To conduct a systematic review to evaluate the effectiveness of therapeutic touch (TT) as a complementary or alternative means of managing the pain of patients with cancer

• Databases searched were PubMed, EBSCO, and Medscape.
• Search keywords were therapeutic touch, cancer pain, and pain management.
• Articles were included if they
  • Reflected observational or experimental studies or investigations involving TT as one option or as one of several complementary or alternative modalities to relieve the pain of any type of cancer
  • Reflected a study that included random assignment to placebo or control
  • Were abstracts published, in English only and between January 2000 and April 2010, in a peer-reviewed journal
• Studies were excluded if they involved TT as a treatment for pain unrelated to cancer.

• The total number of references retrieved was 46.
• Author used a systematic and qualitative evaluation method.
   

• The number of studies included in the analysis was 10. The list of references includes only nine studies, however.
• The total sample size and sample range across studies are uncited.
• Key sample characteristics are uncited.

TT is a therapy that may be useful in decreasing cancer-related pain and improve quality of life, but TT is often overlooked.

The systematic review was not thorough; reported findings were not comprehensive.

To compare the hemodynamic and analgesic effects of patient-controlled thoracic or lumbar epidural analgesia methods in a prospective, randomized study design after thoracotomy operations

One hundred and twenty patients were prospectively randomized to receive either thoracic epidural analgesia (TEA group) or lumbar epidural analgesia (LEA group) for a 24-hour postoperative period. Epidural catheters were administered in both groups. Hemodynamic measurements, Visual Analog Scale scores at rest (VAS-R) and after coughing (VAS-C), analgesic consumption, and side effects were compared at 0, 2, 4, 8, 16, and 24 hours postoperatively.

• N = 120
• AGE RANGE = 48–86 years (TEA group: 55.37 years [SD = 13.3 years], LEA group: 52.73 years [SD = 13.33 years])
• MALES: 87.7% (TEA); 85.7% (LEA), FEMALES: 12.3% (TEA); 14.3% (LEA) 
• KEY DISEASE CHARACTERISTICS: Diagnosis of lung cancer
• OTHER KEY SAMPLE CHARACTERISTICS: Posterolateral thoracotomy American Society of Anesthesiologists (ASA) physical status I, II, or III. Exclusion criteria included ASA physical status > III, known drug allergies, prior lumbar spine surgery, pregnancy, abnormal coagulation tests, a history of comorbidities such as hepatic or renal disease, or a neurologic impairment causing the inability to understand consent or pain measurement.

• SITE: Single site    
• SETTING TYPE: Inpatient    
• LOCATION: Sureyyapasa Chest Disease and Thoracic Surgery Hospital

• PHASE OF CARE: Active antitumor treatment
• APPLICATIONS: Elder care and palliative care 

• Prospective, randomized, double-blinded, controlled study

All measurements were compared at 0, 2, 4, 8, 16, and 24 hours postoperatively.

• Hemodynamic measurements
• Visual Analog Scale at Rest (VAS-R) and after Coughing (VAS-C)
• Analgesic consumption
• Side effects

The VAS-R and VAS-C values were lower in the TEA group when compared to the LEA group at 2, 4, 8, and 16 hours after surgery. The total 24-hour consumption of analgesics was lower in the TEA group. The incidence of hypotension, bradycardia, atelectasis, and the need for intensive care unit treatment was lower in the TEA group. There was no difference in incidence of cardiac or pulmonary complications or the occurrence of epidural morphine-related side effects. Both techniques provided efficient analgesia.

TEA had beneficial hemostatic effects and satisfactory pain relief after thoracotomies in comparison to LEA.

• Findings not generalizable

Epidural analgesia is used after a thoracotomy to diminish the incidence of possible pulmonary and cardiac complications. TEA has beneficial hemodynamic effects in comparison to LEA after thoracotomies along with a more satisfactory pain relief profile during the 24-hour postoperative period.

To study the development of arm lymphedema, pain, and sensation of heaviness in the affected limb after different postoperative rehab programs that involve different physical activity levels of the upper limbs

Women were randomized to one of two groups after surgery: no activity restriction (NAR) and activity restrictions (AR). Patients in the NAR group had a supervised physical therapy program in an outpatient clinic, emphasizing progressive resistance training two to three times per week. Patients in the NAR group were given standard detailed information on the unrestricted program. The AR group was told to restrict use of the affected limb for six months, including avoidance of aerobic or other types of exercise involving heavy upper-limb activity, and to avoid carrying or lifting anything more than 3 kg. Patients in the AR group also participated in the usual care physical therapy, which included six different passive techniques emphasizing flexibility and light massage. Usual care was provided for six months. Arm volumes were measured as three months, six months and two years.

• The study sample was comprised of 204 female patients initially and 152 at two-year follow-up.
• Mean age of patients was 55 years with a range of 32–75 years.
• Patients had early-stage breast cancer, underwent mastectomy or breast conserving surgery with axillary node dissection (levels I and II), and may or may not have had radiotherapy, chemotherapy, or hormone treatment.

The study took place at a mutlisite, outpatient setting in Norway.

The study used a randomized, single-blind, controlled trial design.

• The difference in volume of affected and control arm was compared using simplified water displacement instrument.
• Visual analog scales (VAS) measured pain and heaviness in the affect limb.
• Upper-limb physical activity questionnaire developed by the investigators was completed by patients.
• Body mass index was measured for all patients.

Mean duration of the rehabilitation programs was 21 weeks for the NAR group and 22 weeks for the AR group. Arm volumes at three months, six months and two years did not differ between study groups. In both groups arm edema increased significantly over time. VAS ratings for pain and heaviness for the affect limb were significantly higher in the NAR group at three months and six months (p  < 0.05) but did not differ between groups at two years. Individuals with a body mass index greater than 25 kg/m² had in increased risk of developing arm lymphedema (OR 3.42, p < 0.005) at two years. At three and six months, the amount of home physical activity reported by the NAR group was significantly higher (p = 0.001), but there were no differences in this finding between groups at two years. Approximately 13% of patients in each group had arm lymphedema at two years.

During activity participation in rehabilitation it appears that the use of progressive resistance activity and no activity restrictions were associated with more pain and sensation of heaviness with physical activity than usual care in the short term; however, there were no differences in longer-term development of lymphedema or associated symptoms. Findings suggest that activity restriction does not result in improved outcomes.

• Body mass index, volume difference, and pain and heaviness sensations risk factors were measured at baseline only.
• Subgroup analysis based upon other disease factors or specific aspects of surgical procedures done was not done.
• Supervised rehabilitation lasted for about the first six months, and there is no information about the ongoing participation in any exercise activity between that time and the two-year final follow-up measurement.
• Scoring and results of questionnaires regarding leisure time activity involving the upper extremity are not provided.

Findings suggest that doing progressive resistance exercise may help reduce lymphedema symptoms in the short term among women after breast cancer surgery because those who had restricted activity had no difference in symptoms in longer-term outcomes in the study. Given the relation between high body mass index and lymphedema development, it would be of interest to study whether weight control and weight loss after surgery would have any impact on lymphedema development.

To assess the efficacy and safety of daily FSK0808 injections to treat neutropenia in patients with breast cancer

Daily injections of FSK0808 were used to treat neutropenia experienced by patients in the course of chemotherapy treatment.

• N = 104  
• AGE RANGE = 20–70 years
• AVERAGE AGE = 51.1 years
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: Pre- and post-menopausal patients with breast cancer receiving fluorouracil, epirubicin, and cyclophosphamide (FEC100) before and after surgical intervention.

• SITE: Multi-site 
• SETTING TYPE: Outpatient 
• LOCATION: Japan

• PHASE OF CARE: Active treatment

• Multi-center, non-randomized study

Efficacy was measured by drawing blood to calculate the patients’ absolute neutrophil count. Vital signs also were performed to assess patients for fever.

The study showed that FSK0808 reduced the recovery time from neutropenia caused by the treatment of breast cancer with FEC100. The average of 2.2 days of neutropenia was comparable to the 2.1 days reported in a comparative study that used filgrastim. Adverse drug reactions were similar to those experienced with filgrastim, and most events were mild.

FSK080 is safe and well tolerated in patients with breast cancer going through chemotherapy and successfully stimulated neutrophil recovery.

• Risk of bias (no control group)
• Risk of bias (no blinding) 
• Risk of bias (no random assignment)

This study shows that FSK0808 is a safe and viable alternative to filgrastim, meaning that nurses will have to familiarize themselves with the use and side effects of this new medication.

STUDY PURPOSE: To assess existing research on the effectiveness of manual lymphatic drainage (MLD) as a means of preventing and/or managing lymphedema

TYPE OF STUDY:  Systematic review

DATABASES USED: Google Scholar, PubMed, CINAHL

KEYWORDS: manual lymph drainage, breast cancer–related lymphoedema

INCLUSION CRITERIA: Each article had to be available in full text, published in English from 2008 to the present, regarding patients with lymphedema after breast cancer treatment. Each article needed to define lymphedema, to describe the inclusion and exclusion criteria used for patient selection, the MLD technique used, the compression strategy used, and an evaluation of severity of lymphedema.

TOTAL REFERENCES RETRIEVED: Nine references were retrieved.

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Level of evidence based on the Oxford Centre for Evidence-Based Medicine (Level 1: two systematic reviews; level 2: five randomized, controlled studies; level four: one cross-sectional descriptive study, one longitudinal observation study). 

• FINAL NUMBER STUDIES INCLUDED =  9
• TOTAL PATIENTS INCLUDED IN REVIEW: 1,850 (final sample); 1,807 with upper extremity, 43 with lower extremity

PHASE OF CARE:  Multiple phases of care

Conflicting information regarding the effectiveness of MLD with variability in the application, duration, and frequency of MLD in the different studies

Authors suggested that MLD is unlikely to produce significant volume reduction when added to compression and exercise therapy. The characteristics of individual patients can affect the clinical outcomes.

Further research into the efficacy of MLD is needed.

The current standard of care for lymphedema is complete decongestive therapy, which includes MLD, compression, skin care, and exercise. Current research on individual modalities are conflicting regarding MLD. More research is needed.

STUDY PURPOSE: To evaluate the evidence of effects of yoga on fatigue among cancer survivors

• FINAL NUMBER STUDIES INCLUDED = 10
• TOTAL PATIENTS INCLUDED IN REVIEW = 583
• SAMPLE RANGE ACROSS STUDIES: 18–164
• KEY SAMPLE CHARACTERISTICS: 564 women, 17 men; primarily breast cancer; 80%–100% Caucasian, with the exception of one study with 42% African-American, 31% Hispanic, 23% Caucasian, and 4% other 

PHASE OF CARE: Transition phase after active treatment

Eight of 10 studies only had patients with breast cancer; various stages of cancer; no standard type of yoga intervention; little consistency in measuring fatigue; high risk of selection bias in included studies. In four studies the yoga group reported significant reduction in CRF; three studies reported that there were significant reductions in participants who attended a significant number of classes; four studies reported no differences in self-reported fatigue and no association with number of classes attended.

The authors suggest that yoga may be beneficial for CRF but urge caution. Small sample sizes and lack of standardization affect ability to draw conclusions. None of the studies reported increase in fatigue, thus no evidence that yoga is detrimental. Evidence of significant reduction of fatigue with number of classes attended.

• Small number of studies
• Primarily women with breast cancer
• Methodological bias in many studies

There is suggestion that yoga may be beneficial; therefore, nurses can recommend this to appropriate individuals. Adherence impacts effect; therefore, it is important that the choice of activity fit with an individual’s lifestyle. More well-conducted studies are needed.

To determine comparative effectiveness of oral antibiotics and probiotics as bowel preparation in the prevention of surgical site infection (SSI)

Patients were randomized to one of three groups. The probiotic group took bifidobacteria tablets orally after each meal three times daily for seven days preoperatively, and postoperatively for 10 days. The oral antibiotic group took 0.5 g kanamycin sulfate and 0.5 g metronidazole orally three times on the day before surgery. The control group did not receive any bowel preparation beyond standard care. All patients underwent mechanical bowel prep with sodium picosulfate two days before surgery and polyethylene glycol in the morning of the day of surgery. All patients received a single preoperative 1 g dose of flomoxef IV one hour prior to incision. The same procedures for surgical site disinfection, intraperitoneal irrigation, and suture closures were done. Operative wounds were assessed daily during the hospital stay and in an outpatient clinic four weeks after surgery.

• N = 294
• MEAN AGE = 66.5 years
• MALES: 53.1%, FEMALES: 46.9%
• KEY DISEASE CHARACTERISTICS: All had colon cancer. Patients who had resection of adjacent organs were excluded. Seventy-three percent had open procedures, and the rest had laparoscopic procedures.

• SITE: Single site 
• SETTING TYPE: Inpatient 
• LOCATION: Japan

• PHASE OF CARE: Active antitumor treatment

• RCT
  • Three-group
  • Single-blind

• SSI was classified as incisional or organ/space SSI.
• Stool samples were collected prior to surgery and on postoperative days 7 and 14 for analysis of fecal flora and Clostridium difficile (CD) toxin.

Rates of postoperative infections, including incisional infections, organ/space SSIs, and remote infections, were 24% in the probiotic group, 11.1% in the oral antibiotic group, and 25% in the control group. Group comparisons showed that the difference in infection rate was significantly lower in the oral antibiotic group than in either other group (p < .03). Incidence of incisional SSI was lower in the oral antibiotic group (p = .014). The oral antibiotic group also had a significantly lower rate of leakage (p = .004). SSI-causing pathogens were analyzed in all patients, and most of the bacteria detected were not covered by the spectrum of flomoxef. No significant differences were observed in CD toxin detection between groups.

Findings suggest that bowel preparation with oral antibiotics is helpful in preventing postoperative infections in patients with colon cancer undergoing elective colon surgery. No benefit was shown with the use of preoperative probiotics.

• Measurement/methods not well described
• Other limitations/explanation: Definition of SSI was described minimally.

Findings show that rates of postoperative infections among patients undergoing surgery for colon cancer can be reduced by the addition of oral antibiotics as part of bowel preparation. Probiotic use was not effective. Nurses can advocate for consideration of use of preoperative oral antibiotics as examined in this study and advocate for further research to confirm these findings. CD risk was not shown to be different across groups in this study, but this risk remains a consideration, particularly if oral antibiotic use is prolonged.

To determine whether physical exercise training improves the quality of life and physical fitness of survivors of breast cancer.

Patients were randomized to the exercise intervention or control group. The duration of the exercise intervention was 12 months, with the aim of attaining permanent changes in lifestyle. The intervention consisted of both supervised and home training.  Supervised training, delivered to a group of 15 to 20 individuals, included step aerobics and circuit training. Home training consisted of walking, aerobics cued by a video, cycling, or swimming; participants could choose the activity.

• The sample was comprised of 573 participants.
• Participant age ranged from 35 to 68 years.
• All participants were female.
• All participants had breast cancer; were pre- or postmenopausal; and had undergone adjuvant chemotherapy within four months, started adjuvant endocrine therapy no fewer than four months previously, or had started a combination of chemotherapy and endocrine therapy no fewer than four months previously.

• Multisite
• Outpatient
• Multiple locations in Finland

• Patients were undergoing multiple phases of care.
• The study has clinical applicability for palliative care.

This was a randomized, controlled trial.

• European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire (EORTC QLQ-C30)
• EORTC QLQ-BR-23 questionnaire to assess quality of life of patients with breast cancer
• Functional Assessment of Cancer Therapy-Fatigue (FACT-F)
• Finnish version of the Beck Depression Inventory (BDI)
• Two-hour walking test
• Figure-eight running test

No significant differences were found between the exercise group and control group in regard to changes in quality of life during the intervention or in regard to depression or fatigue.

This study did not show that the exercise intervention had an effect on fatigue, depression, or quality of life. Lack of effect may be due to a ceiling effect in both groups because most study participants had relatively high activity levels at baseline.

• The study had risks of bias due to no blinding, no appropriate attentional control condition, and as a result of sample characteristics. Key sample group differences could have influenced the results.
• Most participants were physically active before the study. (Only a few patients [0.25%] were sedentary before the study.) Control patients were also motivated to remain active. Actual activity levels of control patients were not analyzed.
• Findings were not generalizable.
• One of the physical fitness tests used, two-hour walking test, cannot be generalized to other countries.
• The main strength of this study was its size.   

The ability of physical exercise, especially group exercise, to improve quality of life and reduce fatigue and depression in patients with breast cancer during and following treatment is generally known. The fact that this study did not support the widely held view may be due to the fact that most participants had a high level of activity at baseline. The study did not clarify whether exercise interventions are needed or effective for individuals who already have an active lifestyle and are motivated to maintain it.

To develop, run, and evaluate a program for patients with cancer at any stage of their illness.

Groups of no more than six patients were led by an occupational therapist and a physiotherapist for two to three hours per session for four weeks. The program involved group discussion and support, practical sessions, information, and homework to achieve individual goals. Information was collected through evaluation forms and fatigue scales. Patients were invited to attend the program by clinical nurse specialists (CNSs).

• Twenty-eight patients (23 females, 5 males) completed the fatigue course.
• Age ranged from 37 to 82 years, with the majority being in their 50s and 60s.
• Diagnoses included were gynecological cancer (43%), breast cancer (18%), lung cancer (11%), and other (28%).
• Stages of treatment ranged from curative to palliative.

• Single site
• Patients were recruited from clinical sites through CNSs from groups in Doncaster.

The study was a prospective trial.

Evaluation forms included a linear analog scale using a 0-to-10 scale and a comment field about their opinion of the program.

Patients reported positive thoughts about the time of the course, the location, and the knowledge of the instructors.

The study demonstrated a program that can potentially be used in a fatigue population that desires a group therapy intervention. Patient reports were positive, and no adverse effects were reported.

• The study had risks of bias due to no control or blinding procedures.
• Data were given as patient opinion and, therefore, could not be analyzed statistically.
• There may also be some issue in terms of staff required to lead the group sessions.

The study intervention could be easily taught to nurses desiring this type of intervention for their patients if the intervention proved effective.

To evaluate the effect of zoledronic acid (ZOL) on skeleton-related events (SREs) and bone pain; to determine if baseline bone pain affects clinical outcomes of patients receiving ZOL

Patients were initially randomized to receive placebo or ZOL 4 mg by infusion every three weeks for up to 24 months. Bone pain was assessed at six-week intervals, and investigators recorded data about radiotherapy or surgery to bone, changes in antineoplastic treatment of bone pain, and SREs (e.g., pathologic fracture, spinal cord compression).

• The sample was composed of 422 patients.
• Mean patient age was 72.5 years.
• All patients were male.
• All patients had prostate cancer; 73% had bone pain at baseline, with an average BPI score of 2.84.

• Multisite
• Outpatient
• The report did not state the study locations.

Secondary analysis of phase III placebo-controlled randomized study

Brief Pain Inventory (BPI)

Bone pain increased over time in all patients. However, compared to patients receiving placebo, patients receiving ZOL reported smaller increases in mean BPI composite scores throughout 24 months (p < 0.04). This difference was most significant (p = 0.003) at three months. This difference was seen whether or not patients had reported bone pain at baseline. In patients with pain at baseline, ZOL lengthened the median interval to first SRE by about six months, compared with placebo (p = 0.087). In patients without bone pain at baseline, patients on ZOL had not had SREs at the 24-month follow-up. Those who were on placebo had a median time to SRE of 15 months (p = 0.04). There was no difference in median overall survival between placebo and ZOL groups.

ZOL postponed the onset of severe bone pain and skeletal events in patients with prostate cancer.

• The study did not discuss or analyze the medications taken for pain over the course of the study, so whether differences were due only to the use of ZOL versus other pain management is unclear.
• Authors note that SREs may have been underreported.

This study highlights the importance of intervention before symptoms of bone involvement develop. Some current guidelines have recommended ZOL for treatment of bone metastases; however, this study suggests that administration of ZOL prior to known bone metastases may reduce pain and delay skeletal events. Nurses can advocate for prophylactic approaches to manage these problems in patients with prostate cancer.