The randomized controlled trial described took place in a setting in which both intervention and control groups underwent an identical IO treatment program, within the framework of an evidence-based, standard-of-care protocol. The study findings indicate that the introduction of IO-trained palliative care nurses to the multi-disciplinary IO treatment program, providing additional instruction to patients on self-treatment with IO modalities, is feasible. The guidance provided by these nurses was associated with greater short-term (24-hour) scores for fatigue and appetite in patients undergoing active oncology treatment, though further quantitative research is needed. This finding is particularly significant, since cancer-related fatigue is extremely prevalent and challenging for oncologists, with currently available therapeutic options limited in their effectiveness, with the exception of physical exercise interventions. This contrasts greatly with other QoL-related symptoms such as pain, nausea, constipation and diarrhea, for which conventional medicine offers a number of effective, evidence-based treatment options.
The additive impact of the IO-trained nurse-guided instruction needs to be better understood. It is possible that non-specific effects were generated by the additional guidance provided by the IO-trained nurses, which affirmed the guidance provided by the IO practitioners. The nurse intervention may have enhanced patients’ perceptions of care and compassion, especially by involving two (as opposed to one) IO-trained practitioners. The nurse-mediated guidance may have also promoted a sense of empowerment, as suggested in the short MYCAW patient narratives. At the same time, the presence of specific effects should be recognized, and not only those which are non-specific.
It should be noted that both groups of oncology patients received the same IO treatment regimen, provided by IO practitioners, most frequently including acupuncture. At the same time, all of the study IO practitioners provided instruction to for the self-administration of at least one IO modality (manual, mind-body or herbal-related) at home during the 24-hour period following treatments at the study center. It is possible that the more frequent use of manual/acupressure modalities in the intervention group was related to the addition of nurse-delivered guidance on these practices. Further research is needed to explore why the intervention was shown to be of potential benefit for only ESAS fatigue and appetite scores, and not other QoL-related concerns.
Nurses have the potential to play a leading role in the IO setting: providing the therapies themselves, managing programs, and promoting patient and caregiver education, assessment, and follow-up. Yet this pivotal role has been largely overlooked in most IO settings, where treatments are invariably provided by IO practitioners who, despite high levels of training and extensive experience, have had limited training in the instruction of patients and their caregivers as they transition to home. This gap is especially characteristic of IO modalities in which patients play a more passive role (e.g., acupuncture, reflexology), as opposed to mind-body and movement interventions for which they play a more active role (e.g., Qigong, Yoga, Feldenkrais method) and for those more conducive to self-treatment at home (e.g., listening to a pre-recorded meditation).
In contrast to nurses, IO practitioners are often seen more as healthcare providers when administering treatments in which the patient is more passive (e.g., acupuncture), as opposed to being "teachers" when providing more patient-involved therapies (e.g., yoga). It is possible that the nurse's role in the intervention group extends beyond the limits of the therapeutic process, toward their role as ‘teachers’ who regularly provide guidance and hands-on instruction to patients at home. Patient education and counselling are central to the nursing profession, and these skills may have helped enhance their ability to serve as “teachers" far more significantly than the IO practitioners. Despite their limited experience in providing IO therapies, they may have enhanced and extended the IO therapeutic effect through the self-treatment process.
Self-administration of IO therapies is increasingly becoming the subject of clinical research, though the effect of these interventions remains to be assessed. Molassiotis et al. conducted a randomized controlled trial that demonstrated the feasibility and safety of acupuncture self-needling as maintenance therapy for cancer-related fatigue, following acupuncturist-delivered treatment. Zick at al. investigated self-administered acupressure for persistent cancer-related fatigue in breast cancer survivors, and found the intervention improved fatigue when compared with usual care, along with sleep quality and QoL. The shift toward a more patient-guided treatment approach, with self-administered therapy, has become even more relevant during the current COVID-19 pandemic. This process has been facilitated by the creation of online practice recommendations, such as those published by the Online Task Force of the Society for Integrative Oncology.
The present study has several methodological limitations, including the absence of blinding and the use of sham/wait-list control groups. The IO treatment and guidance protocol was also not fully structured, incorporating a patient-tailored and multi-modal IO approach. However, this pragmatic approach is far more reflective of the "real-world" IO clinical setting, where treatment protocols are semi-structured and attuned to patients’ QoL profile, expectations, and health beliefs. In addition to the above limitations, the study outcomes were measured only over a short-term (24-hour) period, raising the need for future research to assess more long-term effects of the intervention. Further research is also needed to address additional patient-reported outcomes, using not only short-term tools such as the ESAS, which examines the past 24 hours; but also longer-term tools, such as the EORTC QLQ-C30, which measures QoL over the previous week. The studies will need to examine different IO settings, in other countries and in more diverse populations, to allow for generalizability of the findings. Finally, the effectiveness and safety of the nurse-guided IO therapies need to be addressed, using both quantitative outcome measures and qualitative methodologies to assess the perspectives of nurses, patients, and their caregivers.
In conclusion, the study findings suggest that additional guidance provided by IO-trained nurses (in addition to that of IO practitioners) on the self-administration of IO therapies at home is feasible, as well as providing a short-term additive effect in reducing fatigue and improving appetite. Further research is needed to identify the specific and non-specific effects of nurse-led guidance, as well as the value of creating a continuum of care from the cancer center to the patient's home, enhancing accessibility, health equity, and inclusion in the context of IO care.