Controlling chemotherapy-induced nausea requires further improvement: symptom experience and risk factors among Korean patients

The longitudinal effects of chronotype on chemotherapy-induced nausea and vomiting in patients with breast cancer receiving neoadjuvant chemotherapy

OBJECTIVE

The object of this longitudinal cohort study was to investigate whether chronotype affects the incidence of chemotherapy-induced nausea and vomiting (CINV) among patients with breast cancer.

METHODS

The study included a total of 203 breast cancer patients who received neoadjuvant chemotherapy using a regimen of doxorubicin and cyclophosphamide with high emetogenicity. Patients received four cycles of chemotherapy in approximately three months. Patients completed questionnaires including the Munich Chronotype Questionnaire (MCTQ) before the first chemotherapy and the Multinational Association of Supportive Care in Cancer Antiemesis Tool (MAT) after each of the four chemotherapy sessions. To confirm the effect of chronotype on CINV during the four cycles, we performed statistical analyses using a generalized estimating equation (GEE).

RESULTS

CINV occurred in 108 (53.2%), 112 (55.2%), 102 (50.3%), and 62 (30.5%) patients during four cycles of treatment. In the GEE approach, late and early chronotypes (vs. intermediate chronotype) were associated with an increased risk of CINV (late chronotype: odds ratio [OR], 2.06; 95% confidence interval [CI], 1.41-2.99; p < 0.001, early chronotype: OR, 1.84; CI, 1.25-2.73; p = 0.002), which remained significant even after adjusting for age, BMI, antiemetic treatment, history of nausea and vomiting, anxiety, and sleep quality.

CONCLUSION

Chronotype affected CINV across the four cycles of neoadjuvant chemotherapy in patients with breast cancer, suggesting the need to consider chronotype in predicting and managing CINV.

Effects of auricular acupressure on chemotherapy-induced nausea and vomiting in breast cancer patients: a preliminary randomized controlled trial

BACKGROUND

Auricular acupressure (AA) has been viewed as a promising approach to managing chemotherapy-induced nausea and vomiting (CINV) but relevant research evidence has been inconclusive. This study aimed to examine the effects of AA on CINV in breast cancer (BC) patients undergoing chemotherapy.

METHODS

A preliminary randomized controlled trial was conducted in 114 BC patients. Participants were randomly allocated to a true AA group (n = 38), a sham AA group (n = 38), and a standard care group (n = 38). All the participants were provided with standard antiemetic treatment and care, while the true AA group and the sham AA group received an additional 5-day true AA and a 5-day sham AA, respectively. Acute and delayed CINV were assessed by using the MASCC Antiemesis Tool (MAT), anticipatory nausea and vomiting were measured by the Index of Nausea, Vomiting, and Retching (INVR), and patients' quality of life (QoL) was evaluated by the Functional Assessment of Cancer Therapy-Breast (FACT-B).

RESULTS

Both the true and sham AA groups reported improved CINV outcomes than the standard care group, with the true AA demonstrating larger effects than the sham comparison. The true and sham AA groups had higher complete response (CR) rates of CINV when compared with the standard care group, with the difference in the CR of acute CINV achieving statistical significance (p = 0.03). Both the true and sham AA groups demonstrated lower incidence and severity of acute CINV compared with the standard care group with the among-group difference reaching statistical significance for the occurrence (p = 0.04) and severity (p = 0.001) of acute nausea. No significant differences in anticipatory CINV and QoL were found among the groups.

CONCLUSION

The use of AA plus standard antiemetic treatment and care was superior to the use of standard antiemetic treatment and care alone in managing CINV among BC patients receiving chemotherapy. The antiemetic effects of AA were identified to be more profound in improving acute CINV, particularly acute nausea. The antiemetic effects of AA were deemed to be a mixture of specific treatment effects and placebo effects, and the placebo effects were very large and even reached clinical significance.

TRIAL REGISTRATION

ClinicalTrials.gov; NCT02403037 ; Registered March 31, 2015.

Prevention of Chemotherapy-Induced Nausea and Vomiting in the Older Patient: Optimizing Outcomes

Chemotherapy-induced nausea and vomiting (CINV) are still two of the most feared side effects of cancer therapy. Although major progress in the prophylaxis of CINV has been made during the past 40 years, nausea in particular remains a significant problem. Older patients have a lower risk of CINV than younger patients, but are at a higher risk of severe consequences of dehydration and electrolyte disturbances following emesis. Age-related organ deficiencies, comorbidities, polypharmacy, risk of drug–drug interactions, and lack of compliance all need to be addressed in the older patient with cancer at risk of CINV. Guidelines provide evidence-based recommendations for the prophylaxis of CINV, but none of these guidelines offer specific recommendations for older patients with cancer. This means that the recommendations may lead to overtreatment in some older patients. This review describes the development of antiemetic prophylaxis of CINV focusing on older patients, summarizes recommendations from antiemetic guidelines, describes deficiencies in our knowledge of older patients, summarizes necessary precautions, and suggests some future perspectives for antiemetic research in older patients.

Risk factors associated with antineoplastic chemotherapy-induced nausea and vomiting

OBJECTIVE

To estimate the incidence and to evaluate risk factors for antineoplastic nausea and vomiting with high and moderate emetogenic chemotherapy in adult patients in the first treatment cycle.

METHODS

Prospective cohort study with follow-up of 269 adults during the first cycle of antineoplastic chemotherapy. The incidence of nausea and vomiting was evaluated in the acute phase (0-24 hours), in the late phase (24 hours-5th day) and in the total phase (0-5th day).

RESULTS

In total, 152 patients underwent high emetogenic chemotherapy and 117 moderate emetogenic chemotherapy. The relative frequency of nausea was higher when compared with vomiting in the acute phase (p < 0.001) and in the late phase (p < 0.001). The risk factors identified were: age group ≤ 49 years (odds ratio = 0.47; 95%CI 0.23-0.95) and 50-64 years (odds ratio = 0.45; 95%CI 0.23-0.87), tobacco use (odds ratio = 0.35; 95%CI 0.14-0.88), and high emetogenic chemotherapy (odds ratio 0.55; 95%CI 0.31-0.95).

CONCLUSION

The incidence of nausea was higher than that of vomiting, and adverse effects were more frequent in the late phase. The results suggest the risk factors for chemotherapy-induced nausea and vomiting are tobacco, age (young adults), and high emetogenic chemotherapy.

Patient-Related Risk Factors for Chemotherapy-Induced Nausea and Vomiting: A Systematic Review

Background

Studies have reported that patient-related factors significantly impact the risk of Chemotherapy-Induced Nausea and Vomiting (CINV). The objective of this study was to analyze those risk factors of CINV through a systematic literature review.

Methods

We searched MEDLINE to identify articles that addressed patient-related risk factors of CINV through clinical studies.

Results

A total of 49 articles were selected for this study. A total of 28 patient-related risk-factors that significantly impact the risk of CINV were documented. Three factors are demographically related, 17 factors are intrinsic in nature and innate to patient's physiology or influenced by physiology, and eight factors are extrinsic in nature. At least five studies identified seven risk factors with notable summary odds ratio: history of nausea/vomiting (odds ratio: 3.13, 95% CI 2.40–4.07, p < 0.05), female sex (odds ratio: 2.79, 95% CI 2.26–3.44, p < 0.05), expectancy of CINV (odds ratio: 2.61, 95%CI 1.69–4.02, p < 0.05), younger age (odds ratio: 2.59, 95% CI 2.18–3.07, p < 0.05), anxiety (odds ratio: 2.57, 95% CI 1.94–3.40, p < 0.05), history of morning sickness (odds ratio: 1.97, 95% CI 1.46–2.65, p < 0.05), and low alcohol intake (odds ratio: 1.94, 95% CI 1.68–2.24, p < 0.05).

Conclusions

Oncologists can use these factors prior to the initiation of a chemotherapy regimen to identify patients at risk for CINV, in order to focus on more comprehensive antiemetic treatment options for those high-risk patients. This may enable better outcomes and avoid complications.

Individual Factors Contributing to Nausea in First-Time Chemotherapy Patients: A Prospective Cohort Study

Objective

The expectation of developing side effects can enhance the likelihood to develop them – a phenomenon referred to as nocebo effect. Whether nocebo effects can be reduced by lowering negative expectancies, is not clear. The aim of this prospective study was to learn more about the factors contributing to nausea expectancy and their potential role in actual occurrence of nausea in patients undergoing chemotherapy for the first time in their life.

Methods

Patients scheduled for moderately emetogenic chemotherapeutic regimens filled in questionnaires to assess state anxiety and quality of life and to rate the expectancy of nausea as a side effect of chemotherapy. Patient diaries were used to monitor the severity of post-chemotherapy nausea in the 4 days following chemotherapy administration. Bivariate analyses complemented by multiple regression analyses were performed to identify the relationship between nausea expectation and nausea occurrence.

Results

121 female patients (mean age 53 years) with completed questionnaires were included in the analyses. The majority of the patients had a diagnosis of breast cancer (86%). The two main sources for nausea expectancy were positive history of nausea in other situations and state anxiety. Patients with high expectancy levels (first quartile) experienced greater nausea than those with lower expectancy levels. Bivariate analyses revealed a weak but non-significant association between nausea expectation and post-chemotherapy nausea. When controlling for age, type of cancer, history of nausea, state and trait anxiety, and global quality of life, positive history of nausea (OR = 2.592; 95% CI, 1.0 to 6.67; p < 0.05), younger age (OR = 0.95; 95% CI, 0.92 to 0.99; p < 0.05), and a lower quality of life (OR = 0.97; 95% CI, 0.94 to 1.0; p < 0.05), but not nausea expectancy (OR = 1.014; 95% CI, 0.51 to 2.02; p = 0.969), predicted the occurrence of post-chemotherapy nausea.

Conclusion

In this female cohort, younger patients with lower initial quality of life and a positive history of nausea were at higher risk to develop nausea after first time chemotherapy. These patients may benefit from psychological co-interventions that aim to enhance quality of life.

Efficacy of Thalidomide in Preventing Delayed Nausea and Vomiting Induced by Highly Emetogenic Chemotherapy: A Randomized, Multicenter, Double-Blind, Placebo-Controlled Phase III Trial (CLOG1302 study)

Purpose

We examined the efficacy and safety of thalidomide (THD) for the prevention of delayed nausea and vomiting in patients who received highly emetogenic chemotherapy (HEC).

Patients and Methods

In a randomized, double-blind, active-controlled, phase III trial, chemotherapy-naive patients with cancer who were scheduled to receive HEC that contained cisplatin or cyclophosphamide-doxorubicin/epirubincin ≥ 50 mg/m2 regimens were randomly assigned to a THD group (100 mg twice daily on days 1 to 5) or placebo group, both with palonosetron (0.25 mg on day 1) and dexamethasone (12 mg on day 1; 8 mg on days 2 to 4). Primary end point was complete response to vomiting—no emesis or use of rescue medication—in the delayed phase (25 to 120 h). Nausea and anorexia on days 1 to 5 were evaluated by the 4-point Likert scale (0, no symptoms; 3, severe). Quality of life was assessed by the European Organization for Research and Treatment of Cancer QLQ-C30 version 3 questionnaire on days −1 and 6.

Results

Of 656 patients, 638 were evaluable: 317 in the THD group and 321 in the control group. Compared with placebo, delayed and overall (0 to 120 h) complete response rates to vomiting were significantly higher with THD: 76.9% versus 61.7% ( P < .001) and 66.1% versus 53.3% ( P = .001), respectively. Rates of no nausea were also higher in the THD group (delayed: 47.3% v 33.3%; P < .001; overall: 41% v 29.6%; P = .003), and mean scores of anorexia were lower overall (0.44 ± 0.717 v 0.64 ± 0.844; P = .003). Adverse effects were mild to moderate. The THD group had increased sedation, dizziness, constipation, and dry mouth, but experienced better quality of life after chemotherapy.

Conclusion

Thalidomide combined with palonosetron and dexamethasone significantly improved HEC-induced delayed nausea and vomiting prevention in chemotherapy-naive patients.

The Benefit of Pro Re Nata Antiemetics Provided With Guideline-Consistent Antiemetics in Delayed Nausea Control

BACKGROUND

Delayed nausea after chemotherapy remains a symptom of interest. Clinicians often provide additional and/or pro re nata (p.r.n.) antiemetics with guideline-consistent antiemetics in an attempt to achieve further symptom control. Whether the usage of additional and/or p.r.n. antiemetics provide added benefit remains as a question.

OBJECTIVE

The purpose of this study was to determine the benefit of providing additional antiemetics and/or p.r.n. antiemetics with guideline-consistent antiemetics in the control of nausea, functioning, and quality of life (QOL).

METHODS

A secondary data analysis of 143 breast cancer patients who received guideline-consistent antiemetics for anthracycline and cyclophosphamide chemotherapy was conducted. Instruments included vomiting frequency and nausea intensity items of the Multinational Association of Supportive Care in Cancer Antiemesis Tool and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30.

RESULTS

Providing p.r.n. antiemetics alleviated the incidence of significant nausea (intensity, ≥3) in the delayed phase. The experience of nausea contributed to symptom incidence in the next phase and cycle. The intensity of delayed nausea demonstrated a moderate negative correlation with physical and role functioning and global health/QOL.

CONCLUSION

Providing patients with strategies to further control nausea (p.r.n. antiemetics) in addition to guideline-consistent antiemetics is recommended for practice. Because the nausea experience contributes to symptom incidence in the next phase and cycle and because the nausea intensity demonstrated a significant relationship with function and global health/QOL, proactive supportive approaches are strongly recommended.

IMPLICATIONS FOR PRACTICE

Delayed nausea control may be improved by adhering to guideline-consistent antiemetics and using p.r.n. antiemetics. Delayed nausea control would contribute to patients' functioning and QOL.

An Analysis of Behavioral and Genetic Risk Factors for Chemotherapy-Induced Nausea and Vomiting in Japanese Subjects

There are individual differences in the frequency of chemotherapy-induced nausea and vomiting (CINV) in cancer patients. We investigated the individual variability in susceptibility to CINV with focus on both behavioral factors and genetic factors in Japanese cancer patients. We performed a prospective study to investigate the association between patient attributes (backgrounds and habits as well as gene polymorphisms) and anorexia, nausea, or vomiting in 55 Japanese cancer patients undergoing chemotherapy at Nagoya University Hospital. We found that gender (female), use of non-steroidal anti-inflammatory drugs, susceptibility to motion sickness, and anxiety were associated with the frequency of CINV. Gene polymorphisms of rs1076560 (dopamine D₂ receptor gene), rs6766410 (serotonin 5-HT_3C receptor gene) and rs4680 (catechol-O-methyltransferase gene) were also associated. Our data suggest that these attributes may thus be risk factors for CINV. Our results provide novel information that can be used to predict the incidence of CINV in Japanese patients undergoing chemotherapy; this can help provide a substantial improvement in supportive care for patients with different types of cancer.

Gaps exist between patients' experience and clinicians' awareness of symptoms after chemotherapy: CINV and accompanying symptoms

INTRODUCTION

Correlating patients' chemotherapy-induced nausea and vomiting (CINV) experience with clinicians' understanding of the symptom severity and the patients' and clinicians' symptom management goals would aid in advancing symptom management. Identifying rankings of symptom severity after chemotherapy would help prioritizing symptom management.

OBJECTIVE

The purpose of this study was to investigate and compare patients' CINV experience and clinicians' awareness of symptoms and symptom management goals. The study also aimed to identify and compare rankings of the severity of symptoms after chemotherapy by patients and clinicians.

METHODS

A prospective observational study was conducted. Cancer patients starting the first adjuvant highly emetogenic chemotherapy (HEC) or moderately emetogenic chemotherapy (MEC) (n = 313), and oncology clinicians at two university hospitals (n = 73) in Korea participated in the study. The Multinational Association of Supportive Care in Cancer Antiemesis Tool (MAT) items and 20-symptom list were used to generate a symptom diary and survey questions. Descriptive statistics with a 95 % confidence interval and the Mann-Whitney U test were used to analyze the data.

RESULTS

In general, clinicians overestimated the patients' CINV experience. Patients' symptom experiences and clinicians' estimates only corresponded for delayed nausea after the second cycle MEC. For symptom management goals, patients aimed for absolute vomiting control and avoiding significant nausea. Patients' symptom management goals exceeded the clinicians' goals for CINV control except for the goal for delayed nausea control. Clinicians rated chemotherapy-induced nausea as the most problematic symptom followed by vomiting; however, fatigue and loss of appetite were the top rated symptoms by patients.

CONCLUSIONS

Gaps exist between patients' symptom experience and clinicians' symptom awareness. Clinicians overestimated the patients' CINV experience and set less stringent symptom control goals. Enhancing clinicians' understanding of patients' symptom experience and retargeting the CINV management goals are the next steps for advancing symptom management. Symptoms other than CINV require more attention to set symptom management priorities reflecting patient experience and clinical significance.