The latest edition now includes one recommended for practice intervention, Cognitive Behavioral Intervention.

Cognitive behavioral interventions focus on changing caregivers’ perceptions of their ability to control a situation, including challenging their negative thoughts that encourage problematic behaviors; using strategies that facilitate development of problem-solving abilities; and focusing on managing time, work, and emotional reactions. The team found that these interventions are most effective in caregivers who are female or younger than the patient who receives the care.

Eaton, 2009; ONS, 2009

The addition of Tropisetron as a 5HT₃ receptor antagonist choice.

For breakthrough/refractory nausea and/or vomiting, a second cannabinoid option is now available, Nabilone.

Eaton, 2009; Kris, 2006; MASCC, 2008; NCCN, 2008; ONS, 2009

The NK1 receptor antagonist Aprepitant is now available in an IV formulation (fosaprepitant 115 mg IV) and may be considered if the oral route is contraindicated.

A 3-drug antiemetic combination (NK 1 receptor antagonist, 5HT₃ receptor antagonist, and a corticosteroid is recommended.

With regimens, containing doxorubicin and cyclophosphamide, the evidence supports use of this 3-drug antiemetic combination

Delayed nausea can last up to 10 days depending on the sequence of the regimen and the emetogenicity of the last chemotherapy agent administered. It is important to administer the recommended antiemetics for as long as the delayed nausea is expected to occur and not discontinue prematurely.

New intervention added to the effectiveness not established category

New intervention added to the effectiveness not established category

Alvimopan; Methylnaltrexone; Colchicine; Lubiprostone, Misoprostol and PEG 4000. The use or PEG with or without electrolytes showed a higher level of evidence for use in non-oncology patients and was moved to likely to be effective.

Guar Gum, a non pharmacologic product, was added.

Eaton, 2009; ONS, 2009; Zanetti, 2007

Tegaserod was taken off the market.

New pediatric information was added regarding clarification of the use of enemas in infants and children, and also the use of mineral oil, PEG and Milk of Magnesia in children.

The use of phosphate enemas in the very young and old with chronic renal failure, diseases altering GI motility, tumor lysis syndrome and bowel obstruction.

Palliative Care Guidelines were included which further support the benefit of using antidepressant medications for people with cancer and depression. Specifically endorsed by the Palliative Care Guidelines are tricyclic antidepressants (TCAs) or selective serotonin receptor inhibitors (SSRIs).

Eaton, 2009; ONS, 2009

Exercise shows promise as an intervention to improve mood in patients with cancer, but current studies are small and their limitations prevent sufficient evidence for recommendation. Therefore effectiveness is not established for exercise.

Likely to be Effective: Octreotide 150 micrograms SQ three times daily results in near-complete resolution of diarrhea in rectal carcinoma patients with grades 2 or 3 diarrhea receiving concomitant 5-FU & pelvic radiation therapy who are refractory to loperamide

de Jong, 2006; Eaton, 2009; Flieger, 2007; Kehrer, 2001; ONS, 2009; Topkan, 2006

Benefits Balanced with harms

Effectiveness not established

Several meta-analyses and systematic reviews show that patients receiving ESAs to correct anemia less than 10 g/dl may experience increased vigor and diminished fatigue. Only limited evidence exists that ESAs improve fatigue when anemia is less severe. Although both epoetin and darbepoetin are generally well tolerated, the use of these agents specifically for the management of fatigue must be considered in light of safety issues, including an increased risk of thrombotic events, hypertension, and concerns that ESAs may support or extend tumor growth in patients with head and neck cancer, breast cancer, non-small cell lung cancer, or cervical cancer. Particular caution should be ESAs may not be indicated to treat anemia associated with malignancy or the anemia of cancer in patients with solid or non-myeloid hematological malignancies (e.g. myeloma, chronic lymphocytic leukemia or non-Hodgkin’s lymphoma), or in patients at increased risk for thromboembolic complications exercised in the use of ESAs at higher doses, with dosing to target a hemoglobin ≥ 12 g/dL, and with protracted ESA treatment.

Eaton, 2009; Mitchell, 2007; ONS, 2009

New interventions studied, effectiveness not established for all listed below

Effective for mucotoxic chemotherapy and that recent studies suggest a decrease in oral mucositis with longer durations of cryotherapy.

Eaton, 2009; ONS, 2009; Rosen, 2006; Sorensen, 2008

The palifermin intervention was modified to indicate that it is now acceptable for use in allogeneic as well as autologous transplant settings. Further study of palifermin is needed in order to determine its use beyond the transplant setting.

Effectiveness not established: misoprostol, topical Vitamin E, and proteolytic enzymes trialed under the name Wobe-Mugos E.

Caphosol, fluoride chewing gum, gelclair, honey, and L-alanyl-L-glutamine.

Effectiveness not established addition: Recent study which demonstrated a benefit of chlorhexidine rinse over normal saline and cryotherapy for severity and duration of mucositis (clearly stated that the chlorhexidine was alcohol-free) Chlorhexidine with alcohol has not been found to be effective in reducing mucositis and remains in the Not Recommended for Practice section.

An anti-epileptic and mood stabilier has been studied as a potential treatment for CIPN. The study concluded lamotrigine was ineffective in treating chemotherapy - induced peripheral neuropathy.

Eaton, 2009; ONS, 2009; Rao, 2008; Wang, 2007

The study failed to demonstrate the benefit of gabapentin to treat CIPN symptoms.

Glutamine supplementation significantly reduced the incidence and severity of oxaliplatin induced peripheral neuropathy. Results suggest glutamine has a potential neuroprotective effect in patients treated with oxaliplatin but larger placebo controlled, randomized trials are needed to confirm further recommendations.

The hand hygiene recommendation was amended to specify that if patients have suspected or known infection with c. difficile or bacillus mechanical removal with soap and water is required for hand hygiene since spore-forming bacteria are not killed by alcohol

Boyce, 2002; DeMille, 2006; Eaton, 2009; Gardner, 2008; Larson, 2004; Moody, 2002; NCCN, 2008; ONS, 2009; Siegel, 2007a; Siegel, 2007b; Somerville, 1986; van Tiel, 2007; Wilson, 2002

Private rooms are recommended to decrease the transmission of infection for all patients. Routine donning of gowns when entering high risk units is deemed unnecessary. However, contact precautions, including gowns and gloves, are indicated if patients have a multidrug-resistant infection

Recommendations that were added to the PEP card based on these guidelines include: penicillin prophylaxis to prevent pneumococcal infection in patients who have undergone splenectomy or who are functionally asplenic , cytomegalovirus (CMV) prophylaxis for high risk patients, and hepatitis B prophylaxis for at risk patients.

The most noteworthy update to the 2009 PEP card is a change in the recommendation for neutropenic diets from "effectiveness not established" to "effectiveness unlikely." Research is accumulating that demonstrates that neutropenic diets are unlikely to decrease the risk of infection.

Moved to the "Likely to be Effective" category. This recommendation is based on four new studies that were rated as ONS evidence Level I. All of these intervention studies reported positive benefits on patients' sleep; two were during active treatment and two were among survivors. Additional evidence from several smaller studies supported these findings.

Cohen, 2007; Eaton, 2009; ONS, 2009; Page, 2006

Effectiveness not established due to small studies, but show promise