Incidence of nausea and vomiting in breast cancer patients treated with anthracycline plus cyclophosphamide-based chemotherapy regimens in Italy: NAVY observational study

Palonosetron in pediatric patients: A single-center, retrospective evaluation of policy and clinical practice guideline discordance

INTRODUCTION

Clinical practice guidelines (CPGs) recommending palonosetron for the prevention and management of chemotherapy-induced nausea and vomiting (CINV) were adapted for use at our institution. Palonosetron was restricted for use in patients experiencing breakthrough CINV and receiving highly emetogenic chemotherapy (HEC) or undergoing stem cell transplant conditioning and in patients with refractory CINV receiving HEC. Given the significant cost of palonosetron, we aimed to determine the proportion of chemotherapy blocks where palonosetron use was discordant with the institutional policy or source CPG.

METHODS

A retrospective review of the health records of patients who received palonosetron between 1 July 2019 and 30 June 2020 was undertaken. Details of palonosetron use, antiemetic regimen and the date and time of each vomit during the acute and delayed phases were collected for each chemotherapy block where palonosetron was given. Discordance with the institutional policy and the source CPG was determined by assessing the indication for palonosetron and the dose. In the subset of chemotherapy blocks where information regarding vomiting episodes was available, the extent of acute phase chemotherapy-induced vomiting (CIV) control was reported.

RESULTS

Four hundred thirty-eight chemotherapy blocks, representing 122 patients (mean age 9 years), receiving 595 palonosetron doses were included. Palonosetron use was discordant with institutional policy during most (72%; 314/438) of the chemotherapy blocks analyzed. However, palonosetron use was concordant with the source CPG during most chemotherapy blocks (74%; 326/438). Complete CIV control during the acute phase was observed in 66% (195/295) of chemotherapy blocks where palonosetron was given, irrespective of concomitant antiemetics administered.

CONCLUSION

The majority of palonosetron use at our institution was discordant with institutional policy, but concordant with the source CPG. Our institutional policy has since been updated to be more aligned with the source CPG.

Dietary strategies for chemotherapy-induced nausea and vomiting: A systematic review

BACKGROUND & AIMS

Chemotherapy-induced nausea and vomiting (CINV) is one of the most distressing cancer treatment side effects, affecting 20-70% of patients despite routine antiemetic prescription. Although dietary modifications are routinely recommended in clinical practice, there is lack of data synthesis to determine which dietary strategies for managing CINV are supported by quality evidence. This systematic review was conducted to examine the effect of dietary strategies on incidence and severity of CINV in adults compared with no intervention, usual care, or alternative strategies.

METHODS

Five electronic databases were searched from inception to 15th July 2021 for original research studies of interventional or observational design assessing dietary strategies for CINV. The quality of evidence was appraised, data were synthesized narratively, and Grading of Recommendations, Assessment, Development and Evaluations (GRADE) assessment of the certainty of the evidence was applied.

RESULTS

Twenty-one studies were included, 10 (48%) interventional studies and 11 (52%) observational studies. Most interventional and observational studies had a high or neutral risk of bias (70% and 72%, respectively). Of the interventions studied, strongest evidence with highest certainty was found for the very large positive effect of CINV-specific education and support with a personalized meal plan from a dietician, implemented in person or in writing, for reducing the severity of nausea and overall CINV (effect size: very large; GRADE: high). A statistically significant very large positive effect of ginger tea consumption was also found on overall CINV severity; however, certainty in this effect was very low. Although confidence in the findings from observational studies was very low to low, a statistically significant positive association was also found between a moderate intake of alcohol and incidence of nausea, vomiting, or overall CINV as well as nausea severity; the Mediterranean diet and nausea incidence and severity; and adequate intake of energy, protein, fat, or carbohydrate and nausea or vomiting incidence.

CONCLUSION

Improved CINV was associated with CINV-specific nutrition education and support from health professionals. Non-restrictive dietary patterns that include adequate energy and macronutrient intakes, particularly protein, and include ginger, and Mediterranean diet concepts may benefit CINV; however, the confidence in the body of evidence to inform these conclusions is mostly very low to moderate. Future rigorous trials with adequate sample sizes, clearly defined dietary strategies, and valid outcome measures are warranted prior to dietary strategies being routinely prescribed alongside antiemetic regimens.

Effect of Abdominal Massage with and without Salvia officinalis on Nausea and Vomiting in Patients with Cancer Undergoing Chemotherapy: A Randomized Clinical Trial

Objective

The aim of this study was to determine the effect of abdominal massage with and without Salvia officinalis on nausea and vomiting in patients with cancer undergoing chemotherapy.

Methods

In this randomized clinical trial, 60 patients undergoing chemotherapy were placed in one of two intervention groups or in a control group. Abdominal massage with and without Salvia officinalis was performed for 15 minutes twice a day for 3 consecutive days by the patient's companion. The rate of nausea and vomiting was measured with a Visual Analog Scale.

Results

Findings showed that immediately after the intervention, the mean score of nausea in abdominal massage with Salvia officinalis group was lower than that of the control group. The mean score of nausea was not different between abdominal massage and control groups. One week after the intervention, the mean score of nausea was not different among the three groups. In addition, the frequency of vomiting was not different among the three groups.

Conclusion

Abdominal massage with/without Salvia officinalis as a complementary medicine has not considerable effect on reducing nausea and vomiting in patient with cancer undergoing chemotherapy. More studies are needed to achieve better and more accurate results.

Chinese Medicine Syndromes and Stages of Early Breast Cancer: Hierarchical Cluster Analysis and Implication for Clinical Practice

Background: Chinese medicine (CM) has been widely used for women's health, including those with early breast cancer. Contemporary literature varies in descriptions of the CM syndromes that are critical for determining CM treatment options for breast cancer patients. However, the corresponding syndromes have not been standardized to align with the conventional medicine treatment stages. This review aimed to address this knowledge gap to enhance the quality and consistency of CM interventions for early breast cancer patients. Methods: In total, eight Chinese and English language databases were searched, and textbooks and clinical care documents were gathered. Sources were classified according to five treatment stages: preoperative, postoperative, chemotherapy, radiation therapy, and endocrine therapy. Descriptive statistics were used to examine the syndromes, and hierarchical cluster analysis was conducted to investigate clusters of signs and symptoms. Results: The CM syndrome of dual deficiency of qi and Blood was one of the most common syndromes across all treatment stages, whereas lack of strength and lassitude were the most common clinical presentations throughout all stages, except the preoperative stage. Cluster analyses identify three or four syndromes in each treatment stage. Cluster results for the preoperative stage were: Blood stasis, Liver depression and qi stagnation, and Kidney yin deficiency. Dual deficiency of qi and Blood existed at different stages except for the preoperative stage. In the postoperative stage and chemotherapy stages, some symptoms were categorized into clusters that related to the Spleen and Stomach. Syndromes such as yin deficiency with fire toxin and yin deficiency with fluid depletion were unique to the radiation therapy stage. Clusters for endocrine therapy stage included the dual deficiency of Spleen and Kidney, Liver depression and qi stagnation, and Kidney yin deficiency. Conclusions: Systematic review of the contemporary literature for early breast cancer revealed that the most frequently seen CM syndromes and cluster results have some similarities but some important distinctions. Clinical data are needed to confirm whether the syndromes described in contemporary literature reflect those seen in women with early breast cancer.

Management of Chemotherapy-Induced Nausea and Vomiting (CINV): A Short Review on the Role of Netupitant-Palonosetron (NEPA)

Introduction

Antineoplastic drugs may induce several side effects, including chemotherapy-induced nausea and vomiting (CINV). Two neurotransmitters play a central role in mediating the emetic response: serotonin acting on the 5HT3 receptor and the substance P targeting the NK1 receptor. Indeed, a combination of a 5HT3 receptor antagonist (5HT3-RA) and a NK1 receptor antagonist (NK1-RA) together with dexamethasone has been shown to be very effective. In fact, this combination is actually widely used and recommended for CINV prophylaxis for highly emetogenic cisplatin-based adriamycin/cyclophosphamide (AC) and carboplatin-based regimens. NEPA (netupitant/palonosetron) is the only fixed combination antiemetic available and it is composed by the long-lasting second-generation 5HT3-RA palonosetron and the highly selective NK1-RA netupitant.

Aim

The aims of this short review were to analyze the role of NEPA in CINV prophylaxis and management taking in account the risk factors related to the patient and to the antineoplastic treatment.

Evidence Review

CINV development is not only correlated to the emetogenic potential of the antineoplastic drugs but is also very influenced by the patient characteristics and history, such as gender, age, alcohol intake, nausea during pregnancy and motion sickness. In pivotal and post-registration studies, NEPA has demonstrated to be effective and safe in both highly and moderately emetogenic chemotherapy.

Conclusion

A proper assessment of both chemotherapy- and patient-related risk factors is paramount to properly evaluate an appropriate prophylaxis of CINV and NEPA by simplifying the therapy, guarantees fully adherence to antiemetic guidelines, and consequently improves the control of CINV, especially in high risk patients.

Netupitant/palonosetron (NEPA) and dexamethasone for prevention of emesis in breast cancer patients receiving adjuvant anthracycline plus cyclophosphamide: a multi-cycle, phase II study

Background

NEPA is an oral fixed-dose combination of netupitant, a new highly selective neurokinin-1 receptor antagonist, and palonosetron. This study was conducted to evaluate whether the efficacy of NEPA against chemotherapy-induced nausea and vomiting (CINV) in cycle 1 would be maintained over subsequent chemotherapy cycles in breast cancer patients receiving adjuvant anthracycline plus cyclophosphamide (AC). The study also describes the relationship between efficacy on day 1 through 5 (overall period) and control of CINV on day 6 through 21 (very late period) in each cycle.

Methods

In this multicentre, phase II study, patients received both NEPA and dexamethasone (12 mg intravenously) just before chemotherapy. The primary efficacy endpoint was overall complete response (CR; no emesis and no rescue medication use) in cycle 1. Sustained efficacy was evaluated during the subsequent cycles by calculating the rate of CR in cycles 2–4 and by assessing the probability of sustained CR over multiple cycles. The impact of both overall CR and risk factors for CINV on the control of very late events (vomiting and moderate-to-severe nausea) were also examined.

Results

Of the 149 patients enrolled in the study, 139 were evaluable for a total of 552 cycles; 97.8% completed all 4 cycles. The proportion of patients with an overall CR was 70.5% (90% CI, 64.1 to 76.9) in cycle 1, and this was maintained in subsequent cycles. The cumulative percentage of patients with a sustained CR over 4 cycles was 53%. NEPA was well tolerated across cycles. In each cycle, patients with CR experienced a significantly better control of very late CINV events than those who experienced no CR. Among the patients with CR, the only predictor for increased likelihood of developing very late CINV was pre-chemotherapy (anticipatory) nausea (adjusted odds ratio = 0.65–0.50 for no CINV events on cycles 3 and 4).

Conclusion

The high anti-emetic efficacy seen with the NEPA regimen in the first cycle was maintained over multiple cycles of adjuvant AC for breast cancer. Preliminary evidence also suggests that patients achieving a CR during the overall period gain high protection even against very late CINV events in each chemotherapy cycle.

Trial registration

This trial was retrospectively registered at Clinicaltrials.gov identifier (NCT03862144) on 05/Mar/2019.

Weight Gain during Systemic Oncologic Therapy for Breast Cancer: Changes in Food Intake and Physical Activity

Introduction: Weight gain frequently occurs during treatment for breast cancer. Objective: To evaluate changes in dietary intake and physical activity in the weight evolution of women on systemic oncologic treatment for breast cancer. Method: The prospective and comparative study included 89 women submitted to systemic oncologic treatment for breast cancer, grouped according to the occurrence of weight gain in relation to body weight documented before beginning treatment. Patients were classified as 1) Group with weight gain (those with an increase in body weight greater than or equal to 2% over pre-treatment weight); 2) Group without weight gain (those who maintained or lost weight during treatment). We calculated body mass index (BMI) of patients and analyzed their body composition by bioelectrical impedance (BIA). Changes in food intake, gastrointestinal symptoms, and physical activity level, as well as reductions in muscle and fat mass, were documented. Results: Tumor staging (p=0.24), use of antineoplastic drugs (p=0.23) and intention of treatment (p=0.61) were no different between the weight gain group (n=36) and no weight gain group (n=53). No difference was found in anthropometric and BIA data between the groups during oncologic treatment. Frequency of gastrointestinal symptoms was not different between the groups. However, increased food intake and bed rest, and a decrease in physical activity level were more frequent among women who gained weight during therapy. Conclusions: Weight gain in women undergoing systemic oncologic therapy for breast cancer may be, at least in part, caused by higher energy intake and lower physical activity.

Hydration requirements in patients receiving highly emetogenic chemotherapy

AIM

Chemotherapy-induced nausea and vomiting diminishes quality of life and increases healthcare resource use. This retrospective medical records analysis evaluated hydration requirements with emetogenic chemotherapy.

PATIENTS & METHODS

Cancer patients received moderately emetogenic chemotherapy (MEC) or highly emetogenic chemotherapy (HEC), and antiemetics palonosetron or granisetron extended-release subcutaneous (GERSC), neurokinin 1 receptor antagonist and dexamethasone. Unscheduled hydration event rates were determined.

RESULTS

For 186 patients (92 palonosetron, 94 GERSC) overall, mean hydration rate was significantly higher with palonosetron (0.6 vs 0.2; p = 0.0005). Proportion of patients with ≥1 hydration event was significantly higher with palonosetron overall (54 vs 33%; p = 0.0033) and in cycles 2-4 and the HEC subgroup.

CONCLUSION

GERSC within a three-drug antiemetic regimen may reduce unscheduled hydration requirements with MEC or HEC.

Evolving role of neurokinin 1-receptor antagonists for chemotherapy-induced nausea and vomiting

To examine pharmacologic and clinical characteristics of neurokinin 1 (NK₁)-receptor antagonists (RAs) for preventing chemotherapy-induced nausea and vomiting (CINV) following highly or moderately emetogenic chemotherapy, a literature search was performed for clinical studies in patients at risk of CINV with any approved NK₁ RAs in the title or abstract: aprepitant (capsules or oral suspension), HTX019 (intravenous [IV] aprepitant), fosaprepitant (IV aprepitant prodrug), rolapitant (tablets or IV), and fixed-dose tablets combining netupitant or fosnetupi-tant (IV netupitant prodrug) with the 5-hydroxytryptamine type 3 (5HT₃) RA palonosetron (oral or IV). All NK₁ RAs are effective, but exhibit important differences in efficacy against acute and delayed CINV. The magnitude of benefit of NK₁-RA-containing three-drug vs two-drug regimens is greater for delayed vs acute CINV. Oral rolapitant has the longest half-life of available NK₁ RAs, but as a consequence should not be administered more frequently than every 2 weeks. In general, NK₁ RAs are well tolerated; however, IV rolapitant was recently removed from US distribution, due to hypersensitivity and anaphylaxis, and IV fosaprepitant is associated with infusion-site reactions and hypersensitivity presumed related to its polysorbate 80 excipient. Also, available NK₁ RAs have potential drug–drug interactions. Adding an NK₁ RA to 5HT₃ RA and dexamethasone significantly improves CINV control vs the two-drug regimen. Newer NK₁ RAs offer more formulation options, higher acute-phase plasma levels, or improved tolerability, and increase clinicians’ opportunities to maximize benefits of this important class of antiemetics.