To assess feasibility and effectiveness of aquatic-based exercise in the form of deep water running as part of a multimodal physiotherapy program for breast cancer survivors in an effort to decrease cancer-related fatigue

Eight week program of one hour sessions, three times per week, of multimodal physiotherapy program combined with deep water running delivered by physiotherapists in groups of 8–10 participants. Each session included 30 minutes of land-based exercise, followed by 20 minutes of deep water running.

• N = 42  
• MEAN AGE = 47.27 years for the intervention group and 48.67 years for the control group
• FEMALES:100%
• KEY DISEASE CHARACTERISTICS: Patients were within one year of breast cancer diagnosis, were aged 25–65 years, and post-cancer treatment within past six months.
• OTHER KEY SAMPLE CHARACTERISTICS: Patients were excluded if they had a fear of aquatic exercise.

• SITE: Multi-site  
• SETTING TYPE: Outpatient  
• LOCATION: Two primary care centers in Andalusia, Spain

• PHASE OF CARE: Transition phase after active treatment

• Non-randomized study with a wait-list control group 
• Outcomes were measured/evaluated by one assessor who was blinded to participant group allocation.

• Piper Fatigue Scale–Revised
• SF-12 Health Survey
• European Quality of Life (five dimensions)
• European Visual Analog Scale

Statistically significant differences in fatigue were found between groups after eight weeks, with the intervention group reporting greater improvement in behavioral severity, affective/meaning, and sensory fatigue.

Demonstrated positive effects of exercise on cancer-related fatigue. Supports prior studies that demonstrated greater improvement combining educational and exercise programs

• Small sample (< 100)
• Risk of bias (no random assignment)
• Intervention expensive, impractical, or training needs existed
• No long-term follow-up

This is a difficult program to replicate, but it appears that it is likely to be effective in reducing cancer-related fatigue.

To evaluate the efficacy of methadone as a substitute for morphine, and to investigate whether the addition of acetaminophen improves pain control in switching to methadone

Patients using morphine for oncologic pain who were on a stable dose for at least one week were recruited. Patients were rapidly switched to oral methadone without a transition period and randomized to receive acetaminophen or placebo with methadone for seven days. The daily morphine dose was converted to methadone in ratios according to the total daily morphine dose. In case of additional pain, patients were instructed to use extra methadone no more than every two hours using a dose equal to 25% of the total daily dose. Use of coanalgesics such as anti-inflammatory drugs, antidepressants, and neuroleptics was allowed. Pain intensity was evaluated daily and recorded by patients in a diary along with all analgesic medications used. Patients were followed for seven days.

• The study reported on 49 patients.
• Median patient age was 58.5 years (range = 19–81 years).
• The sample was 53% male and 47% female.
• Various tumor types were cited, with the most frequent being colorectal, breast, and lung.
• Eighty-eight percent of patients had non-neuropathic pain.
• Median pain intensity at baseline was 5 in the acetaminophen group and 3.5 in the placebo group. Median morphine daily dose at baseline was 60 mg, with a range of 40–540 mg.

• Single site
• Outpatient setting
• Brazil

The study design was double-blind, randomized, placebo-controlled for use of acetaminophen, and open label for switch to methadone.

• Numeric rating scale (0–10)
• Faces pain rating scale
• Four-point rating scale for side effects
• European Organization for Research and Treatment Cancer Core Quality of Life questionnaire (EORTC QLQ-C30)

Of the original study sample, 16% ended participation early due to treatment failure with intense pain, somnolence, or vomiting. Most patients who completed the study had a significant improvement in pain by the faces (p = 0.05) and numeric (p = 0.03) rating scales. There were no differences between patients who did and did not receive acetaminophen.

Study findings show that most patients can be switched from morphine to methadone with no transition period, with some improvement in side effects of constipation and xerostomia and adequate pain control. The addition of acetaminophen in this process was of no benefit.

• The study had a small sample, with less than 100 participants.
• No data were provided on total opioid consumption or use of rescue doses during the study.
• The study period was very short, and even within this time frame, 16% experienced treatment failure with methadone.
• No information was provided on actual use of adjuvant medications for pain control.

This study shows that patients can be rapidly switched from morphine to methadone; however, this approach failed in 16% of patients. Methadone may be associated with less constipation and dry mouth, and may be a good pain control option for patients with these problems. Acetaminophen did not improve pain control with this switching process.

To evaluate the efficacy and safety of gabapentin for the prevention of acute and delayed chemotherapy-induced nausea and vomiting (CINV) during the first cycle of moderately or highly emetogenic chemotherapy

Chemotherapy naïve patients with cancer who were scheduled to begin moderately or highly emetogenic chemotherapy were randomized to either receive 300 mg gabapentin or a placebo, in addition to a standard regimen of antiemetic prophylaxis (8 mg IV ondansetron, 10 mg IV dexamethasone, and 50 mg IV ranitidine before chemotherapy on day 1 and 4 mg oral dexamethasone twice a day on days 2 and 3).

Patients received either the gabapentin or the placebo five and four days before chemotherapy, once per day; three and two days before chemotherapy, twice per day; and one day before through five days after chemotherapy, three times per day. After chemotherapy was administered until the morning of day 5, patients kept diaries to record episodes of emesis or retching and severity of nausea over the previous 24 hours.

The primary outcome of this study was an evaluation of the number of patients reporting a complete response (CR), defined as the absence of nausea and vomiting and no use of rescue medications, during three timeframes.

• Acute phase of treatment (starting after chemotherapy was administered and ending 24 hours later)
• Delayed phase (starting 24 hours after chemotherapy was administered and ending on day 5 of treatment)
• Overall

• The study consisted of 80 patients.
• The mean age of patients was 53.95 years (SD = 10.15 years).
• The majority of the sample was female (93.75%).
• Cancer diagnoses were lung, breast, and head and neck cancer.
• Patients were chemotherapy-naive and scheduled to receive moderately or highly emetogenic chemotherapy (cisplatin greater than 60 mg/m² or doxorubicin greater than 50 mg/m²).

The study was conducted at a single site at a large medical institution in Brazil.

All patients were in active treatment.

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

• Patients recorded episodes of vomiting or retching using diaries. Patients were asked to record each episode of emesis or retching from the morning of chemotherapy administration until the morning of the sixth day after.
• Nausea was recorded using diaries. Patients were asked to record the intensity of their nausea over the last 24 hours on a 100-mm visual analog scale (VAS) ranging from ”no nausea” to ”nausea as bad as it could be” from the morning of chemotherapy administration until the morning of the sixth day after.
• Patients recorded the impact of CINV on daily life via the Functional of Living Index-Emesis (FLIE).
• Use of rescue medication was recorded in diaries. Patients were asked to record each instance a medication was taken to control nausea or emesis from the morning of chemotherapy administration until the morning of the sixth day after.
• Adverse events were recorded at the post-study visit on day 6 using the National Cancer Institute Common Terminology Criteria for Adverse Events, Version 4.0.

• Patients who received gabapentin in addition to the standard regimen of antiemetic prophylaxis were significantly more likely to experience CR compared to those who received a placebo and standard antiemetic prophylaxis (p = 0.04).
• Patients taking gabapentin also were significantly more likely to experience CR during the acute phase of treatment (the first 24 hours after chemotherapy administration) compared to the placebo group.
• No difference was found between groups for episodes of CR during the delayed phase of treatment (24 hours after chemotherapy administration up to day 5).
• No adverse events were reported.

Gabapentin may be a low-cost, nausea prophylaxis medication that can be used as an alternative to more expensive antiemetic medications. Although the authors described gabapentin as a low-risk medication, recent reports have linked gabapentin to increased rates of depression and suicide. It also has been commonly associated with the side-effects of drowsiness and dizziness.

• This study involved a small sample of fewer than 100 participants.
• The study sample was predominantly women with breast cancer. Generalizing to other cancers and men is difficult.
• The comparative standard regimen did not include an NK1, which is recommended as of this writing.

For patients who are uninsured or underinsured and those living in developing countries where obtaining high-cost medications may be difficult, gabapentin may prove useful as a less-expensive alternative antiemetic prophylactic medication. Research should attempt to compare less expensive alternatives with current best practices.

780 nm 60 mW 4 J/cm² was applied uniformly to five areas of the oral cavity for five consecutive days from initiation of chemotherapy.

The sample was pediatric patients (some with HSCT) receiving a variety of chemotherapies.

Laser group: n = 29
Control group: n = 31
 

The study ran from May 2003-February 2005.

RCT was the study design.

CTC-NCI
Nutritional Status Assessment
Day 8,15
 

Day 8 results: 13 patients in the laser group and 7 patients in the control group with mucositis; median grade of mucositis was 2 for the laser group and 1 for the control group (p = 0.234)

Day 15 results: 13 patients in the laser group and 11 patients in the control group with mucositis; median grade of mucositis was 1 in both groups; prevalence and severity were similar (p = 0.208)
 

Almost identical prevalence of mucositis and other findings; no evidence to support laser for prevention

Rigorous oral care may have masked results.

Optimal timing of laser treatment is unknown.

Small sample
 

To compare prophylaxis with a fluoroquinolone (ciprofloxacin, ofloxacin, perfloxacin, or norfloxacin) in combination with an antibiotic against gram-positive bacteria (penicillins, macrolide, rifampin, or vancomycin) compared to fluoroquinolone alone in neutropenic patients with cancer

DATABASES USED: MEDLINE, CANCERLIT, Database of Abstracts of Reviews of Effects, and Cochrane Library (1984–2002); the bibliographies of retrieved studies also were reviewed.

• FINAL NUMBER STUDIES INCLUDED = 9 RCTs
• TOTAL PATIENTS INCLUDED IN REVIEW: 1,202
• KEY SAMPLE CHARACTERISTICS: Neutropenic patients with cancer

The addition of gram-positive prophylaxis to fluoroquinolones reduced

• Total episodes of bacteremia by 11.1%
• Staphylococcal and streptococcal infections
• Febrile morbidity by 6.7%.

No difference was found between gram-positive prophylaxis and a fluoroquinolone compared with a fluoroquinolone alone with regard to

• Clinically documented infections
• Gram-negative infections
• Unexplained episodes of fever
• Infectious mortality.

However, adding gram-positive prophylaxis significantly increased the occurrence of side effects, primarily gastrointestinal intolerance and liver function test abnormalities seen with rifampin and roxithromycin.

The authors concluded that the evidence does not support routine use of gram-positive coverage in combination with a fluoroquinolone for antibacterial prophylaxis in neutropenic patients with cancer.

DATABASES USED: MEDLINE was searched for literature published from January 1984–October 1994. Current Contents also was used, as were the bibliographies from MEDLINE articles.

KEYWORDS: Key words used in the search were neutropenia/agranulocytosis and bacterial infections.

INCLUSION CRITERIA: Eligible studies were randomized, controlled trials with fluoroquinolones alone or in combination with gram-positive prophylaxis in granulocytopenic patients receiving chemotherapy for cancer.

• FINAL NUMBER STUDIES INCLUDED = 19
• KEY SAMPLE CHARACTERISTICS: The majority of patients had hematologic malignancies. Patients with solid tumor were included in six of the studies.

Prophylaxis with fluoroquinolones alone was shown to significantly reduce the frequency of gram-negative bacteremia. No significant difference was found in terms of gram-positive bacteremia or infection-related mortality. Fluoroquinolone with gram-positive prophylaxis significantly reduced the frequency of gram-positive bacteremia. Fever-related morbidity and infection-related mortality were not affected. Of note, the majority of the studies (four of six) used fluoroquinolone alone in the control group.

Carnitine deficiency is among the many metabolic disturbances that may contribute to fatigue in patients with cancer. Administration of exogenous L-carnitine may hold promise as a treatment for this symptom. Carnitine was prepared by the institutional pharmacy at a concentration of 1 g/mL. The drug was administered in two daily doses for seven days. After the intervention period, patients were allowed to continue L-carnitine supplementation if desired. Patient outcomes were evaluated at baseline and on day seven.

• In total, 27 patients (37% female) with advanced cancer were included.
• Mean age was 59.7 years.
• The majority of patients were Caucasian (59%).
• The most common diagnosis was breast cancer (22%).
• Most patients reported severe fatigue (70%), and all were carnitine-deficient.
• Patients were excluded from the study if they had hemoglobin levels less than 9 g/dL, had increased risk of seizure or heart failure, were receiving current treatment (chemotherapy, radiotherapy, or recombinant erythropoietin), or had renal insufficiency.

Beth Israel Medical Center Continuum Hospice Care, Jacob Perlow Hospice, or the Cancer Center

Patients were undergoing the active treatment phase of care.

The study was an open-label, phase I/II clinical trial.

Brief Fatigue Inventory (BFI)

Patients who received the L-carnitine intervention experienced a significant decline in fatigue (p < 0.001) as BFI scores decreased from baseline (66.1 [standard deviation (SD) = 12]) to one week after treatment to (39.7 [SD = 26]).

• Of the 85 patients who were eligible for study, 47 elected not to participate, the most common reason being that patients were interested in trials that aimed to treat their condition and were less interested in symptom management studies.
• The study lacked a neutral comparison group.
• The assessment of side effects did not rely on validated measures, and a range of potential safety measurements, such as repeated liver function tests, were not performed.

Carnitine is hypothesized to be key in the energy metabolism and regulation of adenosine triphosphate (ATP) promotion and a protective effect of mitochondrial metabolism. Carnitine deficits are common in cancer patients and other chronically ill persons.
 

L-carnitine supplementation was given in dose levels of 250 mg/day. Dose levels were planned to increase by 500 mg until the target dose of 3000 mg/day was reached.

Of 645 adult patients, 13% met following inclusion criteria:

• Age of at least 18 years
• Greater than 3 month life expectancy
• Self-reported fatigue was moderate to severe for at least one week
• Carnitine deficiency
• Karnofsky Performance Status (KPS) of 50% or greater.

Patients were excluded from the study if they had severe disease, brain tumor, or stroke; were unable to complete the assessment tools; had started erythropoietin within less than 3 months; had received radiotherapy or chemotherapy within one week prior to the study; or were unable to consent.

Hospice and Cancer Center

The study used an open-label, dose-finding, safety design, with dose cohorts of three.

• Brief Fatigue Inventory (BFI)
• Center for Epidemiological Studies Depression Scale (CESD)
• Quality of sleep
• Epworth Sleepiness Scale (ESS)
• KPS

• Of the patients, 83% reported fatigue with a significant decrease in BFI score after one week (p = .009).
• CESD decreased (p = 0.028).
• ESS decreased (p = 0.015).
• No significant change occurred in KPS.
• Dose was safely escalated to 1750 mg/d.

• The study had a small sample size.
• Hospice patients often have multiple medical problems. 
• Three higher dose levels were not reached.
• Treatment length was short (one week). 
• The effect of prolonged use is unknown.
• No monitoring of dietary carnitine was performed.
• It is unknown if L-carnitine supplementation accelerates cancer or interferes with the effects of certain agents.

Cost of supplements and monitoring levels of L-carnitine is unknown.

To determine the efficacy of L-carnitine supplementation for fatigue in patients with cancer.

Patients were randomized to receive 1 g of L-carnitine liquid twice daily for four weeks or placebo.  For weeks five to eight, all patients received L-carnitine in an open-label extension. Outcome measures were assessed at baseline and at weeks four and eight.

• In total, 237 patients (42% male, 58% female) were included.
• Age was not reported.
• Disease types were not reported.
• About 80% of patients were currently receiving chemotherapy and 18% were receiving radiotherapy. Slightly less than one-third were receiving antidepressants. 

• Multisite 
• Outpatient 
• United States

Patients were undergoing the active antitumor treatment phase of care.

The study was a randomized, double-blind, placebo-controlled, phase III trial followed by a four-week open-label extension.

• Brief Fatigue Inventory (BFI)
• Center for Epidemiologic Studies Depression Scale (CESD)
• Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F)
• Eastern Cooperative Oncology Group (ECOG) performance status
• Blood sample analysis for plasma carnitine and acylcarnitine
   

The group receiving L-carnitine had a greater increase in plasma carnitine levels. At week four, one-third of those on placebo were carnitine-deficient, compared to 11% of those who were receiving carnitine (p ≤ 0.001). BFI scores improved significantly in both groups by approximately one point (p < 0.001). There were no differences between groups in fatigue, depression, or pain. Over time, there was a significant decrease in the proportion of patients with severe fatigue, pain, and depression; however, there were no significant differences between groups. There were few high-grade toxicities. In one patient, the cause of death was possibly related to treatment.

Supplementation of 1 g of L-carnitine did not improve fatigue, pain, or depression in these patients.

Of the patients, 25% to 30% had missing outcome data; however, power analysis showed that the sample size was sufficient.

The findings showed that dietary supplementation with L-carnitine did not improve fatigue, depression, or pain in patients with cancer. Nurses can advise patients that this approach has not been shown to be helpful, as these results provide strong evidence that L-carnitine is not effective for these symptoms.

To explore how bereaved relatives experienced early intervention with soft tissue massage during the first four months since the death of a family member who received palliative cancer care

Study data resulted from two interactions with Swedish-speaking relatives of deceased patients with cancer who had received care in a large palliative care unit. Demographic and baseline data were collected in an initial 60-minute visit to the relative. Hand or foot soft tissue massage, which is defined as a gentle but firm movement of the skin that activates touch receptors, was done in slow strokes, light pressure, and circling movement using lightly scented vegetable oil.

One week after an eight-week intervention involving either protocol-driven or relative election of either hand or foot soft tissue massage, the first author audiotaped hour-long interviews with the 18 study participants. Open-ended interviews focused on the experience of receiving the massages via a dialectical validation approach to ensure understanding of relatives’ experience. The authors supported trustworthiness and qualitative credibility factors during interviews and data analysis processes based on interview transcriptions and close attention text. An additional follow-up telephone call six to eight months after the interview was intended to encourage participants to reflect on their current life situation in relation to the grieving process.

• The sample (N = 18) was comprised of 14 females (78%) and 4 males (22%) who were bereaved relatives of deceased patients with cancer.
• The age range of participants was 34–78 years (mean age = 56.2 years).
• Diagnoses of the deceased patients were not noted.
• The relationship to the patient was widow (9), widower (4), daughter (3), and sister (2).
• The type of massage chosen was foot (9), hand (8), and hand and foot (1).
• The working status of participants was sick leave (7), retired (6), and working full- or part-time (5).
• Three relatives had previous experience with deep body massage.
• The study authors provided no other information, such as educational status, about the sample. This status may help to interpret the rich textual findings presented by the authors.
• Of the sample, 14 expressed interest in participating the first few weeks of their relative’s death, although the authors planned to contact relatives within three to six weeks of the relative’s death.
• Seven relatives chose not to participate due to living too far away or a lack of interest in study participation.
• Most chose to receive massages in their home, and most massages occurred in a silent environment.

• Single site
• Home or palliative care center
• Stockholm, Sweden

A prospective, descriptive, qualitative design was used.

• Private interviews were audiotaped in which bereaved relatives narrated freely about their experience of receiving soft tissue massage over eight weeks.
• Follow-up telephone conversations were initiated six to eight months postinterview “to see how the relative was doing.”

A qualitative content analysis allowed various levels of interpretation and abstraction to support one predominant theme: Bereaved relatives felt “feelings of consolation and help in learning to restructure everyday life.” The theme derived from four categories: (a) a helping hand at the right time, (b) something to rely on, (c) moments of rest, and (d) moments of retaining energy. Overall, soft tissue massage supported relatives’ need for comfort, as well as hope during a difficult transition time for relatives who sought a balance of grieving and moving on with their lives after the death of a loved one. No analysis of the follow-up telephone conversations appeared in the article.

Early interventions for relatives who grieve the loss of a family member’s death, including sequential soft tissue hand or foot massage, may facilitate relatives’ feelings of belonging, human connection to healthcare staff who cared for their family member before death, sense of self, and energy to structure life after a family member’s death. Too often, delayed interventions cause unnecessary worry and suffering of bereaving relatives. The offering of soft tissue massage to those relatives at a desired time may constitute a cost-effective way to support bereaved relatives early in their grieving process.

• The sample was small, with less than 30 participants.
• Although the sample size appears adequate for qualitative studies, further replication of the study across cultures and healthcare units would expand application of the findings to multiple relatives who experience the death of a family member. For example, in some cultures, there may be limited acceptance of personal touching by a person that is not family.
• Recruitment for this qualitative study occurred in one specialized palliative care unit, thus limiting generalizability of the study findings. The study also occurred in Sweden, and this may influence access and acceptance of soft tissue massage as a culturally-sensitive intervention in the United States. Scope of practice issues in the United States and other countries may influence nurses’ use of massage therapy with population groups, as well as nurses’ continued contact with families following a family member’s death. In this study, it appeared that at least one of the study authors served as a massage therapist, a behavior that may “cross the line” in the United States of inappropriately meshing two distinct healthcare provider roles.
• The authors did not address “member checking,” a common process in qualitative research in which data findings gain support from a person experiencing the topic under study. The input of a grieving caregiver once the study data resulted would have addressed validation of the findings and expanded interpretation of those.

Early support, including that inherent in the delivery of soft tissue massage, to grieving relatives of a family member who died from cancer or other chronic illnesses, offers a cost-effective intervention that may improve the health of those relatives. This intervention needs further testing to determine its efficacy but does highlight the importance of grieving relatives reconnecting with the healthcare professional, physical touch, and getting needed support. Further research with diverse populations in other global communities may extend understanding and acceptance of this potentially future intervention to add quality-of-life care to relatives and other family members. Testing of a soft tissue massage intervention could support evidence for the effectiveness of this intervention and nurses’ referral of caregivers to this intervention for improved quality of life.