To determine the effectiveness of the use of apparatus-assisted exercises with Godoy and Godoy contention (a cotton and polyester sleeve) for volume reduction of the upper limbs in patients with arm lymphedema secondary to breast cancer treatment

Each of the participants was given four apparatus-assisted exercises to complete using a pedal, pulley, horizontal bar, and elevation bar along with a Godoy and Godoy contention device (sleeve made of a cotton and polyester material). Each exercise was used for 15 minutes under low intensity (less than 10 movements per minute) in a seated position.

• The study sample was comprised of female patients who were experiencing edema of the arm (greater than 200 ml) after breast cancer treatment.
• Mean age was 57 years, with a range of 42–72 years.
• Types of breast cancer treatment included radiotherapy, chemotherapy, and surgery with axillary lymph node resection.

The study took place at an inpatient setting in Brazil.

Patients were undergoing transition and active treatment for lymphedema.

 The study used a quasi-experimental design.

• Measurements were taken one hour before and after the completion of each of the four individual exercises.  
• Water displacement volumetry was used to measure the arm volume in the upper limbs.

There was a significant loss in arm volume (mean decrease of 57.32 g) after using the four different apparatus-assisted exercises (p = 0.0032).

The study suggests that there is a positive correlation between the use of apparatus-assisted arm exercises and the reduction of edema in patients with arm lymphedema secondary to breast cancer treatment.  However, the data should only be used for evaluation purposes because the study has many limitations.

• The sample size was small, with less than 30 participants.
• The study had a risk of bias because of no control group, blinding, random assignment, or appropriate attentional control condition.
• The study had a single observation only with immediate pre- and postmeasurement only.
   

The results from this study can be used as a tool to nurses when identifying treatment strategies for patients with arm lymphedema. However, nurses should be aware that not enough research has been done to validate the point that the use of Gody and Godoy during arm assisted-apparatus exercises has a strong relation to a reduction on peripheral edema. Further research needs to be conducted to validate the findings of the study using a more rigorous study design.

To evaluate the influence of low-level laser therapy (LLLT) on the prevention and treatment of oral mucositis (OM)

Patients were distributed by convenience sampling into two groups (A and B) based on the order in which they were hospitalized. Group A was composed of patients who received preventive laser (red or infrared subgroups A1 [n = 10] and A2 [n = 10], respectively) for five days, beginning on the first day of chemotherapy. Group B was composed of patients who did not receive any preventive intervention, and those who developed post-chemotherapy mucositis were subjected to therapeutic laser (red or infrared subgroups B1 [n = 10] and B2 [n = 10]) until full remission of the lesions.

• N = 40  
• AGE = 1–18 years
• MALES: 67.5 %, FEMALES: 32.5%
• KEY DISEASE CHARACTERISTICS: Pediatric population with acute lymphoblastic leukemia who received high-dose methotrexate

• SITE: Single site  
• SETTING TYPE: Inpatient   
• LOCATION: Instituto de Medicina Integral Professor Fernano Figueira

• PHASE OF CARE: Active antitumor treatment
• APPLICATIONS: Pediatrics

The patients were distributed by convenience sampling into two groups (A and B) based on the order in which they were hospitalized. Group A received preventive laser, and Group B received therapeutic laser.

Evaluations were done by daily use of the World Health Organization (WHO) scale grade 0–IV, and patient self-assessed pain was measured by means of the visual analog scale (VAS) (0–10). This assessment was made before each LLLT session.

The overall incidence of OM was 57.5% up to the age of 8 years; the degree of mucositis was significantly higher than that observed among patients older than 8 years. Generally in group A, 40% of patients developed OM, and in Group B, 75% of patients developed OM. In subgroup A1, 30% had mucositis, and in subgroup A2, 50% had mucositis. In subgroup B1, 70% had mucositis, and in subgroup B2, 80% had mucositis. In both groups, 75% did not develop pain symptoms. The Mann-Whitney test showed that there were statistically significant differences between the type of laser with the number of days with pain and severity of mucositis.

This study validates that there are positive results with the use of LLLT in reducing the incidence and severity of OM in patients undergoing anticancer treatment. The study confirmed that there is a reduction in the average duration of OM that occurred in both groups.

• Small sample (< 100)
• Findings not generalizable
• Intervention expensive, impractical, or training needs

Among the pediatric population receiving consolidation chemotherapy with methoexate, the study showed that prophylactic laser (with red laser 660nm) produced a better outcome than when patients did not receive any preventive intervention for OM. For nursing, this is another option to help reduce the severity and duration of OM. It is likely that nurses would need to work in a multidisciplinary setting to provide the patient population with this intervention. The study does not provide information about the professional who is trained and able to provide the LLLT.

To determine the effect of progressive muscle relaxation (PMR) on chemotherapy-induced nausea and vomiting (CINV)

Patients receiving chemotherapy underwent an intervention consisting of 25-minute sessions of PMR (tensing-releasing) and control of respiration in an environment characterized by little artificial illumination and adequate music, without interruptions. Before and after the interventions, specific physiologic and self-report variables were measured. A registered nurse, who was trained in measuring physiologic alterations and muscle reactions, collected the data. Patients were asked to consider the presence of nausea one hour before and one hour after the intervention.

The study consisted of 30 patients who were over 18 years of age, had been diagnosed with hematologic cancers, were receiving chemotherapy, were experiencing nausea and vomiting at the time of data collection, and were hospitalized. Participants were capable of maintaining a logical conversation and had not received antiemetics five hours before undergoing the relaxation intervention. Patients were excluded from the study if they had evolving multiple myeloma or suspected bone fractures.

The study was conducted at a large hospital in Brazil.

This was a pre-and post-test pilot study.

• Physiologic indicators of nausea (e.g., vital signs, perspiration, pupil dilatation, salivation, skin color) were recorded.
• Muscle reactions (e.g., forearm, leg, forehead, eye tension) were recorded.
• Huskisson’s visual analog scale (VAS) (adapted version) for nausea and vomiting intensity levels was used.

PMR was associated with decreased physiologic conditions and muscle reactions, as well as a statistically significant reduction in the intensity of nausea and vomiting levels.

PMR techniques may be an effective intervention to reduce nausea in patients receiving chemotherapy.

• No control group was included.
• The population was heterogeneous.
• The types of chemotherapeutic and antiemetic agents were not controlled.
• Patients were undergoing various chemotherapy cycles.
• RN training is required.

PMR is a low-cost technique that can be easily taught to patients for use as an intervention for the management of CINV.

Patients were stratified on the basis of their conditioning treatment. Patients in the treatment group were given granulocyte-macrophage colony-stimulating factor (GM-CSF) mouthwash, 150 mcg per day in 100 cm³ of sterile water. Patients in the control group received 100 cm³ of sterile water alone as placebo. Both groups were instructed to perform one-minute mouthwashes, four times per day. Treatment started the day after chemotherapy ended and continued until stomatitis resolution, neutrophil recovery, or both.

• The study reported on 90 patients with lymphoma or solid tumors who were hospitalized and receiving high-dose chemotherapy and autologous stem cell transplant.
• The treatment group had 46 patients, and the control group had 44 patients. 
• Patients' ages ranged from 15–61 years, with a median age of 29 years.

The study was conducted between July 1997 and February 2002.

This was a double-blind, randomized, placebo-controlled study.

The National Cancer Institute (NCI) Common Toxicity Criteria (CTC) for mucositis was used.

• Incidence of mucositis was similar in both groups with 87% in the treatment group and 95% in the control group experiencing mucositis.
• Grade 4 stomatitis was also similar with 33% in the treatment group and 34% in the control group.
• No significant difference was found in duration of symptoms.
• Median days with oral pain, maximum mucositis scores, and mean length of time with a mucositis score greater than 4, were all higher in the GM-CSF group than in the control group.

The intervention was not effective.

• All patients received subcutaneous G-CSF 300 mcg each day until hematopoietic reconstitution.
• Observers graded mucositis differently.
• Because 0.2% chlorhexidine solution and amphotericin B were also being used as a rinse, the effect of specific agents was not clear.
• The overall rate of oral mucositis was lower than expected, making the sample size insufficient.

To investigate the treatment of breast cancer–related lymphedema using massage-based manual lymphatic drainage (MLD) and bandaging and compression versus control using only compression garments

Women previously treated for breast cancer with a minimum 10% difference in volume between arms were randomly assigned to two groups. The control received only compression garments while the experimental group received MLD therapy and compression garments, and assessed for reduction in arm volume.

• N = 95  
• AGE = 59–61
• MALES: 0        
• FEMALES: 95%
• KEY DISEASE CHARACTERISTICS: Patients completed all primary and adjuvant therapy. Breast cancer–related lymphedema, treatment for breast cancer, increase in arm volume of 10% in affected arm
• OTHER KEY SAMPLE CHARACTERISTICS: Exclusions: Ongoing active cancer history of contralateral breast cancer, prior complete decongestive therapy (CDT), contraindication factors such as infection, thrombosis

• SITE:  Multi-site  
• SETTING TYPE: Outpatient  
• LOCATION: Six Canadian regional cancer centers

• PHASE OF CARE: Late effects and survivorship
• APPLICATIONS: Elder care 

• Randomized trial 

• Circumferential limb volume 
• Quality of lIfe SF-36 
• Arm function
• DASH

CDT with MLD appears to be more beneficial to patients with lymphedema for more than one year (experimental group), showing increased volume loss, compared to control of garments only. The reduction in excess arm volume for patients in the experimental group was 29% and 22.6% for the control group (p = .34).

No significant difference in group with lymphedema less than one year, suggesting this group may respond to less intensive treatment.  More research is needed.

• Small sample (< 100)
• Baseline sample/group differences of import
• Other limitations/explanation:  Eight patients dropped out, seven from control group may have reduced the study power; use of circumferential limb volume results in some large variability.

Lymphedema identified within the first year may require less intensive therapy.  It is important for nurses to question patients with breast cancer about their affected extremity, and refer to a professional with specialized training in lymphedema management regarding risk reduction.

• FINAL NUMBER STUDIES INCLUDED = 6
• TOTAL PATIENTS INCLUDED IN REVIEW = 550 (prevention intervention); 169 (amelioration intervention)
• KEY SAMPLE CHARACTERISTICS: In both intervention groups, adults aged ≥ 18 years, received radiotherapy for the treatment of brain metastasis, primary or secondary brain tumors, or prophylaxis for other cancer. For amelioration, intervention group documented cognitive impairment in at least one cognitive domain at baseline. At least 80% of the sample had to receive radiotherapy, and radiotherapy may have been provided during childhood, but the cognitive intervention performed in adulthood.

PHASE OF CARE: Multiple phases of care

Three cognitive interventions aimed at preventing cognitive decline during radiation therapy were reported. Two were pharmacologic. One tested memantine versus a placebo and found significant improvement in overall cognitive function, and one tested methylphenidate versus a placebo but failed to detect any significant differences between groups. The third study was nonpharmacologic and investigated the use of a rehabilitation program to prevent cognitive decline but did not statistically compare differences between groups. Three cognitive interventions aimed at ameliorating cognitive decline were reported. All three were pharmacologic studies. Two studies compared methylphenidate versus modafinil and one study examined donepezil versus a placebo. Both methylphenidate and modafinil interventions resulted in improved cognitive function. Combination therapy resulted in greater adverse events. Donepezil was found to improve the domain of memory after radiotherapy.

The authors reported that there was evidence for the use of memantine for preventing cognitive decline in patients receiving radiotherapy for brain metastasis. Likewise, there was supporting evidence for the use of donepezil in improving memory after radiotherapy for primary or metastatic brain tumors. There was limited evidence for cognitive behavioral or training interventions in preventing cognitive decline.

• Small sample sizes of less than 30 subjects
• High risk of bias, particularly for nonpharmacologic interventions
• Large number of patient withdrawals

Patients who receive cranial radiation therapy for primary brain tumors or metastatic lesions are at risk for declining cognitive function. The use of memantine during radiation therapy may aid in preventing cognitive decline. Those who develop cognitive decline after the completion of radiation therapy, even years afterwards, may benefit from donepezil administration. Additional exploration of interventions that may prevent or ameliorate cognitive decline related to cranial radiation therapy is warranted.

To assess appetite response to thalidomide in cancer-associated anorexia

Patients with advanced cancer were given 50 mg of thalidomide at bedtime for two weeks. Those who responded to treatment were kept on the same dose for a total of six weeks. Those who did not respond to the 50 mg dose and were not experiencing dose-limiting toxicity were given 100 mg at night for two more weeks. If there was no response at 100 mg after two weeks and the patient was not having dose-limiting toxicity, the dose was escalated to 200 mg at bedtime.

• The study reported on a sample of 33 patients.  
• Median patient age was 69 years, with a range of 43–87 years.
• The sample was 51% male and 49% female.
• Patients had advanced, active cancer.

• Single site
• Outpatient setting
• United States

• Patients were undergoing end-of-life care.
• The study has clinical applicability for end-of-life care.

A prospective, observational study design was used.

• Medical history
• Neurologic exam
• Appetite, strength, pain, insomnia, night sweats, and nausea measured by 0–10 numerical rating scale (NRS)
• Appetite, tiredness, early satiety, quality of life, and toxicities (muscle cramps, pain, confusion, constipation, dizziness, drowsiness, dry mouth, headache, loss of interest in sex, nervousness, stomach pain, dry skin or pruritius, and limb swelling) measured by categorical scale (patient-perceived severity by a categorical scale [CAT])
• Eastern Cooperative Oncology Group–PS (performance score)
• Weight
• C-reactive protein (CRP)
• Lean body mass by Bioelectric Impedance (BIA)

Thirty-three patients completed at least 14 days of therapy. Sixty-four percent of patients who had completed at least two weeks of thalidomide had statistically significant appetite improvement by both the NRS and CAT (p < 0.001). Other symptoms with statistically significant improved scores included pain (< 0.05), insomnia (night sleep) (< 0.01), and early satiety (< 0.05).

Thalidomide significantly improved appetite, insomnia, pain, and early satiety from baseline in patients with advanced cancer.

• The study count is not clear as to how long patients were on which dose of thalidomide. Thirty-three patients received 50 mg for 14 days. At that time, 17 had improved appetite and 9 of the 16 nonresponders were titrated up to 100 mg. At this point it is not clear what happened with the other seven patients, but the study goes on to say that seven withdrew after two weeks, suggesting that the seven who dropped out received the 100 mg dose, which the manuscript does not corroborate. Although the methods stated that patients were titrated up to 200 mg, the results do not mention this.  
• The study states that side effects were \"negligible,\" yet at least 5 of 33 patients dropped out of the study due to side effects.  
• There was no control group for this study. Some of the lack of response to the study drug could have been due to disease progression or performance status deterioration. A larger study with a control group may have provided comparison data to assess this point.
• Adherence to medication administration was not measured.

Thalidomide may provide benefit for appetite stimulation as well as some other symptoms of advanced disease; however, the drug is not without side effects that may interfere with quality of life. This was a small study, partially funded by a pharmaceutical company, so the results should be interpreted with caution. Patients with advanced cancers on thalidomide should be educated about and assessed frequently for toxicities that may erode what little quality of life they have. Nurses must advocate for their patients who are experiencing unacceptable toxicities.

Patients were randomized to one of three study arms: 36 in the recombinant human leukemia inhibitory factor (rhu LIF) 2 mcg/kg group, 39 in the rhu LIF 4 mcg/kg group, or 42 in a placebo group. The study drug or placebo was administered one day prior to chemotherapy by subcutaneous injection after premedication with acetaminophen 1 g orally. The patient was then observed for two hours. The second injection was administered the following day, two hours prior to chemotherapy. The study drug or placebo was continued by daily subcutaneous injections for a total of seven consecutive doses per treatment cycle (every 21 days for 4–6 cycles).

• The total sample consisted of 117 patients diagnosed with solid tumor requiring chemotherapy of at least four cycles of carboplatin/paclitaxel.
• Exclusion criteria included having a clinically significant medical condition, having more than one prior course of chemotherapy for metastatic disease, having any prior neurotoxic chemotherapy requiring dose modification due to neuropathy, having brain metastasis, a history of alcoholism, or having preexisting neuropathy

The study had a phase II, double-blind, placebo-controlled clinical trial design.

• Neurologic assessments were performed prior to study drug administration following the fourth cycle of chemotherapy and last cycle of chemotherapy and at 3 months post chemotherapy.
• CPNE assessment consisted of peripheral nerve electrophysiology testing (antidromic maximal conduction velocity), amplitudes of three sensory nerves (sural, median and ulnar) and one motor nerve (peroneal) and vibration threshold of the non-dominant great toe.
• Neurologic signs were measured using the Einstein Neurologic Examination, assessed as 0 (absence of deficit) to 3 (severe, bilateral deficit involving proximal sites). A total score is obtained ranging from 0–15.
• Change in symptoms was measured using a subset of questions from the CIPNS-32. The severity of each symptom (0–4) and the extent it interfered with normal function (0–5) were rated on a scale, with a total possible score ranging from 0–100.

rhu LIF was fairly well tolerated, with five patients reporting adverse events that included lightheadedness, rigors or chills, myocardial ischemia, and hypotension. CPNE scores showed small but consistent decrement between baseline and cycle 4 of chemotherapy. Vibration threshold was also altered by chemotherapy. Intent-to-treat analysis showed no significant differences in CPNE scores between the three groups. 

No evidence showed that rhu LIF prevented, delayed, or diminished CIPN.

While sample size was calculated to be adequate by a power analysis, the goal of 40 patients per group was not achieved, and the original calculation may not have been accurate to achieve statistical significance.

Since the measures were sensitive enough to detect CIPN, no further plans to develop rhu LIF as an agent to treat or prevent CIPN were proposed.

Keywords searched were cannabinoids, nabilone, nausea, pain, tetrahydrocannabinol, and vomiting.

This was a review of published English literature, including reviews, meta-analysis, and treatment trials from 1975–1997 on using cannabinoids to control or prevent chemotherapy-induced nausea and vomiting (CINV), with very few trials found after 1997. From this review, 30 randomized control trials were found that looked at cannabinoids to control or prevent CINV. Overall, the trials received low scores for adequacy of randomization, blinding design, and description of withdrawal. Three cannabinoids were studied: nabilone (16), dronabinol (13), and levonantradol (1). The medications were compared to prochloperazine (12), placebo (10), metochlorpramide (4), chlorpromazine (2), domperidone (2), alizapride (1), thiethylperazine (1), and haloperidol (1). Twelve studies involved various scoring systems. No clear separation existed between acute and delayed CINV.

The trials included 1,760 patients, with 394 excluded.

• Nabilone was found to be superior to placebo, domperidone, and prochlorperazine but not metoclorpramide.
• Cannabinoids did not add to the benefits of 5-HT₃ receptor antagonists.
• Side effects were greater for nabilone than prochloperazine in these studies, but patients preferred nabilone to prochloperazine.

• The major limitation of these studies was the grading of response and the inability to differentiate between acute and delayed CINV.
• The adequacy of randomization, blinding design, and description of withdrawal were insufficient.
• The time period for the review was limited to 1975–1997. From 1997–present, many changes in managing CINV have occurred.
• The databases of the search were not indicated.

Cannabinoids, like nabilone, may have a role in reducing delayed or refractory CINV, but more evidence is needed.

The Science Committee of the Association for Palliative Medicine of Great Britain and Ireland convened a task group to produce up-to-date, evidence-based clinical guidelines regarding the management of cancer-related breakthrough pain in adult patients. Literature review provided limited evidence, only case series and expert opinion, and the task group could make no recommendations about any particular intervention.

Face-to-face group meetings initiated the review process and determined the scope of work. A draft set of recommendations was circulated to group members, and all members were in agreement regarding content. Authors did not describe the process of evidence grading or how the recommendations were drafted. A final meeting was held to finalize results. The MEDLINE keywords searched to retrieve reviews were breakthrough pain, incident pain, and episodic pain. The search was for the years 1950–2007. In addition to the MEDLINE search, investigators manually searched reference lists of retrieved papers and major texts. Authors did not specify inclusion or exclusion criteria. Evidence was graded according to the Scottish Intercollegiate Guidelines Network (SIGN) system.

• Authors noted these points regarding breakthrough pain:
  • The definition the authors adopted of the term breakthrough pain was “a transient exacerbation of pain that occurs either spontaneously, or in relation to a specific predictable or unpredictable trigger, despite relatively stable and adequately controlled background pain.” (p. 332)
  • Authors noted that no definition of breakthrough pain is common to much of the work in this area.
  • Breakthrough pain was categorized as either idiopathic (unrelated to a precipitant) and unpredictable or incident (related to an identifiable precipitant).
• Authors noted that the guidelines they provided were based on consensus, not levels of evidence.
• Authors provided a simple algorithm of a dose-titration scheme for opioid rescue medications.

The guidelines make the recommendations that follow.

• Patients with pain should be assessed for the presence of breakthrough pain. Differentiating between uncontrolled background pain and controlled background pain with breakthrough pain is important.
• Patients with breakthrough pain should be assessed specifically for breakthrough pain. Authors note that no assessment tool for breakthrough pain exists, so guidelines recommend assessing breakthrough pain by using standard means of pain assessment.
• Management of breakthrough pain should be individualized—that is, reflect patient-related factors and preferences. In many cases, however, options are limited by availability and affordability of interventions. Guidelines recommend balancing the cost of the intervention with the cost of uncontrolled breakthrough pain.
• Those who determine treatment should consider the underlying cause of pain. Evidence supports the efficacy of cancer treatment in the management of background pain, but no evidence relates to breakthrough pain specifically.
• Caregivers should consider the benefits of avoiding precipitating factors versus treatment of precipitating factors. For example, practical support with activities of daily living and simple adaptation of surroundings could mitigate movement-related pain.
• Those who determine treatment should consider modifying the background analgesic regimen. Modification strategies could include
  • Titration of opioid analgesics.
  • Switching opioid analgesics.
  • Addition of adjuvant analgesics (such as antieleptics for neuropathic pain or antispasmodics for visceral pain).
  • Addition of other adjuvant drugs for relief from the side effects of pain medication.
  • Other strategies (e.g., use of nonanalgesic drugs, anti-inflammatories).
• Opioids are the rescue medication of choice in the management of breakthrough pain. Decisions regarding specific preparations and routes should be based on pain characteristics and the patient’s previous response to opioids. Oral opioids may have a role in breakthrough pain but are not typically the optimal approach.
• Individual titration should determine the dose of opioid rescue medication. Guidelines suggest that the traditional approach—that the dose of opioid rescue medication should be a fixed proportion of the background medication—is not the most effective.
• Nonpharmacologic methods may be useful in the management of breakthrough pain episodes. Guidelines mention rubbing or massage, application of heat or cold, distraction techniques, and relaxation techniques, though authors note that little evidence shows that these methods are effective.
• Nonopioid analgesics may be useful in the management of breakthrough pain episodes. Interventions that have been used include nonsteroidal anti-inflammatory drugs, ketamine, midazolam, and nitrous oxide.
• Intervention techniques may be useful in the management of breakthrough pain. Interventions include neuraxial drug infusion, neural blockade, neuromodulation (e.g., transcutaneous electrical nerve stimulation, or TENS), and interventional radiologic techniques.
• Breakthrough pain, specifically, should be reassessed.
• Patients with pain that is difficult to manage should be referred in a timely manner to a pain specialist or palliative care specialist.

Three members of the task force consult for pharmaceutical companies.

Breakthrough pain is heterogeneous and highly individual; clinicians and caregivers should approach it with these facts in mind. Little evidence guides the management of breakthrough pain. Current teaching is not in concert with recommendations related to the usual practice of prescribing a fixed proportional dose of background opioids as rescue medications. Guidelines point to the need to consider breakthrough pain as an issue separate from background pain. The use of rescue medications is only one aspect of managing breakthrough pain; clinicians should remember other approaches, such as treatment of the underlying causes of the pain. The field of oncology needs research aimed specifically at the management of breakthrough pain.