To evaluate the analgesic effect of electroacupuncture on pancreatic cancer pain

Patients were treated in a comfortable prone position. Disposable stainless steel filiform needles (40 mm in length and 0.3 mm in diameter) were inserted perpendicularly into the Jiaji points from T8 to T12 bilaterally to a depth of 25 mm. After de-qi sensation was achieved, the handles of the needles were respectively connected to a Han's acupoint nerve stimulator (HANS) at a frequency of 2/100 Hz and a current of 1 mA with a disperse-dense waveform. The needles remained in place for 30 minutes. The treatment was given once a day for three days. Sham acupuncture needles were used as a placebo and were put into the same points in the treatment group without inserting into the skin. The needles were then connected to the electric stimulator but with zero frequency and electric current. All patients were to maintain the same analgesic drug treatment.

• N = 60  
• AGE RANGE = 18–75 years
• MALES: 63.3% treatment arm (66.7% control arm), FEMALES: 36.7% treatment arm (33.3% control arm)
• KEY DISEASE CHARACTERISTICS: Histologically confirmed advanced pancreatic cancer at stages III–IV in the staging system of the Union for International Cancer Control
• OTHER KEY SAMPLE CHARACTERISTICS: Pain intensity of 3–6 on numeric rating scale (0–10), stable dose of analgesics at least 72 hours before randomization, estimated survival time greater than one month, never been treated by acupuncture, no other causes of pain (e.g., rheumatoid arthritis, disc disease), no contraindications for acupuncture (e.g., bleeding risk, infectious dermatosis, ulcer or scar at acupuncture points) or history of cerebrovascular accident (CVA) or spinal cord injury, study completed before treatment for pancreatic cancer

• SITE: Single-site    
• SETTING TYPE: Not specified    
• LOCATION: Fudan University Shanghai Cancer Center (FUSCC)

• PHASE OF CARE: Mutliple phases of care
• APPLICATIONS: Palliative care 

Pain intensity as assessed using a numeric rating scale of 0–10 after subjects were given an explanation of the rating scale. Ratings were done before treatment, after one to three treatments, and at one and two days after the completion of the treatments.

• Numeric rating scale from 0–10
• Analgesic record
• Adverse events

Pain intensity decreased compared with baseline after each of the three treatments in the acupuncture group. There was little change in the level of pain in the control group. The difference between the treatment arm and the control arm was statistically significant after each of the three treatments. Follow-up during the two days after treatment also showed a significant reduction in pain intensity in the treatment arm compared to the control arm. No infections at the treated points were noted during the trial, and there were no adverse events.

Pain intensity significantly decreased compared to baseline in the electroacupuncture group, a result that was significantly different than the result for those in the control arm of the study. There was no significant difference in the level of pain at any of the time points for those in the control arm of the study.

• Small sample (< 100)
• Risk of bias (no blinding)
• Findings not generalizable
• Other limitations/explanation: The study only included mild to moderate levels of pain. Pain was only assessed for two days after the treatment.

Pain is a significant problem for individuals diagnosed with pancreatic cancer. Standard treatment options include opioids, radiotherapy, and celiac plexus neurolysis; however, these are not always effective and may be limited due to their side effects. Nurses need to be aware of potential pain management options for patients with pancreatic cancer-associated pain in order to improve the patients' quality of life.

To assess the value of pharmacist-led teams as a model for improving drug delivery and implementing the role of the clinical pharmacist in direct patient care using cancer pain management as a focus area

Clinical guidance teams included clinical pharmacists, nurses registered in oncology, oncologists, and administrators. Pharmacists had at least two years' residency in the oncology department and underwent training in opioid pharmacotherapeutics, National Comprehensive Cancer Network guidelines, and Chinese practice guidelines, and they had to pass an examination. The pharmacist was responsible for patient and physician education, consulting in complex cases, and monitoring for drug efficacy and side effects. Patients with a history of cancer-related pain were enrolled. Patients were assigned consecutively to the intervention group, in which the guidance team was involved, or the control group, in which no guidance from the cancer pain therapy team was given. Outcomes were evaluated after six months. Patients in the experimental group had follow-up appointments via face to face or telephonic interviews twice a month. Study data were obtained from medical records and follow-ups.

• N = 542  
• AGE = 63.7% aged greater than 60 years
• MALES: 49.3%, FEMALES: 50.7%
• KEY DISEASE CHARACTERISTICS: Disease types were not provided.

• SITE: Multi-site  
• SETTING TYPE: Inpatient    
• LOCATION: China

Cohort design

• Numeric or visual scale for pain (mean value from follow-up scores used in analysis)
• Documentation of adverse effects (yes/no evaluation)
• Quality of life questionnaire (not described)

Compared to the control group, there were more frequent pain severity evaluations before opioid administration, more standardized dose titrations, more sustained-release formulations (p < 0.001), and fewer errors in dose conversion to other opioids (p = 0.017) in the experimental group. Pain scores were lower in the experimental group (p < 0.05), and the incidence of constipation, nausea, and vomiting was lower in the experimental group (p < 0.05).

The implementation of the clinical pharmacist role in guidance teams for cancer-related pain was associated with improvements in the process of medication management and pain scores.

The findings of this study suggested that the intervention of a multidisciplinary team to guide pain management can improve medication management, monitoring, and chronic pain outcomes.

To evaluate the effectiveness of a cryotherapy protocol in patients undergoing hematopoietic cell transplantation (HCT)

Medical records of patients undergoing autologous HCT for multiple myeloma were used to obtain data. All received high-dose melphalan as part of the conditioning regimen. Patients who were treated prior to the implementation of the cryotherapy protocol were compared to those who received cryotherapy in terms of the incidence, severity, and duration of mucositis. Data were collected to also compare the use of parenteral narcotics, use of parenteral nutrition, and hospital stay.

• N = 140
• MEAN AGE = 55 years
• MALES: 44%, FEMALES: 56%
• KEY DISEASE CHARACTERISTICS: All had multiple myeloma and received autologous HCT.

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

• PHASE OF CARE: Active antitumor treatment

• Retrospective cohort comparison

• World Health Organization (WHO) mucositis severity scale

Overall incidence of oral mucositis was 95.7% of those with no cryotherapy compared to 71.4% of those who received cryotherapy (p < 0.001). Median severity without cryotherapy was 2.5 compared to 2 with cryotherapy (p = 0.03). More patients without cryotherapy needed parenteral narcotics for pain control (p = 0.02), and duration of mucositis was about two days less with cryotherapy (p = 0.02). No differences existed in parenteral nutrition use or length of hospital stay.

The use of cryotherapy was associated with lower incidence, severity, and duration of mucositis among patients undergoing HCT receiving high-dose melphalan.

• Risk of bias (no blinding)
• Risk of bias (no random assignment)

Cryotherapy has been shown to be effective in reducing the severity of mucositis in patients receiving chemotherapeutic agents with a short half-life.

To introduce key points relating to lower abdominal flap transplantation with vascularized lymph nodes, and to evaluate the effects of breast restoration or reconstruction and lymphatic transplantation to treat upper-arm lymphedema after breast cancer surgery

Ten patients were recruited with postoperative, breast cancer-related lymphedema. Preoperatively, isotope radiography was used to determine lymphatic return obstruction. Patients were operated on in a standing position. A modified deep inferior epigastric perforator artery (DIEP) or microsurgical transverse abdominal myocutaneous island (TRAM) flap was accompanied by lymphatic tissue. The scar contracture of the axilla was relaxed and patients received abdominal transplantation of the lower abdominal flap with vascularized lymph node. Postoperatively, elastic bandages were applied for one year. Follow-up appointments occurred at one, three, six, and 12 months. The measurement indexes that were used included mid- and upper-arm circumference, clinical symptoms, and lymphoscintigraphy.

• N = 10  
• AGE RANGE = 36–50 years
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: Breast cancer-related lymphedema
• OTHER KEY SAMPLE CHARACTERISTICS: All patients had lymphedema for three to five years.

• SETTING TYPE: Inpatient    
• LOCATION: Beijing, China

Controlled clinical trial

• Isotope radiography
• Multidetector-commuted tomography
• Mid- and upper-arm circumference measurement
• Clinical symptoms
• Lymphoscintigraphy

All of the flaps worked. One patient experienced delayed wound healing. There was no obvious improvement in lymphedema in one patient. Seven patients saw improvements in lymphedema clinical symptoms and mean limb perimeter. One patient recovered. The mean reduction was 2.122 cm (SD = 2.331). Limb volume decrease was statistically significant between preoperative and postoperative measures (p < .05).

Abdominal flap transplantation with vascularized lymph nodes and breast reconstruction, paired with treatment to upper-arm lymphedema and the use of elastic bandages as adjuvant treatment, is effective in restoring breast configuration and function.

• Small sample (< 30)
• Risk of bias (no control group)
• Other limitations/explanation: Inconsistent study results, lack of standardized surgical technique, and short follow-up.

This procedure may be effective for treating some women with breast cancer-related lymphedema, and it can guide future research on effective lymphedema therapy and postoperative monitoring.

To examine the effects of PG2 on fatigue in patients with advanced cancer.

PG2 was extracted from Astragalus membranaceus and is a polysaccharide mixture. It was reconstituted and dissolved in normal saline and mixed into 490 mL of normal saline for infusion. Patients were randomly assigned to the PG2 group or the placebo control group, which received infusions of 500 mL of normal saline. Patients received infusions three times a week for four weeks. After four weeks, all patients received open-label treatment with PG2 for another four weeks. Assessment of the outcomes was conducted at baseline and at the end of the first, second, and fourth week of each study cycle. A fatigue response rate was calculated as the percentage of patients who had at least a 10% improvement in fatigue scores at weeks 4 and 8.

• A total of 58 patients completed the full study; there were 84 patients for safety evaluation.
• Mean age was 60.5 years.
• About 39% of patients were men and 61.5% were women.
• Various tumor types were included, but  breast and head and neck cancers were the most common. Of the patients, 68% had metastatic disease.
• Average baseline Brief Fatigue Inventory (BFI) score was 6.04. 

The study was conducted at multiple settings in Taiwan.

Patients were undergoing the end of life and palliative phases of care.

This was a randomized, double-blind, placebo-controlled trial with an open-label extension.

• BFI, Taiwanese version
• Hematology blood tests

About 72% of the entered patients completed four weeks of the study, and 64.4% completed eight weeks. During the first week, PG2 administration resulted in a significantly greater fatigue response rate (PG2 = 57.14%; placebo = 32.3%; p = 0.043). By weeks 2 to 4, no significant differences were observed between the groups. About 82% of those who responded to PG2 reported a sustained benefit after the subsequent open-label use. For those who initially received placebo, after four weeks of open-label use, the fatigue response rate increased significantly after PG2 administration (57.14% response rate). Adverse events associated with PG2 were rashes (n = 3), eczema (n = 2), and pruritis (n = 2); none of these required medical treatment for resolution. White blood counts and differentials were similar between the groups.

PG2 had a positive effect on fatigue in patients with advanced cancer.

• The study had a small sample size, with less than 100 patients.
• Measurements/methods were not well described.
• Patient withdrawals were 10% or greater.
• The method of evaluating adverse events was not well described; the authors just stated that assessments were performed at each visit. 
• The study had a substantial drop-out rate. A few of these were from death with advanced disease; however, 4.4 % withdrew consent and 8.9% had protocol violations in the first cycle.

PG2 appeared to have potential benefit in reducing fatigue among patients with advanced cancer and may provide effective palliation of this symptom. Additional research is warranted to further evaluate efficacy and adverse events.

To evaluate whether patients with breast cancer undergoing radiotherapy (RT) who practiced qigong would report better quality of life, less fatigue, and less sleep disturbance than did patients in a control group.

Patients were randomly assigned to a group that received a qigong intervention or to a wait-list control group. Patients were assigned to cohorts to prevent group contamination during the study. Each week, the qigong group participated in five classes lasting 40 minutes each during RT. These patients received printed materials and a DVD of the qigong program. Patients were encouraged to practice qigong techniques on their own. The intervention included relaxation breathing, meditation, walking in a circle while breathing in sync with arm movement, and self-massage. The control group received standard care. Assessments were performed at baseline, in the middle of the RT schedule, during the last week of RT, and at one and three months after treatment.

• The sample was comprised of 95 participants (100% female).
• Mean age was 45 years (range 25–62).
• All participants had breast cancer.
• Most participants had stage II or stage III disease.
• All participants had undergone mastectomy or lumpectomy.
• Of the participants in both groups, 78% were receiving 25 RT fractions.
• Most participants were married, and 52.5% had some college or higher education.

• Single site
• Multiple settings
• China and the United States

Participants were undergoing the active antitumor treatment phase of care.

The study was a randomized, controlled trial.

• Brief Fatigue Inventory (BFI)
• Center for Epidemiologic Studies Depression (CESD) Scale 
• Pittsburgh Sleep Quality Index (PSQI)
• Functional Assessment of Cancer Therapy-General (FACT-G)
• Salivary cortisol samples taken for two consecutive days at waking, 45 minutes after waking, 45 minutes later, eight hours later, and at bedtime

• Time had a significant effect in reducing depression, with a significantly greater effect in the qigong group (p = 0.05); however, no significant differences were observed between groups at any time point.
• Participants with low measures of depression symptoms at baseline showed no significant differences in fatigue, regardless of group. At the end of the study, of participants who had had high measures of depression symptoms at baseline, those in the qigong group had measures of fatigue that were significantly lower (p < 0.05; 2.93 versus 4.19) than those in the control group.
• No differences were observed between groups in sleep quality, and there was no interaction of depression symptoms with sleep measures.
• One-third of participants attended 100% of the sessions and 78.3% attended more than 50% of the sessions. Attendance ranged from five to 30 sessions.
• Sessions involved one to 10 people at a time.
• No differences were observed between groups in regard to cortisol measures.

Practicing qigong appears to be beneficial in reducing fatigue and depression during RT and appears to be of most benefit to women with high measures of depression symptoms.

• The study had a small sample size, with less than 100 participants.
• The study had risks of bias due to no blinding and no appropriate attentional control condition.
• Adherence varied. No information was provided regarding participants' qigong practice outside the treatment group.
• The study was inconclusive in regard to the effectiveness of qigong itself versus the potential effect of the group activity involved in the qigong intervention.
• Follow-up time was limited.

Qigong, a type of mind-body discipline, appears to have benefit in reducing fatigue and depression over time, particularly among women who have high measures of depression symptoms. Effects were not seen until after RT completion.

To determine the effect and influence of Chinese medicine (CM) treatment on the quality of life (QOL) of patients with opioid-induced constipation, and to determine any changes in analgesic effect

All patients were treated for 14 days. The control group received 100–200 mg tabs of oral phenolphthalein three times per day with the dose adjusted based on patient condition. The study group received a CM combination consisting of Xiaochengqi decoction (a purgative) and Zengye decoction (also a purgative but less effective). The decoction consisted of several types of plants. The basic formulation was adjusted for one of the four potential syndromes that affected patients.

• N = 406  
• AGE = CM 60.66 years (SD = 11.61 years), control 59.32 years (SD = 11.09 years)
• MALES: 56%, FEMALES: 44%
• KEY DISEASE CHARACTERISTICS: Patients with cancer pain, who were over 18 years old, who had constipation, who were using ≥ 80 mg controlled release oxycodone per day, who had signed informed consent, and who were able to communicate well
• OTHER KEY SAMPLE CHARACTERISTICS: No gastrointestinal disorders, acute intestinal obstruction, allergies to study agents, or women who were pregnant or lactating

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

• PHASE OF CARE: Late effects and survivorship
• APPLICATIONS: Palliative care 

Randomized, controlled trials at multiple centers

• Cleveland Constipation Score (CCS)
• The Chinese version of the European Organization for Research and Treatment of Cancer's Quality of Life Questionnaire (EORTC QLQ-C30) version 3
• Numerical pain rating scale
• National Cancer Institute's Common Terminology Criteria for Adverse Events (NCI-CTCAE) version 3

Both study groups had reduced CCS scores after treatment compared to baseline. CCS scores changed more in the CM group than the control group (93.5% versus 86.4%, p < .05). The CM group had better QOL scores in eight variables including constipation, nausea, and vomiting. Pain management was not affected in either group. Side effects included diarrhea, nausea, and abdominal pain.

Analgesia was not affected in this study. CM was effective in managing constipation in patients receiving opioids. The CM group had a 93.5% efficacy rate and the control group had a 86.4% efficacy rate. QOL was improved and side effects were mild.

• Risk of bias (no blinding)
• Findings not generalizable
• Intervention expensive, impractical, or training needs
• Other limitations/explanation: The study medications used in the intervention arm are not readily available. This lack of availability limits the generalizability of the intervention. Because it is not a readily available product and requires adjustments in formulation based on the assessment of the patient, its use requires special training.

The CM intervention was more effective in the management of constipation than the control medication, oral phenolphthalein.

To evaluate the effect of 15 minutes of music on anxiety prior to receiving radiation therapy

Participants were randomly assigned to control or music group. Both took pretests using the State-Trait Anxiety Inventory and filled out demographic questionnaires, and vital signs were obtained. The intervention group received 15 minutes of self-selected music with similar tempo from a provided list. Patients were able to select which day they received intervention, select music that was paced at 60-80 beats/min. Postintervention data were obtained from both groups.

• N = 200  
• MEAN AGE =  55.06 (SD = 13.5); 55.66 (SD = 11.41)
• MALES: 64%; 57%, FEMALES: 36%; 43%
• KEY DISEASE CHARACTERISTICS: Head and neck, gynecologic, breast, digestive tract, lung, and prostate cancers
• OTHER KEY SAMPLE CHARACTERISTICS: Literate, all tumor stages, patients blinded to assignment

• SITE: Single site  
• SETTING TYPE: Outpatient  
• LOCATION: Far Eastern Memorial Hospital, Taipei, Taiwan

• PHASE OF CARE: Active antitumor treatment

• Single blind RCT

• State-Trait Anxiety Inventory (STAI)
• Personal demographics
• Vital signs

STAI scores decreased significantly in both groups, but decreased more in intervention group and was statistically significantly lower in the intervention group (decline of 7.19 with intervention, 1.04 decline in control; p < .001). Both groups had significant decrease in heart rate and resting rate (pre- and postintervention). Music group had statistically significant difference in mean change of systolic blood pressure.

Anxiety levels and systolic blood pressure may decrease when music therapy intervention is provided before radiation therapy treatment.

• Risk of bias (no blinding)
• Risk of bias (no appropriate attentional control condition)  
• Risk of bias (sample characteristics)
• Findings not generalizable
• Other limitations/explanation: Cancer types and stages were varied. Music was organized randomly without any rationale except for constant tempo, and researchers allowed participants to choose their own music. Random assignment was simple random sampling.

A choice of music therapy provided at radiation treatment centers may help to reduce anxiety that is caused by treatment and provide a way for the patient to relax at the treatment center and at home.

TOTAL REFERENCES RETRIEVED: 1,030 references were retrieved.

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Use the CLEAR = NPT quality checklist. Most studies did not provide the information needed for quality assessment. Sixteen studies had good quality, and 17 had moderate or acceptable quality.

• FINAL NUMBER STUDIES INCLUDED = 40; 36 in meta analysis
• SAMPLE RANGE ACROSS STUDIES: 18–207
• KEY SAMPLE CHARACTERISTICS: Only 3 studies included were done with patients with cancer. Several studies were done with healthy subjects and college students.

PHASE OF CARE: Not provided

Interventions incorporating meditative practices have overall positive effects on mood.

Very few studies included patients with cancer, and the review incorporated findings from normal health controls as well as individuals with various acute and chronic diseases. All types of practices including imagery and those involving movement were considered together. Although there are certainly some similarities in the mental components of many of these practices, it is unclear that they would be routinely viewed as the same. Many studies also included counseling, education, and psychoeducational types of components, which can be expected to confound results.

Findings suggest that in the general population and patients with various types of chronic disease, interventions that involve incorporation of mindfulness and meditative types of practice may be beneficial in reducing anxiety. The application specifically forcancer care is difficult to determine because there were so few studies involving patients with cancer. Nurses can expect that some patients may benefit from meditative practices, and these approaches may be more acceptable to some ethnic groups.

To determine the effectiveness of a 12-week, home-based walking exercise program in managing anxiety, depression, and the severity of cancer-related symptoms while investigating the psychological effects of home-based walking exercises on patients with lung cancer

116 patients were randomly assigned to the walking-exercise group (58) or the usual-care group (58). The exercise program consisted of a 12-week, home-based, moderate-intensity walking exercise of 40 minutes per session with three sessions per week and weekly exercise counseling. Patients were given a booklet and instructions on the mode intensity and frequency of exercise, pulse rate measurement, Borg’s rating of perceived exertion scale (RPE), prevention of sports injuries, and the time point of terminating the exercise. The participant was to achieve a target heart rate of 50%–80% based on the Korvonen method and a score of 13–15 on the RPE scale. Measurements were recorded at three time points: baseline, three months, and six months.

• N = 116  
• AGE RANGE = 37–88 years
• MALES: 54, FEMALES: 62
• KEY DISEASE CHARACTERISTICS: Primary lung cancer
• OTHER KEY SAMPLE CHARACTERISTICS: Excluded if patient participated in regular exercise or received cognitive behavior therapy in the past six months

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

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

Parallel, randomized, controlled, single-center trial

• Hospital Anxiety and Depression Scale (HADS)
• Taiwanese MD Anderson Symptom Inventory (MDASI)
• Statistical analysis: Intention-to-treat (ITT) approach

There were no statistically significant differences in the baseline demographic data, disease characteristics, or baseline physical activity between the two groups. 44.8% of the exercise group completed the intervention. The exercise adherence rate was 59.7%. No exercise-related adverse effects were observed during the study period. The mean anxiety score of the walking exercise group declined by 1.04 points between baseline and the six-month completion. This was not statistically significant. The mean anxiety score of the usual care group at the third month increased significantly (mean difference = 1.72, P = 0.012) and remained stable until the sixth month. The anxiety scores of the walking exercise group declined by 0.63 points at the third month and by 1.03 points at the sixth month. A significant interaction term of the model at the third month and sixth month verified that the walking exercise reduced anxiety over time. The mean depression scores of the walking exercise group gradually declined, but there was no statistical significance. The mean depression scores for the usual care group significantly increased by the sixth month (mean difference = 1.35, P = 0.071). Participants engaging in walking exhibited additional reductions in depression over time. The mean symptom scores of the walking exercise group declined from baseline to the third month and remained stable. The mean symptom scores of the usual care group remained unchanged from baseline. A marginally significant difference between both groups was seen at the third month (1.50 versus 2.08, P = 0.053).

The authors concluded that the walking exercise program effectively reduced anxiety and depression over time. The benefits of exercise demonstrated in other cancer populations applied to patients with lung cancer as well. No substantial reduction was observed regarding the effect of the exercise program on symptom relief. However, the symptom scores of the exercise group were marginally lower over time. Adherence and dropout rates suggested that regular follow-up calls and encouragement to continue exercise would be beneficial.

• Risk of bias (no blinding)
• Unintended interventions or applicable interventions not described that would influence results 
• Selective outcomes reporting 
• Measurement validity/reliability questionable
• Other limitations/explanation: Generalized symptom improvements in a large subset of symptoms (i.e., pain, fatigue, nausea, sleep disturbance, sadness, shortness of breath, difficulty remembering, poor appetite, drowsiness, dry mouth, distress, vomiting, numbness) instead of measuring the outcomes of a targeted symptom

Exercise is a valuable intervention for anxiety and depression in patients with cancer. Nurses should consider education and training for patients to establish regular exercise programs as a supportive care intervention.