Steel, J.L., Geller, D.A., Kim, K.H., Butterfield, L.H., Spring, M., Grady, J., . . . Tsung, A. (2016). Web-based collaborative care intervention to manage cancer-related symptoms in the palliative care setting. Cancer, 122, 1270–1282.
To examine the effects of a collaborative care intervention for reducing depression, pain, and fatigue in patients and stress and depression in caregivers
Patients and their caregivers were randomized to receive a web-based stepped intervention or enhanced usual care. The web-based intervention included access to a psychoeducational web site and a care coordinator who contacted participants by telephone every two weeks and in-person during clinic or hospital visits about every two months. The care coordinator communicated with the medical team or primary care physician for recommended interventions. In addition to the psychoeducation, the website provided an area where patients could record and monitor their own symptoms, a library of relaxation and educational videos, a participant chat room, and a general resource library. Care coordinators were trained in cognitive behavioral therapy and used an intervention manual. Weekly supervision of care coordinator adherence to the study protocol was provided. In the enhanced usual care group, if a patient had high depression or pain scores, he or she was contacted by a care coordinator and was provided with education and referrals for symptom management interventions as needed.
PHASE OF CARE: Late effects and survivorship
Randomized, controlled trial
There were 84 page views by caregivers. Most frequently viewed areas were living with cancer, diagnosis and treatment, and managing symptoms. For patients, no differences existed between groups in fatigue or pain. An effect size of 0.748 for caregiver stress was seen at the six-month follow-up. An effect size of 0.372 was seen for caregiver depression.
The web-based psychoeducational intervention did not show significant benefit for patient symptoms compared to enhanced usual care. This intervention aimed at patients but may have had some benefit for caregivers of those patients with significant symptoms.
This study looked at the effects of a web-based system for psychoeducation and support of patients on patient symptoms and associated caregiver stress and depression scores. No significant difference in patient symptoms compared to the usual care study group was seen. This intervention, aimed at management of patient symptoms, may have had some positive benefit for caregivers.
Stearns, L., Boortz-Marx, R., Du Pen, S., Friehs, G., Gordon, M., Halyard, M., . . . Kiser, J. (2005). Intrathecal drug delivery for the management of cancer pain: A multidisciplinary consensus of best clinical practices. Journal of Supportive Oncology, 3, 399–408.
RESOURCE TYPE: Consensus statement
PROCESS OF DEVELOPMENT: Panel members included pain management physicians, neurosurgeons, medical oncologists, radiation oncologists, and palliative care physicians.
DATABASES USED: No search engines were identified.
No level of evidence tables were submitted.
The adoption of intrathecal therapy for pain management by physicians broadens their ability to control pain and limit side effects and supports the use of intrathecal therapy for cancer pain management.
Stearns, V., Slack, R., Greep, N., Henry-Tilman, R., Osborne, M., Bunnell, C., … Isaacs, C. (2005). Paroxetine is an effective treatment for hot flashes: Results from a prospective randomized clinical trial. Journal of Clinical Oncology, 23, 6919–6930.
The study assessed the efficacy of paroxetine compared to placebo in reducing hot flashes in women with or without history of breast cancer.
There were four study arms:
Women with or without history of breast cancer having at least 14 hot flashes per week were eligible, of whom 279 women were screened, and 151 were randomly assigned. 107 patients completed study. Mean age was 53 years. More than 80% had prior history of breast cancer, and 60% were taking an antiestrogen.
Inclusion criteria:
Exclusion criteria: Concomitant use of cytotoxic chemotherapy, radiation therapy, estrogen or progesterone use, antidepressants, monoamine oxidase inhibitors, or treatments for hot flashes
The study was conducted in multi-institutional out-patient oncology clinics.
The trial was stratified, randomized, double-blind, cross-over, and placebo-controlled . Participants were stratified by age group (younger than 60 or older than 60) and antiestrogen use (yes or no).
Measures included:
Paroxetine 10 mg significantly reduced hot flash frequency and composite score by 40.6% and 45.6%, respectively compared to 13.7% and 13.7% for placebo (p = .0006 and p = .0008, respectively). Paroxetine 20 mg significantly reduced hot flash frequency and composite score by 51.7% and 56.1%, respectively compared to 26.6% and 28.8% for placebo (p = .002 and p = .004, respectively). Efficacy was similar between the two doses but women were less likely to discontinue low-dose paroxetine. Paroxetine 10 mg was associated with a significant improvement in sleep compared to placebo (p = .01).
Study attrition was a limitation: 39 women did not complete 9 weeks of therapy; 26 women did not return diaries.
Stanworth, S.J., Hyde, C., Heddle, N., Rebulla, P., Brunskill, S., & Murphy, M.F. (2004). Prophylactic platelet transfusion for haemorrhage after chemotherapy and stem cell transplantation. Cochrane Database of Systemic Reviews, CD004269.
To determine the optimal use of prophylactic platelet transfusion for the prevention of hemorrhage after chemotherapy and stem cell transplantation
The studies provide no indication to change the current practice guidelines recommending prophylactic platelet thresholds of 10 x 109/liter, but uncertainty with this body of literature should be recognized. There is a need for trials with adequate power that compare prophylactic to therapeutic platelet transfusion.
Stanworth, S.J., Estcourt, L.J., Powter, G., Kahan, B.C., Dyer, C., Choo, L., . . . TOPPS Investigators. (2013). A no-prophylaxis platelet-transfusion strategy for hematologic cancers. New England Journal of Medicine, 368(19), 1771–1780.
To determine whether or not having a prophylactic platelet policy was as safe and effective as giving prophylactic platelet transfusions
If their platelet count was less than 10, patients were randomly assigned to one of two groups. One group would receive prophylactic platelet transfusions on the same day of count less than 10. The other group would not receive prophylactic transfusion. The patients would continue the treatment arm for 30 days post-randomization. All patients were given platelet transfusion if bleeding occurred at World Health Organization (WHO) grade 2, before an invasive procedure, or at the discretion of the clinician. If WHO grade 3 or 4 bleeding occurred, patients were treated with platelets and no longer remained on the treatment arm but were still monitored per the protocol.
Randomized, controlled trial
In relation to frequency of bleeding events of WHO grades 2, 3, or 4, the prophylactic group was superior to the no prophylactic group (p = 0.04). The number of days with bleeding events of WHO grades 2, 3, or 4 was higher in the no prophylactic group (p = 0.004). The length of time it took until a patient’s first bleeding event was shorter for the no prophylactic group (p = 0.02). Six patients in the no prophylactic group, as compared to one in the prophylactic group, had a WHO grade 3 or 4 bleeding event although the difference was not significant. The prophylactic group received more transfusions overall. Serious adverse events between the two groups were not significant.
The results of this study support the need for prophylactic platelet transfusions policies at cancer centers to reduce bleeding, although the authors note that their study cannot validate what is safe or effective practice.
Nurses need to become familiar with the WHO grading criteria for bleeding episodes in order to help educate patients on the bleeding risks of low platelet counts. Nurses also need to know the policy of their own institution about what platelet threshold is used for prophylaxis, if such a policy exists. For those nurses who treat hematologic malignancies and/or stem cell transplant patients, the results of this trial could be the basis for an internal PI project.
Centers for Disease Control and Prevention. (2011) . Guide to infection prevention for outpatient settings: minimum expectations for safe care. Retrieved from http://www.cdc.gov/HAI/settings/outpatient/outpatient-care-guidelines.html
This document provides a summary guide of infection prevention recommendations for outpatient settings.
Guidelines
Administrative recommendations:
The guidelines represent the absolute minimum expectations for safe care. They are not all-encompassing, and organizations should refer to original source documents for detailed guidance and references.
Stagl, J.M., Antoni, M.H., Lechner, S.C., Bouchard, L.C., Blomberg, B.B., Gluck, S., . . . Carver, C.S. (2015). Randomized controlled trial of cognitive behavioral stress management in breast cancer: A brief report of effects on five-year depressive symptoms. Health Psychology, 34, 176–180.
To determine if group-based cognitive behavioral therapy (CBT) following surgery for breast cancer had long-term benefits for depressive symptoms
Women who previously participated in a single-blind RCT of 10 weeks of a group-based cognitive behavioral intervention versus a one-day psychoeducational control condition were contacted five years later for follow-up assessment. Patients were mailed a questionnaire to complete.
Women who had participated in the CBT intervention reported fewer depressive symptoms (d = 0.32, p = 0.03). The power to detect this difference was 0.93.
Findings suggest that CBT-approach interventions had long-term benefit in reducing depressive symptoms among women with breast cancer.
Cognitive behavioral interventions have been shown to be effective interventions for depression. This study suggests that CBT benefits can be long lasting. Alhough most nurses do not provide full CBT, principles of the CBT approach can be readily incorporated into nursing care and psychoeducational interventions. This approach can be recommended for use.
Srinivasan, A., Song, X., Ross, T., Merz, W., Brower, R., & Perl, T.M. (2002). A prospective study to determine whether cover gowns in addition to gloves decrease nosocomial transmission of vancomycin-resistant enterococci in an intensive care unit. Infection Control and Hospital Epidemiology, 23, 424–428.
To determine whether cover gowns in addition to gloves decrease the nosocomial transmission of vancomycin-resistant enterococci (VRE) in an intensive care unit.
Medical intensive care unit (teaching hospital)
This was a prospective study.
Gown and Gloves
Gloves Only
Spunt, S.L., Irving, H., Frost, J., Sender, L., Guo, M., Yang, B.B., . . . Santana, V.M. (2010). Phase II, randomized, open-label study of pegfilgrastim-supported VDC/IE chemotherapy in pediatric sarcoma patients. Journal of Clinical Oncology, 28, 1329–1336.
The purpose of this article is to evaluate the safety, clinical response, and pharmacokinetics of pegfilgrastim compared to filgrastim in pediatric patients with sarcoma receiving dose-intensive vincristine-doxorubicin-cyclophosphamide/ifosfamide-etoposide (VDC/IE) chemotherapy.
Pediatric patients with biopsy-proven sarcomas scheduled to receive four cycles of VDC (cycles 1 and 3) / IE (cycles 2 and 4) chemotherapy in three-week intervals were randomized in a 6:1 ratio (pegfilgrastim to filgrastim). Pegfilgrastim group received one subcutaneous injection of 100 mcg/kg and filgrastim group received daily subcutaneous injections 5 mg/kg daily. Both groups received injections starting about 24 hours after completion of week 1 chemotherapy with continuation until a post-nadir absolute neutrophil count (ANC) greater than 10 x 109/L achieved or until 24 hours prior to the next chemotherapy cycle. ANC greater than 1 x 109/L and platelets greater than 100 x 109/L were the minimum acceptable levels for chemotherapy. Chemotherapy modifications were made for infections requiring intensive care or for typhlitis, meningitis, or O2-dependent pneumonia.
10 outpatient settings in the United States and Australia
Phase II randomized, controlled trial (RCT), open-label.
85% of patients in the filgrastim group had febrile neutropenia compared to 68% in the pegfilgrastim group. The duration of grade 4 neutropenia was about equal in both groups with a median duration of 1 day less in the pegfilgrastim group during cycle 1. The median recovery to ANC time was also the same in both groups. One patient in the pegfilgrastim group in cycle 1 and three in cycle 3 failed to have neutrophil recovery. All patients in the filgrastim group had neutrophil recovery. The pharmacokinetics were similar for pegfilgrastim and filgrastim. In the pegfilgrastim group, duration of grade 4 neutropenia was inversely related to age (i.e., the younger the patient, the longer the duration). Adverse events were statistically equivalent between the groups; however, more types of events occurred in the pegfilgrastim group.
The use of pegfilgrastim is as safe and effective to use as filgrastim in pediatric patients with sarcomas and requires just one dose compared to daily doses of filgrastim.
The administration of pegfilgratim as a one-time dose can be as effective as daily doses of filgrastim against neutropenia in pediatric patients being treated with myelosuppressive chemotherapy for sarcomas. Nurses can advocate for the use of pefgilgrastim to decrease the burden of number of injections in pediatric patients with sarcomas.
Sprod, L.K., Palesh, O.G., Janelsins, M.C., Peppone, L.J., Heckler, C.E., Adams, M.J., . . . Mustian, K.M. (2010). Exercise, sleep quality, and mediators of sleep in breast and prostate cancer patients receiving radiation therapy. Community Oncology, 7, 463–471.
To assess the effect of home-based exercise on sleep quality and proinflammatory cytokines in patients with breast and prostate cancer receiving radiation therapy
Patients randomly were assigned to the home-based exercise or control group. Patients in the control group received standard care and were encouraged to remain only as active as they were prior to study inclusion. Patients in the intervention group were given 45 minutes of instruction by an exercise physiologist and given an exercise kit that contained written instructions, a pedometer, and resistance bands. The exercise prescription followed the American College of Sports Medicine guidelines for progressive walking at moderate intensity. Resistance band use was designed for low to moderate intensity, focusing on upper extremities. Patients wore pedometers during the first week. All patients were followed weekly for four weeks. Study measures were obtained at baseline and after the intervention.
Fifteen of the 19 patients in the exercise group reported increased daily steps walked and at follow-up at three months walked significantly more than patients in the control group (p < .05). Twelve of the 19 patients in the intervention group reported doing resistance training for an average of 17 minutes three days per week. Overall sleep quality improved over time in both groups, and no significant difference was seen between groups. Post-intervention levels of IL-6 and TNF-α increased slightly in both groups. Both of these were lower in the exercise group, but the difference was not significant.
These findings do not demonstrate an impact of a home-based exercise program on sleep quality.
Findings show that patients being provided with training and materials to do a home-based exercise program was associated with good adherence by patients. However, findings did not show an effect of this exercise on sleep quality. Exercise is beneficial and should be encouraged but does not appear to have a beneficial effect on sleep-wake disturbance.