Patient Experience of Photobiomodulation Therapy in Head and Neck Chronic Lymphedema

Purpose: Lymphedema is a common late effect of head and neck cancer treatment that causes various symptoms, functional impairment, and poor quality of life. We completed a pilot, prospective, single-arm clinical trial to determine the feasibility and potential efficacy of the use of photobiomodulation (PBM) therapy for head and neck lymphedema. In this study, we report patients' perceived treatment experience of PBM therapy and provide suggestions to better understand head and neck cancer survivors' experience of PBM therapy. Methods: Head and neck cancer patients who underwent PBM therapy completed face-to-face semi-structured interviews. Interviews were audio-recorded and then transcribed verbatim. Qualitative content analysis was used to analyze the transcriptions from the interviews. Results: Among 12 participants who consented for the study, 11 (91.7%) completed the PBM therapy. Participants described positive experiences and unique benefits about the PBM therapy, for example, decreased swelling, reduced tightness, increased range of motion, increased saliva production, and improved ability to swallow. Some participants (n = 5, 45.5%) delineated challenges related to traffic, travel time, and distance from study location. Many participants proposed suggestions for future research on PBM therapy, for example, research on internal edema and its relationship with swallowing, and indicated patients with severe lymphedema and fibrosis may be more likely to benefit. Conclusions: Findings from this study suggested the potential benefits of PBM therapy in treatment of chronic head and neck lymphedema. Rigorously designed clinical trials are needed to evaluate the effect of PBM therapy for head and neck cancer-related lymphedema. Trial Registration Number and Date of Registration: ClinicalTrials.gov Identifier: NCT03738332; date of registration: November 13, 2018.

Health behaviors among head and neck cancer survivors

PURPOSE

To determine to what extent head and neck cancer (HNC) survivors participate in health behaviors (HBs) recommended by the National Cancer Center Network (NCCN®).

METHODS

Participants identified through the tumor registries at the Abramson Cancer Center (ACC), University of Pennsylvania and affiliated sites. Eligibility: (a) diagnosis and treatment HNC; (b) aged 18 to 70 years; (c) ≥ 1-year post-diagnosis; (d) human papillomavirus (HPV) status confirmed; (e) ability to understand written English. Potential participants received an explanation of the study, informed consent, self-reported questionnaire, and self-addressed stamped envelope.

RESULTS

451 individuals eligible, 102 (23%) agreed to participate, HPV positive (74%). Current smoking rare (7%), historical use common (48%). Current alcohol use common (65%), average 2.1 drinks/day, 12 days/month. 22% binge drank with an average of 3.5 binge-drinking sessions per month. Nutritional behavior mean 7.1 (range 0-16), lower scores indicating better nutrition. Body mass index (BMI) 59% overweight/obese. Adequate aerobic exercise 59%, adequate strength and flexibility 64%. Leisure time activity, 18% sedentary, 19% moderately active, 64% active. All participants reported having a primary care physician, 92% seen in the previous 12 months.

CONCLUSIONS

Most HNC survivors participated in some HBs. Current smoking rarely reported, binge drinking and high BMI most common negative HBs. Opportunities remain to improve dietary and exercise behaviors.

IMPLICATIONS FOR CANCER SURVIVORS

The NCCN® has outlined HBs that decrease likelihood of cancer survivors developing comorbidities that could impact overall survival. It is incumbent on healthcare providers to educate and encourage cancer survivors to participate in these HBs.

Predictors of Nurse Practitioner Prescription of Opioids for Cancer Pain: Quantitative Results

Background

Nurse practitioners (NPs) have assumed a greater role in the management of pain related to cancer. Several studies have associated adequate management of cancer pain with improved survival. Opioids are an essential treatment for cancer pain management and thus it is important to understand influences on prescribing these substances. However, due to a lack of previous studies on this topic, little is known about the influences on NP prescription of opioids for patients with pain due to cancer.

Purpose

Competent decision-making is highly correlated with dominant personality characteristics and dominant decision-making styles in everyday life. The rational approach to decision-making has demonstrated superior performance with different daily tasks, including career-related tasks. However, it is unknown whether dominant personality and/or decision-making style impacts the decisions of medical professionals. Using the Diffusion of Innovations theoretical framework, this study evaluated whether dominant personality, dominant decision style, advanced specialty certification, and/or demographic factors influenced oncology NP opioid prescribing proficiency (termed opioid decision score, or ODS) according to the National Comprehensive Cancer Network (NCCN) Guidelines. Other advanced practice providers (APPs) were excluded from the study due to controlled substance prescribing limitations.

Methods

An internet-based descriptive comparative study was performed evaluating the dominant personality characteristic and dominant decision-making style as a predictor of opioid prescribing among NPs working in oncology. Participants were recruited using lists from the Oncology Nursing Society (ONS) and American Association of Nurse Practitioners (AANP). A nationwide convenience sample of NPs working with adult oncology patients was evaluated for opioid prescribing according to recommendations in the NCCN Cancer Pain Guidelines.

Results

Univariate linear regression revealed a statistically significant increase in the ODS as the Big Five Inventory (BFI) Openness scale score increased (estimate = 0.36, standard error [SE] = 0.17, 95% confidence interval [CI] = 0.03-0.69). Nurse practitioners reporting advanced specialty certification in oncology and/or hospice or palliative care scored significantly higher on the ODS compared with those with no advanced specialty certification (n = 81, M = 2.86, 2.34, t = -2.75, df = 178, p = .0065).

Conclusion

This study provides preliminary findings regarding the decision-making of NPs working with oncology patients and prescribing opioids for cancer pain. Nurse practitioners with a dominant personality characteristic of openness and those reporting an advanced specialty certification in oncology and/or hospice or palliative care were more likely to prescribe opioids for patients with cancer according to NCCN Guidelines. Further investigation is needed to determine additional factors impacting prescribing of controlled sub-stance by NPs and other prescribers.

Conducting a supportive oncology clinical trial during the COVID-19 pandemic: challenges and strategies

The coronavirus disease 2019 (COVID-19) pandemic resulted in severe interruptions to clinical research worldwide. This global public health crisis required investigators and researchers to rapidly develop and implement new strategies and solutions to mitigate its negative impact on the progress of clinical trials. In this paper, we describe the challenges, strategies, and lessons learned regarding the continuation of a supportive oncology clinical trial during the pandemic. We hope to provide insight into the implementation of clinical trials during a public health emergency to be better prepared for future instances.

Trial registration: ClinicalTrials.gov, a service of the US National Institute of Health (NCT 03030859). Registered on 22 January 2017.

Self-care for head and neck cancer survivors with lymphedema and fibrosis: A pilot randomized clinical trial

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Background: Lymphedema and fibrosis (LEF) are debilitating late effects in head and neck cancer survivors (HNCS). Initial therapy is usually directed by therapists following which patients undertake a LEF self-care program (SCP). No evidence based LEF-SCP are available. We report on the feasibility and preliminary efficacy data of a multifaceted LEF-SCP. Methods: 59 HNCS with LEF were randomized to: Usual care (n = 20), usual care + LEF-SCP (n = 20), and usual care + LEF-SCP + routine follow-up with a lymphedema therapist (n = 19). Assessments were conducted at baseline, 3-, 6-, 9-, and 12-months. Outcome measures include feasibility and preliminary efficacy (LEF progression, symptom burden, and jaw range of motion [ROM]). Multivariate covariance pattern model analysis was used to test for difference between arms. Results: 1) Feasibility: LEF-SCP training sessions - 80% completion rate; 90% satisfaction with the LEF-SCP; self-care adherence was similar between arms; no adverse event. 2) Preliminary Efficacy: Compared to usual care, participants randomized to LEF-SCP (+/- follow-up) showed a decrease in LEF severity (p < 0.05), reduction in symptom burden (p < 0.05), without significant improvement in jaw ROM. No significant differences were noted between the patients +/- follow-up with a lymphedema therapist. There was a trend to improved self-efficacy in patients participating in the LEF-SCP. Conclusions: The LEF-SCP is feasible and potentially efficacious for HNCS. Further testing is warranted. Clinical trial information: NCT03030859.

Radiopharmaceuticals in the Treatment of Pain in Palliative Care

The incidence of neuroendocrine neoplasm (NEN) has been increasing over the past few decades due to improved diagnostic abilities. NENs secrete large amounts of serotonin and polypeptides, resulting in carcinoid syndrome. While surgical resection is the treatment of choice when feasible, somatostatins have been the primary treatment for control of tumor growth and symptoms of hypersecretion. For patients who have progressed on somatostatin analogues, peptide receptor radionuclide therapy (PRRT) may be another option. This chapter discusses the role of PRRT through application to the case of GJ, a 36-year-old who presents with NEN of the small intestine, which is no longer responding to treatment with octreotide long-acting repeatable (LAR) and who may benefit from treatment with the PRRT, ¹⁷⁷Lu-dotatate.

Photobiomodulation Therapy in Head and Neck Cancer-Related Lymphedema: A Pilot Feasibility Study

Purpose:

Lymphedema is a common debilitating late effect among patients post-head and neck cancer (HNC) treatment. Head and neck lymphedema was associated with symptom burden, functional impairment, and decreased quality of life. The objective of this study was to determine the feasibility and potential efficacy of the use of photobiomodulation (PBM) therapy for head and neck lymphedema, symptom burden, and neck range of motion among HNC survivors.

Methods:

This was a single-arm, pre- and post-design clinical trial. Eligible patients included those with lymphedema after completion of complete decongestive therapy (CDT) and 3 to 18 months after completion of cancer therapy. The intervention included PBM therapy 2 times a week for 6 weeks for a total of 12 treatments. Lymphedema, symptom burden, and neck range of motion were measured at baseline, end-of-intervention, and 4-week post-intervention.

Results:

Of the 12 patients enrolled in the study, 91.7% (n = 11) completed the study intervention and assessment visits, and no adverse events were reported. When comparing the baseline to 4-week post-intervention, we found statistically significant improvements in the severity of external lymphedema, symptom burden, and neck range of motion (all P < .05).

Conclusion:

PBM therapy was feasible and potentially effective for the treatment of head and neck lymphedema. Future randomized controlled trials are warranted to examine the efficacy of PBM therapy for HNC-related lymphedema.

Trial Registration Number and Date of Registration:

ClinicalTrials.gov Identifier: NCT03738332; date of registration: November 13, 2018.

Strengthening palliative care delivery in developing countries: a training workshop model in Botswana

BACKGROUND

The persistent global unmet need for palliative care continues to be felt acutely in Sub-Saharan Africa, where the volume is growing and access to palliative services remains underdeveloped. Recognizing the increasing urgency of bolstering palliative care infrastructure, several countries, such as Botswana, have established national policies and strategies to enhance care delivery. Given that education and training are essential components in pursuing this goal, we present a model for a training workshop that was successful in increasing the palliative care knowledge base and skill set in a group of nurses.

METHODS

A 2-day palliative care workshop was conducted for 15 nurses in Gaborone, Botswana in October 2014. Ten nurses completed pre- and post-workshop tests consisting of 21 questions spanning palliative care topics and delivery skills.

RESULTS

The survey category with the highest pre-test score of 70% was principles of palliative care. Ninety percent of participants demonstrated statistically significant improvement in post-test scores in comparison to pre-test results. The greatest increase in scores were observed in the categories of communication, end-of-life care and syringe driver use for administration of analgesic medications. The lowest post-test score category was spirituality, though it consisted of one survey question.

CONCLUSIONS

Here we provide quantitative data that supports the success of the training workshop model presented. Improvement in palliative care knowledge and treatment skills, as evidenced by the increased scores from pre- to post-test results, suggests the efficacy of this 2-day training program in advancing palliative care education of nurses. Given the unmet need for healthcare workers trained in palliative care, this model could serve as a valuable tool for expanding and strengthening the delivery of care in settings where patients have limited access to palliative care services.

African Americans with cancer pain are more likely to receive an analgesic with toxic metabolite despite clinical risks: a mediation analysis study

PURPOSE

Renal impairment is highly prevalent among patients with cancer, and many patients have undiagnosed chronic kidney disease (CKD) from underlying disease, treatment, or both. African American individuals have disproportionate risk factors (diabetes, hypertension) predisposing them to CKD. We investigated whether African American patients are more likely than white patients to receive morphine with 3- and 6-glucuronide metabolites, which are known to be neurotoxic and accumulate in CKD; whether insurance type mediates the relationship between race and the prescriber's opioid selection; and whether the chosen opioid has a resultant negative effect according to race.

PATIENTS AND METHODS

Patients (N = 182) were recruited from oncology clinics within the University of Pennsylvania Health System. Inclusion was based on self-identified African American or white race, age older than 18 years, and the presence of cancer-related pain plus a prescription for morphine or oxycodone. Kidney function was estimated using the abbreviated Modification of Diet in Renal Disease formula.

RESULTS

Patients with CKD who received morphine reported a greater severity of analgesic-related adverse effects than patients with CKD who received oxycodone (P = .010). Controlling for health insurance type, African American patients had 71% lower odds of receiving a prescription of oxycodone than white patients (P < .001). Limiting analysis to those with CKD, the effect of private insurance became insignificant. However, race still remained a significant predictor of the prescribed opioid selection. Race was a strong predictor of adverse effect severity in the presence of CKD, and the type of opioid selection partially mediated this relationship.

CONCLUSION

Reducing racial disparities in the type of opioid prescription and understanding mechanisms of disproportionate opioid-related adverse effects in African American patients might decrease the clinical disparities in cancer pain outcomes.

Oral transmucosal fentanyl citrate: a novel agent for breakthrough pain related to cancer

Pain is problematic for many cancer patients. As more experience has been gained in treating cancer pain, breakthrough pain has been recognized as a phenomenon that occurs frequently in this population. Breakthrough pain is generally treated with a variety of short-acting opioids via a number of routes. Actiq (oral transmucosal fentanyl citrate) is a formulation of fentanyl citrate delivered via the transmucosal route in a sucrose base. Patients using this agent are instructed to paint the unit on the buccal mucosa in order to achieve relief. The onset of Actiq is reported to be equal to intravenous morphine. There are a wide variety of dosage forms available, allowing 74% of patients involved in clinical studies of the agent to titrate to an appropriate dose. The proper use, side effect profile and advantages/disadvantages will be reviewed for this agent.

Derivation of malignancy status from ICD-9 codes

To assess the severity of illness of oncology patients, it is necessary to distinguish patients with a single primary tumor from patients with metastatic disease occurring at a secondary location remote from the primary site. We developed a ranked list of cancer groupings and an algorithm that could distinguish patients with primary and metastatic cancer even if no specific code for secondary cancer was recorded. In patients with metastatic disease, the algorithm should also distinguish the primary site from the secondary site.

Plasma protein thiol oxidation and carbonyl formation in chronic renal failure

BACKGROUND

Myeloperoxidase-catalyzed oxidative pathways have recently been identified as an important cause of oxidant stress in uremia and hemodialysis (HD), and can lead to plasma protein oxidation. We have examined patterns of plasma protein oxidation in vitro in response to hydrogen peroxide (H2O2) and hypochlorous acid (HOCl). We measured thiol oxidation, amine oxidation, and carbonyl concentrations in patients on chronic maintenance HD compared with patients with chronic renal failure (CRF) and normal volunteers. We have also examined the effect of the dialysis procedure on plasma protein oxidation using biocompatible and bioincompatible membranes.

METHODS

Plasma proteins were assayed for the level of free thiol groups using spectrophotometry, protein-associated carbonyl groups by enzyme-linked immunosorbent assay, and oxidation of free amine groups using a fluorescent spectrophotometer.

RESULTS

In vitro experiments demonstrate HOCl oxidation of thiol groups and increased carbonyl formation. In vivo, there are significant differences in plasma-free thiol groups between normal volunteers (279 +/- 12 micromol/L), CRF patients (202 +/- 20 micromol/L, P = 0.005) and HD patients (178 +/- 18 micromol/L, P = 0.0001). There are also significant differences in plasma protein carbonyl groups between normal volunteers (0.76 +/- 0.51 micromol/L), CRF patients (13.73 +/- 4.45 micromol/L, P = 0.015), and HD patients (16.95 +/- 2.62 micromol/L, P = 0.0001). There are no significant differences in amine group oxidation. HD with both biocompatible and bioincompatible membranes restored plasma protein thiol groups to normal levels, while minimally affecting plasma protein carbonyl expression.

CONCLUSIONS

First, both CRF and HD patients have increased plasma protein oxidation manifested by oxidation of thiol groups and formation of carbonyl groups. Second, HD with biocompatible and bioincompatible membranes restored plasma protein thiol groups to normal levels. Third, these experiments suggest that there is a dialyzable low molecular weight toxin found in uremia that is responsible for plasma protein oxidation.

Implementing a multidisciplinary cancer pain education program

Cancer pain remains problematic for many patients. No standardized guidelines were available for the management of cancer pain until the early 1990s. In addition, many healthcare personnel have not been trained adequately in pain management, despite the abundance of literature. As a result, clinicians often manage patient's pain poorly. This article provides an overview of the process of development and implementation of a 5-year multidisciplinary cancer pain education program, begun in 1989 by the University of Pennsylvania School of Nursing, School of Medicine, and Cancer Center. The program was comprised of a multidisciplinary cancer pain consultation panel that sought to educate healthcare personnel in community hospitals and nursing homes in southeastern Pennsylvania about cancer pain. This was accomplished by providing consultations for agencies with patients experiencing uncontrolled and/or progressive cancer pain. The panel also provided education through lectures, newsletters, and symposia. A total of 1949 healthcare personnel attended 92 consultations, lectures, and symposia during the 5 years that the program has operated. With the linkage approach to innovation diffusion framework used in this consultation program, and the implementation of the guidelines now available, many healthcare personnel may be able to increase their skills and manage pain more effectively, thus reducing and/or eliminating needless suffering for patients. Developing role models in the area of pain management at community hospitals may be the most effective means of incorporating pain control guidelines and fostering innovation.