Linardou, H., & Gogas, H. (2016). Toxicity management of immunotherapy for patients with metastatic melanoma. Annals of Translational Medicine, 4, 272.
RESOURCE TYPE: Expert opinion
PHASE OF CARE: Active antitumor treatment
Expert opinion level only. The evidence is derived only from initial drug clinical trials.
Limited research evidence regarding interventions to prevent and manage side effects of immunotherapies exists, and most relies on corticosteroid treatment with increased dosing according to the severity of the side effects. Nurses need to be aware that diarrhea, in particular, with immunotherapy can lead to severe colitis, which can be life-threatening and require surgical removal of the colon. Patients need to be taught to report side effects promptly, and patients need to be monitored closely for these adverse events, with prompt intervention.
Lin, L. C., Que, J., Lin, L. K., & Lin, F. C. (2006). Zinc supplementation to improve mucositis and dermatitis in patients after radiotherapy for head-and-neck cancers: a double-blind, randomized study. International Journal of Radiation Oncology, Biology, Physics, 65, 745–750.
To determine whether zinc supplementation can accelerate the healing of mucositis and dermatitis after radiation therapy (RT).
There were two randomized groups: the experimental (group A) received 25 mg of zinc three times per day and the control (group B) received the placebo (n = 48).
The principle researcher was blinded. Evaluation and grading of mucositis and dermatitis was performed weekly during treatment andtwo weeks after completion of RT, including the weekends.
Chi-Mei Foundation Medical Center Tainan, Taiwan, China
The study was a randomized, double-blind, placebo-controlled trial.
Radiation Therapy Oncology Group (RTOG) scores for dermatitis
Oral zinc supplementation may delay the onset and reduce the severity of radiodermatitis.
The treatment design for the timing of the study was standard practice; it is not certain if one could correlate the study information to modern treatment delivery.
Lin, L.C., Que, J., Lin, L.K., & Lin, F.C. (2006). Zinc supplementation to improve mucositis and dermatitis in patients after radiotherapy for head-and-neck cancers: A double-blind, randomized study. International Journal of Radiation Oncology, Biology, Physics, 65(3), 745–750.
Zinc – 25 mg versus placebo, 3x/day for 2 months
Patients started capsules on first day of RT and continued until completion of RT.
Block randomization
The study was comprised of 100 patients, 50 zinc, 50 placebo, with a mean age of 50–51 years.
RT dose 180–200 cGy daily in five weekly fractions
41-42% patients receiving RT + chemo
Jan 2003 – Aug 2004
Double-blind, randomized, placebo-controlled study
RTOG acute morbidity scoring
Serum zinc levels were higher in the zinc group: 20.5 versus –1.5 (p = 0.02).
Grade 2 mucositis appeared earlier in the placebo group (p = 0.017 and larger proportion of patients).
Grade 3 mucositis also earlier and larger proportion of patients, p = 0.0003.
Results not as significant for patients receiving concurrent chemo.
Oral analgesics prescribed for pain.
Recommend continuing treatment out past end of RT as patients in both groups had similar recoveries.
Need to determine optimal dose.
Lin, M.F., Hsieh, Y.J., Hsu, Y.Y., Fetzer, S., & Hsu, M.C. (2011). A randomised controlled trial of the effect of music therapy and verbal relaxation on chemotherapy-induced anxiety. Journal of Clinical Nursing, 20, 988–999.
To identify patients in high-anxiety states and to test the effects of a music intervention
Cancer and its treatment provoke a series of changes in the emotional sphere of patient anxiety. In addition, there is a subgroup of patients who are in a high-anxiety state. These patients, when identified, obtain the most benefits from music or verbal relaxation. This study consisted of 98 patients in three groups: the music therapy group, which received 60-minute, single-music sessions; the verbal relaxation group, which received 30 minutes of guided relaxation; and the control group, which received usual care. Because patients were asked to rate their anxiety preintervention, the study also was able to test the intervention's effects on those in high-anxiety states.
Randomized, controlled trial
All groups experienced a significant decline in anxiety. The music intervention group experienced a greater decrease in poststate anxiety (p = .005). Physiologic indicators also changed in patients with high-anxiety states in the music therapy group. This study highlighted the need to target patients in high-anxiety states and to offer additional support, relaxation, and interventions such as music therapy to this population.
Music intervention and relaxation therapy reduces chemotherapy-induced anxiety.
This study highlighted the need to identify patients in high-anxiety states pretreatment. This population can then be offered additional interventions. Music and relaxation can reduce anxiety during chemotherapy. Most infusion centers offer personal music devices or allow patients to bring their own. Music can be offered via headphones if a patient desires. This intervention can be recommended safely.
Lin, S.J., Hatoum, H.T., Buchner, D., Cox, D., & Balu, S. (2012). Impact of 5-HT3 receptor antagonists on chemotherapy-induced nausea and vomiting: A retrospective cohort study. BMC Health Services Research, 12, 215.
To study the effect of step-therapy policy requiring an older 5-HT3 receptor antagonist (RA) prior to palonosetron on the risk of chemotherapy-induced nausea and vomiting (CINV) associated with hospital or emergency department (ED) admissions
Patients with a diagnosis of breast or lung cancer and receiving moderately emetogenic chemotherapy (MEC) (cyclophosphamide, carboplatin) or highly emetogenic chemotherapy (HEC) (cisplatin) were selected from the PharmMetrics claims dataset (providing drug name, quantity dispensed, and length of supply) between January 2005 and June 2008. CINV events were followed for six months from initial chemotherapy administration through ICD-9-CM codes. Study duration was six months from the index chemotherapy date, and antiemetics investigated included dolasetron, granisetron, ondansetron, and palonosetron. Patients were divided into two groups: those initiated with palonosetron and maintained on the drug for the duration of the study and those who began therapy with one of the older 5-HT3 RAs and maintained on the initial drug or alternated between any 5-HT3 RAs. The use of dexamethasone was assessed for both groups. CINV events were calculated using paid and filed claims with ICD-9 codes for nausea, vomiting, or dehydration, and those with hospital admissions were selected.
The study was conducted in multiple settings in the United States. Specific sites were not reported.
All patients were in active antitumor treatment.
This was a longitudinal, retrospective cohort study.
Patients with breast or lung cancer receiving MEC who were initiated and maintained on palonosetron were at significantly lower risk for potentially costly CINV versus those on older 5-HT3 RAs. More studies indicating the impact of step-therapy policy are necessary.
Patients with breast or lung cancer undergoing MEC or HEC who are initiated and maintained on palonosetron experience fewer CINV events compared to patients receiving older 5-HT3 RAs. Nurses should be aware that palonosetron is more expensive than older 5-HT3 RAs, and, thus, patients with low economic status or who are self-insured may not be able to pay for this drug. The reduced antiemetic claims noted here suggest that cost may be equivalent because palonosetron requires fewer doses.
Lua, P.L., Salihah, N., & Mazlan, N. (2015). Effects of inhaled ginger aromatherapy on chemotherapy-induced nausea and vomiting and health-related quality of life in women with breast cancer. Complementary Therapies in Medicine, 23, 396–404.
To assess the effectiveness of inhaled ginger essential oil in reducing the incidence of chemotherapy-induced nausea and vomiting (CINV) in patients with breast cancer as a complementary intervention to standard antiemetic care, and to assess the patients’ quality of life (QOL) related to their health following aromatherapy
An aromatherapy necklace was worn by the participants for five days, 24 hours/day, after receiving highly emetogenic chemotherapy. It was used for patients to inhale at least three times a day. Patients were assigned to two groups: For course 1, Group 1 had a ginger fragrance oil (placebo) in the necklace while Group 2 had ginger essential oil. For course 2, Group 1 had the ginger essential oil while Group 2 used the fragrance oil. Standard antiemetics were also given prior to chemotherapy—IV granisetron and IV dexamethasone in addition to scheduled take-home medications of oral granisetron, oral dexamethasone, and oral metoclopramide. Data were collected at baseline, on days 1–5, and on day 8.
The use of ginger essential oil inhalation significantly lowered the VAS nausea score during the acute phase (p = 0.04) compared to the placebo, but its effect was not sustained over time. No appreciable effect on vomiting was revealed. Inhaled ginger essential oil positively affected the global health status from baseline.
Inhaled ginger essential oil did not demonstrate significant reductions in CINV and may not be effective as complementary therapy for CINV overall. It may be a useful adjunct for nausea symptoms.
No evidence suggested that the use of inhaled ginger essential oil is effective in improving CINV control, but it may be helpful in improving QOL during treatment. Further research is warranted as nausea control continues to be a challenge.
Lin, J.X., Fan, Z.Y., Lin, Q., Wu, D.H., Wu, X.Y., Chen, Y.R., . . . Wan, X.B. (2014). A comparison of dioctahedral smectite and iodine glycerin cream with topical mouth rinse in treatment of chemotherapy induced oral mucositis: A pilot study. European Journal of Oncology Nursing. Advance online publication.
To compare the efficacy of dioctahedral smectite and iodine glycerin (DSIG) cream to a topical mouth rinse in the treatment of chemotherapy-induced oral mucositis
After oral mucositis (OM) developed, patients were randomized to receive DSIG or a topical rinse solution administered by two nurses. Nurses were not blinded to the intervention. The DSIG cream consisted of 3 g of dioctahedral smectite and 10 ml of iodine glycerin. The cream was applied to oral mucosa four times per day for one hour during each application while the patient was fasting. The topical mouth solution consisted of saline 400 ml, gentamicin 640,000 u, and vitamin B12 500 mg. Patients rinsed with the solution four times per day and gargled the solution for one minute with each application. Both treatments were administered for five consecutive days. Data were collected daily once OM was identified and continued for five days.
Randomized, controlled trial
Both groups of patients had OM of similar severity on day 1 of the study. Over the five days of the study, when compared to a topical rinse solution, DSIG improved the severity of OM. Patients who received DSIG healed faster than those who received the topical rinse. DSIG is a promising treatment for chemotherapy-induced OM, and additional studies to compare DSIG to other available OM treatments and to study the efficacy of DSIG over a longer period of time are needed. Studies also are needed to determine whether DSIG has a role in the prevention of chemotherapy-induced OM.
DSIG may be a useful intervention for patients who already developed chemotherapy-induced OM. Patients who received the DSIG treatment had less severe OM than those who received a topical rinse solution, and they had a faster rate of healing and more thorough healing. Nurses can conduct physical assessments of patients to determine the extent to which OM is present and educate patients about the various options for OM treatment.
Lim, H.A., Griva, K., Yoong, R.K., Chua, J., Leow, M.Q., Chan, M.F., . . . Mahendran, R. (2015). Do caregivers of cancer patients receiving care in home hospice services have better quality of life? An exploratory investigation in Singapore. Psycho-Oncology, 25, 471–474.
To examine the differences between caregiver quality of life when caring for a patient in a home hospice program and an ambulatory patient receiving formal palliative care program services
Governmentally supported home hospice services provided to patients with advanced cancer by a multidisciplinary team
Cross-sectional study with combined data from two studies
Significant Pearson intercorrelations (rs = 0.18-0.84, ps < 0.05) for CQOLC total scores and subscales excluding positive adaptation and disruptiveness subscales were found. Males had significantly lower total CQOLC scores (p = 0.012) and disruptiveness scores (p = 0.003). Significantly lower CQOLC scores also resulted in caregivers caring for parents (and tertiary education [all values = p < 0.05]). Chinese ethnic caregivers had better QOL related to burden (p = 0.031) and financial concerns (p = 0.024), but less successful positive adaptation resulted in lower QOL (p = 0.024). Although data analysis controlled for significant differences in age and spousal caregiving, ambulatory patient caregivers were older and more likely to be spousal caregivers. Analysis of covariance (ANCOVA) supported home hospice caregivers experiencing better QOL than ambulatory patient caregivers but only in total CQOLC scores (p = 0.008) and subscales of financial worries and burden (p = 0.004).
Home hospice care programs for patients with palliative cancer care needs appear to benefit caregiver QOL, particularly in minimizing perceptions of burden and financial concerns. Those programs, composed of multidisciplinary teams focused on responding to patient end-of-life needs, seem to improve caregiver confidence in care and satisfy caregivers’ desire for personalized support by healthcare providers.
Models of home hospice services to mutually benefit caregivers and those they care for need further testing in a variety of cultures with variant healthcare systems to more clearly validate the efficiency of and benefits of those models in meeting caregiver improved QOL.
Lim, J.T., Wong, E.T., & Aung, S.K. (2011). Is there a role for acupuncture in the symptom management of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led supportive care. Acupuncture in Medicine, 29(3), 173–179.
To document changes in symptoms after acupuncture or nurse-led supportive care in patients with incurable cancer and to determine the feasibility of carrying out a randomized trial in acupuncture for patients with advanced incurable cancer
Patients were randomly assigned to either an acupuncture group or a nurse-led supportive care group. In the acupuncture group, traditional Chinese medical acupuncture was performed by the principle investigator, a radiation oncologist, and a certified medical acupuncturist. The acupuncture points were chosen based on the symptoms experienced. The acupuncture needles were connected to an electric stimulator, and a 0.3 ms duration, 4 Hz alternating current was delivered. The needles were stimulated for 20 minutes and then removed.
In the nurse-led supportive care group, patients met for 20–30 minutes with an experienced palliative care nurse weekly for four weeks, comparable to the time spent in acupuncture. The nurse explored their most troubling symptoms and discussed medications and nonpharmacologic therapies such as relaxation therapy, professional counseling, exercise, or judicious rest. The patient’s interpretation of the causes of the symptoms and how they could be ameliorated were discussed. The nurse also addressed issues such as improving the scheduling and dosing of the medications and alternative therapies to drugs, such as foods for managing constipation. Useful strategies for coping with daily activities and emotional support were discussed.
This pilot study was a single-blind, randomized controlled trial.
The Edmond Symptom Assessment System (ESAS) was used to measure any changes in the symptoms experienced by patients before and after the intervention.
The treatment was well tolerated with no significant unexpected side effects. The compliance rate was 90% for acupuncture and 80% for nurse-led supportive care. All nine symptoms (pain, tiredness/fatigue, nausea, depression, anxiety, drowsiness, loss of appetite, lack of well-being, and shortness of breath) were improved immediately after acupuncture, with improvement continuing in six of these symptoms after six weeks. Six symptom scores improved immediately following nurse-led supportive care visits, with all nine symptoms showing improvement after six weeks. Total symptoms were reduced by an average of 22% after each acupuncture visit and by 14% after each nurse-led supportive care visit. ESAS scores at the end of the follow-up period were reduced by 19% for the acupuncture group and 26% for the nurse-led supportive care group. At six weeks after acupuncture, symptoms of pain, nausea, and loss of appetite did not maintain improvement. Only 48% of eligible patients consented to the study, and it was closed due to poor recruitment.
The study suggests that patients can benefit from incorporating acupuncture and supportive interventions to help with symptom management in advanced incurable cancer. Findings suggest that nurse attention provided over the long term benefited patients and that acupuncture may provide some immediate symptom improvements.
Nurse-led supportive care can improve symptoms in these patients. These improvements can likely be attributed to increased attention and quality feedback being provided from the nurse to the medical team, who were able to initiate positive changes in medication and other supportive measures.
Gouvea de Lima, A., Antequera, R., Peres, M.P., Snitcosky, I.M., Federico, M.H., & Villar, R.C. (2010). Efficacy of low-level laser therapy and aluminum hydroxide in patients with chemotherapy and radiotherapy-induced oral mucositis. Brazilian Dental Journal, 21, 186–192.
To evaluate the use of low level laser therapy (LLLT) and aluminum hydroxide for the prevention of oral mucositis in patients with head and neck cancer, and to evaluate the impact of LLLT on pain scores.
Group 1 was given LLLT at 830 nm daily since first day of radiotherapy (RT) to end of therapy prior to RT (RT days only). It was applied to 12 areas of the oral cavity. Group 2 received aluminum hydroxide (AH) suspension (310 mg/5 mL) starting on first day of RT and continued throughout, including weekends. Patients used 10 mL of AH 4 times a day and swallowed and had to avoid eating during the first hour after treatment.
This was a single-site, outpatient study conducted in Brazil.
Patients were undergoing the active treatment phase of care.
The study was prospective, comparative, and nonrandomized.
Lower oral mucositis (OM) scores were observed in the LLLT group (p = 0.061). More grade III OM was seen in the AH group, and severe OM was delayed in the LLLT group. LLLT pain scores were lower but not statistically significant overall. Quality-of-life (QOL) scores were all higher (i.e., more symptoms) in the AH group.
LLLT was found to be more effective than AH in delaying severe OM; however, more trials are needed.
Although LLLT was found to be more effective than AH in delaying severe OM, questions exist regrding the best protocols and dosing, as well as how this evidence correlates to other disease types. Additionally, availability of equipment may be an issue.