Treatment of Nausea and Vomiting During Chemotherapy

Human-Delivered Brushstroke Characterization using an Instrumented Brush Focused on Torque

Pleasant brush therapies may benefit those with autism, trauma, and anxiety. While studies monitor brushing velocity, hand-delivery of brush strokes introduces variability. Detailed measurements of human-delivered brushing physics may help understand such variability and subsequent impact on receivers' perceived pleasantness. Herein, we instrument a brush with multi-axis force and displacement sensors to measure their physics as 12 participants pleasantly stroke a receiver's forearm. Algorithmic procedures identify skin contact, and define four stages of arrival, stroke, departure, and airtime between strokes. Torque magnitude, rather than force, is evaluated as a metric to minimize inertial noise, as it registers brush bend and orientation. Overall, the results of the naturally delivered brushing experiments indicate force and velocity values in the range of 0.4 N and 3-10 cm/s, in alignment with prior work. However, we observe significant variance between brushers across velocity, force, torque, and brushstroke length. Upon further analysis, torque and force measures are correlated, yet torque provides distinct information from velocity. In evaluating the receiver's response to individual differences between brushers of the preliminary case study, higher pleasantness is tied to lower mean torque, and lower instantaneous variance over the stroke duration. Torque magnitude appears to complement velocity's influence on perceived pleasantness.

Acupoint Injection for Alleviating Side Effects of Chemotherapy in People with Cancer: A Systematic Review and Meta-Analysis

Objective

This study aimed to investigate the efficacy of acupoint injection for alleviating side effects of chemotherapy in people with cancer.

Methods

PubMed, EMBASE, Cochrane library databases, CNKI, VIP, WanFang Date, and CBM were searched for randomized controlled trials (RCTs) from inception through December 28, 2020. This meta-analysis was performed using Review Manager 5.3.

Results

A total of 8 RCTs including 557 participants were eligible and included in the meta-analysis. The selected RCTs studied acupoint injection for alleviating side effects of chemotherapy in people with cancer. Statistically significant improvements were observed for the incidence of nausea and vomiting (RR = 0.39; 95% CI 0.26, 0.58; P < 0.00001), the number of leukocyte (MD = 1.89; 95%CI 0.74, 3.03; P = 0.001), and the number of platelet (MD = 28.82; 95%CI 19.33, 38.30; P < 0.00001). Two of these studies suggested that acupoint injection can also reduce some other adverse reactions, which showed a statistical difference (RR = 0.29; 95% CI 0.11, 0.75; P = 0.01).

Conclusion

The analysis indicated that acupoint injection can alleviate side effects of chemotherapy in people with cancer. However, due to the high risk of bias and small sample size in the included studies, the results need to be further confirmed by further large, rigorously designed trials.

Pharmacists' Role in Managing Patients with Chronic Lymphocytic Leukemia

Chronic lymphocytic leukemia (CLL) is a hematologic malignancy that has seen significant advances in care over the last 5 years with the approval of oral agents such as ibrutinib and venetoclax for the treatment of this disease. As such, there has been a substantial shift away from the traditional chemotherapy infusions which have allowed patients greater autonomy with oral cancer therapies. This paradigm shift poses new challenges for the medical team, including drug-drug interactions, adherence counseling, and financial toxicity. Pharmacists are uniquely trained and equipped to help to manage the changing landscape of CLL care. From identifying common medications which may impair ibrutinib clearance to ensuring patients are on the appropriate anti-infective prophylaxis while receiving obinutuzumab, pharmacists can play a vital role in ensuring the highest quality of patient care. Furthermore, additional credentialing of clinical pharmacists in select states allows for independent visits with the pharmacists, allowing for greater involvement, particularly for initiation of venetoclax and management of ibrutinib-induced toxicities. Pharmacists are essential to both expanding and enhancing the care of patients with CLL and should be leveraged to improve patient outcomes whenever possible.

Chemotherapy-induced neuroinflammation is associated with disrupted colonic and bacterial homeostasis in female mice

Chemotherapy treatment negatively affects the nervous and immune systems and alters gastrointestinal function and microbial composition. Outside of the cancer field, alterations in commensal bacteria and immune function have been implicated in behavioral deficits; however, the extent to which intestinal changes are related to chemotherapy-associated behavioral comorbidities is not yet known. Thus, this study identified concurrent changes in behavior, central and peripheral immune activation, colon histology, and bacterial community structure in mice treated with paclitaxel chemotherapy. In paclitaxel-treated mice, increased fatigue and decreased cognitive performance occurred in parallel with reduced microglia immunoreactivity, increased circulating chemokine expression (CXCL1), as well as transient increases in pro-inflammatory cytokine/chemokine (Il-1β, Tnfα, Il-6, and Cxcl1) gene expression in the brain. Furthermore, mice treated with paclitaxel had altered colonic bacterial community composition and increased crypt depth. Relative abundances of multiple bacterial taxa were associated with paclitaxel-induced increases in colon mass, spleen mass, and microglia activation. Although microbial community composition was not directly related to available brain or behavioral measures, structural differences in colonic tissue were strongly related to microglia activation in the dentate gyrus and the prefrontal cortex. These data indicate that the chemotherapeutic paclitaxel concurrently affects the gut microbiome, colonic tissue integrity, microglia activation, and fatigue in female mice, thus identifying a novel relationship between colonic tissue integrity and behavioral responses that is not often assessed in studies of the brain-gut-microbiota axis.

Auriculotherapy to control chemotherapy-induced nausea and vomiting in patients with cancer: protocol of a systematic review

BACKGROUND

Due to the worldwide rise in cancer incidence, and therefore the rise in the need for antineoplastic chemotherapy, it is important for both healthcare professionals and patients alike that the side effects of chemotherapy, such as chemotherapy-induced nausea and vomiting (CINV), are treated and prevented. Auriculotherapy is a type of acupuncture and may be a low-cost and safe antiemetic measure to control the side effects of chemotherapy. The goal of this systematic review is to synthesize the available evidence in the literature regarding the auriculotherapy effects to treat CINV in people with cancer.

METHODS

The review will only include randomized controlled trials (RCTs) that compare the clinical effects of the auriculotherapy intervention (used alone or as an add-on), with sham auriculotherapy, routine treatment with antiemetic drugs, or other non-pharmacological interventions in patients with cancer with CINV who are undergoing chemotherapy. The outcomes to be evaluated are nausea and vomiting: in acute, delayed, or anticipated stages, when induced by chemotherapy. A comprehensive search for studies will be carried out in these databases: MEDLINE via PubMed, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, ICTRP, LILACS, CUMED, IBECS, BVS MTCI Americas, Web of Science, Scopus, PEDro, CNKI, and CBMdisc up until December 31, 2018. Only articles in English, Portuguese, and Spanish will be selected. Two independent reviewers will evaluate full texts, extract data, and assess the risk of bias of eligible articles. The quality of evidence will be assessed using Grading of Recommendations, Assessment, Development and Evaluation (GRADE). A meta-analysis will be undertaken to assess the interventions and outcomes' homogeneity, assessing statistical heterogeneity using the Cochran's Q test and quantified using Higgins' inconsistency index. If there is insufficient data for a meta-analysis, a narrative synthesis will be presented. This protocol has been prepared according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) guidelines.

DISCUSSION

The results of this systematic review will summarize the strength of evidence for the use of auriculotherapy in the control of CINV of patients with cancer and will be used to identify evidence gaps.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018117513.

Positive effects of acupressure bands combined with relaxation music/instructions on patients most at risk for chemotherapy-induced nausea

PURPOSE

Research by our group has shown that acupressure bands are efficacious in reducing chemotherapy-induced nausea (CIN) for breast cancer patients who expect nausea, and that their effectiveness in controlling CIN can largely be accounted for by patients' expectations of efficacy, i.e., a placebo effect. The present research examined if the effectiveness of acupressure bands could be enhanced by boosting patients' expectation of the bands' efficacy.

METHODS

Two hundred forty-two chemotherapy-naïve patients with breast cancer who expected nausea were randomized. Arms 1 and 2 received acupressure bands, plus a relaxation MP3 and written handout that were either expectancy-enhancing (arm 1) or expectancy-neutral (arm 2). Arm 3 was the control without bands or MP3 and received standard care. All participants received guideline-specified antiemetics.

RESULTS

Peak CIN for arms 1, 2, and 3 on a 1-7 scale was 3.52, 3.55, and 3.87, respectively (p = 0.46). Because no differences were observed between arms 1 and 2 (primary analysis), we combined these two arms (intervention) and compared them to controls for the following analyses. A significant interaction was found between intervention/control and receiving doxorubicin-based chemotherapy (yes/no) and pre-treatment anxiety (high/low). Intervention patients receiving doxorubicin had lower peak CIN than controls (3.62 vs. 4.38; p = 0.02). Similarly, intervention patients with high pre-treatment anxiety had a lower peak CIN than controls (3.62 vs. 4.62; p = 0.01).

CONCLUSIONS

In breast cancer patients undergoing chemotherapy and having high CIN expectation, acupressure bands combined with a relaxation recording were effective in reducing CIN for patients who received doxorubicin or had high anxiety.

Chinese Herbal Medicines Facilitate the Control of Chemotherapy-Induced Side Effects in Colorectal Cancer: Progress and Perspective

Side effects, including nausea, vomiting, mucositis, peripheral neuropathy, and diarrhea, have been frequently reported in colorectal cancer (CRC) patients undergoing chemotherapy. Chinese Herbal Medicines (CHMs) display distinct clinical outcomes, as a result, they have been increasingly used as an adjuvant therapy to manage chemotherapy-induced side effects. In this review, we aim to intensively explore the molecular mechanisms of CHMs, underline the significance of CHMs in mitigating the side effects induced by chemotherapy, and examine the necessary studies required to understand the role of CHMs in alleviating chemotherapy-induced side effects. Specifically, ginger, Astragali Radix, and Liujunzi Decoction have been verified to ameliorate nausea and vomiting. Banxia Xiexin Decoction and Huangqin Decoction have been confirmed to be beneficial to mucositis and delayed-onset of diarrhea. Moreover, Niuche Shenqi Wan, Guilong Tongluo Decoction, Huangqi Guizhi Wuwu Decoction, and tumeric have been found to display potential therapeutic effects for preventing the genesis and development of peripheral neurotoxicity. These findings have further emphasized the pivotal role of CHMs in improving the outcomes of chemotherapy-induced side effects in CRC. Nonetheless, more molecular evidence is required to comprehensively understand and more appropriately apply CHMs in routine clinical practice for CRC.

Pharmacogenetics of toxicity of 5-fluorouracil, doxorubicin and cyclophosphamide chemotherapy in breast cancer patients

The differences in patients' response to the same medication, toxicity included, are one of the major problems in breast cancer treatment. Chemotherapy toxicity makes a significant clinical problem due to decreased quality of life, prolongation of treatment and reinforcement of negative emotions associated with therapy. In this study we evaluated the genetic and clinical risk factors of FAC chemotherapy-related toxicities in the group of 324 breast cancer patients. Selected genes and their polymorphisms were involved in FAC drugs transport (ABCB1, ABCC2, ABCG2,SLC22A16), metabolism (ALDH3A1, CBR1, CYP1B1, CYP2C19, DPYD, GSTM1, GSTP1, GSTT1, MTHFR,TYMS), DNA damage recognition, repair and cell cycle control (ATM, ERCC1, ERCC2, TP53, XRCC1). The multifactorial risk models that combine genetic risk modifiers and clinical characteristics were constructed for 12 toxic symptoms. The majority of toxicities was dependent on the modifications in components of more than one pathway of FAC drugs, while the impact level of clinical factors was comparable to the genetic ones. For the carriers of multiple high risk factors the chance of developing given symptom was significantly elevated which proved the factor-dosage effect. We found the strongest associations between concurrent presence of clinical factors - overall and recurrent anemia, nephrotoxicity and early nausea and genetic polymorphisms in genes responsible for DNA repair, drugs metabolism and transport pathways. These results indicate the possibility of selection of the patients with expected high tolerance to FAC treatment and consequently with high chance of chemotherapy completion without the dose reduction, treatment delays and decline in the quality of life.

The Effects of the Bali Yoga Program for Breast Cancer Patients on Chemotherapy-Induced Nausea and Vomiting: Results of a Partially Randomized and Blinded Controlled Trial

Complementary and alternative medicine has been shown to be beneficial in reducing chemotherapy-induced nausea and vomiting. However, conclusive results are lacking in order to confirm its usefulness. The purpose of this study was to determine whether a standardized yoga intervention could reduce these adverse symptoms. This was a partially randomized and blinded controlled trial comparing a standardized yoga intervention with standard care. Eligible patients were adults diagnosed with stages I to III breast cancer receiving chemotherapy. Patients randomized to the experimental group participated in an 8-week yoga program. There was no significant difference between the experimental and control groups on chemotherapy-induced nausea and vomiting after 8 weeks. Results suggest the yoga program is not beneficial in managing these adverse symptoms. However, considering preliminary evidence suggesting yoga’s beneficial impact in cancer symptom management, methodological limitations should be explored and additional studies should be conducted.

Palonosetron and hydroxyzine pre-treatment reduces the objective signs of experimentally-induced acute opioid withdrawal in humans: a double-blinded, randomized, placebo-controlled crossover study

BACKGROUND

Treatments for reducing opioid withdrawal are limited and prone to problematic side effects. Laboratory studies, clinical observations, and limited human trial data suggest 5-HT3-receptor antagonists and antihistamines may be effective.

OBJECTIVES

This double-blind, crossover, placebo-controlled study employing an acute physical dependence model evaluated whether (i) treatment with a 5-HT3-receptor antagonist (palonosetron) would reduce opioid withdrawal symptoms, and (ii) co-administration of an antihistamine (hydroxyzine) would enhance any treatment effect.

METHODS

At timepoint T = 0, healthy (non-opioid dependent, non-substance abuser) male volunteers (N = 10) were pre-treated with either a) placebo, b) palonosetron IV (0.75 mg), or c) palonosetron IV (0.75 mg) and hydroxyzine PO (100 mg) in a crossover study design. This was followed at T = 30 by intravenous morphine (10 mg/70kg). At T = 165, 10 mg/70kg naloxone IV was given to precipitate opioid withdrawal. The objective opioid withdrawal score (OOWS) and subjective opioid withdrawal score (SOWS) were determined 5 and 15 minutes after naloxone administration (T = 170, 180, respectively). Baseline measurements were recorded at T = -30 and T = -15.

RESULTS

Comparison of average baseline OOWS scores with OOWS scores obtained 15 minutes after naloxone was significant (p = 0.0001). Scores from 15 minutes post-naloxone infusion showed significant differences in OOWS scores between treatment groups: placebo, 3.7 ± 2.4; palonosetron, 1.5 ± 0.97; and palonosetron with hydroxyzine, 0.2 ± 0.1333.

CONCLUSIONS

Pretreatment with palonosetron significantly reduced many signs of experimentally-induced opioid withdrawal. Co-administration with hydroxyzine further reduced opioid withdrawal severity. These results suggest that 5-HT3 receptor antagonists, alone or in combination with an antihistamine, may be useful in the treatment of opioid withdrawal.

Hypnosis for the Management of Anticipatory Nausea and Vomiting

CASE STUDYBJ is a 34-year-old woman who was diagnosed with metastatic breast cancer. She was treated with surgical removal of the primary tumor and sentinel node biopsy. Following surgery, she received chemotherapy. She was given antiemetic therapy prior to and immediately following chemotherapy. She began to experience significant and persistent nausea with intermittent episodes of vomiting after the second cycle of chemotherapy. She completed her chemotherapy but still experienced nausea and vomiting in response to several cues, such as smelling food cooking and going to the hospital. Her nausea and vomiting resulted in segregation from her family during meal time, which negatively impacted her quality of life. A hypnosis consultation was requested, and BJ was cooperative. She reported feeling very nauseated at the time of the interview. Hypnosis was discussed; her questions were answered, and the potential risks and benefits of hypnosis were reviewed. She agreed that she would like to try hypnosis. A hypnosis assessment was conducted and revealed that she had a history of profound motion sickness and severe, chronic childhood trauma associated with feelings of anxiety and hypervigilance. The therapeutic suggestions that were used with BJ included hypnotic suggestions for relaxation and removal of discomfort. A metaphor describing the central processing of the anticipatory nausea and vomiting as a thermostat that could be adjusted to reduce and eliminate the sensation was used to suggest that she could control her perceptions and in turn control the nausea. Posthypnotic suggestions included that at the earliest awareness of discomfort, rubbing the throat would eliminate that discomfort, and cooking aromas would be transformed into her favorite fragrance. Reversal went smoothly, and BJ reported satisfaction with the experience. BJ experienced significant reduction in symptoms after the first session. She had two more sessions, at which time she was able to eat with her family and go to the clinic without discomfort. She was provided a CD with a recording of her hypnosis script to reinforce the face-to-face intervention. She continues to be symptom-free 3 months after treatment with hypnosis.

Current pharmacotherapy for chemotherapy-induced nausea and vomiting in cancer patients

INTRODUCTION

Nausea and vomiting are two of the most frequent and troubling side effects patients experience during chemotherapy, interfering with compliance with cancer therapies and quality of life. While newly available treatments have improved our ability to manage nausea and vomiting, anticipatory and delayed nausea and vomiting are still major problems for patients receiving chemotherapy. Many cancer patients consider delaying future chemotherapy cycles and some contemplate stopping chemotherapy altogether because of their fear of experiencing further nausea and vomiting.

AREAS COVERED

The purpose of this article is to provide an overview of the pathopsychophysiology of chemotherapy-induced nausea and vomiting (CINV), the recommended guidelines for treatment, and current agents in late-stage clinical trials, and future research needs to address the continued challenges of treatment-related nausea and vomiting.

EXPERT OPINION

Despite advances in pharmaceutical and behavioral therapies, and the provision of standard clinical guidelines for effectively managing CINV, patients continue to experience it. Moreover, control of nausea, acute and delayed, and anticipatory nausea and vomiting remains an important, unmet need among cancer patients. It is critical to focus attention on better understanding the mechanisms underlying nausea, anticipatory symptoms and delayed symptoms.