Journal of Pain & Palliative Care Pharmacotherapy. 2011;25:374–376.Copyright © 2011 Informa Healthcare USA, Inc.ISSN: 1536-0288 print / 1536-0539 onlineDOI: 10.3109/15360288.2011.620696

EVIDENCE-BASED PAIN MANAGEMENT AND PALLIATIVE CARE

Systematic Reviews in Published in the July 2011 Issue ofthe Cochrane Library

Philip J. Wiffen

ABSTRACT

New systematic reviews pertinent to pain and palliative care that appeared in the July 2011 issue of theCochrane Library addressed selenium for cancer prevention, botulinum toxin for subacute/chronic neck pain,arthroscopy for temporomandibular disorders, low-dose rate brachytherapy for men with localized prostate can-cer, arthroscopy for temporomandibular disorders, and home-based end-of-life care.

KEYWORDS Arthroscopy, BoNT type A, botulinum toxin, brachytherapy, cancer, end-of- life care, home-based treatment, neck pain, prostate cancer, selenium, temporomandibular disorders

The Cochrane Library of Systematic Reviews is pub-lished quarterly as a DVD and also monthly online.The July 2011 issue (3rd DVD for 2011) contains4695 complete reviews, 2025 protocols for reviews inproduction, and 15251 one-page summaries of sys-tematic reviews published in the general medical lit-erature. In addition, there are citations of 651,000randomized controlled trials, and 14,761 cited papersin the Cochrane methodology register. The healthtechnology assessment database contains just over10,000 citations. One hundred and one new reviewshave been published in the last 3 months, of whichfive have potential relevance for practitioners in painand palliative medicine. The impact factor of theCochrane Library has increased slightly to 6.186.Readers are encouraged to access the full report forany articles of interest, as only a brief commentary isprovided.

SELENIUM FOR PREVENTING CANCER

This review should be cited as: Dennert G,Zwahlen M, Brinkman M, Vinceti M, Zeegers

Philip J. Wiffen, BPharm, MSc, is a member of the Oxford RegionalPain Relief Unit, an Editor of the Cochrane Collaboration Pain Palliativeand Supportive Care Collaborative Review Group, and Acting Director atthe UK Cochrane Center. He is a visiting Professor at the Department ofPharmacy and Pharmacology, University of Bath, Bath, United Kingdom.

Address correspondence to: Philip J. Wiffen, UK Cochrane Centre, Oxford,OX2 7LG, United Kingdom (E-mail: phil.wiffen@pru.ox.ac.uk).

MPA, Horneber M. Selenium for preventingcancer. Cochrane Database of Systematic Re-views 2011, Issue 5. Art. No.: CD005195. DOI:10.1002/14651858.CD005195.pub2.

Selenium is a trace element essential to humans.Higher selenium exposure and selenium supple-ments have been suggested to protect against severaltypes of cancers. That would be great but is it thecase?

The authors included 49 prospective observationalstudies (around 400,000 participants) and six ran-domised controlled trials (RCTs) (43,000 partici-pants). In epidemiologic data, they found a reducedcancer incidence (summary odds ratio [OR] 0.69,95% confidence interval [CI] 0.53 to 0.91) and mor-tality (OR 0.55, 95% CI 0.36 to 0.83) with higherselenium exposure. Cancer risk seemed to be morereduced in men (incidence: OR 0.66, 95% CI 0.42to 1.05) than in women (incidence: OR 0.90, 95%CI 0.45 to 1.77). But study design, quality, andheterogeneity of the data make the interpretationdifficult.

The RCTs found no protective efficacy of sele-nium yeast supplementation against nonmelanomaskin cancer or L-selenomethionine supplementationagainst prostate cancer. Study results for the preven-tion of liver cancer with selenium supplements wereinconsistent and studies had an unclear risk of bias.Some studies suggested that selenium supplementsmay do more harm than good.

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The authors conclude, “To date, there is no con-vincing evidence that selenium supplements can pre-vent cancer in men, women or children.”

BOTULINUM TOXIN FORSUBACUTE/CHRONIC NECK PAIN

This review should be cited as: Langevin P, PelosoPMJ, Lowcock J, Nolan M, Weber J, Gross A,Roberts J, Goldsmith CH, Graham N, Burnie SJ,Haines T. Botulinum toxin for subacute/chronicneck pain. Cochrane Database of Systematic Re-views 2011, Issue 7. Art. No.: CD008626. DOI:10.1002/14651858.CD008626.pub2.

Botulinum toxin (BoNT) is a nasty substance espe-cially in the hands of the Clostridium bacterium. De-spite this, it has become a fashion drug, constantlylooking for a new indication. This time the targetgroup is patients with neck pain with or without as-sociated cervicogenic headache.

The authors assessed risk of bias using theCochrane Back Review Group criteria. In the absenceof clinical heterogeneity, the authors calculated stan-dardized mean differences (SMDs) and relative risks,and performed meta-analyses using a random-effectsmodel. The quality of the evidence and the strengthof recommendations were assigned an overall gradefor each outcome.

After an extensive search nine trials (503 partici-pants) were included. Only BoNT type A (BoNT-A)was used in these studies. High-quality evidence sug-gests that there was little or no difference in pain be-tween BoNT-A and saline injections at 4 weeks and6 months for chronic neck pain. Even if you add inphysiotherapeutic exercise and analgesics, Botox of-fers no more benefit than saline injection.

LOW-DOSE RATE BRACHYTHERAPYFOR MEN WITH LOCALIZED PROSTATECANCER

This review should be cited as: Peinemann F,Grouven U, Hemkens LG, Bartel C, Borchers H,Pinkawa M, Heidenreich A, Sauerland S. Low-dose rate brachytherapy for men with localizedprostate cancer. Cochrane Database of SystematicReviews 2011, Issue 7. Art. No.: CD008871. DOI:10.1002/14651858.CD008871.pub2.

Brachytherapy is the application of radioisotopes inthe form of seeds. Situated close to the cancer tissue,they are able to deliver a higher dose of radiation lo-cally that should not affect other organs. This reviewaimed to assess the benefits and harms of low dose

brachytherapy compared to radical prostatectomy, orexternal beam radiotherapy.

The authors only found one RCT (N = 200;mean follow-up: 68 months). This trial comparedbrachytherapy and radical prostatectomy. The risk ofbias was deemed high. In terms of benefits, there wasno discernable difference.

The authors claim that “for short-term severe ad-verse events, low-dose rate brachytherapy was morefavorable for urinary incontinence, but radical prosta-tectomy was more favorable for urinary irritation.”Remember this is based on one RCT.

ARTHROSCOPY FORTEMPOROMANDIBULAR DISORDERS

This review should be cited as Rigon M, PereiraLM, Bortoluzzi MC, Loguercio AD, Ramos AL,Cardoso JR. Arthroscopy for temporomandibulardisorders. Cochrane Database of Systematic Re-views 2011, Issue 5. Art. No.: CD006385. DOI:10.1002/14651858.CD006385.pub2.

Temporomandibular disorders (TMDs) can in-volve the masticatory muscles or the temporo-mandibular joint (TMJ) and associated structures, orboth. It is quite common though many manage with-out any medical intervention.

Randomized controlled clinical trials ofarthroscopy for treating TMDs were sought.Seven randomized controlled trials that involved atotal of 349 participants met the inclusion criteria.All studies were either at high or unclear risk ofbias. Pain was evaluated after 6 months in somestudies and after 12 months in some other studies.The authors conclude that both arthroscopy andnonsurgical treatments reduced pain after 6 months.When compared with arthroscopy, open surgery wasmore effective at reducing pain after 12 months.There seemed to be no effect on function.

HOSPITAL AT HOME: HOME-BASEDEND-OF-LIFE CARE

This review should be cited as: Shepperd S, WeeB, Straus SE. Hospital at home: home-based end-of-life care. Cochrane Database of Systematic Re-views 2011, Issue 7. Art. No.: CD009231. DOI:10.1002/14651858.CD009231.

This is an interesting review looking at whetherthe provision of home-based end-of-life care reducesthe likelihood of dying in hospital and what effectthis has on patients’ symptoms, quality of life, healthservice costs, and caregivers compared with inpatient

C© 2011 Informa Healthcare USA, Inc.

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hospital or hospice care. The review was managed bythe Cochrane Effective Practice And Organisationof Care (EPOC) group who consider other studydesigns such as interrupted time series and controlledbefore and after studies alongside RCTs.

The authors included four trials in this review.Those receiving home-based end-of-life care were

statistically significantly more likely to die at homecompared with those receiving usual care and theirwell-being did not appear to be compromised. In ad-dition, there was some evidence of increased patientsatisfaction with home-based end-of-life care. Therewas little about the impact of home care on caregiversand this area needs to be examined further.

Journal of Pain & Palliative Care Pharmacotherapy

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