Feasibility of EASE: a psychosocial program to improve symptom management in head and neck cancer patients

Purpose

Head and neck cancer (HNC) patients experience multiple physical and psychosocial symptoms associated with their cancer treatment. The Easing and Alleviating Symptoms during Treatment (EASE) study utilized a mixed methods design to examine the feasibility of a tailored telephone-based coping and stress management intervention to improve symptom management and psychosocial care among HNC patients.

Methods

An Embedded Correlational Mixed Methods Design was utilized to answer two research questions: (1) is the EASE intervention feasible? and (2) Did EASE participants report improvements in psychosocial outcomes after completion of the EASE intervention? HNC patients were assessed at baseline and 3?months. Psychosocial measures included cancer-specific distress, pain, social support, and quality of life. Project records and exit interviews were conducted to assess acceptability and satisfaction with the intervention.

Results

The mean age of the participants was 60?years (SD?=?9.5), 76?% were male, 47?% married/partnered, and 57?% had a history of tobacco use. Of the 24 participants who were enrolled, 16 completed the intervention. Participants and telephone counselors reported high levels of satisfaction. Although the small sample size and lack of a control group limit our ability to assess the efficacy of the intervention, our findings suggest that the intervention helped to buffer the negative emotional and physical impact of cancer treatment.

Conclusions

This pilot study demonstrated that the EASE intervention is feasible and acceptable to HNC cancer patients undergoing treatment. The study findings revealed some challenges of implementing a psychosocial intervention in HNC patients and inform future intervention studies with this population.     

Topische Schmerztherapie bei oraler Mukositis

Background

The pain provoked by mucositis is often described as the most excruciating symptom of cancer treatment. It often causes reduced ingestion, malnutrition, and sometimes postponement or withdrawal of the therapy. For health care providers, adequate pain treatment is a major challenge. The aim of this article is to present an overview of studies on the topical treatment of mucositis pain.

Methods

A systematic search was performed in PubMed with the keywords “mucositis” “pain” and “topical” or “local”. In addition, reference lists and relevant websites were scanned for appropriate literature.

Results

A total of 47 articles were included. There is only scarce evidence for the topical treatment of mucositis pain. The most convincing studies tested opioids, corticoids and benzydamine. For the other substances, too few studies were performed, the results were contradictory, or the study quality was low.

Conclusion

Based on the information gathered in this systematic search of the literature, topical treatment of mucositis pain today is based on empiricism and not on scientific evidence.     

Schmerztherapie in der Onkologie

Background

Pain is one of the most prevalent and distressing symptoms of patients suffering from cancer. In the field of oncology comprehensive expertise is pursued not only with respect to the administration of anticancer treatment but to all fields that relate to the needs of cancer patients. However, the results of studies have revealed persisting and relevant deficits in pain therapy in the setting of oncology.

Materials and methods

An online survey was performed involving all members of the German Society for Hematology and Medical Oncology (DGHO) with respect to training and continuing education in pain therapy, the relevance for routine oncology and knowledge, to determine the level of expertise in pain therapy and the assessment of tumor-specific therapy.

Results

A total of 183 out of 1,962 questionnaires could be evaluated. Oncologists are often engaged in pain therapy and 80?% of the respondents perceived themselves as being primarily responsible for pain control. Education and assessment were identified as barriers to sufficient pain therapy. Case vignettes revealed only few relevant therapeutic misinterpretations.

Conclusion

This first survey of German oncologists exploring expertise in cancer pain therapy, showed similar problems in education and pain assessment as previous international studies. Despite the claimed responsibility for pain management, there were a small but relevant number of oncologists who showed serious therapeutic misinterpretations in case studies.     

Quality of life and symptoms in patients with malignant diseases admitted to a comprehensive cancer centre

Purpose

Quality of life and symptomatology in patients with malignancies admitted to comprehensive cancer centres are rarely investigated. Thus, this study aimed to investigate symptomatology and health-related quality of life of inpatients with cancer.

Methods

A prospective, cross-sectional study was carried out on two occasions 5 weeks apart in haematology and oncology departments at a comprehensive cancer centre. Assessment included demographic data, WHO performance status (PS), EORTC QLQ-C30 and pain scales of brief pain inventory. Comparisons were analysed using Wilcoxon two-sample test, rank tests and Fisher’s exact test.

Results

One hundred twenty-four patients were analysed, mean age?=?59 years (SD?=?13.7), 42 % admitted to haematological department; lung cancer was the most frequent diagnosis (15 %). Low health-related quality of life and severe symptom burden, especially fatigue and appetite loss, were observed among the inpatients. In addition, role and social functions appeared to be more impaired in haematology patients than in those admitted to oncology (P?=?0.0372 and 0.0167, respectively). On the other hand, pain and constipation were more severely affected in oncology patients (P?=?0.0194 and 0.0064, respectively).

Conclusions

Patients in the wards of haematology and oncology had pronounced symptomatology and low quality of life. A more systematic focus on the amelioration of problems with functioning and symptoms among inpatients with malignant diseases is warranted.     

Bedeutung der gesundheitsbezogenen Lebensqualität und Religiosität für die Akzeptanz von chronischen Schmerzen

Background

Modern medical analgesia is based on a bio-psycho-social model of disease. From this bio-psycho-social perspective it seems essential to include religiosity in the multidimensional and interdisciplinary assessment of pain patients.

Material and methods

A total of 450 consecutively referred in- and outpatients to a neurological department completed an epidemiologic pain questionnaire. This patient self-administered questionnaire included diagnostic screening tests for anxiety and depression, a generic health-related quality of life measure and sociodemographic questions. Pain severity grades and pain chronicity stages were measured. The acceptance of chronic pain was assessed with the chronic pain acceptance questionnaire. The significance of religiosity was measured employing the structure of religiosity test.

Results

Of the neurological patients 82% complained of having had pain within the past 3 months and 79% within the last 12 months. Patients who accepted the pain and pursued their daily activities despite the pain were less depressive and anxious and showed an enhanced health-related quality of life. The importance of religion to the pain patients was associated with a higher level of pain tolerance.

Conclusions

This study proved that the significance of religiosity to the patient is related to psychic distress and health-related quality of life and at the same time may play an important role in the bio-psycho-social pain concept.     

Messung von Behandlungserfolg bei chronischen Rückenschmerzen

Background

The multimodal therapy has proved to be useful for the treatment of patients with chronic back pain. The aim of this methodical study was to test whether specific effects for the individual can be inferred from general effects of the entire sample, in order to define criteria for the success of treatment. These could be helpful when deciding to which patients the multimodal therapy can best be applied.

Patients and methods

A total of 408 patients with chronic back pain took part in a 3-week multimodal therapy program in a day hospital. The patients were questioned regarding parameters such as pain intensity, depression, functional back capacity and quality of life before therapy as well as 6 months after therapy.

Results

On average, a significant improvement of all parameters could be shown after 6 months. However, scatterplots and correlations showed that general results of the entire sample should not be transferred to the individual patient

Conclusion

Taking into account principles of classical test theory this study showed that sufficient systematic coherence of the data must be proven before changes can be calculated. As long as neither an adequate systematic nor useful criteria can be found, there seems to be no reason to exclude any patient from multimodal therapy using pre-selection criteria.     

Subjektive Belastung und Religiosität bei chronischen Schmerzen und Brustkrebs

Background

Studies show that especially ill people turn to their religious faith to find help in dealing with their diseases. However, religiousness is assumed to vary in its extent and effect depending on different kinds of strain.

Material and methods

In order to differentiate patterns of strain and coping, a sample of 178 patients with chronic pain was compared with 167 breast cancer patients.

Results

Pain patients show higher strain and impairment on almost all variables. Regression analyses indicate that patients with chronic pain are less religious in comparison to the breast cancer patients.

Conclusions

Different values of the religious variables can be explained by different characteristics of the strain: Due to the threat to life experienced by the patients, the breast cancer group is more likely to turn to religiousness for help. Specific characteristics of chronic pain (e.g. longer illness duration, a stronger impairment in everyday activities) lead to higher resignation, also concerning religious efforts.     

Manuelle Triggerpunktbehandlung gegen Kopfschmerzen

Background

Tension type headache (TTH) is a common health problem and elicits a considerable socio-economic burden. It has been shown that patients with TTH have more myofascial trigger points (mTrP) in the neck and shoulder region.

Aim

Primary studies were investigated with respect to the effectiveness of manual mTrP treatment of TTH.

Material and methods

A systematic literature review was undertaken in Medline, AMED, Cochrane, CINAHL, PEDro and Academic Journal Databases. A total of five studies fulfilled the inclusion criteria and were analyzed according to the methodological quality. Studies with homogeneous data were pooled for a meta-analysis.

Results

The meta-analysis revealed a small treatment effect of manual mTrP therapy in the neck and shoulder region in comparison to placebo or no therapy for pain intensity. There were either insufficient or methodologically reduced evidence for other pain outcomes.     

Schmerz und Lebensqualität nach Nephrektomie bei Lebendspendern

Background

This survey focusesed on chronic postoperative pain and impairment of quality of life after living donor nephrectomy.

Methods

Out of a total of 82 donors 58 (71%) were examined using the Chronic Pain Grade (CPG) by von Korff and Short-Form 12 (SF-12).

Results

Of the donors 34% suffered from chronic postoperative pain 22 months (range 9-57 months) after nephrectomy and in 55% of these cases the pain interfered with daily life activities. The quality of life was almost comparable with those of the average German population, but was reduced by chronic postoperative pain particularly with respect to the mental state.

Conclusion

Measures have to be taken to prevent chronic postoperative pain and donors should be encouraged to express their pain to ensure an adequate pain therapy.     

Manuelle Medizin in der Behandlung chronischer Schmerzsyndrome

Objectives. The influence of an in-patient manual medical concept for patients suffering from chronic muscular skeletal pain syndromes on the quality of life and on target parameters of a biopsychological and social concept of pain (VAS, PDI, CES-D) was investigated. Methods. A total of 160 patients at the Clinic for Manual Medicine were included in the study.Selected parameters such as pain intensity (VAS), pain distribution (MASK), disability in daily life (PDI), quality of life (SF-36) and grade of depression (CES-D) were evaluated over a 2-year period.The patients were divided into groups according to the Mainz Pain Stages. Results. The patients were well distributed within the Mainz Pain Stages. It was shown that the manual therapy concept influenced different parameters dependent on the Mainz Pain Stages.For stages 1 and 2 the reduction in pain intensity was greatest while for stage 3 the reduction in disability (PDI) was the most significant outcome.After 2 years there was still evidence ofreduction of pain intensity. Conclusions. The therapeutic target should depend on the chronicity of the pain syndrome. Interdisciplinary intervention after approximately 1 year might be necessary to minimise chronicity.     

Ambulante Opiattherapie bei Tumorpatienten in den letzten Lebenstagen

Background

Pain is one of the symptoms that many tumor patients are especially afraid of in the final phase of their illness. Symptoms can change rapidly, making quick adaptation of the therapy necessary. This poses particular challenges to organizational structures in outpatient treatment if the patients’ desire to spend their last days of life in their accustomed surroundings is to be realized.

Methods

Pain intensity and the associated symptoms in a WHO step III opiate therapy during the last 3 days of life were investigated retrospectively among 601 tumor patients who had received medical care from Home Care Berlin. Differences in gender, age, living conditions/care situation and place of death were evaluated with due consideration for the different pain medications administered and for the different forms and routes of administration.

Results

More than 80% of the patients reported freedom from pain or only moderate pain during the opiate therapy. Care provided by the hospice-at-home medical service Home Care Berlin allowed excellent control of tumor patients’ symptoms with only moderate side-effects in their final days of life. Among patients receiving opioids by the transdermal route there were significantly more frequent complaints of pain (p=0.004) and nausea (p=0.001). During the last days of life continuous subcutaneous infusions containing opiates facilitated good analgesia within an acceptable spectrum of side-effects. Most problems with controlling symptoms in outpatients were encountered in younger patients.

Conclusion

Morphine emerged as the drug of first choice in this investigation, because it can be given parenterally and also because of its price. The use of subcutaneous and intravenous administration systems such as PCA pumps requires trained nursing services and regular house visits by physicians experienced in palliative medicine.     

Swallowing dysfunction in cancer patients

Purpose

Dysphagia (swallowing dysfunction) is a debilitating, depressing, and potentially life-threatening complication in cancer patients that is likely underreported. The present paper is aimed to review relevant dysphagia literature between 1990 and 2010 with a focus on assessment tools, prevalence, complications, and impact on quality of life in patients with a variety of different cancers, particularly in those treated with curative chemoradiation for head and neck cancer.

Methods

The literature search was limited to the English language and included both MEDLINE/PubMed and EMBASE. The search focused on papers reporting dysphagia as a side effect of cancer and cancer therapy. We identified relevant literature through the primary literature search and by articles identified in references.

Results

A wide range of assessment tools for dysphagia was identified. Dysphagia is related to a number of factors such as direct impact of the tumor, cancer resection, chemotherapy, and radiotherapy and to newer therapies such as epidermal growth factor receptor inhibitors. Concomitant oral complications such as xerostomia may exacerbate subjective dysphagia. Most literature focuses on head and neck cancer, but dysphagia is also common in other types of cancer.

Conclusions

Swallowing impairment is a clinically relevant acute and long-term complication in patients with a wide variety of cancers. More prospective studies on the course of dysphagia and impact on quality of life from baseline to long-term follow-up after various treatment modalities, including targeted therapies, are needed.     

Does a regional comprehensive palliative care program improve pain in outpatient cancer patients?

Context

Pain is still a major problem for cancer patients, and the effect of a population-based approach on patients’ experience of pain is not fully understood.

Aims

The primary aim of this study was to clarify the changes in pain intensity in outpatients before and after a regional palliative care program. The secondary aim was to clarify the prevalence of patients who had unmet needs for pain treatment and to clarify the reasons for not wanting pain treatment.

Subjects and methods

A regional palliative care program was implemented in four regions of Japan. A region-representative sample of metastatic/locally advanced cancer patients in outpatient settings took part in questionnaire surveys before and after the regional intervention. Responses were obtained from 859 from 1,880 and 857 from 2,123 in the preintervention and postintervention surveys, respectively.

Results

After a regional palliative care program, neither worst, average, nor least pain levels in outpatients changed significantly. A total of 134 patients (16 %) reported that they needed more pain treatment. There were various reasons for not wanting pain treatment, namely, minimum interference with daily life, general nonpreference for medicines, longstanding symptoms before the diagnosis of cancer, concerns about tolerance and addiction, and experienced neuropsychiatric symptoms under current medications.

Conclusion

The regional palliative care program failed to demonstrate improvement of the pain intensity of cancer outpatients. One possible interpretation is that they are less likely to be regarded as target populations and that the study population experienced generally well-controlled pain. Future study including patients with more severe pain is needed, but to improve pain levels of cancer outpatients, intensive, patient-directed intervention seems to be more promising than region-based intervention.     

A systematic review of salivary gland hypofunction and xerostomia induced by cancer therapies: prevalence, severity and impact on quality of life

Purpose

This systematic review aimed to assess the literature for prevalence, severity, and impact on quality of life of salivary gland hypofunction and xerostomia induced by cancer therapies.

Methods

The electronic databases of MEDLINE/PubMed and EMBASE were searched for articles published in English since the 1989 NIH Development Consensus Conference on the Oral Complications of Cancer Therapies until 2008 inclusive. Two independent reviewers extracted information regarding study design, study population, interventions, outcome measures, results and conclusions for each article.

Results

The inclusion criteria were met by 184 articles covering salivary gland hypofunction and xerostomia induced by conventional, 3D conformal radiotherapy or intensity-modulated radiotherapy in head and neck cancer patients, cancer chemotherapy, total body irradiation/hematopoietic stem cell transplantation, radioactive iodine treatment, and immunotherapy.

Conclusions

Salivary gland hypofunction and xerostomia are induced by radiotherapy in the head and neck region depending on the cumulative radiation dose to the gland tissue. Treatment focus should be on optimized/new approaches to further reduce the dose to the parotids, and particularly submandibular and minor salivary glands, as these glands are major contributors to moistening of oral tissues. Other cancer treatments also induce salivary gland hypofunction, although to a lesser severity, and in the case of chemotherapy and immunotherapy, the adverse effect is temporary. Fields of sparse literature included pediatric cancer populations, cancer chemotherapy, radioactive iodine treatment, total body irradiation/hematopoietic stem cell transplantation, and immunotherapy.     

Predictors of high score patient-reported barriers to controlling cancer pain: a preliminary report

Purpose

Pain is one of the most common and devastating symptoms in cancer patients, and misunderstandings on the patient’s part can cause major obstacles in pain management.

Method

We evaluated factors associated with patient’s high barrier score to managing cancer-associated pain by having 201 patients complete the Korean Barriers Questionnaire II, the Brief Pain Inventory—Korean, the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30, and the Korean Beck Depression Inventory. The Pain Management Index (PMI) was also assessed.

Results

The patients were from nine oncology clinics in university hospitals and a veterans’ hospital in South Korea. The median pain score (0–10 scale) was 4, with a median percentage of pain improvement during the last 24 h of 70 %. A total of 150 patients (75 %) received strong opioids, and 177 (88 %) achieved adequate analgesia (positive PMI). Mean scores ± SD for the Barriers Questionnaire II ranged from 1.5 ± 1 to 2.8 ± 1.1, with the harmful effects subscale the highest. In the multiple regression model, depression was significantly associated with total barrier score to pain management (p < 0.0001). Pain reduction was significantly associated with the fatalism subscale.

Conclusions

Depression was associated with high barrier score in patients with cancer pain. Management of cancer pain should include screening for depression, and management of depression could reduce patient-reported barriers to pain management.     

Pain and health-related quality of life in patients with advanced solid tumours and bone metastases: integrated results from three randomized, double-blind studies of denosumab and zoledronic acid

Purpose

This analysis evaluated patient-reported outcomes and analgesic use in patients with bone metastases from solid tumours across three comparative studies of denosumab and zoledronic acid.

Methods

Pooled data were analysed from three identically designed double-blind phase III studies comparing subcutaneous denosumab 120 mg with intravenous zoledronic acid 4 mg monthly in patients with bone metastases from breast cancer (n?=?2,046), castration-resistant prostate cancer (n?=?1,901) or other solid tumours (n?=?1,597). Pain severity, pain interference, health-related quality of life and analgesic use were quantified.

Results

At baseline, approximately half of patients had no/mild pain (53 % [1,386/2,620] denosumab; 50 % [1,297/2,578] zoledronic acid). Denosumab delayed onset of moderate/severe pain by 1.8 months (median, 6.5 vs 4.7 months; hazard ratio, 0.83; 95 % CI, 0.76–0.92; p?<?0.001; 17 % risk reduction) and clinically meaningful increases in overall pain interference by 2.6 months (median, 10.3 vs 7.7 months; hazard ratio, 0.83; 95 % CI, 0.75–0.92; p?<?0.001; 17 % risk reduction) compared with zoledronic acid. Strong opioid use and worsening of health-related quality of life were less common with denosumab.

Conclusions

Across three large studies of patients with advanced solid tumours and bone metastases, denosumab prevented progression of pain severity and pain interference more effectively than zoledronic acid.     

Strength of skeletal muscle and quality of life in patients suffering from “typical male” carcinomas

Aim

This pilot study aimed to compare muscle strength and quality of life (QOL) in cancer patients suffering from two different “typical male” cancer entities (prostate cancer and head and neck cancer).

Methods

The Biodex System 3 device was used for isokinetic strength testing of thigh muscles in both groups. QOL was evaluated by using the SF-36 Health Survey.

Results and discussion

Surprisingly, prostate cancer patients showed significantly higher values for muscular strength of thigh muscles than significant younger patients with head and neck cancer. Furthermore, prostate cancer patients revealed significantly better values in QOL subscales “bodily pain” and “physical functioning”.     

Nichtmedikament?se Ma?nahmen in der Schmerztherapie

Background

The application of non-pharmacologic therapy (NPT) within pain therapy increases patient satisfaction and is, in addition to pharmacologic methods, recommended in the National Expert Standard on Pain Management in Nursing of the German Network of Quality Development in Nursing. If and to what extent non-pharmacologic methods are applied within pain therapy in German hospitals has as yet been unknown.

Materials and methods

Within the project ??Pain-Free Hospital?? 2,840?nurses in 25?hospitals were interviewed via questionnaire forms and oral interviews about the use of NPT.

Results

Of the nurses 80% confirmed the use of NPT. The majority of the interviewed nurses applied superficial cold, bedding and heat for pain relief. We identified barriers to the implementation of NPT, such as the scarce knowledge of nurses about these therapeutic areas and the uncertainty whether NPT needs to be described by doctors or not.

Conclusion

Some of the NPTs are well established in hospitals. For nationwide use of NPT their systematic training and implementation is necessary.     

Rest/activity rhythm is related to the coexistence of pain and sleep disturbance among advanced cancer patients with pain

Purpose

This study aimed to explore the relationships among pain, sleep disturbance, and circadian rhythms in advanced cancer patients.

Methods

This cross-sectional study was conducted in 68 cancer patients from the oncology inpatient unit of a teaching hospital. Their demographic and medical characteristics, questionnaire surveys, including Brief Pain Inventory-Chinese version and Pittsburgh Sleep Quality Index Taiwanese version, and sleep logs and actigraphic recordings in consecutive 3 days and nights were collected and analyzed.

Results

The mean (SD) scores for autocorrelation coefficient at 24 h (r24) and dichotomy index (I<O) were 0.19 (0.16) and 85.29 % (0.13 %), respectively, indicating dampened circadian rhythms in participants. The mean (SD) worst pain score was 5.47 (2.70). The sleep quality global score ranged 4?～?19 with a mean (SD) of 11.19 (4.05). The worst pain levels, the Pittsburgh Sleep Quality Index (PSQI) global score, and most sleep parameters measured by actigraphy were significantly correlated with r24 and I<O. The worst pain score was significantly correlated with the PSQI global score (r?=?0.69, p?<?0.01). The Goodman version of the Sobel test further demonstrated that 45.77 % of the total effect was mediated by pain intensity (t?=?2.76, p?=?0.005). Pain was a complete mediator between circadian rhythms and sleep quality.

Conclusions

The rest/activity rhythm influences the coexisting pain and sleep disturbances. Pain functions as a complete mediator in their relationship. Interventions that improve rest/activity rhythms may improve the management of pain and sleep disturbances in cancer patients.