Brown, J.C., Huedo-Medina, T.B., Pescatello, L.S., Ryan, S.M., Pescatello, S.M., Moker, E., . . . Johnson, B.T. (2012). The efficacy of exercise in reducing depressive symptoms among cancer survivors: A meta-analysis. PloS One, 7(1), e30955.
To perform a meta-analysis and systematic review to determine the efficacy of exercise in reducing the symptoms of depression among cancer survivors
Late effects and survivorship
Findings support the conclusion that exercise has a small positive effect on symptoms of depression among women with breast cancer.
Findings suggest that supervised aerobic exercise may be helpful in reducing mild symptoms of depression among women with breast cancer. Applicability of the findings to patients with other diagnoses is unclear.
Brown, P.D., Pugh, S., Laack, N.N., Wefel, J.S., Khuntia, D., Meyers, C., . . . for the Radiation Therapy Oncology Group (RTOG). (2013). Memantine for the prevention of cognitive dysfunction in patients receiving whole-brain radiotherapy: A randomized, double-blind, placebo-controlled trial. Neuro-Oncology, 15, 1429–1437
To determine the protective effects of memantine on cognitive function in patients receiving whole brain radiotherapy (WBRT)
Patients received a total of 37.5 Gy WBRT over 15 fractions. Patients were randomized to receive escalating doses of memantine or placebo orally for 24 weeks beginning within three days of WBRT initiation. Weekly escalation was: Week 1: 5 mg every morning; Week 2: 5 mg twice daily; Week 3: 10 mg every morning, 5 mg every evening; Weeks 4–24: 10 mg twice daily. Five neuropsychological assessments were performed at baseline, 8 weeks, 16 weeks, 24 weeks, and 52 weeks.
Overall, trends of less cognitive decline were observed over time for those receiving memantine versus those receiving placebo. Significant differences (p < 0.05) between groups for cognitive decline were (1) raw scores and standardized scores for memory recognition (HVLT-Recognition) at 24 weeks, (2) raw scores for global cognitive function (MMSE) at 24 weeks, and (3) fewer individuals experiencing a change of 2 SD in verbal fluency (COWA) at eight weeks. The probability of cognitive failure was greater for the memantine arm (53.5%) than for the placebo arm (64.9%). Likewise, the time to cognitive failure was significantly longer in the memantine arm. Significant differences (p < 0.05) were observed in the memantine arm for COWA scores at 8 weeks and 16 weeks and for TMT-A and MMSE at 24 weeks. There were no differences between groups in progression-free survival, overall survival, use of steroids, or side effects experienced for memantine or placebo.
Use of memantine during and after WBRT was well tolerated and resulted in trends of better cognitive function over time, delays in cognitive failure, and reduced rates of decline for specific cognitive functions involving memory, executive control function, and processing speed. However, generalization of these results is limited due to the small sample size at study conclusion, which resulted in a lack of statistically significant findings.
This study demonstrates the potential application of administering prophylactic memantine during WBRT to reduce cognitive decline observed in individuals with brain metastasis. These results are limited and warrant further study with a larger sample size enrolled throughout study conclusion.
Brown, J.K. (2002). A systematic review of the evidence on symptom management of cancer-related anorexia and cachexia. Oncology Nursing Forum, 29, 517–532.
To review the studies regarding cancer-related anorexia and cachexia symptom management and to make recommendations for future directions
A literature search was conducted using the Cochrane Library, MEDLINE, CancerLit, CINAHL, Embase, CRISP, EBM Reviews: Best Evidence, and dissertation abstracts.
All studies focused on increasing food intake. Studies evaluated included:
Weight, appetite, and well-being were improved with progestational agents, with megestrol acetate having the most supporting evidence. All nonpharmacologic RCTs reported improved caloric intake resulting from nutritional counseling and oral liquid supplements. The meta-analysis concluded that insufficient evidence existed at the time to recommend any of the nursing interventions.
Patients with cancer should be screened at diagnosis and reevaluated at regular intervals for current and potential nutritional problems. If nutritional screening identifies an at-risk patient, a comprehensive nutritional assessment should be completed. A valid screening tool is needed.
Brown, J., Su, Y., Nelleson, D., Shankar, P., & Mayo, C. (2016). Management of epidermal growth factor receptor inhibitor-associated rash: A systematic review. The Journal of Community and Supportive Oncology, 14, 21–28.
STUDY PURPOSE: To summarize epidermal growth factor receptor inhibitor (EGFRI)–induced rash management recommendations and evaluate the scientific evidence of these recommendations
TYPE OF STUDY: Systematic review
PHASE OF CARE: Active antitumor treatment
INTERVENTIONS: Most articles identified in their search recommended both topical and oral antibiotic treatments. All three randomized, controlled trials and five of seven studies with prospective designs supported their use. Other common drug interventions included topical corticosteroids and antihistamines.
EVIDENCE: In the 59 articles, a range of evidence sources were cited for rash management recommendations. The most common basis of evidence for recommendations was expert opinion.
RASH SEVERITY: Data demonstrated a pattern of escalating rash management interventions by rash severity: Topical treatments are mostly recommended for grade 1 rash, oral treatments are recommended for grade 2 rash, and delay or dose interruptions are almost exclusively recommended for grade 3 rash.
VARIATION: Data also revealed that substantial variation exists in the recommendations for rash management. Twenty rash management interventions were reviewed, including oral and topical retinoids, benzoyl peroxide, salicylic acid, and vitamin K cream. Recommended treatments, including oral and topical antibiotics, may be indicated for various grades of rash.
PREVENTION: Three randomized, controlled trials evaluated the prevention of onset of EGFRI-induced rash by using oral antibiotic prior to rash onset. All studies found that preemptive oral antibiotics were well tolerated and showed signs of reducing severe skin toxicities; however, future studies are needed.
Most recommendations for EGFRI-associated rash management relied on expert opinion. Although differences in the rash management recommendations existed, it was generally agreed that interventions for the rash management was dependent on the rash severity. For mild (grade 1) rash, topical treatments were recommended. For grade 2 rash, oral antibiotics or corticosteroids were recommended. For severe (grades 3 and 4) rash, treatment with oral corticosteroids and dose interruptions and delays were recommended. Additional randomized, controlled studies are needed to evaluate preemptive versus reactive treatments for EGFRI-induced rash.
Various interventions are available for managing mild, moderate, and severe EGFRI-induced rash. Nurses need to assess patients who are receiving EGFR inhibitors for severity of skin rash. Also, nurses need to understand the variety of options for managing EGFRI-induced rash and collaborate with physicians to select an appropriate intervention.
Brothers, B.M., Yang, H.C., Strunk, D.R., & Andersen, B.L. (2011). Cancer patients with major depressive disorder: Testing a biobehavioral/cognitive behavior intervention. Journal of Consulting and Clinical Psychology, 79, 253–260.
To evaluate the effectiveness of a combined biobehavioral intervention (CBI) and cognitive behavior therapy (CBT) for depressed patients coping with the stresses of cancer
12–20 individual 75-minute CBI and CBT sessions
Topics: Stress, coping, communication, seeking information
PHASE OF CARE: Late effects and survivorship
Single group pre-post design
Depressive symptoms, fatigue, and mental health significantly improved following intervention.
CBI and CBT showed significant improvement in depression, fatigue, and quality of life and reduced cancer stress.
Cancer survivors who display depressive symptoms may benefit from CBI and CBT.
Brogan, S.E., Winter, N.B., & Okifuji, A. (2015). Prospective observational study of patient-controlled intrathecal analgesia: Impact on cancer-associated symptoms, breakthrough pain control, and patient satisfaction. Regional Anesthesia and Pain Medicine, 40, 369–375.
To assess efficacy of patient-controlled intrathecal analgesia for management of cancer-related pain, emphasizing impact on breakthrough pain control and other symptoms
After patients had placement of an intrathecal pump, patient-controlled analgesia was begun immediately. Usually, the starting PCIA dose was 10% of the daily opioid dose, administered every 2–4 hours as needed. Patients used PCIA in addition to previous breakthrough medications as needed. After hospital discharge, patients were instructed to use PCAI and NSAIDs for any residual incisional pain. Patients completed symptom inventory assessment and were asked to respond to questions about breakthrough pain.
The follow-up period ranged from 12–82 days. On average, worst pain scores were 8.32 prior to the intervention and 4.98 postintervention (p < 0.001). Of the patients, 8% reported worse pain and 12% reported no change. Of the remaining patients, 56% reported at least a 30% reduction in pain, and 44% reported a 50% reduction. The percentage of patients reporting breakthrough pain after the intervention was reduced by 20% (p < 0.013), and efficacy of PCIA was reported to be better than the efficacy of prior breakthrough medications (p < 0.0001). Sixty-five percent had discontinued all nonintrathecal opioid medications at follow-up. Of a total of 98 pumps inserted, there was infection in one case requiring pump removal and antibiotics, and three patients developed postdural puncture headache that resolved in two to three weeks with use of an epidural blood patch.
Patient-controlled intrathecal analgesia was effective for improved chronic and breakthrough pain control.
Findings of this study showed that intrathecal patient-controlled analgesia was associated with improved pain control in patients with refractory and breakthrough cancer-related pain, and this intervention was associated with few complications. These findings are limited by the study design. These results are promising, and further well-designed research to establish the appropriate role of patient-controlled intrathecal analgesia in cancer-related pain control is warranted.
Broderick, J.M., Guinan, E., Kennedy, M.J., Hollywood, D., Courneya, K.S., Culos-Reed, S.N., . . . Hussey, J. (2013). Feasibility and efficacy of a supervised exercise intervention in de-conditioned cancer survivors during the early survivorship phase: The PEACH trial. Journal of Cancer Survivorship: Research and Practice, 7, 551–562.
To evaluate the feasibility and efficacy of an eight-week, supervised exercise program in deconditioned cancer survivors within two to six months of chemotherapy completion
Twice-weekly, aerobically-based group sessions in a hospital setting for a duration of eight weeks plus a home exercise program.
Prospective, two-arm, randomized controlled trial
Feasibility: 81% eligible patients were recruited to the study. Conflicting data on drop-outs were presented. Exercise intervention was positively received as noted in exit interviews with subjects. Adherence to supervised and home-based exercise intervention was good (76% to 105%, respectively). There were no statistically significant differences between the groups for any health-related fitness outcomes. Total FACIT and fatigue subscale scores were better in the exercise group at three months (mean difference = 6.2, 95%, CI 1.4–11.0).
Data support the benefit of exercise to address cancer-related fatigue in the early survivorship period. However, sample was “healthy” with few co-morbidities and, although deconditioned, did not include older adults (> 65 years of age), which raises questions about safety and which type and dose of exercise should be recommended to the large group of cancer survivors who continue to experience cancer-related fatigue.
Brocken, P., Prins, J.B., Dekhuijzen, P.N., & van der Heijden, H.F. (2012). The faster the better? A systematic review on distress in the diagnostic phase of suspected cancer, and the influence of rapid diagnostic pathways. Psycho-Oncology, 21(1), 1-10.
STUDY PURPOSE: To synthesize the evidence regarding the effect of rapid diagnostic approaches on anxiety in patients with cancer
TYPE OF STUDY: Systematic review
PHASE OF CARE: Diagnostic
Patients receiving a benign diagnosis showed significant decreases in anxiety. Women eventually diagnosed with breast cancer had either increased or sustained anxiety levels; however, increases were not statistically significant in all but one study. Findings were mixed in this regard across studies involving prostate and ovarian cancer and melanoma. Among suspected breast cancer cases, 46%-73% had anxiety scores (Hospital Anxiety and Depression Scale [HADS] instrument) that were ≥ 8, indicating at least borderline clinically relevant anxiety. In studies using the State-Trait Anxiety Inventory (STAI) tool, suspected patients with breast cancer had mean STAI scores between 40.1 and 60, with a score of 44 being considered high anxiety. Three studies examined the effect of rapid diagnostic evaluation in breast cancer. One study found significantly larger reduction in anxiety after 24 hours in a one-stop evaluation versus two-stop evaluation; however, this difference disappeared after three weeks. In all studies, anxiety declined significantly among those who had benign result when results were obtained more quickly. In all studies, there were small numbers of patients who were diagnosed with benign disease.
Rapid diagnostic pathways reduce anxiety in patients with benign disease.
No evaluation of the quality of studies was included.
Findings that anxiety declines in patients with benign disease are not surprising. Findings confirm that the more quickly one receives a benign diagnosis, the more quickly related anxiety is reduced. The emotional impact during the diagnostic phase related to cancer can be substantial. Use of one-stop rapid diagnosis can result in a shorter period of uncertainty and related anxiety.
Brito, M., Esteves, S., Andre, R., Isidoro, M., & Moreira, A. (2016). Comparison of effectiveness of biosimilar filgrastim (Nivestim), reference Amgen filgrastim and pegfilgrastim in febrile neutropenia primary prevention in breast cancer patients treated with neo(adjuvant) TAC: A non-interventional cohort study. Supportive Care in Cancer, 24, 597–603.
To compare the effectiveness of a new biosimilar colony-stimulating factor (CSF) compared to reference CSF medications
Data were obtained from medical records in a tertiary cancer center for women with breast cancer who had received TAC chemotherapy. The febrile neutropenia management protocol was the same in all cohorts. Outcomes were compared across cohorts of patients who had received the biosimilar filgrastim, reference filgrastim, and pegfilgrastim.
FN episode rates were 16%, 9%, and 16% in the reference filgrastim, pegfilgrastim, and biosimilar groups respectively. ANC at the time of FN diagnosis was lower in the biosimilar group in comparison with reference filgrastim (p = 0.015), and FN episodes were more frequent in the biosimilar group compared to both other groups (p ≤ 0.02). There were more chemotherapy delays in the biosimilar group compared with pegfilgrastim (p = 0.04). There were no other differences between groups.
Findings suggest the need for ongoing studies to determine comparative efficacy of this biosimilar CSF for prevention of febrile neutropenia and related complications in patients receiving cancer treatment.
There are a growing number of biosimilar CSF agents being produced, and it is not yet clear if there are important clinical differences in bioavailability and activity in the clinical setting. Nurses should be aware of patients who are receiving biosimilar agents and monitor them for signs of FN or infection. Ongoing research is needed to determine safety and efficacy of these newer CSF agents over time.
Brick, N. (2013). Laxatives or methylnaltrexone for the management of constipation in palliative care patients. Clinical Journal of Oncology Nursing, 17(1), 91–92.
PHASE OF CARE: End of life care
APPLICATIONS: Palliative care
All of the studies investigated variables in laxative types, opioid doses, and frequency of stools. Outcome measures included change in frequency of bowel movements, ease of defection, relief of systemic and abdominal symptoms of constipation, change in quality of life, and the use of rescue laxatives. There were no significant cross-findings, except all participants required rescue laxatives despite the initiation of a constipation prevention regimen. In two studies of (288) participants using methylnaltrexone versus a placebo, a statistically significant difference favored the intervention of rescue-free laxation 4 hours and 24 hours after the first dose of methylnaltrexone. Thirty percent of those participants experienced adverse effects. One study of 33 participants with methylnaltrexone showed a statistical difference favoring higher doses. Adverse effects were similar.
There were no recommendations for optimal laxative management of constipation in palliative care patients.
There was little concrete evidence and too many variables across the studies. There was no information on how the search was conducted. It was very difficult to follow the evidence summary.
The effectiveness of laxatives and the optimum management of constipation in palliative care patients requires further investigation involving the measurement of standardized, clinically relevant outcomes in a clearly defined population.