Cancer and Chemotherapy-Induced Nausea and Vomiting

Over the last four decades, the occurrence of gastric cancer dropped dramatically in developed countries. Before the 1950s, the disease was the most popular cause of cancer deaths among men and third in popularity among women. Nevertheless, it is crucial not to underestimate gastric cancer today or make any delays in treatment, which can hurt patients’ health. Fortunately, the investigation of the pathogenesis of cancer and the identification of possible risk factors along with the treatment that includes the usage of advanced endoscopic techniques can be very effective for detecting gastric cancer in its early stages.

Background and Significance of the Problem

According to the American Cancer Society (2017), around twenty-eight thousand cases of stomach cancer will be diagnosed the following year (17,750 cases among men and 10,250 among women). Around 10,960 people will die from gastric cancer in 2017 (around 6,720 men and 4,240 women) (American Cancer Society, 2017). In the majority of cases, gastric cancer affects older people, with the average age of the diagnosed patients being 69.

Furthermore, the average risk of a person developing stomach cancer is one in one hundred and eleven, with the risk being higher among men than women. It is crucial to note that cancer is a persistent problem for the less developed countries that lack resources for the proper storage of food and their consumption. If to look at the occurrence of gastric cancer by country, the Republic of Korea, Mongolia, Japan, Guatemala, and China has the highest rate of the disease’s occurrence, which presents a massive challenge for the global health care.

Cancer is the leading cause of deaths among the Hispanic/Latino population, and approximately 3,200 Hispanic men and women are diagnosed with gastric cancer each year, with 1,700 of the diagnosed patients dying. Rates of gastric cancer among the population are similar to that of the population of Asia and Pacific Islands, the black population, as well as Native Americans and Alaska Natives (Siegel et al., 2015). It is crucial to mention that the rate of occurrence of gastric cancer in Hispanics is twice higher than of Non-Hispanic Whites. Furthermore, the rates of gastric cancer vary between Hispanic subgroups, with lethal implications being twice as high for Mexicans than Cubans, which suggests that gastric cancer occurrence varies depending on the location since the condition has become rare for high-income countries such as the US (Ferlay et al., 2012).

More than 90% of gastric cancers are predominantly adenocarcinomas classified as cardia and non-cardia based on tumor location. Non-cardia tumors usually drive the ethnic disparity in gastric cancer, the incidence rate for which is 6.2 (per 100,000 individuals) among Hispanics compared with 2.2 among non-Hispanic whites (Siegel et al., 2015). The rate of cardia tumors is lower for the Hispanic population (1.5 per 100,000 individuals) compared to non-Hispanic whites. On the other hand, the chronic infection of Helicobacter pylori is the most prevalent risk factor for non-cardia cancer development, although it is inversely associated with cardia tumors. The risk of gastric cancer within the Hispanic population is consistent with the patterns of Helicobacter pylori seroprevalence (Siegel et al., 2015).

It is important to mention that the incidence and death rates of stomach cancer have been falling in Hispanics since the 1990s, and the reasons are not clearly understood. Although improved hygiene and progress in the preservation of food products have had a significant impact on the decline. Nevertheless, the rate of decline among Hispanics was lower than that of non-Hispanic whites, which led to a crossover between Hispanic women and Non-Hispanic white men (Siegel et al., 2015). When the death rates for Hispanic women in the 1990s were at least 21% lower than among non-Hispanic men, they increased as high as 17% in 2012 (Siegel et al., 2015). To some degree, such a change reflects the growing rate of disease among the incoming immigrants.

Statement of the Problem and Purpose of the Study

The problem of the greater likelihood of gastric cancer within the Hispanic population remains unsolved. Moreover, cancer treatments available today present a challenge of side effects, such as chemotherapy-induced nausea and vomiting (CINV), that significantly limits patients’ overall well-being and recovery. Thus, it is important to include the exploration of CINV Pathophysiology, methods of management, and alternative treatments for developing a cohesive intervention strategy for reducing the occurrence of CINV among Hispanic gastric cancer patients. This study will focus on reviewing relevant literature on the topic of gastric cancer in the Hispanic population, outlining the key management procedures of CINV, and formulating a proposal for an intervention to improve the health outcomes of Hispanic patients. They have gastric cancer and elevating the burden of chemotherapy-induced nausea and vomiting.

Literature Review

Gastric Cancer in Hispanic Population

Since the current research focuses on the incidence rates of gastric cancer within the Hispanic population, it is important to understand the patterns of the disease by socioeconomic status, acculturation, and birthplace for improving preventative strategies and disease models, as hypothesized by Chang et al. (2012). The research focused on calculating the rate ratios, incidence rates. It estimated annual percent changes in rates of histologic and anatomic subtype-specific gastric cancer by age, sex, and nativity among the Hispanic population (Chang et al., 2012). The results obtained identified that incidence rates of diffuse gastric cancer increased among U.S.-born Hispanic women and foreign-born Hispanic men.

However, incidence rates of intestinal gastric cancer declined significantly, and both cardia and noncardia gastric cancers were steady or declined among foreign-born and U.S.-born Hispanic men and women. Also, noncardia, intestinal, and diffuse gastric cancers were more common in foreign-born than U.S.-born Hispanic men and women, and in those with lower socioeconomic status and higher-enclave neighborhoods. By contrast, among younger and middle-aged Hispanic men, cardia tumors were more common in the U.S.-born than the foreign-born, and in higher socioeconomic status and lower enclave neighborhoods (Chang et al., 2012).

Another research that explored the epidemiology of gastric cancer in the Hispanic population was the review conducted by Corral et al. (2015). They analyzed the incidence of gastric adenocarcinoma from 1985 to 2011. According to the findings, noncardia gastric cancer was the most prevalent in Central America, both among American Hispanics and Central American Hispanics. When speaking of Central America, antrum cancers are the most widespread, while corpus cancers are more prevalent among the Hispanic population of the United States. It is crucial to mention that three-fourth of the reported cancer cases in Central America came from Costa Rica, which accounts for only 11% of the population (Corral et al., 2015).

Moreover, the study was limited due to the absence of observations of differences in age, gender, histologic subtype, and anatomical distribution between other populations and Costa Rica (Corral et al., 2015). Nevertheless, the study is useful for the current research since it concluded that gastric cancer is a significant health problem for the Hispanic population of Central America and that there are differences in rates among Hispanics in the United States and Central America. The study also provided a useful suggestion for strengthening population-based registries for enhancing cancer control in Central America since there could be a negative effect experienced by the expanding Hispanic population of the United Staves (Corral et al., 2015).

While the research mentioned above-compared cancer incidence rates among the Hispanic population of Central America and the United States, Duma et al. (2016) reviewed clinicopathologic differences among Hispanics and non-Hispanic whites to understand the variation in implementing future treatment, management, and control. It was found that the Hispanic population was more likely to have distal cancer and poorly differentiated tumors compared to the non-Hispanic white population (Duma et al., 2016).

Also, the study found a significant difference in the overall survival between the two populations: 99 moths for non-Hispanic whites and 51 months for Hispanics, which points to the discrepancies in access to health care, available resources, as well as the quality of life. It is also important to mention that Hispanic patients were usually diagnosed with gastric cancer at an earlier age compared to non-Hispanic whites, and had shorter survival, which presents a significant challenge to healthcare. The ethnicity-based analysis provided by Duma et al. (2016) is relevant for the current research since it offered evidence for the discrepancies of socioeconomic and biological factors within the studied population.

In the background section of the paper, it was identified that men usually experience a higher incidence of gastric cancer than women. Merchant et al. (2017) studied trends in gastric cancer incidence among young Hispanic men to identify high-risk populations. The trends in gastric cancer incidence were identified through measuring the levels of APC (Adenomatous polyposis coli) across three age groups and four ethnic groups (Hispanics, non-Hispanic whites, Pacific Islanders, and Blacks).

In the course of the study, the levels of APC decreased or were flat for studied populations except for young Hispanic men, whose average levels reached as high as 1.6%, according to Merchant et al. (2017). Moreover, young Hispanic men were the only group that had increased incidence of stage IV disease and poorly differentiated tumors, which presents a challenge to future intervention.

Sierra, Cueva, Bravo, & Forman (2016) studied the differences in the burden of gastric cancer in the population of Central and South America. The researchers found that gastric cancer was in the top five of the most frequently diagnosed cancers and was the leading cause of cancer mortality. Between Central and South America, mortality from gastric cancer varied by 5-6-fold, and the incidence of the disease varied by 6-fold (Sierra et al., 2016). The highest gastric cancer rates were found in Costa Rica, Peru, Brazil, Chile, Ecuador, and Colombia. Moreover, from 60% to 96% of all cases of cancer were unspecified because of the gastric sub-site. Nevertheless, among the cases that were specified, non-cardia cancers were from two to thirteen times more frequent compared to cardia cancers (Sierra et al., 2016).

Chemotherapy-Induced Nausea and Vomiting: Challenges and Management

Chemotherapy-induced nausea and vomiting (CINV) is a common side effect of cancer treatment that has a detrimental impact on the quality of patients’ lives (Navari & Aapro, 2016). The vomiting response to treatment is controlled by the emetic center, which is situated in the reticular formation of the brainstem that receives input from the periphery, the cortex, and the chemoreceptor trigger zone (Rao & Faso, 2012). When the emetic center is triggered, cranial, salivatory, vasomotor, and respiratory centers receive signals that influence organs associated with the vomiting reflex (diaphragm, stomach, esophagus, and the abdominal muscles) (Rao & Faso, 2012).

Among the available agents for reducing and suppressing CINV, 5-HT3 receptor antagonist, NK1 receptor antagonist, and corticosteroids are the most prevalent. Among the additional options, dopamine receptor antagonists, benzodiazepines, olanzapine, cannabinoids, and ginger are the most popular.

Navari and Aapro (2016) reviewed the effectiveness of antiemetic prophylaxis for elevating the burden of CINV for patients that have 10% and greater risk of experiencing the side effect. It was found that in patients with refractory chemotherapy-induced emesis, the adherence should be reevaluated along with the change of treatment regimens. In the majority of cases, such changes are associated with an addition of a different class of drug, adjustment of the 5-HT3–receptor antagonist dose, or a complete change to a new agent within the same class of drugs (Navari & Aapro, 2016). For those patients who receive highly emetogenic agents, it is recommended to introduce an olanzapine-containing regimen to elevate the burden of CINV. Moreover, those patients for whom CINV is predominantly associated with high levels of anxiety, it is recommended to add alprazolam or lorazepam (Navari & Aapro, 2016).

Nevertheless, the main challenge for overcoming CINV is associated with a lack of education for both patients and healthcare professionals. It is important to provide patients with adequate information regarding the possible changes in their regime, educate the healthcare staff on how to guide their patients towards elevating the burden of CINV. On the other hand, it may be ineffective to disseminate the relevant materials among patients and the staff directly. According to Navari and Aapro (2016), the most appropriate solution is the “audit-and-feedback” strategy paired with the educational outreach visits for increasing the implementation of guideline-recommended prophylactic treatment of CINV.

Navari (2013) also studied the effectiveness of such elements as PALO, NK1, RA, and 5-HT3 RA for managing CINV. The mentioned elements have shown to be quite useful for helping patients who experience a range of adverse physiological side effects of chemotherapy. Moreover, Navari (2013) explored the range of positive effects produced by olanzapine.

Even though the drug is considered an effective antipsychotic agent, it has shown to provide mitigating qualities for suppressing nausea and vomiting, which patients with cancer experience during chemotherapy. It is also important to distinguish that Navari (2013) supported the usage of gabapentin, ginger, and cannabinoids for treating the symptoms of vomiting and nausea among cancer patients. Throughout previous research, there have been no explicit findings to support the positive effect of the mentioned substances for reducing nausea and vomiting induced by chemotherapy, so it is important to study the effects further for formulating a cohesive intervention strategy.

When it comes to other alternative methods of CINV management, it is important to mention the review conducted by Garcia et al. (2013) concerning the benefits of acupuncture on the side effects of chemotherapy among cancer patients. Through screening more than two thousand articles, researchers found that acupuncture can be a beneficial supplementary tool for treating CINV. Nevertheless, it is still imperative to investigate different methods of treatment and biological responses to get a definite answer to the question of whether acupuncture can bring real results. Moreover, the investigation should involve more diverse populations and the availability of acupuncturists within them.

As to the perceptions of healthcare providers regarding the suppression of CINV, Krishnasamy et al. (2014) found a significant lack of cohesive assessment tools that the nursing staff can use. There should also be an alignment between the international standards of cancer treatment since there is a universal risk of many patients undergoing chemotherapy experiencing CINV. It is important to mention that there is a gap in research literature when it comes to exploring the effectiveness of the nursing staff and other healthcare providers in educating their patients and being educated themselves on the various methods of suppressing CINV.

The current research and intervention should place nurses’ education high on the agenda when it comes to CINV management because, without appropriate instructions, the integration of effective treatment will likely be impossible.

Research Questions, Hypothesis, and Variables

The review of the literature on the topics of gastric cancer among Hispanic patients and CINV management during chemotherapy showed a significant gap in research regarding appropriate interventions targeted at elevating the burden of CINV among Hispanic patients with gastric cancer. The current research should also investigate the discrepancies in access to health care among the Hispanic population as well as the quality of their life that influences the increased rates of gastric cancer incidence.

The research question will focus on the exploration of alternative treatment interventions that could elevate the burden of CINV:

Hispanic patients with gastric cancer, does the prevalence of chemotherapy-induced nausea and vomiting differ in patients treated with conventional medicine compared to patients who receive herbal treatment in the form of ginger?

Based on the research questions presented above and the review of relevant literature, it can be hypothesized that Hispanic patients in Central America have less access to resources necessary for appropriate gastric cancer treatment and overall prevention compared to the Hispanics that live in the United States. As to the most appropriate treatment and management strategy for addressing CINV among Hispanic patients with stomach cancer, a combination of appropriate education, planning, and effective medication will be the most effective. Lastly, with regards to the alternative treatment interventions for managing CINV among patients with gastric cancer, it can be hypothesized that the administration of cannabinoids, olanzapine, and other non-traditional treatments can act as an “add-on” for the outlined treatment and management strategy.

As to participant variables, the personal backgrounds of each patient can have the most impact on the research. Among these, background knowledge regarding both methods of treatment, the statuses of their health, different rates of nausea and vomiting, as well as the beliefs in the effectiveness of either traditional or alternative treatment methods are the most prominent. With regards to situational variables, environmental factors that may have the most effect on the findings are noise, light, smell, and other physical factors that can exasperate nausea and vomiting among patients undergoing chemotherapy.

Theoretical Framework

Overview and Guiding Propositions

The guiding propositions for the present research will refer to the equity of access to healthcare and adherence to either traditional or alternative treatment. According to Richard et al. (2016), closing the gap in the equity of access to healthcare is an issue that influences healthcare outcomes within those populations or ethnic groups that do not have enough resources for improving their health.

Equity theory is focused on determining whether resources are distributed evenly. The theory postulates that populations value fair treatment, which causes them to motivate themselves to maintain fairness within the population. Adherence to either alternative or traditional or alternative methods of treatment is another point that relates to ethnic differences between populations. For example, an ethnic Hispanic population that lives in Central America could adhere to alternative treatments better compared to those living in the United States due to the cultural differences of how illnesses are approached.

Application of Theory to Study Focus

It is important to apply the theory of equity to determine whether the Hispanic population has different access to healthcare compared to other ethnics groups. Gastric cancer has shown to be prevalent among the Hispanic population and remains a persistent problem that could be addressed by closing the gap in access to resources. On the other end of the spectrum, it is worth studying the adherence to treatment theory based on ethnic characteristics.

Methodology

Sample/Setting

To study discrepancies in access to healthcare within the Hispanic population and then to determine the effectiveness of traditional and alternative treatment of CINV, it is necessary to include males and females of different ages. The sample will include fifty patients selected from three different hospitals. Nevertheless, the size of the sample may change depending on the expected data analysis method and the t-test that requires preferably fifteen or more subjects.

The first inclusion criterion for the sample will include patients’ ethnic background, i.e., only patients from the Hispanic population will become participants as defined by the research question. The second inclusion criterion will include patients’ current treatment of chemotherapy for gastric cancer. The exclusion criterion will be associated with the ending of patients’ chemotherapy for any reason. The study set will include three hospitals in the Los Angeles area: the LAC Medical Center, the Norris Comprehensive Cancer Center, and the Keck Medical Center.

Sampling Strategy

Convenience sampling will be the most appropriate in the present scenario since the research will include three hospitals, and it will be complicated for the researcher to select a sample that will be representative of the entire Hispanic population with gastric cancer. An effective sampling strategy will include enrolling volunteering patients as subjects for the research. Patients will be found in local hospitals, clinics, and treatment centers – any patient aged between 21 and 65 of Hispanic ethnicity diagnosed with gastric cancer will be suitable for investigating the issue of access to appropriate care. To investigate the effectiveness of either alternative or traditional method of managing CINV, any patient diagnosed with gastric cancer and aged between 21 and 65 with a risk of 10% and higher of experiencing CINV will be suitable for the research.

Research Design

For investigating the effectiveness of alternative and traditional methods of CINV management and determining the access gap within the Hispanic population, the United Staves, a case-control study is the most appropriate. The case-control study is an easy way of comparing treatments. One group of patients selected for the study will be administered a traditional treatment for suppressing chemotherapy-induced vomiting.

In contrast, another group will undergo alternative treatments that will include ginger remedies. The research will also review the historical picture of patients’ lives to highlight any trends for taking action. Statistical analysis will allow the researcher to conclude whether a specific situation in their life led to the development of gastric cancer, whether the lack of access to healthcare exasperated the disease, and whether alternative (or traditional) treatment was the most effective.

Extraneous Variables

Extraneous variables are those that are undesirable and unpredicted and have an influence on the experiment results due to the change in the relationship between the variables in which the researcher is interested. For example, an extraneous variable will be the differences in patients’ backgrounds and their prior knowledge about the effectiveness of either alternative or traditional treatment methods.

Instruments

For ensuring accurate results’ estimation, the researcher will use two instruments: the Functional Assessment of Cancer Therapy (FACT) and a patient record survey. A patient record survey is a useful instrument for collecting patients’ background information, which has a higher degree of validity. For supplementing the medical records, the researcher will use the FACT that will help to attain suitable patient-reported outcome measures in the questionnaire form. It will include 27 questions on a five-point scale (0 to 4), where the largest scale will indicate a better state of the patients. The reliability and validity testing will be assessed by calculating the coefficient of correlations between questions and outcome variables, application of logical reasoning (e.g., do the results fit the research question), finding logical links with the objectives, and ensuring that each research aspect has a similar representation in questions.

Description of the Intervention

The intervention will be associated with the introduction of two different types of CINV management among Hispanic patients treated in US hospitals in the LA area. Participants will be divided into two groups, one of which will receive the traditional treatment of CINV, and another will be treated with the help of herbal remedies. The traditional management methods will include the administration of the 5-HT3 receptor antagonist, NK1 receptor antagonist, and corticosteroids. Alternative treatment will include the administration of ginger remedies.

Data Collection Procedures and Data Analysis Plans

Data collection procedures will include finding and analyzing patients’ records and notes made by their healthcare providers, eliminating any errors, checking the availability of information, discussing results with a physician, sending out FACt questionnaires to both groups, comparing results, and repeating the test for ensuring the effectiveness of each method of treatment.

This study will include an experiment with a research sample of two groups: intervention and control. For ensuring accuracy, it is imperative to take into consideration the demographic dependent variables such as ethnicity, age, sex, weight, and access to healthcare. These variables are the patients’ characteristics required for describing the population group and determining whether the sample is representative. Outcome variables, on the other hand, are dependent and will appear as a result of the implemented intervention; they will show the cause and effect relationship between the initial state of participants and their condition after the intervention.

For data analysis, a t-test was chosen for catering to the small sample size of the study and allowing to identify differences between two groups of patients. The inferential test will be used in the research since it is associated with repeated measures since participants will be tested several times on the same variable, which is the appearance and severity of nausea and vomiting after traditional and alternative treatments. Moreover, the obtained results from the statistical analysis will be compared with patients’ self-reported assessment, which will be collected through the FACT questionnaire.

Ethical Issues

Key ethical issues in research will be associated with participants’ consent to use their medical history, accepting the treatment methods, and willingness to share important health information with the researcher. The researcher will address the ethical issues by providing each participant with an informed consent form (Appendix A) to make sure that all Hispanic patients living in the territory of the United States do not experience any ethical concerns during the intervention.

Limitations

The key limitation of the research will be the sample that may not be representative of the entire population of Hispanic patients diagnosed with stomach cancer. Since the research will involve two samples of patients in two different countries for comparing their access to effective cancer management and their adherence to two opposing types of treatment, it was impossible for the researcher to include a random sampling technique due to inconvenience.

Implications for Practice

Further implications for practice are vast. Both alternative and traditional treatment methods could potentially show an improvement in the management of CINV among gastric cancer patients, which could significantly elevate the burden of the side effects and provide the sphere of healthcare with a cohesive framework of how to elevate the burden of chemotherapy-induced nausea and vomiting. The intervention could be effective in helping develop a unified strategy for CINV management among gastric cancer patients with higher risks of the side effects occurrence. Moreover, the study will provide a basis for further research regarding the benefits of alternative treatment for managing the severe implications of chemotherapy-induced nausea and vomiting and exploring how such methods can support the traditional treatment for gastric cancer patients of any ethnicity.

References

American Cancer Society. (2017). What are the key statistics about stomach cancer? Web.

Chang, E., Gomez, S., Fish, K., Schupp, C., Parsonnet, J., DeRouen,… Glaser, S. (2012). Gastric cancer incidence among Hispanics in California: patterns by time, nativity, and neighborhood characteristics. Cancer Epidemiology, Biomarkers & Prevention, 21(5), 709-719.

Corral, J., Hurtado, J., Dominguez, R., de Cuellar, M., Cruz, C., & Morgan, D. (2015). The descriptive epidemiology of gastric cancer in Central America and comparison with United States Hispanic populations. Journal of Gastrointestinal Cancer, 46(1), 21-28.

Duma, N., Sanchez, L., Castro, Y., Jennis, A., McCain, A., Gutierrez, M., & Bamboat, Z. (2016). Gastric adenocarcinoma: clinicopathologic differences among Hispanics and non-Hispanic whites. A single Institution’s experience over 14 years. Annals of Gastroenterology, 29(3), 325-331.

Ferlay, J., Soerjomataram, I., Ervik, M., Dikshit, R., Eser, S., Mathers, C.,… Bray, F. (2012). Estimated cancer incidence, mortality and prevalence worldwide in 2012. Web.

Garcia, M., McQuade, J., Haddad, R., Patel, S., Lee, R., Yang, P.,… Cohen, L. (2013). Systematic review of acupuncture in cancer care: A synthesis of the evidence. Journal of Clinical Oncology, 31(7), 952-960.

Krishnasamy, M., So, W., Yates, P., de Calvo, L., Annab, R., Wisniewski, T., & Aranda, S. (2014). The nurse’s role in managing chemotherapy-induced nausea and vomiting: An international survey. Cancer Nursing, 37(4), 27-35.

Merchant, S., Kim, J., Choi, A., Sun, V., Chao, J., & Nelson, R. (2017). A rising trend in the incidence of advanced gastric cancer in young Hispanic men. Gastric Cancer, 20 (2), 226-234.

Navari, R. (2013). Management of chemotherapy-induced nausea and vomiting. Drugs, 73(3), 249-262.

Navari, R., & Aapro, M. (2016). Antiemetic prophylaxis for chemotherapy-induced nausea and vomiting. The New England Journal of Medicine, 374(14), 1356-1367.

Rao, K., & Faso, A. (2012). Chemotherapy-induced nausea and vomiting: Optimizing prevention and management. American Health Drug Benefits, 5(4), 232-240.

Richard, L., Furler, J., Densley, K., Haggerty, J., Russell, G., Levesque, J., & Gunn, J. (2016). Equity of access to primary healthcare for vulnerable populations: the IMPACt international online survey of innovations. International Journal for Equity in Health, 15(64), 1-20.

Siegel, R., Fedewa, S., Miller, K., Goding-Sauer, A., Pinheiro, P., Martinez-tyson, D., & Jemal, A. (2015). Cancer statistics for Hispanics/Latinos, 2015. A Cancer Journal for Clinicians, 65(6), 457-480.

Sierra, M., Cueva, P., Bravo, L., & Forman, D. (2016). Stomach cancer burden in Central and South America. Cancer Epidemiology, 44(1), 62-73.

Appendix A

Informed Consent

Dear potential participant, you are invited to become a part of the research project dedicated to cancer treatment methods in Hispanic patients. You are absolutely welcome to discuss this invitation with your friends, relatives, or anyone else prior to accepting this invitation. Please, be sure to take your time in order to make an informed decision concerning our proposal. The ultimate decision concerning whether you want or do not want to join the research project is undeniably up to you. Within the framework of the current study, we expect to investigate the influence of conventional medicine compared to herbal treatment in terms of chemotherapy-induced nausea and vomiting.

We certify that all the necessary information will be presented briefly and clearly so as to ensure that we can outline the end results of the study correctly. At this stage, we cannot disclose some sensitive parts of our research project, but you can check the additional documentation that we provide so as to get acquainted with the background of the study and why we decided to conduct it. We would also like to ask you to share with us the things that you expect/ want to learn within the framework of the current research.

In the case if you finally decide to become a part of our research project, you will have to fill in a custom-designed survey. We believe that this will take you not more than 30-45 minutes. We expect you to be courteous and professional. Overall, your role in this project is to answer the questions presented in the survey and hand in the blanks. We are going to collect your papers and then analyze them in order to synthesize the findings and make several conclusions regarding the end data that you will provide us with. Please, be aware of the fact that you are going to be a part of this research until we make all the necessary steps and disclose the findings of the study. The approximate length of this study is four months.

You should also remember that we will have the ability to stop the research project at any given moment or take you out of the latter if we believe that the project may harm you in some way. You can be removed from the study for a number of other unrelated reasons (these may include wrongful behavior, personal reasons, inability to follow research guidelines, and many other). Please, remember that this can be done without your consent. Also, you have the full right to drop out of the study if you want. You will not lose anything, and your information will not be disclosed.

There are several risks that we believe can be important within the framework of this study. The first one is the unreliability of the results due to research bias. The second one is inaccuracy caused by the size of the sample. We guarantee that you will not be exposed to any types of risks that cannot be predicted. Please, be aware of the fact that there are no non-physical or physical risks associated with our research project. To expand on this topic, we are making sure that our investigation does not cause economic harm to you and does not impose any psychological or social risks on any participant of the study. Your employability and social status will not be affected.

On the basis of the information presented above, we can conclude that there are several benefits that can be interesting to you. Within the framework of the current research, you will most probably learn critical things regarding the effectiveness of herbal treatment methods and their influence on the organism. Besides that, the researchers do not guarantee any personal benefits. It may only be expected that you will benefit from the research by means of addressing the findings of the study if necessary.

It is also important to mention that the researchers guarantee that the project will be confidential and all the information will be stored properly. The researchers take the issues of confidentiality rather seriously and will make sure that no damage is caused and unauthorized data disclosure is impossible. The obtained data will only be available to the researchers throughout the whole lifetime of the project. After the project is completed, the outcomes and discussion of the study will be published online (no personal info will be disclosed). So as to ensure the safety of the data, the surveys will be kept in electronic format and protected by a complex password (the PC on which the files will be stored is also going to be password-protected).

You will not receive anything for participating in the current research project due to the fact that your contribution to the investigation is voluntary. You have the full right to drop out of the study at any given moment. This decision will not end up in you being penalized, losing any benefits, or harming your interpersonal relationships with your family and relatives. If you decide to leave the project, your information will be withdrawn, and we will not use it at all.