Wiffen, P.J., Derry, S., Naessens, K., & Bell, R.F. (2015). Oral tapentadol for cancer pain. Cochrane Database of Systematic Reviews, 9, CD011460.
STUDY PURPOSE: To assess the efficacy of tapentadol for relief of cancer pain
TYPE OF STUDY: Systematic review
PHASE OF CARE: Late effects and survivorship
APPLICATIONS: Palliative care
Tapentadol was as effective as oxycodone or morphine in comparator studies. No substantial differences in side effects were seen between tapentadol and comparators.
Tapentadol is as effective as oxycodone or morphine for chronic pain management.
Tapentadol was shown to be effective for management of cancer-related pain, but little suggests that it should be considered above other opioids. Further research would be helpful. The authors suggest that a reduction of pain intensity of at least 50% should be used to establish treatment efficacy, and note that tapentadol, as with all opioids, presents challenges in terms of benefits and side effects of treatment.
Wiese, C.H., Barrels, U.E., Graf, B.M., & Hanekop, G.G. (2009). Out-of-hospital opioid therapy of palliative care patients with \"acute dyspnoea\": A retrospective multicenter investigation. Journal of Opioid Management, 5(2), 115-122.
The objective was to investigate and compare emergency medical treatment of acute dyspnea in palliative care patients with advanced-stage cancer on the basis of several emergency medical therapy schemes.
The study consisted of a retrospective evaluation of emergency medical treatment initiated in response to palliative client complaints of “acute dyspnea” over a 24-month period. Data collected were based on the emergency service protocol of four different German emergency medical services. Patients were categorized into five groups based on the intervention utilized by emergency physicians in the management of their dyspnea. Group 1 used therapy with morphine IV and oxygen; Group 2 used morphine IV, bronchodilator-effective drugs (IV and per inhalation), and oxygen; Group 3 used bronchodilator therapy (IV and per inhalation); Group 4 used oxygen therapy only; and Group 5 utilized no therapy. The extent to which the symptom was relieved was measured by patients’ numeric rating of intensity of dyspnea compared to extent of “vital sign normalization” on the basis of patients’ arterial oxygen saturation and respiratory rate.
The study was conducted during multiple out-of-hospital emergency response/home visits by four emergency medical services in Germany.
This was a retrospective, descriptive study.
Based on improvement in respiratory rate, arterial oxygen saturation, and patient’s numeric rating of dyspnea, 47 patients (41%) experienced relief of dyspnea from emergency medical treatment. Dyspnea was relieved in 14 Group 1 patients (67%), 15 Group 2 patients (52%), 8 Group 3 patients (22%), 5 Group 4 patients (18%), and 5 Group 5 patients (71%). Though no significant differences regarding relief of dyspnea were noted between Groups 1 and 2 and between Groups 3 and 4 (P > 0.05), a statistically significant difference was noted when Groups 1 and 2 were compared to Groups 3 and 4 (P < 0.001), indicating a higher success among the two groups that utilized opioid therapy in the management of dyspnea. Only Group 5 experienced a correlation between subjective dyspnea ratings and objective measurements (i.e., oxygen saturation and respiratory rate). The high success rate in dyspnea alleviation observed in Group 5 (no medical treatment) was achieved by the transfer of a tracheostomy tube, which was the noted cause of dyspnea in five patients. Morphine was the only medication used during opioid therapy, and no respiratory sedation was noted by emergency physicians.
Significant relief of acute dyspnea was observed when IV opioid therapy was used as opposed to oxygen and bronchodilator therapy alone.
The study was purely descriptive, with no structured study protocol with measures for comparison or randomization of subjects. Thoroughness and accuracy of each documented encounter analyzed is also questionable. The investigation was carried out on the basis of a German system of emergency/pre-hospital treatment options that are not wholly generalizable to the American paramedic emergency response system.
IV opioid therapy for the management of acute dyspnea in out-of-hospital encounters for palliative care patients appears to be more beneficial than use of oxygen therapy and bronchodilator (IV and per inhalation) alone. Integration of a palliative care team (preferably with 24-hour accessibility) in the subsequent alleviation of dyspnea in out-of-hospital emergency palliative encounters may prove beneficial. This study raises the question of how dyspnea among palliative care patients may be managed by pre-hospital services in the United States and pre-hospital service staff knowledge of symptom management for this group of patients.
Wickham, R. (2010). Best practice management of CINV in oncology patients: II. Antiemetic guidelines and rationale for use. Journal of Supportive Oncology, 8(2, Suppl. 1), 10–15.
The search strategy was not applicable or stated.
This article discussed underlying shared principles in chemotherapy-induced nausea and vomiting (CINV) guidelines from the American Society of Clinical Oncology (ASCO), the Multinational Association for Supportive Care in Cancer (MASCC), and the National Comprehensive Cancer Network (NCCN).
Currently recommended agents for breakthrough CINV are prochlorperazine, metoclopramide with or without diphenhydramine, haloperidol, dexamethasone, dronabinol nabilone, lorazepam, alternating 5-HT3 receptor antagonists, olanzapine, and promethazine. The author noted that guidelines are useful, but guideline adherence can only go to a certain extent in preventing CINV, particularly with delayed symptoms, multiple-day chemotherapeutic regimens, high-dose chemotherapy, breakthrough CINV, and refractory CINV.
CINV guidelines are a good clinical tool to help clinicians implement evidence-based practice; however, their use needs to be accompanied by accurate patient assessments throughout the period of CINV risk. A standard guideline may not fit the needs of all patients and recommendations need to be viewed as a starting point for individualized patient care. More study and attention needs to be given to issues of delayed, breakthrough, and refractory CINV. This article is expert opinion-based and does not provide evidence for all information provided.
White, V.M., Young, M., Farrelly, A., Meiser, B., Jefford, M., Williamson, E., . . . Winship, I. (2014). Randomized controlled trial of a telephone-based peer-support program for women carrying a BRCA1 or BRCA2 mutation: Impact on psychological distress. Journal of Clinical Oncology, 32, 4073–4080.
To determine if peer telephone intervention would reduce distress among women with BRCA1/2.
Recruitment through familial cancer clinics; baseline questionnaire completed and then those who indicated interest in talking with a peer were randomly assigned to the intervention group (IG) or usual care group. Those in the IG received surveys four and six months after baseline. IG matched with peer to support. Peers were recruited and received a program manual and three days of training. Contact between peer and participant was to occur six times in a four-month period.
Baseline questionnaires for socioeconomic information, cancer history and treatment, family history of cancer, age when notified of mutation status, BRCA1/2 mutation status of female relatives, risk-reducing surgeries, screening behaviors, and supportive care services used. At time 2, peer satisfaction was asked; Impact of Event Scale (IES) measuring distress; a single item question for anxiety; 16-item scale to measure unmet needs. 10-item cognitive appraisals about genetic testing scale.
There was little change in the mean scores on most outcome measures during the three time points. Unmet needs was the only outcome measure that decreased consistently over time. Breast cancer distress (IES) showed a significantly lower level of stress in the IG (p < 0.01). Anxiousness and stress were lower in the IG at the first two time points (p < 0.03), but there was no difference after that. Telephone based intervention reduced distress and unmet information needs for this group. Percent of patients contacted continued to decline over time, and by the sixth phone call less than 25% had any contact.
Peer support programs may be effective at reducing distress and anxiety in those who are BRCA1/2 carriers.
Peer support among women with genetic mutations may prove to reduce distress. This type of support may be beneficial for other patient populations. Findings from this study suggest that the greatest needs and efficacy may be in the short term, since many patients did not have contact after the third phone call. As anxiety tends to decline over time, it is unclear from this study what the actual efficacy was for anxiety.
White, V.M., Macvean, M.L., Grogan, S., D'Este, C., Akkerman, D., Ieropoli, S., . . . Sanson-Fisher, R. (2012). Can a tailored telephone intervention delivered by volunteers reduce the supportive care needs, anxiety and depression of people with colorectal cancer? A randomised controlled trial. Psycho-Oncology, 21, 1053–1062.
To assess the effectiveness of a volunteer-delivered, tailored telephone-based intervention in reducing unmet supportive care needs and elevated levels of anxiety and depression among people with colorectal cancer
The intervention utilized a checklist of unmet needs that patients with colorectal cancer completed. Specially trained volunteers then followed up with patients, by means of telephone consultation, to review needs and devise an action plan.
Transition phase of care
Randomized controlled trial
This study suggests that a volunteer-delivered, telephone-based intervention is plausible and acceptable to patients with cancer and that the intervention was effective in getting patients to use available services. This approach was associated with reduced anxiety over time, but did not have an impact on depression or prevalence of unmet needs as identified by the patients.
Tailoring support and interventions to only those patients with unmet needs might be a better allocation of resources while producing significant results.
Wheat, J., Currie, G., & Coulter, K. (2007). Management of acute radiation skin toxicity with wheatgrass extract in breast radiation therapy: pilot study. Australian Journal of Medical Herbalism, 19, 77–80.
To examine the potential benefits of wheatgrass extract in reducing severity and delaying the onset of acute radiation skin toxicity in breast irradiation.
Patients were undergoing the active treatment phase of care.
The study was a prospective, pilot, single-blind (patients), randomized, controlled clinical trial with two arms: wheatgrass extract (experimental) and sorbolene cream (control).
No statistically significant difference existed between the wheatgrass group and the sorbolene group with regard to onset and peak radiodermatitis development. There was a significant difference in QOL between the wheatgrass (M = 9.5) and sorbolene (M = 9.8; p = 0.014) groups when all time periods were measured, with better QOL in the wheatgrass group.
The study design and results were not strong enough to include as evidence for or against wheatgrass as a deterrent to the development of radiodermatitis.
This potential intervention needs further study in a larger group. The findings are not valid for use as evidence at this stage of investigation.
Weze, C., Leathard, H. L., Grange, J., Tiplady, P., & Stevens, G. (2004). Evaluation of healing by gentle touch in 35 clients with cancer. European Journal of Oncology Nursing, 8, 40–49.
The healing touch method was a noninvasive, noncondition-specific method in which hands were placed on various parts of the body for about 40 minutes; particular attention was given to areas of pain or discomfort. Four one-hour sessions were conducted over four to six weeks (or withdrawn).
Patients were undergoing the active treatment and long-term follow-up phases of care.
The study used a one-group, pre- and posttest feasibility design.
A statistically significant improvement was found from pre- to posttest for sleep disturbance.
Weycker, D., Li, X., Barron, R., Li, Y., Reiner, M., Kartashov, A., . . . Garcia, J. (2016). Risk of chemotherapy-induced febrile neutropenia with early discontinuation of pegfilgrastim prophylaxis in US clinical practice. Supportive Care in Cancer, 24, 2481–2490.
To investigate the receipt of colony-stimulating factor (CSF) prophylaxis and associated risks of febrile neutropenia (FN)
Data from two large U.S. claims repositories from 2006–2014 were obtained for analysis. Data included patients aged older than 18 years who received at least two cycles of myelosuppressive chemotherapy. The analysis was focused on the use of pegfilgrastim; patients who received other CSFs were excluded from the analysis. Patients who received and did not receive pegfilgrastim prophylaxis were matched according to variables in multivariate regression, including the being at intermediate/high risk for neutropenia and cancer type.
FN episodes were identified based on hospital admission with a diagnosis of neutropenia, fever, or infection. FN episodes requiring outpatient care, including emergency department visits, were defined as Healthcare Common Procedure Coding System (HCPCS) code for IV antimicrobial therapy on the same date as a diagnosis of neutropenia, fever, or infection.
Of the patients, 5.3% were not given second-cycle pegfilgrastim prophylaxis. Second-cycle FN among comparison patients was 3.8% versus 2.2% among those who received propylaxis (95% confidence interval [CI] [1.2, 2.5], p = 0.002). With a narrower definition of FN, 3.5% without prophylaxis had FN compared to 0.8% in the group that received second-cycle pegfilgrastim (odds ratio [OR] = 3.5, p < 0.001).
The findings suggest that the odds of developing FN in the second cycle of chemotherapy are higher among patients who discontinue CSF prophylaxis compared to those who continue prophylaxis.
Some evidence suggest that ongoing CSF prophylaxis is not consistently provided in at-risk patients. This study, although it had some limitations, suggests that the discontinuation of prophylaxis along the course of treatment with myelosuppressive chemotherapy for patients at an intermediate or high risk for FN is associated with an increased incidence of FN.
Weycker, D., Barron, R., Edelsberg, J., Kartashov, A., Legg, J., & Glass, A.G. (2014). Risk and consequences of chemotherapy-induced neutropenic complications in patients receiving daily filgrastim: The importance of duration of prophylaxis. BMC Health Services Research, 14, 189-6963-14-189.
To determine if the duration of filgrastim prophylaxis affects the risk of chemotherapy-induced neutropenic complications (CINC), healthcare costs, and mortality
This is a retrospective study of medicals claims from two large healthcare claims databases, the Thomson Reuters MarketScan Commercial Claims and Encounters and Medicare Supplemental and Coordination of Benefits Database (MarketScan Database, 2001–2010) and the Intercontinental Marketing Services LifeLink Database (LifeLink Database, 2001–2008). Claims for chemotherapy, filgrastim, and hospital admissions were analyzed to determine the number of daily filgrastim doses following a chemotherapy cycle and neutropenic complications.
Retrospective study of medical claims
If patients were treated with one to three days of filgrastim prophylaxis, the risk of CINC during a cycle of chemotherapy was 2.9%. If they were treated with four to six days of filgrastim prophylaxis, the risk of CINC was 2.7%. If the patient was treated with seven or more days, the risk of CINC was 1.8%. In adjusted analyses, the odds of CINC were 2.4 (95% = CI, 1.6–3.4) higher with one to three days of filgrastim prophylaxis versus seven or more days and 1.9 (1.3–2.8) times higher with four to six days of filgrastim prophylaxis versus seven or more days. In the pivotal trials of filgrastim prophylaxis, 10–11 days of filgrastim prophylaxis were needed for adequate neutrophil recovery, yet this study demonstrated that in actual practice, 95% of patients received fewer than 10 days of filgrastim prophylaxis and 58% received only one to three days. In a subgroup of 358 patients who developed CINC and the healthcare expenditures were available, CINC-related healthcare expenditures were $18,912 (14,570– 23,581) with one to three days of prophylaxis (n = 225), $14,907 (11,155–19,728) with four to six days (n = 94), and $13,165 (9,595–17,144) with seven or more days (n = 39). In a subgroup of 228 patients for whom discharge status was available, in-hospital mortality was 8.4% (4.6–14.8) with one to three days of prophylaxis (n = 119), 4% (1.4–11.1) with four to six days (n = 75), and 0% (0–10.2) with seven or more days (n = 34).
Administration of less than seven days of daily filgrastim was not as effective as seven or more days of daily filgrastim to prevent chemotherapy-induced neutropenic complications. The use of seven or more days of filgrastim as primary prophylaxis to prevent chemotherapy-induced neutropenic complications also decreased healthcare costs and mortality.
In clinical trials evaluating the efficacy of CSF prophylaxis, patients were treated with 10 or more daily doses of filgrastim. However, in actual practice, the majority of patients receive prophylaxis with fewer than 10 doses of daily filgrastim, which increases the risk of chemotherapy-induced neutropenic complications, mortality, and healthcare costs. Clinicians need to be aware of most effective CSF dosing requirements.
Weycker, D., Malin, J., Barron, R., Edelsberg, J., Kartashov, A., & Oster, G. (2012). Comparative effectiveness of filgrastim, pegfilgrastim, and sargramostim as prophylaxis against hospitalization for neutropenic complications in patients with cancer receiving chemotherapy. American Journal of Clinical Oncology, 35, 267–274.
The purpose of this study was to assess differences in risk of hospitalization for neutropenic complications among patients with solid tumors who received prophylactic filgrastim, pegfilgrastim, or sargramostim during their first observed course of chemotherapy from July 2001 to June 2007.
Prophylactic administration of filgrastim, pegfiltrastim, or sargramostim
Retrospective cohort study
Statistical analyses included using medical claims information from two large databases (Thomson Reuters MarketScan Commercial Claims and Encounters and Medicare Supplemental and Coordination of Benefits Database), calculation of duration in days of use of each CSF, independent samples t test for continuous factors and chi-square for multilevel categorical factors. Generalized estimating equations were used to assess risk of hospitalizations.
Risk of hospitalization for neutropenia was 2.1% (filgrastim prophylaxis, n = 8,286), 1.1% (pegfilgrastim prophylaxis, n = 67,247), and 2.5% (sargramostim prophylaxis, n = 1,736) and, for nuetropenia, fever, or infection for prophylactic use of filgratim, pegfilgratim, and sargramostim was 4%, 2.6%, and 2.5%, respectively. Risk of hospitalizations for all causes was 7.9%, 5.3%, and 9.6%, respectively. Adjustments were made in the statistical analysis for patient characteristics, type of cancer, and chemotherapy regimen.
Prophylactic pegfilgrastim administration is associated with less risk of hospitalizations for neutropenia/neutropenic-related complications than either prophylactic filgrastim or sargramostim in patients undergoing chemotherapy treatments for a variety of cancers.
Recommendation of the use of prophylactic pegfilgratim may be warranted. Patient education regarding neutropenia, neutropenic-related complications, and side effects of pegfilgratim is essential. Nurse-led discussions of using pegfilgratim instead of filgratim or sargramostim with the oncology healthcare team could ensue.