To evaluate the effectiveness of treating epidermal growth factor receptor–inhibitor (EGFRI)-induced rash using a topical antibiotic or a combination of an antibiotic and benzoyl peroxide for grade 1 rash, or systemic treatment (oral antibiotics) for grade 2 or higher rash eruption.

On initiation of EGFRIs, all patients started sunscreen, a mild skin cleanser, and oatmeal cream daily. Patients with a grade 1 rash were treated with a topical antibiotic or an antibiotic and benzoyl peroxide. Patients with a grade 2 or higher rash eruption were treated with systemic treatment (oral antibiotics).

The study reported on a sample of 19 patients with lung and colorectal cancer who initiated therapy with EGFRI agents (erlotinib or cetuximab) and had skin alterations.

Portugal

This was a prospective, descriptive study.

• Clinical and photographic evaluation
• National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE), version 3

• Eighteen of 19 patients developed a grade 2 rash.
• Of those 18 patients, 50% had a complete response to treatment with tetracyclines (mainly doxycycline).
• Only one patient had grade 3 rash, which did not respond to minocycline.
• None of the patients had to stop treatment with EGFRI therapy.

Tetracyclines were effective in completely resolving grade 2 EGFRI-induced rash in 50% of the sample.

• This was a small, noncontrolled study.
• No statistical analysis of the difference in prevalence rates was reported.

To conduct a systematic review to identify which nursing interventions are used to reduce fatigue caused by cancer treatment and to identify the level of evidence for those interventions.

Databases searched were PubMed and CINAHL (1995–February 2005).

Search keywords were cancer, cancer treatment, chemotherapy, distraction, education, exercise, fatigue, nursing intervention, radiotherapy, and sleep promotion.

Studies were included in the review if 

• The intervention was performed by nurses
• The study was conducted by nurses
• The intervention was performed with adults
• The intervention was performed during cancer treatment.

An initial search was performed to find systematic reviews. No reviews of studies meeting the inclusion criteria were found. A second search to locate intervention studies yielded 192 studies in CINAHL and 78 in PubMed. Screening for inclusion criteria resulted in the identification of 18 studies that were then included in the review. Ten studies reported the effects of exercise, five reported education and counseling, two reported distraction and relaxation, and one reported sleep promotion.

The sample was comprised of 904 patients across 18 studies.

Exercise Studies

• Sample sizes varied from 22 to 119 patients.
• Kind of exercise varied from a seated video exercise program to an aerobic program at home or in a supervised clinic.
• Intensity of exercise varied.
• Patient adherence to exercise programs was a problem, and not all studies accounted for this factor.
• Only five studies divided patients into exercisers and nonexercisers based on usual activity. 
• Five studies demonstrated significant effects in the intervention group.
• One qualitative study was found in which fatigue changed from a negative to a positive experience with exercise, and patients experienced increased physical activity and increased level of energy.

Education and Counseling

• Three studies were randomized, controlled trials (RCTs), one used a pre-/posttest design, and one was longitudinal.
• Information was provided on tape, by telephone, or in person.
• Information was given in 3 to 10 sessions and included information about other symptoms in addition to fatigue in four out of the five studies.
• In two studies, fatigue increased with the intervention, and in three studies, a decrease was found in the experimental group.
• Talking to someone was an important aspect, a trend associated with group interaction was found, and one study found a significant effect over time.

Distraction and Relaxation

• One RCT used relaxation breathing every day for six weeks in patients who received stem cell transplantation. The intervention group experienced significantly less fatigue.
• One crossover design study used virtual reality during intravenous chemotherapy treatment. There was a significant effect, but the posttest was performed immediately after treatment.

Sleep Promotion

• One study used a pre-/posttest design using an individualized sleep promotion plan. No significant effects were found.

Sleep promotion was identified as a promising intervention despite the single study results because other studies have shown a relationship between fatigue and sleep disorders. More research is warranted in this area. Lack of effect seen with education and counseling studies may be due to small sample sizes, lack of equivalent control groups, and lack of sensitivity in fatigue measurement. It is also possible that education alone is not enough to change patient behavior. Exercise is shown to be effective, but nothing is known about the long-term effects of exercise after treatment and whether exercise can prevent the beginning of fatigue. Adherence to exercise programs is an area that requires attention. No data were available regarding the level of activity prior to cancer treatment, which might influence the findings in this area.

• None of the studies used a theoretical framework, likely explained by the fact that no satisfactory theory has been formulated to explain fatigue in this population. Some studies did not even use a definition of fatigue.
• Fatigue was measured differently, and three different measures were used.
• In two-thirds of the studies, the sample was breast cancer patients receiving chemotherapy, limiting the external validity of the findings.
• Half of the studies had very small sample sizes of less than 30 patients.
• Study of distraction and relaxation was limited by the timing of fatigue measurement.
• No long-term effects or ongoing intervention was studied.

There are several promising interventions that can be provided by nurses. It is likely that a combination of interventions may be most helpful for patients. More research is specifically needed on the effects of interventions that enhance the quality of sleep, education, and counseling related to fatigue management and prevention.

To evaluate whether expressive writing (EW) was an effective stress management intervention for patients with breast cancer.

Women were assigned to write about their cancer experience (EW group; n = 24) or neutral topics (neutral writing [NW] group; n = 25). Women were asked to write for 20 minutes a day for a total of four writing sessions that were completed over a seven-day period. Patients were reassessed approximately three days before and two weeks after surgery.

• The sample was comprised of 49 women.
• Patients were older than 18 years; mean age was 56.89 years (standard deviation = 10.79 years).
• Women were recruited two or more months from neoadjuvant chemotherapy.
• Of the patients, 58% were white, 13% were black, 13% were Latina, and 16% were other; 52% were college graduates or had some graduate training; 44% had an annual income of greater than $50,000, 79% were married/cohabitating; and 49% had stage II and 54% had stage III.

• Cancer outpatient clinic
• MD Anderson Cancer Center, Texas

Patients were undergoing the active treatment phase of care.

The study was a randomized, controlled trial.

• Brief Symptom Inventory 18 (BSI 18)
• Perceived Stress Scale (PSS)
• Pittsburgh Sleep Quality Index (PSQI)
• Social Constraints Scale (SCS)
• Brief Pain Inventory (BPI)
• Impact of Events Scale (IES)
• Emotional Approach Coping Scale (EACS)
• Linguistic Inquiry and Word Count (LIWC)

The EW intervention did not significantly decrease women’s distress, perceived stress, sleep disturbance, or pain. There was some evidence that the EW group used more sleep medication at the presurgical assessment than the NW group. Social constraints moderated the effect of the intervention. Among women with high social constraints, the EW group reported lower average daily pain than the NW group. Among women with low social constraints, the EW group reported higher average daily pain than the NW group.

EW was not as broadly effective as a stress management intervention for women with breast cancer.

• The study had a small sample size and lacked statistical power.
• There was high attrition and inconsistent adherence.

These data do not support the use of EW as a presurgical mind-body complementary medicine program for this population.

The study included four weekly sessions of expressive writing associated with the first four cancer vaccines; patients were randomly assigned to neutral health issues writing or expressive writing of the group’s deepest thoughts and feelings.

Outcomes were psychological and behavioral adjustment, symptoms of distress, perceived stress, mood, and sleep.

• The sample was comprised of 42 patients (85% male) with newly diagnosed stage IV metastatic renal cell carcinoma who were four to six weeks postoperative.
• Mean age was 56.4 years.

• Outpatient
• Southwestern United States

Patients were undergoing the active treatment phase of care.

This was a pilot, randomized, controlled trial.

Pittsburgh Sleep Quality Index (PSQI)

Statistically significant improvements in the expressive writing group were found for four of the sleep disturbance measures on the PSQI (total score and subscales of Sleep Quality, Sleep Duration, and Daytime Dysfunction).

• The study had a small sample size.
• Generalizability was questionable because of the nature of the illness.
• Space is needed for the writing to occur, prior to the injection.

An expressive writing intervention involved four writing sessions. Patients were randomized to an expressive writing (EW) group in which they were instructed to write their deepest thoughts and feelings about their cancer or to a neutral writing (NW) group in which they were instructed to write about a different health behavior at each session. Writing instructions were developed from the Pennebaker and Beall model. Repeated measures at baseline, end of intervention, and 4, 6, 8, and 10 weeks later.

• N = 42 (EW = 21, NW = 21)
• AVERAGE AGE: 56.4 years
• MALES: 85%
• KEY DISEASE CHARACTERISTICS: Patients had newly diagnosed stage IV metastatic renal cell carcinoma and were participating in a phase II vaccine trial. Of the participants, 76% had metastases and 76% had no lung involvement.
• OTHER KEY SAMPLE CHARACTERISTICS: Patients were four to six weeks post-operation.

It is implied that the setting is outpatient, in which patients are participating in a phase II clinical trial using vaccine therapy.

• PHASE OF CARE: Active treatment

• Pilot study
• Randomized controlled trial  

• Profile of Mood States (POMS)

There was 86% and 81% adherence with each group. No differences in the POMS fatigue subscale were found; the POMS vigor subscale was significantly higher in the EW group.

• Sample size was small.
• Generalizability is questionable due to the nature of illness.
• Follow-up scores were averaged over multiple measures.
• Space for the writing to occur is required prior to the injection.

RESOURCE TYPE: Evidence-based guideline

Not provided

Nothing has been listed regarding the updated antiemetic guidelines and the used databases.

Nurses should know about pharmaceutical antiemetics advancement, assess patients' nausea and vomiting, and discuss the efficacy of the antiemetics with physicians if it is not within the recommended guidelines. Although some differences across guidelines exist, evidence and most guidelines support triplet therapy for HEC. It is unclear in these guidelines why multiday HEC recommendations do not include an NK₁.

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.