To describe differences in bowel function with oral or IV opioids.

Patients who were admitted to a palliative inpatient unit for pain management had data retrospectively collected related to morphine-induced constipation. After IV morphine was administered and dose requirements were determined, patients were converted to oral morphine and then discharged.

• The study reported on a sample of 11 patients with cancer.
• Mean patient age was 43 years.
• The sample comprised eight men and three women.
• Patients were included in the study if they were admitted to a palliative care unit for IV morphine.
• Patients were excluded if they had gastrointestinal malignancy or disorders.

• Single site
• Inpatient
• India

The study has clinical applicability to end-of-life and palliative care.

This was a retrospective, descriptive study.

Visual analog scale

• Patients on IV morphine did not require laxatives for bowel movements to occur.
• Of patients switched to oral morphine, seven of 11 needed laxatives during their inpatient stay and were discharged with laxative prescriptions.

Patients on IV morphine were less likely to need laxative therapy to promote bowel function compared with patients on oral morphine. All patients on oral morphine needed laxative therapy.

• The sample size was extremely small.
• The design was retrospective and descriptive only.

Implications are limited because of the small sample size and other uncontrolled variables. More research is needed to determine whether IV morphine is less constipating than oral morphine and the applicability of this information in patient care.

To determine if massage therapy was effective relief for chemotherapy-induced nausea and vomiting (CINV) in children with cancer

Patients in the intervention group received a 20 minute massage 24 hours and 30 minutes before a chemotherapy infusion and 24 hours postinfusion. A trained massage therapist used a Swedish massage technique with effleurage, petrissage, friction, and tapping movements. Mild to moderate pressure was used. Subjects were randomized by a randomized number table. Patients could elect to use olive oil with the massage. No music was used during the therapy. The control group received normal care, but the therapist was present 24 hours and 30 minutes before an infusion as well as 24 hours postinfusion. Data were collected during chemotherapy and 48 hours postinfusion.

• N = 70  
• MEAN AGE = 8.6 years
• MALES: 52%, FEMALES: 48%
• KEY DISEASE CHARACTERISTICS: Majority of patients had acute lymphocytic leukemia 
• OTHER KEY SAMPLE CHARACTERISTICS: Pediatrics, ages 4–18 years

• SITE: Single-site  
• SETTING TYPE: Outpatient    
• LOCATION: Iran

• PHASE OF CARE: Active antitumor treatment
• APPLICATIONS: Pediatrics

Randomized, controlled trial

• Baxter Animated Retching Faces (BARF) scale (ages 4–9)
• Visual Analog Scale (VAS) (ages 9–18)

There were no significant differences between the intervention and the control group in terms of gender, type of cancer, or emetic potential of chemotherapy. There was no difference between groups in regard to nausea during chemotherapy. There was a significant difference in frequency (p = 0.001), duration (p = 0.002), and severity (p = 0.002) of nausea 48 hours after chemotherapy. There was no difference in vomiting at the time of chemotherapy, but there was a significant difference in the severity (p = 0.005) and frequency (p = 0.013) of vomiting 48 hours postinfusion.

Massage therapy may effectively decrease nausea and vomiting 48 hours after chemotherapy infusion in children.

• Small sample (< 100)
• Risk of bias (no blinding)
• Other limitations/explanation: Two different measurement instruments were used depending on the age of the child in the study.

Massage therapy, administered both before and after a chemotherapy infusion, may be effective in limiting CINV in the pediatric population. Massage was not effective at relieving anticipatory CINV that occurred at the time of infusion.

To assess the effectiveness of oxymorphone in the treatment of chronic pain

• Databases searched were MEDLINE, EMBASE, PubMed, and the Cochrane Central Register of Controlled Trials (CENTRAL).
• Search keywords were oxymorphone, oxymorphone ER, OPANA, oxycodone, randomized trial, randomized controlled study, pain, chronic pain, treatment, analgesia, human, cancer, back pain, and osteoarthritis. In addition, investigators performed manual searches based on reference lists.
• Studies were included in the review if they included level 1 evidence.
• The search did not involve exclusion criteria.

The search retrieved nine studies. Authors chose six studies for analysis. Five of the chosen studies were appropriate for meta-analysis. Only one study involved chronic pain resulting from a malignancy. Investigators, using guidelines published by the National Health Service Centre for Reviews and Dissemination, evaluated allocation procedures, concealment of allocation, blinding procedures,  distribution of known confounders between groups, whether study groups were treated the same except for the intervention, and whether intention-to-treat analysis was performed. Two reviewers independently reviewed and assessed all studies.

• The sample for analysis was composed of 1,426 patients. The sample range was 42–467 patients. Investigators analyzed data from 42 patients who experienced pain related to malignancies.
• The sample included adult patients with chronic low-back pain and pain related to osteoarthritis and cancer. The sample included opioid-naive patients and those who were taking opioids.
• Excluded from the study of cancer pain were patients who had undergone radiotherapy within the last two weeks.

In this study, oxymorphone 40–100 mg was associated with a significant reduction in the pain intensity experienced by patients with chronic pain unrelated to a malignancy. Total mean difference across studies was –12.88 (CI –17.08 through –8.68, p < 0.00001). Studies in which doses were titrated rather than fixed showed greater effect size. Adverse events were mild to moderate and similar to those associated with other opioids. The study of pain associated with malignancy, though small, demonstrated that oxymorphone was effective in the treatment of cancer pain and that switching between oxymorphone and oxycodone was feasible.

Findings suggest that oxymorphone is effective in chronic pain management. Note that the conversion ratio, oxymorphone to oxycodone, was 1:2.

Authors noted the high discontinuation rates in placebo groups; the high rates relate to the fact that some studies do not allow use of rescue medication. This fact has important implications regarding the design of studies in the field of pain management. Authors noted that regulators mandate placebo-controlled trials, and the authors highlighted the ethical concerns that such a requirement raises. In addition, authors noted the lack of placebo-controlled studies of patients with cancer pain.

To contribute preliminary evidence for the feasibility and potential effectiveness of a structured walking intervention on reducing cancer-related fatigue in order to plan for a full-scale study of effectiveness

The study consisted of an eight-week program with three intervention groups: one with the STEPS (a walking program using a pedometer) during rehabilitation, one with STEPS after rehabilitation, and one group with only the rehabilitation program for people with advanced cancer and a > 4 fatigue level on a Visual Analog Scale (VAS).

• SITE: Single-site    
• SETTING TYPE: Outpatient    
• LOCATION: McGill University Health Centre, Montreal, Canada

• PHASE OF CARE: Late effects and survivorship

A pilot randomized trial. The STEPS program was based on the participants’ current walking status and progressed according to fatigue level.

Instruments chosen to measure fatigue and symptoms of anxiety and depression included the following.

• Functional Assessment of Chronic Illness Therapy (FACIT) Measurement System
• Fatigue Symptom Inventory (FSI)/Two-Minute Walk Test (2MWT)
• RAND-36 Survey
• Community Healthy Activities Model Program for Seniors (CHAMPS)
• EuroQol System
• Functional Assessment of Cancer Therapy (FACT-G)
• Hospital Anxiety and Depression Scale (HADS)
• Pittsburgh Sleep Quality Index (PSQI)
• Fatigue Visual Analogue Scale (VAS)

Results demonstrated that the pedometer-facilitated walking intervention adapted to fatigue levels (STEPS program) showed promise as an intervention to decrease cancer-related fatigue.

Compared to rehabilitation alone, the eight-week adaptive walking intervention reduced fatigue and improved physical function and well-being over a 16-week period and was sustained to six months.

• Small sample (< 30)
• Subject withdrawals ≥ 10%

Walking intervention is associated with a trend toward less fatigue; however, this study needs replication in the advanced cancer population. Effectiveness not established.

To compare efficacy and development of bacterial resistance with prophylactic antibiotic regimens of either COT/COL or CIP

Patients with acute myeloid leukemia (AML) were given antibiotic prophylaxis with either 960 mg cotrimoxazole twice daily and colistin 200 mg three times daily or 500 mg ciproloxacin twice daily. Those receiving CIP were also given cotrimoxazole twice daily two times per week for pneumocystis prophylaxis. All received antifungal prophylaxis. Colony-stimulating factors were given to some patients at the doctor's discretion. Patients receiving CIP did not receive antiviral prophylaxis. Infection-related outcomes were compared between these two cohorts. The study included patients over a four-year span of time. Environmental antimicrobial interventions were standard across both groups.

• N = 204  
• MEDIAN AGE = 62 years
• MALES: 59%, FEMALES: 41%
• KEY DISEASE CHARACTERISTICS: All had AML. The majority were receiving induction chemotherapy (61%), and 34% of chemotherapy courses were for consolidation.

• SITE: Single site  
• SETTING TYPE: Inpatient    
• LOCATION: Germany

• PHASE OF CARE: Active antitumor treatment

• Retrospective

• Fever defined at axillary temperature of at least 38º C
• Infections defined as occurrence of fever and detection of bacterial or fungal pathogens in at least one culture from sterile body sites
• Pneumonia defined as fever with infiltrates on radiological imaging
• Common Terminology Criteria for Adverse Events (CTCAE)

In both groups, the incidence of febrile neutropenia was about 80%. There were no differences between groups in infections. There were no differences between groups in detection or colonization of resistant organisms. There were no differences between groups in ICU useor differences in mortality related to underlying disease, infection, or septic shock. In both groups, infection was the major cause of death (70%). Overall, 8% of patients died. There were no differences between groups in treatment toxicity.

Both antibiotic prophylactic regimens resulted in similar patient outcomes, and both appeared to have similar efficacy.

• Risk of bias (no random assignment)

Although antibiotic prophylaxis with quinolones is generally preferred, antibiotic prophylaxis with COT/COL was essentially equally effective in this study, and might be considered an effective combination. Some studies have shown increase in quinolone-resistant organisms with standard quinolone prophylaxis. COT/COL prophylaxis may provide an alternative.

MEDLINE was searched for the 14 medical conditions for which the National Institutes of Health Acupuncture Consensus Development Panel (NIHCDP) concluded acupuncture was effective or could be useful. The two conditions in which acupuncture was found to be effective are the treatment of chemotherapy-induced nausea and vomiting (CINV) and postoperative nausea and vomiting. The remaining 12 conditions reviewed in the article were the effect of acupuncture on pain and the treatment of other conditions (e.g., addiction, stroke rehabilitation, and asthma).

Three of the studies reviewed examined the effect of P6 acupuncture on CINV. Although the chemotherapy agents were variable and various carcinomas were studied, strong evidence supported the use of acupuncture for greater antiemetic effect than antiemetics alone.

Evidence supports the use of acupuncture in the treatment of CINV and postoperative nausea and vomiting.

To compare the efficacy of two schedules of palonosetron versus ondansetron given by continuous IV infusion for treatment of chemotherapy-induced nausea and vomiting (CINV)

• Patients were randomly assigned to 1 of 3 intervention arms.
  • 8 mg of ondansetron IV bolus over 15 minutes followed by 24 mg of ondansetron given by continuous IV infusion starting 30 minutes before chemotherapy and lasting until 12 hours after chemotherapy infusion ended
  • 0.25 mg of palonosetron as IV bolus over 30 seconds, 30 minutes before start of chemotherapy daily during the chemotherapy cycle
  • 0.25 mg palonosetron as an IV bolus over 30 seconds, 30 minutes before the start of chemotherapy on days 1, 3, and 5 of treatment.
• All patients received 40 mg methylprednisolone as an IV bolus before each cytarabine infusion.
• Patient diaries were used to record episodes of vomiting, severity of nausea, use of rescue medication, and degree of impact on daily activities.
• Patients were followed for 7 days.

• The sample consisted of 143 patients.
• Median age was 53 years.
• The sample consisted of 47.6% female and 52.4% male patients.
• All subjects had acute myeloid leukemia, and all but five patients were undergoing induction therapy with idarubicin plus cytarabine or fludarabine plus cytarabine.

The study was conducted at an inpatient setting at the University of Texas M.D. Andersen Cancer Center.

All patients were in active treatment.

This was a randomized prospective study.

• Patients recorded nausea and vomiting severity in diaries.
• Nausea severity was measured on a Likert-type scale.
• Complete response (CR) was defined as no emesis and no use of rescue medications.
• Partial response (PR) was defined as one or fewer emesis episodes, no use of rescue medication during the study, and no more than grade 2 nausea.

• No significant difference was found in the proportion of patients who achieved a CR among groups.
• On day 1, more than 77% of patients in each group were free of nausea. The proportion of patients without nausea was similar across groups on days 2 through 5. On days 6 and 7, more patients receiving palonosetron than ondansetron were free of nausea (p < 0.03).
• No between-group differences in severity of nausea were recorded during days 1–5.
• Predictors of nausea in multivariate analysis were younger age, (p = 0.02), high-dose cytarabine plus idarubicin (p = 0.04), and prophylactic antibiotics (p = 0.009).
• The most commonly reported adverse events were headache and constipation.

Palonosetron was superior to ondansetron in reducing the prevalence of delayed nausea.

The study has potential bias because no control group or blinding was used.

Daily palonosetron appears to be more effective than the alternative used here for the prevention of delayed nausea. All the regimens here were similar in the early days of the therapy course, but palonosetron was significantly better in later days. Findings suggest that different drugs might be more helpful on different days throughout the course of chemotherapy, in concert with patterns seen in nausea.

To examine the effect of cognitive behavioral therapy (CBT) on sleep-wake outcomes in breast cancer survivors

Women who met criteria for chronic insomnia and had completed breast cancer treatment randomly were assigned to CBT intervention or a placebo behavioral intervention. Individual, weekly CBT sessions consisted of education, stimulus control, sleep hygiene education, and cognitive therapy provided by an advanced practice nurse with specialized training. The placebo intervention was based on desensitization therapy that had been used in previous insomnia trials as a placebo treatment. For both groups, sessions 1, 3, and 6 were provided in person, and sessions 4 and 5 were provided by telephone. Sessions were audiotaped and independently reviewed by a CBT therapist to ensure fidelity. Women were evaluated at three- and six-month follow-ups.

• N = 56
• MEAN AGE = 52 years
• FEMALES:100%
• KEY DISEASE CHARACTERISTICS: All had breast cancer and were 1–36 months post-initial treatment. Most had previous radiation and chemotherapy.
• OTHER KEY SAMPLE CHARACTERISTICS: The majority were Caucasian, well educated, and employed part- or full-time.

• SITE: Single site  
• SETTING TYPE: Outpatient
• LOCATION: Colorado

• PHASE OF CARE: Late effects and survivorship

• Randomized, single-blind RCT with attention control

• Sleep diary
• Piper Fatigue Scale
• Hospital Anxiety and Depression Scale
• Dysfunctional Beliefs and Attitudes About Sleep (DBAS-16)
• Patient knowledge test
• ISI measure of perceived insomnia
• Attentional function index
• EORTC-QLQ-C30

The CBT group did not show a significantly greater improvement in sleep outcomes immediately after the intervention, but scores were significantly better by the follow-up period (p = .003). Sleep efficiency increased by more than 11% in the CBT group, compared to an increase of 6.34% in the control group (d = 0.63). Sleep latency also improved more in the CBT group (d = 0.48, p = .007). No differences between groups were found for anxiety, depression, or fatigue.

Findings show that patients receiving CBT for sleep improved several sleep outcomes compared to individuals receiving a control intervention. The intervention did not demonstrate an effect on anxiety, depression, or fatigue.

• Small sample (less than 100)
• Findings not generalizable
• Other limitations/explanation: The sample had little diversity. The average baseline scores suggested that patients did not have clinically relevant levels of anxiety or depression.

Results of this study provide evidence of a moderate and significant effect of CBT on sleep outcomes among breast cancer survivors. This adds to the body of evidence that suggests effectiveness of this approach in managing sleep-wake disturbances.

To examine the proportion of patients who achieve a complete response (no emetic episodes and no rescue medication during the overall phase in each arm) with the treatment

Patients were receiving chemotherapy with carboplatin and paclitaxel for a gynecologic malignancy. All patients received a single IV dose of palonosetron (0.75 mg) on day 1 as a bolus given 30 minutes prior to chemotherapy, dexamethasone at 9.9 mg if patients were on dose-dense chemotherapy, and 20 mg for traditional carboplatin paclitaxel within 45 minutes prior to chemotherapy. Patients were then randomly assigned to two groups. Dexamethasone 8 mg was given on days 2 and 3, but no additional dexamethasone. Rescue medication was allowed. Evaluation of emetic events and nausea were measured using a diary and a 4-stage Likert-type scale. Randomization was done at a registration center with a minimization method with stratification according to institution, cancer type, age, and chemotherapy regimen.

• N = 109   
• AGE = 45–68 years
• FEMALES: 100%
• CURRENT TREATMENT: Chemotherapy
• KEY DISEASE CHARACTERISTICS: Ovarian, endometrial, or cervical cancer
• OTHER KEY SAMPLE CHARACTERISTICS: Type of regimen, either conventional paclitaxel 175 mg/m²/carboplatin AUC 6 every three weeks or dose dense with carboplatin AUC 6 on day 1, taxol 80 mg/m² on days 1, 8, and 15; alcohol consumption, motion sickness, and age; patients were chemotherapy naïve or had received single-agent low emetogenic potential therapy

• SITE: Multi-site   
• SETTING TYPE: Not specified    
• LOCATION: Japan

PHASE OF CARE: Active antitumor treatment

Randomized, controlled, non-placebo trial

• Used a patient diary to evaluate emetic events and nausea
• Nausea was measured using a 4-stage Likert-type scale.
• Multivariate logistic regression analysis showed relationships to other variables, such as motion sickness.
• Complete control was measured as no emetic episodes, no rescue medications, and mild nausea.
• Total control was defined as no emetic episodes, no rescue medications, and no nausea.

In the overall period, total control was 49.1% in the three-day dexamethasone group and 37.5% of the one-day dexamethasone group. In the acute phase, it was 90.6% in the three-day group and 92.9% in the one-day group. For delayed, it was 50.9% in the three-day group and 39.3% in the one-day group. Complete control in the overall period was 67.9% in the three-day group and 58.9% in the one-day group. In the acute phase, it was 98.1% in the three-day group and 96.4% of the one-day group. When looking at the responses, there were differences with motion sickness (p = 0.037), favoring the three-day dexamethasone regimen.

The authors concluded that one day of dexamethasone is as effective as three days of dexamethasone, except in special populations, such as those with motion sickness or severe hyperemesis gravidarum. Differences in efficacy were not found in patients with other risk factors, such as alcohol use and age.

Findings not generalizable

Nurses play a key role in assessing patient risk for chemotherapy-induced nausea and vomiting. Knowing past history of morning sickness or motion sickness should clue nurses into collaborating with providers to consider three days of dexamethasone as opposed to one day.

To investigate the effect of duloxetine for cancer-related neuropathic pain in patients for whom treatment with pregabalin was unsuccessful

Data were retrospectively reviewed for patients experiencing neuropathic pain who were treated with duloxetine because pregabalin could not be administered, was ineffective, or where the dosage could not be increased due to side effects. Patients were given 20 mg of duloxetine per day, increased to 40 mg/day if needed. Pain was assessed for two weeks.

• The study reported on a sample of 15 patients. 
• Patient age range was 31–79 years.
• The sample was 60% male and 40% female.
• Cancer diagnoses included breast, colon, and lung.
• Most patients were also receiving strong opioids.

• Single site
• Outpatient setting
• Japan

A retrospective study design was used.

Numeric rating scale for pain

Pain was reduced in 7 of the 15 patients. Baseline pain ranged from 5 to 10. After two to four weeks, pain ratings ranged from 2 to 9.

Duloxetine may be effective for relief of neuropathic pain.

• The study has a small sample, with less than 30 participants.
• The study has risk of bias due to no control group, no blinding, and no random assignment.
• There was no magnitude analysis of individual pain rating changes.
• There was no discussion of opioid dose changes, or any use of breakthrough medications.
• It appears that pain rating was done at a single time point per week; it is not clear whether this was self-report or of average, current, or worst pain.

Findings suggest that duloxetine may be helpful for patients with neuropathic pain as an alternative to pregabalin. This study provides weak evidence due to multiple study limitations. Further well-designed research is needed to identify the most effective management for cancer-related neuropathic pain.