To update the recommendations for the prophylaxis of delayed emesis induced by moderately emetogenic chemotherapy via a systematic review

The database searched was PubMed.

Search keywords were moderately, chemotherapy emesis, casopitant, aprepitant, granisetron, ondansetron, dolasetron, tropisetron, palonosetron antagonists, and dopamine receptor antagonists

Studies were included in the review if they 

• Were randomized, controlled trials (RCTs).
• Described subjects receiving moderately emetogenic chemotherapy (MEC) as defined by the Multinational Association of Supportive Care in Cancer (MASCC).

Papers were excluded if they were not in English.

The number of references retrieved was not provided. The method of study evaluation was the presence of vomiting.

• The final number of studies included in the review was nine RCTs.
• The total sample size was 4,177; however, not all numbers were included. The study sample sizes ranged from 99–1,114 participants.
• All patients were receiving MEC.

• Patients were undergoing the active treatment phase of care.
• The study has clinical applicability for late effects and survivorship.

• This study of aprepitant and casopitant demonstrated that, when added to a 5-HT₃ receptor antagonist and dexamethasone, a neurokinin 1 (NK1) receptor antagonist reduces the incidence of acute and delayed emesis induced by anthracycline- and cyclophosphamide-based chemotherapy.
• For patients receiving MEC, one dose of palonosetron administered before chemotherapy was more efficacious in reducing the incidence of delayed emesis than a single dose of a 5 -HT₃ receptor antagonist with a shorter half-life.
• Weak evidence suggested that a dopamine receptor antagonist may improve the control of delayed emesis.

• Patients receiving MEC, which is known to be associated with significant incidence of delayed nausea and vomiting, should receive antiemetic prohylaxis for delayed emesis.
• In patients with breast cancer receiving a combination of anthracycline plus cyclophosphamide treated with a combination of aprepitant, a 5-HT₃ receptor antagonist, and dexamethasone to prevent acute nausea and vomiting, aprepitant should be used to prevent delayed nausea and vomiting.
• Multiday oral dexamethasone is the preferred treatment for the prevention of delayed emesis in patients receiving chemotherapy with moderate emetic risk. 
• Insurance concerns continue with 5-HT₃ as well as NK1 receptor agonsists.  Nurses need to consider this when assisting patients with nausea, and they should consider the need for precertification or prior authorization of medications.

To examine mediators of fatigue effects of an exercise intervention

Patients were randomized to an exercise intervention or control group. The intervention combined walking and strength training with resistance bands. Walking was gradually increased by week 9 to 40 minute sessions of moderate intensity, four times per week, and participants attended 26 individual exercise sessions supervised by an exercise specialist. Resistance training was two times per week in the last 10 weeks of the study with the supervised aerobic walking sessions. Resistance was advanced as tolerated. Six group meetings with a psychologist also were provided every other week to provide support and improve exercise adherence. The control group was instructed to maintain usual exercise behavior.

• N = 42  
• MEAN AGE = 56.2 years (SD = 7.7)
• KEY DISEASE CHARACTERISTICS: All patients had breast cancer, were at least four weeks post-completion of primary treatment, had an average fatigue score of at least 3 in the past week, or had sleep dysfunction
• OTHER KEY SAMPLE CHARACTERISTICS: Multiple chronic concurrent conditions were excluded

• RCT

• MTI actigraph
• Fatigue Symptom Inventory
• PROMIS general fatigue scale
• PROMIS scales for depression, anxiety, and sleep/wake disturbance
• Serum samples for interleukins (IL-6, -8, -10) and tumor necrosis factor alpha

Adherence to supervised exercise sessions was 91%–93%. Exercise goals for at home were met in 65% of the weeks during the study. General fatigue declined significantly in the intervention group compared to controls (d = –0.49, p < .01). Fatigue interference (d = –0.38, NS) declined in the intervention group. Fatigue intensity increased in the intervention group and declined in controls (d = 0.3, NS). There were no significant differences in depression. Anxiety declined in the intervention group (d = –0.54, p < .05). Sleep/wake dysfunction declined in both groups over time, but more in the intervention group (d = –0.054, p < .01). Positive effects in fatigue intensity were significantly mediated by IL-6, IL-10, IL-6:IL-10, and TNF alpha:IL-10.

The exercise program used here showed a small to medium non-significant effect on fatigue intensity and interference, as measured in this study. Effects of exercise on fatigue were mediated by some cytokine system responses.

• Small sample (< 30)
• Baseline sample/group differences of import
• Risk of bias (no blinding)
• Risk of bias (no appropriate attentional control condition)
• Other limitations/explanation: Fatigue and sleep disruption measures at baseline were lower in the intervention group, although the difference was not statistically significant, these could have influenced the general trends shown in the study.

Although this study has limitations, findings do provide additional support for positive effects of exercise on cancer-related fatigue among cancer survivors. Findings here show evidence of potential effects through the cytokine system. Adherence to the exercise program in this study was very good, using a support group interaction and the combination of supervised exercise sessions and home-based exercise recommendations. This type of additional support may help many patients adhere to an exercise program.

To determine the feasibility of conducting a randomized, controlled trial of exercise in patients with head and neck cancer receiving radiation therapy

Patients were randomly assigned to the intervention group or a control group. Control patients received only nutritional counseling from a registered dietician. Patients in the intervention group received nutritional counseling plus the exercise intervention. Exercise included twice-weekly, supervised exercise sessions for six weeks followed by six weeks of twice-weekly home-based sessions supported by weekly telephone counseling, written materials, and a DVD.

• N = 13 (completed 12 weeks); 15 (completed six weeks)  
• MEAN AGE = 60.5 years (SD = 43–88 years)
• MALES: 80%, FEMALES: 20%
• KEY DISEASE CHARACTERISTICS: All patients had head and neck cancer. About one half had had neck dissection, and one half also received concurrent chemotherapy.

• SITE: Single-site  
• SETTING TYPE: Outpatient  
• LOCATION: Illinois

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

Pilot randomized, controlled trial

• Lean body mass measured by biometric impedance
• Functional Assessment of Cancer Therapy–Fatigue (FACT-F)
• Functional Assessment of Cancer Therapy–Head and Neck (FACT-H&N)
• Physical performance tests

Over the first six weeks, fatigue increased in both groups with no significant difference between groups. Between weeks 6 and 12, fatigue declined in both groups but showed a greater decline in the intervention group. Exercise adherence was 87% in the first six weeks and 57% weeks 7–12.

Less than one half of patients offered the study consented to participate, suggesting low interest and limited feasibility. The final sample size was very small, so no firm conclusions about effects can be drawn.

• Small sample (< 30)
• Risk of bias (no blinding)
• Risk of bias (no appropriate attentional control condition)

This study provides minimal support for the feasibility and efficacy of implementing an exercise intervention among patients with head and neck cancer undergoing radiation therapy. These findings are not in concert with findings from other similar studies.

STUDY PURPOSE: To assess the effects of compression bandages, sleevers, intermittent pneumatic compression, and active exercise on lymphedema related to breast cancer

TYPE OF STUDY: Meta-analysis and systematic review

• FINAL NUMBER STUDIES INCLUDED = 60 (32 in systematic review, 9 in RCT meta-analysis, and 19 in pre/post meta-analysis)
• TOTAL PATIENTS INCLUDED IN REVIEW = 1,340
• SAMPLE RANGE ACROSS STUDIES: 14–141
• KEY SAMPLE CHARACTERISTICS: All had breast cancer.

PHASE OF CARE: Multiple phases of care

The findings suggest that the use of compression bandaging and exercise in combination has the strongest beneficial effects for lymphedema management among women with breast cancer–related lymphedema. Bandaging had consistent positive effects, whereas other interventions as stand alone approaches yielded somewhat inconsistent results.

• Mostly low quality/high risk of bias studies
• Low sample sizes

The findings suggest that the combination of active exercise and compression bandaging is more effective than other interventions for managing upper extremity lymphedema. This review did not include an examination of complete decongestive therapy along with other interventions, which has been shown to be effective as well. Nurses can educate patients about the use of compression bandaging and exercise for lymphedema management. The findings here suggest that compression sleeves do not aid in lymphedema reduction in the acute phase but may be helpful in the maintenance phase.

To compare the efficacy of hydrocodone-acetaminophen with that of tramadol in the management of cancer pain; to compare the tolerability of hydrocodone-acetaminophen and tramadol used to relieve cancer pain

Patients were assigned to receive either hydrocodone-acetaminophen (25 mg hydrocodone, 2,500 acetaminophen) or tramadol (200 mg) for 21 days. Patients rated pain intensity at the beginning of the study, two days after the beginning of the study, and once weekly for three weeks. Patients were to note all adverse events.

• The sample was composed of 118 patients.
• In the hydrocodone-acetaminophen group, mean patient age was 62 years. In the tramadol group, mean patient age was 57.1 years.
• In the hydrocodone-acetaminophen group, 35.5% were female and 64.5% were male. In the tramadol group, 62.5% were female and 37.5% were male.
• In the entire sample, 13.5% of patients had pain due to gastric cancer; 12%, to breast cancer; 13.5%, to prostate cancer; and 89%, to lung cancer.

• Multisite
• Outpatient
• Colombia

Randomized double-blind comparative trial

• Visual analog scale, 100 mm, to measure pain intensity
• Scale of adverse events (none = 0, mild = 1, moderate = 2, severe = 3)

• The difference in pain relief between the groups was not significant. Tramadol caused significantly more nausea (P = 0.03), vomiting (P = 0.02), dizziness (P = 0.03), loss of appetite (P = 0.02), and weakness (P = 0.019) than did hydrocodone-acetaminophen.
• Authors noted no significant differences between groups in regard to dry mouth or constipation.

In this study, tramadol and hydrocodone-acetaminophen were equally efficacious in relieving cancer pain. Patients taking hydrocodone-acetaminophen experienced fewer side effects than did patients who took tramadol.

All analgesics, except medications for neuropathic pain, were discontinued. Note that the group that took tramadol contained significantly more women than did the group that took hydrocodone-acetaminophen. This difference may relate to the differing side-effect profiles.

This study showed that hydrocodone-acetaminophen and tramadol were equally effective at treating cancer pain; however, tramadol was associated with more adverse effects. Nurses should keep this in mind and provide patients with anticipatory guidance as appropriate.

To determine if methylnaltrexone is an effective treatment for opioid-induced constipation in pediatric patients with cancer

Data were collected from pharmacy records and medical chart reviews. They included demographic data, history of constipation, history of vinca alkaloid use, history of abdominal surgery, history of laxative use and dose, duration of opioid use prior to methylnaltrexone administration, the dose and frequency of methylnaltrexone administration, and the patients' responses to the intervention. Opioid doses were converted to oral morphine equivalents. Bowel regimens were compared to pediatric practice guidelines to determine if the bowel regimen had been optimized prior to administration of methylnaltrexone. Patients were given methylnaltrexone in a single subcutaneous injection. The mean dose was 0.15 ± 0.02 mg/kg per dose (range = 3–12 mg per dose).

• N = 15  
• MEDIAN AGE = 14 years (range = 4–17)
• MALES: 33%, FEMALES: 67%
• KEY DISEASE CHARACTERISTICS: Sarcoma, lymphoma, and neuroblastoma

• SITE: Single-site    
• SETTING TYPE: Inpatient    
• LOCATION: Canada

• APPLICATIONS: Pediatrics

Retrospective chart review

• Naranjo Adverse Drug Reaction Probability Scale (Naranjo Scale)

Ten patients had a bowel movement within 30 minutes of receiving methylnaltrexone. Four patients had a bowel movement between 30 minutes and 4 hours of administration. Four patients were noted to have decreased abdominal girth and active bowel sounds after the intervention. No patients reported a decrease in pain control.

Methylnaltrexone is one effective intervention to treat opioid-induced constipation for pediatric patients after other interventions have failed. The use of methylnaltrexone to relieve constipation did not lead to an increase in pain for the patients in this study.

• Small sample (< 30)
• 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) 
• Measurement/methods not well described
• Other limitations/explanation: Very small sample size; retrospective review

Methylnaltrexone should be considered for pediatric patients when other interventions have failed to relieve opioid-induced constipation.

STUDY PURPOSE: To provide a critical analysis of the contemporary published research that pertains to complementary, alternative, and other noncomplete decongestive therapies for treatment of lymphedema (LE) and to provide practical applications of that evidence to improve care of patients with or at risk for LE

TYPE OF STUDY: Systematic review

DATABASES USED: PubMed, CINAHL, Cochrane Database of Systematic Reviews, Cochrane Controlled Trials Register, PapersFirst, Proceedings-First, Worldcat, PEDro, National Guideline Clearing House, ACP Journal Club, DARE, and the authors' archives

KEYWORDS: Best practice for the management of lymphoedema, plus expanded terms for all literature related to lymphedema (2004–2012)

INCLUSION CRITERIA: No specific inclusion criteria identified

EXCLUSION CRITERIA: No gray literature was included; nonrefereed articles, abstracts, and dissertations were excluded. Exclusion of 574 articles took place due to duplication, inability to obtain the English translation, inadequate sample size, insufficient level of evidence due to study design, and failure to meet inclusion criteria. Another 47 articles were rejected because they fell outside the systematic review inclusion criteria by definition of four categories (i.e.,botanical, pharmaceutical, physical agent modalities, and modalities of contemporary value), by design, or for lack of an English translation. The categories of pharmaceuticals and botanicals were excluded as well.

TOTAL REFERENCES RETRIEVED: 659 articles were reviewed.

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: The authors used first screening, second screening, and third screening to determine final body of reviewed articles. The level of evidence for each study assessed by using the research grading system from the Putting Evidence into Practice (PEP) level of evidence guidelines.

• FINAL NUMBER STUDIES INCLUDED = 22
• SAMPLE RANGE ACROSS STUDIES/TOTAL PATIENTS INCLUDED IN REVIEW: Not applicable; included several singles and several review articles
• KEY SAMPLE CHARACTERISTICS: Human being with lymphedema and animal model with lymphedema (i.e., a rabbit ear model with “created” secondary lymphedema and rat tail model with “created” secondary lymphedema)

PHASE OF CARE:  Multiple phases of care

Limited high-level evidence was available for all categories. Well-constructed randomized, controlled trials related specifically to lymphedema were limited. Objective outcome measures over time were absent from several studies. The rationale for the use and benefits of the specific modality, as related to lymphedema, was often anecdotal. Participant numbers were fewer than 50 for most studies.

No interventions were ranked as "recommended for practice." Two treatment modalities (low-level laser therapy and Kinesio taping combined with decongestive lymphatic therapy and pneumatic compression, with Kinesio taping compared with compression bandaging) in three studies were ranked as "likely to be effective." The literature review indicated that many of the physical agent modalities demonstrated long-standing support within the literature, with broad parameters for therapeutic application and benefit for secondary conditions associated with lymphedema. However, additional investigation regarding the individual contributory value and the factors that contribute to their efficacy specific to lymphedema is critically needed.

Inclusion criteria were not clearly stated. Sample range across studies and total patients included in review were not specified.

More rigorous human research in complementary and alternative modalities is needed to optimize patient outcomes.

To evaluate the efficacy of pharmacologic and nonpharmacologic treatments for depression in patients with cancer

Literature review of works, published through June 2005, conducted by the Supportive Care Guidelines Group (Ontario). Databases searched were MEDLINE, EMBASE, CINAHL, PsycINFO, and the Cochrane Database.

Authors identified seven pharmacologic randomized control trials and four nonpharmacologic trials.

Pharmacologic trials: Three trials detected significant differences (symptom improvement) among treatment groups on a measure of depression. Two compared the antidepressant mianserin to placebo. The third, which compared use of alprazolam to muscle relaxation, found reduction in symptoms of depression with the use of alprazolam. Two studies compared active treatments—fluoxetine versus desipramine and paroxetine versus amitriptyline. They found improvement of symptoms of depression in all groups, with no differences in treatment efficacy. The remaining two trials found no significant differences among patients randomized to fluoxetine versus placebo; however, only low-dose fluoxetine was evaluated in one of the studies, and both studies were for a short duration, only five weeks.

Nonpharmacologic trials: Two of the four studies reported greater improvement in symptoms of depression in the intervention groups rather than in groups with usual care. Interventions included an orientation program with educational information and a multicomponent intervention. One of the remaining studies found that adjuvant psychotherapy did not significantly affect patients’ Hospital Anxiety and Depression Scale (HADS) subscores for depression. The final study found no significant difference among patients receiving cognitive-existential group therapy plus relaxation and those receiving relaxation therapies alone.

The evidence of treatment effectiveness for depressive disorders in patients with cancer is limited and of modest quality.

At present, treatment guidelines must be based on limited evidence and on data derived from the general population, other medically ill populations, and on expert opinions.

To assess the effect of leptospermum honey as a primary dressing for managing wounds with radiation-impaired healing

The cases involved patients who experienced fragile friable areas of damaged skin that did not respond to conventional treatment. Patients 1, 2, and 4 had long-term effects from radiation therapy treatment received several years or months earlier. Patient 3 experienced short-term effects from radiation therapy treatment received immediately before referral. Dressings to suit the condition of the wound had been applied before referral. The study product, Medihoney Antibacterial Honey is a mix of gamma-irradiated, sterile Australian and New Zealand leptospermum honeys, licensed in the United Kingdom and indicated for use in chronic wound care.

• The study examined four cases.
• Age ranged from 63–93 years.
• Three patients were female and one was male.
• Patient diagnoses were local cord carcinoma, squamous cell carcinoma of left cheek, ductal carcinoma of the left breast status postmastectomy, and vulvar cancer.

The study took place at the Wound Clinic in a United Kingdom hospital.

The study used a case series design.

• No tools were used to measure outcome.
• Progress report was descriptive with photographs of the patients’ progress.
• No pain measurement tool was used.

In all cases, a change from conventional dressings to the topical application of honey was followed by a noticeable improvement in healing. No adverse events were observed and even though one patient had type 2 diabetes, daily honey applications to her wound had no adverse effect on her blood sugar levels. All patients readily accepted honey as a dressing for their wounds.

No adverse events were reported. Honey as an adjunct to conventional wound and skin care post radiation therapy shows promise for less painful healing in these chronic wounds. Prospective, randomized, controlled clinical studies are needed to confirm these observations.

• The study was very small, with less than five cases.
• No recognized pain scale was used.
• Vehicle or dressing type was not consistent for honey application.
• Multiple other products were used in conjunction with the honey for wound care.

To determine whether a larger trial using acupuncture and acupressure therapies would be feasible.

Patients were randomized into three groups. The acupuncture group received three 20-minute sessions per week for two weeks using the same points. The acupressure group was taught self-treatment techniques for the same points. Pressure was held for one minute every day for two weeks. The sham group was taught to hold pressure on three points not related to energy for one minute each day for two weeks.

• Mean age was 54 years.
• Patients were reported as being “predominantly female.” 
• Patients were at least one month from completing chemotherapy and reported a fatigue score of at least 5 on a 0-to-10 scale.

Not reported

The study was a randomized, controlled trial.

• Patients completed the Multidimensional Fatigue Inventory (MFI) before randomization, at the completion of treatment, and two weeks after.
• Patients in the acupressure and sham groups also filled out a diary reporting whether they had applied pressure to the points each day.

Improvements were noted in fatigue scores in the acupuncture and acupressure groups in general fatigue, physical fatigue, reduced activity, and motivation. The sham group showed no significant improvements.

The use of acupuncture may be helpful for fatigue. Because such little data was provided, it is difficult for readers to make this same conclusion. The report of significant improvements was not cited with statistical methodologies. A larger, multicenter trial is needed.

• The study examined a small, homogenous population with limited data collection.
• The results were poorly reported.
• The implementation of these two treatments in practice may be difficult for smaller institutions.