Lori Williams, PhD, RN, Assistant Professor, Department of Symptom Research, The University of Texas M.D. Anderson Cancer Center, Houston, has worked in oncology nursing for more than 30 years, and focuses her research on symptoms of cancer and cancer treatment. Dr Williams is an active member of the Oncology Nursing Society (ONS), where she was previously a director-at-large on the Board of Directors, and is a member of the executive boards for the Patient Advocate Foundation and National Patient Advocate Foundation. She was also the recipient of an American Cancer Society scholarship for doctoral study in oncology nursing. In a recent interview, Dr Williams discussed chemotherapy-induced nausea and vomiting (CINV), including who is most at risk for this side effect, methods of prevention, and options for treatment.
TON: Can you provide a brief overview of chemotherapy-induced nausea and vomiting?
Lori Williams: CINV is a debilitating side effect that occurs in ≤80% of patients receiving chemotherapy, and can greatly affect quality of life.1 There are 3 main types of CINV: anticipatory CINV, which typically occurs within 12 hours before chemotherapy is initiated2; acute CINV, which occurs during the first 24 hours postchemotherapy; and delayed CINV, which occurs after the first 24 hours, and can last up to 5 days or longer postchemotherapy.3,4
TON: Why is prevention of chemotherapy-induced nausea and vomiting important?
Dr Williams:Preventing CINV can help to minimize interruptions in a patient’s chemotherapy treatment, which can impact overall disease management and clinical outcomes. It is also important to prevent and treat CINV because it reduces anxiety that can lead to anticipatory nausea and vomiting.3,4
TON: Why is there no cure for chemotherapy-induced nausea and vomiting?
Dr Williams: It can be very difficult for healthcare providers to find the right antiemetic or combination of antiemetic medications that will prevent or alleviate symptoms of nausea and vomiting. Of course, this can be very frustrating for the patient as well.
Nurses and other clinicians must be knowledgeable about current antiemetic guidelines so that they can treat patients to the best of their ability. It is important to collaborate with oncologists when antiemetic strategies are not achieving desired results.
TON: Who is most at risk for developing chemotherapy-induced nausea and vomiting?
Dr Williams: Patients receiving highly and moderately emetogenic chemotherapy are at high risk for developing CINV. Combination therapy and multiday regimens can also be more emetogenic and put patients at high risk for acute and delayed CINV.4
Certain genetic and lifestyle factors can also place patients at a high risk for CINV. Women and individuals aged <50 years are at a higher risk for developing CINV than others receiving chemotherapy.5 Additional factors that may increase risk for CINV include having had previous chemotherapy treatments, a history of little to no alcohol intake, current use of antidepressants or antianxiety medications, and a history of motion sickness or morning sickness.6
TON: How is chemotherapy-induced nausea and vomiting treated?
Dr Williams: Although there has been a decline in the number of patients who experience CINV in recent years, it still remains a debilitating side effect for many patients undergoing chemotherapy.6,7 Finding the right antiemetic requires a collaborative effort between the patient, nurse, and physician. In many cases, it takes time to find the most effective regimen.
Organizations such as the American Society of Clinical Oncology (ASCO), the National Comprehensive Cancer Network, and the Multinational Association of Supportive Care in Cancer/European Society for Medical Oncology have published antiemetic guidelines for patients undergoing chemotherapy.8-10 Recommendations for preventing and treating CINV are generally determined by the level of emetogenicity of anticancer therapies.
TON: Is there a preferred method to treat chemotherapy-induced nausea and vomiting?
Dr Williams:The simple answer to this question is “no.” Each patient is different, and will therefore respond differently than another patient to a treatment option. Although a patient may be a candidate for a specific antiemetic therapy, he or she may respond negatively to it. Therefore, it is important to always have a backup option.
Two of the biggest challenges clinicians face regarding the prevention and treatment of CINV are finding the right antiemetic therapy, and administering that therapy in a way that is the most beneficial to the patient. There are several methods of administration, but the 3 most common ones are orally, by injection, and with a transdermal patch.
Ondansetron is an oral medication that can be effective in the prevention and treatment of CINV.11 Dosage of this drug will vary based on whether the patient is receiving highly emetogenic or moderately emetogenic chemotherapy. However, oral medications are not the ideal option for patients who experience emesis, who have difficulty swallowing because of dysphagia or oral mucositis, or who are unable to absorb or retain oral medications. For these patients, intravenous injections or transdermal patches may be viable alternatives.
Palonosetron is an injectable medication that is administered through the same intravenous line as a patient’s chemotherapy. It is a preventive option used for the treatment of acute and delayed CINV.12
Granisetron transdermal patches are another option for patients with emesis who have difficulty taking a pill. These patches, which are placed on intact, clean skin of the upper, outer arm, release the medication into the patient’s bloodstream.13 Granisetron transdermal patches last for 1 week and are used as treatment for CINV that occurs with highly emetogenic and moderately emetogenic chemotherapy regimens.
TON: What resources can oncology nurses use to support their patients?
Dr Williams: The ONS offers a variety of resources for nurses to use when educating themselves on how to better help their patients, including:
- Putting Evidence Into Practice. A library of resources designed by teams of nurse scientists, advanced practice nurses, and staff nurses to help summarize and synthesize evidence available on a variety of oncology-related topics. These include resources for the prevention and management of CINV
- ASCO/ONS Chemotherapy Administration Safety Standards. In partnership with ASCO, the ONS has developed comprehensive guidelines for safe chemotherapy administration
- Get Up, Get Moving. A national campaign aimed at encouraging oncology nurses to implement strategies that will help patients receiving anticancer therapy participate in physical activity.
1. Ware MA, Daeninck P, Maida V. A review of nabilone in the treatment of chemotherapy-induced nausea and vomiting. Ther Clin Risk Manag. 2008;4:99-107.
2. Rice MM. Management of chemotherapy-induced nausea and vomiting. OncoLink. Updated July 16, 2011. www.oncolink.org/healthcare-professionals/o-pro-portal/articles-about-cancer-treatment-and-medications/management-of-chemotherapy-induced-nausea-and-vomiting. Accessed January 5, 2017.
3. Mustian KM, Devine K, Ryan JL, et al. Treatment of nausea and vomiting during chemotherapy. US Oncol Hematol. 2011;7:91-97.
4. Celio L, Ricchini F, De Braud F. Safety, efficacy, and patient acceptability of single-dose fosaprepitant regimen for the prevention of chemotherapy-induced nausea and vomiting. Patient Prefer Adherence. 2013;7:391-400.
5. National Cancer Institute. Nausea and vomiting (PDQ)-patient version. Updated September 2, 2015. www.cancer.gov/about-cancer/treatment/side-effects/nausea/nausea-pdq#link/_25. Accessed June 23, 2016.
6. Canosa R, Gentry S. Helping your patients manage chemotherapy-induced nausea and vomiting. Journal of Oncology Navigation & Survivorship. 2012;3:22-26.
7. Camp-Sorrell D. Chemotherapy: toxicities and management. In: Yabro CH, Wujcik D, Gobel BH, eds. Cancer Nursing: Principles and Practice. 7th ed. Sudbury, MA: Jones and Bartlett Publishers; 2011:458-503.
8. Hesketh PJ, Bohlke K, Lyman GH, et al. Antiemetics: American Society of Clinical Oncology focused guideline update. J Clin Oncol. 2016;34:381-386.
9. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Antiemesis. Version 2.2016. www.nccn.org/professionals/physician_gls/pdf/antiemesis.pdf. Accessed January 5, 2017.
10. Multinational Association of Supportive Care in Cancer/European Society for Medical Oncology (MASCC/ESO) Antiemetic Guideline 2016. Updated March 2016. www.mascc.org/assets/Guidelines-Tools/mascc_antiemetic_guidelines_english_2016_v.1.2.pdf. Accessed January 5, 2017.
11. Zofran (ondansetron) [package insert]. Dorval, Quebec: Novartis Pharmaceuticals Canada. Revised January 14, 2016.
12. Aloxi (palonosetron HCI) [package insert]. Woodcliff Lake, NJ: Eisai. Revised December 2015.
13. Sancuso (granisetron transdermal system) [package insert]. Bridgewater, NJ: ProStrakan. Revised September 2015.