NEW YORKPatients may talk about many treatment issues with
their doctors but keep mum about treatment-related nausea. When
they go to their chemotherapy nurse, thats when they say,
It was awful. I was sick for 3 days after
chemotherapy, Terri Maxwell, RN, MSN, said at a
teleconference sponsored by Cancer Care Inc.
Cancer patients often say in surveys that treatment-related nausea
and vomiting are among their worst problems. Yet, in most
cases, these problems can be controlled or prevented by medication
and an individualized approach, said Ms. Maxwell, executive
director, Center for Palliative Care, Thomas Jefferson University, Philadelphia.
The best approach is prevention, she said, and that requires
determining who is most at risk. I think its important
for those of us who are giving these treatments to take an individual
look at our patients and recognize some of the patient-related
factors that might make somebody more susceptible to
treatment-related nausea and vomiting, Ms. Maxwell commented.
Premenopausal women experience more nausea and vomiting than men or
postmenopausal women, Ms. Maxwell noted, and patients who are highly
anxious because of previous bouts of severe nausea and vomiting are
also at greater risk. So are those with a history of motion sickness
and women who experienced severe vomiting during pregnancy. However,
people over age 50 and people who have a history of high daily
alcohol intake are at lower risk.
Factors that can exacerbate treatment-related nausea and vomiting
include dehydration, delayed stomach emptying caused by bowel
obstruction, severe fatigue, unrelieved pain, narcotic analgesia, and
some nonsteroidal anti-inflammatory drugs (NSAIDs).
In general, the quicker the chemotherapy is administered, the more
likely it is to cause symptoms. Radiation does not usually cause
nausea and vomiting, Ms. Maxwell pointed out, unless the person is
having radiation treatment to the epigastric area. In these patients,
symptoms generally occur an hour or two after treatment and can
usually be prevented with antinausea medication taken about a half
hour before radiation and sometimes repeated later in the afternoon
Colon cancer patients or gynecologic cancer patients who are
receiving radiation in the pelvic area may get diarrhea but will not
have nausea related to the radiation, she said.
The acute form of nausea occurs within the first 24 hours after
chemotherapy or radiation. The serotonin antagonists, ondansetron
(Zofran), granisetron (Kytril), and dolasetron (Anzemet), are
approved to prevent this form and are given prior to chemotherapy.
Using these agents to treat the delayed form is still controversial
and under investigation.
The oral forms of the serotonin antagonists are just as
effective as the IV forms and are ideal for home use, Ms.
Maxwell said. Clinics will sometimes use the IV form because of
reimbursement issues, she noted.
There are only a few side effects associated with the serotonin
antagonists, she said. They may cause headache, she said, and, over a
7-day period, some constipation.
Their biggest drawback, Ms. Maxwell observed, is that they are very
expensive. They are for use only with those chemotherapy
regimens that are known to cause significant nausea, she added.
She pointed out that drugs such as prochlorperazine (Compazine and
generics), thiethylperazine (Torecan), and promethazine (Phenergan
and others) are less expensive and can be effective when used with
chemotherapy regimens with mild-to-moderate emetogenic potential.
These agents can be a bit more sedating, she said, and
sometimes patients dont like taking them quite as much because
they feel sleepy on them. But they can be extremely helpful and work
in a different way than Kytril, Zofran, and Anzemet. Sometimes you
need to use both kinds of agents.
The delayed form of chemotherapy-induced nausea is the most difficult
to manage, Ms. Maxwell said. It occurs the day after treatment and
can last up to 5 days. It is only associated with a few drugs,
including cisplatin (Platinol) and carboplatin (Paraplatin).
Antinausea regimens in the delayed setting are still evolving. Ms.
Maxwell said that some clinicians have tried granisetron, usually in
combination with a drug like prochlorperazine and IV dexamethasone.
She cautioned that if nausea develops the day after treatment,
patients should take their antinausea medication as soon as it
develops. Waiting until the nausea is stronger will just make it more
difficult to treat.
The anticipatory type of nausea develops when the other types have
not been well managed, a classic conditioned response to the stimuli
surrounding therapy. Ms. Maxwell told a story about a patient who ran
into her chemotherapy nurse at the mall and promptly threw up.
Usually, anticipatory nausea is treated with antianxiety agents prior
to the appointment; the one most often prescribed is lorazepam
(Ativan and generics).
Cancer patients also need to know that their nausea can arise from
other things. Patients have called thinking they were sick from
their chemotherapy when, in actuality, they had a GI virus, Ms.
Maxwell said, so carefully assessing the nausea and questioning
the patient about other possible causes is important.
Tips for Cancer Patients to Avoid Treatment-Related Nausea and Vomiting
Do not arrive for chemotherapy hungry.
Limit (but do not eliminate) food intake on the day of therapy. It
Use lemon drops. They reduce nausea by cutting the flow of saliva.
Eat whatever tastes good to you.
Try to eat foods that taste good cold. The odor of hot foods can lead
Do not prepare food yourself. Buy prepared food or have someone else
Finally, Ms. Maxwell provided some basic tips for avoiding
treatment-related nausea and vomiting that nurses can offer patients
(see Table above).