Clinical Predictors of Chemotherapy-Induced Nausea and Vomiting in Breast Cancer Patients Receiving Adjuvant Doxorubicin and Cyclophosphamide

Association of illness perception with chemotherapy-induced nausea and vomiting: a Turkish Oncology Group (TOG) study

Chemotherapy-induced nausea and vomiting (CINV) may be linked to the psychological status of cancer patients. Therefore, the authors aimed to better understand the underlying risk factors for CINV using the Brief Illness Perception Questionnaire. A total of 238 patients were recruited during three cycles of chemotherapy. Patient, disease and treatment characteristics were noted at the onset of chemotherapy. The Brief Illness Perception Questionnaire was administered face-to-face prior to chemotherapy. The relationship between illness perceptions and CINV was analyzed using Spearman's rank correlation. Positive illness perception parameters, including personal and treatment control, were negatively correlated, whereas negative illness perception parameters, including consequences, timeline, identity, concern and emotions, were positively correlated with CINV after adjusting for age, sex and emetogenic potential of chemotherapy (p < 0.001). Illness perception may be an underlying risk factor for CINV.

Patient-Related Risk Factors for Chemotherapy-Induced Nausea and Vomiting: A Systematic Review

Background

Studies have reported that patient-related factors significantly impact the risk of Chemotherapy-Induced Nausea and Vomiting (CINV). The objective of this study was to analyze those risk factors of CINV through a systematic literature review.

Methods

We searched MEDLINE to identify articles that addressed patient-related risk factors of CINV through clinical studies.

Results

A total of 49 articles were selected for this study. A total of 28 patient-related risk-factors that significantly impact the risk of CINV were documented. Three factors are demographically related, 17 factors are intrinsic in nature and innate to patient's physiology or influenced by physiology, and eight factors are extrinsic in nature. At least five studies identified seven risk factors with notable summary odds ratio: history of nausea/vomiting (odds ratio: 3.13, 95% CI 2.40–4.07, p < 0.05), female sex (odds ratio: 2.79, 95% CI 2.26–3.44, p < 0.05), expectancy of CINV (odds ratio: 2.61, 95%CI 1.69–4.02, p < 0.05), younger age (odds ratio: 2.59, 95% CI 2.18–3.07, p < 0.05), anxiety (odds ratio: 2.57, 95% CI 1.94–3.40, p < 0.05), history of morning sickness (odds ratio: 1.97, 95% CI 1.46–2.65, p < 0.05), and low alcohol intake (odds ratio: 1.94, 95% CI 1.68–2.24, p < 0.05).

Conclusions

Oncologists can use these factors prior to the initiation of a chemotherapy regimen to identify patients at risk for CINV, in order to focus on more comprehensive antiemetic treatment options for those high-risk patients. This may enable better outcomes and avoid complications.

Netupitant/palonosetron (NEPA) and dexamethasone for prevention of emesis in breast cancer patients receiving adjuvant anthracycline plus cyclophosphamide: a multi-cycle, phase II study

Background

NEPA is an oral fixed-dose combination of netupitant, a new highly selective neurokinin-1 receptor antagonist, and palonosetron. This study was conducted to evaluate whether the efficacy of NEPA against chemotherapy-induced nausea and vomiting (CINV) in cycle 1 would be maintained over subsequent chemotherapy cycles in breast cancer patients receiving adjuvant anthracycline plus cyclophosphamide (AC). The study also describes the relationship between efficacy on day 1 through 5 (overall period) and control of CINV on day 6 through 21 (very late period) in each cycle.

Methods

In this multicentre, phase II study, patients received both NEPA and dexamethasone (12 mg intravenously) just before chemotherapy. The primary efficacy endpoint was overall complete response (CR; no emesis and no rescue medication use) in cycle 1. Sustained efficacy was evaluated during the subsequent cycles by calculating the rate of CR in cycles 2–4 and by assessing the probability of sustained CR over multiple cycles. The impact of both overall CR and risk factors for CINV on the control of very late events (vomiting and moderate-to-severe nausea) were also examined.

Results

Of the 149 patients enrolled in the study, 139 were evaluable for a total of 552 cycles; 97.8% completed all 4 cycles. The proportion of patients with an overall CR was 70.5% (90% CI, 64.1 to 76.9) in cycle 1, and this was maintained in subsequent cycles. The cumulative percentage of patients with a sustained CR over 4 cycles was 53%. NEPA was well tolerated across cycles. In each cycle, patients with CR experienced a significantly better control of very late CINV events than those who experienced no CR. Among the patients with CR, the only predictor for increased likelihood of developing very late CINV was pre-chemotherapy (anticipatory) nausea (adjusted odds ratio = 0.65–0.50 for no CINV events on cycles 3 and 4).

Conclusion

The high anti-emetic efficacy seen with the NEPA regimen in the first cycle was maintained over multiple cycles of adjuvant AC for breast cancer. Preliminary evidence also suggests that patients achieving a CR during the overall period gain high protection even against very late CINV events in each chemotherapy cycle.

Trial registration

This trial was retrospectively registered at Clinicaltrials.gov identifier (NCT03862144) on 05/Mar/2019.

Teneligliptin prevents doxorubicin-induced inflammation and apoptosis in H9c2 cells

Doxorubicin is a common chemotherapy treatment with numerous negative ramifications of use such as nephropathy and radiation-induced cardiotoxicity. Doxorubicin has been shown to cause overexpression of proinflammatory cytokines including MCP-1 and IL-1β via activation of the NF-κB pathway. Furthermore, apoptosis marked by dysregulation of the Bax/Bcl-2 ratio and oxidative stress and the production of reactive oxygen species (ROS) are also exacerbated by doxorubicin administration. Teneligliptin is part of the wider dipeptidyl peptidase-4 (DPP-4) inhibitor family which has until recently been almost exclusively used to treat type 2 diabetes mellitus. DPP-4 inhibitors such as teneligliptin control the overexpression of glucagon-like peptidase 1 (GLP-1) which has the downstream effects of general insulin resistance and high blood sugar levels. Our findings indicate a significant protective effect of teneligliptin against the aftereffects of doxorubicin as a chemotherapy treatment. This protective effect includes but is not limited to the reduction of inflammation and the mitigation of dysregulated apoptosis, as evidenced by reduced expression of IL-1β and MCP-1, inhibition of NF-κB activation, and improvement of the Bax/Bcl-2 ratio. The aim of the present study was to establish teneligliptin as a potentially useful agent for the treatment of radiation-induced cardiotoxicity, and our findings support this notion.

An investigation into the effect of gabapentin capsules on the reduction of nausea and vomiting after chemotherapy in cancerous patients under platinum-based treatment

Introduction and Objective:

Chemotherapy-induced nausea and vomiting (CINV) is a condition that occur in most patients. This study aimed to investigate the effect of gabapentin capsules on the reduction of chemotherapy-induced nausea and vomiting in patients admitted in the hematological ward for adult patients with platinum-based treatment.

Materials and Methods:

The present study was a randomized clinical trial, which consisted of a control group and an experimental one. The study population consisted of 126 women and men with colonic and gastric cancer who were admitted to Ahwaz Shafa Hospital of adult hematology ward. Of these, 120 subjects were eligible to enter the study. Immediately after chemotherapy, gabapentin capsules were taken. Up to 72 hours later, nausea and vomiting were compared. Descriptive statistics was used to investigate the demographic characteristics. Paired t-test, independent t-test and ANOVA were used to compare the results.

Results:

The results showed that most of the patients had gastric cancer in the experimental (70%) and control group (66.66%). The results also showed that chemotherapy-induced nausea and vomiting in gabapentin recipient group was different from the placebo group. Accordingly, chemotherapy induced nausea and vomiting in gabapentin group was lower than the placebo group.

Conclusion:

Post-operative nausea and vomiting is an unpleasant experience. Today, the patients find it worse than pain, and they believe it is hard to afford the cost of treatment. Gabapentin seems to be a good drug for reducing nausea and vomiting.

A Hypericin Delivery System Based on Polydopamine Coated Cerium Oxide Nanorods for Targeted Photodynamic Therapy

Photodynamic therapy (PDT) as a non-aggressive therapy with fewer side effects has unique advantages over traditional treatments. However, PDT still has certain limitations in clinical applications, mainly because most photosensitizers utilized in PDT are hydrophobic compounds, which will self-aggregate in the aqueous phase and cause undesirable effects. In order to resolve this, we utilized the self-polymerization of dopamine molecules under alkaline conditions to coat cerium oxide nanorods (CeONR) with a dense polydopamine (PDA) film. Thereafter, thiolated galactose (Gal-SH) and hypericin (Hyp) were modified and loaded onto the surface to construct CeONR@PDA-Gal/Hyp, respectively, which can be used for targeted photodynamic therapy of human hepatoma HepG2 cells. CeONR@PDA-Gal/Hyp was characterized by transmission electron microscope (TEM), Zeta potential, Ultraviolet-visible (UV-Vis), and fluorescence spectroscopy, respectively. This hypericin delivery system possesses good biocompatibility and specific targeting ability, where the galactose units on the surface of CeONR@PDA-Gal/Hyp can specifically recognize the asialo-glycoprotein receptors (ASGP-R), which overexpress on HepG2 cell membrane. Furthermore, Hyp will detach from the surface of CeONR@PDA-Gal/Hyp after the nanorods enter cancer cells, and shows excellent PDT effect under the irradiation of light with a wavelength of 590 nm. Our work exemplifies a novel targeted delivery of hydrophobic photosensitizers for cancer treatment.

A medicinal and edible formula YH0618 ameliorates the toxicity induced by Doxorubicin via regulating the expression of Bax/Bcl-2 and FOXO4

Chemotherapy is the most common and powerful cancer treatment. Although the nasty side effects seriously influence the clinical practice, no better ways can displace it. Therefore, searching for safe and effective strategies designed to ameliorate chemotherapy-induced toxicity has become an urgent issue in cancer research area. In clinical, a medicinal and edible formula YH0618 showed the effects of reducing the DOX-induced toxicity, especially improving alopecia, nail discoloration, skin hyperpigmentation and fatigue. This study was to investigate the role and mechanism of YH0618 in ameliorating DOX-induced toxicity by in vitro and in vivo experiments. YH0618 selectively attenuated DOX-induced growth inhibition and apoptosis in human normal liver L02 cells and kidney HEK-293 cells, and simultaneously potentiated the anti-cancer effect of DOX in breast cancer MCF-7 and MDA-MB-231 cells by apoptosis pathways. Western blotting results revealed that YH0618 attenuated DOX-induced apoptosis in normal liver and kidney cells through FOXO4-mediated mitochondria-dependent mechanism. Animal experiments demonstrated that, YH0618 did not interfere in DOX-induced reduction in tumor volume and significantly improved DOX-induced hair loss and the increase of alanine aminotransferase (ALT). Histological characteristics showed that YH0618 attenuated DOX-induced heart, liver and kidney damage. The study may shed light on the potential application of YH0618 as a novel medicinal food against chemotherapy-induced toxicity.

Anti-emetic Action of the Brain-Penetrating New Ghrelin Agonist, HM01, Alone and in Combination With the 5-HT3 Antagonist, Palonosetron and With the NK1 Antagonist, Netupitant, Against Cisplatin- and Motion-Induced Emesis in Suncus murinus (House Musk Shrew)

Ghrelin has well-known activity to stimulate appetite and weight gain. Evidence suggests that ghrelin may also have effects in reducing chemotherapy-induced emesis via growth hormone secretagogue receptors (GHS-R1A) in the brain. However, it is not known whether the stimulation of GHS-R1A has broad inhibitory anti-emetic effects. In the present studies, we used Suncus murinus to investigate the potential of the new and novel orally bioavailable brain-penetrating GHS-R1A mimetic, HM01 (1-[(1S)-1-(2,3-dichloro-4-methoxyphenyl)ethyl]-3-methyl-3-[(4R)-1-Methyl-3,3-dimethyl-4-piperidyl]urea), to reduce emesis induced by a variety of emetic challenges. HM01 (1 to 30 mg/kg, p.o.) antagonized emesis induced by cisplatin (30 mg/kg, i.p.) and by motion (4 cm horizontal displacement, 1 Hz) but was ineffective against emesis induced by nicotine (5 mg/kg, s.c.) and copper sulfate (120 mg/kg by intragastric gavage). In other experiments, HM01 (3 mg/kg, p.o.) enhanced the anti-emetic control of a regimen of palonosetron (0.01 mg/kg, p.o.) alone and palonosetron (0.01 mg/kg p.o.) plus netupitant (1 mg/kg, p.o.). HM01 (10 mg/kg, p.o.) also had positive effects in increasing feeding and drinking in nicotine-treated animals, and it shortened the latency to drink in animals treated with cisplatin. These data indicate that brain-penetrating GHS-R1A agonists may have use alone and/or in combination with standard anti-emetic regimens for the treatment of chemotherapy-induced nausea and vomiting and motion sickness.

Applicability of the National Comprehensive Cancer Network/Multinational Association of Supportive Care in Cancer Guidelines for Prevention and Management of Chemotherapy-Induced Nausea and Vomiting in Southeast Asia: A Consensus Statement

A meeting of regional experts was convened in Manila, Philippines, to develop a resource-stratified chemotherapy-induced nausea and vomiting (CINV) management guideline. In patients treated with highly emetogenic chemotherapy in general clinical settings, triple therapy with a serotonin (5-hydroxytryptamine-3 [5-HT3]) antagonist (preferably palonosetron), dexamethasone, and aprepitant is recommended for acute CINV prevention. In resource-restricted settings, triple therapy is still recommended, although a 5-HT3 antagonist other than palonosetron may be used. In both general and resource-restricted settings, dual therapy with dexamethasone (days 2 to 4) and aprepitant (days 2 to 3) is recommended to prevent delayed CINV. In patients treated with moderately emetogenic chemotherapy, dual therapy with a 5-HT3 antagonist, preferably palonosetron, and dexamethasone is recommended for acute CINV prevention in general settings; any 5-HT3 antagonist can be combined with dexamethasone in resource-restricted environments. In general settings, for the prevention of delayed CINV associated with moderately emetogenic chemotherapy, corticosteroid monotherapy on days 2 and 3 is recommended. If aprepitant is used on day 1, it should be continued on days 2 and 3. Prevention of delayed CINV with corticosteroids is preferred in resource-restricted settings. The expert panel also developed CINV management guidelines for anthracycline plus cyclophosphamide combination schedules, multiday cisplatin, and chemotherapy with low or minimal emetogenic potential, and its recommendations are detailed in this review. Overall, these regional guidelines provide definitive guidance for CINV management in general and resource-restricted settings. These consensus recommendations are anticipated to contribute to collaborative efforts to improve CINV management in Southeast Asia.

Genetic Risk Factors Associated With Antiemetic Efficacy of Palonosetron, Aprepitant, and Dexamethasone in Japanese Breast Cancer Patients Treated With Anthracycline-based Chemotherapy

INTRODUCTION

Breast cancer patients often receive anthracycline-based chemotherapy, and chemotherapy-induced nausea and vomiting (CINV) remains one of the most uncomfortable and distressing adverse reactions. Poor control of CINV reduces the relative dose intensity of chemotherapy agents, which has been associated with poor clinical outcomes and shorter survival. The aim of the present study was to identify genetic risk factors associated with anthracycline-based CINV.

PATIENTS AND METHODS

We evaluated CINV attributable to anthracycline-based chemotherapy in Japanese breast cancer patients treated with an antiemetic regimen that included palonosetron, aprepitant, and dexamethasone. Furthermore, we investigated the associations between CINV and single nucleotide polymorphisms in 6 candidate genes.

RESULTS

Emesis episodes were rarely observed in the 125 patients included in the present survey (7.2%; n = 9); however, significant nausea occurred in more than one half of the patients (52.8%; n = 66). In particular, acute significant nausea was not effectively controlled. Multivariate logistic regression analysis revealed that the ABCG2 (rs2231142) AA genotype is significantly associated with acute significant nausea (odds ratio, 4.87; 95% confidence interval, 1.01-23.60; P = .049).

CONCLUSION

The findings of the present study provide significant insights for developing personalized antiemetic strategies for breast cancer patients receiving anthracycline-based chemotherapy.

Late chronotypes are associated with neoadjuvant chemotherapy-induced nausea and vomiting in women with breast cancer

Neoadjuvant chemotherapy, that is, the administration of chemotherapy before surgery, has been commonly used for locally advanced breast cancer to improve the surgical outcomes and increase the opportunity for breast-conserving therapy. Women with breast cancer often receive an anthracycline-based regimen as the neoadjuvant chemotherapy, which is associated with a high risk of emesis. Despite the development of novel antiemetics, chemotherapy-induced nausea and vomiting (CINV) has been commonly reported as a major adverse effect, affecting the quality of life of the patients. However, the factors predicting CINV in women with breast cancer undergoing neoadjuvant chemotherapy remain unclear. In this single-institution, prospective, observational study conducted at an outpatient cancer centre in the Republic of Korea from November 2013 to March 2016, we analysed women with breast cancer who planned to be treated with neoadjuvant chemotherapy before surgery. Candidate factors associated with CINV were assessed before neoadjuvant chemotherapy using the Munich Chronotype Questionnaire, Pittsburgh Sleep Quality Index and Hospital Anxiety and Depression Scale. CINV was assessed after chemotherapy by using the Multinational Association of Supportive Care in Cancer Antiemesis Tool. Of a total of 143 participants, 7 patients were lost to follow-up and 2 patients were excluded due to changes in their treatment plan; thus, 134 patients were finally included in the analyses. Overall, 48.5% of the participants experienced CINV, with delayed CINV prevalence (42.5%) being more common than acute (39.6%). In the univariate analyses, overall CINV was significantly associated with late chronotypes (odds ratio [OR], 3.49; 95% confidence interval [CI], 1.37-8.87; p = 0.009), a history of nausea/vomiting (OR, 2.19; 95% CI, 1.10-4.37; p = 0.026) and anxiety (OR, 2.25; 95% CI, 1.05-4.81; p = 0.036). In the multivariate analyses, late chronotypes (OR, 3.53; 95% CI, 1.27-9.79; p = 0.015) and a history of nausea/vomiting (OR, 2.83; 95% CI, 1.31-6.13; p = 0.008) remained significantly associated with CINV. In conclusion, in women with breast cancer undergoing neoadjuvant chemotherapy before surgery, late chronotypes were found to have an increased risk of CINV; these data suggest that clinicians need to assess and consider the chronotype in the management of CINV.

Single nucleotide polymorphisms might influence chemotherapy induced nausea in women with breast cancer

Background

Women receiving FEC (5 fluorouracil, epirubicin and cyclophosphamide) chemotherapy (CT) for breast cancer (BC) often experience side effects such as nausea and vomiting. Individual variations of side effects occur in patients despite similar cancer therapy. The purpose of this study was to investigate a possible genetic background as a predictor for individual variations in nausea induced by CT.

Methods

114 women were included in the study. All women received adjuvant CT for BC. Self-reported nausea and vomiting was recorded in a structured diary over ten days following treatment. Blood samples were collected before the treatment and used for the detection of 48 single nucleotide polymorphisms (SNPs) in 43 genes. SNPs from each individual woman were analyzed for their relation to the patient-reported frequency and intensity of nausea and vomiting.

Results

Eighty-four percent (n = 96) of the women reported acute or delayed nausea or combined nausea and vomiting during the ten days following CT. Three out of the forty-eight SNPs in the following genes: FAS/CD95, RB1/LPAR6 and CCL2 were found to be associated with a risk of nausea.

Conclusion

SNPs in the FAS/CD95, RB1/LPAR6 and CCL2 genes were found to be associated with nausea among women treated with adjuvant FEC for BC. SNPs analysis is fast and cost effective and can be done prior to any cancer therapy. The association between individual SNPs and severe side effects from FEC may contribute to a more personalized care of patients with BC.

Integrative review of factors related to the nursing diagnosis nausea during antineoplastic chemotherapy

Objective

to identify factors related to the nursing diagnosis nausea among cancer patients undergoing chemotherapy.

Method

integrative review conducted in four electronic databases (PUBMED, EMBASE, CINAHL and LILACS) using the key words: neoplasia, antineoplastic agents and nausea.

Results

only 30 out of 1,258 papers identified met the inclusion criteria. The most frequent related factors were: being younger than 50 years old, motion sickness, being a woman, emetogenic potential of the chemotherapy, anxiety, conditioned stimulus, and expecting nausea after treatment.

Conclusion

this review's findings, coupled with the incidence of nausea among cancer patients undergoing chemotherapy, reveal an important difference between evidence found and that used by NANDA International, Inc. Even though it provides an appropriate definition of related factors, it does not mention chemotherapy, despite the various studies addressing the topic using different designs and presenting various objectives and outcomes.

Longitudinal Association of Poor Sleep Quality With Chemotherapy-Induced Nausea and Vomiting in Patients With Breast Cancer

OBJECTIVE

Risk factors for chemotherapy-induced nausea and vomiting (CINV) include older age, female sex, alcohol consumption, and a history of motion sickness. Although gastrointestinal symptoms are found to be related with sleep and mood in other conditions, little is known about their effects on CINV.

METHODS

This prospective observational study recruited patients with early-stage breast cancer who had recovered from surgery before receiving a first cycle of anthracycline and cyclophosphamide-based chemotherapy. Candidate factors associated with CINV were assessed before chemotherapy by using the following: the Pittsburgh Sleep Quality Index, the Insomnia Severity Index, the Epworth Sleepiness Scale, and the Hospital Anxiety and Depression Scale. Chemotherapy-induced nausea (CIN) and chemotherapy-induced vomiting (CIV) were defined according to a numeric rating scale (0-10) as follows: ≥3, nausea; ≥1, vomiting.

RESULTS

Between February 2012 and May 2014, data were collected from 198 patients. Chemotherapy-induced nausea occurred in 35.4% of patients, and CIV occurred in 31.3%. Chemotherapy-induced nausea was significantly associated with poor sleep quality (odds ratio [OR], 2.48; 95% confidence interval [CI], 1.13-5.46; p = 0.024) and pretreatment nausea (OR, 4.81; 95% CI, 1.84-12.62; p = 0.001). Likewise, CIV was significantly associated with poor sleep quality (OR, 2.64; 95% CI, 1.21-5.78; p = 0.015) and pretreatment nausea (OR, 3.07; 95% CI, 1.23-7.66; p = 0.016).

CONCLUSIONS

Poor sleep quality increases risk of CINV in patients with breast cancer. Sleep problems should be assessed and considered in the management of CINV.

Profile of Antiemetic Activity of Netupitant Alone or in Combination with Palonosetron and Dexamethasone in Ferrets and Suncus murinus (House Musk Shrew)

Background and Aims: Chemotherapy-induced acute and delayed emesis involves the activation of multiple pathways, with 5-hydroxytryptamine (5-HT; serotonin) playing a major role in the initial response. Substance P tachykinin NK₁ receptor antagonists can reduce emesis induced by disparate emetic challenges and therefore have a clinical utility as broad inhibitory anti-emetic drugs. In the present studies, we investigate the broad inhibitory anti-emetic profile of a relatively new NK₁ receptor antagonist, netupitant, alone or in combination with the long acting 5-HT₃ receptor antagonist, palonosetron, for a potential to reduce emesis in ferrets and shrews.

Materials and Methods: Ferrets were pretreated with netupitant and/or palonosetron, and then administered apomorphine (0.125 mg/kg, s.c.), morphine (0.5 mg/kg, s.c.), ipecacuanha (1.2 mg/kg, p.o.), copper sulfate (100 mg/kg, intragastric), or cisplatin (5–10 mg/kg, i.p.); in other studies netupitant was administered to Suncus murinus before motion (4 cm horizontal displacement, 2 Hz for 10 min).

Results: Netupitant (3 mg/kg, p.o.) abolished apomorphine-, morphine-, ipecacuanha- and copper sulfate-induced emesis. Lower doses of netupitant (0.03–0.3 mg/kg, p.o.) dose-dependently reduced cisplatin (10 mg/kg, i.p.)-induced emesis in an acute (8 h) model, and motion-induced emesis in S. murinus. In a ferret cisplatin (5 mg/kg, i.p.)-induced acute and delayed emesis model, netupitant administered once at 3 mg/kg, p.o., abolished the first 24 h response and reduced the 24–72 h response by 94.6%; the reduction was markedly superior to the effect of a three times per day administration of ondansetron (1 mg/kg, i.p.). A single administration of netupitant (1 mg/kg, p.o.) plus palonosetron (0.1 mg/kg, p.o.) combined with dexamethasone (1 mg/kg, i.p., once per day), also significantly antagonized cisplatin-induced acute and delayed emesis and was comparable with a once-daily regimen of ondansetron (1 mg/kg, p.o.) plus aprepitant (1 mg/kg, p.o.) in combination with dexamethasone (1 mg/kg, i.p.).

Conclusion: In conclusion, netupitant has potent and long lasting anti-emetic activity against a number of emetic challenges indicating broad inhibitory properties. The convenience of protection afforded by the single dosing of netupitant together with palonosetron was demonstrated and also is known to provide an advantage over other therapeutic strategies to control emesis in man.

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.

Pharmacogenetics of chemotherapy-induced nausea and vomiting

Chemotherapy-induced nausea and vomiting (CINV) is associated with distressing adverse effects observed in patients during cytotoxic chemotherapy. One of the potential factors explaining suboptimal response to currently used antiemetics is variability in genes encoding enzymes and proteins that play a role in the action of antiemetic drugs. Pharmacogenomics studies of CINV are sparse and focus mainly on polymorphisms associated with serotonin receptor, drug metabolism and drug transport. Currently, the role of pharmacogenetics in mechanisms of CINV has not been fully unraveled, and it is premature to implement results of pharmacogenetic association studies of antiemetic drugs in clinical practice. More uniform studies, with genetic profiles and biomarkers relevant for the proposed target and transporter mechanisms, are needed.

Addressing the value of novel therapies in chemotherapy-induced nausea and vomiting

Chemotherapy-induced nausea and vomiting (CINV) is a troubling side effect of cancer treatment and is often poorly controlled. As a consequence, CINV is associated with substantially increased costs of care and significant interference with patients' lives. Inadequate control over CINV results from factors that include failure to provide guideline-adherent prophylactic medication and limitations in available therapies. Newer serotonin receptor antagonists, such as palonosetron, and addition of neurokinin-1 (NK-1) receptor antagonists to treatment have significantly decreased both acute and delayed CINV. A fixed-dose combination of palonosetron and a new NK-1 receptor, netupitant, is significantly superior to palonosetron alone and has small, but consistent, numerical advantages over aprepitant plus palonosetron for prevention of CINV. The combination of a serotonin receptor antagonist plus an NK-1 receptor antagonist has been shown to be cost-effective for prevention of CINV and the availability of a fixed-dose combination of netupitant and palonosetron may enhance this benefit.

Fasting Reduces the Incidence of Delayed-Type Vomiting Associated with Doxorubicin Treatment in Dogs with Lymphoma

Fasting reduces gastrointestinal cellular proliferation rates through G1 cycle blockade and can promote cellular protection of normal but not cancer cells through altered cell signaling including down-regulation of insulin-like growth factor 1 (IGF-1). Consequently, the purpose of this study was to determine the effects of fasting on delayed-type chemotherapy-induced nausea and vomiting in dogs receiving doxorubicin. This prospective randomized crossover study involved intended administration of two doses of doxorubicin. Cancer-bearing dogs were randomized to be fasted for 24 hours beginning at 6 P.M. the night before the first or second doxorubicin administration, and all treatments were administered within an hour before or after 12 P.M. Dogs were fed normally before the alternate dose. Circulating IGF-1 concentrations were determined from serum samples obtained immediately before each doxorubicin treatment. Data from 35 doses were available from 20 dogs enrolled. Dogs that were fasted exhibited a significantly lower incidence of vomiting, when compared to fed dogs (10% compared to 67%, P = .020). Furthermore, among the 15 dogs that completed crossover dosing, vomiting was abrogated in four of five dogs that experienced doxorubicin-induced vomiting when fed normally (P = .050). No differences in other gastrointestinal, constitutional, or bone marrow toxicities or serum IGF-1 levels were observed.

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.

Variations in self-reported nausea, vomiting, and well-being during the first 10 days postchemotherapy in women with breast cancer

Women with breast cancer undergoing chemotherapy experience nausea and vomiting, both common symptoms affecting quality of life. The aim of the current study was to describe how nausea, vomiting, and well-being vary during the first 10 days after chemotherapy in women with breast cancer. A pilot study with a repeated-measurements design was conducted at a Swedish county hospital where 39 women with breast cancer treated with adjuvant chemotherapy were observed. A structured 10-day diary was used for data collection. Of the 39 women in the study, 33 experienced nausea and 6 also experienced vomiting after chemotherapy. Changes in well-being as a result of nausea or vomiting during any part of the day, as well as distress for other reasons, were reported. Well-being also varied among the individuals. The pattern of change in experienced levels of well-being was not homogeneous, nor did it move in any certain direction. The results of this study show that an individualized treatment approach is required to better meet individual women's needs.

Assessment of chemotherapy-induced nausea and vomiting in women with breast cancer: a Neuman systems model framework

The importance of nursing theory and models for the development of the nursing profession is becoming increasingly evident in literature. This article demonstrates the use of the Betty Neuman Systems Model (NSM) to assess, as well as determine the predictors of chemotherapy-induced nausea and vomiting (CINV) in patients diagnosed with breast cancer receiving doxorubicin-based chemotherapy. The selection of the model for practice reflects the congruency between the level of severity of CINV and the patient-related risk factors. In addition, the NSM was used to determine the appropriate nursing interventions necessary to strengthen the flexible lines of defense and the lines of resistance in addition to maintaining system stability.

Exploring Chemotherapy-Induced Toxicities through Multivariate Projection of Risk Factors: Prediction of Nausea and Vomiting

Many risk factors exist for chemotherapy-induced nausea and vomiting (CINV). This study utilized a multivariate projection technique to identify which risk factors were predictive of CINV in clinical practice. A single-centre, prospective, observational study was conducted from January 2007~July 2010 in Singapore. Patients were on highly (HECs) and moderately emetogenic chemotherapies with/without radiotherapy. Patient demographics and CINV risk factors were documented. Daily recording of CINV events was done using a standardized diary. Principal component (PC) analysis was performed to identify which risk factors could differentiate patients with and without CINV. A total of 710 patients were recruited. Majority were females (67%) and Chinese (84%). Five risk factors were potential CINV predictors: histories of alcohol drinking, chemotherapy-induced nausea, chemotherapy-induced vomiting, fatigue and gender. Period (ex-/current drinkers) and frequency of drinking (social/chronic drinkers) differentiated the CINV endpoints in patients on HECs and anthracycline-based, and XELOX regimens, respectively. Fatigue interference and severity were predictive of CINV in anthracycline-based populations, while the former was predictive in HEC and XELOX populations. PC analysis is a potential technique in analyzing clinical population data, and can provide clinicians with an insight as to what predictors to look out for in the clinical assessment of CINV. We hope that our results will increase the awareness among clinician-scientists regarding the usefulness of this technique in the analysis of clinical data, so that appropriate preventive measures can be taken to improve patients' quality of life.

Impact of cancer-related fatigue on chemotherapy-induced nausea and vomiting in Asian cancer patients

INTRODUCTION

Cancer-related fatigue (CRF) has been suggested to be associated with the occurrence of chemotherapy-induced nausea and vomiting (CINV). This study aims to evaluate the potential of CRF in predicting the occurrence of CINV.

METHOD

This is a prospective, observational study. Recruited patients received moderately to highly emetogenic single-day chemotherapy regimens. On the day of chemotherapy, patients were instructed to provide a score (Likert scale of 0-10) to describe how CRF interfered with his or her ability to engage in daily activities and a score for how severe it was. Patients were then given a standardized 5-day diary to document their CINV events.

RESULTS

A total of 473 eligible patients (median age: 55 years, interquartile range (IQR): 48-61 years) were recruited, with most of the patients diagnosed with gastrointestinal (45%) and breast (37%) cancers. The median score of fatigue interference was 3 (IQR: 0-5). After confounders were adjusted for, patients with low fatigue interference scores (≤3) were more likely to achieve complete protection (no nausea, no vomiting, and no breakthrough antiemetics) of CINV (adjusted odds ratio = 1.57, 95%CI [1.05, 2.35], p = 0.027).

CONCLUSION

This is the largest study to date to evaluate the association between CRF and CINV. Patients experiencing CRF possessed a higher risk of poor control for CINV.

Novel dynamic measures of emetic behavior in musk shrews

The emetic reflex occurs as a pattern of motor responses produced by a network of neurons in the hindbrain. Despite an understanding of the sequence of motor outputs that form an emetic episode (EE), the variability in the dynamics of multiple EEs across time remains a mystery. Many clinical investigations rely on once a day patient recall of total amount of vomiting, and preclinical studies frequently report only the total number of EE per unit time. The aim of the current study was to develop novel temporal measures of emetic activation in a preclinical model. Male and female musk shrews were tested with prototypical emetic stimuli: motion exposure (1 Hz), nicotine (5 mg/kg, sc), and copper sulfate (120 mg/kg, ig). New emetic measures included duration (time from first to last episode), rate, standard deviation of the inter-episode interval (SD-I), and a survival analysis of emetic latency (analyzed with Cox regression). Behavioral patterns associated with emesis were also assessed using statistical temporal pattern (T-pattern) analysis to measure nausea-like behaviors (e.g., immobility). The emetic stimuli produced different levels of total EE number, duration, rate, and SD-I. A typical antiemetic, the neurokinin 1 receptor antagonist CP-99,994, suppressed the number of EEs but was less effective for reducing the duration or prolonging the emetic latency. Overall, the current study shows the use of novel dynamic behavioral measures to more comprehensively assess emesis and the impact of therapies.

Development and preliminary validation of a risk prediction model for chemotherapy-related nausea and vomiting

BACKGROUND

A number of risk factors have been implicated in the development of chemotherapy-induced nausea/vomiting (CINV). Our aim was to develop a risk prediction model and identify patients at high risk for developing CINV before their chemotherapy treatment.

PATIENTS AND METHODS

A multisite, observational, prospective longitudinal design was used. Participants were 336 chemotherapy-naïve cancer patients providing 791 assessments. They completed measures to assess potential risk factors for CINV, including socio-demographic and clinical/treatment-related characteristics, symptom distress, expectations for CINV and state-trait anxiety. CINV was measured with the MASCC Antiemesis Tool. Participants were divided randomly to a training set (=286) and a test set (=50). Random-effects models were run to ascertain the contribution of risk factors in the development of CINV using the training sample. Specificity and sensitivity of the model were assessed in both sets of samples.

RESULTS

Younger age, history of nausea/vomiting, trait anxiety and fatigue were linked with higher levels of CINV, and use of moderately and low emetogenic chemotherapy were linked with lower CINV. The model's specificity were 55.4 and 50.0 % and sensitivity were 80.3 and 79.0 % in the training and test sample, respectively. A dynamic web-based tool is freely available for use by clinicians.

CONCLUSION

This model of risk prediction for CINV can be an aid to clinical decision-making and assist clinicians to rationalise antiemetic use with their patients.

Feasibility and acceptance of a pharmacist-run tele-oncology service for chemotherapy-induced nausea and vomiting in ambulatory cancer patients

BACKGROUND

The use of telemedicine for cancer patients is limited, particularly in Asia. These patients need to be monitored because more are being treated as outpatients, so that any treatment-related side effects can be managed. We assessed the feasibility and acceptance of a pharmacist-run tele-oncology service to monitor chemotherapy-induced nausea and vomiting (CINV) in ambulatory cancer patients.

PATIENTS AND METHODS

A single-center, prospective study was conducted at a local cancer center. Patients' CINV symptoms were monitored through short message service (SMS) for 5 days post-chemotherapy. Feasibility was measured by patients' adherence to the service, patient satisfaction, and number of pharmacist interventions. Acceptance was measured by the accrual rate.

RESULTS

The accrual rate was 37.6% (68/181 patients). Sixty patients (median age, 49.5 years) completed the study. Overall adherence was 73.3%. The majority (90.0%) were comfortable with the duration of SMS monitoring, especially adherent patients (95.5% versus 75.0%, p=0.038). Over half (61.7%) found the SMS advice useful. Twenty-two intervention calls were made by pharmacists for uncontrolled CINV.

CONCLUSIONS

A pharmacist-run tele-oncology service for real-time monitoring of CINV is feasible in ambulatory cancer patients. Incorporating the monitoring of other side effects will enhance its value and acceptance by patients for post-chemotherapy symptom management.

Optimizing treatment outcomes in patients at risk for chemotherapy-induced nausea and vomiting

Prevention of chemotherapy-induced nausea and vomiting (CINV) is crucial in maximizing patients' quality of life and optimizing outcomes of cancer therapy, and can be done more effectively than ever before. Appropriate antiemetic therapy combined with targeted patient education, clear communication, and management of patient expectations results in optimal emetogenic control. Oncology nurses play a critical role in the prevention and management of CINV. This column reviews the history and pathophysiology of treatments for CINV, as well as patient- and chemotherapy-specific risk factors that should be considered to optimize treatment outcomes in patients with CINV.

[Comparative study of the efficacy and safety of two anti-emetic protocols in gynecological chemotherapy]

OBJECTIVES

To evaluate the efficacy and safety of an update to an anti-emetic protocol in chemotherapy for gynecological tumours.

METHOD

Prospective observational study performed over 12 months in a general hospital with 400 beds. We evaluated the efficacy of the old anti-emetic protocol, a new protocol was implemented, and its efficacy was determined. We included patients with gynaecological tumours that sought treatment at the Day Hospital. After each chemotherapy cycle, patients filled out a survey that registered the number and severity of episodes of nausea/vomiting and other adverse effects. The efficacy of treatment was measured as complete response (no nausea or vomit) in the acute phase (first 24h after chemotherapy) and late phase (2-5 days after chemotherapy). We also evaluated whether age, the type of protocol, and the emetogenous power of the different treatment schemes could influence patient response.

RESULTS

We analysed 102 chemotherapy cycles under the old protocol (52 patients) and 293 cycles under the new protocol (98 patients). We observed significant differences in complete response rates in the late phase between old and new protocols (36.27% vs 67.38%, P<.0001). The probability of obtaining a complete response using the new protocol was twice as high as with the old protocol in acute emesis (OR=1.85, 95% CI: 1.05-3.24, P=.03) and four times higher in late emesis (OR=4.27, 95% CI: 2.59-7.02, P<.0001).

CONCLUSIONS

A greater percentage of complete responses to late emesis was obtained using the new protocol. Age and the low emetogenous power of the treatment schemes were predictive factors for complete response in acute emesis.

Computational prediction of state anxiety in Asian patients with cancer susceptible to chemotherapy-induced nausea and vomiting

State anxiety, a risk factor for chemotherapy-induced nausea and vomiting (CINV), is a subjective symptom and difficult to quantify. Clinicians need appropriate anxiety measures to assess patients' risks of CINV. This study aimed to determine the anxiety characteristics that can predict CINV based on computational analysis of an objective assessment tool. A single-center, prospective, observational study was carried out between January 2007 and July 2010. Patients with breast, head and neck, and gastrointestinal cancers were recruited and treated with a variety of chemotherapy protocols and appropriate antiemetics. Chemotherapy-induced nausea and vomiting characteristics and antiemetic use were recorded using a standardized diary, whereas patients' anxiety characteristics were evaluated using the Beck Anxiety Inventory. Principal component (PC) analysis was performed to analyze the anxiety characteristics. A subset known as principal variables, which had the highest PC weightings, was identified for patients with and without complete response, complete protection, and complete control. Chemotherapy-induced nausea and vomiting events and anxiety characteristics of 710 patients were collated; 51%, 30%, and 20% were on anthracycline-, oxaliplatin-, and cisplatin-based therapies, respectively. Most patients suffered from delayed CINV, with decreasing proportions achieving complete response (58%), complete protection (42%), and complete control (27%). Seven symptoms (fear of dying, fear of the worst, unable to relax, hot/cold sweats, nervousness, faintness, numbness) were identified as potential CINV predictors. This study demonstrates the usefulness of PC analysis, an unsupervised machine learning technique, to identify 7 anxiety characteristics that are useful as clinical CINV predictors. Clinicians should be aware of these characteristics when assessing CINV in patients on emetogenic chemotherapies.

Prevalence of Delayed Nausea and/or Vomiting in Patients Treated With Oxaliplatin-Based Regimens for Colorectal Cancer

PURPOSE

To measure the prevalence of nausea and vomiting 2 to 5 days after oxaliplatin-based chemotherapy.

PATIENTS AND METHODS

Sixty-four patients (55% men; 44% women) enrolled onto this cross-sectional study. Fifty-three (83%) had colon cancer and received oxaliplatin biweekly. Eleven (17%) had rectal cancer and received oxaliplatin weekly. We collected data on 23 patients for the first cycle and on 41 patients for the first two cycles, for a total of 105 cycles. Nausea and vomiting was graded using Common Toxicity Criteria. Patients maintained a 7-day postinfusion diary of nausea and vomiting and antiemetic use.

RESULTS

All patients received antiemetics and steroids on day 1 of each cycle. For patients with data collected for both cycles, the occurrence of nausea was the same during cycles one and two. Thirty-nine percent used rescue antiemetics in cycle one, and 34% did so in cycle two. Sixty-eight percent of men reported no nausea in cycle one compared with 33% of women; for cycle two, these figures were 67% and 36%, respectively. Eighty-nine percent of patients reported no vomiting in cycle one, and 85% did so in cycle two. Seven patients (11%) had a history of motion sickness; 13 of 28 women (46%) reported history of pregnancy-induced morning sickness. Palonosetron slightly but significantly reduced the occurrence of nausea. Female sex and history of chemotherapy were significant risk factors for nausea.

CONCLUSION

Delayed nausea associated with oxaliplatin was well controlled and evenly divided between grades 1 and 2; vomiting was rare. Factors associated with nausea were intrinsic to the patient and mostly unrelated to the antiemetics used. Sex and previous experience with emesis should be considered for efficient antiemetic management.

Neuro-cognitive impairment in breast cancer patients: pharmacological considerations

Post-chemotherapy cognitive impairment has been an issue of concern in cancer survivors. While most reviews are focused on patient-related factors, it is proposed that drug-related factors may also be determinants. The objective of this review is to study the relationship between the types and dose intensities of chemotherapy regimens on cognitive impairment in breast cancer patients through a systematic literature search. Eighteen prospective studies were selected. The types, dose intensities and durations of chemotherapy regimens received by subjects were compared against prevalence results obtained in individual studies. It was observed that the duration of impairment varied across different generations of chemotherapy regimens. Concurrent administration of multiple cytotoxic agents can lead to a synergistic decline on cognition. Current clinical evidence is insufficient to evaluate the relationship between the types, dose intensities of chemotherapy regimens and cognitive impairment. More investigation is needed to examine the role of pharmacological factors in chemotherapy-associated cognitive changes.

Static and dynamic autonomic response with increasing nausea perception

BACKGROUND

Nausea is a commonly occurring symptom typified by epigastric discomfort with urge to vomit. The relationship between autonomic nervous system (ANS) outflow and increasing nausea perception is not fully understood.

METHODS

Our study employed a nauseogenic visual stimulus (horizontally translating stripes) while 17 female subjects freely rated transitions in nausea level and autonomic outflow was measured (heart rate, HR; heart rate variability, HRV; skin conductance response, SCR; respiratory rate). We also adopted a recent approach to continuous high-frequency (HF) HRV estimation to evaluate dynamic cardiovagal modulation.

RESULTS

HR increased from baseline for all increasing nausea transitions, especially transition to strong nausea (15.0 +/- 11.4 bpm), but decreased (-6.6 +/- 4.6 bpm) once the visual stimulus ceased. SCR also increased for all increasing nausea transitions, especially transition to strong nausea (1.76 +/- 1.68 microS), but continued to increase (0.52 +/- 0.65 microS) once visual stimulation ceased. LF/HF HRV increased following transition to moderate (1.54 +/- 2.11 a.u.) and strong (2.57 +/- 3.49 a.u.) nausea, suggesting a sympathetic shift in sympathovagal balance. However, dynamic HF HRV suggested that bursts of cardiovagal modulation precede transitions to higher nausea, perhaps influencing subjects to rate higher levels of nausea. No significant change in respiration rate was found.

CONCLUSIONS

Our results suggest that increasing nausea perception is associated with both increased sympathetic and decreased parasympathetic ANS modulation. These findings corroborate past ANS studies of nausea, applying perception-linked analyses and dynamic estimation of cardiovagal modulation in response to nausea.

Recent Publications on Medications and Pharmacy

Hospital Pharmacy presents this feature to keep pharmacists abreast of new publications in the medical/pharmacy literature. Articles of interest regarding a broad scope of topics are abstracted monthly. Suggestions or comments may be addressed to Jacyntha Sterling, Drug Information Specialist at Saint Francis Hospital, 6161 S Yale Ave, Tulsa, OK 74136 or e-mail: jasterling@saintfrancis.com .