Supportive Oncology Treatment of Nausea and Vomiting During Chemotherapy
Karen M Mustian, PhD, MPH, Katie Devine, PhD, Julie L Ryan, PhD, MPH, Michelle C Janelsins, PhD, Lisa K Sprod, PhD, Luke J Peppone, PhD, MPH, Grace D Candelario, MD, Supriya G Mohile, MD, MPH and Gary R Morrow, PhD, MS James P Wilmot Cancer Center, University of Rochester School of Medicine and Dentistry
Abstract
Nausea and vomiting are two of the most troubling adverse effects patients experience during chemotherapy. While newly available treatments have improved our ability to manage nausea and vomiting, anticipatory and delayed nausea and vomiting are still a major problem for patients receiving chemotherapy. Many cancer patients will delay or refuse future chemotherapy treatments and contemplate stopping chemotherapy altogether because of their fear of experiencing further nausea and vomiting. The purpose of this article is to provide an overview of the patho-psychophysiology of chemotherapy-induced nausea and vomiting and the recommended guidelines for treatment.
Keywords Cancer, chemotherapy, nausea, vomiting
Disclosure: The authors have no conflicts of interest to declare. Received: April 19, 2011 Accepted: May 31, 2011 Citation: US Oncology & Hematology, 2011;7(2):91–7 Correspondence: Gary R Morrow, PhD, MS, University of Rochester School of Medicine and Dentistry, James P Wilmot Cancer Center, Box 704, 601 Elmwood Avenue, Rochester, NY 14642. E:
gary_morrow@urmc.rochester.edu
Support: The publication of the article was funded by Eisai Inc. The views and opinions expressed are those of the authors and not necessarily those of Eisai Inc.
Cancer patients will delay chemotherapy treatments and contemplate refusing future treatments because of fear of further CINV.1–4
Cancer treatments are quite challenging for cancer patients to endure. The cancer treatments and subsequent adverse effects patients experience often make them feel worse than the disease itself.1–3 Chemotherapy-induced nausea and vomiting (CINV) are two of the most common and troublesome adverse effects experienced by cancer patients.1–3
While significant advances have been made in the treatment of acute chemotherapy-induced vomiting (CIV), chemotherapy-induced nausea (CIN), anticipatory nausea and vomiting (ANV), and delayed nausea and vomiting (DNV) remain substantial problems for cancer patients.1,2 Anticipatory nausea is reported by 30 % of patients who experienced nausea during earlier chemotherapy treatment cycles.1
Anticipatory
vomiting is reported in 20 % of patients who experienced vomiting during earlier chemotherapy treatment cycles.5,6
Anticipatory, acute,
and delayed CINV lead to poorer chemotherapy adherence, impaired function, increased anxiety and depression, and diminished quality of life among patients.4,7–9
In turn, physicians and patients increase usage
of healthcare resources to manage these adverse effects, substantially increasing the public health burden of cancer and its effective treatment.2–9
The purpose of this article is to provide an overview of the patho-psychophysiology of CINV and the recommended guidelines for its treatment.
© TOUCH BRIEFINGS 2011
Pathophysiology of Chemotherapy-induced Nausea and Vomiting—The Role of Neurotransmitters CIN and CIV are distinct symptoms; however, they often go hand in hand and are among the most unpleasant adverse effects of most chemotherapy regimens for cancer patients. It is important to note that nausea can occur without vomiting. CINV can be acute (during the first 24 hours post-treatment) and delayed (after the first 24 hours post-treatment and up to five to eight days post-treatment).10
CINV, once
Many of the clinical symptoms commonly reported by patients in association with nausea are manifestations of autonomic nervous system activity in response to chemotherapy delivery. For example, physical manifestations such as pallor, sweating, and feeling hot or cold all over commonly precede or accompany nausea.7,12 Vomiting is a reflex triggered by toxic substances, such as chemotherapeutic agents, causing cell damage within the stomach and small intestines. Broadly, these agents are sensed in the gastric or small bowel mucosa and cause stimulation of vagal afferents that interact with the hindbrain of the central nervous system (CNS), resulting in efferent vagal action that ultimately leads to an emetic response.
experienced during early chemotherapy cycles, can create a conditioned response that leads to anticipatory nausea in future cycles of treatment.11
Numerous classic neurotransmitters affect the emetic response, including serotonin, substance P, dopamine, acetylcholine, and
γ-aminobutyric acid (GABA). Other chemical messengers, acting as neurotransmitters, that affect the emetic response include histamine,
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