Robenshtok, E., Gafter-Gvili, A., Goldberg, E., Weinberger, M., Yeshurun, M., Leibovici, L., & Paul., M. (2007). Antifungal prophylaxis in cancer patients after chemotherapy or hematopoietic stem-cell transplantation: systematic review and meta-analysis. Journal of Clinical Oncology, 25, 5471–5489.
To determine the effect of antifungal prophylaxis on all-cause mortality, invasive fungal infections (IFIs), and adverse events in patients with cancer treated with chemotherapy or hematopoietic stem cell transplantation (HSCT).
Databases searched were PubMed (January 1966–January 2007) and the Cochrane Library (CENTRAL) (through 2007). Conference proceedings in oncology, hematology, and infectious diseases were also searched. The references of all included trials and reviews were searched for additional studies.
Search keywords were neutropenia, chemotherapy and similar, specific antifungals or antifungal and similar, and prophylaxis and similar.
The authors included studies that were randomized, controlled trials comparing a systemic antifungal drug with placebo, no intervention, or other antifungal agents for prophylaxis of fungal infections in afebrile patients with cancer after chemotherapy or hematopoietic cell transplantation (HCT).
Studies were excluded if they lacked a randomized, controlled design or used empiric or pre-emptive antifungal therapy.
Systemic Antifungals Versus Placebo, No Treatment, or Nonsystemic Antifungals All-Cause Mortality
Subgroup Analysis
Specific Antifungals
Fluconazole Versus IV Amphotericin B
Posaconazole Versus Fluconazole or Itraconazole
Fluconazole Versus Antifungals with Antimold Activity
Other Trials
Current data support the use of fluconazole, itraconazole suspension, or posaconazole for prophylaxis.
Antifungal prophylaxis in patients with solid tumors and autologous HCT is not recommended. Prophylaxis should be administered to patients with acute leukemia during induction chemotherapy and to other patients with high-risk leukemia.
Robb, K.A., Bennett, M.I., Johnson, M.I., Simpson, K.J., & Oxberry, S.G. (2008). Transcutaneous electric nerve stimulation (TENS) for cancer pain in adults. Cochrane Database of Systematic Reviews, 3, CD006276.
To determine the effectiveness of transcutaneous electric nerve stimulation (TENS) in management of cancer-related pain and to provide guidance for optimal parameters of TENS for pain relief
Databases searched were The Cochrane Library, MEDLINE, Embase, CINAHL, AMED, PEDro, and PsycINFO. Hand-searching of reference lists of articles retrieved was also done.
MeSH terms were Neoplasms [*complications]; Pain [etiology;*therapy] Randomized controlled trials as Topic; Transcutaneous Electric Nerve Stimulation (TENS) [*methods] Adults; Humans. An extensive listing of search strategies and terms for each database used are provided.
Studies were included in the review if they
Studies were excluded if they
The search identified 36 studies from 1975 to 2008, and reference lists identified an additional 7 studies. Only two studies met all inclusion criteria. Study quality was assessed using the Oxford Quality Scale (Jadad scale).
The majority of studies initially retrieved from the search were eliminated due to design that was either not an RCT or where clinical results were not reported. No meta-analysis could be done due to the small sample size with final studies included. In one study, TENS was compared to sham TENS in women. The only outcome measure with significant differences between groups was one dimension of a patient satisfaction questionnaire. In the other study, there were no significant differences between groups.
No conclusions regarding the effectiveness of TENS could be made due to the lack of studies that met criteria.
This review was limited by the inclusion criteria that TENS had to be compared to no treatment. The ethics of having such a control or placebo group in patients with chronic pain and in end-of-life care is questionable, and the inability to find enough studies that met this strict criteria is not surprising. Results were inconclusive due to lack of suitable RCTs.
There is little data to demonstrate effectiveness of TENS for cancer-related pain. In patients with chronic pain, the insistence upon a placebo control group in an RCT is not reasonable and appropriate, and such limitations will not serve to advance knowledge in this area. Additional research with adequate sample sizes is needed in this area.
Rizzo, J. D., Wingard, J. R., Tichelli, A., Lee, S. J., Van Lint, M. T., Burns, L. J., . . . Socié, G. (2006). Recommended screening and preventive practices for long-term survivors after hematopoietic cell transplantation: joint recommendations of the European Group for Blood and Marrow Transplantation, the Center for International Blood and Marrow Transplant Research, and the American Society of Blood and Marrow Transplantation. Biology of Blood and Marrow Transplantation, 12, 138–151.
To summarize recommendations for care providers regarding screening and prevention practices for adult autologous and allogeneic hematopoietic cell transplantation survivors.
This was classified as an expert opinion.
Recommended practices were developed by a consensus panel from three major blood and marrow transplantation organizations. Most recommendations were developed from studies (not cited) identifying specific complications and associated risk factors in long-term survivors.
Guidelines for the prevention of infection for all transplantation patients include Pneumocystis carinii pneumonia prophylaxis for six months and immunization with inactivated vaccines beginning at one year posttransplantation and annually thereafter. Other infection prevention recommendations include antibiotic prophylaxis for encapsulated microorganisms during immunosuppressive therapy for chronic graft-versus-host disease (cGVHD), possible antifungal prophylaxis for patients on chronic steroids, adhering to the American Heart Association (AHA) guidelines of antibiotic prophylaxis for oral procedures, cytomegalovirus antigen or polymerase chain reaction testing for allogeneic hematopoietic cell transplantation recipients with chronic immunosuppression or cGVHD, and possible prophylaxis for the herpes simplex virus for those on chronic immunosuppressants for cGVHD. This article also includes recommendations for many other aspects of posttransplantation care. Recommendations are summarized in two tables, one organized by body system and the other organized by time after transplantation.
The authors did not include the sources used to arrive at the consensus recommendations, with the following exceptions:
Rizza, L., D'Agostino, A., Girlando, A., & Puglia, C. (2010). Evaluation of the effect of topical agents on radiation-induced skin disease by reflectance spectrophotometry. The Journal of Pharmacy and Pharmacology, 62(6), 779–785.
To evaluate the effects of two topical agents (Biafin and an emulsion made of natural extracts containing Capparis spinosa, Opuntia coccinellifera, and olive leaf extracts) used supportively to minimize radiation-induced erythema and skin reactions using noninvasive instrumental methods
Patients applied a thin layer of one of the two topical agents twice daily starting the first day of radiotherapy. The topical formulations were not applied within four hours of the radiation session. Skin regions in the radiation field that were assessed were divided into three areas: lateral breast, medial breast, and area under the breast. For each skin region, skin reaction was evaluated by an instrumental erythema index obtained from non-invasive reflectance spectrophotometry and recorded once per week. Visual assessment regarding erythema, edema, desquamation and ulceration of each region was performed in weekly inspections using the Radiation Therapy Oncology Group/European Organisation for Research and Treatment of Cancer (RTOG/EORTC) scoring system. Photo documentation of treated skin was done to verify the RTOG/EORTC visual score.
The study took place at the Department of Radiotherapy at Humanitas Centro Catanese di Oncologia in Italy.
Patients were undergoing active treatment for cancer. The study has clinical applicability for late effects and survivorship.
The study used a double-blinded, computer-generated, randomized design with nontreatment control groups monitored over eight weeks.
The 68 patients were randomized as follows: 26 subjects randomly received treatment A (the topical emulsion made of herbal extracts), 24 patients received treatment B (Biafin), and 18 subjects received no treatment. A significant increase in erythema index was seen in the nontreatment group after the second week of radiation, with maximal values recorded between weeks 4 and 6 of treatment. Formulation A was significantly more effective than B in preventing or reducing radiotherapy-induced skin reactions (p < 0.05). The modified RTOG/EOTRC visual score system showed that both treatment A and treatment B were effective against the development of erythema in comparison with the nontreatment group (p < 0.01). There was no significant difference in the RTOG/EOTRC visual score system between treatment A and treatment B in reducing skin erythema induced by radiation therapy.
Use of topical emollients at the onset of radiation therapy and throughout treatment twice per day is effective at reducing the appearance of skin erythema for patients with breast cancer undergoing radiation therapy. Patients not using topical emollients at all during radiation treatment results in increased erythema and desquamation in irradiated skin areas. The use of reflectance spectrophotometry showed that early erythema could be reduced with the application of topical emollients.
The use of topical agents applied to radiated skin fields at least twice per day throughout treatment is more effective than no treatment at all to reduce the incidence of skin reactions and early erythema. The research study article supports the use of topical agents containing ingredients that can provide protective effects against skin damage incurred during radiation therapy. The reduction of skin irritation with the use of Biafin or herbal extracts supports recommendation of the routine use of topical emollients for all patients receiving radiotherapy who have the potential for skin reactions with treatment.
Rivera, I.V., Garrido, J.C.M., Velasco, P.G., de Enciso, I.E.X., & Clavarana, L.V. (2014). Efficacy of sublingual fentanyl vs. oral morphine for cancer-related breakthrough pain. Advances in Therapy, 31, 107–117.
To determine the efficacy, tolerability, and patient satisfaction with treatment for breakthrough pain with sublingual fentanyl citrate and oral morphine
Patients were allocated consecutively to receive either oral morphine or sublingual fentanyl. Doses were adjusted individually until an effective dose was obtained. Effective dose was defined as the dose needed to achieve a 50% pain reduction in each breakthrough episode. Patients maintained a pain diary. Side effects were assessed by a physician who was blinded to group allocations in each visit. Outcomes were assessed at three, seven, 15, and 30 days.
Prospective, double-blinded, two-group trial
Mean pain intensity was consistently lower for those receiving sublingual fentanyl at all time points (p < 0.0001). Sublingual fentanyl gave faster relief onset at all time points with an average of 5–8.5 minutes for fentanyl compared to 15–23 minutes for oral morphine (p < 0.001). The titration period for fentanyl was a mean of 6.6 days compared to 13.3 days for oral morphine (p < 0.001). No patients treated with fentanyl were dissatisfied with treatment compared to 37.5% of those receiving oral morphine who were dissatisfied or very dissatisfied. There were no significant differences in side effects, and the side effects reported were typical of those seen with opioid medications.
The findings of this study showed that compared to oral morphine, sublingual fentanyl citrate had a faster onset and was associated with greater reductions in pain intensity for episodes of breakthrough pain in patients with cancer. It took less time to titrate to an effective dose with sublingual fentanyl.
Sublingual fentanyl was more effective than oral morphine for breakthrough pain in terms of faster onset and greater reduction in pain intensity. In this study, it also was quicker to titrate to the effective dosage with sublingual fentanyl. This study added to the growing body of evidence suggesting superior results with transmucosal opioids for breakthrough pain. Effective pain control is a critical aspect of care for patients with cancer, and the goal in the management of breakthrough pain episodes is the achievement of rapid relief, including the length of time it takes to titrate doses and the length of time for onset of relief. Nurses need to advocate for the most effective interventions to manage breakthrough pain for their patients.
Rivard, C., Vogel, R.I., & Teoh, D. (2015). Effect of intraperitoneal bupivacaine on postoperative pain in the gynecologic oncology patient. Journal of Minimally Invasive Gynecology, 22, 1260–1265.
To evaluate the effect of intraperitoneal bupivacaine on postoperative pain in patients undergoing minimally invasive gynecologic surgeries
At the end of the surgical procedure, a single dose of 20 ml of 0.25% bupivacaine was given intraperitoneally. Patients receiving this intervention were compared with historical control subjects who had the same types of surgical procedures. Regimens for postoperative pain management were the same for both groups of patients, including IV fentanyl during surgery and in the postanesthesia care unit, ketorolac until discharge or 24 hours postoperatively, and transition to ibuprofen 600 mg orally every six hours. Oral oxycodone/acetaminophen and IV hydrocodone or hydromorphone was used as needed if oral medications were insufficient. Patient-reported pain scores and narcotic analgesic use were obtained on the day of surgery and for two days postoperatively.
Median narcotic use was significantly lower in the bupivacaine group on the day of surgery (p = 0.007) and postop day 1 (p < 0.001). On postop day 2, narcotic use in the bupivacaine group was lower, but the difference was not significant. Pain score on the day of surgery was lower in the bupivacaine group (p = 0.05). Pain ratings were also lower on postop days 1 and 2, but differences were not statistically significant.
Instillation of local anesthetic into the peritoneal cavity was associated with improved postoperative pain control among women undergoing minimally invasive gynecologic procedures.
This study adds to the body of evidence showing efficacy of local anesthetic instillation into the surgical site area for improvement in acute pain control. Nurses can advocate for consideration of this type of approach for acute pain management.
Ritterband, L. M., Bailey, E. T., Thorndike, F. P., Lord, H. R., Farrell-Carnahan, L., & Baum, L. D. (2012). Initial evaluation of an internet intervention to improve the sleep of cancer survivors with insomnia. Psycho-Oncology, 21, 695–705.
To determine the feasibility and efficacy of an internet-based, cognitive-based therapy (CBT-I) program—Sleep Healthy Using the Internet (SHUTi)—to improve insomnia symptoms in cancer survivors.
To explore whether an internet-based CBT-I intervention would improve fatigue, mood, and quality of life (QOL).
Patients completed preassessment questionnaires and sleep diaries for 10 days over a two-week period. Patients randomized to the intervention group were enrolled in the SHUTi program. They were given nine weeks to complete six interactive core programs, each lasting about 45 to 60 minutes. During the program, they entered daily sleep diary information. The first core, “Overview,” introduced the SHUTi program, and the next two cores, Behavior 1 and Behavior 2, introduced sleep restriction and stimulus control. The “Education” core focused on sleep hygiene, and the “Sleep Thoughts” core helped users identify and restructure faulty beliefs about sleep. Lastly, patients received “Problem Prevention,” which covered relapse prevention. Upon completion, all patients completed postassessment questionnaires and sleep diaries for 10 days.
The study was a randomized, controlled trial with a wait-list control.
The internet group showed marked improvement in insomnia severity from pre-/postassessment, and the control group showed no significant change (p < 0.01). The internet group ISI score decreased from 17.1 preassessment to 8.2 postassessment (p < 0.01), and control group scores showed no significant changes from preassessment (15.9) to postassessment (14.4). In addition, the internet group showed clinically significant changes, pre-/postintervention, with 64% having clinically significant insomnia preintervention to 14% having clinically significant insomnia postintervention. Postintervention, 50% of internet group scored “no insomnia” versus 14% in the control group. Effect size for insomnia severity, sleep efficiency, sleep onset latency (SOL), and wake after sleep onset (WASO) were all d > .72.
Improvements were also shown in sleep efficiency and SOL for the internet group. No effect was noted in total sleep time, WASO, and time in bed.
Improvements were seen in the internet group's overall fatigue scores over time (p < 0.01), especially when compared to the control, who showed no improvement over time. There were no significant changes in HADS scores or the SF-12 QOL scores over time or between groups.
An internet-based CBT-I intervention is feasible and efficacious in improving insomnia and fatigue in some cancer survivors in a small sample of highly educated, white, married women.
There seemed to be excellent response to this intervention in this population. However, a wider study with a more diverse sample is required.
Rithirangsriroj, K., Manchana, T., & Akkayagorn, L. (2015). Efficacy of acupuncture in prevention of delayed chemotherapy induced nausea and vomiting in gynecologic cancer patients. Gynecologic Oncology, 136, 82–86.
To compare the efficacy of ondansetron versus acupuncture in the prevention of delayed chemotherapy-induced nausea and vomiting (CINV)
Patients were randomized to receive acupuncture (applied to wrists) or ondansetron (8 mg IV for 30 minutes) before chemotherapy. Acupuncture also was applied the day after chemotherapy. All patients received dexamethasone at 5 mg orally twice per day for three days following chemotherapy. Ondansetron at 4 mg was administered orally every 12 hours for vomiting. During subsequent chemotherapy infusions, patients received the other intervention in a crossover design. Data on CINV were collected for five days after the administration of chemotherapy, and quality-of-life data were collected on the seventh day following chemotherapy.
Randomized, crossover study
Patients in the intervention group had a higher rate of complete response for delayed CINV (p = 0.02), less delayed nausea (p = 0.004), lower nausea scores (p < 0.001), and fewer doses of additional ondansetron (p = 0.002). Fewer patients reported adverse side effects when receiving acupuncture. Forty patients reported that they preferred acupuncture to ondansetron.
Acupuncture was effective in the prevention of delayed CINV and nausea. Patients receiving acupuncture also required fewer doses of ondansetron during the delayed phase of CINV.
Although additional research with a larger and more diverse sample is needed, the use of acupuncture to manage CINV could represent an effective nursing intervention for patients receiving platinum-based chemotherapy.
Rissanen, R., Arving, C., Ahlgren, J., & Nordin, K. (2014). Group versus individual stress management intervention in breast cancer patients for fatigue and emotional reactivity: A randomised intervention study. Acta Oncologica, 53, 1221–1229.
To evaluate if stress management delivered in group or individual settings improved fatigue and emotional reactivity among newly diagnosed patients with breast cancer
Group stress management (GSM) consisted of 10 two-hour sessions over three months. Homework was assigned between sessions and discussed in the group. Sessions were cognitive behavioral (CBT) therapy-based with specific subjects: introduction to stress and stress response, negative thoughts and stress behavior, irritability and anger, quality of life, expectations of life, reactions to a cancer diagnosis, sexuality, and recapturing. Individual stress management (ISM) consisted of four to eight one-hour sessions over four and a half months using the same subjects from thee GSM group. Subjects were offered additional sessions as needed. Subjects also were given homework assignments between sessions. Both groups were led by a nurse trained in the intervention, which was also manual-based.
Nonblinded, randomized, controlled trial that was randomized at three-month timepoints after enrollment if cutoff scores on the Hospital Anxiety and Depression Scale or the Impact of Events Scale were met or were higher
At the three-month evaluation, 304 women met eligibility requirements for randomization and 149 declined. Forty-two of 77 (52%) women who were randomized to the GSM group attended group sessions and completed an average nine of 10 sessions. Seventy-one of 78 women who were randomized to the ISM group completed an average of five of eight sessions. Those who declined participation in both groups reported significantly less activity. Results were compared at 12 months to three months. There were no significant changes over time and no significant changes between the GSM and ISM groups on fatigue or emotional reactivity. There was no significant difference over time in MFI-20 or ELSS scores. Thirty-one percent of participants who refused participation cited a lack of distress as the reason.
This study demonstrated no significant improvement in fatigue for patients breast cancer who participated in a CBT-based group or an individual intervention.
The willingness of patients to participate in group interventions should be considered when developing such programs.
Ripamonti, C.I., Santini, D., Maranzano, E., Berti, M., Roila, F., & European Society for Medical Oncology (ESMO) Guidelines Working Group. (2012). Management of cancer pain: ESMO Clinical Practice Guidelines. Annals of Oncology, 23(Suppl. 7), vii139–vii154.
To provide clinical guidance regarding the assessment and management of pain in patients with cancer
The development process for these evidence-based guidelines was not described.
These guidelines are for use in patients undergoing multiple phases of care.
The search and full body of evidence were not described. Evidence and recommendation level relating to each management guideline was included.
This resource provides general clinical practice guidelines regarding the management of pain of cancer. The authors note that cancer-related pain is generally undertreated. Nurses should be aware of the potential for the undertreatment of pain and advocate for effective pain management.