Kroenke, K., Theobald, D., Wu, J., Norton, K., Morrison, G., Carpenter, J., & Tu, W. (2010). Effect of telecare management on pain and depression in patients with cancer: A randomized trial. JAMA: The Journal of the American Medical Association, 304(2), 163–171.
To determine whether centralized telephone-based care management cued by automated symptom monitoring can improve depression and pain in patients with cancer
In this study, called the Indiana Cancer Pain and Depression Trial, centralized telecare management was conducted by a nurse-physician specialist team that worked in concert with automated home-based symptom monitoring. The means of monitoring was interactive voice recording or Internet. A nurse care manager assessed symptom response and medication adherence, provided pain- and depression-specific education, and made treatment adjustments according to evidence-based guidelines. Intervention patients received scheduled calls (at baseline, at 1 week, and at 4 and 12 weeks) and received calls when automated monitoring indicated problems in symptom management. Control group received usual care. Data were collected at baseline and at months 1, 3, 6, and 12.
Randomized controlled trial
This study showed that centralized telecare management with automated symptom monitoring may be a feasible approach for geographically dispersed urban and rural oncology practices. This approach may be effective in improving the pain and depression of cancer patients.
Lack of control of the type of cancer treatment and of the time lapse since treatment might have affected study findings.
Cost will be involved in training the care manager and in the hiring of trained personnel. The cost-effectiveness of the collaborative care model needs to be further examined. Findings suggest that telecare management used with automatic systems cued by patient problems can be an effective approach.
Kroenke, K., Theobald, D., Wu, J., Norton, K., Morrison, G., Carpenter, J., & Tu, W. (2010). Effect of telecare management on pain and depression in patients with cancer: A randomized trial. JAMA, 304, 163–171.
To determine whether centralized telephone-based care management and automated symptom monitoring can reduce depression and pain in patients with cancer
Participants in the intervention group received centralized telecare management, conducted by a nurse-physician specialist team, and automated home-based symptom monitoring by means of interactive voice recording or Internet. The control group received usual care. Data were collected at baseline and at months 1, 3, 6, and 12.
Random controlled trial with double blinding, with stratified randomization by symptom type (pain only, depression only, or both pain and depression)
The intervention may be effective at reducing pain and depression. The intervention proved to be a feasible care approach for geographically dispersed urban and rural oncology practices.
Lack of control over type of cancer treatment and over the time lapse since treatment might have affected study findings.
Cost will be involved in training the care manager and in hiring trained personnel. The cost-effectiveness of the collaborative care model needs to be further examined. Studies show mixed results regarding effect of by-telephone patient management; further work in this area is warranted. Use of technology may be a viable approach to ongoing patient support.
Krischer, M.M., Xu, P., Meade, C.D., & Jacobsen, P.B. (2007). Self-administered stress management training in patients undergoing radiotherapy. Journal of Clinical Oncology, 25, 4657–4662.
The intervention was a self-administered stress management training (SSMT) program for patients treated with radiation therapy. The usual care only (UCO) intervention included the usual psychosocial care typically provided at the institution where patients were receiving treatment. Participants in the SSMT program met individually with a nurse for approximately five minutes to receive instructional materials and explanations. The instructional materials consisted of a 15-minute prerecorded videotape, a 12-page booklet, and a 35-minute prerecorded audiotape titled “Active Relaxation,” which taught paced breathing, active relaxation, and positive thinking with guided imagery instructions. Data were collected at baseline and weeks 1, 2, and 3.
Multiple centers in South Florida
A randomized controlled trial design was used.
SSMT is effective only in those patients receiving radiotherapy with initially higher levels of psychological distress at baseline.
Special training needs include the creation of the SSMT tool (instructional materials, video tables, and audiotapes).
Intervention requires screening for psychological distress.
Kris, M.G., Hesketh, P.J., Somerfield, M.R., Feyer, P., Clark-Snow, R., … Grunberg, S.M. (2006). American Society of Clinical Oncology guideline for antiemetics in oncology: Update 2006. Journal of Clinical Oncology, 24(18), 2932–2947.
To update the 1999 American Society of Clinical Oncology (ASCO) guideline for antiemetics in oncology
The update committee reviewed studies identified through a literature search.
Databases searched were MEDLINE, the National Library of Medicine, and the Cochrane Collaboration Library (1998-Feb. 2006).
Studies were included if they were phase II and III randomized, controlled trials.
The search identified the following studies.
Additional materials provided to the committee were
Kress, H.G., Von der Laage, D., Hoerauf, K.H., Nolte, T., Heiskanen, T., Petersen, R., . . . Jensen, N.H. (2008). A randomized, open, parallel group, multicenter trial to investigate analgesic efficacy and safety of a new transdermal fentanyl patch compared to standard opioid treatment in cancer pain. Journal of Pain and Symptom Management, 36(3), 268–279.
To compare, in clinical practice, the effect and safety of a new matrix fentanyl patch (Fentanyl Improved Transdermal [FIT]) patch) to oral and other transdermal opioid treatment
Patients were randomly assigned to either FIT patch or standard opioid treatment via oral or transdermal route. Morphine was the only rescue medication allowed. Patients could receive radiotherapy and chemotherapy as well as nonpharmacologic and pharmacologic pain management therapies. Patients randomized to FIT therapy switched from existing regimens to FIT therapy by means of standard conversion ratios. Patients had an initial screening visit and four additional visits. Each evening each patient assessed his or her pain and recorded the pain rating in a diary. Adverse events were monitored in follow-up visits through the 30-day trial period and for one week longer. Patients assessed adverse events on a four-point scale and recorded the rating.
Randomized open-label parallel-group design
Results showed no differences, in terms of pain management or adverse effects, between the new transdermal patch and standard transdermal or oral opioid treatment. Findings suggest that the new type of patch is safe and, in terms of efficacy, similar to standard treatments.
Transdermal fentanyl, delivered by means of conventional patch or FIT patch, is an effective means of controlling cancer pain.
Kress, H.G., Oronska, A., Kaczmarek, Z., Kaasa, S., Colberg, T., & Nolte, T. (2009). Efficacy and tolerability of intranasal fentanyl spray 50 to 200 microg for breakthrough pain in patients with cancer: A phase III, multinational, randomized, double-blind, placebo-controlled, crossover trial with a 10-month, open-label extension treatment period. Clinical Therapeutics, 31(6), 1177–1191.
To assess the efficacy and long-term tolerability of infranasal fentanyl spray (INFS)
In an initial titration phase, the effective dose of INFS was determined for each patient. An effective dose was defined as one that was successful in treating three of four episodes of breakthrough pain. If pain relief was insufficient, an additional dose was administered in the alternate nostril. Titration was repeated if the patients’ background opioid dosage was adjusted during the trial. During the efficacy phase patients received, in randomized double-blind sequence, the titrated effective dose of INFS or placebo for administration at home. Patients were randomized to treatment sequences for eight episodes of breakthrough pain. Patients used a diary to record pain intensity at 0, 10, 20, 40, and 60 minutes after administration. Pain ratings were according to a numeric rating scale. Patients were monitored during the 10-month open-label extension phase. Patients received 30-day supplies of INFS, in appropriate doses, during monthly clinic visits. Weekly telephone contact provided data about adverse events, concurrent medications, and INFS efficacy.
Double-blind randomized, double-dummy two-way crossover study
INFS titrated to an effective dose demonstrated some effectiveness in relieving breakthrough pain in this group of patients. Long-term tolerability could not be clearly determined because of the small number of patients who completed the extension phase of the study. Most patients appeared to tolerate IFNS well.
Findings suggest that INFS may be a useful adjunctive approach to deal with the breakthrough pain of patients with cancer who have chronic opioid-managed pain. INFS may be more useful as a short-term, rather than a long-term approach; the matter of long-term efficacy and tolerability requires further study.
Kress, H.G., Koch, E.D., Kosturski, H., Steup, A., Karcher, K., Lange, B., . . . Eerdekens, M. (2014). Tapentadol prolonged release for managing moderate to severe, chronic malignant tumor-related pain. Pain Physician, 17, 329–343.
To determine whether tapentadol prolonged-release (PR) is effective and tolerable for managing moderate to severe tumor-related pain
Patients whose pain was rated 5 or above on an 11-point scale were randomized (2:1) and titrated to an optimal dose of tapentadol PR (100–250 mg BID) or morphine sulfate CR (40–100 mg BID) over two weeks. Immediate-release morphine sulfate was allowed as needed as a breakthrough medication. During the last three days of titration, patients who achieved an average pain intensity of less than 5 and took less than 20 mg per day of rescue pain medication entered a four-week maintenance period. Patients who received tapentadol were rerandomized (1:1) to either tapentadol BID or a placebo for the maintenance period. Response at the end of titration and response at the end of the maintenance were assessed. Tolerability and side effects were evaluated.
Randomized-withdrawal, parallel-group, active- and placebo-controlled, double-blinded study
During the study, pain levels were evaluated with an 11-point Numeric Rating Scale (NRS) twice daily. The proportion of patients classified as responders (patients who completed 28 or more days, had a mean pain intensity score < 5, and had a mean total daily dose of ≤ 20 mg rescue medication during the maintenance period) was evaluated as a primary endpoint during the titration and maintenance periods. Mean pain intensity at the start of the maintenance period was calculated as the mean daily pain intensity scores during the last three days of the titration period. Mean weekly pain intensity during the maintenance period was calculated from the mean daily pain intensity scores during each week of the maintenance period. Adverse events were coded using the Medical Dictionary for Regulatory Activities v15.0. The treatments for emergent adverse events in all groups were collected and compared as were specific gastrointestinal and nervous system effects and general disorders or administration site effects.
Patients receiving tapentadol were twice as likely to respond than the patients who received a placebo. Tapentadol PR was noninferior to morphine CR (p < 0.001). Mean pain intensity scores improved in both the tapentadol PR and morphine CR groups during titration. These reductions were sustained throughout the maintenance period. There were no statistically significant differences between the tapentadol and placebo groups in changes in pain intensity from the start of maintenance to weeks 1–4 (p ≥ 0.0152). A higher percentage of patients in the placebo group (72.1%) took ≥ 20 mg per day of rescue morphine immediate-release compared to the tapentadol (71.4%) or morphine CR (61.5%) groups. During titration, 50% of patients in the tapentadol group and 63.9% of patients in the morphine group reported one or more treatment-emergent adverse effects (TEAEs). A smaller percentage of patients receiving tapentadol PR had any TEAEs (p = 0.0039) than those receiving morphine CR.
Tapentadol PR 100–250 mg BID was effective in the treating tumor-related pain. The analgesic effect of tapentadol PR was not inferior to morphine CR and had better overall and gastrointestinal tolerability than morphine CR. However, more tapentadol users required rescue pain medication than those taking morphine CR.
Tapentadol, one of a new class of centrally acting analgesics, was effective in treating tumor pain and was generally better tolerated than morphine CR. Nurses should be familiar with the common side effects associated with this medication including nausea, vomiting, constipation, dizziness, sleepiness, and fatigue to safely care for patients receiving this drug.
Krebber, A.M., Jansen, F., Witte, B.I., Cuijpers, P., de Bree, R., Becker-Commissaris, A., . . . Verdonck-de Leeuw, I.M. (2016). Stepped care targeting psychological distress in head and neck cancer and lung cancer patients: A randomized controlled trial. Annals of Oncology, 27, 1754–1760.
To evaluate the effects of a stepped psychotherapeutic intervention on patients with baseline anxiety
Patients who had completed curative therapy, were referred for follow-up, found to have relevant levels of distress, and consented to participation had a telephone interview at baseline. After the interview, they were randomized to usual care or the stepped program, which included watchful waiting, guided self-help via the Internet or a booklet, face-to-face problem-solving therapy, and psychological interventions and/or medications. Time frames for data collection varied depending upon the duration of the stepped program. General measures were obtained at 3, 6, 9, and 12 months after study entry. Usual care consisted of no psychosocial care in 64% of the group.
PHASE OF CARE: Transition phase after active treatment
Single-blind, randomized, controlled trial
The course of anxiety (p = 0.046) and depression (p = 0.007) was better for the intervention group than for the controls. When corrected for baseline anxiety and depression, depression was better for the intervention group over time (p < 0.001), but anxiety was not significantly different (p = 0.061). The stepped program had more influence over the course of symptoms among patients with a depression or anxiety disorder compared to those without a psychiatric disorder (p = 0.001). Among those without a psychiatric disorder, no differences in anxiety or depression scores were observed after a six-month measurement.
The stepped psychological intervention approach was shown to be effective to reduce anxiety and depression in the short-term, and had particular effectiveness for individuals with psychiatric disorders.
Psychiatric and stepped psychological interventions resulted in relatively short-term improvement in anxiety and depression among patients with cancer and anxiety. Interventions were most helpful for individuals with anxiety or depressive disorders over a longer period of time as well.
Kravitz, R.L., Tancredi, D.J., Grennan, T., Kalauokalani, D., Street, R.L., Jr., Slee, C.K., . . . Franks, P. (2011). Cancer Health Empowerment for Living without Pain (Ca-HELP): Effects of a tailored education and coaching intervention on pain and impairment. Pain, 152, 1572–1582.
To determine the effectiveness of a lay-administered tailored education and coaching intervention on cancer pain severity, pain-related impairment, and quality of life
Patients with baseline “worst pain” of more than 4 on a 0–10 scale or at least moderate functional impairment were randomized to tailored education coaching (TEC) or enhanced usual care (EUC). TEC was delivered by a health educator in a private room one hour prior to the patients' visit with their healthcare provider. The intervention was a brief, patient-centered, tailored education and coaching intervention designed to enhance skills and self-efficacy for communicating with the oncologist while also correcting common misconceptions. The EUC intervention included review of selected aspects of a National Cancer Institute (NCI) booklet on pain control by a health educator. The TEC patients also received the NCI booklet. Patients completed questionnaires before and after the visit and were interviewed by telephone at 2, 5, and 12 weeks. Oncologists and follow-up assessors were blinded to patient group assignments.
Patients were undergoing multiple phases of care.
The study was a randomized controlled trial.
The TEC patients had an improvement in pain-related impairment at two weeks (–0.025 points on a five-point scale, 95% confidence interval –0.43 to –0.06, p = 0.01), but it was not sustained at 6 and 12 weeks (p > 0.20). Pain severity was not improved at two weeks (–0.21 points on an 11-point scale, –0.60 to 0.17, p = 0.27). Pain misconceptions in both the intervention and control group decreased significantly between baseline and the two-week follow-up interview (p < 0.001), but there was no significant effect of the intervention on misconceptions at the two-week follow-up (p = 0.8). Communication self-efficacy increased more among the TEC patients than in the control group (p < 0.001).
TEC provides a temporary improvement in pain impairment but not in pain severity.
The TEC intervention was designed to be brief and easy to deliver, but the health educator needed 30–40 hours of training and regular reinforcement (several hours every three to six months) in order to deliver the intervention appropriately. Physicians were not randomized to the study, so they may have learned from the TEC patients and applied it to the EUC patients. Generalizability of findings is limited due to the fact that the study was conducted in a metropolitan area in California, with no blinding.
Because the TEC provided only temporary relief of pain impairment and no improvement of pain severity, it is not recommended for use in cancer-related pain management.
Kravitz, R.L., Tancredi, D.J., Jerant, A., Saito, N., Street, R.L., Grennan, T., & Franks, P. (2012). Influence of patient coaching on analgesic treatment adjustment: Secondary analysis of a randomized controlled trial. Journal of Pain and Symptom Management, 43, 874–884.
To estimate the effect of patient-centered tailored education and coaching (TEC) on the likelihood of analgesic treatment adjustment during oncology visits; to estimate the influence of treatment adjustment on subsequent cancer pain control
Patients with at least a moderate baseline pain received TEC or control just prior to a scheduled oncology visit. Just after the visit, they reported on whether the physician recommended a new pain medication or a change in the dose of an existing medication. Pain severity and pain-related impairment were measured 2, 6, and 12 weeks later. TEC included assessing knowledge, attitude, and preferences; correcting misconceptions; teaching about pain control and communication with providers; planning communication; and rehearsing communication with physicians. Sessions occurred one hour before initial clinic visits and were conducted on an individual basis. Sessions were recorded on audiotape. Control patients received the Natiional Cancer Institute booklet on pain control. Patients completed questionnaires immediately after a clinic visit.
Settings included three health systems—academic medical center, health maintenance organization, and Veterans Affairs hospital—and one private practice, all in Sacramento, California.
Randomized controlled trial
TEC increases the likelihood of self-reported, physician-directed adjustments in analgesic prescribing. Treatment intensification is associated with improved cancer pain outcomes.
A routine oncology visit is an opportunity to adjust a patient’s analgesic regimen. Available evidence suggests that clinicians often miss opportunities to intensify analgesic regimens appropriately. Oncologists are often unaware of patients’ pain. Patients may be reluctant to discuss pain because of misconceptions about pain management or fear of distracting the physician. The findings of this study suggest that interventions to counter this reluctance, and to improve pain management, include education, including role-playing, that helps patients plan communication with physicians.