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

Prophylactic Neurokinin-1 Receptor Antagonist Use Pre- and Post-Choosing Wisely Initiative Among Women With Invasive Breast Cancer

OBJECTIVE

To examine the impact of Choosing Wisely (CW) on prophylactic NK1-RA use among women with breast cancer.

STUDY SETTING AND DESIGN

This was a retrospective cohort study conducted using administrative claims data. The exposure variable was the start of chemotherapy relative to the implementation date for the CW antiemetic measure. The outcome was prophylactic NK1-RA use. Interrupted time series using segmented regression was used to assess the effect of CW on prophylactic NK1-RA use.

DATA SOURCES AND ANALYTIC SAMPLE

Optum's de-identified Clinformatics Data Mart Database (2010-2018) was used. This study included women aged ≥ 18 years with breast cancer with at least one newly initiated claim for low/minimal/moderate emetic risk chemotherapy (n = 25,549).

PRINCIPAL FINDINGS

The prophylactic use of NK1-RAs among patients with breast cancer receiving low/minimal/moderate emetic risk chemotherapy decreased from 11.1% pre-CW to 7.7% post-CW. Segmented regression analysis showed a significant increase of 0.11 per 100 patients per quarter in the use of prophylactic NK1-RAs prior to CW recommendation (95% CI = 0.10-0.12; p < 0.0001). However, immediately after the CW (occurred in Q4 2013), there was a significant decline in the prophylactic NK1-RA use by 1.03 per 100 patients in Q2 2014 (-0.93 to -1.13; p < 0.0001). For the time after intervention, there was a significant decline in NK1-RA use by 0.37 per 100 patients per quarter in the post-CW period compared to the pre-CW period (95% CI = -0.36 to -0.38; p < 0.0001).

CONCLUSION

This study highlights a significant but modest decline in the use of prophylactic NK1-RAs. Educational efforts for the dissemination of CW recommendations are needed to facilitate appropriate prophylactic NK1-RAs use.

Identifying risk factors for vomiting during diarrhea: A secondary analysis of a randomized trial of zinc supplementation

OBJECTIVES

Supplemental zinc during acute diarrhea reduces illness duration but also increases vomiting. In a recent trial, we found that children receiving lower daily doses of zinc (5 mg or 10 mg vs. 20 mg) had lower rates of vomiting with comparable stool output and duration of diarrhea. We performed a secondary analysis to identify sociodemographic and clinical factors associated with vomiting in children with acute diarrhea.

METHODS

We performed a secondary data analysis of 4500 children aged 6-59 months with an acute episode of diarrhea (<72 h before enrollment) in a randomized, double-blind controlled trial in India and Tanzania. To identify clinically important risk factors for overall, regimen-related, and regimen-unrelated vomiting, we created log-binomial models with relative risks (RRs) and 95% confidence intervals (CIs).

RESULTS

The trial enrolled 4500 children, of whom 1203 (26.7%) had any vomiting. After adjusting for multiple demographic and clinical characteristics, the presence of dehydration (RR: 1.45, 95% CI: 1.10-1.92), being underweight (RR: 1.22, 95% CI: 1.05-1.41), receipt of the rotavirus vaccine (RR: 1.89, 95% CI: 1.69-2.12), and household wealth above the median (RR: 1.17, 95% CI: 1.07-1.29) were factors associated with an increased risk of vomiting. Rotavirus vaccine receipt was nearly 100% concordant with the study site of Tanzania. Older age and lower zinc dosing were associated with a lower risk of vomiting.

CONCLUSIONS

Young, underweight, or dehydrated children are more likely to have concurrent vomiting with zinc supplementation. Identification of these factors may allow providers to better monitor such children, thus reducing the chances of recurrent dehydration or inadequate dietary intake.

Predictive factors of chemotherapy‑induced nausea and vomiting in elderly patients with gynecological cancer undergoing paclitaxel and carboplatin therapy: A retrospective study

Chemotherapy-induced nausea and vomiting (CINV) is a common and distressing adverse effect in elderly patients with gynecological cancer undergoing paclitaxel and carboplatin therapy. The present study aimed to identify predictors of CINV in this population. A retrospective analysis was conducted of 209 elderly patients with gynecological cancer treated with paclitaxel and carboplatin chemotherapy at The Affiliated Hospital, Southwest Medical University (Luzhou, China) between May 2019 and July 2023. The Multinational Association of Supportive Care in Cancer Antiemesis Tool (MAT) was used to assess the presence, frequency, and severity of CINV. Patients were categorized into the CINV group (n=76) and non-CINV group (n=133) based on the MAT results. Age, hypertension, pre-chemotherapy sleep duration and pre-chemotherapy anxiety level were identified as significant predictors of CINV in the univariate analysis. In the multivariate analysis, age, pre-chemotherapy sleep duration and pre-chemotherapy anxiety level remained significant predictors. In conclusion, age, pre-chemotherapy sleep duration and pre-chemotherapy anxiety level are significant predictors of CINV in elderly patients with gynecological cancer undergoing paclitaxel and carboplatin therapy. These findings could help in tailoring preventative strategies for CINV in this population.

Evaluation of chemotherapy-induced nausea and vomiting in low, moderate, and highly emetogenic schemes between sexes

PURPOSE

Sex influences chemotherapy-induced nausea and vomiting (CINV). However, in clinical practice, males and females receive the same antiemetic prophylaxis. We compared CINV between sexes in patients with different emetic risk schemes and evaluated the predisposing factors and main adverse effects caused by antiemetics.

METHODS

Prospective observational study conducted in a tertiary-care hospital from February 2023 to May 2024 in patients starting chemotherapy or a new treatment line. CINV was evaluated using MASCC antiemetic tool, in acute (< 24 h) and delayed phases (24-120 h). Results were analyzed using χ2 test or Fisher's exact test. The primary endpoint was complete response (CR) rate, defined as no CINV and no use of rescue medication. Univariate and multivariate logistic regressions were used to identify patient-related risk factors associated with non-CR.

RESULTS

A total of 176 completed questionnaires (CQ): 94 for males and 82 for females were collected. The proportion of males who remained emesis-free was superior to females in the acute phase (100% versus 92.7%, p = 0.009). Likewise, a higher proportion of males remained nausea-free in the acute (91.5% versus 79.3%, p = 0.021) and delayed phase (90.4% versus 79.3%, p = 0.037). In females, young age (< 60 years) and previous nausea and vomiting during pregnancy may contribute to non-CR. A high proportion of patients reported adverse events like constipation and insomnia. Females suffered more constipation than males (52.4% versus 37.2%, p = 0.043).

CONCLUSION

Females experienced more CINV than males, with the consequences that entail. Antiemetic prophylaxis should be personalized, considering sex and age and not only the chemotherapy emetic potential.

Endocannabinoid signaling in stress, nausea, and vomiting

BACKGROUND

Classical antiemetics that target the serotonin system may not be effective in treating certain nausea and vomiting conditions like cyclic vomiting syndrome (CVS) and cannabinoid hyperemesis syndrome (CHS). As a result, there is a need for better therapies to manage the symptoms of these disorders, including nausea, vomiting, and anxiety. Cannabis is often used for its purported antiemetic and anxiolytic effects, given regulation of these processes by the endocannabinoid system (ECS). However, there is considerable evidence that cannabinoids can also produce nausea and vomiting and increase anxiety in certain instances, especially at higher doses. This paradoxical effect of cannabinoids on nausea, vomiting, and anxiety may be due to the dysregulation of the ECS, altering how it maintains these processes and contributing to the pathophysiology of CVS or CHS.

PURPOSE

The purpose of this review is to highlight the involvement of the ECS in the regulation of stress, nausea, and vomiting. We discuss how prolonged cannabis use, such as in the case of CHS or heightened stress, can dysregulate the ECS and affect its modulation of these functions. The review also examines the evidence for the roles of ECS and stress systems' dysfunction in CVS and CHS to better understand the underlying mechanisms of these conditions.

The Role of Cannabinoids and the Endocannabinoid System in the Treatment and Regulation of Nausea and Vomiting

Despite using the recommended anti-emetic treatments, control of nausea and vomiting is still an unmet need for cancer patients undergoing chemotherapy treatment. Few properly controlled clinical trials have evaluated the potential of exogenously administered cannabinoids or manipulations of the endogenous cannabinoid (eCB) system to treat nausea and vomiting. In this chapter, we explore the pre-clinical and human clinical trial evidence for the potential of exogenous cannabinoids and manipulations of the eCB system to reduce nausea and vomiting. Although there are limited high-quality human clinical trials, pre-clinical evidence suggests that cannabinoids and manipulations of the eCB system have anti-nausea/anti-emetic potential. The pre-clinical anti-nausea/anti-emetic evidence highlights the need for further evaluation of cannabinoids and manipulations of eCBs and other fatty acid amides in clinical trials.

Action of cocaine- and amphetamine-regulated transcript (CART) peptide to attenuate cisplatin-induced emesis in Suncus murinus (house musk shrew)

Cocaine- and amphetamine-regulated transcript (CART) peptide is a brain-gut neuropeptide that has been implicated in a range of physiological functions including appetite, which is disturbed during chemotherapy. The aims of the present study were to identify the distribution and expression of CART mRNA and CART peptide, and to examine the potential of CART (55-102) to attenuate cisplatin-induced emesis in Suncus murinus. CART mRNA and peptide were detected throughout the entire brain, including the forebrain, hypothalamus, and brainstem, and also in the gut wall and stomach. In conscious, freely moving animals, intracerebroventricular administration of CART (55-102) did not modulate food and water intake or alter locomotor activity when administered alone. Cisplatin induced emesis and upregulated the expression of CART mRNA in the brainstem. However, CART (55-102) reduced the number of cisplatin-induced retches. Both CART (55-102) and cisplatin increased the number of c-Fos positive cells in the nucleus tractus solitarius, lateral hypothalamus, paraventricular hypothalamus, and bed nucleus of the stria terminalis (BNST), compared to saline-treated animals, whereas cisplatin also induced c-Fos expression in the area postrema (AP), arcuate nucleus, and central nucleus of the amygdala. Pre-treatment with CART (55-102) significantly attenuated the increased c-Fos positive cells in the BNST and AP. These data indicate that CART mRNA and peptide were localized to regions involved in reward/enforcement, emotion, feeding and emesis. The anti-emetic effect of CART (55-102) against cisplatin-induced emesis may involve both the forebrain limbic system and the brainstem.

Are the Common Genetic 3'UTR Variants in ADME Genes Playing a Role in Tolerance of Breast Cancer Chemotherapy?

We studied the associations between 3'UTR genetic variants in ADME genes, clinical factors, and the risk of breast cancer chemotherapy toxicity. Those variants and factors were tested in relation to seven symptoms belonging to myelotoxicity (anemia, leukopenia, neutropenia), gastrointestinal side effects (vomiting, nausea), nephrotoxicity, and hepatotoxicity, occurring in overall, early, or recurrent settings. The cumulative risk of overall symptoms of anemia was connected with AKR1C3 rs3209896 AG, ERCC1 rs3212986 GT, and >6 cycles of chemotherapy; leukopenia was determined by ABCC1 rs129081 allele G and DPYD rs291593 allele T; neutropenia risk was correlated with accumulation of genetic variants of DPYD rs291583 allele G, ABCB1 rs17064 AT, and positive HER2 status. Risk of nephrotoxicity was determined by homozygote DPYD rs291593, homozygote AKR1C3 rs3209896, postmenopausal age, and negative ER status. Increased risk of hepatotoxicity was connected with NR1/2 rs3732359 allele G, postmenopausal age, and with present metastases. The risk of nausea and vomiting was linked to several genetic factors and premenopausal age. We concluded that chemotherapy tolerance emerges from the simultaneous interaction of many genetic and clinical factors.

Multi-day vs single-day dexamethasone for the prophylaxis of chemotherapy-induced nausea and vomiting: systematic review and meta-analysis

INTRODUCTION

Over the past decade, several randomized controlled trials have compared single-day dexamethasone (dexamethasone-sparing) regimens to the current standard multi-day dexamethasone antiemetic regimen for chemotherapy-induced nausea and vomiting (CINV). The aim of this systematic review and meta-analysis is to compare the efficacy and safety of dexamethasone-sparing regimens to standard multi-day dexamethasone, used for the prophylaxis of CINV.

METHODS

Ovid Medline and Embase were searched from database inception to March 2024. Studies were included if they reported on randomized controlled trials of adult cancer patients receiving different scheduling of dexamethasone, for the endpoints of complete response, complete control, no nausea, no vomiting, and no use of rescue medication. Safety was also assessed. Meta-analysis, leave-one-out meta-analysis, and cumulative meta-analysis were conducted to generate summary effect estimates and assess the influence of single trials on the summary effect estimate.

RESULTS

Ten trials reporting on 2234 patients were included. Dexamethasone-sparing regimens were found to be no different to control arm in the acute (Risk Ratio [RR] 1.01; 95% CI, 0.94-1.08), delayed (RR 0.97; 95% CI, 0.89-1.05) and overall phases (RR 0.98; 95% CI, 0.90-1.06) for complete response. There was likewise no difference for complete control, no nausea, no vomiting, and no use of rescue medication. Safety profile was similar. There was no concern for bias in the published literature. No difference was found between studies reporting on anthracycline/cyclophosphamide-based highly emetogenic chemotherapy (HEC) and moderately emetogenic chemotherapy (MEC).

CONCLUSION

In this comprehensive systematic review and meta-analysis, dexamethasone-sparing regimens were found to be no different to current multi-day regimens with respect to efficacy and safety for MEC and anthracycline/cyclophosphamide-based regimens. Clinicians and future guidelines should strongly consider greater adoption and endorsement of dexamethasone-sparing regimens.

Corticosteroid therapy in older adults with cancer: Expert recommendations from a task force of the International Society of Geriatric Oncology

Corticosteroids are used frequently in oncology and many patients require short- or long-term corticosteroid therapy. General clinical guidelines and recommendations exist on the use of corticosteroids; however, evidence is lacking for recommendations on their appropriate use in older adult with cancer. Treatment of chemotherapy-induced nausea and vomiting (CINV) has dramatically improved over the last decade with 5-hydroxytryptamine type 3 (5-HT3) receptor antagonists and neurokinin-1 (NK-1) receptor antagonists or a combination of both. However, corticosteroids continue to play an important role in the management of acute and delayed CINV prevention. While highly efficacious, the toxicity profile of corticosteroids must be considered, particularly in heterogeneous older patients with multiple comorbidities and polypharmacy. Guidance on corticosteroid-reducing/sparing strategies in this specific population is needed. This consensus, supported by the International Society of Geriatric Oncology, aims to provide evidence-based recommendations for the use of corticosteroid therapy in older adults with cancer.

Integrating nutrition, physical exercise, psychosocial support and antiemetic drugs into CINV management: The road to success

Over the years, advancements in antiemetic drugs have improved chemotherapy-induced nausea and vomiting (CINV) control. However, despite the antiemetics therapies, in a relevant number of adult patients (∼30 %), CINV is still persistent, leading to several complications, such as electrolyte imbalances, anorexia, and treatment discontinuation. Supportive care interventions have gained credibility in cancer care, helping to improve patients' psycho-physical condition, quality of life, and managing symptoms, including CINV. Physical exercise and tailored nutritional counseling have demonstrated benefits in reducing the severity of nausea and vomiting. Psychological intervention has been postulated as a key approach in controlling anticipatory nausea/vomiting, as well as acupuncture/acupressure has been shown to decrease nausea and vomiting after chemotherapy treatments. In the current review, we aim to provide a clinical update on current prophylactic and delayed antiemetic guidelines for CINV and an overview of the non-pharmacological interventions tested for alleviating CINV in patients with cancer.

Auriculotherapy and acupuncture treatments for chemotherapy-induced nausea and vomiting: a multicenter clinical trial

PURPOSE

Nausea and vomiting complicating chemotherapy (CINV) remain side effects despite preventive and curative treatments. We hypothesize that acupuncture (ACU), auriculotherapy (AUR), and their combination (ACU-AUR), could decrease, compared to usual treatment (UT), the intensity of acute nausea in patients already treated according to the antiemetic guidelines and presenting nausea with or without vomiting in the earlier cycle.

METHODS

In this multicenter study, patients were treated just before chemotherapy according to randomization. ACU consisted of implanting bilaterally on each forearm, one semi-permanent needle at point P6. AUR consisted of implanting bilaterally on each pavilion of the ear, one semi-permanent needle at point O. All patients received systematic preventive drug treatment according to antiemetic guidelines. Main outcome was intensity of nausea at 24 h after chemotherapy using a numeric scale ranging from 0 (no nausea) to 10 (maximum symptoms).

RESULTS

One hundred and fifteen patients were included. Baseline characteristics were similar between groups at inclusion. Intensity of nausea at 24 h after chemotherapy, was statistically different between the groups (covariance intergroup analysis, p = 0.005) and was significantly lower for the all-treatment groups vs UT group (p = 0.007 for AUR, p = 0.008 for ACU, and p = 0.0009 for AUR-ACU). AUR-ACU also decreased intensity of delayed nausea when compared to UT (p = 0.023). AUR, ACU and AUR-ACU had no effect on acute and delayed vomiting episodes. No serious adverse event due to the studied treatments was reported in our study.

CONCLUSION

AUR or ACU reduce intensity of acute and delayed nausea in patients treated by optimal antiemetic treatment.

TRIAL REGISTRATION NUMBER

CLINICALTRIALS

gov identifier NCT02767791, registered on May 10, 2016.

Differences in severity of chemotherapy-induced nausea and vomiting between neoadjuvant and adjuvant chemotherapy in patients with breast cancer: analysis of data from two prospective observational studies

PURPOSE

We assessed the differences in chemotherapy-induced nausea and vomiting (CINV) severity in patients with breast cancer, receiving neoadjuvant chemotherapy (NAC) and adjuvant chemotherapy (AC).

METHODS

CINV severity in patients on anthracycline-based NAC (n = 203) and AC (n = 79) was assessed at baseline (C0) and after the first and fourth chemotherapy using a 10-point Likert scale. Group-by-time interaction term was used to evaluate the effect of the group on changes in CIN (cCIN) and CIV (cCIV) from C0 to the follow-up periods (C1, C4). If insignificant, group effects were analyzed without the interaction term. Subgroup analysis was performed based on age 50. In statistical analyses, sociodemographic and clinical variables that differed between groups were adjusted for.

RESULTS

The effect of group by follow-up period was not significant in cCIN and cCIV. The AC group showed a significantly higher change in the severity of cCIN compared to the NAC group (estimated mean = 1.133, 95% CI = 0.104-2.161, p = 0.031), but there was no difference in cCIV. In those ≤ 50 years, significant differences in cCIN severity (estimated mean = 1.294, 95% CI = 0.103-2.484, p = 0.033) were observed, but not in cCIV. In those > 50 years, neither cCIN nor cCIV differed significantly between groups.

CONCLUSIONS

NAC in breast cancer patients showed less severe CIN than adjuvant chemotherapy AC, but not in those over 50. Clinicians should recognize that the severity of CIN may vary across different chemotherapy settings and adjust their management accordingly.

TRIAL REGISTRATION

The clinical trial registration ( www.

CLINICALTRIALS

gov ) numbers were NCT01887925 (the registration date is from June 20, 2013, to November 27, 2015) and NCT02011815 (the registration date is from December 10, 2013, to September 22, 2019).

Effectivity of oral ginger supplementation for chemotherapy induced nausea and vomiting (CINV) in children: A systematic review of clinical trials

Chemotherapy-induced nausea and vomiting (CINV) affects over 50% of pediatric patients undergoing chemotherapy, a higher proportion than in adults. CINV often occurs despite adequate antiemetic prophylaxis, hampering patients' willingness to continue the chemotherapy regimen. As an ayurvedic medicine, ginger (Zingiber officinale) has an antiemetic effect by inhibiting serotonin in gastrointestinal nerves and as an NK1 antagonist. Therefore, we aimed to review oral ginger supplementation in children with CINV systematically. Systematic searching was performed in June 2023 from Pubmed, Embase, CINAHL, Cochrane, and hand searching. The search consisted of PICO "children chemotherapy", "ginger", and "CINV incidence". We limited the search to only human studies. Studies that meet inclusion and exclusion criteria were included for analysis. Out of 116 studies found with our selection criteria, four were compatible with inclusion and exclusion criteria. Two studies had a small Risk of Bias (RoB), while the others had a high RoB. All studies statistically significantly reduced acute and delayed CINV with the number needed to treat (NNT) 2-4. No adverse effects were reported. However, these studies still had high heterogeneity based on cancer treatment, chemotherapy regimen, ginger dosing, and ginger processing. Ginger has the potential to reduce both the acute and delayed phases of CINV in children. Additional research employing standardized methodologies is recommended to validate this effect.

A nurse-led multidomain intervention to improve the management of chemotherapy-induced nausea and vomiting in patients with head and neck cancers: A randomized controlled trial

PURPOSE

This study aimed to investigate the effect of a nurse-led multidomain intervention on chemotherapy induced nausea and vomiting (CINV) in patients with head and neck squamous cell carcinomas (HNSCC).

METHODS

Ninety-two HNSCC patients who received cisplatin-based chemotherapy were divided into intervention group (n = 45) and control group (n = 47). The control group received usual care of CINV, which consisted of administration of antiemetics according to physicians' preference, education about CINV control and dietary recommendations provided by primary nurses. The intervention group received nurse-led, evidence-based multidomain management, including nurse-led CINV risk factors assessment, education on prevention and control of CINV, antiemetics following guidelines, dietary strategies, and relaxation therapy. The number of patients who experienced CINV was collected. The severity of CINV was graded according to the Common Terminology Criteria for Adverse Events v3.0. The influence of CINV on patient's quality of life was assessed by the Functional Living Index-Emesis (FLIE).

RESULTS

The incidence and the severity of nausea and vomiting in the intervention group were significantly lower than those in the control group within 5 days after chemotherapy, and the scores of the dimension of nausea and vomiting in the intervention group were significantly higher than those in the control group [63.00 (50.00-63.00) vs 40.00(28.00-63.00), 63.00(63.00-63.00) vs 63.00 (43.00-63.00)], the differences were statistically significant (P < 0.05).

CONCLUSIONS

Nurse-led multidomain intervention can reduce the incidence and the severity of CINV in patients with HNSCC who were treated with cisplatin-based chemotherapy, and thus reduced the influence of CINV on patients' quality of life.

THE CLINICAL TRIAL REGISTRATION NUMBER

NCT05792228.

Anti-Emetics in Children Receiving Chemotherapy for Solid Tumors and Leukemia: Pharmacology and Optimization of Therapy for Nausea and Vomiting

The management of chemotherapy-induced nausea and vomiting (CINV) in children remains challenging due to differences in the chemotherapy regimens, their relative emetogenicity compared to that in adults and differences in drug metabolism and the available formulations. The common four classes of anti-emetics used for the treatment and prophylaxis of CINV in children include dexamethasone, neurokinin-1 receptor antagonists, 5-hydroxytryptamine-3 receptor antagonists (5HT3RAs), and olanzapine. The appropriate dose of dexamethasone for CINV prophylaxis in children is unknown, with a significant variability in dosage ranging between 6 and 32 mg/m2/day. The dose of dexamethasone is decreased by 30% when this drug is combined with (fos)aprepitant in children, in contrast to a decrease of 50% required in adults. The use of aprepitant in younger children (<12 years) is often hampered by the non-availability of oral suspension formulations in many countries; alternatively, 80 mg capsules are administered for 1-3 days in certain institutes to children weighing between 15 and 40 kg. Among the different 5HT3RAs, palonosetron is comparatively metabolized faster in children than in adults, requiring a higher dosage for similar efficacy to that achieved in adults. Olanzapine is a newer agent, used in doses between 0.1 and 0.14 mg/kg/day in children, with good anti-emetic efficacy, but has sedation and hyperglycemia as concerning adverse effects. Drug interactions between anti-emetics and between anti-emetics and chemotherapy/supportive agents (azole antifungals, cyclosporine, arsenic trioxide), especially QTc prolongation, should be considered during prescription.

Effects of aromatherapy on nausea and vomiting in patients with cancer: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

and purpose: Aromatherapy offers a low-risk solution for effectively managing common nausea and vomiting in cancer patients. This systematic review and meta-analysis aimed to assess its impact on these symptoms to facilitate practical guidelines establishment.

METHODS

PubMed, Web of Science, Cochrane Library, MEDLINE, CINAHL, and Embase were searched for articles published until April 30, 2023. Inclusion criteria were randomized controlled trials (RCTs) on the effect of aromatherapy on nausea and vomiting in patients with cancer (age ≥18 years). The effect size was calculated using standardized mean differences (SMDs) with a random effects model. Subgroup analyses, meta-analysis of variance, and meta-regression were performed using the "meta" package in R version 4.0.2. Heterogeneity was assessed using I2 statistics. Sensitivity and publication bias analyses were performed; two reviewers independently assessed risk of bias using Cochrane's risk-of-bias tool 2.0.

RESULTS

Twenty-five RCTs across 10 articles revealed that aromatherapy reduced overall nausea and vomiting in patients with cancer with significant efficacy (SMD = -0.81, 95 % confidence interval [CI]: -1.11 to -0.52). Furthermore, aromatherapy reduced nausea (SMD = -0.85, 95 % CI: -1.23 to -0.46) and combined nausea and vomiting (SMD = -1.08, 95 % CI: -1.68 to -0.47), but not vomiting alone (SMD = -0.24, 95 % CI: -1.03 to 0.55). Inhalation and massage yielded positive results, especially in chemotherapy-induced cases; peppermint oil was particularly successful.

CONCLUSION

Our findings underscore aromatherapy's value in managing cancer treatment-associated nausea and vomiting. Conclusive evidence on aromatherapy-led nausea reduction is lacking due to limited RCTs; research is warranted for robust conclusions.

The clinical effect of an electric massage chair on chemotherapy-induced nausea and vomiting in cancer patients: randomized phase II cross-over trial

PURPOSE

Chemotherapy-induced nausea and vomiting (CINV) is a common adverse events in cancer patients and can negatively affect their quality of life (QoL). This study aimed to evaluate the clinical efficacy of an electric massage chair (EMC) for the treatment of CINV.

METHODS

A randomized phase II cross-over trial was conducted on solid cancer patients who received moderate (MEC) to high emetogenic chemotherapy (HEC). The participants were randomly assigned to receive their first chemotherapy either on a standard bed (Group A) or in an EMC (Group B) during the infusion. The patients were then crossed over to the next cycle. CINV and QoL questionnaires were collected from the participants.

RESULTS

A total of 59 patients completed the trial protocol and were included in the analysis, with 29 and 30 patients in Groups A and B, respectively. The mean INVR (Index of Nausea, Vomiting, and Retching) score in the 2nd day of the first cycle was higher in Group B (3.63 ± 5.35) than Group A (2.76 ± 4.78), but the difference was not statistically significant (p = 0.5367). The complete response rate showed little difference between the groups. Among the high-emetic risk subgroups, patients who received HEC (p = 0.04595), younger patients (p = 0.0108), and non-colorectal cancer patients (p = 0.0495) presented significantly lower CINV scores when EMC was applied.

CONCLUSION

Overall, there was no significant difference in INVR scores between standard care and EMC. Applying EMC at the first chemotherapy infusion may help preserve QoL and reduce CINV in high-risk patients.

TRIAL REGISTRATION

KCT0008200, 17/02/2023, Retrospectively registered.

Risk Factors Associated with Chemotherapy-Induced Nausea and Vomiting Among Women with Breast Cancer Receiving Highly Emetogenic Chemotherapy: Individual Patient-Based Analysis of Three Prospective Antiemetic Trials

PURPOSE

Although risk factors related to chemotherapy-induced nausea and vomiting (CINV) have been identified in previous studies, only a few studies have evaluated the risk factors associated with contemporary antiemetic prophylaxis, including olanzapine/aprepitant- or NEPA-containing regimens. This study aimed to identify the risk factors associated with CINV development in Chinese breast cancer patients receiving doxorubicin and cyclophosphamide chemotherapy.

METHODS

Data from 304 patients enrolled in 3 previously reported prospective antiemetic studies were included. Multivariate logistic regression models were used to predict risk factors associated with CINV occurrence. Additionally, the likelihood of treatment failure in relation to the number of risk factors in individual patients was evaluated.

RESULTS

Multivariate analysis of the entire study group revealed that obesity status (defined as body mass index/= 25.0 kg/m2) and the use of olanzapine/aprepitant- or NEPA-containing anti-emetic regimens were associated with a high likelihood, while a history of motion sickness was associated with a lower likelihood, complete response (CR), and "no nausea" in the overall phase. A history of vomiting during pregnancy was also associated with a lower likelihood of an overall CR. Patients with an increasing number of risk factors had a higher likelihood of treatment failure and shorter time to first vomiting. Those who did not achieve CR and "no nausea" in the first cycle were less likely to achieve these parameters in the subsequent cycle of chemotherapy.

CONCLUSION

The present study confirmed previously reported risk factors for CINV in Chinese breast cancer patients receiving doxorubicin and cyclophosphamide. Further optimization of CINV control is required for patients with identifiable risk factors; olanzapine/aprepitant- or NEPA- containing prophylaxis are the preferred contemporary anti-emetics regimens for Chinese breast cancer patients undergoing doxorubicin and cyclophosphamide chemotherapy.

Low-dose versus standard-dose olanzapine with triple antiemetic therapy for prevention of highly emetogenic chemotherapy-induced nausea and vomiting in patients with solid tumours: a single-centre, open-label, non-inferiority, randomised, controlled, phase 3 trial

BACKGROUND

Olanzapine is an effective antiemetic agent but it results in substantial daytime somnolence when administered at the standard dose. Our aim was to compare the efficacy of low-dose versus standard-dose olanzapine after highly emetogenic chemotherapy in patients with solid tumours.

METHODS

This was a single-centre, open-label, non-inferiority, randomised, controlled, phase 3 trial done in a tertiary care referral centre in India (Tata Memorial Centre, Homi Bhabha National Institute, Mumbai). Patients aged 13-75 years with an Eastern Cooperative Oncology Group performance status of 0-2, who were receiving doxorubicin-cyclophosphamide or high-dose cisplatin for a solid tumour were eligible. Patients were randomly assigned (1:1), with block randomisation (block sizes of 2 or 4) and stratified by sex, age (≥55 or <55 years), and chemotherapy regimen, to receive low-dose (2·5 mg) oral olanzapine or standard-dose (10·0 mg) oral olanzapine daily for 4 days, in combination with a triple antiemetic regimen. Study staff were masked to treatment allocation but patients were aware of their group assignment. The primary endpoint was complete control, defined as no emetic episodes, no rescue medications, and no or mild nausea in the overall phase (0-120 hours), assessed in the modified intention-to-treat (mITT) population (ie, all eligible patients who received protocol-specified treatment, excluding those who had eligibility violations and who withdrew consent after randomisation). Daytime somnolence was the safety endpoint of interest. Non-inferiority was shown if the upper limit of the one-sided 95% CI for the difference in the complete control proportions between the treatment groups excluded the non-inferiority margin of 10%. This study is registered with the Clinical Trial Registry India, CTRI/2021/01/030233, is closed to accrual, and this is the final data analysis.

RESULTS

Between Feb 9, 2021, and May 30, 2023, 356 patients were pre-screened for eligibility, of whom 275 patients were enrolled and randomly assigned (134 to the 2·5 mg olanzapine group and 141 to the 10·0 mg olanzapine group). 267 patients (132 in the 2·5 mg group and 135 in the 10·0 mg group) were included in the mITT population, of whom 252 (94%) were female, 15 (6%) were male, and 242 (91%) had breast cancer. 59 (45%) of 132 patients in the 2·5 mg olanzapine group had complete control in the overall phase versus 59 (44%) of 135 in the 10·0 mg olanzapine group (difference -1·0% [one-sided 95% CI -100·0 to 9·0]; p=0·87). In the overall phase, there were significantly fewer patients in the 2·5 mg olanzapine group than in the 10·0 mg olanzapine group with daytime somnolence of any grade (86 [65%] of 132 vs 121 [90%] of 135; p<0·0001) and of severe grade on day 1 (six]5%] vs 54 [40%]; p<0·0001).

INTERPRETATION

Our findings suggest that olanzapine 2·5 mg is non-inferior to 10·0 mg in antiemetic efficacy and results in reduced occurrence of daytime somnolence among patients receiving highly emetic chemotherapy and should be considered as a new standard of care.

FUNDING

Progressive Ladies Welfare Association.

Dexamethasone-Free Antiemetic Prophylaxis for Highly Emetogenic Chemotherapy: A Double-Blind, Phase III Randomized Controlled Trial (CINV POD study)

PURPOSE

The effectiveness of a dexamethasone (DEX)-free regimen for chemotherapy-induced nausea and vomiting (CINV) prophylaxis in patients receiving highly emetogenic chemotherapy (HEC) is not known.

METHODS

This was a double-blind, phase III trial designed to show the noninferiority of a DEX-free regimen (olanzapine, palonosetron, and fosaprepitant [OPF]) compared with the DEX-containing regimen (olanzapine, palonosetron, and DEX [OPD]). Chemotherapy-naïve patients age 18-80 years receiving single-day HEC were randomly assigned 1:1 to receive either the OPD regimen or the OPF regimen. The primary objective was to compare complete response (CR) rates for vomiting during the overall period (start of chemotherapy to 120 hours). Secondary objectives included CR for vomiting during the acute period (0-24 hours) and delayed period (24-120 hours), CR for nausea, and comparison of toxicities and patient-reported outcomes.

RESULTS

Three hundred forty-six patients received the study interventions, 174 in the OPD arm and 172 in the OPF arm. The DEX-free OPF arm had significantly higher CR rates for vomiting compared with the DEX-containing OPD arm in acute (94.7% v 85.6%; P < .004), delayed (81.9% v 50.5%; P < .001), and overall (79.6% v 48.8%; P < .001) periods. For nausea, CR rates in the OPF arm were higher in delayed (53.4% v 39.6%; P = .009) and overall (50.5% v 39.1%; P = .031) periods but not in the acute period (77.9% v 81.6%; P = .39). Fatigue (P = .009) and drowsiness (P = .002) were more in the OPF arm in the acute period and insomnia (P < .001) in the OPD arm in the overall period.

CONCLUSION

This study shows that a DEX-free OPF regimen is efficacious and should be considered a standard option for acute and delayed CINV prophylaxis for HEC.

Analysis of the Efficacy and Safety of Palonosetron Hydrochloride in Preventing Nausea And Vomiting After TACE: A Retrospective Analysis

PURPOSE

To investigate the mechanism of nausea and vomiting after TACE, and analyze the efficacy and safety of palonosetron hydrochloride in the prevention of nausea and vomiting after TACE.

METHODS

The data of 221 patients who underwent TACE in the Department of Intervention Therapy from August 2018 to August 2020 were collected. The patients were divided into two groups: those who did not use palonosetron hydrochloride before TACE (TACE group, N=116); and those who used palonosetron hydrochloride before TACE (TACE+palonosetron group, N=105). Primary study endpoint: The control rate of nausea and vomiting in the two groups at 0-24 h (acute), 24-120 h (delayed), and 0-120 h. Secondary Study Endpoints: Adverse events of palonosetron hydrochloride.

RESULTS

TACE group vs TACE+palonosetron group: 0-24 h, 74 vs. 44 patients with nausea (63.8% vs. 41.9%); 24-120 h, 50 vs. 16 patients with nausea (43.1% vs. 15.2%); 0-120 h after TACE, 81 vs. 50 patients with nausea (69.8% vs. 47.6%). 0-24 h, 52 vs. 26 patients with vomiting (44.8% vs. 24.8%); 24-120 h, 24 vs. 8 patients with vomiting (20.7% vs. 7.6%); 0-120 h after TACE, 64 vs. 26 patients with vomiting (55.2% vs. 24.8%). The incidence of nausea and vomiting after TACE was significantly lower in the TACE+palonosetron group than in the TACE group (p < 0.05).

CONCLUSION

Palonosetron hydrochloride can significantly reduce the incidence of nausea and vomiting in patients after TACE, with exact effect and high safety.

Evaluation of Sex Differences in the Potential of Δ9-Tetrahydrocannabinol, Cannabidiol, Cannabidiolic Acid, and Oleoyl Alanine to Reduce Nausea-Induced Conditioned Gaping Reactions in Sprague-Dawley Rats

Introduction: Cancer patients report nausea as a side effect of their chemotherapy treatment. Using the pre-clinical rodent model of acute nausea-lithium chloride (LiCl)-induced conditioned gaping-our group has demonstrated that exogenous cannabinoids may have antinausea potential. Materials and Methods: With the goal of evaluating the role of sex as a factor in pre-clinical research, we first compared the conditioned gaping reactions produced by varying doses of LiCl in male and female rats using the taste reactivity test (Experiment 1). Results: LiCl produced dose-dependent conditioned gaping similarly in male and female rats with the highest dose (127.2 mg/kg) producing robust conditioned gaping, with this dose used in subsequent experiments. Next, we examined the antinausea potential of THC (Experiment 2), CBD (Experiment 3), cannabidiolic acid (CBDA; Experiment 4) and oleoyl alanine (OlAla; Experiment 5) in both male and female rats. THC, CBD, CBDA, and OlAla dose dependently reduced conditioned gaping in both male and female rats in a similar manner. Conclusions: These results suggest that cannabinoids may be equally effective in treating nausea in both males and females.

Curcumin as a hepatoprotective agent against chemotherapy-induced liver injury

Despite significant advances in cancer therapeutics, chemotherapy remains the cornerstone of treatment for many tumors. Importantly, however, chemotherapy-induced toxicity, including hepatotoxicity, can lead to the interruption or discontinuation of potentially effective therapy. In recent years, special attention has been paid to the search for complementary therapies to mitigate chemotherapy-induced toxicity. Although there is currently a lack of specific interventions to mitigate or prevent hepatotoxicity in chemotherapy-treated patients, the polyphenol compound curcumin has emerged as a potential strategy to overcome this adverse effect. Here we review, firstly, the molecular and physiological mechanisms and major risk factors of chemotherapy-induced hepatotoxicity. We then present an overview of how curcumin has the potential to mitigate hepatotoxicity by targeting specific molecular mechanisms. Hepatotoxicity is a well-described side effect of cytotoxic drugs that can limit their clinical application. Inflammation and oxidative stress are the most common mechanisms involved in hepatotoxicity. Several studies have shown that curcumin could prevent and/or palliate chemotherapy-induced liver injury, mainly due to its anti-inflammatory, antioxidant, antifibrotic and hypolipidemic properties. Further clinical investigation using bioavailable curcumin formulations is warranted to demonstrate its efficacy as an hepatoprotective agent in cancer patients.

Clinical Guidance on the Monitoring and Management of Trastuzumab Deruxtecan (T-DXd)-Related Adverse Events: Insights from an Asia-Pacific Multidisciplinary Panel

Trastuzumab deruxtecan (T-DXd)-an antibody-drug conjugate targeting the human epidermal growth factor receptor 2 (HER2)-improved outcomes of patients with HER2-positive and HER2-low metastatic breast cancer. Guidance on monitoring and managing T-DXd-related adverse events (AEs) is an emerging unmet need as translating clinical trial experience into real-world practice may be difficult due to practical and cultural considerations and differences in health care infrastructure. Thus, 13 experts including oncologists, pulmonologists and a radiologist from the Asia-Pacific region gathered to provide recommendations for T-DXd-related AE monitoring and management by using the latest evidence from the DESTINY-Breast trials, our own clinical trial experience and loco-regional health care considerations. While subgroup analysis of Asian (excluding Japanese) versus overall population in the DESTINY-Breast03 uncovered no major differences in the AE profile, we concluded that proactive monitoring and management are essential in maximising the benefits with T-DXd. As interstitial lung disease (ILD)/pneumonitis is a serious AE, patients should undergo regular computed tomography scans, but the frequency may have to account for the median time of ILD/pneumonitis onset and access. Trastuzumab deruxtecan appears to be a highly emetic regimen, and prophylaxis with serotonin receptor antagonists and dexamethasone (with or without neurokinin-1 receptor antagonist) should be considered. Health care professionals should be vigilant for treatable causes of fatigue, and patients should be encouraged to use support groups and practice low-intensity exercises. To increase treatment acceptance, patients should be made aware of alopecia risk prior to starting T-DXd. Detailed monitoring and management recommendations for T-DXd-related AEs are discussed further.

Risk factors associated with nausea and vomiting in children with cancer receiving chemotherapy

INTRODUCTION

Despite treatment with antiemetic medications, nausea remains uncontrolled for many children receiving chemotherapy. One reason is that risk factors for nausea in children remain poorly explored. The purpose of this study was to identify risk factors for chemotherapy-induced nausea (CIN) in children.

METHODS

Prospective, observational study including 101 children (median age 6.4 years, range 0.8-17.9) with cancer receiving moderately or highly emetogenic chemotherapy. Primary endpoints were complete control of acute and delayed CIN, defined as no nausea in the acute phase 0-24 h after chemotherapy and in the delayed phase starting after the acute phase and ending 5 days later. Multivariable analyses included age, sex, cancer type, susceptibility to motion sickness, chemotherapy duration, numbers of antiemetics, co-administration with opioids or tricyclic antidepressants, and previously uncontrolled nausea or vomiting.

RESULTS

Acute CIN was associated with susceptibility to motion sickness (odds ratio [OR] 5.73, 95% confidence interval [CI] 1.36-33.7) and older age (OR 4.19, 95% CI 1.30-14.7), comparing age group 8-18 years with 0-3 years. Delayed CIN was associated with uncontrolled acute nausea or vomiting (OR 10.3, 95% CI 2.65-50.9), highly emetogenic chemotherapy (OR 8.26, 95% CI 1.17-76.8), and having a hematologic cancer type (OR 7.81, 95% CI 1.05-79.2).

CONCLUSIONS

Susceptibility to motion sickness and age can influence the risk of acute CIN. More research is needed on how best to integrate risk information in preventive antiemetic strategies. Sufficient acute nausea and vomiting control are crucial to prevent delayed CIN.

Influence of menopause on chemotherapy-induced nausea and vomiting in highly emetogenic chemotherapy for breast cancer: A retrospective observational study

BACKGROUND

Female sex and younger age are reported risk factors for chemotherapy-induced nausea and vomiting (CINV) in highly emetogenic chemotherapy, but the underlying mechanism has not been elucidated. The purpose of this study was to clarify the impact of menopause on CINV.

METHODS

This retrospective observational study analyzed data from consecutive patients who received their first cycle of perioperative anthracycline-based chemotherapy for breast cancer between January 2018 and June 2020. The endpoints were association between CINV (vomiting, ≥Grade 2 nausea, complete response [CR] failure) and menopause as well as the association between CINV and follicle-stimulating hormone [FSH]/estradiol [E2].

RESULTS

Data for 639 patients were analyzed. Among these patients, 109 (17.1%) received olanzapine (four antiemetic combinations) and 530 (82.9%) did not (three antiemetic combinations). Premenopausal state (amenorrhea lasting ≥12 months) was significantly associated with ≥Grade 2 nausea and CR failure in univariate analysis but not in multivariate analysis. The premenopausal FSH/E2 group (defined by serum levels; FSH <40 mIU/mL and E2 ≥20 pg/mL) had a significantly higher rate of ≥Grade 2 nausea than the postmenopausal FSH/E2 group (FSH ≥40 mIU/mL and E2 <20 pg/mL) (48.8% vs. 18.8%, p = 0.023).

CONCLUSIONS

Our results suggest that changes in FSH and E2 due to menopause may affect the severity of nausea and that FSH and E2 (especially FSH) levels might be useful indicators for CINV risk assessment.

A deep learning-based interpretable decision tool for predicting high risk of chemotherapy-induced nausea and vomiting in cancer patients prescribed highly emetogenic chemotherapy

OBJECTIVE

This study aims to develop a risk prediction model for chemotherapy-induced nausea and vomiting (CINV) in cancer patients receiving highly emetogenic chemotherapy (HEC) and identify the variables that have the most significant impact on prediction.

METHODS

Data from Tianjin Medical University General Hospital were collected and subjected to stepwise data preprocessing. Deep learning algorithms, including deep forest, and typical machine learning algorithms such as support vector machine (SVM), categorical boosting (CatBoost), random forest, decision tree, and neural network were used to develop the prediction model. After training the model and conducting hyperparameter optimization (HPO) through cross-validation in the training set, the performance was evaluated using the test set. Shapley additive explanations (SHAP), partial dependence plot (PDP), and Local Interpretable Model-Agnostic Explanations (LIME) techniques were employed to explain the optimal model. Model performance was assessed using AUC, F1 score, accuracy, specificity, sensitivity, and Brier score.

RESULTS

The deep forest model exhibited good discrimination, outperforming typical machine learning models, with an AUC of 0.850 (95%CI, 0.780-0.919), an F1 score of 0.757, an accuracy of 0.852, a specificity of 0.863, a sensitivity of 0.784, and a Brier score of 0.082. The top five important features in the model were creatinine clearance (Ccr), age, gender, anticipatory nausea and vomiting, and antiemetic regimen. Among these, Ccr had the most significant predictive value. The risk of CINV decreased with increased Ccr and age, while it was higher in the presence of anticipatory nausea and vomiting, female gender, and non-standard antiemetic regimen.

CONCLUSION

The deep forest model demonstrated good discrimination in predicting the risk of CINV in cancer patients prescribed HEC. Kidney function, as represented by Ccr, played a crucial role in the model's prediction. The clinical application of this predictive tool can help assess individual risks and improve patient care by proactively optimizing the use of antiemetics in cancer patients receiving HEC.

Portuguese consensus on the prevention and treatment of nausea and vomiting induced by cancer treatments

Chemotherapy-induced nausea and vomiting (CINV) and radiotherapy-induced nausea and vomiting (RINV) strongly affect the quality of life of patients with cancer. Inadequate antiemetic control leads to the decline of patients' quality of life, increases rescue interventions, and may even compromise adherence to cancer treatment. Although there are international recommendations for controlling CINV and RINV, these recommendations focus mainly on pharmacological management, with scarce information on additional measures that patients may adopt. Moreover, the prophylaxis and management of CINV/RINV are not always applied. Thus, we identified the need to systematize the strategies for preventing and managing CINV/RINV and the associated risk factors to implement and promote effective prophylactic antiemetic regimens therapy in patients with cancer. This review sought to create a set of practical recommendations for managing and controlling CINV/RINV, according to the current international recommendations for antiemetic therapy and the main risk factors. Conclusively, we intended to produce a patient-centered guidance document for health care professionals focused on the awareness, monitoring, and treatment of CINV/RINV.

Creation of a Peptide Antagonist of the GFRAL-RET Receptor Complex for the Treatment of GDF15-Induced Malaise

Growth differentiation factor 15 (GDF15) is a contributor to nausea, emesis, and anorexia following chemotherapy via binding to the GFRAL-RET receptor complex expressed in hindbrain neurons. Therefore, GDF15-mediated GFRAL-RET signaling is a promising target for improving treatment outcomes for chemotherapy patients. We developed peptide-based antagonists of GFRAL that block GDF15-mediated RET recruitment. Our initial library screen led to five novel peptides. Surface plasmon resonance and flow cytometric analyses of the most efficacious of this group, termed GRASP, revealed its capacity to bind to GFRAL. In vivo studies in rats revealed that GRASP could attenuate GDF15-induced nausea and anorexia resulting from cisplatin. Combined with Ondansetron, GRASP led to an even greater attenuation of the anorectic effects of cisplatin compared to either agent alone. Our results highlight the beneficial effects of GRASP as an agent to combat chemotherapy-induced malaise. GRASP may also be effective in other conditions associated with elevated levels of GDF15.

Screening study of anti-emetics to improve GDF15-induced malaise and anorexia: Implications for emesis control

Considerable preclinical and clinical attention has focused on the food intake and body weight suppressive effects of growth differentiation factor 15 (GDF15) and its elevated blood levels as a consequence of disease states and disease treatment therapeutics. We have previously reported that exogenous administration of GDF15 induces anorexia through nausea and emesis in multiple species. Importantly, GDF15 signaling as a meditator of chemotherapy-induced anorexia and emesis has recently been demonstrated in both murine and nonhuman primate models. The mechanism, however, by which GDF15 induces malaise and the utility of existing therapeutic targets to counteract its effects remain largely unknown. Using a dose of GDF15 that mimics stimulated levels following chemotherapy administration and reliably induces malaise, we sought to screen anti-emetics that represent distinct pharmacotherapeutic classes hypothesized to reduce GDF15-induced effects in rats. Strikingly, our results showed that none of the tested compounds were effective at preventing GDF15-induced malaise. These results illustrate the complexity of GDF15 signaling mechanism and may have important implications for medical conditions characterized by elevated GDF15 levels and incomplete symptom control, such as chemotherapy-induced nausea and vomiting.

Single-dose NEPA versus an aprepitant regimen for prevention of chemotherapy-induced nausea and vomiting in patients receiving moderately emetogenic chemotherapy

INTRODUCTION

Non-inferiority of NEPA (fixed combination of NK1 receptor antagonist (RA), netupitant, and 5-HT3 RA, palonosetron) versus an aprepitant regimen was previously shown in a pragmatic study in patients receiving anthracycline cyclophosphamide (AC) and non-AC moderately emetogenic chemotherapy (MEC). In the MEC group a numerically higher complete response (CR: no emesis, no rescue) rate was seen for NEPA during the overall 0-120 h phase (NEPA 76.1% vs. 63.1% aprepitant). As NEPA exhibits long-lasting efficacy, this study evaluated a prolonged period up to 144 h, beyond the traditional 120 h post-chemotherapy. In this post-hoc analysis we explore the comparative efficacy of NEPA versus the aprepitant regimen in the MEC group up to 144 h, while also assessing the impact of risk factors on CINV prevention.

METHODS

This was a pragmatic, multicenter, randomized, prospective study. Oral NEPA was administered as a single dose on day 1, while aprepitant was given on days 1-3 + ondansetron on day 1; all patients were to receive dexamethasone on days 1-4. Patients were chemotherapy-naïve and receiving MEC, with a subset evaluation of those with a risk factor for developing CINV (i.e., female, male <60 years, male ≥60 years who received carboplatin, or male ≥60 years with anxiety). CR rates were compared during the extended overall (0-144 h) phase.

RESULTS

The MEC group included 211 patients; of these 181 were in the risk factor subset. Significantly higher CR rates were seen for NEPA than aprepitant during the extended overall phase for the total MEC group (NEPA 77.1%, aprepitant 57.8%, p = 0.003) and also in the subset of patients with CINV risk factors (NEPA 73.9%, aprepitant 56.2%, p = 0.012).

CONCLUSION

A single dose of NEPA, administered on day 1 only, was more effective than a 3-day aprepitant regimen in preventing CINV for an extended duration in patients receiving MEC and in those with emetic risk factors.

Fosaprepitant: current options to prevent chemotherapy-induced nausea and vomiting: A review

Background. Chemotherapy (CT) is a mainstay of treatment for malignant tumors. CT-induced nausea and vomiting are observed in 3090% of patients within 0120 h after moderate and highly emetogenic CT administration. These adverse events can severely impact the quality of treatment, daily life, and adherence to treatment, thus reducing the effectiveness of therapy and survival. Materials and methods. The author provides the results of a systematic review of research papers, including clinical studies, on the efficacy of the neurokinin-1 receptor antagonist fosaprepitant to prevent CT-induced nausea and vomiting. Data from the PubMed database were reviewed. Results. The prevention and treatment of CT-associated nausea and vomiting are vital during special therapy, including symptomatic therapy. International organizations recommend using a triple combination with antagonists of neurokinin-1 and 5-hydroxytryptamine-3 receptors and dexamethasone. According to the data obtained, the efficacy of fosaprepitant has been proven in delayed and general phases in several large, well-planned studies; the drug reduces the incidence of adverse events by 2.74.4 times compared with aprepitant. Conclusion. Fosaprepitant is an antagonist of neurokinin-1 receptors; when administered intravenously, it rapidly converts into aprepitant. When used as part of a triple combination with 5-hydroxytryptamine-3 receptor antagonists and dexamethasone in patients receiving moderate and highly emetogenic CT leads to a higher rate of complete response when controlling nausea and vomiting. In general, fosaprepitant is well tolerated.

Cisplatin-Induced Anorexia and Pica Behavior in Rats Enhanced by Chronic Stress Pretreatment

Background: Chemotherapy-induced nausea and vomiting severely impairs the treatment and prognosis of cancer patients. Depressive mood disorder might aggravate nausea and vomiting in cancer patients; however, the role of neurotransmitters and receptors involved in the mediation of emesis and nausea is still not well elaborated.

Methods: The study was carried out based on the chronic unpredictable mild stress–induced depression-like phenotype rat model and cisplatin-induced pica rat model establishment. Forty male Sprague–Dawley rats were randomized into the non-treated control group and the chronic stress group, which were exposed to 8 weeks of stress. Each group was then sub-divided into vehicle subgroups (n = 10) and cisplatin subgroups (n = 10) which were given cisplatin to induce pica behavior. Kaolin and food intake were recorded after administration. The medulla oblongata and ileum tissues were obtained. Neurotransmitters involved in the mediation of emesis and nausea (5-HT, DA, SP, and AEA) were detected using an ELISA kit. Vomit-related receptors (5-HT₃R, DA₂R, NK₁R, and CB₁R) in tissues were assayed for mRNA and protein expression by RT-qPCR and Western blotting.

Results: Behavioral test and sucrose preference validated that depression-like phenotype rat models were established successfully. The kaolin consumption test confirmed that chronic stress pretreatment aggravated anorexia and pica behavior. Vomiting-related molecules’ data showed that chronic stress exposure increased 5-HT and SP levels in the medulla oblongata. Vomiting-related receptor expression data showed that chronic stress pretreatment upregulated 5-HT₃R, DA₂R, and NK₁R expressions and downregulated the CB₁R expression in the medulla oblongata. However, chronic stress pretreatment downregulated 5-HT₃R, DA₂R, and NK₁R expressions and upregulated the CB₁R expression in the ileum.

Conclusion: Chronic stress pretreatment aggravates anorexia and vomiting progress, which might be via altering neurotransmitters and receptors involved in the mediation of emesis and the nausea level and expression in the central nervous system.

Economic Value of Fosaprepitant-Containing Regimen in the Prevention of Chemotherapy-Induced Nausea and Vomiting in China: Cost-Effectiveness and Budget Impact Analysis

Objective

The purpose of this study was to evaluate the cost-effectiveness and budget impact of fosaprepitant (FosAPR)-containing regimen for the prevention of chemotherapy-induced nausea and vomiting (CINV) among patients receiving high emetogenic chemotherapy (HEC) from the Chinese payer's perspective.

Methods

A decision tree model was established to measure the 5-day costs and health outcomes between the APR-containing regimen (aprepitant, granisetron, and dexamethasone) and FosAPR-containing regimen (fosaprepitant, granisetron, and dexamethasone). Clinical data were derived from a randomized, double-blind controlled trial on Chinese inpatients who received HEC. Quality-adjusted life-years (QALYs) were used to estimate the utility outcomes and the incremental cost-effectiveness ratio (ICER) was calculated to assess the economics of FosAPR. A static budget impact model was developed to assess the impact of FosAPR as a new addition to the National Reimbursement Drug List (NRDL) on the medical insurance fund within 3 years in Nanjing, China.

Results

Compared with APR, FosAPR had a mean health-care savings of ¥121.56 but got a reduction of 0.0001815 QALY, resulting in an ICER of ¥669926.19 per QALY. Deterministic sensitivity analysis revealed that the cost of APR was the most influential factor to the ICER. The cost of FosAPR and the complete control rate of the delayed period also had a high impact on the results. According to the probabilistic analysis, the acceptability of FosAPR was more than 80% when the Chinese willingness-to-pay (WTP) was ¥215,999. FosAPR would lead to a 3-year medical insurance payment increase of ¥1.84 million compared with ¥1.49 million before FosAPR entered NRDL in Nanjing. The total budget increased with a cumulative cost of ¥694,829 and covered an additional 341 patients who benefited from FosAPR in Nanjing. Deterministic sensitivity analysis showed that the model of budget impact analysis was stable.

Conclusion

FosAPR had a similar treatment effect to APR but was cost-effective in China at the current WTP threshold. The total budget of medical insurance payments of Nanjing slightly increased year by year after the inclusion of FosAPR. Its inclusion in the NRDL would be acceptable and also expand the coverage of patients who benefited from FosAPR.

FOLFOXIRI and bevacizumab in patients with early-onset metastatic colorectal cancer. A pooled analysis of TRIBE and TRIBE2 studies

BACKGROUND

We performed a pooled analysis of TRIBE and TRIBE2 studies to assess the efficacy and safety of the intensification of upfront chemotherapy backbone - from doublets to the triplet FOLFOXIRI - in combination with bevacizumab (bev) in patients with early-onset metastatic colorectal cancer (EO-mCRC; aged <50 years) and to explore whether EO-mCRCs have a peculiar tumour genomic profiling.

MATERIALS AND METHODS

Subgroup analyses according to age (<50 versus ≥50 years) and treatment (FOLFOXIRI/bev versus doublets/bev) were carried out for rates of any grade and grade ≥3 (≥G3) overall and singular adverse events, progression-free survival (PFS), overall survival (OS) and objective response rate (ORR). Tumour genomic profiling was obtained using a DNA-based next-generation sequencing platform.

RESULTS

Of 1187 patients included, 194 (16%) patients were aged <50 years. Females were more frequently diagnosed with EO-mCRC (P = 0.04). Patients aged <50 years showed a lower risk of ≥G3 neutropenia (P = 0.07), diarrhoea (P = 0.04), asthenia (P = 0.008) and a higher risk of any grade nausea (P < 0.01) and vomiting (P < 0.01). Patients receiving FOLFOXIRI/bev more frequently experienced ≥G3 chemotherapy-related adverse events respect to doublets/bev, regardless of age (Pinteraction = 0.60). FOLFOXIRI/bev was associated to a lower incidence of neutropenia (P = 0.04) and asthenia (P = 0.01) in patients <50 years old, than those aged ≥50 years. PFS, OS and ORR did not differ according to age (PFS P = 0.81, OS P = 0.44, ORR P = 0.50) and no interaction between age and the benefit from the intensification of upfront chemotherapy was observed (PFS Pinteraction = 0.72, OS Pinteraction = 0.54, ORR Pinteraction = 0.65). Genomic profiling was assessed in 296 patients, showing an enrichment of FBXW7 and POLE mutations in EO-mCRC.

CONCLUSIONS

Upfront FOLFOXIRI/bev shows a favourable efficacy/safety balance in EO-mCRC.

TRIAL REGISTRATION

Clinicaltrials.gov Identifiers NCT00719797, NCT0233-9116.

A Practical 5-Step Approach to Nausea and Vomiting

Nausea and vomiting (N/V) are common presenting complaints in the outpatient and inpatient settings. These symptoms can be associated with high morbidity and poor quality of life, particularly in those with chronic symptoms. The clinical approach to N/V can be challenging, given the numerous possible underlying causes as well as the vast array of diagnostic and therapeutic options. In this concise review, we provide a practical 5-step approach to the clinical evaluation and treatment of N/V, suitable for application in the primary care and subspecialty settings. The 5-step approach includes (1) defining what the patient means by N/V, (2) determining whether symptoms are acute or chronic, (3) considering medication or toxin adverse effects, (4) using the patient's presentation, severity of symptoms, and physical examination findings to formulate a differential diagnosis and to guide evaluation, and (5) directing treatment on the basis of knowledge of neurotransmitters and receptors involved in the emetic pathways. We discuss the pathophysiology (neuronal pathways and neurotransmitters), differential diagnosis (medication and toxin adverse effects, neurologic causes, gastrointestinal diseases, metabolic and endocrine conditions, and psychogenic disorders), initial evaluation and risk stratification, and management and treatment options. Management of symptoms that are acute in onset or mild in severity may involve an empirical trial of antiemetics without extensive testing. In contrast, when symptoms are chronic or moderate-severe, testing for an underlying cause should be performed, and medication adverse effects, neurologic causes, gastrointestinal diseases, metabolic or endocrine conditions, and psychogenic disorders should be considered in particular.

Background sensitivity to chemotherapy-induced nausea and vomiting and response to antiemetics in paediatric patients: a genetic association study

Chemotherapy-induced nausea and vomiting (CINV) remains a common adverse effect for children with cancer. In children, chemotherapy emetogenicity and patient factors such as susceptibility to motion sickness and age group determine a patient's risk of CINV. Besides known risk factors, genetic factors may play a role in interindividual variation in the occurrence of CINV. We investigated the influence of candidate gene polymorphisms on the efficacy of antiemetics and on the background sensitivity to CINV in children. This prospective study included 100 children with cancer (median age 6.4 years, range 0.8-17.9) who received moderately to highly emetogenic chemotherapy. Participants registered nausea and vomiting episodes in a mobile app. Genotypes were determined by whole-genome sequencing (n = 79) or Sanger sequencing (n = 21) for 71 genetic polymorphisms involved in motion sickness and antiemetic pathways. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated to estimate associations between acute CINV and genotypes adjusting for susceptibility to motion sickness and age group. Rs3782025 in the 5-hydroxytryptamine type 3 (5-HT3) receptor gene (HTR3B) [minor allele frequency (MAF): 0.48] affected response to 5-HT3 receptor antagonists; acute CINV occurred in 76% of patients with GA/AA genotypes and in 41% of patients with GG genotype (OR 5.59; 95% CI 1.74-17.9, dominant genetic model). Rs2975226 in the dopamine transporter gene (SLC6A3) (MAF: 0.54) was associated with acute CINV (OR 5.79; 95% CI 1.09-30.67, recessive genetic model). Polymorphisms in HTR3B and SLC6A3 may contribute to the variability in response to antiemetic prophylaxis for CINV in children.

A Comparison of the Efficacy of 5 mg Olanzapine and Aprepitant in the Prevention of Multiple-Day Cisplatin Chemotherapy-Induced Nausea and Vomiting

OBJECTIVE

The significance of this article is to talk about aprepitant and olanzapine 5 mg, compare them, and deeply explore the safety or effectiveness during the whole process of multiple-day cisplatin chemotherapy-induced vomiting and nausea.

METHODS

This trial was randomized and prospective. It is needed to receive cisplatin chemotherapy (25 mg/m2/d) for three days. Its patients would need to choose to use 5 mg olanzapine or aprepitant for this treatment, combined with 5-HT3 receptor antagonist plus dexamethasone. The primary endpoints were the total protection (TP) during the acute phase (AP) (0-24 hours), delayed phase (DP) (25-120 hours), and overall phase (OP) (0-120 h) between the two groups. The secondary endpoints were the complete response (CR) and total control (TC) during the three phases. The first time of the whole process is particularly important and needs to be observed vigorously. However, the time of the patient's first vomiting symptom is also compared accurately by using the Kaplan-Meier curve. The functional life index vomiting (FLIE) was used to calculate and carefully evaluate the serious impact of nausea and vomiting (CINV) induced by the whole chemotherapy process on the quality of life. About olanzapine, its related symptoms and other side effects and aprepitant were also recorded.

RESULTS

(1) The primary endpoint TP rates of the olanzapine and aprepitant groups were similar; for the AP, they were 94.23% (98/104) vs. 95.45% (98/106) P=0.61(P=0.61); for the DP, they were 54.81% (57/104) vs. 54.72% (58/106) (P=0.99), and for the OP, the values were 53.79% (58/105) and 55.31% (56/104), respectively (P=0.99). The secondary endpoints, the TC rates, and CR rates were also comparable in the three phases (P > 0.05). (2) After research and display, the results showed that there was no significant difference between the two groups when they were used for the first time of vomiting and the FLIE index (P > 0.05). (3) The main olanzapine-related adverse event was drowsiness, while that of aprepitant was constipation.

CONCLUSION

The efficacy of 5 mg olanzapine was similar to that of aprepitant, and it also showed an advantageous economic potency ratio in preventing CINV induced by multiple-day cisplatin chemotherapy with increased sedation side effects.

Multiple Gastrointestinal Symptoms Are Associated With Chemotherapy-Induced Nausea in Patients With Breast Cancer

BACKGROUND

Unrelieved chemotherapy-induced nausea (CIN) is a significant problem for patients with breast cancer (BC).

OBJECTIVE

In a sample of patients with BC who were assessed before their second or third cycle of chemotherapy, study purposes were to evaluate for the occurrence, severity, frequency, and distress associated with CIN; evaluate for differences in demographic and clinical characteristics and gastrointestinal (GI) symptom occurrence rates between patients who did and did not report CIN; and determine which demographic, clinical, and symptom characteristics were associated with the occurrence of CIN.

METHODS

Patients completed demographic and clinical questionnaires and the Memorial Symptom Assessment Scale for nausea and common GI symptom assessments. Univariate analyses evaluated for differences in demographic and clinical characteristics and GI symptom occurrence between patients who did and did not report CIN. Multiple logistic regression analysis evaluated for characteristics associated with CIN.

RESULTS

Of the 532 patients with BC, 47.2% reported CIN occurrence. Characteristics associated with CIN group membership were poorer functional status, receipt of chemotherapy on a 14-day cycle, and higher occurrence rates of 5 GI symptoms (ie, dry mouth, vomiting, constipation, change in the way food tastes, and lack of appetite; all P < .001).

CONCLUSIONS

Unrelieved CIN is a common symptom in patients with BC. This study is the first to demonstrate that 5 co-occurring GI symptoms were associated with CIN occurrence.

IMPLICATIONS FOR PRACTICE

This study identified new risk factors for CIN occurrence in patients with BC. Clinicians may be able to initiate additional interventions to alleviate CIN.

A Smartphone-Based Decision Support Tool for Predicting Patients at Risk of Chemotherapy-Induced Nausea and Vomiting: Retrospective Study on App Development Using Decision Tree Induction

BACKGROUND

Chemotherapy-induced nausea and vomiting (CINV) are the two most frightful and unpleasant side effects of chemotherapy. CINV is accountable for poor treatment outcomes, treatment failure, or even death. It can affect patients' overall quality of life, leading to many social, economic, and clinical consequences.

OBJECTIVE

This study compared the performances of different data mining models for predicting the risk of CINV among the patients and developed a smartphone app for clinical decision support to recommend the risk of CINV at the point of care.

METHODS

Data were collected by retrospective record review from the electronic medical records used at the University of Missouri Ellis Fischel Cancer Center. Patients who received chemotherapy and standard antiemetics at the oncology outpatient service from June 1, 2010, to July 31, 2012, were included in the study. There were six independent data sets of patients based on emetogenicity (low, moderate, and high) and two phases of CINV (acute and delayed). A total of 14 risk factors of CINV were chosen for data mining. For our study, we used five popular data mining algorithms: (1) naive Bayes algorithm, (2) logistic regression classifier, (3) neural network, (4) support vector machine (using sequential minimal optimization), and (5) decision tree. Performance measures, such as accuracy, sensitivity, and specificity with 10-fold cross-validation, were used for model comparisons. A smartphone app called CINV Risk Prediction Application was developed using the ResearchKit in iOS utilizing the decision tree algorithm, which conforms to the criteria of explainable, usable, and actionable artificial intelligence. The app was created using both the bulk questionnaire approach and the adaptive approach.

RESULTS

The decision tree performed well in both phases of high emetogenic chemotherapies, with a significant margin compared to the other algorithms. The accuracy measure for the six patient groups ranged from 79.3% to 94.8%. The app was developed using the results from the decision tree because of its consistent performance and simple, explainable nature. The bulk questionnaire approach asks 14 questions in the smartphone app, while the adaptive approach can determine questions based on the previous questions' answers. The adaptive approach saves time and can be beneficial when used at the point of care.

CONCLUSIONS

This study solved a real clinical problem, and the solution can be used for personalized and precise evidence-based CINV management, leading to a better life quality for patients and reduced health care costs.

Development of a prediction models for chemotherapy-induced adverse drug reactions: A retrospective observational study using electronic health records

PURPOSE

Chemotherapy-induced adverse drug reactions (ADRs) are common and diverse, and not only affect changes or interruptions to treatment schedules, but also negatively affect the patient's quality of life. This study aimed to predict eight chemotherapy-induced ADRs based on electronic health records (EHR) data using machine-learning algorithms.

METHODS

We used EHR data of 6812 chemotherapy cycles for 935 adult patients receiving four different chemotherapy regimens (FOLFOX, 5-fluorouracil + oxaliplatin + leucovorin; FOLFIRI, 5-fluorouracil + irinotecan + leucovorin; paclitaxel; and GP, gemcitabine + cisplatin) at a tertiary teaching hospital between January 2015 and June 2016. The predicted ADRs included nausea-vomiting, fatigue-anorexia, diarrhea, peripheral neuropathy, hypersensitivity, stomatitis, hand-foot syndrome, and constipation. Three machine learning algorithms were used to developed prediction models: logistic regression, decision tree, and artificial neural network. We compared the performance of the models with area of under the ROC (Receiver Operating Characteristic) curve (AUC) and accuracy.

RESULTS

The AUCs of the logistic regression, decision tree, and artificial neural network models were 0.62-0.83, 0.61-0.83, and 0.62-0.83, respectively, and the accuracies were 0.59-0.84, 0.55-0.88, and 0.57-0.88, respectively. Among the algorithms, the logistic regression models performed best and had the highest AUC for six ADRs (range 0.67-0.83). The nausea-vomiting prediction models performed best with an AUC of 0.83 for the three algorithms.

CONCLUSIONS

The prediction models for chemotherapy-induced ADRs were able to predict eight ADRs using EHR data. The logistic regression models were best suited to predict ADRs. The models developed in this study can be used to predict the risk of ADRs in patients receiving chemotherapy.

Risk factors for chemotherapy-induced vomiting after general anesthesia in children with retinoblastoma: a retrospective study

BACKGROUND

The chemotherapy-induced vomiting (CIV) severely affects the daily function, nutritional status, treatment compliance, therapeutic efficacy, curability, and the quality of life of patients. The aim of this study was to find the risk factors for CIV after general anesthesia in patients with retinoblastoma (RB).

METHODS

A retrospective review of the hospital records of children with RB, who underwent chemotherapy between January 2017 and December 2019, was conducted at our hospital.

RESULTS

Data of a total of 803 children with RB were reviewed. The incidence of CIV in children with RB was 19.30%. Univariate analysis showed statistically significant differences in age, height, weight, chemotherapy regimen, anesthesia dose, duration of surgery and general anesthesia, platelet count, platelet distribution width, lymphocytes, and indirect bilirubin between patients with and without vomiting (P<0.05). Multivariate logistic regression analysis showed that the main predictors of CIV in children with RB included older age [odds ratio (OR), 1.32; 95% confidence interval (CI): 1.11-1.56; P<0.01], low platelet count (OR, 0.997; 95% CI: 0.995-0.999; P<0.05), and chemotherapy regimen (intravenous chemotherapy versus intra-arterial chemotherapy; OR, 0.47; 95% CI: 0.29-0.76; P<0.01).

CONCLUSIONS

This study revealed age, chemotherapy regimen, and platelet count as risk factors of CIV after general anesthesia in children with RB. Younger age and higher platelet count were protective factors for CIV. Compared with intravenous chemotherapy, the incidence of CIV was lower than that of intra-arterial chemotherapy. Although these factors cannot be modified, they can predict whether a patient may experience vomiting, assisting medical staff to formulate measures and intervenes in advance.

KEYWORDS

Retinoblastoma (RB); chemotherapy-induced vomiting (CIV); general anesthesia; multivariate analysis; risk factors.

Palonosetron versus Granisetron in Combination with Aprepitant and Dexamethasone for the Prevention of Chemotherapy-Induced Nausea and Vomiting after Moderately Emetogenic Chemotherapy: A Single-Institutional Retrospective Cohort Study

The triplet antiemetic regimen is administered to prevent chemotherapy-induced nausea and vomiting (CINV) after moderately emetogenic chemotherapy (MEC). However, the superiority of palonosetron over first-generation 5-hydroxytryptamine-3 receptor antagonists in triplet antiemetic therapy remains unclear. In this study, we evaluated the efficacy of palonosetron (PALO) and granisetron (GRA) in triplet antiemetic therapy for CINV. This study included 267 patients who received MEC at our hospital between April 2017 and September 2020. Patients were pretreated with antiemetic therapy comprising PALO or GRA and dexamethasone on day 1 and aprepitant on days 1-3. We evaluated the rate of complete response (CR) (i.e., no vomiting and no use of rescue medication) in the acute phase (0-24 h), delayed phase (24-120 h), and overall phase (0-120 h) after first-cycle chemotherapy. Furthermore, multivariate analysis was conducted to identify risk factors for non-CR. The rate of CR in the overall and delayed phases was significantly higher in the PALO group (91.9 and 91.9%, respectively) than in the GRA group (74.1 and 75.5%, respectively). In the acute phase, the incidence was not different between the GRA and PALO groups (96.5 and 99.2%, respectively). Multivariate analysis revealed that female sex and the use of GRA were risk factors for non-CR. Subgroup analysis revealed the superiority of PALO over GRA in female patients, but not in male patients. In conclusion, PALO was more effective than GRA in triplet antiemetic therapy in preventing CINV during MEC, especially for female patients.

Symptom Clusters in Head and Neck Cancer: A Systematic Review and Conceptual Model

OBJECTIVE

The two approaches to symptom-cluster research include grouping symptoms and grouping patients. The objective of this systematic review was to examine the conceptual approaches and methodologies used in symptom-cluster research in patients with head and neck cancer.

DATA SOURCES

Articles were retrieved from electronic databases (CINAHL, MEDLINE via Ovid, APA PsycINFO, Scopus, Embase, and Cochrane Central Register of Controlled Trials-CENTRAL), five grey literature portals, and Google Scholar. Seventeen studies met the eligibility criteria. Eight studies grouped symptoms to identify symptom clusters, of which two used qualitative methods. The number of symptom clusters ranged from two to five, and the number of symptoms in a cluster ranged from 2 to 11. Nine studies grouped patients based on their experiences with multiple symptoms. Cluster analysis and factor analysis were most commonly used. Despite variable names and composition of symptom clusters, synthesis revealed three prominent symptom clusters: general, head and neck cancer-specific, and gastrointestinal. Being female and quality of life were significantly associated with high symptom group or cluster severity. Biological mechanisms were sparsely examined.

CONCLUSION

Symptom cluster research in head and neck cancer is emerging. Consensus on nomenclature of a symptom cluster will facilitate deduction of core clinically relevant symptom clusters in head and neck cancer. Further research is required on understanding patients' subjective experiences, identifying predictors and outcomes, and underlying mechanisms for symptom clusters.

IMPLICATIONS FOR NURSING PRACTICE

Identification of clinically relevant symptom clusters would enable targeted symptom assessment and management strategies, thus improving treatment efficiencies and patient outcomes.