الفهرس 
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Abstract
Breast cancer is the most common and lethal cancer type in women. It’s the second leading cause of cancer death in women worldwide. Chemotherapy is a type of cancer treatment that uses one or more anti-cancer drugs as part of a standardized chemotherapy regimen. Adriamycin and Cyclophosphamide (AC) are the two major classes of drugs for breast cancer treatment which have many side effects like any other chemotherapy agent as it has effects not only on cancer cells, but healthy cell as well. The most common side effects are diarrhea, nausea, vomiting, fatigue, mucositis, neuropathy and hematologic complications.
Adriamycin and Cyclophosphamide (AC) classified as highly emetogenic chemotherapy which is defined as one in which more than 90 % of patients experience acute emesis so it is most frequently reported with this agents. Fatigue is a well document side-effect of chemotherapy and is often reported as the most distressing symptom. It had been observed that during the first 24 to 48 hours of chemotherapy, there is a spiked rise in fatigue levels
Pharmacological therapy is not sufficiently effective in managing chemotherapy induced nausea, vomiting and fatigue in patients with cancer. Non-pharmacologic treatments have provided promising results. Complementary and alternative medicine (CAM) such as reflexology provided great results.
Oncology nurses play a pivotal role in the care of patients receiving chemotherapy and are in a prime position to facilitate better care of patients experiencing chemotherapy-induced nausea, vomiting (CINV) and fatigue.
The use of complementary and alternative medicine (CAM) by cancer patients is of vital importance. Reflexology is one of the available interventions in manual complementary therapies, which provides a good opportunity for nurses to take care of patients.
Reflexology is a form of massage that regulates mixed-body functions and, thus, provides relief and relaxation. It’s frequently used to manage symptoms of cancer patients and to increase their quality of life. Since reflexology is based on simple manual techniques that do not require any drugs or invasive intervention, it is considered to be a safe procedure.
The aim of this study was
To determine the effect of foot reflexology on chemotherapy induced nausea, vomiting and fatigue.
Material and methods:
• Research design: the study followed a quasi-experimental design
• Setting: The present study was conducted in the Chemotherapy Units at the Alexandria Main University and Ayadi Almostakbal Hospital Alexandria city.
• Subjects: Fifty adult female patients receiving Adriamycin and cyclophosphamide. They were randomly recruited into 2 groups; group one (control group) and group two (study group), 25patients for each group. according to the following criteria:
• Adult female patients aged from 21-60 years.
• Read and write.
• Have been diagnosed with stage II & III breast cancer and treated with chemotherapy.
• Patients who were receiving the same chemotherapy cycle (4 cycles), which is 21 days apart and was continuing to receive standard antiemetic treatments during the study period.
• Patients who were receiving Adriamycin and cyclophosphamide because it was classifying as high-emetic risk chemotherapy.
• Having no metastasis.
• Free from associated chronic diseases such as diabetes mellitus, hypertension, liver and kidney disease.
• Free from injury including (lesions, fractures, sprains, bruises, open wounds and or burns of the lower extremities), thrombosis, hemorrhage, epilepsy, irregular heart rate and hypotension as a contraindication of reflexology.
• Able to communicate, oriented to time, place and persons.
• Willing to participate in the study.
• Not received reflexology therapy at previous time.
Tools of the study:
Two tools were used in this study for data collection, in addition to patient’s Bio- sociodemographic data.
Tool I: Rhodes Index of Nausea, Vomiting, and Retching self-report assessment tool: - (Appendix II - A)
Rhodes index of nausea, vomiting, and retching (INVR) was developed by Rhodes and McDaniel in (1999) and was adapted and translated into the Arabic language according to review of literature by the researcher to assess the effectiveness of reflexology on the experience of nausea, vomiting and retching among patients receiving chemotherapy.
Rhodes index of nausea, vomiting, and retching (INVR) include an eight self-report questions was used to assess experience, occurrence and distress from nausea, vomiting and retching.
Tool II: The Brief Fatigue Inventory (BFI) self-report assessment tool: - (Appendix II - B)
This tool was developed by Anderson (1997) and was adapted and translated into the Arabic language according to review of literature by the researcher to assess subjective perception of fatigue in cancer populations. The Brief Fatigue Inventory (BFI) was a 9-item, 11-point rating scale. The time period for all questions was over the past 24 hours. The first three questions, measure fatigue severity while, the following six questions assess fatigue interference with daily activities.
Additionally, socio-demographic data tool was attached; which include patient name, age, sex, educational qualification, marital status, occupation and residence area. In addition to clinical data such as diagnosis, patient weight, height, body mass index and laboratory values.
Data collection:
The data were collected over a period of 9months, starting from July 2019 to March 2020.
• Participants meeting the inclusion criteria were selected and they were equally, and sequentially recruited into either control or study group (25 patients each) as following:
- Control group who would receive the routine hospital care (Antiemetic medication only).
- Study group who would receive the routine hospital care and foot reflexology.
The study was carried out in four phases:
I. Assessment phase:
It was carried out using tool I& II to collect baseline data for all the subjects (study and control group) of the study after 24 from first chemotherapy cycle before using foot reflexology intervention.
• The control and study group were interviewed individually in the first chemotherapy cycle before chemotherapy infusion. sociodemographic and clinical data was collected in this phase. Initial assessment (Pretest) of both the study and control patients was carried out for the 24 hours after the first chemotherapy cycle using tool I and II to collect baseline data before starting the foot reflexology program.
II. Planning Phase:
Foot reflexology program was designed by the researcher after reviewing recent review of literature and after receiving training program in reflexology.
Foot Reflexology was planned to be applied by the researcher for the study group in the second chemotherapy cycle at the beginning of chemotherapy infusion in totally three sessions in each chemotherapy cycle (every 21 days).
III. Implementation phase:
Foot reflexology intervention was implemented individually for each patient in the study group. General foot reflexology was done by making foot massage on all reflex zones and cover all body system for each foot followed by specific foot reflexology by making foot massage to the reflex point of organs of the gastrointestinal and urinary systems, heart, pituitary gland and lymph node were the primary focus. Each session was started on the right foot and continued on the left one. The researcher was guided by foot reflexology chart.
IV. Evaluation phase:
Evaluation(Posttest) for control group was done 24 hour after second, third, fourth chemotherapy cycle following routine hospital care which was done in each chemotherapy cycle. While evaluation for study group was done 24 hour after second, third and fourth foot reflexology session which was done in each chemotherapy cycle. Both groups were carried out using the same tools used in assessment phase (Tool I&II). Comparison between the two groups was implemented to determine effect of reflexology among breast cancer patients undergoing chemotherapy.
Statistical analysis:
o Reliability statistics was assessed using Cronbach’s Alpha test.
o Data were fed to the computer and analyzed using IBM SPSS software package version 20.0.
o Qualitative data were described using number and percent. Quantitative data were described using minimum and maximum, mean and standard deviation.
o Comparison between the control and study groups regarding categorical variables was tested using Chi-square test. When more than 20% of the cells have expected count less than 5, correction for chi-square was conducted using Fisher’s Exact test or Monte Carlo correction.
o Correlate between two normally distributed quantitative variables using Pearson coefficient.
o For normally distributed quantitative variables, comparison between the control and study groups was analyzed using Student t-test.
o Significance of the obtained results was judged at the 5% level.
o Body mass index (BMI, ratio of height and weight, expressed as body weight in kg/ height in cm2)
The main results of the study:
• There were no statistically significant difference between patients in the study and control group regarding sociodemographic and clinical characteristics (P<0.05).
• The highest percentage of patients in both control and study group (52%, and 48% respectively) were between 40< 50 years of age.
• The highest percentage of patients in both control and study group (84% and 72% respectively), were married.
• The highest percentage of patients in both control and study group (72% and 52% respectively) were secondary school.
• The highest percentage of patients in both control and study group (64% and 68% respectively) were housewives.
• The majority of patients in the control and study group (80% and 56% respectively) were did not have enough monthly income from the patient’s point of view.
• Highly statistically significant differences were detected between study and control group after 2nd & 3rd foot reflexology intervention in relation to total score of experience, occurrence and distress of nausea, vomiting and retching(P<0.001).
• Highly statistically significant differences were detected between control and study group after 2nd and 3rd foot reflexology intervention in relation to fatigue severity and fatigue effect on living activities (P<0.001).
• A statistical significant relation was found between Nausea, Vomiting, and Retching which was negatively correlated with patient’s age.
• A statistical significant relation was found between Nausea, Vomiting, and Retching which was positively correlated with patient’s body mass index (BMI).
• Fatigue severity and fatigue effect on life activities significantly correlated negatively with patient’s age while, it was significantly correlated positively with BMI.
• Patients with chemotherapy induced nausea, vomiting should seek ongoing foot reflexology as complementary alternative medicine and it should be practices by specialized health care provider to improve the patients’ health and quality of life.
The main recommendations of the study:
1- Oncology nurses should seek courses of foot reflexology as complementary therapy which help decrease cancer and cancer treatment related symptoms including chemotherapy induced nausea, vomiting and fatigue.
2- Oncology nurses should perform foot reflexology intervention for patients in hospital, teach and train them and their relative to perform it at home with a regular schedule to reach optimum effect.
3- Administrator should encourage nurses to take courses of complementary alternative medicine and encourage its application in chemotherapy units.
4- Specific rooms for health education for breast cancer patients receiving chemotherapy should be available at any time to teach patients about foot reflexology technique to be able to make self care using foot reflexology at home.
5- It is essential to increase the level of awareness among public, patients and health care providers regarding importance of performing foot reflexology intervention especially during receiving chemotherapy.
6- Further research is recommended to be done to determine the effect of foot reflexology on quality of life among breast cancer patients receiving chemotherapy.
7- Further research recommended for larger number of subjects, as well as long period of study time to confirm the results of the current study.