Nausea and Vomiting in Advanced Cancer

Symptoms, Symptom Profiles, and Healthcare Utilization in Patients with Hematologic Malignancies: A Retrospective Observational Cohort Study and Latent Class Analysis

Symptom burden is known to be high in patients with hematologic malignancies and can adversely impact patients' quality of life. The aims of this retrospective observational cohort study were to explore symptoms in patients with hematologic malignancies, including during the last year of life, to explore symptom profiles in patients with hematologic malignancies, and to explore associations among symptoms/symptom profiles and demographic, clinical, and treatment-related variables. Symptom prevalence and severity and symptom profiles were explored in patients with hematologic malignancies who completed patient-reported outcome measures (n = 6136) between October 2019 and April 2020. Emergency department visits and hospital admissions during the study period were reviewed. Chart audits were undertaken for patients who died within a year of completing patient-reported outcome measures (n = 432) to explore symptoms and healthcare utilization in the last year of life. Patients with hematologic malignancies in this study reported multiple symptoms co-occurring, with more than 50% of patients reporting four or more symptoms. Classes of co-occurring symptoms (symptom profiles) were associated with demographic and clinical factors as well as with healthcare utilization, particularly emergency department visits. The most reported symptoms were tiredness, impaired well-being, and drowsiness. The findings emphasize the need for more supports for patients with hematologic malignancies, particularly for symptom management.

Symptom clusters and impact on quality of life in lung cancer patients undergoing chemotherapy

PURPOSE

To identify symptom clusters (SCs) in lung cancer patients undergoing chemotherapy and explore their impact on health-related quality of life (HRQoL).

METHODS

Patients were invited to complete the Chinese version of the M.D. Anderson Symptom Inventory with the Lung Cancer Module and the Quality of Life Questionnaire-core 30. Network analysis was employed to identify SCs. The associations between SCs and each function of HRQoL were examined using the Pearson correlation matrix. Multiple linear regression was applied to analyze the influencing factors of each function of HRQoL.

RESULTS

A total of 623 lung cancer patients who were receiving chemotherapy were recruited. The global health status of lung cancer patients was 59.71 ± 21.09, and 89.73% of patients developed symptoms. Three SCs (Somato-psychological SC, Respiratory SC, and Gastrointestinal SC) were identified, and Somato-psychological SC and Gastrointestinal SC were identified as influencing factors for HRQoL in lung cancer patients.

CONCLUSION

Most lung cancer patients who undergo chemotherapy experience a range of symptoms, which can be categorized into three SCs. The Somato-psychological SC and Gastrointestinal SC negatively impacted patients' HRQoL. Health care providers should prioritize monitoring these SCs to identify high-risk patients early and implement targeted preventive and intervention measures for each SC, aiming to alleviate symptom burden and enhance HRQoL.

Gene polymorphisms of TACR1 serve as the potential pharmacogenetic predictors of response to the neurokinin-1 receptor antagonist-based antiemetic regimens: a candidate-gene association study in breast cancer patients

PURPOSE

The current candidate gene association study aims to investigate tag SNPs from the TACR1 gene as pharmacogenetic predictors of response to the antiemetic guidelines-recommended, NK-1 receptor antagonist-based, triple antiemetic regimens.

METHODS

A set of eighteen tag SNPs of TACR1 were genotyped in breast cancer patients receiving anthracycline and cyclophosphamide (with/without docetaxel) applying real-time PCR-HRMA. Data analysis for 121 ultimately enrolled patients was initiated by defining haplotype blocks using PHASE v.2.1. The association of each tag SNP and haplotype alleles with failure to achieve the defined antiemetic regimen efficacy endpoints was tested using PLINK (v.1.9 and v.1.07, respectively) based on the logistic regression, adjusting for the previously known chemotherapy-induced nausea and vomiting (CINV) prognostic factors. All reported p-values were corrected using the permutation test (n = 100,000).

RESULTS

Four variants of rs881, rs17010730, rs727156, and rs3755462, as well as haplotypes containing the mentioned variants, were significantly associated with failure to achieve at least one of the defined efficacy endpoints. Variant annotation via in-silico studies revealed that the non-seed sequence variant, rs881, is located in the miRNA (hsa-miR-613) binding site. The other three variants or a variant in complete linkage disequilibrium with them overlap a region of high H3K9ac-promoter-like signature or regions of high enhancer-like signature in the brain or gastrointestinal tissue.

CONCLUSION

Playing an essential role in regulating TACR1 expression, gene polymorphisms of TACR1 serve as the potential pharmacogenetic predictors of response to the NK-1 receptor antagonist-based, triple antiemetic regimens. If clinically approved, modifying the NK-1 receptor antagonist dose leads to better management of CINV in risk-allele carriers.

Bibliometric and visual analysis of chemotherapy-induced nausea and vomiting (2004-2023)

Background

Patients undergoing chemotherapy often encounter troubling and common side effects, notably Chemotherapy-induced nausea and vomiting (CINV). This side effect not only impairs the patient's quality of life but could also result in the interruption or discontinuation of the chemotherapy treatment. Consequently, research into CINV has consistently remained a focal point in the realm of clinical medicine. In this research domain, bibliometric analysis has not been conducted. The purpose of this study is to deliver a thorough summary of the knowledge framework and key areas of interest in the field of Chemotherapy-induced nausea and vomiting, using bibliometric methods. This approach aims to furnish novel concepts and pathways for investigators working in this area.

Methods

Publications focusing on Chemotherapy-induced nausea and vomiting, spanning from 2004 to 2023, were identified using the Web of Science Core Collection (WoSCC) database. Tools such as VOSviewer, CiteSpace, and the R package "bibliometrix" were employed for this bibliometric analysis.

Results

This research covers 734 publications from 61 countries, with the United States and China being the primary contributors. There has been a significant rise in the volume of papers published in the most recent decade compared to the one before it, spanning over the past twenty years. However, the annual publication rate in the last ten years has not shown a significant upward trend. The University of Toronto, Merck & Co., Sun Yat-sen University, and Helsinn Healthcare SA emerged as the principal research institutions in this field. Supportive Care in Cancer stands out as the most frequently published and cited journal in this domain. These works are contributed by 3,917 authors, with Rudolph M Navari, Matti Aapro, Shimokawa Mototsugu, and Lee Schwartzberg being among those who have published the most. Paul J. Hesketh is notably the most co-cited author. The primary focus of this research field lies in exploring the mechanisms of CINV and the therapeutic strategies for managing it. Key emerging research hotspots are represented by terms such as "Chemotherapy-induced nausea and vomiting," "nausea," "vomiting," "chemotherapy," and "antiemetics."

Conclusion

This represents the inaugural bibliometric study to thoroughly outline the research trends and advancements in the field of CINV. It highlights the latest research frontiers and trending directions, offering valuable insights for scholars engaged in studying CINV.

The antiemetic actions of GIP receptor agonism

Nausea and vomiting are primitive aspects of mammalian physiology and behavior that ensure survival. Unfortunately, both are ubiquitously present side effects of drug treatments for many chronic diseases with negative consequences on pharmacotherapy tolerance, quality of life, and prognosis. One of the most critical clinical examples is the profound emesis and nausea that occur in patients undergoing chemotherapy, which continue to be among the most distressing side effects, even with the use of modern antiemetic medications. Similarly, antiobesity/diabetes medications that target the glucagon-like peptide-1 system, despite their remarkable metabolic success, also cause nausea and vomiting in a significant number of patients. These side effects hinder the ability to administer higher dosages for optimal glycemic and weight management and represent the major reasons for treatment discontinuation. Our inability to effectively control these side effects highlights the need to anatomically, molecularly, and functionally characterize novel neural substrates that drive and inhibit nausea and emesis. Here, we discuss clinical and preclinical evidence that highlights the glucose-dependent insulinotropic peptide receptor system as a novel therapeutic central target for the management of nausea and emesis.

Nutritional Management of Oncological Symptoms: A Comprehensive Review

Throughout their experience of illness and during the course of treatment, a substantial proportion of cancer patients are prone to develop nutritional and/or metabolic disturbances. Additionally, cancer patients often encounter long-term side effects from therapies, which may lead to impaired digestion, nutrient absorption or bowel motility. Therefore, the preservation and maintenance of an optimal and balanced nutritional status are pivotal to achieving a better prognosis, increasing the tolerance and adherence to cancer therapies and improving the overall quality of life. In this context, personalized nutritional programs are essential for addressing conditions predisposing to weight loss, feeding difficulties, digestion problems and intestinal irregularity, with the goal of promoting adequate nutrient absorption and minimizing the detrimental effects of treatment regimens. The focus of this research is to examine the most common clinical conditions and metabolic changes that cancer patients may experience, including stomatitis, xerostomia, diarrhea, nausea, vomiting, dysphagia, sub-occlusion, dysgeusia, dysosmia, anorexia, and cachexia. Furthermore, we present a pragmatic example of a multidisciplinary workflow that incorporates customized recipes tailored to individual clinical scenarios, all while maintaining the hedonic value of the meals.

Using Bayesian Neural Networks to Select Features and Compute Credible Intervals for Personalized Survival Prediction

An Individual Survival Distribution (ISD) models a patient's personalized survival probability at all future time points. Previously, ISD models have been shown to produce accurate and personalized survival estimates (for example, time to relapse or to death) in several clinical applications. However, off-the-shelf neural-network-based ISD models are usually opaque models due to their limited support for meaningful feature selection and uncertainty estimation, which hinders their wide clinical adoption. Here, we introduce a Bayesian-neural-network-based ISD (BNN-ISD) model that produces accurate survival estimates but also quantifies the uncertainty in model's parameter estimation, which can be used to (1) rank the importance of the input features to support feature selection and (2) compute credible intervals around ISDs for clinicians to assess the model's confidence in its prediction. Our BNN-ISD model utilized sparsity-inducing priors to learn a sparse set of weights to enable feature selection. We provide empirical evidence, on 2 synthetic and 3 real-world clinical datasets, that BNN-ISD system can effectively select meaningful features and compute trustworthy credible intervals of the survival distribution for each patient. We observed that our approach accurately recovers feature importance in the synthetic datasets and selects meaningful features for the real-world clinical data as well, while also achieving state-of-the-art survival prediction performance. We also show that these credible regions can aid in clinical decision-making by providing a gauge of the uncertainty of the estimated ISD curves.

Nutrition impact symptoms: Noteworthy prognostic indicators for lung cancer

BACKGROUND

Nutrition impact symptoms (NIS) in head and neck cancer are well-studied and are found to be heavy contributors of poor outcome. However, the prevalence and role of NIS in other cancer are less addressed. In this study, we investigated the incidence and prognostic role of NIS in patients with lung cancer.

METHODS

NIS, evaluated by patient-generated subjective global assessment (PG-SGA) in a multicenter real-world prospective study, included loss of appetite, nausea, vomiting, mouth ulcer, constipation, diarrhea, dry mouth, taste change, altered smell, dysphagia, early satiety, and pain. The endpoints were the patients' overall survival (OS) and quality of life (QoL). The COX analysis was used to investigate the relationship between NIS and OS. Interaction analysis and mediation analysis were performed to determine the modifiers and mediator.

RESULTS

3634 patients with lung cancer were enrolled in this study, of which 1533 patients had NIS. During the average follow-up of 22.65 months, 1875 deaths occurred. The OS of patients with lung cancer with NIS was lower than that of patients without NIS. NIS (HR, 1.181, 95% CI, 1.073-1.748), loss of appetite (HR, 1.266, 95% CI, 1.137-1.409), vomiting (HR, 1.282, 95% CI, 1.053-1.561), and dysphagia (HR, 1.401, 95% CI, 1.079-1.819) were independent prognostic factors in patients with lung cancer. There were interactions between chemotherapy and primary tumor on NIS . In the relationship between different types of NIS (NIS, loss of appetite, vomiting, dysphagia) and prognosis, the mediating effects of inflammation accounted for 15.76%, 16.49%, 26.32%, and 18.13%, respectively. Meanwhile, these three NIS were closely associated with the occurrence of severe malnutrition and cancer cachexia.

CONCLUSIONS

42% patients with lung cancer experienced different types of NIS. NIS were independent indicators of malnutrition, cancer cachexia and shorter OS, and closely related to QoL. NIS management is of clinical significance.

GI Symptoms in Pancreatic Cancer

This review will apply a multidisciplinary approach to GI symptoms with attention to symptom assessment (instruments and qualitative aspects), differential diagnosis, and recent findings relevant to management of symptoms and underlying diseases. We conclude that further development of supportive interventions for GI symptoms for both patient and caregivers has the potential to reduce distress from GI symptoms, and anticipate better symptom control with advances in scientific knowledge and improvement of the evidence base.

Prediction of Survival Time in Advanced Lung Cancer: A Retrospective Study in Home-Based Palliative Care Unit

Background: There is a large group of patients suffering from lung cancer and receiving home hospice care in China. However, little is known about the prediction of their survival time. The purpose of this study was to determine whether quality of life independently predicts survival among advanced lung cancer survivors who are receiving home-based palliative care. Methods: In this retrospective study, we analyzed data from 937 advanced lung cancer patients who had received home-based palliative care between March 2010 and March 2020. We used Kaplan-Meier survival curves to determine the factors associated with survival time and applied the Cox proportional hazards model to examine the effect of quality of life on survival. Results: The study included 928 patients with a mean age of 63 years; and 72.1% of them were men. Factors associated with shortened survival included age, sex, place of residence, weight loss, anorexia, nausea, edema, quality of life, and Karnofsky performance status. After adjusting for other variables in a multivariate Cox proportional hazards model, we found that quality of life was an independent positive predictor of survival. Conclusions: As an independent factor predicting the survival of advanced lung cancer patients, quality of life should be taken seriously. Medical staff and healthcare workers need to pay special attention to this predictive factor since it may serve as early risk identification indicator for professionals who provide home-based palliative care, helping them to create effective personalized care plans.

Efficacy and safety of anamorelin in patients with cancer cachexia: Post-hoc subgroup analyses of a placebo-controlled study

BACKGROUND

Cachexia, a disorder associated with anorexia, inflammation, and muscle wasting, is frequent in cancer patients. We performed post-hoc analyses of the ONO-7643-04 study to investigate the efficacy and safety of anamorelin in subgroups of Japanese patients with non-small cell lung cancer (NSCLC).

METHODS

The patients were divided into subgroups by baseline characteristics, including sex, age, body mass index, prior weight loss, performance status (PS), concomitant anticancer therapy, and number of previous chemotherapy regimens. The changes from baseline through to 12 weeks for lean body mass (LBM), body weight, and appetite were calculated. Appetite was evaluated using the quality of life questionnaire for cancer patients treated with anticancer drugs (QOL-ACD) item 8 score. Responder rates were defined as the maintenance/improvement of LBM (≥0 kg), body weight (≥0 kg), or QOL-ACD item 8 score (≥0) from baseline to all evaluation time points. Safety was evaluated in patients subgrouped by age and PS.

RESULTS

Anamorelin resulted in greater improvements versus placebo in LBM, body weight, and appetite in most subgroups. Anamorelin was also associated with greater LBM, body weight, and appetite responder rates than placebo in nearly all subgroups. Among anamorelin-treated patients, adverse drug reactions (ADRs) tended to be more frequent with increasing age (<65 years, 19.2%; ≥65 to <75 years, 45.9%; ≥75 years, 60.0%) and PS score (PS 0-1, 38.4%; PS 2, 60.0%). The frequency of serious ADRs was 2.7% and 0% in the PS 0-1 and PS 2 subgroups, respectively.

CONCLUSION

This study of NSCLC patients with cancer cachexia revealed consistent improvements in LBM, body weight, and appetite across most subgroups of anamorelin-treated patients. This study also demonstrated the tolerability of anamorelin regardless of age and PS, with a low incidence of serious ADRs in each subgroup.

Male and female rats exhibit comparable gaping behavior but activate brain regions differently during expression of conditioned nausea

Twenty-five to fifty percent of patients undergoing chemotherapy will develop anticipatory nausea and vomiting (ANV), in which symptoms occur in anticipation of treatment. ANV is triggered by environmental cues and shows little response to traditional antiemetic therapy, suggesting that unique neural pathways mediate this response. Understanding the underlying neural mechanisms of this disorder is critical to the development of novel therapeutic interventions. The purpose of the present study was to identify brain areas activated during ANV and characterize sex differences in both the behavior and the brain areas activated during ANV. We used a rat model of ANV by pairing a novel context with the emetic drug lithium chloride (LiCl) to produce conditioned nausea behaviors in the LiCl-paired environment. We quantitated gaping, an analog of human vomiting, after acute or repeated LiCl in a unique environment. To identify brain regions associated with gaping, we measured c-fos activation by immunochemical staining after these same treatments. We found that acute LiCl activated multiple brain regions including the supraoptic nucleus of the hypothalamus, central nucleus of the amygdala, nucleus of the solitary tract and area postrema, none of which were activated during ANV. ANV activated c-fos expression in the frontal cortex, insula and paraventricular nucleus of the hypothalamus of males but not females. These data suggest that therapies such as ondansetron which target the area postrema are not effective in ANV because it is not activated during the ANV response. Further studies aimed at characterizing the neural circuits and cell types that are activated in the conditioned nausea response will help identify novel therapeutic targets for the treatment of this condition, improving both quality of life and outcomes for patients undergoing chemotherapy.

Drug repositioning: Using psychotropic drugs for the treatment of glioma

Psychotropic drugs can penetrate the blood-brain barrier and regulate the levels of neurotransmitters and neuromodulators such as γ-aminobutyric acid, glutamate, serotonin, dopamine, and norepinephrine in the brain, and thus influence neuronal activity. Neuronal activity in the tumor microenvironment can promote the growth and expansion of glioma. There is increasing evidence that in addition to their use in the treatment of mental disorders, antipsychotic, antidepressant, and mood-stabilizing drugs have clinical potential for cancer therapy. These drugs have been shown to inhibit the malignant progression of glioma by targeting signaling pathways related to cell proliferation, apoptosis, or invasion/migration or by increasing the sensitivity of glioma cells to conventional chemotherapy or radiotherapy. In this review, we summarize findings from preclinical and clinical studies investigating the use of antipsychotics, antidepressants, and mood stabilizers in the treatment of various types of cancer, with a focus on glioma; and discuss their presumed antitumor mechanisms. The existing evidence indicates that psychotropic drugs with established pharmacologic and safety profiles can be repurposed as anticancer agents, thus providing new options for the treatment of glioma.

Overview of nutritional approach in hematopoietic stem cell transplantation: COVID-19 update

The coronavirus disease 2019 (COVID-19) is caused by the newly discovered SARS-CoV-2. Hematopoietic stem cell transplantation (HSCT) is a high-risk procedure. The novelty of COVID-19 has created more uncertainty during all phases of HSCT. It is thought that HSCT patients taking immunosuppressive agents are more likely to contract COVID-19 than healthy individuals are. Appropriate care precautions should be taken with patients undergoing HSCT to minimize the risk of COVID-19, and appropriate treatment methods must be followed in patients infected with COVID-19. Malnutrition has become a significant problem in HSCT patients during the COVID-19 pandemic. The causes of malnutrition in HSCT patients are multifactorial. However, the most important reason is the decrease in energy and nutrient intake. The HSCT procedure can lead to many complications such as dysgeusia, mucositis, diarrhea, constipation, xerostomia and vomiting/nausea. Improving the nutritional status of HSCT patients by managing each of these special complications with an appropriate nutritional approach is essential for successful engraftment. This review aims to provide a comprehensive overview of the specific complications affecting the nutritional status of HSCT patients and their nutritional approach during the challenging COVID-19 pandemic.

MASCC antiemetics in advanced cancer updated guideline

BACKGROUND

Nausea and vomiting are a common clinical symptom in the advanced cancer patient. Pharmacologic management is important. Evidence for drug choices and guidelines are needed to help clinicians manage nausea and vomiting in this population METHODS: Evidence from a systematic review published in 2010, initial MASCC guidelines developed from a systematic review of literature to 2015, and a new systematic review of randomized trials published between 2015 and February 2, 2021, was combined to establish a new guideline.

RESULTS

A search of the literature between 2015 and February 2, 2021, revealed 257 abstracts of which there was one systematic review and 4 randomized trials which were used to modify the guideline. The new guideline is as follows: First Line: Metoclopramide (II) multiple small RCTs including a placebo-controlled trial, haloperidol (II) multiple non-placebo-controlled RCTs, high consensus. Second line: Methotrimeprazine (II) 1 well-powered non-placebo-controlled RCT, olanzapine (II) 1 placebo-controlled pilot RCT, high consensus. Third line: Tropisetron (II) large unblinded lower quality non-placebo-controlled RCT, levosulpiride (II) 1 blinded non-placebo-controlled pilot RCT, high consensus.

DISCUSSION

Haloperidol, metoclopramide, methotrimeprazine, olanzapine tropisetron, and levosulpiride have been antiemetics used in randomized trials with antiemetic activity demonstrated. There are only three placebo-controlled randomized trials we could find in our literature review. Placebo responses varied significantly between two randomized trials. More randomized placebo-controlled trials with either metoclopramide or haloperidol rescue are needed to clarify antiemetic choices in advanced cancer.

CONCLUSION

First-line antiemetics for nausea and vomiting in advanced cancer are metoclopramide and haloperidol, and second-line medications are methotrimeprazine and olanzapine.

The Management of Nausea and Vomiting Not Related to Anticancer Therapy in Patients with Cancer

OPINION STATEMENT

In cancer patients, the management of nausea and vomiting that is not directly related to treatment is challenging. Much current practice is based on expert opinion and anecdote. Fortunately, over recent years, a number of quality trials have been undertaken to strengthen the evidence base that guides the care of our patients with these distressing symptoms. Much is still unknown however. In this article, we present the latest literature that addresses some of the outstanding issues.

The Benefits of Olanzapine in Palliating Symptoms

OPINION STATEMENT

Olanzapine has become a major drug in the management of chemotherapy-induced nausea and vomiting as a prophylactic agent. In addition, a recent randomized trial has demonstrated its benefits in treating nausea and vomiting associated with advanced cancer. The added benefit to olanzapine is that it also stimulates appetite. As a result, since it treats multiple symptoms associated with advanced cancer, it is likely to become the antiemetic of choice in palliative care at least in the USA. The added benefit of treating insomnia and the avoidance of benzodiazepines should place olanzapine in at the top of the list of drugs to use for patients who do complain of insomnia. There is no good evidence that it potentiates the respiratory depression of opioids unlike benzodiazepines. The evidence is weak that olanzapine in as an adjuvant analgesic. Hopefully, future trials will explore this in greater depth. The benefits of adding olanzapine to potent opioids are that it may reduce craving, drug cues, and opioid misuse. Other symptoms like anxiety and depression may be addressed by the addition of olanzapine to standard antidepressants.

The use of olanzapine as an antiemetic in palliative medicine: a systematic review of the literature

BACKGROUND

Olanzapine is an atypical antipsychotic that has affinity for many central nervous system receptors. Its efficacy is supported by several studies in the prevention and treatment of chemotherapy-induced nausea and vomiting. No recommendations exist on the antiemetic use of olanzapine in the palliative care setting. The aim of this work is to complete the initial work of Fonte et al. published in 2015, to determine whether the literature supports the use of olanzapine as an antiemetic in palliative situations and, in practice, to propose a therapeutic schema adapted to the palliative setting.

METHODS

Systematic review of the literature according to the PRISMA criteria. We searched the PubMed, Cochrane, RefDoc, EMBase databases and the gray literature databases. The bibliographic search was conducted between November 2016 and August 2017.

RESULTS

Thirteen articles were included: 2 case studies, 3 case series, 3 retrospective studies, 2 prospective studies, 2 literature reviews. All studies concluded on the efficacy of olanzapine as an antiemetic in the palliative care setting. No serious adverse effects were reported. Based on the data from the literature review, we propose a therapeutic scheme adapted to the palliative care context.

CONCLUSION

Action of olanzapine on many receptors and its tolerance profile make it an interesting antiemetic treatment in palliative medicine. But to date, studies are scarce and have a low statistical power. Further investigation is therefore needed to determine the benefit of this treatment in palliative care patients, compared to usual treatments.