Laser energy 35 J/cm² once a day for five days after the development of chemotherapy-induced \"moderate\" mucositis.

Laser has an 830 nm wavelength with a potency of 250 mW.  
 

Each patient was informed of the oral hygiene protocol:       
Avoid spicy food acid fruits, alcohol, and food and drinks with high temperature.
Use a soft toothbrush and avoid dental floss.
Only use mouth solution provided by health personnel (3% bicarbonate).
Do not smoke.       

The study was conducted March-August 2002.

Thirteen individuals were treated. Convenience sample for chemo-induced mucositis-related pain.
Mucositis was determined using the Brown methodology. Patients determined to have moderate mucositis (score 13-18) were included in the study.

Non-parametric study

VAS pain scale

Brown methodology for classification of mucositis.
 

Significantly lower pain (p = 0.007) after each treatment. Average pain reduction was 67%. Pain reduction across the five days of treatment was also significant (p = 0.000).

Authors note that after five days, pain is usually reduced to such an extent not to require further treatment.

 Limited sample size, short study – no control

Other factors may have contributed to pain reduction, including normal healing and placebo effect.

Optimal energy level is not determined.

Cost is high, and treatment is not available at most centers.

Main focus of study was on pain .
 

• FINAL NUMBER STUDIES INCLUDED = 6
• TOTAL PATIENTS INCLUDED IN REVIEW = 805
• SAMPLE RANGE ACROSS STUDIES: n = 19 up to n = 79 across the six studies 
• KEY SAMPLE CHARACTERISTICS: Breast cancer survivors with, or at risk for, BCRL; RET was part of the intervention or the only intervention; no restrictions on age, nationality, or ethnicity but presumed all patients were female in these six studies; control group in each study; studies not written in English excluded

PHASE OF CARE: Late effects and survivorship

• No adverse effects were reported.
• Blinding was either not conducted or was less than acceptable across all six studies.
• Five of the six studies were high quality per evaluation results.
• BCRL was not increased and triggered by RET.
• Moderate to high intensity RET was superior to moderate intensity aerobic exercise in relation to building strength safely in BCRL at-risk patients.

Performing structured RET is safe and effective in increasing muscle strength in patients with breast cancer.

• Limited search
• Limited number of studies included
• Gender of study participants not clarified (women only?)

• Nurses can—and should—encourage and reassure patients with breast cancer that moderate-intensity RET is an effective means of increasing strength and regaining physical health, without risk for BCRL or any increase of existing BCRL. 
• More research is needed to focus on and to isolate the multiple variables within the different exercise options and their effects on BCRL to further compare benefits and risks in this population.

To evaluate the efficacy of a low dose of megestrol acetate (MA) in debilitated patients with cancer experiencing cachexia

Participants received 80 mg of MA twice daily after meals. After a two-week treatment period, participants were evaluated for efficacy, side effects, and satisfaction.

Consecutive patients (convenience sample)

Patients with advanced cancer and any degree of weight loss were eligible for the study. Of the 20 patients who were evaluable,

• 12 were female and 8 were male.
• The median age was 68.
• The most common malignancy was lung cancer.
• The median ECOG performance status was 2.

Excluded from the study were patients with

• A life expectancy of less than four weeks
• An ECOG performance status of less than 3
• Breast or prostate cancer who were currently receiving hormonal or cytotoxic therapy
• The presence of pleural effusion or ascites
• Uncontrolled hypertension, diabetes mellitus, or congestive heart failure 
• A history of deep-vein thrombosis (DVT) or in treatment for DVT.

This single-site study took place in a large midwestern city at a large academic medical center with a cancer center.

The study was a phase II trial with a nonrandomized design and a descriptive, observational setup.

Outcomes included appetite, satisfaction, and side effects. Appetite and satisfaction were evaluated using a questionnaire that included one question for appetite (0 = absent, 4 = better than normal) and one yes/no question on satisfaction (Are you satisfied with the way the medication affected your appetite?). This empirical indicator appears to have been developed by the research team, although this is not clearly explicated. Side effects were measured using a “Side Effect Profile” (a list of MA side effects developed from a number of previous studies using varying doses of MA).

Fifteen out of 20 patients were deemed “responders.” Most responders had an appetite change of one degree in the categorical question, and 16 answered that they were “satisfied” with the way the medication affected their appetite. There were no significant differences in results based on gender, age, or performance status. The third outcome, side effects, was not specifically reported according to the Side Effect Profile. Researchers reported that five patients developed symptoms not present before the study; in three patients, these were considered drug-related.

The researchers concluded that a low dose of MA given twice daily was an effective appetite stimulant in patients with advanced cancer.

• The study lacked a constitutive definition of anorexia, appetite, satisfaction, and side effects. 
• Participants were considered evaluable for side effects after two doses and for efficacy after four doses. This time period (1 to 2 days) does not allow time for the drug to take effect.
• Eligibility criteria lack specificity.
• The validity and reliability of the instrument used to measure appetite and satisfaction are absent.
• Researchers indicated that appetite improvement by one degree on the categorical scale was a response, but how or why one degree constituted a response was not specified.
• The recruitment sites were listed, but these settings were not described.
• The statistical discussion was weak, with no explanation of sample-size calculation, power, or effect size.
• There was limited discussion of the statistical methods used to assess outcomes.
• Cost implications were not discussed.

To assess the benefit of an intervention of two face-to-face education sessions at the bedside and four interventions for patients with breast cancer and their caregivers

Sixty patients with breast cancer and their caregivers (60 pairs) were randomized to either the usual care group or the intervention group. Both groups received a comprehensive medication review and education after the pretest. The intervention group received two face-to-face education sessions reviewing a booklet that discussed patient needs; informational needs, such as nutrition, medication, rest, and activity; and chemotherapy side effect management, as well as four telephone calls assessing educational needs, followed by a post-test three weeks later.

• N = 60 patient–caregiver pairs   
• AGE: 30–50 years
• MALES (%): Not described, FEMALES (%): Not described
• CURRENT TREATMENT: Chemotherapy. Patients with breast cancer referred to the Hematology and Oncology Research Center of Tabriz University of Medical Sciences 
• KEY DISEASE CHARACTERISTICS: Patients newly diagnosed with breast cancer and new to chemotherapy

• SITE: Single site. Recruitment from the Hematology and Oncology Research Center of Tabriz University of Medical Sciences (patients treated at a large hematology/oncology research center in Northwest Iran)
• SETTING TYPE: Outpatient 
• LOCATION: Iran

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

• Randomized, experimental, two-group design (blinding to the research designer)

• Caregiver Strain Index Questionnaire-12 items (yes/no)

The mean caregiver strain score of the intervention dropped from 8.3 (SD = 2) to 2.3 after the intervention. The paired t-test results indicated that both the intervention and control groups were statistically different after the intervention in terms of caregiver strain scores (p < 0.001).

The caregiver group that received the intervention showed a statistical improvement in the pretest/post-test caregiver scores. The results showed an impressive improvement in the reduction of caregiver strain.

• Small sample (< 100)
• Findings not generalizable
• Small group
• The authors mentioned that the recruitment of patients newly diagnosed with breast cancer might have swayed the results.

The authors described a benefit from an oncology nurse-focused intervention to decrease caregiver strain and burden. This intervention lacked specificity. Further areas of exploration should be depression, anxiety, and future use of additional tools to assess the effectiveness. Future studies should obtain larger sample sizes.

To determine whether ghrelin stimulates appetite in patients with cancer who have anorexia. Ghrelin is an appetite-stimulating hormone.

Patients received ghrelin (5 pmol/kg/min) or saline; four patients received ghrelin then saline (n = 4) or saline followed by ghrelin (n = 3).

• The study reported on a sample of seven patients with metastatic cancer experiencing appetite loss and a mean weight loss of 13%.
• Patients were assigned numbers in order of recruitment.
• The sample was comprised of six females and one male, with an age range of 41–66 years.

Patients were recruited from oncology clinics at Charing Cross Hospital (United Kingdom).

The study was a prospective, randomized, placebo-controlled, crossover clinical trial.

• Edmonton Symptom Assessment Scale (for appetite as an individual item and all nine items as an overall measure of quality of life)
• Energy intake from a buffet meal designed to be in excess
• Meal appreciation assessed through visual analog scales (0–100 scale to the prompt “how pleasant was this meal?”)
• 24-hour food intake completed after each infusion through the use of food diaries
• Plasma ghrelin, insulin, glucose, triglyceride, and growth hormone levels

Energy intake from a buffet meal during saline or ghrelin infusion indicated there was a 31% increase in energy intake in patients during the ghrelin infusion, and greater meal appreciation (by 28 +/- 8%). No side effects of the ghrelin therapy were observed. No changes were reported in levels of insulin, glucose, or triglycerides. Patients recorded greater food consumption on the days they received the ghrelin.

Further investigations are needed before conclusions can be drawn.

• The study had a small sample size.
• Ghrelin had been administered to only 100 patients worldwide at the time of this investigation.
• The long-term effects of ghrelin have not yet been established.

The results of literature search were not provided, and the only database cited was PubMed.

These guidelines provided dosing recommendations for the use of nonsteroidal anti-inflammatory drugs, opioids, etc. for various levels of pain. It recommended many types of adjuvant pharmacologic and nonharmacologic interventions, from energy conservation  to cognitive behavioral therapy. It specifically suggested opioids for breakthrough pain at a standard percentage of basal opioid dose, education, and anxiolytics for acute pain.

Many of the guidelines were based on consensus and did not provide specific information about the evidence for each recommendation. The scope of the guideline was holistic in nature but less clear in terms of the actual evidence base

These guidelines provided useful information about dosing, equivalents across multiple medication types, and strategies for opioid rotation but did not provide clarity in terms of the actual strength of recommendations based on evidence.

RESOURCE TYPE: Consensus-based guideline

PHASE OF CARE: Active antitumor treatment

• Prophylactic use of colony-stimulating factors (CSFs) for individuals at greater than 20% risk for febrile neutropenia (FN) based on chemotherapy regimen, patient risk factors, and treatment intent. For high risk patients (greater than 20%), all treatment intents are considered for CSF recommendation.
• Prophylactic use should be considered for all treatment intents in those at 10%–20% risk for FN.
• Recommends no CSFs for those with less than a 10% risk for FN
• Secondary prophylaxis with CSFs is recommended for consideration among those with FN or a dose-limiting neutropenic event in a prior cycle who had no prior use of CSFs.
• Suggests that prophylactic use of biosimilars in the general oncology population at high risk, but inclusion for stem-cell mobilization or use in those with chronic neutropenia has not been fully accepted.

Limited database to PubMed, no full evidence evaluation provided. Although they suggest prophylaxis based on a percentage risk and suggest chemotherapy dosages accordingly, it does not match current practice in which dosages and regimens may not always be standard, causing a lack of clarity for clinical implementation of these standards.

Both chemotherapy regimens as well as patient-specific risk factors need to be considered to determine patients’ level of risk for developing FN. CSFs have been shown to reduce the incidence of FN and some infection events; however, evidence suggests that relevant guidelines and recommendations regarding the use of CSFs are not routinely followed in clinical practice. Nurses can advocate for adherence to CSF prophylaxis in at-risk patients.

The purpose of this article is to provide guidance regarding the use of myeloid growth factors for adult patients with cancer. The study focused on chemotherapy-induced neutropenia.
 

Consensus-based guideline

• There were multiple phases of care
• Applicatin was for palliative care

Not applicable or stated

Recommends prophylactic use of colony-stimulating factors (CSFs) in patients with 20% risk of febrile neutropenia, consideration of CSFs with 10%–20% risk, and no CSF for less than 10% risk.

Suggests consideration of secondary prophylaxis in cases of prior febrile neutropenia or dose-limiting neutropenic event.

Recommends continuation of CSFs during chemotherapy cycle in the setting of febrile neutropenia for those on prophylactic CSF, and consideration of initiating CSFs in patients with risk factors for infection-associated complication.

Provides extensive listing of factors indicating, 20%, 10%–20% risks. Provides information on toxicity risks with growth factors as well as dose and timing recommendations.

Most recommendations are based on low level of evidence and consensus.

Provides expert opinion and consensus-based recommendations regarding the use of CSFs in patients undergoing chemotherapy for cancer.

PURPOSE: To provide guidance for the clinical practice of preventing and treating infection in patients with cancer

PHASE OF CARE: Multiple phases of care

One thousand one hundred sixty-two publications were retrieved. No method of study quality evaluation or results were reported.

The combination of evidence- and consensus-based recommendations and the differentiation between them are not clearly stated. For vascular access device prevention of infection, the guidelines only address antimicrobial-coated catheters and not any other aspect of management.

The guidelines provide a comprehensive reference to assess patient risk of infection and expert recommendations regarding interventions aimed at the prevention and treatment of infection in patients with cancer. They do not discuss long-term survivorship issues in this area.

To provide guidance for clinical practices for the prevention and treatment of infection in patients with cancer.

This resource is a consensus-based guideline.

Patients were undergoing the active antitumor treatment phase of care.

The guideline

• Recommends the consideration of general antibacterial prophylaxis in patients at intermediate and high risk for infection, consideration of antifungal prophylaxis during neutropenia and for anticipated mucosits, and antiviral prophylaxis for intermediate- and high-risk patients.
• Provides suggestions for specific agents for prophylaxis and treatment in various clinical scenarios.
• Outlines treatment and diagnostic/assessment approaches for neutropenic fever and specific clinical presentations.
• Notes that chlorhexidine and sliver sulfadiazine-coated short-term central catheters have been shown to decrease the incidence of catheter colonization and bloodstream infections, but not in patients with hematologic malignancies requiring indwelling catheters for approximately 20 days.
• Notes that vaccination recommendations for transplantation recipients and their household members should be performed.
• Recommends the pneumococcal vaccine in asplenic patients.

The National Comprehensive Cancer Network (NCCN) does not currently endorse the use of a vancomycin lock solution for long-term vascular access devices due to concerns about the emergence of bacterial resistance if widely used. Influenza vaccination with a vaccine that does not use live attenuated organisms can be safely given, and the guideline recommends administration at least two weeks before receiving cytotoxic therapy.

This study lacked high-quality evidence, with most recommendations being based on consensus.

This guideline provided comprehensive references to assess patient risk of infection and expert recommendations regarding interventions aimed at the prevention and treatment of infection in patients with cancer. The guideline does not discuss long-term survivorship issues in this area.