PURPOSE: The goal of this study was to systematically review and synthesize the evidence for Tai Chi and Qigong interventions for supportive cancer care, specifically focusing on five clinical outcomes (fatigue, sleep difficulty, mood, pain, and quality of life), to identify the strengths and gaps in the evidence for theses interventions, and suggest directions for future research.

TYPE OF STUDY: Meta analysis and systematic review

• DATABASES USED: PubMed, CINAHL, Web of Science, and Embase
• YEARS INCLUDED: From inception until January 30, 2017
• INCLUSION CRITERIA: RCTs, prospective non-randomized controlled and prospective non-controlled studies, in English, with cancer as primary disease and Tai Chi and Qigong as the primary interventions. 
• EXCLUSION CRITERIA: Review articles, other intervention, not cancer, outcome unrelated, other language, observational study.

• TOTAL REFERENCES RETRIEVED: 478
• EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Cochrane Collaboration Risk of Bias Tool updated 2009; individual domains endorsed with low or high risk of bias; low risk of bias with at least 50% of criteria designates as low risk; high risk of bias when more than 50% of criteria endorsed with high bias or unclear.

• FINAL NUMBER OF STUDIES INCLUDED: 22 for qualitative analysis and 15 for quantitative analysis
• TOTAL PATIENTS INCLUDED IN REVIEW: 1,571
• SAMPLE RANGE ACROSS STUDIES: 12-197
• KEY SAMPLE CHARACTERISTICS: 10 studies included women with breast cancer only, 2 included men with prostate cancer only, 5 studies included mixed solid cancers, and single studies exclusively included patients with lung cancer, non-Hodgkin lymphoma, nasopharyngeal cancer, and gastric cancer.

• PHASE OF CARE: Multiple phases of care
• APPLICATIONS: Elder care

TCQ interventions varied in content, dosage, duration, and intensity. Of the 22 studies, Tai Chi was applied in 7 studies, Qigong in 10 studies, and Tai Chi and Qigong were explicitly combined in 4 studies. All results based on a random effects model due to statistical heterogeneity. Ten studies pooled for analysis revealed an overall effect size that indicated a beneficial effect of TCQ on fatigue in patients with cancer (Hedges g = − 0.53, 95% CI [−0.97, −0.28], p < 0.001). Six studies pooled for analysis revealed an overall effect size with a beneficial effect of TCQ on sleep difficulty in patients with cancer (Hedges g = − 0.49, 95% CI [−0.89, −0.09], p = 0.018). The overall effect size based on seven studies favored TCQ on depression in patients with cancer (Hedges g = −0.27, 95% CI [−0.44, −0.11], p = 0.001). Four pooled studies suggested that a statistically non-significant trend was in favor of TCQ on cancer-related pain (Hedges g = −0.38, 95% CI [−0.89, 0.12], p = 0.136). Quality of life was assessed with eleven studies and favored TCQ in patients with cancer (Hedges g = 0.33, 95% CI [0.1, 0.56], p = 0.004). Findings from non-RCTs paralleled meta-analysis results. Funnel plots suggest some degree of publication bias.

Findings support that TCQ may be effective in reducing multiple symptoms commonly experienced by cancer survivors. Statistically significant and clinically meaningful medium effect sizes in favor of TCQ were observed for symptoms of fatigue and sleep difficulty. Smaller but statistically significant effect sizes were also observed for QOL and depression, and a non-significant trend in favor of TCQ was observed for pain.

• High heterogeneity
• Low sample sizes

Tai chi and Qigong are mind-body interventions that show promise for reducing cancer-related symptoms, including fatigue, sleep problems, and depression as well as improving quality of life. Evidence from this review comes from a qualitative synthesis as well as a meta-analysis. The review included studies that included patients with different types of cancer.

To determine the dose-response effect of aerobic exercise on health-related quality of life outcomes among colon cancer survivors after treatment completion, including functional status, sleep, fatigue, fear of recurrence, and bowel function.

The intervention was a prescription for home-based aerobic exercise over six months–either low-dose aerobic exercise (150 minutes per week) or high-dose aerobic exercise (300 minutes per week). Each participant received a treadmill and a heart rate monitor. An exercise physiologist provided ongoing in-person, telephone, and email support, individualized to each participant, and monitored adherence to the exercise protocol.   Exercise intensity was prescribed at 50%-70% of age-predicted maximum heart rate and gradually increased for each participant to meet their goal.

• N = 39  
• AGE: Younger than 60, n = 25 (64%); older than 60, n = 14 (36%)
• MALES: 38%  
• FEMALES: 62%

• SITE: Single site   
• SETTING TYPE: Home    
• LOCATION: Philadelphia, PA

PHASE OF CARE: Transition phase after active treatment

Randomized controlled trial with three groups: usual care (usual recommendations for activity), low-dose aerobic exercise (150 minutes per week), and high-dose aerobic exercise (300 minutes per week).

Medical Outcomes Survey Short Form (SF-36), Functional Assessment of Cancer Therapy–Colorectal (FACT-C), Pittsburgh Sleep Quality Index (PSQI), Fear of Cancer Recurrence Inventory (FCRI), Fatigue Symptom Inventory (FSI), North Central Cancer Treatment Group questionnaire (bowel function)

Physical health score in SF-36 improved by 1.2 (d = 0.08) in the low-dose group and 13.1 (d = 0.58) in the high-dose group. FACT-C scores increased by 7.6 (d = 0.49) in the low-dose group and 6.8 (d = 0.58) in the high-dose group. PSQI scores decreased by 0.3 in the low-dose group (d = -0.11) and by 1.1 (d = -0.3) in the high-dose group. PSQI subscales of sleep quality and sleep latency showed improvement. FSI scores increased by 0.8 (d = 0.08) in the low-dose group and decreased by 6 (d = -0.75) in the high-dose group. There were no changes observed in mental health scores of SF-36, FCRI scores, or bowel function scores.

The six-month home-based aerobic exercise intervention for survivors of colon cancer improved health-related outcomes, including physical function, quality of life, sleep quality, and fatigue. Improvements were dose-related, such that a higher dose of aerobic exercise resulted in greater improvement in outcomes.

• Small sample (< 100)
• Risk of bias (no blinding)
• Findings not generalizable
• Other limitations/explanation: The home-based intervention included giving each participant a treadmill and individualized support from an exercise physiologist for six months, which may not be feasible for the larger population.

Moderate intensity aerobic exercise in excess of the recommended 150 minutes per week showed clinically meaningful improvements in health-related outcomes, including physical function, quality of life, sleep quality, and fatigue in survivors of colon cancer who have completed treatment.

To determine baseline sleep characteristics of endometrial cancer survivors, the impact of demographic and treatment characteristics on sleep quality, the association of sleep quality with quality of life and stress levels, and the impact of physical activities on sleep.

Individualized exercise prescriptions based on baseline function. Adherence to the American College of Sports Medicine Guidelines requiring 30 minutes of moderate exercise five or more days per week or at least 20 minutes of rigorous exercise three or more days per week with telephone-based counseling sessions, printed materials, and pedometers. Decreasing frequency of counseling telephone calls from weekly to twice monthly to monthly over six months.

• N = 95   
• AGE: 57.1 years (range = 25-76)
• FEMALES: 100%
• CURRENT TREATMENT: Radiation, other
• KEY DISEASE CHARACTERISTICS: 76% stage I

• SITE: Single site   
• SETTING TYPE: Outpatient    
• LOCATION: Houston, TX

• PHASE OF CARE: Transition phase after active treatment
• APPLICATIONS: Elder care 

Secondary analysis of Steps to Health, a single-arm cohort study.

Sleep quality measured with the Pittsburgh Sleep Quality Index (PSQI). Physical activity measured with the Community Health Activities Model Program for Seniors (CHAMPS). Quality of life (QOL) measured with the SF-36.

At baseline, 61% of the sample had poor sleep quality (PSQI > 5). Obese survivors were more likely to have sleep disturbances than were their normal-weight counterparts (p = 0.029). At baseline, poor sleepers had higher stress levels than good sleepers (p = 0.002). Poor sleep quality was associated with lower health-related QOL: vitality (p = 0.001), bodily pain (p = 0.004), general health (p = 0.002), social functioning (p = 0.005), role limitations caused by emotional problems (p = 0.005), mental health (p = 0.002), and the mental component score (p = 0.003). Sleep quality improved in cancer survivors who increased their weekly total physical activity or moderate-vigorous intensity physical activities (MPVA) throughout the intervention (p = 0.004 and 0.05, respectively). Adjusting for covariates (e.g., age, time since diagnosis, obesity status, disease stage, treatment), improvement in sleep quality was associated with increased hours of total activity (p = 0.026).

Poor sleep quality was common in endometrial cancer survivors and an increase in physical activity was associated with improved sleep quality.

• Small sample (< 100)
• Risk of bias (no control group)

Sleep problems are common in women following treatment for endometrial cancer and are associated with stress and poor QOL. Increasing physical activity may improve sleep quality for these women.

To determine the effects of lavender oil aromatherapy on anxiety and sleep quality in patients undergoing paclitaxel-based chemotherapy.

Patients were randomized to lavender essential oil (Lavandula hybrid), tea tree oil, or control. During the first chemotherapy infusion, three drops of lavender essential oil or tea tree oil were put onto a piece of cotton that was placed on each patient’s neck and shoulders, about 10 inches below the nose. No aromatherapy was administered to the control group. Patients randomized to lavender and tea tree oils continued to smell the oil for five minutes every night for one month. Lavender and tea tree oil were purchased from a herbal product firm with quality certifications. Tea tree oil does not have a sedative or relaxing effect; therefore, it was used as a placebo. Patients were evaluated at baseline, after the first chemotherapy infusion, and after one month of chemotherapy infusions.

• N = 70    
• MEAN AGE: 58.22 years
• MALES: 16%  
• FEMALES: 84%
• CURRENT TREATMENT: Chemotherapy
• KEY DISEASE CHARACTERISTICS: Mixed cancers; 66% breast cancer, 16% lung cancer, 18% other cancers
• OTHER KEY SAMPLE CHARACTERISTICS: All chemotherapy regimens included weekly paclitaxel

• SITE: It appears that the data was collected at a single site, but this is not clearly stated.      
• SETTING TYPE: Outpatient
• LOCATION: Private hospital in Turkey

• PHASE OF CARE: Active anti-tumor treatment
• APPLICATIONS: Not available

Randomized control trial with three arms (lavender oil, tea tree oil, control)

Pittsburgh Sleep Quality Index (PSQI), State-Trait Anxiety Inventory (STAI), measured before and after chemotherapy treatment

A significant improvement in sleep quality as measured by mean score of PSQI before and after chemotherapy in the lavender group (time, p = 0.001), with group differences between lavender and the other groups based on assessments (group*time, p = 0.001). Trait anxiety values before and after chemotherapy were significantly decreased in the lavender group (p = 0.0003); however, there was no difference state anxiety by time or group.

Lavender oil inhalation at bedtime for outpatients with mixed cancer treated with paclitaxel-based chemotherapy may be useful for improving sleep quality and trait anxiety.

• Small sample (< 100)
• Risk of bias (no blinding)
• Findings not generalizable
• Other limitations/explanation: Small study arms (n = 30, 20, and 20), non-blinded participants because most people are familiar with lavender scent, lack of data analysis details–difficult to understand results.

Lavender oil inhaled at bedtime appears to be an acceptable and helpful intervention for adults treated with paclitaxel-based chemotherapy for mixed cancer types with poor sleep quality and medium levels of state and trait anxiety. Additional research in larger samples is warranted before recommending for practice in general oncology populations.

To determine if aromatherapy by diffusion of essential oils improves insomnia in hospitalized patients with newly diagnosed acute leukemia undergoing induction chemotherapy.

Patients served as their own controls and were randomized to receive aromatherapy over 3 weeks in the following fashion. 1 week placebo or aromatherapy, followed by a 1 week washout period, and a third week of placebo or aromatherapy. Patients were allowed to choose their preferred essential oil for the aromatherapy, lavender, chamomile, or peppermint.  Rose water served as the placebo control.  The aromatherapy diffuser was placed in the same location in all hospital rooms. 8 blinded drops of placebo or essential oil were placed in a diffuser each evening at 9 pm and ran until drops were gone (approx. 8 hours). Sleep quality and disturbance were measured at baseline and after each week of the intervention (placebo or aromatherapy), a general symptom assessment was completed daily during the intervention weeks, and the evaluation of aromatherapy was completed at the end of each week of the intervention.

• N = 50    
• AGE: 19-72 yrs
• MALES: 56%  
• FEMALES: 44%
• CURRENT TREATMENT: Chemotherapy
• KEY DISEASE CHARACTERISTICS: Newly diagnosed patients with acute leukemia
• OTHER KEY SAMPLE CHARACTERISTICS: initiating 4 weeks of induction chemotherapy

• SITE: Single site   
• SETTING TYPE: Inpatient    
• LOCATION: Midwestern university medical center

PHASE OF CARE: Active antitumor treatment

Randomized control trial.  Trial was a crossover over trial with a washout period in which patients served as own control.

Pittsburgh Sleep Quality Index (PSQI), Edmonton Symptom Assessment Scale-Revised (ESASr), Final evaluation of aromatherapy (FEA)

Sleep quality as measured by mean scores on the PSQI improved with aromatherapy (p=0.0001) with specific improvements in sleep duration (p=0.03),  sleep quality (p=0.05), and sleep disturbance (p=0.04).  General symptom scores as measured by the EASSr , all subscales, improved with aromatherapy treatment (p=0.0006)

Aromatherapy for hospitalized patients with acute leukemia undergoing induction chemotherapy improves sleep disturbances and other symptoms.

• Small sample (< 100)
• Findings not generalizable
• Other limitations/explanation:  Participants were allowed to choose their own oil, may have biased results?  Were nurses really blinded to the assignment?  FEA form used for evaluation of aromatherapy is an investigator developed tool that has no reliability or validity data.

Aromatherapy appears to be an effective intervention for improving sleep wake disturbances and other symptoms in hospitalized patients with acute leukemia.  Nurses may want to explore ways to use aromatherapy for patients in their institutions as well as educate patients and families about the potential positive benefits of aromatherapy as a non-pharmacological method to treat sleep wake disturbances as well as a variety of other symptoms.

The purpose of the systematic review and meta-analysis was to identify if there is a difference between tranexamic acid (TXA) and a control group in blood loss, transfusion rates, hemoglobin levels, and thromboembolic events in prostate surgery patients.

• TYPE OF STUDY: Meta analysis and systematic review
• DATABASES USED: Medline, Cochrane Central Register of Controlled Trials, EBSCO, and Web of Science
• YEARS INCLUDED: 1976,1980, 2004, 2011, 2016, 2017
• INCLUSION CRITERIA: Randomized controlled trials comparing use of TXA with a control group
• EXCLUSION CRITERIA: None stated

• TOTAL REFERENCES RETRIEVED: 145
• EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Grading of Recommendations Assessment, Development, and Evaluation methodology was used for evaluation

• FINAL NUMBER STUDIES INCLUDED: 9 
• TOTAL PATIENTS INCLUDED IN REVIEW: 978 
• SAMPLE RANGE ACROSS STUDIES: 494 received TXA and 484 enrolled in the control group
• KEY SAMPLE CHARACTERISTICS: TXA was administered via IV in six of the studies, orally in two, and local spray in one.

PHASE OF CARE: Diagnostic

The results were reported on nine studies. Of the nine studies, six reported on the interoperative blood loss showing overall blood loss was lower in the TXA group (p < 0.000001). Transfusion rate was identified less in the TXA group (p < 0.00004) in six of the nine studies with the prostatectomy cases but not the TURP cases. Hemoglobin level was monitored 24 hours after surgery, but there was no noted significant difference between the TXA and the control groups in four of the studies. Eight studies monitored for DVT and PE, and no statistical difference was found.

This systemic review and meta-analyses concluded that patients who received TXA treatment during prostate surgery had a reduction in interoperative blood loss and decrease need for transfusion with no increased risk of DVT or PE.

• Limited number of studies included
• High heterogeneity

Although there was no increase in risk for DVT or PE using TXA, nurses should still be aware of the potential risk and monitor the patient with discretion.