Psychoeducation/Psychoeducational Interventions

 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 determine the kind of nonpharmacological interventions used by Turkish patients with cancer for symptom management during chemotherapy, whether a relationship exists between symptom experience and nonpharmacological intervention use, and what personal and illness-related variables predict the symptom experience and nonpharmacological interventions use in this population

Patients completed the following. If patients were unable to complete the tools themselves, a friend or relative verbally asked the patient the questions.

• Patient Characteristics Form
• Eastern Cooperative Oncology Group (ECOG) Performance Status scale
• Nightingale Symptom Assessment Scale (N-SAS)
• Use and perceived effectiveness of nonpharmacological interventions used during chemotherapy using dichotomous responses (0 = not effective, 1 = yes, effective)

• The study reported on 202 pages with a mean age of 48.82 years (SD = 1.44 years).
• The sample was 41.6% male and 58.4% female.
• Cancer diagnoses were breast (27.2%), colorectal (16.8%), gynecologic (14.4%), lung (13.4%), lymphoma (7.4%), urologic (6.4%), gastric (5.4%), bone (4.5%), head and neck (2.5%), skin and sarcomas (2.0%).
• Other key sample characteristics include that 66.8% of patients had primary disease and 33.2% had metastatic disease; 58.4% had ECOG performance status of 0 (fully active), 29.7% had ECOG performance status of 1, and 11.9 % had ECOG performance state of 2.

The study was conducted at a single site, outpatient setting at the Istanbul University Institute of Oncology in Turkey.

Patients were undergoing the active phase of treatment care.

This was a descriptive study.

• The Patient Characteristics Form had 17 items that addressed demographic, disease, and treatment characteristics at the time of initial diagnosis. 
• The Eastern Cooperative Oncology Group (ECOG) Performance Status assesses performance status of patients with cancer using six possible number responses.
• The Nightingale Symptom Assessment Scale (N-SAS) is a Likert -type, quality-of-life scale that includes 38 items addressing symptom experience of patients with cancer during chemotherapy. Three subscales (psychological well-being, social well-being, and physical well-being) are used. The original study using this author-developed scale reported that the subscales have high internal reliability and Cronbach’s alpha values between 0.81 and 0.87 and 0.93 for the overall tool. This study reported Cronbach’s alpha reliability for the subscales as follows.
  • Psychological, 0.88
  • Social, 0.80
  • Physical, 0.85
• Effective nonpharmacological interventions were identified from the literature and grouped into three subgroups based on the scale’s subgroups of psychological, social, and physical.

• Physical symptom distress was higher than psychological and social symptom distress.  The most frequent symptoms reported were fatigue (85.1%), nausea (70.8%), alopecia (68.3%), dry mouth (64.4%), and impaired sleep habits (62.9%).  Nonpharmacological interventions used to relieve physical distress included resting (38.2%) and sleeping (12.9%) for fatigue; drinking liquids (9%) and oral care (15.9%) for dry mouth; and exercise (8%) and massage (5.5%) for other physical symptoms. Most subjects (72.5%) preferred pharmacological interventions for physical symptoms.
• Psychological symptom distress was most frequently addressed by support (7.5%), resting (6.5%), and exercise (1.5%). Only 3% of patients preferred pharmacological interventions for psychological symptoms. Social interventions included pomades for skin and nail changes (19.4%) and berets, scarves and wigs for alopecia (6.5%).  An increase in symptoms “enhanced” the use of the physical and all nonpharmacological interventions in general.  The well-being of women and younger patients and patients who had metastatic disease, surgery, and high ECOG performance scores were low for all subgroups and overall (p < 0.05).
• Social well-being was lower in patients with breast cancer, patients who received taxane-based therapy, and those who were housewives. Social interventions were more frequently used by university graduates (p = 0.024). Psychological interventions were more often used by students compared to housewives, retired, self-employed people, and working people (p = 0.028). Patients below the age of 50 preferred to use psychological interventions using logistic regression (overall response [OR] = 3.06 [95% confidence interval (CI) = 1.17–7.96]).

Most patients with cancer in Turkey preferred pharmacologic interventions for symptom management.  Exercise, as a recognized evidence-based intervention, was only reported to be used by a few patients. The authors recommended that oncology nurses teach patients more about the side effects of chemotherapy and associated nonpharmacological interventions. Although other studies have produced such evidence-based recommendations, they were not developed from this study of self-reported symptoms and interventions of Turkish people receiving chemotherapy. The authors did not report if or how teaching occurred from the perspective of the nurse or the patient or family.

• No appropriate control group was included.
• Only patient survey data was used.
• Data was exclusively from a Turkish patient population at one point in time (which differed among patients) and with various diagnoses and treatments . 
• No discussion was included comparing these results to results from similar symptom and intervention surveys in other countries and cultures.

An individualized assessment of each patient's knowledge and preferences is important to all cultures and practices.

To evaluate a multi-modular self-care program, Self-Care Improvement through Oncology Nursing (SCION), consisting of emesis treatment, nutritional support, counseling, and relaxation interventions to reduce anorexia, nausea, and emesis (ANE)

Patients were randomized to receive either standard care (control) or the SCION program, which included four modular, algorithm-based protocols. In the intervention group, all patients received Module 1, \"Information leaflet,\" and Module 2, \"Structured consultation,\" at various times during treatment. Module 3 “Nutrition counseling” and Module 4 “Relaxation” were given if a patient developed significant nausea, emesis, or weight loss. Patients in the control group received set emesis prophylaxis. Assessments were made on days 1–5 of two chemotherapy cycles and day 8 of the second cycle.

• The study consisted of 208 participants.
• Mean age in the control group was 53.38 years (SD = 13.69 years). Mean age in the intervention group was 50.52 years (SD = 13.21 years).
• In the control group, 48% of the sample was female. In the intervention group, 71.4% of the sample was female.
• Diagnoses were gynecologic (47%), urologic (5%), hematologic (16%), other (32%).
• In the control group, 40% of patients were receiving chemotherapy with level 4 emetogenic potential and 60% were receiving chemotherapy with level 5 emetogenic potential. In the intervention group, 22% were receiving level 4 emetogenic potential and 78% were receiving level 5 emetogenic potential.
• In the control group, 11% of patients were receiving NK1 receptor antagonists (RAs) in addition to 5-HT₃ RAs and steroids. In the intervention group, 20% were receiving NK1 RAs in addition to 5-HT₃ RAs and steroids.

The study was conducted in inpatient and outpatient settings at two German university hospitals.

All patients were in active treatment.

This was a randomized, controlled study.

• All patients were assessed on days 1-5 of two chemotherapy cycles for nausea, vomiting, anorexia, and weight loss using Common Terminology Criteria for Adverse Events, version 3.0 (CTCAE v3.0).
• A summative score was used to bring each symptom to a 0-10 range; formula: ANE = 2.5 x (anorexia, nausea, vomiting) + 3.33 x weight loss.
• A 100-mm visual analog scale (VAS), ranging from insufficient to very good, was used to capture patient knowledge of chemotherapy-related side effects and effective self-care activities
• The Appraisal of Self-Care Agency (ASA-A) scale was used to assess self-care agency.
• The Self-Care Chemotherapy Side Effect Questionnaire was used to assess self-care activities.
• Quality of life was assessed by the European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ).

• No significant differences were found between the intervention and control groups in the reduction of ANE or chemotherapy side effect knowledge, self-care activities, or efficacy of competence activities.
• Quality of life (QOL) was significantly better in the control group (p = 0.017).
• Interactions between ANE intensity and the covariates were not statistically significant.
• Nausea (46%) was reported as the most frequent side effect.

The initial hypothesis, that a structured intervention for patients receiving chemotherapy with moderate or high emetogenic potential would significantly decrease ANE intensity, was not supported. The effectiveness of the nursing intervention to reduce chemotherapy-induced ANE and increase QOL could not be supported. Rather, the intervention was reported to have a negative effect on QOL.

• No appropriate control group was included.
• A 16% dropout rate occurred in the intervention group, because of imbalances in randomization (a higher number patients with hematologic cancers with additional radiotherapies).
• No evidence of standardized teaching or written materials was provided.
• A potential for bias existed because the nurses who administered the intervention and assessed the outcomes were aware of group allocation.
• Descriptions of the validity and reliability of the measurement tool were poor.
• The results did not reflect whether the program was effective or if effectiveness was a result of low ANE incidence and intensity.

The SCION program had no effect in reducing distressing ANE.

To examine the effect of a planned educational program on symptom control

Patients were randomly assigned to the education or waitlist control/usual care group. The educational intervention consisted of face-to-face educational sessions prior to each chemotherapy cycle provided to patients, caregivers, and family members. Symptom management education, support, and opportunity for discussion were provided.

• N = 140   
• MEAN AGE = 58.9 years
• MALES: 45%, FEMALES: 55%
• CURRENT TREATMENT: Chemotherapy
• KEY DISEASE CHARACTERISTICS: All had hematologic cancers and were beginning initial chemotherapy.
• OTHER KEY SAMPLE CHARACTERISTICS: Sixty-four percent were married, and 22% had no more than primary education.

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

PHASE OF CARE: Active antitumor treatment

Randomized, controlled trial

Not specified

The prevalence of chemotherapy-induced nausea and vomiting and difficulty sleeping were significantly lower after the intervention in the education group (p < 0.001), whereas the prevalence of these symptoms increased in the control group.

The findings suggest that an educational intervention can be beneficial in managing symptoms related to cancer treatment.

• Risk of bias (no blinding)
• Risk of bias (no appropriate attentional control condition)
• Measurement/methods not well described
• Measurement validity/reliability questionable
• Method of randomization not described
• How symptom data were measured/obtained is unclear.

Patient education may be helpful in managing symptoms during cancer treatment. Education is necessary but may not be sufficient for symptom control.

To determine the effectiveness of audiotapes on self-care behaviors, state anxiety, and the use of self-care behaviors and to describe the occurrence and intensity of common side effects in patients with breast cancer

Two 20-minute audiotapes provided information on nutritional management of side effects, exercise, and relaxation techniques along with written transcripts that were professionally developed at a fifth-grade reading level. All participants received standard education for the clinic but not standardized education. The experimental group received audiotapes and transcripts via mail and were provided with a cassette player if they did not have one at home. All participants were interviewed three times via telephone.

The study reported on 70 women with newly diagnosed stage I or II breast cancer starting the first cycle of chemotherapy treatment. Most of the women were receiving docorubicin and cyclophosphamide.

The setting was outpatient chemotherapy clinics operated by a university center in satellite clinics in rural areas of southeastern United States that covered 29 counties.

The design was an experimental, randomized, clinical trial.

• The Spielberger State-Trait Anxiety Instrument and modified Nail Self-Care Diary were used.
• Anxiety and self-care measures were recorded in diaries (nausea, fatigue, taste change, difficulty sleeping).

• Women who used the audiotapes demonstrated effective self-care behaviors over time, whereas the control group appeared to experiment to find effective self-care behaviors.
• Anxiety was high in both groups, but the symptoms decreased among women who received audiotapes and telephone calls.
• The most frequently experienced side effects were fatigue, nausea and vomiting, and taste changes.
• The number of women reporting nausea and vomiting decreased by half from the first to second self-care diaries.
• More self-care behaviors were used for nausea and vomiting than any other side effect that patients experienced.
• Prescription medications were the most frequently used self-care behavior and were effective over time.

• Informational audiotapes are effective teaching tools.
• Self-care behaviors can be taught and can be effective in managing side effects.

• The amount and type of information received in clinics and from community was not controlled.
• A limitation of the study was its small sample size.
• The telephone intervention may have had a substantial effect on patients’ behaviors. The questions asked during the phone interview reinforced self-care behaviors in the experimental group and provided information to women in the control group that they may not have had otherwise.
• The age of the population (half were younger than age 50) should be considered.
• The intervention was expensive; costs were incurred when developing the audiotapes in a studio with a professional speaker.