McNichol, E., Strassels, S.A., Goudas, L., Lau, J., & Carr, D.B. (2005). NSAIDs or paracetamol, alone or combined with opioids, for cancer pain. Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD005180.
The search retrieved 42 trials. Eight trials compared an NSAID with a placebo, 13 compared one NSAID with another, 23 compared an NSAID with an opioid or an NSAID-opioid combination, and 9 assessed the effect of increasing the NSAID dose. Sixteen of the 42 studies were conducted over seven days or longer, and 11 studies were single-dose studies. No study lasted longer than 12 weeks. Treatments studied included weak opioids, strong opioids, and agonist or antagonists. Nine studies examined dose range. Outcomes measured included differences in pain intensity, pain relief, and incidence and severity of adverse effects. Many studies used a visual analog scale; few studies used validated scales.
The 42 trials reviewed included 3,084 patients.
On the basis of limited data, NSAIDs appear to be more effective than placebo in treating cancer pain. Data to support the use of one NSAID over another, in regard to safety or efficacy, are insufficient. Compared to an NSAID alone or an opiod alone, NSAID-opioid combinations were no more effective or, at most, had a slight statistical advantage. The World Health Organization (WHO) method of cancer pain relief is considered the gold standard. Regarding the first step in the WHO method, the management of mild pain, results of this review support the WHO recommendations: Results strongly suggest that an NSAID alone is superior to placebo and adequate for at least short-term pain relief. Regarding the second step: Evidence is insufficient to refute or support the WHO recommendation to use an NSAID-opioid combination as a means to manage moderate cancer pain. Increasing the dose of an NSAID or adjuvant drug to the maximum acceptable dose may be the better course.
Clinicians should be cautious regarding the use of NSAIDs, especially in the population studied. This population takes many prescription drugs, some of which may increase NSAID-related toxicity.
McNeely, M.L., Peddle, C.J., Yurick, J.L., Dayes, I.S., & Mackey, J.R. (2011). Conservative and dietary interventions for cancer-related lymphedema: A systematic review and meta-analysis. Cancer, 117(6), 1136–1148.
To update evidence from randomized controlled trials (RCTs) regarding benefits of conservative and dietary interventions for all cancer-related lymphedema
Databases searched were MEDLINE, EMBASE, CINAHL, PubMed, Dissertation Abstracts, PEDro, and Cochrane Collaboration. Keywords were neoplasm, axillary dissection lymph node excision, lymphedema, conservative treatments (e.g., stockings compression, manual drainage), and publication types of random allocation and clinical trial. Studies were included in the review if they were RCTs with a sample of at least 80% patients with cancer comparing a conservative or dietary intervention to placebo, control, or comparison intervention in secondary lymphedema from cancer. Exclusion criteria were not specified.
Of the 157 papers that were initially retrieved, a final set of 25 were included. A modified Jadad scoring was used to evaluated the quality of the evidence. Only eight studies met criteria for high quality. Meta-analysis was done for studies examining the effect of manual lymph drainage (MLD)for upper-extremity lymphedema with breast cancer.
Results were synthesized in terms of effects on lymphedema volume and patient-rated outcomes of pain, heaviness, tenderness and quality of life for nine interventions. Most studies were limited to upper extremities; where lower extremities were included is stated below.
Meta-analysis demonstrated significant but relatively small benefit from the addition of MLS in patients with breast cancer-related lymphedema. Findings support the growing body of evidence that participation in exercise does not exacerbate lymphedema and can reduce the severity of symptoms. Only two studies were found that examined nutrition and dietary interventions; these reported benefit in terms of volume reduction, but were of relatively low quality. Evidence suggests that compression garments and bandaging are effective in reducing limb volume with various types of cancer.
Only eight studies in this review were deemed to be of high quality.
Inclusion of MLD provides a relatively small added benefit and may be associated with substantial costs. It is not clear if the benefits outweigh the cost and MLD may be most useful for patients who do not achieve sufficient improvement with other effective approaches. Findings related to dietary interventions are promising, pointing to the value of additional research in this area. Breast cancer continues to be the most frequently studied group. Research in other groups and with lower-limb lymphedema is needed.
McNeely, M.L., Campbell, K., Ospina, M., Rowe, B.H., Dabbs, K., Klassen, T. P., . . . Courneya, K. (2010). Exercise interventions for upper-limb dysfunction due to breast cancer treatment. Cochrane Database of Systematic Reviews (Online), 6, CD005211.
To examine the evidence of effectiveness from randomized controlled trials involving exercise interventions for preventing, minimizing, and improving upper-limb dysfunction because of breast cancer treatment
Databases searched were Specialised Register of the Cochrane Breast Cancer Group, MEDLINE, EMBASE, CINAHL, and LILACS (to August 2008). Experts, hand-searched reference lists, conference proceedings, clinical practice guidelines and other unpublished literature sources were also considered. Search keywords were neoplasm, tumor, tumour, mastectomy, axillary dissection, sentinel node dissection, adhesive capsulitis, cording, axillary web syndrome, physical therapy, physiotherapy, rehabilitation, exercise, stretching, mobilization, physical activity, exertion, range of motion, strength, lymphedema, pain, and quality of life. Studies were included if they were randomized controlled trials evaluating the effectiveness and safety of exercise for upper-limb dysfunction. Studies were excluded if they included cancers other than breast cancer (e.g., melanoma) unless separate data were available for a breast cancer subgroup.
The total number of studies reviewed initially was 82. Two authors independently performed the data abstraction. One author performed the initial pre-screen of all the databases to identify potential trials and screened the results to exclude articles that were clearly irrelevant. Two independent authors screened the reduced search results. If either or both authors felt that the article potentially met the inclusion criteria, or if there was inadequate information to make a decision, full-text copies of the article were retrieved. Using the defined eligibility criteria, the two authors independently decided on trial inclusion. A priori, authors made the decision to exclude any data that were available only in abstract form. Review authors were not blinded to study authors, journal, or study results. Agreement was measured and assessed using kappa statistics. Three investigators independently assessed quality of the trials and extracted data independently using a standardized form. Investigators were contacted for missing data.
Exercise can result in a significant and clinically meaningful improvement in shoulder ROM in women with breast cancer. There is evidence that patients benefit from exercise interventions that include more structured instruction and supervision when compared to exercise instruction through a pamphlet or no exercise instruction. Of note, larger benefits were found for shoulder range of motion and shoulder function outcomes from physical therapy treatment that was introduced in the early weeks following surgery. There was no evidence of a negative effect from upper-extremity exercise on the incidence of upper-limb lymphedema at any time point following surgery.
In the postoperative period, consideration should be given to early implementation of exercises, although this approach may need to be carefully weighed against the potential for increases in wound drainage volume and duration. High-quality research studies that closely monitor exercise prescription factors (e.g., intensity) and address persistent upper-limb dysfunction are needed.
McNeely, M.L., Parliament, M.B., Seikaly, H., Jha, N., Magee, D.J., Haykowsky, M.J., & Courneya, K.S. (2008). Effect of exercise on upper extremity pain and dysfunction in head and neck cancer survivors: A randomized controlled trial. Cancer, 113, 214–222.
To examine the effects of progressive resistance exercise training on upper extremity pain and dysfunction in postsurgical head and neck cancer survivors
Participants were randomly assigned to either standard therapeutic exercise or progressive resistance exercise training (PRET). All were asked to attend at least two supervised sessions per week for 12 weeks. Standard exercise involved active and passive range of motion and stretching, postural exercise, and strengthening with light weights (1–5 kg) and elastic resistance bands targeting specific muscle groups. The PRET group received the same exercises except that the strengthening was replaced with individualized exercise on the same muscle groups designed with the intent to provide progressive overload to those muscles. Outcomes were assessed at baseline and postintervention.
The study was a prospective randomized controlled trial.
The PRET program significantly reduced shoulder pain and disability (p = 0.001) and improved upper extremity muscular strength and endurance. Patients participating in the PRET program had a 52% reduction in pain. The effect size for change in pain was d = 0.84. PRET was better than the standard exercise for all strength endpoints measured, and endurance was more improved with PRET (p = 0.039).
Findings show that a program of individualized progressive resistance exercise in patients with specific shoulder dysfunction postsurgery for head and neck cancer as provided here can reduce pain and disability.
Survivors of head and neck cancer can be burdened with pain and loss of strength and function associated with damage to the spinal accessory nerve. It is important that nurses consider means that will help to minimize these residual effects. Exercise is a noninvasive tool that enables patients to actively participate in their recovery. This study shows that a PRET program had a beneficial effect, with reduction in pain of 52% in the PRET group. Improvement in pain was also associated with increases in upper extremity strength and endurance.
McNeely, M.L., Magee, D.J., Lees, A.W., Bagnall, K.M., Haykowsky, M., & Hanson, J. (2004). The addition of manual lymph drainage to compression therapy for breast cancer related lymphedema: A randomized controlled trial. Breast Cancer Research and Treatment, 86(2), 95–106.
To compare the reduction in arm lymphedema volume achieved from manual lymphatic drainage (MLD) in combination with compression bandaging (CB) to that achieved by CB alone
All subjects receive four weeks of allocated treatment, which also included standard education on proper arm and skin care. The MLD and CB group received 45 minutes of daily MLD Monday through Friday each week. Both groups receive CB.
Patients were included in the study if they
Patients were excluded from the study if they
The study took plact at the Cross Cancer Center in Edmonton, Canada.
The study used a prospective, randomized controlled study design.
A total of 45 participants completed the study. A significant reduction in lymphedema volume was found over a four-week period for both groups. No significant difference was noted in volume reduction (p = 0.812) or percent reduction (p = 0.297) between the groups. Therefore, a reduction in lymphedema volume occurred over the time period irrespective of the treatment group. The findings from the calculated volume determined from circumference measurements were consistent with the water displacement findings.
Findings suggest that CB alone should be considered as a primary treatment option in reducing lymphedema arm volume. It also suggests that treatment of lymphedema should be implemented as soon as possible after onset of the condition when treatment is likely to be more effective.
McNeely, M. L., Campbell, K. L., Rowe, B. H., Klassen, T. P., Mackey, J. R., & Courneya, K. S. (2006). Effects of exercise on breast cancer patients and survivors: a systematic review and meta-analysis. Canadian Medical Association Journal, 175, 34–41.
Databases seached were MEDLINE, CINAHL, EMBASE, PsycINFO, CANCERLIT, Cochrane Library, PEDro, and SPORTDiscus through March 2005.
Fourteen randomized trials were included. Nonrandomized trials, pilot studies, and studies reported only in abstract form were excluded. Therapeutic exercise regimens addressing only specific impairments to shoulder and arm were not included. Studies with an additional treatment arm or combined intervention (e.g., exercise with diet modification) were included only if the effects of exercise could be isolated. Studies were required to have quality of life, cardiorespiratory fitness, or physical functioning as a primary outcome. Secondary outcomes of interest included symptoms of fatigue, body composition, and adverse events resulting from the exercise intervention. Methodologic quality of each included study was evaluated using eight quality criteria specified a priori.
Outcomes were quality of life, cardiorespiratory fitness, physical functioning, symptoms of fatigue, body composition, and adverse events resulting from the exercise intervention.
There was wide variability in the exercise interventions evaluated. Interventions included Tai Chi Chuan, aerobic exercise (walking, cycle ergometer, and arm ergometer), resistance training (weights and resistance bands), and mixed aerobic and resistance exercise. Exercise programs were of moderate or low intensity, and the interventions included a mixture of supervised and self-directed programs, delivered individually or in groups. Overall, study reports provided too little detail concerning the frequency, intensity, time, and type of exercise to allow for determination for an exercise dose-response. Similarly, limited detail about the adherence to the exercise program was provided, and few studies had been designed to include monitoring of activity in the comparison group, so that potential contamination could be gauged.
Six studies involving 319 patients assessed the effect of exercise on symptoms of fatigue. Although all of the studies showed improvements in symptoms of fatigue with exercise, only two reported statistically significant improvements. These two studies were also the only studies performed following breast cancer treatment. The pooled results from all six studies showed that exercise significantly improved symptoms of fatigue (standardized mean difference [SMD] = 0.46; 95% confidence interval [CI] [0.23, 0.70]). The pooled results from the four studies performed during adjuvant cancer treatment showed a nonsignificant effect on fatigue (SMD = 0.28; 95% CI [-0.02, 0.57]). Four studies reported adverse events; in one study, two of 23 participants reported that participation in the home-based exercise program (self-monitored walking program) resulted in worsening of fatigue.
McMurray, V. (2006). Managing bleeding malignant skin lesions. Nursing Times, 102, 58–60.
PURPOSE: To review an article from a non-peer–reviewed journal on managing bleeding malignant skin lesions
The journal is not peer-reviewed.
McMillan, S.C., Small, B.J., & Haley, W.E. (2011). Improving hospice outcomes through systematic assessment: A clinical trial. Cancer Nursing, 34, 89–97.
To determine if providing, to hospice patients and caregivers, systematic feedback from standardized assessment tools improves the quality of hospice care
Hospice teams were formed, each with a similar composition. Patients were randomly assigned to receive standard care (control) or standard care plus systematic assessment. Patient-caregiver dyads were identified and screened, within 24–72 hours of admission, with the Short Portable Mental Status Questionnaire. Research assistants (RAs, an RN and a social worker) collected baseline data from both the patient and caregiver, respectively, and then collected data one and two weeks later, using identified tools. Verbal and written reports were given at two interdisciplinary team conferences after each data collection. RAs performed a chart audit for both groups during the study. The control group completed the same standardized assessments, but no reports were made to the interdisciplinary team.
Randomized controlled trial
The control and intervention groups were comparable in regard to every variable except patients' years of education. Attrition was greater than 51%. In dyads that completed the study, patients were older and had higher functional status scores at baseline. No other comparisons were statistically significant. Results showed improved patient depression (p < 0.001) as a result of the intervention and improvement in both groups in patients’ QOL (p < 0.001). No other patient outcomes (symptom distress, spiritual needs) or caregiver outcomes (depression, support and spiritual needs) were statistically significant.
The addition of the systematic assessment of depression to usual care probably had a greater effect because it is not a symptom on which hospice staff normally focus. Improving depression is an important way of improving overall QOL of patients and their families during hospice treatment. The lack of improvement in caregiver variables in either group over time may suggest the need for greater attention to this symptom.
Hospice is an effective service, and efforts to improve hospice care should be a priority. Caregivers as well as patients should be a focus of hospice care. The study supports the systematic assessment of depression in hospice patients. The study also supports the need for greater attention, via research and systematic assessment, to caregivers in the hospice setting.
McMillan, E.M., & Newhouse, I.J. (2011). Exercise is an effective treatment modality for reducing cancer-related fatigue and improving physical capacity in cancer patients and survivors: A meta-analysis. Applied Physiology, Nutrition, and Metabolism = Physiologie Appliquee, Nutrition Et Metabolisme, 36, 892–903.
To determine if exercise interventions can effectively mitigate cancer-related fatigue (CRF)
DATABASES USED: PubMed, CINAHL, PsycINFO, ProQuest, SPORTDiscus
KEYWORDS: exercise, physical activity, exercise therapy, exercise training, aerobic exercise, resistance exercise, physical training, exercise prescription, cancer, oncology, malignancy, neoplasm cancer treatment, chemotherapy, radiotherapy, hormonal therapy, fatigue, CRF, QOL, depression
INCLUSION CRITERIA:
EXCLUSION CRITERIA:
TOTAL REFERENCES RETRIEVED = 948 articles initially identified
EVALUATION METHOD: No quality scoring of retrieved studies was described.
FINAL NUMBER STUDIES INCLUDED = 16 studies included in meta-analysis
SAMPLE RANGE ACROSS STUDIES, TOTAL PATIENTS INCLUDED IN REVIEW: Study sample sizes ranged from 22–242; 1,426 patients in treatment and control groups
KEY SAMPLE CHARACTERISTICS: Subjects were at various phases in cancer treatment, with some in active treatment of various modes and others post-treatment. Eight trials were in patients with breast cancer. Other studies included prostate cancer, mixed disease types, and acute myelogenous leukemia.
Overall effect of exercise on CRF showed a small but significant effect size with overall reduction in CRF ( SMD = 0.28, 95% CI 0.17–0.38, p <.001).
Subgroup analysis of exercise mode:
Interventions provided in a supervised setting (15 trials) significantly reduced CRF (SMD = 0.29, 95% CI 0.17–0.46, p < .001).
Unsupervised exercise showed a positive trend but no significant difference with exercise.
Effects in phase of treatment:
Effects in patients with cancer other than breast cancer:
Exercise intervention produced improvement in aerobic fitness and musculoskeletal fitness (p < .001).
Findings from meta-analysis provide strong support for the positive effect of exercise on CRF. Effect sizes are small.
Findings suggest that various modes of exercise show a trend toward a positive impact on CRF in patients with breast cancer, as well as patients with other types of cancer.
There may be differences in effect based on mode of exercise.
Findings suggest positive effects in supervised and unsupervised exercise programs, but only those that were supervised demonstrated statistical significance in this study. It is unclear if this represents a real difference in effectiveness, or the fact that there were only four studies of unsupervised exercise included.
Findings support the use of exercise to reduce CRF during and after completion of cancer treatment. Subgroup analyses in this study begin to provide additional useful information regarding the modes and types of exercise interventions that may be most effective. Further research comparing effectiveness of various approaches is warranted.
Effect sizes of exercise are small, suggesting that studies that include patients with very low fatigue or interventions to prevent fatigue may not readily show significant changes.
McMillan, S.C., Small, B.J., Weitzner, M., Schonwetter, R., Tittle, M., Moody, L., & Haley, W.E. (2006). Impact of coping skills intervention with family caregivers of hospice patients with cancer: A randomized clinical trial. Cancer, 106, 214–222.
To evaluate whether adding a brief problem-solving intervention (i.e., COPE) to caregivers of patients receiving hospice cancer care would be superior to either standard hospice care alone or standard hospice care with emotional support
Intervention group: In addition to standard hospice care, the intervention involved giving three training sessions to caregivers using the COPE problem-solving technique as a coping skill to manage caregiving stress. COPE involves training caregivers how to use Creativity, Optimism, Planning, and obtaining Expert information when needed as well as how to use a homecare guide for advanced cancer. The intervention was done during visits to the caregiver by a trained nurse while a home health aide stayed with the patient. The visits were conducted within seven to nine days of recruitment, but the schedule was not clearly reported.
Control group II: Caregivers and patients received standard hospice care and supportive visits that focused on emotional support only. These visits were scheduled at the same times and frequencies as the COPE training occurred in the intervention group.
A three-group randomized controlled trial design was used.
Results of random effect regression models showed significant interactions (time by group) in the intervention group for three of the caregivers’ measured outcomes.
There were statistically significant group by time effects, showing that caregiver QOL was higher in the COPE (p = 0.033) and support groups, and symptom burden was lower in the COPE (p < 0.001) and support groups when compared to the usual care group.
Overall, the study findings show strong evidence of effectiveness of the COPE treatment among caregivers of patients in hospice care. In this group of caregivers, COPE improved caregivers’ overall QOL and caregiver symptom-related burden.
Nursing care of caregivers of patients in hospice should involve focused interventions that extend beyond emotional support. COPE is an intervention that can be used with caregivers of patients with cancer in general, hospice or otherwise. This intervention is very promising. The fact that it improved some caregivers’ outcomes in hospice suggests that it can also be very effective under different contexts.