Chemotherapy Induced Nausea & Vomiting

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Chemotherapy Induced Nausea & Vomiting

A Nurse’s Perspective

Michael Flynn MSc, PG Cert, RGN

Chemotherapy Nurse Consultant Guy’s and St Thomas’ NHS Foundation Trust


Guy’s and St Thomas NHS Foundation Trust

Two of London’s oldest teaching hospitals

– St Thomas’ Hospital – Waterloo

– Guy’s Hospital – London Bridge

One of the largest Foundation Trusts in the UK

– Serving a culturally diverse population with high levels of

socio-economic deprivation.

One of five Academic Health Sciences Centres

King’s Health Partners

– Guy’s and St Thomas’ NHS Foundation Trust

– King’s College London

– King’s College Hospital NHS Foundation Trust


GSTFT Cancer Services

Offers a full range of services for the diagnosis

treatment and follow up of all adult cancers.

– 17000 chemotherapy attendances per annum

– 6 Linear Accelerators, 4 upgraded Accelerators, Tomotherapy, high dose brachytherapy & Stereotatic body, image guided and inverse planned image modulated radiotherapy

– Surgery (including laprascopic and robotic assisted surgery offered on day-case and inpatient basis at both hospitals)

– Hospital & Community Palliative care services

– A full range of support services including Dimbleby Cancer Care

Underpinned by a comprehensive electronic Cancer


A Quick recap of CINV


Nausea – The unpleasant, subjective feeling of the need to vomit

Vomiting – The forceful release of stomach contents through the mouth caused by strong contractions of the stomach muscles.


A Quick recap of CINV

Physiological Rationale

What function do nausea & vomiting perform in the body?

Vomiting – The physical expulsion of toxins from the stomach.

Nausea – Trigger for the vomiting reflex.

Nausea – deterrent from repeat exposure to the toxic substance.


Causes of Nausea & Vomiting in Cancer Patients

Chemotherapy Uraemia

Radiation Concomitant drug treatments

Bowel obstruction Gastroparesis: chemo or disease

Vestibular dysfunction Anxiety

Brain metastases Anticipation


Vomiting pattern generator

Also called the vomiting centre Activates the vomiting reflex

Located in the medulla area of the brain.

Is activated by one or a combination of neuronal pathways.


Neuronal Pathways


Ach(M) Cholinergic muscarinic

D Dopamine

H Histamine

NK neurokinin

5HT 5-hydroxytryptamine


Factors influencing chemotherapy induced emesis

Emetogenic risk of chemotherapeutic agent

History of motion sickness

Gender Performance status

Age Other drugs

History of alcohol Concomitant medical conditions


Types of CINV

Acute – onset within 24hrs following chemo administration.

Delayed – onset after 24hrs following chemo administration.

Anticipatory – onset before chemo administration.

Breakthrough – responds to ‘rescue’.


Principles of Emesis Control

The goal is to prevent nausea and/or vomiting.

The risk of emesis and nausea for persons receiving

chemotherapy of high & moderate emetogenic potential lasts

at least 4 days and 3 days respectively. Patients need to be

protected throughout the full period of risk.

Oral and IV antiemetic formulations have equivalent efficacy

NCCN 2009


Principles of Emesis Control

The toxicity of the specific antiemetic(s) should be considered.

Antiemetic regimens should be chosen based on the drug with the

highest emetic risk in the chemotherapy regimen, previous

experience with antiemetics, and patient-specific risk factors.


Present GSTFT Antiemetic Prophylaxis

Emetogenic risk


High (>90%) Moderate (30-90%)


Nausea & vomiting prophylaxis (0 to 24 hours after chemotherapy) Aprepitant 125mg PO stat Ondansetron 16mg PO stat Dexamethasone 8mg PO stat Ondansetron 8mg PO stat Dexamethasone 8mg PO stat Delayed

Nausea & Vomiting prophylaxis

(24 or more hours after chemotherapy)

Aprepitant 80mg PO days 2&3 Ondansetron 16mg PO stat day 2 Dexamethasone 8mg PO OD 3/7 Metoclopramide 20mg PO TDS 3/7

Dexamethasone 8mg PO OD 3/7 Metoclopramide 20mg PO TDS 3/7


Surely therefore since the development of 5HT


receptor antagonists the problem


sorted. Just

attach the correct antiemetic prophylaxis to the

chemotherapy regime and the patient will be



Chemotherapy induced nausea and vomiting

‘Most feared side effect’

Hawkins (2009)

‘…Consistently list chemotherapy induced nausea and vomiting as one of their greatest fears.’

Hesketh (2008)

‘..continues to have a great impact on the quality of life.’


Current incidence of CINV

Approximately 70 to 80% of all cancer patients receiving

chemotherapy experience nausea and/or vomiting.


Audit planning

Plan to audit 50 patients

Patients would be receiving Cisplatin based therapy. Cisplatin known to cause acute and delayed CINV.

Audit would cover both nausea & vomiting. Although

anecdotal reports of vomiting were the primary reason for auditing, it was expected that nausea would be the major issue.

Questionnaire based on the MASCC designed tool.

Vomiting – objective number of times

 Acute

 Delayed

Nausea – subjective rating from 1 to 10

 Pretreatment

 Acute


Audit Results n=73

Gender Age Diagnosis

Male 30 <40 3 Upper GI 17

Female 29 40-49 9 Gynae 17

Undisclosed 14 50-59 19 Head & Neck 14

>59 38 Lung 4

Undisclosed 4 Melanoma 2

Liver 2

Colorectal 2


Audit Results - 2009

Findings of note

Acute Nausea (AN) n=37

Median onset 12 hours

Median patient subjective rating 5

Delayed Nausea (DN) n= 38

Median onset Day 2

Median patient subjective rating 5

DN without experiencing AN n=8

Median onset Day 2


Audit Results - 2009

Diagnosis Number Pre% AV% AN% DV% DN%

Upper GI 17 6 0 29 12 41

Gynae 17 12 0 53 18 53

Head & Neck 14 29 21 57 21 50

Age & Gender showed no significant differences in any reported field

Presence of delayed vomiting without acute vomiting suggests duration of prophylaxis not adequate at present.

Diagnosis may contribute to a disposition to nausea however treatment intensity and anatomical factors are more likely.


Audit findings interpretation - 2009


Nausea is an expected and accepted side effect of treatment

This has led to an underreporting of nausea to healthcare professionals during the treatment phase.

Anticipatory nausea is a real threat to patients receiving treatment

2nd line prophylaxis escalation is not consistent or sustained and unlikely to be successful

Delayed vomiting suggests either under treatment or delay in prophylaxis commencement


Audit findings interpretation - 2009

Organisational Process

Assessment of Nausea & Vomiting

Present lack of structure coordination and communication of proactive assessment between outpatient clinics and treatment units.

Lack of consistent approach to 1st line prophylaxis

utilisation of out of date paper proformas and failure to adjust proformas to current guidelines suggest lack of knowledge of and access to current guidelines.

Inconsistent approach to 2nd line prophylaxis


Recommendations based on Audit for HEC*

Increase Dexamethasone dose to 12mg.

Include PPI coverage in prophylaxis

Use Aprepitant 1


line in patients classified as high risk.

Use Palonosetron as 5HT3 receptor antagonist of choice in


Re-evaluation of CINV - 2012

MASCC inspired questionnaire re-used

Audit group all patients receiving HEC and MEC regimes Target to audit 100 patients


What changed between 2009 and 2012?

All patients receiving HEC regimes receive Aprepitant first line.

Complete e-prescribing and electronic medical record.

Pre treatment consultations delivered in a clinic structure by competency assessed nurses.

Pro-active telephone monitoring 24hrs after 1st treatment episode.

Tumour specific chemotherapy link nurses

Nurse led Acute oncology assessment unit with telephone triage 0830 to 1830hrs (Oncall medical service out of hours)


CINV related calls to AOAU

Month Calls Month Calls

June 2012 19 October 2012 23

July 2012 29 November 2012 34

August 2012 20 December 2012 18


Audit was expected to show significant

improvement in CINV occurrence and


CINV Audit 2012 compared with 2009

Year Pre Nausea % Acute Vomiting % Acute Nausea % Delayed Vomiting % Delayed Nausea % Total Nausea % 2009















CINV Audit 2012 compared with 2009

Year Pre Nausea % Acute Vomiting % Acute Nausea % Delayed Vomiting % Delayed Nausea % Total Nausea % 2009














Median 5 Median 4 Median 4.5 Median 4.5


CINV Audit 2012 compared with 2009

Year Pre Nausea % Acute Vomiting % Acute Nausea % Delayed Vomiting % Delayed Nausea % Total Nausea % 2009




















Median 5 Median 4 (5) Median 4.5(6) Median 4.5


Pre-chemotherapy CINV Assessment

80 clinic entries for patients receiving HEC and MEC regimes –

week commencing 10


of September 2012.

– 22 Entries CINV grading of previous cycle

10 Grade 0

6 Grade 1 – 1/6 prophylaxis adjusted

5 Grade 2 – 4/5 prophylaxis adjusted

1 Grade 3 – 1/1 prophylaxis adjusted

– 4 Entries document ‘Nil other toxicity’


What does it all mean?

Patients expect to feel nauseated?

Is CINV really preventable in all patients?

We expect patients to feel nauseated?

There is an acceptable level of nausea for different regimens?

We continue to underestimate the effect of CINV on patients?

Patients don’t or can’t contact us when they feel nauseated?


Way forward - GSTFT

Joint working project with Pharma – understanding the significance of other risk factors apart from agent emetogenic risk.

Continue development of the pre-treatment consultation in regards to assessment of CINV risk.

Continued development of pre-treatment consultation effectiveness in regards to access of acute oncology services.

Expansion of proactive telephone monitoring for patients identified as high risk.

Development of a prophylaxis kit for moderate emetogenic risk patients.

Further development of multiprofessional chemotherapy on treat clinics.