PEP Topic 
Chemotherapy-Induced Nausea and Vomiting—Adult

Acupuncture is a  method of producing analgesia or altering the function of a body system by inserting fine, wire-thin needles (about the diameter of a strand of hair) into acupoints along a specific meridian (meridians are channels in the body that transport energy) on the body.  Electroacupuncture involves the application of a pulsating electrical current to acupuncture needles to stimulate the acupoint via an electrode that is attached to the acupuncture needles. The electrical current substitutes for maneuvering the needles by hand.

Effectiveness Not Established

Systematic Review/Meta-Analysis

Chao, L.F., Zhang, A.L., Liu, H.E., Cheng, M.H., Lam, H.B., & Lo, S.K. (2009). The efficacy of acupoint stimulation for the management of therapy-related adverse events in patients with breast cancer: A systematic review. Breast Cancer Research and Treatment, 118, 255–267.

doi: 10.1007/s10549-009-0533-8


To scrutinize the evidence of using acupoint stimulation (APS) by any modality on managing adverse events related to anticancer therapies in patients with breast cancer

Search Strategy:

English databases searched were PubMed, Cochrane library, Embase, the Cumulative Index to Nursing and Allied Health, and PsycINFO.

Chinese databases searched were CNKI, CEPS, and WanFang as well as manual searching.

Search keywords were medical terms of breast cancer (e.g., breast neoplasm, breast carcinoma, breast tumor) combined separately with at least one of the following: acupuncture, acupressure, auricular acupuncture, ear acupuncture, acupuncture points, electroacupuncture, acupoint, transcutaneous electric nerve stimulation,  moxibustion.

Studies were included if they

  • Were in English or Chinese language.
  • Reported on adults diagnosed with breast cancer at any stage and undergoing treatments such as surgery, radiotherapy, chemotherapy, hormonal therapy, or palliative treatment and experiencing treatment-induced adverse events.
  • Utilized an intervention that involved stimulation of acupuncture points by any modality.
  • Had at least one clinically related outcome variable, as well as condition-specific outcomes or generic health status outcomes.

Studies were excluded if they were

  • Animal studies.
  • Case reports and anecdotal evidence.
  • Qualitative studies or descriptive surveys.
  • Reports available only in abstract form.
  • Trials that included diagnosis other than breast cancer unless separate data was available for the breast cancer group.

Literature Evaluated:

Initial review involved 843 titles and abstracts and 51 full-text articles. Of those, 26 studies were included in the report.

Study evaluation began with two independent reviewers using a modified Jadad scale, assessing 3 aspects: randomization procedure (2 points); dropout and withdrawal discussion (1 point); and blinding (2 points). Studies were classified as high quality if they attained a score of 3 or higher.

Evaluated literature included 18 randomized controlled trials (RCTs) and eight controlled clinical trials published between 1999 and 2008. Nine trials included conventional acupuncture, 6 included electroacupuncture, 5 included drug injection in acupoints, 3 included self-acupressure, and 3 included acupoint stimulation by wristbands or acumagnet. Eighteen were in English, and 8 were in Chinese.

Sample Characteristics:

  • The total sample size was 1,548.
  • Age range across across studies was 28–76 years.
  • Five studies reported the participant’s body mass index, which ranged from 23.1 to 28.8.
  • Information on participants’ education, background of acupuncturists, symptom distress before management, and measurement tool reliability was reported in too few studies to provide a meaningful summary.


Nine of the 26 studies were rated as high quality. Adverse effects (outcomes) of the APS included vasomotor syndrome, chemotherapy-induced nausea and vomiting (CINV), post-mastectomy pain, joint symptoms, lymphedema, leukopenia, and adverse events.

Eleven studies investigated CINV and APS with acupoints P6 and ST36. Ten of the CINV studies reported APS significantly improved emesis caused by breast cancer therapy.


The most common outcome evaluated by APS in the studies was CINV. APS was noted to be effective in reducing acute emesis caused by breast cancer therapy. Authors reported that APS is beneficial in the management of CINV, especially in the acute phase.

Nursing Implications:

Healthcare providers should consider using APS as an option for the management of CINV.

Ezzo, J., Vickers, A., Richardson, M.A., Allen, C., Dibble, S.L., Issell, B., … Zhang, G. (2005). Acupuncture-point stimulation for chemotherapy-induced nausea and vomiting. Journal of Clinical Oncology, 23, 7188-7198.

doi: 10.1200/JCO.2005.06.028

Search Strategy:

Database searched was MEDLINE (1966-Dec 2003).

Search keywords were acupuncture, alternative medicine, electroacupuncture, moxibustion, “injections, intramuscular”, “Medicine, Traditional Chinese”, acupressure, transcutaneous electrical nerve stimulation (TENS), and TENS. These were combined with nausea, vomiting, emesis, antiemetic therapy, and antineoplastic agents/adverse effects.

Studies were included in the review if they

  • Were randomized.
  • Involved patients receiving chemotherapy.
  • Included an intervention that stimulated acupuncture points.
  • Reported on nausea or vomiting as outcomes.

Studies were excluded from the review if they had a high possibility of bias.

Sample Characteristics:

In all, 14 studies were identified and reviewed.


In the nine studies that evaluated acute vomiting management via acupuncture-point stimulation, acute vomiting was reduced but nausea severity was not.

In the seven studies that assessed acute nausea via acupressure, acute nausea severity was reduced.

Three studies that evaluated delayed vomiting did not support the intervention.

In the five studies using acupuncture-point stimulation, the intervention did not reduce delayed vomiting.

The pooled results of 11 studies using acupuncture-point stimulation plus antiemetics for chemotherapy-induced nausea and vomiting (CINV) showed significant reduction in acute vomiting and marginal statistical significance for reducing acute nausea.


Electroacupuncture provided protective effects for acute vomiting, but acupuncture did not. Acupressure was effective for acute nausea in patients using “state-of-the-art” antiemetics. However, placebo effects may have influenced results.

Silva, D.R.F., dos Reis, P.E.D., Gomes, I.P., Funghetto, S.S., & Ponce de Leon, C.G.R.M. (2009). Non pharmacological interventions for chemotherapy induced nausea and vomits: Integrative review. Online Brazilian Journal of Nursing, 8(1).

doi: 10.5935/1676-4285.20092098


 To identify the evidence in scientific literature related to nonpharmacologic interventions for the treatment of chemotherapy-induced nausea and vomiting (CINV)

Search Strategy:

Databases searched were Cochrane, PubMed, Latin American and Caribbean Health Sciences Literature (LILACSO), and Brazilian Nursing Database (BDENF).

Search keywords were nausea, vomiting, chemotherapy, nursing care, cursing care protocols for cancer chemotherapy, and chemotherapy induced nausea and vomiting.

Studies were included in the review if they

  • Addressed nonpharmacological interventions for nausea and vomiting.
  • Were completed within the past 10 years (1998–2008).
  • Were conducted in English or Spanish.

Literature Evaluated:

  • An initial set of 111 articles were identified. Of these, 102 were related to pharmacological management and were eliminated. A final sample of nine studies was included in the review.
  • The authors developed an instrument to analyze the literature related to method, journal type, and author.
  • The articles were published in English (78%), Portuguese (11%), and Spanish (11%).
  • The majority of the articles (67%) were written by physicians in collaboration with psychologists and pharmacists.

Sample Characteristics:

  • Across the nine studies, a total sample of 1,635 patients were studied.
  • The majority of studies involved the use acupuncture, acupressure, or electroacupuncture (5 trials and 1 meta-analysis).
  • Studies involved patients receiving highly emetogenic chemotherapy or those with refractory CINV.


  • One of the studies involved patient dietary education and adherence to antiemetic therapy in which patients reported a better sense of security with the provision of written information.
  • One study, which had 16 participants, found hypnosis to be effective in reducing anticipatory CINV.
  • One randomized, controlled trial of 62 patients using a yoga program showed no decrease in frequency or intensity of CINV with the intervention.
  • Findings among studies of acupuncture and acupressure had mixed results, with most showing no significant difference in symptoms with the intervention.
  • The meta-analysis showed a reduction in the proportion of patients with acute vomiting but not in the severity of nausea.
  • Electrical stimulation did not improve results.


This review demonstrated no substantial effects among the interventions included. Findings regarding the use of acupuncture, acupressure, and electroacupuncture were mixed. Most studies using acupuncture and acupressure involved use of the p6 point on the wrist.


This review included a limited number of studies.

Nursing Implications:

The evidence does not demonstrate significant effect of these interventions for CINV. However, these interventions may be useful as adjuncts to pharmacologic treatment. Nonpharmacologic interventions appear to be most effective in the prevention of acute vomiting rather than symptoms of nausea.

Research Evidence Summaries

Choo, S.P., Kong, K.H., Lim, W.T., Gao, F., Chua, K., & Leong, S.S. (2006). Electroacupuncture for refractory acute emesis caused by chemotherapy. The Journal of Alternative and Complementary Medicine, 12, 963-969.

doi: 10.1089/acm.2006.12.963

Study Purpose:

To evaluate the use of electroacupuncture in preventing anthracycline-based chemotherapy-related nausea and vomiting (CINV) refractory to combination 5-HT3-antagonist and dexamethasone

Intervention Characteristics/Basic Study Process:

Patients received electroacupuncture in addition to standard antiemetic prophylaxis. Acupuncture was started 10 minutes prior to start of chemotherapy infusion and then continued for an additional 20 minutes. The P6 acupuncture point was used, a second needle was inserted at a different point, and electrical stimulation was delivered. 

Sample Characteristics:

  • The study consisted of 27 patients with breast cancer.
  • All patients were receiving their second cycles of doxorubicin and cyclophosphamide; cyclophosphamide, doxorubicin, and prednisone; or doxorubicin only.
  • Patients were defined as having refractory emesis (defined as vomiting three or more times, 24-48 hours after cycle one).
  • Patients received standard antemetic prophylaxis.

Study Design:

This was a prospective trial.

Measurement Instruments/Methods:

  • Patients completed a questionnaire assessing their attitudes toward acupuncture. 
  • Patients recorded frequency of vomiting in diaries.
  • A trained doctor interviewed patients via telephone 24-48 hours after chemotherapy to grade nausea and vomiting using the National Cancer Institute Common Toxicity Criteria (NCI-CTC).


  • Ten patients (37%) reported no vomiting after the second cycle of chemotherapy with the addition of electroacupuncture.
  • The majority of patients (96%) reported significantly less nausea and vomiting, but one patient experienced increased vomiting after electroacupuncture.
  • Overall, mean emetic episodes decreased from 7 to 3 after the intervention (p < 0.0001).
  • NCI grade of vomiting decreased significantly (p = 0.0120).
  • The number of patients reporting grade 3-4 vomiting dropped from 14 prior to the electroacupuncture to 5 after the electroacupuncture.
  • NCI grade of nausea improved as well after the intervention (p < 0.0001).
  • Most patients (93%) reported that they thought that electroacupuncture was an acceptable procedure and helpful in reducing emesis.


  • All patients participated in the intervention group; no control group was provided.
  • Two subjects complained of severe headaches after the electroacupuncture, lasting for several days; otherwise it was well-tolerated.
  • The intervention was delivered by trained acupuncturists.