Patient expectation is a strong predictor of severe nausea after chemotherapy

Acupressure bands are effective in reducing radiation therapy-related nausea

Previous studies have shown that acupressure bands can reduce chemotherapy-related nausea. Patients' expectations of efficacy account for part of this outcome. We conducted a three-arm randomized clinical trial to investigate the effectiveness of acupressure bands in controlling radiation therapy-induced nausea and to test whether an informational manipulation designed to increase expectation of efficacy would enhance the effectiveness of the acupressure bands. Patients who experienced nausea at prior treatments were randomized to either standard care (Arm 1, n=29) or standard care plus acupressure bands with either neutral (Arm 2, n=30) or positive (Arm 3, n=29) information regarding the efficacy of the bands. Patients reported nausea for two days prior to randomization (baseline) and for five days following using a seven-point semantic rating scale (1=not nauseated to 7=extremely nauseated). Patients in Arms 2 and 3 combined reported greater reduction in average nausea than patients in Arm 1 (P=0.01; mean(bands)=0.70, mean(no bands)=0.10). This equates to a 23.8% decrease in nausea in the band groups compared to a 4.8% decrease in the control group, a 19% difference. The informational manipulation failed to alter efficacy expectations and there was no statistically significant difference in nausea between patients in Arms 2 and 3. Acupressure bands are an effective, low-cost, nonintrusive, well-accepted, and safe adjunct to standard antiemetic medication. An attempt to boost the efficacy of the acupressure bands by providing positive information was not successful.

Insight in the prediction of chemotherapy-induced nausea

PURPOSE

To identify risk factors for chemotherapy-related nausea.

METHODS

We examined risk factors for nausea in 1,696 patients from three multicenter studies conducted from 1998 to 2004. All patients were beginning a chemotherapy regimen containing cisplatin, carboplatin, or doxorubicin. Nausea was assessed on a 1-7 scale four times a day for 4 days by diary.

RESULTS

First, average nausea for breast cancer patients receiving doxorubicin (mean = 2.31) was significantly greater than for other patients receiving doxorubicin (mean = 1.82), patients receiving cisplatin (mean = 1.88), and patients receiving carboplatin (mean = 1.45), Ps < 0.01. Second, mean nausea decreased steadily with age, P < 0.0001. Third, patients rating themselves more susceptible to nausea had significantly more nausea (adjusted mean = 2.51) than patients rating themselves less susceptible (adjusted mean = 1.92) and were 2.8 times more likely to experience severe nausea, Ps < 0.0001. Fourth, expected nausea was a significant predictor of average nausea, P = 0.034, but not severe nausea, P = 0.31. Last, no evidence that gender is a significant predictor of nausea in 299 patients with gender neutral cancers, P = 0.35.

CONCLUSIONS

Specific patient characteristics, especially younger age and perceived susceptibility to nausea, can help clinicians in the early identification of patients who are more susceptible to treatment-related nausea.

Reduction of chemotherapy-induced anorexia, nausea, and emesis through a structured nursing intervention: a cluster-randomized multicenter trial

OBJECTIVES

The purpose of this present study was to evaluate Self-care Improvement through Oncology Nursing (SCION) program to reduce distressing anorexia, nausea, and emesis (ANE) in cancer patients undergoing chemotherapy.

METHODS

Two hundred eight patients receiving chemotherapy with moderate to high emetogenic potential participated in a cluster randomized trial on 14 wards in two German university hospitals. Additionally to standard antiemetic treatment, patients from the intervention wards received the SCION program consisting of four modules: advisory consultation, optimizing emesis prophylaxis, nutrition counseling, and relaxation. Patients from the control group received standard antiemetic treatment and standard care. Primary outcome was the group difference in ANE intensity assessed by Common Terminology Criteria for adverse events (CTCAE).

MAIN RESULTS

The SCION program did not result in a significant difference in the incidence of ANE symptoms as compared to standard care: mean difference on CTCAE scale was 0.24 pts (95%CI, -1.17 to 1.66 pts; P = 0.733). No difference could be found regarding patients' knowledge of side effects, self-care interventions, and agency. Health-related quality of life was significantly better for patients in the control group (mean difference 10.2 pts; 95%CI, 1.9 to 18.5; P = 0.017).

CONCLUSIONS

Contrary to our expectations, the groups did not differ in ANE intensity caused by the overall low acute or delayed symptom intensity. Symptom hierarchy in cancer patients alters and challenges nursing interventions targeting the patients' self-care strategies.

Acute and long-term gastrointestinal consequences of chemotherapy

There are many anti-neoplastic agents in cancer treatment. Combination regimens are often the main standard treatment, particularly for gastrointestinal malignancies. The introduction of new regimens that combine fluoropyrimidines with irinotecan or oxaliplatin and recently also with antibodies against the Epidermal Growth Factor Receptor (EGFR) (cetuximab and panitumumab) and against the Vascular Endothelial Growth Factor (VEGF) (bevacizumab) pathways, has dramatically improved the progression free survival and survival of patients with metastatic colorectal cancer. This rapid extension of available anti-neoplastic drugs has, however, also highlighted the urgent need for clinicians to better understand and identify the spectrum of acute and late toxicities of these drugs. Acute and long-term adverse effects are inherent to non-surgical cancer treatment using chemotherapy and/or radiation therapy, which can profoundly affect the gastrointestinal tract leading to a wide spectrum of acute and late toxicities. An improved knowledge of the aetiology, incidence, supportive measures and of the prevention of these toxicities is warranted to improve patient care. We herein review and discuss the main acute and late gastrointestinal toxicities of chemotherapy and/or radiotherapy for patients with gastrointestinal malignancies.

How do patient expectancies, quality of life, and postchemotherapy nausea interrelate?

BACKGROUND

Increasing evidence suggests a relation between patient expectancies and chemotherapy-induced nausea. However, this research has often failed to adequately control for other possible contributing factors. In the current study, the contribution of patient expectancies to the occurrence and severity of postchemotherapy nausea was examined using more stringent statistical techniques (namely hierarchical regression) than other similar studies that have relied on bivariate correlations, chi-square tests, and stepwise regression, and further extended upon previous research by including quality of life (QoL) in the analysis.

METHODS

In all, 671 first-time chemotherapy patients taking part in a trial comparing antiemetic regimens answered questions regarding their expectancies for experiencing nausea. Patients then completed a diary assessing both the occurrence and severity of their nausea in the 4 days after their first infusion.

RESULTS

Stronger expectancies for nausea corresponded with greater average and peak nausea after chemotherapy and this was after controlling for age, sex, susceptibility to motion sickness, diagnosis, and QoL. Interestingly, patients classified as highly expectant (first quartile) experienced significantly greater average and peak nausea than those classified as somewhat expectant, slightly expectant, and not expectant (second, third, and fourth quartiles, respectively), whereas there were no significant differences between these lower levels of expectancy. Furthermore, increases in average nausea led to a significant reduction in QoL after chemotherapy.

CONCLUSIONS

Patient expectancies appear to contribute to postchemotherapy nausea and patients that are highly expectant of experiencing nausea appear to be at particular risk. Interventions that target these patients should reduce the burden of nausea and may also improve QoL.

Effect of a nausea expectancy manipulation on chemotherapy-induced nausea: a university of Rochester cancer center community clinical oncology program study

Several studies have shown that patients' expectancies for the development of nausea following chemotherapy are robust predictors of that treatment-related side effect, and some studies have shown that interventions designed to influence expectancies can affect patients' reports of symptoms. In this randomized, multicenter, Community Clinical Oncology Program trial, we investigated the effect of an expectancy manipulation designed to reduce nausea expectancy on chemotherapy-induced nausea in 358 patients scheduled to receive chemotherapy treatment. Patients in the intervention arm received general cancer-related educational material plus specific information about the efficacy of ondansetron, specifically designed to diminish nausea expectancy. Patients in the control arm received only the general cancer-related educational material. Nausea expectancy was assessed both prior to and following the educational intervention. We observed a significant reduction in nausea expectancy in the intervention group (P=0.024) as compared to the control group (P=0.34). In the intervention group, patients' expectations of nausea assessed prior to the intervention correlated significantly with average nausea (r=0.27, P=0.001), whereas nausea expectancy assessed following the intervention did not (r=0.1, P=0.22). Although the expectancy manipulation reduced patients' reported expectations for the development of nausea, the occurrence of nausea was not reduced. Furthermore, post-intervention nausea expectancy compared to pre-intervention expectancy was less predictive of subsequent nausea. Explanations for these findings include the possibility that the expectancy manipulation was not strong enough, and the possibility that changing nausea expectancies does not change occurrence of nausea.

Chemotherapy-Induced Nausea and Vomiting

Despite treatment advances, nausea and vomiting, especially anticipatory nausea and vomiting, delayed nausea and vomiting and nausea alone, are still the most common, expected and feared side effects among patients receiving chemotherapy. Of the 70 to 80% of cancer patients who experience chemotherapy-induced nausea and vomiting many will delay or refuse future chemotherapy treatments and contemplate stopping all treatments because of fear of further nausea and vomiting. The purpose of this chapter is to provide an overview of the patho-psychophysiology of CINV, the recommended guidelines for standard treatment, and highlight newer targeted treatment approaches.

Chemotherapy-induced nausea, vomiting, and fatigue--the role of individual differences related to sensory perception and autonomic reactivity

BACKGROUND

In spite of antiemetics, postchemotherapy side effects continue to be common and may affect compliance to cancer treatment. Among the known factors associated with increased symptom severity are: younger age, treatment toxicity, expected severity, and distress, but little is still known about the role of other factors. The aim of our study was to investigate the role of individual differences related to sensory perception for posttreatment side effects.

METHODS

Hundred and twenty-five women receiving adjuvant chemotherapy for breast cancer completed measures of absorption, autonomic perception, somatosensory amplification, trait anxiety, and expected severity at baseline. Pretreatment distress and posttreatment nausea, vomiting, and fatigue were assessed at the 1st, 4th, 6th and last cycles of chemotherapy.

RESULTS

While univariate analyses showed several factors to be associated with side effects, only absorption and pretreatment distress remained independent predictors of nausea and fatigue when controlling for the remaining factors. Posttreatment vomiting was only predicted by expected severity of vomiting.

CONCLUSION

Chemotherapy-induced side effects are related to increased autonomic nervous system activity, and absorption has been associated with increased autonomic nervous system reactivity to stress. The results suggest that individuals with high absorption may be at greater risk for developing side effects. Improved precision in identifying patients at risk of experiencing more severe side effects after cancer treatment will increase the ability to target treatments aimed at reducing these side effects.

Gastrointestinal cancer web sites: how do they address patients' concerns?

BACKGROUND

We studied the quality of web sites containing information on gastrointestinal cancer, focusing on the way these web sites dealt with the special concerns of these patients.

MATERIALS AND METHODS

Searching the Internet for German-language gastroenterological cancer web sites, we collected 9,947 web pages from 14 search engines. Evaluation was done with a 36-item questionnaire. Information quality, availability of the web sites, and web site attributes considering patients' concerns and potential embarrassment were analyzed using a scoring system.

RESULTS

Belonging to 165 web sites, 1,763 of 9,947 (17.7%) web pages found by search engines provided relevant information. Five hundred forty-seven (5.5%) hits were partly relevant, and 7,637 (76.8%) were irrelevant or not available. Most web sites reported about surgery (92.1%), chemotherapy (88.5%), and radiotherapy (73.9%). Of the web sites, 46.7% (n=77), 34.6% (n=57), and 21.8% (n=36) gave information about the author(s) itself, their qualifications, and references of their information, respectively. Search engines ranked web sites giving no information on evidence-based medicine higher than other web sites, whereas web sites providing this information accurately showed higher link popularities. Patients' concerns and potential embarrassment were best addressed by gastrointestinal web sites initiated by private individuals or web sites directed to both a patient and physician audience.

CONCLUSIONS

With regard to gastrointestinal cancer web sites, many search engines may be ineffective, and patient emotional needs and concerns are often disregarded. Also, physicians should guide their patients through the Internet to find high-quality information and use link-popularity-based search strategies.

Distress before chemotherapy predicts delayed but not acute nausea

INTRODUCTION

Posttreatment nausea (PTN) is a common side effect of cytotoxic cancer chemotherapy. Previous retrospective research has suggested that the severity of PTN may be, in part, related to pretreatment psychological factors (e.g., emotional distress and expectations for nausea).

MATERIALS AND METHODS

The purpose of the present study was to examine these relationships prospectively, with distress and nausea expectations assessed by validated self-report measures completed in the clinic before the participants' first outpatient treatment infusion and with PTN (0-100) assessed by end-of-day diaries completed at home on each of the first 5 days after treatment. The participants were chemotherapy-naive women (N=56) scheduled for standard adjuvant treatment for stage I-II breast cancer (mean age=45.6 years). PTN was evaluated for acute (days 0-1) and delayed (days 2-5) responses.

RESULTS

The results revealed a significant relationship between pretreatment distress and the severity of the patients' subsequent delayed nausea (p<0.007) but not a relationship with acute PTN (p<0.19). No significant relationships were seen between expectations and PTN. However, there was evidence of an additive effect of nausea expectations and distress, with the highest levels of delayed PTN seen in patients with both expectations and higher distress before treatment. The results suggest a selective effect of pre-infusion psychological variables on the delayed phase of nausea after chemotherapy, consistent with an emerging view that the different phases of nausea are mediated by different neural pathways.

CONCLUSION

Future research should examine the possibility that delayed nausea, which the literature suggests is more resistant to antiemetic drugs than acute nausea, might be responsive to psychological interventions before initial treatments.

The Pathophysiology of Chemotherapy-Induced Nausea and Vomiting

Chemotherapy-induced nausea and vomiting is a major debilitating side effect of oncology treatment despite recent advances in pharmaceutical management. Nurses who provide care to patients experiencing nausea and vomiting are often only marginally aware of the pathophysiological processes involved in the treatment. A better understanding of the science behind current interventions to reduce nausea and vomiting may help nurses use those interventions more effectively. This article reviews current knowledge about the pathophysiology of chemotherapy-induced nausea and vomiting. By understanding the pathophysiology behind this patient experience, gastroenterology nurses can develop a better understanding of the common symptoms of nausea and vomiting in general. When a nurse understands the complexity of factors causing nausea and vomiting, he or she will be better able to provide appropriate interventions to reduce these symptoms.