Efficacy of progressive muscle relaxation training and guided imagery in reducing chemotherapy side effects in patients with breast cancer and in improving their quality of life

Nonpharmacological Interventions for Management of the Pain-Fatigue-Sleep Disturbance Symptom Cluster in Breast Cancer Patients: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials

Background

The pain-fatigue-sleep disturbance symptom cluster is commonly experienced by breast cancer patients, and a variety of nonpharmacological interventions are used to treat this symptom cluster.

Objective

To compare the efficacy of nonpharmacological interventions in improving the symptoms of the pain-fatigue-sleep disturbance symptom cluster in breast cancer patients.

Methods

A comprehensive literature search was conducted in the PubMed, EMBASE, Cochrane Library, CINAHL, CNKI, and Wanfang databases to identify randomized controlled studies from database inception to May 2022. Two reviewers independently performed data retrieval and risk of bias assessments. The consistency model was used to conduct network meta-analyses (NMA) based on the frequentist framework to assess the interventions, which were ranked by the surface under the cumulative ranking curve (SUCRA). Finally, the CINeMA application was used to evaluate the results of the NMA and the evidence of quality. The results Twenty-three eligible studies assessing 14 interventions were included. According to SUCRA values, among the management effects of the three symptoms, the effect of progressive muscle relaxation (PMR) ranked first, followed by mindfulness-based stress reduction (MBSR). The overall evidence quality of our study ranges from very low to moderate.

Conclusion

PMR and MBSR were effective interventions for the pain-fatigue-sleep disturbance symptom cluster in breast cancer patients. Clinical recommendations prioritize PMR for symptom management, followed by MBSR. However, this should be interpreted cautiously, as the confidence in the evidence was not high.

Development and validation of audio-based guided imagery and progressive muscle relaxation tools for functional bloating

Mind-body techniques, including Guided Imagery (GI) or Progressive Muscle Relaxation (PMR), may effectively manage bloating. The current study aimed to develop and validate (psychometric and psychological responses) audio-based GI and PMR techniques for bloating. Audio scripts were first developed from literature reviews and in-depth interviews of participants with bloating diagnosed based on the Rome IV criteria. Scripts were validated using psychometric (content & face validity index) and physiological approaches (brain event-related potentials & heart rate variability). 45/63 participants completed the in-depth interview, and ‘balloon’ emerged as the synonymous imagery description for bloating, of which inflation correlated with a painful sensation. The final tools consisted of narrated audio scripts in the background of a validated choice of music. Overall, the content and face validity index for PMR and GI ranged from 0.92 to 1.00. For ERP and HRV, 17/20 participants were analyzed. For ERP, there was a significant difference between GI and PMR for alpha waves (p = 0.029), delta waves (p = 0.029), and between PMR and control for delta waves (p = 0.014). For HRV, GI and PMR exhibited similar autonomic responses over controls (overall p<0.05). The newly developed GI and PMR audio-based tools have been validated using psychometric and physiological approaches.

Psychological Interventions in Chemotherapy-Induced Nausea and Vomiting in Women with Breast Cancer: A Systematic Review

Background

Nausea and vomiting are considered the most common side effects of chemotherapy, and they can affect different dimensions of the lives of women with breast cancer. Thus, the management of these complications is of great significance. Various interventions are drawn upon to alleviate nausea and vomiting. This review aimed to investigate the effects of psychological interventions on chemotherapy-induced nausea and vomiting among women with breast cancer.

Methods

A systematic review of clinical or quasi-experimental clinical trials published from 2000 to 2020 on the effects of psychological interventions on nausea and vomiting induced by chemotherapy in women with breast cancer was conducted via a comprehensive search in web search engines including Google Scholar and PubMed and databases such as Web of Science, Scopus, ScienceDirect, Cochrane Library, Springer, Elsevier, Magiran, and Scientific Information Database (SID). Medical Subject Heading (MeSH) was employed with the following keywords: nausea, vomiting, breast cancer, chemotherapy, and psychological intervention. The quality of the included studies was assessed via the Jadad scale.

Results

Nine studies were included in this systematic review. Psychological interventions in chemotherapy-induced nausea and vomiting in women with breast cancer consisted of cognitive-behavioral therapy, progressive muscle relaxation training, yoga, and guided imagery. The results indicated that in all the studies, except one, the interventions improved conditions and reduced chemotherapy-induced nausea and vomiting.

Conclusion

The results of this study indicated that psychological interventions such as cognitive-behavioral therapy, progressive muscle relaxation training, guided imagery, and yoga alleviated nausea and vomiting induced by chemotherapy in women with breast cancer. Therefore, it is recommended that these interventions be applied by healthcare providers to ameliorate nausea and vomiting in these patients.The abstract was presented in the 15th International Congress on Obstetrics and Gynecology, Tehran, Iran, 8-11 October 2019, as a poster and published in the congress book.

Progressive Muscle Relaxation and Guided Imagery in Breast Cancer: A Systematic Review and Meta-analysis of Randomised Controlled Trials

Breast cancer affects the mental well-being of patients who may need psychological support. The combined practice of progressive muscle relaxation (PMR) and guided imagery (GI) is known to improve psychological health. Its effect has been studied in patients with breast cancer. We need to systematically review and analyse the available data to outline its role in various stages of disease management. We wanted to evaluate the effect of the combined practice of PMR and GI on stress, anxiety, depression and mood. We also wanted to study the impact on quality of life and chemotherapy-related adverse effects. A systematic search and evaluation of the literature was performed. Five randomised controlled trials were selected for data extraction and construction of forest plots. The intervention was effective for stress and anxiety. It positively improved the quality of life but saw no significant improvement in chemotherapy-related adverse effects.

Patient-Reported Outcomes From Phase III Neoadjuvant Systemic Trial Comparing Neoadjuvant Chemotherapy With Neoadjuvant Endocrine Therapy in Pre-Menopausal Patients With Estrogen Receptor-Positive and HER2-Negative, Lymph Node-Positive Breast Cancer

We aimed to evaluate the patient-reported outcomes (PROs) in a prospective phase III clinical trial, comparing neoadjuvant endocrine therapy (NET) with conventional neoadjuvant chemotherapy (NCT) in patients with hormone status positive, lymph node-positive premenopausal breast cancer (NCT01622361). The patients were randomized prospectively to either 24 weeks of NCT with adriamycin plus cyclophosphamide followed by taxane or NET with gonadotropin-releasing hormone agonist and tamoxifen. The patients were examined at the surgery unit of a large tertiary care hospital with a comprehensive cancer center. PROs were assessed on the first day of the trial (day 1, baseline) and at the end of treatment, using the breast cancer module of the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 23 (EORTC QLQ BR23). One hundred and eighty-seven patients were randomly assigned to chemotherapy (n=95) or endocrine therapy (n=92), and 174 patients completed 24 weeks of the neoadjuvant treatment period (n=87, in each group). Baseline scores were similar between the groups. After treatment, there were no statistically significant differences in the function scales, including body image, sexual functioning, and sexual enjoyment between the groups, although the endocrine treatment group showed a significant improvement in the future perspective (hazard ratio, 8.3; 95% confidence interval, 1.72-18.38; P = 0.021). Similarly, there were no statistically significant differences in the symptom scales between the groups, including adverse effects of systemic therapy, breast symptoms, arm symptoms, and upset about hair loss. In conclusion, overall PROs were similar in both treatment groups, except for "future perspective," which was significantly better in the NET group than in the NCT group.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.Gov, identifier NCT01622361.

Reducing Depression, Anxiety, and Fatigue Level in Cervical Cancer through Physical Exercise Intervention

Background: To identify the effect of physical exercise on depression, anxiety, and fatigue in cervical cancer patients. Methods: A quasi-experimental study ith a pretest-posttest with control group design was used. 30 respondents were selected using purposive sampling. The data were gathered by a focus group discussion. The Piper Fatigue Scale (PFS) was used to measure fatigue levels. Hospital Anxiety and Depression Scale (HADS) were used to measure anxiety and depression level. Paired t-test was used for data analysis. Results: There was a significant difference between depression level after physical exercise with t=3.552 (p<0.05). There was a significant difference between anxiety level after physical exercise with t=11.297 (p<0.05). There was a significant difference between fatigue level after physical exercise with t=17.457 (p<0.05). Conclusion: Physical exercise reduces anxiety, depression, and fatigue in patients with cervical cancer that will improve the quality of life of patients.

The effect of breathing exercise on nausea, vomiting and functional status in breast cancer patients undergoing chemotherapy

OBJECTIVE

The aim of this study is to determine the effect of breathing exercise on nausea, vomiting, and functional status in breast cancer patients undergoing chemotherapy.

METHODS

This randomized controlled trial was conducted with a total of 60 breast cancer patients in the ambulatory chemotherapy unit of a university hospital. The data were collected using Patient Information Form, Functional Living Index-Cancer (FLI-C), Visual Analog Scale, and Patient Diary. The patients were followed up for the first seven days. While the control group received routine nursing care until the posttest, the intervention group received breathing exercise for six days. On the seventh day, FLI-C was repeated for all the patients.

RESULTS

It was determined that the patients in the intervention group had less number of nausea, vomiting, and retching episodes after the breathing exercise (p < 0.05) and experienced lower severity of nausea (p < 0.05) compared to patients in the control group.

CONCLUSION

Consequently, it was determined that the breathing exercise reduced chemotherapy-induced nausea, vomiting and retching in breast cancer patients and affected positively functional status of patients.

Underlying Mechanisms of Psychological Interventions in Magnetic Resonance Imaging and Image-Guided Radiology Procedures

Positive patient care and healthcare facility outcomes are associated with using various psychological interventions during magnetic resonance imaging and interventional radiology procedures. Interventions such as hypnosis, relaxation, guided imagery, and empathic communication can improve anxiety, pain, and hemodynamic stability during procedures, as well as improve claustrophobia and anxiety during magnetic resonance imaging. Little is understood as to the potential underlying mechanisms of how these interventions operate and contribute to positive outcomes. Thus, this article seeks to address that question by integrating autonomic nervous system functioning, neuropsychological concepts, and common factors theory of psychotherapy as potential underlying mechanisms. Opportunities for future directions in the field are also included.

Investigating the Effects of the Progressive Muscle Relaxation-Guided Imagery Combination on Patients with Cancer Receiving Chemotherapy Treatment: A Systematic Review of Randomized Controlled Trials

BACKGROUND

Previous systematic reviews indicate that progressive muscle relaxation (PMR) and guided imagery (GI) are both effective interventions to decrease the psychological impact and to alleviate the adverse events in cancer patients undergoing chemotherapy treatment. To date, no review studies have investigated the effectiveness of a combination of PMR and GI.

AIM

To systematically review the current state of knowledge regarding the effects of the PMR-GI combination on cancer patients receiving chemotherapy.

METHODS

A search for relevant records was carried out in four electronic databases (AMED, Cochrane Library, Pubmed and Scopus). After removing the duplicates 342 publications were screened and 71 were considered as potentially relevant. The flow of information of this study was in line with the PRISMA statement. Original articles investigating the application of both PMR and GI through a randomized trial on patients receiving chemotherapy were included. Those using PMR or GI alone and those combining other techniques together with PMR and GI were excluded. The trials' quality was assessed using the Jadad Scale.

RESULTS

Eight papers reporting the results of seven independent trials were finally included. All of them included only breast cancer patients, apart from a single trial using a mixed sample of breast and prostate cancer patients. Seven of the included trials reported beneficial effects on mental state (mood, anxiety, and depression) and on toxicity (nausea and vomiting). Three trials reported an effect on biomarkers (heart rate, blood pressure, cortisol, and immunity). Four trials scored three of five points on the Jadad Scale, two trials scored two points and a single trial scored zero.

CONCLUSIONS

Independent trials indicate that the PMR-GI combination is an effective way to tackle the impact of nausea and vomiting and to improve patients' mental state. However, studies involving other types of primary tumors would be useful because seven of the eight clinical trials only included breast cancer patients. Future research on the identification of potential effects on disease-related parameters (e.g., cytokines and disease-recurrence) and on patient survival is highly needed.

Clinical practice guidelines on the evidence-based use of integrative therapies during and after breast cancer treatment

Answer questions and earn CME/CNE Patients with breast cancer commonly use complementary and integrative therapies as supportive care during cancer treatment and to manage treatment-related side effects. However, evidence supporting the use of such therapies in the oncology setting is limited. This report provides updated clinical practice guidelines from the Society for Integrative Oncology on the use of integrative therapies for specific clinical indications during and after breast cancer treatment, including anxiety/stress, depression/mood disorders, fatigue, quality of life/physical functioning, chemotherapy-induced nausea and vomiting, lymphedema, chemotherapy-induced peripheral neuropathy, pain, and sleep disturbance. Clinical practice guidelines are based on a systematic literature review from 1990 through 2015. Music therapy, meditation, stress management, and yoga are recommended for anxiety/stress reduction. Meditation, relaxation, yoga, massage, and music therapy are recommended for depression/mood disorders. Meditation and yoga are recommended to improve quality of life. Acupressure and acupuncture are recommended for reducing chemotherapy-induced nausea and vomiting. Acetyl-L-carnitine is not recommended to prevent chemotherapy-induced peripheral neuropathy due to a possibility of harm. No strong evidence supports the use of ingested dietary supplements to manage breast cancer treatment-related side effects. In summary, there is a growing body of evidence supporting the use of integrative therapies, especially mind-body therapies, as effective supportive care strategies during breast cancer treatment. Many integrative practices, however, remain understudied, with insufficient evidence to be definitively recommended or avoided. CA Cancer J Clin 2017;67:194-232. © 2017 American Cancer Society.

Complementary Therapies for Symptom Management in Cancer Patients

Cancer patients are often poly-symptomatic which distressingly affects their quality of lives (QOLs). Alhough, conventional management provides adequate symptom control, yet is coupled with some limitations. Complementary therapies (CTs) have shown beneficial effects in cancer patients for symptomatic relief. The aim of this article is to provide evidence-based review of commonly used CTs for symptom management in cancer care. Hypnosis has promising evidence to be used for managing symptoms such as pain, chemotherapy-induced nausea/vomiting, distress, fatigue, and hot flashes. Guided imagery increases comfort and can be used as a psycho-supportive therapy. Meditation substantially improves psychological function, mental health, and QOL. Cognitive behavioral therapies effectively reduce pain, distress, fatigue, anxiety, and depression; and improve subjective sleep outcomes along with mood and QOL. Yoga has short term beneficial effects for anxiety, depression, fatigue, perceived stress, QOL, and well-being. T'ai Chi and qigong are beneficial adjunctive therapies for supportive cancer care, but their role in reducing cancer pain is not well proven. Acupuncture is effective for reducing treatment related side-effects, pain and fatigue. Other therapies such as massage techniques, energy therapies, and spiritual interventions have also demonstrated positive role in managing cancer-related symptoms and improve overall well-being. However, the clinical effectiveness of these therapies for symptom management in cancer patients cannot be concluded due to poor strength of evidence. Nonetheless, these are relatively free from risks and hence can be given along with conventional treatments. Only by tailoring these therapies as per patient's beliefs and preferences, optimal patient-centered holistic care can be provided.

Guided imagery effects on chemotherapy induced nausea and vomiting in Iranian breast cancer patients

BACKGROUND

The objective of this study was to examine the effect of guided imagery on chemotherapy induced nausea and vomiting in breast cancer patients.

DESIGN

This was a quasi-experimental study in which a group of sample was evaluated pre and post intervention. A convenience sample of 55 eligible breast cancer patients enrolled to participate in this study after giving informed consent. They completed the Morrow Assessment of Nausea and Vomiting, before and after the intervention. The intervention consisted of listening to the two guided imagery tracks.

FINDINGS

After the intervention, patients at the third session of chemotherapy had significantly lower mean scores in the frequency and severity of nausea and vomiting pre and post chemotherapy (p < 0.05).

CONCLUSIONS

Guided imagery, as an inexpensive and noninvasive method, is particularly appealing option to alleviate chemotherapy induced nausea and vomiting. It can be used in addition to pharmacological strategies and can be implemented by patients independently with sufficient training. Therefore, this therapy will considerably improve severity and frequency of chemotherapy induced nausea and vomiting.

Guided Imagery And Progressive Muscle Relaxation as a Cluster of Symptoms Management Intervention in Patients Receiving Chemotherapy: A Randomized Control Trial

Objective

Patients receiving chemotherapy often experience many different symptoms that can be difficult to alleviate and ultimately negatively influence their quality of life. Such symptoms include pain, fatigue, nausea, vomiting and retching, anxiety and depression. There is a gap in the relevant literature on the effectiveness of cognitive-behavioural and relaxation techniques in symptom clusters. The study reflects this gap in the literature and aimed to test the effectiveness of Guided Imagery (GI) and Progressive Muscle Relaxation (PMR) on a cluster of symptoms experienced by patients undergoing chemotherapy.

Methods

This was a randomized control trial with 208 patients equally assigned either in the intervention or the control group. Measurements in both groups were collected at baseline and at completion of intervention (4 weeks). Patients were assessed for pain, fatigue, nausea, vomiting and retching, anxiety and depression. The overall management of the cluster was also assessed based on the patients’ self-reported health related quality of life-HRQoL. Chi-square tests (X²), independent T-tests and Linear Mixed Models were calculated.

Results

Patients in the intervention group experienced lower levels of Fatigue (p<0.0.0225), and Pain (p = 0.0003) compared to those in the control group and experienced better HRQoL (p<0.0001) [PRE-POST: Intervention: Pain 4.2(2.5) - 2.5(1.6), Fatigue 27.6(4.1) - 19.3(4.1), HRQoL 54.9(22.7) - 64.5(23), Control: Pain 3.5(1.7) - 4.8(1.5), Fatigue 28.7(4.1) - 32.5(3.8), HRQoL 51.9(22.3)– 41.2(24.1)]. Nausea, vomiting and retching occurred significantly less often in the intervention group [pre-post: 25.4(5.9)– 20.6(5.6) compared to the control group (17.8(6.5)– 22.7(5.3) (F = 58.50 p<0.0001). More patients in the control group (pre:n = 33-post:n = 47) were found to be moderately depressed compared to those in the intervention group (pre:n = 35-post:n = 15) (X² = 5.93; p = 0.02).

Conclusion

This study provided evidence that the combination of GI and PMR can be effective in the management of a cluster of symptoms in cancer patients receiving chemotherapy. These techniques can complement existing management measures to achieve a comprehensive management of this symptom cluster and increase patients HRQoL.

Trial Registration

ClinicalTrials.gov NCT01275872

Forming a Stress Management and Health Promotion Program for Women Undergoing Chemotherapy for Breast Cancer: A Pilot Randomized Controlled Trial

OBJECTIVE

To assess the effects of an 8-week stress management and health promotion program on women undergoing breast cancer chemotherapy treatment. Patients and methods A total of 61 patients were recruited in 2 cancer centers and were randomly assigned to the intervention program (n = 30) or control group (n = 31). The intervention program consisted of different stress management techniques, which were combined with instructions for lifestyle modification. Assessments were carried out through questionnaires and measurement of body mass index (BMI) at baseline and at the end of the 8-week program.

RESULTS

In all, 25 participants completed the intervention program, whereas 28 participants completed the observational control program. The intervention program resulted in a small effect size on internal dimension of Health Locus of Control (HLC) and a medium effect size on stress, depression, anxiety, night sleep duration, and chance dimension of HLC. A strong effect size was recorded for BMI and sleep onset latency. Self-rated health, spiritual well-being, and powerful others dimension of HLC were not significantly affected. Additionally, some of the participants reported a reduction in the side effects caused by chemotherapy.

CONCLUSIONS

The intervention resulted in several benefits for the general health status of patients. Therefore, it should be considered as feasible and potentially beneficial for women undergoing breast cancer chemotherapy. However, it is necessary for this intervention to be tested through a randomized controlled trial in a larger sample of patients before adopting this program in standard cancer care.

Complementary and integrative medicine for breast cancer patients - Evidence based practical recommendations

On average half of the breast cancer patients' population uses complementary and integrative medicine (CIM) therapies and many of them would like to receive information on CIM from their conventional treatment team. However, often they don't feel comfortable in discussing CIM related questions, with their conventional treatment team, because they think they don't have enough expertise and available time to deal with this topic. Furthermore, information on the evidence of CIM is not easily accessible and the available information is not always reliable. The purpose of the current paper is to provide: 1) an overview about the CIM interventions that have shown positive effects in breast cancer patients and might be useful in supportive cancer care, 2) practical guidance on how to choose and find a qualified referral to a CIM treatment: 3) recommendations on how these interventions could be integrated into Breast Cancer Centers and which factors should be taken into consideration in this setting. This paper takes available CIM practice guidelines for cancer patients and previous research on CIM implementation models into account. There are CIM interventions that have shown a potential to reduce symptoms of cancer or cancer treatments in breast cancer patients and the vast majority uses a non-pharmacological approach and have a good potential for implementation. Nevertheless, further and more rigorous research is still needed.

Treating Post-traumatic Stress Disorder in Patients with Multiple Sclerosis: A Randomized Controlled Trial Comparing the Efficacy of Eye Movement Desensitization and Reprocessing and Relaxation Therapy

OBJECTIVE

Multiple Sclerosis (MS) is a demyelinating autoimmune disease that imposes a significant emotional burden with heavy psychosocial consequences. Several studies have investigated the association between MS and mental disorders such as depression and anxiety, and recently researchers have focused also on Post-traumatic Stress Disorder (PTSD). This is the first study that investigates the usefulness of proposing a treatment for PTSD to patients with MS.

METHODS

A randomized controlled trial with patients with MS diagnosed with PTSD comparing Eye Movement Desensitization and Reprocessing (EMDR; n = 20) and Relaxation Therapy (RT; n = 22). The primary outcome measure was the proportion of participants that no longer meet PTSD diagnosis as measured with Clinician Administered PTSD Scale 6-months after the treatment.

RESULTS

The majority of patients were able to overcome their PTSD diagnosis after only 10 therapy sessions. EMDR treatment appears to be more effective than RT in reducing the proportion of patients with MS suffering from PTSD. Both treatments are effective in reducing PTSD severity, anxiety and depression symptoms, and to improve Quality of Life.

CONCLUSION

Although our results can only be considered preliminary, this study suggests that it is essential that PTSD symptoms are detected and that brief and cost-effective interventions to reduce PTSD and associated psychological symptoms are offered to patients, in order to help them to reduce the psychological burden associated with their neurological condition.

TRIAL REGISTRATION

NCT01743664, https://clinicaltrials.gov/ct2/show/NCT01743664.

Effects of Progressive Muscle Relaxation Therapy in Colorectal Cancer Patients

This study aimed to examine the effect of progressive muscle relaxation therapy (PMRT) on cortisol level, the Stress Arousal Checklist (SACL) score, blood pressure, and heart rate in colorectal cancer patients undergoing laparoscopic surgery. Forty-six patients were divided into control and experimental groups. Cortisol levels, blood pressure, and heart rate were measured before surgery and between 8:00 and 11:00 a.m. on the first, third, and fifth days after surgery. SACL score was measured before surgery and on the fifth day after surgery at the same time points. PMRT was performed twice a day for 5 days. Analyses of covariance with advanced covariate levels and t tests showed that PMRT helps colorectal cancer patients achieve a lower stress response and provides an important basis for stress control.

The effect of progressive muscle relaxation on pregnant women's general health

Background:

Pregnancy may be accompanied by serious physiological and psychological changes as it is a stressful period in a woman's life. So, this study was conducted to determine the effect of progressive muscle relaxation on pregnant women's general health.

Materials and Methods:

In this clinical trial, 60 primigravida women admitted to the prenatal clinic of selected hospitals in Iran constituted the study population. Using purposive sampling method, the level of general health of the women was measured with General Health Questionnaire-28 (GHQ-28). Then, the samples were randomly divided into control and experimental groups. Three 1.5–2 h relaxation training sessions were held for the experimental group. After 8 weeks, the level of general health of both groups was measured again. Finally, the collected data were analyzed using Chi-square and paired t-test (P < 0.05).

Results:

Total mean score of general health of the experimental group and the control group before the intervention was 35.83 (6.92) and 29.46 (8.3), respectively, and after the intervention, the respective scores were 20.2 (5.61) and 27.85 (8.24). Although after the intervention both groups showed an increased level of general health, the difference in general health between before and after intervention was significant in the experimental group (P < 0.001). Furthermore, comparison of variations in mean scores of general health level before and after intervention in the two groups showed a significant difference (P < 0.001).

Conclusions:

Given that the results showed the effectiveness of progressive muscle relaxation on pregnant women's general health, the prenatal clinics can include a training program for progressive muscle relaxation in the routine training programs for pregnant women.

Clinical practice guidelines on the use of integrative therapies as supportive care in patients treated for breast cancer

BACKGROUND

The majority of breast cancer patients use complementary and/or integrative therapies during and beyond cancer treatment to manage symptoms, prevent toxicities, and improve quality of life. Practice guidelines are needed to inform clinicians and patients about safe and effective therapies.

METHODS

Following the Institute of Medicine's guideline development process, a systematic review identified randomized controlled trials testing the use of integrative therapies for supportive care in patients receiving breast cancer treatment. Trials were included if the majority of participants had breast cancer and/or breast cancer patient results were reported separately, and outcomes were clinically relevant. Recommendations were organized by outcome and graded based upon a modified version of the US Preventive Services Task Force grading system.

RESULTS

The search (January 1, 1990-December 31, 2013) identified 4900 articles, of which 203 were eligible for analysis. Meditation, yoga, and relaxation with imagery are recommended for routine use for common conditions, including anxiety and mood disorders (Grade A). Stress management, yoga, massage, music therapy, energy conservation, and meditation are recommended for stress reduction, anxiety, depression, fatigue, and quality of life (Grade B). Many interventions (n = 32) had weaker evidence of benefit (Grade C). Some interventions (n = 7) were deemed unlikely to provide any benefit (Grade D). Notably, only one intervention, acetyl-l-carnitine for the prevention of taxane-induced neuropathy, was identified as likely harmful (Grade H) as it was found to increase neuropathy. The majority of intervention/modality combinations (n = 138) did not have sufficient evidence to form specific recommendations (Grade I).

CONCLUSIONS

Specific integrative therapies can be recommended as evidence-based supportive care options during breast cancer treatment. Most integrative therapies require further investigation via well-designed controlled trials with meaningful outcomes.

A Randomized Controlled Trial for the Effectiveness of Progressive Muscle Relaxation and Guided Imagery as Anxiety Reducing Interventions in Breast and Prostate Cancer Patients Undergoing Chemotherapy

Objective. To test the effectiveness of guided imagery (GI) and progressive muscle relaxation (PMR) as stress reducing interventions in patients with prostate and breast cancer who undergo chemotherapy. Methods. Patients were randomly assigned to either the control group or the intervention group (PMR and GI). Patients were observed for a total duration of 3 weeks and assessed with the SAS and BECK-II questionnaires for anxiety and depression, respectively, in addiotion to two biological markers (saliva cortisol and saliva amylase) (trial registration number: NCT01275872). Results. 256 patients were registered and 236 were randomly assigned. In total 104 were randomised to the control group and 104 to the intervention group. Intervention's mean anxiety score and depression score changes were significantly different compared to the control's (b = −29.4, p < 0.001; b = −29.4, p < 0.001, resp.). Intervention group's cortisol levels before the intervention (0.30 ± 0.25) gradually decreased up to week 3 (0.16 ± 0.18), whilst the control group's cortisol levels before the intervention (0.21 ± 0.22) gradually increased up to week 3 (0.44 ± 0.35). The same interaction appears for the Amylase levels (p < 0.001). Conclusions. The findings showed that patients with prostate and breast cancer undergoing chemotherapy treatment can benefit from PMR and GI sessions to reduce their anxiety and depression.

The Kuala Lumpur Qigong trial for women in the cancer survivorship phase-efficacy of a three-arm RCT to improve QOL

BACKGROUND

Qigong is highly favoured among Asian breast cancer survivors for enhancing health. This study examined the hypothesis that quality of life (QoL) in the Qigong group is better than the placebo (aerobic) or usual care group.

MATERIALS AND METHODS

A total of 197 participants were randomly assigned to either the 8-week Kuala Lumpur Qigong Trial or control groups in 2010-2011. Measurement taken at baseline and post- intervention included QoL, distress and fatigue. Analysis of covariance (ANCOVA) and Kruskal Wallis were used to examine for differences between groups in the measurements.

RESULTS

There were 95 consenting participants in this 8week trial. The adherence rates were 63% for Qigong and 65% for the placebo group. The Qigong group showed significant marginal improvement in Quality of life scores compared to placebo (mean difference=7.3 unit; p=0.036), compared to usual care (mean difference=6.7 unit; p=0.048) on Functional Assessment Cancer Therapy-Breast measure. There were no significant changes between the placebo and usual care groups in fatigue or distress at post intervention (8-week).

CONCLUSIONS

Cancer survivors who participated in the Qigong intervention showed slightly better QOL. Follow up studies are greatly needed to evaluate which subgroups may best benefit from Qigong. With a steep rise of cancer survivors, there is an urgent need to explore and engage more cultural means of physical activity to fight side effects of treatment and for cancer control in developing countries.

The Effects of Guided Imagery on Heart Rate Variability in Simulated Spaceflight Emergency Tasks Performers

Objectives. The present study aimed to investigate the effects of guided imagery training on heart rate variability in individuals while performing spaceflight emergency tasks. Materials and Methods. Twenty-one student subjects were recruited for the experiment and randomly divided into two groups: imagery group (n = 11) and control group (n = 10). The imagery group received instructor-guided imagery (session 1) and self-guided imagery training (session 2) consecutively, while the control group only received conventional training. Electrocardiograms of the subjects were recorded during their performance of nine spaceflight emergency tasks after imagery training. Results. In both of the sessions, the root mean square of successive differences (RMSSD), the standard deviation of all normal NN (SDNN), the proportion of NN50 divided by the total number of NNs (PNN50), the very low frequency (VLF), the low frequency (LF), the high frequency (HF), and the total power (TP) in the imagery group were significantly higher than those in the control group. Moreover, LF/HF of the subjects after instructor-guided imagery training was lower than that after self-guided imagery training. Conclusions. Guided imagery was an effective regulator for HRV indices and could be a potential stress countermeasure in performing spaceflight tasks.

The effects of body position on chemotherapy-induced nausea and vomiting: a single-blind randomized controlled trial

Background:

Chemotherapy is the cornerstone of cancer treatment; however, alongside therapeutic effects, nausea and vomiting are two common complications of chemotherapy.

Objectives:

The aim of this study was to investigate the effects of body position on chemotherapy-induced nausea and vomiting.

Materials and Methods:

This was a single-blind randomized controlled clinical trial. We recruited a convenience sample of 79 patients and randomly allocated them to either experimental or control groups. Patients in the control group received chemotherapy in supine position while the experimental group received chemotherapy in semi-Fowler’s position. All patients were assessed for the severity, duration, and frequency of nausea and vomiting episodes every three hours up to 24 hours, ie, in nine time-points. Study data was analyzed by SPSS v. 16.

Results:

The severity, duration, and frequency of nausea and the severity and frequency of vomiting episodes in the control group differed significantly across the nine measurement time-points (P < 0.001). In the experimental group, the severity (P = 0.254) and frequency of nausea (P = 0.002) episodes as well as the frequency of vomiting (P = 0.008) episodes differed significantly across the measurement time-points. Moreover, the study groups differed significantly across the measurement time-point in terms of the severity (P < 0.001), duration (P < 0.001), and frequency of nausea (P = 0.002) and the severity (P < 0.001) and frequency (P < 0.001) of vomiting episodes.

Conclusions:

Compared to supine position, semi-Fowler’s position is more effective in relieving chemotherapy-induced nausea and vomiting.

Outcomes of guided imagery in patients receiving radiation therapy for breast cancer

Guided imagery is an established intervention in integrative oncology. This study was initiated to evaluate the impact of guided imagery on patients undergoing radiation therapy for breast cancer. Eligible patients receiving guided imagery sessions were monitored via biofeedback before and after each session. Monitored measures included blood pressure, respiration rate, pulse rate, and skin temperature. In addition, the EuroQoL Group's EQ-5D questionnaire was used for subjective assessment and patient feedback was collected at the end of radiation therapy through a satisfaction survey. Measured parameters revealed statistically significant improvement from baseline, with decreases noted in respiration rate and pulse rate as well as systolic and diastolic blood pressure. Skin temperature increased, indicating more peripheral capillary flow secondary to a decrease in the sympathetic response. Overall, 86% of participants described the guided imagery sessions as helpful, and 100% said they would recommend the intervention to others. The results of this study illustrate the positive impact of guided imagery as measured through subjective and objective parameters. Improving the overall care for patients with breast cancer supports the value of incorporating practices of integrative oncology into standard practice.

Anticipatory nausea and vomiting due to chemotherapy

As a specific variation of chemotherapy-induced nausea and vomiting, anticipatory nausea and vomiting (ANV) appears particularly linked to psychological processes. The three predominant factors related to ANV are classical conditioning; demographic and treatment-related factors; and anxiety or negative expectancies. Laboratory models have provided some support for these underlying mechanisms for ANV. ANV may be treated with medical or pharmacological interventions, including benzodiazepines and other psychotropic medications. However, behavioral treatments, including systematic desensitization, remain first line options for addressing ANV. Some complementary treatment approaches have shown promise in reducing ANV symptoms. Additional research into these approaches is needed. This review will address the underlying models of ANV and provide a discussion of these various treatment options.

Impact of relaxation training according to the Yoga In Daily Life® system on anxiety after breast cancer surgery

The purpose of this pilot study was to gather information on the immediate and short-term effects of relaxation training according to the Yoga In Daily Life® (YIDL®) system on anxiety of breast cancer patients. The YIDL® system is a holistic system being practised and taught worldwide and has been proven to be highly effective in the prevention and treatment of various diseases. The system aims to establish physical, mental, spiritual, and social health. Thirty-two patients at the Institute for Oncology Ljubljana were randomized to the experimental (n=16) and to the control groups (n=16). Both groups received the same standard physiotherapy for 1 week, while the experimental group additionally received 1-hour group relaxation training session according to the YIDL® system per day. At discharge, the experimental group was issued with audiocassette recordings containing similar instructions for relaxation training to be practiced for 3 weeks individually at home. Anxiety measures were obtained by blinded assessors using standardized questionnaires. The results indicate that relaxation training according to the YIDL® system could be a useful clinical physiotherapy intervention for breast cancer patients experiencing anxiety.

Effects of Psycho-Oncologic Interventions on Emotional Distress and Quality of Life in Adult Patients With Cancer: Systematic Review and Meta-Analysis

Purpose

This study aimed to evaluate the effects of psycho-oncologic interventions on emotional distress and quality of life in adult patients with cancer.

Methods

Literature databases were searched to identify randomized controlled trials that compared a psycho-oncologic intervention delivered face-to face with a control condition. The main outcome measures were emotional distress, anxiety, depression, and quality of life. Outcomes were evaluated for three time periods: post-treatment, ≤ 6 months, and more than 6 months. We applied standard meta-analytic techniques to analyze both published and unpublished data from the retrieved studies. Sensitivity analyses and meta-regression were used to explore reasons for heterogeneity.

Results

We retrieved 198 studies (covering 22,238 patients) that report 218 treatment-control comparisons. Significant small-to-medium effects were observed for individual and group psychotherapy and psychoeducation. These effects were sustained, in part, in the medium term (≤ 6 months) and long term (> 6 months). Short-term effects were evident for relaxation training. Studies that preselected participants according to increased distress produced large effects at post-treatment. A moderator effect was found for the moderator variable “duration of the intervention,” with longer interventions producing more sustained effects. Indicators of study quality were often not reported. Small-sample bias indicative of possible publication bias was found for some effects, particularly with individual psychotherapy and relaxation training.

Conclusion

Various types of psycho-oncologic interventions are associated with significant, small-to-medium effects on emotional distress and quality of life. These results should be interpreted with caution, however, because of the low quality of reporting in many of the trials.

Long-term effect of the self-management comprehensive coping strategy program on quality of life in patients with breast cancer treated with high-dose chemotherapy

BACKGROUND

This study aims to examine the effectiveness of a self-management multimodal comprehensive coping strategy program (CCSP) on quality of life (QOL) among breast cancer patients 1 year after treatment.

METHODS

Patients (n = 110) with stage II, III, or IV breast cancer scheduled to receive high dose chemotherapy and autologous hematopoietic stem cell transplantation were randomized to either CCSP treatment or control group. The CCSP intervention was taught 2 week before hospital admission with reinforcement at specified times during treatment and 3 months after discharge. The CCSP components included educational information, cognitive restructuring, coping skills enhancement, and relaxation with guided imagery. Instruments administered at baseline included the following: Quality of Life Index-Cancer Version (QOLI-CV), State-Trait Anxiety Inventory, Beck Depression Inventory, and Coping Strategies Questionnaire. At 1-year follow-up, patients (n = 73) completed and returned the follow-up QOLI-CV.

RESULTS

Patients were mainly ≥ 40 years of age, married, Caucasian, and diagnosed with advanced breast cancer. A model measuring effectiveness of CCSP on QOL (total and subscale) at 1-year follow-up showed that the CCSP group (n = 38) had significant improvement in overall QOL (p < 0.01), health and functioning (p < 0.05), and socioeconomic (p < 0.05) and psychological/spiritual well-being (p < 0.01) compared with the control group (n = 35). The CCSP patients frequently used the CCSP to manage psychological (51%) and sleep problems (60%).

CONCLUSIONS

The CCSP improved QOL for patients at 1-year follow-up. Patients overwhelmingly reported that CCSP was beneficial. The CCSP as an effective coping intervention has potential as a self-management program for breast cancer survivors.

Impact of relaxation training according to Yoga In Daily Life® system on self-esteem after breast cancer surgery

OBJECTIVES

The purpose of this pilot study was to gather information on the immediate and short-term effects of relaxation training according to the Yoga In Daily Life(®) system on the self-esteem of patients with breast cancer.

DESIGN

This is a parallel-groups design.

SETTINGS/LOCATION

Baseline interventions took place at the Institute for Oncology of Ljubljana (Slovenia). At discharge, the experimental group was issued with audiocassette recordings containing the instructions for relaxation training to be practiced individually at home for an additional 3 weeks.

SUBJECTS

The convenience sample of 32 patients with breast cancer was recruited from an accessible population of hospitalized women. Patients were randomized to the experimental (n=16) and to the control group (n=16).

INTERVENTIONS

Both groups received the same standard physiotherapy for 1 week, while the experimental group additionally received a group relaxation training sessions according to the Yoga in Daily Life(®) system. At discharge, the experimental group was issued with audiocassette recordings containing similar instructions for relaxation training to be practiced individually at home for an additional 3 weeks.

OUTCOME MEASURES

Outcome measures were obtained by blinded investigators (physiotherapists) using standardized questionnaires (Rosenberg Self-Esteem Scale) at baseline (after the surgery); at 1 week (1 week postattendance; at discharge); and at 4 weeks (4 weeks postattendance); prior the commencement of radiation.

RESULTS

Analysis of variance showed that there were statistically significant differences between the experimental and control group in all measuring self-esteem scores over the study period (p<0.0005). At the same time, the control group's scores remained unchanged over the study period (p>0.05).

CONCLUSIONS

The results indicate that relaxation training according to the Yoga in Daily Life system could be a useful clinical physiotherapy intervention for patients who have breast cancer and who are experiencing low self-esteem. Although this kind of relaxation training can be applied to clinical oncology in Slovenia, more studies need to be done.

Methodological reflections on body-mind intervention studies with cancer patients

OBJECTIVE

Methodological reflection on the content, results and limitations of three body-mind intervention studies with cancer patients (CPs) in order to improve the quality of studies on body-mind interventions and to raise the potential value for CPs.

METHODS

A secondary analysis of a study on haptotherapy and two studies applying relaxing face massage, using a variety of well-being effect measures. Six methodological themes are discussed: (1) drop-out; (2) characteristics of participating patients, (3) participation of patients in other complementary interventions; (4) satisfaction of participants; (5) effects of the three interventions, and (6) role of response shift.

RESULTS

The three interventions showed limited effects after controlling for relevant confounding factors. They are mainly the small sample sizes, the low intensity of the intervention, the possible inadequate measure moments and the use of other CAM that may be responsible for the absence of effects.

CONCLUSIONS

Body-mind interventions require more methodological reflections to develop attractive and effective interventions for CPs. Attention needs to be paid to measuring short term effects, practically fitting research designs, and response shift.

PRACTICE IMPLICATIONS

Interventions should be intensive, repeated and not too short. The implementation of interventions requires attention to several organizational factors in the health care.

Quality-of-life measurement in randomized clinical trials in breast cancer: an updated systematic review (2001-2009)

BACKGROUND

Quality-of-life (QOL) measurement is often incorporated into randomized clinical trials in breast cancer. The objectives of this systematic review were to assess the incremental effect of QOL measurement in addition to traditional endpoints (such as disease-free survival or toxic effects) on clinical decision making and to describe the extent of QOL reporting in randomized clinical trials of breast cancer.

METHODS

We conducted a search of MEDLINE for English-language articles published between May-June 2001 and October 2009 that reported: 1) a randomized clinical trial of breast cancer treatment (excluding prevention trials), including surgery, chemotherapy, hormone therapy, symptom control, follow-up, and psychosocial intervention; 2) the use of a patient self-report measure that examined general QOL, cancer-specific or breast cancer-specific QOL or psychosocial variables; and 3) documentation of QOL outcomes. All selected trials were evaluated by two reviewers, and data were extracted using a standardized form for each variable. Data are presented in descriptive table formats.

RESULTS

A total of 190 randomized clinical trials were included in this review. The two most commonly used questionnaires were the European Organization for Research and Treatment of Cancer QOL Questionnaire and the Functional Assessment of Cancer Therapy/Functional Assessment of Chronic Illness Therapy. More than 80% of the included trials reported the name(s) of the instrument(s), trial and QOL sample sizes, the timing of QOL assessment, and the statistical method. Statistical power for QOL was reported in 19.4% of the biomedical intervention trials and in 29.9% of the nonbiomedical intervention trials. The percentage of trials in which QOL findings influenced clinical decision making increased from 15.2% in the previous review to 30.1% in this updated review for trials of biomedical interventions but decreased from 95.0% to 63.2% for trials of nonbiomedical interventions. Discordance between reviewers ranged from 1.1% for description of the statistical method (yes vs no) to 19.9% for the sample size for QOL.

CONCLUSION

Reporting of QOL methodology could be improved.

Impact of relaxation training according to Yoga In Daily Life® system on perceived stress after breast cancer surgery

The purpose of this pilot study was to gather information on the immediate and short-term effects of relaxation training according to Yoga In Daily Life(®) (YIDL) system on the psychological distress of breast cancer patients. 32 patients at the Institute for Oncology of Ljubljana were randomized to the experimental (N=16) and to the control group (N=16). Both groups received the same standard physiotherapy for 1 week, while the experimental group additionally received a group relaxation training sessions according to YIDL(®) system. At discharge the experimental group was issued with audiocassette recordings containing the similar instructions for relaxation training to be practiced individually at home (for further 3 weeks). An experimental repeated measures design was used to investigate the differences over 1 month period in stress levels, changes in mental health and psychological parameters. Measures were obtained at three time points during the study period: baseline, at 1 week, and at 4 weeks, by blinded investigators using standardized questionnaires General Health Questionnaire-12 (GHQ-12), Rotterdam Symptom Checklist (RSCL) psychological subscale, Perceived Stress Scale (PSS). Patients who received relaxation training reported feeling significantly less distressed during hospitalization and after discharge-period than did the controls that did not receive relaxation training. The results indicate that relaxation training according to Yoga in Daily Life(®) system could be useful clinical physiotherapy intervention for breast cancer patients experiencing psychological distress. Although this kind of relaxation training can be applied to clinical oncology in Slovenia, more studies need to be done.

Anticipatory nausea and vomiting

A commonly reported consequence of post-treatment nausea or vomiting is the development of anticipatory nausea and vomiting (ANV). In most published work, nausea is reported to occur before chemotherapy drugs are administered by approximately 20% of patients at any one chemotherapy cycle and by 25-30% of patients by their fourth chemotherapy cycle. Most studies in adult patients strongly support the view that the development of ANV involves elements of classical conditioning. The best method to avoid development of ANV is to adequately prevent both vomiting and nausea from the first exposure to chemotherapy. If anticipatory side effects develop, behavioral treatment techniques, such as systematic desensitization, have been shown effective. Benzodiazepines used in combination with behavioral techniques or antiemetics may also be useful. The evidence on which these conclusions are based is reviewed in this article.

Effects of relaxation training on sleep quality and fatigue in patients with breast cancer undergoing adjuvant chemotherapy

AIM

The purpose of this study was to investigate the effect of progressive muscle relaxation training on sleep quality and fatigue in Turkish women with breast cancer undergoing adjuvant chemotherapy.

BACKGROUND

Sleep problems and fatigue are highly prevalent in patients with breast cancer. Progressive muscle relaxation training is a promising approach in ameliorating the sleep quality and reducing the fatigue associated with cancer and its treatment.

DESIGN

A prospective, repeated measures, quasi-experimental design with control group.

METHODS

The study sampling consisted of 27 individuals (14 individuals formed the progressive muscle relaxation group, 13 individuals formed the control group) who met the criteria for inclusion in the study. Progressive muscle relaxation training was given to the progressive muscle relaxation group, but not to the control group. The effect of the progressive muscle relaxation training was measured at different stages of the treatment. A data collection form, Pittsburgh Sleep Quality Index and Piper Fatigue Scale were used to collect the data for this study.

RESULTS

The progressive muscle relaxation group experienced a greater increase in improved sleep quality and a greater decrease in fatigue than the control group.

CONCLUSIONS

The findings indicated that progressive muscle relaxation training would improve sleep quality and fatigue in patients with breast cancer undergoing adjuvant chemotherapy.

RELEVANCE TO CLINICAL PRACTICE

Progressive muscle relaxation training given by a nurse can improve sleep quality and fatigue in patients with breast cancer. It is important to start relaxation training just before chemotherapy to decrease the frequency and severity of sleep problems and symptoms such as fatigue during chemotherapy.