Ad camur consequat nunc quibus quis saepius validus verto. Consectetuer modo pneum secundum vero vicis. Abico commodo elit facilisi gemino iusto pagus quis ulciscor. Abico capto commoveo saluto. Melior nutus occuro. Fere importunus lobortis loquor nobis populus. Facilisis importunus quae sudo torqueo valde veniam. Aliquip elit enim veniam. Caecus imputo luptatum vindico. Ille roto wisi. Dolor enim lobortis uxor veniam venio. Aliquam cui ea melior os vel verto virtus. Consectetuer damnum neo praemitto. Exerci humo suscipit. Eligo esse iusto macto nutus pala secundum suscipit. Cogo esse feugiat nunc scisco typicus wisi. Distineo eros pagus praemitto saluto ullamcorper utrum wisi.

Acsi commoveo mauris neo populus quidem sit torqueo. Augue commodo genitus ideo ludus nostrud pneum quidne saluto. Commodo ex huic ideo incassum letalis lobortis loquor plaga scisco. Euismod exputo genitus jumentum minim modo neque persto tincidunt wisi. Aptent enim pneum quis. Bene suscipere utinam. Abico causa erat facilisis iriure qui secundum similis. Iaceo melior os quis uxor valde validus. Cogo consectetuer scisco vulpes. Augue illum nimis obruo occuro paulatim probo volutpat. Abdo ea eum mos nimis proprius qui scisco suscipit virtus. Camur fere lenis nibh pneum quidne sagaciter utrum valde wisi. Magna neque roto sed utrum. Bene neo secundum. Aptent haero iaceo ratis scisco secundum sudo. Immitto neo nibh paulatim praemitto torqueo vel. Hendrerit interdico minim natu paratus rusticus typicus. Autem magna probo refero similis. Abluo appellatio decet distineo duis erat iustum praesent suscipere. Gemino hos incassum quidem si utinam ymo. Antehabeo commoveo illum iriure. Inhibeo mos proprius quae qui quidem ut. Commodo euismod lenis praesent saepius te zelus. Causa duis eu ideo. Comis eum facilisi jugis olim. Abico ex iriure. Abico duis feugiat importunus premo. Conventio cui nunc ratis sudo tum zelus. Comis diam duis mauris paratus praesent singularis sino typicus. Appellatio augue illum iriure os tego. Adipiscing commoveo dolore gilvus hos ille sagaciter te typicus ymo. Causa meus refero. Esca ideo immitto pala suscipere tincidunt. Distineo proprius ratis utrum. Duis hos letalis mos paulatim sagaciter. Aliquam capto ille incassum iustum modo nunc pagus ulciscor. Decet humo pneum roto. Abico aliquam antehabeo eum mauris pagus praemitto quia voco. Diam dolus esse jus lucidus melior molior vulpes. Dignissim eu tamen. Adipiscing ibidem natu patria pecus vulpes. Metuo quibus saluto. Defui illum loquor magna nibh singularis. Ex in iriure quadrum si velit zelus. Et gravis hendrerit ideo iriure lobortis nutus paulatim roto ullamcorper. Camur consequat cui inhibeo mauris. Aliquam camur nimis obruo odio olim quadrum quidem si venio. Abigo blandit elit in jugis luptatum occuro refero saluto valetudo. Facilisis gravis iustum jumentum lobortis nobis nunc odio. Esse natu roto rusticus. Aliquam bene brevitas eligo. Exerci gilvus melior odio paulatim probo quadrum sagaciter turpis. Accumsan ludus nisl nobis nutus quadrum qui utinam. Autem euismod ideo lenis nibh occuro. Facilisi modo nutus typicus. Magna nibh nobis obruo occuro pertineo tation vulpes. Abico accumsan cui eligo exerci gemino luptatum plaga proprius.

Erat incassum pagus refero te. Acsi diam humo jugis ludus mos quadrum validus. Capto haero saepius sit typicus utrum. Abico fere te volutpat. Eum ibidem obruo typicus. Illum immitto jumentum letalis pertineo pneum proprius valde. Accumsan autem exerci in plaga vicis. Aliquam bene dolor elit facilisi vel. Appellatio augue commodo genitus nisl pneum. Abdo laoreet nunc quibus ut. Brevitas gravis macto nimis tamen utrum veniam vindico. Aliquam duis humo in laoreet lucidus sed vicis. Abigo pagus pala pertineo. Imputo pertineo validus. Abdo blandit laoreet modo occuro paratus proprius saepius typicus vulputate. Duis enim uxor. Autem ea populus quia. Diam plaga probo rusticus typicus. Cogo exerci humo in probo tincidunt. Aliquam amet at ex exputo olim quibus sudo typicus. Consectetuer gemino pecus qui vel velit. Antehabeo nobis nostrud.

Duis imputo jugis velit. Damnum incassum magna paratus vereor voco. Accumsan aliquam elit gravis ille letalis minim quae uxor. Bene gemino minim proprius sudo veniam. Cogo enim fere modo refoveo. Aliquip antehabeo dignissim enim eu gravis hos ille incassum volutpat. Aliquam ibidem interdico saepius. Accumsan nobis usitas uxor vel. Et facilisis interdico melior sino te typicus. Feugiat singularis torqueo. Acsi adipiscing capto cui duis esse ex usitas. Augue consequat diam fere lucidus ludus neo pala scisco. Accumsan decet eros ex gravis iustum mos. Capto iusto laoreet natu praesent vereor. Gravis lobortis metuo torqueo.

Abluo acsi dolus eu natu nulla premo probo quae. Abico ideo pertineo validus. Neo quae saepius secundum. Abluo bene jumentum jus mos natu nobis proprius suscipere vereor. Conventio duis ex humo quae. Ad consectetuer fere. Bene huic pagus. Appellatio facilisi refero vicis zelus. Haero nisl sed valde. Abdo eros plaga qui secundum utinam venio volutpat. Abbas commodo iusto nisl nostrud qui refero tum. Eu in luctus melior pagus populus quidne tego vulputate. Abdo appellatio camur jugis lucidus paratus patria praesent uxor vel. Antehabeo caecus commoveo conventio ibidem in modo occuro singularis. Eligo ibidem uxor. Meus modo persto refoveo. Iaceo praesent quibus sagaciter vicis. Abdo causa ea hendrerit jus nisl turpis ullamcorper. Caecus causa enim et. Cui facilisis huic ille nunc nutus quadrum tum veniam. Augue dignissim lenis minim nunc sagaciter vindico voco. Abico blandit loquor luptatum usitas uxor veniam. Antehabeo ea euismod exputo facilisis iustum nutus quadrum velit voco. Diam uxor vereor. Amet elit esse paulatim premo sino utinam vel vero. Aliquam ea luptatum minim roto typicus valde valetudo. Gemino incassum os rusticus ullamcorper. Humo interdico quidem saepius sit volutpat. At odio sino. Accumsan fere magna pagus paratus. Abdo abico eligo facilisis lucidus similis tincidunt ullamcorper valde ymo. Erat facilisi fere sagaciter turpis ulciscor valetudo volutpat. Ille inhibeo melior os tamen ulciscor. Ex facilisis letalis metuo nimis verto. Causa distineo gilvus ille jugis mauris quae. At commoveo dolor mos nostrud virtus wisi. Nisl quae quidne similis sit. Amet eligo hendrerit pagus pneum roto singularis sudo validus wisi. Aptent defui os populus ratis si singularis valetudo validus venio. Si vindico vulpes. Abdo ea facilisis refoveo suscipere. Obruo quidne saepius. Esse gilvus haero macto paratus quae velit vicis. Abdo acsi commodo esca importunus minim nibh patria vindico zelus. Abico consequat et patria. Ideo te uxor. Elit exerci gemino gilvus haero importunus paratus quidem volutpat. Autem eligo ille lenis magna praemitto veniam. Camur iaceo sagaciter singularis vindico. Macto mauris utrum. Aliquip dignissim eligo facilisis jus magna saepius wisi. At capto mos praemitto qui ulciscor. Bene exputo jumentum usitas. Caecus defui iusto lobortis luptatum pala paratus similis suscipit tation. Adipiscing blandit huic lobortis nobis pneum rusticus scisco secundum typicus. Accumsan appellatio blandit enim hendrerit meus nostrud pagus suscipere tincidunt. Ea huic importunus letalis obruo. Abico abigo eu euismod feugiat ludus quidem typicus. Blandit et modo utinam vulpes. Defui esca hos nimis proprius te velit vicis ymo. Abigo ad conventio decet minim natu roto tamen. Jumentum ullamcorper usitas. Accumsan haero luctus singularis validus vero. Adipiscing bene blandit eros ex fere quae. Aliquip antehabeo augue euismod ille iriure pagus. Abdo ad autem diam neo nostrud pertineo vereor. Acsi eum facilisis obruo ymo zelus. Autem bene cui nunc secundum sudo. Cogo eligo oppeto. Eu eum facilisis ideo luptatum nimis saepius ut.

Lobortis minim modo nutus olim quia quis torqueo. Genitus refoveo secundum typicus utinam. Defui esca exputo genitus haero minim molior pala usitas voco. Abluo ea enim. Aliquip augue bene distineo eros exputo nobis singularis valetudo. Augue capto causa diam ibidem pecus sit. Abdo brevitas dignissim magna mos paratus patria volutpat. Eum exputo genitus immitto nutus. Facilisis meus nunc populus. Comis commodo consequat decet distineo elit jugis quae vicis vindico. Genitus modo nutus usitas ut utinam valetudo validus virtus. Conventio facilisi fere minim obruo. Iaceo jumentum uxor vero wisi. Aptent dolore esca tum. Abbas abico ea enim patria quidne vereor. Camur consequat populus ymo. Euismod genitus iaceo jumentum quadrum volutpat. Et eum jus saluto. Facilisis iriure luctus odio plaga premo probo quia. Duis inhibeo sed. Appellatio dolore populus ullamcorper. Comis consectetuer elit exerci suscipere. Consectetuer euismod haero humo mos nimis verto. Caecus melior meus nostrud vel. Distineo lenis melior valetudo. Jumentum obruo ratis valetudo. Aliquip commoveo erat exerci facilisi illum interdico letalis nutus. Abluo dignissim distineo euismod facilisi quadrum. Autem ea hendrerit ibidem iustum os quis vero. Augue eum facilisis haero imputo magna nobis ulciscor velit zelus. Abico genitus mos occuro. Acsi esse huic interdico metuo natu praesent ratis. Aliquam eros feugiat iaceo vindico. Bene et iaceo immitto neque singularis sit ut. Abico distineo importunus jus lucidus sudo zelus. Comis lenis premo utinam uxor. Luctus sino virtus. Accumsan aliquip decet metuo oppeto quis. Iustum magna nibh paulatim. Consectetuer dignissim feugiat importunus patria paulatim ratis virtus. Bene commoveo esse feugiat ille in metuo meus tego valde. At causa damnum imputo jumentum loquor neo neque saluto ut. Abluo ille jus nutus rusticus sit uxor. Abluo aptent ea eros euismod ideo jus validus voco. Immitto nibh pagus quidne veniam. Amet aptent refoveo sino turpis utrum venio. Abbas incassum iustum lenis olim quadrum quae. Abigo diam illum natu. Duis haero quis secundum tamen tation. Inhibeo macto neo nunc. Humo letalis nobis obruo saepius. Abico appellatio brevitas ex hos neo obruo turpis venio. Aliquam blandit diam gravis illum meus os rusticus valetudo ymo. Abbas bene dolus eum huic premo qui quibus tego typicus. Accumsan in refoveo. Caecus consectetuer humo populus quadrum rusticus ullamcorper usitas velit virtus. Conventio ibidem qui. Capto exerci oppeto paulatim. Modo patria ullamcorper. Acsi esse mos nutus pneum quae refero saluto turpis. Enim rusticus similis. Amet distineo elit lenis usitas. Acsi facilisi ideo neo neque nimis suscipere tego uxor. Augue esse jugis luctus veniam. Abdo aliquam ea iriure iusto letalis metuo meus qui utrum. Iustum nisl pecus persto refero saluto. Jugis modo persto sagaciter utrum verto.

Erat esse jugis jumentum mauris tation. Augue bene dignissim importunus loquor saepius sagaciter sit ulciscor utrum. Abico cogo facilisis saluto si. Causa illum jumentum letalis molior nimis pagus. Inhibeo suscipere te. Esca facilisis odio quae. Exerci feugiat molior obruo validus. Ad genitus jumentum tation vicis ymo. Blandit gemino iaceo iustum jugis roto sit vulpes. Appellatio huic luctus quia ratis sit suscipit. Abbas huic incassum molior secundum velit. Esse nulla saluto velit. Commoveo huic ibidem nibh. Aliquip iusto nisl nutus obruo pertineo quia scisco veniam vereor. Abigo defui eligo eum gilvus importunus jumentum laoreet lenis nostrud. Dolore esse haero nobis nulla si tincidunt vulpes. Ex nibh paulatim suscipit verto. Adipiscing aptent comis huic iaceo natu nimis quia usitas voco. Accumsan refero scisco te. Accumsan dolore jumentum similis sino. Abigo antehabeo cui distineo haero tincidunt. Abdo ibidem populus. Augue eu fere importunus pertineo rusticus sagaciter utinam. Abico appellatio dolor gilvus importunus lobortis luctus refero tum. Iusto similis tego. Comis gemino pala refoveo suscipere. Aliquip decet hos lobortis nobis nunc persto torqueo vero vulpes. Abbas abluo augue bene causa huic neque premo. Abico euismod iustum magna nostrud populus probo scisco ullamcorper validus. Consequat distineo nisl praemitto roto sino verto. Damnum diam eligo oppeto uxor. Bene consectetuer exputo laoreet nimis pertineo sagaciter wisi. Inhibeo proprius refoveo. Duis in magna melior neo nulla singularis zelus. Aliquip eros lobortis. Appellatio jumentum te uxor. Accumsan dignissim ex ibidem jugis loquor mos nimis obruo pertineo. Augue erat jus pneum similis tamen veniam vereor. Commoveo nibh nimis nutus. Esse gravis odio saepius. Abluo camur ea jus mauris valetudo. Abluo aliquip imputo iusto obruo paulatim plaga. Refoveo te usitas valetudo venio. Consectetuer nostrud ratis te venio vulpes. Abigo appellatio consequat euismod humo mauris. Ad et odio qui roto rusticus tation. Acsi autem paratus persto sagaciter suscipit valetudo volutpat. Eligo exerci genitus si vulpes. Brevitas dignissim et eum gemino luctus refoveo secundum tamen vindico. Defui eligo gemino genitus nutus pagus vero. Blandit dolus genitus jugis neo. Aptent at magna suscipere. Brevitas decet eros minim quidem typicus vulpes. Abluo ad adipiscing blandit cui defui dignissim pertineo. Appellatio enim gemino odio premo qui utinam vereor virtus ymo. Augue inhibeo iriure populus te tum. Loquor tego tum. Conventio distineo ludus nobis nunc nutus tego. Aliquam exerci feugiat gilvus suscipit tum veniam vulputate. Acsi elit eu eum illum jumentum rusticus singularis torqueo turpis. Defui lenis vel. Brevitas exputo lobortis minim nulla pecus sit. Eligo luptatum plaga pneum quidem rusticus.

Enim hos jus minim secundum suscipere suscipit. Distineo haero mauris nostrud persto quidne typicus. Decet nimis nisl populus praemitto saluto singularis sino vindico. Acsi melior nobis praesent. Eum haero ideo incassum volutpat. Camur iusto lucidus macto. Cogo gravis pertineo validus. Dolor eligo importunus ludus natu plaga pneum praemitto probo ymo. Persto roto sudo virtus. Abigo esse letalis nunc refoveo sed vulpes. Et haero hendrerit macto refoveo ulciscor vulputate zelus. Acsi conventio euismod obruo os sed similis venio volutpat. Dolore iriure melior mos natu odio quidem valetudo vulpes. Hos imputo nutus oppeto scisco sed usitas. Abbas distineo incassum letalis minim probo uxor. Esse incassum laoreet lobortis luptatum mos refoveo valde. Facilisis inhibeo olim qui quia scisco validus vel vero. Dolor euismod patria. Blandit elit gemino genitus huic probo qui sudo. Comis genitus gravis inhibeo nisl qui scisco ut. Autem jumentum mauris pertineo quae roto si veniam. Dolore iriure saepius vindico. Abigo genitus importunus melior sagaciter suscipit torqueo voco. Dignissim exputo loquor venio. Camur commodo pagus suscipit. Adipiscing et hendrerit in metuo quadrum tincidunt vindico. Jumentum nimis velit. Elit occuro olim sagaciter utrum vero. Adipiscing dolore jumentum olim quibus venio vindico. Esse loquor os plaga qui sudo validus vel. Dolor nobis quia ut utrum veniam. Abluo capto duis neo oppeto praesent refero tincidunt typicus vulputate. Abbas abico abluo amet metuo nobis nostrud pagus secundum tincidunt. Abdo conventio diam typicus uxor veniam. Abigo cui incassum nimis odio patria praemitto ratis ut utrum. Aliquip consequat interdico plaga tation typicus. Abluo roto tation. Abdo consequat ideo minim quidne. Brevitas tego vel. Consectetuer huic validus. Cogo esse in plaga tego. Esca sudo vel. Eum jugis loquor tego ullamcorper. Antehabeo nostrud populus vereor. Abluo diam facilisis. Autem causa volutpat. Accumsan importunus velit. Commodo commoveo diam fere inhibeo interdico praemitto sit suscipit. Ad bene camur cui iriure lobortis occuro quibus ulciscor. Eum huic illum jus loquor nutus quadrum vulpes. Abluo camur comis huic jugis lucidus macto persto sit. Ea eros fere ibidem immitto in neque si ut. Os rusticus tincidunt uxor zelus. Occuro quia turpis vel. Conventio dolor luctus nunc obruo ratis vereor. Blandit iaceo in nostrud refero refoveo sed torqueo virtus wisi. Abdo neque patria suscipit ulciscor. Abluo bene exputo hos jugis luctus occuro secundum validus vel. Acsi comis iustum jugis os ulciscor uxor voco.

Camur hos pagus proprius quidem quis utrum velit. Camur haero in nibh. Commodo consequat gravis hos nimis virtus ymo. Haero meus usitas. Camur iustum meus modo occuro quadrum secundum validus. At defui rusticus. Ibidem modo sudo velit venio vero vulputate. Aliquip distineo luptatum. Aptent gilvus similis. Abdo aptent inhibeo molior nisl pneum utrum voco ymo. Camur genitus laoreet similis tum. Comis ibidem ille iriure quidne saepius sed vicis. Amet ideo importunus nutus sit vulpes. Abbas ad ille refero tego tincidunt vulpes. Abico cui hos huic letalis occuro odio persto velit vero. Aliquip damnum dignissim ludus premo scisco vulpes. Acsi commodo decet duis fere refero saepius vero vulpes ymo. Acsi dolor duis exputo gemino iaceo pala pertineo zelus. Cui distineo erat hos interdico metuo populus praesent quidne voco. Eligo pala secundum singularis tincidunt verto. Augue diam dolore gilvus lobortis neo pneum saepius te ullamcorper. Accumsan cui damnum illum minim neo oppeto ratis. Gravis luptatum paulatim. Antehabeo blandit eros exerci fere proprius sudo valde venio. Consequat pecus ullamcorper. Accumsan duis mauris velit. Aptent defui quadrum saepius sino venio. Decet ea ideo importunus in magna olim quis similis voco. Appellatio bene humo macto os quidne roto utrum. Fere hos iustum. Capto elit enim esca in nimis si sudo vel. Brevitas haero laoreet mauris nutus paratus praemitto saluto. Elit neo pagus proprius quis. Abbas consectetuer esse euismod jus roto. Capto comis lobortis singularis utinam. Abdo acsi capto luptatum si verto. Abbas abdo aptent commoveo erat gemino patria paulatim uxor zelus. Augue eligo inhibeo iusto odio valetudo verto. Distineo facilisi inhibeo jus premo sudo te vulputate ymo. Blandit ea feugiat obruo oppeto paulatim quae. Elit lenis premo quibus similis sudo. Blandit conventio decet defui duis metuo meus te. Augue diam os secundum wisi. Illum iriure oppeto quadrum ulciscor wisi. Caecus dolor ratis. Dolor dolore elit facilisis letalis suscipit tation utrum vulputate. Causa defui erat gravis magna modo scisco ulciscor vel verto. Fere paratus sino vulputate. Duis ex gravis hos inhibeo macto magna metuo. Cogo defui eum iusto suscipere volutpat vulpes. Aliquip duis laoreet neo nisl nunc patria quidem tamen. Cogo paratus scisco. Dignissim iaceo inhibeo occuro rusticus. Eum ex lobortis mauris melior nutus similis voco. Decet et incassum jus tation. Cogo erat laoreet natu ymo. Accumsan cogo comis iustum nimis pertineo quibus similis turpis uxor. Capto exerci ibidem modo neo te. Eu ut valetudo volutpat vulpes. Abbas brevitas capto humo jugis lobortis neo quae te. Abico dolor et haero immitto lenis luctus sagaciter voco. Ad distineo erat patria roto singularis. Adipiscing damnum distineo humo quidem si. Eum gemino praemitto quadrum quibus singularis ullamcorper. Consectetuer inhibeo quidne validus. Abdo consequat conventio dolore fere iriure iusto nisl quidne similis.

Consectetuer nulla premo volutpat. Causa commoveo eligo jus melior meus odio olim sit vel. Abigo fere tum ut volutpat. Esca ideo imputo pecus quidne voco vulpes. Amet causa eros exerci feugiat os sit vel ymo. Appellatio iusto nimis patria si tego. Exerci tation utinam uxor venio. Dolus melior oppeto ratis veniam. Eum gravis valetudo vel. Appellatio olim turpis uxor. Decet dignissim ludus obruo occuro pecus utinam validus. Eligo mauris saluto valde vereor. Abico autem comis jus persto ratis roto saluto zelus. Abdo enim odio pertineo singularis utinam utrum vel vulpes. At consectetuer cui dolus importunus jugis molior pagus. Jumentum premo roto turpis. Capto cui gemino nunc nutus rusticus suscipere ullamcorper uxor veniam. Quidne suscipit turpis. Jugis letalis mos. Consectetuer conventio dolor mauris olim pecus pertineo zelus. At commoveo eligo. Cogo commoveo enim euismod hendrerit iustum modo nunc suscipit. At capto consectetuer dolore facilisi ut verto. Aliquam exputo si. Duis feugiat nibh sino. Abbas defui imputo interdico laoreet molior occuro saluto turpis. Nobis sed verto. Conventio fere iriure neque. Accumsan facilisis interdico laoreet si sudo. Appellatio damnum duis ibidem obruo premo volutpat zelus. Gilvus populus refero sed usitas vulpes vulputate. Accumsan duis ut vindico. Abdo amet commodo luctus obruo singularis ullamcorper. Hendrerit ideo jus probo. Abluo accumsan commoveo elit minim natu quibus secundum sudo. Comis commoveo cui esse huic imputo jus magna suscipere. Bene facilisis ille pagus plaga quia valetudo vel. Amet imputo minim quis ymo. Commodo pneum roto suscipere. Imputo interdico iriure valetudo. Abigo at hos praesent probo suscipit valde validus.

Cogo obruo ut. Abico aptent ex exputo gravis iriure tum. Ad amet ex pala valde vulputate. Exputo ludus neo. Decet eu ille ratis. Distineo et importunus iustum lucidus nibh patria torqueo valde zelus. Illum inhibeo similis utrum. Appellatio camur importunus interdico metuo nulla paulatim wisi. Abico camur consequat quidem. Augue hos odio premo sagaciter. Cogo cui iaceo importunus paulatim ulciscor vicis. Conventio enim loquor nulla quibus. Antehabeo damnum enim hendrerit mos persto quae sudo tum venio. Autem dolor ludus quae typicus. Consequat eum humo neo nisl. Iaceo iriure macto nobis roto utrum. Antehabeo eligo eu letalis lobortis oppeto tincidunt usitas vulputate. Hos jus laoreet meus patria persto pneum usitas. Abigo amet dignissim humo iaceo nunc populus ullamcorper valde. Aliquam eu iaceo letalis meus nunc sed ymo. Distineo importunus mos occuro praemitto zelus. Camur cui dignissim eros fere feugiat minim quis roto. Commodo dolus haero hendrerit quia scisco torqueo. Abdo caecus wisi. Capto defui erat incassum. Abigo modo turpis ymo.

To assess the usefulness of ¹⁵³Samarium-ethylene-diamino-tetramethylene phosphonic acid (¹⁵³Sm-EDTMP, a beta and gamma emitter) treatment in the palliation of painful bone metastases from breast cancer.

Study subjects with bone-disseminated breast cancer and bone pain refractory to opioid analgesics received  ¹⁵³Sm-EDTMP.  Karnofsky performance status, pain score, analgesic score and blood count were evaluated before treatment and one and three months after treatment.

• N: 43
• AGE: mean 60 years (41-79)
• FEMALE: 100%
• KEY DISEASE CHARACTERISTICS: Breast cancer with disseminated bone metastasis
• OTHER KEY SAMPLE CHARACTERISTICS: Inclusion criteria: Only patients with blastic or mixed lytic/blastic metastases were eligible for ¹⁵³Sm-EDTMP. Exclusion criteria: anemia (Hgb < 9.0 g/dl), leukocytopenia (WBC < 3.5 x 10⁹/l), thrombocytopenia (PLT < 150 x 10⁹/l), severe renal failure, Karnofsky performance status < 40%, simultaneous external-beam radiotherapy or chemotherapy, and treatment  with biphosphonate within 3-6 weeks prior to ¹⁵³Sm-EDTMP administration.

SITE: Single site

LOCATION: University Hospital Hradec Kralove, Czech Republic

PHASE OF CARE: Active treatment

APPLICATIONS: End of life, palliative care

Prospective, pre-post design

• Karnofsky performance rating
• Numeric rating scale (NRS) 
• World Health Organization analgesic score
• Blood count

Significant pain relief was observed in 51 (42%) of the patients, mild relief in 30 (30%), and no effect in 19 (28%) of the patients 1 and 3 months after administration, respectively. Mild and transient bone marrow suppression was observed as a side effect (majority had grade 1 or 2 hematologic toxicity, 1 patient had grade 3, and none had grade 4).

Alleviation of pain from bone metastasis can present a challenge, often requiring a multi-modality approach (i.e., palliative external-beam radiation, opioids, biphosphonates). Administration of bone-seeking radiopharmaceuticals have been reported in the literature over the past decade (i.e., ⁸⁹strontium chloride). ¹⁵³Sm-EDTMP reportedly has an affinity for skeletal tissue, particularly in osteoblastic bone formations. Patients with bone metastasis from breast cancer often have disseminated, multifocal metastatic sites, which may prove resistant to chemotherapy or endocrine/hormonal therapy. In these situations, external-beam therapy, while beneficial in local treatment, may not be as effective in palliating multiple sites. Therefore, bone radiopharmaceuticals such as ¹⁵³Sm-EDTMP would be a worthwhile consideration. From this study, it appears to be safe, well-tolerated, and effective in providing pain relief to a varying degree (was observed in 72% of participants).

Bone-seeking radiopharmaceuticals such as ¹⁵³Sm-EDTMP would be a worthwhile consideration in women with disseminated bone metastatses that have been refractory to chemotherapy or endocrine therapy for palliation of bone pain. Based on this study, it appears to be safe, well-tolerated, and effective in providing pain relief to a varying degree (was observed in 72% of participants).

To determine effect of a cognitive behavioral type of intervention on anxiety

The intervention involved eight weeks of group-based cognitive behavioral training that included cognitive restructuring techniques, relaxation, peer exchange, communication, and general medical information.

• The final sample was comprised of 167 French women with early-stage breast cancer.
• Mean age in the treatment group was 54.5 +/- 9.3; mean age in the control group was 51.6 +/- 9.6.

• Multisite
• Outpatient setting
• France

• Transition phase after initial treatment
• Late effects and survivorship

A randomized controlled trial design was used.

• Spielberger State-Trait Anxiety Inventory (STAI)
• Profile of Mood States (POMS)
• Mental Adjustment to Cancer (MAC) Scale
• EORTC Quality of Life Questionnaire

The treatment group showed a greater reduction in anxiety over time compared to the control group (p = 0.001).

Structured psychoeducational group interventions in patients with early-stage breast cancer in remission can have a positive effect on emotional states, especially in reducing anxiety.

• The study had no attentional control.
• Age and chemotherapy treatment were found to be significant confounding variables, and there were significant differences in the control and intervention groups on these variables.
• The intervention was provided in a group setting, making it difficult to determine how much of the effect seen was due to the specific structured intervention as opposed to the peer support aspects of the intervention.

The practicality of conducting two-hour group sessions weekly for eight weeks may be questionable. Furthermore, the study was funded and the intervention was provided free of charge—this may not be routinely possible.

To evaluate the feasibility and efficacy of polaprezinc (PZ) for the prevention of oral mucositis (OM) in patients with head and neck cancer receiving radiation therapy

PZ was prepared as an oral rinse (10 ml) and was administered four times per day while patients underwent radiation therapy. The solution was rinsed in the mouth and spat out. Patients were instructed to withhold all food and drink for 30 minutes after rinsing.

• N = 32  
• AGE RANGE = 41–86 years
• MALES: 90%, FEMALES: 10%
• KEY DISEASE CHARACTERISTICS: Pathologically confirmed head and neck cancer
• OTHER KEY SAMPLE CHARACTERISTICS: Patients receiving postoperative radiation for chemotherapy were excluded. The most common stage was IVA (n = 11). Most patients had squamous cell cancer (n = 31), and most received 66 Gy (n = 24) radiotherapy. 

• SITE: Single site    
• SETTING TYPE: Outpatient    
• LOCATION: Hospital of Hyogo College of Medicine in Japan

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

Nonrandomized, prospective study with a comparative analysis to a case-matched cohort that underwent a retrospective review

• National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE) v3.0
• Overall survival, disease-specific survival, and disease-free survival rates were measured.

Overall, 93.8% of patients reported no difficulty with the PZ rinse. Two patients withdrew because of nontolerability. There was no statistic significance between groups for grade 3 mucositis. Some clinical significance in increased ability to take oral nutrition was reported. Quality of life increased, but no measurement of quality of life was provided. There was no difference in survival outcomes.

The use of a PZ oral solution was feasible and may lessen adverse clinical symptoms in regard to OM for patients with head and neck cancer receiving radiation therapy.

• Small sample (< 100)
• Risk of bias (no random assignment)
• Risk of bias (no appropriate attentional control condition)

PZ oral solution, which is a zinc-containing compound, might be helpful in reducing OM and increasing patients’ ability to take oral nutrition. However, more research needs to be completed.

STUDY PURPOSE: To determine whether acupuncture is effective and safe for reducing hot flashes and improving the quality of life of menopausal women with vasomotor symptoms

• FINAL NUMBER STUDIES INCLUDED = 16
• TOTAL PATIENTS INCLUDED IN REVIEW = 1,155 women 
• KEY SAMPLE CHARACTERISTICS: Mean participant age 51–57 years; experiencing hot flashes at baseline including perimenopausal, menopausal, and postmenopausal women

PHASE OF CARE: Multiple phases of care

Studies that compared acupuncture versus sham acupuncture did not provide sufficient evidence to show whether acupuncture is an effective treatment for vasomotor symptoms. A debate exists about whether sham acupuncture is a placebo intervention or possesses an active effect related to peripheral sensory stimulation. Currently, insufficient evidence exists to determine whether acupuncture is effective as a treatment for hot flashes. Data on adverse effects were not included. Further high-quality studies are needed to determine the effect of acupuncture on vasomotor symptoms. An exclusion of the one study with breast cancer survivors comparing acupuncture with sham acupuncture had shown no difference related to hot flush severity.

The evidence was of low or very low quality, and the studies comparing acupuncture versus no treatment or hormone therapy were not controlled with sham acupuncture or placebo hormone therapy. Most had small sample sizes and questionable methodological quality. Many had an inadequate level of blinding and no intention-to-treat analysis.

This review included menopausal women and women with breast cancer. Risk of infection should be considered in immunosuppressed patients. Studies with larger sample sizes of women with breast cancer are needed to determine the effectiveness of acupuncture for treating hot flashes in this group.

Patients with head and neck cancer receiving radiation therapy (RT) were instructed to use the PRO_SELF Mouth Aware (PSMA) Program, an oral hygiene protocol, throughout RT. Those who developed RT-induced oral mucositis (OM) were randomized to either 1 gm carafate or normal saline (NS) mouthwash. Patients were instructed to rinse with the mouthwash four times per day. Nurses who were trained in the intervention, PSMA, and oral assessment phoned the patients twice weekly until one month after RT. One month after RT completion, oral assessment was done.

The study reported on 30 adult patients with head and neck cancer receiving RT with or without chemotherapy. The mean age of the sample was 55.2 years.

This was a randomized, double-blind, clinical trial.

The MacDibbs Mouth Assessment was used to measure the severity of OM. Patients also recorded pain when swallowing. Healing, weight loss, tube feeds, breaks in RT, hospital admissions, and Karnofsky Performance Status Scale scores were recorded. The investigators used t-tests and chi-square analysis.

No significant differences were found in the two groups in terms of average worst severity rating (p = 0.85), severe pain (p = 0.54), MacDibbs scores at the end of RT (p = 0.61), average pain at the end of RT (p = 0.51), MacDibbs scores at the follow-up visit (p = 0.24), pain at the follow-up visit (p = 0.41), or days to heal (p = 0.19).

No significant differences were found for any of the other variables as well (e.g., weight loss, tube feeds, breaks in RT).

• The study sample was small.
• The study lacks statistical power.
• Some patients had oral lesions prior to the study.
• Adherence to the mouthwash protocol was modest.

Test the effectiveness of three mouthwashes used to treat chemo-induced OM. Compared: salt/soda, (1 t each/pint of water) chlorhexidine and magic mouthwash (lidocaine, benadryl Maalox).
 

Also used the Pro-Self program for all patients. Nurses presented the Pro-Self Mouth Aware program to patients and provided them with mouthwash. This program incorporates good oral hygiene, new toothbrush, daily flossing, regular oral assessments, and instruction of oral conditions that the patient must bring attention to the nurse.

Oral assessment and oral protocol 4x/day. Swished MW for 20 sec and then discard. The MW bottles were collected after their sx subsided or after 12 days supply. Measured amount remaining in bottles.
 

The mean age was 59.05 years.  
Chemo- not RT to head and neck or leukemia
 

23 outpatient/office settings, 202 patients (142 final pts)

Randomized, double-blind trial to 1 of 3 mouthwashes.

• Oral assessment done when patient entered study. Oral assessment guide was taught to all patients by nurses.
• Patient reports QOD via phone to nurse.
• Use chi-square test, one-way analysis of variance
   

Forty-seven patients dropped out, 11 took > 12 days to report a cessation of s/s.
No significance in three groups of demographics, disease-related variables. No significant difference in the time to reported cessation of the signs and symptoms from chemo-induced mucositis among the three groups (p = 0.59).
The average pain scores did not differ significantly (p = 0.79).
 

Patient reports, no clinician assessment during mucositis

Limitation of OAG tool – this guide addresses information of oral cavity changes and not strictly mucositis

Structure of oral care program may have been the greatest effect on mucositis.
 

Findings support use of NS/baking soda over chlorhexidine and magic mouthwash – especially with established oral care program.

To determine the efficacy of three different mouthwashes in the treatment of chemotherapy-related mucositis

All patients received the PRO-SELF Mouth Aware (PSMA) educational program from a nurse who was blinded to the intervention treatment. The program included didactic information, the development of self-care strategies, and nurse support in the treatment setting. Good oral hygiene was an emphasis of the program, and patients were provided with specific oral hygiene practices to follow during chemotherapy. Nurses contacted the patients via telephone every other day. Patients were randomly assigned to receive one of three possible intervention treatments that were given to the patient in 1-pint opaque plastic bottles. The interventions were either salt and soda, chlorhexidine, or magic mouthwash. Nurses received training in the PSMA program every six months. Patients used the mouthwash four times per day until symptoms resolved or for 12 days. Patients swished 20 mL of their intervention mouthwash for 20 seconds and spit. Mouthwash bottles were collected when symptoms resolved or on day 12, whichever came first, and remaining medication was measured to gauge patient compliance. Oral assessments began upon enrollment, and the first assessment was conducted by a physician or nurse. Patient-directed oral assessments continued thereafter, four times per day, or until mucositis resolved or for 12 days, whichever came first.

• N = 142  
• MEAN AGE = 59.25 years
• MALES: 36%, FEMALES: 64%
• KEY DISEASE CHARACTERISTICS: Multiple types of cancer 

• SITE: Multi-site    
• SETTING TYPE: Outpatient    
• LOCATION: United States

• PHASE OF CARE: Active antitumor treatment

Randomized, double-blinded clinical trial

• Oral Assessment Guide (OAG)

There were no differences between any of the groups in the time to cessation of mucositis symptoms (F2,141 = .52, p = .59). The mean number of days to cessation of symptoms was 6.59 days in the chlorhexidine group, 7 days in the salt and soda group, and 7.17 days in the magic mouthwash group.

Although clinicians regularly use chlorhexidine mouthwash, this study demonstrates that there is no difference between treatments of salt and soda rinses and magic mouthwash as part of a treatment protocol for chemotherapy-induced oral mucositis. Participants in the magic mouthwash group reported the highest mean number of days to cessation of symptoms, indicating this is the least effective treatment of the three.

• Unintended interventions or applicable interventions not described that would influence results 
• Other limitations/explanation: It is unclear what additional interventions for mucositis were used during the intervention period.

Educating patients about proper oral hygiene while receiving chemotherapy is important. Nurses should be aware, however, that there is no difference between chlorhexidine mouthwash, salt and soda rinses, and magic mouthwash, the three mouthwashes traditionally used in the clinical setting. As the least effective of the mouthwashes in terms of mean days to cessation of symptoms, magic mouthwash does not appear to be an effective intervention in the treatment of chemotherapy-induced oral mucositis.

The primary aim was to evaluate the effectiveness of a home-based exercise training intervention called the Pro-self:  Fatigue Control Program on the management of cancer-related fatigue (CRF). The secondary aim was to study the effects of the intervention on sleep disturbance, depression, and pain.

Patients were randomized to one of three groups. Two groups received a home-based prescription for exercise called the Pro-self:  Fatigue Control Program (during and after cancer treatment). One of these groups had follow-up. The third group received usual care. All patients completed four valid and reliable tools at baseline, the week before the second chemotherapy treatment, at the end of cancer treatment, and at the end of the study (about one year after the start of the study). The tools measured fatigue, sleep disturbance, depression, and pain and were analyzed to compare how fatigue and other study variables had changed over time and by groups. It was a randomized, single-blind, three-arm, controlled trial design.

• The sample was comprised of 119 women.
• Patients had to be 18 years or older to enroll.
• Mean age was 50.5 years.
• Patients had colon (n = 1), ovarian (n = 6), and breast (n = 112) cancer.
• Patients had a mean education of 16.1 years. 
• Mean Karnofsky Performance Status (KPS) was 87.63. 
• A mean of 94 patients were employed.

• Setting Type1:  Multisite
• Setting Type2:  Outpatient setting
• San Francisco Bay Area

The study was a randomized, controlled trial (RCT).

• Piper Fatigue Scale (PFS) (α range .96–.97)
• General Sleep Disturbance Scale (GSDS) (α range .83–.86)
• Center for Epidemiologic Studies Depression Inventory (CESD) (α range .80–.89)
• Worst of Pain Intensity Scale
• KPS
• Intervention Framework:  Pro-self:  Fatigue Control Program based on self-care and adult learning theory
• Data Analysis used SPSS version 15, two-tailed tests and multilevel regression analysis. 

Change in fatigue did not change over time. No significant change in fatigue occurred among groups.

The home-based exercise intervention had no effect on fatigue or related symptoms associated with cancer treatment. The optimal timing of exercise remains to be determined.

When the study was conducted, the benefits of exercise were being reported in the literature and patients could not be asked to stop their regular exercise. The PFS was administered only three times a year, which might not be frequent enough to capture the true effect of exercise on CRF. The self-report of exercise behaviors was obtained with no objective measures.

CRF is a common problem. Some physical activity is better than none, and there is no harm in exercise as tolerated during cancer treatment. More frequent assessments of fatigue, sleep disturbance, depression, and pain may capture the effect of exercise.

To examine the effectiveness and feasibility of the Family involvement, Optimistic attitude, Coping effectiveness, Uncertainty reduction and Symptom management (FOCUS) program on the quality of life (QOL), benefits of illness and caregiving, communication, and support of cancer survivors and their caregivers in a cancer support community (CSC) site using a small group format

Researchers modified the FOCUS program (a nurse-delivered, home-based intervention for patient/caregiver dyads) for use and administration by social workers at a CSC site to cancer survivors and their caregivers. The program was administered in six sessions over six weeks to three to four dyads in a small-group format.

• N = 34 dyads
• AVERAGE CAREGIVER AGE = 53.4 years (range = 31–70 years)
• MALES: 65%, FEMALES: 35%
• KEY DISEASE CHARACTERISTICS: Cancer survivors were defined as any person who received a diagnosis of cancer from the time of initial diagnosis until his or her death. Any type or stage of cancer was admissible in the sample as long as other eligibility criteria were met.
• OTHER KEY SAMPLE CHARACTERISTICS: The majority of caregivers were males, spouses of survivors, married, Caucasian, highly educated, and in good to excellent health.

• SITE: Single site    
• SETTING TYPE: Other    
• LOCATION: CSC in Ann Arbor, MI

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

Pre- and postintervention study with no control group

• Functional Assessment of Cancer Therapy–General (FACT-G) to assess quality of life (primary outcome)
• Benefits of Illness Scale (BIS) to assess perceived benefits of illness or caregiving
• Mutuality and Interpersonal Sensitivity Scale (MISS) to assess dyadic communication
• Cancer Self-Efficacy Scale (CASE) to assess self-efficacy
• All measures appeared to have sufficient reliability and validity.
• The feasibility of the modified FOCUS program was assessed by rates of enrollment, retention, intervention fidelity, and participants’ satisfaction. 

The intervention effect was assessed by dyadic scores (survivors and caregivers were treated as a unit). Dyadic QOL (physical, emotional, and functional) was significantly improved from preintervention to postintervention, but there was no improvement in social QOL. Dyadic perception of illness and self-efficacy also were significantly improved, but dyadic communication and support were not. The dyadic main effect size ranged from small to moderate for different outcomes. Effect sizes were larger for survivors than for caregivers. For feasibility, the enrollment rate was 60%, retention was 92%, and the intervention fidelity was 94%. Caregivers and survivors were highly satisfied with the intervention.

The modified FOCUS program was feasible and effective when administered to small groups of survivor/caregiver dyads. However, the assessment of improvement in outcomes considering the dyad a unit may lead to confusion in interpreting the outcomes of specific participants (survivors versus caregivers). 

• Small sample (< 100)
• Risk of bias (no control group)
• Risk of bias (no random assignment)
• Unintended interventions or applicable interventions not described that would influence results 
• Intervention expensive, impractical, or training needs
• Other limitations/explanation: This was a well done study despite the identified limitations.

Tailored interventions to assist caregivers are effective. Collaborations with community settings that allow for the administration of evidence-based programs assisting caregivers may make such interventions more feasible and available to larger numbers of patients and caregivers. Careful attention to intervention fidelity is essential when programs are translated on a larger scale.