Patient- and treatment-related risk factors for nausea and emesis during concurrent chemoradiotherapy

Nutrition outcomes and treatment toxicities in patients with head and neck cancer receiving helical intensity-modulated radiotherapy

BACKGROUND

Helical intensity-modulated radiotherapy (H-IMRT) provides excellent limitation of dose to tissues not requiring treatment, although acute toxicity still occurs. The present study aimed to determine how treatment-related acute toxicities affect nutrition outcomes in patients with head and neck cancer.

METHODS

A prospective observational study was conducted in 194 patients undergoing curative intent H-IMRT with or without other treatment modalities. Weight outcomes (kg) and acute toxicity and dysphagia data were collected during treatment using Common Toxicity Criteria for Adverse Effects (CTCAE), version 4.0.

RESULTS

Significant weight loss (> 10%) was observed in 30% of high nutritional risk patients and 7% of low nutritional risk patients. Nausea, adjusted for baseline dysphagia, in high nutritional risk patients and nausea, dysphagia and pharyngeal mucositis in low nutritional risk patients were significant factors in explaining the percentage loss in baseline weight to treatment completion.

CONCLUSIONS

Significant weight loss remains an issue during treatment, despite improvements in radiotherapy technology and high-level multidisciplinary care.

Antiemetic prophylaxis for chemoradiotherapy-induced nausea and vomiting in locally advanced head and heck squamous cell carcinoma: a prospective phase II trial

Background

There is sparse research reporting effective interventions for preventing nausea and emesis caused by concurrent chemoradiotherapy (CCRT) in locally advanced head and neck squamous cell carcinoma (LA-HNSCC).

Methods

Treatment-naïve LA-HNSCC patients received intensity-modulated radiotherapy with concomitant cisplatin 100 mg/m² (33 mg/m²/days [d]1–3) every 3 weeks for two cycles. All patients were given oral aprepitant 125 mg once on d1, then 80 mg once on d2–5; ondansetron 8 mg once on d1; and dexamethasone 12 mg once on d1, then 8 mg on d2–5. The primary endpoint was complete response (CR). Pursuant to δ = 0.2 and α = 0.05, the expected CR rate was 80%.

Results

A total of 43 patients with LA-HNSCC were enrolled. The median age was 53 years, and 86.0% were male. All patients received radiotherapy and 86.0% of patients completed both cycles as planned. The overall CR rate was 86.0% (95% confidence interval [CI]: 72.1–94.7). The CR rates for cycles 1 and 2 were 88.4% (95% CI: 74.9–96.1) and 89.2% (95% CI: 74.6–97.0). The complete protection rate in the overall phase was 72.1% (95% CI: 56.3–84.7). The emesis-free and nausea-free responses in the overall phase were 88.4% (95% CI: 74.9–96.1) and 60.5% (95% CI: 44.4–75.0), respectively. The adverse events related to antiemetics were constipation (65.1%) and hiccups (16.3%), but both were grade 1–2. There was no grade 4 or 5 treatment-related toxicity with antiemetic usage.

Conclusion

The addition of aprepitant into ondansetron and dexamethasone provided effective protection from nausea and emesis in patients with LA-HNSCC receiving radiotherapy and concomitant high-dose cisplatin chemotherapy.

Factors Associated with Chemotherapy Induced Nausea in Cancer Patients: A Case-Control Study

Background: Chemotherapy-induced nausea (CIN) is one of the most common and uncomfortable symptoms in cancer patients, and different factors can be associated with it. Objectives: This study aimed to determine different factors associated with CIN in cancer patients. Methods: A total of 144 cancer patients were selected by convenience sampling. The patients at acute phase of chemotherapy were assigned to case group (n = 58) if they had nausea or to control group (n = 86) if they did not have nausea. The patients' data were collected using a researcher-made questionnaire including items on potential factors for CIN through interviews with the patients and according to their medical records. Logistic regression models were used to conduct data analysis, and the correlations in question were expressed as odds ratio (OR) at 95% confidence interval (CI). Results: The results showed that the chance of nausea increased by 6.4, 2.4, 1.2, and 1.5 times in case of expected nausea, pain, carbohydrate intake, and smelling a specific odor, respectively. The increasing nausea-inducing effect of drugs led to increased chance of post-chemotherapy nausea (OR = 2.366). Conclusions: Having pain, expecting nausea, carbohydrate intake, smelling a certain odor, and high emetogenic potential of chemotherapy are effective in the development of CIN.

Nutritional Counseling for Head and Neck Cancer Patients Undergoing (Chemo) Radiotherapy-A Prospective Randomized Trial

Background: Locally advanced head and neck cancer is managed either by combined surgery and (chemo) radiotherapy or definitive (chemo) radiotherapy, which may deteriorate nutritional status. Previous data have shown that intensive nutritional intervention by a dietician reduces radiation-induced adverse events including weight loss. Objective: To determine if on-demand nutritional counseling (ODC, control group) would be as efficacious as intensive nutritional counseling (INC, experimental group) in patients undergoing (chemo) radiotherapy. Methods: Fifty-eight patients were randomly assigned to receive INC (n = 26) or ODC (n = 32). Outcome measures were nutritional status (PG-SGA), weight loss, handgrip strength (HGS), body composition, and survival. Results: Weight loss and impaired nutritional parameters during oncological treatment were seen equally in both groups (NS). Leaner patients at baseline maintained their weight, while overweight patients lost both weight and handgrip strength during treatment. Disease-free survival (DFS) (median = 43 months) was not affected by weight loss during treatment. Lower baseline HGS and malnutrition were associated with worse DFS (low vs. normal HGS: 15 vs. 42 months; p = 0.05 and malnutrition vs. good nutrition status: 17 vs. 42 months; p = 0.014, respectively). Survival according to low vs. normal HGS in the INC group was 4 vs. 44 months (p = 0.007) and in the ODC group 28 vs. 40 months (p = 0.944). According to malnutrition vs. good nutritional status in the INC group, DFS was 21 vs. 43 months (p = 0.025) and in the ODC group 15 vs. 41 months (p = 0.03). Conclusions: As for our primary endpoint, individualized on-demand nutritional counseling was as efficacious as intensive counseling in preventing deterioration of nutritional status and incidence of malnutrition during (chemo) radiotherapy. This should be verified with larger number of patients. Additional findings were that overweight patients had more severe weight loss, but not poorer survival. Low HGS and malnutrition at baseline were associated with poor survival. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT02159508.

Guidelines versus individualized care for the management of CINV

Numerous groups have published guidelines for the prevention and management of chemotherapy-induced nausea and vomiting (CINV). The current management of CINV, however, remains suboptimal, due in part to poor adherence to existing antiemetic guidelines. Challenges in clinical trial design have also slowed progress and complicated the selection of optimal antiemetic therapy. In addition, patient-specific characteristics and factors are not included in current CINV guidelines and are an important contributor to an individual’s risk for nausea and vomiting. CINV risk prediction algorithms have now emerged and provide the opportunity to individualize antiemetic prophylaxis. Further studies are underway to examine the precise role for risk model-guided antiemetic prophylaxis in patients with cancer.

Correlation between delivered radiation doses to the brainstem or vestibular organ and nausea & vomiting toxicity in patients with head and neck cancers - an observational clinical trial

Objective

Today intensity modulated radiation therapy (IMRT) can be considered the standard of care in patients with head and neck tumors. IMRT treatment plans are proven to reduce acute treatment related side effects by optimal sparing of organs at risk (OAR). At the same time, areas that were out of the former 3D fields now receive low radiation doses. Amongst those areas the brainstem (BS) and the vestibular system (VS) are known to be physiologically connected to nausea and vomiting (NV). In our study we tried to find out, if doses to these areas are linked to NV.

Material & Methods

NV were assessed at different time points during treatment in 26 patients leading to 98 documented toxicity scores that were later correlated to dose deposition in the described areas. Patients were either treated with normo-fractionated or simultaneously integrated boost IMRT plans in a curative approach. Subareas of the BS as well as the VS were delineated. Toxicity was rated based on the common toxicity criteria (CTCAE Version 4.0). Other factors such as age, gender, chemotherapy, location of the tumor, irradiated volume and unilateral dose to the VS were taken into account and analyzed also.

Results

The majority (65.4%) of our patients experienced an episode of NV at least once during treatment. NV was more frequent when treating the oropharyngeal region compared to the hypopharyngeal region, as well as when patients were female and/ or of a younger age. Nevertheless, upon statistical analysis (ROC analysis, ‘within/ between analysis’) no significant association between delivered doses to subareas and toxicity could be demonstrated.

Conclusion

In our analysis, no significant correlation between radiation dose to the BS or the VS and the occurrence of NV could be found. Therefore, until conclusive data are available, we recommend to rely on the published data regarding OAR tolerance within the BS and not to compromise on dose coverage.

Electronic supplementary material

The online version of this article (doi:10.1186/s13014-017-0846-4) contains supplementary material, which is available to authorized users.

An Analysis of Behavioral and Genetic Risk Factors for Chemotherapy-Induced Nausea and Vomiting in Japanese Subjects

There are individual differences in the frequency of chemotherapy-induced nausea and vomiting (CINV) in cancer patients. We investigated the individual variability in susceptibility to CINV with focus on both behavioral factors and genetic factors in Japanese cancer patients. We performed a prospective study to investigate the association between patient attributes (backgrounds and habits as well as gene polymorphisms) and anorexia, nausea, or vomiting in 55 Japanese cancer patients undergoing chemotherapy at Nagoya University Hospital. We found that gender (female), use of non-steroidal anti-inflammatory drugs, susceptibility to motion sickness, and anxiety were associated with the frequency of CINV. Gene polymorphisms of rs1076560 (dopamine D₂ receptor gene), rs6766410 (serotonin 5-HT_3C receptor gene) and rs4680 (catechol-O-methyltransferase gene) were also associated. Our data suggest that these attributes may thus be risk factors for CINV. Our results provide novel information that can be used to predict the incidence of CINV in Japanese patients undergoing chemotherapy; this can help provide a substantial improvement in supportive care for patients with different types of cancer.

Control of chemotherapy-induced nausea in patients receiving outpatient cancer chemotherapy

BACKGROUND

Control of chemotherapy-induced nausea is still incomplete, regardless of adherence to the antiemetic guideline. The present study was designed to assess the control rates of nausea and vomiting in the outpatient chemotherapy clinic and to determine risk factors for nausea.

METHODS

A single-center prospective observational study was carried out in 779 patients who received 5511 chemotherapy cycles from January 2013 to December 2014 in the outpatient chemotherapy clinic. A checklist for adverse events was provided to all patients, and nausea and vomiting were monitored on the next visit. Complete protection from nausea and vomiting during acute (within 24 h) and delayed (during 2-7 days) periods was assessed.

RESULTS

Under the condition of 76-99 % rates of adherence to the Japanese Society of Clinical Oncology guideline for antiemesis, the rates of complete protection from acute and delayed nausea in the first cycle of chemotherapy were 60 % and 45 %, respectively, for high emetic risk chemotherapy (HEC), and 85 % and 70 % for moderate emetic risk chemotherapy (MEC). The rates were improved in the overall cycles. On the other hand, vomiting was well controlled, in which complete protection ranged from 83 % (HEC) to 99 % (minimum). A multivariate analysis indicated that being female, age less than 60 years, high or moderate risk chemotherapy, and anthracycline/cyclophosphamide (A/C) were significant risks for overall nausea. Indeed, the control of delayed nausea was extremely poor in the first cycle of A/C, although there was no difference in the control of nausea among MEC.

CONCLUSION

Antiemetic medication in consideration of the risk factors is required to improve the control of nausea.

Testing the effectiveness of antiemetic guidelines: results of a prospective registry by the CINV Study Group of Japan

BACKGROUND

Many cancer patients suffer from the common side effect of chemotherapy-induced nausea and vomiting (CINV). Guidelines recommend a combination of two prophylactic antiemetics for moderately emetogenic chemotherapy (MEC) and three for highly emetogenic chemotherapy (HEC) and certain MEC regimens.

METHODS

This multicenter, prospective, observational study analyzed data for 1,910 patients in Japan scheduled for MEC or HEC. Use of antiemetic prophylaxis in relation to type of chemotherapy, incidences of and risk factors for nausea, vomiting, and acute versus delayed CINV, and estimated incidence of CINV by staff were analyzed using Fisher's exact test and multivariate logistic regression. The patients recorded the incidence of CINV and severity of nausea by visual analogue scales daily for 7 days after receiving chemotherapy.

RESULTS

A total of 240 (20.1 %) HEC and 476 MEC patients (66.6 %) received 2 antiemetics, compared with 883 (73.9 %) and 200 (28.0 %), respectively, who received 3 antiemetics. Approximately 74 % of HEC and 95 % of MEC patients received antiemetic therapy in compliance with guidelines. Acute nausea and vomiting were well controlled, but high incidences of delayed nausea occurred in both HEC and MEC patients. Delayed vomiting (p < 0.0001) was significantly less frequent in patients receiving three compared with 2 antiemetics. Female sex was a major risk factor for CINV. Medical staff tended to overestimate the incidence of CINV. Among HEC regimens, the incidence of CINV and the degree of nausea on day 1 of anthracycline-cyclophosphamide combination therapy were higher than with a cisplatin-based regimen.

CONCLUSIONS

Adherence to antiemetic guidelines effectively controls vomiting but is less effective against delayed nausea in HEC and MEC patients. Identification of individual risk factors, such as female sex, will assist in the development of personalized treatments for CINV. More intensive antiemetic therapy or a different modality of prophylaxis should be considered for the control of acute CINV in an anthracycline-cyclophosphamide regimen.

Evaluation of risk factors predicting chemotherapy-related nausea and vomiting: results from a European prospective observational study

CONTEXT

Demographic, personal, clinical, and behavioral factors predicting chemotherapy-induced nausea and vomiting (CINV) have been assessed in the past, but inconsistencies exist in the literature, studies have methodological shortcomings, and many risk factors have been examined in cross-sectional studies and univariate analyses.

OBJECTIVES

To evaluate the predictive power of personal and treatment-related characteristics in the development of CINV, using a large and prospectively evaluated sample of a heterogeneous group of cancer patients receiving routine chemotherapy.

METHODS

This was a multicountry, multisite prospective study over three cycles of chemotherapy. Adult patients from eight European countries about to receive highly and moderately emetogenic chemotherapy were recruited. Clinicians completed a case report form at or before the initial chemotherapy treatment, recording patient demographic and baseline clinical characteristics. Participants completed a daily patient diary for six days per chemotherapy cycle describing their CINV experience. Baseline patient data also included a history of nausea/vomiting (yes/no), patient expectation of nausea (0-100 mm visual analogue scale [VAS]), prechemotherapy anxiety (0-100 mm VAS), and prechemotherapy nausea (0-100 mm VAS) measured during the 24-hour period before chemotherapy initiation.

RESULTS

There were 991 evaluable patients with complete Cycle 1 data, 888 for Cycle 2 data, and 769 for Cycle 3 data. A complex picture of predictor variables was shown, with different contribution of variables to the acute, delayed, and overall phases of CINV. Key predictor variables included the use of antiemetics inconsistent with international guidelines, younger age, prechemotherapy nausea, and no CINV complete response in an earlier cycle (all at P < 0.05). Anxiety, history of nausea/vomiting, and expectations of nausea were important predictors for some phases and cycles but not consistently across the CINV pathway.

CONCLUSION

The results of this study provide clarity for the relative contribution of a set of characteristics in the development of CINV. Following evidence-based clinical antiemetic guidelines is of paramount importance, alongside treating patients with increased risk for CINV more aggressively, which both could lead to more optimal CINV management. These data can assist clinicians in making decisions about the antiemetic management of their patients.

Beam path toxicity in candidate organs-at-risk: assessment of radiation emetogenesis for patients receiving head and neck intensity modulated radiotherapy

BACKGROUND

To investigate potential dose-response relationship between radiation-associated nausea and vomiting (RANV) reported during radiotherapy and candidate nausea/vomiting-associated regions of interest (CNV-ROIs) in head and neck (HNC) squamous cell carcinomas.

METHODS AND MATERIAL

A total of 130 patients treated with IMRT with squamous cell carcinomas of head and neck were evaluated. For each patient, CNV-ROIs were segmented manually on planning CT images. Clinical on-treatment RANV data were reconstructed by a review of the records for all patients. Dosimetric data parameters were recorded from dose-volume histograms. Nausea and vomiting reports were concatenated as a single binary "Any N/V" variable, and as a "CTC-V2+" variable.

RESULTS

The mean dose to CNV-ROIs was higher for patients experiencing RANV events. For patients receiving IMRT alone, a dose-response effect was observed with varying degrees of magnitude, at a statistically significant level for the area postrema, brainstem, dorsal vagal complex, medulla oblongata, solitary nucleus, oropharyngeal mucosa and whole brain CNV-ROIs.

CONCLUSION

RANV is a common therapy-related morbidity facing patients receiving HNC radiotherapy, and, for those receiving radiotherapy-alone, is associated with modifiable dose to specific CNS structures.

Risk factors for clinician-reported symptom clusters in patients with advanced head and neck cancer in a phase 3 randomized clinical trial: RTOG 0129

BACKGROUND

Chemoradiotherapy has become the standard of care for head and neck squamous cell carcinoma; however, those patients often experience multiple treatment-related symptoms or symptom clusters. Two symptom clusters have been identified for this population. Little is known about the risk factors of these symptom clusters.

METHODS

Subjects comprised 684 patients who were treated with concurrent chemoradiotherapy in a phase 3 randomized clinical trial. This trial compared standard fractionation radiotherapy to accelerated fractionation radiotherapy. Symptom clusters were evaluated at the end of the first and the second cycle of chemotherapy, and 3 months after the start of radiotherapy. Mixed-effect modeling was used to observe risk factors for symptom clusters.

RESULTS

Race and education were independent predictors for the head and neck cluster, whereas sex and history of tobacco use were independent predictors for the gastrointestinal cluster. Primary cancer site was only significant for the head and neck cluster when other factors were not controlled: patients with oropharyngeal cancer had more severe symptoms in the head and neck clusters than did patients with laryngeal cancer. In addition, patients receiving accelerated fractionation radiotherapy experienced more symptoms of radiomucositis, pain, and nausea at 3 months after the start of radiotherapy than those receiving standard fractionation radiotherapy.

CONCLUSIONS

Demographic characteristics were more predictive to symptom clusters, whereas clinical characteristics, such as cancer site and treatment arms, were more significant for individual symptoms. Knowing the risk factors will enhance the capability of clinicians to evaluate patients' risk of severe symptom clusters and to personalize management strategies.

Chemotherapy-induced nausea and vomiting: pathophysiology and therapeutic principles

Chemotherapy-induced nausea and vomiting (CINV) is a major determinant of quality of life in cancer patients. In addition, the perceptions that oncology professionals have about CINV quite often do not coincide with reality. Antineoplastic agents and their combinations can be categorised according to their emetogenic level, and this categorisation is helpful for classifying the severity of CINV and treating it. All CINV treatment guidelines emphasise the need to administer prophylaxis to patients who receive highly or moderately emetogenic chemotherapy. With the introduction of NK1 receptor antagonists, the control of acute and delayed CINV after highly or moderately emetogenic chemotherapy schedules has improved in the great majority of patients. NK1 receptor antagonists have been demonstrated to improve the control of CINV in all risk subgroups of patients.

Postoperative versus definitive chemoradiation in early-stage anal cancer. Results of a matched-pair analysis

BACKGROUND AND PURPOSE

The goal of the present study was to comparatively assess the results of definitive chemoradiation (CRT) with or without previous macroscopically complete resection in patients with early-stage node-negative (T1-2 N0) anal carcinoma.

PATIENTS AND METHODS

A total of 20 patients with T1-2 N0 anal carcinoma who received radiotherapy (RT) with or without chemotherapy following incidental R0/1 tumor resection (S/CRT group) were selected. These were matched to 20 comparable patients who underwent definitive chemoradiation without previous surgery (CRT group). Major objectives of this analysis were treatment outcomes in terms of locoregional tumor control (LRC), overall survival (OS), colostomy-free survival, and toxicity.

RESULTS

Patients treated postoperatively received significantly lower RT doses (median 54.0 Gy vs. 59.7 Gy; p < 0.001) and less frequently concomitant chemotherapy than those treated definitely. The 5-year LRC and 5-year OS rates were 97.5% and 90.0%, respectively, without significant differences between the S/CRT and the CRT groups. The distribution of acute and late toxicities was comparable, and the 5-year colostomy-free survival was 95% in both groups.

CONCLUSION

This matched-pair comparison of incidental R0/1 resection plus dose-reduced CRT with standard definitive CRT of early-stage anal cancer shows similar treatment results. Thus, dose-reduced RT with or without chemotherapy may be considered in R0/1 resected patients with T1-2 N0 anal carcinoma.

TRAIL-activated EGFR by Cbl-b-regulated EGFR redistribution in lipid rafts antagonises TRAIL-induced apoptosis in gastric cancer cells

Most gastric cancer cells are resistant to tumour necrosis factor-related apoptosis-inducing ligand (TRAIL). Since TRAIL resistance is associated with lipid rafts, in which both death receptors and epidermal growth factor receptors (EGFR) are enriched, our aim is to identify how lipid raft-regulated receptor redistribution influences the sensitivity of TRAIL in gastric cancer cells. In TRAIL-resistant gastric cancer cells, TRAIL did not induce effective death-inducing signalling complex (DISC) formation in lipid rafts, accompanied with EGFR translocation into lipid rafts, and activation of EGFR pathway. Knockdown of casitas B-lineage lymphoma-b (Cbl-b) enhanced TRAIL-induced apoptosis by promoting DISC formation in lipid rafts. However, knockdown of Cbl-b also enhanced EGFR translocation into lipid rafts and EGFR pathway activation induced by TRAIL. Either using inhibitors of EGFR or depletion of EGFR with small interfering RNA (siRNA) prevented EGFR pathway activation, and thus increased TRAIL-induced apoptosis, especially in Cbl-b knockdown clones. Taken together, TRAIL-induced EGFR activation through Cbl-b-regulated EGFR redistribution in lipid rafts antagonised TRAIL-induced apoptosis. The contribution of DISC formation and the inhibition of EGFR signal triggered in lipid rafts are both essential for increasing the sensitivity of gastric cancer cells to TRAIL.