Rebecca Clark-Snow, RN, BSN, OCN
When a group of experts came together for an OncLive Peer Exchange on the topic, there was a clear consensus on the importance of preventing CINV and engaging a multidisciplinary team in the effort.
Underpinning that team approach must be a commitment to patient–provider communication so that patients feel comfortable discussing their symptoms and do not fear that doing so will cause a dose reduction or treatment delay.
Not surprisingly, the practitioner with which patients are most likely to discuss their CINV concerns is their nurse. “It’s the nurses who are the ones in contact with patients most often,” said panelist Rebecca Clark-Snow, RN, BSN, OCN, oncology clinical nurse coordinator at the University of Kansas Cancer Center.
“We hear patients who have, at some point in time, heard a horror story from a relative or loved one,” she continued. Nurses are well-positioned to provide them with the facts about CINV and the options to prevent it.
CINV: Who’s at Risk?
In addition to heightened risk due to the agents themselves, patient-related factors can impact whether an individual is more susceptible to have difficulty in controlling CINV—for example, those who are younger, especially those with breast cancer, said Clark-Snow. “Motion sickness is also part of a history we take with patients, and surprisingly, individuals with a history of high alcohol intake have a lower risk of emesis.”
Another panelist, Charles L. Loprinzi, MD, an oncologist specializing in breast cancer and supportive care research at the Mayo Clinic in Rochester, Minnesota, added that a history of anesthesia-related nausea and vomiting can indicate higher risk, which he theorized, involves how a patient responds to toxins.
For some patients, anxiety can lead to anticipatory nausea, along with conditioned responses to triggers, such as a certain smell or even driving by the cancer center. Panelist Eric Roeland, a palliative care specialist in oncology at UC San Diego, recalled a time when he saw one of his patients in the supermarket, and how seeing him caused her to vomit.
The agents themselves are classified according to their emetogenic potential, eg, high or moderate. In the former category, Loprinzi would place cisplatin and AC chemotherapy (Adriamycin [doxorubicin] and cyclophosphamide). Though the AC regimen was once thought to be moderately emetogenic, Loprinzi said that because the combination is frequently used to treat young women with breast cancer, it often increases the likelihood a patient will be prone to CINV.
“It’s up to nurses to provide patients with the facts about CINV and the options to prevent it.” —Rebecca Clark-Snow, RN, BSN, OCN
Patient Assessment Tools for CINV
Clark-Snow noted that several good antiemesis-assessment tools are available, but she finds that the Multinational Association of Supportive Care in Cancer™ (MASCC) Antiemesis Tool (MAT) is especially easy for practitioners and patients to use. Patients can use it at home to keep track of the episodes and degree of nausea and vomiting, not only during the initial 24 hours, but in the subsequent days, known as the delayed period.
“It’s an opportunity for patients to provide feedback to the nurses, the physicians, and the pharmacists, so we can see how well they are doing and to make changes to their treatment plan if necessary,” she explained. Patients record the number of vomiting episodes; a visual analog scale helps them to rate their nausea. They record their symptoms at 24-hour intervals, so clinicians don’t have to rely on 3- to 5-day recall. The tool can also be downloaded to a smartphone or tablet, and is available in multiple languages. The information can be transferred to the healthcare professional in real time.
“I’m hearing that monitoring patients using a simple tool like this is really valuable,” commented moderator Lee S. Schwartzberg, MD, medical director at the West Clinic in Memphis, Tennessee. “It helps patients communicate, and we really need to do more of that.”
CINV Prophylaxis and Treatment
The introduction of 5-HT3 receptor antagonists, “really transformed the field of CINV treatment in the early 1990’s,” noted Schwartzberg, and these include first-generation ondansetron, granisetron, and dolasetron, and second-generation palonosetron.
Panel member James Natale, PharmD, BCOP, clinical pharmacy specialist at the University of Pittsburgh Medical Center (UPMC) Cancer Center, noted that palonosetron has made an impact in the control and prevention of CINV on several levels: “It certainly has a longer half-life, and it sticks around longer…it shows better control in the delayed phase [of CINV], as well as the overall phases, and equivalent efficacy in the acute phase.”
A newer class of CINV drugs are the NK1 receptor antagonists (eg, oral aprepitant and IV fosaprepitant) has proven especially beneficial in patients receiving highly emetogenic chemotherapy. Rolapitant is the most recently approved orally available NK1 receptor antagonist. Schwartzberg is a researcher on studies showing that the addition of rolapitant to the CINV regimen conferred a clinically meaningful benefit with no added toxicity.
Reviewing some of the research, Loprinzi noted, “In the acute setting, the 5-HT3 receptor antagonist is better, but in the chronic or delayed settings, aprepitant was better than granisetron. If you add them both together, you get even more benefit from them.”
“One new kid on the block,” in this regard, Roeland said, is netupitant, which is available in combination with palonestron as an oral regimen (NEPA). He said the combination has several advantages, including decreasing drug interactions among patients who are taking many other medications. Additionally, he said, “neutupitant has a very long half-life, and you’re combining it with palonesetron, which many of us prefer.”
Also important to consider when prescribing the newer oral agents, said Natale, is the issue of insurance reimbursement. “There may be some work that needs to be done on the front end to make sure there’s coverage and that they’re put on the same tier as some of the older agents.”
Research also suggests a role for the antipsychotic agent olanzapine in CINV. “The olanzapine story is really developing and getting interesting,” said Schwartzberg. “In my own practice, I use it typically after there has been a breakthrough and then add it as a fourth drug in subsequent cycles. It seems to work well, and, when given with dexamethasone, that counteracts the sedative effect.”
Despite this progress in controlling vomiting, nausea remains a challenge, in part because it is subjective and difficult to measure, Clark-Snow noted. “It’s whatever the patient says it is.” Loprinzi suggested that nausea can be measured as a patient-reported outcome in a manner similar to pain. “It’s best for patients to write down their experiences daily, as opposed to trying to summarize 2 weeks later when talking to their doctor or nurse.”
CINV: Practically SpeakingManaging Side Effects With Antiemetics
- Be aware of patient risk factors: history of motion sickness, anesthesia-related nausea and vomiting, and anxiety (anticipatory nausea and vomiting)
- Use a validated assessment tool: one user-friendly tool these experts recommend is the MAT (the antiemesis tool developed by the Multinational Association of Supportive Care in Cancer™ [MASCC]). The tool is available as an Apple or Android app.
- Start on the right foot: Initiate CINV prophylaxis during the first or second cycle of chemotherapy; controlling CINV at the outset will go a long way in preventing problems during later lines of therapy.
- Remind patients about possible side effects: Antiemetics have their own side effects, and practitioners recommend that patients be reminded of them at each visit, not just the first consultation.
- Keep polypharmacy in mind: At each visit, ask patients what other medicines they are taking, and this includes not only prescription drugs, but also over-the-counter and herbal/nutritional supplements.
- Engage a multidisciplinary team: This includes not only physicians, nurses, and pharmacists, but also social workers, nutritionists, and financial counselors—even before a patient starts treatment, they need to meet with a financial counselor and go over a plan.
- Stay in touch: A quick, 5-minute, follow-up phone call to the patient or caregiver to see how they’re doing can make all the difference.
Clark-Snow stressed that it is especially important in discussions with patients about chemotherapy’s potential adverse events, that side effects of the supportive agents be addressed, as well—for example, constipation and headache with the 5-HT3 receptor antagonists. Such a discussion will prevent patients being surprised when they do experience them. “When patients come back for their treatments, we reiterate those side effects over and over again, so that it’s really drilled in to bring it back home.” Concurred Roeland: “Patients can just be so inundated with information during the first cycle that they don’t always remember; it’s important to review.”
Knowing what other medicines the patient is taking is critical, added Clark-Snow, to find out if these substances are implicated in any side effects being attributed to the supportive care agent.
Overall, in the prevention and management of CINV, concluded Clark-Snow, “I can clearly say we’ve come a long way from years past.” All panelists agreed that the research and practitioner community need to build on these advances.
In the meantime, “Communication is key,” Clark-Snow stressed. This means “providing all the information we have to our patients and discussing it with our team to make sure patients have the best possible outcomes.”
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