Cancer Survivorship: Managing Nausea and Vomiting

By Barrie Cassileth, MS, PhD

Most often associated with chemotherapy, nausea and vomiting are side effects that many cancer patients experience. This is an issue not only during treatment, as nausea can be anticipatory, meaning it can start in advance of chemotherapy. The sight of the hospital might trigger nausea because of its association with chemotherapy in the mind of the patient. Sometimes delayed, low-grade nausea can continue for a few days after treatment.

Fortunately, there are a variety of therapies that can help. Medicines called antiemetics are fairly effective at reducing nausea and vomiting symptoms and are the first line of defense. Several complementary therapies, such as acupuncture, mind-body, and massage, can have similar effects—or even extend the effects of drugs when used together. These complementary options can be used alone for mild nausea, and they are often especially helpful for anticipatory nausea before chemotherapy or delayed nausea afterward. Antiemetic drugs are not always as helpful in these cases, and complementary therapies can help fill that void.

Managing Nausea and Vomiting with Acupuncture

Acupuncture is particularly effective as a complementary treatment for nausea and vomiting in cancer patients. It can help control these symptoms after chemotherapy, radiation, and surgery, and acupuncture’s effects can last for hours if not longer. The most commonly studied acupuncture point for relief of such symptoms is called Nei guan or PC6. This acupoint is centered on the wrist about two and a half finger widths up from the crease between hand and wrist. Several variations of acupuncture have been studied, including electroacupuncture, in which the needles are hooked up to a device that generates a slight electric current.

In one trial of breast cancer patients receiving a particularly nausea-inducing form of chemotherapy, electroacupuncture diminished symptoms of both nausea and vomiting. Compared with patients taking only antiemetic drugs, those who received electroacupuncture at the PC6 point once daily for five days had significantly fewer instances of vomiting. Patients in the acupuncture group had an average (median) of five episodes, compared with 15 in the medication-only group.1

Notably, the well-respected Cochrane Collaboration published reviews on this topic in 2006 and 2009. After examining all the existing evidence, reviewers concluded that acupuncture can reduce the nausea and vomiting in cancer patients caused by chemotherapy or surgery. The first review, published in 2006, evaluated 11 randomized controlled trials and determined that electroacupuncture helps reduce chemotherapy-induced nausea and vomiting. Further, they found that self-acupressure—in which the patient stimulates certain acupoints on their own by pressing, without needles—can help prevent nausea.2

The second Cochrane review, published in 2009, concluded that acupuncture at the PC6 point can effectively reduce nausea and vomiting after surgery. This was based on an examination of 40 prior randomized controlled trials. It was not clear, however, whether acupuncture was more effective than conventional antiemetic drugs alone (no significant difference was found).3

Remarkably, needles may not be required to reduce nausea in this way. A recent randomized controlled trial in craniotomy patients found that transcutaneous electrode stimulation—that is, electrical stimulation without actually inserting a needle—at the PC6 point before, during, and after surgery significantly reduced the incidence of nausea and vomiting over the course of 24 hours after the operation. Craniotomy is a procedure in which a section of bone is removed from the skull to expose the brain. Afterward nausea and vomiting are very common, affecting up to 60 percent of patients despite the use of antiemetic medications. Patients who received the acupoint stimulation experienced a 40 percent lower incidence of nausea and a 60 percent decrease in vomiting compared with the placebo group, who received electrical stimulation at a non-acupoint.4

Although acupuncture is frequently more effective than usual care, some studies have found that some beneficial effects of properly performed acupuncture are mimicked by sham procedures, in which needles are inserted at non-acupoints (and should theoretically not have any effect). A recent investigation of acupuncture’s effects on radiation-induced nausea, for example, found no significant difference in nausea frequency or intensity between the groups receiving true or sham acupuncture, although both groups experienced less intense nausea than patients receiving usual antiemetic care. As a result, some wonder whether acupuncture’s benefits are at least partly the result of attention, doctor/patient interaction, or a placebo response.5

Actually, it hardly matters what exactly produces the benefit—whether it is attention, doctor/patient interaction, a placebo response, the acupuncture alone, a combination of these possibilities, or something else—so long as it works. Further research will help sort this out, but for purposes of the patient it really doesn’t matter. Whatever the specific mechanism by which acupuncture works, it is very safe, is relatively inexpensive, and can provide a significant benefit, particularly if nausea and related symptoms are an issue for you.

Managing Nausea and Vomiting with Mind-Body Therapies

Mind-body therapies, including meditation, hypnosis, and guided imagery, can greatly reduce nausea and vomiting. These methods help you relax or distract you and help put you in control of your body and mind.

Mind-body practices are particularly effective for anticipatory nausea, which is itself an example of the mind affecting the body. Just as vomiting can be a result of stage fright, there is no physical cause for anticipatory nausea. It is the body’s response to the mind’s anticipation of something unpleasant, such as chemotherapy. Using techniques such as self-hypnosis or guided imagery, you can learn to disrupt this process—to break the association and bring about relief.

Self-hypnosis was one of the first mind-body techniques used to control nausea and vomiting. It puts you in a state of deep attention or “restful alertness” and makes you receptive to new ideas. Hypnosis has been shown to effectively treat anticipatory nausea in both adult and pediatric cancer patients. In a study of 54 pediatric patients, children were assigned to receive either hypnosis, distraction/relaxation techniques, or no intervention. Patients in the hypnosis group had a substantial reduction in both anticipatory and post-chemotherapy nausea. In contrast, nausea levels in the children who practiced distraction/relaxation remained unchanged, and symptoms in the no-intervention group consistently worsened over time. In another study, however, adding distraction and relaxation training reduced nausea prior to chemotherapy more effectively than when these techniques were not used.6

Training in guided imagery also can be valuable. This technique allows you to mentally remove yourself from your current situation and arrive at a place that is pleasant and relaxing. Without leaving the treatment room, you can imagine what you would be feeling, hearing, and seeing in this other, more restful place. In so doing it is possible to mentally block physical symptoms such as nausea and vomiting. Guided imagery is a relaxation technique that can be worthwhile for many aspects of day-to-day life, and it is not hard to learn.

Trained therapists can teach you self-hypnosis, guided imagery, and other mind-body techniques, and then you can practice them on your own. Some hospitals may have these therapists on staff; otherwise, you can ask for a referral.

Managing Nausea and Vomiting with Massage Therapy

A few studies suggest that massage can help ease nausea in patients undergoing cancer therapy, most likely by providing a source of relaxation and distraction. In one small randomized controlled trial, 39 breast cancer patients currently undergoing chemotherapy were assigned to a massage group (five 20-minute visits with massage) or to a control group (five 20-minute visits without massage). The massage treatments significantly reduced nausea levels. In another randomized study, patients’ nausea scores decreased by about one-third after a single massage, with little or no change in the control subjects who did not receive the massage.

Massage therapy is probably most worthwhile if you have low-grade nausea, but it may not be the best or most helpful option if nausea is more severe. Still, massage is extremely relaxing and can help treat a wide range of other symptoms, from pain to stress and anxiety.

Managing Nausea and Vomiting with Music Therapy

Music therapy is conducted by specially trained professionals who use music to help alleviate symptoms. They bring portable instruments to the bedside and may perform music for or with patients. When used with typical antiemetic medications, music therapy may help further reduce nausea and vomiting from chemotherapy. At the very least, it can relieve stress, reduce blood pressure, lower heart rate, and promote general well-being. Even something as simple as music can be very powerful.

References
1 Choo SP, Kong KH, Lim WT, Gao F, Chua K, Leong SS. Electroacupuncture for refractory acute emesis caused by chemotherapy. Journal of Alternative and Complementary Medicine. 2006;12(10):963-9. doi: 10.1089/acm.2006.12.963.

2 PubMed Health. Acupuncture for nausea and vomiting which has been induced by having chemotherapy treatment. Cochrane Database of Systematic Reviews: Plain Language Summaries. First published April 19, 2006.

3 PubMed Health. P6 acupoint stimulation prevents postoperative nausea and vomiting with few side effects. Cochrane Database of Systematic Reviews: Plain Language Summaries. First published April 15, 2009.

4 Ni JW, Meng YN, Xiang HF, Ren QS, Wang JL. Effect of transcutaneous acupoint electrical stimulation on lipid peroxidation and cognitive function in patients experiencing craniotomy. Zhen Ci Yan Jiu. 2009;34(1):52-56 (abstract in English; article in Chinese).

5 Azad A, John T. Do randomized acupuncture studies in patients with cancer need a sham acupuncture control arm? Correspondence. Journal of Clinical Oncology. 2013;31(16):2057-58. doi: 10.1200/JCO.2012.47.8750.

6 Richardson J, Smith JE, McCall G, Pilkington K. Hypnosis for procedure-related pain and distress in pediatric cancer patients: A systematic review of effectiveness and methodology related to hypnosis interventions. Journal of Pain and Symptom Management. 2006;31(1):70-84. doi: 10.1016/j.jpainsymman.2005.06.010.

Prescribed Reading

In Survivorship: Living Well during and after Cancer (Spry, 2014; $16.95), Barrie Cassileth, PhD, offers a comprehensive overview of evidence-based integrative cancer treatment, providing a welcome resource for patients and their loved ones. Dr. Cassileth provides background on complementary therapies, describing various options and their potential to alleviate symptoms of cancer treatment and including important information about current research related to each topic. Written in a clear, accessible style, the book also provides insight throughout to differentiate effective, evidence-based options from dangerous “alternative” therapies. The result of Dr. Cassileth’s work is a book that is at once easy to understand and backed by considerable research—a valuable resource for anyone facing a cancer diagnosis.

Excerpted with permission from Survivorship: Living Well during and after Cancer (Spry, 2014; $16.95), by Barrie Cassileth, PhD. © Spry Publishing 2014. Available for purchase at cancercarestore.com.