To examine the effects of yoga on shoulder and arm pain, quality of life (QOL), depression, and physical performance in patients with breast cancer

A 10-week Hatha yoga program was evaluated in this study. Hatha yoga is a mind-body exercise program of breathing exercises, flexibility, and relaxation components. The program in this study was supervised by a certified trainer and the session was taught at a beginner level. Sessions lasted one hour and were offered two days per week. All study participants (intervention and control) received education about cancer, lymphedema, and coping with ADLs. This included a booklet with information on exercises to stimulate lymph circulation. All participants were asked to practice these exercises twice a day.

• N = 42   
• AGE: Mean age = 51.9 years
• FEMALES: 100%
• CURRENT TREATMENT: Not applicable
• KEY DISEASE CHARACTERISTICS: Study participants had completed breast cancer treatment and had no evidence of disease. 
• OTHER KEY SAMPLE CHARACTERISTICS: Study participants had not participated in a regular exercise program in the past six months.

• SITE: Single site   
• SETTING TYPE: Outpatient    
• LOCATION: An academic medical center in Turkey

PHASE OF CARE: Transition phase after active treatment

Randomized controlled trial (RCT) with a usual care control group. Study outcomes were assessed by personnel blinded to the study assignment.

Visual analog scale for pain, European Organization for Research and Treatment of Cancer Quality of Life Core 30 (EORTC QLQ-C30) questionnaire, Beck Depression Inventory, 6-minute walk test, and evaluation of lymphedema. Measures were completed pre- and post-treatment. Study measures were also completed at 2.5 months post-treatment, but because most of the control group did not show up for their follow-up visit, data for the control group were not included in the analysis.

The two study groups did not differ significantly on demographic characteristics, types of breast cancer treatment, and baseline study measure scores. The yoga group demonstrated a significant improvement in pain severity from baseline to post-treatment for shoulder (p = 0.01) and arm (p = 0.01) pain; however, there was no significant difference between the yoga and control groups in regard to pre- and post-treatment pain. The yoga group’s improvement in pain severity was maintained at 2.5 months post-treatment (p = 0.01). There was no difference in depression, 6-minute walk, and QOL scores between groups from baseline to post-treatment. The yoga group demonstrated significantly improved QOL from baseline to 2.5 months post-treatment for functional (p = 0.01) and symptom (p = 0.03) scores, and improvement in their 6-minute walk time (p = 0.04). No evidence of worsening of lymphedema was found in either study group.

It is unclear if the yoga intervention truly relieved the shoulder and arm pain of the women with breast cancer since the control group also experienced a decrease in pain severity from baseline to 10 weeks. Shoulder and arm pain may normally decrease over time for this patient population. However, the Hatha yoga program appears to be a safe intervention which could be recommended if patients are interested in pursuing it.

• Small sample (< 100)
• Other limitations/explanation: The control group did not complete the 2.5 month follow-up questionnaires, so there is no comparison group for the yoga group findings at this time point.
   

Although Hatha yoga was not found to be more effective than usual care in relieving shoulder and arm pain, it appears to be a safe form of exercise. In addition, women in this study liked it as evident by the 95.5% adherence rate. Nurses should have an understanding of Hatha yoga so, if patients ask about it, they can explain that it is a safe form of exercise but its effectiveness in relieving pain needs to be studied further.

To determine whether performing a preoperative ultrasound-guided transversus abdominis plane block is an effective pain control measure for laparoscopic surgery for colorectal cancer.

After anesthesia induction, the patient received 0.5 ml/kg of either 0.25% bupivacaine or normal saline, depending on their predetermined group assignment. Pain was assessed at rest and when coughing 1 hour after surgery, on post-op day 1, post-op day 2, and post-op day 3.

• N = 55   
• AGE: 20-80 years old
• MALES: 67%  
• FEMALES: 33%
• CURRENT TREATMENT: Not applicable
• KEY DISEASE CHARACTERISTICS: Colorectal cancer 
• OTHER KEY SAMPLE CHARACTERISTICS: Laparoscopic surgery for colorectal cancer pain

• SITE: Single site   
• SETTING TYPE: Inpatient    
• LOCATION: National Cancer Center, Korea

• PHASE OF CARE: Diagnostic
• APPLICATIONS:  Elder care, palliative care

Randomized, double-blind, placebo-controlled trial

Pain was measured using the numeric rating scale (NRS). Cumulative opioid use was recorded from post-anesthesia recovery, post-op day 1, post-op day 2, and post-op 3.

Insignificant differences between the treatment group and control group exists when comparing post-op pain and opioid use.

When comparing the treatment group and control group, the differences in the postoperative pain assessments was not significant enough to support that receiving a transversus abdominis plane (TAP) block provides superior benefits.

Small sample (< 100)

The purpose of this study was to determine whether performing a preoperative ultrasound-guided transversus abdominis plane block is an effective pain control measure for laparoscopic surgery for colorectal cancer. No differences were seen between the treatment and control group. Based on this study a transversus abdominis plane block requires additional research prior to being recommended in this indication.

To determine if using a different morphine amount in a morphine/bupivacaine combination would be more effective in pain management in patients after a radical mastectomy for breast cancer.

Registered clinical trial with 90 patients allocated to receive 10 ml plain bupivacaine 0.5% plus either 5, 10, or 15 mg morphine diluted with saline 0.9% to 20 ml and topically to mastectomy site prior to closing. The three groups were compared for the following: time to first postoperative analgesia; IV patient-controlled analgesia (PCA) morphine consumption; pain scores; hemodynamics; sedation; adverse events in first postoperative 48 hours; and Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) scores in first and third postoperative months. Each patient participated in two study phases: an initial two-day treatment phase (48 hours post-op), phase 1, followed by a one- and three-month follow-up, phase 2. All clinical staff and patients were blinded to treatment group assignment.

• N = 90   
• AGE: Mean = 50.8 years (SD = 7.73) (morphine 5 mg: 50.43, SD = 7.84; morphine 10 mg: 49.83, SD = 7.78; morphine 15 mg: 52.13, SD = 7.65)
• FEMALES: 100%
• CURRENT TREATMENT: Not applicable
• KEY DISEASE CHARACTERISTICS: Patients with breast cancer

• SITE: Single site   
• SETTING TYPE: Multiple settings    
• LOCATION: Assiut University, Assiut, Egypt

PHASE OF CARE: Active anti-tumor treatment

Prospective, randomized, double-blind comparative study.

Visual analog scale (VAS), analgesia time, cumulative morphine consumption in first 48 hours, LANSS pain scale

There was a significant difference in analgesia-free time between the three groups. Morphine 15 mg had no patients requiring postoperative analgesics in the first 48 hours compared to 8 patients (27%) in the morphine 10 mg group and 19 patients (63%) in the morphine 5 mg group (p < 0.002). Regarding the time to analgesia use, the morphine 5 mg group was 7.31 hours (SD = 3.12) versus 14 hours (SD = 3.54) in the morphine 10 mg group (p < 0.000).

The morphine 15 mg group had the lowest LANSS recorded score in the first postoperative month when compared to the morphine 5 mg and 10 mg groups (1.1 [SD = 0.37] versus 5.76 [SD = 3.26] versus 4.73 [SD = 2.87], respectively) (p < 0.0001).

The increase in topical morphine (specifically up to 15 mg) in combination with bupivacaine, when compared to lower doses of morphine, has shown a decrease in postmastectomy pain through the reduction of analgesic use within 48 hours after surgery as well as lower LANSS scores within the first postoperative month.

• Small sample (< 100)
• Risk of bias (no control group)

15 mg topical morphine with bupivacaine may decrease postoperative pain and reduce the rate of PMPS.

To compare the efficacy of tetrodotoxin (TTX) to placebo in patients with pain secondary to advanced cancer or treatment related to treatment of advanced cancer.

Patients with moderate to severe cancer pain for at least two weeks or longer were randomized to receive a dose of TTX 30 µg or placebo twice daily at least six hours apart for four consecutive days. Participants were then seen on days 5, 8, and 15 in clinic for safety and efficacy evaluations and then on a weekly basis for evaluation by phone or in clinic until pain returned to baseline level.

• N = 165 (intent to treat, N = 149)
• AGE: 25-84 years
• MALES: 43%  
• FEMALES: 57%
• CURRENT TREATMENT: Not applicable, other
• KEY DISEASE CHARACTERISTICS: Any diagnosis of cancer; wide range of solid and other tumors
• OTHER KEY SAMPLE CHARACTERISTICS: Aged 18 years or older, stable baseline pain score greater or equal to 4/10 (worst pain in past 24 hours based on BPI, no greater than a three-point differed between highest and lowest scores, and no greater than 50% change in opioid analgesic use without addition of new analgesic), and all had a history or analgesics and maintained the regimens of opioids and co-analgesics. Exclusions: Clinically relevant hypoxia or history of CO₂ retention, severe renal impairment, prolonged QTc, plan for initiation of a new anticancer therapy, and female with positive pregnancy test.

• SITE: Multi-site   
• SETTING TYPE: Multiple settings    
• LOCATION: Full-service hospital or private clinic in Canada, Australia, or New Zealand

• PHASE OF CARE: Multiple phases of care
• APPLICATIONS: Elder care, palliative care

Multi-center, randomized, double-blind, placebo-controlled, parallel-design trial

Brief Pain Inventory form completed, patient diary

Clinical benefit of TTX over placebo with estimate effect size of 16.2% (p = 0.046) after adjustment with Holm method, p value was nominally significant for two primary endpoints but not at the prespecified two-side 5% level.  Average analgesic response was 57.6 days with TTX compared to placebo at 9.9 days; however, when pain was combined with QOL, there was not a statistically significant difference between those treated with TTX and those with placebo.

TTX administration provides a potential option for uncontrolled moderate to severe cancer pain in patients with advanced cancer that is a non-opioid. TTX provides a different approach to pain via the mechanism of action. However, this drug does not come without side effects/potential adverse effects and, while clinical significance has been demonstrated, this is a modest benefit. The pain reduction was only nominally statistically significant and because of statistical penalties for multiplicity, the study is not considered statistically positive. Therefore, additional study is needed to determine the usefulness of TTX for clinical practice, particularly in those who require high doses of opioids to manage their pain.

Other limitations/explanation: Conflict of interest: funded by Wex Pharmaceuticals; several doctors received operational funding, Dr. Hagen received honorarium, and some of the authors are employees or consultants for Wex Pharmaceuticals. Patients could be on existing pain regimens, unsure if fixed dosing or not

Patients would have to receive via subcutaneous injection. In the study, there were no fatalities and seemed to have a favorable benefit/risk profile. Non-opioid option, although mishandling could cause devastating consequences (TTX can cause paralysis and be fatal in high doses). Patients on high doses of opioids are poor candidates for TTX.

STUDY PURPOSE: Literature review with goals to synthesize current studies and update findings in order to obtain a current, comprehensive estimate of the benefits of pain education.

TYPE OF STUDY: Systematic review

DATABASES USED: PubMed

YEARS INCLUDED: 1987 to March 2014

INCLUSION CRITERIA: Keywords: cancer AND pain AND patient AND education. MeSH terms: pain, pain management, patient education as topic, self-care methods, health knowledge, attitudes, practice, and neoplasms. 

EXCLUSION CRITERIA: No specific exclusion criteria.

TOTAL REFERENCES RETRIEVED: 37

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Criteria used to evaluate: Pain experience, patient satisfaction, and patients’ communication skills and decision making.

FINAL NUMBER STUDIES INCLUDED: 44

TOTAL PATIENTS INCLUDED IN REVIEW: 6,308

SAMPLE RANGE ACROSS STUDIES: 30-970

KEY SAMPLE CHARACTERISTICS: Patients with cancer

PHASE OF CARE: Multiple phases of care

Pain experience: 85% of the studies reported that PEP (Pain Education Programs) significantly improved knowledge and beliefs, 52% of studies showed a statistically significant reduction in pain intensity when using PEP, but none of the studies (except one) showed that the intervention had any clear benefits on QOL.

Patient satisfaction: 90% of patients believed that PEP was helpful and 78% said that PEP made them more involved in pain management. 

Patients’ communication skills and decision making: Communication with clinicians was the most frequently developed behavior, and those patients who scored higher in active communication reported better pain relief and fewer barriers to pain management.

Research indicates a growing interest in therapeutic education of patients with cancer pain. PEP objectives have shifted from a focus on improving patients’ knowledge about pain management to enhancing their communication skills and attitudes. Additional research is warranted to better evaluate PEP effectiveness.

• Limited search
• No quality evaluation
• High heterogeneity
• Only English or French

PEP has been proven to increase patient knowledge of pain management, so it would be wise to increase training for nurses to conduct these interventions properly.

To investigate the effect of bone pain education on pegfilgrastim-related bone pain in patients with breast cancer receiving chemotherapy and pegfilgrastim. Patients were either shown a general video or specific bone pain video and then bone pain was assessed using patient surveys that asked about bone pain severity and location, medications usage, and information from adverse reporting.

Patients were randomized 1:1 to view either a generalized education video on chemotherapy side effects or a video on bone pain following chemotherapy and pegfilgrastim.

• N = 300   
• AGE: Older than 18 years
• FEMALES: 100%
• CURRENT TREATMENT: Chemotherapy, other
• KEY DISEASE CHARACTERISTICS: Stage I-III newly diagnosed patients with breast cancer 
• OTHER KEY SAMPLE CHARACTERISTICS: Planning on getting four cycles of neoadjuvant or adjuvant chemotherapy with pegfilgrastim support starting in cycle 1. Pegfilgrastim was given within 72 hours of chemotherapy. All received a 6 mg dose of pegfilgrastim and all were English speaking.

• SITE: Multi-site   
• SETTING TYPE: Outpatient    
• LOCATION: 48 community oncology clinics in the United States

• PHASE OF CARE: Active anti-tumor treatment
• APPLICATIONS: Elder care

Randomized single-blind study

• Severity of pain by a 0-10 scale
• Location of pain noted on a body map
• Both videos were developed by oncology nurses and oncologists but professionally produced by Amgen
• Adverse effects were graded using the CTCAE standards
• Medication logs
• Every patient watched the video at least twice and could take the video home. The videos did not replace existing patient education.  
• Area under the curve was used to capture both the magnitude and duration of pain in a single continuous measure.

Patient-reported maximum bone pain was similar in both groups. General versus specific C1 3.2 versus 3.5 (p = 0.3479); across all cycles, 4.1 versus 4.6 (p = 0.2196). Other measures of bone pain were also similar between groups. 

Bone pain was highest in C1 and then decreased and remained stable in subsequent cycles. Bone pain medication usage was also similar between the two groups with the highest usage in C1. 

The only area that showed significance was in the 65-75 age group. Maximum bone pain for general video was 2.9 versus 4.6 (p = 0.0599); mean bone pain was 1.3 versus 2.6 (p = 0.0220) and AUC was 5.3 versus 10.9 (p = 0.018).

The bone pain-specific education did not improve patient’s perception of bone pain reported in this patient population. However, this study did provide information on the prevalence, timing, severity, and location of pegfilgrastim-related bone pain. This may help focus future research on treatments for bone pain.

• Unintended interventions or applicable interventions not described that would influence results
• Key sample group differences that could influence results
• Measurement validity/reliability questionable
• Findings not generalizable
• Other limitations/explanation: Pain is highly subjective and could be influenced by other factors. It is difficult to predict and assess. Supplemental teaching was not standardized between sites. Age also could influence patient’s perception of pain.  
• The videos were only two minutes in length, which may not have been significant to generate a meaningful difference in reported pain. The videos may have been too similar.
• No control for patients watching video at home for other distractions. No pain management counseling given.

The major nursing implication is that pain is highest in C1. It is important to educate patients so they do not stop pegfilgrastim treatments due to pain. They need to know the amount of pain decreased is subsequent cycles. Education must always be individualized to be effective. Videos do not replace one-on-one teaching, but new educational methods need to be developed. More research is needed in different patient populations and on specific treatment experiences.

STUDY PURPOSE: To summarize the evidence-base of psychological interventions for women with metastatic breast cancer by mode of delivery and to synthesize data regarding core intervention elements and context factors.

TYPE OF STUDY: Systematic review

DATABASES USED: Medline, PsycINFO, CINAHL, SCOPUS

YEARS INCLUDED: Inception to May 2016

INCLUSION CRITERIA: Articles published or in press in a peer-reviewed journal between database inception to May 2016. Intervention targeted adult woman with a diagnosis of MBC or recurrent breast cancer. Studies including woman with MBC as part of a larger sample with other cancers if data could be extracted about MBC patients. The therapies were psychotherapeutic. Outcomes included survival, distress, coping, QOL, or somatic symptoms. All studies were RCT, quasi-RCT, or feasibility RCT in English.

EXCLUSION CRITERIA: Grey literature

TOTAL REFERENCES RETRIEVED: 740

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Meta-analysis (PRISMA) and a review protocol was developed.

FINAL NUMBER STUDIES INCLUDED: 15 RCTs across 23 articles

TOTAL PATIENTS INCLUDED IN REVIEW: 1,638

SAMPLE RANGE ACROSS STUDIES: 37 to 235

KEY SAMPLE CHARACTERISTICS: Age, years since MBC diagnosis, English speaking, race, partnership, education, employment

PHASE OF CARE: Multiple phases of care     

APPLICATIONS: Palliative care

Overall interventions improved distress in 8 of 13 RCTs, coping in 4 of 5 RCTs, and pain in 4 of 5 RCTs. No evidence of survival benefit was found. For remaining outcomes the evidence was either insufficient or too mixed to draw conclusions. Group programs had the strongest evidence base for efficacy. Individual and low-intensity therapy had insufficient evidence to form conclusions. Group interventions had longest intervention duration and lowest uptake and adherence. Low-intensity interventions had shortest duration and highest uptake and adherence. Disparities in uptake, adherence, and reach were evident with demographic profiles of age, race, language, and partnered woman (young, White, English-speaking, married women).

There remains a parity of psychological interventions for women with MBC. Those that exist have an inconsistent evidence base across the range of patient-reported outcomes. Further research is needed to evaluate accessible delivery formats that ensue efficacy as well as uptake and adherence. There were only five new articles from the last systematic review in 2013.

• Limited number of studies included
• High heterogeneity
• Outcomes varied between studies and used multiple different follow-up assessment tools.

More research is needed on the psychological therapies used in MBC patients in regards to survival, distress, coping, QOL, pain, fatigue, and sleeping, all of which contribute to depression. There is little research on this population and their psychologic concerns, particularly in minority populations. It is important that nurses reach a broader range of women with MBC. Research is also needed on how to deliver more accessible evidence-based interventions.

STUDY PURPOSE: To review in literature the effectiveness of sympathetic blocks in clinical trials. Both, neurolytic blocks of sympathetic as celiac plexus block (CPB) and superior hypogastric plexus block (SHPB), used for visceral abdominal pain in patients with pancreatic and gynaecologic cancer

TYPE OF STUDY: Systematic review

DATABASES USED: MedLine, Embase, and Cochrane Central Register of Controlled Trials

YEARS INCLUDED: Through February 2014

INCLUSION CRITERIA: Trials, both; neurolytic blocks of sympathetic as celiac plexus block (CPB) and superior hypogastric plexus block (SHPB), compared to analgesia or placebo, adult cancer patients and English language

EXCLUSION CRITERIA: Double publications, other clinical indications related, if only complications from sympathetic blocks reported

TOTAL REFERENCES RETRIEVED: 121

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Eligible trials were analyzed using the GRADE system

FINAL NUMBER STUDIES INCLUDED: 27 clinical trials 

TOTAL PATIENTS INCLUDED IN REVIEW: Not specified

SAMPLE RANGE ACROSS STUDIES: Sample range from 20 to 137

KEY SAMPLE CHARACTERISTICS: Pancreatic cancer for the CPB and pelvic pain related to gynecologic cancer for SHPB all of them requiring analgesia for their pain

PHASE OF CARE: Not specified or not applicable     
APPLICATIONS: Palliative care

CPB versus analgesia significantly decreased pain intensity, use of opioids, and reported less side-effect and better quality of life. SHPB versus morphine was more effective in only one RCT with 50 patients with gynecologic cancer that resulted in decrease in pain and less morphine.

Both, neurolytic blocks techniques, are sure and with few complications. Both are effective to reduce pain and to decrease use of opioids, less data is available from SPHB. Individual complete assessment in each patient is needed before deciding the technique to be done.

• Mostly low quality/high risk of bias studies
• High heterogeneity
• Low sample sizes
• No intention to treat analysis

No evidence can indicate the use of one or the other of the neurolytic blocks. Although celiac plexus block (CPB) seems recommended for pancreatic cancer pain, best timing for the technique is still uncertain. For superior hypogastric plexus block (SHPB) only after personalized evaluation in each case.

STUDY PURPOSE: Review the available evidence in literature to determine the effectiveness on the use of peripheral nerve blocks to treat cancer pain in adult patients.

TYPE OF STUDY: Systematic review

DATABASES USED: PubMed, EMBASE, and Cochrane

YEARS INCLUDED: All available data through February 2014

INCLUSION CRITERIA: No experimental studies of effectiveness of peripheral nerve blocks, adult patients with chronic cancer pain, data includes pain level outcomes, English language.

EXCLUSION CRITERIA: Double publications, management of postoperative pain, studies involving non-cancer patients, lack of pain assessment, experimental studies.

TOTAL REFERENCES RETRIEVED: 155

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Only case reports were used in the systematic review. No randomized controlled trials were retrieved.

FINAL NUMBER STUDIES INCLUDED: 16 

TOTAL PATIENTS INCLUDED IN REVIEW: 79

SAMPLE RANGE ACROSS STUDIES: The cancer diagnoses were identified, but not limited to, thoracic, tongue, renal, breast, lung, and ovarian. Some cases involved metastasis.

KEY SAMPLE CHARACTERISTICS: Patients with cancer, different diagnoses

PHASE OF CARE: Not specified or not applicable     
APPLICATIONS: Palliative care

Majority of cases yielded adequate pain relief with few side effects reported.

No conclusion can be made based on the lack of formal evidence. Greater than four types of nerve blocks were included in the 16 reviews.

• Limited number of studies included
• High heterogeneity
• Limited evidence

Although pain control is reported with peripheral nerve blocks, lack of sufficient evidence exists to support this intervention in practice based on this review.