Derry, H.M., Jaremka, L.M., Bennett, J.M., Peng, J., Andridge, R., Shapiro, C., . . . Kiecolt-Glaser, J.K. (2014). Yoga and self-reported cognitive problems in breast cancer survivors: A randomized controlled trial. Psycho-Oncology. Advance online publication.
To determine the effects of yoga on self-reported cognitive function
Certified yoga instructors led two 90-minute yoga group classes per week for 12 weeks. Each group contained 4–20 participants. Hatha yoga poses targeting relaxation, mindful breathing, chest opening, spinal extension, upper-body strength, and mobility were predetermined for each of the 24 sessions, and protocol drift was monitored. Pamphlets describing the poses from the classes and a yoga DVD were provided for home practice. Participants recorded weekly home and class time to determine dose effects. Participants who missed a class were called to improve adherence. Waitlist control participants continued regular activities and were directed not to begin yoga practice until after their final assessments. Measures were assessed before the behavioral intervention, immediately after the 12-week intervention, and three months after the intervention.
Randomized, waitlist-controlled trial
At baseline, the average self-reported cognitive impairment was slight to moderate and did not differ between groups. Overall group and group-by-time effects were found (p < .05, both). Although no differences were found immediately after the 12-week intervention, the intervention group reported significantly less cognitive impairment than controls three months after the intervention ended (p < .01). However, these effects did not remain after controlling for symptom covariates (e.g., anxiety, depression, fatigue, sleep quality). Participants with more daily yoga practice (mean of 29 minutes) reported less cognitive impairment postintervention through three months (p = .011), and participants with less daily yoga practice (mean of 18 minutes) or no daily yoga practice did not report these changes. This dose response remained when controlling for symptom covariates. At three months, the intervention group reported more physical activity than controls (p = .032). Cytokine levels did not predict changes in self-reported cognitive impairment.
A 12-week, group Hatha yoga intervention provided by a trained instructor may improve self-reported cognitive impairment in breast cancer survivors. This effect may be mediated by improvements in co-occurring symptoms. Practicing yoga for at least 30 minutes per day may be required for a significant improvement over time in cognitive impairment.
A group Hatha yoga class delivered by a trained facilitator may improve cognitive impairment for breast cancer survivors. However, more research with a longer follow-up period is warranted to determine whether the intervention is effective, what component of the intervention is active, and whether yoga is practical for implementation in practice.
de Raaf, P.J., de Klerk, C., Timman, R., Busschbach, J.J., Oldenmenger, W.H., & van der Rijt, C.C. (2013). Systematic monitoring and treatment of physical symptoms to alleviate fatigue in patients with advanced cancer: A randomized controlled trial. Journal of Clinical Oncology, 31, 716–723.
To investigate whether nurse monitoring and protocol management of physical symptoms alleviates fatigue
Patients were randomized to receive either usual care or nurse management patient-tailored treatment using treatment management protocols. In the experimental group, nurse specialists recorded interventions for multiple physical symptoms. During outpatient meetings with the nurse, symptom severity was monitored. When any symptoms were rated ≥ 4 on an 11-point scale, the nurse referred the patient to the oncologist for further assessment and initiation of treatment according to palliative care guidelines, such as medication adjustment, other referrals, or other interventions. Nurses managed as many symptoms independently as possible. Highly specific interventions for pain, nausea, vomiting, constipation, diarrhea, anorexia, dyspnea, cough, and dry mouth were used. No specific interventions aimed at fatigue were identified. Patients met with the nurse at 1, 2–4, 5–7, and 8–10 weeks. Study assessments were done via mail at baseline and one, two, and three months.
A randomized controlled trial design was used.
Patients reported that the most troublesome symptoms were pain, dyspnea, and anorexia. Patients had a median of two symptoms with NRS scores of at least 4 at baseline. MFI scores for general fatigue declined significantly over time in the intervention group compared to controls, with effect size ranging from 0.26 to 0.35 (p = 0.01). NRS fatigue scores also demonstrated decline compared to usual care controls (p < 0.001). BFI scores were not reported. Overall symptom burden was reported to decrease over time in the intervention group, while there was no change in controls (maximal effect size = 0.64, p = 0.002). Anxiety decreased in the intervention group compared to controls (maximal effect size = 0.32, p < 0.001).
Findings suggest that comprehensive management and monitoring for symptom control by nurse specialists was effective in reducing anxiety and fatigue in patients with cancer.
Findings suggest that continued symptom management and monitoring with a protocol approach can be effective for reducing symptoms overall, and reducing fatigue and anxiety. There were no specific intervention approaches identified that were used for fatigue, so the suggestion is that reducing other symptoms can have a positive impact on fatigue. There were also no specific interventions identified for anxiety, but anxiety also declined over time. These results suggest that ongoing monitoring and attention to patients alone may positively impact these symptoms.
Deplanque, G., Gervais, R., Vergnenegre, A., Falchero, L., Souquet, P.J., Chavaillon, J.M., . . . Chosidow, O. (2016). Doxycycline for prevention of erlotinib-induced rash in patients with non-small-cell lung cancer (NSCLC) after failure of first-line chemotherapy: A randomized, open-label trial. Journal of the American Academy of Dermatology, 74, 1077–1085.
To evaluate the efficacy of doxycycline in the prevention of erlotinib-induced rash (folliculitis) in patients with non-small cell lung cancer (NSCLC)
Patients were randomized via a computer website to receive either erlotinib 150 mg/d per os or erlotinib 150 mg/d per os plus 100 mg/d of doxycycline. Doxycycline began on day 0 (day of randomization) and was continued for four months and as long as 12 months at the primary investigator's discretion. Erlotinib began on day 1 and was administered for as long as 12 months or beyond or until disease progression or intolerable toxicity. Patients were evaluated on days 14 and 28 and at months 2, 4, 7, 10, and 12. Patients with grade 2 or higher folliculitis received treatment as appropriate.
Open-label, randomized, prospective, phase II trial
FOLLICULITIS: During the first four months of treatment, 52 patients (71%) in the doxycycline arm and 59 patients (81%) in the control arm developed folliculitis (p = 0.18). The mean duration of folliculitis was similar in both treatment arms (no p value given). Sixty-two percent of patients in the intervention arm developed grade 1 folliculitis compared to 19% in the control arm. Grade 3 folliculitis developed in 4% of patients in the intervention arm and 19% in the control arm (p < 0.001).
Doxycycline did not reduce the incidence of erlotinib-induced folliculitis but significantly reduced its severity. In fact, more patients in the intervention arm developed grade 1 folliculitis compared to the control arm. The duration of folliculitis was similar in both the intervention and control arm in this study. Compliance with erlotinib was higher in the doxycycline arm during the whole treatment period.
Nurses can collaborate with physicians to verify that doxycycline is combined with erlotinib treatment to improve the level of toxicity of folliculitis. Doxycycline has the potential to decrease the severity of folliculitis in patients with NSCLC who are receiving erlotinib. It does not, however, reduce the incidence of folliculitis in these patients during the first four months of treatment with erlotinib, nor does it reduce the duration of folliculitis.
Dennett, A.M., Peiris, C.L., Shields, N., Prendergast, L.A., & Taylor, N.F. (2016). Moderate-intensity exercise reduces fatigue and improves mobility in cancer survivors: A systematic review and meta-regression. Journal of Physiotherapy, 62, 68–82.
STUDY PURPOSE: To evaluate if a dose response effect of exercise on inflammation and fatigue in cancer survivors exists
TYPE OF STUDY: Meta-analysis and systematic review
PHASE OF CARE: Multiple phases of care
Exercise interventions included aerobic, resistance, flexibility, and combinations of these. Interventions included supervised, unsupervised, home-based, hospital- or other setting–based, and group or individual exercise sessions. Moderate quality evidence that exercise had a positive effect on fatigue compared to usual care existed (standard mean deviation = 0.32, 95% confidence interval [0.13, 0.52]). A combination of aerobic and resistance provided the largest treatment effect. Aerobic intensity was negatively related to treatment effect. No relationships existed between resistance exercise and treatment effect.
Exercise has a beneficial effect on fatigue. Moderate intensity exercise appears to be most beneficial.
Varied study quality and sample sizes
This analysis adds to the body of evidence that exercise has a beneficial effect on fatigue among patients with cancer. This study suggests that moderate level aerobic exercise is more beneficial than more intense exercise. This information can be used to guide patient counseling and teaching to incorporate moderate exercise into daily routines.
Denlinger, C.S., Ligibel, J.A., Are, M., Baker, K.S., Demark-Wahnefried, W., Friedman, D.L., . . . National Comprehensive Cancer Network. (2014). Survivorship: Cognitive function [v.1.2014]. Journal of the National Comprehensive Cancer Network, 12, 976–986.
A uniform NCCN consensus determined that recommendations were appropriate (NCCN Category of Evidence and Consensus = 2A).
Some interventions that may be useful to improve or maintain cognitive function might not be included in these guidelines because this manuscript did not detail search strategies, inclusions and exclusions, or the number of articles included in the recommendations.
The NCCN cognitive function algorithm aids healthcare professionals considering the assessment and treatment of cancer-related cognitive function. Nonpharmacologic interventions should be recommended to oncology survivors experiencing cognitive issues. Pharmacologic interventions may be considered when medical conditions permit and potential contributing factors are ruled out or managed.
Deng, B., Jia, L., & Cheng, Z. (2016). Radix Astragali-based Chinese herbal medicine for oxaliplatin-induced peripheral neuropathy: A systematic review and meta-analysis. Evidence-Based Complementary and Alternative Medicine, 2016, 2421876.
STUDY PURPOSE: To conduct a systematic review of the research evidence for the effects of Radix Astragali (RA)–based Chinese herbal medicine in the prevention and treatment of oxaliplatin-induced peripheral neuropathy (PN)
TYPE OF STUDY: Meta-analysis and systematic review
PHASE OF CARE: Not specified or not applicable; cannot determine if studies were in palliative care setting
APPLICATIONS: Elder care
This meta-analysis indicated that RA-based interventions may provide potential benefit for oxaliplatin-induced PN. Although this meta-analysis did not show significant heterogeneity for different trial results, it did show considerable heterogeneity in the variables, treatments, and outcome measures studied. Studies included RA-based interventions with no reliable measures of drug composition, varied drug doses, self-made drug preparations, or RA combined with herbal compositions with variation in drug delivery methods. Therefore, it is premature to interpret these results as beneficial because of the substantial limitations for reliability and validity of the study results.
It remains unclear if RA provides benefit in alleviating oxaliplatin-induced PN. Additional RCTs are required to evaluate the reliable preparations of RA to investigate its full effects isolated in simple form versus its combined effect with other herbs. The effect of RA on the antitumor activity of oxaliplatin or other chemotherapeutic agents needs further study. Large multisite RCTs are needed to further evaluate drug safety in all phases of treatment and to identify the most effective dose, delivery method, duration of treatment, and quality of life.
Deng, G., Rusch, V., Vickers, A., Malhotra, V., Ginex, P., Downey, R., . . . Cassiletha, B. (2008). Randomized controlled trial of a special acupuncture technique for pain after thoracotomy. The Journal of Thoracic and Cardiovascular Surgery, 136(6), 1464-1469.
Deng, G., Vickers, A., Yeung, S., D’Andrea, G.M., Xiao, H., Heerdt, A.S., … Cassileth, B. (2007). Randomized, controlled trial of acupuncture for the treatment of hot flashes in breast cancer patients. Journal of Clinical Oncology, 25, 5584–5590.
Compare the immediate and long-term effects of true acupuncture versus sham acupuncture on hot flash frequency in women with breast cancer
The study included 72 women with breast cancer experiencing three or more hot flashes per day.
Patients were randomly assigned to receive either true or sham acupuncture.
The primary outcome measurement was hot flash frequency. Participants completed a hot flash diary for one day at days 7, 14, 21, 28, and 35.
The mean number of hot flashes per day was reduced from 8.7 to 6.2 in the true acupuncture group. The mean number of daily hot flashed was reduced from10.0 to 7.6 in the sham group. The true acupuncture was associated with 0.8 fewer hot flashes per day when compared to the sham at six weeks. This difference was not statistically significant. During the cross-over phase, participants in the sham group who received true acupuncture reported a further reduction in the frequency of hot flashes. The overall reduction in hot flash frequency persisted for up to 6 months after the completion of treatment.
The study was limited by a reliance on self-report instruments and recall. No physiologic measurements were used. The study may not have been of a sufficiently long duration and employed a modest sample size.
Deng, G., Chan, Y., Sjoberg, D., Vickers, A., Yeung, K.S., Kris, M., . . . Cassileth, B. (2013). Acupuncture for the treatment of post-chemotherapy chronic fatigue: a randomized, blinded, sham-controlled trial. Supportive Care in Cancer, 21, 1735–1741.
To determine if acupuncture reduced cancer-related fatigue (CRF) more effectively than did sham acupuncture.
Patients were randomized to an acupuncture or sham control group. Treatments were given once a week over six weeks. In the acupuncture group, a total of 14 needles were inserted at defined points during each session. The needles were stimulated manually and retained for 20 minutes. Sham needles, used in the control group, were blunt-tipped, moved up inside their handles when pressed against the skin, and did not penetrate the skin. In the control group, sham needles were applied in the same number and using the same technique as were the needles in the acupuncture group. Outcome measures were obtained at two weeks and at one week prior to the start of interventions and again at 42 and 49 days after completion.
Patients were undergoing the transition phase after initial treatment.
The study was a double-blind, randomized, sham-controlled trial.
The study showed that acupuncture had no effect on the symptoms of fatigue, anxiety, or depression.
The study did not demonstrate that acupuncture had an effect on fatigue, anxiety, or depression. The study contributes to a growing body of research that shows conflicting results regarding the effectiveness of this intervention for the management of fatigue. It has been shown that symptoms such as fatigue and anxiety tend to decline over time among patients with cancer. It is unclear if the timing in this study affected the results; symptoms may have declined with or without the intervention.
Demmy, T.L., Nwogu, C., Solan, P., Yendamuri, S., Wilding, G., & DeLeon, O. (2009). Chest tube-delivered bupivacaine improves pain and decreases opioid use after thoracoscopy. The Annals of Thoracic Surgery, 87(4), 1040–1046; discussion 1046–1047.
To compare, in thorascopy patients, the efficacy of intrapleural bupivacaine versus that of PCA fentanyl
All patients underwent a thorascopic operation during the study. Afterward, the F group received IV fentanyl (F) by means of patient-controlled analgesia (PCA). The IB group received intermittent intrapleural bolus delivery of bupivacaine plus fentanyl. The CB group received continuous intrapleural delivery of bupivacaine plus fentanyl.
PCA fentanyl was given as 40 mcg/hour basal rate with 30 mcg every 10 min as needed to a 160 mcg/hour maximum. Patients in the IB group received an initial bolus of 0.25% bupivacaine and the same PCA fentanyl dosage as the fentanyl-only group. If the fentanyl escalation was insufficient, the patient was prescribed additional 50 mcg boluses as needed. Patients in the CB group received 5 ml/hour continuous infusion bupivacaine via chest tube as well as PCA fentanyl. In the CB group, if fentanyl escalation was insufficient, 15–30 mg ketorolac was administered intervenously.
Nurses obtained baseline pain measures at the first postoperative complaint of pain and request for additional analgesia. Pain was also measured at 6, 12, 18, and 24 hours after the operation.
Nonblinded prospective randomized controlled trial
Administering local anesthetic through a chest tube catheter can reduce fentanyl consumption and pain after a thoracoscopy.
Intrapleural bupivacaine can be used to reduce pain after a thoroscopy; however, this approach may require ongoing adjustment and dosage escalations to achieve sufficient pain control. Intrapleural infusion may reduce total opioid consumption and attendant side effects; however, the study evidenced no differences in terms of prevalence or severity of effects. The most appropriate and effective doses of intrapleural bupivacaine remain unclear. Authors note that the continuous intrapleural infusion approach is much more costly than the other interventions. Whether study findings warrant the increased cost is unclear.