Chemotherapy-Induced Nausea and Vomiting: Optimizing Prevention and Management

Background

Nausea and vomiting are serious side effects of cancer chemotherapy that can cause significant negative impacts on patients’ quality of life and on their ability to tolerate and comply with therapy. Despite advances in the prevention and management of chemotherapy-induced nausea and vomiting (CINV), these side effects remain among the most distressing for patients.

Objective

To discuss CINV and the current pharmacologic approaches to its management.

Discussion

This article outlines the mechanism of CINV followed by a review of current approaches to pharmacologic therapy and current practice guidelines from national cancer organizations. This information will help providers and payers understand the optimal management of patients with CINV including practical considerations and value-based decision-making that considers cost issues.

Conclusion

Numerous preventive and treatment options are available to manage CINV Addressing antiemetic regimens requires ongoing patient evaluation to determine the best approach for each individual patient.Nausea and vomiting are 2 serious and related side effects of cancer chemotherapy. These adverse effects can cause significant negative impacts on patients’ quality of life and on their ability to comply with therapy. Also, nausea and vomiting can result in anorexia, decreased performance status, metabolic imbalance, wound dehiscence, esophageal tears, and nutritional deficiency.1,2 Despite advances in the prevention and management of chemotherapy-induced nausea and vomiting (CINV), these side effects remain among the most distressing for patients. The use of emerging antiemetic medications has reduced the incidence of vomiting substantially, but evaluations show that approximately 30% to 60% of patients still experience either acute or delayed nausea after chemotherapy.3 Serial evaluations throughout the 1980s and into the 2000s show that, although vomiting has fallen further down on the list of side effects that patients perceive as being their most severe, nausea remains either the first or second most severe side effect of chemotherapy.4–8Risk factors for CINV can be divided into patient-specific and treatment-specific risk factors. Female sex and history of motion or morning sickness are clear risk factors for nausea and vomiting.5,6 Younger age has also been correlated with increased risk, although this may be explained by the more aggressive chemotherapy regimens that tend to be administered to younger patients who have more aggressive diseases.5–7 Finally, alcohol intake tends to be inversely correlated with the risk of developing CINV. Many factors contribute to the treatment-specific risk, including (1) the emetogenicity of the agents being used, (2) the dose and schedule of each agent, and (3) in the case of radiation-induced or postoperative nausea, the site of radiation or surgery.“Emetogenicity” refers to an agent''s tendency to cause nausea and/or vomiting. Initially described in 1997, the emetogenicity scale, also known as the Hesketh scale, divided chemotherapy agents and doses into 5 levels, based on their likelihood to cause CINV.9 Since then, the American Society of Clinical Oncology (ASCO) and the National Comprehensive Cancer Network (NCCN) have modified this scale to be divided into the following 4 categories10,11:

• Highly emetogenic: medications or doses that cause CINV in >90% of patients
• Moderately emetogenic: medications that induce CINV in 30% to 90% of patients
• Low emetogenic: medications that are associated with CINV rates of 10% to 30%
• Minimally emetogenic: medications that cause CINV in <10% of patients.

“CINV” is a broad term used to describe the many types of nausea and vomiting that can occur in patients with cancer. The major subtypes of nausea and vomiting associated with chemotherapy are12–16:

• Acute: onset of nausea and vomiting within minutes to hours after administration of chemotherapy and resolving within 24 hours
• Delayed: occurs 24 hours or later after administration of chemotherapy
• Anticipatory: occurs before chemotherapy administration; thought to be an indicator of previous poor control of nausea and vomiting
• Breakthrough/refractory: nausea and vomiting that occur despite appropriate prophylaxis; requires the use of rescue medications.

Because there are so many independent and variable risk factors that can influence the risk for CINV in any particular patient, it becomes paramount for providers to individualize the approach to the prevention and treatment of CINV in every patient case.