Anticipatory nausea and vomiting

Nausea and vomiting in advanced cancer

Nausea and vomiting are distinct symptoms, commonly occurring together but which should be assessed separately. Both are prevalent in patients with advanced cancer. Data are taken from The Cochrane Library (2010) and Ovid MEDLINE (1966-2010). Most current guidelines advocate an aetiology-based approach to the management of nausea and vomiting. Choice of anti-emetic is based on a clinical assessment of the likely pathophysiological component of the emetogenic pathway that is being triggered and selecting an anti-emetic drug that blocks the key receptors involved. Some authors propose a more empirical approach. The limited available evidence would suggest that both an empirical or aetiology-based approach may have similar overall efficacy. There are no published studies directly comparing the two. Standardized assessment and outcome tools are needed to enable well-designed studies to establish efficacy for conventional agents and also compare efficacy with the newer, more expensive ones.

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.

Nausea and vomiting in HIV: a symptom review

Nausea and vomiting are two of the most common symptoms experienced by those with HIV. While the causes are most commonly attributed to medication side effects, infectious causes, gastroparesis and psychosomatic, therapy aimed at controlling symptoms has not been well studied. Since nausea and vomiting have been identified as the most common cause of discontinuation of highly active antiretroviral therapy (HAART) therapy, and due to the extensive morbidity associated with these symptoms, we sought to review and discuss causes and management of these symptoms in HIV-infected patients and demonstrate the need for further research in this area. Such studies could include investigation into the prophylactic use of antiemetics with initiation or modification of HAART therapy to monitor patient compliance. In addition, anticipatory nausea and vomiting should be further studied, as it could prove to be quite prevalent, as in cancer patients.

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.

Guidelines for antiemetic treatment of chemotherapy-induced nausea and vomiting: past, present, and future recommendations

Clinicians should be aware that chemotherapy-induced nausea and vomiting (CINV) is still one of the most feared side effects of chemotherapy. With the correct use of antiemetics, CINV can be prevented in almost 70% to up to 80% of patients. Treatment guidelines are useful tools that enable physicians to integrate the latest clinical research into their practices. The large volume of rapidly evolving clinical data has been summarized and incorporated into treatment recommendations by well-known and reliable institutions, including the Multinational Association of Supportive Care in Cancer, the American Society of Clinical Oncology, and the National Comprehensive Cancer Network. Despite the availability of such guidelines, however, there is evidence that adherence to and implementation of treatment recommendations are less than optimal. This review focuses, in particular, on the conformity and differences of these three guidelines. Furthermore, open questions and trends in the field of antiemesis are discussed as well.

A prospective observational study of chemotherapy-related nausea and vomiting in routine practice in a UK cancer centre

OBJECTIVE

The aim of the study was to assess levels of chemotherapy-induced nausea and vomiting (CINV) in routine practice.

MATERIALS AND METHODS

The study was an observational prospective evaluation using patient self-reports. One hundred and two patients with cancer in a single cancer centre in UK receiving their first chemotherapy treatment participated in the study and were followed up over four cycles, providing a total of 272 assessments of nausea and vomiting. Data was collected with the use of the MASCC Antiemesis Tool (MAT), which is an eight-item short clinical scale assessing acute and delayed nausea and vomiting after chemotherapy.

RESULTS

Results indicated that acute vomiting was experienced by 15.7% of the patients in cycle 1 and delayed vomiting by 14.7%, while acute nausea was present in 37.3% of the patients and delayed nausea in 47.1%, increasing over the subsequent cycles. Moderately emetogenic and highly emetogenic chemotherapy had the highest incidence of CINV, whereas patients receiving highly emetogenic chemotherapy showed significant levels of delayed nausea. Acute symptoms were more easily controlled than delayed symptoms.

DISCUSSION

The data suggest that, while vomiting is well controlled, nausea remains a significant problem in practice, and optimal management of CINV is yet to be achieved. Understanding more clearly the biological basis of nausea will assist in managing this complex symptom more effectively in practice.

Exposure to a context previously associated with nausea elicits conditioned gaping in rats: a model of anticipatory nausea

Following one or more chemotherapy treatments, many patients report that they experience anticipatory nausea. This phase of nausea has been interpreted as a classically conditioned response where a conditional association develops between the contextual clinic cues and the nausea and/or vomiting that developed following treatment. Although rats do not vomit, they display a distinctive gaping reaction when exposed a flavored solution previously paired with a toxin. Here we report that, even in the absence of a flavored solution, rats display conditioned gaping reactions during exposure to a distinctive context previously paired with a high dose of lithium (Experiment 1 with a distinctive odor and Experiment 3 without a distinctive odor), a low dose of lithium (Experiment 2) or provocative vestibular stimulation (Experiment 2). These results suggest that the conditioned gaping reaction in rats is selectively elicited by nausea-paired contextual stimuli, as well as flavors. This rat model of anticipatory nausea may serve as a valuable preclinical tool to evaluate the effectiveness of anti-nausea treatments and the side effect of nausea produced by newly developed pharmaceutical compounds intended for other clinical treatments.

Role of classical conditioning in learning gastrointestinal symptoms

Nausea and/or vomiting are aversive gastrointestinal (GI) symptoms. Nausea and vomiting manifest unconditionally after a nauseogenic experience. However, there is correlative, quasiexperimental and experimental evidence that nausea and vomiting can also be learned via classical (Pavlovian) conditioning and might occur in anticipation of the nauseogenic event. Classical conditioning of nausea can develop with chemotherapy in cancer patients. Initially, nausea and vomiting occur during and after the administration of cytotoxic drugs (post-treatment nausea and vomiting) as unconditioned responses (UR). In addition, 20%-30% of cancer patients receiving chemotherapy report these side effects, despite antiemetic medication, when being re-exposed to the stimuli that usually signal the chemotherapy session and its drug infusion. These symptoms are called anticipatory nausea (AN) and/or anticipatory vomiting (ANV) and are explained by classical conditioning. Moreover, there is recent evidence for the assumption that post-chemotherapy nausea is at least partly influenced by learning. After summarizing the relevant assumptions of the conditioning model, revealing that a context can become a conditioned stimulus (CS), the present paper summarizes data that nausea and/or vomiting is acquired by classical conditioning and, consequently, may be alleviated by conditioning techniques. Our own research has focussed on two aspects and is emphasized here. First, a conditioned nausea model was established in healthy humans using body rotation as the nausea-inducing treatment. The validity of this motion-sickness model to examine conditioning mechanisms in the acquisition and alleviation of conditioned nausea and associated endocrine and immunological responses is summarized. Results from the rotation-induced motion sickness model showed that gender is an important moderator variable to be considered in further studies. This paper concludes with a review of the application of the demonstrated conditioning principles as interventions to ameliorate distressing AN/ANV in cancer patients undergoing chemotherapy, which is the second focus of our work.

Comparative activity of antiemetic drugs

Nausea and vomiting continues to be an important problem for cancer patients receiving chemotherapy. Chemotherapy-induced nausea and vomiting (CINV) are classified as acute, occurring within the first 24h, or delayed, occurring after the first 24h. A number of antiemetic agents are available for the management of nausea and vomiting, including 5-HT3-receptor-antagonists, corticosteroids, NK-1-receptor-antagonists, dopamine-receptor antagonists, benzodiazepines, neuroleptics and cannabinoids. With modern antiemetic therapy, vomiting can be prevented in 70-80% of patients, whereas the control of nausea remains suboptimal. The development of acute emesis is known to depend on serotonin. The pathophysiology of delayed emesis is less well understood, and multiple mechanisms may contribute, including substance P. Here, the most recent developments in the antiemetic therapy, including new antiemetic drugs and the latest guidelines for antiemetic prophylaxis, are reviewed.

The effects of P6 acupressure in the prophylaxis of chemotherapy-related nausea and vomiting in breast cancer patients

BACKGROUND

Nausea, and to a lesser extend vomiting, remain significant clinical problems after the administration of chemotherapy, with up to 60% of patients reporting nausea despite use of antiemetics. Combining antiemetics with other non-pharmacological treatments may prove more effective in decreasing nausea than antiemetics alone. Hence, the aim of the current study was to evaluate the effectiveness of using acupressure in Pericardium 6 (Neiguan) acu-point in managing chemotherapy-induced nausea and vomiting.

METHODS

This was a randomised controlled trial. Acupressure was applied using wristbands (Sea-Band) which patients in the experimental group had to wear for the 5 days following the chemotherapy administration. Assessments of nausea, retching and vomiting were obtained from all patients daily for 5 days. Thirty-six patients completed the study from two centres in the UK, with 19 patients allocated to the control arm and 17 to the experimental arm.

RESULTS

It was found that nausea and retching experience, and nausea, vomiting and retching occurrence and distress were all significantly lower in the experimental group compared to the control group (P<0.05). The only exception was with the vomiting experience, which was close to significance (P=0.06).

DISCUSSION

Results highlight the important role of safe and convenient non-pharmacological complementary therapies, such as acupressure, in the management of the complex symptoms of chemotherapy-related nausea and vomiting.

Pavlovian conditioning of nausea and vomiting

Cancer patients undergoing cytotoxic drug treatment often experience side-effects, the most distressing being nausea and vomiting. Despite antiemetic drugs, 25-30% of the chemotherapy patients report these side-effects when being re-exposed to the stimuli that usually signal the chemotherapy session and its drug infusion. These symptoms are called anticipatory nausea and anticipatory vomiting. The present paper summarizes the evidence that anticipatory vomiting is acquired by Pavlovian conditioning, and, consequently, may be alleviated by conditioning techniques. To explore the mechanisms that induce and alleviate conditioned nausea and vomiting further, a conditioned nausea model was established in healthy humans using body rotation as the nausea-inducing treatment. The validity of this motion sickness model to examine conditioning mechanisms in the acquisition and alleviation of conditioned nausea was demonstrated. Cortisol and tumor-necrosis factor-alpha were elevated as endocrine and immunological correlates of nausea. Data in the rotation-induced motion sickness model indicated that gender is an important moderator variable to be considered in further studies. The paper concludes with a review of applications of the demonstrated conditioning principles as interventions to ameliorate distressing anticipatory nausea or anticipatory vomiting in cancer patients undergoing chemotherapy.

The impact of chemotherapy-induced nausea and vomiting on health-related quality of life

GOAL OF WORK

The objectives of this prospective observational study were to estimate the frequency of patients who reported an impact of chemotherapy-induced nausea and vomiting (CINV) on their daily life and to evaluate the determinants of such an impact.

MATERIALS AND METHODS

Adult cancer patients at seven Italian oncology centers who were receiving cisplatin-containing regimens reported incidence and intensity of CINV for eight consecutive days in a diary and completed a Functional Living Index for Emesis (FLIE) questionnaire.

MAIN RESULTS

Overall, 34% of patients reported vomiting and 62% reported nausea after chemotherapy. On days 1 to 5 after receiving chemotherapy, 67% of patients who had at least one emetic episode and 77% of those who suffered from at least mild nausea experienced an impact on their daily activities as measured on the FLIE questionnaire. More than 90% of all patients with both acute and delayed nausea or vomiting reported an impact on their daily life. Both acute and delayed vomiting contributed in similar measure to impact daily life; however, the importance of delayed nausea was greater than that of acute nausea.

CONCLUSIONS

Despite antiemetic prophylaxis, CINV is still prevalent and often impacts the daily life of patients in Italy, especially in the delayed phase. The duration more than the severity seems to be responsible for the impact of CINV on the patients' daily lives.

The continuing problem of post chemotherapy nausea and vomiting: contributions of classical conditioning

Despite continuing improvements in antiemetic therapies, nausea and vomiting following chemotherapy treatments for cancer remain significant clinical problems for many patients. The role of classical conditioning in patients' anticipatory nausea is well known, but little attention has been paid to possible conditioning effects on post treatment nausea. The present study statistically examined the contribution of anticipatory (conditioned) nausea to patients' subsequent post treatment nausea. Forty early stage breast cancer patients who developed anticipatory nausea were analyzed. Results revealed a significant correlation between the intensity of anticipatory nausea in the clinic prior to their treatment infusion and subsequent post treatment nausea during the 24 h after the infusion. These results provide support for the hypothesis that, once established, conditioned nausea may contribute to the severity of subsequent post treatment nausea in patients receiving repeated cycles of chemotherapy for cancer. The results suggest the importance of considering the contribution of conditioning process to nausea and other post treatment side effects.