Frontiers of Nursing • 10(1) • 2023

DOI: 10.2478/fon-2023-0002

Frontiers of Nursing

Non-pharmacological management for

chemotherapy-induced nausea and vomiting
in patients with cancer: a scoping review†

Review

Dewi Maulidawatia, Erna Rochmawatia,*, Nina Granelb

a
Department of Medical Surgical Nursing, Nursing Program, Universitas Muhammadiyah Yogyakarta, Jl Brawijaya, Tamantirto, Kasihan,
Bantul 55183, Indonesia
b
Department of Nursing, Universitat Autònoma de Barcelona, Cerdanyola del Valles, Spain

Received: 25 June 2022; Accepted: 30 September 2022; Published: 20 March 2023

Abstract:  Objective: This review aimed to map and summarize published studies that tested non-pharmacological management for chemotherapy-
induced nausea and vomiting (CINV).
Methods: We searched for eligible studies in 5 electronic databases and screened the retrieved studies using the inclusion and
exclusion criteria. Data were then collated according to the types of interventions, measurement tool, and outcomes.
Results: The search yielded 2343 records, of which 11 were included. Four categories of non-pharmacological CINV management
were made; manipulative and body-based therapy (n = 5 studies); mind–body therapy (n = 3 studies); biologically based practice
(n = 1 study), and energy therapy (n = 2 studies). Seven different scales were used to measure CINV. Nine studies reported
improvement in CINV.
Conclusions: This scoping review demonstrates the breadth of non-pharmacological management to address CINV. Various types of
CINV scales were used to measure CINV severity. The management and scale can be utilized to improve nursing care, particularly in
cancer care.

Keywords:  cancer • chemotherapy-induced nausea and vomiting • complementary therapies • nausea and vomiting • review

© Shanxi Medical Periodical Press Co., Ltd.

1. Introduction
The prevalence of cancer is increasing every year effects among patients undergoing chemotherapy.2
globally with approximately 19.3 million new cases
­ CINV is experienced in varying degrees and increases
in 2020.1 Patients with cancer experience several the cancer burden of patients, and suboptimal CINV
­symptoms that may be primary or due to the impacts management negatively impacts the physical, psycho-
of the treatment. Chemotherapy-induced nausea and logical, and social functioning of the patients, leading to
vomiting (CINV) is one of the most common adverse a decrease in the quality of life.3,4

†
This project was supported by the Institute of Research and Innovation of Universitas Muhammadiyah Yogyakarta (No. 034/PEN-LP3M/II/2021).

How to cite this article: Maulidawat D, Rochmawati E, Granel N. Non-pharmacological management for
­chemotherapy-induced nausea and vomiting in patients with cancer: a scoping review. Front Nurs. 2023;1:9–20.

*Corresponding author.
E-mail: [email protected] (E. Rochmawati). 9

Open Access. © 2023 Maulidawati et al., published by Sciendo. This work is licensed under the Creative Commons
Attribution 4.0 License.
 Non-pharmacological management for CINV

The incidence of CINV is high; for instance, a study of studies, (d) mapping data, and (e) compilation, sum-
in Jordan reported that 71.4% of patients who undergo mary, and reporting of results. Arskey and O’Malley14
chemotherapy suffered from CINV,5 while an Italian state that the method of identification of the sample
study reported an incidence between 40% and 70%.6 is iterative, requires researchers to interact with each
Although the incidence is high and the negative effect phase reflexively, and if required, repeat the steps to
exists, such symptoms continue to be underestimated ensure that the literature is thoroughly discussed. This
and undertreated by nurses and physicians. Therefore, approach allows reviews to extract and create data
it is important to prevent and control CINV, in which meaningfully and comprehensively manner.15 Details
nurses can play a substantial role.7 Nursing care that of each steps as explained by Cooper et al.16 are also
addresses physical needs, such as recovering from the adopted in the current review. For example, in the step
adverse effects of cancer treatment, especially CINV, is of defining the study aim and research questions, we
a critical unmet need.8 stated the purpose for scoping review and a well-defined
Nurses can provide nursing interventions that include research question to guide the scope of the review.
non-pharmacological management and collaborate with A well-defined research question that includes the scope
physicians in managing CINV. The Oncology Nursing of the study is fundamental, as it will allow researchers
Society recommends the use of a non-pharmacologi- to conduct a more practical and efficient review.17 The
cal approach alone or in combination with pharmaco- scoping review questions address Patient Concept and
logical measures to prevent, manage, and treat CINV.9 Context (PCC). There were 2 research questions for the
Generally, the pharmacological treatment for CINV is review: (1) What type of non-pharmacological interven-
5-HT3 antagonist therapy combined with corticosteroid tions (Concept) for CINV (Population) have been trialed
therapy.5 However, the management of CINV remains on patients with cancer (Context)? (2) How has CINV
inadequate due to poor adherence to existing antiemetic been assessed in available studies?
guidelines.10 In addition, the treatment often adds to the
symptom burden experienced by patients across physi- 2.2. Search strategy
ological, emotional, and mental domains, which leads
patients to complementary and alternative medicine.11 In the scoping review checklist developed by Cooper
Available non-pharmacological management of et al.16, an in-depth literature and comprehensive search
CINV includes ginger extract, massage and inhalation is required to enable identifying the relevant literatures.
aromatherapy, dietary counseling, and auricular acu- In the scoping review, 4 electronic databases were
pressure. The available interventions can potentially searched: PubMed (Medline), CINAHL, PsycINFO,
have a positive impact on CINV. However, to date there Scopus, and Cochrane to identify published studies
­
is no available summary of the potential non-pharmaco- meeting the inclusion criteria. We determined keywords
logical management for patients with cancer and expe- based on the research questions before identifying the
riencing CINV. Therefore, there is a need to map and relevant journal articles. MeSH search keywords were
summarize the available evidence on non-pharmaco- then used jointly: “nausea or vomiting,” “chemotherapy,”
logical and nurse-led interventions for managing CINV. “non-pharmacological,” and “complementary therapy.”
This scoping review aimed to map and summarize pub- The keywords were searched individually, then com-
lished research on non-pharmacological interventions bined using the Boolean term AND. Box 1 shows an
tested to manage CINV. example of the search strategy used in Cochrane.

Box 1. Logic grid search example in Cochrane database.

2. Methods
#1 nausea OR vomiting (n = 59058)
2.1. Research design #2 chemotherapy (n = 85319)
A scoping review was carried out. Scoping reviews #3 cancer (n = 193085)
map the available literature and provide an overview of #4 non-pharmacological with Cochrane Library pub-
the evidence to provide contextual information or con- lication date between January 2015 and January
cepts.12 In contrast to systematic review, practical guid- 2021 (n = 2829)
ance states that critical appraisal of individual studies is #5 #1 AND #2 AND #3 AND #4 with Cochrane
not required in a scoping review.12,13 Library publication date between January 2015
The methodological guideline from Arskey and and January 2021, in Trials (n = 10)
O’Malley14 was used as a frame for this scoping review.
The steps include: (a) identification of research ques- The Participants/Concept/Context structure was used to
tions, (b) identification of relevant studies, (c) selection define the scoping review search strategy:
10
Maulidawati et al.

(P) Population: patients with cancer experiencing CINV author and publication year, (b) aim of the study (c) set-
(C) Concept: non-pharmacological management ting for study (country, hospital, clinic), (d) study design,
(C) Context: cancer care (e) ­participants (number of participants, age, type of
During the data selection process, we defined a clear cancer), (f) intervention (type, duration, length), (g)
­
inclusion and exclusion criteria and conducted an itera- ­outcome measures used, (h) study outcomes, and (i)
tive process to select the relevant studies as suggested category of interventions.
by Cooper et al.16. Inclusion criteria for this review
included: (i) studies or interventions that addressed
non-pharmacological management for CINV, (ii) adult
3. Results
patient with cancer and experiencing CINV as partici- A total of 2343 papers were identified, and there were
pants, and (iii) studies published from 2015 onwards, to 25 duplicates (Figure 1). After removing duplicates,
ensure relevancy to current nursing practice. The exclu- 2318 articles were reviewed by examining their title and
sion criteria for this review include: (i) qualitative studies, abstract, resulting in the exclusion of 2307 articles that
(ii) review paper, and (iii) publications in language other were not relevant to the study aim. Finally, a total of 11
than English. full-text of papers were reviewed.

2.3. Study selection 3.1. Description of included studies

All identified records in the initial search were exported Table 1 shows the descriptive data for each included
to Endnote X9 Software (Clarivate Analytics, PA, USA) study including the following: study descriptive,
and duplicates were automatically removed using it. research design, participants, measures, ­ intervention
Two reviewers (DM and ER) independently assessed and its ­category, and findings. Most of the studies,
the articles based on the relevance according to titles, approximately one-third (36.4%), were conducted in
­
abstracts, and full-text information. Subsequent to the Turkey, followed by China (18%) and Iran (18%). Each
individual review, all reviewers gathered to discuss the of the following 3 countries published a single study
review following the inclusion criteria. Any discrepan- ­during the period under review: Canada, Jordan, and
cies between the 2 reviewers at any stage of the selec- the United States. After reviewing the literature, we
tion process were discussed and settled with the third summarized the availability of non-pharmacological
­
reviewer. therapy and its types, and instruments for measuring
First, we independently examined relevant stud- the outcomes of interventions.
ies using the information of titles and abstracts and
retrieved the full-text for all studies that met the eligibil- 3.2. Participants
ity criteria. The 2 reviewers independently (DM and ER)
assessed the full-text of the articles to confirm that they The total number of participants included in the review
met the inclusion criteria. Following that, the reviewers was 1159. The number of participants in each included
gathered to discuss the analysis. study ranged from 40 to 240, and the average sample
size of the included studies was 105. Approximately
2.4. Extraction of results two-third of the studies (72.7%) had samples of
50–150 participants. The remaining studies included
The goal of this scoping review was to map and >150 (18.2%) or <50 (9%) participants. The combined
­summarize the available literature related to CINV non- mean age of participants in the included studies was
pharmacological management from 2015 onwards. A 52.18 (SD = 10.51). The populations studied were
table for extracting details, characteristics, and result predominantly diagnosed with breast cancer (n = 7,
of studies based on the Joanna Briggs model was 63.6%). Four studies involved patients with different
­developed.13 In the fourth stage of the review, we charted cancers such as lung, ovarian, cervical, gastrointes-
the data. To capture all of the relevant information and tinal, hematology, and respiratory. Of 11 studies, 6
ensure that no important information was missed, studies included patients with cancer from stages I–III.
each of the 11 selected full-text papers was thoroughly Regarding the setting of the included study, 4 ­studies
read several times by the 2 authors. The papers’ data- were conducted in the ambulatory oncology unit, 1
set was built by extracting the results relevant to the study was conducted in the cancer wards, and the
questions asked. The review authors discussed the
­ remaining studies did not explicitly state the setting.
design of this dataset to ensure that all relevant infor- All the studies reported that the participants received
mation was included. Categories included in the data standard treatment with antiemetics and non-pharma-
extraction tool and spreadsheet were as follows: (a) cological interventions.
11
 Non-pharmacological management for CINV

Records identified through a systematic search on

databases (N = 2343):
 PubMed (n = 1650)
 CINAHL (n = 655)
 PsycINFO (n = 13)
 Cochrane (n = 10)
 Scopus (n = 15)

Duplicate removed (N = 25)

Records screened (title and abstract) (N = 2318) Records excluded with reasons
(N = 2295):
 Non relevant population
(n = 261)
 Review (n = 485)
 Protocol (n = 373)
 Non relevant topic (n = 1176)
Full-text articles assessed for eligibility (N = 23)

Full-text excluded (N = 12)

 non relevant measurement
(n = 12)

Articles included in this study (N = 11)

Figure 1. PRISMA process of the systematic literature search.

3.3. Characteristics of non-pharmacological include: massage, reflexology, cupping, and acupunc-

interventions for CINV ture.29 Another category, that is, mind–body therapy is
Most of the reviewed studies predominantly included primarily based on the theory that mental and emotional
an experimental group and a control group (n = 10 factors regulate physical health by connecting between
studies, 90.9%) and 1 study (9.1%) incorporated an hormonal, and immunologic throughout the body. The
additional experimental group. There are various non- mind–body therapy includes biofeedback, guided
pharmacological interventions for CINV, including acu- imagery, hypnotherapy, meditation, including mindful-
puncture, the use of the hologram bracelet, reflexology, ness, and relaxation.29 The category that is biologically
yoga, breathing exercise, consumption of ginger extract, based practices uses naturally occurring substances to
massage and inhalation aromatherapy, peppermint aro- affect health. This type of therapy includes the follow-
matherapy, auricular acupressure, and the use of acu- ing: botanical medicine and natural products, chelation
pressure wrist band. We categorized the interventions therapy, and diet therapies.29
applied in the studies based on Millstine’s category Most frequently, the studies focused on manipula-
of complementary and alternative therapy.29 The cat- tive and body-based therapy, such as massage and
egories include manipulative and body-based therapy; inhalation therapy,20 acupressure bands,21 auricular
mind–body therapy; biologically based practice, and acupressure,22 Bali yoga,18 and reflexology.19 Mind–
energy therapy. Manipulative and body-based therapy body therapy includes interventions such as guided
is based on the belief that the human body can regu- imagery,24 breathing exercises,25 and peppermint oil.23
late and heal itself and that its parts are interdependent. Two studies focused on energy therapy: hologram
Therapies in the manipulative and body-based therapy bracelets27 and acupuncture.26 The last category was

12
 No. Author(s) Aim Design Participants Intervention Measurement Results Category of non-
pharmacological
therapy

1. Anestin et al.18 To determine Randomized 82 patients (n = 52 in 8 weekly group sessions of Morrow Assessment There was no Manipulative and
the effects of a controlled trial intervention, n = 30 in 90 min with 5 participants of Nausea and significant difference body-based therapy
standardized yoga (single blind) control). The mean age is 50.4 per group, led by a trained Emesis Scale: between the
Maulidawati et al.

program on CINV (SD = 8.9). instructor. frequency, intensity, experimental and

among breast The characteristics: Participants were also given worst moment, control groups on
cancer patients be 18 years or older, have a DVD of the intervention with duration CINV after 8 weeks
a breast cancer diagnosis a 20- and 40-min session
(stages I–III), receive format
chemotherapy, consent from Antiemetic still consumed
medical team, no regular
practice of yoga, no current
psychotherapy, no psychiatric
diagnosis, and no heart failure
2. Özdelikara and Tan19 To determine the Pretest and 60 patients with breast cancer Three sessions of reflexology Rhodes INVR Reflexology Manipulative and
effect of reflexology posttests stages I–III in Ataturk Hospital, by a trained nurse (one in each can decrease body-based therapies
on chemotherapy‐ experimental Turkey of 3 chemotherapy cycles). the experience,
induced nausea, design Mean age: 50.93 ± 11.27 in Each reflexology session took development,
vomiting, and fatigue the experimental group and approximately 30–40 min. distress of nausea,
in breast cancer 51.06 ± 10.97 in the control Antiemetic treatment was still vomiting
patients group consumed
3. Zorba and Ozdemir20 To evaluate the Quasi RCT 75 patients with breast cancer Group 1: receiving 20-min A nausea, vomiting, Nausea severity was Manipulative and
feasibility and stages I–III in an oncology aromatherapy foot massage, and retching patient significantly lower body-based therapy
preliminary effects polyclinic in Turkey Group 3: received 3-min follow-up form was in the massage
of massage Mean age: 44.96 (SD: 9.91) inhalation aromatherapy used to evaluate and inhalation
and inhalation years before their second, third, and nausea severity by aromatherapy
aromatherapies fourth chemotherapy cycles visual analog scale groups than in
on chemotherapy- and frequency of the control group.
induced acute vomiting and retching Nausea and
nausea/vomiting. retching incidence
was reduced in
the aromatherapy
groups compared
with that in the
control group
4. Peoples et al.21 To examine the Randomized 226 patients with breast The intervention group 1: Self-report 5-d diary Acupressure bands Manipulative and
effectiveness of control trial cancer stages I–III at 4 cancer Wearing band for 5 d with combined with a body-based therapy
acupressure bands clinics in USA. MP3 enhancing relaxation relaxation recording
on CINV The total mean age was 57 Group 2: Wearing band with were effective in
(SD: 0.07). The age ranged natural relaxation. reducing nausea
from 24 years to 76 years old. The control group receive for patient receiving
The sample had MP3 relaxation only doxorubin
chemotherapy regimen
containing doxorubicin, or
docetaxel with carboplatin,
or docetaxel with
cyclophosphamid
(Continued)

13
14
Table 1. Continued.

No. Author(s) Aim Design Participants Intervention Measurement Results Category of non-
pharmacological
therapy

5. Eghbali et al.22 To determine the Randomized 48 patients with breast cancer The researcher placed an Morrow Assessment The use of auricular Manipulative and
effect of auricular control trial (stages I–III) from 2 hospitals ear seed on each point and of nausea and acupressure body-based therapy
acupressure in in an urban area of Iran. pasted it with a special non- vomiting decreased in the
relieving nausea and The total mean age was: latex adhesive. frequency and
vomiting among the 46.02 (SD = 7.23) and the age The researcher trained the intensity of nausea
women who received ranged: 32–65 years old patients to press each point and vomiting in
chemotherapy at least 3 times every day both the acute and
(morning, noon, and night) delayed phases in
for 3 min. experimental group
Auricular acupressure for 5
d until started having mild
tingling sensation or a slight
sense of discomfort
6. Efe Ertürk and Taşcı23 To evaluate A quasi- 90 patients from ambulatory The participants in the Visual analog scale The VAS nausea Mind–body therapy
the effects of randomized chemotherapy unit in Turkey. intervention group applied for nausea severity. score was
peppermint oil on the controlled The mean age of the patients one drop of the aromatic INVR significantly lower
frequency of nausea, study in the intervention group was mixture on the spot between after peppermint
vomiting, retching, 49.94 (SD = 10.47) in the their upper lip and their oil applying in the
and the severity of control group: 54.63 (SD = nose, 3 times a day for the patients receiving
nausea in cancer 10.15). 5 d following chemotherapy Folfirinox; Paclitaxel-
patients undergoing The participants’ diagnosis administration, in addition Trastuzumab;
chemotherapy include: breast cancer, colon to the routine antiemetic Carboplatin-
cancer, ovary cancer, lung treatment Paclitaxel and
cancer, rectum cancer, and Cyclophosphamide-
pancreas cancer Adriamycin
excluding cisplatin
schedule
7. Hosseini et al.24 To examine the effect Quasi 55 female patients with breast The patients were asked to Morrow assessment Mean score of Mind–body therapy
of guided imagery experimental cancer (stages I–III) in an listen to 2 audio-recorded of nausea and nausea and vomiting
on CINV in breast study Iranian hospital. guided imagery scripts, vomiting severity decrease
cancer patients The mean age of 57.5 years formatted as 2 separate after the intervention
(SD = 8.43) tracks on 2 CDs. Each track
was 10 min in length to elicit
imagery response.
The first track consisted of
soft, slow-tempo, mixed
nature sounds. The second
track of the intervention
included a pleasant scene
imagery script.
Antiemetic was consumed
(Continued)
Non-pharmacological management for CINV
 Table 1. Continued.

No. Author(s) Aim Design Participants Intervention Measurement Results Category of non-
pharmacological
therapy
Maulidawati et al.

8. Aybar et al.25 To determine the Randomized 60 patients with breast cancer Trained patients with Visual Analog Scale The patients in the Mind–body therapy
effect of breathing controlled trial stages I–IV in an ambulatory breathing exercise 15–20 intervention group
exercise on nausea, chemotherapy unit in Turkey. patients. Patients then had less number of
vomiting, and The mean age of the patients were asked to do breathing nausea, vomiting,
functional status in the intervention group was exercise at least 5 min in case and retching
in breast cancer 43.03 (SD = 7.07) in the of sensation of nausea and episodes after the
patients undergoing control group: 51.43 (SD = vomiting, for 6 d breathing exercise
chemotherapy 9.46). With antiemetic (P < 0.05) and
experienced lower
severity of nausea
(P < 0.05) compared
with patients in the
control group
9. Li et al.26 To compare the Randomized 134 participants from 4 Participants in both groups The primary Compared with Energy therapy
effectiveness of true controlled trial hospitals in China. received acupuncture session outcome was the SA group, the
acupuncture vs. The mean age of the patients twice (30 min) on the first day using the CTCAE TA group did not
sham acupuncture in the intervention group was of chemotherapy, and once to assess CINV show significant
in controlling CINV 60, median 56.84–60.48), consecutively on the following improvement in
among patients with and in the control group: 58 4 d. (total 5 d) complete response
advanced cancer median 54.99–60.04 Patients in the study were rates of CINV (all
The participants’ diagnosis randomized in a 1:1 ratio into P > 0.05). However,
include: breast cancer, ovary a TA or SA group receiving the True acupuncture
cancer, cervical cancer, the following acupuncture group could
endometrial cancer and lung treatment modestly reduce the
cancer (stages I–IV) severity of nausea
The patients received cisplatin, (from day 3 to day-
anthracycline, or taxane-based 21, P < 0.05) or
chemotherapy regimens vomiting (from day-4
to day-21, P < 0.05),
which is notably
superior to the
control group
10. Akhu-Zaheya et al.27 To assess the clinical Experiment In a cancer center in Jordan Hologram bracelet worn The Functioning The mean total Energy therapy
effectiveness of the double 175 oncology patients were for 5 d Living Index Emesis Functioning Living
hologram bracelet in blinded randomly assigned to 3 was used to Index Emesis score
the management of groups: placebo examine the impact was significantly
CINV among adult (n = 53), control (n = 54), of CINV lower in the
patients with cancer and intervention (hologram intervention group
bracelet) (n = 68). for total vomiting and
The mean age was 42.3 (SD = total nausea
14) years, and ranged from 18
years to 75 years.
Types of cancer: Breast
cancer, Hematology,
Gastrointestinal, Respiratory,
Genitourinary, Gynecology and
Head and neck Bone.
(Continued)

15
 Non-pharmacological management for CINV

biologically based therapy that included interventions

such as g ­ inger extract.28

Biologically based

Note: CINV, chemotherapy-induced nausea and vomiting; DVD, digital video disc; VAS, Visual Analog Scale; CDs, compact discs; SA, sham acupuncture; TA, true acupuncture; CTCAE, common terminology
The interventions in the included studies were
Category of non-
pharmacological

conducted by nurses, either a general nurse24,25,28 or

­
those who had trained and certified in the particular
therapy

therapy

intervention.19 Other included studies did not ­ provide

in detail who had conducted the interventions. The
interventions varied based on content or intent, as
­
in ameliorating CINV
in patients with lung
antiemetic therapy,

additional efficacy

well as on duration and intensity. The durations of the

drug to standard

cancer receiving
cisplatin-based
As an adjuvant

ginger had no

interventions for the participants ranged from 5 d to 3

chemotherapy cycles. The interventions included at
­
regimens
Results

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 reflexol-
ogy per cycle for 3 cycles of chemotherapy.19 Six studies
MASCC Antiemesis

reported that the duration of the i­nterventions was 5–6 d,

Measurement

and the intensity of the intervention was 20–40 min/d.

Tool (MAT)

Other interventions in 3 studies were conducted for

3 chemotherapy cycles, while 1 study reported that
the majority of the i­nterventions were p ­rovided daily
within 5 d. The ­interventions in these studies ranged
criteria for adverse events; INVR, index of nausea, vomiting, and retching; MASCC, Multinational Association of Supportive Care in Cancer.
(0.5 g, 2 capsules/d, 0.25 g/

beginning on the first day of

capsule, every 12 h) for 5 d

from 5 d of ­breathing exercises for 5 min to reflexology

Ginger root powder was

and c­ ombined m ­ assage and inhalation ­therapy d ­ uring

administered orally

each chemotherapy session conducted for up to 3

chemotherapy

­chemotherapy cycles. Two studies included an in-depth

Intervention

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 car-
group. And 57.46 (SD = 7.82)
140 patients with lung cancer

ried. For example, the authors explain the guided imagery

(SD = 7.24) in intervention

are: cisplatin, carboplatin,

Chemotherapy regimens
from 3 cancer wards in a

intervention that contains 3 sessions of ­listening 2 tracks

The mean age: 57.52

of audio-recorded guided imagery.24 First, the patients

in placebo group.
Hospital, China.

were provided with small and ­easy-to-use headphones

to prevent environmental noise to ensure their concen-
Participants

oxaliplatin

tration on the audio. Then, the patients in the interven-

tion group were asked to listen to the first track the night
before the third session for 10 min. The first track included
controlled trial

the soft and slow tempo as background music, and the

Randomized

second track consisted of a pleasant scene of imagery

Design

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.
in ameliorating acute

in patients with lung

antiemetic therapy,

and delayed CINV

efficacy of ginger,

An aromatherapy practice guide was developed and

drug to standard

cancer receiving
cisplatin-based
To examine the

as an adjuvant

stated in the study conducted by Erturk and Tasci.23 The

regimens

procedure for aromatherapy is as follows: (1) ­getting

permission after explaining the study; (2) choosing
­
Aim

a quiet and comfortable place; (3) handwashing for

the practitioner; (4) dropping 1 drop of pre-prepared
Data extraction.

­aromatic oil and applying between patient’s lip and nose

Continued.

and asking patients to take a deep breath; (5) tightly

closing the cap of the aromatherapy bottle; (6) ­repeating
Author(s)

Li et al.28

the protocol for 5 d at the same hour in the morning,

Table 1.

Table 1.

at noon, and in the evening; and (7) documenting the

procedure and writing down any problems related to
No.

11.

aromatherapy administration.23
16
Maulidawati et al.

3.4. CINV measurement 4. Discussion

All the studies based their measurement solely on In this scoping review, 7 of the 11 included studies
patient-reported outcome measures, such as existing focused on patients with breast cancer. This confirms
CINV inventories (90.9%) and diaries (9.1%). Seven the previous review on intervention for cancer-related
different scales were used to measure CINV. The most fatigue conducted by Pearson et al.33 These authors
common measures were the Morrow Assessment identified that the majority of included studies were
Scale22,18,24 and the visual analog scale.20,25,23 Other the breast cancer population, while relatively few ­trials
inventories were the Common Terminology Criteria for focused on people with other types of cancers. The
Adverse Events (CTCAE)26; functioning Living Index results of our review show that manipulative and body-
Emesis27; self-report diary21; Rhodes INVR19; and the based therapy, mind–body therapy, energy therapy, and
MASCC Antiemesis Tool28 (Table 2). biologically based therapy represent the common non-
pharmacological interventions for CINV. The majority of
3.5. Outcome of the intervention findings from the studies corroborate the positive effects
of non-pharmacological therapy with the standard anti-
All the reviewed studies included pre- and post-­ emetics for managing CINV.
measurements, whereas none of them included The reviewed literature pinpointed several inter-
­follow-up measures. Reductions in the frequency and ventions which positively decrease the severity and
severity of nausea as the primary outcome were speci- frequency of CINV. The interventions were auricular
fied in all the studies. Over two-third of the studies acupressure and acupressure band21,22; inhalation and
(72.7%) reported a significant improvement in CINV massage20; peppermint oil23; guided imagery24; reflex-
based on frequency and severity immediately after the ology19; breathing exercise25; and hologram bracelet.27
intervention. The patients who were provided the fol- Several studies provided detail explanations on how
lowing interventions had less number of nausea and the interventions were carried out and the interven-
vomiting and significant improvement on their condi- tions were conducted by nurses.20,25,23 The procedure
tions. The following interventions are auricular acu- guideline that was provided in the included studies
pressure and acupressure band21,22; inhalation and could be a further guidance for nurses in the clinical
massage20; peppermint oil23; guided imagery24; reflex- setting. Breathing exercise as an independent nursing
ology19; breathing exercise25; and hologram bracelet.27 intervention presented promising results for improving
Among the 11 reviewed studies, 3 reported no signifi- CINV as it is easy and does not need any instruments.
cant CINV changes after measurement. The interven- The mechanisms of change that lead to reduced CINV
tions that did not have a positive outcome include Bali severity are still unclear, but a trial stated that breath-
Yoga, acupuncture, and the administration of ginger ing at a rate 3–7 rpm can be a protective factor against
root powder.18,26,28 emesis, particularly motion sickness.34
The inclusion criteria of this review were met by
very few primary studies on some intervention. There
CINV outcome measure Used in Language is limited evidence that most of the measures were suc-
N trials other than
English cessful types recommended in all treatment guidelines,
Morrow Assessment Scale 3 1
such as breathing exercises, acupuncture/acupressure,
and guided imagery. However, there are challenges in
Visual Analog Scale 3
interpreting the results due to a lack of homogeneity of
CTCAE 1
the antiemetic drugs as the main treatments of CINV
Functioning Living Index Emesis 1
with components that have not been evaluated sepa-
MASCC antiemesis tool 1
rately in an RCT.10 The NCCN guidelines recommend
Rhodes INVR 1 that patients should be protected from CINV by prescrib-
Self-reported diary 1 ing antiemetic therapy before chemotherapy and for up
Note: CINV, chemotherapy-induced nausea and vomiting; CTCAE, to 4 d later.32 Surprisingly, only 1 study referred to the
common terminology criteria for adverse events; INVR, index of nausea, recommendation of the method. Prospective evaluation
vomiting, and retching; MASCC, Multinational Association of Supportive
Care in Cancer. of the practice guidelines and further research into com-
monly prescribed interventions are needed to increase
Table 2. Used CINV outcome measures. the level of evidence for the current guidelines.

17
 Non-pharmacological management for CINV

The review highlighted variations in the self-reports CINV may enable a more accurate estimate of the effec-
used to measure CINV of the included studies, which tiveness of interventions and allow comparisons across
can limit the comparison of studies. This also means studies. The findings from this study have important
that the same construct or domain may not have been implications for nursing practice. Integrating non-phar-
assessed.35 Most of the measures in the studies are macological interventions with standard antiemetics can
valid and reliable in practical clinical settings.36,37 How- improve CINV. This highlights the importance of facilitat-
ever, they are not recommended as primary measures ing and improving the use of non-pharmacological inter-
in research studies because of issues of validity and ventions in clinical settings.
reliability.38 Although there is no gold standard for CINV
assessment,35 the lack of recommendations may hinder
research. More rigorous study eligibility criteria related
6. Implication for nursing practice,
to CINV and a recommended shortlist of robust instru- policy, and research
ments or methods for assessing the severity, duration,
and effects of CINV will facilitate a better understanding This study highlights the importance of non-pharma-
of CINV.6 cological management for patients experiencing CINV.
A strength of this review is that scoping was con- This scoping review provides evidence from studies of
ducted according to a standard methodology. In addi- non-pharmacological interventions relevant to manage
tion, the search was comprehensive, and it included CINV that can be administered by either a general or
the non-pharmacological interventions for CINV and certified nurse. In practice, nurses spend more time with
their outcomes and the available CINV tool. Most of the patients and must be prepared with strategies to identify
papers describe the interventions in detail, which may and manage CINV. Updated information on non-phar-
inform the implementation of interventions in clinical macological interventions to complement standard anti-
practice. emetics treatment is critically needed to address CINV
However, there are limitations to the scoping review. and to provide quality nursing care.
We only searched and included the published litera- This review identified non-pharmacological inter-
ture in English for our review, which may have caused ventions which have proved, through clinical ­studies, to
missing relevant information from studies reported in be effective for managing CINV. Therefore, this scop-
languages other than English. The date and language ing review also makes a substantial contribution to the
limitations we set may have excluded some relevant development of a practical and evidence-based clinical
studies. In addition, we excluded qualitative studies so guide for nursing, with recommendations that can be
that awareness or perceptions of nurses in the area adapted to deliver quality nursing care. The development
of managing the symptoms with non-pharmacological of nursing policies should be based on evidence-based
interventions which may be more relevant for nursing practice to enable a more feasible framework to imple-
cannot be summarized in this review. ment non-pharmacological symptom m ­ anagement, par-
ticularly CINV, for patients undergoing chemotherapy.

5. Conclusions
Most patients undergoing chemotherapy experience
Ethical approval
CINV. This review maps several types of non-pharma- Ethical issues are not involved in this paper.
cological interventions for CINV in people with different
cancers. The use of consistent CINV inclusion criteria
and a smaller selection of robust outcome measures
Conflict of interest
that assess the severity, duration, type, and effect of All contributing authors declare no conflicts of interest.

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