To study the efficacy of prophylactic antibiotics in pediatric patients with agranulocytosis and to investigate the efficacy and safety of different prophylactic protocols

Antibiotics included the combination of vancomycin and cefepime or single-use piperacillin/tazobactam. Control patients did not receive antibiotics prophylactically. Both groups were given oral voriconazole to prevent invasive fungal infections.

• N = 38  
• MEAN AGE: 8.3 years
• MALES: 63%, FEMALES: 37%
• KEY DISEASE CHARACTERISTICS: All had Acute myeloid leukemia (AML) and agranulocytosis after high-intensity chemotherapy

• SITE: Single-site    
• SETTING TYPE: Not specified    
• LOCATION: China

• PHASE OF CARE: Active antitumor treatment
• APPLICATIONS: Pediatrics

Nonrandomized, observational trial

• Febrile events defined as a single-axillary temperature > 38.3° centigrade
• Cultures

There were no differences found between the two preventive protocols used. The prophylactic group had less frequent fever (p < .001), a longer interval to fever (p = .007), and an average of seven fewer hospital days (p < .001). Pulmonary and oral infection were most common. In the prophylactic group, three patients had diarrhea and one patient developed a rash. There were no other antibiotic-related side effects.

There were no differences found between the two preventive protocols used. The prophylactic group had less frequent fever (p < .001), a longer interval to fever (p = .007), and an average of seven fewer hospital days (p < .001). Pulmonary and oral infection were most common. In the prophylactic group, three patients had diarrhea and one patient developed a rash. There were no other antibiotic-related side effects.

• Small sample (< 100)
• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Measurement validity/reliability questionable
• Other limitations/explanation: The main outcome measure was a single episode of fever.

The findings showed that prophylactic antibiotics after high-intensity chemotherapy can be effective in children with minimal side effects. Findings should be considered with some caution given the study's limitations.

DATABASES USED: MEDLINE, CINAHL, British Nursing Index, EMBASE, AMED, PsycINFO, SIGLE, and CancerLit were searched, as well as Dissertation Abstracts International.

COMMENTS ON LITERATURE USED: From 1966–2002

FINAL NUMBER STUDIES INCLUDED = 8 RCTs, 10 reports

The most consistent effect was on anxiety. Only one reported an effect on depression.

Insufficient evidence

Databases searched were CENTRAL (Cochrane Library, Issue 1, 2002), MEDLINE (1966-May 2002), CINAHL (1982-April 2002), British Nursing Index (1994-April 2002), EMBASE (1980-week 25, 2002), AMED (1985-April, 2002), PsycINFO (1887-April, 2002), SIGLE (1980-March, 2002), CancerLit (1975-April, 2002), and Dissertation Abstracts International (1861-March, 2002). Reference lists of relevant articles were searched for additional studies.

Reviews were included if they

• Were randomized controlled trials (RCTs).
• Were controlled before-and-after studies or interrupted time-series studies.
• Studied aromatherapy or massage for patients with cancer.
• Measured changes in patient-reported levels of physical or psychological distress or quality of life (QOL) using reliable and valid tools.

• A total of 10 reports met inclusion criteria. Of these, 8 were RCTs, representing 357 patients.
• Most studies measured anxiety, depression, and pain; two demonstrated a reduction in nausea.

Two studies assessed the symptom of nausea. Both studies showed a reduction in nausea in hospitalized patients.

• Although the studies were RCTs, the sample sizes were small.
• Assessing the effect of aromatherapy was difficult because different essential oils were used.
• The degree to which variation in massage style affects outcomes is not known.

• Longer follow-up studies are needed with larger samples.
• No harm was involved, but evidence was mixed as to effect of aromatherapy enhancement to massage to a clinically significant level.

To evaluate the effectiveness of massage and aromatherapy for symptom relief in patients with cancer

The search used the following sources from 1966–2002: MEDLINE, CINAHL, British Nursing Index, EMBASE, AMED, PsycINFO, and CancerLit.

• A total of 1,322 references were initially retrieved.
• Two reviewers independently assessed trials for inclusion in the review, assessing study quality and extracted data.

Ten reports met the inclusion criteria; eight randomized controlled trials that included 357 patients were reviewed.

• The most consistently found effect of massage or aromatherapy massage was on anxiety.
• Four trials (207 patients total) detected a reduction in anxiety postintervention.
• There was no reported decrease in anxiety with the addition of aromatherapy.

While there is sufficient evidence to support the effectiveness of massage in decreasing anxiety in patients with cancer, there is insufficient evidence to draw conclusions about the effectiveness of aromatherapy massage for patients with cancer. Further research is needed.

To examine the effects of a palliative rehabilitation program on depression, and explore the impacts and interactions between depression, inflammation, exercise, and self-efficacy.

All patients received group physiotherapy twice a week; all patients also received as treatment plan based on assessment of individual functioning and goals that was implemented during the course of the study, including support, encouragement, feedback, and guidance to motivate patients and encourage positive change. The program was provided during an eight-week period. Study measures were obtained at baseline and at the completion of the program.

• N = 80
• AGE = Not provided
• MALES: 47.5%, FEMALES: 52.5%
• KEY DISEASE CHARACTERISTICS: Multiple tumor types existed. Patients were in stage III or IV. Breast and hematological cancers were most common.
• OTHER KEY SAMPLE CHARACTERISTICS: ECOG status of 2 or better. 21.3% were taking antidepressants.

• SITE: Single site  
• SETTING TYPE: Outpatient  
• LOCATION: Ottawa, Canada

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

• Quasi-experimental

• C-reactive protein (CRP) as a marker of inflammation
• Six-minute walk test (6MWT)
• General Self-Efficacy Scale
• Hospital Anxiety and Depression Scale (HADS)

Completion rate for sessions was 69%. There was no change in CRP. Performance on the 6MWT increased (p < 0.001). Self-efficacy scores increased from a mean of 27.86 to 31.23 (p <  0.01). Depression scores decreased on average from 7.14 to 5.95 (p = 0.002).  Analysis showed that exercise results and self-efficacy were significant predictors of change in depression scores. Changes in the 6MWT explained 3% of the change in depression and self-efficacy explained 11%.

The multicomponent rehabilitative intervention tested here was associated with reduced depression scores. Exercise and self-efficacy were shown to be significant predictors of depression scores.

• Small sample (less than 100)
• 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
• Subject withdrawals of 10% or greater 
• Almost 50% who entered the study did not complete it; about half of these were due to disease progression.
• Authors state that use of antidepressants was not correlated with change in depression scores; however, it would not necessarily be expected that scores would decline further, and there was no subgroup analysis based on use of antidepressants.
• The measure used for exercise was a measure of stamina, not exercise intensity or regularity, so their conclusions that exercise may not be as effective for depression is not necessarily accurate.
• Mean depression score changes were not at a level that was clinically significant, and floor effects of the measure at baseline are possible.
• It is not known if participants were doing any other interventions for support.

Participation in exercise has been associated with improvement in depressive symptoms, and exercising in a group setting may enhance support and its effects on self-efficacy and mood. Findings of this study, however, showed statistically significant changes in depression, but the size of these changes on the measures used was not clinically significant. Research in this area should be aimed at individuals who have clinically relevant depressive symptoms.

STUDY PURPOSE: To assess the effect of low level laser therapy (LLLT) for oral mucositis

TYPE OF STUDY: Systematic review

• FINAL NUMBER STUDIES INCLUDED = 24
• TOTAL PATIENTS INCLUDED IN REVIEW = 1,383
• SAMPLE RANGE ACROSS STUDIES: 1–221 patients
• KEY SAMPLE CHARACTERISTICS: Patients who have had hematopoietic cell transplantation (HCT), patients with head and neck cancer receiving chemotherapy and radiation therapy, patients with other tumor types receiving chemotherapy, and two studies including pediatric cases

PHASE OF CARE: Active antitumor treatment
 
APPLICATIONS: Pediatrics

Most evidence showed a positive effect of LLLT on oral mucositis in delayed time of onset, lower peak severity, and shortened duration. One study in children showed no benefit of LLLT when optimal dental and oral care were provided.

LLLT is beneficial for the management of oral mucositis; however, ideal wavelengths, timing, and frequency of treatment are unclear.

• Limited search
• No study quality evaluation

LLLT has been shown to be effective in reducing the symptoms of oral mucositis in patients undergoing transplantation and those receiving treatment for head and neck cancer. The specifics for optimal LLLT timing, duration, and so forth have not been determined. Further research on these aspects is needed.

To examine the risk of uncontrolled chemotherapy-induced nausea and vomiting (CINV) among patients with lung cancer receiving multiday chemotherapy and ondansetron- or palonosetron-initiated prophylactic antiemetic regimens in a community oncology setting

The Georgia Cancer Specialists electronic medical records database was used to identify patients with lung cancer who received multiday cisplatin or carboplatin regimens with ondansetron or palonosetron on day 1 between April 1, 2006, and July 31, 2009. Uncontrolled CINV was identified. Risk for uncontrolled CINV, up to 7 days after last chemotherapy administration, was analyzed at cycle level using logistic regression.

• The study reported on 362 patients; 209 of these patients received a total of 702 cycles of palonosetron, and 153 patients received 515 cycles of ondansetron.
• The palonosetron group was significantly older than the ondansetron group (66.8 years old versus 63.9 years old [p < 0.01]).
• The palonosetron group was 54% female, and the ondansetron group was 53% female.    
• Patients were diagnosed with lung cancer, received multiday cisplatin or carboplatin regimens, and used palonosetron or ondansetron on day 1 (and did not receive aprepitant on day 1). The palonosetron group received antiemetics every other day, whereas patients in the ondansetron group received ondansetron every day except for the last day, in which they received palonosetron.
• The palonosetron group had a Charlson comorbidity index of 3.6 and the ondansetron group had a Charlson comorbidity index of 3.5.
• The palonosetron group included 25 patients with multicancer diagnoses and the ondansetron group included 27 patients with multicancer diagnoses.

This was a multi-site study based on electronic medical records data from Georgia Cancer Specialist, a community-based practice that included 30 offices and 46 medical oncologists throughout Georgia.

• Patients were in active treatment.
• This study has application to late effects and survivorship.

This was a retrospective descriptive study using data from an electronic medical records review.

The rate of uncontrolled CINV events measured from first chemotherapy agent administration of the cycle (start date) through 7 days after the last chemotherapy agent administration (end date) for

• Assessment of a CINV event using
  • ICD-9-CM codes 787, 787.01, 782.02, 787.03 (nausea/vomiting), and 265.51(dehydration).
  • CPT codes 09760, 90761, 96360, and 96361 (hydration).
• Rescue medications (NDC code for dexamethasone/Decadron, diphenhydramine/Benadryl, olanzapine/Zyprexa, promethazone/Phenergan, haloperidol/Haldol, prochlorperazine/Compazine, lorazepam/Ativan, or metoclopramide/Reglan).
• Nausea/vomiting hospitalizations.
• Oral antiemetic medications and administration of fosaprepitant and aprepitant.
• IV antiemetic therapy after last chemotherapy administration of the cycle.

Rescue antiemetic after the first day chemotherapy or IV antiemetic after the last chemotherapy administration date were considered as nonprophylactic use.

• Overall, 273 uncontrolled CINV events were found during 702 platinum cycles in the palonosetron cohort (38.9%) and 455 events were found during 515 cycles (88.4%) in the ondansetron cohort (p < 0.01).
• Palonosetron cycles had 63% lower risk for uncontrolled CINV events versus ondansetron cycles (OR = 0.37, p < 0.01).
• Subanalysis by chemotherapy agents supported overall analysis (cisplatin OR = 0.09, p < 0.01, carboplatin OR = 0.46, p < 0.01).

Among patients with lung cancer receiving multiday chemotherapy cycles, administration of palonosetron on day 1 was associated with a significantly lower risk for uncontrolled CINV events versus ondansetron-initiated chemotherapy cycles.

• No appropriate control group was included.
• Retrospective EMR reviews introduce some limitations. For example, CINV events or hospitalization may have been underestimated, and at-home antiemetic use is not detectable.
• The palonosetron group was significantly older, which may have lowered CINV risk. Significantly more patients in the palonosetron group received moderately emetogenic chemotherapy than in the ondonsetron group, which may have influenced the comparison between the two.
• Race, smoking status, and alcohol use were not assessed.

For the patients receiving multiple day, platinum based chemotherapy for the treatment of lung cancer, every-other-day palonosetron would be an option to lower the risk of the incidence of uncontrolled CINV.

To evaluate the applicability and effectiveness of existential behavioral therapy (EBT)  to informal caregivers of palliative care patients with regards to psychological distress and quality of life when compared with treatment as usual

The intervention was six group sessions totaling 22 hours. The sessions focused on introductions and mindfulness, death, bereavement and mindfulness, activating resources, finding meaning, self-care and stress management, personal values for (re-)orientation, and moving forward. Sessions were administered in small (10 participants or fewer), closed groups by a trained behavioral therapist following a study manual. Evaluations occurred at baseline, pre- and post-intervention, and at 3- and 12-month follow-up (five time points).

• N = 133  
• MEAN AGE = 54.5 years (13.2 years)
• MALES: 30.1%, FEMALES: 69.9%
• KEY DISEASE CHARACTERISTICS: Primarily (92.7%) various cancer diagnoses and neurological diseases; six months or less to live; currently in an inpatient palliative care unit
• OTHER KEY SAMPLE CHARACTERISTICS: German speaking; 61.7% identified as partners, 26.3% as parents, 4% as children, and 12% as other

• SITE: Multi-site    
• SETTING TYPE: Inpatient  
• LOCATION: Munich, Germany

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

• RCT

• Brief Symptom Inventory (BSI) subscales—somatization, anxiety, and depression
• Quality of life
  • Satisfaction With Life Scale (SWLS)—cognitive aspects
  • World Health Organization Quality of Life (WHOQOL)-BREF
  • Numeric rating scale for quality of life—QOL-NRS (single-item, scale of 1–10)
• Positive and Negative Affect Scale (PANAS)

EBT showed medium effects at the pre-/immediate post-test evaluation with improvement in anxiety (p 0.006) and on all measures of quality of life (p 0.009, 0.007, < 0.001). At the three-month evaluation, EBT showed no significant effects, with only small effect sizes on one-third of the quality-of-life measure SWLS (p 0.04). However, at the 12-month evaluation, EBT demonstrated medium effects on depression (p 0.04) and QOL-NRS (p 0.002). Interestingly, similar patterns resulted when examining secondary outcomes of affect, with significantly less negative affect demonstrated at post-test (p 0.003), which then was not noted at the three-month evaluation, and at 12 months, significantly less negative affect was measured again (p 0.003). Positive affect, although never significant, always was trending more positive than when compared with controls. High level of satisfaction existed with the group, the therapist, information, mindfulness, and values.

EBT shows promise as an intervention to improve psychological distress and quality of life for carers of patients with cancer at end of life. The effect is greatest immediately following the intervention. Additional work is required with attentional control groups and outpatient patient populations to further support the benefits of this intervention.

• Risk of bias (no appropriate attentional control condition)  
• Risk of bias (sample characteristics)
• Intervention expensive, impractical, or training needs
• Other limitations/explanation: Heterogeneous sample—variety of care types, partners versus relatives and carers of living and dead patients were included in the same groups, meaning that for some, they already were in the grieving process at the start of the intervention. When compared to treatment as usual, which is no intervention, whether EBT or just being part of a group, or having attention of the therapist accounted for the improved outcomes is unclear. Intervention included specially trained behavioral therapist, not nurses.

Interventions such as EBT that target informal carers of patients with cancer have the potential to relieve distress and improve quality of life for the carer and the patient.

RESOURCE TYPE: Expert opinion

PHASE OF CARE: Active antitumor treatment

Review article

Literature review of common checkpoint inhibitor adverse and serious adverse events. No evidence quality review was provided.

Research is needed on the management of checkpoint inhibitor therapy toxicities.

To evaluate the effects of a specialized breathlessness intervention service compared to usual care

The breathlessness intervention service (BIS) was a multidisciplinary complex intervention including nonpharmacologic and pharmacologic interventions to support patients with advanced disease and dyspnea. The BIS used first-stage interventions such as positioning to reduce the work of breathing, education, individualized exercise plans, relaxation techniques, sleep hygiene, cognitive behavioral therapy approaches, and other supports. Second-stage interventions applied concurrently included opioids, antidepressants, anxiolytics, etc. Patients referred to this service were randomly assigned to the intervention or to a wait-list control group. Study measures were obtained at baseline and after the intervention. Interviews were done before randomization, at two weeks, and at five weeks. The interviews were recorded and transcribed verbatim for analysis. A final qualitative analysis was done from 20 intervention transcripts that were purposefully sampled to obtain a diverse group from those who improved and did not improve.

• N = 54 (47 completed five-week evaluations, 39 respondents)
• MEAN AGE = 69 years (SD = 11.5 years)
• MALES: 59%, FEMALES: 41%
• KEY DISEASE CHARACTERISTICS: Lung cancer was most prevalent

• SITE: Single site  
• SETTING TYPE: Not specified    
• LOCATION: United Kingdom

• PHASE OF CARE: Active antitumor treatment
• APPLICATIONS: Palliative care 

Randomized, controlled trial

• Distress scores caused by breathlessness
• Hospital Anxiety and Depression Scale (HADS)
• Chronic Respiratory Questionnaire (CRQ)
• Numeric Rating Scale (NRS) for distress
• EuroQol Five Dimensions Questionnaire (EQ 5-D) for generic health status

Patients in the intervention group had greater reductions in breathlessness (1.68 versus 0.23 points, p = 0.049). There were no other significant differences in outcomes for patients or caregivers between study groups. Interventions identified as helpful were providing and teaching the use of a handheld fan, encouraging exercise, coaching in breathing techniques and positioning, medication changes, and referrals to other services. Total costs were lower for the intervention group, and a cost effectiveness analysis showed a 66.4% likelihood that the intervention would result in lower cost and better outcomes in terms of reduced distress from breathlessness. Scores for mastery of symptom management did not change significantly.

This complex psychoeducational and pharmacologic intervention was associated with reduced distress from breathlessness. No effects on patient or caregiver distress, anxiety, or depression were found.

• Small sample (< 100)
• Risk of bias (no blinding)
• Risk of bias (no appropriate attentional control condition)
• Other limitations/explanation: With this complex, multicomponent intervention, it was not possible to determine which aspects were most effective in achieving improved outcomes.

Individual interventions such as opioid use have been shown to reduce dyspnea, so it was not possible to determine the relative value and utility of the combined interventions examined here. These study findings suggested that multicomponent, complex interventions to improve symptoms of breathlessness can be cost effective and improve outcomes.