Hegg, R., Mattar, A., Matos-Neto, J.N., Pedrini, J.L., Aleixo, S.B., Rocha, R.O., . . . van-Eyll-Rocha, S. (2016). A phase III, randomized, non-inferiority study comparing the efficacy and safety of biosimilar filgrastim versus originator filgrastim for chemotherapy-induced neutropenia in breast cancer patients. Clinics, 71, 586–592.
To compare the efficacy and safety of two filgrastim formulations for controlling chemotherapy-induced neutropenia and to evaluate the noninferiority of the test drug against the original
Patients with grade 4 neutropenia were randomized 1:1 to Eurofarma filgrastim or Roche filgrastim. Doses were administered subcutaneously daily 5 mg/kg until absolute neutrophil count was 10,000/mm3 or greater or until the 15th day of the chemotherapy cycle (V14). Only a single event of febrile neutropenia was considered during the study period per patient. Neutrophil counts were drawn every two days.
Phase III, open-label, noninferiority, randomized, two-group trial
To assess the noninferiority of the test drug to the original the 90% confidence interval for the difference in the rates of grade 4 neutropenia between the two groups were initially calculated.
No significant difference (p = 0.9971) in the rate of grade 4 neutropenia existed in the total number of patients in each group during the first chemotherapy cycle.
Risk of bias (no blinding)
The increased surveillance of patients’ neutrophils may have produced better outcomes. The difference between the two drugs was negligible. Strong patient teaching is warranted, regardless of the process of events during the chemotherapy cycle.
Heggie, S., Bryant, G. P., Tripcony, L., Keller, J., Rose, P., Glendenning, M., & Heath, J. (2002). A phase III study on the efficacy of topical aloe vera gel on irradiated breast tissue. Cancer Nursing, 25, 442–451.
To see if topical aloe vera gel would be beneficial in reducing the skin side effects of radiation therapy (RT).
Participants were stratified according to bra cup size, history of lymphocele drainage, and smoking. Participants were randomized to use of aloe vera or an aqueous cream for control.
Mater Centre, Australia, and the Royal Brisbane Hospital Centre, Australia
The study was a randomized, controlled, double-blind trial.
Aqueous cream was significantly better than aloe vera gel in reducing the incidence of dry desquamation and moderate or higher pain (p < 0.001). Participants with cup size D or more in either treatment arm experienced a significantly greater incidence of moderate or higher erythema compared with smaller-breasted women (p < 0.02). For non-chemotherapy participants, the aloe vera arm experienced a significantly reduced incidence of moderate or higher erythema (p = 0.02). The control group arm experienced a significantly reduced incidence of moderate or higher pain (p = 0.03). The most important predictors of development of skin reaction were radiation dose, breast size, patient smoking, and damage to the lymphatic system manifested by one or more lymphocele drainage. Cumulative dose was greater than 2,700 cGy, and there was a delay to onset of erythema (p = 0.013).
Aqueous cream is superior to aloe vera in reducing the acute RT skin reactions of dry desquamation and pain.
Hegarty, F., & Wong, M. (2014). Polymeric membrane dressing for radiotherapy-induced skin reactions. British Journal of Nursing, 23, S38–S46.
To clinically evaluate the use of a polymeric membrane for the management of radiodermatitis in terms of skin integrity, management of desquamation, relief of pain and inflammation, and healing time
Patients with Radiation Therapy Oncology Group (RTOG) scores of 1–3 and early signs of skin reactions were followed for four weeks during treatment. Study data and patient assessments were obtained weekly. The polymeric dressing provided a mild cleansing agent activated by exudate that supported natural debridement. The dressing also contained glycerine, which provided moisture, and surfactant, which has been reported to reduce tension between healthy and unhealthy tissue.
Observational
From baseline to week 3, RTOG scores improved. Diary pain scoring showed an overall reduction in pain from an average of 6.5 to 1.6. Fixation of the dressing was a challenge, particularly among patients with breast and gynecologic cancers. Themes from a qualitative analysis of patient diaries identified skin improvement, a cooling effect of the dressing, and pain reduction.
Polymeric dressing use may be helpful for the prevention and treatment of radiodermatitis.
Polymeric dressings may be helpful for the prevention and treatment of radiodermatitis. Additional, well designed, clearly reported studies are warranted. Keeping this specific dressing in place was found to be a challenge for some patients.
Kim, Y.H., Kim, H.J., Ahn, S.D., Seo, Y.J., & Kim, S.H. (2013). Effects of meditation on anxiety, depression, fatigue, and quality of life of women undergoing radiation therapy for breast cancer. Complementary Therapies in Medicine, 21(4), 379–387.
Investigate the effects of meditation on the symptoms of anxiety, depression, and fatigue in women who were receiving radiation therapy for breast cancer
The intervention group received a total of 12 meditation therapy sessions during its six-week radiation therapy period. The control group received only conventional radiation therapy. The meditation intervention was Brain Wave Vibration meditation, which is based on a Korean traditional exercise, simple movements, music, and positive messages (changing weekly). This focuses on the senses of the body, relaxing the body and mind and relieving negative thoughts through natural rhythmic movements.
Randomized, controlled trial
Patients who received meditation therapy saw mild improvements, with a reduction in anxiety and fatigue. Patients in the control group also showed significant reduction in fatigue and anxiety, and post-intervention scores actually were lower for both of these in the control group. No effect was seen for depression.
The study states that an “affirmation” can be made that meditation can be used as a non-invasive intervention for improving fatigue and anxiety. However, results showed significant reductions in these symptoms for patients in the control group as well. This provides minimal support for effectiveness of the approach used here.
Nurses likely would not have any options of referral to meditation resources. Something more generalizable, like relaxation or mindfulness, would have been a better option for a study. The study is Korean; typically educated Korean women may have had previous exposure to meditation, and the intervention would be more acceptable to them than to American women.
Heckman, K.D., Weiner, G.J., Davis, C.S., Strauss, R.G., Jones, M.P., & Burns, C.P. (1997). Randomized study of prophylactic platelet transfusion threshold during induction therapy for adult acute leukemia: 10,000/microL versus 20,000/microL. Journal of Clinical Oncology, 15, 1143–1149.
To compare two common prophylactic platelet transfusion thresholds for patients receiving induction chemotherapy for acute leukemia
Patients were divided into four groups: new diagnosis of leukemia in patients aged less than 60 years; new diagnosis in patients 60 years or greater; relapsed disease in patients aged less than 60 years; and relapsed disease in patients aged 60 years or greater. Patients were randomized by selecting cards from an envelope to receive platelets when their morning platelet counts were either 10,000 microliters or 20,000 microliters. All platelet apheresis product transfusions were given according to the same transfusion orders. Controls for failure to respond to platelet transfusion for all participants were included in the study as well as guidelines for removing patients if warranted. For serious and life threatening bleeding, and as otherwise directed by the treating physician, therapeutic platelets were administered to study participants.
Prospective, randomized trial
The study found that there was no statistical difference in the total number of bleeding episodes between the two groups of patients (p = .12). Of note, there was a significant increase in platelet reactions in the platelet group receiving ≤ 20,000 microliters (p = 0.005).
Administration of prophylactic platelets at a threshold of 10,000 microliters can cut back the utilization of platelets and reduce the incidence of viral exposure without a statistically significant effect on morbidity.
Nurses need to be familiar with professional guidelines and institutional policies regarding platelet transfusions. This would include the use of premedications, post-transfusion blood drawing, and reporting of platelet reactions. For those institutions that use platelet thresholds higher than 10,000 microliters, it may be time to revisit practice based on the findings of this study.
Heckler, C.E., Garland, S.N., Peoples, A.R., Perlis, M.L., Shayne, M., Morrow, G.R., . . . Roscoe, J.A. (2016). Cognitive behavioral therapy for insomnia, but not armodafinil, improves fatigue in cancer survivors with insomnia: A randomized placebo-controlled trial. Supportive Care in Cancer, 24, 2059–2066.
To assess the combined and comparative effect of cognitive behavioral therapy (CBT) and armodafinil to improve sleep and daytime functioning in survivors of cancer.
Participants were randomized to (a) CBT-I and placebo, (b) CBT-I and armodafinil 50 mg b.i.d., (c) placebo BID, or (d) armodafinil 50 mg BID. All received written sleep hygiene guidelines. Participants had CBT-I in 30–60-minute individual, in-person sessions during weeks 1, 2, and 4; and had 15–30-minute phone sessions during weeks 3, 5, and 7. Study medicine was taken for 47 days from 7 am to 9 am and 12 pm to 2 pm.
Improvement in fatigue was noted with CBT for insomnia (p = 0.002 on BFI; p < 0.001 on FACIT-F). No improvement in fatigue was noted with placebo, on armodafinil alone, or on armodafinil with CBT-I.
CBT for insomnia appears to improve fatigue in patients with insomnia, and armodafinil was not shown to improve fatigue in patients with insomnia and fatigue.
This study shows that CBT for insomnia may be beneficial to patients with fatigue and that armodafinil does not improve fatigue.
Hecht, J.R., Pillai, M., Gollard, R., Heim, W., Swan, F., Patel, R., . . . Malik, I. (2010). A randomized, placebo-controlled phase ii study evaluating the reduction of neutropenia and febrile neutropenia in patients with colorectal cancer receiving pegfilgrastim with every-2-week chemotherapy. Clinical Colorectal Cancer, 9, 95–101.
The purpose of this study is to evaluate whether prophylactic pegfilgrastim administered with first- or second-line chemotherapy was feasible and reduced the incidence of grade 3/4 neutropenia and neutropenia-related complications in patients receiving 14-day oxaliplatin- or irinotecan-containing 5-FU–based chemotherapy regimens for advanced or metastatic colorectal cancer (CRC).
One of three chemotherapy regimens (FOLFOX 4, FOLFIRI, or FOIL) was selected by physician discretion. Patients were randomized to receive either pegfilgrastim 6 mg or placebo on day 4 of each 14-day regimen. During the study period (the first four cycles of chemotherapy), the incidence of grade 3/4 neutropenia and febrile neutropenia were compared between the pegfilgrastim and placebo groups.
Active treatment
Randomized, controlled trial, double-blinded. The control group received placebo.
Patients treated with pegfilgrastim were significantly less likely (13%) to develop grade 3/4 neutropenia than those who received a placebo (43%) (p < 0.05). The pegfilgrastim group also experienced significantly fewer dose delays or dose reductions (33.4% versus 45%) (p < 0.05).
The study compares pegfilgrastim versus placebo, but does not consider pegfilgrastim versus filgrastim, which may have similar efficacy at reduced expense. Additional study is warranted, including a cost-benefit analysis.
Patients with CRC receiving every-two-week chemotherapy regimens may benefit from supportive medications to stimulate neutrophil production.
Hebert, R.S., Schulz, R., Copeland, V.C., & Arnold, R.M. (2009). Pilot testing of a question prompt sheet to encourage family caregivers of cancer patients and physicians to discuss end-of-life issues. American Journal of Hospice and Palliative Medicine, 26, 24–32.
To develop a question prompt sheet (QPS) for use by physicians and family members of seriously ill patients
QPS development: HCPs from various disciplines including medicine, nursing, psychology, social work, clergy, and ethics who had at least two years of experience in end-of-life care helped define the QPS. Family caregivers used a large community-based hospice consult service for care of a seriously ill family member who had a life expectancy of less than six months. Bereaved caregivers included those who had lost a family member within the past year. Bereaved caregivers were either African American (n = 15; 45%) or Caucasian (n = 18; 55%). Primary patient illnesses (n = 23) were cancer (n = 10; 82%) and cardiovascular disease (n = 6; 26%).
QPS pilot testing: Caregivers were Caucasian (95%), African American (2%), or other (2%). The relationship to the patient was spouse (55%) or nonspouse (45%). The mean number of months providing care to the patient was 28 months. The mean hours per week providing care was 132 hours. Patients mainly had a diagnosis of cancer.
Prospective tool development and a feasibility pilot study were used.
The QPS, which encompasses medical, practical, psychological, and religious/spiritual informal caregiver concerns, had high content validity (> 0.80) and appeared in a satisfactory structure and layout based on caregiver feedback. Caregivers noted 17 of 25 questions as important for caregiver–physician discussion, including patient medication effects (46%), what to expect in the future (45%), patient depression (39%), who to call for help (32%), addiction (30%), hospice (25%), home-health services (23%), treatment risk (23%), whether the patient will have pain (21%), nutrition and anorexia (21%), suffering (21%), what to expect when the patient is dying (21%), recovery from illness and life expectancy (20%), and bereavement support (20%). Caregivers found the QPS easy to understand and felt comfortable completing the form in the clinic. Physicians involved in the study believed the QPS was valuable and nondistracting to clinical work. Family caregivers (70%–75%) reported that the QPS made it easier to ask questions in front of the family.
The QPS was evaluated by informal caregivers who found the tool acceptable and feasible for use in an outpatient palliative care setting. A QPS used in caregiver–physician clinical discussions can facilitate informal caregivers’ ability to ask important questions that increase their comfort during end-of-life care of a loved one.
The QPS or a similar tool outlines possible informal caregiver questions that nurses could address in care delivery. The main questions that caregivers chose to use in the study, such as those pertaining to medication side effects, what to expect in the future, or patient depression, highlight and provide guidance for discussion with family caregivers.
Inclusion of caregivers in conversations with the nurse may build rapport and trust that may facilitate initiation of discussion regarding end-of-life concerns and caregiver coping and health promotion issues. An interdisciplinary approach, including nursing involvement, allows meeting of complex patient–caregiver needs throughout the trajectory of care of a serious illness, including cancer.
Further refinement and testing of the QPS is important since it addresses the need to improve communication and stimulate discussions between informal caregivers and HCPs about an ill patient. Areas for further development include the unique perspective of the woman caregiver, literacy level of the QPS user, and testing in other populations.
The questions this study raises regarding good communication for future study are important. The QPS, although providing a structure for question asking, does not address the caregiver–physician relationship aspect that supports understandable and comfortable delivery of information between both parties. The QPS questions seem to focus on the patient’s needs and how the caregiver can respond to those needs. Few focus on caregiver needs as a result of caregiving to support continued care or recovery from bereavement. Continued work must address ways, including use of appropriate screening tools, to facilitate optimal caregiver and physician communication throughout the care cycle of a seriously ill family member to increase quality of life for carers.
He, X.R., Wang, Q., & Li, P.P. (2013). Acupuncture and moxibustion for cancer-related fatigue: A systematic review and meta-analysis. Asian Pacific Journal of Cancer Prevention, 14, 3067–3074.
STUDY PURPOSE: To evaluate the auxiliary effectiveness of acupuncture and moxibustion in the treatment of cancer-related fatigue (CRF)
TYPE OF STUDY: Systematic review and meta analysis
PHASE OF CARE: Active anti-tumor treatment
Fatigue declined over time for all groups: true acupuncture, sham acupuncture, and controls. However, no significant difference between groups was noted. Three studies looked at moxibustion lacking information on adverse effects and inadequate methodology.
The authors concluded that data is currently insufficient to recommend as an intervention for CRF other than when traditional interventions fail. No data exist to recommend this over conventional interventions, which are not described in this article.
Insufficient date to recommend.
Haywood, A., Good, P., Khan, S., Leupp, A., Jenkins-Marsh, S., Rickett, K., & Hardy, J.R. (2015). Corticosteroids for the management of cancer-related pain in adults. Cochrane Database of Systematic Reviews, 4, CD010756.
Studies included were of steroids used as a treatment with pain assessed as an outcome. Dexamethasone was used in eight studies. Nine of the studies were designed with pain as an outcome. Six were placebo-controlled studies, one was a crossover study with a placebo, five had active controls, one was an open-label study, and two were low- versus high-dose studies. There did not appear to be a statistic benefit to the use of corticosteroids for all patients with cancer-related pain. Studies compared corticosteroids to standard therapy. A meta-analysis was done of six studies, and the others were not included because of missing data. There was insufficient data to do a subgroup analysis. A data point of one week was used as a standardization point for the interventions of the six studies in the meta-analysis. The meta-analysis showed an overall mean difference of –0.84 (p = 0.002) in favor of corticosteroids. There was insufficient evidence to evaluate side effects.
Evidence appeared to be weak in regard to the efficacy of corticosteroids for pain relief in patients with cancer. Although the meta-analysis suggested some benefit, the confidence interval was wide, and the quality of the studies included was low.
There was limited evidence to support the use of corticosteroids for chronic pain. If used, their benefit should be evaluated frequently and discontinued if none is found. Corticosteroids have numerous side effects, and the benefits versus harms must be weighed before their use in patients with cancer-related pain.