Chemotherapy-Induced Nausea and Vomiting
Background
Chemotherapy-induced nausea and vomiting (CINV) can occur with most chemotherapeutic agents and is considered one of their most feared side effects.1 The incidence of CINV varies according to chemotherapy protocol and individual patient risk factors for the symptom. Patients at higher risk for CINV may include those
- Younger age (< 50)
- Female gender
- Little or no history of alcohol intake
- Emesis with past pregnancy
- History of motion sickness1
Agents commonly used in the treatment of CRC generally carry a lower (10%–30%) emetic risk of CINV, particularly fluorouracil, capecitabine, and the biologic agents. Oxaliplatin and irinotecan have been categorized as moderately (30%–90%) emetogenic, but for some patients these are considered highly (> 90%) emetogenic. Bevacizumab, approved for treating metastatic CRC, has a minimal (< 10%) emetic risk.2,3
Guidelines for the American Society of Clinical Oncology (ASCO), Multinational Association of Supportive Care in Cancer (MASCC), Oncology Nursing Society (ONS), and National Comprehensive Cancer Network (NCCN) all agree that highly emetogenic chemotherapy regimens require triple antiemetic therapy, including the administration of:
- a NK1 receptor antagonist (aprepitant: first agent in this new category)
- a 5-HT3 serotonin receptor antagonist (dolasetron, granisetron, ondansetron, tropisetron, palonosetron)
- Corticosteroids (dexamethasone)
For patients receiving moderately emetogenic chemotherapy other than an anthracycline-cyclophosphamide combination, the recommendation is generally a 5-HT3 agent with dexamethasone, although ONS and NCCN recommend the addition of aprepitant for selected patients in this setting as well.
Because individual risk factors for emesis must be considered along with the emetogenic classification of specific chemotherapy protocols, comprehensive assessment is necessary to truly assess risk for emesis. Adequate control of CINV is essential to help ensure the patient’s quality of life and ability to complete therapy, as well as to prevent the physiologic effects of uncontrolled CINV, such as dehydration or gastrointestinal or pulmonary effects. Nurses are key in the assessment and management of CINV.2
Assessment Tools
National Cancer Institute (NCI) (US National Institutes of Health)
Classification and criteria for grading the severity of nausea and vomiting are useful assessment tools. Go to: http://www.cancer.gov/cancertopics/pdq/supportivecare/nausea.
Multinational Association of Supportive Care in Cancer (MASCC)
MASCC, an international multidisciplinary organization, is dedicated to research and education in all areas of supportive care, regardless of a patient’s stage of cancer. On the home page at http://www.mascc.org, click on the MASCC Antiemesis Tool (MAT).
Oncology Nursing Society (ONS)
The ONS Web site includes a section on symptom management, which contains the latest news and developments in supportive care. You can access symptom management through the ONS home page at http://www.ons.org by clicking on Clinical Practice, or through the direct Web site address: http://www.ons.org/clinical/SymptomManagement/
The ONS has released new “Putting Evidence Into Practice” cards (PEP) for management of nausea and vomiting. These can be accessed here.
Clinical Practice Guidelines
National Comprehensive Cancer Network (NCCN)
The NCCN promotes awareness of the importance of continuous improvement in quality of care and recognizes the significance of creating clinical practice guidelines appropriate for use by patients, clinicians, and other health care decision makers. The home page at http://www.nccn.org offers links to guidelines for patients and professionals; click on Clinical Practice Guidelines in Oncology. Antiemesis is also reached directly through http://www.nccn.org/professionals/physician_gls/PDF/antiemesis.pdf.
Multinational Association of Supportive Care in Cancer (MASCC)
MASCC publishes guidelines, consensus papers and the monthly journal Supportive Care in Cancer. On the home page at http://www.mascc.org, click on Antiemetic Guidelines, or visit this link.
American Society of Clinical Oncology (ASCO)
Nine oncology organizations participated in producing the ASCO Guideline for Antiemetics in Oncology: Update 2006. They anticipate that this collaborative effort will result in more consistency in implementation of the guidelines. Available here.
Patient Care Management Protocols and Algorithms
The NCCN at http://www.nccn.org and the MASCC at http://www.mascc.org have sections for patients.
References
- Viale PH. Integrating aprepitant and palonosetron into clinical practice: a role for the new antiemetics. Clin J Oncol Nurs. 2005;9:77-84. [ Pub Med ]
- Bender CM, McDaniel RW, Murphy-Ende K, et al. Chemotherapy-induced nausea and vomiting. Clin J Oncol Nurs. 2002;6:94-102. [ Pub Med ]
- Kris MG, Hesketh PJ, Somerfield MR, et al. American Society of Clinical Oncology Guideline for Antiemetics in Oncology: Update 2006. J Clin Oncol. 2006;24:2932-2947.
Key Definitions
Emetogenic—Describes a substance that causes vomiting. Also called emetic.
NK1 receptor antagonist—The endogenous receptor for Substance P is neurokinin 1 receptor (NK1-receptor, NK1R). It belongs to the tachykinin receptor sub-family of G protein-coupled receptors (GPCRs.) The vomiting center in the brainstem contains high concentrations of substance P and its receptor. Their activation stimulates the vomiting reflex. Different emetic pathways exist, and substance P/NK1R appears to be within the final common pathway to regulate vomiting.
5-HT3 Serotonin receptor antagonist—5-hydroxytryptamine 3 receptor antagonist. An antiemetic drug used to relieve nausea and vomiting. Also called type 3 serotonin receptor antagonist.
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