analgesic consumption in the first 48 hours.

• N: 50  
• AGE: 49.8 (SD = 3.5) 
• FEMALES: 100%
• CURRENT TREATMENT: Not applicable
• KEY DISEASE CHARACTERISTICS: Breast cancer

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

PHASE OF CARE: Active anti-tumor treatment

Randomized, double-blind trial

Time to first request for analgesia and total analgesic consumption in the first 48 hours were analyzed. Group differences were compared using the independent samples Student's t-test or Mann-Whitney for numerical variables. Chi-square test was used to examine the relationship between qualitative variables. Two-way analysis of variance was used to test the interaction between the two groups' hemodynamic variables. Observer’s Assessment of Alertness/Sedation (OAA/S) and the visual analog scale (VAS) were also used.

The VAS score was significantly lower in TDF group than PVB group from 30 minutes postoperatively up to 24 hours. The time to the first request of additional analgesia was significantly longer in the TDF group (p < 0.001). The total dose of morphine consumption in 48 hours was significantly lower in TDF group (p = 0.039)

The use of fentanyl patches preoperatively and BVP appears to reduce the amount of morphine requested within the first 48 hours postoperatively for breast surgery and correlate with lower VAS scores.

Small sample (< 100)

Preemptive analgesia, if TFP is applied before surgery, it can be used to relieve postoperative pain.

To evaluate the efficacy and tolerability of high-dose oxycodone-naloxone (OXN-PR) in chronic cancer pain.

Patients aged 18 years or older with chronic cancer pain of moderate to severe intensity on analgesic therapy and/or who were intolerant to pain medications due to gastrointestinal side effects were switched to OXN-PR. Intensity of pain was measured on a 0 to 10 numerical rating scale. Patients were prescribed oral OXN-PR for pain control at the first visit with doses equivalent to morphine dosage. All patients were evaluated by trained clinicians at baseline and after 14, 30, 45, and 60 days. Components of the evaluation included quality of life, symptoms of constipation, and safety evaluations.

• N: 119 entered; 101 final  
• AGE: 28-94 years old (median = 64 years) 
• MALES: 61.3%  
• FEMALES: 38.7% 
• CURRENT TREATMENT: Not applicable
• KEY DISEASE CHARACTERISTICS: Pulmonary, GI, and GU cancers. 
• OTHER KEY SAMPLE CHARACTERISTICS: 91.6% with metastatic disease; 75.6% with bone involvement.

• SITE: Multi-site (seven pain centers)   
• SETTING TYPE: Outpatient    
• LOCATION: Italy

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

Multicenter, prospective 60-day observation on consecutive patients with cancer with uncontrolled moderate to severe chronic pain or intolerant to other analgesics.

Brief Pain Inventory Short Form 7; Bowel Function Index; 0- to 10-point safety evaluation.

At 60 days, 18 (15.1%) of patients had prematurely discontinued the OXN-PR due to death, disease progression, major side effects, lack of efficacy, or personal reasons. OXN-PR was associated with reduction in acute pain intensity compared to baseline at all measurement intervals (p = 0.009). A lower response rate was found in patients without metastatic disease. Bowel function improved after OXN-PR (p < 0.0001). There was also a significant decline in patients utilizing laxatives/enemas. The number of other side effects, such as nausea, somnolence, dizziness, tremors, or confusion was decreased by nearly 50% (p < 0.001).

OXN-PR agonist-antagonist combination was highly effective in managing cancer-related pain, reduced bowel dysfunction, and minimized opioid side effects.

• Risk of bias (no control group)
• Other limitations/explanation: Relatively small final sample size of 101 patients.

Oxycodone-naloxone is an effective therapy for the management of patients with cancer-related pain who may be intolerable to other therapies.

To establish whether the analgesic effect of morphine improves in patients with cancer when administered in combination with magnesium

Patients with moderate or severe cancer pain and starting morphine were randomized to 656.6 mg sulfate BID or placebo.

• N: 40   
• AGE: Mean = 58.5 years in intervention group and 58.2 years in the placebo group
• MALES: 22 (55%)
• FEMALES: 18 (45%)
• KEY DISEASE CHARACTERISTICS: Not stated
• OTHER KEY SAMPLE CHARACTERISTICS: Only gender, age, height, and weight were reported. No information on current treatment

• SITE: Not stated/unknown   
• SETTING TYPE: Not specified    
• LOCATION: Not specified

PHASE OF CARE: Not specified

Prospective, randomized, double-blind trial

Pain intensity measured on 0 to 10 scale at baseline and weeks 1, 2, 3, and 4. Functional performance as assessed by Karnofsky and QOL assessed by the EORTC at first and last interview. Dose of morphine and side effects were recorded.

No difference in participant characteristic, pain intensity, morphine dose, functional performance, or QOL. Pain intensity was significantly reduced in both groups. No difference was found in the side effects of morphine except for constipation in week 1.

Morphine combined with magnesium did not lead to better analgesic effects, QOL, or functional performance.

• Small sample (< 100)
• Risk of bias (sample characteristics)
• Selective outcomes reporting
• Other limitations/explanation: Minimal details on study population

The use of morphine and magnesium did not induce a better analgesic effect or improve functional status or QOL.

To test the intelligent pain management system (IPMS) on mobile phones among patients with cancer with pain.

Data regarding pain assessments, satisfaction, and effectiveness of pain management, and change in QOL was recorded through a mobile phone app, the IPMS.

• N = 46   
• MEAN AGE: Trial group, 76 years; control group, 68 years
• MALES: 70%  
• FEMALES: 30%
• CURRENT TREATMENT: Chemotherapy, other: Not specified which type of treatment. Not radiation-exclusion criteria.

• SITE: Single site   
• SETTING TYPE: Outpatient    
• LOCATION: Oncology Center of Xinhua Hospital affiliated to Shanghai Jiao Tong University School of Medicine, Chongming Branch, China

PHASE OF CARE: Active anti-tumor treatment

Randomized controlled trial

• Karnofsky Performance Status (KPS)
• Pain Management Knowledge
• Paon Assessment

Over the 14-day trial period, the trial group had on a score of on average 0.28 less than the control group (p < 0.001) and at the end of the trial period, 0.75 less than the control group (p < 0.001).

IPMS use as a way to assess pain in patients with cancer has shown promising results. A larger study with a variety of patients with cancer is needed to assess for generalizability.

• Small sample (< 100)
• Baseline sample/group differences of import
• Key sample group differences that could influence results
• Other limitations/explanation: Short duration of the trial period

Using technology such as mobile device apps can be a novel way to maintain constant contact and management of patient pain. It is worthwhile to invest resources in expanding research in this area.

STUDY PURPOSE: The purpose of this systematic review of the literature was to determine the impact of hypnosis on the most common symptoms patients with cancer experience at the end-of-life: fatigue, sleep disturbances, pain, appetite loss, and dyspnea.

TYPE OF STUDY: Systematic review

DATABASES USED: EMBASE, MEDLINE, COCHRANE, PsycINFO, and SCOPUS

YEARS INCLUDED: From inception through November 2016

INCLUSION CRITERIA: Published in peer-reviewed journal; English language; RCT methodology and efficacy data; assessed at least one of five symptoms: fatigue, sleep disturbances, pain, appetite loss, or dyspnea; included hypnosis intervention; included patients with cancer at end-of-life 

EXCLUSION CRITERIA: Not stated

TOTAL REFERENCES RETRIEVED: 94

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: None of the studies met the inclusion criteria

FINAL NUMBER STUDIES INCLUDED: 0

TOTAL PATIENTS INCLUDED IN REVIEW: 0

SAMPLE RANGE ACROSS STUDIES: 0

KEY SAMPLE CHARACTERISTICS: None

PHASE OF CARE: Not specified or not applicable

Results from this systematic review revealed no studies were identified that rigorously tested hypnosis as an intervention to improve five of the most common symptoms experienced by patients with cancer at end-of-life. A review of 100 abstracts revealed that none of the identified studies met the inclusion criteria. These results were consistent with previous research that failed to identify RCTs using hypnosis for management of sleep disturbances, fatigue, pain, appetite loss, or dyspnea in terminally ill patients with cancer (Rajasekaran et al., 2005).

Patients with cancer at the end of life commonly experience a multitude of challenging symptoms, specifically, sleep disturbances, fatigue, pain, appetite loss, and dyspnea. Management of these symptoms at end of life is a key part of care and finding interventions to relieve them is a National Institutes of Health (NIH) priority. Although hypnosis proved to be effective in improving symptoms in patients with cancer and other chronic illnesses, hypnosis has not been rigorously studied for symptoms in patients with cancer at the end of life.

Limited number of studies included

The future of hypnosis for improving symptom in patients with cancer at the end of life is promising. However, as a result of the current lack of rigorous research on hypnosis for symptom management in patients with cancer at the end of life, hypnosis cannot be recommended.