Methodological quality of patient-reported outcome research was low in complementary and alternative medicine in oncology

Complementary and Alternative Medicine in Radiotherapy: A Comprehensive Review

Complementary and alternative medicine (CAM) approaches are widely used by patients throughout a broad range of medical fields and diseases, and often self-administered by patients without the involvement of physicians or other members of the health care team. CAM use is well documented in cancer and chronic illnesses, and emerging data in radiation oncology show CAM usage of 26% to 97% in radiation therapy patients. No information is, however, available on CAM usage in radiology and in the imaging procedure fields. This article reviews the fundamental principles and the experience with the wide spectrum of CAM in radiation oncology-a field that shares many parallels with radiology, such as prevalence of imaging, procedural requirements, and cooperation demanded from patients.CAM is defined as "approaches and practices that are typically not part of conventional medical care," and includes the use of mind- and body-based practices (eg, meditation, massage, acupuncture), natural products (eg, herbs, vitamins, minerals), and other interventions. Supplements are used frequently to alleviate side effects of therapy and promote overall well-being. Specifically, the mindfulness/meditation approaches of CAM are known to reduce anxiety and enhance physical and emotional wellbeing in patients with chronic diseases, such as cancer or neurologic diseases, through physiological, psychological, and perhaps placebo mechanisms. Such patients often require repetitive and invasive imaging examinations or procedures, such as for cancer treatment, cancer surveillance/follow-up, or monitoring of chronic diseases, for example, surveillance MRI in multiple sclerosis. Such parallels suggest that the vastly understudied area of CAMs deserve further investigation in both the radiation oncology and the imaging fields. Further research on CAM is needed to develop refined recommendations and national/and international guidelines on its use.

A systematic review of complementary and alternative medicine in oncology: Psychological and physical effects of manipulative and body-based practices

Background

Complementary and Alternative Medicines (CAM) are widely used by cancer patients, despite limited evidence of efficacy. Manipulative and body-based practices are some of the most commonly used CAM. This systematic review evaluates their benefits in oncology.

Method

A systematic literature review was carried out with no restriction of language, time, cancer location or type. PubMed, CENTRAL, PsycArticle, PsychInfo, Psychology and Behavioral Sciences Collection and SOCindex were queried. Inclusion criteria were adult cancer patients and randomized controlled trials (RCT) assessing manipulative and body-based complementary practices on psychological and symptom outcomes. Effect size was calculated when applicable.

Results

Of 1624 articles retrieved, 41 articles were included: massage (24), reflexology (11), acupressure (6). Overall, 25 studies showed positive and significant effects on symptom outcomes (versus 9 that did not), especially pain and fatigue. Mixed outcomes were found for quality of life (8 papers finding a significant effect vs. 10 which did not) and mood (14 papers vs. 13). In most studies, there was a high risk of bias with a mean Jadad score of 2, making interpretation of results difficult.

Conclusion

These results seem to indicate that manipulative CAM may be effective on symptom management in cancer. However, more robust methodologies are needed. The methodological requirements of randomized controlled trials are challenging, and more informative results may be provided by more pragmatic study design.

Are outcomes reported in surgical randomized trials patient-important? A systematic review and meta-analysis

BACKGROUND

The dangers of using surrogate outcomes are well documented. They may have little or no association with their patient-important correlates, leading to the approval and use of interventions that lack efficacy. We sought to assess whether primary outcomes in surgical randomized controlled trials (RCTs) are more likely to be patient-important outcomes than surrogate or laboratory-based outcomes.

METHODS

We reviewed RCTs assessing an operative intervention published in 2008 and 2009 and indexed in MEDLINE, EMBASE or the Cochrane Central Register of Controlled Trials. After a pilot of the selection criteria, 1 reviewer selected trials and another reviewer checked the selection. We extracted information on outcome characteristics (patient-important, surrogate, or laboratory-based outcome) and whether they were primary or secondary outcomes. We calculated odds ratios (OR) and pooled in random-effects meta-analysis to obtain an overall estimate of the association between patient importance and primary outcome specification.

RESULTS

In 350 included RCTs, a total of 8258 outcomes were reported (median 18 per trial. The mean proportion (per trial) of patient-important outcomes was 60%, and 66% of trials specified a patient-important primary outcome. The most commonly reported patient-important primary outcomes were morbid events (41%), intervention outcomes (11%), function (11%) and pain (9%). Surrogate and laboratory-based primary outcomes were reported in 33% and 8% of trials, respectively. Patient-important outcomes were not associated with primary outcome status (OR 0.82, 95% confidence interval 0.63-1.1, I2 = 21%).

CONCLUSION

A substantial proportion of surgical RCTs specify primary outcomes that are not patient-important. Authors, journals and trial funders should insist that patient-important outcomes are the focus of study.

The Development of a Checklist to Enhance Methodological Quality in Intervention Programs

The methodological quality of primary studies is an important issue when performing meta-analyses or systematic reviews. Nevertheless, there are no clear criteria for how methodological quality should be analyzed. Controversies emerge when considering the various theoretical and empirical definitions, especially in relation to three interrelated problems: the lack of representativeness, utility, and feasibility. In this article, we (a) systematize and summarize the available literature about methodological quality in primary studies; (b) propose a specific, parsimonious, 12-items checklist to empirically define the methodological quality of primary studies based on a content validity study; and (c) present an inter-coder reliability study for the resulting 12-items. This paper provides a precise and rigorous description of the development of this checklist, highlighting the clearly specified criteria for the inclusion of items and a substantial inter-coder agreement in the different items. Rather than simply proposing another checklist, however, it then argues that the list constitutes an assessment tool with respect to the representativeness, utility, and feasibility of the most frequent methodological quality items in the literature, one that provides practitioners and researchers with clear criteria for choosing items that may be adequate to their needs. We propose individual methodological features as indicators of quality, arguing that these need to be taken into account when designing, implementing, or evaluating an intervention program. This enhances methodological quality of intervention programs and fosters the cumulative knowledge based on meta-analyses of these interventions. Future development of the checklist is discussed.

Methodological and Reporting Quality of Comparative Studies Evaluating Health-Related Quality of Life of Colorectal Cancer Patients and Controls: A Systematic Review

BACKGROUND

Health-related quality of life is an important outcome measure in patients with colorectal cancer. Comparison with normative data has been increasingly undertaken to assess the additional impact of colorectal cancer on health-related quality of life.

OBJECTIVE

This review aimed to critically appraise the methodological details and reporting characteristics of comparative studies evaluating differences in health-related quality of life between patients and controls.

DATA SOURCES

A systematic search of English-language literature published between January 1985 and May 2014 was conducted through a database search of PubMed, Web of Science, Embase, and Medline.

STUDY SELECTION

Comparative studies reporting health-related quality-of-life outcomes among patients who have colorectal cancer and controls were selected.

MAIN OUTCOME MEASURES

Methodological and reporting quality per comparison study was evaluated based on a 11-item methodological checklist proposed by Efficace in 2003 and a set of criteria predetermined by reviewers.

RESULTS

Thirty-one comparative studies involving >10,000 patients and >10,000 controls were included. Twenty-three studies (74.2%) originated from European countries, with the largest number from the Netherlands (n = 6). Twenty-eight studies (90.3%) compared the health-related quality of life of patients with normative data published elsewhere, whereas the remaining studies recruited a group of patients who had colorectal cancer and a group of control patients within the same studies. The European Organisation for Research and Treatment of Cancer Quality-of-Life Questionnaire Core 30 was the most extensively used instrument (n = 16; 51.6%). Eight studies (25.8%) were classified as "probably robust" for clinical decision making according to the Efficace standard methodological checklist. Our further quality assessment revealed the lack of score differences reported (61.3%), contemporary comparisons (36.7%), statistical significance tested (38.7%), and matching of control group (58.1%), possibly leading to inappropriate control groups for fair comparisons.

LIMITATIONS

Meta-analysis of differences between the 2 groups was not available.

CONCLUSIONS

In general, one-fourth of comparative studies that evaluated health-related quality of life of patients who had colorectal cancer achieved high quality in reporting characteristics and methodological details. Future studies are encouraged to undertake health-related quality-of-life measurement and adhere to a methodological checklist in comparison with controls.

'Trial Exegesis': Methods for Synthesizing Clinical and Patient Reported Outcome (PRO) Data in Trials to Inform Clinical Practice. A Systematic Review

Purpose

The CONSORT extension for patient reported outcomes (PROs) aims to improve reporting, but guidance on the optimal integration with clinical data is lacking. This study examines in detail the reporting of PROs and clinical data from randomized controlled trials (RCTs) in gastro-intestinal cancer to inform design and reporting of combined PRO and clinical data from trials to improve the ‘take home’ message for clinicians to use in practice.

Materials and Methods

The case study was undertaken in gastro-intestinal cancer trials. Well-conducted RCTs reporting PROs with validated instruments were identified and categorized into those combining PRO and clinical data in a single paper, or those separating data into linked primary and supplemental papers. Qualitative methods were developed to examine reporting of the critical interpretation of the trial results (trial exegesis) in the papers in relation of the PRO and clinical outcomes and applied to each publication category. Results were used to inform recommendations for practice.

Results

From 1917 screened abstracts, 49 high quality RCTs were identified reported in 36 combined and 15 linked primary and supplemental papers. In-depth analysis of manuscript text identified three categories for understanding trial exegesis: where authors reported a “detailed”, “general”, or absent PRO rationale and integrated interpretation of clinical and PRO results. A total of 11 (30%) and 6 (16%) combined papers reported “detailed” PRO rationale and integrated interpretation of results although only 2 (14%) and 1 (7%) primary papers achieved the same standard respectively. Supplemental papers provide better information with 11 (73%) and 3 (20%) achieving “detailed” rationale and integrated interpretation of results. Supplemental papers, however, were published a median of 20 months after the primary RCT data in lower impact factor journals (median 16.8 versus 5.2).

Conclusion

It is recommended that single papers, with detailed PRO rationale and integrated PRO and clinical data are published to optimize trial exegesis. Further work to examine whether this improves the use of PRO data to inform practice is needed.

Chinese herbal medicine for oesophageal cancer

BACKGROUND

Oesophageal cancer is the seventh leading cause of cancer death worldwide. Traditional Chinese herbal medicine is sometimes used as an adjunct to radiotherapy or chemotherapy for this type of cancer. This review was first published in 2007 and updated in 2009; this 2016 update is the latest version of the review.

OBJECTIVES

To assess the efficacy and possible adverse effects of the addition of Chinese herbal medicine to treatment with radiotherapy or chemotherapy for oesophageal cancer.

SEARCH METHODS

We searched the Cochrane Upper Gastrointestinal and Pancreatic Diseases Group Trials Register, the Cochrane Library, MEDLINE, EMBASE, Allied and Complementary Medicine Database (AMED), China National Knowledge Infrastructure (CNKI), VIP database, Wanfang database and the Chinese Cochrane Centre Controlled Trials Register up to 1 October, 2015. We also searched databases of ongoing trials, the Internet and reference lists.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing the use of radiotherapy or chemotherapy with and without the addition of Chinese herbal medicine.

DATA COLLECTION AND ANALYSIS

At least two review authors independently extracted data and assessed trial quality.

MAIN RESULTS

We tried to contact the 142 study authors by telephone, and finally included nine studies with 490 participants. All included studies were conducted in China, and allocated advanced oesophageal cancer patients to radiotherapy or chemotherapy groups, with and without additional Chinese herbal medicine. Quality of life, short-term therapeutic effects, TCM symptoms and adverse events caused by radiotherapy or chemotherapy were reported in these studies. Overall, we considered the trials to be at unclear or high risk of bias.The quality of life measure was conducted before and after the intervention; our analysis showed a beneficial effect, both in number of participants experiencing an improvement (risk ratio (RR) 2.20, 95% confidence interval (CI) 1.42 to 3.39; 5 RCTs, 233 participants, change of performance status score ≥ 10) and number of participants experiencing a deterioration (RR 0.41, 95% CI 0.27 to 0.62; 6 RCTs, 287 participants, change of performance status score ≤ 10). We judged this to have low quality evidence, downgrading quality of evidence for risk of bias and imprecision, and upgrading quality of evidence for the large effect.For short-term therapeutic effects, the results suggest that traditional Chinese medicine (TCM) has a positive impact on improvement (complete response + partial response) (RR 1.17, 95% CI 1.02 to 1.35; 8 RCTs, 450 participants), moderate quality evidence and downgrading for risk of bias. There was no significant difference for progressive disease (RR 0.73, 95% CI 0.52 to 1.01; 8 RCTs, 450 participants), low quality evidence and downgrading for risk of bias and imprecision. Three studies assessed this outcome after four weeks or three months' follow-up, the remaining studies gave no detailed information for this outcome. TCM symptoms, which was similar to short-term therapeutic effects evaluated with TCM clinical criteria, was diagnosed in two studies of 88 people at the end of the intervention. The results suggest that TCM has a positive impact on both total effectiveness (RR 1.84, 95% CI 1.20 to 2.81) and ineffectiveness (RR 0.22, 95% CI 0.05 to 0.93); we judged the studies to have very low quality evidence, downgrading for risk of bias and imprecision.Nine studies reported a series of adverse events caused by radiotherapy or chemotherapy at the end of the intervention, including mucositis, radiation oesophagitis, arrest of bone marrow, gastrointestinal reactions, renal and hepatic impairment, white blood cell descent, neurotoxicity, cardiac toxicity and anaemia. For those containing multiple studies, we conducted a pooled analysis. As a result, TCM showed a significant effect on radiation oesophagitis (RR 0.66, 95% CI 0.47 to 0.94; 2 RCTs, 90 participants), gastrointestinal reactions (RR 0.54, 95% CI 0.36 to 0.81; 4 RCTs, 268 participants) and white blood cell descent (RR 0.60, 95% CI 0.44 to 0.83; 4 RCTs, 224 participants). The quality of evidence was low or very low, downgrading for risk of bias and imprecision.

AUTHORS' CONCLUSIONS

We currently find no evidence to determine whether TCM is an effective treatment for oesophageal cancer. The effect of TCM on short-term therapeutic effects is uncertain. TCM probably has positive effects on quality of life and on some adverse events caused by radiotherapy or chemotherapy in advanced oesophageal cancer patients undergoing radiotherapy or chemotherapy. The results of the review need to be interpreted cautiously owing to overall low quality evidence. Future trials should be large and correctly designed to detect important clinical effects and minimise risk of bias.

Androgens for the anaemia of chronic kidney disease in adults

BACKGROUND

Anaemia occurs when blood contains fewer red blood cells and lower haemoglobin levels than normal, and is a common complication among adults with chronic kidney disease (CKD). Although a number of approaches are applied to correct anaemia in adults with CKD, the use of androgen therapy is controversial.

OBJECTIVES

The aim of this review was to determine the benefits and harms of androgens for the treatment of anaemia in adult patients with CKD.

SEARCH METHODS

We searched CENTRAL, the Cochrane Renal Group's Specialised Register, the Chinese Biomedicine Database (CBM), CNKI, VIP and reference lists of articles without language restriction. The most recent search was conducted in August 2014.

SELECTION CRITERIA

All randomised controlled trials (RCTs) that assessed the use of androgens for treating anaemia of CKD in adults were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and assessed risk of bias in the included studies. Meta-analyses were performed using relative risk (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95% confidence intervals (CI).

MAIN RESULTS

We included eight studies that reported data from 181 participants. Study quality was assessed as moderate in six studies, one was low quality, and one was high quality. The small number of included studies, and low participant numbers adversely influenced evidence quality overall.We found limited evidence (1 study, 24 participants) to indicate that oxymetholone can increase haemoglobin (Hb) (MD 1.90 g/dL, 95% CI 1.66 to 2.14), haematocrit (HCT) (MD 27.10%, 95% CI 26.49 to 27.71), change in albumin (MD 4.91 g/L, 95% CI 3.69 to 6.13), alanine aminotransferase (ALT) (MD 54.50 U/L, 95% CI 43.94 to 65.06), and aspartate aminotransferase (AST) (MD 47.33 U/L, 95% CI 37.69 to 56.97); and decrease high-density lipoprotein (HDL) (MD -15.66 mg/dL, 95% CI -24.84 to -6.48). We also found that compared with erythropoietin alone, nandrolone decanoate plus erythropoietin may increase HCT (3 studies, 73 participants: MD 2.54%, 95% Cl 0.96 to 4.12). Compared with erythropoietin (1 study, 27 participants), limited evidence was found to suggest that nandrolone decanoate can increase plasma total protein (MD 0.40 g/L, 95% CI 0.13 to 0.67), albumin (MD 0.20 g/L, 95% CI 0.01 to 0.39), and transferrin (MD 45.00 mg/dL, 95% CI 12.61 to 77.39) levels. Compared with no therapy (remnant kidney), evidence was found to suggest that nandrolone decanoate can increase Hb (2 studies, 33 participants: MD 1.04 g/dL, 95% Cl 0.66 to 1.41) and HCT (1 study, 24 participants: MD 3.70%, 95% Cl 0.68 to 6.72). Compared with no therapy (anephric), evidence was found (1 study, 5 participants) to suggest that nandrolone decanoate can increase Hb (MD 1.30 g/dL, 95% Cl 0.57 to 2.03), but nandrolone decanoate did not increase HCT (MD 2.00%, 95% Cl -0.85 to 4.85).However, oxymetholone was not found to reduce blood urea nitrogen (BUN), serum creatinine (SCr), cholesterol, or triglycerides; or increase plasma total protein, prealbumin, or transferrin. No evidence was found to indicate that nandrolone decanoate increased prealbumin or decreased BUN, SCr, AST, ALT, cholesterol, triglycerides, HDL or low-density lipoprotein (LDL). Adverse events associated with androgen therapy were reported infrequently.

AUTHORS' CONCLUSIONS

We found insufficient evidence to confirm that use of androgens for adults with CKD-related anaemia is beneficial.

Observational studies on evaluating the safety and adverse effects of traditional chinese medicine

Background. This study aims to share our experiences when carrying out observational studies of traditional Chinese medicine (TCM). Methods. We have proactively monitored the safety profiles of Duhuo Jisheng Tang (DJT), Suan Zao Ren Tang (SZRT), and TMN-1. A list of adverse events (AEs), complete blood counts, and liver and kidney function tests were obtained from the participants during their scheduled hospital visits. Retrospective observational studies were conducted based on the reimbursement database of the National Health Insurance system, Taiwan, to explore the relationship between the use of TCM that have been adulterated by aristolochic acid and the risk from both nephrotoxins and carcinogens. Results. A total of 221, 287, and 203 AEs were detected after SZRT, DJT, and TMN-1 had been taken, respectively. Dizziness, headache, stomach ache, and diarrhea were judged to be probably related to SZRT treatment. Retrospective observational studies found an association between the consumption of aristolochic acid-containing Chinese formulae such as Mu Tong and an increased risk of CKD, ESRD, and urinary tract cancer. Conclusion. Prospective and retrospective observational studies seem to have specific advantages when investigating the safety and adverse effects of TCM therapies, as well as possibly other alternative/complementary therapies.

Patient-reported outcomes in studies of complementary and alternative medicine: problems, solutions, and future directions

Patient-reported outcome (PRO) measures are frequently used to assess therapeutic efficacy and effectiveness of complementary and alternative medicine (CAM). Although CAM investigators are increasingly making use of valid, self-report instruments to assess patient-relevant outcomes, the sheer number of available instruments poses challenges. Two of the more pressing issues are discussed: the lack of guidance for selecting measures and the limited attention paid to the clinical meaningfulness of PRO results. Solutions are offered that may support selection and standardization of outcome measures for future CAM studies. This includes testing of tools from the National Institutes of Health's Patient-Reported Outcomes Measurement Information System (PROMIS). Increased standardization of outcome measurement in CAM studies will allow for more cross-study comparisons and facilitate the statistical pooling of results, ultimately leading to a more informative evidence base.

Compensation scheme for complementary and alternative medicine use in asbestos-related diseases in New South Wales, Australia

WHAT IS KNOWN AND OBJECTIVE

Asbestos use has resulted in a high global incidence rate of asbestos-related diseases (ARDs). These diseases require high costs of compensation and medical expense, although definite cures have yet to be found. Complementary and alternative medicine (CAM) has been used as a means to attenuate symptoms of ARDs. Our objective is to describe the compensation scheme for CAM use for a population with ARDs in New South Wales (NSW), Australia.

COMMENT

Expenses of CAM have conditionally been compensated by the workers compensation dust-diseases board (DDB) to a population with ARDs. The DDB approves patients` claim for the use of CAM if it is justifiable and related to compensable ARDs. To obtain the DDB`s approval for the CAM cost, a written recommendation letter by the treating medical doctors is required that justifies the use of CAM and that this option does not pose any adverse effects on the compensated patients.

WHAT IS NEW AND CONCLUSION

The use of CAM in a subject with ARDs does not have significant benefits of overall survival but does somewhat improve quality of life. However, awareness of the provisions of the compensation scheme for CAM use in a population with ARDs should be carefully informed and also emphasized any side effects on progress of ARDs.

Effects of immunosuppressants after penetrating keratoplasty: meta-analysis of randomized controlled trials

AIM

To assess the effectiveness of immunosuppressants in the prophylaxis of corneal allograft rejection after high-risk keratoplasty and normal-risk keratoplasty.

METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CNKI, VIP and reference lists of articles. Date of most recent search: 18 June, 2011. All randomised controlled trials (RCTs) assessing the use of immunosupressants in the prevention of graft rejection, irrespective of publication language. Two authors assessed trial quality and extracted data independently. Only dichotomous outcomes (clear graft survival, ratio of immune reactions and side effects) were available and were expressed as relative risk (RR) and 95% confidence intervals (CI).

RESULTS

Seven studies were included in this review. In the comparing of mycophenolate mofetil (MMF) with placebo, the results showed MMF could significantly reduce immune reactions compared with placebo (RR 1.08 95% Cl 0.95 to 1.21), but no effect on clear graft survival (RR 1.11 95% Cl 0.90 to 1.35). In clear graft survival and immune reactions, MMF and cyclosporine A (CsA) showed similar effect (RR 1.11 95% Cl 0.90 to 1.35, and RR 1.48, 95% Cl 0.56 to 3.93, respectively). Tacrolimus (FK506) and steroid showed similar effects on clear graft survival and immune reactions (RR 0.32, 95% CI 0.02 to 6.21, and RR 1.00, 95%CI 0.88 to 1.14, respectively). No drug relative side effect has been found.

CONCLUSION

MMF may reduce immune reactions in both normal-risk and high-risk rejection of penetrating keratoplasty. CsA and FK506 showed similar effects as MMF. However, due to the lack of large clinical trials, the evidence remain weak, the quality of evidences were rated as very low to moderate. Large, properly randomised, placebo-controlled, double masked trials are needed to evaluate the effect of immunosuppressants.

Intervention fidelity: aspects of complementary and alternative medicine research

BACKGROUND

The Treatment Fidelity Workgroup (TFW) established by the National Institutes of Health provides a 5-point structure for intervention fidelity: dosing, interventionists' consistency, intervention delivery, receipt, and enactment of the intervention. Using our reflexology trial, we apply the first 3 points.

OBJECTIVES

Study objectives were to (1) evaluate key dosage dimensions associated with complementary and alternative medicine (CAM) research, (2) evaluate approaches to interventionists' consistency of delivery of CAM protocols, and (3) evaluate and discuss data that reflect CAM intervention fidelity.

METHODS

Women with late-stage breast cancer (N = 318) were randomly assigned to either 4 weeks of reflexology, placebo, or standard care.

RESULTS

Dosing consists of 3 dimensions: frequency (4 sessions), duration (30 minutes), and interval between sessions (5-9 days). Interventionist consistency revealed more than a 90% accuracy rate in following the protocol; 84% and 89% completion rate of the 4 sessions in the reflexology and placebo groups, respectively; and no differences in attrition after randomization between reflexology and placebo groups (17% and 15%, respectively). Intervention delivery, examined through debriefing data, indicated a significantly higher rate of correct guesses on group assignment in the reflexology group as compared with the placebo (82% vs 46%, P = .0002).

CONCLUSION

This study points out the relevance of dosing, interventionists' consistency, and delivery data within a CAM clinical trial, as well as the challenges of blinding.

IMPLICATIONS FOR PRACTICE

Monitoring intervention fidelity by using the key areas identified by the TFW ensures that findings from a clinical trial are meaningful and have the potential to be translated to clinical practice.

Recruitment and early retention of women with advanced breast cancer in a complementary and alternative medicine trial

More than 80% of women with breast cancer are now reported to be using complementary and alternative medicine (CAM) therapies during conventional treatment. A randomized clinical trial (RCT) of reflexology with late stage breast cancer patients serves as the data source for this article. The purposes were to investigate: (i) reasons for refusal to participate in a RCT of reflexology; (ii) the differences between those who completed the baseline interview and those who dropped out before baseline; and (iii) the utility of the Palliative Prognostic Score (PPS) as a prognostic screening tool in minimizing early attrition (before baseline) from the trial. Eligible women (N = 400) approached at 12 cancer centers in the Midwest had advanced breast cancer, were on chemotherapy or hormonal therapy, and had a PPS of 11 or less. Comparisons of those who dropped out early (N = 33) to those who stayed in the trial (N = 240) were carried out using Wilcoxon rank, t-, chi-squared and Fisher's exact tests. The reasons of being "too sick" or "overwhelmed" were given by less than 12% of the women who refused to participate. There was a higher early dropout rate among black women compared to other (primarily white) women (P = .01). Cancer recurrence and metastasis, age, and the PPS were not predictive of early retention of women. Specialized techniques may be needed to ensure black women remain in the trial once consented. Women with advanced disease were likely to enter and remain in the trial despite deterioration in health.

Methodological issues in trials of complementary and alternative medicine interventions

BACKGROUND

Complementary and alternative medicine (CAM) use is widespread among cancer patients. Information on safety and efficacy of CAM therapies is needed for both patients and healthcare providers. Well-designed randomized clinical trials of CAM therapy interventions can inform both clinical research and practice.

OBJECTIVES

The aim of this study was to review important issues that affect the design of randomized clinical trials for CAM interventions.

METHODS

Using the methods component of the Consolidated Standards for Reporting Trials as a guiding framework and a National Cancer Institute-funded reflexology study as an exemplar, methodological issues related to participants, intervention, objectives, outcomes, sample size, randomization, blinding, and statistical methods were reviewed.

DISCUSSION

Trials of CAM interventions designed and implemented according to appropriate methodological standards will facilitate the needed scientific rigor in CAM research. Interventions in CAM can be tested using proposed methodology, and the results of testing will inform nursing practice in providing safe and effective supportive care and in improving the well-being of patients.

Chinese herbal medicines for esophageal cancer

BACKGROUND

Esophageal cancer is the seventh leading cause of cancer death worldwide. Traditional Chinese herbal medicines are sometimes used as an adjunct to radiotherapy or chemotherapy for this type of cancer.

OBJECTIVES

To assess the efficacy and possible adverse effects of the addition of Chinese herbal medicines to treatment with radiotherapy or chemotherapy for esophageal cancer.

SEARCH STRATEGY

We searched the Cochrane Upper Gastrointestinal and Pancreatic Diseases Group Trials Register, The Cochrane Library, MEDLINE, EMBASE, AMED (Allied and Complementary Medicine Database), CBM (Chinese Biomedical Database), China National Knowledge Infrastructure, the Chinese Cochrane Centre Controlled Trials Register and CISCOM (The Research Council for Complementary Medicine) (up to 10 July, 2008). Databases of ongoing trials, the Internet and reference lists were also searched.

SELECTION CRITERIA

Randomised controlled trials comparing the use of radiotherapy or chemotherapy with and without the addition of Chinese herbal medicines.

DATA COLLECTION AND ANALYSIS

At least two review authors extracted data and assessed trial quality.

MAIN RESULTS

We identified 43 trials which claimed to use random allocation. The first authors of all the RCTs we initially identified were contacted by telephone and we discovered that the authors had misunderstood the randomisation procedure. Using this new information, we reassigned all the identified RCTs as non-randomised trials. Because we identified no authentic randomised controlled trials, we were unable to perform a meta-analysis.

AUTHORS' CONCLUSIONS

We were unable to find any evidence from RCTs on the effectiveness of TCM in the treatment of esophageal cancer. New trials should be carried out and we recommend that they are large scaled, correctly randomised and that the assessors of the results are blinded to the conditions of allocation.

Assessing the Usefulness of Health-Related Quality-of-Life Trials: A Clinician's Perspective Using Two COPD Examples

Objective:

To empower clinicians to discern when health-related quality-of-life (HRQoL) evidence from a single trial, or from constituent trials within a systematic review or meta-analysis, is compelling enough to after clinical practice.

Data Sources:

To determine the criteria that would be most useful in assessing the quality of HRQoL data, recommendation statements or consensus guidelines that offer guidance to those conducting HRQoL trials were located through a MEDLINE search (1950–April 2009) using the search terms health-related quality of life and recommendations or guidelines.

Study Selection and Data Extraction:

Recommendation statements or consensus guidelines that offer guidance to investigators conducting HRQoL trials were evaluated to determine what criteria would be the most useful in assessing the quality of HRQoL data.

Data Synthesis:

We discuss how quality of HRQoL data may be assessed by evaluating the following broad questions: (1) Is the HRQoL analysis hypothesis-driven? (2) How is HRQoL being measured? (3) Are the HRQoL data being collected adequately and analyzed correctly? and (4) To what extent do investigators discuss the results of HRQoL analyses? Using select examples from the literature on chronic obstructive pulmonary disease, we applied the 4 broad questions in the assessment of their quality. Also, the use of scoring systems for quality rating for HRQoL data is discussed and applied to the example cases.

Conclusions:

HRQoL data are an important outcome because they capture treatment impact on physical, social, and psychological well-being. Assessing the quality and usefulness of HRQoL data requires an understanding of the advantages, limitations, and caveats of their use. Because of the potential lack of quality in HRQoL outcomes, clinicians should thoroughly assess the validity and usefulness of the evaluation. Tools are available to aid clinicians and decisionmakers in the assessment of HRQoL outcomes, but additional research needs to be conducted on the topic of quality assessment of HRQoL studies to improve the usefulness of these evaluations to clinicians.

Japanese herbal medicine in functional gastrointestinal disorders

Management of functional gastrointestinal disorders is hindered by both poor efficacy and adverse effects of traditional pharmacological therapy. Herbal medicine may be an attractive alternative based on the perception of its 'natural' approach and low risk of side effects; however, the lack of standardization of drug components has limited the ability to perform rigorous clinical studies in Western countries. Japanese herbal medicine (JHM) is a standardized form of herbal medicine with regards to the quality and quantities of ingredients. While extensively studied and widely used in Asia, there is a paucity of data upon which physicians in other parts of the world may draw conclusions regarding the effectiveness of herbal medicine for gastrointestinal disorders. The aim of this study was to summarize the most recent developments in JHM for treatment of functional gastrointestinal disorders. Animal and human studies were systematically reviewed to identify published data of JHM used for treatment of gastrointestinal disorders. The herbal components of JHM were examined. Results describing the physiological and clinical effects of JHM were abstracted, with an emphasis on functional gastrointestinal disorders. JHM are associated with a variety of beneficial physiological on the gastrointestinal system. Patient-based clinical outcomes are improved in several conditions. Rikkunnshi-to reduces symptoms and reverses physiological abnormalities associated with functional dyspepsia, while dai-kenchu-to improves symptoms of postoperative ileus and constipation in children. This updated summary of JHM in the field of gastrointestinal disorders illustrates the potential for herbal medication to serve a valuable role in the management of patients with functional gastrointestinal disorders.

Traditional Chinese medicinal herbs in the treatment of patients with esophageal cancer: a systematic review

Traditional Chinese medicines are sometimes used as an adjunct to radiotherapy or chemotherapy for esophageal cancer. These medicines may have a benefit on the survival and quality of life of patients who have advanced esophageal cancer. Evidence from current studies appears weak due to methodological limitations. Due to conflicting reports, it is difficult to argue for or against the use of traditional Chinese medicines as a treatment for esophageal cancer.

A systematic review of the use and validation of health-related quality of life instruments in older cancer patients

AIM

The aim of this paper is to systematically review the use and validation of HRQOL instruments in older cancer patients.

METHOD

A systematic review of 5 databases and 3 research registers identified studies reporting the use and validation of HRQOL instruments in cancer patients aged over 65 years from 1995 to mid 2007.

RESULTS

Thirty-one studies reported the use of HRQOL measures in older people, using a range of generic and disease-specific instruments. Little work was reported in patients aged over 80 years. All studies exhibited methodological limitations. Fourteen studies were identified with variable evidence on the psychometric properties and clinical usefulness of identified instruments.

CONCLUSION

Our review identified that the development, validation and use of HRQOL instruments often ignore the specific needs of older people. This review highlights the need for a HRQOL instrument specifically designed to capture the issues and concerns most relevant to older cancer patients.

Quality, interpretation and presentation of European Organisation for Research and Treatment of Cancer quality of life questionnaire core 30 data in randomised controlled trials

AIM

To review reporting standard, presentation and interpretation for quality of life (QOL) outcomes in randomised controlled trials (RCTs) using the European Organisation for Research and Treatment of Cancer quality of life questionnaire core 30 (EORTC QLQ-C30).

METHODS

Cancer RCTs reporting EORTC QLQ-C30 data were identified and reviewed against a reporting quality checklist. Interpretation/presentation methods for QOL data were also recorded.

RESULTS

Eighty-two papers were reviewed. Seventy percent met criteria for high quality reporting; 94% reported mean scores; 84% presented results in tables/graphs; 80% reported p-values or statistical significance. Clinical significance was addressed in 38%. Where clinical significance was not addressed, reliance was usually on statistical significance to interpret the results.

DISCUSSION

EORTC QLQ-C30 results are generally reported well, although it was common to rely on statistical significance alone for interpreting results. Whilst interpretation in terms of clinical significance has improved in recent years, there is still a lack of robust clinical interpretation of QOL results even in papers reported to a high standard.

Health-related quality of life assessment and reported outcomes in leukaemia randomised controlled trials - a systematic review to evaluate the added value in supporting clinical decision making

Health-related quality of life (HRQOL) is increasingly reported as an important outcome in cancer clinical trials. However, very little evidence exists on the impact of such evaluation in randomised controlled trials (RCTs) of leukaemia patients. A systematic search of the literature from 1980 to 2007 was undertaken and studies were identified and evaluated independently, according to a pre-defined coding scheme, by three reviewers. Both HRQOL outcomes and traditional clinical reported outcomes were systematically analysed to evaluate their consistency and their relevance for supporting clinical decision making. Nine RCTs were identified, involving 3838 patients overall. There were four RCTs involving acute myeloid leukaemia patients (AML), three with chronic myeloid leukaemia (CML) and two with chronic lymphocytic leukaemia (CLL). Six studies were published after 2000 and provided fairly robust methodological quality. Imatinib greatly improved HRQOL compared to interferon based treatments in CML patients and fludarabine plus cyclophosphamide does not seem to have a deleterious impact on patient's HRQOL when compared to fludarabine alone or chlorambucil in CLL patients. This study revealed the paucity of HRQOL research in leukaemia patients. Nonetheless, HRQOL assessment is feasible in RCTs and has the great potential of providing valuable outcomes to further support clinical decision making.

Prospective evaluation of quality of life and neurocognitive effects in patients with multiple brain metastases receiving whole-brain radiotherapy with or without thalidomide on Radiation Therapy Oncology Group (RTOG) trial 0118

PURPOSE

Radiation Therapy Oncology Group (RTOG) 0118 randomized patients with multiple brain metastases to whole-brain radiotherapy (WBRT) +/- thalidomide. This secondary analysis of 156 patients examined neurocognitive and quality of life (QOL) outcomes.

METHODS AND MATERIALS

Quality of life was determined with the Spitzer Quality of Life Index (SQLI). The Folstein Mini-Mental Status Exam (MMSE) assessed neurocognitive function. SQLI and MMSE were administered at baseline and at 2-month intervals. MMSE was scored with a threshold value associated with neurocognitive functioning (absolute cutoff level of 23) and with the use of corrections for age and educational level.

RESULTS

Baseline SQLI predicted survival. Patients with SQLI of 7-10 vs. <7 had median survival time (MST) of 4.8 vs. 3.1 months, p = 0.05. Both arms showed steady neurocognitive declines, but SQLI scores remained stable. Higher levels of neurocognitive decline were observed with age and education-level corrections. Of patients considered baseline age/educational level neurocognitive failures, 32% died of intracranial progression.

CONCLUSIONS

Quality of life and neuropsychological testing can be prospectively administered on a Phase III cooperative group trial. The MMSE should be evaluated with adjustments for age and educational level. Baseline SQLI is predictive of survival. Despite neurocognitive declines, QOL remained stable during treatment and follow-up. Poor neurocognitive function may predict clinical deterioration. Lack of an untreated control arm makes it difficult to determine the contribution of the respective interventions (i.e., WBRT, thalidomide) to neurocognitive decline. The RTOG has developed a trial to study the role of preventative strategies aimed at forestalling neurocognitive decline in this population.

WITHDRAWN: Medicinal herbs for esophageal cancer

BACKGROUND

Esophageal cancer is the seventh leading cause of cancer death worldwide. Traditional Chinese medicinal herbs are sometimes used as an adjunct to radiotherapy or chemotherapy for this type of cancer.

OBJECTIVES

To assess the efficacy and possible adverse effects of the addition of Chinese medicinal herbs to treatment with radiotherapy or chemotherapy for esophageal cancer.

SEARCH STRATEGY

We searched the Cochrane Upper Gastrointestinal and Pancreatic Diseases Group Trials Register, The Cochrane Library, MEDLINE, EMBASE, AMED (Allied and Complementary Medicine Database), CBM (Chinese Biomedical Database), China National Knowledge Infrastructure, the Chinese Cochrane Centre Controlled Trials Register and CISCOM (The Research Council for Complementary Medicine) (up to June 2004). Databases of ongoing trials, the internet and reference lists were also searched.

SELECTION CRITERIA

Randomised controlled trials comparing the use of radiotherapy or chemotherapy with and without the addition of Chinese medicinal herbs.

DATA COLLECTION AND ANALYSIS

At least two review authors extracted data and assessed trial quality.

MAIN RESULTS

We identified 43 trials which claimed to use random allocation. Sixteen study authors were contacted by telephone and we discovered that they misunderstood the randomisation procedure and the trials were identified as non-RCTs. The situation of lack of authentic randomised controlled trial leads us cannot draw a conclusion to recommend or against the use of TCM as a treatment for esophageal cancer.

AUTHORS' CONCLUSIONS

There was no evidence of effect of TCM in the treatment of esophageal cancer due to no any authentic RCT in this field yet. New trials should be large scaled, correctly randomised and results assessor blinded in the future.