Commissioning lymphoedema services for people living with and beyond cancer in London.

The Transforming Cancer Services Team (TCST) in London has produced comprehensive commissioning guidance for commissioners to improve the commissioning of lymphoedema services for people living with and beyond cancer. The guidance identifies how services are commissioned in London, sets out what good looks like and recommends how it can be achieved. The guidance was developed with the support of a task and finish group and was informed by telephone interviews with seven GP commissioners. A comprehensive mapping of specialist services was undertaken and has shown shortfalls in commissioning processes and significant gaps in provision across London. There is considerable opportunity to make cost-savings through investment in lymphoedema services and education and training of the workforce is a clear priority moving forward. TCST is now supporting commissioners to examine their lymphoedema services, benchmark themselves against best practice, and work with others to deliver the best possible care for their communities.

Interventions for promoting habitual exercise in people living with and beyond cancer.

BACKGROUND: The beneficial effects of regular exercise for people living with or beyond cancer are becoming apparent. However, how to promote exercise behaviour in sedentary cancer cohorts is not as well understood. A large majority of people living with or recovering from cancer do not meet exercise recommendations. Hence, reviewing the evidence on how to promote and sustain exercise behaviour is important. OBJECTIVES: To assess the effects of interventions to promote exercise behaviour in sedentary people living with and beyond cancer and to address the following questions: Which interventions are most effective in improving aerobic fitness and skeletal muscle strength and endurance? What adverse effects are attributed to different exercise interventions? Which interventions are most effective in improving exercise behaviour amongst patients with different cancers? Which interventions are most likely to promote long-term (12 months or longer) exercise behaviour? What frequency of contact with exercise professionals is associated with increased exercise behaviour? What theoretical basis is most often associated with increased exercise behaviour? What behaviour change techniques are most often associated with increased exercise behaviour? SEARCH METHODS: We searched the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 8, 2012), MEDLINE, EMBASE, AMED, CINAHL, PsycLIT/PsycINFO, SportDiscus and PEDro from inception to August 2012. We also searched the grey literature, wrote to leading experts in the field, wrote to charities and searched reference lists of other recent systematic reviews. SELECTION CRITERIA: We included only randomised controlled trials (RCTs) that compared an exercise intervention with a usual care approach in sedentary people over the age of 18 with a homogenous primary cancer diagnosis. DATA COLLECTION AND ANALYSIS: Two review authors working independently (LB and KH) screened all titles and abstracts to identify studies that might meet the inclusion criteria, or that cannot be safely excluded without assessment of the full text (e.g. when no abstract is available). All eligible papers were formally abstracted by at least two members of the review author team working independently (LB and KH) and using the data collection form. When possible, and if appropriate, we performed a fixed-effect meta-analysis of study outcomes. For continuous outcomes (e.g. cardiorespiratory fitness), we extracted the final value, the standard deviation of the outcome of interest and the number of participants assessed at follow-up in each treatment arm, to estimate standardised mean difference (SMD) between treatment arms. SMD was used, as investigators used heterogeneous methods to assess individual outcomes. If a meta-analysis was not possible or was not appropriate, we synthesised studies as a narrative. MAIN RESULTS: Fourteen trials were included in this review, involving a total of 648 participants. Only studies involving breast, prostate or colorectal cancer were identified as eligible. Just six trials incorporated a target level of exercise that could meet current recommendations. Only three trials were identified that attempted to objectively validate independent exercise behaviour with accelerometers or heart rate monitoring. Adherence to exercise interventions, which is crucial for understanding treatment dose, is often poorly reported. It is important to note that the fundamental metrics of exercise behaviour (i.e. frequency, intensity and duration, repetitions, sets and intensity of resistance training), although easy to devise and report, are seldom included in published clinical trials.None of the included trials reported that 75% or greater adherence (the stated primary outcome for this review) of the intervention group met current aerobic exercise recommendations at any given follow-up. Just two trials reported six weeks of resistance exercise behaviour that would meet the guideline recommendations. However, three trials reported adherence of 75% or greater to an aerobic exercise goal that was less than the current guideline recommendation of 150 minutes per week. All three incorporated both supervised and independent exercise components as part of the intervention, and none placed restrictions on the control group in terms of exercise behaviour. These three trials shared programme set goals and the following behaviour change techniques: generalisation of a target behaviour; prompting of self-monitoring of behaviour; and prompting of practise. Despite the uncertainty surrounding adherence in many of the included trials, interventions caused improvements in aerobic exercise tolerance at 8 to 12 weeks (from 7 studies, SMD 0.73, 95% confidence interval (CI) 0.51 to 0.95) in intervention participants compared with controls. At six months, aerobic exercise tolerance was also improved (from 5 studies, SMD 0.70, 95% CI 0.45 to 0.94), but it should be noted that four of the five trials used in this analysis had a high risk of bias, hence caution is warranted in interpretation of results. Attrition over the course of these interventions is typically low (median 6%). AUTHORS' CONCLUSIONS: Interventions to promote exercise in cancer survivors who report better levels of adherence share some common behaviour change techniques. These involve setting programme goals, prompting practise and self-monitoring and encouraging participants to attempt to generalise behaviours learned in supervised exercise environments to other, non-supervised contexts. However, expecting most sedentary survivors to achieve current guideline recommendations of at least 150 minutes per week of aerobic exercise is likely to be unrealistic. As with all well-designed exercise programmes in any context, prescriptions should be designed around individual capabilities, and frequency, duration and intensity or sets, repetitions, intensity or resistance training should be generated on this basis.

Transcutaneous electric nerve stimulation (TENS) for cancer pain in adults.

BACKGROUND: Cancer-related pain is complex and multi-dimensional but the mainstay of cancer pain management has predominantly used a biomedical approach. There is a need for non-pharmacological and innovative approaches. Transcutaneous Electric Nerve Stimulation (TENS) may have a role in pain management but the effectiveness of TENS is currently unknown. This is an update of the original review published in Issue 3, 2008. OBJECTIVES: The aim of this systematic review was to determine the effectiveness of TENS for cancer-related pain in adults. SEARCH METHODS: The initial review searched The Cochrane Library, MEDLINE, EMBASE, CINAHL, PsychINFO, AMED and PEDRO databases in April 2008. We performed an updated search of CENTRAL, MEDLINE, EMBASE, CINAHL and PEDRO databases in November 2011. SELECTION CRITERIA: We included only randomised controlled trials (RCTS) investigating the use of TENS for the management of cancer-related pain in adults. DATA COLLECTION AND ANALYSIS: The search strategy identified a further two studies for possible inclusion. One of the review authors screened each abstract using a study eligibility tool. Where eligibility could not be determined, a second author assessed the full paper. One author used a standardised data extraction sheet to collect information on the studies and independently assess the quality of the studies using the validated five-point Oxford Quality Scale. The small sample sizes and differences in patient study populations of the three included studies (two from the original review and a third included in this update) prevented meta-analysis. For the original review the search strategy identified 37 possible published studies; we divided these between two pairs of review authors who decided on study selection; all four review authors discussed and agreed final scores. MAIN RESULTS: Only one additional RCT met the eligibility criteria (24 participants) for this updated review. Although this was a feasibility study, not designed to investigate intervention effect, it suggested that TENS may improve bone pain on movement in a cancer population. The initial review identified two RCTs (64 participants) therefore this review now includes a total of three RCTs (88 participants). These studies were heterogenous with respect to study population, sample size, study design, methodological quality, mode of TENS, treatment duration, method of administration and outcome measures used. In one RCT, there were no significant differences between TENS and placebo in women with chronic pain secondary to breast cancer treatment. In the other RCT, there were no significant differences between acupuncture-type TENS and sham in palliative care patients; this study was underpowered. AUTHORS' CONCLUSIONS: Despite the one additional RCT, the results of this updated systematic review remain inconclusive due to a lack of suitable RCTs. Large multi-centre RCTs are required to assess the value of TENS in the management of cancer-related pain in adults.

Transcutaneous electric nerve stimulation (TENS) for cancer pain in adults.

BACKGROUND: Cancer-related pain is complex and multi-dimensional but the mainstay of cancer pain management has predominately used a biomedical approach. There is a need for non-pharmacological and innovative approaches. Transcutaneous Electric Nerve Stimulation (TENS) may have a role for a significant number of patients but the effectiveness of TENS is currently unknown. OBJECTIVES: The aim of this systematic review was to determine the effectiveness of TENS for cancer-related pain in adults. SEARCH STRATEGY: We searched The Cochrane Library, MEDLINE, EMBASE, CINAHL, PsychINFO, AMED and PEDRO databases (11/04/08). SELECTION CRITERIA: Only randomised controlled trials (RCTS) investigating the use of TENS for the management of cancer-related pain in adults were included. DATA COLLECTION AND ANALYSIS: The search strategy identified 37 possible published studies which were divided between two pairs of review authors that decided on study selection. A study eligibility form was used to screen each abstract and where study eligibility could not be determined from the abstract, the full paper was obtained and assessed by one pair of review authors. A standardised data extraction sheet was used to collect information on the studies and the quality of the studies was assessed independently by two review authors using the validated five-point Oxford Quality Scale. Final scores were discussed and agreed between all four review authors. The small sample sizes and differences in patient study populations of the two included studies prevented meta-analysis. MAIN RESULTS: Only two RCTs met the eligibility criteria (64 participants). These studies were heterogenous with respect to study population, sample size, study design, methodological quality, mode of TENS, treatment duration, method of administration and outcome measures used. In one RCT, there were no significant differences between TENS and placebo in women with chronic pain secondary to breast cancer treatment. In the other RCT, there were no significant differences between acupuncture-type TENS and sham in palliative care patients; this study was underpowered. AUTHORS' CONCLUSIONS: The results of this systematic review are inconclusive due to a lack of suitable RCTs. Large multi-centre RCTs are required to assess the value of TENS in the management of cancer-related pain in adults.

Transcutaneous electrical nerve stimulation vs. transcutaneous spinal electroanalgesia for chronic pain associated with breast cancer treatments.

Chronic pain associated with breast cancer treatment is becoming increasingly recognized. Patients with this condition can experience significant physical and psychological morbidity and may benefit from nonpharmacological interventions as part of a multidisciplinary team approach. We compared the effectiveness of transcutaneous electrical nerve stimulation (TENS), transcutaneous spinal electroanalgesia (TSE), and a placebo (sham TSE) in a randomized controlled trial. The study sample comprised 41 women with chronic pain following breast cancer treatment, and outcome measures included pain report, pain relief, pain interference, anxiety and depression, arm mobility, and analgesic consumption. There was little evidence to suggest that TENS or TSE were more effective than placebo. All three interventions had beneficial effects on both pain report and quality of life, a finding that may be due to either psychophysical improvements resulting from the personal interaction involved in the treatment or a placebo response. Although electrical stimulation appears to be well tolerated in this population, further research is needed to establish its effectiveness for chronic cancer treatment-related pain.

A pain management program for chronic cancer-treatment-related pain: a preliminary study.

UNLABELLED: A large proportion of patients may develop chronic pain following cancer treatments such as surgery, radiotherapy, or chemotherapy. These patients can experience significant levels of physical and psychological morbidity. Our aim was to investigate a cognitive-behavioral pain management program (PMP) for cancer patients with chronic treatment-related pain. Thirteen patients (1 man, 12 women; mean age 52 yrs) completed the study, 9 of whom had a history of breast cancer and had received extensive medical treatment, including surgery. A combination of physical and psychological techniques were adapted from previous work in chronic benign pain and implemented by two therapists. Interventions included education, relaxation, exercise training, and goal setting. A variety of outcomes were examined to assess general fitness, psychological distress, coping success, activities of daily living, and pain report. The median number of interventions by each therapist was 10 (4 to 15). Postintervention, there was a significant trend toward improvement in many variables, including anxiety and depression (P < .01), fitness (walking: P < .05), and coping with pain (P < .01). This was a feasibility study and has several limitations. It appears, however, that all patients had a positive outcome. Further research is now required to assess the effectiveness of this approach. PERSPECTIVE: Results of this preliminary study are clinically relevant, as they suggest that a pain management program that uses cognitive-behavioral principles is worthy of further investigation for patients with chronic cancer-treatment-related pain.