Lim, H.A., Griva, K., Yoong, R.K., Chua, J., Leow, M.Q., Chan, M.F., . . . Mahendran, R. (2015). Do caregivers of cancer patients receiving care in home hospice services have better quality of life? An exploratory investigation in Singapore. Psycho-Oncology, 25, 471–474.
To examine the differences between caregiver quality of life when caring for a patient in a home hospice program and an ambulatory patient receiving formal palliative care program services
Governmentally supported home hospice services provided to patients with advanced cancer by a multidisciplinary team
Cross-sectional study with combined data from two studies
Significant Pearson intercorrelations (rs = 0.18-0.84, ps < 0.05) for CQOLC total scores and subscales excluding positive adaptation and disruptiveness subscales were found. Males had significantly lower total CQOLC scores (p = 0.012) and disruptiveness scores (p = 0.003). Significantly lower CQOLC scores also resulted in caregivers caring for parents (and tertiary education [all values = p < 0.05]). Chinese ethnic caregivers had better QOL related to burden (p = 0.031) and financial concerns (p = 0.024), but less successful positive adaptation resulted in lower QOL (p = 0.024). Although data analysis controlled for significant differences in age and spousal caregiving, ambulatory patient caregivers were older and more likely to be spousal caregivers. Analysis of covariance (ANCOVA) supported home hospice caregivers experiencing better QOL than ambulatory patient caregivers but only in total CQOLC scores (p = 0.008) and subscales of financial worries and burden (p = 0.004).
Home hospice care programs for patients with palliative cancer care needs appear to benefit caregiver QOL, particularly in minimizing perceptions of burden and financial concerns. Those programs, composed of multidisciplinary teams focused on responding to patient end-of-life needs, seem to improve caregiver confidence in care and satisfy caregivers’ desire for personalized support by healthcare providers.
Models of home hospice services to mutually benefit caregivers and those they care for need further testing in a variety of cultures with variant healthcare systems to more clearly validate the efficiency of and benefits of those models in meeting caregiver improved QOL.
Lim, J.T., Wong, E.T., & Aung, S.K. (2011). Is there a role for acupuncture in the symptom management of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led supportive care. Acupuncture in Medicine, 29(3), 173–179.
To document changes in symptoms after acupuncture or nurse-led supportive care in patients with incurable cancer and to determine the feasibility of carrying out a randomized trial in acupuncture for patients with advanced incurable cancer
Patients were randomly assigned to either an acupuncture group or a nurse-led supportive care group. In the acupuncture group, traditional Chinese medical acupuncture was performed by the principle investigator, a radiation oncologist, and a certified medical acupuncturist. The acupuncture points were chosen based on the symptoms experienced. The acupuncture needles were connected to an electric stimulator, and a 0.3 ms duration, 4 Hz alternating current was delivered. The needles were stimulated for 20 minutes and then removed.
In the nurse-led supportive care group, patients met for 20–30 minutes with an experienced palliative care nurse weekly for four weeks, comparable to the time spent in acupuncture. The nurse explored their most troubling symptoms and discussed medications and nonpharmacologic therapies such as relaxation therapy, professional counseling, exercise, or judicious rest. The patient’s interpretation of the causes of the symptoms and how they could be ameliorated were discussed. The nurse also addressed issues such as improving the scheduling and dosing of the medications and alternative therapies to drugs, such as foods for managing constipation. Useful strategies for coping with daily activities and emotional support were discussed.
This pilot study was a single-blind, randomized controlled trial.
The Edmond Symptom Assessment System (ESAS) was used to measure any changes in the symptoms experienced by patients before and after the intervention.
The treatment was well tolerated with no significant unexpected side effects. The compliance rate was 90% for acupuncture and 80% for nurse-led supportive care. All nine symptoms (pain, tiredness/fatigue, nausea, depression, anxiety, drowsiness, loss of appetite, lack of well-being, and shortness of breath) were improved immediately after acupuncture, with improvement continuing in six of these symptoms after six weeks. Six symptom scores improved immediately following nurse-led supportive care visits, with all nine symptoms showing improvement after six weeks. Total symptoms were reduced by an average of 22% after each acupuncture visit and by 14% after each nurse-led supportive care visit. ESAS scores at the end of the follow-up period were reduced by 19% for the acupuncture group and 26% for the nurse-led supportive care group. At six weeks after acupuncture, symptoms of pain, nausea, and loss of appetite did not maintain improvement. Only 48% of eligible patients consented to the study, and it was closed due to poor recruitment.
The study suggests that patients can benefit from incorporating acupuncture and supportive interventions to help with symptom management in advanced incurable cancer. Findings suggest that nurse attention provided over the long term benefited patients and that acupuncture may provide some immediate symptom improvements.
Nurse-led supportive care can improve symptoms in these patients. These improvements can likely be attributed to increased attention and quality feedback being provided from the nurse to the medical team, who were able to initiate positive changes in medication and other supportive measures.
Gouvea de Lima, A., Antequera, R., Peres, M.P., Snitcosky, I.M., Federico, M.H., & Villar, R.C. (2010). Efficacy of low-level laser therapy and aluminum hydroxide in patients with chemotherapy and radiotherapy-induced oral mucositis. Brazilian Dental Journal, 21, 186–192.
To evaluate the use of low level laser therapy (LLLT) and aluminum hydroxide for the prevention of oral mucositis in patients with head and neck cancer, and to evaluate the impact of LLLT on pain scores.
Group 1 was given LLLT at 830 nm daily since first day of radiotherapy (RT) to end of therapy prior to RT (RT days only). It was applied to 12 areas of the oral cavity. Group 2 received aluminum hydroxide (AH) suspension (310 mg/5 mL) starting on first day of RT and continued throughout, including weekends. Patients used 10 mL of AH 4 times a day and swallowed and had to avoid eating during the first hour after treatment.
This was a single-site, outpatient study conducted in Brazil.
Patients were undergoing the active treatment phase of care.
The study was prospective, comparative, and nonrandomized.
Lower oral mucositis (OM) scores were observed in the LLLT group (p = 0.061). More grade III OM was seen in the AH group, and severe OM was delayed in the LLLT group. LLLT pain scores were lower but not statistically significant overall. Quality-of-life (QOL) scores were all higher (i.e., more symptoms) in the AH group.
LLLT was found to be more effective than AH in delaying severe OM; however, more trials are needed.
Although LLLT was found to be more effective than AH in delaying severe OM, questions exist regrding the best protocols and dosing, as well as how this evidence correlates to other disease types. Additionally, availability of equipment may be an issue.
Lima, M.T., Lima, J.G., de Andrade, M.F., & Bergmann, A. (2014). Low-level laser therapy in secondary lymphedema after breast cancer: Systematic review. Lasers in Medical Science, 29, 1289–1295.
STUDY PURPOSE: To discuss the treatment of breast cancer-related lymphedema with low-level laser therapy (LLLT), its usefulness, and safety
TYPE OF STUDY: General review/\"semi\" systematic review
PHASE OF CARE: Late effects and survivorship
Three of four studies were able to show statistical significance in limb volume after treatment; however, follow-up times varied. Carati et al. reported a significance of 0.017 (89.7 ml versus 32.1 ml) three-months post-treatment, Kaviani et al. reported a greater reduction in all weeks except one (no statistical reference), Kozanoglu et al. reported a greater reduction with LLLT (p = 0.04 at post-treatment and p = 0.02 at 12 months), and Lau et al. reported a statistically significant reduction at four weeks post-treatment (448.2 to 320.9 ml, p = 0). Two studies reported significance in a decrease in tissue hardness. No improvement in subjective symptoms were reported (pain, range of motion [ROM], heaviness, grip strength); however, Lau et al. reported significantly decreased mean scores on the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire in the treatment group (p = 0.04) post-treatment, but they were not statistically significant at four weeks follow-up.
Nurses need to be knowledgeable of clinical trials involving LLLT and stay current with lymphedema management, as well as educate patients on LLLT.
Lilleby, K., Garcia, P., Gooley, T., McDonnnell, P., Taber, R., Holmberg, L., … Bensinger, W. (2006). A prospective, randomized study of cryotherapy during administration of high-dose melphalan to decrease the severity and duration of oral mucositis in patients with multiple myeloma undergoing autologous peripheral blood stem cell transplantation. Bone Marrow Transplantation, 37, 1031–1035.
This was a randomized trial.
Cryotherapy was associated with improved outcomes. Research is needed to determine the required length of cryotherapy.
Liljegren, A., Gunnarsson, P., Landgren, B. M., Robeus, N., Johansson, H., & Rotstein, S. (2012). Reducing vasomotor symptoms with acupuncture in breast cancer patients treated with adjuvant tamoxifen: a randomized controlled trial. Breast Cancer Research and Treatment, 135, 791-798.
The study evaluated the value of true acupuncture in management of hot flashes in women with breast cancer receiving tamoxifen.
Patients on tamoxifen who experienced vasomotor symptoms were randomly assigned to true acupuncture or control acupuncture groups. All patients were treated for 20 minutes twice weekly for 5 weeks in an outpatient clinic. In the true acupuncture group, 8 needles were inserted at defined points. In the control group, needles did not penetrate the skin, but were rotated until the patient felt a superficial sensation on the skin. In the control group, the needles were placed at 8 sites, as well. Study data were collected at baseline, week 6, and week 18.
The study enrolled 74 women with a mean age of 58 years.
The study was conducted in an outpatient clinic in Sweden.
PHASE OF CARE: Transition phase after active treatment
The study was a single-blind, randomized, sham-controlled trial.
Instruments/measures included:
There were no significant differences between groups in frequency of hot flushes and sweating over time. The acupuncture group reported less severity of symptoms of sweating at night ( p = .03). Both groups demonstrated significant improvement in symptoms over time. Of those who received true acupuncture, 69.4% thought they had receiving true acupuncture, while 63.9% of those in the control group thought they had received true acupuncture, suggesting that patient blinding was accomplished. One adverse event of bleeding and bruising was reported in 1 control patient.
Findings suggest little difference in symptoms between those who received acupuncture versus those who received sham acupuncture. Acupuncture may have some benefit, but it is unclear if this also reflects a placebo effect from the intervention.
Study limitations included:
This study provides limited evidence regarding the effect of acupuncture for vasomotor symptoms in women with breast cancer treated with tamoxifen. It does demonstrate questions regarding potential placebo effects of acupuncture or placebo effects of sham acupuncture procedures that complicate research design in this area. Appropriate placebo or comparison control groups for this type of research need to be identified.
Likun, Z., Xiang, J., Yi, B., Xin, D., & Tao, Z.L. (2011). A systematic review and meta-analysis of intravenous palonosetron in the prevention of chemotherapy-induced nausea and vomiting in adults. Oncologist, 16, 207–216.
To evaluate the effectiveness and adverse effects of palonosetron in prevention of chemotherapy-induced nausea and vomiting (CINV)
Databases searched were Medline, Embase, Chinese VIP database, Evidence-Based Medicine Review, Cochran Central Register, Current Controlled Trials, National Research Register, and Clinicaltrials.gov.
Search keywords were palonosetron, chemotherapy-induced nausea and/or vomiting, CINV.
Studies were included if they were randomized, controlled trials (RCTs) that compared palonosetron with first generation 5-HT3 receptor antagonists (RAs).
Studies were excluded if they involved pediatric patients.
An initial 235 references were identified. Eight RCTs were identified for inclusion. Studies were evaluated in terms of randomization, blinding, allocation concealment, crossover design, and intention to treat analysis.
The final sample included eight RCTs involving 3,592 patients receiving highly or moderately emetogenic chemotherapy.
In comparing the effectiveness of palonosetron with first-generation 5-HT3 RAs for acute CINV
In comparing the effectiveness of palonosetron with first-generation 5-HT3 RAs for delayed CINV, both the 0.25-mg and 0.75-mg palonosetron doses yielded better prevention of delayed CINV (p < 0.00001).
Studies that included dexamethasone (two trials) reported that dexamethasone plus palonosetron reduced the risk of CINV by 38%–40% (p < 0.00001).
The 0.75-mg palonosetron dose was associated with a higher risk of constipation than lower-dose palonosetron or first-generation medications (p = 0.01).
Meta-analysis demonstrated that palonosetron was more effective in risk reduction for both acute and delayed CINV than first-generation 5-HT3 RAs. This effect was seen with both 0.25- and 0.75-mg dosages, and with or without concomitant use of dexamethasone. A 0.75-mg dose of palonosetron was associated with more constipation.
A limited number of studies were used in some subgroup analysis, and no studies looked at lower-dose palonosetron and dexamethasone compared to first-generation drugs. This research is warranted, because lower dosages are associated with less constipation.
Palonosetron is a safe and effective alternative for prevention of CINV. Nurses need to be aware of the potential for constipation with higher dosages, particularly in patients with other treatments that affect bowel function.
Lihua, P., Su, M., Zejun, Z., Ke, W., & Bennett, M.I. (2013). Spinal cord stimulation for cancer-related pain in adults. Cochrane Database of Systematic Reviews, 2, CD009389.
To review the evidence regarding spinal cord stimulation for pain management in cancer
This study is a systematic review.
Databases searched were the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Chinese Biomedical Database (up to July 2012), National Cancer Institute trial registry, World Health Organization International Clinical Trials Registry Platform, and clinicaltrials.gov, supported by the National Institutes of Health. The authors also hand-searched relevant articles.
Search terms were text words combined with medical subject headings (MeSH) terms for electrostimulation and cancer.
Studies were included in the review if they were randomized controlled trials (RCTs) or nonrandomized trials comparing spinal cord stimulation with another intervention for cancer pain.
All studies had to report on adult patients.
A total of 430 references were retrieved.
The authors assessed risk of bias from sequence assignment and allocation concealment. No specific rating scale is mentioned. The STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) checklist was used for observational studies, as no RCTs were found.
The study has clinical applicability for palliative care.
There were very few studies, and prospective studies were pre-post case series reports. More than 80% of patients reported at least a 50% reduction in pain severity, and more than 50% reported reduction in opioid use. Minor complications included headache, asthenia, dizziness, and muscle twitches. Major complications included infection, cerebrospinal fluid leak, pain at electrode sites, and system failure. Follow-up ranged from one week to one year. All studies were of low quality.
There is insufficient evidence to evaluate the potential role of spinal cord stimulation for cancer-related pain control.
Limitations included few publications and low-quality research.
Effectiveness of spinal cord stimulation for management of cancer-related pain cannot be determined. There is a need for high-quality research in this area.
Liguori, V., Guillemin, C., Pesce, G.F., Mirimanoff, R.O., & Bernier, J. (1997). Double-blind, randomized clinical study comparing hyaluronic acid cream to placebo in patients treated with radiotherapy. Radiotherapy and Oncology, 42, 155–161.
To determine if prophylactic use of hyaluronic acid cream postpones acute radiodermatitis or reduces its severity and to evaluate the efficacy of hyaluronic acid to delay the onset of necrosis or to accelerate recovery in case of ulceration
Hyaluronic or placebo cream was applied to irradiated skin area twice daily. The first application was one-to-two hours after the radiation therapy session and the second was in the evening. The topic treatment was continued over a six-week period.
The study took place at Ospedale San Giovanni and Centre Hospitlier Universitaire, both in Switzerland.
The study used a randomized placebo-controlled double-blind trial design.
The prophylactic use of hyaluronic acid cream is shown to reduce the incidence of high-grade radiodermatitis.
Liguori, S., Gottardi, M., Micheletto, G., & Bruno, L. (2010). Pharmacological approach to chronic visceral pain. Focus on oxycodone controlled release: An open multicentric study. European Review for Medical and Pharmacological Sciences, 14(3), 185–190.
To determine the incidence of visceral pain and to evaluate the efficacy of oxycodone in the context of visceral pain
Patients with visceral pain stopped existing drug treatment and instead used controlled-release oxycodone for 15 days. Conversion was according to international guidelines. Dosage of the study drug was individualized. If by day 7 a patient did not achieve a pain-score reduction of at least 50% or if he or she experienced a severe adverse event, clinicians administered an alternative opioid. Investigators gathered pain scores at baseline and after 3, 7, and 15 days of treatment. The regimen permitted use of rescue medication, morphine sulfate.
Prospective observational single-group trial
All patients who entered the study completed the study. None had to switch to another opioid. Mean dose after titration was 50.1 mg/day controlled-release (CR) oxycodone. At all time points, pain scores had decreased from a baseline mean of 7.04. At day 15, the mean pain score was 2.37 (p < 0.00001). Authors noted some improvement in all domains of the SF-12, but these changes were not statistically significant. Few patients experienced more than mild adverse evens. The most frequent adverse events were nausea, constipation, and sleepiness.
In this study, use of CR oxycodone was associated with significant reduction in mean pain scores over a 15-day period, with minimal adverse events.
This study showed CR oxycodone to be effective in producing significant pain reduction within three days and over 15 days. This finding warrants a study of long-term effect. CR oxycodone is one medication in the armamentarium of opioid formulations for pain management. The side effects of CR oxycodone are those to be expected with opioid use.