• FINAL NUMBER STUDIES INCLUDED = 143
• TOTAL PATIENTS INCLUDED IN REVIEW = 14,039
• SAMPLE RANGE ACROSS STUDIES: 30–326 patients
• KEY SAMPLE CHARACTERISTICS: Most studies included patients with various types of cancer.

The meta-analysis was completed using all studies in a single analysis. The interventions were highly varied, including patient education, relaxation, cognitive behavioral therapy, etc. An analysis showed an overall effect size of SMD = 1.199 (95% CI 1.095 – 1.303, p < 0.001) for depression in 122 studies and an overall effect size SMD = 1.298 (95% CI 1.187-1.408, p < 0.001) for anxiety in 131 studies. There was high heterogeneity in the analysis. An analysis showed a significant publication bias for both depression and anxiety. A subgroup analysis showed significant effects of cancer type, patient selection, intervention format, and the method of measurement used in moderating results. The findings of this analysis suggested that interventions appeared to be more useful for patients with increased levels of psychological distress.

The findings of this review suggest that various psychological interventions can benefit patients with cancer dealing with symptoms of anxiety and depression.

The major limitation of this analysis was that the meta-analysis was done considering all studies together. This is questionable because it is difficult to see interventions such as cognitive behavioral therapy as equivalent to general patient education or relaxation techniques. The analysis showed high heterogeneity, which is not surprising given the range of interventions considered together and the variety of types of patients. The high risk of publication bias also limits the potential validity of these findings. Reports were restricted to studies involving patients from mainland China, so it is unclear if the findings would be applicable to other cultural groups. Databases outside of China were limited.

This meta-analysis did not provide substantial or useful support for various types of interventions aimed at managing the symptoms of depression and anxiety. To determine which interventions are most effective as supported by evidence, the interventions that are very similar if not exactly the same must be grouped for analysis. This was a major limitation of this report, and it is reflected in its high heterogeneity. Its findings need to be viewed with some caution given the limitations of this study.

To evaluate a web-based cognitive behavioral (CB) stress reduction program

Participants were assigned to receive either the web-based CB program (CBSM group) or a web-based health information program (HP group). The CB program was delivered by a group facilitator according to a manual for treatment. Group web sessions were used to provide education in relaxation techniques, support management, and stress management. The health information program was provided by a group facilitator according to a manual for the intervention. The sessions provided general wellness education but did not include any of the behavioral techniques. Sessions were recorded and reviewed during weekly clinical supervision to ensure treatment fidelity. All sessions lasted for 10 weeks.

• N = 61   
• MEAN AGE = 68.84 (SD = 9.23)
• MALES: 100%  
• CURRENT TREATMENT: Radiation, other
• KEY DISEASE CHARACTERISTICS: Advanced prostate cancer (APC), stage 3 or 4 at diagnosis
• OTHER KEY SAMPLE CHARACTERISTICS: Patients aged 50 years of age or older, treatment with androgen-deprivation therapy alone or in combination with radiation within the past six months, no history of surgery or chemotherapy in the past six months, no prior inpatient psychiatric treatment, a score 20 or greater on the Mini-Mental State Examination (MMSE)

• SITE: Multi-site   
• SETTING TYPE: Home    
• LOCATION: Participants were recruited at Robert H. Lurie Comprehensive Cancer Center of Northwestern University and Jesse Brown VA Medical Center in Chicago; however, group interventions occurred over the Internet with participants accessing them from their homes.

PHASE OF CARE: Transition phase after active treatment

Parallel, two-group trial

• Feasibility/acceptability assessed through recruitment, retention, and group attendance rates
• Efficacy evaluated using the Impact of Event Scale-Revised (IES-R) for cancer-related distress, the Patient-Reported Outcomes Measurement Information System (PROMIS) for depressive symptoms, and the Functional Assessment of Cancer Therapy-General (FACT-G) for health-related quality of life outcomes

Feasibility: 31.3% enrollment rate; many refused because of significant time requirements with participation or lack of interest in the intervention. The retention rate was 85.7% at six months for the CBSM group and 86.1% for the HP group. Both groups completed most sessions (more than 70%); however, the HP group completed significantly more sessions and weekly assessments.

Acceptability: Participants in both groups reported liking the study “quite a bit”; no differences existed between groups.

Efficacy (intent to treat analysis): The CBSM group had fewer depressive symptoms than the HP group at six-month follow-up (p = 0.06) and higher scores for relaxation (p = 0.09); however, the HP group reported better social well-being on the FACT-G (p = 0.07).

Efficacy (study completers only): Significantly (p = 0.03) fewer depressive symptoms were reported in the CBSM group as well as improved relaxation (p < 0.01) at the six-month follow-up.

The results generally support the feasibility, acceptability, and preliminary efficacy of web-based psychosocial intervention for patients with APC. Both the CBSM and HP interventions were rated favorably. Clinically meaningful decreases in depressive symptoms and improvements in relaxation (related to functional well-being) were seen in the CBSM group at six-month follow-up, revealing that the results were evident even months after the intervention was provided.

• Small sample (< 100)
• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Findings not generalizable
• Subject withdrawals ≥ 10%  
• The sample size was underpowered, which limits the detection of significant results. Participants were provided with a tablet and/or Internet as needed to complete intervention, which was not feasible for all patients, limiting its generalizability.

Web-based psychosocial interventions for men with APC have the potential to reduce symptom burden and improve health-related quality of life, specifically for patients who have computer and Internet access. Additional research is needed regarding these types of interventions in advanced disease (stages 3 and 4). Because both the CBSM and HP groups showed some improvement in this study, the positive benefits of social, group-based interventions should be explored further in this population.

• FINAL NUMBER STUDIES INCLUDED = 48 
• TOTAL PATIENTS INCLUDED IN REVIEW = Unknown
• SAMPLE RANGE ACROSS STUDIES: 20–498 patients
• KEY SAMPLE CHARACTERISTICS: Patients with cancer-related pain treated with gabapentin and postsurgical patients with related pain being treated with gabapentin

APPLICATIONS: Pediatrics, elder care, and palliative care

Gabapentin was found to be effective in reducing pain and the use of analgesics when used perioperatively for otolaryngology, orthopedic, abdominal, and pelvic surgeries as well as mastectomies. There was scant efficacy noted following cardiothoracic surgery. Studies of cancer-related pain management regimens that included gabapentin demonstrated a substantial outcome, which included mild to moderate pain relief with increased efficacy noted in patients with neuropathic pain as well as cancer-related pain.

Gabapentin was proved to be therapeutic as an adjuvant treatment for cancer-related pain. The authors found multiple studies concluding that gabapentin was effective as part of an analgesic regimen for cancer-related pain. They also effectively described the results of double-blinded, randomized, placebo-controlled research supporting the conclusion in favor of the perioperative use of gabapentin as an adjuvant analgesic.

The articles that were reviewed incorporated disproportionately more patients with breast, lung, and colorectal cancers.

Nurses are in a position to gather additional data and contribute to research, providing more evidence to support the use of gabapentin as an adjuvant analgesic as a part of an effective procedure in the case of perioperative pain. Nurses also are in a position to provide efficient research reviews of studies that evaluate the effect of gabapentin.

To compare the efficacy and safety of neurolytic celiac plexus blockade (NCPB) to the efficacy and safety of standard treatment of patients with unresectable pancreatic cancer

• Databases searched were Ovid, PubMed, MEDLINE, EMBASE, HealthSTAR, and the Cochrane Library. In addition, investigators performed manual searches of revelant materials. The date range searched was 1966–2005.
• Search keywords were celiac block, celiac plexus block, celiac plexus neurolysis, and splanchnicectomy.
• Studies were included if they
  • Were randomized controlled trials that compared NCPB to standard treatment.
  • Involved patients with pancreatic cancer.
• Studies were excluded if they involved NCPB as a treatment for conditions other than pancreatic cancer.

The search retrieved 491 articles. Authors described the data-abstraction procedures, quality-rating method, and meta-analysis procedures.

The sample included five randomized controlled trials whose results were published 1993–2004. The sample was composed of 302 patients.

• Effect of NCPB on pain as measured by a visual analog scale:
  • Weighted mean difference (WMD) at two weeks was not significantly different between control group and NCPB group.
  • At four weeks, NCPB showed a benefit, with WMD –0.50, 95% CI –0.85 through –0.15, p = 0.005.
  • At eight weeks with NCPB, WMD was –0.60, 95% CI 0.82 through –0.37, p < 0.00001.
• Effect of NCPB on opioid use:
  • At week 2, NCPB was associated with significantly lower opioid use (WMD –39.99 mg, 95% CI –60.08 through –19.91, p < 0.0001).
  • The difference in opioid intake increased over time, with the maximum reported difference at week 8: WMD –80.45 mg, 95% CI –134.66 through –26.24, p = 0.0004).
• Survival and quality of life (QoL): Authors observed no survival benefit with NCPB.  Two studies provided information about QoL. QoL decreased in a general pattern of decline in both treatment and control groups, with no significant difference between groups
• Adverse effects: In the NCPB group, constipation decreased significantly (RR 0.67, p = 0.01). The NCPB group showed a trend toward hypotension, but the trend was not statistically significant.

Compared with standard treatment, NCPB was associated with significant improvement in pain. Although the average change in pain score was small, the change was accompanied by a significant reduction in opioid use for pain control. The durability of NCPB impact is unknown. Effect seems to increase within eight weeks, but no data are available regarding use beyond that period. The study demonstrated no significant intergroup differences in the relative risk of adverse events.

Nurses should be aware that NCPB is an option for managing the pain of patients with unresectable pancreatic cancer. Awareness will enable nurses to advocate for the procedure when appropriate and to inform patients of potential treatment options. The duration of NCPB is unknown.

To test the effectiveness of royal jelly on the prevention of mucositis in patients with head and neck cancer receiving chemotherapy and radiation

The royal jelly (RJ) was collected from the species Apis mellifera with a primary diet of nectar and pollen from flowers in China. Patients in the intervention group applied 1 g of royal jelly three times per day for the duration of radiation treatment (RT), and patients in the control group did not apply royal jelly. Data were collected during radiation twice per week and one month after radiation was complete.

• N = 13  
• AGE RANGE = 51–84 years
• MALES: 92.3%, FEMALES: 7.6%
• KEY DISEASE CHARACTERISTICS: Hypopharyngeal, oropharyngeal, laryngeal, oral cavity squamous cell carcinoma
• OTHER KEY SAMPLE CHARACTERISTICS: Three different chemotherapy regimens; radiation therapy dose 33–35 fractions (60–70 Gy)

• SITE: Single-site    
• SETTING TYPE: Not specified    
• LOCATION: Kyorin University School of Medicine, Tokyo, Japan

• PHASE OF CARE: Active antitumor treatment
• APPLICATIONS: Elder care  

Randomized, single-blinded (physician-blinded) trial

• Inspection 
• Fiberscope 
• National Cancer Institute's Common Terminology Criteria for Adverse Events (NCI-CTCAE) version 3 used to grade mucositis

In the control group, 100% (six) patients experienced grade 3 oral mucositis at the end of radiation compared to the 71.4% (five) who experienced grade 3 in the RJ group and the 28.6% (two) who experienced grade 2 mucositis in the RJ group. RJ delayed the progression to grade 2 mucositis (19 ± 4.1 days in the RJ group, 25.9 ± 9.6 days in the control group, p < .001). RJ also significantly delayed the progression to grade 3 mucositis (37.4 ± 11.8 days in the RJ group, 31 ± 5.8 days in the control group, p < .001).

The results of this study suggest that the topical application of RJ is effective in preventing accelerated mucositis induced by chemoradiotherapy.

• Small sample (< 30)
• Unintended interventions or applicable interventions not described that would influence results
• Other limitations/explanation: Different chemotherapy regimens; no description of regimens; RT dose may have differed based on the disease site

Chemoradiotherapy for head and neck cancer continues to cause significant mucositis, which is debilitating and can impact nutritional status, comfort, and often patients' ability to complete therapy without treatment breaks. The topical administration of RJ offers one intervention that could improve this side effect; however, further studies are needed to support these findings.

To investigate the efficacy of a traditional Japanese medicine, hangeshashinto (TJ-14), in the prevention of chemoradiation-induced oral mucositis

Records were reviewed retrospectively. All patients underwent fractioned radiation with or without concurrent chemotherapy. Researchers compared data from 40 patients who were treated with TJ-14 to those of 40 patients who underwent radiotherapy or concurrent chemoradiotherapy treatment during the study period and did not receive TJ-14 (the control group). Those who received TJ-14 rinsed and gargled with 2.5 g of the intervention drug dissolved in 100 mL of oral rinse solution. Patients rinsed and gargled with the solution three times per day for 30 seconds after meals and during and after chemoradiation treatment and then swallowed or expectorated the solution. No food or drink was allowed for 30 minutes after treatment. Both groups brushed and gargled with six drops of 4% sodium gualenate hydrate and tap water as well as lidocaine gargle, NSAIDs, and opioids as needed.

• N = 80  
• AVERAGE AGE = 68 years
• MALES: 95%, FEMALES: 5% 
• KEY SAMPLE CHARACTERISTICS: Patients who underwent whole-neck radiation of > 60 Gy with or without chemotherapy

• SITE: Single-site
• SETTING TYPE: Outpatient  
• LOCATION: Japan

• PHASE OF CARE: Active treatment

Retrospective chart review comparing those who used the study medication and those who did not.

• National Cancer Institute's Common Terminology Criteria for Adverse Events (NCI-CTCAE) version 4 for oral mucositis

A mulivariate analysis indicated that the use of TJ-14 (p = .019), a patient's gender (p = .024), and a patient's primary tumor location (p = .028) were significant factors associated with the severity of oral mucositis. TJ-14 was associated with a significantly improved rate of completion of chemoradiation with cisplatin (p = .002). However, the study purpose was to prove the effectiveness in preventing oral mucositis. No primary endpoint was ever mentioned.

Additional studies to determine effectiveness are needed. Future studies should be more specific as to the type of chemotherapy used and how by whom oral assessments are completed. The authors of this study were trying to measure too many variables within one small study. Study purpose was too general.

• Small sample (< 100)
• Baseline sample/group differences of import
• Risk of bias (no random assignment)
• Key sample group differences that could influence results 
• Measurement/methods not well described 
• Measurement validity/reliability questionable 
• Findings not generalizable
• Other limitations/explanation: No way to validate whether the oral assessments were reliable, valid, or reproducible. The measurement method was questionable. The written report was confusing and contained too many study variables.

This retrospective record review provides a platform on which well-designed, randomized, controlled studies can be based to evaluate the effectiveness of TJ-14 for the prevention of oral mucositis. Well-designed studies are needed to prove the effectiveness of this medication.

To determine the effectiveness of efferent lymphatic vessel anastomosis on subclinical lower extremity lymphedema and on the prevention of lower extremity lymphedema in patients with gynecologic cancer

Fourteen patients with unilateral lower extremity subclinical lymphedema received the intervention of supermicrosurgical efferent lymphatic vesssel-to-vessel anastomosis under local anesthesia. Leg dermal backflow (LDB) was used to determine preoperative and postoperative lymphedema volume. Patients were re-evaluated at a one-year interval.

• N = 14  
• AGE RANGE = 34–79 years
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: All gynecologic cancers including ovarian, uterine, and cervical
• OTHER KEY SAMPLE CHARACTERISTICS: No inguinal lymph node dissection; five had a history of pelvic radiation; six had a history of cellulitis 

• SITE: Not stated
• SETTING TYPE: Outpatient    
• LOCATION: Toranomon Hospital and University of Tokyo in Japan

• PHASE OF CARE: Late effects and survivorship

Pre- and post-test design

• Lower Extremity Lymphedema (LEL) Index 
• Leg Dermal Backflow (LDB) Staging
• Student paired T test and two tests for statistic analyses

All 14 of the surgeries were without perioperative issues. Tension sensation in patients was decreased (significant finding), and a downstaging of LDB stage also was significant.

This study was an important start for investigating improved surgical techniques to reduce and prevent the burden of lower extremity lymphedema. However, the sample size was too small, and other possible variables (such as history of certain chemotherapies or current treatments) were not discussed. It also was unclear how the participants were chosen or if they were randomized properly.

• Small sample (< 30)
• Risk of bias (no random assignment) 
• Other limitations/explanation: Unclear whether patients continued to receive chemotherapy; body surface area unknown

For nurses, having knowledge of these interventions is important to understanding how to educate patients on current and future options. Being up to date on current interventions and knowing if one's facility is current is important to each nurse's individual practice and professional growth. However, this is not an intervention that nurses can directly affect at this point.

To evaluate the effectivness of 1% chlorhexidine-gluconate ethanol (CHG-EtOH) versus 10% povidone-iodine among patients with hematologic malignancies and central line catheters

• N = 94 patients (107 CVCs)
• MEAN AGE = 54.9 years (range = 17–86 years)
• MALES: 42%, FEMALES: 58%
• KEY DISEASE CHARACTERISTICS: Malignant lymphoma, acute myeloid leukemia, acute lymphoblastic leukemia, and multiple myeloma
• OTHER KEY SAMPLE CHARACTERISTICS: Sites of CVCs were jugular, subclavian, and inguinal

• SITE: Single site    
• SETTING TYPE: Multiple settings    
• LOCATION: Japan

• PHASE OF CARE: Transition phase after active treatment

Randomized, controlled trial 

• Exit site infections and ​central line-associated bloodstream infections (CLABSIs) were measured as defined by the Centers for Disease Control and Prevention.

CVC exit site colonization rates were 11.9% with chlorhexidine and 29.2% with povidone-iodine (p = 0.03). CLABSI rates were 3.4% with chlorhexidine and 14.6% with povidone-iodine (p = 0.08). The incidence per catheter days was higher in the povidone iodine group (RR = 0.23, p = 0.041).

This study suggests that the use of 1% CHG-EtOH while preparing patients for the insertion of a central line and while dealing with central lines on a daily basis decreases the CLABSI rate as compared to the use of 10% povidone-iodine. This affects the length of a patient's stay in the hospital and delays the discharge process.

• Small sample (< 100)
• Risk of bias(sample characteristics)
• Other limitations/explanation: About 30% of patients had CVCs in the inguinal area, which is known to be associated with higher infection rates, and the percent of patients with inguinal catheters was higher in the povidone-iodine group. There was high attrition in the povidone-iodine group.

Nurses always are on the front line giving care to patients, and it is their responsibility to prevent the transmission of infection and provide quality care. One of the most certain ways of giving an infection to a patient is through a central line. These findings suggest that the use of 1% CHG-EtOH while manipulating central lines helps decrease the chance of CVC site contamination and may be more effective than povidone-iodine. However, study limitations reduce the strength of this particular finding. Additional studies of the most effective methods for skin preparation would be helpful.

PURPOSE: To summarize the recommendations and rationale for the pharmacologic management of cancer pain and identify the best practices in cancer pain management

TYPES OF PATIENTS ADDRESSED: Patients with cancer pain

RESOURCE TYPE: Consensus-based guideline  

PROCESS OF DEVELOPMENT: Task force established with 56 physicians, 25 pharmacists, 23 nurses, one epidemiologist, and seven other professionals; conducted systematic review; drafted recommendations using Delphi methods; developed recommendations based on GRADE system

DATABASES USED: PubMed, PaPaS, Cochrane, review of references in relevant guidelines, textbook review, review of JPSM and Palliative Medicine from January 2000–July 2008  

INCLUSION CRITERIA: Studies that evaluated drugs available in Japan

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

Sixty-five recommendations were created—24 for general cancer pain management, 24 for managing specific etiologic pain syndromes, 15 for managing opioid-induced adverse effects, and 2 for patient education.

Management of cancer pain includes assessment and an individualized approach to treating mild, moderate-to-severe, severe, and breakthrough pain. Opioids are the mainstay of treatment. Immediate-release (IR) or parenteral opioids should be used for unstable pain, whereas extended-release (ER) and IR opioids can be used for stable pain. Neuropathic pain should be managed with adjuvants (e.g., anticonvulsants, antidepressants, antiarrhythmics, ketamines, corticosteroids), metastatic bone pain with bisphosphonates, epigastric pain with celiac plexus block (pancreatic cancer), thoracic pain with nerve blocks, perineal pain with saddle block or superior hypogastric plexus block, malignant psoas syndrome with muscle relaxants or nerve block, and malignant bowel obstruction with octreotide, scopolamine, or corticosteroids. Adverse events of opioids should be judiciously treated: 1) nausea and vomiting with anti-dopaminergics, prokinetics, and antihistamines; opioid rotation, change of route, 2) constipation with laxatives; consider rotation to fentanyl, 3) drowsiness with psycho-stimulants; opioid rotation, route rotation. Patient education should be employed for all patients.

Only medications available in Japan are included. The focus is on pharmacologic interventions, but some psycho-educational aspects are included.

Patient education is an important part of pain management. In addition, nurses can recommend pharmacologic and procedural strategies to help manage pain in specific patient populations.

RESOURCE TYPE: Evidence-based guideline, as well as expert consensus

No information was provided on the volume of evidence. The grading system developed by the Medical Information Network Distribution Service (MINDS) was used to evaluate the level of evidence, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to evaluate the strengths of the recommendations.

• Oxygen therapy is recommended in patients with hypoxemia and not recommended in patients without hypoxemia.
• Noninvasive positive pressure ventilation (NPPV) suggested to be used in patients with hypoxemia and hypercapnia
• High-flow nasal cannula oxygen therapy suggested in patients with hypoxemia refractory to standard oxygen therapy

• Systemic morphine is recommended.
• Systemic codeine/dihydrocodeine is recommended.
• Nebulized morphine is not recommended.
• Systemic fentanyl is not recommended.

• Benzodiazepines are not recommended to be used alone.
• Benzodiazepines are recommended to be used in combination with opioids.

• Nebulized furosemide is not recommended.

• Caution against routine use of systemic corticosteroids without the consideration of the cause of dyspnea
• Corticosteroids recommended for patients with lymphangitis carcinomatosa, superior vena cava syndrome, or major airway obstruction

The authors declared that, because of the lack of rigorous evidence, most recommendations statements were based on level of evidence and mostly on expert consensus. Some evidence reviewed were not wholly based on patients with cancer. The authors were unable to find adequate information on treatment effect on quality of life and pharmaco-economic outcomes.

The low level of evidence on which these recommendations are based point to a need for stronger studies on the management of dyspnea in patients with cancer. More research is also needed to investigate the effect of recommended interventions for dyspnea on patient quality of life, as well as cost-effectiveness.