Non-pharmacological management for chemotherapy-induced nausea and vomiting in patients with cancer: a scoping review^†

A scoping review was carried out. Scoping reviews map the available literature and provide an overview of the evidence to provide contextual information or concepts.¹² In contrast to systematic review, practical guidance states that critical appraisal of individual studies is not required in a scoping review.^12,13

The methodological guideline from Arskey and O’Malley¹⁴ was used as a frame for this scoping review. The steps include: (a) identification of research questions, (b) identification of relevant studies, (c) selection of studies, (d) mapping data, and (e) compilation, summary, and reporting of results. Arskey and O’Malley¹⁴ state that the method of identification of the sample is iterative, requires researchers to interact with each phase reflexively, and if required, repeat the steps to ensure that the literature is thoroughly discussed. This approach allows reviews to extract and create data meaningfully and comprehensively manner.¹⁵ Details of each steps as explained by Cooper et al.¹⁶ are also adopted in the current review. For example, in the step of defining the study aim and research questions, we stated the purpose for scoping review and a well-defined research question to guide the scope of the review. A well-defined research question that includes the scope of the study is fundamental, as it will allow researchers to conduct a more practical and efficient review.¹⁷ The scoping review questions address Patient Concept and Context (PCC). There were 2 research questions for the review: (1) What type of non-pharmacological interventions (Concept) for CINV (Population) have been trialed on patients with cancer (Context)? (2) How has CINV been assessed in available studies?

In the scoping review checklist developed by Cooper et al.¹⁶, an in-depth literature and comprehensive search is required to enable identifying the relevant literatures. In the scoping review, 4 electronic databases were searched: PubMed (Medline), CINAHL, PsycINFO, Scopus, and Cochrane to identify published studies meeting the inclusion criteria. We determined keywords based on the research questions before identifying the relevant journal articles. MeSH search keywords were then used jointly: “nausea or vomiting,” “chemotherapy,” “non-pharmacological,” and “complementary therapy.” The keywords were searched individually, then combined using the Boolean term AND. Box 1 shows an example of the search strategy used in Cochrane.

The Participants/Concept/Context structure was used to define the scoping review search strategy:

During the data selection process, we defined a clear inclusion and exclusion criteria and conducted an iterative process to select the relevant studies as suggested by Cooper et al.¹⁶. Inclusion criteria for this review included: (i) studies or interventions that addressed non-pharmacological management for CINV, (ii) adult patient with cancer and experiencing CINV as participants, and (iii) studies published from 2015 onwards, to ensure relevancy to current nursing practice. The exclusion criteria for this review include: (i) qualitative studies, (ii) review paper, and (iii) publications in language other than English.

All identified records in the initial search were exported to Endnote X9 Software (Clarivate Analytics, PA, USA) and duplicates were automatically removed using it. Two reviewers (DM and ER) independently assessed the articles based on the relevance according to titles, abstracts, and full-text information. Subsequent to the individual review, all reviewers gathered to discuss the review following the inclusion criteria. Any discrepancies between the 2 reviewers at any stage of the selection process were discussed and settled with the third reviewer.

First, we independently examined relevant studies using the information of titles and abstracts and retrieved the full-text for all studies that met the eligibility criteria. The 2 reviewers independently (DM and ER) assessed the full-text of the articles to confirm that they met the inclusion criteria. Following that, the reviewers gathered to discuss the analysis.

The goal of this scoping review was to map and summarize the available literature related to CINV non-pharmacological management from 2015 onwards. A table for extracting details, characteristics, and result of studies based on the Joanna Briggs model was developed.¹³ In the fourth stage of the review, we charted the data. To capture all of the relevant information and ensure that no important information was missed, each of the 11 selected full-text papers was thoroughly read several times by the 2 authors. The papers’ dataset was built by extracting the results relevant to the questions asked. The review authors discussed the design of this dataset to ensure that all relevant information was included. Categories included in the data extraction tool and spreadsheet were as follows: (a) author and publication year, (b) aim of the study (c) setting for study (country, hospital, clinic), (d) study design, (e) participants (number of participants, age, type of cancer), (f) intervention (type, duration, length), (g) outcome measures used, (h) study outcomes, and (i) category of interventions.

Table 1 shows the descriptive data for each included study including the following: study descriptive, research design, participants, measures, intervention and its category, and findings. Most of the studies, approximately one-third (36.4%), were conducted in Turkey, followed by China (18%) and Iran (18%). Each of the following 3 countries published a single study during the period under review: Canada, Jordan, and the United States. After reviewing the literature, we summarized the availability of non-pharmacological therapy and its types, and instruments for measuring the outcomes of interventions.

The total number of participants included in the review was 1159. The number of participants in each included study ranged from 40 to 240, and the average sample size of the included studies was 105. Approximately two-third of the studies (72.7%) had samples of 50–150 participants. The remaining studies included >150 (18.2%) or <50 (9%) participants. The combined mean age of participants in the included studies was 52.18 (SD = 10.51). The populations studied were predominantly diagnosed with breast cancer (n = 7, 63.6%). Four studies involved patients with different cancers such as lung, ovarian, cervical, gastrointestinal, hematology, and respiratory. Of 11 studies, 6 studies included patients with cancer from stages I–III. Regarding the setting of the included study, 4 studies were conducted in the ambulatory oncology unit, 1 study was conducted in the cancer wards, and the remaining studies did not explicitly state the setting. All the studies reported that the participants received standard treatment with antiemetics and non-pharmacological interventions.

Most of the reviewed studies predominantly included an experimental group and a control group (n = 10 studies, 90.9%) and 1 study (9.1%) incorporated an additional experimental group. There are various non-pharmacological interventions for CINV, including acupuncture, the use of the hologram bracelet, reflexology, yoga, breathing exercise, consumption of ginger extract, massage and inhalation aromatherapy, peppermint aromatherapy, auricular acupressure, and the use of acupressure wrist band. We categorized the interventions applied in the studies based on Millstine’s category of complementary and alternative therapy.²⁹ The categories include manipulative and body-based therapy; mind–body therapy; biologically based practice, and energy therapy. Manipulative and body-based therapy is based on the belief that the human body can regulate and heal itself and that its parts are interdependent. Therapies in the manipulative and body-based therapy include: massage, reflexology, cupping, and acupuncture.²⁹ Another category, that is, mind–body therapy is primarily based on the theory that mental and emotional factors regulate physical health by connecting between hormonal, and immunologic throughout the body. The mind–body therapy includes biofeedback, guided imagery, hypnotherapy, meditation, including mindfulness, and relaxation.²⁹ The category that is biologically based practices uses naturally occurring substances to affect health. This type of therapy includes the following: botanical medicine and natural products, chelation therapy, and diet therapies.²⁹

Most frequently, the studies focused on manipulative and body-based therapy, such as massage and inhalation therapy,²⁰ acupressure bands,²¹ auricular acupressure,²² Bali yoga,¹⁸ and reflexology.¹⁹ Mind–body therapy includes interventions such as guided imagery,²⁴ breathing exercises,²⁵ and peppermint oil.²³ Two studies focused on energy therapy: hologram bracelets²⁷ and acupuncture.²⁶ The last category was biologically based therapy that included interventions such as ginger extract.²⁸

The interventions in the included studies were conducted by nurses, either a general nurse^24,25,28 or those who had trained and certified in the particular intervention.¹⁹ Other included studies did not provide in detail who had conducted the interventions. The interventions varied based on content or intent, as well as on duration and intensity. The durations of the interventions for the participants ranged from 5 d to 3 chemotherapy cycles. The interventions included at least 3 min of auricular acupressure per day for 5 d,²² 90 min of yoga over 8 weeks,¹⁸ and 30–40 min of reflexology per cycle for 3 cycles of chemotherapy.¹⁹ Six studies reported that the duration of the interventions was 5–6 d, and the intensity of the intervention was 20–40 min/d. Other interventions in 3 studies were conducted for 3 chemotherapy cycles, while 1 study reported that the majority of the interventions were provided daily within 5 d. The interventions in these studies ranged from 5 d of breathing exercises for 5 min to reflexology and combined massage and inhalation therapy during each chemotherapy session conducted for up to 3 chemotherapy cycles. Two studies included an in-depth assessment of fatigue as recommended in the NCCN clinical guidelines.^30–32

Three studies that were included in the mind–body therapy provided details of how the interventions were carried. For example, the authors explain the guided imagery intervention that contains 3 sessions of listening 2 tracks of audio-recorded guided imagery.²⁴ First, the patients were provided with small and easy-to-use headphones to prevent environmental noise to ensure their concentration on the audio. Then, the patients in the intervention group were asked to listen to the first track the night before the third session for 10 min. The first track included the soft and slow tempo as background music, and the second track consisted of a pleasant scene of imagery scripts. The researcher in Hosseini et al.’s²⁴ study asked the patients to write the frequency and severity of their nausea and vomiting during and after the intervention.

An aromatherapy practice guide was developed and stated in the study conducted by Erturk and Tasci.²³ The procedure for aromatherapy is as follows: (1) getting permission after explaining the study; (2) choosing a quiet and comfortable place; (3) handwashing for the practitioner; (4) dropping 1 drop of pre-prepared aromatic oil and applying between patient’s lip and nose and asking patients to take a deep breath; (5) tightly closing the cap of the aromatherapy bottle; (6) repeating the protocol for 5 d at the same hour in the morning, at noon, and in the evening; and (7) documenting the procedure and writing down any problems related to aromatherapy administration.²³

All the studies based their measurement solely on patient-reported outcome measures, such as existing CINV inventories (90.9%) and diaries (9.1%). Seven different scales were used to measure CINV. The most common measures were the Morrow Assessment Scale^22,18,24 and the visual analog scale.^20,25,23 Other inventories were the Common Terminology Criteria for Adverse Events (CTCAE)²⁶; functioning Living Index Emesis²⁷; self-report diary²¹; Rhodes INVR¹⁹; and the MASCC Antiemesis Tool²⁸ (Table 2).

All the reviewed studies included pre- and post-measurements, whereas none of them included follow-up measures. Reductions in the frequency and severity of nausea as the primary outcome were specified in all the studies. Over two-third of the studies (72.7%) reported a significant improvement in CINV based on frequency and severity immediately after the intervention. The patients who were provided the following interventions had less number of nausea and vomiting and significant improvement on their conditions. The following interventions are auricular acupressure and acupressure band^21,22; inhalation and massage²⁰; peppermint oil²³; guided imagery²⁴; reflexology¹⁹; breathing exercise²⁵; and hologram bracelet.²⁷ Among the 11 reviewed studies, 3 reported no significant CINV changes after measurement. The interventions that did not have a positive outcome include Bali Yoga, acupuncture, and the administration of ginger root powder.^18,26,28