Support Care Cancer (2005) 13: 826833

DOI 10.1007/s00520-005-0806-7 ORIGINA L A RTICLE

Hee J. Yoo
Se H. Ahn
Efficacy of progressive muscle relaxation
Sung B. Kim
Woo K. Kim
training and guided imagery in reducing
Oh S. Han chemotherapy side effects in patients
with breast cancer and in improving
their quality of life

Received: 20 September 2004

Accepted: 1 March 2005
Published online: 23 April 2005
# Springer-Verlag 2005
H. J. Yoo (*) . O. S. Han
Department of Psychiatry,
Asan Medical Center, University of
Ulsan College of Medicine,
# 388-1, Pungnap-dong Songpa-gu,
138-736 Seoul, South Korea
e-mail: junhkl@hanafos.com
Tel.: +82-2-30103418
Fax: +82-2-4858381
S. H. Ahn
Department of Surgery,
Asan Medical Center, University of
Ulsan College of Medicine,
Seoul, South Korea
S. B. Kim . W. K. Kim
Department of Oncology,
Asan Medical Center, University of
Ulsan College of Medicine,
Seoul, South Korea
Abstract Goals: This study was
designed to assess the effectiveness of
progressive muscle relaxation training
(PMRT) and guided imagery (GI) in
reducing the anticipatory nausea and
vomiting (ANV) and postchemother-
apy nausea and vomiting (PNV) of
patients with breast cancer and to
measure their effects on the patients
quality of life (QoL). Patients and
methods: Thirty chemotherapy-naive
patients with breast cancer were ran-
domized to the PMRT and GI group
and 30 to the control group. Before
each of six cycles of adjuvant chemo-
therapy, each patient was administered
a self-report Multiple Affect Adjective
Checklist (MAACL), and incidents
of ANV and PNV for the first three
postchemotherapy days were record-
ed. All patients were administered
the Functional Assessment of Cancer
TherapyBreast (FACT-B) at base-
line and after 3 and 6 months.
Results: We found that the PMRT and
GI group was significantly less anx-
ious, depressive, and hostile than the
control group. We also found that the
PMRT and GI group experienced
significantly less ANV and PNV and
that 6 months after CT, the QoL of the
PMRT and GI group was higher than
that of the control group.
Conclusion: These results indicate
that PMRT and GI were associated
with both the improvements in ANV
and PNV and in the QoL of patients
with breast cancer.
Keywords Breast cancer .
Anticipatory side effects .
Postchemotherapy side effects .
Progressive muscle relaxation .
Guided imagery . Quality of life

Introduction ipatory nausea has proven resistant to treatment with com-

A successful course of chemotherapy (CT) can produce a
variety of unpleasant side effects such as decreased immu-
nity to other diseases, changes in liver enzymes, hair loss,
loss of appetite, nausea, vomiting, temporary or permanent
frigidity or impotence, as well as negative affects such as
anxiety and depression [2, 7, 17]. Patients younger than 50
years have been found to develop nausea and vomiting
(NV) frequently than older patients [19, 22], and females
more than males [12, 19, 23].
In addition to these pharmacologically induced symp-
toms, approximately one in four CT patients also experi-
ence conditioned side effects that are thought to develop
through the learning process [8, 27]. Unfortunately, antic-
monly used antiemetic drugs [21, 24]. Patients who have
experienced CT will be at risk of developing anticipatory
nausea and vomiting (ANV) [1].
Fortunately it was reported that behavioral treatment,
including progressive muscle relaxation training (PMRT)
[7, 8] and hypnosis [24], may be effective in reducing ANV.
PMRT plus guided imagery (GI) have been shown effective
in groups of patients with cancer [3, 18, 20]. In patients with
breast cancer, PMRT and GI have been shown to allevi-
ate the side effects of CT [6, 20]. Nonpharmacological
factors have been reported to be more effective in managing
CT-induced NV [19], and relaxation plus GI had more
positive effects on mood than did relaxation alone [6]. One
of the best methods of prevention for the patients ANV

might be to treat acute nausea/vomiting effectively and thus
to decrease the patients anxiety about anticipatory side
effects. In the study of Molassiotis et al. [20], each patient in
the experimental group received a PMRT session with the
therapist 1 h before chemotherapy administration (at hos-
pital) and on each of the next 5 days (in the patients homes)
for a total of six sessions. After chemotherapy, delayed
nausea was at its highest point on day 3 of chemothera-
py, declining steadily thereafter; delayed vomiting was its
highest point on day 2 after chemotherapy [20].
There also have been studies on post-CT nausea and
vomiting (PNV) in CT-nave patients with breast cancer
[14, 20, 23]. In preventing post-infusional NV, the use of
effective antiemetics is the primary approach for dealing
with subsequent anticipatory effects [27].
The rate of ANV is much less than observed in older
studies, which used less satisfactory antiemetic programs.
ANV is difficult to control by pharmacological means,
whereas behavioral therapies involving relaxation can be
used to effectively treat ANV [1]. If we reduce patients
ANV with PMRT and GI, this may reduce patients PNV,
thus making it difficult to determine the effect of reduction
methods on PNV.
Along with physiological and psychological assess-
ments, it is important to determine the effects of treatment
on patients quality of life (QoL). In patients with advanced
breast cancer who underwent adjuvant CT, the patients with
higher QoL scores in their QoL assessment before their
treatment predicted a better response to CT [16, 26]. The
potential psychological, sexual and physical dysfunction
caused by both the diagnosis and treatments in breast cancer
can have a deleterious impact on the quality of a womans
life [14]. Health-related quality of life (HRQoL) can be
profoundly affected by breast cancer treatment [13]. There-
fore, monitoring quality of life in breast cancer should be
mandatory part of follow-up in clinical trial. Assessment
of QoL can help identifying those patients who might
profit from psychosocial interventions [14].
Disease-specific scales, such as the Functional Assess-
ment of Cancer TherapyBreast (FACT-B) [5, 9], have
been found effective in assessing the general and disease-
specific well-being of patients with breast cancer. The ef-
fects of the use of PMRT on anxiety and QoL in patients
with colorectal cancer after stomach surgery were evaluated
with repeated measures assessment over 10 weeks post-
stomach surgery [10]. Nevertheless, there has been no study
on the efficacy of PMRT and GI training along with
assessing the QoL of patients with breast cancer who re-
ceive CT.
The aim of the study was to evaluate the effects of PMRT
and GI in reducing chemotherapy side effects and in im-
proving the QoL of patients with breast cancer.
The subjects in our study were a homogeneous group of
patients with breast cancer, who received six cycles of cy-
clophosphamide, methotrexate, and 5-fluorouracil (CMF).
We had performed PMRT and GI on the patients in each
827
session of their six-cycle CT session and measured how
much PMRT and GI reduced their CT side effects. Based on
the study of Molassiotis et al. [20], we asked the patients to
self-report their home records during 3 days after CT to see
their PNV.
More effective management of treatment-related NV
could also improve patients QoL [23]. Fairclough et al.
[15] had used three times repeated measures to compare the
HRQoL of the patients in six 28-day cycles of cyclophos-
phamide, doxorubicin, and 5-fluorouracil (CAF) with that
of the patients in a 16-week regimen. They limited the
assessment to that before therapy within 14 days of start
of chemotherapy. The assessment during treatment of 4
[6] of CAF, the assessment of following therapy was to
occur 4 months after the completion of therapy. Based on
the Fairclough et al. study [15], we assessed the QoL of
the patients using three repeated measures at baseline, 3
months, and 6 months after their receiving CT.
The hypotheses of the study are as follows:
1. The PMRT and GI group will significantly reduce the
negative emotions (anxiety, depression, and hostility),
intensity of anticipatory side effects (anxiety, nausea,
and vomiting), and postchemotherapy side effects than
the control group.
2. At 3 months after chemotherapy, the PMRT and GI
group will significantly improve in emotional well-
being; at 6 months after chemotherapy, the PMRT and
GI group will significantly improve in general and
breast-cancer-specific well-being.
Patients and methods
An experimental, randomized controlled trial was designed
to examine the effectiveness of the PMRT and GI in a group
of patients with breast cancer. To keep the sample as ho-
mogeneous as possible, all subjects consisted of the out-
patients of the same type of cancer who were receiving CT
for the first time at the Department of Oncology in Asan
Medical Center in Seoul. The subjects were randomly allo-
cated to experimental and control groups by simple random
sampling. Randomization was carried out by using the en-
velope method [10]. Each patient had to pick an envelope
out of a box of 70 identical envelopes.
The sample size was calculated using the formula for
estimating sample size for repeated measures analysis of
variance [11]. As the previous literature is in favor of PMRT
[10], one-tailed test was used and the significance level was
set at 0.05 with the power set at 80%. With the estimation of
an average of 37% attrition in longitudinal studies over 10
weeks [3], the required sample size would be at least 35 in
each group.
In Korea, most patients with breast cancer usually are
in their forties and fifties (about 5060% of all patients
with breast cancer), which are different from the cases in
828

Western countries; cases of Korean patients with cancer 4. Ability to read and write Korean
who were both over 60 years old and receiving CT were 5. Agreement to give written informed consent
very few in this study (n=3). When we started this study, we
excluded only the patients who were in breast cancer stage Patients were excluded if they had a known CNS metas-
IV with a life expectancy of <6 months, and no restrictions tases, a history of intestinal obstruction, prior mental ill-
were made with regard to the patients age or performance ness, and end-stage malignancy.
status. As the study went on, there was a tendency for the Antiemetic therapy consistent with current guidelines
patients older than 60 years to drop out of our study, pri- was used in treating these patients. All patients received
marily because they were physically very weak and their antiemetic regimens including dexamethasone and a 5-HT3
families were not cooperative to participate in this study. antagonist. Antiemetics were given 30 min before the che-
Especially, Korean caretakers of the patients over 60 years motherapy was administered. Metoclopromide 15 mg and
old were usually the patients family members, and they lorazepam 1 mg p.r.n. were also prescribed for each patient
had always complained of arriving at the hospital 1 h earlier for their use at home, and the patients were told to take them
than the time due of their patients receiving CT to partic- when necessary.
ipate in this study. So we made a decision to drop them
because the number of their cases (n=3) was very few.
However, owing to the time limit and unexpected events Procedures
during the study period, such as noncooperation of the
caretakers or the CT dropout because of the patients se- Patients willing to participate in the study were given a
rious physical weakness, we had to randomize only 60 pa- short interview with two clinical psychologists to be told
tients into a PMRT and GI group (n=30) and a control group the purpose of the study and an information sheet. A pilot
(n=30). The groups were well matched for demographic study lasting for 1 month was conducted before the main
variables such as age, educational level, and marital status study, and minor adjustments were made to the quiet room,
(Table 1). questionnaire, and design. The study was carried out over a
Inclusion criteria were the following: period of 20 months, starting in early 2002. Both control
and experimental groups were seen 1 h before the initiation
1. Diagnosis of primary breast cancer, surgery within 12
of chemotherapy and were guided to the quiet room. All
months, nave to CT
patients completed questionnaires relating to their negative
2. Female, age 30 years and above, and suitability for
emotions (anxiety, depression, and hostility) and the QoL.
chemotherapy
3. Patients with one to three involved axillary lymph
nodes receiving cytotoxic therapy consisting of six cy-
PMRT and GI group
cles of CMF every 28 days
In the first session, experimental group patients were led
to a relaxation training room approximately 1 h before re-
Table 1 Sociodemographic and clinical characteristics ceiving CT treatment. Each patient also received a cassette
PMRT and Control group Significance
tape with a record of her own first PMRT session for home
GI group (n=30)
use. Each patient in the experimental group received a
PMRT and GI session with the therapist 1 h before che-
(n=30)
motherapy administration (at hospital) and on each of the
Age (years), mean (SD) 42.91(10.1) 44.00 (7.2) NS next chemotherapy cycles (at hospital), for a total of six
Education (years), 11.91(3.2) 11.67 (4.8) NS PMRT and GI sessions. The PMRT and GI group received
mean (SD) the antiemetic treatment according to the standard protocol
Employment NS 30 min before chemotherapy.
Homemaker 19 (63.3) 19 (63.3) The majority of patients experiencing postinfusional
Full time 5 (16.7) 4 (13.3) symptoms indicated that their symptoms persisted for more
Part time 6 (20.0) 7 (23.3) than 24 h and were worse a day or two after CT admin-
Marital status NS
istration [27]. We took account of the possibility of delayed
Single 3 (10.0) 2 (6.7)
emesis and vomiting, so that we asked the PMRT and GI
group to do home practice at least more than 3 days with the
Married 25 (83.3) 26 (86.6)
recorded tape we had provided them. Patients were asked to
Widowed 2 (6.7) 2 (6.7)
rate the extent to which they vomited or felt anxious or
Stage of disease NS
nauseous on 7-point scales, ranging from 0 (not at all) to 6
II 22 (73.3) 22 (73.3)
(extremely), and the number of vomiting episodes. There
III 8 (26.7) 8 (26.7)
were 12 consecutive blocks of time, each lasting approxi-
NS nonsignificant mately 6 h (morning, afternoon, evening, and night).

The control group
The control group consisted of patients who did not par-
ticipate in the PMRT and GI, underwent the identical CT
treatment, or completed the same self-report forms in the
hospital and at home. The control group received the anti-
emetic treatment according to the standard protocol 30 min
before chemotherapy.
Measurement scales
Multiple Affect Adjective Checklist
The Multiple Affect Adjective Checklist (MAACL) is a
self-report index of anxiety (20 items), depression (20
items), and hostility (30 items) [29]. Participants marked
their level of affect for each item on a yes/no scale. Inter-
nal consistency of the three subscales was high (Kuder
Richardson reliability coefficients=0.78, 0.80, and 0.74,
respectively, with a testretest reliability of 0.74, 0.81, and
0.77, respectively) in this study.
Records of patients and nurses
The patients who were participated in this study did not like
to check too many items on anxiety, nausea, and vomiting at
hospital and at their homes, so we decided to make the
number of the items short and thus to construct a 7-point,
one-item, Likert scale method because the patients had to
check the items 12 times within 3 days.
A rating scale was constructed as described previously
[18]. Immediately before CT, patients were asked to rate the
extent to which they vomited or felt anxious or nauseous on
7-point scales, ranging from 0 (not at all) to 6 (extreme-
ly). All of the patients in this study were outpatients, and
they had received the CT in the outpatient clinic and went
home on the same day. The nurses who participated in the
patient CT completed the assessment of NV immediately
after the patient had received CT. The nurses could not
know which group the patients were allocated to. After they
checked the questionnaires, they only attached them to their
charts. Only the principal investigator (HJ Yoo) knew
which group the patients were allocated to. Nurses who
administered the CT were also asked to rate these param-
eters independently on identical scales.
Home records of the patients
The 3-day postchemotherapy home record rating scale we
used was identical to that above, with the addition of the
number of vomiting episodes at home. There were 12 con-
secutive blocks of time, each lasting approximately 6 h
(morning, afternoon, evening, and night).
829
Functional Assessment of FACT-B scale Version 4
The FACT-B scale Version 4 is a disease-specific evalua-
tion for patients with breast cancer. It consists of 36 items,
subdivided into four primary QoL domains [physical
(PWB), social/family (SFWB), emotional (EWB), and func-
tional (FWB)] and containing additional concerns for breast
cancer (BCS). The FACT-B was translated by employing
the standard Functional Assessment of Chronic Illness
Therapy (FACIT) translation methodology [5, 9]. Korean
FACT-Bs internal consistency of both the subscales and
total FACT-B were high: PWB (0.81), SFWB (0.86), EWB
(0.79), FWB (0.83), FACT-G (0.87), BCS (0.67), and total
FACT-B (0.90) [28].
The technique of PMRT and GI
PMRT includes progressive muscle relaxation (tensere-
lease) of 15 of 16 groups of muscles (right hand and fore-
arm, right upper arm, left hand and forearm, left forearm,
forehead, upper cheeks and nose, lower face, neck, abdo-
men, right upper leg, right calf, right foot, left upper leg, left
calf, left foot) according to PMRT techniques [3], but
modified according to the area of pain in the chest, shoul-
ders, and upper back.
Therapists tried to establish positive relationships with
their patients. The therapist directed the patient on which
group of muscles to tense and release each time and ex-
plained the deep breathing instructions [20]. In the second
session, it was emphasized that the ability to relax is a
learned skill, requiring active participation and frequent
practice by the patient [4]. Generally the procedures and
methods of the first and second sessions were virtually
identical. GI was initiated after the third session of PMRT,
during which patients were taught to imagine a peaceful
scene of their own choice to enhance relaxation. After
PMRT, the patient was guided in the use of visual imagery
to achieve an even deeper state of relaxation. Generally the
procedures and methods from the third to the sixth session
were identical. At the fifth session, we notified the patients
that the next session would be the last session and that the
treatment would be terminated after the sixth session. We
also told them to ask us any question at the last session if
they had any problems during their session period.
Statistical analyses
Descriptive statistics are summarized in Table 1. The data
from the six training sessions were analyzed by the methods
below:
To analyze patients emotional states immediately after
PMRT and GI and immediately before CT, data from the
MAACL from each six training session were analyzed by 2
(PMRT and GI vs control)6 (sessions) mixed ANOVA.
830

The same method was used to compare records of patients 14

and nurses on ANV during CT. To analyze home records of 12
the patients during CT, the data from six training sessions 10
were analyzed by 2 (PMRT and GI vs control)3 (days)4 Control
8
times (morning, afternoon, evening, night) mixed ANOVA. All
To analyze the QoL changes at three times, the data of 6
PMRT & GI
FACT-B and its subscales were analyzed by 2 (PMRT and 4
GI vs control)3 (sessions) mixed ANOVA. 2
All statistical procedures were performed using the pro-
gram SPSS for windows (Version 11.0). 0
1st 2nd 3rd 4th 5th 6th

Fig. 1 Anxiety levels immediately after PMRT and GI and

Results immediately before CT during six sessions

The mean age of the 60 subjects was 43.10 years. Most

(88.5%) of the patients were married, with 7.7% being GI group reported significantly less nausea before CT than
single and 3.8% widowed (Table 1). did the control group (Fig. 2). In addition, the PMRT and GI
The analyzed results of MAACL are presented in Table 2. group showed two peak points of vomiting tendency during
Whereas analyses of the anxiety, depression, and hostility of the first and third sessions, but did not differ during the
patients revealed a significant main effect for treatment fourth to sixth session.
condition, there was no Treatment Session interaction. When we analyzed the nurses observational ratings, we
During the six sessions, there were significant between- observed significant effects of PMRT and GI on NV during
group differences in patients anxiety, depression, and hos- CT (Table 2). Furthermore, for nausea, there was a sig-
tility variables, but only anxiety showed a significant nificant Group Session interaction (Fig. 2). Analyses of
session effect. As shown in Fig. 1, when data from the the home records of patients revealed significant treatment
PMRT and GI and control groups were combined, we found effects on anxiety, nausea, vomiting, and the number of
that anxiety levels peaked during the first and fifth sessions. vomiting episodes. There were significant time effects on
We also observed significant treatment effects on pa- nausea and vomiting (Fig. 3). In contrast, we observed
tients self-reported anxiety, nausea, and vomiting imme- Group Day (Fig. 4) and Time Day (Fig. 5) interactions
diately before CT (Table 2). The PMRT and GI group was only in the number of vomiting episodes.
less anxious and experienced less nausea and vomiting than
the control group. There was no significant difference in
nausea between the two groups from the first to the fourth Effects of PMRT and GI on the QoL of the patients
sessions, but by the fifth and sixth sessions, the PMRT and
When we compared QoL changes in the two groups, we
found no Session or Treatment Session interaction effect.
Table 2 MAACL, patients records of ANV immediately before CT, At baseline, there were no between-group differences in all
and nurses report
PMRT and Control, Significant F 3
GI, mean mean (SD) effect
2.5 Patient
(SD)
(PMRT)
MAACL 2 Patient
Anxiety 7.01(3.81) 9.75(3.48) G, S 10.11**, 4.98** (Control)
1.5
Depression 7.43(7.21) 15.62(5.52) G 19.89*** Nurse (PMRT)
Hostility 3.53(3.25) 5.99(3.47) G 9.98** 1
Records of ANV Nurse
0.5 (Control)
Anxiety 1.52(1.21) 2.67(1.40) G 9.11**
Nausea 0.97(1.12) 1.99(1.35) G, GS 4.16*, 2.78* 0
Vomiting 0.49(1.02) 1.24(1.51) GS 2.56* 1st 2nd 3rd 4th 5th 6th
Nurses record
Fig. 2 Self-reported nausea immediately before CT. Patient (PMRT)
Nausea 1.27(1.21) 1.91(0.93) G, GS 16.62***, 2.92* self-reported nausea of the patient who received PMRT and GI.
Vomiting 0.26(0.4) 0.95(1.27) G 12.12** Patient (Control) self-reported nausea of the patient in control group.
Nurse (PMRT) nurse-reported nausea of Patient (PMRT) during CT.
G group, S session, G S GroupSession Nurse (Control) nurse-reported nausea of Patient (Control) during
*p<.05, **p<.01, ***p<.01 CT
 831

means. After 3 months, however, the PMRT and GI group Discussion

showed higher EWB (F=6.28, p<0.05) than the control
group, but there were no differences in PWB (F=1.13, As hypothesis 1, the PMRT and GI group could signifi-
p>0.29), SFWB (F=0.04, p>0.95), FWB (F=1.97, p>0.17), cantly reduce the negative emotions (anxiety, depression,
FACT-G (F=2.25, p>0.14), BCS (F=1.67, p>0.20), and and hostility), intensity of anticipatory side effects (anxiety,
FACT-B (F=2.45, p>0.13). After 6 months, the PMRT and nausea, and vomiting), and postchemotherapy side effects
GI group showed higher PWB (F=3.92, p<0.05), EWB than control group. As hypothesis 2, the PMRT and GI
(F=7.12, p<0.05), BCS (F=9.95, p<0.01), and FACT-B group could significantly improve in emotional well-being
(F=5.78, p<0.05) than the control group, but were no at 3 months after chemotherapy, and the PMRT and GI
differences in SFWB (F=0.78), FWB (F=0.28, p>0.59), group would significantly improve in general and breast-
and FACT-G (F=3.57, p<0.06). cancer-specific well-being at 6 months after chemotherapy.
These results indicate that PMRT and GI had a significant
effect on both ANV and PNV (Table 3).
3 We found that the two peak points of anxiety imme-
2.5 diately before CT occurred before the first and fifth sessions
and observed a clear session effect in the PMRT and GI
2 Nausea(PMRT)
Nausea(Control)
group. It is possible that the most anxious patients may
1.5 condition more easily or that highly anxious patients may
Vomiting(PMRT)
1 Vomiting(Control) be more aware of their environment [24]. The patients in the
0.5
PMRT and GI group reported significantly less nausea than
the control group during the fifth and sixth sessions, but did
0
morning afternoon evening night
not differ during earlier sessions in self-reports immediately
before CT. As CT progresses, patients may feel greater
Fig. 3 Nausea and vomiting based on the patients home records. anticipatory anxiety. Thus, pharmacological and psycho-
Nausea (PMRT) self-reported nausea at home of the patient who logical factors may act in a kind of equilibrium in deter-
received PMRT and GI. Nausea (Control) self-reported nausea at
home of the patient in control group. Vomiting (PMRT) self-reported mining the development of nausea [25].
vomiting at home of the patient who received PMRT and GI. Vomiting Patients may also mislabel their anxiety as nausea [25].
(Control) self-reported vomiting at home of the patient in control The experience of vomiting alone was rare, and analyses of
group the postinfusional state of patients consider nausea and
vomiting as a combined reaction [27]. Nausea levels in both
groups increased gradually until the fifth session in nurses
1.2 reports. In the final session, however, the level of nausea
1 was significantly lower in the PMRT and GI group (M=0.1),
falling below that observed before the first session. Fur-
0.8
PMRT & GI thermore, physiological measurements, such as NV imme-
0.6 diately before CT treatment, showed a significant session
control
0.4 effect, whereas psychological measurements of anxiety did
0.2 not.
0
1st day 2nd day 3rd day
Table 3 Follow-up home records of PNV
Fig. 4 Number of vomiting incidents during 3 days after CT
Variables PMRT and Control, Significant F
GI, mean mean effect
1 (SD) (SD)

0.8 Anxiety 1.11 (1.03) 2.27 (1.31) G 14.39***

1st Nausea 1.23 (1.11) 2.51 (1.93) G,T 14.11***, 4.13*
0.6
2nd Vomiting 0.56 (0.61) 1.63 (1.22) G, T 8.37**, 4.44*
0.4 3rd Vomiting
0.2 No. 0.83 (0.82) 1.51 (1.33) G, GD, 10.15**, 2.88*,
T, TD 3.96*, 2.87*
0
morning afternoon evening night G group, S session (16), D day (13), T time (morning, afternoon,
evening, night)
Fig. 5 Number of vomiting episodes during 3 days after CT *p<0.05, **p<0.01, ***p<0.001
832

Table 4 Mean scores of the FACT-B at baseline, 3 months after, and 6 months after the patients received CT
Baseline 3 months after CT 6 months after CT
PMRT Control PMRT Control p PMRT Control p

PWB 19.17 (5.44) 19.38 (4.35) 19.88 (5.13) 19.21 (4.98) NS 22.77 (4.88) 18.88 (5.36) <0.05
SFWB 17.03 (4.91) 17.30 (4.32) 16.35 (5.12) 15.58 (4.89) NS 16.55 (6.12) 14.75 (6.10) NS
EWB 18.40 (3.18) 16.94 (5.46) 19.38 (3.94) 17.01 (3.49) <0.05 20.37 (2.97) 17.55 (2.89) <0.05
FWB 14.72 (4.96) 12.16 (4.45) 15.43 (4.72) 15.11 (5.22) NS 17.61 (6.06) 16.72 (3.56) NS
FACT-G 69.32 (13.51) 65.80 (13.22) 71.00 (14.38) 67.73 (12.85) NS 76.61 (16.02) 67.92 (11.14) NS
BCS 24.09 (4.54) 22.07 (3.88) 24.42 (4.73) 21.05 (3.69) NS 25.38 (4.84) 20.26 (4.96) <0.01
FACT-B 93.41 (16.90) 87.88 (14.96) 97.01 (18.24) 88.13 (16.18) NS 102.00 (19.94) 88.18 (14.02) <0.05

Although the PMRT and GI group was significantly ef-
fective during the treatment sessions, their effectiveness
decreased somewhat after terminating PMRT and GI. Al-
though the PMRT and GI group reported lower levels
of vomiting immediately before CT than did the control
group, the two peak points of vomiting tendency were the
first and third sessions.
We found that the PMRT and GI group showed generally
lower levels of PNV and number of vomiting episodes.
Generally, NV levels in both groups showed a significant
but gradual decrease over time. Although the PMRT and GI
group experienced less frequent vomiting episodes than the
control group, they reported more vomiting episodes on
the last day than on the second day. Furthermore, the two
groups showed significant differences in the number of
vomiting episodes on the first and second days, but showed
little difference on the third day.
There were no significant differences in the QoL between
the two groups in baseline. Three months after CT, EWB of
the PMRT and GI group was significantly higher than that
of the control group. In almost 3 months, we can expect that
patients would be experiencing the cumulative effects of
chemotherapy without yet experiencing the psychological
lift that occurs at the end of treatment [15] (Table 4).
Six months after CT, not only EWB but BCS and the
FACT-B total were significantly higher in the PMRT and
GI group than in the control group. The range of possible
treatments may have similar outcomes in terms of response
and survival, but can produce very different effects on
emotional well-being [14]. These results show that PMRT
and GI improved the QoL of patients with breast cancer
who had received CT.
Conclusion
Patients receiving PMRT and GI showed reliable improve-
ments in self-reported measurements of ANV and PNV,
both in the hospital and at home. Administering nurses also
reported that the PMRT and GI group showed less nausea
and vomiting than the control group. These results indicate
that PMRT and GI have a positive effect on patients with
breast cancer, reducing ANV and PNV and improving their
QoL. The limitations of this study were the use of a rel-
atively small number of patients and a relatively short-term
follow-up. Increasing the number of the cases and follow-
up for at least 1 year is therefore needed.
These findings may reveal time-efficient and cost-effec-
tive methods for reducing ANV and PNV in patients with
breast cancer receiving CT.
Acknowledgements This work was supported by a grant from the
Asan Institute for Life Sciences (2001-156).

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