To determine the incidence and severity of acute skin toxicity with IMRT compared to conventional RT

Women treated with breast conserving surgery and IMRT were matched one to one with historical controls based on bra size and chest wall separation. Maximum recorded skin toxicity during six weeks of RT was compared between the two groups using Chi-squared analysis or Fisher-exact tests. Cases were grouped for analysis by bra size.

• The study sample was comprised of 133 female cases, with 73 IMRT and 60 conventional historical controls cases.
• All patients had breast cancer in stage 0, I, or II.
• Breast dose ranged from 46–50 Gy, with a median of 46; the total dose ranged from 50–64 Gy, with a median of 60 in IMRT and 64 in conventional.

The study took place at Fox Chase Cancer Center.

The study used a prospective comparison with matched historical controls design.

Acute skin toxicity was scored using the National Cancer Institute (NCI) common terminology criteria (CTC) for acute radiation dermatitis by the physician or nurse weekly during treatment. Scores given to evaluate erythema were grade 1 for mild and grade two for moderate. Scores given for desquamation were grade 1 for dry and grade 2 or 3 for moist. Additional variables included in analysis were chest wall separation, total energy megavoltage, use and timing of chemotherapy, use and timing of tamoxifen, and tumor stage.

The degree of desquamation was greater for conventional patients (p = 0.0001). In the IMRT group, 21% had grade 2, compared to 38% in the RT group. Grade 1 desquamation was higher in the IMRT group (37% IMRT, 10% RT). No patient had grade 3 desquamation. There were no differences between the two groups in CTC or erythema scores. Subgroup analysis showed that the incidence and severity of desquamation by bra size was significantly lower in the IMRT group for small and large breast sizes (p < 0.04) but not for medium sizes. Use of IMRT (p = 0.0011) and breast size (p < 0.0001) were the only significant predictors for having moist desquamation.

IMRT was associated with reduced incidence and severity of desquamation.

Although CTV was found to be a significant predictive variable, it was not included in the stepwise regression analysis.

To evaluate the feasibility and efficacy of palliative radiation therapy given via static ports of tomotherapy

Tomotherapy is a treatment modality that delivers a series of highly modulated linear beam paths for hypofractionated palliative radiation therapy (RT). Doses given were 3 Gy in 10 fractions, 4 Gy in five fractions, or 8 Gy in one fraction. The selection of a schedule was individualized to patients. Pain was evaluated by physicians immediately before RT for current, worst within the past 24 hours, least, and average pain. Opioid consumption in the previous 24 hours was evaluated.

• N = 130
• MEDIAN AGE = 68 years (range = 36–89 years)
• MALES: 41%, FEMALES: 59%
• KEY DISEASE CHARACTERISTICS: Various tumor types were included with the most common being non-small cell lung, breast, and prostate cancers. All participants had painful bone metastases. The most common RT sites were the pelvis, lumbar region, and thoracic columns.
• OTHER KEY SAMPLE CHARACTERISTICS: In total, 64% of participants were receiving active antitumor treatment.

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

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

Prospective, observational study

• 11-point Numeric Rating Scale (NRS) for pain
• Pain response definitions were identified according to score reductions or increases by two points and by stable, increased, or decreased opioid consumption.

At two weeks, response rates ranged from 49%–55% with no significant difference between the fractionation groups. Among all patients, opioid consumption decreased (p < 0.001). At two months, response rates decreased to 40%. The rate of no response was highest in the 8 Gy single fraction group. This group also had increased opioid use and more frequent retreatment.

RT is effective for pain relief in patients with painful bone metastases. This study suggested that the TomoDirect™ delivery of RT can be feasible and effective.

• Risk of bias (no control group)
• Risk of bias (no blinding)
• Risk of bias (no random assignment) 
• Unintended interventions or applicable interventions not described that would influence results 
• Measurement/methods not well described
• Measurement validity/reliability questionable
• Other limitations/explanation: No information regarding the use of bone modifying agents was given. Pain was assessed by physicians rather than patient-reported. Which pain scores were used for analysis was not clear.

RT was effective for pain reduction in patients with painful bone metastases; however, the duration of palliation may be brief. Studies have suggested that multiple fractionation for RT delivery may be more effective.

To test the effectiveness of the application of a mixture of turmeric and honey on treatment-induced oral mucositis in patients receiving chemotherapy and radiation therapy

Patients were randomly assigned to receive the mixture of turmeric and honey or to a control group that did not receive the intervention. The mixture was applied for five minutes before treatment and again five minutes after treatment. Study measures were obtained on days 2, 4, and 6 of treatment.

• N = 60
• AGE = 50% were between 50–60 years
• MALES: Not provided, FEMALES: Not provided
• KEY DISEASE CHARACTERISTICS: Not provided
• OTHER KEY SAMPLE CHARACTERISTICS: Fifty-five percent were rinsing their mouth after eating, 56.7% were using toothpaste, and 51.7% were brushing their teeth once a day.

• SITE: Single site  
• SETTING TYPE: Not specified  
• LOCATION: India

• PHASE OF CARE: Active antitumor treatment

• Randomized, controlled trial

• World Health Organization Oral Mucositis Scale

The mucositis score was significantly lower at all post measurements in the experimental group (p < 0.05). Scores were similar between groups at baseline, but subsequent measures were lower in the experimental group.

The combination of turmeric and honey may provide some protection against the development of oral mucositis and may provide benefit for treatment.

• Small sample (< 100)
• Risk of bias (no blinding)
• Questionable protocol fidelity
• Not all patients were performing mouth care, and the differences in this aspect between groups is unknown. The method of randomization was not stated. Treatment and disease type information were not provided.

The results of this study suggest that turmeric and honey may have some promise in the management of oral mucositis, but this study has several substantial limitations. Further well-designed research is needed. One of the basic needs for preventing and managing oral mucositis is regular mouth care, the foundation of any intervention.

• This article reviewed the neurotransmitter and receptor systems involved with chemotherapy-induced nausea and vomiting (CINV) and a brief history of development of antiemetic therapies. CINV classifications was defined as follows.
  • Acute—occurring and resolving within 24 hours of chemotherapy
  • Delayed—occurring more than 24 hours after chemotherapy administration
  • Breakthrough—occurring despite antiemetic therapy
  • Refractory—unmanageable with current antiemetics
  • Anticipatory—conditioned response after prior inadequately controlled CINV.
• The article stated that anticipatory CINV is the most common kind.
• The article reviewed the mechanism of action and current knowledge regarding common antiemetic regimens and noted that given the physiology involved, optimal treatment requires a combination of therapies targeting multiple systems.

• Dexamethasone in combination with 5-HT₃ receptor antagonists is recommended (unless contraindicated or not tolerated). The author noted that this is too often not included.
• In delayed emesis, metoclopramide has been shown to be equivalent to ondansetron in controlling delayed CINV. Metoclopramide is also associated with extrapyramidal symptoms.
• Differences among 5-HT₃ receptor antagonists were noted.
  • Among first generation drugs, overall efficacy of the agents are similar.
  • Palonosetron is a second generation drug with a longer half-life, which appears to be associated with some preventive benefits.
  • Results of studies indicate that without some combination therapy, these drugs alone will fail in 40%–50% of patients.
  • The author noted that some individuals have a genetic tendency to metabolize these drugs differently and those with ultra-rapid metabolism have less therapeutic benefit. Palonosetron appears to have a smaller effect in this area.
• The effects of 2 mg per day of oral granisetron and 3.1 mg per day via epidermal patch appear to be similar.
• The addition of aprepitant (a neurokinin 1 [NK1] antagonist) to 5-HT₃ receptor antagonists and dexamethasone has demonstrated success. A larger benefit has been found for women than for men. The current approved regimen for aprepitant is a three-day regimen; however, ongoing studies are under way to determine if additional doses are helpful. When using aprepitant, the dexamethasone dosage should be reduced. A potential interaction between aprepitant and chemotherapeutic agents such as ifosfamide have been noted. In one study, the combination was associated with increased neurotoxicity.
• Olanzapine is an antipsychotic that blocks multiple neurotransmitters involved in CINV. Trials of olanzapine in combination with granisetron plus dexamethasone and palonosetron plus dexamethasone have demonstrated effectiveness in preventing CINV.

This article demonstrated the importance of combination therapy for prevention and management of CINV. The author provides a good overview of relevant physiology, mechanism of action of current agents, and current regimens used. The article points to the need for additional research with the use of olanzapine for CINV.

To test the proof of concept for a web-based intervention for fatigue designed to enhance self-efficacy in the management of cancer-related fatigue to inform the design of an effectiveness trial

This study was a multi-center, parallel-group, two-armed (1:1), exploratory, randomized (RESTORE or written leaflet), controlled trial with qualitative process evaluation. Patients were randomly assigned to receive an informational leaflet or participate in the use of a web-based program. The web-based program consisted of five sessions, including mandatory sessions on fatigue and goal setting and four other sessions that patients could choose from, that were presented to the patient at weekly intervals. The program also included videos of patient stories and automated tailored feedback components.

• N = 118 in trial, 159 in ITT
• AGE: 29–80 years
• MALES: 23.3%, FEMALES: 76.7%
• KEY DISEASE CHARACTERISTICS: Invasive cancer diagnosed five or less years prior to study, no evidence of metastatic disease, completed curative-intent cancer treatment 
• OTHER KEY SAMPLE CHARACTERISTICS: Self-reported moderate-to-severe fatigue, access to the Internet, had or were willing to establish an email account

• SITE: Multi-site  (N = 12)  
• SETTING TYPE: Not specified  
• LOCATION: United Kingdom sites

• PHASE OF CARE: Late effects and survivorship
• APPLICATIONS: Elder care

• Parallel group, two-armed (1:1), exploratory, randomized, controlled trial

• Fatigue self-efficacy
• Cancer survivor self-efficacy (Confidence in performing disease-related care activities)
• Brief Fatigue Inventory (BFI)
• Personal Wellbeing Index (PWI) (Satisfaction with life)
• Functional Assessment of Cancer Therapy-General (FACT–G) (Physical, social, emotional, and functional well-being)
• Patient Health Questionnaire-9 (PHQ-9) (Depression screen) 

FEASIBILITY: Forty-one percent of eligible patients consented to the study (16% of screened patients). The randomization process resulted in generally balanced groups with the exception of “not working” and “days since last cytotoxic treatment.” ACCEPTABILITY: Fifty percent indicated that the timing of program delivery was “about right”; others would have preferred earlier. Participants reported feeling supported and reassured that someone was interested in their fatigue. The attrition rate from consent to T2 was 36%. Seventy-one percent of participants determined to have adhered to intervention (completed sessions 1 and 2 and one of the remaining three sessions). No significant differences in symptoms or self-efficacy existed between groups.

Web-based resource (RESTORE) for the enhancement of self-efficacy in the management of cancer-related fatigue, pending recommended revisions, may be feasible and acceptable for use in research studies. Further study is needed to determine effectiveness.

• Baseline sample/group differences of import
• Risk of bias (no control group)
• Risk of bias (no blinding)
• Risk of bias (no appropriate attentional control condition)
• Risk of bias (sample characteristics)
• Unintended interventions or applicable interventions not described that would influence results
• Findings not generalizable
• Subject withdrawals ≥ 10%
• Dropout rate in RESTORE group was significant, and the significance of missing data limits the study.

Nursing implications include the cautious use of feasibility, acceptability, and adherence data for the completion of a web-based program to enhance self-efficacy in the management of cancer-related fatigue based on responses from multi-site participants in the United Kingdom.

To identify predictive factors of response to decongestant treatment through univariate and multivariate analysis

Patients received complex decongestive treatment with manual lymphatic drainage (45 minutes) and pressotherapy with pneumatic multichambered device between 50 and 80 mm Hg (30 minutes). Treatment also included wearing a multilayered bandage until the next day. Sessions were performed consecutive days until a plateau in reduction was reached, which was normally between 10–20 sessions. Compliance with bandages was measured.

• The study sample (N = 171) was comprised of patients with breast cancer who had lymphedema.
• Median age was 60.4 years, with a range of 32–84 years.
• Patients were included in the study if they were 18 years of age or older, were free from malignant disease, and had no decongestant treatment for your year.

The study took place across multiple sites in Spain.

The study used a prospective, multicenter controlled cohort design.

• Factors associated with response were testing in a univariate and multivariate analysis using linear regression.
• Hypothesis testing was two-tailed with a 5% level of significance.
• Analyses were made with SPSS version 15.

Eleven variables were retained after initial screening. Venous insufficiency, treatment in autumn, and compliance were associated with better outcome while higher baseline excess volume and percentage reduction, heaviness, numbness, chemotherapy, axillary radiation, total dose of radiation, and treatment in winter were associated with poorer outcome.

The most important predictor of response to treatment was compliance. Early intervention is key.

• The descriptive analysis is only to identify potential risk factors.

Patient education and support to promote early intervention and patient compliance with treatment may have a positive effect in response to lymphedema treatment

To compare, after open nephrectomy, the efficacy of continuous wound site infusion with ropivacaine with that of saline; to examine morphine consumption, side effects, bowel function, and hospital length of stay in two study arms

Patients received continuous surgical wound site infusion of either 0.5% ropivacaine or 0.9% saline. For breakthrough pain, all patients received standard care with PCA morphine and ketorolac.

• The sample was composed of 168 patients.
• The age range of patients was 47–71 years. In the ropivacaine group, the mean age was 58.7 years. In the saline group, the mean age was 60.2 years.
• Of all patients, 61% were females and 38.1% were males.
• During the study all patients underwent open nephrectomy through lumbotomic access. Authors did not report underlying diagnoses.

• Single site
• Inpatient
• Rome, Italy

Prospective randomized, double-blinded, placebo-controlled study

• Visual analog scale, 0–10 score, to measure incident pain at mobilization
• Consumption of PCA morphine
• Time to bowel recovery
• Level of sedation
• Length of hospital stay

• Pain at rest and while coughing was significantly less (p < 0.0001) in the ropivacaine group than in the control group.
• Morphine consumption was significantly greater in the control group than in the ropivacaine group. Mean total morphine consumption was significantly greater in the control group (p < 0.0001).
• Compared to the control group, time to bowel recovery was significantly shorter and sedation was less in the ropivacaine group (p < 0.0001).
• Time to discharge was 3.2 days in the control group versus 2.1 days in the ropivacaine group (p < 0.001).
• Use of ropivacaine resulted in substantial cost savings per patient, primarily because ropivacaine was associated with shorter length of stay.

Continuous wound infusion with ropivacaine improved pain relief and accelerated recovery and discharge.

A single surgeon peformed all procedures and placed all catheters. Because of the various locations of nociceptive receptors, this makes generalizing study findings questionable; placement of catheters for local infusion relates to results.

Multimodal pain management that includes continuous wound infusion of anesthetic and systemic opioid can reduce postoperative pain, thereby reducing length of stay and hospitalization costs.

To investigate the effects of qigong exercises on upper extremity lymphedema, arterial resistance, and blood flow velocity in breast cancer survivors

Experimental group performed approximately six minutes of the 18 forms tai chi qigong exercises, and the control group rested.

• N = 23
• MEAN AGE = 58 years (intervention), 54 years (control)
• MALES: 0%, FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: Females older than age 18, treated with mastectomy, lymphedema of greater than 2 cm circumferential measurement in affected versus unaffected extremity, no known neurological deficits
• OTHER KEY SAMPLE CHARACTERISTICS: Exclusions included current adjuvant treatment, recurrence of disease, lumpectomy, pregnancy, or performing other regular exercise.

• SITE: Single site 
• SETTING TYPE: Outpatient 
• LOCATION: Hong Kong

• PHASE OF CARE: Late effects and survivorship
• APPLICATIONS: Elder care

• Pilot, single-blind, nonrandomized, controlled trial

• Circumferential limb volume
• Tape measurement
• Doppler for arterial resistance
• Resistance Index

There was an immediate circumferential decrease and blood flow resistance decrease, with increase in blood flow velocity in the experimental group. However, no girth changes between groups may indicate only temporary effects.

More rigorous randomized, controlled studies are needed to confirm the effects of this exercise.

• Small sample (< 30)
• Risk of bias (no random assignment)
• Findings not generalizable

Nurses should encourage limb movement and range of motion exercises for breast cancer survivors.

STUDY PURPOSE: To evaluate the evidence regarding the effects of physical activity in cancer survivors

TYPE OF STUDY: Meta-analysis and systematic review

• FINAL NUMBER STUDIES INCLUDED = 54 in qualitative review and 34 in meta-analysis
• SAMPLE RANGE ACROSS STUDIES: Median sample size was 93 patients
• KEY SAMPLE CHARACTERISTICS: Various tumor types with the most common being breast, colorectal, and endometrial; mean age was 55 years (range = 39–74 years)

PHASE OF CARE: Late effects and survivorship

The median duration of the exercise intervention was 13 weeks (range = 3–60). A meta-analysis of results for body mass index, body weight, and other physiologic measures was reported. A meta-analysis was completed for three studies regarding effect on fatigue, and slightly reduced fatigue was demonstrated using the Piper Fatigue Scale (p = 0.03). However, sample sizes were small in these studies. A meta-analysis of effects on depression included four studies and showed reduced depression using the Beck Depression Inventory (p < 0.01). Three of the four studies had relatively small sample sizes. Quality of life outcomes showed improved Short Form-36 physical functioning scores (p = 0.01) and mental health scores (p = 0.01). The authors noted substantially different results based on the measurement scales used in the included studies.

This analysis supports the effectiveness of exercise in general on cancer-related fatigue and depression.

It was suggested that the intensity of the exercise could affect results, and intensity was not consistently reported in the studies included. The mean duration of the intervention was as high as 13 weeks and as low as three weeks. The relatively short duration limits the ability to assess long-term outcomes. Most studies were completed in patients with breast cancer. There were very few studies in the analysis, and it was surprising that more studies were not found for inclusion. The studies of fatigue and depression included in this meta-analysis had relatively small sample sizes.

This report adds to the already large body of evidence demonstrating that exercise can improve fatigue and depression outcomes in cancer survivors. Current evidence, however, involves relatively short-term interventions and assessments. For long-term benefits, it is generally believed that physical activity needs to be incorporated into everyday life. Nursing interventions and future research should consider the examination of approaches to address this need for ongoing behavior change. Most exercise studies continue to involve women with breast cancer. Although there is some evidence in other groups, it is limited. Continued research to examine exercise's effects in more varied patients would be beneficial.

• FINAL NUMBER STUDIES INCLUDED = 15
• TOTAL PATIENTS INCLUDED IN REVIEW = 1,077
• KEY SAMPLE CHARACTERISTICS: Six studies addressed RE during treatment, and four were conducted during androgen deprivation therapy, one during chemotherapy, and two during radiation therapy. The remaining nine studies focused on RE in participants following the completion of active cancer treatment with a curative intent. This included participants with BRCA (n = 6), prostate cancer (n = 4), head and neck cancer (n = 3), lung cancer (n = 1), and a mixed group (n = 1).

Pertaining to fatigue outcomes, two randomized, controlled design studies showed insignificant changes in fatigue with BRCA survivors. One nonrandomized trial showed insignificant change in patients with prostate cancer. Two randomized, controlled studies showed moderate to large effect sizes in patients with BRCA and prostate cancer patients over time after three and six months. Large effects were seen in the Schmidt study with BRCA survivors. A moderate effect was seen in the Segal study of patients with prostate cancer receiving androgen deprivation therapy. Small effect sizes were seen in BRCA patients undergoing chemotherapy at a midpoint and post-treatment.

The results of this study suggested that RE may improve fatigue in patients with BRCA undergoing chemotherapy, patients with prostate cancer undergoing androgen deprivation therapy, and in BRCA survivors.

Although methodologic quality was good overall, an increase of intent-to-treat analyses of future randomized, controlled trials is needed.

Few studies examined this type of exercise, and additional study is indicated.