Husebo, A.M., Dyrstad, S.M., Mjaaland, I., Soreide, J.A., & Bru, E. (2014). Effects of scheduled exercise on cancer-related fatigue in women with early breast cancer. The Scientific World Journal, 2014, 271828.
To compare the effects of a scheduled, home-based exercise intervention to the effects of advising patients to exercise on fatigue, physical fitness, and physical activity level
Patients who had surgical treatment and were receiving adjuvant chemotherapy for breast cancer were randomly assigned to the scheduled exercise or control comparison groups. The intervention combined resistance and aerobic exercise with resistance bands and strength training three times per week along with 30 minutes of brisk walking daily. Those in the experimental group received motivational phone calls every two weeks. Patients in the control group were advised to continue their regular activity levels and had one follow-up phone call. Study measures were obtained at baseline, prior to chemotherapy, 8–24 weeks at the end of chemotherapy, and about six months after completing chemotherapy.
Randomized controlled trial (RCT)
Fatigue scores increased significantly from baseline to the end of chemotherapy for all patients (p = .003) with no difference between groups. Fatigue returned to baseline levels after the end of chemotherapy with no difference between groups. A similar pattern was shown for all patients in physical fitness. There were no differences between groups in mean levels of physical activity per week, though there was a slight trend toward more exercise in the intervention group.
There were no additional effects of a scheduled home exercise program to reduce fatigue compared to individuals who were simply encouraged to maintain appropriate exercise levels.
Study findings show a pattern of fatigue such that fatigue increases significantly during chemotherapy and then declines after the end of treatment. Both groups of patients in this study performed exercise at general recommended levels, which likely accounts for the lack of differences in fatigue found. These results suggest that patients do not necessarily need to have scheduled approaches to exercise, and that encouraging patients to maintain at least moderate exercise levels can be effective. Nurses can encourage patients to maintain exercise and choose approaches that they prefer in order to maintain motivation for regular activity.
Hurlow, A., Bennett, M.I., Robb, K.A., Johnson, M.I., Simpson, K.H., & Oxberry, S.G. (2012). Transcutaneous electric nerve stimulation (TENS) for cancer pain in adults. Cochrane Database of Systematic Reviews, 3, CD006276.
To review and summarize the evidence regarding the effect of transcutaneous electric nerve stimulation (TENS) for management of cancer-related pain
The type of study is systematic review.
Databases searched were MEDLINE, CINAHL, PEDro, AMED, EMBASE, PsycINFO, and the Cochrane Central Register of Controlled Trials.
An extensive listing of search terms per database are provided.
Studies were included in the review if they evaluated TENS-administered monophasic or biphasic pulsed electrical currents, reported on participants 18 years or older, and were randomized controlled trials (RCTs) not involving active treatment control.
Studies reporting on percutaneous interventions were excluded.
The total of four references were retrieved.
The Jadad scale was used for evaluation as well as the Cochrane risk of bias tool.
Three studies were included in the review; two studies were added to prior review of two studies.
Sample range across studies was 15–49, with a total of 68 patients included in the review.
Results were inconclusive due to lack of suitable RCTs for inclusion. One study indicated that bone pain may improve with TENS, but this was not well designed and underpowered. Two studies showed no significant difference with TENS.
No conclusions regarding the effectiveness of TENS can be made.
There is insufficient evidence to determine whether TENS is effective for management of pain in patients with cancer.
Hunter, M. S., Coventry, S., Hamed, H., Fentiman, I., & Grunfeld, E. A. (2009). Evaluation of a group cognitive behavioural intervention for women suffering from menopausal symptoms following breast cancer treatment. Psycho-Oncology, 18, 560–563.
To evaluate a group cognitive-behavioral intervention to alleviate menopausal symptoms (hot flushes [HF] and/or night sweats [NS]) in women who have had treatment for breast cancer.
Following a two-week daily diary assessment, patients were offered six 90-minute weekly sessions of group cognitive-behavioral therapy (CBT). CBT included: information and discussion about menopausal symptoms; monitoring and modifying stimulants that precipitate symptoms; relaxation and paced breathing; and techniques to reduce stress and manage HF, NS, and sleep. The primary outcome measures were HF frequency and HF problem rating. Secondary outcomes included scores on the Women’s Health Questionnaire (WHQ) and scores pertaining to health-related quality of life (HRQOL) as measured by the SF-36®. Beliefs about HF were monitored to examine the effects of CBT.
The study was a single-group, exploratory trial with pre- and posttreatment assessment after six weeks and three months.
Nurses could be trained to conduct structured, interactive, group CBT with individual treatment goals. A randomized, controlled trial is recommended for further investigation.
Hunter, M.S., Coventry, S., Hamed, H., Fentiman, I., & Grunfeld, E. A. (2009). Evaluation of a group cognitive behavioural intervention for women suffering from menopausal symptoms following breast cancer treatment. Psycho-Oncology, 18, 560–563.
Primary aim: To evaluate the effectiveness of group cognitive behavioral therapy (CBT) on hot flashes and night sweats in women who have had breast cancer
Secondary aim: To evaluate the effect of group CBT on depressed mood, anxiety, sleep, and quality of life
The intervention consisted of six group sessions using a psychoeducational approach with education regarding hot flushes, relaxation, stress management, and sleep strategies.
The intervention was delivered by a psychologist plus a trainee/intern.
Relaxation and paced breathing were demonstrated and practiced in each session, and participants were given a CD for ongoing use.
A pre/post-test design was used.
Depression and anxiety decreased from baseline to post-treatment (p < 0.006; p < 0.02). Reductions maintained at the three-month follow-up.
Results suggest that group CBT may be an effective option for women who have menopausal symptoms following breast cancer treatment.
Participants had a mean duration of hot flushes of more than two years, suggesting that symptoms may have been unrelated to their recent cancer treatment and more associated with menopause.
Hunter, A., Mahendra, P., Wilson, K., Fields, P., Cook, G., Peniket, A., … Marcus, R. (2009). Treatment of oral mucositis after peripheral blood SCT with ATL-104 mouthwash: Results from a randomized, double-blind, placebo-controlled trial. Bone Marrow Transplantation, 43, 563–569.
To assess the tolerability of three ATL-104 doses and to assess the efficacy and safety of ATL-104 on mucositis in patients requiring high-dose melphalan or BEAM (carmustine, etoposide, cytarabine, and melphalan) before peripheral blood SCT (PBSCT)
This study included two parts. In the first part, patients were randomized to receive placebo or ATL-104 in doses of 50, 100, or 150 mg orally by mouthwash as a 15 mL total volume swilled in the mouth for 15-30 seconds and then swallowed. ATL-104 is a plant lectin associated with mitogenic activity and epithelial cell growth. Following harvest of PBSCs, patients received study treatment for three days before beginning a course of chemotherapy. For patients receiving BEAM, chemotherapy lasted for six days, whereas patients receiving high-dose melphalan had one day of treatment. PBSCT was administered 1–2 days after completion of chemotherapy, and patients then received three once daily doses of ATL-104. In the second part, patients were randomized to placebo or to one of the three ATL-104 doses.
The study was conducted in an inpatient setting in the United Kingdom.
Treatment with ATL-104 substantially reduced the median duration of severe oral mucositis compared with placebo (median duration: ATL-104 for two to three days, placebo 10.5 days) (p < 0.001). The effect of ATL-104 on the incidence of severe oral mucositis was inconclusive. Adverse events (AEs) were mild to moderate in intensity with gastrointestinal (GI) AEs being most common.
ALT-104 substantially reduced the duration of severe mucositis and was well tolerated.
This study had inconclusive results regarding the incidence of severe mucositis. Further studies with a larger number of patients are needed to establish the effects of ATL-104 on the duration and severity of mucositis. Limited range of ATL-104 doses may be responsible for the lack of dose-response.
Mouthwashes are easy to administer; however, adherence is a concern when used preventatively or when the patient has oral discomfort or fatigue. The hospital setting allows for easier monitoring and assistance in promoting adherence. If further studies show a benefit to patients, cost and availability will be influencing factors toward good outcomes.
Huisman, M., van den Bosch, M.A., Wijlemans, J.W., van Vulpen, M., van der Linden, Y.M., & Verkooijen, H.M. (2012). Effectiveness of reirradiation for painful bone metastases: A systematic review and meta-analysis. International Journal of Radiation Oncology, Biology, Physics, 84, 8–14.
STUDY PURPOSE: To assess pain response after reirradiation in patients with painful bone metastases not sufficiently responding to initial radiation therapy or exhibiting recurrent pain after initial response
TYPE OF STUDY: Combined systematic review and meta-analysis
DATABASES USED: MEDLINE, EMBASE, and Cochrane Collaboration library
KEYWORDS: Radiotherapy, reirradiation, retreatment, bone metastases, palliative treatment
INCLUSION CRITERIA: All types of studies were allowed. Participants received reirradiation at the initial site of radiation for radiation-refractory metastatic bone pain. Both the initial treatment and retreatment consisted of external beam radiation therapy (EBRT). Reported outcomes were reported at least in response to initial reirradiation, and original research data were reported. If eligibility for inclusion could not be decided based on abstract screening, or if the abstract was not available, the full-text article was reviewed. To qualify for the meta-analysis, the study had to meet additional criteria: outcomes were available on an individual patient level, and the size of the study population was 10 patients or more.
EXCLUSION CRITERIA: Languages other than English, German, French, and Dutch
TOTAL REFERENCES RETRIEVED: 707
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Authors were contacted for missing data. Publication quality was assessed using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) method. Data extraction and quality assessment was performed independently by two observers.
PHASE OF CARE: Transitional care after initial treatment
APPLICATIONS: Late-effects, survivorship, and palliative care
In this meta-analysis, 264 out of 440 patients achieved either complete or partial response with an overall response rate of 58%. Sensitivity analysis was not feasible. The complete response rate for reirradiation ranged from 16%–28%, and partial response rates were 28%–45%. Pooling was not appropriate due to the low number of studies. The time to response after reirradiation ranged from three to five weeks.
Approximately 60% of patients derived some benefit from the reirradiation of radiation-refractory bone pain. The time to response was three to five weeks. For those receiving reirradiation in a circumstance in which the end of life is near, this method may not be effective. Remission of pain, however, was reported to last anywhere from 15–22 weeks.
Not all studies reported drop-out rates and so an intention to treat analysis was not feasible. If reported, however, drop-out rates ranged from 14%–35%. These rates were attributed to death and symptomatic relief but were not clear, so bias could not be excluded. Further, no randomized, controlled trial has been published on reirradiation treatment for radiation-refractory metastatic bone pain. There is limited evidence on reirradiation effectiveness, study quality is mediocre, and populations are small. Also, the difference in study design, clinical differences between study populations, lack of clinical guidelines for reirradiation, and changes in insight over time contributed to the heterogeneity observed in the included studies. All of these factors again support the need for ongoing investigation of reirradiation for bone metastases and further investigation of palliative care measures to provide optimal relief for patients with painful bone metastases.
Huisman, M., Verkooijen, H.M., van der Linden, Y.M., van den Bosch, M.A., & van Vulpen, M. (2015). Effectiveness of repeat radiotherapy for painful bone metastases in clinical practice: A 10 year historical cohort study. Clinical Oncology, 27, 472–478.
To assess the effectiveness of retreatment with radiotherapy for painful bone metastases
Data were collected from medical records. Only evaluable patients with pain response documentation were included in the analysis. Information from records was used to categorize pain because no numerical pain scores were recorded. For patients with available data, the pain response proportion was calculated. For those with no response data, it was assumed that these were nonresponders for the calculation of a worst-case scenario.
Retrospective, descriptive study
Not applicable
Overall, 66% of evaluable patients indicated responses with decreases in pain. In the worst-case analysis, the overall response rate was 43%. The use of systemic analgesia (overall response [OR] = 0.39, p = 0.037) and prior pain response to radiotherapy (OR = 1.01, p = 0.049) were predictors of response to repeat radiotherapy. Patients who had an initial response were more likely to respond to retreatment, and those having used systemic therapy were less likely to respond. The toxicities experienced were all grades 1 and 2, including nausea and vomiting, fatigue, diarrhea, and skin reactions. In 4% of patients, a pathologic fracture at the retreated site was reported, and one patient developed radiation-induced femoral head necrosis requiring a total hip replacement. For the initial treatment, it was reported that 13% of patients received no pain medication, and 43% had only levels 1 and 2 analgesia according to the World Health Organization analgesic ladder.
The findings of this study suggested that retreatment with radiation therapy for bone metastases can be effective for pain reduction. Prior response to radiation therapy for pain suggested better odds that retreatment would produce a response.
Patients who have initial pain responses to radiation therapy for bone metastases may benefit from repeat radiotherapy.
Hui, D., Morgado, M., Chisholm, G., Withers, L., Nguyen, Q., Finch, C., . . . Bruera, E. (2013). High-flow oxygen and bilevel positive airway pressure for persistent dyspnea in patients with advanced cancer: A phase II randomized trial. Journal of Pain and Symptom Management, 46, 463–473.
To examine changes in dyspnea through a randomized trial of high-flow oxygen (HFO) and bilevel positive airway pressure (BiPAP) in patients with cancer
Patients were randomized using a computer-generated randomization scheme in a 1:1 ratio to receive either two hours of HFO followed by a washout period and then two hours of BiPAP or two hours of BiPAP followed by a washout period followed by two hours of HFO. Data on dyspnea were collected every 10 minutes after the first intervention for as much as one hour. Patients participated in the second intervention if their dyspnea level was ≥ baseline dyspnea level minus one or ≥ 3/10 after one hour.
Randomized, open-label study with a parallel design and an optional second intervention
HFO and BiPAP were found to alleviate dyspnea and improve physiologic parameters. The results of this study justify larger randomized, controlled studies to validate these findings. The authors of this study proposed that HFO and BiPAP be examined separately.
Dyspnea is one of the most common symptoms for patients with cancer. This study shows that HFO and BiPAP may alleviate dyspnea. These devices are safe for patients to use. Larger randomized, controlled clinical trials are needed to confirm the findings of this study.
Hui, D., Xu, A., Frisbee-Hume, S., Chisholm, G., Morgado, M., Reddy, S., & Bruera, E. (2013). Effects of prophylactic subcutaneous fentanyl on exercise-induced breakthrough dyspnea in cancer patients: A preliminary double-blind, randomized, controlled trial. Journal of Pain and Symptom Management, 47, 209–217.
To study the feasibility of a randomized, controlled trial exploring the effects of fentanyl on breakthrough dyspnea, walking distance, vital signs, and adverse events in patients with cancer
Double-blinded, placebo-controlled, randomized trial
The prophylactic administration of subcutaneous fentanyl appears to be a safe and well-tolerated method for reducing dyspnea, fatigue, and respiratory rate while also enhancing physiologic function and activity levels among patients with cancer. However, the generalizability of these findings are limited because of the small sample size.
Huether, K., Abbott, L., Cullen, L., Cullen, L., & Gaarde, A. (2016). Energy Through Motion©: An evidence-based exercise program to reduce cancer-related fatigue and improve quality of life. Clinical Journal of Oncology Nursing, 20, E60–E70.
To implement and evaluate an evidence-based practice change to encourage exercise for fatigue
The Iowa Model of Evidence-Based Practice Change was used to guide implementation and measure impact on patient outcomes and care processes. An intervention to implement physical activity for patients to combat fatigue was selected. Activity kits for patients were developed, and included information on the benefits of physical activity, activity logs, instructions for workouts, as well as strategies to improve sleep, and nutrition. A pedometer and resistance bands were also provided. A nurse made regular connections with patients to encourage physical activity. Fatigue assessment was done at clinic visits at baseline and three months later. Results from the physical activity group were compared to those of patients receiving usual care.
PHASE OF CARE: Multiple phases of care
Prospective cohort comparison
Brief Fatigue Inventory (BFI)
Patients who received the activity intervention experienced a significant reduction in fatigue (p = 0.0006) and increase in general activity (p = 0.0066).
The intervention to improve physical activity was effective to improve fatigue.
The findings showed that the use of the activity kit and follow-up in this study was effective in increasing physical activity and reducing fatigue in patients with cancer.