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Oral Intake of Ginger for Chemotherapy-

Induced Nausea and Vomiting Among Women
With Breast Cancer

Article in Clinical journal of oncology nursing October 2015

DOI: 10.1188/15.CJON.E92-E97

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n Online Exclusive Article

Oral Intake of Ginger

for Chemotherapy-Induced Nausea and Vomiting
Among Women With Breast Cancer
Mzeyyen Arslan, RN, MSc, PhD, and Leyla Ozdemir, RN, MSc, PhD

Background: Chemotherapy-induced nausea and vomiting (CINV) is among the most com-
mon and distressing symptoms experienced by patients receiving cancer treatment. Nurses
play a substantial role in the prevention and management of CINV. Ginger (Zingiber officinale
Roscoe) is often advocated as beneficial for nausea and vomiting. Whether the herb is truly
efficacious for this condition is, however, still a matter of debate.
canyonos/iStock/Thinkstock Objectives: This experimental randomized, controlled trial was done to assess the effect of
ginger on chemotherapy-related nausea and vomiting.
Methods: All patients in the study (N = 60) received standard antiemetic drugs. The patients in the study group (n = 30)
also received oral ginger for the first three days of the chemotherapy cycle. No intervention was performed in the control
group (n = 30) except for the routine antiemetic treatment. Nausea severity and the number of vomiting and retching
episodes were measured four times each day for the first five days of the chemotherapy cycle in the patient diary. Nausea
severity was evaluated using a numeric scale ranging from 0 (no nausea) to 10 (very severe nausea).
Findings: The researchers analyzed the five-day mean score of nausea severity and the number of vomiting and retching
episodes. Based on this comparison, nausea severity and the number of vomiting episodes were significantly lower in the
intervention group than in the control group (p > 0.05). However, the change in the number of retching episodes between
the intervention and control groups was not statistically significant (p > 0.05).
Mzeyyen Arslan, RN, MSc, PhD, is an assistant professor and lecturer in the School of Nursing at Turgut Ozal University, and Leyla Ozdemir, RN, MSc, PhD, is
an associate professor in the Faculty of Nursing at Hacettepe University, both in Ankara, Turkey. The authors take full responsibility for the content of the article.
The authors did not receive honoraria for this work. The content of this article has been reviewed by independent peer reviewers to ensure that it is balanced,
objective, and free from commercial bias. No financial relationships relevant to the content of this article have been disclosed by the authors, planners, indepen-
dent peer reviewers, or editorial staff. Mention of specific products and opinions related to those products do not indicate or imply endorsement by the Clinical
Journal of Oncology Nursing or the Oncology Nursing Society. Arslan can be reached at muzeyyen24@hotmail.com, with copy to the editor at CJONEditor@ons
.org. (Submitted August 2014. Revision submitted November 2014. Accepted for publication December 14, 2014.)
Key words: chemotherapy; nausea and vomiting; breast cancer; ginger
Digital Object Identifier: 10.1188/15.CJON.E92-E97

B
reast cancer is the second major cause of cancer-
related mortality in women, after lung cancer (Youl-
den et al., 2012). Because of an increase in the occur-
rence of breast cancer, the prevention of complica-
tions from systemic chemotherapy administration,
early detection of symptoms, and symptom control gradu-
ally have gained more significance. Although chemotherapy-
induced nausea and vomiting (CINV) is the side effect most fre-
quently reported by patients receiving breast cancer therapy, its
severity and intensity vary among patients. CINV can be broadly
categorized as acute (occurring within 24 hours of therapy),
delayed (persisting for 67 days after therapy), or anticipa-
tory (occurring prior to chemotherapy administration). The
problems arising from CINV may include fluid and electrolyte
imbalance, malnutrition, or delay of chemotherapy administra-
tion (Panahi et al., 2012; Rhodes & McDaniel, 2001). Despite
the developments in pharmacologic treatment, 70%87% of
patients with breast cancer experience nausea and/or vomiting
from chemotherapy (Cohen, de Moor, Eisenberg, Ming, & Hu,
2007; Lindley et al., 2005; Yap, Low, & Chan, 2012).
Patients frequently adopt complementary and alternative
medicine (CAM) for CINV despite pharmacologic treatment.

E92 October 2015 Volume 19, Number 5 Clinical Journal of Oncology Nursing
More than half of the patients in Europe, North America, and
other industrialized regions use at least one CAM method (Har-
ris, Cooper, Relton, & Thomas, 2012). Among CAM methods,
herbal therapy has become widespread, particularly in patients
with cancer (Saghatchian et al., 2014). Kav, Hanoglu, and Algi-
er (2008) have reported that the rate of CAM usage in patients
with cancer in Turkey ranged from 22%84%, and the average
rate was 46%. Women with breast cancer may adopt CAM
methods to reduce the side effects of treatment and psychologi-
cal stress, as well as to achieve a sense of control during the
treatment. In addition, a sufficient benefit is not gained from
traditional medical treatments (Kav et al., 2008; Ozlem, Seda,
Nimet, Alper, & Celalettin, 2008; Sebahat, Ayfer, & Mehmet,
2003; Yavuz, Ile, Kaymaki, Bildik, & Diramali, 2007). Plant
derivatives are used alone or as a mixture for the treatment of
diseases. In this context, ginger (Zingiber officinale Roscoe) is
one of the most frequently used plant derivatives (Konuklugil
& zelikay, 2004). Ginger is a tropical and subtropical plant
that belongs to the Zingiberaceae family. For centuries, it has
been commonly used in many regions of the world as a spice
or food supplement, as well as for treatment in traditional
medicine (Konuklugil & zelikay, 2001). Ginger can be con-
sumed fresh or as dried root. The dosage of ginger reported
in the literature is from 250 mg to 1 g powdered root in the
capsular form, consumed one to four times per day (White,
2007). Recommended therapeutic doses range from 5001,000
mg fresh root three times per day or 500 mg dried root two
to four times per day (Newall, Anderson, & Phillipson, 1996).
In a study involving 1,489 people with sea sickness, Kili
(2001) reported that 940 mg of ginger root powder was more
effective than dimenhydrinate (Dramamine). Ebrahimi,
Maltepe, and Einarson (2010) indicated that ginger was used
in the complementary treatment of hyperemesis gravidarum.
Ginger has an antiemetic effect in hyperemesis gravidarum and
postoperative nausea and/or vomiting (Bilir, Akdemir, Ozden,
Cevrioglu, & Bilir, 2013; Hines, Steels, Chang, & Gibbons, 2012;
Marcus & Snodgrass, 2005). However, these studies were rather
limited in how ginger may affect CINV (Alparslan et al., 2012;
Chrubasik, Pittler, & Roufogalis, 2005). The current study was
conducted to determine the effect of powdered ginger on CINV
in patients with breast cancer receiving adjuvant anthracycline
chemotherapy.
Methods
Sample
The final study sample included 60 patients undergoing che-
motherapy in the outpatient clinic of an oncology hospital in
Turkey. The sample size was estimated a priori using G*Power,
version 3.1.7. At the level of a = 0.05 and an effect size of 0.1
and at 90% power, 60 patients were needed for the analyses to
achieve statistical significance. The patients were randomized
sequentially to the two groups (control and intervention); that
is, the first patient was assigned to the control group and the
next one to the intervention group. Inclusion criteria for the
study were being a female with stage II or III breast cancer,
having received previous surgical treatment for breast cancer,
currently receiving chemotherapy with adjuvant anthracycline
Clinical Journal of Oncology Nursing Volume 19, Number 5 Oral Intake of Ginger in Women With Breast Cancer E93
(chemotherapy protocols: anthracycline, cyclophosphamide
[Cytoxan], doxorubicin [Adriamycin], and 5-fluorouracil
[Adrucil]), receiving palonosetron-aprepitant antiemetic
treatment, being at least in the second cycle of chemotherapy,
and having experienced chemotherapy-induced nausea with a
severity of 3 or higher during the previous cycles.
Data Collection
The data were collected in two stages during two cycles of
chemotherapy. The data were collected using two forms: pa-
tient information form and patient diary. In the first stage, the
patient information form and patient diary were recorded on
the first day of chemotherapy. In the second stage, the patient
diary was collected on completion of the treatment. Nausea and
the number of vomiting and retching episodes were evaluated
four times each day for five days by the patient beginning on
day 1the day of chemotherapy infusionin the patient di-
ary. Nausea severity was evaluated using a numeric scale with
a severity of 3 or higher on a 110 rating scale, with a score of
12 being mild, 36 being moderate, and 710 being severe.
Procedure
Nausea severity and the number of vomiting and retching
episodes were followed up for five days, starting from the
first day of chemotherapy. The patient diary was given to the
patients in the intervention and control groups, and they were
asked to complete the diary four times a day at home. Patients
in both groups were contacted by phone during the five days
and were reminded to fill the diary. The researcher also re-
minded the patients to bring their diary to the hospital during
the next cycle.
Patients in the intervention group consumed powdered gin-
ger 30 minutes before chemotherapy administration. In total,
500 mg powdered ginger, mixed with a spoonful of yogurt to
make swallowing easier, was administered to patients twice
a day for three days. Patients in the intervention group took
the first dose of ginger 30 minutes before the chemotherapy
administration on day 1 under the researchers supervision.
The remaining five doses of powdered ginger (five packages of
500 mg each) were given to the patients to be used at home. For
patients in the control group, no intervention was performed
other than the standard of care provided at the hospital.
Before the administration of chemotherapy, all patients re-
ceived the standard of care per the antiemetic protocol followed
on the unit: 5-HT3 receptor antagonists palonosetron (Aloxi),
dexamethasone (Decadron), an antihistamine, and ranitidine
(Zantac) administered via IV on day 1, the day of chemother-
apy infusion. Thirty minutes before chemotherapy, aprepitant
(Emend) treatment was given orally, administering 125 mg on
day 1 and 80 mg per day on days 2 and 3.
Ethical permissions were granted by the ethics committee
of Turgut Ozal University Medical School in Ankara, Turkey.
Informed consent and written approval of the patients who
participated in the study were obtained.
The data were evaluated using SPSS, version 18.0. To com-
pare the two independent groups, a significance test between
their means or the MannWhitney U test was used. A signifi-
cance level of 0.05 for a two-tailed test was used for all analyses.
Findings TABLE 1. Changes in Nausea Severity and Number
The majority of the patients in the control and intervention of Vomiting and Retching Episodes by Day (N = 30)
groups were aged from 4958 years. The average age of partici-
Group X SD t df p
pants was 48.5 years. In total, 11 patients in the intervention
group and 16 patients in the control group had completed Day 1
elementary schoollevel education. Most patients were married Nausea severity 1.46 58 < 0.150
(28 in the intervention group and 26 in the control group) and Control 1.2 1.1
had children (25 in the intervention group and 23 in the control Intervention 0.8 0.9
group). In total, 24 patients in the intervention group and 21 Vomiting episodes 1.27 58 < 0.210
the patients in the control group were overweight (body mass Control 0.1 0.2
index of 25 and higher). No significant differences were seen Intervention 0.1
between the intervention and control group with respect to Retching episodes 1.81 58 < 0.080
age, education level, marital status, number of children, or body Control 0.3 1.0
mass index (p > 0.05). Intervention
No significant differences were seen between groups in can- Day 2
cer stage or chemotherapy characteristics (p > 0.05). About half
Nausea severity 5.10 58 < 0.001
of the patients in both groups (14 in the intervention group and Control 6.3 1.9
12 in the control group) had stage III breast cancer. The majority Intervention 3.8 1.9
of patients (21 in the intervention group and 24 in the control Vomiting episodes 2.64 58 < 0.010
group) received the cyclophosphamide-doxorubicin protocol. Control 0.3 0.6
Most patients were in the second cycle of chemotherapy (18 in Intervention 0.1
the intervention group and 22 in the control group). No statisti- Retching episodes 1.07 58 < 0.290
cally significant differences were seen between the two groups Control 0.7 1.5
with respect to nausea and vomiting/retching episodes before Intervention 0.3 1.0
the research intervention (p > 0.05). Day 3
Following the intervention, a statistically significant differ-
Nausea severity 5.88 58 < 0.001
ence was found with respect to nausea severity on days 25,
Control 6.5 1.8
in favor of the intervention group (p < 0.05). The number of Intervention 3.8 1.8
vomiting/retching episodes decreased on days 2, 3, and 5 in
Vomiting episodes 2.56 58 < 0.010
patients in the intervention group (p < 0.05). Although the num-
Control 0.2 0.4
ber of retching episodes also decreased within five days after Intervention 0.1
receiving chemotherapy, this decrease was not determined to
Retching episodes 1.40 58 < 0.170
be statistically significant (p > 0.05) (see Table 1).
Control 0.7 1.4
The researchers analyzed the five-day mean scores of nausea Intervention 0.3 1.1
severity and the number of vomiting/retching episodes. Based
on this comparison, nausea severity and the number of vomit- Day 4
ing/retching episodes were significantly lower in the interven- Nausea severity 5.54 58 < 0.001
tion group than in the control group (p < 0.05). However, the Control 6.3 1.8
change in the number of vomiting/retching episodes was not Intervention 3.7 1.9
statistically significant (p > 0.05) (see Table 2). Vomiting episodes 1.83 58 < 0.070
Acute and delayed nausea severities were compared in the Control 0.1 0.4
Intervention 0.1
intervention and control groups following the intervention. The
MannWhitney U test was used in patients with acute nausea Retching episodes 1.44 58 < 0.160
because the sample size (less than 30) is small. The researchers Control 0.7 1.5
Intervention 0.2 1.0
found that acute and delayed nausea severities in the interven-
tion group significantly decreased following the intervention Day 5
(p < 0.001) (see Table 3). Nausea severity 4.89 58 < 0.001
Control 5.4 2.3
Intervention 2.8 1.7
Discussion Vomiting episodes 2.09 58 < 0.040
Nausea severity and the number of vomiting/retching epi- Control 0.2 0.4
Intervention
sodes were lower in the intervention group than in the control
group following the administration of oral ginger. The decrease Retching episodes 0.82 58 < 0.420
in nausea severity and the number of vomiting/retching epi- Control 0.4 1.1
Intervention 0.2 1.0
sodes was not statistically significant on day 1. However, on
days 2, 3, and 5, nausea severity decreased and fewer vomiting/ dfdegrees of freedom
retching episodes occurred, which was statistically significant Note. Scores ranged from 010, with 0 indicating no nausea and 10
(p < 0.05). On day 4, only nausea severity showed a significant indicating very severe nausea.

E94 October 2015 Volume 19, Number 5 Clinical Journal of Oncology Nursing
 was observed to decrease the acutely observed nausea score of
TABLE 2. Changes in Nausea Severity and Number the patients. Panahi et al.s (2012) findings were similar to those
of Vomiting and Retching Episodes Before and After in the current study in terms of decrease in nausea severity.
Administration of Ginger (N = 30) In a randomized, controlled study by Pillai, Sharma, Gupta,
and Bakhshi (2011), children and adolescents undergoing che-
Group X SD t df p
motherapy with standard antiemetics (ondansetron [Zofran]
Before research intervention and dexamethasone) were randomized to receive starch powder
Nausea severity 0.115 58 < 0.900 (control group) or a ginger capsule (intervention group). Ginger
Control 5.2 1.5 was administered to the intervention group five or six times per
Intervention 5.3 1.0 day at a concentration of 1 or 2 g, according to body weight. Gin-
Vomiting episodes 0.453 58 < 0.653 ger root powder was effective in decreasing the severity of nau-
Control 0.2 0.4 sea and vomiting following acute- and late-period chemotherapy.
Intervention 0.1 0.3 The methodology of Pillai et al.s (2011) study was similar to that
Retching episodes 0.823 58 < 0.414 of the current study in terms of administering ginger in addition
Control 0.7 1.5 to standard antiemetic treatment to decrease nausea severity.
Intervention 1.2 2.6 In a study by Ryan et al. (2012), 576 adult patients with cancer
were randomized to four groups: (a) three capsules of placebo
After research intervention
three times per day, (b) two capsules of placebo and one cap-
Nausea severity 5.582 58 < 0.001 sule of ginger, (c) one capsule of placebo and two capsules
Control 5.1 1.5
of ginger, or (d) three capsules of ginger daily. The patients
Intervention 3.0 1.5
consumed the capsules three days before and after the che-
Vomiting episodes 2.632 58 < 0.011 motherapy regimen for a total of six days. Nausea severity and
Control 0.2 0.3 the number of vomiting episodes were recorded for four days,
Intervention
starting from the first day of the chemotherapy regimen. At the
Retching episodes 1.492 58 < 0.141 end of the study, a decrease in the severity of acute nausea was
Control 0.6 1.2 seen in patients specifically receiving 500 mg and 1 g of ginger
Intervention 0.2 0.8
daily, and no decrease was seen in delayed nausea severity when
dfdegrees of freedom compared with the placebo group.
Note. Scores ranged from 010, with 0 indicating no nausea and 10 In a similar study by Manusirivithaya et al. (2004), the effect
indicating very severe nausea. of ginger was investigated in 48 patients with gynecologic can-
cer receiving chemotherapy with cisplatin (Platinol). In this
study, the antiemetic was administered on the first day, and
decrease in the intervention group (p < 0.05). Compared with the patients were divided into two groups. In the first group,
the control group, the five-day mean for scores on nausea sever- 250 mg of ginger capsules were administered orally four times
ity and the number of vomiting episodes following the research a day (1 g ginger per day) for five days following the first che-
intervention were significantly lower than the control group (p < motherapy administration. In the second group, placebo was
0.05). Although the number of retching episodes in the inter- administered on the first day of chemotherapy (day 1), and oral
vention group decreased, this decrease was not statistically metoclopramide (Reglan) was administered the next four days.
significant (p > 0.05). Ginger successfully controlled acute nausea and vomiting, but
The significant decrease in scores on nausea severity and no benefit in controlling late nausea and vomiting was found.
number of vomiting episodes for four days following the first In this study, ginger was compared with a standard antiemetic.
day of the research intervention in the current study is paral- In contrast to the study by Manusirivithaya et al. (2004), in the
lel to the emetic effect of chemotherapy agents. Although no current study, ginger administration affected acute and delayed
vomiting was observed on day 1, when administration of che- nausea severity. This difference may have resulted from the
motherapy agents occurred, vomiting/retching episodes were
commonly experienced (Moradian et al., 2014). More nausea
and vomiting/retching episodes were observed during days TABLE 3. Mean Severity Scores of Acute and Delayed
25. Therefore, using ginger along with the standard protocol Nausea
for antiemetics was effective in controlling nausea and vomiting
Nausea n X SD p
during the days following chemotherapy administration.
The current study demonstrated that ginger administration Delayed < 0.001
was effective in decreasing the severity of acute and delayed Intervention 30 3.6 1.8
nausea in women with breast cancer receiving anthracycline- Control 30 6.1 1.7
based chemotherapy. In a study by Panahi et al. (2012), 78 female Acute < 0.001
patients with advanced breast cancer who were undergoing Intervention 15 1.6 1.1
chemotherapy (docetaxel [Taxotere], epirubicin [Ellence], Control 21 3.9 1.6
and cyclophosphamide protocol) were randomly assigned to
Note. Scores ranged from 010, with 0 indicating no nausea and 10
receive 500 mg of ginger versus no administration of ginger daily
indicating very severe nausea.
for five days, in addition to the treatment. Ginger administration

Clinical Journal of Oncology Nursing Volume 19, Number 5 Oral Intake of Ginger in Women With Breast Cancer E95

Implications for Practice
u Assess for chemotherapy-induced nausea and vomiting (CINV)
in patients with cancer.
u Recommend evidence-based practice to patients in the man-
agement of CINV.
u Offer ginger to patients experiencing CINV in addition to
antiemetic treatment.
administration of ginger along with standard antiemetic treat-
ment.
In the double-blind study by Sontakke, Thawani, and Naik
(2003) involving the comparison of ginger with other antiemet-
ics in 50 adult patients with cancer undergoing a chemother-
apy regimen consisting of cyclophosphamide, patients were
randomly divided into three groups. In total, 500 mg of ginger
capsules were administered to the first group 20 minutes before
the first day of chemotherapy. In total, 20 mg metoclopramide
was administered via IV to the second group, and a 5 mg meto-
clopramide tablet was orally administered after six hours. On-
dansetron was IV administered at 4 mg to the third group, and
2 mg of ondansetron was orally administered after six hours.
These groups were followed up in the next two cycles of treat-
ment in terms of vomiting. At the end of the study, complete
control of nausea was observed in 62% of patients who received
ginger, 58% of patients who received metoclopramide, and 86%
of patients who received ondansetron. Control of vomiting was
observed in 68% of patients who received ginger, 62% of pa-
tients who received metoclopramide, and 86% of patients who
received ondansetron. At the end of the study, no significant dif-
ferences were observed between ginger and metoclopramide
and ondansetron. The antiemetic efficacy of ginger was found
to be equal to that of metoclopramide, but ondansetron was
found to be better than both. In a similar study, Alparslan et
al. (2012) evaluated 45 patients with hematologic cancer who
were undergoing chemotherapy in two groups (30 patients in
the control group and 15 in the test group) to determine the
effect of ginger on CINV. Before the chemotherapy regimen,
400 mg of ginger capsules were administered twice a day to
the experiment group without any other antiemetic. Standard
antiemetic medicine (3 mg setron) was provided to the control
group. Ginger was more effective than the antiemetic in con-
trolling nausea and vomiting at the end of the study (p < 0.05).
The studies by Sontakke et al. (2003) and Alparslan et al. (2012)
differ from the current study in terms of comparing ginger with
an antiemetic. However, results of these studies are similar to
the current study in terms of decreasing the severity of nausea
and vomiting using ginger. Therefore, the administration of
ginger may have a similar effect as that of standard antiemetics.
In addition, ginger has advantages over antiemetics because it
does not lead to side effects, is economical, and is easy to use.
Although the previously mentioned studies differ from the
current study in terms of some characteristics (e.g., sample size,
cancer types, presence of blindness, use of different criteria
for evaluating CINV, management of ginger in different doses
and formulations, different starting days of ginger administra-
E96 October 2015 Volume 19, Number 5 Clinical Journal of Oncology Nursing
tion, administration of ginger along with an antiemetic), their
results are parallel to those of the current study in terms of the
effectiveness of ginger administration in decreasing nausea
and/or vomiting.
In the literature, ginger has been used in varying doses. The
suggested daily dosage of ginger in the literature is from 250
1,000 mg a day. This suggested amount can be administered as
a single dose or by dividing it into four doses (Chaiyakunapruk,
Kitikannakorn, Nathisuwan, Leeprakobboon, & Leelasettagool,
2006; Ernst & Pittler, 2000; Fahimi et al., 2011; Konuklugil &
zelikay, 2004; Zick et al., 2009). In addition, the quality of
ginger is influenced by its shelf life and freshness. The use of
fresh granulated root is suggested because its active ingredient
has the characteristics of essential oils (Kili, 2001; Konuklugil
& zelikay, 2001). In addition, microbiologic analysis of ginger
should be performed because patients undergoing chemother-
apy may have a weakened immune system.
Conclusion
In the current study, 500 mg powdered ginger administered
twice a day during the first three days of chemotherapy was
effective in reducing the severity of chemotherapy-induced
nausea in women with breast cancer receiving anthracycline-
based chemotherapy. No adverse effects attributable to ginger
were recorded. Although the patients in the intervention group
experienced fewer vomiting/retching episodes than patients in
the control group, this was not statistically significant. Favor-
able clinical effects of ginger on nausea severity and number
of vomiting/retching episodes associated with chemotherapy
were achieved using powdered ginger. At the end of the study,
500 mg powdered ginger administered twice a day for three
days was concluded to be able to be safely used to reduce nausea
severity and the number of vomiting episodes in women with
breast cancer experiencing nausea and/or vomiting associated
with anthracycline-based chemotherapy.
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