Leenstra, J.L., Miller, R.C., Qin, R., Martenson, J.A., Dornfeld, K.J., Bearden, J.D., ... Loprinzi, C.L. (2014). Doxepin rinse versus placebo in the treatment of acute oral mucositis pain in patients receiving head and neck radiotherapy with or without chemotherapy: A phase III, randomized, double-blind trial (NCCTG-N09C6 [Alliance]). Journal of Clinical Oncology, 32, 1571–1577.
To test the efficacy of doxepin hydrochloride in reducing radiotherapy-induced oral mucositis pain
Arm 1: Doxepin oral rinse 10 mg/ml x 2.5 ml = 25 mg diluted with sterile or distilled water for a total of 5 ml. Arm 2: Placebo rinse prepared in similar manner with flavored syrup added. Study dose was prepared by unblinded nurse or pharmacist. Blinded personnel administered the rinse. On day 1, the patients swished for one minute, gargled, and spit. On day 2, patients received the opposite rinse. Patients completed symptom questionnaires at set time intervals during the hour following administration and then again at home at two and four hours. No analgesics or oral rinses were allowed 60 minutes prior to and following the study doses. Patients returned the next time their oral pain was ≥ 4/10 and received their second study dose, after which they were unblinded and given the option to continue use of doxepin rinses prn. Patient-reported questionnaires with numerical pain analog scale (0–10) done at BL, 5, 15, 30, 60, 120, and 240 minutes after the rinse on days 1 and 2 to measure pain, taste, stinging or burning, and drowsiness.
Randomized, double-blind, placebo-controlled, phase III trial with crossover phase followed by continued use of active agent
Primary outcome: AUC for mean mouth and throat pain reduction was greater for doxepin compared with placebo (–4.4 difference p < .001). Crossover data revealed similar findings with –2.3 difference p < .001.
Largest placebo-controlled trial to date for oral mucositis pain with positive results
This is a promising option for mucositis pain although there are concerns about how the solution will be made, the cost, the ease of use, the side effects, and adherence to the rinse. Additional questions exist concerning whether or not this data can also be applied to patients receiving chemotherapy or those who have cancers other than head and neck cancer.
Lee-Robichaud, H., Thomas, K., Morgan, J., & Nelson, R.L. (2010). Lactulose versus polyethylene glycol for chronic constipation. Cochrane Database of Systematic Reviews, 7, CD007570.
To identify and review all relevant data to determine whether lactulose or polyethylene glycol (PEG) is more effective in treating chronic constipation.
Databases searched were Medline, Embase, CINAHL, and the Cochrane Central Register of Controlled Trials. Bibliographies of studies and conference proceedings were hand searched.
Search keywords were fecal impaction, chronic constipation, delayed bowel movement, obstipation, irregularity, polyethylene glycol, ethylene glycol, PEG, ethylene oxide, PEG 3350, lactulose, and disaccharide.
Studies were included in the review if they
One hundred three initial references to January 24, 2008, were identified. A final set of 10 trials was included in this review. Studies were evaluated for various sources of bias and overall methodological quality. Trials were conducted in different countries in a variety of settings.
One study included a sample of patients on methadone maintenance, which may have some relevance for constipation associated with opioid use.
Lee, K.H., Kim, M.K., Hyun, M.S., Kim, J.Y., Park, K.U., Song, H.S., . . . Cho, Y.Y. (2012). Clinical effectiveness and safety of OROS® hydromorphone in break-through cancer pain treatment: A multicenter, prospective, open-label study in Korean patients. Journal of Opioid Management, 8, 243–252.
To evaluate the effectiveness of OROS hydromorphone in reducing the use of medication for breakthrough pain (BTP) in Korean patients with chronic cancer pain
Patients were stabilized on the existing pain regimen for three days. After stabilization, pain medication was converted to OROS hydromorphone at a dose equivalent to oxycodone in effectiveness. Dose equivalence was calculated using the ratio 2.5:1 controlled-release oxycodone to hydromorphone hydrochloride. The minimum starting dose of hydromorphone was 8 mg, which was provided in the form of 8, 16, or 32 mg tablets. Patients took the medication at 8 am each morning, swallowing tablets whole, with water, and without chewing, dividing, or crushing. Immediate-release hydromorphone was used as the rescue medication at a dose equaling 10%–15% of OROS hydromorphone. No other opioid medications were permitted postconversion to OROS hydromorphone. Patients were allowed to use nonopioid and adjuvant analgesics. On day 7, if the patient required more than four rescue doses per day, medication was increased in increments of 8 or 16 mg. Investigators collected data at baseline and on days 7 and 14.
Prospective open-label phase IV study
Compared to the mean of BTP frequencies at baseline, the mean of BTP frequencies decreased significantly (p < 0.001) on days 7 and 14. Also compared to baseline, BTP subtypes decreased on days 7 and 14. Compared to baseline measures, measures of pain intensity at its worst (p < 0.001) and average pain intensity (p < 0.005) decreased on day 14. Compared to baseline measures, measures of physical functioning improved significantly (p = 0.015) on day 14. Emotional, cognitive, and social functioning were stable after drug conversion (p > 0.05). At the end of the trial, 61.2% of patients rated the medication as effective and 91.2% of patients reported mild or moderate adverse events. (Authors reported that 32% of adverse events were considered related to study treatment.) Of all patients, 88% preferred the study regimen to their previous regimen, based on ease of use.
OROS hydromorphone was effective in reducing pain intensity in patients with chronic cancer pain. Physical function improved over 14 days while cognitive and emotional functioning remained intact. Although most patients reported adverse events, the majority of events were mild or moderate and unrelated to the study drug. In regard to ease of use, the overwhelming majority of patients preferred the study regimen to their previous regimen.
The study had risks of bias due to no control group, no blinding, and no random assignment.
Because this study showed that OROS hydromorphone therapy could decrease pain severity and that patients found the medication easy to use, clinicians should consider the drug in the treatment of patients with chronic cancer-related pain. The results of this study warrant a randomized, blinded trial.
Lee, S.H., Kim, J.Y., Yeo, S., Kim, S.H., & Lim, S. (2015). Meta-analysis of massage therapy on cancer pain. Integrative Cancer Therapies, 14, 297–304.
STUDY PURPOSE: To investigate the effects of massage therapy on cancer pain
TYPE OF STUDY: Meta-analysis and systematic review
PHASE OF CARE: Multiple phases of care
APPLICATIONS: Palliative care
Massage was associated with lower pain (SMD = –1.25, p = 0.0001). Subgroup analysis according to type of intervention, massage, aromatherapy massage, or foot reflexology showed positive effect of each type, though few studies in each subgroup existed. PEDro scores indicated that only three studies were low quality, and the rest were high quality; however, risk of bias evaluation varied widely and showed that most studies had moderate to high risk of bias. Effects of massage were more positive in those studies with higher risk of bias.
Findings show that massage therapy has positive benefits for cancer-related pain.
Massage therapy is effective in reducing pain among patients with cancer. This low-risk intervention can be helpful in pain management.
Lee, J.W., Lee, W.B., Kim, W., Min, B.I., Lee, H., & Cho, S.H. (2015). Traditional herbal medicine for cancer pain: A systematic review and meta-analysis. Complementary Therapies in Medicine, 23, 265–274.
STUDY PURPOSE: To evaluate the effects of herbal medicine as adjunctive treatment for cancer-related pain
The results of this meta-analysis showed an overall standard mean difference in favor of the herbal intervention across four studies (SMD = -0.51, p < 0.05). In a second meta-analysis, the risk ratio reported was 1.6. The direction of this risk ratio was not clear in the results reported. A meta-analysis was done for studies using herbal interventions in combination with traditional cancer therapy versus only traditional cancer therapy rather than treatment aimed specifically at pain control. Types of in interventions included botanicals, processed animal products, and processed minerals. In some studies, herbal interventions were compared to chemotherapy, aspirin, NSAIDs, Tylenol, diets, placebos, or unnamed analgesic drugs. Most studies showed a high risk of bias according to a study evaluation. A single study that was of high quality across all aspects showed no effect for the intervention.
Although the quantitative analysis showed a statistic significance, the comparisons studied for pain relief did not appear to be appropriate. Although herbal medicine may have better results on pain than no intervention or low-level analgesics, the efficacy of herbal medicine for pain should compare results with those obtained from other interventions shown to be effective for cancer-related pain.
Most studies were of low quality. Many study comparison groups were not adequate because well-recognized, effective interventions for pain were not used in the controls. The results reported in the meta-analysis of risk ratios were unclear. The methods described the use of an odds ratio analysis, but a risk ratio was reported, and it was not clear which study group was considered at-risk.
The findings of this analysis suggested that traditional herbal medicine may have a role in cancer-related pain control. However, the included studies did not provide strong evidence. The potential effects of herbal medicine for pain management remain unclear. Additional well-designed research, including comparisons to pain interventions with strong supportive evidence, are needed to determine any benefits of herbal medicine.
Lee, Y.J., Hyun, M.K., Jung, Y.J., Kang, M.J., Keam, B., & Go, S.J. (2014). Effectiveness of education interventions for the management of cancer pain: A systematic review. Asian Pacific Journal of Cancer Prevention, 15, 4787–4793.
STUDY PURPOSE: To evaluate evidence of the effectiveness of education interventions in pain management
The most frequent educational used tool was a booklet. A few studies involved the discussion of self-control and relaxation, but most of the content was description of pain management and misconceptions regarding the use of opioids. An analysis of seven randomized, controlled trials' (using the Brief Pain Inventory) effects on severe pain showed an SMD –0.34 (CI = 95%, –0.55, –0.13, p = 0.001). The SMD of average pain was –0.73 (CI = 95%, –0.64, –0.15, p = 0.002). The effects on pain in studies using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire showed no significant effect.
This analysis suggests that educational interventions have a positive effect on pain control.
The findings of this meta-analysis need to be viewed with some caution given the heterogeneity found in the analysis, the risk of bias determined. and the lack of differentiation between the education provided via booklets or other materials and the psychoeducational interventions that also included counseling, discussion, and relaxation techniques. However, it is clear that patients who need pain management also need education for self-management. Yet it is not clear if simple education alone is sufficient to facilitate effective patient self-management with analgesics.
Lee, S., & Chun, M. (2012). Pain relief by Cyberknife radiosurgery for spinal metastasis. Tumori, 98, 238–242.
To describe pain relief in patients with spinal metastasis treated with the CyberKnife® Robotic Radiosurgery System, and to analyze the factors associated with a relapse in pain after pain relief
Radiosurgery was performed using CyberKnife®, a unique, image-guided, frameless stereotactic radiosurgery delivery system. The CyberKnife® is a lightweight 6-MV linear accelerator (LINAC) attached to the end of a robotic arm with six axes of freedom. An MRI or PET-CT scan was obtained of all patients prior to treatment to evaluate the extent of spinal lesions, and the MRI was fused with a planning CT to better contour the target volume. An appropriate immobilization device was used to treat patients in the supine position. The clinical target volume (CTV) and the planning target volume (PTV) were the same, a 1–2 mm margin around the gross tumor volume. The delivered dose was kept at less than 13 Gy in a single fraction and less than 21.4 Gy in three fractions. The total dose of radiation delivered to the spinal cord was 15–35 Gy in one to five fractions. Pain was measured before radiosurgery, “soon after” radiosurgery, and then every one to three months (last measurement was done by telephone). Analgesic use was measured before and after treatment.
Retrospective pre/post design
Pain was measured using a 0–10 Visual Analog Scale (VAS). Pain relief was considered a reduction in the pain score by three levels, and pain progression was considered an increase in the pain score by three levels. No use of analgesics or a score of 0 or 1 was considered complete relief. The latency to pain relief was calculated beginning from the first day of radiosurgery. The duration of pain relief was measured from the first day of pain relief to the time of pain progression or until the last follow-up. Analgesic use was recorded before and after treatment.
Pain relief was obtained in 88% of the painful lesions (59 of 67 lesions), and complete relief was obtained in 51% (34 of 67 lesions). No radiation-induced myelopathy occurred. Those patients (n = 6) who did not have painful lesions prior to radiosurgery remained pain-free without disease progression. For the majority of patients who received pain relief from treatment, pain relief was obtained within seven days of beginning radiosurgery. The median duration of pain relief was 3.2 months (range = 1–30 months). Factors associated with pain relapse were the presence of spinal cord compression (p = 0.001) and an Eastern Cooperative Oncology Group (ECOG) performance status of ≥ 2 (0 = 0.01).
Although the sample size was small, this study found similar results as previous studies examining the use of spinal radiosurgery for pain relief. CyberKnife® is an effective method for treating pain related to spinal metastasis. Long-term follow-up of patients treated with spinal radiosurgery is needed to determine the duration of pain relief and any long-term effects related to treatment.
The use of spinal radiosurgery in treating pain related to metastatic cancer is an important palliative care treatment for pain relief as patients tolerate it well and there appear to be no side effects. Although CyberKnife® treatment is not available at all hospitals and medical centers, nurses should be aware of this effective pain relief intervention.
Lee, S. (2015). Mineral derivatives in alleviating oral mucositis during cancer therapy: A systematic review. PeerJ, 3, e765.
TOTAL REFERENCES RETRIEVED: 1,027
PHASE OF CARE: Multiple phases of care
Outcome mineral derivatives included zinc (n = 549, seven studies), calcium phosphate (n = 227, three studies), povidone-iodine (n = 228, two studies), and selenium (n = 116, two studies). The severity of OM was measured across variable OM grading systems. In 13 studies, individuals in treatment groups (n = 958) experienced peak OM less than controls (g = −0.47,95% CI −0.7 to −0.2, p = 0.0006). In five studies, time to OM onset was significantly delayed in treatment versus controls (g = −0.51, 95% CI−0.8 to −0.2, p = 0.0002), but the mean duration of OM, pain incidence, and analgesic use was not significantly different.
The general positive effect trend suggested that individuals taking mineral derivatives during cancer therapies were less likely to experience peak OM. However, the significant bias and heterogeneity in this analysis indicated the need for additional methods because of diverse protocols and novel recordings (serum mineral levels and cell signals) in estimating a uniform true effect. The decision analysis favored selenium.
This review was limited in recommending a definitive mineral derivative to alleviate OM. Limitations included high heterogeneity implicated by variable conditions (i.e., different protocols, diverse cancer therapies). In addition, a placebo effect may have undermined nonblinded studies at a high risk of bias.
Future trials should consider serum levels and computer simulations when designing mineral tolerance thresholds to weigh benefits and harms.
Lee, K.H., Kim, J.Y., Lee, M.H., Han, H.S., Lim, J.H., Park, K.U., . . . Im, S.A. (2015). A randomized, multicenter, phase II/III study to determine the optimal dose and to evaluate the efficacy and safety of pegteograstim (GCPGC) on chemotherapy-induced neutropenia compared to pegfilgrastim in breast cancer patients: KCSG PC10-09. Supportive Care in Cancer, 24, 1709–1717.
To identify an optimal dose of GCPGC and compare its safety and efficacy to that of pegfilgrastim
This study involved two phases—a phase II trial to identify optimal dosage followed by a phase III study to determine efficacy and safety of GCPGC in comparison to standard pegfilgrastim. In phase II, patients were randomized to receive either 3.6 mg or 6 mg of GCPGC on day 2 of a cycle. There were no differences in neutropenic outcomes between groups, and researchers decided to use 6 mg for phase III. In phase III, patients were randomized to receive either 6 mg pegfilgrastim or 6 mg GCPGC on day 2 of their treatment cycle. Outcomes per treatment cycle were evaluated. During phase III, prophylactic antibiotics were not permitted in the first cycle but could be used in subsequent cycles according to physician discretion.
There were no significant differences in outcomes between groups other than time to ANC recovery. ANC recovery time after cycle 1 was a mean of 8.85 in the GCPGC group compared to 9.83 in the pegfilgrastim group (p < 0.0001). Incidence of treatment delay or dose reduction was higher in the pegfilgrastim group (p < 0.09). Adverse drug reactions that may have been associated with the study drug were 5.3% in the GCPGC group and 3.4% in the pegfilgrastim group, and included dizziness, eukocytosis, blurred vision, injection-site pain, pyrexia, headache, and peripheral sensory neuropathy.
GCPGC was not inferior to pegfilgrastim for prevention of febrile neutropenic complications in women receiving myelosuppressive chemotherapy. Additional research is needed to confirm its efficacy and safety.
GCPGC provided similar results as pegfilgrastim in terms of neutropeni- related complications with this type of myelosuppressive chemotherapy. However, adverse events appeared to be somewhat higher in the GCPGC group. Additional research is needed to confirm the safety profile of this new CSF.
Lee, S., Knox, A., Zeng, I.S., Coomarasamy, C., Blacklock, H., & Issa, S. (2013). Primary prophylaxis with granulocyte colony-stimulating factor (GCSF) reduces the incidence of febrile neutropenia in patients with non-Hodgkin lymphoma (NHL) receiving CHOP chemotherapy treatment without adversely affecting their quality of life: Cost-benefit and quality of life analysis. Supportive Care in Cancer, 21, 841–846.
To examine the cost-benefit of primary prophylaxis with granulocyte colony-stimulating factor (G-CSF) in patients with non-Hodgkin lymphoma (NHL) receiving cyclophosphamide, vincristine, doxorubicin, and prednisone (CHOP) chemotherapy
In 2007, the study site implemented standard primary prophylaxis with G-CSF in this group of patients. Outcomes were compared to a historical control group that had not received primary prophylaxis. Analysis of cost was based on institutional direct costs for treatment of febrile neutropenia (FN).
Patients who received primary G-CSF prophylaxis were compared to a group of patients who did not receive primary prophylaxis prior to 2007, when primary prophylaxis was instituted as the standard of care for these patients. Among those who received prophylaxis, the incidence of FN was 5%, compared to 60% of those who had not received prophylaxis (p < .0001). Cost-benefit analysis using the number needed to treat and the average cost of an FN episode showed that prophylaxis increased the cost by $238 (New Zealand dollars), including only direct costs.
Primary G-CSF prophylaxis was associated with a significant reduction in the incidence of FN for a small additional cost of overall care throughout CHOP chemotherapy.
Primary G-CSF prophylaxis was associated with significantly lower prevalence of FN. Based only on direct healthcare costs, this study showed that primary prophylaxis was associated with a small, incremental increased cost, but these data do not account for other indirect costs and the full range of healthcare utilization that may be associated with treatment of FN. The authors concluded that primary prophylaxis in this group of patients was cost-effective. The cost-benefit of primary G-CSF prophylaxis has been a recent area of interest in oncology care. Further, well-designed economic analyses would be useful in exploring these questions among varied groups of patients.