To perform a combined systematic review and meta-analysis to assess the effectiveness of acupuncture for treating cancer pain

• Databases searched were MEDLINE, Allied and Complementary Medicine Database (AMED), EMBASE, CINAHL, PsycINFO, the Cochrane Library 2011, Korean Studies Information, DBpia (a database of Korean publications), Korean Institute of Science and Technology Information, Research Information Centre for Health Database, KoreaMed, Korean National Assembly Library, Chinese Medical Database of the China Academic Journal, and China Doctor/Master’s Dissertations.  
• Search keywords were the English terms that follow and their Korean and Chinese equivalents: (acupuncture OR electro-acupuncture OR auricular acupuncture OR scalp acupuncture OR needle OR acupuncture point OR meridian OR acupoint OR acupuncture treatment OR acupuncture therapy) AND (cancer OR tumour OR neoplasm OR pain).
• Studies were included if
  • Acupuncture was used as the sole intervention or as an adjunct to another standard treatment for any cancer pain.
  • The control group received the same concomitant treatments as the acupuncture group.
  • They were controlled by means of a placebo or they controlled against a drug-therapy or no-treatment group.
• Studies were excluded if they were nonrandomized trials, were trials with designs that did not allow the effectiveness of acupuncture to be evaluated, adopted comparison treatments or groups that were expected to have effects similar to acupuncture or used herbal medicines, were trials that studied cancer pain mixed with other types of pain, were trials that were conducted on patients during or a few days after an operation on malignant tumors, or were trials in which outcome measures were irrelevant to cancer pain.

• The search retrieved 494 references published through April 2011.
• Two independent reviewers read all articles. Reviewers extracted data from the articles according to predefined criteria. Risk of bias was assessed using criteria from the Cochrane classification.
• Nine studies were included in the meta-analysis. Data were pooled for a meta-analysis by using a random-effects model.

• The final number of studies included was 15; all were randomized controlled trials (RCTs).
• Total sample size was 1,157.
• Fourteen studies were conducted in China; these studies included a total of 1,070 participants. One study was conducted in France; this study included 87 participants.
• Three RCTs contained cases of liver cancer, one RCT contained at least one case of stomach cancer, and one RCT contained at least one late-stage cancer. 
• The focus of the meta-analysis was traditional Chinese acupuncture.

The study has clinical applicability for palliative care.

Most of the studies involved manual acupuncture based on traditional Chinese medicine. In regard to effect on cancer pain, the majority of the studies found the effects of acupuncture and conventional drug therapy to be comparable; however, equivalence of effects is unclear in those studies reporting no differences between acupuncture and conventional drug therapies.

Acupuncture may be an effective intervention for controlling pain; however, due to the small number of RCTs, low methodological quality, and small sample sizes, the results of the meta-analysis did not provide strong evidence of such effectiveness.

• All the RCTs had a high risk of bias.
• Because all the research evaluated was published in China, authors were uncertain of the accuracy of the findings.

Further research is needed to evaluate this nonpharmacologic intervention for relieving cancer pain.

STUDY PURPOSE: To evaluate the efficacy of acupuncture to relieve cancer-related insomnia

TYPE OF STUDY: Systematic review

• FINAL NUMBER STUDIES INCLUDED = 6
• TOTAL PATIENTS INCLUDED IN REVIEW = 475
• SAMPLE RANGE ACROSS STUDIES: 45–120
• KEY SAMPLE CHARACTERISTICS: Adults with various types and in various stages of cancer

PHASE OF CARE: Not specified or not applicable

Two trials compared acupuncture to sham acupuncture in patients with breast cancer: one trial showed positive effects as reported in a sleep diary, and one trial did not show that acupuncture was beneficial as measured by the Pittsburgh Sleep Quality Index (PSQI). Three trials compared acupuncture to sleeping medications: two trials showed improved sleep with acupuncture as measured by PSQI when compared to drugs, and one trial did not show a benefit. One trial that compared acupuncture to hormone therapy in patients with breast cancer showed improved sleep with acupuncture. Overall, the trials had a low risk of bias, except for participant and personnel blinding, because of the nature of acupuncture. Few adverse events were reported with acupuncture but included fatigue, pruritis, and nausea.

Mixed evidence about the effectiveness of acupuncture to relieve cancer-related insomnia compared to medications exists. In the current review, acupuncture may be superior to sham acupuncture, conventional drug therapy, and hormone therapy for the management of cancer-related insomnia. The level of evidence is low because of a limited number of trials and total sample size.

• Limited number of studies included
• Details of acupuncture procedures, such as treatment times, duration of sessions, length of follow-up, and practitioner background, varied between trials or were not reported.  
• Sleep outcomes in all trials were subjective measures.  
• Half the trials were from China, which may limit generalizability to other countries.

Acupuncture has been examined as an intervention to relieve cancer-related insomnia, and a small number of studies show mixed evidence about its effectiveness. Additional trials that report standard acupuncture methodology and use objective sleep outcome measures are needed before nurses can recommend acupuncture as an effective treatment to relieve insomnia.

To describe one institution’s experience with using aprepitant to control chemotherapy-induced nausea and vomiting (CINV) in children with cancer who were receiving highly emetogenic chemotherapy (HEC) or moderately emetogenic chemotherapy (MEC) by conducting a retrospective chart review

This was a retrospective review of charts from Aug 2005 until May 2007 in the authors’ institution. The authors divided children into two groups based on whether they were given two or three antiemetic agents. Children in regimen 1 (n = 20) received 0.15 mg/kg ondansetron three times per day, 0.15 mg/kg (maximum of 20 mg) dexamethasone, and 125 mg aprepitant on day 1 followed by 80 mg aprepitant on days 2 and 3. Children in regimen 2 (n=12) received only ondansetron and aprepitant. Aprepitant was given to 24 out of 32 children whose weight was more than 20 kg at the above mentioned dosing. Children weighing less than 20 kg received 80 mg days 1–3. One child whose weight was less than 15 kg received 80 mg on day 1 and 40 mg on day 2 and 3.

• The study reported on 32 patients aged 18 years or younger at the beginning of chemotherapy treatment.
• The mean age was 10 and the range was 32 months–19 years.
• The sample was 50% male and 50% female.
• All patients had been diagnosed with childhood cancers, including sarcomas, lymphomas, leukemia, and central nervous system (CNS) tumors.

The study was conducted at a single inpatient setting in the United States.

All patients were undergoing the active phase of treatment care.

This was a retrospective chart review.

The authors reported that children younger than 12 years or weighing less than 40 kg received reduced aprepitant doses. However, they did not report how many children fell into this group, only that the mean age was 10.

Based on this report, we know that 19 children in the regimen 1 (dexamethasone,  ondansetron, and aprepitant) group did very well compared to the younger children in the regimen 2 group (ondansetron and aprepitant). In this report, dexamethasone was not reduced as suggested (12 mg on day 1 followed by 8 mg on days 2 and 3).

This retrospective study shows that aprepitant triple therapy, when combined with standard antiemetics, was well-tolerated in pediatric patients (mean age of 10 years) receiving HEC or MEC. Aprepitant was safe and well tolerated in patients age 18 or younger and improves control of CINV in children.

• The sample size was small.
• No comparison or control group was included.
• Applicability and practicality issues exist.
• Using aprepitant in children under 10–12 years of age or under 40 kg is not well established because of the effects P450 enzymes and drug-drug interactions in young children.

Aprepitant in combination with standard antiemetics is well tolerated in children. More prospective studies are needed to identify the most effective way to use aprepitant for children undergoing chemotherapy. Children with cancer who weigh more than 20 kg benefit if aprepitant is given at 125 mg on day 1 and 80 mg on days 2–3. Dexamethesone may need to be adjusted from standard dosing to 12 mg on day 1 and 8 mg on days 2 and 3 because of altered metabolism of corticosteroids by aprepitant’s inhibition of CYP3A4. Pediatric oncology nurses should be knowledgeable in cytochrome P450 enzymes and drug-drug interactions. Future research should focus on using aprepitant in very young children (less than 10 years of age or less than 40 kg weight).

To investigate the efficacy and safety of fentanyl patches for pain relief after endoscopic submucosal dissection

Patients were randomized to a fentanyl patch or placebo control group. Patients in the patch group were instructed in the use of the patch, which they applied the night before the procedure. Pain was assessed immediately before and immediately after the endoscopy. Maximum pain during the 24 hours following the endoscopy was assessed at discharge. All patients received IV propofol and cimetropium bromide during the procedure. Fentanyl patches used were 12 mcg patches.

• The sample was composed of 104 patients.   
• Mean patient age was 62 years.
• Of all patients, 71% were male and 29% were female.
• Patients underwent a diagnostic endoscopy. Approximately two-thirds were diagnosed with dysplasia and one-third had early gastric cancer.

• Single site
• Inpatient
• South Korea

Phase of care: diagnostic

Randomized double-blind placebo-controlled trial

The study used a numeric rating scale to measure pain.

• Prior to the procedure, there were no differences between groups in regard to pain rating.
• Right after the endscopy, average pain rating with placebo was 5.17 and with the fentanyl patch, 4.26 (p = 0.03).
• Maximum pain in the 24 hours after the procedure was slightly lower in those using fentanyl (p = 0.03) than in the placebo group. One day after the procedure, pain was lower in the patch group (1.20) versus those on placebo (2.98) (p < 0.001).
• There were no differences between groups in regard to side effects.

Findings show that fentanyl patches applied prior to endoscopic submucosal dissection are safe and effective in reducing postprocedural pain.

• Authors did not describe unintended interventions or applicable interventions that would have influenced results.
• Authors do not state whether patients on placebo received any medication for pain.

Usual treatment for endoscopy pain can involve frequent injections. Since fentanyl patches can be applied prior to a procedure, they may provide more comfort than injected as-needed pain medications can. This study showed that, compared to placebo, a low-dose fentanyl patch applied prior to endoscopic dissection was effective in reducing pain and was not associated with adverse effects. The approach the study outlines is novel and may be applicable to various groups of patients who could experience acute pain.

To study the effects of thoracic a sympathetic ganglion block (TSGB) in treating breast cancer-related lymphedema

The medical records of patients who received a TSGB were reviewed. Findings were compared between patients who were grouped according to therapeutic efficacy. TSGBs were performed under fluoroscopic guidance. An injection of contrast agent was used to confirm the proper positioning for the injection of lidocaine. Patients had arm circumference measurements and completed the Lymphedema and Breast Cancer Questionnaire two weeks and two months after the TSGB procedure. Arm circumference was measured at the axilla, upper arm, elbow, lower arm, and wrist.

• N = 35  
• MEAN AGE = 55.8 years (SD =1.99 years, range = 38–80 years)
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: All participants received a mastectomy for breast cancer and either axillary lymph node dissection with sentinel a lymph node biopsy or a sentinel lymph node biopsy alone. All participants had unilateral lymphedema.
• OTHER KEY SAMPLE CHARACTERISTICS: The mean onset of lymphedema after surgery was 10.97 months. The mean time from lymphedema onset till the procedure was 23.47 months.

• SITE: Single site  
• SETTING TYPE: Not specified    
• LOCATION: South Korea

• PHASE OF CARE: Late effects and survivorship

Retrospective, descriptive study

• Arm circumference
• Effective TSGB was defined as at least a 50% reduction in arm circumference difference between the affected and unaffected arm.
• Lymphedema was staged from 0–3 according to the observation of physical signs.
• Lymphedema and Breast Cancer Questionnaire (LBCQ)

The most frequent lymphedema severity was stage 2, which involved visible edema, usually with pitting and hardened, thickened skin and tissue (37.5% of cases). Arm circumference measures at all locations decreased significantly at two weeks after the procedure (p < 0.05). There was no significant additional decrease between two weeks and two months after the procedure. Questionnaire results also showed a significant reduction in symptoms at two weeks (p < 0.001) with no additional improvement between two weeks and two months. Overall, 65.7% of participants were deemed to have effective TSGB results. Those with more severe lymphedema tended to have the most improvement.

TSGBs may be a useful option for the management of breast cancer-related arm lymphedema. The mechanism by which this may be effective is unclear, and the duration of any improvement is not yet clear.

• Small sample (< 100)
• Risk of bias (no control group)
• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Measurement/methods not well described
• Measurement validity/reliability questionable

TSGBs may be an alternative option for patients with breast cancer-related arm lymphedema for whom conservative and standard treatments were unsuccessful. Additional research providing sufficient evidence for the effectiveness and identification of patients for whom the intervention is appropriate is needed.

To investigate the effects of the implementation of a central line catheter care bundle on infection rates.

A working group comprised of physicians specializing in pediatric hematology-oncology, infectious diseases, anesthesiology, and surgery, as well as infection-control professionals, a phlebotomy service leader, and several nursing leaders, was formed to focus on improvement in central line-associated blood stream infection (CLABSI) rates. Team members were educated in quality improvement for a four-month period and developed techniques to improve the safety culture, identify best practices for insertion and line maintenance, and disseminate information to clinical care providers. A catheter care bundle was implemented, including proper hand hygiene, dressing change frequency, skin cleansing with chlorhexidine, tubing changes at least every 96 hours, chlorhexidine used for bathing, and standards for central line entry. Pre- and postimplementation data were analyzed at six months from the beginning of the effort and at 17 months.

• One hundred thirty patients were included.
• One hundred two CLABSI events occurred.  
• All participants were pediatric patients with cancer; some had undergone hematopoietic cell transplantation (HCT).

• Single site 
• Inpatient
• Michigan

This was a descriptive observational study.

• Nurse self-report of bundle care compliance
• CLABSI rate (calculated as events by number of patient days)
• Agency for Healthcare Research & Quality (AHRQ) patient safety culture survey
• CLABSI identification according to National Healthcare Safety Network (NHSN) methods

Self-reported adherence to catheter bundle care was more than 90% in most areas.  Lowest compliance areas were bathing practices and “all or none” (compliance with everything) areas in the first six months.  These both improved to more than 85% at 17 months. The preintervention CLABSI rate was 5.55% in patients undergoing bone marrow transplantation (BMT) and 1.81% in non-BMT patients. Postintervention CLABSI rates were 2.96% in BMT patients and 1.04% in non-BMT patients (p < 0.04). Patient safety culture survey results reflected improvement; however, sample sizes were small with low response rates, and comparisons were not statistically significant.

Findings showed that the institutional initiative used here was effective in reducing CLABSI rates.

• Measurement validity/reliability was questionable.
• CLABSI calculation did not use catheter patient days as the denominator, which influenced the results. 
• Self-reported compliance may not be accurate. 
• Specific implementation, dissemination, monitoring, and feedback methods were not described.

Comprehensive institutional initiatives can improve quality of care. Catheter care bundle implementation was effective in reducing overall CLABSI rates as measured here. Results showed that it took time to achieve improvement in compliance with all aspects of catheter care.

To evaluate the efficacy of aprepitant, ramosetron, and dexamethasone 20 mg on chemotherapy-induced nausea and vomiting (CINV) in women with ovarian cancer receiving paclitaxel/carboplatin

On day 1, one hour before chemotherapy, patients received 125 mg oral aprepitant, 0.6 mg IV ramosetron, and 20 mg IV dexamethasone (over 30 minutes). On days 2 and 3, patients received 80 mg aprepitant. Vomiting episodes and use of rescue therapy were recorded for 120 hours after chemotherapy was administered. A daily Visual Analog Scale was completed on the first five mornings after chemotherapy. Rescue medications were permitted throughout the study, and type of medication was at the treating physicians' discretion.

• N = 85  
• MEDIAN AGE = 55 years (range = 28–88 years)
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: Ovarian cancer

• SITE: Single-site    
• SETTING TYPE: Outpatient    
• LOCATION: South Korea

• PHASE OF CARE: Active antitumor treatment

Prospective, nonrandomized trial

• Visual Analog Scale (VAS, 0–100) of nausea
• Number of emetic episodes
• Number of rescue medications
• Complete response (CR, defined as no vomiting or emesis for five days)

98.8% of patients had CR in the acute phase, 89.4% in the delayed phase, and 89.4% overall. Patients over age 55 had a significantly higher rate of CR (97.8%) than those younger than 55 (80%) (p = 0.011). 95.3% of patients experienced no vomiting in the overall phase, and 91.8% took no rescue medications in the overall phase. Overall CR (89.4%) achieved in cycle 1 was maintained in cycles 2–6. Four hundred and sixty cycles were analyzed for adverse events. Results are as follows: ≥ 1 adverse event occurred in 179 (38.9%) cycles, drug-related adverse events occurred in 35 (7.6%) cycles, and serious adverse events occurred in 10 (2.2%) cycles. No patients discontinued therapy due to adverse events.

The combination of aprepitant, ramosetron, and dexamethasone for CINV is highly effective in the acute and delayed phases after chemotherapy administration. CR is achieved by a high number of patients for the six days following chemotherapy.

• Small sample (< 100)
• Risk of bias (no control group)
• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Findings not generalizable
• Other limitations/explanation: All subjects were women with ovarian cancer.

Nurses can educate patients on the available pharmacologic options to control CINV, including the combination of aprepitant, ramosetron, and dexamethasone.

• FINAL NUMBER STUDIES INCLUDED = 9
• TOTAL PATIENTS INCLUDED IN REVIEW = 476 
• SAMPLE RANGE ACROSS STUDIES: 19–127 patients
• KEY SAMPLE CHARACTERISTICS:
  • Comparisons: Honey (manuka honey) vs placebo,  Honey (manuka honey) vs. placebo (sugar-free placebo), Honey (Western Ghats forests) vs. placebo (lignocaine), Honey (Dabur honey) vs. placebo (Tantum), Honey (manuka and kanuka honey) vs. placebo (sterile water) or no gargle, Honey (Egypt honey) vs. placebo (Tantum), Honey (thyme and astragale) vs. placebo (saline), Honey (manuka honey) vs. no gargle, Honey (tea plant) vs. placebo (Tantum)
  • Treatments: Radiotherapy plus chemoradiotherapy, radiotherapy alone, and chemoradiotherapy alone

PHASE OF CARE: Active antitumor treatment 
 
APPLICATIONS: None stated

• The incidence of moderate to severe mucositis was significantly lower in patients receiving honey versus those who received a placebo or no treatment (control group) (p < 0.0001).
• A subanalysis of honey efficacy pertaining to type of regimen demonstrate that honey administration had significantly greater effect in preventing moderate to severe mucositis in patients receiving radiotherapy alone than those receiving chemotherapy (p < 0.0001).
• The onset of mucositis was significantly later in the honey group versus the control group (p = 0.0036).
• The mean mucositis grade for first three weeks of radiotherapy or chemotherapy was significantly lower in the honey group than in the control group (p = 0.0114).

Administration of Honey Versus Control (Mucositis-Related Adverse Effects)

• No statistically significant differences between honey and control groups were found regarding incidences of bacterial or fungal colonization and pain experience (p = 0.3804, p = 0.1831, and p = 0.2903, respectively).
• There was a statistically significant difference for the incidence of weight loss in patients in the honey group versus the placebo group (p < 0.0001).

This study demonstrated the potential efficacy of honey administration in the prevention of oral mucositis and weight loss during radiotherapy and chemotherapy in patients with head and neck cancer. 

• Only two studies that analyzed the incidence of bacterial and fungal colonization were included. 
• Small sample sizes
• Different types of honey and anticancer regimens were used.
• The heterogeneity of the incidence of moderate to severe mucositis in patients receiving chemoradiotherapy could not be decreased in this analysis.

• This study indicated potential prevention interventions for oral mucositis in patients with head and neck cancer.
• Its findings pointed to areas for future nursing research.
• The honey interventions used were low-cost with easy administration and accessibility, which will assist nursing interventions if future studies support their use.   

To examine the incidence and outcomes related to the treatment of invasive fungal infection (IFI) with posaconazole versus fluconazole prophylaxis

Records of patients undergoing remission induction chemotherapy were reviewed for data collection. Results of those who received fluconazole versus posaconazole antifungal prophylaxis were compared. Both agents were begun 1–2 days prior to chemotherapy and continued until the patients' absolute neutrophil count (ANC) was > 500/mm³.

• N = 424
• MEAN AGE = 45.6 years
• MALES: 56.1%, FEMALES: 43%
• CURRENT TREATMENT: Chemotherapy
• KEY DISEASE CHARACTERISTICS: All had either acute myeloid leukemia (AML) or myelodysplastic syndrome

• SITE: Single site
• SETTING TYPE: Not specified
• LOCATION: Korea

• PHASE OF CARE: Active antitumor treatment

• Retrospective cohort comparison

• Neutropenia defined as ANC < 500/mm³ and severe neutropenia as < 100 500/mm³
• IFI categorized according to European Organization for Research and Treatment of Cancer (EORTC) criteria
• Breakthrough IFIs were defined as proven or probable if developed after at least seven days of antifungal prophylaxis.
• Charlson comorbidity index

The incidence of breakthrough IFIs and the use of empirical antifungal treatment were lower in those who received posaconazole (p < 0.001). Overall, IFI-related mortality was 1.9% in the posaconazole group compared to 12.1% in the fluconazole group (p = 0.028). No difference existed between groups in overall survival.

The findings suggest that posaconazole was more effective than early generation azoles for antifungal prophylaxis in at-risk patients with cancer.

• Risk of bias (no blinding)
• Risk of bias (no random assignment) 
• Measurement/methods not well described
• Length of follow-up for data collection was not described.

The findings suggest that newer azoles may be more effective for antifungal prophylaxis in at-risk patients with cancer.

To determine the effect of watching a music relaxation video on pain and anxiety in women diagnosed with gynecological cancer who were undergoing intra-cavitary brachytherapy

A music relaxation video was played four times for a total of 120 minutes during the first 44 hours of brachytherapy treatment, with monitoring of pain scores, opioid consumption, and perceived anxiety scores compared to usual nursing care during the same time period.

• N = 60  
• MEAN AGE = 46 years (range = 23-70 years)
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: Gynecological cancer, cervix, uterus. 
• OTHER KEY SAMPLE CHARACTERISTICS: 51% white women, 67% married, 55% high school as the highest degree

• SITE: Single site    
• SETTING TYPE: Inpatient    
• LOCATION: Academic cancer care center in the southwestern United States

• PHASE OF CARE: Active antitumor treatment

• Randomized, controlled trial

• Pain severity was measured with a visual rating scale
• Opioid consumption was measured with a PCA pump
• Anxiety was measured using the Strat-Trait Anxiety Inventory

Women in the intervention group reported less pain. There was no difference in levels of opioid consumption between the intervention and control groups. Participants in the music viewing group indicated significantly reduced anxiety levels in analysis (p = 0.001).

Nurses and other medical personnel should consider using music relaxation videos to help reduce pain and anxiety during intracavitary brachytherapy and other procedures that may be uncomfortable.  The intervention is non-invasive, with beneficial effects.

• Small sample (less than 100 participants)
• Risk of bias (no appropriate attentional control condition)
• Other limitations/explanation: Baseline pain was higher in the experimental group

This non-invasive intervention could be nurse-driven without a physician’s order.  Women undergoing brachytherapy must lie still in a shielded isolation room for 2-3 days with limitations on visitors, resulting in physical and psychological discomforts, including pain. This study shows that pain experiences may be lessened with music relaxation videos.