To examine efficacy of eight weeks of behavioral activation and problem-solving therapies toward reducing depression and suicidal ideation

Patients who had breast cancer and met the Harvard National Depression scale criteria for symptoms of major depression were randomized to behavioral activation or problem-solving psychotherapy interventions. Sessions were provided by clinical psychology doctoral students who were skilled in both interventions. All sessions were one on one and audiotaped, and 15% of tapes were randomly selected for review of competence and adherence by an independent therapist.

• N = 80 in ITT analysis, 65 completed treatment  
• MEAN AGE: 55.4 years (SD = 11.9 years)
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: Breast cancer; average time since diagnosis was 3.2 years
• OTHER KEY SAMPLE CHARACTERISTICS: 43% had prior psychotherapy and, on average, had moderate level depression and mild to moderate suicidal ideation at baseline; 93% were Caucasian; and research included people taking antidepressants, but the number of those on antidepressants was not reported.

• SITE: Single site  
• SETTING TYPE: Not specified  
• LOCATION: New York, NY

PHASE OF CARE: Transition phase after active treatment

• Randomized trial

• Hamilton Rating Scale for Depression (HRSD) 
• Beck Depression Inventory (BDI)
• Center for Epidemiological Studies Depression scale (CES-D)

For all measures, there was a significant main effect for time (p < 0.05), showing decline in depression; but there were no differences between groups. There was a significant linear reduction in suicidal ideation and an increase in hopefulness at post-treatment and at the 12-month follow-up.

Both types of psychotherapy examined here were associated with reduced depression and suicidal ideation.

• Small sample (less than 100)
• Unintended interventions or applicable interventions not described that would influence results
• Key sample group differences that could influence results
• Subject withdrawals of 10% or greater 
• Proportion of the sample on antidepressants is not described, and there is no subgroup analysis of outcomes between those on or not on antidepressants

Psychotherapy can be helpful for patients with cancer who also suffer from depression and may have suicidal ideation. This study adds to the body of evidence on efficacy of psychotherapy for these patients. Psychotherapy should be considered as part of treatment options for individuals who have clinically relevant depression or a major depressive disorder.

To test the efficacy of behavioral activation for depression therapy (BADT) compared to problem-solving therapy (PST) in depressed breast cancer patients

Patients were randomly assigned to either BADT or PST. Each therapy was delivered in individual sessions over eight weeks. In the BADT group, patients engaged in self-monitoring exercises and identified the level of reward or pleasure for behaviors and activities. Then researchers emphasized identifying values and goals within multiple life areas and targeting behaviors for attention. The patient and therapist collaboratively set goals and activities each week, and patients progressed through activities, from easiest to hardest, aimed at reducing aversive experiences. Sessions included muscle relaxation, assertiveness training, and graduated exposure to anxiety-producing stimuli. PST involved therapy to increase patients' understanding of the connection between current depression and anxiety symptoms with everyday problems, to help patients define current problems, and to teach patients a specific problem-solving method. Therapists were experienced in providing the intervention they delivered. Sessions were recorded, and a 15% sample was independently evaluated to assess fidelity of the intervention. The principal investigator supervised all therapists weekly and individually.

• The sample was composed of 65 patients with breast cancer (100% female).
• Mean patient age was 55.4 years (SD = ±11.9 years).
• Average time since diagnosis was 3.1 years.
• Most patients had stage 0–II disease; 95% had had surgery, 74% had had chemotherapy, and 64% had had radiation therapy; 52% were currently taking antidepressants.
• Approximately 42% were working either full- or part-time.
• All patients had to meet screening criteria that demonstrate a diagnosis of major depression of at least moderate severity.

• Outpatient settings, specific sites unstated or unknown 
• Tennessee and Maryland

Late effects and survivorship

Randomized controlled trial design

• Beck Depression Inventory (BDI)
• Environmental Reward Observation Scale (EROS)
• Beck Anxiety Inventory (BAI)
• Quality of Life Inventory (QOLI)
• 36-item Short-Form Health Survey (SF-36)
• Multidimensional Scale of Perceived Social Support (MSPSS)
• Hamilton Rating Scale for Depression (HRSD)

BDI and HRSD sales demonstrated significant improvement in depression (p = 0.04). Mental health and general health scales on the SF-36 also improved (p = 0.02). Results revealed no significant difference between groups, and both interventions demonstrated a strong effect size.

Findings demonstrate that both the BADT and PST interventions were effective in reducing depression in the groups of patients studied.

• The study had a small sample size, with fewer than 100 participants.
• The study had risk of bias due to no blinding.
• Of all participants, 19% dropped out. Authors had determined sample size to accommodate this, given previous research.
• Findings relate to patients with major depression and may not relate to patients with symptoms of depression that is less severe than major depression.

Findings show that both of the interventions were effective in reducing the level of depression among patients with breast cancer with major depression. The drop-out rate over the eight-week study period suggests that participating in the target intervention may be difficult or impractical for many patients.

To assess, in a medical care setting, the effectiveness of a brief cognitive behavioral treatment for depression on depressed patients with cancer

• Patients were screened for depression; researchers administered the Anxiety Disorders Interview Schedule-IV (ADIS-IV) to eligible participants and considered all self-report measures.
• Participants completed nine-week one-on-one cognitive behavior therapy for depression. Sessions were weekly. The same clinical graduate student assessed and treated all patients.
• Variables were examined pretreatment, post-treatment, and at three months after the therapy.

• The study reported on a sample of 13 patients (11 females, 2 males).
• Mean patient age was 52.2 years (SD = 10.9 years).
• Tumor-type distribution was breast (n = 7), lung (n = 1), stomach (n = 1), colon (n = 1), prostate (n = 1), pancreatic (n = 1), and bone cancer (n = 1); all had stage I or II cancer.
• All participants were Caucasian. The average length of education was 14.8 years.
• Mean level of major depression was 5.7 (SD = 1.1), suggesting moderate clinical depression.
• Average time since diagnosis was 1.5 years; three participants were actively on treatment. Coexistent diagnoses included generalized anxiety disorder (n = 7), social phobia (n = 3), panic disorder (n = 1), obsessive compulsive disorder (n = 1), specific phobia (n = 1), and anxiety disorder not specified (n = 1).
• Participants were included if not on antidepressants or antianxiety medications or if stabilized for eight weeks on consistent dose prior to study assessment.

• Single site
• Outpatient setting
• Cancer institute in Tennessee

Patients were undergoing the active treatment and transition phases of care.

A pre/post-test, convenience sample design was used.

• Harvard Department of Psychiatry National Depression Screening (HANDS) scale
• 10-item Anxiety Disorders Interview Schedule–IV (ADIS-IV)
• Hamilton Rating Scale for Depression (HRSD), a 24-item semistructured interview designed to measure symptom severity
• Beck Depression Inventory–II (BDI-II)
• Center for Epidemiological Studies of Depression Scale (CESD), a 20-item self-report questionnaire regarding symptoms of depression
• Beck Anxiety Inventory (BAI), a 21-item questionnaire designed to distinguish cognitive and somatic symptoms of anxiety
• Quality of Life Inventory (QOLI), a 16-item self-report measuring life satisfaction across a range of domains
• Medical Outcomes Study Short Form–36 (SF-36)
• Multidimensional Scale of Perceived Social Support, a 12-item scale that assesses adequacy of social support
• Client satisfaction questionnaire

• Patients completed an average of 118.9 (SD = 49.8) assigned activities, resulting in an overall patient adherence score of 82%. Post hoc analysis showed significant pre- and post-treatment improvement on measures of depression, anxiety, quality of life, and medical outcomes; improvements were clinically significant as indicated by moderate-to-large effect sizes (R = 0.6 to 2.0).
• All treatment gains were maintained at three-month follow-up. Somatic anxiety did increase slightly at follow-up.
• Patients were strongly satisfied with cognitive behavior therapy for depression.
• All patients improved significantly on the RCI, and all but one patient (92% of total) improved on the BDI and HRSD.
• 54% of patients demonstrated statistically significant improvement in somatic anxiety, according to the BAI, and 62% reported increased quality of life as measured by the QOLI.
• The SF-36 showed significant clinical change as follows: physical functioning (62%), mental health (62%), role emotional (54%), role physical (54%), general health (62%), bodily pain (54%), vitality (69%), and social functioning (62%).

Behavioral therapy interventions, especially when paired with cognitive techniques, may represent a practical medical care treatment to improve psychological outcomes for and quality of life of patients with cancer.

• The study had a small sample size, with less than 30 participants.
• The study lacked randomization, had no control group, included one site, and provided no assessment of anxiety symptoms and disorders and their relation to outcome.
• The study lacked multiple-baseline design.
• Longer-term follow-up is needed.
• A clinical graduate student was used instead of an experienced therapist.
• A comprehensive protocol was not used for the interview.

Depression is a major concern for patients with cancer. To identify patients who need treatment, tools should be developed that are more nurse-friendly and easier to administer.

To review patient–family psychosocial interventions in cancer care on physical, psychological, social, and quality-of-life effects

To evaluate associated theoretical models and measured effects

• Databases used in the search were MEDLINE, EMBASE, PsycINFO, and CINAHL.
• Keywords were cancer, systematic, review, couple, family, psychosocial intervention, symptom, and quality of life.
• Inclusion criteria: English-language adults with cancer (18 years or older) from resource-rich countries; family/couples/partners (all gender combinations); relationship of caregiving between patient and other(s); illness-related (not long-term relationship) problems; studies with experimental design (e.g., randomized controlled trial [RCT], case control, systematic review); nonpharmacologic interventions; illness-related disruption in relationships and/or illness-related conflict; and evaluation of an outcome (e.g., satisfaction, distress, quality of life, pain)
• Exclusion criteria: Teenagers and children; people in residential care and other institutions where primary carers are professionals; pharmacologic interventions; intervention that cannot be delivered in a community setting (i.e., patient’s home); non-Western culture; intervention that is targeted at long-standing family dysfunction; intervention that is delivered over a long period of time (more than 2.5 months); intervention where the effect is not expected for longer than 2.5 months; study of past cause of family dysfunction; study of future prevention of family dysfunction; nonillness-related family problems; care/support/intervention for carer independent of patient (e.g., management of carer problem); care/support/intervention for patient independent of carer (e.g., management of patient problem); patient–healthcare professional relationships; carer–healthcare professional relationships; education or support for healthcare professionals; and organization/delivery of a service

• A total of 80 references were retrieved.
• One author performed a title and abstract scan on each retrieved study. The second author reviewed 10% of studies for reliability.
• Disagreements were resolved through discussion.

• A final number of 27 studies were included in the review.
• Sample range across studies was 14–480.
• Of the 27 studies (published between 1999 and 2009), 22 interventions focused on patients and family caregiver (dyad focus; too few studies focused on a multi-member family unit were found to include).
• Sample studies included patients with early-stage breast, gynecologic, and prostate cancers; all stage central nervous system tumors; and cancer-related pain; as well as patients undergoing chemotherapy.

• Active antitumor treatment phase   
• Elder care; palliative care

Dyad-focused nonpharmacologic interventions may improve coping and emotional support. High attrition related to the practical burdens associated with trial participation and care of a seriously ill patient impact the design and conduct of RCTs to test these interventions, but adverse events are few. Interventions that promote interactions within the dyad are more likely to have a measurable effect on emotional health outcomes than those targeted to a single member of the pair. Few studies are theory-based.

Dyadic interventions that promote interaction appear to be beneficial to impact anxiety, depression, and distress in patients with cancer and the family members who care for them.

The review was limited to English language studies.

High attrition rates in studies imply that it is important to match the intensity/complexity of an intervention with the dyad’s ability/willingness to participate fully, or risk drop out. Further theory development and testing are needed to guide design and conduct of future studies in this area.

To explore the current state of the science regarding acupuncture as a treatment modality for cancer pain

TYPE OF STUDY: Systematic review

Databases searched were PUBMED and CINAHL, in addition to websites from the National Cancer Institute, the National Institute of Health's Complementary and Alternative Medicine Program, and the American Cancer Society.

Keywords were acupuncture for cancer pain and cancer pain management acupuncture.

Studies that focused on cancer pain and acupuncture using human participants, were English language, and described attitudes associated with acupuncture or complementary and alternative medicine were included in the search.

Studies that focused on postoperative pain and studies that combined acupuncture with other modalities, such as massage, were excluded from the search.

A total of 130 studies from  2000 to 2009 were retrieved.

• A final number of 11 studies were included in the review.
• The 11 studies included 3 randomized controlled trials, 1 pilot study, 1 meta-analysis, 1 case-control study, 1 prospective cohort study, and 4 expert reviews.

• Level I evidence: The administration of true acupuncture resulted in decreased pain when compared to the sham acupuncture and the control group (p < 0.05). No long-term difference in pain improvement was noted among groups.
• Level III evidence: The low statistical power of this study and the lack of attempts to control for confounding variables affected the external validity.
• Level V evidence: A decrease in pain was reported at one month for 16 of the 34 patients treated with acupuncture (p < 0.05) and at the six-month follow-up for 14 of the 34 patients treated with acupuncture (p < 0.05).

The use of acupuncture as a complementary treatment for the management of cancer pain may have the potential to improve the quality of life of patients with cancer. Benefits of the addition of acupuncture for cancer pain management must be supported by evidence of safety and effectiveness. A synthesis of the current evidence reveals a lack of level I and level II studies pertaining to acupuncture as an intervention for the management of cancer pain. The nonexperimental studies cannot adequately infer causality.

To test the hypothesis that the use of aloe would lead to a one-point reduction in radiation-induced skin rash (RISR) severity and a decrease in symptom severity compared to a traditional dry powder skin care regimen

Potentially eligible patients underwent a skin test to rule out allergic reactions. Informed consent was obtained, and patients were randomized to each arm (aloe, placebo cream, or control powder). The creams were dispensed in identically labeled containers to the patients with study protocol directions. Two radiation oncology nurses trained to identify RISR assessed acute skin reactions and completed scoring at weeks 1, 2, and 4. All patients were asked to either use no soap or mild soap and to apply baby powder or cornstarch to the treatment skin markings. Patients in the powder arm applied powder during treatment followed by one month of a moisturizing cream. Those in the cream arm applied it three times per day throughout treatment and for one month after completion. Additional treatment for moist desquamation and other skin reactions was administered according to individual physician preferences.

• N = 237
• AGE = > 18 years
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: Nonmetastatic breast cancer
• OTHER KEY SAMPLE CHARACTERISTICS: Previous mastectomy or segmented resection; agreement to comply with the study protocol; received either 45 Gy in 20 fractions or 50 Gy in 25 fractions; approximately 40% were current smokers

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

• PHASE OF CARE: Active antitumor treatment

Single-blinded, placebo-controlled, randomized trial

• Modified 10-point Catterall skin scoring profile

Patients were studied during a 21-month period. Ten withdrew before the start of the study, and one withdrew because of a selection error. Skin rashes occurred in all three arms with the greatest number of skin rashes noted in the aloe cream arm (31% compared to 15.6% with a placebo). Skin reaction scores were consistently higher with aloe than with the standard treatment of powder (p < 0.02). The study also showed that patients in the powder arm reported more dryness, pain, and itching (p = 0.0163). This study did not meet the endpoint of a change in the RISR severity of one point. Women with breast cup sizes C and greater experienced a significantly higher severity of skin reactions (p < 0.02). It also was noted that erythema and dry desquamation occurred more with powder, and moist desquamation (< 50%) occurred most with aloe cream and (> 50%) occurred most with powder.

The results of the study showed that known-quality aloe or placebo creams did not improve skin reactions or symptoms; they made them worse. The study also concluded that dry skin was better than moist treatment during radiation treatment.

• Baseline sample/group differences of import
• Measurement/methods not well described
• Other limitations/explanation: The treatment of moist desquamation was not standardized, so physicians could order whatever was deemed medically necessary. The study did not disclose whether any of the study patients fell into that category. A significantly higher proportion of patients in the aloe and placebo arms received chemotherapy as well. It appears that radiation therapy did not employ intensity-modulated radiation therapy. The use of powder on the skin is not common as a standard of practice.

Patient education is very important, and patients should be instructed to use only skin care products that will be effective in managing radiodermatitis. This study had some limitations, but it adds to the growing body of evidence that aloe can make radiation skin reactions worse. Patients should be instructed to not use aloe products on their skin.

PHASE OF CARE: Multiple phases of care
 
APPLICATIONS: Pediatrics, elder care, palliative care

Various psychosocial interventions, including educational interventions, cognitive behavioral therapy, relaxation training, and supportive group therapy, were found to reduce the length of patients’ hospital stays, decrease the number of days to proficiency in self-care for stoma, decrease levels hospital anxiety and depression, and increase quality of life.

Various forms of psychosocial interventions were used to improve outcomes, but no clear winner was found. All forms seemed to improve patient outcomes.

• A limited number of studies met the inclusion criteria.

Evaluate the wound healing effects of RhEGF in patients with radiation-induced oral mucositis.

RhEGF 25 mcg/day was applied topically to the oral cavity twice daily for seven days.

The study was comprised of 11 patients, with an age range of 34-70 years.

Females: 2, Males: 9

Diagnosis Information: Nine patients with head and neck cancer, two patients with lymphoma

Other Key Characteristics: Concurrent chemo/RT five patients. Patients had severe mucositis at the point of study entry.

Single site: Seoul, Korea

Prospective trial--pilot study

Unaided oral and soft palate evaluation was done on day seven.

Oral mucositis was scored according to RTOG criteria.

All patients showed improvements in oral mucositis, with decreased mean RTOG grades. Two patients with grade 4 improved to grade 3; two patients with grade 4 improved to grade 2; five patients with grade 3 improved to grade 2; and two patients with grade 3 improved to grade 1. None of the patients had to interrupt RT because of acute mucositis.

Topical treatment with RhEGF has a therapeutic effect on RT-induced oral mucositis.

Small sample size (pilot study). Mucositis evaluated by unaided eye and restricted or oral and soft palate-may have not been consistent grading if done by different individuals. Sample was too varied, including nasopharyngeal tumors, oropharynx tumors, and hypopharynx tumors and lymphoma. These all differ greatly in the treatment techniques, amount of radiation given, and severity of reaction.

More data are needed to determine effectiveness. Topical applications have limitations as far as adherence to the intended amount of drug and effective coverage of mucosa with medication. Topical application may be easier to apply, but not for everyone, and depending on the taste, an aversion to the taste may occur over time.

To compare the efficacy, side effects, and use of rescue medication associated with two two-hour sustained-release morphine preparations: SR1 (MS Contin, Purdue Frederick Co., CN) and SR2 (Oramorph SR, Roxane Laboratories, Columbus, Ohio)

Patients' pain had been stabilized prior to treatment-group random assignment. Stabilization was defined as pain requiring fewer than four rescue doses in the previous 24 hours and pain rated as moderate or less for 48 consecutive hours. Patients were randomly assigned to SR1 or SR2 medication every 12 hours for five days. Investigators gathered data about side effects and compliance by means of daily telephone calls. Investigators assessed the acceptability of the medications at the end of the study, by asking patients if they wanted to continue taking the drug they were receiving.

• The sample was composed of 32 patients.
• Mean patient age was 63.5 years. The age range was 27–79 years.
• Of all patients, the percentage of females was 44% and the percentage of males was 56%.
• Most frequent cancer types were lung cancer and gynecologic and colorectal cancers. The majority of patients had metastatic disease.

• Single site
• Outpatient
• Cleveland Clinic, Cleveland, Ohio, United States

Randomized open-label, parallel-group trial

Five-point rating scale (0 = none, 4 = severe), to measure pain

Authors noted an overall trend toward lower pain rating scores in the SR2 group. This difference was statistically significant (p = 0.05)  on day 3 only. The total accumulative rescue dose over the study period was significantly higher for SR1 (p = 0.03). Authors noted no significant differences in side effects between the two groups. All patients taking SR2 elected to remain on that medication; 75% of patients preferred to continue taking SR1. Median morphine dose overall was higher in the SR1 group. The sample size was determined by power analysis.

The study suggests that, compared to SR1, SR2 may provide better analgesic efficacy, resulting in less overall need for rescue medication.

• The study had a small sample size, with fewer than 100 participants.
• The study used only one measure of pain intensity.
• The study duration was very short, just five days.

Findings suggest that the efficacy of various formulations of controlled- and sustained-release oral morphine preparations can be different. Nurses should be aware of this in the context of managing chronic pain. Researchers should undertake long-term studies to provide clinically relevant data in this regard.

A phase II study of methylphenidate for depression in patients with advanced cancer

Patients who were identified as being depressed by a palliative medicine attending physician were treated with methylphenidate twice daily. Doses were titrated per regimen until response was obtained. Patients were assessed during a telephone call or bedside interview. The study timeframe was seven days.

• N = 30
• MALES: 50%, FEMALES: 50%
• KEY DISEASE CHARACTERISTICS: Primary cancer sites: breast (5), esophagus (4), head and neck (4), lung (4), pancreas (4), colorectal (2), and other (7)
• OTHER KEY SAMPLE CHARACTERISTICS: Inclusion criterion was the answer of “yes” to the question, “Are you depressed?” with no current or previous antidepressant use.

• SITE: One center was included.
• SETTING TYPE: Inpatients and outpatients were enrolled in the palliative care program.

• Question, “Are you depressed?”
• Other symptoms (anorexia, concentration problems, fatigue, and sedation) were assessed by a categorical rating (none, mild, moderate, or severe) before starting methylphenidate and daily thereafter.
• Pain was assessed using a 0–10 scale.
• Known side effects of methylphenidate also were assessed.
• Satisfaction question: ”Are you satisfied with the way the drug affected your mood?” was asked at the end of the study on day seven.

Depression was resolved in all patients, most on day three. The maximum daily dose needed was 20 mg. Other symptoms also improved, mean pain scores significantly decreased, and all who responded to treatment were satisfied with therapy.

• Small sample with no randomization
• Long-term efficacy and side effect data are needed.
• Single-site data are less transferable than multi-site data.