As healthcare professionals who work with people living with cancer, we often see patients when they are most vulnerable. For many patients, their moments of greatest vulnerability are at the time of diagnosis and while discussing treatment. During such moments, patients typically feel overwhelmed and inundated with a large amount of information to process and assimilate, while at the same time dealing with the emotional impact of a cancer diagnosis. Much of that information consists of basics on their type of cancer and the recommended course of therapy, including instructions on adhering to the therapeutic regimen. Not surprisingly, information and instructions from doctors and nurses may not be fully integrated, or may easily get “scrambled,” during such a tender time. Patients may therefore lack a full understanding of the importance of following those instructions, or may even forget them. While forgetting or not fully understanding disease-related information may have tremendous ramifications for many aspects of cancer care, it can be particularly impactful when dealing with the nausea and vomiting that is often caused by chemotherapy.
Chemotherapy-Induced Nausea and Vomiting: The Scope of the Problem
The benefits of cytotoxic chemotherapy are undisputed. It is a type of therapy that has extended the lives of untold millions of cancer patients. Yet chemotherapy is often associated with unpleasant side effects that negatively affect patients’ quality of life. One of the more debilitating side effects is chemotherapy-induced nausea and vomiting (CINV), a term that describes the symptoms of nausea and vomiting that occur in reaction to chemotherapeutic agents.1 For cancer patients receiving chemotherapy or radiation therapy, CINV can compromise or negate the benefits of treatment by making it very difficult for the patient to adhere to the therapeutic regimen, or by triggering an interruption or delay of treatment.
While all patients undergoing chemotherapy are at risk of CINV, there are numerous factors that can heighten a patient’s risk of this dreaded complication. Such risk factors include2,3:
- Age less than 50 years
- Being female
- Low alcohol intake (one or fewer drinks per day)
- History of motion sickness, or of morning sickness with pregnancy
- Fear of nausea from chemotherapy or a history of CINV
- Anxiety or nausea associated with past stress
- Current use of antidepressants or antianxiety medication
There are also numerous treatment-related factors that can affect the incidence and severity of CINV. These include the dosage, schedule, and route of administration of the chemotherapy regimen; the level of emetogenicity (likelihood of causing vomiting) of the regimen; the use of multiple agents in the regimen; and multiple cycles of chemotherapy.2,4 Chemotherapeutic agents can be categorized according to emetogenicity. Highly emetogenic chemotherapy (HEC) denotes a regimen that induces emesis (vomiting) in more than 90% of patients in the absence of effective prophylactic antiemetic therapy,4 although only about 30% of these patients will vomit if they receive antiemetic prophylaxis before administration of HEC.3,5,6 A moderately emetogenic chemotherapy (MEC) regimen is one that carries a 30% to 90% risk of emesis.4 Regimens carrying a low risk of emesis are those that induce emesis in only 10% to 30% of patients, and treatments with minimal emetogenic risk cause emesis in less than 10% of patients.4
While CINV is quite common, its incidence can vary greatly and is difficult to determine. In a 1996 clinical trial, CINV was reported in 47 of 48 patients (98%) receiving HEC without antiemetic therapy.7 In a 2004 trial in which 298 patients were treated with antiemetics while receiving MEC or HEC, one-third of the participants experienced acute nausea (ie, that which occurs within a few minutes to several hours after a chemotherapy dose), and the incidence of delayed nausea (ie, more than 24 hours after chemotherapy administration) was 60%.8 In a 2005 study of 857 women with breast cancer who received antiemetic prophylaxis while on MEC, half of the patients experienced CINV.9 Although the incidence of CINV has declined over the past decade, CINV remains a threat to patients with cancer.
CINV can have a profound impact on patients’ quality of life, potentially leading to metabolic imbalances, a decline in patients’ self-care and functional ability, worsening of patients’ perfor-mance status and mental status, nutrient depletion, anorexia, surgical wound dehiscence (bursting open or splitting), esophageal tears, and patients’ refusal, delaying, or prevention of additional therapy.10-13 CINV can also impose a significant socioeconomic burden by reducing employee productivity and boosting overall healthcare costs due to prolonged hospitalization and increased nursing expenses.14 A recent retrospective study calculated the mean cost of a CINV-related hospital visit at $5299, with a mean per-patient cost of $731.15
The Value of Antiemesis
In our experience, CINV is easier to prevent than to treat. Many patients experience cancer as a chronic disease, and can benefit from the use of antiemetic medications during all phases of treatment. A variety of antiemetic agents are available, including those that can be administered by the oral, rectal, intravenous (IV), intramuscular, or transdermal route. IV agents may be appropriate for patients who are unable to swallow or digest tablets due to emesis, while others may benefit from having antiemetic medication delivered via a transdermal patch, which may help reduce the pill burden and simplify treatment for these patients. The National Comprehensive Cancer Network, in its latest antiemesis treatment guidelines,4 cautions that while some studies suggest that certain agents are equally effective on a population basis, individual patients may respond differently, and a patient’s individual experience may drive the selection of antiemesis therapy.
Serotonin (5-HT3) antagonists, a class of agents that includes dolasetron mesylate, granisetron, ondansetron, and palonosetron, are commonly used for the prevention and treatment of CINV. The oral and IV forms of these agents have been shown to have equivalent efficacy when administered at the appropriate doses,16,17 and granisetron is also available as a transdermal patch with demonstrated effectiveness for up to 5 days from first application. Another common preventive regimen is a “cocktail” containing the neurokinin-1 (NK-1) receptor antagonist aprepitant (or its IV version fosaprepitant), the corticosteroid dexamethasone, and a benzodiazepine agent such as olanzapine.4 Other types of agents, such as phenothiazines, benzamides, antihistamines, butyrophenones, and cannabinoids, have also been used for antiemesis, although these have largely been replaced by the 5-HT3 antagonists.4
Challenges in Adhering to Antiemetic Medication Regimens
Once a patient has started chemotherapy, anxiety and emotional stress may complicate any efforts to adhere to antiemesis therapy. This is especially true of patients having their first experience with chemotherapy, although it may still be a lingering issue through subsequent rounds. All too often, when a patient is taught what to expect from chemotherapy, she nods and appears to understand the educational information and is sent home after round one. Three days later she feels sick and anxious. She may be experiencing a “drop-off” effect from the antiemesis regimen, or may not have taken the drugs as instructed. Even if she followed instructions, the drugs may not have worked as expected. “I don’t know what to do,” she says, adding that she feels so bad that the emergency room (ER) seems a reasonable option.
Two key nursing actions can help the patient through this vulnerable time. The first action is the “teach-back” method (also known as the “show-me” method or “closing the loop”), which must be undertaken before the patient leaves her first chemotherapy treatment session.18 Once the patient has been briefed on strategies to manage CINV, the “teach-back” method largely consists of asking the patient questions such as, “Tell me what you are going to do if you feel nauseous or have uncontrolled vomiting.” The patient’s answers may reveal that she did not fully understand the information you have provided and that more information is required. In such situations, chances are that the patient’s anxiety and insecurity made her afraid to speak up during the briefing, or that she does not feel comfortable enough to ask questions about the antiemesis medication and its accompanying instructions. Whenever possible, it is important that the briefing include family members or whoever will be with the patient after treatment.
The second key action is to have a nurse navigator or clinical nurse call the patient at home after treatment. A review of the educational content, as well as an assessment of the efficacy of the antiemesis medications, can confer a measure of control to the patient at this critical time. Documentation of “real-time” symptoms can lead to needed medication changes prior to the next cycle of treatment. In a 2010 article, Sprandio documented how a community oncology practice achieved a drop in ER visits as well as a decrease in unscheduled office visits when this quality check was implemented.19 The resulting cost savings from avoiding CINV-related hospital visits can thus be an important metric for nurse navigators to support their role.
Sometimes, financial difficulties can interfere with patients’ efforts to adhere to antiemetic therapy. For some patients, the cost of treatment is simply too high. Others may struggle to pay the co-pay, even if their insurance covers the rest of the cost. As a result, patients may skip or delay an antiemesis dose, an omission that can have a ruinous effect on their quality of life, not to mention their chemotherapy experience as a whole. Some patients may have limited access to antiemesis treatment. A lack of reliable transportation may make it difficult, if not impossible, to get to the doctor’s office, clinic, or pharmacy. Needless to say, a patient will have trouble adhering to a medication regimen if he lacks the means to obtain it. The role of the social worker or nurse navigator is critical in identifying such patients so financial issues can be addressed before they become a concern.
Oftentimes, adherence to antiemesis therapy is compromised by patients’ misperceptions of treatment. Fear of addiction (the risk of which is minimal with antiemesis medications) is a powerful force in our society, and some patients may opt to forgo antiemesis medication rather than endure the perceived stigma of being “on drugs.”
The challenges of managing CINV make it crucial for the oncology nurse, nurse navigator, and oncology social worker to encourage patients to communicate proactively with the health professionals who are coordinating their care. We need to tell patients not to be afraid to speak up if the antiemesis medication is not working, or if they do not fully understand the instructions for taking it. We need to make it clear that it’s OK to ask questions, and that a patient should not wait until the next appointment or next round of chemotherapy to raise her concerns.
In our experience, treatment-related information needs to be reinforced repeatedly. Not only is it important to ask patients if they truly understand what is expected of them, but it is also important to follow up and ask if they have been taking the medication as directed. Before they leave the clinic, it is helpful to have patients repeat the instructions back to you to make sure they understand them.
The importance of adhering to antiemesis medication cannot be overemphasized. We need to help patients overcome whatever fears or beliefs may be preventing them from adhering to antiemetic therapy. None of these fears or beliefs is a reason for any cancer patient to have to endure CINV, or to refuse or delay antiemesis therapy.
Above all, patients need to feel empowered and equipped with the information they need to help them manage their disease. Organizations such as CancerCare offer a variety of educational resources specifically focusing on CINV (see Box). It is our obligation to share that information; we cannot assume that people will get it from some other source. At the same time, we need to work to ensure patients have the financial, logistical, and emotional support they need to access their medications and supportive care resources. In some cases, that support may consist of connecting patients with co-pay assistance programs, compassionate-use initiatives, or clinical trials. In other cases, we can help arrange transportation, or facilitate the involvement of family members, friends, or other caregivers to ease the burden on the cancer patient. If we are to give patients permission to be proactive in managing their disease, we must be proactive ourselves in helping them.
Helping patients manage CINV:
CancerCare educational resources
- Limit the use of satisfaction surveys to navigator-specific patient satisfaction tools and use data from the survey not only to assess patient satisfaction but also to identify opportunities to refine your navigation program.
- Connect® Education workshops and podcasts:
- Advances in Treating Chemotherapy-Related Nausea and Vomiting
- Understanding and Managing Chemotherapy Side Effects
- Coping With Nausea and Vomiting From Chemotherapy
- Tips for Managing Nausea and Increasing Appetite During Cancer Treatment
- Understanding and Managing Chemotherapy Side Effects
- “Doctor, Can We Talk?” Tips for Communicating With Your Health Care Team
- Online forums
- Ask CancerCare: experts answer questions about coping with cancer
From the time of diagnosis, the patient with cancer embarks upon a life-changing journey marked by multiple rounds of treatment and follow-up. The journey may include treatment response and cancer remission. On the other hand, the itinerary for the journey may change to account for disease progression and downstream treatment options. In most cases, the patient has not planned for this journey and may feel vulnerable, alone, and unprepared for the inevitable bumps in the road. If managed correctly and appropriately, CINV is a bump that can be avoided, or at least made less disruptive to the patient’s life. As oncology nurses, nurse navigators, and patient advocates, we are in an important position to help patients negotiate those challenges by providing and reinforcing treatment- and supportive care-related information, facilitating communication with doctors and other health professionals, and encouraging patients to be proactive in managing the various aspects of their care. In so doing, we can demonstrate to our patients that they are not alone. By serving as trusted guides, we may be able to make the cancer journey a bit less harrowing.
Disclosures: Rosalie Canosa, LCSW-R, has no conflict of interest or financial interest to disclose. Sharon Gentry, RN, MSN, AOCN, CBCN, has no conflict of interest or financial interest to disclose.
- Chemotherapy-induced nausea and vomiting. Mosby’s Medical Dictionary, 8th ed. Elsevier, Inc; 2009. TheFreeDictionary Web site. http://medical-dictionary.thefreedictionary.com/chemotherapy-induced+nausea+and+vomiting. Accessed June 25, 2012.
- Stricker CT, Eaby-Sandy B. Chemotherapy-induced nausea and vomiting. In: Brown CG, ed. A Guide to Oncology Symptom Management. Pittsburgh, PA: Oncology Nursing Society; 2010:91-122.
- Hesketh PJ, Grunberg SM, Herrstedt J, et al. Combined data from two phase III trials of the NK1 antagonist aprepitant plus a 5HT3 antagonist and a corticosteroid for prevention of chemotherapy-induced nausea and vomiting: effect of gender on treatment response. Support Care Cancer. 2006;14(4):354-360.
- National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Antiemesis. Version 1.2012. http://www.nccn.org/professionals/physician_gls/pdf/antieme sis.pdf. Accessed November 7, 2011.
- Hesketh PJ, Kris MG, Grunberg SM, et al. Proposal for classifying the acute emetogenicity of cancer chemotherapy. J Clin Oncol. 1997;15(1):103-109.
- Roila F, Herrstedt J, Aapro M, et al. Guideline update for MASCC and ESMO in the prevention of chemotherapy- and radiotherapy-induced nausea and vomiting: results of the Perugia consensus conference. Ann Oncol. 2010;21(suppl 5): v232-v2343.
- Kris MG, Cubeddu LX, Gralla RJ, et al. Are more antiemetic trials with a placebo necessary? Report of patient data from randomized trials of placebo antiemetics with cisplatin. Cancer. 1996;78(10):2193-2198.
- Grunberg SM, Deuson RR, Mavros P, et al. Incidence of chemotherapy-induced nausea and emesis after modern antiemetics: perception versus reality. Cancer. 2004;100(10): 2261-2268.
- Warr DG, Hesketh PJ, Gralla RJ, et al. Efficacy and tolerability of aprepitant for the prevention of chemotherapy-induced nausea and vomiting in patients with breast cancer after moderately emetogenic chemotherapy. J Clin Oncol. 2005;23(12): 2822-2830.
- Laszlo J. Emesis as limiting toxicity in cancer chemotherapy. In: Laszlo J, ed. Antiemetics and Cancer Chemotherapy. Baltimore, MD: Williams & Wilkins; 1983:1-5.
- Ingle RJ, Burish TG, Wallston KA. Conditionability of cancer chemotherapy patients. Oncol Nurs Forum. 1984;11(4):97-102.
- Mitchell EP. Gastrointestinal toxicity of chemotherapeutic agents. Semin Oncol. 1992;19(5):566-579.
- Richardson JL, Marks G, Levine A. The influence of symptoms of disease and side effects of treatment on compliance with cancer therapy. J Clin Oncol. 1988;6(11):1746-1752.
- O’Brien BJ, Rusthoven J, Rocchi A, et al. Impact of chemotherapy-associated nausea and vomiting on patients’ functional status and on costs: survey of five Canadian centres. CMAJ. 1993;149(3):296-302.
- Burke TA, Wisniewski T, Ernst FR. Resource utilization and costs associated with chemotherapy-induced nausea and vomiting (CINV) following highly or moderately emetogenic chemotherapy administered in the US outpatient hospital setting. Support Care Cancer. 2011;19:131-140.
- Kris MG, Gralla RJ, Clark RA, et al. Incidence, course, and severity of delayed nausea and vomiting following the administration of high-dose cisplatin. J Clin Oncol. 1985;3(10):1379-1384.
- Kris MG, Hesketh PJ, Somerfield MR, et al. American Society of Clinical Oncology guideline for antiemetics in oncology: update 2006. J Clin Oncol. 2006;24(18):2932-2947.
- North Carolina Program on Health Literacy. Health Literacy Toolkit. Tool 5. http://www.nchealthliteracy.org/toolkit/tool5.pdf. Accessed September 7, 2012.
- Sprandio JD. Oncology patient-centered medical home and accountable cancer care. Commun Oncol. 2010;7(12):565 -572.