RESOURCE TYPE: Consensus-based guideline

PHASE OF CARE: Multiple phases of care

Not provided

The influenza vaccine is recommended in patients with active malignancy undergoing chemotherapy, patients with acute leukemia after chemotherapy, and all patients during maintenance treatment. Insufficient evidence exists for acyclovir prophylaxis for preventing herpes simplex virus (HSV), Epstein-Barr virus (EBV), and varicella-zoster virus (VZV) reactivation. The guidelines provide an algorithm for hepatitis B virus (HBV) reactivation prophylaxis, including screening, monitoring, and intervention based on positive HSs antigen and units of HBc DNA identified. Primary antiviral prophylaxis with nucleoside analogues for hepatitis B are effective in reducing risk. The guidelines identify risk factors for HBV reactivation:

• Treatment with anthracyclines
• Treatment with steroids (greater than 10–20 mg daily or equivalent for four weeks or more)
• Treatment with monoclonal antibodies
• Breast cancer or malignant lymphoma

• Limited search documentation

These guideline add to the body of evidence recommending influenza vaccination in patients undergoing cancer treatment. This guideline does not recommend other routine prophylaxis and does provide suggestions regarding specific agents for prophylaxis according to individual patient risk factors based on disease, history, and treatment type.

To quantify immediate and short-term benefits and harms of gabapentin in hospice and palliative care patients

Data recorded at baseline, day 7, and day 21 were obtained from participating sites for patients receiving gabapentin for neuropathic pain. Benefits and harms factors were predefined by an expert committee. Overall benefit was defined as a one-point reduction in the National Cancer Institute's Common Terminology Criteria for Adverse Events (CTCAE), and harms were attributed to gabapentin if the day 7 data showed higher CTCAE scores. The Naranjo Scale was used to determine attribution to the drug itself in scores above three.

• N = 127   
• MEDIAN AGE = 68 years
• AGE RANGE = 26–89 years
• MALES: 80%, FEMALES: 20%
• CURRENT TREATMENT: Not applicable
• KEY DISEASE CHARACTERISTICS: 95.3% of patients had cancer.

• SITE: Multi-site   
• SETTING TYPE: Multiple settings    
• LOCATION: Australia

• PHASE OF CARE: End-of-life care
• APPLICATIONS: Palliative care 

• Prospective cohort

• National Cancer Institute's Common Terminology Criteria for Adverse Events (CTCAE)
• Charlson Comorbidity Index (CCI)

Data were available at day 21 in 69 patients. Of these, 78% had improvement in their pain and 32% had associated harms. The most frequent harms were somnolence, cognitive disturbance, and fatigue. Twenty-nine patients had medication stopped or dosages reduced. The total number of patients who had benefit without harms was 9.4%. Regression analysis showed higher odds ratio of harm associated with comorbidities (p = 0.013).

Only 9% of palliative care/hospice patients receiving gabapentin had benefit for pain control without any associated harms.

• Risk of bias (no control group)
• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Unintended interventions or applicable interventions not described that would influence results 
• Measurement validity/reliability questionable
• Subject withdrawals ≥ 10%
• High missing data
• Other interventions used for pain were not accounted for in the analysis, which could have contributed to harms identified

Gabapentin is a common adjuvant pain medication. Findings from this study suggest that relatively few patients achieve benefits without harms. This study has multiple design and reporting limitations; however, it does raise the question of relative benefits of this medication in the hospice/palliative care population. Further well designed research to further evaluation risk/benefits of gabapentin are warranted. Nurses need to be aware of potential harms from various medications and monitor patient responses for appropriate care to identify and reduce harms. Potential for harm from gabapentin may be of greater concern among patients with multiple comorbid conditions.

To determine if a nutritional supplement taken by patients with advanced non-small cell lung cancer receiving paclitaxel with cisplantin/carboplatin chemotherapy can improve body composition, fatigue, health-related quality of life (HRQOL), and overall survival.

The patients were randomized to isocaloric diet or isocaloric diet plus eicosapentaenoic-acid (EPA) supplement ProSure^®.  Evaluations were conducted at baseline, after the first chemotherapy cycle, and after the second chemotherapy cycle.

• N = 92  
• AGE: 44-72 years
• MALES: control group 23 (50%), intervention group 20 (43.5%); FEMALES: control group 23 (50%), intervention group 26 (56.5%)
• KEY DISEASE CHARACTERISTICS: Stage IIIb and IV non-small cell lung cancer
• OTHER KEY SAMPLE CHARACTERISTICS: Life expectancy greater than 12 weeks. All patients receiving chemotherapy with paclitaxel and cisplatin or carboplatin every three weeks for two cycles.

• SITE: Single site    
• SETTING TYPE: Other    
• LOCATION: Mexico

PHASE OF CARE: Active antitumor treatment

• Randomized, controlled trial

• Subject Global Assessment (SGA)
• Bodystat Quadscan 4000 multifrequency
• Food frequency questionnaire (FFQ)
• Supplement intake diaries
• Biochemical analysis
• EORTC Quality of Life Core 30 Questionnaire (EORTC-QLQ-C30)
• EORTC QLQ-LC13
• Common Terminology Criteria for Adverse Events (CATCAE)

The ONS-EPA group exhibited significant differences in weight (p = 0.01) and lean body mass (p = 0.01). Significant improvement was also seen in calorie and protein intake (p <  0.001) when the nutritional supplement was included. The ONS-EPA group also exhibited significant improvement in inflammatory markers between time points (p = 0.02 to p = 0.05). In HRQOL, there was significant improvement in global health status between time points for the ONS-EPA group (p = 0.021). Differences were seen between groups in fatigue (p = 0.04), appetite loss (p = 0.05), and neuropathy (p = 0.05)

In this study, ONS-EPA supplementation appears to be effective in improving nutritional status and decreasing side effects (appetite loss) in patients receiving chemotherapy for non-small cell lung cancer.

• Small sample (less than 100)
• Risk of bias (no blinding)
• Findings not generalizable
• Subject withdrawals of 10% or greater 
• Only patients with non-small cell lung cancer were included.
• There was a high rate of attrition in the control group (6 of 46) due to disease trajectory (worsening condition and death)

More studies need to be done with EPA supplementation in this and other cancers.

To determine the effect of ginger and chamomile capsules on chemotherapy-induced nausea and vomiting (CINV)

• N = 65   
• AGE = 20–60 years 
• FEMALES: 100%
• CURRENT TREATMENT: Chemotherapy
• KEY DISEASE CHARACTERISTICS: Breast cancer
• OTHER KEY SAMPLE CHARACTERISTICS: Single-day chemotherapy, history of vomiting with previous chemotherapy

• SITE: Single site   
• SETTING TYPE: Not specified    
• LOCATION: Tehran, Iran

PHASE OF CARE: Active antitumor treatment

Randomized, double-blind clinical trial

VAS for frequency and severity of nausea and vomiting

Ginger and chamomile did not affect the intensity of nausea, whereas both had an effect on the frequency of vomiting (p < 0.0001). Ginger also was shown to be have a statistically significant effect on the frequency of nausea (p = 0.006). Neither had an effect on intensity of nausea.

Ginger and chamomile may have some benefit as adjuncts to antiemetics for the prevention of CINV. Additional research is needed to evaluate these.

• Small sample (< 100)
• Findings not generalizable
• Subject withdrawals ≥ 10%

Ginger may be beneficial in CINV, but ongoing studies are needed.

To compare the efficacy of two medication schemes for the management of pain after gynecologic surgery

Consecutive patients were randomly assigned to two groups. Group 1 received, on the day of surgery, 1 mg morphine/10 kg body mass subcutaneously (SC) every four hours. After surgery Group 1 received 1 g acetaminophen IV every six hours and 500 mg naproxen per rectum every 12 hours daily. Group 2 received 1 mg morphine/10 kg body mass SC every 4 hours, 1 g metamizol IV every 6 hours, and 500 mg naproxen per rectum every 12 hours. For all patients, in instances of pain rated 5 or more, an additional 100 mg of ketoprofen IV was administered. Pain was rated throughout hospitalization.

• The sample was composed of 128 patients.
• Mean patient age was 68 years; the age range of patients was 42–82 years.
• All patients were female.
• All patients underwent operations of category III or IV, a classification indicating extensive tissue injury and significant postoperative acute pain.

• Single site
• Inpatient
• Poland

Randomized parallel group

Numeric pain rating scale of  0–10

• Patients in group 1 had significantly less pain than did the other group (p < 0.05).
• On the operative day, 34% of group 1 patients required rescue medication compared to 52% of patients in group 2.
• By postoperative day 3, 3.12% of group 1 patients required rescue medication compared to 4.69% in group 2.
• During the entire postoperative period, no side effects were associated with either treatment regimen.

For the management of postoperative pain following gynecologic surgery, the combination of morphine, acetaminophen, ketoprofen, and metamizol as used in this study was more effective than the combination of morphine, metamizol, and ketoprofen.

• Authors did not report the anesthesia regimen used.
• Authors did not analyze the demographic differences or other factors, such as type of surgery, that could impact pain scores.

This study describes a perioperative pain management regimen that appears to have decreased the pain of patients who underwent  extensive gynecologic surgery. Note, however, that the more effective regimen did not provide complete control for more than 30% of patients on the day of surgery and for more than 15% on the first postoperative day. This study adds to the growing research regarding  perioperative adjuvant medications for acute pain control.

To study the analgesic effect of honey for mucositis-related pain in patients with head and neck cancer receiving chemotherapy and radiation therapy

Patients were randomized to honey treatment and control groups. Patients were given 20 ml of honey 15 minutes before, 15 minutes after, and six hours after radiation treatment (RT). They were instructed to rinse the honey on the oral mucosa then swallow slowly to smear it on oral and pharyngeal mucosa. All patients also were told to gargle salt soda and benzydamine alternatively every three hours throughout RT and for three months after completion. Pain scores were obtained weekly. As needed, IV antibiotics were given for positive oral cultures, steroids were given for grade 3 mucositis, and gentian violet was applied for moist desquamation.

• N = 69  
• MEAN AGE = 53.4 years
• MALES: 52.2%, FEMALES: 47.8%
• KEY DISEASE CHARACTERISTICS: All participants had locally advanced head and neck cancer.
• OTHER KEY SAMPLE CHARACTERISTICS: In both groups, 72% pf participants had T3, T4, and stage 4A disease. Both groups received a mean RT dose of 69.76 Gy, and the majority received six cycles of cisplatin.

• SITE: Single site  
• SETTING TYPE: Outpatient  
• LOCATION: India

• PHASE OF CARE: Active antitumor treatment

Randomized, controlled trial

• Faces Visual Analog Scale (VAS) for pain (0–10 scale)

In the experimental group, pain scores ranged from 1.83–3.08, and in the control group, scores ranged from 1.36–6.54 across the seven weeks of RT. From week 2 onward, the mean pain score in the experimental group was lower than that of control group (p = 0.000). After RT, mean scores ranged from 1.36–0.36 in patients using honey and from 4.87–1.57 in controls (p < 0.002). Some patients experiened dyspepsia, nausea, and vomiting with honey.

The use of honey was associated with less pain from mucositis in this study.

• Small sample (< 100)
• Risk of bias (no appropriate attentional control condition)
• Unintended interventions or applicable interventions not described that would influence results 
• Measurement validity/reliability questionable
• Other limitations/explanation: There was no mention of any other analgesic use. Compliance with oral protocols was not discussed. No information was provided regarding the use of steroids or antibiotics as outlined in the study protocol.

The findings of this study suggested that honey may be beneficial in reducing pain associated with mucositis caused by chemoradiation therapy in patients with head and neck cancer. Honey is known to have antioxidant and anti-inflammatory properties, which may be helpful for this purpose. Honey is a low-risk intervention, and based on this study's findings, additional well-designed research in larger samples is warranted.

To review the evidence for approaches to prevention and management of radiodermatitis

Databases used were MEDLINE, PubMed, and Cochrane Library. Keywords searched were skin reactions, radiation, radiation adverse effects, erythema, desquamation, and radiodermatitis. Studies were included in the review they

• Were published reports or abstracts from January 1, 2000 to October 1, 2008.
• Reported the method of skin grading.

Studies were excluded from the review if they were letters, comments, editorials, case reports, practice guidelines, systematic reviews, or meta-analyses.
 

The total references retrieved and the quality rating approach were not reported.
 

• Thirty-nine trials were included in the review.
• Patients were receiving radiation therapy.

Patients were undergoing active antitumor treatment.

Washing practice, topical corticosteroids, aloe vera, biafine, hyauronidase-based creams, sucralfate, miscellaneous creams, Amifostine, oral enzymes, pentosifylline, dressings, non-steroidal topical cream, topical colony-stimulating factors supplements, and mode of radiation delivery were reviewed. Other agents studied included beladonna 7CH and a Chinese remedy, lian bai liquid.

There is lack of support for Biafine use. There is some evidence to suggest that topical corticosteroids may be beneficial. Evidence for non-steroidal topical agents is conflicting. Evidence does not support use of Aloe Vera or sucralfate cream. Some evidence to suggest that light-emitting diode, pentoxifylline, sliver-leaf dressings, washing, zinc supplements and intensity-modulated radiation therapy are beneficial.

• The trials were small and had numerous design and reporting limitations.
• Secondary trials evaluated the same agent or treatment, making comparison very difficult.

Further research is needed in this area. Intervention goals, prevention or treatment need to be clear and further work is needed to develop and validate more sensitive assessment tools. Further work is also needed to evaluate differences in risk based on anatomical sites.

To assess the effectiveness and feasibility of implementing an oral cryotherapy plus oral care protocol to reduce oral mucositis (OM) severity in patients with multiple myeloma undergoing autologous stem cell transplant (ASCT)

Participants were randomized into an oral cryotherapy study group or a standard oral care control group. Patients in the oral cryotherapy study group received verbal and written instructions on oral cryotherapy plus an oral care protocol in place at the study site. Oral cryotherapy consisted of sucking on ice chips five minutes before, during, and after melphalan administration for a total of 60 minutes. The standard oral care protocol included education regarding oral self care, brushing with Toothette® brushes dipped in sodium bicarbonate, mouth rinsing with sodium bicarbonate mouthwash, and applying moisturizer to lips or the oral cavity. Patients were permitted to floss until their platelet counts fell below 50,000. Patients in the standard oral care control group received only the instructions on the oral care protocol (no cryotherapy). Outcomes were evaluated on days 3, 6, 9, and 12 after stem cell rescue. A research assistant who was blinded to group assignment assessed each participant and recorded the results of the assessment on data collection forms.

• The study reported on 46 patients aged 18 years and older.
• Patients' ages ranged from 43–72 years.
• The sample was 58% male and 42% female.
• Patients had been diagnosed with multiple myeloma and were undergoing ASCT. They were scheduled to receive 200 mg/m² high-dose melphalan. Additionally, they were scheduled to receive growth factors. They had no preexisting oral disease.
• Statistically significant differences existed between the study group and the control group related to age and education.

The study was conducted at a single-site, inpatient setting in Ontario, Canada.

• Patients were undergoing the active treatment phase of care.
• The study has clinical applicability for palliative care.

This was a prospective, pilot, randomized control trial with repeated measures.

• The World Health Organization (WHO) mucositis grading scale was used.
• Pain was assessed using a 100-mm visual analog scale.
• Opioid use was assessed quantiatively by converting into morphine-equivalent units.
• A nutritional assessment form was used to record functional intake of food and fluids.
• Lengths of stay were recorded from medical records.
• An oral therapy questionnaire was used to assess the tolerability of cryotherapy.

• All participants were free of OM symptoms on days -1 and +3. Signs and symptoms of OM were observed on day +6 and were most pronounced on day +9. Symptoms of OM began to resolve on day +12.
• The overall mean severity scores for OM on the WHO scale were statistically significant (0.43 to 1.14, p < 0.001) on days +9 and +12 (p = 0.03), both in favor of the study group. On day +6, the statistically significant difference (p = 0.02) favored the control group.
• Pain scores were lower for the study group (p  < 0.01), and more participants in the control group used opioid analgesics than in the experimental group (41% versus 13%).
• No significant differences were found related to functional intake of food and fluids.
• The study group experienced a one-day decrease in length of stay, but this was not statistically significant.
• Cryotherapy was somewhat or well tolerated by 87% of patients. Side effects of teeth sensitivity and chills were reported by 17.4% of participants in the study group.

Cryotherapy in addition to an oral care protocol (as described above) is likely to be beneficial in reducing the severity of OM as well as decreasing pain and the need for opioid analgesics. In terms of lengths of stay, cryotherapy offered a clinical benefit, although not statistically significant.

• The sample size was small with fewer than 100 patients.
• Some data collection required patients to self-report.
• The study observed only adult patients diagnosed with multiple myeloma and undergoing stem cell tranplant.
• The study was limited in that the only OM-causing agent was melphalan.
• The study was not blinded.

Cryotherapy is inexpensive, and the protocol is relatively simple. In conjunction with an oral care protocol, this is a reasonable approach to take. A larger trial would be helpful.

To evaluate the effect of low-dose methadone as the primary long-acting opioid in a hospice setting

Two hundred and forty charts of patients who were admitted to a community-based hospice setting from July 1, 2011–April 1,2012 were reviewed. Patients received short-acting doses of opiates equivalent to 5 mg every four hours as needed. Once two or more doses were needed, 2.5 mg methadone was initiated and titrated up by 2.5 mg increments every four to seven days as needed. Median dose of methadone was 5 mg daily, but max dose was 15 mg. Haloperidol was the most commonly prescribed adjuvant nonopoid medication, with a median dose of 3 mg daily. Pain was assessed during each nursing visit on a 0–10 scale and every time the short-acting opiate dose was used more than two times a day. If patients were on long-acting opiates and their life expectancy was greater than a week, they were offered conversion to methadone. Nonopioid agents were used for pain and other symptoms, with Haldol^® being the primary agent for the purpose of NMDA inhibition. If patients were unresponsive, their pain was assessed by their caregiver.

• N = 103 patients with cancer (236 total patients with and without cancer) 
• MEAN AGE = 75 years in patients with cancer (81 years in patients with and without cancer)
• MALES: 33% in patients with cancer (39% in patients with and without cancer), FEMALES: 67% in patients with cancer (61% in patients with and without cancer)
• KEY DISEASE CHARACTERISTICS: 44% had cancer diagnoses, 56% had noncancer diagnoses
• OTHER KEY SAMPLE CHARACTERISTICS: Evaluated patients admitted for hospice care only

• SITE: Single site 
• SETTING TYPE: Other 
• LOCATION: Community-based hospice service

• PHASE OF CARE: End-of-life care
• APPLICATIONS: Elder care, palliative care

A retrospective review of electronic records in those admitted to a community-based hospice service from July 1, 2011–April 1, 2012. Information was reviewed until patients were discharged from hospice or until April 30, 2012.

• Demographics, medication regimens, and pains scores were extracted from electronic medical records.
• Descriptive statistics were used to summarize results.
• Median and peak pain scores (on a scale of 0–10) were recorded.
• Pain scores greater than 4 were considered moderate to severe.

Two-thirds of patients never reported a score greater than 3 on a 0–10 numeric scale. The median reported score was 2 with a peak pain score of 3, with similar reports looking at cancer versus noncancer groups separately.

Methadone provided good pain control for the majority of patients. Methadone could be used with Haldol in pain control, particularly in circumstances in which patients experience a paradoxical reaction (caused by desensitization because of tolerance) and sensitization of the NMDA pathway responding to opioid receptor stimulation. More controlled trials will need to be conducted to consider this as a first-line treatment for management of pain.

• Baseline sample/group differences of import
• Risk of bias (no control group)
• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Risk of bias (no appropriate attentional control condition)
• 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: Other agents used in symptom management could have an effect on reporting or perception of pain. Pain assessment not was not rigorous in this study. This was a retrospective, observational study with no control. This study is not generalizable. Pain was not assessed at baseline for more than half of the patients, causing inability to assess short-term effect.

Methadone is low-cost. Education to providers would be needed because the use of methadone may not be a common practice and conversion may be difficult. Risk of constipation is lower with the use of methadone, which may improve quality of life for those suffering from pain and perhaps lower overall pain. Working with high doses of methadone comes with large risk, so careful consideration should be used when prescribing.

STUDY PURPOSE: To evaluate the effectiveness of acupuncture in treating hot flashes in women with breast cancer

TYPE OF STUDY: Systematic review and meta-analysis

• FINAL NUMBER STUDIES INCLUDED = 12
• TOTAL PATIENTS INCLUDED IN REVIEW = Did not report
• SAMPLE RANGE ACROSS STUDIES: 10–84 patients
• KEY SAMPLE CHARACTERISTICS: Women with breast cancer receiving acupuncture for hot flashes

PHASE OF CARE: Transition phase after active treatment
 
APPLICATIONS: Elder care

The meta-analysis without any subgroup or moderator did not support favorable effects of acupuncture in reducing the frequency of hot flashes after the intervention in women with breast cancer.

This meta-analysis did not conclude that data support the effectiveness of using acupuncture therapy to decrease the frequency of hot flashes in women with breast cancer. Limitations of the study included heterogeneous studies with a limited number of patients. The author noted the poor quality of the primary data.

• Limited number of studies included
• Mostly low quality/high risk of bias studies
• High heterogeneity
• Low sample sizes
• Patient selection was not clearly defined to describe the full characteristics of the patient selection.
• Did not document if patients were on hormonal therapy or if they were experiencing hot flashes
• Total number of subjects not reported

The findings did not support the therapeutic use of acupuncture to decrease the frequency of hot flashes in women with breast cancer.