Editor’s note: One of a series of articles on managing cancer-related symptoms from the Oncology Nursing Society.
Chemotherapy-induced nausea and vomiting (CINV) is one of the most feared side effects of cancer treatment for patients with cancer (de Boer-Dennert et al., 1997; Hickok et al., 2003). However, healthcare providers may underestimate the impact CINV has on their patients (Grunberg et al., 2004). Approximately 50% to 60% of patients with cancer receive highly emetogenic chemotherapy, and about 70% to 80% of that population may experience CINV if not properly treated (Grunberg et al., 2004). Uncontrolled CINV with administration of chemotherapy can lead to anticipatory nausea and vomiting (a learned response to an earlier, uncontrolled episode of CINV) with the next treatment. This, in turn, can create significant quality-of-life and treatment adherence issues for patients.
Nausea is a subjective sensation associated with the will or desire to vomit. Vomiting is described as the oral expulsion of stomach or intestinal contents with a person having signs and symptoms such as a rapid or irregular heartbeat, dizziness, sweating, pallor, pupil dilation, and retching (de Carvalho, Martins, and dos Santos, 2007). CINV can be acute (taking place minutes or hours after treatment), delayed (taking place 24 hours or longer after treatment), anticipatory, breakthrough (occurring even after preventative medications have been taken), or refractory (antinausea medications that worked in the past no longer control the symptoms) (National Comprehensive Cancer Network [NCCN], 2008) and can lead to dehydration, electrolyte imbalance, malnutrition, decreased self-care, decrease functioning, depression, and fatigue (Lohr, 2008; NCCN, 2008).
Oncology nurses are in a key position to monitor and assess patients’ CINV. Ongoing assessment (see Table 1) also can lead to treatment changes or new management strategies (Friend & Johnston, 2009). A thorough assessment can help oncology nurses and the healthcare team to fully understand the impact of CINV on patients.
Table 1. Assessment for the impact of CINV
- Assess the number of episodes of retching.
- Document the timing of the CINV (acute phase within the first 24 hours, delayed phase after initial 24 hours)
- Assess the patient’s ability to eat after chemotherapy.
- Note the patient’s oral intake.
- Document antiemetics taken by the patient.
- Track other related symptoms or problems affecting the patient.
Several clinical measurement tools are available to augment the assessment steps. The Common Terminology Criteria for Adverse Events (CTCAE) from the National Cancer Institute (2006) is one of the more common tools. The Index of Nausea, Vomiting, and Retching (INVR) and the Functional Living Index–Emesis (Friend & Johnston, 2009) also are useful forms of measure. Finally, the Multinational Association of Supportive Care in Cancer ([MASCC], 2004) developed an antiemesis tool (MAT) that measures the frequency and intensity of acute and delayed nausea and vomiting.
Putting evidence into practice
To promote nursing practice that is based on evidence, ONS launched the Putting Evidence Into Practice (PEP) program in 2005. ONS PEP teams consisting of advanced practice nurses, staff nurses, and a nurse scientist were charged with reviewing the literature to determine what treatments and interventions are proven to alleviate many cancer-related problems that are sensitive to nursing interventions. Each team classified interventions under the following categories: recommended for practice, likely to be effective, benefits balanced with harms, effectiveness not established, effectiveness unlikely, and not recommended for practice.
Recommended for practice
The following are recommended for practice based on effectiveness established through rigorously designed studies, meta-analysis, systemic reviews, or professional guidelines.
Anticipatory nausea and vomiting:
Several treatments exist for this learned response to an earlier, uncontrolled episode of CINV. Among the nonpharmacologic methods are behavior therapies such as relaxation, hypnosis, guided imagery, and acupuncture. Benzodiazepines are used for pharmacologic treatment, with alprazolam (0.5-2 mg orally three times per day) and lorazepam (0.5-2 mg orally the night before and the morning of treatment) as being recommended for practice (American Society of Health-System Pharmacists [ASHP], 1999; Gralla et al., 1999; NCCN, 2008; Plovich, White, & Kelleher, 2005).
Acute or delayed nausea and vomiting:
Certain regimens have shown great effectiveness in controlling acute and delayed CINV. Table 2 contains of list of these agents based on emetogenic properties (Oncology Nursing Society, 2008).
Table 2. Medications recommended for controlling CINV based on emetogenic properties of chemotherapeutic agents
Highly and moderately emetogenic
- 5-HT3 receptor antagonists
- Neurokinin 1 (NK1) receptor antagonist
- Metoclopramide with or without diphenhydramine
- No routine antiemesis prophylaxis is recommended
Note. Effective dosage, timing, and combinations of medications may vary according to the emetogenic properties of the chemotherapy regimen and onset of CINV. More information about dosage and schedule information can be found in Friend and Johnston (2009).
Note. Based on information from ASHP, 1999; Gralla et al., 1999; MASCC, 2008; NCCN, 2008; Polovich et al., 2005).
Breakthrough or refractory nausea and vomiting:
According to NCCN (2008), prevention of breakthrough or refractory CINV is much easier than treatment. The general principle is to give an agent from a different drug class than was previously used, to consider around-the-clock dosing instead of PRN, and to use parenteral or rectal routes since oral would be contraindicated (Friend & Johnston, 2009). Treatment options would be similar to those shown in Figure 2 with the exception of an NK1 receptor antagonist.
Likely to be effective
The ONS PEP team found several avenues that were likely to be effective when treating patients with cancer suffering from CINV. In order to be classified as likely to be effective in the PEP program, an intervention must have effectiveness demonstrated by strong evidence from rigorously designed studies, meta-analyses, or systemic reviews. Also, expectation of harm must be small compared with benefits (Eaton & Tipton, 2009).
Three randomized, controlled trials (Dibble, Chapman, Mack, & Smith, 2000; Klein & Griffiths, 2004; Shin, Kim, Shin, & Juon, 2004) found some evidence that acupressure reduced CINV compared to no intervention at all. The noted benefits were decreased severity, frequency, and duration and were seen in a patient population of mixed cancers. A study by Molassiotis, Helin, Dabbour, and Hummerston (2007) found significant decreases in occurrence and distress among patients with breast cancer. Finally, Dibble et al. (2007) concluded that acupressure significantly reduced the frequency of CINV over time when compared to placebo or usual care.
Collins and Thomas (2004) and Mayer (2000) found that acupuncture provided a clinically significant reduction in CINV. Shen et al. (2000) came to a similar conclusion when comparing acupuncture and pharmacotherapy to pharmacotherapy alone. However, in a systematic review by Klein & Griffiths (2004), acupuncture reduced vomiting but not nausea.
Guided imagery, music therapy, and muscle relaxation:
A collection of studies found that these three strategies reduced nausea, vomiting, and/or retching for anticipatory CINV (Arakawa, 1997; Ezzone, Baker, Rosselet, & Terepka, 1998; King, 1997; Luebbert, Dahme, & Hasenbring, 2001; Miller & Kearney, 2004; Molassiotis Yung, Yam, Chan, & Mok, 2002; Sahler, Hunter, & Liesveld, 2003; Troesch, Rodehaver, Delaney, & Yanes, 1993). In addition, these strategies can be used together (i.e., guided imagery with music) or separately.
Psychoeducational support and information:
Two studies documented that a reduction in nausea and an improvement in well-being occurred after oncology nurses provided increased support and education (coupled with standard antiemetics) (Borjeson, Hursti, Tishelman, Peterson, & Steineck, 2002; Williams & Schreier, 2004). Both studies provided verbal, written, and audiotaped information to a population of women with ovarian or breast cancer. Friend and Johnston (2009) suggest that this is an area for additional study.
Effectiveness not established
The following interventions contain insufficient data or data or inadequate quality; however, no clear indication of harm has been noted. Further in-depth research should be considered for the following methods:
- Acustimulation with a wristband device
- Chinese herbal medicine
- Hypnosis (for the presence of nausea)
- Massage and aromatherapy
- Progressive muscle relaxation (for the presence of nausea).
Nurses are in a unique position to support patients suffering from CINV by using evidence-based interventions. In addition to initiating treatments, nurses should assess the impact of CINV on patients and their families, provide instruction and information about potential management options, and help patients maintain treatment adherence.
Sean Pieszak is a copy editor in the Publications department at the Oncology Nursing Society in Pittsburgh, PA. More information about the ONS PEP classification for CINV can be found at http://www.ons.org/Research/PEP/Nausea.
American Society of Health System Pharmacists. (1999). ASHP therapeutic guidelines on the pharmacologic management of nausea and vomiting in adult and pediatric patients receiving chemotherapy or radiation therapy or undergoing surgery. American Journal of Health System Pharmacy, 56, 729-764.
Arakawa, S. (1997). Relaxation to reduce nausea, vomiting, and anxiety induced by chemotherapy in Japanese patients. Cancer Nursing, 20, 342-349. http://dx.doi.org/10.1097/00002820-199710000-00005
Borjeson, S., Hursti, T.J., Tishelman, C., Peterson, C., & Steineck, G. (2002). Treatment of nausea and emesis during cancer chemotherapy: Discrepancies between antiemetic effect and well-being. Journal of Pain and Symptom Management, 24, 345-358. http://dx.doi.org/10.1016/S0885-3924(02)00543-2
Collins, K.B., & Thomas, D.J. (2004). Acupuncture and acupressure for the management of chemotherapy-induced nausea and vomiting. Journal of the American Academy of Nurse Practitioners, 16 (2), 76-80. http://dx.doi.org/10.1111/j.1745-7599.2004.tb00376.x
de Boer-Dennert, M., de Wit, R., Schmitz, P.I., Djontono, J. v Beurden, V., Stoter, G., & Verweij, J. (1997). Patient perceptions of the side-effects of chemotherapy: The influence of 5HT3 antagonists. British Journal of Cancer, 76, 1055-1061. http://dx.doi.org/10.1038/bjc.1997.507
de Carvalho, E.C., Martins, F.T.M., & dos Santos, C.B. (2007). A pilot study of a relaxation technique for management of nausea and vomiting in patients receiving cancer chemotherapy. Cancer Nursing, 30, 163-167. http://dx.doi.org/10.1097/01.NCC.0000265007.87311.d0
Dibble, S.L., Chapman, J., Mack, K.A., & Shih, A. (2000). Acupressure for nausea: Results of a pilot study. Oncology Nursing Forum, 27, 41-47.
Dibble, S.L., Luce, J., Cooper, B.A., Israel, J., Cohen, M., Nussey, B., & Rugo, H. (2007). Acupressure for chemotherapy-induced nausea and vomiting: A randomized clinical trial. Oncology Nursing Forum, 34, 813-820. http://dx.doi.org/10.1188/07.ONF.813-820
Eaton, L.H., & Tipton, J.M. (Eds.). (2009). Putting evidence into practice: Improving oncology patient outcomes. Pittsburgh, PA: Oncology Nursing Society.
Ezzone, S., Baker, C., Rosselet, R., & Terepka, E. (1998). Music as an adjunct to antiemetic therapy. Oncology Nursing Forum, 25, 1551-1556.
Friend, P.J., & Johnston, M.P. (2009). Chemotherapy-induced nausea and vomiting. In L.H. Eaton and J.M. Tipton (Eds.), Putting evidence into practice: Improving oncology patient outcomes (pp. 63-83). Pittsburgh, PA: Oncology Nursing Society.
Gralla, R.J., Osoba, D., Kris, M.G., Kirkbride, P., Hesketh, P.J., Chinnery, L.W., . . . Pfister, D.G. (1999). Recommendations for the use of antiemetics: Evidence-based, clinical practice guidelines. Journal of Clinical Oncology, 17, 2971-2994.
Grunberg, S.M., Deuson, R.R., Mavros, P., Geling, O., Hansen, M., Cruciani, G., . . . Daugaard, G. (2004). Incidence of chemotherapy-induced nausea and emesis after modern antiemetics. Cancer, 100, 2261-2268. http://dx.doi.org/10.1002/cncr.20230
Hickok, J.T., Roscoe, J.A., Morrow, G.R., King, D.K., Atkins, J.N., & Fitch, T.R. (2003). Nausea and emesis remain significant problems of chemotherapy despite prophylaxis with 5-hydroxytryptamine-3 antiemetics: A University of Rochester James P. Wilmot Cancer Center Community Hospital Clinical Oncology Program study of 360 cancer patients treated in the community. Cancer, 97, 2880-2886. http://dx.doi.org/10.1002/cncr.11408,/a>
King, C.R. (1997). Nonpharmacologic management of chemotherapy-induced nausea and vomiting. Oncology Nursing Forum, 24 (7, Suppl.), 41-48.
Klein, J., & Griffiths, P. (2004). Acupressure for nausea and vomiting in cancer patients receiving chemotherapy. British Journal of Community Nursing, 9, 383-387.
Lohr, L. (2008). Chemotherapy-induced nausea and vomiting. Cancer Journal, 14(2), 85-93. http://dx.doi.org/10.1097/PPO.0b013e31816a0f07
Luebbert, K., Dahme, B., & Hasenbring, M. (2001). The effectiveness of relaxation training in reducing treatment-related symptoms and improving emotional adjustment in acute non-surgical cancer treatment: A meta-analytical review. Psycho-Oncology, 10, 490-502. http://dx.doi.org/10.1002/pon.537,/a>
Mayer, D.J. (2000). Acupuncture: An evidence-based review of the clinical literature. Annual Review of Medicine, 51, 49-63. http://dx.doi.org/10.1146/annurev.med.51.1.49
Miller, M., & Kearney, N. (2004). Chemotherapy-related nausea and vomiting-Past reflections, present practice and future management. European Journal of Cancer Care, 13, 71-81. http://dx.doi.org/10.1111/j.1365-2354.2004.00446.x
Molassiotis, A., Helin, A.M., Dabbour, R., & Hummerston, S. (2007). The effects of P6 acupressure in the prophylaxis of chemotherapy-related nausea and vomiting in breast cancer patients. Complementary Therapies in Medicine, 15(1), 3-12. http://dx.doi.org/10.1016/j.ctim.2006.07.005
Molassiotis, A., Yung, H.P., Yam, B.M.C., Chan, F.Y.S., & Mok, T.S.K. (2002). The effectiveness of progressive muscle relaxation training in managing chemotherapy-induced nausea and vomiting in Chinese breast cancer patients: A randomised controlled trial. Supportive Care in Cancer, 10, 237-246. http://dx.doi.org/10.1007/s00520-001-0329-9
Multinational Association of Supportive Care in Cancer. (2008). Antiemetic guidelines. Retrieved from http://www.mascc.org
National Cancer Institute. (2006). Common terminology criteria for adverse events. Retrieved from http://ctep.cancer.gov/protocolDevelopment/electronic_applications/ctc.htm
National Comprehensive Cancer Network. (2008). Clinical Practice Guidelines in Oncology™: Antiemesis [v.2.2008]. Retrieved from http://www.nccn.org
Oncology Nursing Society. (2008). Quick view: Chemotherapy-induced nausea and vomiting. Retrieved from http://www.ons.org/Research/PEP/media/ons/docs/research/outcomes/nausea/quickview.pdf
Polovich, M., White, J.M., & Kelleher, L.O. (Eds.). (2005). Chemotherapy and biotherapy guidelines and recommendations for practice (2nd ed.). Pittsburgh, PA: Oncology Nursing Society.
Sahler, O.J.Z., Hunter, B.C., & Liesveld, J.L. (2003). The effect of using music therapy with relaxation imagery in the management of patients undergoing bone marrow transplantation: A pilot feasibility study. Alternative Therapies<, 9, 70-74.
Shen, J., Wenger, N., Glaspy, J., Hays, R.D., Albert, P.S., Choi, C., & Shekelle, P.G. (2000). Electroacupuncture for control of myeloablative chemotherapy-induced emesis: A randomized controlled trial. JAMA, 284, 2755-2761. http://dx.doi.org/10.1001/jama.284.21.2755
Shin, Y.H., Kim, T.I., Shin, M.S., & Juon, H. (2004). Effect of acupressure on nausea and vomiting during chemotherapy cycle for Korean postoperative stomach cancer patients. Cancer Nursing, 27, 267-274. http://dx.doi.org/10.1097/00002820-200407000-00002
Troesch, L.M., Rodehaver, C.B., Delaney, E.A., & Yanes, B. (1993). The influence of guided imagery on chemotherapy-related nausea and vomiting. Oncology Nursing Forum, 20, 1179-1185.
Williams, S.A., & Schreier, A.M. (2004). The effect of education in managing side effects in women receiving chemotherapy for treatment of breast cancer [Online exclusive]. Oncology Nursing Forum, 31, E16-E23. http://dx.doi.org/10.1188/04.ONF.E16-E23