Supportive Oncology Treatment of Chemotherapy-induced Nausea in Cancer Patients Julie L Ryan Assistant Professor, Departments of Dermatology and Radiation Oncology, James P Wilmot Cancer Center, University of Rochester Medical Center
Abstract
For over 30 years, chemotherapy-induced nausea and vomiting have been the most severe and troublesome symptoms for cancer patients receiving chemotherapy. Unresolved chemotherapy-induced nausea and vomiting can lead to metabolic disorders, dehydration, nutritional depletion and oesophageal tears, and can reduce the daily functioning and quality of life of and interfere with treatment schedules. Despite the widespread use of antiemetics, chemotherapy-induced nausea continues to be problematic. Unlike vomiting, nausea is a subjective and unobservable phenomenon, making it extremely difficult to accurately assess and treat. Current research suggests that management of chemotherapy-induced nausea should focus on treating the symptoms before they occur rather than after they develop. This article highlights evidence-based interventions for the treatment of chemotherapy-related nausea.
Keywords Chemotherapy, nausea, vomiting
Disclosure: The author is supported by National Cancer Institute (NCI) Public Health Service (PHS) grants 1R25CA10618 (Cancer Control Research) and U10CA37420 (Community Clinical Oncology Program). Received: 17 October 2009 Accepted: 11 August 2010 Citation: European Oncology, 2010:6(2);14–6 Correspondence: Julie L Ryan, Departments of Dermatology and Radiation Oncology, University of Rochester Medical Center, 601 Elmwood Ave, Box 697, Rochester, NY 14642, US. E:
julie_ryan@urmc.rochester.edu
Chemotherapy-induced nausea continues to be reported by up to 70% of adult patients receiving moderately and highly emetogenic chemotherapy agents and 58% of school-age and adolescent-age children receiving highly emetogenic chemotherapy, despite the extensive use of antiemetics.3,4
Cancer patients rate nausea the most distressing side effect of chemotherapy.1,2
Currently, the standard of care for chemotherapy-induced nausea is antiemetics, most notably
serotonin (5-HT3) receptor anatagonists. However, research has shown that antiemetics are clinically effective against emesis but not nausea.5–7
Successful treatments have proved to be those given prophylactically before chemotherapy to prevent the onset of nausea and/or vomiting.8–10
Interventions for nausea administered after the insult of chemotherapy are ineffective. Furthermore, clinical studies have shown that control of chemotherapy-induced nausea and vomiting in the acute period correlates with the control of delayed nausea and vomiting.
Nausea is a subjective and unobservable phenomenon that originates from a connection between the brain and the gut.8,11
The gut contains
more neuronal innervations than the spinal cord. Nausea is not the same as vomiting and is most accurately measured by self- assessment tools, such as diaries and visual analogue scales (VAS).12 Most antiemetic medications are antagonist for neurotransmitter receptors located in the gut and designed to inhibit the emetic signalling of these receptors. Although antiemetics do not completely control feelings of nausea, the biological mechanism for nausea most likely involves these neurotransmitters in the gut, such as serotonin, neurokinin and dopamine. Previously reported risk factors for severe
14
nausea include female gender, young age, prescribed chemotherapy regimen and vomiting during previous chemotherapy, as well as the expectancy of nausea of patients.11–15
women who believed they would have severe nausea after chemotherapy were five times more likely to experience severe nausea compared with those who did not believe they would have severe nausea.15
Chemotherapy-induced nausea can be categorised into three types: anticipatory, acute and delayed. Anticipatory nausea occurs before the start of chemotherapy in anticipation of the treatment and develops in 8–20% of patients.7,16,17
Anticipatory nausea is reported by approximately
20% of patients at any one chemotherapy cycle and by 25–30% of patients by the fourth chemotherapy cycle. The incidence of anticipatory nausea reported in two studies of children varied from 15 to 54%, partially explained by the degree of emetic control of the previous cycle.18,19
No pharmacological agents have had success in treating anticipatory nausea once it has occurred.17,20,21
behavioural method of systematic desensitisation can be effective, but it is not readily available in most clinic settings.20,22
By contrast, the Acute nausea occurs
within 24 hours post-chemotherapy, whereas delayed nausea occurs over 24 hours and up to five days post-chemotherapy. The majority of patients report the most severe nausea on day one of chemotherapy and are less likely to have severe nausea on subsequent days if they do not experience it on day one.23
Delayed nausea occurs in
approximately 50–80% of patients and is most often associated with highly emetogenic chemotherapy regimens, such as doxorubicin and cisplatin. Delayed post-chemotherapy nausea and vomiting are difficult
© TOUCH BRIEFINGS 2010
Roscoe et al. showed that
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