A qualitative study investigating chemotherapy-induced nausea as a symptom cluster

Effect of a Standardized Ginger Root Powder Regimen on Chemotherapy-Induced Nausea and Vomiting: A Multicenter, Double-Blind, Placebo-Controlled Randomized Trial

BACKGROUND

There is substantial interest in the role of ginger as an adjuvant therapy for chemotherapy-induced nausea and vomiting (CINV). However, available evidence lacks robust methodology.

OBJECTIVE

To assess the effect of adjuvant ginger compared with placebo on chemotherapy-induced nausea-related quality of life (QoL) and CINV-related outcomes.

DESIGN

A parallel, double-blind, placebo-controlled randomized trial with 1:1 allocation was conducted.

PARTICIPANTS/SETTING

One hundred three chemotherapy-naïve adults scheduled to receive moderately to highly emetogenic chemotherapy at two hospitals in Australia were enrolled and analyzed.

INTERVENTION

Four standardized ginger capsules (totaling 84 mg/day active gingerols/shogaols), or placebo, were administered commencing the day of chemotherapy and continuing for 5 days for chemotherapy cycles 1 through 3.

MAIN OUTCOME MEASURES

The primary outcome was chemotherapy-induced nausea-related QoL. Secondary outcomes were vomiting- and CINV-related QoL; anticipatory, acute, and delayed nausea and vomiting; fatigue; nutritional status; depression and anxiety; health-related QoL; and adverse events.

STATISTICAL ANALYSES PERFORMED

Intention-to-treat analysis was performed. Mixed analysis of variance with repeated measures determined differences between groups. The null hypothesis was no difference between groups. After applying a Bonferroni multiple testing correction, evidence against the null hypothesis was considered at P= 0.003.

RESULTS

One hundred three participants (ginger: n = 52; placebo: n = 51) were enrolled and analyzed. There was clinically relevant evidence against the null hypothesis, favoring ginger, in change scores for nausea-related QoL (F[df] = 9.34[1,101]; P = 0.003; partial η2 = 0.09), overall CINV-related QoL (F[df] = 12.26[1,101]; P < 0.001; partial η2 = 0.11), delayed nausea severity (F[df] = 9.46[1,101]; P = 0.003; partial η2 = 0.09), and fatigue (F[df] = 10.11[1,101]; P = 0.002; partial η2 = 0.09). There was a clinically meaningful lower incidence of delayed nausea and vomiting in the ginger group at Cycle 2 (53% vs 75%; P = 0.020 and 4% vs 27%; P = 0.001, respectively) and Cycle 3 (49% vs 79%; P = 0.002 and 2% vs 23%; P = 0.001, respectively). There was a clinically meaningful lower incidence of malnutrition in the ginger group at Cycle 3 (18% vs. 41%; P = 0.032) and in change scores for Patient-Generated Subjective Global Assessment (F[df)] = 4.32[1,100]; P = 0.040; partial η2 = 0.04). Change scores between groups favored ginger for vomiting-related QoL and number of vomiting episodes; however, findings were not clinically meaningful. There was no effect of ginger on anticipatory or acute CINV, health-related QoL, anxiety, or depression. No serious adverse events were reported.

CONCLUSIONS

Ginger supplementation was a safe adjuvant to antiemetic medications for CINV that enhanced QoL during chemotherapy treatment. Future trials are needed to examine dose-dependent responses to verify optimal dosing regimens.

GIP receptor agonism blocks chemotherapy-induced nausea and vomiting

OBJECTIVE

Nausea and vomiting remain life-threatening obstacles to successful treatment of chronic diseases, despite a cadre of available antiemetic medications. Our inability to effectively control chemotherapy-induced nausea and vomiting (CINV) highlights the need to anatomically, molecularly, and functionally characterize novel neural substrates that block CINV.

METHODS

Behavioral pharmacology assays of nausea and emesis in 3 different mammalian species were combined with histological and unbiased transcriptomic analyses to investigate the beneficial effects of glucose-dependent insulinotropic polypeptide receptor (GIPR) agonism on CINV.

RESULTS

Single-nuclei transcriptomics and histological approaches in rats revealed a topographical, molecularly distinct, GABA-ergic neuronal population in the dorsal vagal complex (DVC) that is modulated by chemotherapy but rescued by GIPR agonism. Activation of DVCGIPR neurons substantially decreased behaviors indicative of malaise in cisplatin-treated rats. Strikingly, GIPR agonism blocks cisplatin-induced emesis in both ferrets and shrews.

CONCLUSION

Our multispecies study defines a peptidergic system that represents a novel therapeutic target for the management of CINV, and potentially other drivers of nausea/emesis.

Symptom Cluster Experiences of Patients Operated for Oral Cancer: A Mixed Methods Study

OBJECTIVE

This convergent mixed methods study aimed to obtain a comprehensive understanding of symptom cluster experiences in patients with oral cancer. Survey and phenomenological interviews were conducted in parallel to identify distinct patient subgroups based on symptom cluster experiences along with their predictors and explore experiences of living with symptom clusters, respectively.

DATA SOURCES

A convenience sample of 300 patients with oral cancer who had completed surgery provided the quantitative data, and a maximum variation purposive subsample of 20 participants, drawn from the survey sample, provided the qualitative data. Agglomerative hierarchical cluster analysis was used to identify subgroups, multivariate analyses were done to identify predictors, and thematic analysis was used for patient narratives.

CONCLUSION

Almost 94% of the survey participants had two or more co-occurring symptoms. The four most severe and prevalent symptoms were dysphagia, problems with teeth or gums, speech difficulty, and dry mouth. A distinct subgroup consisting of 61% of patients reported severe dysphagia and teeth problems, which was associated with age, oral cancer stage and site. Interviews revealed the causes and the context influencing the perception and response to these symptoms. Thus, the quantitative data provided information on severity and patient subgroups based on symptom cluster experiences, while the qualitative data validated these conclusions and additionally provided in-depth details and meaningful insight on perceived causes and contextual influences of their experiences. This comprehensive picture of symptom cluster experiences can aid in the development of patient-centered interventions for people with oral cancer.

IMPLICATIONS FOR NURSING PRACTICE

An interdisciplinary approach to targeting concurrent symptoms incorporating psychological and physical interventions is necessary. Older patients treated for Stage IV cancers and for buccal mucosa tumors are at high-risk of having severe dysphagia postoperatively, and these patients should be targeted for dysphagia interventions. The contextual factors play an important role in developing patient-centered interventions.

Neural networks involved in nausea in adult humans: A systematic review

Nausea is a common clinical symptom, poorly managed with anti-emetic drugs. To identify potential brain regions which may be therapeutic targets we systematically reviewed brain imaging in subjects reporting nausea. The systematic review followed PRISMA statements with methodological quality (MINORS) and risk of bias (ROBINS-I) assessed. Irrespective of the nauseagenic stimulus the common (but not only) cortical structures activated were the inferior frontal gyrus (IFG), the anterior cingulate cortex (ACC) and the anterior insula (AIns) with some evidence for lateralization (Left-IFG, Right-AIns, Right-ACC). Basal ganglia structures (e.g., putamen) were also consistently activated. Inactivation was rarely reported but occurred mainly in the cerebellum and occipital lobe. During nausea, functional connectivity increased, mainly between the posterior and mid- cingulate cortex. Limitations include, a paucity of studies and stimuli, subject demographics, inconsistent definition and measurement of nausea. Structures implicated in nausea are discussed in the context of knowledge of central pathways for interoception, emotion and autonomic control. Comparisons are made between nausea and other aversive sensations as multimodal aversive conscious experiences.

On a pathway to resigned acceptance: Patients' experiences of living with symptom clusters in oral cancer

PURPOSE

Patients treated for oral cancer experience multiple concurrent symptoms. A larger mixed-methods study was conducted among patients who were treated with surgery alone or in combination with other modalities. The aim of the qualitative strand was to explore the experiences of living with symptom clusters.

METHODS

A phenomenological design was used to explore the lived experiences. Participants were recruited for the larger study from two outpatient units of a tertiary teaching hospital (N = 300). After completion of a survey, a maximum variation purposive subsample of 20 participants was drawn from the larger sample and were interviewed in-depth about their experiences. Thematic analysis was conducted.

FINDINGS

All participants experienced multiple concurrent symptoms, commonly including chewing difficulties + dry mouth + speech difficulties; chewing difficulties + dry mouth + diminished taste; and chewing difficulties + dry mouth + speech difficulties + trismus. Analysis of their experiences of living with these symptom clusters revealed six themes: Acknowledged Disruptions, Inner Dialogue, Shifting Expectations, Floods of Emotions, Exercising Control over Life, and Resigned Acceptance. These themes portrayed that time and living with symptom clusters lead to what we describe as a pathway to resigned acceptance. This pathway is intermingled with disruptions, self-reflections on 'why me' and karma, negative emotions, and failed expectations regarding symptom recovery. Attempts to exercise control over their lives were also revealed through coping strategies, watchful living, future planning, and being health advocates. On realizing with time that further symptom alleviation is unlikely, and considering symptom-cluster experiences as being written in their fate, they move towards a state of resigned acceptance. However, unlike passive acceptance, their belief in fate was accompanied with resilience, evidenced by their ongoing efforts to explore pragmatic ways to live with symptom clusters.

CONCLUSIONS

Findings provide key insights into patient perspectives which most often remain unexpressed in clinical settings. Further research is required to explore watchful living, fate as a coping strategy, and intertwining of faith, fate, and karma.

Emotions are associated with the genesis of visually induced motion sickness in virtual reality

Visually induced motion sickness (VIMS) is a well-known side effect of virtual reality (VR) immersion, with symptoms including nausea, disorientation, and oculomotor discomfort. Previous studies have shown that pleasant music, odor, and taste can mitigate VIMS symptomatology, but the mechanism by which this occurs remains unclear. We predicted that positive emotions influence the VIMS-reducing effects. To investigate this, we conducted an experimental study with 68 subjects divided into two groups. The groups were exposed to either positive or neutral emotions before and during the VIMS-provoking stimulus. Otherwise, they performed exactly the same task of estimating the time-to-contact while confronted with a VIMS-provoking moving starfield stimulation. Emotions were induced by means of pre-tested videos and with International Affective Picture System (IAPS) images embedded in the starfield simulation. We monitored emotion induction before, during, and after the simulation, using the Self-Assessment Manikin (SAM) valence and arousal scales. VIMS was assessed before and after exposure using the Simulator Sickness Questionnaire (SSQ) and during simulation using the Fast Motion Sickness Scale (FMS) and FMS-D for dizziness symptoms. VIMS symptomatology did not differ between groups, but valence and arousal were correlated with perceived VIMS symptoms. For instance, reported positive valence prior to VR exposure was found to be related to milder VIMS symptoms and, conversely, experienced symptoms during simulation were negatively related to subjects’ valence. This study sheds light on the complex and potentially bidirectional relationship of VIMS and emotions and provides starting points for further research on the use of positive emotions to prevent VIMS.

Chewing gum reduces visually induced motion sickness

Visually induced motion sickness (VIMS) is a common side-effect of exposure to virtual reality (VR). Its unpleasant symptoms may limit the acceptance of VR technologies for training or clinical purposes. Mechanical stimulation of the mastoid and diverting attention to pleasant stimuli-like odors or music have been found to ameliorate VIMS. Chewing gum combines both in an easy-to-administer fashion and should thus be an effective countermeasure against VIMS. Our study investigated whether gustatory-motor stimulation by chewing gum leads to a reduction of VIMS symptoms. 77 subjects were assigned to three experimental groups (control, peppermint gum, and ginger gum) and completed a 15-min virtual helicopter flight, using a VR head-mounted display. Before and after VR exposure, we assessed VIMS with the Simulator Sickness Questionnaire (SSQ), and during the virtual flight once every minute with the Fast Motion Sickness Scale (FMS). Chewing gum (peppermint gum: M = 2.44, SD = 2.67; ginger gum: M = 2.57, SD = 3.30) reduced the peak FMS scores by 2.05 (SE = 0.76) points as compared with the control group (M = 4.56, SD = 3.52), p < 0.01, d = 0.65. Additionally, taste ratings correlated slightly negatively with both the SSQ and the peak FMS scores, suggesting that pleasant taste of the chewing gum is associated with less VIMS. Thus, chewing gum may be useful as an affordable, accepted, and easy-to-access way to mitigate VIMS in numerous applications like education or training. Possible mechanisms behind the effect are discussed.

Psychological predictors of chemotherapy-induced nausea in women with breast cancer: Expectancies and perceived susceptibility

Objective

Chemotherapy‐induced nausea is challenging to predict and treat. Research indicates that pretreatment psychological variables including patients' perceptions of their susceptibility to nausea, expectancies of treatment‐related nausea and nausea history (i.e., motion sickness, morning sickness and baseline levels of nausea) may aid in predicting nausea severity during chemotherapy. However, this research is dated and limited in quantity. We investigated whether psychological variables could improve prediction of nausea severity to inform interventions targeting chemotherapy‐induced nausea.

Methods

In this secondary analysis, a subgroup of women receiving chemotherapy (for the first time) for breast cancer completed pretreatment measures: perceived nausea susceptibility, nausea expectancies, nausea history and baseline nausea. They rated subsequent nausea severity across 4‐days, during treatment and posttreatment in a self‐report diary. Structural Equation Modelling was used to explore associations.

Results

Across the women (N = 481), perceived nausea susceptibility predicted subsequent nausea severity (β = 0.16), but nausea expectancies did not (β = 0.05). Nausea history variables demonstrated small‐moderate associations with perceived susceptibility (β = 0.21–0.32) and negligible‐small associations with nausea expectancies (β = 0.07–0.14).

Conclusion

Perceived nausea susceptibility appears to capture patients' nausea history, to a degree, and is related to nausea severity during treatment. This is an important variable to include in pretreatment prediction of patients at risk of severe nausea.

"It's natural so it shouldn't hurt me": Chemotherapy patients' perspectives, experiences, and sources of information of complementary and alternative medicines

BACKGROUND AND PURPOSE

Minimal evidence regarding the safety and efficacy of complementary and alternative medicine (CAM) use during chemotherapy is accompanied with a high prevalence of use and nondisclosure to health professionals. This study aimed to explore patients' perspectives, experiences, support needs, and sources of information regarding CAM use during chemotherapy.

MATERIALS AND METHODS

Semi-structured interviews with ten adult participants who recently completed chemotherapy treatment at a large hospital in Australia were transcribed verbatim. Three investigators thematically analysed the interviews.

RESULTS

These participants receiving chemotherapy valued CAMs as a natural complement to chemotherapy to improve wellbeing, with their use most strongly influenced by past experiences rather than expert advice.

CONCLUSION

Health professionals would benefit from education on how to best inform patients of the potential risks, harms and lack of efficacy for CAM use during chemotherapy in a way that does not lead to patient non-disclosure of CAM use.

Exploring the nausea experience among female patients with breast cancer; A pilot interview study

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Nausea is a complicated symptom to report and measure in clinical trials.

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Better understanding the nausea experience will improve clinical trial designs.

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Patients have preferences for symptom definitions and nausea grading scales.

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Patients experience different intensities of nausea.

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Describing nausea sub-features like duration, timing and character is difficult.

Introduction

Nausea is a difficult symptom to report and measure in clinical trials. We conducted a pilot interview study to improve our understanding of the nausea experience.

Materials and methods

Female patients with breast cancer that had experienced nausea during radiation therapy and/or chemotherapy underwent semi-structured interviews that focused on patient-defined and standard definitions, preferences for nausea grading scales, and nausea sub-features: intensity, location, timing/duration, character, associated symptoms, precipitating/alleviating factors, impact on quality of life.

Results

10 patients were interviewed. Patients defined nausea more variably than vomiting and retching/dry heaving. An ordinal grading scale with a 0–10 intensity range was preferred over visual-analogue and qualitative scales. Patients had experienced different intensities of nausea and deemed reporting their worst, average and least intensities feasible. High-intensity episodes were deemed more problematic than low-intensity episodes regardless of their duration. The duration and character of nausea were difficult to describe. A range of associated symptoms, precipitating and alleviating factors were documented. Nausea had a detrimental impact on quality of life.

Conclusions

Nausea has a range of subjective and objective features. Our pilot study provided valuable information that will inform the design of a planned larger survey study. Creating an operational clinical trial definition for nausea appears feasible.

Supplemental prophylactic intervention for chemotherapy-induced nausea and emesis (SPICE) trial: Protocol for a multicentre double-blind placebo-controlled randomised trial

AIM

There is significant recent interest in the role of ginger root (Zingiber officinale) as an adjuvant therapy for chemotherapy-induced nausea. The supplemental prophylactic intervention for chemotherapy-induced nausea and emesis (SPICE) trial aims to assess the efficacy by reduced incidence and severity of chemotherapy-induced nausea and vomiting, and enhanced quality of life, safety and cost effectiveness of a standardised adjuvant ginger root supplement in adults undergoing single-day moderate-to-highly emetogenic chemotherapy.

METHODS

Multisite, double-blind, placebo-controlled randomised trial with two parallel arms and 1:1 allocation. The target sample size is n = 300. The intervention comprises four capsules of ginger root (totalling 60 mg of active gingerols/day), commencing the day of chemotherapy and continuing for five days during chemotherapy cycles 1 to 3. The primary outcome is chemotherapy-induced nausea-related quality of life. Secondary outcomes include nutrition status; anticipatory, acute and delayed nausea and vomiting; fatigue; depression and anxiety; global quality of life; health service use and costs; adverse events; and adherence.

RESULTS

During the five-month recruitment period from October 2017 to April 2018 at site A only, a total of n = 33 participants (n = 18 female) have been enrolled in the SPICE trial. Recruitment is expected to commence at Site B in May 2018.

CONCLUSIONS

The trial is designed to meet research gaps and could provide evidence to recommend specific dosing regimens as an adjuvant for chemotherapy-induced nausea and vomiting prevention and management.

Non-invasive High Frequency Median Nerve Stimulation Effectively Suppresses Olfactory Intensity Perception in Healthy Males

Median nerve stimulation (MNS) had been performed in the existing literature to alleviate symptoms of nausea and vomiting. The observed facilitative effects are thought to be mediated by the vagal pathways, particularly the vagus nerve (VN) brainstem nuclei of the dorsal motor nucleus of vagus and nucleus tractus solitarius (DMV-NTS). Sense of smell is one of the major sensory modalities for inducing vomiting and nausea as a primary defense against potentially harmful intake of material. This study aimed to test effects of non-invasive, high and low frequency MNS on human olfactory functioning, with supplementary exploration of the orbitofrontal cortex (OFC) using near-infrared spectroscopy (NIRS). Twenty healthy, male, adults performed supra-threshold odor intensity tests (labeled magnitude scale, LMS) for four food-related odorant samples (presented in three different concentrations) before and after receiving high-, low frequency MNS and placebo (no stimulation), while cortical activities in the OFC was monitored by the NIRS. Data of the NIRS and LMS test of separate stimulation parameters were statistically analyzed using mixed-model analysis of variance (ANOVA). Only the high frequency MNS showed effects for suppressing the intensity perception of the moderate concentration of Amyl Acetate (p:0.042) and strong concentration of Isovaleric Acid (p:0.004) and 1-Octen-3-ol (p:0.006). These behavioral changes were coupled with significant changes in the NIRS recordings of the left (p:0.000) and right (p:0.003) hemispheric orbitofrontal cortices. This is the first study that applied non-invasive, high frequency MNS to suppress the supra-threshold odor ratings of specific concentrations of odors. The vagal networks are potential relays of MNS to influence OFC. Results from the current article implore further research into non-invasive, high frequency MNS in the investigation of its modulatory effects on olfactory function, given its potential to be used for ameliorating nausea and malnutrition associated with various health conditions.

Risk factors for delayed chemotherapy-induced nausea and vomiting with low-emetic-risk chemotherapy: a prospective, observational, multicenter study

Purpose

Improvement in the control of delayed chemotherapy-induced nausea and vomiting (CINV) is needed. There is limited information on antiemetic prophylaxis for patients undergoing low-emetic-risk chemotherapy (LEC), and the optimal antiemetic treatment is not well understood. Therefore, we analyzed the risk factors for delayed CINV to aid in the development of individualized treatments.

Patients and methods

This prospective multicenter study was conducted in 13 hospitals and included patients with solid cancers undergoing LEC. A total of 222 patients were enrolled between September 2013 and November 2014. The participants completed a daily diary for 5 days after the commencement of the first cycle of LEC to describe the daily incidence of CINV (yes/no). Furthermore, the participants described the severity of nausea and the amount of food intake with the help of VAS.

Results

Two hundred and ten patients provided their data that were analyzed using multivariate logistic regression to examine the risk factors for delayed CINV. History of CINV, Eastern Cooperative Oncology Group performance status score ≥1, acute CINV, and single-day antiemetic prophylaxis were identified as independent risk factors for delayed CINV.

Conclusion

The current use of antiemetic prophylaxis according to the recommended guideline appears to effectively control delayed CINV in patients undergoing LEC. Therefore, patients with the abovementioned risk factors should be carefully observed, and their treatment should be adjusted according to their symptoms. The use of multiple-day dexamethasone may be beneficial for those patients who develop acute CINV, especially when it is accompanied by anorexia.

A Cognitive-Behavioral Intervention for the Symptom Clusters of Chinese Patients With Gastrointestinal Tract Cancer Undergoing Chemotherapy: A Pilot Study

BACKGROUND

Patients with gastrointestinal tract (GIT) cancer undergoing chemotherapy often experience several symptoms that constitute symptom clusters and can cause patients to suffer. Effective interventions are lacking for this kind of patients.

OBJECTIVE

The aims of this study were to test the feasibility and acceptability of a cognitive-behavioral (CB) intervention developed for Chinese patients with GIT cancer undergoing chemotherapy and to estimate the efficacy of the intervention for symptom clusters.

METHODS

In this pilot, quasi-randomized controlled trial, 40 patients were assigned to the CB intervention or control group. The CB intervention, considering characteristics of patients and Chinese culture, contained 4 sections including cognitive reframing, cancer-diet education, relaxation, and exercise techniques. Symptom clusters, illness perception, anxiety, and depression were measured.

RESULTS

Thirty-nine patients (97.5%) completed the study program and expressed willingness to follow the intervention. Compared with the control group, all outcomes were improved (all P < .05) in the CB group after the intervention, except for the gastrointestinal symptom cluster (t = 0.25, P = .802). In the CB group, the scores of all outcomes (all P < .05) decreased except for depression (t = 1.76, P = .095).

CONCLUSION

The CB intervention is partially feasible and acceptable. It may also help to improve part of the symptom clusters of Chinese patients with GIT cancer undergoing chemotherapy. However, some modifications are needed in future studies to better test effectiveness.

IMPLICATIONS FOR PRACTICE

Symptom management remains a major problem in clinical nursing. Such a CB intervention can be beneficial to the clinical management of symptom clusters.

Analysis of Dietary Intake during Consecutive-Day Chemotherapy for Bone and Soft-Tissue Sarcomas

Background

Bone and soft tissue sarcomas are commonly treated with consecutive-day chemotherapy regimens consisting of multiple anticancer agents. Chemotherapy-induced nausea and vomiting (CINV) is a serious adverse effect of these regimens and may result in decreased energy intake during chemotherapy. Decreased energy intake may lead to undernutrition and may cause adverse effects on patient quality of life and survival.

Methods

Patients with bone and soft tissue sarcomas who received consecutive-day chemotherapy were retrospectively evaluated. CINV and dietary energy intake were assessed, as well as the occurrences of hiccups and constipation during chemotherapy.

Results

A total of 13 patients, 10 males and 3 females, with a total 16 chemotherapy courses were included in the study. All patients received antiemetic prophylaxis. The CINV control rate, defined as no emesis and no rescue therapy, gradually decreased from chemotherapy day 1 (94%) to day 5 (75%). Four patients experienced emesis, two of whom had been treated with a cisplatin-containing regimen. Decreased dietary energy intake was possibly associated with CINV during chemotherapy. Anorexia was grade 2 except for one case of grade 3. The incidences of hiccups and constipation were high on days 3–5.

Conclusion

Antiemetic prophylaxis treatment did not prevent emesis due to consecutive-day chemotherapy, especially with cisplatin-containing regimens, in patients with bone and soft-tissue tumors. Dietary energy intake decreased during chemotherapy, and this appeared to be associated with CINV. In addition, the incidence of hiccups and constipation increased during the course of consecutive-day chemotherapy regimens. Although these results are based on a small number of patients, it may be important to observe nutritional status during chemotherapy, as this may reflect a patient’s general condition. Nutritional counseling might be useful in supporting nutritional status in patients undergoing chemotherapy.

Advancing Symptom Science Through Symptom Cluster Research: Expert Panel Proceedings and Recommendations

An overview of proceedings, findings, and recommendations from the workshop on "Advancing Symptom Science Through Symptom Cluster Research" sponsored by the National Institute of Nursing Research (NINR) and the Office of Rare Diseases Research, National Center for Advancing Translational Sciences, is presented. This workshop engaged an expert panel in an evidenced-based discussion regarding the state of the science of symptom clusters in chronic conditions including cancer and other rare diseases. An interdisciplinary working group from the extramural research community representing nursing, medicine, oncology, psychology, and bioinformatics was convened at the National Institutes of Health. Based on expertise, members were divided into teams to address key areas: defining characteristics of symptom clusters, priority symptom clusters and underlying mechanisms, measurement issues, targeted interventions, and new analytic strategies. For each area, the evidence was synthesized, limitations and gaps identified, and recommendations for future research delineated. The majority of findings in each area were from studies of oncology patients. However, increasing evidence suggests that symptom clusters occur in patients with other chronic conditions (eg, pulmonary, cardiac, and end-stage renal disease). Nonetheless, symptom cluster research is extremely limited and scientists are just beginning to understand how to investigate symptom clusters by developing frameworks and new methods and approaches. With a focus on personalized care, an understanding of individual susceptibility to symptoms and whether a "driving" symptom exists that triggers other symptoms in the cluster is needed. Also, research aimed at identifying the mechanisms that underlie symptom clusters is essential to developing targeted interventions.

Differential clinical pharmacology of rolapitant in delayed chemotherapy-induced nausea and vomiting (CINV)

Rolapitant is a highly selective neurokinin-1 receptor antagonist, orally administered for a single dose of 180 mg before chemotherapy with granisetron D1, dexamethasone 8 mg BID on day 2-4. It has a unique pharmacological characteristic of a long plasma half-life (between 163 and 183 hours); this long half-life makes a single use sufficient to cover the delayed emesis risk period. No major drug-drug interactions between rolapitant and dexamethasone or other cytochrome P450 inducers or inhibitors were observed. The clinical efficacy of rolapitant was studied in two phase III trials in highly emetogenic chemotherapy and in one clinical trial in moderately emetogenic chemotherapy. The primary endpoint was the proportion of patients achieving a complete response (defined as no emesis or use of rescue medication) in the delayed phase (>24-120 hours after chemotherapy). In comparison to granisetron (10 μg/kg intravenously) and dexamethasone (20 mg orally) on day 1, and dexamethasone (8 mg orally) twice daily on days 2-4 and placebo, rolapitant showed superior efficacy in the control of delayed and overall emesis. This review aims at revising the pharmacological characteristics of rolapitant, offering an updated review of the available clinical efficacy and safety data of rolapitant in different clinical settings, highlighting the place of rolapitant in the management of chemotherapy-induced nausea and vomiting (CINV) among currently available guidelines, and exploring the future directions of CINV management.

Symptom clusters during palliative chemotherapy and their influence on functioning and quality of life

INTRODUCTION

Symptom management in patients undergoing palliative chemotherapy is challenging, as patients may suffer from cancer symptoms as well as symptoms related to chemotherapy. Symptom clusters are interrelated symptoms occurring simultaneously that exert a negative impact on survival. Identification of symptom clusters and effective symptom management for patients receiving palliative chemotherapy is crucial.

OBJECTIVES

The purpose of this study was to identify symptom clusters among cancer patients undergoing palliative chemotherapy and examine the relationship between symptom clusters and functioning and quality of life (QOL) in these patients.

METHODS

A total of 300 patients undergoing palliative chemotherapy participated in the study. Symptom experience during previous palliative chemotherapy was evaluated using a symptom questionnaire including 20 symptoms. The European Organization for Research and Treatment of Cancer Quality of Life-C30 was used to measure patients' symptoms, functioning and QOL. Factor and hierarchical cluster analyses were performed to identify symptom clusters. Structural equation modeling was used to identify relationships between symptom clusters, functioning and QOL in patients.

RESULTS

Four symptoms clusters including 14 symptoms were identified of the 20 symptoms experienced by patients undergoing palliative chemotherapy. The emotional cluster had negative influence on role and social functioning. The nausea and vomiting/appetite/taste change cluster had a negative impact on role functioning. The fatigue/cognitive and other cluster (dyspnea, pain, constipation, neuropathy, and sleep disturbance) negatively influenced physical functioning. Among the functioning subscales, only role functioning had a direct influence on QOL. Indirect relationships between symptom clusters and QOL were mediated by physical and role functioning. The final model, which consisted of four symptom clusters and three functioning subscales, accounted for 23.3% of the variance in the QOL.

CONCLUSIONS

Four symptom clusters occurring during palliative chemotherapy demonstrated negative influences on functioning and QOL. Differential contributions of symptom clusters to functioning were identified that eventually contributed to QOL through role functioning. The identified symptom clusters and their relationships with functioning and QOL may help guide approaches to symptom management. Implementation of interventions targeting symptom clusters would contribute to improving functioning and QOL in patients.

Chemotherapy-Induced Nausea and Vomiting: A Narrative Review to Inform Dietetics Practice

Chemotherapy-induced nausea and vomiting (CINV) are common symptoms experienced by patients with cancer that influence nutrition. They exert a detrimental effect on dietary intake, risk of malnutrition, and quality of life. Whereas CINV are primarily managed with medication, nutrition and dietetics practitioners play an important role in the management of CINV-related complications such as reduced dietary intake. This review discusses the burden of nausea and vomiting that patients with cancer can experience, including the effect on quality of life, nutritional status, and treatment outcomes. Implications for dietetics practice include the need to explore the nature of reported symptoms, identify predisposing risk factors, and to consider the use of a variety of interventions that are individualized to a patient's symptoms. There are little clinical data regarding effective dietetic interventions for nausea and vomiting. In summary, this review discusses dietetics-related issues surrounding CINV, including the pathophysiology, risk factors, prevalence, and both pharmacologic and dietetic treatment options.

Detecting unplanned care from clinician notes in electronic health records

PURPOSE

Reduction in unplanned episodes of care, such as emergency department visits and unplanned hospitalizations, are important quality outcome measures. However, many events are only documented in free-text clinician notes and are labor intensive to detect by manual medical record review.

METHODS

We studied 308,096 free-text machine-readable documents linked to individual entries in our electronic health records, representing care for patients with breast, GI, or thoracic cancer, whose treatment was initiated at one academic medical center, Stanford Health Care (SHC). Using a clinical text-mining tool, we detected unplanned episodes documented in clinician notes (for non-SHC visits) or in coded encounter data for SHC-delivered care and the most frequent symptoms documented in emergency department (ED) notes.

RESULTS

Combined reporting increased the identification of patients with one or more unplanned care visits by 32% (15% using coded data; 20% using all the data) among patients with 3 months of follow-up and by 21% (23% using coded data; 28% using all the data) among those with 1 year of follow-up. Based on the textual analysis of SHC ED notes, pain (75%), followed by nausea (54%), vomiting (47%), infection (36%), fever (28%), and anemia (27%), were the most frequent symptoms mentioned. Pain, nausea, and vomiting co-occur in 35% of all ED encounter notes.

CONCLUSION

The text-mining methods we describe can be applied to automatically review free-text clinician notes to detect unplanned episodes of care mentioned in these notes. These methods have broad application for quality improvement efforts in which events of interest occur outside of a network that allows for patient data sharing.

Identifying Severe Adverse Event Clusters Using the National Cancer Institute's Common Terminology Criteria for Adverse Events

PURPOSE

Exploring the relationships among adverse events is important because those that arise from a common mechanism are amenable to a common intervention, which can improve symptom management, quality of life, and treatment adherence. To date, symptom cluster studies have used patient-reported data, which are not always available in clinical trials. In this study, we proposed using the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE) to identify adverse event clusters because the CTCAE data are collected as standard practice and can therefore be used when patient-reported outcomes are unavailable.

METHODS

The CTCAE data from a randomized clinical trial conducted by SWOG that compared docetaxel plus estramustine versus mitoxantrone plus predinsone in patients with advanced prostate cancer were used to identify severe adverse event clusters. A variable based hierarchical cluster analysis was conducted using the CTCAE for the 323 patients who experienced at least one grade 3 or higher adverse event.

RESULTS

A total of 109 adverse event types were captured using the CTCAE. Four clusters had moderate associations: nausea, vomiting, and anorexia (n = 35, r = 0.45); joint/bone(myalgia, arthralgia, and arthritis) and muscle weakness (n = 26, r = 0.29); anemia and transfusion (n = 20, r = 0.38); and neutrophils/granulocytes, febrile neutropenia, and leukocytes/lymphopenia (n = 114, r = 0.29). Two clusters had weak associations: fatigue/malaise/lethargy and dehydration (n = 66, r = 0.12); and constipation, infection without neutropenia, and abdominal pain/cramping (n = 35, r = 0.13).

CONCLUSION

Several severe adverse event clusters were identified in patients with advanced prostate cancer. Identifying adverse event clusters using CTCAE data from clinical trials is feasible.

Nausea and Vomiting during the First 3 Intercycle Periods in Chemo-naive Cancer Patients Receiving Moderately/Highly Emetogenic Therapy

Aims and Background

There is a paucity of data regarding the incidence, intensity, and treatment of nausea and vomiting during the intercycle periods of chemotherapy (CHT). The aims of the study were to assess the incidence and intensity of intercycle nausea and vomiting, to assess the use of rescue antiemetic medications, and to define the more uncomfortable symptom between nausea and vomiting.

Methods

In a prospective study, 108 chemotherapy-naive patients treated with highly or moderately emetogenic CHT for different primary cancers were enrolled. All patients filled out the Edmonton Symptom Assessment System tool before the first cycle of CHT (T0) and on 14-16 days thereafter for the first 3 cycles of CHT (i.e., T1, T2, T3).

Results

Sixty-seven patients completed the study. During CHT administration, all patients received antiemetics according to international guidelines. During the intercycle periods, nausea was reported in 6.0% of patients at T0, 10.5% at T1, and 26.9% at T2 and T3, respectively. The intensity of nausea was mild for 6.0%, 21%, and 18% of patients at T1, T2, and T3, respectively; moderate for 1.5%, 3.0%, and 6.0% at T1 to T3; and severe in only 3.0% of patients at any time. Vomiting was present in 1.5% and 10.5% of patients at T2 and T3. Rescue antiemetic medication was required for 41.8% at T1, 53% at T2, and 47.8% at T3. At the end of the study, 70.1% of patients described nausea as the more uncomfortable symptom compared to vomiting.

Conclusions

Nausea has a higher burden of impact over vomiting and should be assessed and treated separately throughout multiple cycles of CHT.

Effect of Relaxation With Guided Imagery on The Physical and Psychological Symptoms of Breast Cancer Patients Undergoing Chemotherapy

Background:

Breast cancer patients frequently experience psychological distress during the chemotherapy period.

Objectives:

This study aimed to evaluate the effect of relaxation with guided imagery on patients with breast cancer.

Patients and Methods:

A two-group, pretest-posttest, quasi-experimental design with a randomized controlled trial was conducted. Sixty-five breast cancer patients from one medical center in Taiwan were enrolled in the study. These patients were randomly assigned to the experimental group (n = 32) or to the control group (n = 33). Both groups received chemotherapy self-care education, but the experimental group also received relaxation with guided imagery training. The training on relaxation with guided imagery was conducted before chemotherapy, and the patients were supplied with a compact disc detailing the performance of relaxation with guided imagery for 20 minutes daily at home for 7 days after chemotherapy.

Results:

The experimental group showed significant decreases in insomnia (-0.34 ± 0.83, P < 0.05), pain (-0.28 ± 0.58, P < 0.05), anxiety (-3.56 ± 2.94, P < 0.00), and depression (-2.38 ± 2.70, P < 0.00) between the pretest and the posttest. Comparing the two groups, statistically significant differences were found in the overall symptom distress (B = 0.11, P < 0.05), insomnia (B = 0.50, P <0.05), depression (B = 0.38, P < 0.05), and numbness in physical symptoms (B = 0.38, P < 0.05), as well as in anxiety (B = 3.08, P < 0.00) and depression (B = 1.86, P < 0.00) in psychological distress. One week of relaxation with guided imagery can significantly improve the overall symptoms of distress, insomnia, depression, physical symptoms, and anxiety, and can decrease psychological distress.

Conclusions:

Relaxation with guided imagery had a positive effect on mediating anxiety and depression in breast cancer patients.