Acupressure

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

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.

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.

• 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.

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

To review existing research on the use of acupuncture and acupressure in the management of nausea and vomiting in order to provide nurses the information required to assist their patients receiving chemotherapy and experiencing chemotherapy-induced nausea and vomiting (CINV)

Databases searched were described as scientific and internet sources, Institutes of Health Consensus statement, and federal regulations.

Search keywords included acupuncture and acupressure in combination with chemotherapy-induced nausea and vomiting.

Numerous studies tested the effectiveness of acupressure, acupuncture, and the combination. Few focused on acupressure alone for managing CINV.

A total of five studies were found, representing a total of 409 patients.

Very few studies were found, but, overall, results indicated improvement in nausea and vomiting, supporting the use of acupressure and acupuncture of the treatment of CINV. Acupuncture and acupressure were found to be safe and effective for the relief of CINV in combination with current antiemetic drugs.

The sample sizes were small in the studies; therefore, determining applicability to various practice settings and populations is difficult.

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.

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.

Databases searched were MEDLINE, Embase, AMED, the Cochrane Database, Cancerlit, and CINAHL.

Search keywords were adult patients receiving chemotherapy, with nausea and vomiting duration or intensity measured as outcomes.

Two randomized controlled trials were identified involving 482 patients. The studies compared acupressure to no intervention control. However, the second study did not meet inclusion criteria, as transcutaneous electrical nerve stimulation (TENS) of antiemetic point was used.

Results suggested that acupressure may decrease nausea in patients receiving chemotherapy, but further work is required before conclusively advising patients on the efficacy of acupressure in preventing and treating chemotherapy-induced nausea and vomiting (CINV).

STUDY PURPOSE: Assess effectiveness of acupressure on chemotherapy-induced nausea and vomiting (CINV)

TYPE OF STUDY: Meta-analysis and systematic review

• DATABASES USED: PubMed, CINAHL, EMBASE, Science Direct, China Biology Medicine, Chinese National Knolwedge Infrastructure, Wan Fang, Database for Chinese Technical Periodicals, Cochrane collaboration
• INCLUSION CRITERIA: Patients on IV chemotherapy, acupressure was used with or without antiemetics, comparisons were antiemetics or nursing care, English or Chinese language
• EXCLUSION CRITERIA: Auricular acupressure

• TOTAL REFERENCES RETRIEVED: 1,326
• EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Cochrane risk of bias assessment; if any item was considered high risk, the study was deemed high risk of bias.

• FINAL NUMBER STUDIES INCLUDED: 12
• TOTAL PATIENTS INCLUDED IN REVIEW: 1,419
• SAMPLE RANGE ACROSS STUDIES: 17-500
• KEY SAMPLE CHARACTERISTICS: Various tumor types. Where reported, chemotherapy was MEC or HEC

PHASE OF CARE: Active anti-tumor treatment

Relative risk for incidence of acute vomiting across five trials was 0.84 in favor of acupressure, but this was not significant (p = 0.08). There was not a significant difference in relative risk with or without acupressure (p = 0.29) (two trials). Acupressure combined with antiemetics decreased nausea severity in the delayed phase (SMD = -0.33, p = 0.04), but there was no significant effect on incidence and frequency of delayed vomiting. P6 was the most frequently used acupoint. Interventions used either a wristband or manual acupressure, and findings for these two approaches differed. Sham control trials did not demonstrate a significant effect.

Acupressure may reduce the severity of nausea, particularly in the delayed phase in patients receiving MEC or HEC

• High heterogeneity
• No description of antiemetics used.

Acupressure might be a useful adjunct to antiemetics for management of CINV.  Findings suggest that this may be helpful to reduce the severity of nausea, which has remained a problem even with maximum antiemetics. Findings of this analysis showed differences with sham controlled trials, suggesting there may be a placebo effect of acupressure.

• Databases searched were MEDLINE and CINAHL (1990-2002).
• Search keywords were nausea, vomiting, chemotherapy and neoplasm, assessment, management, complementary therapies, pharmacological, and nonpharmacological.
• Studies were included in the review if they included primary research, literature reviews, opinion articles, and information leaflets/booklets.
• Studies were excluded if they involved anticipatory nausea and vomiting associated with chemotherapy, because the authors felt that symptoms with a psychological basis should be addressed in a separate paper.

• Nonpharmacologic management interventions were reviewed with the intention that they do not replace standard antiemetic therapies but, rather, are adjuncts to improve quality of life (QOL).
• Intervention articles were reviewed for progressive muscle relaxation, guided imagery, self-hypnosis, acupressure/acupuncture, transcutaneous electrical nerve stimulation, biofeedback, cognitive distraction, and music therapy.

Support for the use of nonpharmacologic interventions for the treatment of chemotherapy-induced nausea and vomiting (CINV) was weak.

Many studies were flawed because of small sample sizes and confounding variables (e.g., stage of disease, various chemotherapy regimens, culture, patient compliance).

Preliminary available evidence suggests positive benefits through nonpharmacologic techniques; however, larger randomized trials are needed to demonstrate the exact benefits, including economic.

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

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.

• 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.

• 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.

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.

To investigate the effectiveness of acupressure in reducing chemotherapy-induced nausea and vomiting (CINV) and to analyze the correlation between CINV and functional status

The study began on the second day of chemotherapy. Patients were assigned to experimental and control groups that matched patients on gender and type of chemotherapy regimen. Acupressure was provided by the researcher by applying firm pressure to selected acupressure points for 3 minutes bilaterally in the morning and evening for three days. Both groups received standard antiemetics. Patients were asked to complete study assessment self-reports daily for CINV. Metoclopramide was given as an antiemetic.

• N = 40
• AGE = Data not provided; majority > 40 years
• MALES: 65%, FEMALES: 35%
• KEY DISEASE CHARACTERISTICS: Disease types not provided
• OTHER KEY SAMPLE CHARACTERISTICS: 70% of the sample had feeding tubes

• SITE: Single site  
• SETTING TYPE: Not specified  
• LOCATION: India

• PHASE OF CARE: Active antitumor treatment

Two-group, prospective, post-test study

• Rhodes Index of Nausea, Vomiting, and Retching (RINVR)
• Measure for functional status not described

Over the three-day period, nausea scores were lower in the experimental group (p = 0.002). There was a weak negative correlation between nausea and functional status (p = 0.03).

Acupressure might be helpful in reducing CINV. Because of reporting and design limitations, this study does not provide strong evidence for the effectiveness of acupressure.

• Small sample (< 100)
• Risk of bias (no blinding)
• Risk of bias (no random assignment) 
• Risk of bias (no appropriate attentional control condition)
• Measurement/methods not well described
• Measurement validity/reliability questionable
• Other limitations/explanation: No disease-related demographic information provided; dosage of chemotherapy not described; current recommended antiemetic regimens not provided

This study provided weak evidence that acupressure may be helpful in the management of CINV.

To assess the effect of wristband acupressure applied at the P6 (Neiguan) acupuncture point on chemotherapy-induced nausea and vomiting (CINV) in patients with acute myeloblastic leukemia (AML)

Ninety patients with AML receiving the same chemotherapy regimen (high emetogenic chemotherapy, idarubicin and cytarabine) and who received at least the first cycle of chemotherapy were randomized to the control, pressure, or wristband (bilaterally) group for four days. All the patients received the same antiemetics regimen. The researcher applied pressure and instructed patients in the pressure and wristband groups on how to apply pressure on the P6 point (for 15 minutes on each arm) 30 minutes before chemotherapy; patients in the wristband group wore it 30 minutes before chemotherapy and were asked to wear it almost continuously.

• N = 90 (30 in each group; power analysis was conducted and achieved)   
• AGE: 17–62 years
• MALES: 55.6% (50 patients [15, 19, 16 in the three groups]), FEMALES: 44.4% (40 patients [15, 11, 14 in the three groups])
• CURRENT TREATMENT: Chemotherapy
• KEY DISEASE CHARACTERISTICS: Patients diagnosed with AML who did not have lymphedema, no communication, visual or hearing problems, and no psychiatric disorder
• OTHER KEY SAMPLE CHARACTERISTICS: Received the same chemotherapy regimen, had adequate understanding of and speaking skills in Turkish, received at least one chemotherapy cycle, and experienced nausea and vomiting in their previous chemotherapy cycles

• SITE: Single site   
• SETTING TYPE: Inpatient    
• LOCATION: Turkey

PHASE OF CARE: Active antitumor treatment

Three-arm, randomized, controlled trial

• Face-to-face interviews to fill in the questionnaire (for demographical data, disease, chemotherapy protocol, antiemetics)
• Visual analog scale (VAS) to measure the severity of nausea and vomiting every 24 hours for four days

Severity of nausea was less in the wristband group on all study days (p = 0.001) as was severity of vomiting (p < 0.001) and the number of vomiting episodes (p = 0.001). The pressure group had the lowest number of nausea episodes (p = 0.002), and vomiting of that group was lower than in the controls (p = 0.006). Nausea and vomiting declined in all groups over the four study days.

The acupressure band was effective in reducing CINV, and direct pressure application prior to chemotherapy was better than no treatment.

• Small sample (< 100)
• Baseline sample/group differences of import
• Risk of bias (no blinding)
• Risk of bias (no appropriate attentional control condition)
• Measurement validity/reliability questionable
• Using the VAS to measure CINV
• Not measuring anticipatory nausea and vomiting
• No double blinding
• Not considering the cross-sectional research design to control the bias
• The baseline CINV was lowest in the wristband group.

Acupressure (using the wristband) is a complement antiemetic method to control CINV. It is an easy to apply, safe, and cost-efficient, with no side effects. It is also easily taught and learned.

To compare the effects of usual care (regular antiemetics) versus usual care plus acupressure training on nausea and its intensity in women receiving chemotherapy for breast cancer

The intervention involved finger acupressure bilaterally at the P6 and ST36 acupressure points located on the forearm and knee for a maximum of three minutes for each point every morning or as needed for nausea. Baseline and poststudy questionnaires and a daily log were used to collect data.

• The study consisted of 17 adult women undergoing chemotherapy for breast cancer (cyclophosphamide, methotrexate, and fluorouracil or doxorubicin-containing regimens). The control group had nine patients, and the experimental group had eight patients.
• The mean age of both groups was 49 years old.
• More than half (59%) of participants were Caucasian.

The study was conducted in two sites located in urban areas in the western United States: an outpatient oncology clinic in a major teaching medical center and a private outpatient oncology practice.

• Nausea was measured at baseline and poststudy via questionnaires and daily logs.
• Nausea experience and its intensity were measured with the Rhodes Inventory of Nausea, Vomiting, and Retching.

Significant differences existed between the two groups in regard to nausea experience (p < 0.01) and nausea intensity (p < 0.04) during the first 10 days of the chemotherapy cycle, with the acupressure group reporting less intensity and experience of nausea.

• The study only looked at a single cycle of treatment.
• The sample size was small.
• The sample was limited to women with breast cancer.
• The ST36 acupressure point was difficult to reach.

To compare the differences in chemotherapy-induced nausea and vomiting (CINV) in women receiving chemotherapy for breast cancer among three groups: acupressure, acupressure placebo, and usual care

Subjects were randomized to one of three groups: acupressure to P6 point (active), acupressure to S13 point (placebo), or usual care. Participants in the acupressure groups were taught to apply acupressure wrist devices by research assistants unaware of the active pressure point. All participants completed daily logs for 21 days. Patients measured nausea and vomiting and recorded methods for controlling the symptoms, including antiemetics and acupressure. Research assistants, who had received two hours of training on the study protocol, instructed participants. In an examination or private room, the participants were taught to find a quiet place each morning to perform the acupressure treatment to both P6 points sequentially either as treatment or practice. During the day, participants in the acupressure groups were encouraged to apply digital pressure to one of the points whenever nausea occurred regardless of where they were. Each session was six minutes in the morning and three minutes each during the rest of the day. Self-ratings were completed on a daily basis prior to bedtime. All participants were called or seen on day eight for review of the log and coaching, if needed.

• The study consisted of 160 women beginning their second or third cycle of chemotherapy for breast cancer.
• Participants had experienced moderate nausea intensity scores with previous cycles of chemotherapy, based on a score of at least 3 on the Morrow Assessment of Nausea and Emesis.
• Participants were able to read and write in English.

The study was conducted in community oncology programs associated with M.D. Anderson Cancer Center and nine independent sites.

This was a multicenter, longitudinal, randomized controlled trial.

• The Rhodes Index of Nausea and Vomiting (three-item nausea; single-item vomiting subscales) was used.
• Nausea intensity also was rated with a descriptive, numeric rating scale, ranging from 0–10.
• The State-Trait Anxiety Index also was used.

• No significant differences were found in demographic data, disease, or treatment variables among the groups.
• No significant differences were identified in acute nausea and vomiting among the treatment groups.
• With delayed nausea and vomiting, the acupressure group demonstrated a statistically significant reduction in the amount of vomiting and intensity of nausea over time when compared with the placebo or usual care groups.
• No significant differences were found between the placebo and usual care groups.

In conjunction with pharmaceutical management, acupressure at P6 was  found to reduce the amount and intensity of delayed CINV in women undergoing treatment for breast cancer.

• The same research assistants and nurses taught both pressure points. Although most did not know which pressure point was active, a few referenced the Internet for the information.
• Some patients with uncontrolled nausea also broke the blind by pursuing more information online.
• Some participants had challenges finding the location consistently; some needed markings on their wrist. Two participants found application of pressure difficult because of long fingernails.
• Staff training on the technique and return demonstration were not specifically described.
• No men or children were included in the study population.

Acupressure is a safe and effective tool to be offered to women undergoing breast cancer chemotherapy treatment.

To determine if the use of auricular acupressure is effective in relieving nausea and vomiting in patients with breast cancer who are receiving chemotherapy

Random assignment of patients: The experimental group received standard antiemetics for chemotherapy-induced nausea and vomiting (CINV) and auricular acupressure (AA) for five days. The control group received standard antiemetics only. Acute and delayed CINV was measured with the Morrow questionnaire daily for five days after receiving chemotherapy. The questionnaire has 16 items measured with a 7-degree Likert-type scale. Patients self-reported. For the second cycle of chemotherapy, the groups were switched.

• N = 48   
• AGE = 32–65 years
• MEAN AGE = 46.02 years
• FEMALES: 100%
• CURRENT TREATMENT: Chemotherapy
• KEY DISEASE CHARACTERISTICS: Breast cancer
• OTHER KEY SAMPLE CHARACTERISTICS: Use of anthracycline, cyclophosphamide, and taxane—high-risk for CINV

• SITE: Multi-site   
• SETTING TYPE: Outpatient    
• LOCATION: Iran

PHASE OF CARE: Active antitumor treatment

Crossover clinical trial

Morrow (Moro) questionnaire

• Number and intensity of nausea in acute and delayed phases in the AA group was significantly lower than in the control group (p < 0.001).
• The number and intensity of vomiting in the AA group was significantly lower (p < 0.005). 

The use of auricular acupressure was shown to help alleviate CINV when used along with standard antiemetics in patients with breast cancer receiving moderate to high-risk emetogenic chemotherapy.

• Small sample (< 100)
• Risk of bias (no blinding)
• The experimental group's and control group’s intervention was changed in the second cycle.

Auricular acupressure is a safe, noninvasive, easy, patient-administered, nursing-centered, nonpharmacologic treatment and was shown to lower the number and intensity of nausea in both the acute and delayed phases of treatment.

To confirm the potential therapeutic efficacy of PC6 stimulation by acupressure in patients with cancer experiencing chemotherapy-induced nausea and vomiting (CINV) after failure with pharmacologic approaches

PC6 acupoint was stimulated by acupressure with a button (P6 nausea control Sea-Band^®) for eight hours per day at home, starting before the onset of chemotherapy, and for at least three days after chemotherapy.

The study consisted of 100 consecutive patients with metastatic solid tumors admitted to receive chemotherapy for advanced disease.

Patients were included in the study if they had

• Histologically proven metastatic solid tumor.
• Measurable lesions.
• No double tumor or brain metastasis.
• No previous chemotherapy for metastatic disease.
• No concomitant illnesses other than cancer.
• Grade 3 or 4 vomiting.
• No response to conventional antiemetic therapies.

The study was conducted in Italy.

World Health Organization criteria were used.

Overall, 68% of patients achieved control of emesis.

No significant differences in efficacy were observed in relation to tumor histotype.

The percentage of efficacy varied in relation to type of chemotherapy. The lowest results were observed in patients treated with anthracyclines, whereas more benefit was seen in patients with other chemotherapy agents. However, the efficacy achieved was greater than 50% in the treatment of vomiting because of anthracyclines.

The study confirmed the efficacy of acupressure in the treatment of CINV with a larger number of patients than previously studied. Acupressure appears to be effective in reducing vomiting experienced as a result of most commonly used chemotherapy agents.

• Only vomiting was measured; nausea was not.
• This population was heterogeneous with different tumor types and chemotherapy agents.
• Antiemetics before and after chemotherapy were not described.
• No specific exclusion criteria were listed.
• Several questions arose related to the intervention: who taught the patients how to use the Sea-Bands; what training did that person have; and how, when, and who evaluated the effectiveness of the intervention.

To examine the efficiency of acupressure in controlling chemotherapy-induced nausea and vomiting (CINV) and to determine the factors that affect this efficiency

Turkish researchers recruited patients with lung, breast, and gynecological cancer who were undergoing active treatment with medicines such as doxorubicin- or cisplatin-based drugs. The researchers randomized and assigned 67 patients in the experimental group and 53 patients in the control group. The experimental group was given a real nausea wristband (Sea-Band), and the control group was given a placebo nausea band. All patients in both groups also were given standard antiemetic treatment. They were instructed to use the wristband on both of their wrists for five days, except when sleeping at night, washing their hands, and taking a shower.

• The study reported on 120 patients.
• Mean age was 55.11 years in the experimental group and 52.73 years in the control group.
• The sample was 50.8 male and 49.2 female.
• Cancer diagnoses were breast-gynecology (experimental group: n = 40 [59.7%], control group: n = 34 [64.2%]) and lung cancer (experimental group: n = 27 [40.3%], control group: n = 19 [35%]).
• Other key sample characteristics included the use of the following regimens.
  • Adriamycin-cyclophosphamide (experimental group: n = 12, control group: n = 4)
  • Cisplatin–etoposide (experimental group: n = 12, control group: n = 15)
  • Cisplatin–docetaxel (experimental group: n= 10, control group, n = 9)
  • Cisplatin–alimta/camptosar (experimental group: n = 5, control group: n = 5)
  • Cisplatin–gemcitabine (experimental group: n = 13, control group: n = 8)
  • 5 fluorouracil–adriamycin–cyclophosphamide/5 fluorouracil–epirubicin–cyclophosphamide (experimental group: n = 8, control group: n = 9)
  • Taxotere–adriamycin–cyclophosphamide (experimental group: n = 7, control group: n = 3)
  • Anthracycline-based (experimental group: n = 27, control group: n = 16)
  • Cisplatin-based (experimental group: n = 40, control group: n = 37)

The study was conducted at a single site in Turkey. The setting type was not specified.

Patients were undergoing the active treatment phase of care.

The study was a cross-sectional, single blinded study.

The researchers stated that they created a patient description form to collect the demographic information, chemotherapy medications, and characteristics of the condition of the patients. They also used two measurements. 

• The first was the Rhodes Index of Nausea Vomiting and Retching (INVR) scale, of which validity and reliability were confirmed in another Turkish study. Patients were asked to complete the INVR scale for five consecutive days. They rated their nausea and vomiting on a 0–4 scale, with a high score indicating a severe complaint.
• The second was the Functional Assessment of Cancer Therapy-General (FACT-G), which is a quality-of-life scale. They completed the FACT-G quality-of-life scale on the fifth day only. A high score in this scale indicates a high quality of life.

The researchers investigated whether acupressure affected the patients’ quality of life, as well as their experiences and development of nausea, vomiting, and retching. After five days of treatment, the results indicated that no statistically meaningful difference was observed between the control and experimental groups. Therefore, real acupressure application was not an effective strategy to increase the quality of life or to decrease the experience of CINV.

The statistical results show that after five days, both experimental and control groups had almost identical scores. Therefore, the real nausea wristband does not affect CINV or the quality of life.

The study shows that wristband acupressure is not effective in controlling CINV in patients with cancer. Additional studies are needed to confirm or refute this conclusion. Acupressure may need to be organ-site specific to control CINV.

To determine the effects of acupressure applied to the pericardium 6 (P 6) acupuncture point on chemotherapy-induced nausea and vomiting (CINV) and anxiety in patients with breast cancer undergoing chemotherapy

Stage 1–3 patients with breast cancer who were receiving cycle two and more advance-cycle chemotherapy in an ambulatory setting were trained to apply P 6 acupressure. Patients were randomly selected from a sample that met the study inclusion criteria. An acupressure wrist band was utilized with the research group. Patients were taught how to use the band with repeat demonstration. Patients continuously wore the acupressure band on both wrists for five days. Antiemetic medications used for the experimental and control group were not described.

• N = 64 
• AVERAGE AGE: 51.21 years (research arm); 50.87 years (control arm)
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: Stage 1–3 breast cancer after cycle two and more advance-cycle chemotherapy
• OTHER KEY SAMPLE CHARACTERISTICS: Breast cancer, female patients

• SITE: Single-site  
• SETTING TYPE: Outpatient  
• LOCATION: Turkey

• PHASE OF CARE: Active antitumor treatment
• APPLICATIONS: Elder care 

• Quasi-experimental with a control group.
• Patients selected via randomized sample

• Beck Anxiety Inventory (BAI)
• Index of Nausea, Vomiting and Retching (INVR)
• Patient information form

The authors concluded that acupressure wristbands applied at the P 6 point decreased patients' nausea occurrence and experience and the overall experience and occurrence of nausea, vomiting, and retching combined. There was no effect on the occurrence or experience of vomiting or retching. Acupressure is an inexpensive intervention that may be able to provide additional relief to patients above and beyond recommended antiemetic therapy. Effects on anxiety are unclear.

• Small sample (< 100)
• Risk of bias (sample characteristics)
• Key sample group differences that could influence results
• Findings not generalizable
• Other limitations/explanation: No discussion on why the researchers waited till cycle two to start intervention; prevention at the first cycle is key to good control; no sham band/possible placebo effect; significantly lower anxiety at baseline in the experimental group

Acupressure is inexpensive, is easy to use, and can be considered in conjugation with medication or CINV prophylaxis. Acupressure can be considered in addition to recommended antiemetic therapy for additional support of patients experiencing CINV.

To explain the relationship between the intensity of chemotherapy-induced nausea and vomiting (CINV) and the frequency of P6 digital acupressure in a group of patients with breast cancer who received moderately to highly emetogenic chemotherapy and applied P6 digital acupressure as an additional intervention for CINV control.

This was a secondary analysis of a multicenter, longitudinal, randomized, clinical trial that compared differences in CINV among three groups (P6 acupressure, placebo digital acupressure, and usual care). The original study was published in 2007.

Patients in the group receiving P6 acupressure in the parent study were instructed to perform digital acupressure for three minutes or point release at the P6 points on both arms in the morning plus an additional three minutes of acupressure to one arm whenever nausea occurred. Secondary analysis was conducted of this group’s data from the patient information questionnaire and daily log.

• The study consisted of 53 participants.
• Participant mean age was 49 years (SD = 10.55) with a range of 27–74 years.
• All of the participants were female patients with breast cancer who were beginning their second or third cycle of moderately to highly emetogenic chemotherapy (cyclophosphamide with or without 5-fluorouracil; doxorubicin with paclitaxel or docetaxel; or 5-fluorouracil, epirubicin, and cyclophosphamide).
• All participants had been in the group in the parent study which applied P6 digital acupressure in addition to antiemetics to control CINV.
• All participants had had a nausea intensity score with previous chemotherapy of at least 3.

This was a multisite study conducted at 15 different sites in the United States.

All patients were in active treatment.

The study was design was a descriptive secondary analysis.

• A Patient Information Questionnaire was used to record demographic information and predisposing factors.
• A disease and treatment questionnaire was used to collect medical information.
• Participants recorded nausea and use of P6 digital acupressure each evening in daily logs for 11 days after chemotherapy.
• Nausea was measured on a 0-10 nausea intensity numeric rating scale (NRS) and on the 0-12 nausea score from the Index of Nausea, Vomiting and Retching (INVR). Interrater reliability for these two scales has been reported as having a significant high correlation (r = 0.75–0.95).

• The average amount of acupressure use over 11 days was two times per day.
• Participants used acupressure for an average of seven days after chemotherapy.
• The most frequent day of acupressure was day 3.
• An increase in nausea intensity ratings from days 1–3 was not associated with the frequency of acupressure (incidence rate ratio [IRR] = 0.96; p = 0.02).
• A decrease in nausea intensity ratings for days 4—11 was associated with the frequency of the acupressure (IRR = 1.11; p < 0.01).
• Women who used acupressure more than five times on day 4 experienced the highest nausea intensity over the 11 days, and their peak of nausea intensity was different from the other groups. Hierarchical generalized linear model (HGLM) analysis did not support this difference as significant.
• Age was the only significant predisposing factor for nausea intensity in the acute phase. With each year increase in age, a significant decrease in NIR and the use of acupressure on day 4 was found.

Nausea intensity was not found to be consistently related to frequency of acupressure use.

Types and dosages of antiemetics used were not described.

Based on the results of the parent study and the indepth secondary analysis of the acupressure group, patients with CINV may benefit from P6 acupressure throughout the first 11 days after chemotherapy. Because each patient is different, individualized patient teaching and resources for managing CINV are important.

To study the effectiveness of acupuncture and acupressure in reducing chemotherapy-induced nausea

Patients were treated for one cycle of chemotherapy with acupuncture and acupressure at point P6 and for one cycle at a close sham point. Participants were randomized to acupuncture at P6 or at a close nonacupuncture point, and it was delivered by one of two physicians with training and experience in acupuncture. Participants wore acupressure bands for 72 hours at the same points on both arms and could wear them for an additional four days if needed. The bands were covered with a mull bandage to blind the staff. Participants completed diaries for seven days, documenting intensity (on a 0-6 rating scale), frequency, and duration of nausea and vomiting; additional antiemetics taken; and, on day 7, rate the effectiveness of side effects or impairment by acupuncture or acupressure. Patients completed the Morrow Assessment of Nausea and Emesis (MANE). Oncology staff checked that the diaries were completed accurately, standard antiemetics regimens were followed, and if any adverse reactions related to acupuncture occurred.

• The study consisted of 28 patients receiving moderately emetogenic chemotherapy (MEC) or highly emetogenic chemotherapy (HEC).
• Patients were eligible for the study if they
  • Were 18-75 years old.
  • Were scheduled to receive MEC or HEC and standard antiemesis additional medication for rescue predefined for two cycles of chemotherapy.
  • Had a Karnofsky index of 50%.
• Patients were excluded from the study if they had
  • Received chemotherapy within the last three months.
  • Experienced anticipatory nausea and vomiting, cerebral metastasis, chronic ileus or subileus, or lymphedema in arms.
  • Prior knowledge of acupressure points.

The study was conducted by the hematology and gastroenterology departments of a large university hospital in Germany.

This was a randomized, crossover pilot study.

• The MANE, shortened version, was used to measure nausea.
• Patients recorded the Intensity, frequency, and duration of nausea in patient diaries.

• No difference was found between combined acupuncture and acupressure at the P6 point and at the sham point.
• The study was stopped early because of recruitment problems and low incidence of nausea and vomiting in the sham group.
• Half of the participants reported an irradiating feeling, which is a sign of effective acupuncture.

• The sample size was small.
• Incidence of nausea was low in the sham group.
• No acupuncture control group was included.
• No control was included for type of cancer or chemotherapy regimen.
• The sham point may have been too close to P6 or the needle was too deep.

To study the effects of P6 acupressure in the prophylaxis of chemotherapy-induced nausea and vomiting (CINV) in patients with breast cancer.

Participants were randomized to the control or experimental arm and received standard antiemetics before chemotherapy with prescriptions for antiemetics for delayed CINV that were variable.

For the experimental group, acupressure was applied using a Sea-Band® (Sea-Band Ltd.) for five days after chemotherapy administration. Researchers taught patients how to wear the bands bilaterally with the stud pressing the P6 acupoint in brief education sessions. Patients were given daily logs with the hours of the day and asked to put a mark at the hour each time that they pressed the wristband’s stud. Patients were instructed to press the stud for two to three minutes every two hours throughout the day, marking it in their log.

The control group was given antiemetics and told that they would receive acupressure instructions and wristbands with their next cycle of chemotherapy.

All participants completed questionnaires every evening after chemotherapy for five evenings. Completed questionnaires were returned directly to researchers or via pre-paid envelopes.

• The study consisted of 36 participants.
• All patients were newly diagnosed and chemotherapy naïve, starting their first cycle of chemotherapy for breast cancer, stages I-III, receiving doxorubicin or epirubicin and cyclophosphamide.
• Patients were excluded if they had received palliative chemotherapy, had a life expectancy of less than three months, had bowel obstruction, were receiving radiation therapy, or had lymphedema.

This study was conducted at a general hospital and a cancer hospital in the United Kingdom.

This was a randomized, controlled trial.

The Rhodes Index of Nausea and Vomiting was used.

Nausea and retching experience and nausea, vomiting, and retching occurrence and distress were significantly lower in the acupressure group than the control group.

At day 3, the acupressure group had a high level of nausea, vomiting, and retching, which was equal to the control group.

Acupressure at P6 is an effective intervention for managing CINV in patients with breast cancer.

• The sample size was small.
• Antiemetics for days 2-5 were not controlled.
• The study relied on patients completing daily questionnaires and returning them.

Use of the acupressure bands is easy to teach, and the bands are low in cost.

To determine the effectiveness of self-acupressure using wrist bands in the management of acute and delayed chemotherapy-induced nausea and vomiting (CINV) and to assess if the wrist bands are more effective in high, moderate, or low emetogenic chemotherapies

Patients were randomized using a method of minimization with a random element. Randomization was balanced for gender, age, and levels of emetogenic chemotherapy. Both patients and treating physicians were blinded to group. Patients received an acupressure wrist band, a sham acupressure wrist band, or no wrist band. All patients received the standard antiemetic regimen based on American Society of Clinical Oncology (ASCO) and Multinational Association of Supportive Care in Cancer (MASCC) guidelines with the exception of NK1-receptor antagonists, which were not available. The acupressure wrist bands are elastic with a 1 cm round plastic button. The button was worn at the P6 acupoint after patients were trained on the appropriate location to wear the button. The sham wrist bands had the button on the outside of the elastic band, and the button was worn facing away from the P6 point. Patients wore the wrist bands beginning the morning before chemotherapy and for six days after each cycle. Main outcome data were collected at baseline the day before chemotherapy and daily for up to seven days after chemotherapy, and additional data were collected on day 10. Some patients also participated in a qualitative interview.

• N = 361  
• AGE = Unable to determine
• MALES: 31.5%, FEMALES: 68.5%
• KEY DISEASE CHARACTERISTICS: Heterogeneous

• SITE: Multi-site    
• SETTING TYPE: Outpatient   
• LOCATION: United Kingdom

• PHASE OF CARE: Active antitumor treatment

Randomized, three-group, sham-controlled trial (Phase III)

• Rhodes Index of Nausea, Vomiting and Retching (INVR)
• MASCC Antiemesis Tool
• European Quality of Life-5 Dimensions (EQ-5D) utility scale
• Functional Assessment of Cancer Therapy—general quality of life scale
• Baseline measures—anxiety and depression, nausea/vomiting expectations, expectations from using the acupressure wrist bands

After the first cycle, there was no difference in the nausea level between any group, though there was a trend towards lower nausea scores for both the wrist band and sham wrist band groups. Qualitative interviews indicate that patients perceived both real and sham wrist bands as helpful in managing CINV.

Acupressure wrist bands are not an effective intervention in the management of CINV.

• Subject withdrawals ≥ 10%  
• Other limitations/explanation: 500 patients were randomized and data were only used on 361.

Nurses can educate patients that acupressure wrist bands are not an effective intervention to manage CINV.

To determine the effectiveness of acupressure in the management of chemotherapy-induced nausea and vomiting (CINV)

Patients were randomly assigned to one of three groups: use of P6 acupressure wristband, sham acupressure wristband, or usual care only. 

Prior to randomization, subjects were stratified by age group, gender, and emetogenicity of planned chemotherapy.  Patients were instructed to wear wristbands on both arms from the morning before chemotherapy administration and for the following 6 days, and to only remove them for showering or bathing. 

All patients received antiemetics based on American Society of Clinical Oncology (ASCO) and Multinational Association of Supportive Care in Cancer (MASCC) guidelines with the exception that NK1 receptor antagonists were not used with highly emetogenic chemotherapy, as these were not widely available in the country. 

All patients had rescue antiemetics available.  Study questionnaires were completed on day 10 of each cycle. Patients graded nausea daily.

• The study consisted of 372 patients.
• Two-thirds of the patients were over age 50. The sample included a few children. No other data was available.
• The majority (77.2%) of patients were female.
• A variety of tumor types and regimens were represented, with breast cancer as the most frequent.
• The majority of patients were receiving moderately emetogenic treatments.
• Almost all patients were Caucasian.

The study was conducted at multiple outpatient sites in the United Kingdom.

All patients were in active antitumor treatment.

This was a randomized controlled trial.

Measurement tools used were

• Rhodes Index of Nausea Vomiting and Retching
• MASCC Antiemesis Tool
• Functional Assessment of Cancer Therapy (FACT)-General
• The Hospital Anxiety and Depression Scale
• Patient expectations of nausea/vomiting, a two item, 11-point scale.

• The entire group showed relatively low levels of nausea. No significant differences were found between the three study groups in the experiences and measures of nausea; some improvement was found in both the actual and sham intervention groups. 
• The sham acupressure group had better odds ratio in improving nausea than the acupressure group. 
• No differences were found between groups in MASCC tool results for either acute or delayed nausea. 
• No differences were found in other outcome measures.
• Auditing of wristband use showed that compliance was good, with only four cases observed where use was incorrect. 
• Regression analysis showed that older age and male gender were predictive of better nausea outcomes (p = 0.005).

P6 acupressure was not shown to have a significant impact on prevention of CINV.  Findings suggest a potential placebo effect with both acupressure and sham acupressure wristbands.

• This study had unintended interventions or applicable interventions not described that would influence results.
• Participant withdrawals were 10% or more.
• No information about the use of any rescue medication was provided. 
• This study had very low nausea levels.

Findings did not show a significant effect of P6 acupressure on CINV; however, use of an actual and sham acupressure wristband may have a placebo effect.

To test whether providing information about the expected efficacy of acupressure bands would enhance their effectiveness in reducing nausea

• Chemotherapy naïve patients completed baseline questionnaires then received acupressure wristbands.
• Patients were randomized to the following groups.
  • 1: neutral handout and neutral compact disk (CD)
  • 2: acupressure-enhancing handout and neutral CD
  • 3: neutral handout and acupressure-enhancing CD
  • 4: acupressure-enhancing handout and acupressure-enhancing CD
• Patients were instructed to use the acupressure wristband and CD as needed during chemotherapy to prevent or alleviate nausea.
• Patients recorded antiemetic use, severity of nausea and vomiting, and wristband and CD usage in diaries.

• The study consisted of 74 participants.
• Mean age was 51.5 years with a range of 28–74.
• All participants were female patients with breast cancer.
• The majority of patients were White (93%), married (76%), had graduated from high school (99%), and had graduated or attended college (66%).
• The majority of patients were receiving doxorubicin-based chemotherapy (82%). The remaining were receiving docetaxel combined with either cyclophosphamide or carboplatin.

The study was conducted in a single outpatient setting. The location was not stated.

All patients were in active treatment.

This was a double-blind, four-arm, randomized, clinical intervention study.

• Patients reported their experiences in diaries.
• A nausea tool developed by Burish and Carey was used to measured nausea and vomiting on a 7-point Likert-type scale. No reliability or validity information was provided.
• Patients rated nausea expectancy on a 5-point Likert-type scale.
• Patients rated wristband effectiveness expectancy on a 5-point Likert-type scale.
• A study data questionnaire was used to gather demographic and clinical information.
• A feedback questionnaire evaluated the use of and recommendations for the acupressure wristband and CD.

• Results indicated that 15% of the sample experienced vomiting.
• The interaction of high-versus-low levels of nausea expectancy and neutral-versus-enhanced intervention showed a statistically significant difference for peak nausea (p = 0.030) but not for average nausea (p = 0.084).
• Patients who received the neutral materials took more antiemetic than patients who received the acupressure enhancing materials (p = 0.003).
• Expected nausea correlated with average nausea (p = 0.014) and peak nausea (p = 0.002).

Patients with enhanced information required less antiemetics and had less nausea than patients with neutral information. Managing expectations may facilitate chemotherapy-induced nausea and vomiting (CINV) management.

• The sample size was small with fewer than 100 patients.
• Differences in the types of chemotherapy and antiemetic medications and providers' discussion about nausea could have affected the study outcomes.
• The placebo effect of nausea intervention could have modified patients' expectations and response to the treatment.

This study illustrates the need for nurses to assess and be aware of patient’s nausea expectations during chemotherapy. Patients with high expectations may benefit from information or discussion of the expected benefits of interventions on reducing nausea.

To explore the effects of acupressure on chemotherapy-induced nausea and vomiting (CINV)

A convenience sample of patients was recruited, and patients were randomized to receive acupressure on two sites on both sides of the body or acupoint patches on a single site on both sides of the body. All patients were receiving standard triplet antiemetics. Study data were collected prior to and after the acupressure intervention and 48 hours after chemotherapy. Study data were collected three times—before chemotherapy, before dinner on the day of chemotherapy, and before breakfast on the following day. The acupressure group had pressure applied to the PC6 and SP4 points on both sides of the body, for three minutes on each point.

• N = 70   
• MEAN AGE = 58.6 years (SD = 0.2)
• MALES: 61.4%, FEMALES: 29.6%
• CURRENT TREATMENT: Chemotherapy
• KEY DISEASE CHARACTERISTICS: All had lung cancer and were receiving cisplatin-based chemotherapy.

• SITE: Single site   
• SETTING TYPE: Not specified    
• LOCATION: Taiwan

PHASE OF CARE: Active antitumor treatment

Two group, randomized trial

• Morrow Assessment of Nausea and Emesis (MANE)
• Meridian Energy Analysis Device

The mean meridian energy was significantly higher in the group receiving acupressure after the intervention (p = 0.003) compared to those who had acupoint patches. Analysis showed an effect on study groups across all study measurement times, with lower nausea (p < 0.001) and vomiting (p = 0.023) severity in the acupressure group.

Acupressure on PC6 and SP4 acupoints prior to chemotherapy and meals was associated with a lower severity of nausea and vomiting.

• Small sample (< 100)
• Risk of bias (no control group)
• Risk of bias (no blinding)
• Risk of bias (no appropriate attentional control condition)
• Findings not generalizable

The use of acupressure as an adjunct to standard antiemetic treatment may reduce the severity of CINV in patients receiving emetogenic chemotherapy. Nausea is still not well controlled in most individuals with maximal antiemetic use. Acupressure is a low-risk intervention that may be helpful for CINV control, specifically nausea control.

• Both the control and intervention groups received regular antiemetics.
• The intervention group also received acupressure training, and patients were instructed to perform the finger acupressure maneuver for five minutes on the P6 point at least three times per day before chemotherapy and mealtimes or as needed.
• Both groups received frequent nursing visits and consultations. The intervention was given with first cycle of 5-fluorouracil and cisplatin chemotherapy.

• This study consisted of 40 patients, 20 in the control group and 20 in the intervention group.
• Patients were 47–52 years old.
• All participants were postoperative patients with gastric cancer.

The study took place in a university medical center in metropolitan South Korea. Participants were on inpatient oncology wards.

This study had a nonequivalent control group design for a single cycle of chemotherapy.

• Demographic data, including family background, diagnosis and treatment, and assessment of nausea and vomiting, were recorded.
• The Rhode’s Index of Nausea, Vomiting and Retching was translated into Korean and back-translated to English to ensure equivalency.
• Patients recorded in daily logs their ratings of nausea experience using a four-point scale and intensity of nausea experience during the past 24 hours.

Significant differences existed between the control and intervention groups in the severity of nausea and vomiting, duration of nausea, and frequency of vomiting.

• Self-report has some degree of measurement error.
• Generalizability is limited because of regional study and small sample size.

To evaluate the effects of pericardium 6 (P6) acupressure and nurse-provided counseling on chemotherapy-induced nausea and vomiting (CINV) in patients with breast cancer

Participants were randomized to one of four treatment groups. The control group received sham acupressure on SI3 point—the ulnar side of the metacarpophalangeal joint of the little finger of both hands. The three experimental groups consisted of counseling only, P6 acupressure-only, and P6 acupressure and counseling.

Counseling consisted of a one-hour cognitive behavioral session which included an introduction, cognitive preparation, symptom acceptance, the use of available resources, and question and answer session. Participants were instructed to perform the cognitive-behavioral session daily for 5 days (C2, D 1-5). 

The P6 acupressure groups wore Sea-Band® bands on both wrists for 5 days.

All participants completed baseline data then received a booklet of instruments and a daily log. They were asked to check their gastrointestinal (GI) distress level nine different times the evening of the first day of cycle 2 of chemotherapy and then once in the morning and once in the evening of days 2–5. Patients were asked to keep a daily log of the antiemetic medications taken and the overall status of their GI symptoms. The research assistants called each participant once and sent two text messages during the 5-day period to increase adherence.

• The study consisted of 105 patients.
• The mean age of patients was 45 years (SD = 8.661). To be included, patients must have been older than 20 years.
• All of the patients were female and had been diagnosed with stage I-III breast cancer.                                                       
• Participants had previously received definitive breast surgery and were currently undergoing the second cycle of adjuvant chemotherapy with either the FAC (5-fluorouracil, Adriamycin, and cyclophosphamide) or ACT (Adriamycin, cyclophosphamide, and paclitaxel) regimen. All participants had experienced more than mild levels of nausea and vomiting with the first cycle of chemotherapy.  
• Patients who agreed to participate had their level of acute and delayed nausea measured on the 5th day of the first cycle, and only those with an average nausea level of more than 4 on a scale of 1–10 were included in the study.
• More than half of the participants had at least some college education, claimed a religion, were married at the time of the data collection, had stage II breast cancer, and had received the FAC regimen.
• Antiemetics used were granisetron (39%), aprepitant plus dexamethasone (30%), aprepitant only (20%), and ondansetron (9%).
   

This study was conducted at a single outpatient setting in Seoul, South Korea.

All patients were in active treatment.

This was a randomized, controlled trial.

• The Index of Nausea, Vomiting and Retching (INVR, Rhodes & McDaniel) self-report instrument was translated into Korean to measure frequency, distress, and duration of nausea, vomiting, and retching.
• Antiemetic medications taken and the severity of GI distress were reported daily in logs.

• CINV levels were significantly different among the groups from day 2 to day 5.
• These differences were attributed mainly to the difference between the control group and the group with P6 acupressure plus nurse-provided counseling (p = 0.01).
• The effects of acupressure were proven from day 2 to day 5 (p = 0.005, 0.002, 0.001, 0.001 respectively), and the effects of the nurse-provided counseling were proven on day 4 (p = 0.025) and close to significance on day 5.

Synergic effects of P6 acupressure with nurse-provided counseling appeared to be effective in reducing CINV in patients with breast cancer.

• Generalizability is limited because the study involved only women in one cancer center.
• The relatively small sample size of each treatment group may have limited that ability to measure the isolated effect of either P6 acupressure or counseling.  
• Substantially different antiemetics were used in the different study groups. 
• Overall, 17% of patients dropped out before completing the study.

The addition of P6 acupressure and nurse-provided counseling focused on cognitive awareness, affective readiness, symptom acceptance, and the use of available resources both appear to be effective as adjuncts to antiemetic medicine for the control of CINV in patients with breast cancer.

To evaluate the effect of a wristband acupressure for the prevention of chemotherapy-induced nausea and vomiting (CINV) in patients with gynecologic cancers

Patients completed diaries daily for five days while they were receiving chemotherapy. Based on their treatment protocol, patients received a wristband 21 to 28 days later, along with written and verbal instructions and demonstration on its use. Patients were instructed to wear the wristbands constantly and to complete the patient diaries for the five days while receiving chemotherapy. On the sixth day, patients completed questionnaires about the wristbands. All patients received standard antiemetics and recorded medication use in their diaries.

• The study consisted of 34 patients.
• The mean age of patients was 50.55 ± 10.55 years, with a range of 24–69 years.
• All of the patients were female.
• The majority of patients (76.5%) had ovarian cancer, with the balance having cancer of the endometrium, cervix, or fallopian tubes (23.5%).
• The majority of patients (85.3%) had completed primary/middle school, and 14.7% were high school/university graduates.
• Nearly half (47%) of patients had or were experiencing motion sickness, and 65.6% had histories of nausea or vomiting during the first months of pregnancy.
• Patients were receiving different chemotherapy regimens, but all were receiving carboplatin along with various other chemotherapy (cisplatin + cyclophosphamide, cisplatin + paclitaxel, doxorubicin, or docetaxel).

The study was conducted at multiple outpatient sites in Turkey.

All patients were in active treatment.

This was a prospective clinical trial with a pre/post-test design.

• Sociodemographic information and medical histories were recorded.
• Patients recorded nausea severity on a 0–10 scale (0 for no nausea; 10 for very severe nausea) in diaries and completed wristband questionnaires.
• Vomiting, retching, number of antiemetics taken, and amount of time the wristband was worn were recorded on graphs.

• Mean nausea significantly decreased after wristband use compared to before wristband (p = 0.000).
• No significant difference was noted in vomiting or retching.
• The mean use of antiemetic medication with wristbands was significantly less than before wristbands (p = 0.000).

Acupressure wristbands worn by patients with gynecologic cancers during chemotherapy administration were associated with a significant reduction in nausea but not vomiting or retching. Less antiemetic medication was used with the acupressure wristband.

• The sample was small with fewer than 100 patients.
• The majority of patients had less than a high school education, which may have influenced the information recorded in the patient diaries. 
• Patients may have over- or underestimated the time they wore the acupressure wristband.
• A placebo effect could have arisen with patients expecting any treatment would reduce their symptoms, especially since the time of wristband use had no effect on outcome measures.
• How delayed nausea was defined and analyzed was not clear, because patients recorded their symptoms only during their chemotherapy treatment.
• How often or when the nausea and vomiting measurements were recorded was not clear.
• No reliability or validity information was provided for any of the tools used.

Acupressure wristbands may provide some relief of nausea during chemotherapy treatment; however, they do not appear to provide relief from retching or vomiting.

4,900 references were identified that were published between January 1, 1990 and December 31, 2013. 203 articles were included in the final review although only 174 were referenced. Grades used and reported here were A: recommended, high certainty of benefit, B: recommended, high certainty of moderate to substantial benefit, D: recommends against use, moderate to high certainty of no net benefit, and H: recommends against use, moderate to high certainty that harms outweigh benefits.

Interventions for specific symptoms that had strong recommendations for or against use were:

• Anxiety: Music therapy during RT and chemotherapy sessions, meditation, and yoga for patients undergoing therapy (B-level recommendation)
• Depression: Mindfulness-based stress reduction for patients undergoing radiotherapy, relaxation, and yoga (level A recommendation); massage and music therapy (level B)
• Fatigue: Energy conservation (level B)
• CINV: Acupressure and electroacupuncture in addition to antiemetics (B level)
• Neuropathy: Acetyl L carnitine was not recommended because of harm (H level).
• Radiodermatitis: Aloe vera and hyaluronic acid cream were not recommended as standard therapy because of lack of effect (D level).

It appears that only specific types of interventions were included, and there are numerous types of integrative or complementary interventions that were not considered in this review. The findings considered were limited to women with breast cancer. Quality rating of evidence was not discussed individually.

These guidelines provided an evidence-based evaluation of various integrative therapies in women with breast cancer. This set of interventions is not all-inclusive; however, it does provide some guidance to clinicians and others regarding evidence strength in these areas as assessed by this specific study group.