Chow, E., Meyer, R.M., Ding, K., Nabid, A., Chabot, P., Wong, P., . . . Wong, R.K. (2015). Dexamethasone in the prophylaxis of radiation-induced pain flare after palliative radiotherapy for bone metastases: A double-blind, randomised placebo-controlled, phase 3 trial. Lancet Oncology, 16, 1463–1472.
To compare the efficacy of dexamethasone to placebo for prevention of pain flare after palliative radiotherapy
Patients were randomized to receive either 8 mg dexamethasone or placebo at least one hour before the start of radiotherapy and then daily while receiving radiotherapy. Patients completed study assessments at baseline, day 10, and day 42 after radiation treatment.
Median follow-up ranged from 1-39 months. Ninety-two patients experienced pain flare on days 0–10, 26% in the dexamethasone group and 35% in the placebo group (p = 0.05). The incidence of pain flare was 11.8% lower in the dexamethasone group (p = 0.01). No significant differences were noted between groups in overall pain reduction from radiotherapy or analgesic intake. Three patients on dexamethasone stopped the study medication due to hyperglycemic events. Two of these had preexisting diabetes.
Provision of 8 mg dexamethasone prior to and daily during palliative radiation therapy for bone metastases was effective in the prevention of radiation-associated pain flare compared to placebo.
This study showed that administration of dexamethasone during palliative radiation therapy for bone metastases was effective in preventing bone flare pain. A few patients developed hyperglycemic episodes while on dexamethasone, so nurses need to be aware of this potential, particularly in patients with preexisting diabetes. The purpose of palliative radiation is pain reduction, so it also makes sense to intervene to prevent pain flare that can occur from that treatment. Further research is warranted to compare prophylactic versus treatment of bone flare pain, and potential efficacy of other adjuvant medications.
Chow, E., van der Linden, Y.M., Roos, D., Hartsell, W.F., Hoskin, P., Wu, J.S., . . . Wong, R.K. (2014). Single versus multiple fractions of repeat radiation for painful bone metastases: A randomised, controlled, non-inferiority trial. The Lancet Oncology, 15, 164–171.
To assess two different radiation therapy fractionation approaches in patients with painful bone metastases needing repeat radiation therapy
Patients with radiologically confirmed bone metastases that had previously been treated with radiation were randomized to receive 8 Gy in a single fraction or 20 Gy in multiple fractions. Those getting 20 Gy received treatment in five fractions unless the target field was the spine or whole pelvis. Bone-modifying agents and systemic therapy were allowed at the discretion of the physician. Overall response to treatment was the primary endpoint at two months after beginning treatment. Pain assessments were done at days 7 and 14, monthly for 6 months, and at 9 and 12 months after radiation therapy. A difference of 10% with treatment response was established to determine noninferiority.
Unblinded, randomized, controlled noninferiority trial
In the ITT analysis, 28% in the 8 Gy group had response, and 32% of those in the 20 Gy group had overall response with a confidence interval that did not meet the noninferiority margin. In the per-protocol analysis, 45% of patients in the 8 Gy group and 51% in the 20 Gy group had overall response with a 95% confidence interval that met the 10% noninferiority margin. Patients in the 20 Gy group had more skin reddening and more frequent and severe anorexia, vomiting, and diarrhea (p < .05).
The per-protocol analysis showed that multiple fractionation was associated with slightly better pain response to treatment, but was also associated with more side effects.
Radiation therapy to areas of painful bone metastases is effective in reducing pain. Though a higher total dose was slightly more effective, it was also associated with more side effects. Nurses can use this knowledge to educate patients and to monitor appropriate patients for treatment side effects.
Chow, R., Chiu, L., Navari, R., Passik, S., Chiu, N., Popovic, M., . . . DeAngelis, C. (2015). Efficacy and safety of olanzapine for the prophylaxis of chemotherapy-induced nausea and vomiting (CINV) as reported in phase I and II studies: A systematic review. Supportive Care in Cancer, 24, 1001–1008.
STUDY PURPOSE: To summarize evidence from phase I and II trials in which olanzapine was used for the prophylaxis of chemotherapy-induced nausea and vomiting (CINV)
PHASE OF CARE: Active antitumor treatment
The rate of complete control (no emesis, no rescue medication, and no significant nausea) was only identified in one study. Complete response rates were reported in three studies, and they ranged from 75%–100% in the acute phase and 72%–92.5% in the overall phase. In four trials, olanzapine was used as an adjunct with other antiemetics. One study was a retrospective chart review.
The findings of this study suggest that olanzapine can be beneficial in preventing CINV.
The potential role of olanzapine in the prevention and management of CINV is unclear. This review provides limited evidence of the effects of olanzapine for CINV. Future studies need to compare olanzapine as an adjuvant to recommended antiemetics or olanzapine as a single agent compared to regimens with clear efficacy for the prevention of CINV.
Chow, K.M., Chan, C.W., Chan, J.C., Choi, K.K., & Siu, K.Y. (2014). A feasibility study of a psychoeducational intervention program for gynecological cancer patients. European Journal of Oncology Nursing, 18, 385–392.
To test the feasibility of the implementation of a psychoeducational intervention program for patients with gynecologic cancer
This study consisted of a series of interventions consisting of multiple components based on a thematic counseling model for patients with newly diagnosed gynecologic cancers. Blinding was performed at randomization. Quantitative data on sexual functioning, uncertainty, quality of life, anxiety, depression, and support systems were collected at recruitment, following surgery, during hospitalization, and eight weeks following surgery. Both quantitative and qualitative methods were used in the data analysis. The intervention consisted of four psychoeducational sessions. An individual format was used for the first three sessions and a group format was used for the last session. All intervention sessions were conducted by the researcher. The researcher also met with the control group on four occasions during the same period: at recruitment, after surgery, once in-hospital, and once via telephone four weeks following surgery during which participants were invited to attend a support group. The researcher was a registered nurse experienced in gynecologic cancer care.
Single-blinded, randomized trial with a mixed-methods design
Thirteen patients were in the intervention group and 13 were in the control group. There were no statistical differences between the populations of the two groups. The compliance rate was 69.2% in the intervention group with the greatest lack of compliance occurring during the final session. The compliance rate for the control group was 46.2%. Statistic significance regarding trends of change in the outcome variables was not obtained. There was no statistic significance in the comparison of baseline outcome variables of the two groups. There was no statistic significance of intervention effects between the two groups, except in the area of uncertainty. The inconsistency subscale showed a statistic significance between the two groups with the intervention group receiving less inconsistent information regarding their illnesses. The intervention group demonstrated better trends for improvement than the control group in all categories although there were contradictory results in the scales measuring quality of life, perceived social support, anxiety, and depression.
This patient population has healthcare needs that currently are not being met. This particular study did not show statistically significant results regarding anxiety, depression, quality of life, and sexual functioning in patients with gynecologic cancer. Further research is indicated.
Further research is indicated regarding anxiety, depression, quality of life, and sexual functioning in patients with gynecologic cancer, particularly during the postoperative period. This study showed trends for overall improvement, indicating the importance of nursing in this population. Understanding the implications of cultural differences regarding the effects of gynecologic therapies is an important nursing responsibility.
Choo, S.P., Kong, K.H., Lim, W.T., Gao, F., Chua, K., & Leong, S.S. (2006). Electroacupuncture for refractory acute emesis caused by chemotherapy. The Journal of Alternative and Complementary Medicine, 12, 963-969.
To evaluate the use of electroacupuncture in preventing anthracycline-based chemotherapy-related nausea and vomiting (CINV) refractory to combination 5-HT3-antagonist and dexamethasone
Patients received electroacupuncture in addition to standard antiemetic prophylaxis. Acupuncture was started 10 minutes prior to start of chemotherapy infusion and then continued for an additional 20 minutes. The P6 acupuncture point was used, a second needle was inserted at a different point, and electrical stimulation was delivered.
This was a prospective trial.
Choi, T.Y., Lee, M.S., Kim, T.H., Zaslawski, C., & Ernst, E. (2012). Acupuncture for the treatment of cancer pain: A systematic review of randomised clinical trials. Supportive Care in Cancer, 20, 1147–1158.
To perform a combined systematic review and meta-analysis to assess the effectiveness of acupuncture for treating cancer pain
The study has clinical applicability for palliative care.
Most of the studies involved manual acupuncture based on traditional Chinese medicine. In regard to effect on cancer pain, the majority of the studies found the effects of acupuncture and conventional drug therapy to be comparable; however, equivalence of effects is unclear in those studies reporting no differences between acupuncture and conventional drug therapies.
Acupuncture may be an effective intervention for controlling pain; however, due to the small number of RCTs, low methodological quality, and small sample sizes, the results of the meta-analysis did not provide strong evidence of such effectiveness.
Further research is needed to evaluate this nonpharmacologic intervention for relieving cancer pain.
Choi, T.Y., Kim, J.I., Lim, H.J., & Lee, M.S. (2016). Acupuncture for managing cancer-related insomnia: A systematic review of randomized clinical trials. Integrative Cancer Therapies. Advance online publication.
STUDY PURPOSE: To evaluate the efficacy of acupuncture to relieve cancer-related insomnia
TYPE OF STUDY: Systematic review
PHASE OF CARE: Not specified or not applicable
Two trials compared acupuncture to sham acupuncture in patients with breast cancer: one trial showed positive effects as reported in a sleep diary, and one trial did not show that acupuncture was beneficial as measured by the Pittsburgh Sleep Quality Index (PSQI). Three trials compared acupuncture to sleeping medications: two trials showed improved sleep with acupuncture as measured by PSQI when compared to drugs, and one trial did not show a benefit. One trial that compared acupuncture to hormone therapy in patients with breast cancer showed improved sleep with acupuncture. Overall, the trials had a low risk of bias, except for participant and personnel blinding, because of the nature of acupuncture. Few adverse events were reported with acupuncture but included fatigue, pruritis, and nausea.
Mixed evidence about the effectiveness of acupuncture to relieve cancer-related insomnia compared to medications exists. In the current review, acupuncture may be superior to sham acupuncture, conventional drug therapy, and hormone therapy for the management of cancer-related insomnia. The level of evidence is low because of a limited number of trials and total sample size.
Acupuncture has been examined as an intervention to relieve cancer-related insomnia, and a small number of studies show mixed evidence about its effectiveness. Additional trials that report standard acupuncture methodology and use objective sleep outcome measures are needed before nurses can recommend acupuncture as an effective treatment to relieve insomnia.
Choi, M.R., Jiles, C., & Seibel, N.L. (2010). Aprepitant use in children, adolescents, and young adults for the control of chemotherapy-induced nausea and vomiting (CINV). Journal of Pediatric hematology/oncology, 32(7), 268-271.
To describe one institution’s experience with using aprepitant to control chemotherapy-induced nausea and vomiting (CINV) in children with cancer who were receiving highly emetogenic chemotherapy (HEC) or moderately emetogenic chemotherapy (MEC) by conducting a retrospective chart review
This was a retrospective review of charts from Aug 2005 until May 2007 in the authors’ institution. The authors divided children into two groups based on whether they were given two or three antiemetic agents. Children in regimen 1 (n = 20) received 0.15 mg/kg ondansetron three times per day, 0.15 mg/kg (maximum of 20 mg) dexamethasone, and 125 mg aprepitant on day 1 followed by 80 mg aprepitant on days 2 and 3. Children in regimen 2 (n=12) received only ondansetron and aprepitant. Aprepitant was given to 24 out of 32 children whose weight was more than 20 kg at the above mentioned dosing. Children weighing less than 20 kg received 80 mg days 1–3. One child whose weight was less than 15 kg received 80 mg on day 1 and 40 mg on day 2 and 3.
The study was conducted at a single inpatient setting in the United States.
All patients were undergoing the active phase of treatment care.
This was a retrospective chart review.
The authors reported that children younger than 12 years or weighing less than 40 kg received reduced aprepitant doses. However, they did not report how many children fell into this group, only that the mean age was 10.
Based on this report, we know that 19 children in the regimen 1 (dexamethasone, ondansetron, and aprepitant) group did very well compared to the younger children in the regimen 2 group (ondansetron and aprepitant). In this report, dexamethasone was not reduced as suggested (12 mg on day 1 followed by 8 mg on days 2 and 3).
This retrospective study shows that aprepitant triple therapy, when combined with standard antiemetics, was well-tolerated in pediatric patients (mean age of 10 years) receiving HEC or MEC. Aprepitant was safe and well tolerated in patients age 18 or younger and improves control of CINV in children.
Aprepitant in combination with standard antiemetics is well tolerated in children. More prospective studies are needed to identify the most effective way to use aprepitant for children undergoing chemotherapy. Children with cancer who weigh more than 20 kg benefit if aprepitant is given at 125 mg on day 1 and 80 mg on days 2–3. Dexamethesone may need to be adjusted from standard dosing to 12 mg on day 1 and 8 mg on days 2 and 3 because of altered metabolism of corticosteroids by aprepitant’s inhibition of CYP3A4. Pediatric oncology nurses should be knowledgeable in cytochrome P450 enzymes and drug-drug interactions. Future research should focus on using aprepitant in very young children (less than 10 years of age or less than 40 kg weight).
Choi, H.S., Kim, K.O., Chun, H.J., Keum, B., Seo, Y.S., Kim, Y.S., . . . Ryu, H.S. (2012). The efficacy of transdermal fentanyl for pain relief after endoscopic submucosal dissection: A prospective, randomised controlled trial. Digestive and Liver Disease , 44, 925–929.
To investigate the efficacy and safety of fentanyl patches for pain relief after endoscopic submucosal dissection
Patients were randomized to a fentanyl patch or placebo control group. Patients in the patch group were instructed in the use of the patch, which they applied the night before the procedure. Pain was assessed immediately before and immediately after the endoscopy. Maximum pain during the 24 hours following the endoscopy was assessed at discharge. All patients received IV propofol and cimetropium bromide during the procedure. Fentanyl patches used were 12 mcg patches.
Phase of care: diagnostic
Randomized double-blind placebo-controlled trial
The study used a numeric rating scale to measure pain.
Findings show that fentanyl patches applied prior to endoscopic submucosal dissection are safe and effective in reducing postprocedural pain.
Usual treatment for endoscopy pain can involve frequent injections. Since fentanyl patches can be applied prior to a procedure, they may provide more comfort than injected as-needed pain medications can. This study showed that, compared to placebo, a low-dose fentanyl patch applied prior to endoscopic dissection was effective in reducing pain and was not associated with adverse effects. The approach the study outlines is novel and may be applicable to various groups of patients who could experience acute pain.
Choi, E., Nahm, F.S., & Lee, P.B. (2015). Sympathetic block as a new treatment for lymphedema. Pain Physician, 18, 365–372.
To study the effects of thoracic a sympathetic ganglion block (TSGB) in treating breast cancer-related lymphedema
The medical records of patients who received a TSGB were reviewed. Findings were compared between patients who were grouped according to therapeutic efficacy. TSGBs were performed under fluoroscopic guidance. An injection of contrast agent was used to confirm the proper positioning for the injection of lidocaine. Patients had arm circumference measurements and completed the Lymphedema and Breast Cancer Questionnaire two weeks and two months after the TSGB procedure. Arm circumference was measured at the axilla, upper arm, elbow, lower arm, and wrist.
Retrospective, descriptive study
The most frequent lymphedema severity was stage 2, which involved visible edema, usually with pitting and hardened, thickened skin and tissue (37.5% of cases). Arm circumference measures at all locations decreased significantly at two weeks after the procedure (p < 0.05). There was no significant additional decrease between two weeks and two months after the procedure. Questionnaire results also showed a significant reduction in symptoms at two weeks (p < 0.001) with no additional improvement between two weeks and two months. Overall, 65.7% of participants were deemed to have effective TSGB results. Those with more severe lymphedema tended to have the most improvement.
TSGBs may be a useful option for the management of breast cancer-related arm lymphedema. The mechanism by which this may be effective is unclear, and the duration of any improvement is not yet clear.
TSGBs may be an alternative option for patients with breast cancer-related arm lymphedema for whom conservative and standard treatments were unsuccessful. Additional research providing sufficient evidence for the effectiveness and identification of patients for whom the intervention is appropriate is needed.