STUDY PURPOSE: To review the evidence for the intraspinal administration of analgesics for refractory cancer-related pain

TOTAL REFERENCES RETRIEVED: 2,672

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: A four-point quality scoring system was described.

• FINAL NUMBER STUDIES INCLUDED = 9
• TOTAL PATIENTS INCLUDED IN REVIEW = Not provided
• SAMPLE RANGE ACROSS STUDIES: Not provided
• KEY SAMPLE CHARACTERISTICS: Not provided

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

Four studies compared combinations of opioids and adjuvant drugs to opioids alone. Two studies compared a neuraxial drug bolus with a continuous infusion, one study compared a single drug with a placebo, and two studies compared neuraxial drug administration with comprehensive medical management. Pain relief was reported in all studies comparing opioids alone or in combination with adjuvant drugs. Better analgesic effects were reported with continuous infusion compared to bolus infusion. Sample sizes were small, and the quality of the studies was low.

There was limited evidence regarding neuraxial analgesic administration for intractable pain in patients with cancer.

There were multiple methodologic concerns regarding study design and sample size. There were few studies for each type of study reviewed. Quality issues identified included loss to follow-up, unclear descriptions of setting, and no report of a power calculation. This review did not report sample sizes and graded items such as lack of setting description alone as equivalent to design issues.

There was limited evidence regarding the efficacy of intrathecal analgesic administration compared to other aggressive forms of pain control for patients with refractory pain, and the most effective drugs or drug combinations for this mode of delivery were not clear. Neuraxial treatment requires appropriate resources for safe administration and patient observation. Nurses have an important role to play regarding the selection of patients for safe home-based care delivery and the assessment of patient risks. Additional research comparing the efficacy of various aggressive pain management interventions is needed.

To conduct a randomized, double-blind, placebo-controlled efficacy study evaluating the effects of oral melatonin in improving sleep in patients with cancer experiencing symptoms of insomnia

The investigators randomized participants who consented into group A (melatonin) or group B (placebo) using a fishbowl technique. Melatonin (3 mg) or placebo (multivitamin tablet) was provided by a pharmacist. Tablets were similar in color (light yellow) and shape, and were wrapped in similar envelopes and given to participants. Instructions were to take tablets two hours prior to bedtime every day for 14 days. The Athens Insomnia Scale (AIS) was given by phone or in person on days 1, 7, and 14. Patients and evaluators were blinded to the drug group, and the group was revealed to research staff at the end of the study. Results were compared using a paired t test.

• N = 50    
• MALES: 13% (group A), 13% (group B); FEMALES: 12% (group A),12% (group B)
• CURRENT TREATMENT: Other
• KEY DISEASE CHARACTERISTICS: Any patients with cancer with sleep complaints were included. No specific exclusion criteria were noted.

• SITE: Single site   
• SETTING TYPE: Outpatient    
• LOCATION: India

• PHASE OF CARE: Multiple phases of care
• APPLICATIONS: Palliative care

Prospective, randomized, double-blind, placebo-controlled study

The AIS self-assessment psychometric tool for measurement of sleep difficulty is an eight-item scale, and the first five items assess sleep induction, nighttime awakenings, final awakening, total sleep duration, and sleep quality. The remaining three items assess daytime well-being, functional capacity, and sleepiness. Items are scaled using 0–3 ratings, from 0 (no problem) to 3 (no sleep at all). The scale cut-off is 10 to predict outcomes.

Power for a sample size of 25 was verified (90% and alpha = 5%). No significant differences in demographic characteristics of age and sex existed (p > 0.05). Each group had one dropout. The sample was predominantly stage 1 (44% [group A], 40% [group B]) and stage 2 (32% [group A], 36% [group B]), and stage 3–4 was 24% in each group. The majority of subjects (54%) had head and neck cancer (e.g., tongue, larynx) followed by cervix cancer (12%), and 14% had ovarian, gastrointestinal, breast, and sarcomas. Group A had significantly improvements in sleep (p < 0.05) on the AIS at week 1 with intragroup improvements in group A in week 2 (p = 0.00001). The percent change in sleep improvement within group A was significant (p = 0.0001) but not significant in group B (p > 0.05).

The use of 3 mg of melatonin two hours prior to bedtime is an effective nonpharmacological treatment for increasing sleep induction and sleep quality in patients with cancer experiencing insomnia.

• Small sample (< 100)
• Measurement validity/reliability questionable
• Questionable protocol fidelity

Additional large-scale randomized studies are needed to determine efficacy. Melatonin has emerging data to support the nonpharmacological treatment of sleep problems in patients with cancer.

To test the safety and efficacy of treatment with localized radiotherapy and capecitabine for management of painful bone metastases

Women with bone metastases from breast cancer received radiation with 30Gy in 10 fractions to cover all metastatic bone regions, given 5 days per week.  Oral capecitabine at 1400mg/m² was given 5 days per week, concurrently with radiation therapy.  Patients were evaluated weekly during treatment and for every 4 weeks after treatment, for a total of 12 weeks after completion of treatment.

• N = 29  
• MEDIAN AGE = 59 years (range = 35–84 years)
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: All patients had one to three areas of bone metastases from breast cancer.
• OTHER KEY SAMPLE CHARACTERISTICS: Eleven patients were also on bisphosphonates.

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

• PHASE OF CARE: Late-effects and survivorship
• APPLICATIONS: Palliative care 

Phase-II, observational study

• National Cancer Institute's Common Terminology Criteria for Adverse Events (NCI's CTCEA) version 3
• Pain intensity evaluated on four-point scale 
• Side effects graded on 0–4 scale
• Analgesic consumption graded on a five-point World Health Organization (WHO) scale
• Response graded according to International Bone Metastases Consensus grading

Side effects were mild. The most prevalent were nausea (33%), diarrhea (24%), weakness (21%), and mucositis (10%). The mean pain score decreased from 2.93 to 2.28 after one week (p < .002), to 1.45 after two weeks (p < .0001), and to 1.14 after four weeks (p < .01). Changes in pain scores after four weeks were not significant. Declines in analgesic use were noted during the first four weeks of treatment (p < .02) and were stabilized thereafter. The response rate was 31% at one week and 38% at 12 weeks. There were no differences between patients who did and did not receive bisphosphonates.

Combined radiation therapy with capecitabine was effective for the short-term reduction on pain from bone metastases with relatively mild side effects in the majority of subjects.

• Small sample (< 30)
• Risk of bias (no control group)
• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Other limitations/explanation: No information was provided regarding pain medications used or pain duration.

Combined radiation therapy and capecitabine may be a promising intervention for the palliation of painful bone metastases. Further research is needed to fully determine its efficacy and toxicity.

To review the evidence for skin care management and conduct a survey to assess current practices in Australia and New Zealand.

Databases searched were MEDLINE, PubMed, CINAHL, Google Scholar, and Google search. Searches were also completed by hand for the time period of 1980 to 2008.

Search keywords were radiation dermatitis, skin reaction, management, skin care, skin toxicity, moist desquamation, dry desquamation, erythema, sorbolene aqueous cream, and aloe vera.

Inclusion and exclusion criteria were not specified.

Thirty-one references were retrieved. Literature was evaluated on the basis of sample size. Meta-analysis was performed on studies reporting at least grade II skin toxicity.

• The final number of studies included was 31.
• The sample size across studies was 3,174 participants (range 413–506).
• Participants had various tumor types.
• All participants received radiation therapy (RT).

Patients were undergoing the active antitumor treatment phase of care.

Findings were reviewed for washing, topical aloe vera, topical sucralfate, Biafine cream, corticosteroids, hyaluronic acid, barrier film, dressings, and wheatgrass extract for prophylaxis. For management, interventions included were topical steroid cream, sucralfate, and dressings. Meta-analysis across studies using any topical prophylaxis showed that any intervention was associated with lower odds of development of skin toxicity (p = 0.02). There were no significant results for management interventions. There was consistent evidence in favor of gentle washing with mild soap during RT. There was some evidence in support of corticosteroids, bepanthan, topical hyaluronic acid, calendula, and barrier films. Aloe vera was associated with higher toxicity. Evidence did not support the use of sucralfate, Biafine, or dressing for prevention. Evidence regarding interventions for management of skin toxicity was conflicted, and none produced significant effects.

Findings support the use of washing. There was some evidence in support of using corticosteroids, bepanthan, barrier films, calendula, and topical hyaluronic acid. Findings suggest that use of any topical therapy for prophylaxis may be more effective than no intervention.

• Analysis was limited by combining all types of interventions together, which did not allow for differentiation between those agents individually shown to be effective and not effective.
• Methods for evaluation of the quality of the research were not well described or incorporated into the analysis. 
• Findings regarding management were questionable because of high heterogeneity among studies included in the meta-analysis. 
• Actual odds ratios or effect sizes from the meta-analysis were not reported. 
• Final recommendations stated by the authors were not consistent with the rest of the conclusions stated elsewhere in the article. 
• The basis for recommendations, concerning evaluation of the quality of the evidence, was not clear. 
• The authors stated that they weighted studies by sample size, but this method was not described.

Washing during RT should not be restricted. There is some evidence in support of using calendula, hyaluronic acid, no-sting barrier film, bepanthan, and topical steroids. Evidence does not support the use of aloe vera.

To evaluate the effect of the administration of tranexamic acid (TA) upon blood loss and the need for transfusions in patients undergoing head and neck surgery

Patients undergoing supramajor head and neck surgeries were randomized to receive TA (10 mg/kg) or placebo (normal saline). The patients were stratified a priori based upon their anticipated surgical procedure. The attending anesthesiologist, blinded to the drug, administered 100 ml of solution of normal saline with or without TA (10 mg/kg) during 20 minutes postinduction of anesthesia, and, if the surgery was prolonged, every three hours during the surgery. Blood loss was measured during surgery and postoperatively for the first 24 hours. A transfusion trigger was established.

• N = 219   
• AGE = 51.9 years (TA) and 50.67 (placebo)
• MALES: 77%, FEMALES: 23%
• CURRENT TREATMENT:  Other
• KEY DISEASE CHARACTERISTICS: Resectable squamous cell carcinoma oral cavity
• OTHER KEY SAMPLE CHARACTERISTICS: Undergoing surgical resection and reconstructive procedures

• SITE: Single site   
• SETTING TYPE: Inpatient    
• LOCATION: Tertiary referral cancer center in India

PHASE OF CARE: Active antitumor treatment

Randomized, placebo-controlled, double-blind, prospective study

Gravimetry, blood collection in suction bottles, and visual inspection were used to calculate intraoperative blood loss; postoperative blood loss was calculated with a measure of the blood collected in suction bottles during 24 hours.

Differences in intraoperative blood loss between the groups was not significant (p = 0.22); however, the placebo group demonstrated a significantly greater amount of blood loss postoperatively than the TA group (p = 0.009). This difference, however, did not translate to a significant difference between groups in the number of transfusions (p = 0.51).

The administration of TA in patients undergoing head and neck cancer surgery did not decrease intraoperative blood loss or overall blood loss; although it did reduce postoperative bleeding, this did not translate to a reduction in the number of transfusions.

Nurses must assess perioperative blood loss because it places patients at risk for serious complications. An ongoing need to evaluate measures exists to decrease this risk. 

To evaluate the efficacy of low level laser therapy (LLLT) for the treatment of chemotherapy-induced oral mucositis (OM) in pediatric patients undergoing chemotherapy or stem cell transplant

Children and adolescents with cancer receiving chemotherapy or hematopoietic stem cell transplantation (HSCT) who developed grade II OM were included. OM was scored daily by the same investigator. In the experimental group, the treatment was applied to each OM lesion for five consecutive days. The control group received sham treatments to each OM lesion for five consecutive days also.

• The study reported on 14 patients with an age range of 4.8–12.3 years.
• The sample was 19% female and 81% male.
• The sample had three patients diagnosed with solid tumors, 15 patients with lymphoma/leukemia, and three patients undergoing stem cell transplant.

This was a single site, inpatient study conducted in the Pediatric Oncology Unit of the Hospital de Clinicas de Porto Alegre at Federal University of Rio Grande do Sul, Brazil.

The study was a randomized, placebo-controlled trial.

• The National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE) version 2.0 was used.
• One examinator assessed mean, standard deviation, and percentiles for age, localization and grade of mucositis, and mucositis severity daily.

No differences were found in grades of mucositis as a function of the LLLT protocol. Mucositis was diagnosed 5.0 to 7.5 days postchemotherapy. On the seventh day after the diagnosis of mucositis, 1 out of 9 patients in the laser group and 9 out of 12 patients in the sham group had grade II or greater OM (p = 0.029). The mean OM duration in the laser group as compared to the sham group was 3.1 days less (p = 0.004).

LLLT can significantly reduce the duration of chemotherapy-induced OM in children.

• The sample size was small with fewer than 30 patients.
• The study did not evaluate pain or functional impairment.

Laser therapy is effective in treatment of mucositis, but it is very high tech and requires special equipment and highly trained personnel.

The primary purpose of this study was to determine the percentage of patients experiencing febrile neutropenia. A secondary goal was to examine infection-related mortality, all early mortality during chemotherapy, bone pain or musculoskeletal pain, and relative dose intensity.

Medline, EMBASE, Cancerlit, Cochrane, Database of Systematic Reviews,and Cochrane Central Register of Controlled Trials database were reviewed.

Key words include G-CSF, granulocyte–colony-stimulating factor, colony-stimulating factors (CSFs), recombinant G-CSF, lenograstim, filgrastim, pegfilgrastim, and pegylated filgrastim, randomized controlled trials

Inclusion criteria was primary and secondary G-CSF prophylaxis   

Studies were excluded if they encompassed those with granulocyte macrophage–colony-stimulating factor (GM-CSF), RCTs in children, leukemia or multiple myeloma, bone marrow or peripheral blood stem cell transplantation, and studies of established neutropenia or febrile neutropenia.
 

12,128 potentially relevant papers were reviewed.

Cochran’s Q statistic and inconsistency index of Higgins,fixed-effects model, and random effects models.

The Jadad scale was used to evaluate study quality.

17 randomized, controlled trials (RCTs) were included.

The total sample size was 3,493 patients  

The sample across all studies ranged from 31–928

Key characteristics included filgrastim in 10 trials (59%), lenograstim in six trials (35%), and pegfilgrastim in one trial (6%). Eleven trials (65%) involved patients with solid tumors and six (35%) were in patients with lymphoma, including four (24%) limited to older adult patients, eight studies using placebo control, and three that permitted secondary G-CSF in control patients (two prohibited its use and the remaining studies did not specify). Five RCTs prohibited the use of prophylactic antibiotics and three used antibiotic prophylaxis. The remaining did not specify.

Active treatment

Reductions in infection-related and early mortality with G-CSF were seen in patients with solid tumors but not among those with lymphoma.

This analysis and review confirms that primary prophylaxis with G-CSF significantly reduces the risk of febrile neutropenia while sustaining and enhancing chemotherapy dose delivery in patients receiving conventional chemotherapy across a broad range of baseline risk in eligible trials. The most important and previously unreported observation that emerged from this overview is the observed reduction in infection-related (RR = 0.552, p = 0.018) and all-cause (RR = 0.599, p = 0.002) early mortality in patients randomized to receive primary prophylaxis with G-CSF. There were no differences based on whether or not patients also received prophylactic antibiotics or between those receiving G-CSF as primary or secondary prophylaxis. 

• Early mortality was not defined in this analysis.
• Although methods for determination of heterogeneity were discussed, findings regarding heterogeneity were not reported.

To evaluate primary granulocyte colony-stimulating factor (G-CSF) prophylaxis versus a placebo or untreated control group

DATABASES USED: Electronic databases through December 2006: MEDLINE, EMBASE, CANCERLIT, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effect, and Conference Proceedings (American Society of Clinical Oncology and American Society of Hematology). In addition, references from included articles and relevant published reports were hand searched, and references from leaders in the field were solicited. The literature search had no language restrictions.

INCLUSION CRITERIA:

• Eligible studies were those of adult patients with cancer receiving conventional-dose chemotherapy for solid tumors or malignant lymphoma and randomly assigned to primary G-CSF prophylaxis versus a placebo or untreated control group.
• Primary G-CSF prophylaxis refers to G-CSF administration in the first cycle of chemotherapy before the onset of neutropenia, whereas secondary G-CSF prophylaxis is defined as G-CSF prophylaxis started in the chemotherapy cycle after the first episode of febrile neutropenia (FN). Patients may have received prophylactic antibiotics as long as they were permitted equally in both study arms.
• G-CSF must have been administered continuously until neutrophil recovery. Previous studies and guidelines concluded that myeloid growth factors are less effective if administered on the same day as chemotherapy, delayed more than four days following chemotherapy, or delayed until the onset of neutropenia. Therefore, studies were eligible only if the initiation of G-CSF was one to three days after the completion of myelosuppressive chemotherapy in each cycle.
• Studies in which control patients received secondary G-CSF prophylaxis after the first cycle with the same myeloid growth factor were permitted.

EXCLUSION CRITERIA:

• Studies were excluded if they used granulocyte-macrophage colony stimulating factor, were studies of children or patients with leukemia or multiple myeloma, included bone marrow or peripheral blood stem cell transplantation, or represented an economic analysis.
• Studies also were excluded if G-CSF was administered for established neutropenia or FN. Studies of patients receiving dose-dense or dose-escalation chemotherapy were excluded, as were studies that allowed differing drugs, doses, or schedules of chemotherapy or G-CSF in the different study arms.

FINAL NUMBER STUDIES INCLUDED = 17 RCTs of primary prophylactic G-CSF

TOTAL PATIENTS INCLUDED IN REVIEW = 3,493 patients

KEY SAMPLE CHARACTERISTICS:

• Ten studies (59%) used filgrastim, six (35%) used lenograstim, and one (6%) used pegfilgrastim.
• The cancer types consisted of solid tumors in 11 trials (65%) and aggressive non-Hodgkin lymphoma in six RCTs (35%).
• Four RCTs (24%) were limited to elderly patients with lymphoma.
• Eight studies used placebo control.
• At least three trials permitted secondary prophylaxis with G-CSF in control patients, with only two reports explicitly prohibiting this use of G-CSF. Eleven trials failed to specify whether secondary prophylaxis with G-CSF was allowed in controls.
• Prophylactic antibiotics were used in three trials, prohibited in five trials, and not specified in eight trials.

The occurrence of FN was reported as an outcome in 15 trials with 3,182 patients.

• G-CSF reduced the risk of FN by 46%.
• FN occurred one or more times in 39.5% of controls and 22.4% of G-CSF patients, resulting in a weighted summary RR of 0.54 (95% CI, 0.43 to 0.67; P < .0001).
• Filgrastim (RR = 0.61; 95% CI, 0.53 to 0.72) and lenograstim (RR = 0.62; 95% CI, 0.44 to 0.88) had similar efficacy.
• The single pegfilgrastim study demonstrated significantly greater efficacy (RR = 0.08; 95% CI, 0.03 to 0.18) compared with filgrastim and lenograstim (P < .0001).

Infection-related mortality was reported as an outcome in 12 trials including 1,454 control patients and 1,463 patients receiving G-CSF.

• Overall, infection-related mortality was observed in 2.8% of controls and 1.5% of G-CSF patients, for a weighted summary RR of 0.55 (95% CI, 0.34 to 0.90; P = .018).
• Reductions in infection-related mortality with G-CSF were observed among studies of filgrastim (RR = 0.53; 95% CI, 0.30 to 0.92; P = .024). Statistical analysis of the subset of patients who received lenograstim or pegfilgrastim was not possible because the sample size was too low to detect differences.

Early mortality was reported in 13 trials with 3,122 patients.

• Overall, early mortality was observed in 5.7% of control patients and 3.4% of G-CSF patients, resulting in a weighted summary RR of 0.60 (95% CI, 0.43 to 0.83; P = .002).
• Reductions in early mortality with G-CSF were observed among studies of filgrastim (RR = 0.60; 95% CI, 0.41 to 0.89; P = .010) and pegfilgrastim (RR = 0.36; 95% CI, 0.13 to 0.99; P = .047) but not lenograstim (RR = 0.84; 95% CI, 0.38 to 1.83; P = .657).

Relative dose intensity (RDI) was reported as an outcome in 10 trials. The average RDI among control patients in these studies ranged from 71.0%–95.0%, with a mean RDI of 86.7% (median RDI: 88.5%).

• Among G-CSF-treated patients, the average RDI ranged from 91.0%–99.0%, with a mean RDI of 95.1% (median RDI: 95.5%). RDI differences between study arms ranged from 2.8%–20.0%, with average differences of 8.4% (P = .001). None of the 10 G-CSF treatment arms reported an average RDI of less than 90%, whereas 6 of 10 control groups reported a mean RDI of less than 90%, with four control arms averaging an RDI of 85% or less.

Bone or musculoskeletal pain during the course of chemotherapy was reported as an outcome in 14 trials including 3,029 patients.

• Bone pain was reported in 10.4% of controls and 19.6% of G-CSF-treated patients, for a weighted summary RR of 4.023 (95% CI, 2.156 to 7.52; P < .0001).

To investigate the protective effects of glutamine on radiation-induced diarrhea

Patients were divided into two groups. One group received 15 g oral glutamine each day beginning one week prior to radiotherapy and continuing until one week after radiation therapy completion. The other group was given an oral glucose solution.

• The study consisted of 36 patients with a mean age of 66 years.
• The sample was 62% male and 38% female.
• Renal, prostate, bladder, and gynecologic were the most common cancers.
• All were receiving radiation therapy in the range of 45–70 Gy. Some also had received concomitant chemotherapy with 5 fluorouracil (5FU) or cisplatin.

The study was conducted at a single outpatient site in Turkey.

Patients were undergoing the active treatment phase of care.

This was a two-group prospective trial.

• Patient diaries were used. 
• The National Cancer Institute (NCI) Common Toxicity Criteria (CTC), version 3.0, for diarrhea was used.
   

No between-group differences were found in overall incidence of diarrhea. None of the patients in the glutamine group developed grade 3–4 diarrhea, compared to 69% of those in the placebo group (p = 0.0000). More patients in the placebo group required loperamide and parenteral supportive therapy.

Findings suggest that oral glutamine may be helpful in the prevention and management of severe radiation-induced diarrhea.

• The sample size was small with fewer than 100 patients.
• A risk of bias exists because no blinding or random assignment was used.
• More patients in the placebo group received 5FU and had rectal cancer. 
• Diarrhea grading depends on patient recall of stool frequency, so reliability and accuracy may be questionable.
• The authors did not clarify how the criteria were applied and what toxicity value was used in analysis, because grading was apparently done twice weekly. 
• A 10% drop-out rate occurred because of a lack of compliance with the oral medication. 
• The glucose solution used as placebo was not well described. The nature of this solution could have worked as an osmotic laxative in the placebo group. 
• The authors did not explain how patients were assigned to study groups.

Findings suggest that oral glutamine may help in the prevention of severe radiation-induced diarrhea. However, study design issues limit the quality of this study. Use of glutamine warrants further investigation in large, well-designed randomized studies.

To determine if patients receiving treatment for cancer experienced less treatment-related fatigue if they participated in a regular committed exercise regimen, compared to those who did not exercise regularly.

Databases searched were CINAHL, MEDLINE, Ovid, and ProQuest between January 2000 and October 2006.

Search keywords were fatigue, cancer, and exercise.

Studies were included in the review if

• The date range was January 2000 to October 2006
• The participants were 18 years or older
• They were written in the English language
• They were published in peer-reviewed nursing and healthcare journals
• They were quantitative or qualitative studies.

Two unpublished doctoral dissertations were also included.

Initially, 400 articles addressing the topics of fatigue, cancer, and exercise were found. When the inclusion criteria were applied, 10 studies were included. Levels of evidence presented were established using the Priority Symptom Management (PRISM) system developed by the Oncology Nursing Society.  No meta-analysis was performed due to differing definitions and methods of measurement of fatigue across studies.  All studies demonstrated strong levels of evidence of PRISM level I or II. Brief summaries of study design, exercise regimen, outcomes, limitations, level of evidence, and study recommendations were provided. Studies were identified within two major categories: home-based exercise interventions and out-of-home exercise interventions.

• There were 523 total participants across 10 studies.
• Sample sizes of studies ranged from 12 to 108 participants.

The majority of studies (eight of 10) used home-based exercise interventions.

Eight of the studies had findings that supported exercise during treatment to reduce fatigue.  In the two studies that did not show differences in fatigue, one had a very small sample size and one showed poor patient adherence to the exercise regimen.

Exercise was generally well tolerated by participants, and there were no adverse events associated with exercise.

Components of the regimens that were found to be beneficial were

• Ease of treatment (home-based, use of own equipment, etc.)
• Interest in treatment (allowing patients to choose an aerobic activity of interest to them, such as biking, walking, swimming, etc.)
• Inclusion of a daily diary to record frequency and intensity of exercise, as well as other symptoms
• Design of a program based upon a physician’s assessment of individual abilities
• Participation in a group exercise program provided support and increased motivation.

Theoretical foundations of studies were reviewed. These included

• Transtheoretical Model
• Roy’s Adaptation Theory
• Adherence
• Multidimensional conceptual framework interrelating psychosocial and physiologic dimensions of fatigue.

The evidence suggested that an individualized exercise program should be included in the treatment of patients receiving chemotherapy and/or radiation therapy. Studies have not shown any adverse effects, such as increased fatigue or falls, as a result of exercise. Studies retrieved were limited to four types of cancer: multiple myeloma, breast, lung, and prostate. Studies reviewed encompassed both early and late stages of disease.

Common limitations found among the studies reviewed included

• Lack of a universal definition of fatigue
• Lack of a universal instrument or method to measure fatigue and evaluate the effectiveness of interventions.

Use of common definitions and methods of measurement of outcome variables is needed to further advance this area of study. Evidence supports the inclusion of scheduled exercise in the care plan of patients undergoing cancer treatment. It was noted that approximately 50% of healthy Americans have been shown to have difficulty initiating and maintaining an exercise program for more than three months. This suggests that individuals with cancer are likely to need professional support to begin and maintain an exercise program. Nurses’ awareness of the role of exercise can enable better education that benefits patients.