Nausea and vomiting are two of the most common and debilitating side-effects of chemotherapy and can result in significant morbidity and adversely impact patient quality of life.1–4 Nausea and vomiting secondary to chemotherapy may lead to poor compliance with further chemotherapy treatments and result in metabolic imbalances, decline of the patient’s mental and performance status, degeneration of self-care and functional ability, anorexia, and withdrawal from potentially useful or curative anticancer treatment.5 The frequency of nausea and vomiting depends primarily on the emetogenic potential of the chemotherapeutic agents used, but can also be affected by patient-factors. Risk factors include age younger than 50 years, female sex, vomiting during previous chemotherapy, history of pregnancy-induced nausea and vomiting, anxiety, history of limited alcohol intake, and history of motion sickness.6,7
Chemotherapy-induced nausea and vomiting (CINV) are classified into acute and delayed phases based on time of onset. With the introduction of the 5-HT3 receptor antagonists in combination with corticosteroids (e.g., dexamethasone) in the early 1990s, 70% to 90% of patients receiving highly emetogenic chemotherapy were protected from acute emesis.8 However, 40% to 60% of patients have symptoms in the delayed phase.9 More recently, another class of antiemetics were introduced, the neurokinin-1 (NK1) receptor antagonists. The addition of NK1 receptor antagonists to standard therapy significantly improves emesis protection in the acute and, in particular, delayed phase by approximately 20%.10
Despite progress in symptom control, CINV continues to be a problem, especially in the delayed phase. Nausea and vomiting remain among the most feared adverse effects of chemotherapy among patients with cancer.11 Delayed CINV typically occurs with administration of chemotherapeutic agents such as cisplatin, carboplatin, doxorubicin, or cyclophosphamide, and occurs more than 24 hours after chemotherapy administration.12 This underscores the problem that delayed CINV usually occurs after hospital or clinic discharge, when patients do not have immediate contact with their providers, thus requiring patient initiative to make the provider aware of the problem.
Providers and patients differ in their perceptions of the efficacy of CINV management. Grunberg et al.7 showed that oncologists and oncology nurses underestimated the incidence of delayed nausea and vomiting by approximately 30%, and found gaps in perception between professionals and patients. Because even a modest amount of nausea and vomiting can have a significant effect on quality of life,13,14 clear and accurate communication between oncology health care providers and patients is particularly important. This study attempted to identify opportunities for improving the treatment of CINV through enhancing this communication. Survey data regarding perceptions of patients and providers about CINV management, including efficacy and use of current antiemetics, were collected to identify similar and differing perceptions of communication, management, and barriers to quality care of CINV.
The authors would like to acknowledge the contributions of Project Steering Committee Member Diane Blum, MSW, as well as Project Team Members Jessica Noonan, BA; Nan Rothrock, PhD; Sarah Rosenbloom, PhD; and Susan Yount, PhD. The authors would also like to thank Donna Scharff at NCCN for her role in provider recruitment and data collection.
GriffinAMButowPNCoatesAS. On the receiving end. V: patient perceptions of the side effects of cancer chemotherapy in 1993. Ann Oncol1996;7:189–195.
CohenLMoorCEisenbergP. Chemotherapy-induced nausea and vomiting--incidence and impact on patient quality of life at community oncology settings. Support Care Cancer2007;15:497–503.
Bloechl-DaumBDeusonRRMavrosP. Delayed nausea and vomiting continue to reduce patients’ quality of life after highly and moderately emetogenic chemotherapy despite antiemetic treatment. J Clin Oncol2006;24:4472–4478.
EttingerDSArmstrongDKBarbourS. NCCN Clinical Practice Guidelines in Oncology: Antiemesis. Version 12012. Available at: http://www.nccn.org/professionals/physician_gls/pdf/antiemesis.pdf. Accessed January 4 2012.
GrunbergSMDeusonRRMavrosP. Incidence of chemotherapy-induced nausea and emesis after modern antiemetics. Cancer2004;100:2261–2268.
GrallaRJOsobaDKrisMG. Recommendations for the use of antiemetics: evidence-based, clinical practice guidelines. J Clin Oncol1999;17:2971–2994.
WarrDGGrunbergSMGrallaRJ. The oral NK(1) antagonist aprepitant for the prevention of acute and delayed chemotherapy-induced nausea and vomiting: pooled data from 2 randomised, double-blind, placebo controlled trials. Eur J Cancer2005;41:1278–1285.
PassikSDKirshKLRosenfeldB. The changeable nature of patients’ fears regarding chemotherapy—implications for palliative care. J Pain Symptom Manage2001;21:113–120.
NavariRM. Overview of the updated antiemetic guidelines for chemotherapy-induced nausea and vomiting. Community Oncology2007;4(Suppl 1):3–11.
GrunbergSMBoutinNIrelandA. Impact of nausea/vomiting on quality of life as a visual analogue scale-derived utility score. Support Care Cancer1996;4:435–439.
SunCCBodurkaDCDonatoML. Patient preferences regarding side effects of chemotherapy for ovarian cancer: do they change over time?Gynecol Oncol2002;87:118–128.
GrunbergSMWarrDGrallaRJ. Evaluation of new antiemetic agents and definition of antineoplastic agent emetogenicity—state of the art. Support Care Cancer2011;19(Suppl 1):S43–47.
PassikSDKirshKLDonaghyK. Patient-related barriers to fatigue communication: initial validation of the fatigue management barriers questionnaire. J Pain Symptom Manage2002;24:481–493.
BurkeTWisniewskiTErnstF. Resource utilization and costs associated with chemotherapy-induced nausea and vomiting (CINV) following highly or moderately emetogenic chemotherapy administered in the US outpatient hospital setting. Support Care Cancer2011;19:131–140.
Tina ShihYCXuYEltingLS. Costs of uncontrolled chemotherapy-induced nausea and vomiting among working-age cancer patients receiving highly or moderately emetogenic chemotherapy. Cancer2007;110:678–685.
SchragDHangerM. Medical oncologists’ views on communicating with patients about chemotherapy costs: a pilot survey. J Clin Oncol2007;25:233–237.
MolassiotisABrearleySStamatakiZ. Use of antiemetics in the management of chemotherapy-related nausea and vomiting in current UK practice. Support Care Cancer2011;19:949–956.
KrisMGHeskethPJSomerfieldMR. American Society of Clinical Oncology guideline for antiemetics in oncology: update 2006. J Clin Oncol2006;24:2932–2947.
ASHP therapeutic guidelines on the pharmacologic management of nausea and vomiting in adult and pediatric patients receiving chemotherapy or radiation therapy or undergoing surgery. Am J Health Syst Pharm1999;56:729–764.
MertensWCHigbyDJBrownD. Improving the care of patients with regard to chemotherapy-induced nausea and emesis: the effect of feedback to clinicians on adherence to antiemetic prescribing guidelines. J Clin Oncol2003;21:1373–1378.
DavisKYountSDel CielloK. An innovative symptom monitoring tool for people with advanced lung cancer: a pilot demonstration. J Support Oncol2007;5:381–387.