To compare effects of cardiovascular and resistance exercise on functional mobility in people with advanced cancer

Individuals were randomly assigned to either resistance or cardiovascular exercise groups. Exercise sessions were held in a hospital-based fitness facility twice weekly for 10 weeks. Both groups  participated in flexibility exercises. Sessions lasted 30–60 minutes and were supervised by oncology-trained exercise specialists. Participants completed the study assessments at baseline and one week after study completion.

• N = 52    
• MEAN AGE = 62.35 years (SD = 13.49)
• MALES: 45%, FEMALES: 55%
• KEY DISEASE CHARACTERISTICS: Multiple tumor types. All had advanced cancer determined by an oncologist to be in a terminal stage.
• OTHER KEY SAMPLE CHARACTERISTICS: More than 90% of the patients were currently receiving chemotherapy, radiation therapy, or a combination of these. Baseline mean fatigue was 37.02 on a 0–100 scale.

• SITE: Single site
• SETTING TYPE: Outpatient
• LOCATION: New England

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

• Randomized, parallel group trial

• Short Physical Performance Battery (SPPB)
• 100 mm visual analog scale for fatigue and pain

On average, participants attended 70% of exercise sessions. SPPB scores improved in all over time (p < .001), but improved slightly more in the cardiovascular group (p = .045). Intent-to-treat analysis did not confirm this difference between groups. Fatigue declined over time in all (p = .05), with no difference between groups. There were no significant changes in pain by group or by time.

Findings show improved functional mobility and reduced fatigue over time. This study did not show a difference associated with the type of exercise provided.

• Small sample (< 100)
• Risk of bias (no control group)
• Risk of bias (no blinding)
• Measurement validity/reliability questionable
• Other limitations/explanation: VAS score was only for fatigue. There was a 21% dropout rate and reasons for this are not described. Relatively low levels of fatigue at baseline, suggesting possible measurement floor effect.

This study suggests that both cardiovascular and resistance exercise can be used in appropriate patients with advanced disease, and findings showed that there were no significant changes in pain or fatigue with these interventions.

To determine if there was an improvement in fatigue, strength, and quality of life (QOL) in individuals within one year of treatment for an individualized physical therapist–prescribed exercise intervention.

Cancer survivors participated in an exercise class (one hour two times weekly) that included instruction and supervision in cardiovascular, strength training, and flexibility exercises. Measurement of fatigue, strength, and repetition of prescribed exercises occurred. The individualized exercise program was prescribed by a single therapist and was based on the patient’s medical history, diagnosis, age-related changes, treatment stage, and goals. Flexibility, strength, and balance assessments were conducted, and participants were retested at the conclusion of the program. Patients were encouraged to exercise two times weekly.

• Two hundred patients (91 females and 41 males) were enrolled; 132 (66%) completed the program.
• Mean age was 57.48 years. One patient was younger than 21 years and five patients were between 81 and 90 years; the majority (n = 36) were between 61 and 70 years.
• Stages of cancer were I through IV.
• Diagnoses included breast, colorectal, lung, ovarian, non-Hodgkin lymphoma, prostate, and other cancers.
• Most patients were undergoing active treatment, and most had undergone surgery, chemotherapy/hormonal, and radiation therapy.

• Single site
• Cancer Well-Fit Exercise Program at Synergy Health and Fitness Center on the campus of Exeter Hospital, Exeter, New Hampshire

This study included a pre- and posttest and a two-tailed t test. 

• Visual analog scale (VASF) to measure fatigue (Glaus reported validity and reliability but did not report the actual number)
• Jamar dynamometer to measure upper extremity strength (Bohannan reported as valid and predictive of postoperative complications and related to functional loss but did not report the actual number)
• Cybex VR2 seated leg press machine to measure lower extremity strength
• Segal tested lower-extremity muscular fitness with repetitions to fatigue for prediction, and Sale and MacDougall published data regarding repetitions to fatigue. The amount of weight lifted and the total number of repetitions performed were used to estimate a predicted one repetition maximum according to Brzycki’s regression equation.
• Short Form 36 Health Survey (SF-36) was used to measure QOL. This total score and eight subscales were analyzed pre- and post exercise intervention. They included physical functioning, physical role, bodily pain, general health, vitality, social functioning, emotional role, mental health, and reported health transition.

Overall fatigue improved significantly (p = 0.004). Overall lower-extremity anaerobic endurance increased significantly (p = 0.000). Overall nondominant grip strength increased significantly (p = 0.000). Overall QOL improved significantly (p < 0.01). The intervention was well tolerated in all of the diagnostic, stage, and age groups with no adverse events. The 81- to 90-year-old group had the highest completion rate, followed by the 71- to 80-year-old group. Survivors with stage IV disease had statistically significant improvement in lower extremity anaerobic endurance and QOL, whereas survivors of lung cancer had statistically significant reductions in their fatigue.

Virtually all patients with various cancer diagnoses and stages of disease, as well as a wide age range and both genders, can safely participate in and will benefit from a strength training program in terms of less fatigue, improved QOL, and increased strength. Oncology rehabilitation is necessary for survivors of cancer.

• The study lacked an appropriate control group.
• The population was primarily Caucasian, and there was limited cultural diversity.
• The study lacked randomization and control group.
• Combination exercise was used; the authors were unable to determine the most effective type of exercise for this population.

Exercise can be performed safely with careful planning. Exercise programs do not need to be restricted to those who are relatively well. Oncology rehabilitation is as necessary for survivors as cardiac rehabilitation. This study is supportive of a comprehensive exercise program.

To compare the analgesic effects of remifentanil target-controlled infusion via patient-controlled analgesia (PCA) to morphine PCA after uterine artery embolization

Nineteen patients were randomized into either the remifentanil group or the morphine group. Pain was evaluated every 15 minutes for 2 hours after the procedure and then at 4, 8, 12, and 16 hours after the procedure. Hemodynamic stability and respiratory stability were also measured.

• The sample was composed of 19 patients.
• Information about the age of patients is unavailable.
• All patients were female.
• All patients had a leiomyomata.
• All patients underwent uterine artery embolization.
   

• Single site
• Inpatient
   

Phase of care: active treatment

Double-blinded randomized controlled trial

• Numeric pain scale, 0–10    
• etCO₂ readings, SpO₂ measurements, respiratory rate/minute, to measure respiratory stability
• Heart rate, measures of blood pressure, to measure hemodynamic stability
   

• During the first four hours after surgery, pain scores were significantly lower (p < 0.02) in the remifentanil group than in the morphine group. After that, morphine and remifentanil showed similar effectiveness in controlling pain.
• One patient in the remifentanil and morphine groups, respectively, needed rescue pain therapy.
• Respiratory and hemodynamic stability were not significantly different between the groups.

The study concludes that, in the first four hours after surgery, remifentanil was more effective than morphine in reducing pain scores and that remifentanil PCA was as safe as morphine PCA.

The study had a small sample size, with fewer than 30 patients.

Further studies should evaluate the ability of remifentanil to control pain after uterine artery embolization.

To investigate the hypothesis that stellate ganglion block (SGB) can be a safe and effective treatment for hot flushes (HF) and sleep dysfunction in patients with breast cancer.

Thirteen women with breast cancer (in remission) experiencing severe HF and night awakenings were treated with SGB at the anterolateral aspect of the C6 vertebra on the right side under fluoroscopy. Patients recorded HF in a daily diary by use of the Hot Flash Score and night awakenings by use of the Pittsburgh Sleep Quality Index (PSQI). Both instruments were used one week before the procedure and then weekly after the procedure for 12 weeks. The generalized-estimating-equations method was used to analyze the longitudinal measurements of the number of HF and night awakenings over time.

• The sample was comprised of 13 women.
• Age ranged from 38 to 71 years.  

• Single site
• Outpatient oncology clinic
• Midwest

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

This pilot study used a prospective, single-arm, pre/post design.

• Demographic and clinical information form 
• Hot Flash Score and daily sleep diary (daily log detailing the frequency and severity of HF and sleep disturbances)
• PSQI

No adverse events resulted from the SGB, although patients had temporary Horner's syndrome, indicating the effectiveness of the block. Five patients had only one SGB, and eight had two SGBs. The total number of HF decreased from a mean of 79.4 (standard deviation [SD] = 37.4) per week before the procedure to a mean of 49.9 (SD = 39.9) per week during the first two weeks after the procedure (p = 0.0002). The total number of HF continued to decrease over the remaining follow-up period (weeks 3–12) and stabilized at a mean of 8.1 (SD = 5.6) per week (p < 0.0001). The number of very severe HF was decreased to near zero by the end of the follow-up period (week 12; p < 0.0001). Night awakenings decreased from a mean of 19.5 (SD = 14.8) per week before the procedure to a mean of 7.3 (SD = 7.1) per week during the first two weeks after the procedure (p < 0.0001). The total number of night awakenings continued to decrease over the remaining follow-up period (weeks 3–12) and stabilized at a mean of 1.4 (SD = 1.2) per week (p < 0.0001).

The findings suggest that SGB can provide survivors of breast cancer with relief from HF and sleep dysfunction, with few or no side effects. Long-term symptom relief has the potential to improve overall quality of life (QOL) and increase compliance with antiestrogen medications for breast cancer.

• The study lacked an appropriate control group.
• The study had a small sample size.
• The majority of patients required repeat block procedures.

The findings suggest that SGB can provide breast cancer survivors with relief from HF and sleep disturbances, with potential to improve overall QOL.

Researchers employed a pilot study to investigate the safety and effectiveness of a stellate-ganglion block to ameliorate hot flashes in women with breast cancer .

Anesthetic was injected  at the anterolateral aspect of the C6 vertebra on the right side under fluoroscopy.

The study treated 13 breast cancer survivors who were experiencing severe hot flashes, night awakenings.

Participants recorded hot flashes in a daily diary by use of the Hot-Flash Score. Scores were recorded 1 week before the procedure and then weekly after the procedure for 12 weeks.

The total number of hot flashes decreased from 79.4 mean episodes to 49.9 in the first two weeks, and continued to decrease during the follow-up period to 8.1 per week. Night awakenings decreased from 19.5 mean episodes per week to 7.3 during treatment then to 1.4 per week during follow up. Very severe hot flash episodes decreased to near zero at follow up.

No adverse events resulting from the stellate-ganglion block were reported, although patients had temporary Horner’s syndrome indicating the effectiveness of the block.

This was a limited pilot study with a very small sample size.

To provide access to methylnaltrexone for patients who participated in a prior study of the agent, and to continue to evaluate the safety and efficacy of methylnaltrexone in patients with opioid-induced constipation.

This open-label drug extension study recruited participants from both the control and active treatment groups of a prior methylnaltrexone study. All patients were at the end of life, were not pregnant, and were using birth control. Patient received methylnaltrexone 0.15 mg/kg subcutaneously as needed once per day. The dose was increased to 0.3 mg/kg if the agent was not effective in four hours.  The dose was reduced to 0.075 mg/kg if the patient had adverse events. 

• The study reported on a sample of 89 participants (39% male and 61% female).
• Mean age was older than 65 years (range 66.9–68.9).
• Most participants (55.9%) were diagnosed with cancer.

• Multi-site
• Inpatient and outpatient
• United States
   

• Patients were undergoing the end-of-life phase of care.
• The study has clinical applicability for end-of-life and palliative care.

This was a nonrandomized, single-arm, drug continuation study.

• Rescue-free laxation time period    
• Efficacy endpoints identified by the research team
• Modified Himmelsbach Scale
• Global Clinical Impression of Change
   

All patients (control group and active treatment group, as defined in the prior study) received a minimum of one drug dose. Patient laxation effect was similar between the active treatment (45.3%) and control (48.3%) groups. Most patients had an effect in less than one hour. Side effects included abdominal pain, nausea, and vomiting. Serious adverse events considered drug related were muscle spasms, abdominal pain, and pain exacerbation. The effect on patient pain levels was minimal. Opioid withdrawal symptoms ranged from none to mild.  

Patients obtained benefit from methylnaltrexone for up to three months, and the agent was well tolerated.

•  The sample size was small (less than 100).
•  The study had no true control group, as control patients also received methylnaltrexone in this extension study.
   

Patients at the end of life who have an ongoing need for methylnaltrexone may continue to receive an effect from the drug for up to three months when it is used as needed.

To compare the efficacy of EMLA cream to EMLA plus hypnosis in the relief of venipuncture-induced pain and anxiety; to determine whether the intervention has a beneficial effect on parents’ anxiety levels during their child’s venipuncture

Patients arriving at the unit had 2.5 g EMLA cream 5% applied over a prominent vein. Those who agreed to the study were randomized to one of three groups: EMLA alone, EMLA plus hypnosis, or EMLA plus attention. Hypnosis included a 15-minute session with a therapist in a private room. The therapist provided analgesic suggestions and led the patient in relaxation. The attention group received a 15-minute session with the therapist and engaged in conversation unrelated to the procedure. Investigators collected measures of pain and anxiety immediately after the intervention and during two follow-up venipunctures. EMLA was removed after 60 minutes.

• The sample was composed of 45 participants.
• Mean patient age was 8.4 years (SD = 2.21 years). The age range was 6–14 years.
• The sample consisted of 25 females and 20 males.
• All patients were pediatric patients with cancer.

• Single site
• Outpatient
• Children’s hospital in Greece

Randomized blinded, controlled trial

• Visual analog scale (VAS), 0–100 mm, to measure pain intensity
• VAS, 0–100 mm, to measure the intensity of anxiety of children and parents
• Procedure behavioral checklist, to document presence and intensity of 10 behaviors indicative of pain and anxiety (inter-rater reliability = 0.85), conducted on 22 procedures

• The EMLA plus hypnosis group experienced less anticipatory anxiety, procedure-related pain, anxiety, behavioral distress, and parental anxiety than did the other two groups (p < 0.001).
• The benefits that the EMLA plus hypnosis group enjoyed continued through the two consecutive venipunctures: significant change in mean self-reported pain over time (p < 0.001) and anxiety over time (p = 0.007).

The study showed that hypnosis, used in conjunction with the local anesthetic EMLA, helped to decrease procedure-related pain anxiety, and distress in pediatric cancer patients. In addition, the intervention helped to decrease parental anxiety.

• The study had a small sample, with fewer than 100 patients.
• The study had a risk of bias due to lack of blinding.
• The intervention must be implemented by a trained therapist. This fact could decrease the feasibility of the intervention.

Oncology nurses in the pediatric setting may want to advocate for the use of hypnosis, along with local anesthetic, to decrease the pain and anxiety of venipuncture.

The purpose of this study was to determine the effect of zinc supplementation on radiation-induced mucositis in patients with nasopharyngeal carcinoma (NPC) and those with oral cancers (OC).
 

Patients were randomly assigned to experimental or control groups. The experimental group received 75 mg zine 4 times/day for three months during radiation therapy. Control group patients received soy bean capsules.  Patients were evaluated if mucositis was detected, weekly. Patients were followed at 3 and 12 months post-radiation therapy completion. Side effects were evaluated by a blinded physician observer.

The study was comprised of 83 patients, age >18 years of age.

MALES 85.5%, FEMALES 14.5%

KEY DISEASE CHARACTERISTICS: 40 were patients with nasopharyngeal cancers (NPC) and 43 were patients with oral cavity cancers (OC).

OTHER KEY SAMPLE CHARACTERISTICS: zinc supplementation
 

SITE: Single site

PHASE OF CARE: Active treatment

Randomized double blind study

Serum zinc, cell count, blood urea nitrogen (BUN), creatinine, glutamic oxalacetic transaminase (GOT), glutamic pyruvic transaminase (GPT), transferrin, and body weight were checked one week prior to radiotherapy and were repeated biweekly until radiotherapy was completed. The serum zinc level was checked using the atomic absorption method.
 

The study found that there is a discrepancy in the effects of zinc supplementation in preventing mucositis between patients with NPC and those with OC, as there were significant effects of zinc supplementation in improving mucositis in patients with OC. Grade 2-3 mucositis occurred earlier in patients receiving placebo.
 

Further studies need to be done to investigate the effect of zinc supplementation in preventing the severity of mucositis in relation to the different radiation fields between those associated with patients diagnosed with oral cancer and nasopharyngeal cancer. This study was focused on subgroup analysis of a previous report.

 Small sample <100

Zinc supplementation may be of benefit in the prevention of oral mucositis. It appears that efficacy may differ according to the specific type and location of the tumor.

To complete a systematic review to evaluate the effect of patient education on the pain intensity, pain interference, and quality of life of patients with cancer 

• Databases searched were MEDLINE, CINAHL, PubMed, EMBASE, PsycINFO, and Database of Abstracts of Reviews of Effects (DARE).
• Search keywords were cancer, malignancy, neoplasm, tumor, nursing, pain, pain management, educational intervention, coaching, training, barriers, mood, well-being, wellness, anxiety, functional ability, patient teaching, patient education, quality of life, and systematic review.
• Studies were included if they
  • Were randomized controlled trials of pain education for cancer patients
  • Were published in English
  • Involved adults with cancer-related pain and educational intervention in the form of information, instructions, or advice via written or auditory means by a healthcare provider to a patient with cancer
  • Included quality-of-life measures based on functional status, perceived pain control, well-being, anxiety, satisfaction with pain treatment, pain interference, physical functioning, and pain intensity and interference
• Studies were excluded if they involved only caregivers or family members or if they used measures of quality of life or pain as the only outcome measures.
   

The search retrieved 68 references. Authors considered 23 references. Authors evaluated studies on the basis of methodological quality assessment; two independent reviewers assessed all studies by using the Jadad scoring system. In the event of a discrepancy, a third reviewer evaluated the study. Data were obtained by means of the PICO (participants, interventions, comparison, and outcomes) approach. The study employed six different instruments to measure quality of life across four studies; two instruments were used to evaluate pain (three studies used the Brief Pain Inventory).

• The final number of studies analyzed was four.
• The sample size, across studies, was 647 patients. The sample range was 97–189 patients.
• Patients were American or Australian, 55–62 years old, and recruited from outpatient clinics. The sample included various types of pain and cancer diagnoses.

Clinical applications: late effects and survivorship, palliative care

Pain scores decreased as a result of the educational interventions in each study, but effects of education on quality of life were not statistically significant.

A limited number of studies evaluating effects of education on cancer pain and quality of life are available. Based on available studies, education about pain has little effect on quality of life in the specified patient population.

• The studies used different tools to evaluate quality of life
• Whether authors assessed methodological quality is unclear.

• FINAL NUMBER STUDIES INCLUDED = 11
• TOTAL PATIENTS INCLUDED IN REVIEW = 731
• SAMPLE RANGE ACROSS STUDIES: 13–302 patients
• KEY SAMPLE CHARACTERISTICS: Age range was 20–81 years; average age was 52–59 years; variety of diagnoses but mainly breast cancer

PHASE OF CARE: All phases

Seven out of eight acupuncture studies showed improvement in CRF, but only four reached statistic significance. All four acupressure studies showed significant improvement. The four studies that showed improvement during initial treatment determined that results could be maintained for as many as 12 weeks. However, the maintenance study did not determine any extra benefit. Three studies reported no side effects. In other studies, adverse events were identified as minor and transient. Four studies used acupressure. These showed positive results. However, three studies were underpowered, and the comparability of study groups was questionable.

Acupuncture and acupressure may be helpful in reducing fatigue. However, because of multiple methodologic flaws in studies reviewed, no firm conclusions can be made regarding the effectiveness of these interventions.

• Heterogeneity of the samples, sizes, types of cancer, treatments administered, length, dose, and intensity of treatment
• Studies had multiple flaws

Acupuncture and acupressure appear to be safe and may be effective. Therefore, this intervention may be suggested for patients with CRF. Additional research is needed to confirm their effectiveness.